consultation-liaison psychiatry – Page 11

Glitch in the Matrix or Something Else?

I saw one of the paranormal shows the other night and there were a few videos supposedly demonstrating possible proof that our reality is actually a computer simulation that sometimes gets glitchy.

One of the images was a bird stopped and motionless in mid-flight. It looked like a still photo which bounced around a little. Sure, the bird was motionless—but so was everything else.

The other two were actual videos and looked more interesting. One showed a large flock of sheep that were not moving much. There was an ear or tail flip here and there so they weren’t really motionless or “frozen.”

The other video showed a pretty interesting episode of what looked like what some would call tonic immobility in a squirrel. A person was hand-feeding the squirrel nuts and it suddenly froze for a short period of time and later just snapped out of it and acted normally. I wonder how a person got a wild squirrel to take food by hand.

Both the sheep flock and squirrel videos are available on the web. Some think the sheep become still because of a change in the weather, possibly rain. There was no explanation for the squirrel freezing.

Glitch in the matrix?

The squirrel might have been displaying tonic immobility, which can occur in certain animals. Probably the best-known example is the opossum. When it senses it’s in danger from a predator, it plays dead. There’s even a saying for this, “He’s just playing ‘possum!”

You can find the immobile squirrel story on the web by searching the term “catatonic squirrel.” In the article, the squirrel is called catatonic.

Catatonia is a complex neuropsychiatric condition in humans often marked by immobility and muteness. In a small percentage of cases, people can show purposeless agitation, or automatic, stereotyped motion.

In many cases, a small dose of benzodiazepine (usually injectable) can quickly reanimate a person who has catatonia, although the improvement is often only temporary. The usual course of treatment is to look for an underlying reversible medical or psychiatric cause and to apply effective treatment quickly, which can be life-saving.

Catatonia can lead to all kinds of complications because afflicted persons can’t eat or move. Some people who recover say that they felt extremely anxious or fearful during the catatonic episode.

Catatonia in humans is not the same thing as tonic immobility, a condition that is thought to be a survival mechanism in some prey animals in response to intense fear. If they “play dead”, a predator might not notice them or might let them go. But I can see why some people speculate there might be an evolutionary link between the two conditions.

These are interesting situations, but they aren’t evidence for a glitch in the matrix.

Overdiagnosis of Psychiatric Disorders Still Happens

I read an excellent article in Clinical Psychiatry News recently in the Hard Talk section. The title is “A prescription for de-diagnosing” by psychiatrists Nicholas Badre, MD and David Lehman, MD in the July 2022 issue (Vol 50, No. 7).

The bottom line is that too many psychiatric patients have too many psychiatric diagnoses. A lot of patients have conflicting diagnoses (both unipolar and bipolar affective disorder for example) and take many psychotropic medications which may be unnecessary and lead to side effects.

It takes time to get to know patients in order to ensure you’re not dropping diagnoses too quickly. Discussing them thoroughly in clinic or in the hospital is an excellent idea. And after getting to know patients as people, it makes sense to discuss reduction in polypharmacy, which can be quite a burden.

This reminds me of the Single Question in Delirium (SQiD), a test to diagnose delirium by simply asking a friend or family member of a patient whether their loved one seems to be more confused lately. It’s a pretty accurate test as it turns out.

This also reminds me of the difficulty in making an accurate diagnosis of bipolar disorder. I and a Chief Resident wrote an article for The Carlat Report in 2012 (TCPR, July / August 2012, Vol 10, Issue 8, “Is Bipolar Disorder Over-Diagnosed?”) which warned against overdiagnosis of bipolar disorder. Excerpts below:

Some argue that bipolar disorder is actually under-diagnosed. They have support from abundant literature showing that bipolar disorder tends to present more often with depression than mania or hypomania (Judd LL et al, Arch Gen Psychiatry 2002:59(6):530–537). As many as 10% of patients with unipolar depression ultimately are shown to have bipolar illness instead, according to some experts (Goodwin GM et al, Eur Neuropsychopharm 2008:18(7):535–549). (See this month’s Q&A with Claudia Baldassano for more on this.) In addition, a new emphasis on subthreshold mood symptoms and more rapid mood shifts has led some psychiatrists to promote the concept of a “bipolar spectrum disorder” (Youngstrom EA et al, Curr Psychiatry Rep 2010;12(6):479–489).

While it’s important to remain vigilant about a history of manic and hypomanic symptoms, we think the problem of over-diagnosis is probably greater. For instance, in a 2008 study, Zimmerman and colleagues performed a comprehensive diagnostic interview on 700 patients, nearly 21% of who self-reported a history of “bipolar disorder.” However, when using the gold-standard SCID (structured clinical interview), only 13% had the diagnosis; they also had more first-degree relatives with bipolar disorder than the others (Zimmerman M, Ruggero CJ et al, J Clin Psychiatry 2008:69(6):935–940). The authors hypothesized that over-diagnosis of bipolar disorder might be a consequence of efforts to improve recognition of it and avoid under-detection. In fact, the same authors studied 40 depressed patients previously diagnosed with bipolar disorder and found that, by the SCID, they had specific phobia, PTSD, drug abuse/dependence, or a personality disorder instead (Zimmerman M et al, Compr Psychiatry 2010;51(2):99–105).

Over-diagnosis can also occur when apparent mood episodes are defined as psychiatric when in fact, they have a different etiology altogether. Decreased need for sleep, disorganized or racing thoughts, increased activity and agitation, and delusional thinking, even when they occur together, can represent a sort of “final common pathway” for medical conditions and other syndromes. The manic phenotype can occur in patients with agitated delirium, brain tumors, corticosteroid treatment, and of course substance intoxication (Bunevicius A et al, CNS Spectr 2008;13(11):950–958; Brooks JO and Hoblyn JC, Am J Psychiatry 2005;162(11):2033–2038). These other phenotypes can be distinguished by recognition of key features such as the fluctuating nature of consciousness in delirium, neuroimaging findings, and positive urine drug screens.

Unfortunately, physicians may also be susceptible to diagnostic shortcuts. When faced with limited time for diagnostic interviews and the pressure to prescribe by patients and their families, well-meaning clinicians may give the diagnosis after a single brief interview. Not uncommonly, we find that it was diagnosed on the basis of mood fluctuation over minutes, temper tantrums, and fleeting insomnia. The rapidly expanding repertoire of medications approved for bipolar disorder, and their relative ease of use, may also contribute to over-diagnosis. Unfortunately, in some cases the treatment may be worse than the symptoms themselves (Iordache I and Low NC, J Psychiatry Neurosci 2010;35(3): E3–4).

I was accustomed to asking what I called the Single Question in Bipolar (SQiB). I frequently saw patients who said their psychiatrists had diagnosed them with bipolar disorder. I would ask them, “Can you tell me about your manic episodes?”

Often, they looked puzzled and replied, “What’s a manic episode?” I would describe the typical symptoms and they would deny ever having them.

The article by Drs. Badre and Lehman is a bit disappointing in that it doesn’t look as though we’ve improved our diagnostic acumen much in the last decade.

We need to try harder.

Thoughts on the GuideLink Center Incident

The attack a few days ago by what was most likely a mentally ill person on staff at the recently opened GuideLink Center in Iowa City reminded me of what may appear to be disparate views by mental health professionals on the link between mental illness and mass violence perpetrators.

The GuideLink incident involved a person who assaulted GuideLink staff and who also left bags containing incendiary devices at the center and another building in Iowa City. The person is being charged with terrorism and is currently in custody in the Johnson County Jail.

I have not seen information about any injuries sustained by the mental health center staff. There were no explosions or fires at either location where incendiary devices were left. Bomb squad experts removed the devices. It’s not clear whether the perpetrator had been a GuideLink Center client.

The GuideLink Center opened in February 2021 and by all reports is a welcome and very much needed crisis stabilization mental health resource in the community. The staff members are dedicated to their calling.

Dr. H. Steven Moffic, MD, a retired psychiatrist who writes for Psychiatric Times, readily says that the perpetrators sometimes do have mental illness that at least contributes to committing acts of mass violence. Dr. George Dawson, MD, another retired psychiatrist, seems to say that the major reason for mass shootings is the ready availability of guns, a culture of gun extremism, and mental illness accounts for a small proportion of acts of mass violence.

But neither Dr. Moffic nor Dr. Dawson say that it’s only either mental illness or guns (or other instrument of mass violence) that lead to acts of mass violence. Both are important.

I’m a third retired psychiatrist and by now some readers might be asking themselves whether they should listen to any retired psychiatrist. Experience counts.

Speaking for myself, as a general hospital psychiatric consultant I was frequently faced with violent patients in the general hospital. Often, I found it necessary to ask a judge for a court order to involuntarily hospitalize a violent and/or suicidal patient on a locked psychiatric unit by transfer from an open medical or postsurgical unit.

In order to obtain an order in the state of Iowa, I had to be able to state to the judge that the patient in question had a treatable mental disorder and was an acute threat to himself and/others. In most situations, I had an open bed on a locked psychiatric unit available ahead of time.

Even if a Code Green was necessary, I usually had an inpatient resource to which I could move the patient. A Code Green is a show of force or takedown maneuver by a specially trained team to control a violent patient while minimizing injury to everyone involved.

I don’t know if that kind of approach is even possible in a community crisis stabilization setting like the GuideLink Center. I think it’s fortunate that it partners with many other community resources including the Johnson County Sheriff’s Office.

The outcome of the incident at the GuideLink Center was that the overall safety of the staff, the patient, and the community was preserved. More resources like this are needed everywhere. They deserve all the support we can give them.

Short History of C-L Psychiatry Fellowship at Iowa

I read a short article, “The case for pursuing a consultation-liaison psychiatry fellowship” by Samuel P. Greenstein, MD in Current Psychiatry (Vol. 1, No. 5, May 2022). After 3 years as an attending, he found his calling as a C-L psychiatrist, especially after getting teaching awards from trainees. But when he applied to academic institutions for position as a C-L academic psychiatrist, people kept advising him to complete a fellowship training program in the subspecialty first. He gave it careful thought and did so, even he called it going “backwards” in his career.

On the other hand, he believes C-L fellowships will help meet the challenges of addressing rising health care costs and improving access to what most people see as the critically important goal of providing access to integrated mental health and medical care.

I’ve been retired from consultation-liaison psychiatry for two years now. I get an enormous sense of achievement on the rare occasions when I hear from former trainees who say things like “For me you were…one of the most outstanding attendings I had at my time at Iowa.” And “I can at least take comfort that University of Iowa is still at the forefront of psychiatry.”

Several years ago, one of the residents suggested starting a Psychosomatic Medicine Interest Group (PMIG). This was before the name of the subspecialty was formally changed to Consultation-Liaison Psychiatry in 2018. I know many of us were very pleased about that.

I sent a short survey (see the gallery below the slide show) to the faculty and residents in an effort gauge support for the idea and readiness to participate. I used a paper published at the time to guide the effort, (Puri NV, Azzam P, Gopalan P. Introducing a psychosomatic medicine interest group for psychiatry residents. Psychosomatics. 2015 May-Jun;56(3):268-73. doi: 10.1016/j.psym.2013.08.010. Epub 2013 Dec 18. PMID: 25886971.).

You’ll notice on slide 4 one faculty member’s comment, “I think it doesn’t matter whether faculty are certified in PM.” As Dr. Greenstein discovered, it probably does matter, at least if you want to be board certified.

I was initially certified by the American Board of Psychiatry & Neurology (ABPN), but I objected to the whole Maintenance of Certification (MOC) program, as did many other psychiatrists. I eventually declined to continue participating in the MOC process. However, I notice that the Delirium Clinical Module that I and a resident put together is still accessible on the ABPN website.

Although response numbers were low, there was clearly an interest in starting the interest group. There was also an incentive to reapply to the ACGME for approval of a Psychosomatic Medicine (Consultation-Liaison Psychiatry now) fellowship.

My attempt years earlier had been frustrating. While it was approved, I couldn’t attract any fellows, forcing me to withdraw it without prejudice (meaning another application for approval could be attempted). Fortunately, that situation changed later. The Psychiatry Department at The University of Iowa now has an early career C-L psychiatrist who graduated from the reinstated C-L fellowship.

As the saying goes, “What goes around comes around.” Although the origin of that saying might have originated in the 1970s, at least one person thought his grandmother had her own version in the 1950s: “You get what you give.”

Looking Back on Gunslingers and Chess Masters

I was looking at an early version of the handbook of consultation-liaison psychiatry that eventually evolved into what was actually published by Cambridge University Press. I wrote virtually all of the early version and it was mainly for trainees rotating through the consult service. The published book had many talented contributors. I and my department chair, Dr. Robert G. Robinson, co-edited the book.

In the introduction I mention that the manual was designed for gunslingers and chess masters. The gunslingers are the general hospital psychiatric consultants who actually hiked all over the hospital putting out the psychiatric fires that are always smoldering or blazing. The main problems were delirium and neuropsychiatric syndromes that mimic primary psychiatric disorders.

The chess masters were those I admired who actually conducted research into the causes of neuropsychiatric disorders.

Admittedly the dichotomy was romanticized. I saw myself as a gunslinger, often shooting from the hip in an effort to manage confused and violent patients. Looking back on it, I probably seemed pretty unscientific.

But I can tell you that when I followed the recommendations of the scientists about how to reverse catatonia with benzodiazepines, I felt much more competent. After administering lorazepam intravenously to patients who were mute and immobile before the dose to answering questions and wondering why everyone was looking at them after the dose—it looked miraculous.

Later in my career, I usually thought the comparison to a firefighter was a better analogy.

The 2008 working manual was called the Psychosomatic Medicine Handbook for Residents at the time. This was before the name of the specialty was changed back to Consultation-Liaison Psychiatry. I wrote all of it. I’m not sure about the origin of my comment about a Psychosomatic Medicine textbook weighing 7 pounds. It might relate to the picture of several heavy textbooks on which my book sits. I might have weighed one of them.The introduction is below (featured image picture credit pixydotorg):

“In 2003 the American Board of Medical Specialties approved the subspecialty status of Psychiatry now known as Psychosomatic Medicine. Long before that, the field was known as Consultation-Liaison Psychiatry. In 2005, the first certification examination was offered by the American Board of Psychiatry and Neurology. Both I and my co-editor, Dr. Robert G. Robinson, passed that examination along with many other examinees. This important point in the history of psychiatry began many decades ago, probably in the early 19th century, when the word “psychosomatic” was first used by Johann Christian Heinroth when discussing insomnia.

Psychosomatic Medicine began as the study of psychophysiology which in some quarters led to a reductionistic theory of psychogenic causation of disease. However, the evolution of a broader conceptualization of the discipline as the study of mind and body interactions in patients who are ill and the creation of effective treatments for them probably was a parallel development. This was called Consultation-Liaison Psychiatry and was considered the practical application of the principles and discoveries of Psychosomatic Medicine. Two major organizations grew up in the early and middle parts of the 20th century that seemed to formalize the distinction (and possibly the eventual separation) between the two ideas: the American Psychosomatic Society (APS) and the Academy of Psychosomatic Medicine (APM). The name of the subspecialty finally approved in 2003 was the latter largely because of its historic roots in the origin of the interaction of mind and body paradigm.

The impression that the field was dichotomized into research and practical application was shared and lamented by many members of both organizations. At a symposium at the APM annual meeting in Tucson, AZ in 2006, it was remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

I think it is ironic how organizations that are both devoted to teaching physicians and patients how to think both/and instead of either/or about medical and psychiatric problems could have become so dichotomized themselves.

My motive for writing this book makes me think of a few quotations about psychiatry in general hospitals:

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods.”

“All staff conferences in general hospitals should be attended by the psychiatrist so that there might be a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems.”

“The time should not be too long delayed when psychiatrists are required on all our medical and surgical wards and in all our general and surgical clinics.”

The first two quotes, however modern they might sound, are actually from 1929 in one of the first papers ever written about Consultation Psychiatry (now Psychosomatic Medicine), authored by George W. Henry, A.B., M.D. The third is from the mid-1930s by Helen Flanders Dunbar, M.D., in an article about the substantial role psychological factors play in the etiology and course of cardiovascular diseases, diabetes, and fractures in 600 patients. Although few hospital organizations actually practice what these physicians recommended, the recurring theme seems to be the need to improve outcomes and processes in health care by integrating medical and psychiatric delivery care systems. Further, Dr. Roger Kathol has written persuasively of the need for a sea change in the way our health care delivery and insurance systems operate so as to improve the quality of health care in this country so that it compares well with that of other nations (2).

This book is not a textbook. It is not a source for definitive, comprehensive lists of references about all the latest research. It is not a thousand pages long and does not weigh seven pounds. It is a modest contribution to the principle of both/and thinking about psyche and soma; consultants and researchers; — gunslingers and chess masters.

In this field there are chess masters and gunslingers. We need both. You need to be a gunslinger to react quickly and effectively on the wards and in the emergency room during crises. You also need to be a chess master after the smoke has cleared, to reflect on what you did, how you did it—and analyze why you did it and whether that was in accord with the best medical evidence.

This book is for the gunslinger who relies on the chess master. This book is also for the chess master—who needs to be a gunslinger.

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat”—Sun Tzu.”

References:

1. Kathol, R.G., and Gatteau, S. 2007. Healing body and mind: a critical issue for health care reform. Westport, CT: Praeger Publishers. 190 pp.

2. Kornfeld, D., and Wharton, R. 2005. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Psychosomatics 46:95-103.

They Did Learn How to Check for Delirium!

Here’s another oldie but goodie blog post, “It’s Survey Time.” It’s a blast from the past (May of 2011) but it needs a short introduction on why I’m reposting it.

So, I’m about a week out from my surgery for a detached retina. I’m doing pretty well. I keep thinking about a question a nurse asked me right after I was taken to the recovery room from the operating room. I was a little hazy because I’m pretty sure I got some sedation medication, although I was definitely mostly awake for the procedure. The nurse asked me, “Well, can you answer a question for me; will a stone float on water?”

First of all, I gave the right answer, “No.” More importantly, I was momentarily stunned because I recognized the question is from the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). And I told the nurse that. It reminded me of my early career as a general hospital consultation-liaison psychiatrist.

Most of my old blog posts from The Practical Psychosomaticist are about my frustration over what seemed to be my fruitless efforts to teach nurses and physicians about how to prevent, assess, and manage delirium.

I can’t tell you how happy I was that my recovery room nurse asked me a CAM-ICU delirium screening question.

I mentioned the American Delirium Society (ADS) in the post and also found a fairly recent article on the CAM ICU. Among the authors were those I met at one of t he first ADS meetings: Malaz Boustani and Babar Kahn.

“It’s Survey Time!”:

“I know, I know, I can hear it out there, “Doesn’t Dr. Amos ever learn? Nobody does surveys and polls!” Hey, that’s OK; I have so much fun doing them anyway. Of course, it would be nice to get some responses… I’ve talked to you and I’ve talked to you, and I’m done talkin’ to you! Come back here, I’m not done talkin’ to you!

Anyway, the new poll for what’s hot and what’s not about delirium screening scales is up on the home page. The original one was partly to help our delirium prevention project committee to decide on which one to use. Well, the original got only 16 responses…but they were great responses! The amazing thing was that, despite the paucity of votes, the results were plausible. See the results:

Recall that at our 7th project meeting we selected the DOSS. What? There is good literature supporting all of these scales and a lot of factors influence selection of any tool, not the least of which is feasibility, which is mainly ease of use. That means it’s quick and doesn’t require a lot of training or additional assessments. And you should use a tool that’s validated for the patient population you want to protect from delirium. I probably got a lot of questioning looks at the screen when this poll came out because the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) was not on the list. Well, you heard it from one of the main dudes on the team that developed the CAM-ICU that it’s probably not appropriate for use on general medical units…Dr. E. Wesley Ely himself (see post April 29, 2011). Hey, as far as the ICU patient population goes, the CAM-ICU is the holy grail. We need to keep looking for a sensitive and specific tool which is quick and easy for nurses to administer on general medical units.

We’re going with the DOSS. And one of my neuropsychologists, John, is offering to run neuropsychology test batteries on the patients that nurses screen with the DOSS. Atta boy, John! Neuropsychologists are going to be indispensable in this area. I remember pushing for the addition of subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), especially the Coding test in order to detect delirium early as possible. It didn’t make it, but it was close. This has been advanced by another one of our neuropsychologists here who’s done some delirium research in the bone marrow transplant unit with delirious patients. Hey, I still wonder what we could accomplish if the Coding test were added to the DOSS or even the Nursing Delirium Screening Scale (Nu-DESC). Maybe there’s already somebody out there putting a practical implementation plan for that into the real world.

So why do the poll again? Because I’d like to see if I could persuade nurses from large American and world organizations to put the nickel down and vote. And if I keep shoving this thing out there, maybe somebody will let us know that, hey, we’re not in this alone and offer to collaborate.

And I stole a couple of survey questions from our group to see what physicians and nurses think about how they manage delirium. It’s a way to take a snapshot of the culture of how docs and nurses work together on delirium recognition and interventions. And hey, why am I doing that? Because I’m a thief…no, no, I mean the reason is delirium is a medical emergency and we all need to work together to find ways to understand it better in order to prevent it. The American Delirium Society (ADS) tell you why delirium prevention is critical in the endless search to find ways to deliver high-quality medical care to patients:

Delirium Simple Facts:

More than 7 million hospitalized Americans suffer from delirium each year.
Among hospitalized patients who survived their delirium episode, the rates of persistent delirium at discharge, 1, 3 and 6 months are 45%, 33%, 26%, and 21% respectively.
More than 60% of patients with delirium are not recognized by the health care system.
Compared to hospitalized patients with no delirium and after adjusting for age, gender, race, and comorbidity, delirious patients suffer from:
Higher mortality rates at one month (14% vs. 5%), at six months (22% vs. 11%), and 23 months (38% vs. 28%);
Hospital stay is longer (21 vs. 9 days); Receive more care in long-term care setting at discharge (47% vs. 18%), at 6 months (43% vs. 8%) and at 15 months (33% vs. 11%); and
Have higher probability of developing dementia at 48 months (63% vs. 8%).

And have you registered for the ADS inaugural conference on June 5-7 in Indianapolis? Good for you! And are you going to bring back something from that conference for The Practical Psychosomaticist, and I don’t mean doughnuts? That’s the spirit! The surveys have spaces for free-text comments as well, which I want to hear!”

The Chicken Finally Lays An Egg

Below is an old post from a previous blog that I published on June 6, 2010. Although the title in my record is simply PM Handbook Blog, there must have been another title. Maybe it should have been more like The Chicken Has Finally Laid an Egg (you’ll get the joke later).

There are two reasons for posting it today. One is to illustrate how the Windows voice recognition dictation app works. It’s a little better than I thought it would be. The last time I used it, it was ugly. I’m using it now because I thought it might be a little easier than trying to type it since I still have problems with vision in my right eye because of the recent retinal tear injury repair. So, instead of doing copy paste, what you’re seeing is a dictation—for the most part.

On the other hand, I’m still having to proofread what I dictate. And I still find a few mistakes, though much fewer than I expected.

The other reason for this post is to help me reflect on how far the fellowship has come since that time. It did eventually attract the first fellow under a different leader. That was shortly after I retired. It was a great step forward for the department of psychiatry:

“Here is one definition of a classic:

“Classic: A book which people praise but don’t read.” Mark Twain.

When I announced the publishing of our book, Psychosomatic Medicine, An Introduction to Consultation Liaison Psychiatry, someone said that it’s good to finally get a book into print and out of one’s head. The book in earlier years found other ways out of my head, mainly in stapled, paperclipped, spiral bound, dog eared, pages of homemade manuals, for use on our consultation service.

It’s a handbook and meant to be read, of course, but quickly and on the run. As I’ve said in a previous blog, it makes no pretension to being the Tour de Force textbook in America that inspired it. However, any textbook can evolve into an example of Twain’s definition of a classic. The handbook writer is a faithful and humble steward who can keep the spirit of the classic lively.

We must have a textbook as a marker of Psychosomatic Medicine’s place in medicine as a subspecialty. It’s like a Bible, meant to be read reverently, venerated, and quoted by scholars. But the ark of this covenant tends to be a dusty bookshelf that bows under the tome’s weight. A handbook is like the Sunday School lesson plan for spreading the scholar’s wisdom in the big book.

Over the long haul, the goal of any books should mean something other than royalties or an iconic place in history. No preacher ever read a sermon to our congregation straight out of the Bible. It was long ago observed by George Henry that there will never be enough psychiatric consultants. This prompts the question of who will come after me to do this work. My former legacy was to be the Director of a Psychosomatic Medicine Fellowship in an academic department in the not-so-distant past. Ironically, though there will never be enough psychiatric consultants, there were evidently too many fellowships from which to choose. I had to let the fellowship go. My legacy then became this book, not just for Psychosomatic Medicine fellows, but medical students, residents, and maybe even for those who see most of the patients suffering from mental illness—dedicated primary care physicians.

My wife gave me a birthday card once which read: “Getting older: May each year be a feather on the glorious Chicken of Life as it Soars UNTAMED and BEAUTIFUL towards the golden sun.” My gifts included among the obligatory neckties, a couple of books on preparing for retirement.

Before I retire, I would like to do all I can to ensure that the next generation of doctors learn to respect the importance of care for both body and mind of each and every one of their patients. That’s the goal of our book. And may the glorious chicken of life lay a golden egg within its pages to protect it from becoming a classic.”

Chicken picture credit: Pixydotorg.

The Connection Between The University of Iowa and Factitious Disorder

I found another old blog post, Thoughts on Munchausen’s Syndrome, which reminded me of a psychiatric disorder I saw probably more frequently than most psychiatrists unless they are consultation-liaison specialists. I wrote it in June of 2011. I still don’t understand the disorder and I doubt anyone else does either. The interesting connection to Iowa is that a patient with Factitious Disorder was admitted to the University of Iowa Hospital in the 1950s. The treating doctor published a paper about him in the Journal of the American Medical Association.:

“I ran across an old poem written by William Bennett Bean, M.D., who was a physician in the Department of Medicine at the University of Iowa. It’s called “The Munchausen Syndrome” and it was published in 1959 [1]. Dr. Bean was Professor and Chairman of the Department of Medicine at the University of Iowa in 1948. Of course, he did more than write interesting poetry. He specialized in nutrition. He was named the Sir William Osler Professor of Medicine at Iowa in 1970. He was well-known as a clinician and teacher. He was also called a “masterful teller of tales”, which may explain in part why he wrote “The Munchausen Syndrome.” One quotation is “The one mark of maturity, especially in a physician, and perhaps it is even rarer in a scientist, is the capacity to deal with uncertainty.”

The poem is about a psychiatric disorder about which there is a great deal of uncertainty, formerly called Munchausen’s Syndrome, now known as Factitious Disorder. It’s based on an actual case of the disorder, an account of which was published in the medical literature [3]. An excerpt from the beginning of the work follows:

THE MUNCHAUSEN SYNDROME

By WILLIAM B. BEAN, M.D.

IOWA CITY, IOWA

The patient who shops around from doctor to doctor, the dowager alert for some new handsome young physician to hear her flatulent and oleaginous outpourings, the bewildered neurotic who has had a dozen operations for a thousand misunderstood complaints—these we recognize as interesting patients or as nuisances we have to deal with as charitably as we may. They occupy the lower end of the spectrum of humanity with all its infinitely various people. Nearby reside the malingerer and the deadbeat, a shoplifter of medical aid who escapes just ahead of the policeman. At the frayed end of this spectrum we find a fascinating derelict, human flotsam detached from his moorings, the peripatetic medical vagrant, the itinerant fabricator of a nearly perfect facsimile of serious illness—the victim of Munchausen’s syndrome. This is the tale of such a patient. He had our medical department in an uproar off and on for forty days and forty nights. His Odyssey I outline here in verse. I find to my anguish that much of the verse does not scan, some does not rhyme, and all is obscure. I proceed.

THE MUNCHAUSEN SAGA

In the summer of Nineteen and Fifty-four At Iowa City, our hospital door,—

Mecca for hundreds every day—

A merchant seaman came our way—A part time wrestler, in denim jacket

Crashed through the door with a horrible racket,

Two hundred sixty pounds at least,

He was covered with blood like a wounded beast.

Try to excuse the tone of the piece; it was written in another era when a more intolerant attitude toward illness mimicry was viewed as malicious undermining of the physician-patient relationship. In fact, it’s virtually impossible to distinguish Factitious Disorder from Malingering. We think of the former as belonging in the category of mental illness and the latter as, well, not an illness at all, but lying in order to get something or to get out of something. Factitious Disorder is marked by lying as well and some try to make the case that the lying which patients with Factitious Disorder engage in, sometimes called “pseudologia fantastica” or pathologic lying, is somehow different from ordinary lying. According to Bean, it’s like this:

He gave us a history, in elegant diction, Which later we found was all out fiction. Carpenter, wrestler and bosun’s mate And stevedore. He could exaggerate! His body was covered with many a scar He said from surgeons near and far

His appendix went in County Cork A navel hernia in New York.

Once, he declared, in Portland, Maine,

A surgeon stripped out his saphenous vein. Surgical scars above one kidney

Came from an ectomy done in Sidney. Scarred, he was, on his abdomen

From a wreck, he said, when with women roamin.’ Another injury he wouldn’t reveal us

Messed up his left internal malleolus. From time to time, as he wove this story

He boasted of prowess and wealth and glory. By courage he ruled his fellow sailors

But he didn’t say much of his many jailors.

In fact, we understand very little about so-called pathologic lying, though the telling of tales is engaged in not just by psychiatric patients. One of the most fascinating consequences of the frustration physicians feel about Factitious Disorder was the fraudulent case report about Factitious Munchausen’s Syndrome. The paper was published by a couple of resident physicians in the New England Journal of Medicine and was a spurious account of an emergency room patient named Norman U. Senchbau, who claimed to actually have Munchausen’s Syndrome and who demanded admission to hospital for treatment [2]. He supposedly confessed to having undergone many surgeries and to prove it, displayed many scars on his abdomen…which washed off with soap and water. Of course, the name of the patient is just an anagram of Baron Munchausen.

I occasionally get calls from internists and surgeons about patients whom they suspect of manufacturing illness for the sake of taking the role of patient (part of the definition of the disorder in the Diagnostic and Statistical Manual of Mental Disorders). As often as not, I have no clear idea of how to proceed with interviewing someone who probably does deliberately produce illness, other than to do my best to listen for understanding, to avoid confronting them, and to seek some way to interrupt their self-destructive behavior. In the end I don’t believe we now know much more than Bean did:

What do we know of the pathogenesis

Of hospital vagrants and doctors menaces? Maybe the person acts unenlightened

From a real disease which has him frightened. Does part of the reason he may vex you all Lurk in dark leanings homosexual?

What is the cause, and what are the reasons He wandered pitifully through the seasons? Lonely pilgrim out of orbit

Peace and quiet lost in forfeit.

Hospital haunters, doctor deceivers

Their acting confounds even nonbelievers. Derelicts lost in a cold society

Wanderlusting, without satiety.

Social pariah or medical freak

Whence does he come and what does he seek?

I cannot relieve my brain’s congestion By unveiling an answer to this question In the age of sputniks, the fall of parity We all should try to think with clarity.

L’Envoi

Princes and wise men of many conditions

Beautiful ladies and honored physicians

I’m sorry I cannot fasten my claws in

What causes the Syndrome named Munchausen, This off again, on again, gone again Finnegan

Comes in, than goes out and at length comes in again. Munchausen’s victims must be expected

To plague our lives unless detected.

Those we identify when we sight ’em

Should be restricted ad infinitum

So be alert for this great nonesuchman Munchausen syndrome’s flying Dutchman.

1. Bean, W.B., The Munchausen syndrome. Perspectives in biology and medicine, 1959. 2(3): p. 347-53.

2. Gurwith, M. and C. Langston, Factitious Munchausen’s syndrome. The New England journal of medicine, 1980. 302(26): p. 1483-4.

3. Chapman, J.S., Peregrinating problem patients; Munchausen’s syndrome. Journal of the American Medical Association, 1957. 165(8): p. 927-33.”

Quiz Show on Delirium

Here’s an old post from February 15, 2011 from my previous blog The Practical Psychosomaticist called Quiz Show Versus Grand Rounds for Delirium Education:

“So you want to put on a game show contest to educate clinicians about delirium? Contact David Meagher, a psychiatrist in (where else?) Limerick, Ireland. He reported on this innovative educational workshop in the November 2010 Vol. 3 issue of the Annals of Delirium, the newsletter for the European Delirium Association (EDA). He also published the study which describes the contest in International Psychogeriatrics[1].

The workshop focused on clinician attitudes toward drug therapy for distressed delirious patients. It explored pre-existing attitudes and practice toward the use of medications to manage delirium and exposed participants to a very interactive educational event modeled after a popular TV quiz show. There were two teams (skeptics versus neuroleptics) furnished with a list of statements about delirium pharmacotherapy. The participants later completed a post-workshop questionnaire that explored changes in attitudes as a result of the workshop.

The participants were all experts on the subject and there was a good deal of variability in attitudes and practice. Some of the questions put to the teams involved using antipsychotics prophylactically to prevent delirium, the mechanism of action of antipsychotics, and what role benzodiazepines play in the treatment of non-alcohol withdrawal delirium.

One of the more puzzling findings was that the frequency of antipsychotic use was inversely proportional to the perception of the strength of supporting evidence. In other words, the less they knew about antipsychotics, the more often they used them. Most participants seemed to believe that the principal mechanism of action of antipsychotics is sedation, despite the lack of supporting evidence.

Some clinicians used antipsychotics to relieve the stress of caregivers rather than that of delirious patients, an example of patients getting the right treatment for the wrong reasons as observed by Meagher—and many of us in the field.

The workshop also highlighted the tendency of clinicians to focus on risk management rather than effective therapeutic intervention in the management of delirious patients with disruptive behavior and severe distress. This mainly relates to focus on the potential adverse effects of antipsychotics such as extrapyramidal side effects, metabolic, and cerebrovascular effects.

The quiz show activity was fun and challenging. The device of dividing the participants into two small teams with larger audience participation cut down on the anxiety that could be provoked by giving the “wrong answer”. The questions were true/false and didn’t always have clear right or wrong answers. It was highly interactive, a component of continuing medical educational (CME) activities that is increasingly encouraged because it’s more likely to lead to changes in clinician attitude and practice. The one-time Grand Rounds CME “seat time” is going the way of the dinosaur.

So a couple of findings from the quiz show post-activity questionnaire were that clinicians were more likely to use antipsychotics prophylactically and to use antipsychotics to manage hypoactive delirium.

Our delirium intervention project group members are not quite as enthusiastic yet about these two interventions. We’re a bit more inclined at least initially to focus on non-pharmacologic multicomponent strategies such as the example below:

Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
Avoid immobility, early mobilization
Monitor nutrition
Provide visual and hearing aids
Monitor closely for dehydration
Control pain
Monitor fluid-electrolyte balance
Monitor bowel and bladder functioning
Review medications
Reorient communications with the patient
Place an orientation board, clock, or familiar objects (ie, family photographs) in patient rooms
Encourage cognitively stimulating activities such as word puzzles
Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage
Minimize noise and interventions at bedtime, e.g., by rescheduling medication times

But I’m just as enthusiastic about interactive educational methods to engage learners in order to build a culture more likely to produce champions who will lead the delirium prevention effort—try the delirium multicomponent criss-cross puzzle below. The clues are contained in the list of multicomponent tactics above.”

Meagher, D.J., Impact of an educational workshop upon attitudes towards pharmacotherapy for delirium. Int Psychogeriatr, 2010. 22(6): p. 938-46.

Going Down Blogging Memory Lane

I’ve been going down the blogging memory lane lately and thought I’d repost what was probably the very first post I published on my first blog, The Practical Psychosomaticist. The title was “Letter from a Pragmatic Idealist.”

While a lot of water has gone under the bridge since mid-December of 2010, some principles remain the same. Some problems still remain, such as the under-recognition of delirium.

Just a few thoughts about words, just because I’m a writer and words are interesting. The word “Psychosomaticist” is clunky and I’ve joked about it. I tried to think of another name for the blog. I thought “Pragmatic Idealist” was original until I googled it—someone already had coined it. Then I considered “The Practical Idealist”, with the same result. The same thing happened with “The Practical Psychiatrist.” All of the terms had been used and the associations didn’t fit me. I couldn’t find anyone or any group using the term “The Practical Psychosomaticist.”

Finally, after the Academy of Psychosomatic Medicine (APM) changed its name to the Academy of Consultation-Liaison Psychiatry (ACLP) in 2016, I changed the name of the blog to The Practical C-L Psychiatrist, finally dropping the name “psychosomatic” along with its problematic associations.

I guess the chronicle would be incomplete without an explanation of what happened to that blog. Around 2016, the General Data Protection Regulation (GDPR) was adopted by the European Parliament. WordPress, a popular blogging platform which I use, eventually decided that even hobby bloggers had to come up with a quasi-legal policy document to post on their websites to ensure they were complying with the GDPR regulation and not misusing anyone’s personal data.

I didn’t think that applied to hobby bloggers like me yet it was required. I wasn’t collecting anyone’s personal data and not trying to sell anything. I deleted my blog in July of 2018. Because I loved to write, I eventually started a new blog around the last year of my phased retirement contract with my hospital in 2019.

Anyway, here’s the December 15, 2010 post, “Letter from a Pragmatic Idealist.”

“I read with interest an article from The Hospitalist, August 2008 discussing the Center for Medicare and Medicaid Services (CMS) requirement for hospitals to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA)[1]. The topic of the article was whether or not delirium would eventually make the list of diagnoses that CMS will pay hospitals as though that complication did not occur, i.e., not pay for the additional costs associated with managing these complications. At the time this article was published, CMS was seeking public comments on the degree to which the conditions would be reasonably preventable through application of evidence-based guidelines.

I have no idea whether delirium due to any general medical condition made the list or not. But I have a suggestion for a delirium subtype that probably should make the list, and that would be intoxication delirium associated with using beverage alcohol in an effort to treat presumed alcohol withdrawal. There is a disturbing tendency for physicians (primarily surgeons) at academic medical centers to try to manage alcohol withdrawal with beverage alcohol, despite the lack of medical literature evidence to support the practice [2, 3]. At times, in my opinion, the practice has led to intoxication delirium in certain patients who receive both benzodiazepines (a medication that has evidence-based support for treating alcohol withdrawal) combined with beer—which generally does not.

I’ve co-authored a couple of articles for our institution’s pharmacy newsletter and several of my colleagues and pharmacists petitioned the pharmacy subcommittee to remove beverage alcohol from the formulary at our institution, where beer and whiskey have been used by some of our surgeons to manage withdrawal. Although our understanding was that beverage alcohol had been removed last year, it is evidently still available through some sort of palliative care exception. This exception has been misused, as evidenced by cans of Old Style Beer with straws in them on bedside tables of patients who are already stuporous from opioid and benzodiazepine. A surgical co-management team was developed, in my opinion, in part to address the issue by providing expert consultation from surgeons to surgeons about how to apply evidence-based practices to alcohol withdrawal treatment. This has also been a failure.

I think it’s ironic that some professionals feared being sanctioned by CMS for using Haloperidol to manage suffering and dangerous behavior by delirious people as reported by Stoddard in the winter 2009 article in the American Academy of Hospice and Palliative Medicine (AAHPM) Bulletin[4]. Apparently, CMS in fact did have a problem with using PRN Haloperidol (not FDA approved of course, but commonly used for decades and recommended in American Psychiatric Association practice guidelines for management of delirium), calling it a chemical restraint while having no objection to PRN Lorazepam, which has been identified as an independent predictor of delirium in ICU patients[5]. Would the CMS approve of using beer to treat alcohol withdrawal, which can cause delirium?

As a clinician-educator and Psychosomatic Medicine “supraspecialist” (term coined by Dr. Theodore Stern, MD from Massachusetts General Hospital), I’ve long cherished the notion that we, as physicians, advance our profession and serve our patients best by trying to do the right thing as well as do the thing right. But I wonder if what some of my colleagues and trainees say may be true—that when educational efforts to improve the way we provide humanistic and preventive medical care for certain conditions don’t succeed, not paying physicians and hospitals for them will. I still hold out for a less cynical view of human nature. But if it will improve patient care, then add this letter to the CMS suggestion box, if there is one.”

1. Hospitalist, D. (2008) Delirium Dilemma. The Hospitalist.

2. Sarff, M. and J.A. Gold, Alcohol withdrawal syndromes in the intensive care unit. Crit Care Med, 2010. 38(9 Suppl): p. S494-501.

3. Rosenbaum, M. and T. McCarty, Alcohol prescription by surgeons in the prevention and treatment of delirium tremens: historic and current practice. General Hospital Psychiatry. 24(4): p. 257-259.

4. Stoddard, J., D.O. (2009) Treating Delirium with Haloperidol: Our Experience with the Center for Medicare and Medicaid Services. Academy of Hospice and Palliative Medicine Bulletin.

5. Pandharipande, P., et al., Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 2006. 104(1): p. 21-6.