Category: Psychiatry

Another Look at an Old Blog Post on Psychiatric Case Formulation

I just had a look at a blog post on case formulation I wrote about 12 years ago. Aside from sounding a little pompous, I decided to check on the title I gave it back then: “What Kind of Disease Does the Person Have And What Kind of Person Has the Disease?”

I looked at the web site that researches who said what as far as quotes go. It’s Quote Investigator and their conclusion is that the above quote should be attributed to Henry George Plimmer, a lecturer on Pathology and Bacteriology at St. Mary’s Hospital Medical School. He said:

“You will have to acquire, too, for any success to be given you, an accurate knowledge of human nature, and you will find that it is quite as important for the doctor to know what kind of patient the disease has for host, as to know what sort of disease the patient has for guest.”

Anyway, the post is below; the cases are all fictional:

I recently had the pleasure of evaluating one of our junior residents using the new clinical skills exam format. These evaluations are taking the place of the oral board examinations for certification in Psychiatry. The oral board exams have been the bane of examinees for many years in part because of the extreme anxiety they provoke. Preparing a resident in psychiatry involves a rigorous educational program over 4 to 6 years and they must master a vast amount of content knowledge just to become certified as safe and competent practitioners as defined by regulatory organizations. Elements of the clinical skill exam include interviewing skills, a mental status exam, case presentation, and case formulation.

Case formulation is the most demanding element. There are many references trainees can Google on line to find. A classic paper often cited is the one by Perry and others[1]. It helps doctors and patients by balancing the focus on both what kind of disease the person has, and what kind of person has the disease. Case formulation is an essential skill which takes years of practice to master and I’m inclined to give a lot of latitude to trainees in their ability to demonstrate it, especially in the first year of residency. Formulations can be used by psychiatrists in every subspecialty, including Psychosomatic Medicine, as the fictionalized examples will demonstrate.

Making useful case formulations can be frustrating for both trainees and experienced clinicians. On the other hand, if it’s not, there’s a good chance that oversimplification is becoming a problem. One pitfall that ironically comes with experience is dashing off a formulation that sounds deep using “psychobabble” but which misses the mark in describing the patient’s problems in the real world. Striking a balance between over inclusiveness and superficiality takes practice. Often, tying the formulation to only one model seems constrictive.

In general, making an integrative synthesis of the relevant factors in a patient’s clinical situation (abstracted from the history) is easier than making an integrative inference about why her problem exists. It helps to look for clues in the form of repetitive themes in a patient’s life which lead to conflicts that are resolved in maladaptive ways. There is no standardized format, and so there may seem to be as many formulation strategies as there are clinicians. Starting with a manageable framework can help. The phrases in bold type are the connectors that guide thinking and writing about the patient and help keep the focus on central issues:

This is a  age, employment status, illness state (acutely v. chronically ill), marital status, male/female, with  psychiatric symptoms list, duration of,  complicated by,  head injury, substance abuse, medical syndromes, that we were asked to evaluate because of  consult requestor question.  She meets criteria for Diagnostic and Statistical Manual-IV-TR diagnosis.

Her psychiatric symptoms can be associated with or precipitated by medical diagnoses. They are also known to have familial pattern, affected/exacerbated by drugs, environmental triggers.

The current behavior may have been determined by a developmental background marked by abuse, neglect, conflict in family of origin, maintained longitudinally by pattern of maladaptive management of relationships and situational stressors.  Although cross-sectional exam cannot typically confirm one central conflict, she may have difficulties with independence v. dependence, intimacy v. isolation, generativity v. stagnation.

Typical defenses may include acting out, denial, reaction formation, etc., which appears to be interfering with medical management, not an issue on the ward, and may be predictive of chronic noncompliance with therapy, conflict with caregivers, eventual return to adaptive coping, etc.

Although the scaffold looks unwieldy and long, in practice (and with practice) it can be tailored to fit the clinical need. Certain neuropsychiatric problems seen by consultants don’t require any detailed analysis of defenses, e.g., uncomplicated drug-induced deliria in patients without any psychiatric histories. But just because someone does have a complicated psychiatric history doesn’t imply that the formulation must be long and detailed. The goal is always to succinctly summarize the central issues that describe and explain the patient’s current problems so as to guide recommendations for management.

Example case formulations:

  • 44-year-old multiply divorced, alcoholic, unemployed white male without formal psychiatric history, but with acute subsyndromal depressive symptoms without suicidality in the context of recent diagnosis of diabetes mellitus after being hospitalized with diabetic ketoacidosis. His father (who also had diabetes) died of suicide when the patient was 9 years old. Consult triggered by patient refusing to get up to toilet himself, crying, insulting the nurses, yet constantly on his call light. Depression is known to be associated with Diabetes Mellitus and can run in families. He may be conflicted between dependence and independence or struggling with stagnation developmentally, given his social and occupational marginalization. Regression appears to be major defense. Tolerance of nonthreatening behavior and allowing him control over non-essential features of his care may facilitate face-saving return to more adaptive coping with grief. Monitor for development of a more well-defined depressive syndrome; supportive approach with encouragement of affect but engage effective coping by modeling; query into past successful problem solving.
  • 37-year-old divorced white female teacher aide with abrupt onset of medically unexplained slow, garbled speech. Previous psychiatric history notable for one brief hospitalization in her mid-teens after impulsive overdose over a breakup with boyfriend. Temporal association of dysarthria with her discovering her current boyfriend in bed with her teenage daughter (reported by a friend). Her presentation is consistent with conversion reaction. Major conflict is desire to confront boyfriend but fear of rejection and abandonment. Major defense is somatization. Confrontation generally contraindicated; suggest that recovery will be fairly rapid; no invasive procedures or specialist referrals needed and the condition is not dangerous. Quick follow-up in mental health clinic scheduled.
  • 57-year-old disabled man who had a liver transplant and who has polysubstance dependence in remission and longstanding antisocial behavior referred for subsyndromal depression and anxiety along with insomnia. Recently arrested for shoplifting. Also engaging in reckless driving and fistfights, neither of which he’s done in decades either. No organic brain disease identified that could explain the behavior. Possibly struggling with generativity v. stagnation because of chronic unemployment leading to regressive acting out. Refer to psychotherapy, although resistance expected with more acting out and non-adherence.
  • 49-year-old woman with Hepatitis C (HCV) on interferon (IFN) for last 3 months and with gradually increasing symptoms of syndromal depression, personality change with marked irritability, and somatic complaints. Previously diagnosed recurrent depression in the context of Cluster B personality traits complicated by alcoholism and cocaine abuse, now in sustained full remission. Consult triggered by her erupting in the GI clinic at the gastroenterologist’s suggestion that cutting interferon dose might be recommended in light of her psychiatric status. She thinks that this means she’ll get cirrhosis, be denied liver transplant because of her drug history, and be condemned to die of liver failure. She blames doctors for missing the HCV diagnosis for years, yet feels stigmatized by everyone because of the diagnosis, and at the mercy of doctors who control the only effective treatment. Several cognitive distortions could be the issues in her depression including personalization, catastrophizing, control fallacies and blaming. Interferon is also known to be associated with depression and cognitive impairment. Cognitive Behavioral Therapy (CBT) intervention may be influenced by the latter side effect; antidepressants are an effective drug treatment of IFN-induced depression.

1.       Perry, S., A.M. Cooper, and R. Michels, The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. Focus, 2006. 4(2): p. 297-305.

Shout Out to the European Delirium Association

I just want to give an enthusiastic shout out to the European Delirium Association (EDA). I rediscovered the website. It’s updated and an extremely helpful organization in the study of delirium. It provides excellent education about the disorder.

I met one of the past presidents of the EDA, Alasdair MacLullich back in the early 2010s. In fact, while I was staffing the University of Iowa Hospital consultation-liaison service, he was generous enough to send us one of the pieces of technology which was designed to test for delirium: The Edinburgh Delirium Test Box or Delbox.

I wrote a blog post years ago about the EDA. At that time, the group published a newsletter called the Annals of Delirium. Here’s an excerpt from one of the issues in 2010:

Delirium has a long way to go before it gets the attention it deserves, before it is present in the public consciousness in the way cancer is, or even HIV. Bearing in mind the prevalence of delirium and the impact it has on patients and families we may believe it is only a matter of time, but I believe that the process is going far too slowly. Some countries are doing better than others and some areas of medicine are making greater inroads, which can only benefit us all in the long run. In the UK, however, if you search for delirium on the BBC website you are directed to the music page and the group Delirium Tremens.

I remember thinking that the anecdote reminded me of how that sounded a lot like the way things were going in the United States at that time.

And the EDA announcement about the new delirium organization in the U.S. that was just getting it’s start around that time, in 2011—the American Delirium Society (ADS).

There are educational videos about delirium on the EDA website and I’m excited to learn more about them.

Further, there was a sort of word search game I rediscovered that was made by the EDA. Some of the words are on the diagonal. Give it a shot! I finished it, but it was very challenging. If you need the key, please comment.

Gratitude to Pastor Robert Stone

I came across a couple of items that prompted my renewed gratitude. One of them was an article in Bloomberg on the web, “US Medical Schools Grapple With First Admissions Since End of Affirmative Action” by Richard Abbey, Ilena Peng, and Marie Patino, published on December 14, 2023. It’s about how hard it is for black students to get into and graduate from medical school. Just getting to college is a major hurdle.

The other item is an obituary of one of the most important persons in my life, Pastor Robert Leroy Stone. He authorized scholarships for two years of my undergraduate college education, which were at Huston-Tillotson College (now Huston-Tillotson University, one of the HBCUs) in Austin, Texas. That was back in the 1970s, ancient history now. The issue of Affirmative Action was widely discussed during that time.

As usual, I’m dumbfounded by how often I miss the passing of the critically important people who made my success in life possible. And there is this astonishing connection which followed me even to Iowa City—but of which I was unaware. After he retired, Pastor Stone moved from Mason City to Iowa City in November of 2001. At that time, I had graduated from The University of Iowa College of Medicine, finished my residency in psychiatry in 1996, and was on staff in University of Iowa Dept of Psychiatry. I never knew he was so close. He died in 2002.

Pastor Stone was a Board Member and Chair of the Mason City YMCA, where I lived for a while. He was also a Member of the Board of Chemical Dependency Services of North Iowa as well as the Mental Health Center of North Iowa.

Although I didn’t graduate from Huston-Tillotson College, I was able to transfer credit to Iowa State University. And from there I went to medical school at The University of Iowa.

I’ve read other stories about how hard it is for Black students to get into and finish medical school. My path was indirect and not easy, but Pastor Stone made it possible. And for that, I am grateful.

Time for Another Blast from the Past

I found an interesting blog post from my previous blog, The Practical Psychosomaticist. I wrote it in 2011 and it’s about the patient experience of delirium. I was delirious briefly after a colonoscopy many years ago. I don’t remember much about it. But from what Sena tells me about it, it was similar to other delirium episodes I’ve seen in the hospitalized medically ill. Thankfully, it was not severe.

“Recalling the Experience of Delirium: The Delirium Experience Questionnaire (DEQ)

Have you ever been delirious and recalled the experience? Many patients do and they usually are frightened by the experience which can be marked by delusions and hallucinations that are remembered as fragments of a harrowing nightmare. This has been studied by Breitbart, et al using an instrument they developed called the Delirium Experience Questionnaire (DEQ). In the article there’s a description of the scale:

The DEQ is a face-valid, brief instrument that was developedby the investigators specifically for this survey study andassesses recall of the delirium experience and the degree ofdistress related to the delirium episode in patients, spouses/caregivers,and nurses. The DEQ asks six questions of patients who haverecovered from an episode of delirium including: 1) Do you rememberbeing confused? Yes or No; 2) If no, are you distressed thatyou can’t remember? Yes or No; 3) How distressed? 0–4numerical rating scale (NRS) with 0 = not at all and 4 = extremely;4) If you do remember being confused, was the experience distressing?Yes or No; 5) How distressing? 0–4 NRS; and 6) Can youdescribe the experience? This final question allowed for a qualitativeassessment of the delirium experience through the verbatim transcriptionof patients’ description of the experience (not reported inthis paper). In addition, spouse/caregivers and nurses wereeach asked a single question: 1) Spouse/caregiver: How distressedwere you during the patient’s delirium? 0–4 NRS; 2) Nurse:Your patient was confused, did you find it distressing? 0–4NRS. The DEQ was administered on resolution of delirium[1].

54% of patients recalled their delirium experience. Perceptual disturbances were among the best predictors of recall. Delusions were the most significant predictor of distress. Patients with hypoactive delirium were just as distressed as those with hyperactive delirium. Mean distress levels for patients were rated at around 3 by patients and their nurses and close to 4 by family members.

In another more recent and similar study using the DEQ, the numbers were even more sobering. 74% of patients recalled being delirious and 81% reported the experience as distressing with a median distress level of 3[2].

In my work as a consultant, I’ve interviewed many patients who are delirious and their relatives and friends, who suffer as well from the experience of watching someone they love suffer from delirium. It’s very difficult to watch this kind of mental torture caused by medical disorders and medications.

The 6th question of the DEQ often produced accounts that sound terrifying. The point of the article was that the subjective report of delirium sufferers confirms that the distress levels are very high indeed and remind us of the major reason for developing systematic methods of preventing it or detecting it early and managing the syndrome—reducing suffering.”

1.            Breitbart, W., C. Gibson, and A. Tremblay, The Delirium Experience: Delirium Recall and Delirium-Related Distress in Hospitalized Patients With Cancer, Their Spouses/Caregivers, and Their Nurses. Psychosomatics, 2002. 43(3): p. 183-194.

2.            Bruera, E., et al., Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer, 2009. 115(9): p. 2004-12.

Rearranging My Books

The other day, I finally rearranged my bookshelf. I’ve put it off for a long time. While I was doing it, I remembered where I spend the most time in my thoughts. I don’t have a very broad library, which probably illustrates where my mind wanders. It has changed very little over the years. Retirement affected it some, but not a great deal. After I rearranged the books, it was not just better organized. It made me think about the past, the present, and the future.

I have a lot of books by Malcolm Gladwell for some reason. The Tipping Point was published around the time when all of my immediate family members died for one reason for another. They died within a few years of each other. It was a difficult time. I remember hoping I would just get through it. I did.

I’m still a fan of Stephen Covey. The 7 Habits Manual for the Signature Program marks a time when I was contemplating leaving my position at The University for a position in private practice. It didn’t work out, and it’s just as well.

Of course, there are many books about consultation psychiatry, including the one I wrote with my former Dept. of Psychiatry Chair, Robert Robinson. Every once in a while, I search the web to find out what former colleagues and trainees are doing now. I can’t find a few, which makes me wonder. A couple have died. I’m a little less eager to look around each time I find out about those. Finding obituaries is a sad thing—and it makes me a little nervous about my own mortality. One or two have apparently simply dropped off the face of the earth.

I read some books for fun. I’m a fan of humorists, which is no surprise. The most recent is The Little Prince. That book and others like it inspire me.

I like books that make me laugh and give me hope. It’s difficult to sustain hope in humanity, if you read much of the news, which I tend to avoid.

I feel better when we go out for walks. Recently we did that about a week ago when there were a couple of warm days. On one day, we saw a couple of bald eagles and northern shovelers (the latter of which we’ve never seen before), at Terry Trueblood Recreation Area.

On another warm day we saw a couple Harvest Preserve staff members preparing to hang a big Christmas wreath on the side of a barn on the property that faces Scott Boulevard. They’d got some evergreen branches from an “overgrown Christmas tree farm.” It had a big red bow. They were going to decorate it further and hang it. We hoped it would be finished by the time we returned that day, but it wasn’t done.

When we returned a day later, it was very cold but the wreath was on the barn wall and it was festooned with gorgeous decorative balls. It was worth waiting for.

Video music credit:

Canon and Variation by Twin Musicom is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/

Artist: http://www.twinmusicom.org/

A Study Shows Mindfulness Is Non-Inferior to SSRI for Anxiety Disorders And What the Heck Does That Mean?

I ran across this study showing Mindfulness Based Stress Reduction (MBSR) is “noninferior” to escitalopram in the treatment of adults with anxiety disorders.

I passed my Biostatistics course in medical school—barely. I have been practicing MBSR daily (for the most part) since 2014 when I really needed to address my struggle with burnout. I’m probably a worrier but I doubt I have a clinically significant anxiety disorder. I’m admittedly biased in favor of MBSR. Otherwise, I wouldn’t still be practicing it after about 10 years.

On the other hand, I don’t have a great handle on the statistical concept of noninferiority in clinical studies. I found a little YouTube presentation on it and I think I’m a little more comfortable with it now. I said “a little bit.” I’m not taking questions.

Reference:

Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. 2023;80(1):13–21. doi:10.1001/jamapsychiatry.2022.3679

When Should Psychiatrists Retire?

In answer to the question in the title, I’ll confess right away I don’t know the answer. The impetus for my writing this post is the Medscape article about an 84-year-old physician who was forced to take a cognitive test required by her employer as a way of gauging her ability to continue working as a doctor. She’s suing her employer on the grounds that requiring the cognitive test violated the American with Disabilities Act (ADA), the Age Discrimination in Employment Act, and two other laws in her state.

I didn’t retire based on any cognitive test. I recall my blog post “Gauging My Readiness for Retirement,” which I posted in 2019 prior to my actual retirement. In it I say:

I spent 4 years in medical school, 4 years in residency, and have worked for more than 23 years as a psychiatrist, mostly as a general hospital consultant. Nothing used to jazz me as much as running around the hospital, seeing patients in nearly all specialties, evaluating and helping treat many fascinating neuropsychiatric syndromes, teaching medical students and residents, and I even wrote a book.

On the other hand, I don’t want to hang on too long. When people ask me why I’m retiring so early (“You’re so young!”), I just tell them most physicians retire at my age, around 65. I also say that I want to leave at the top of my game—and not nudged out because I’m faltering.

In it, I mention a blog post written by a physician blogger, Dr. James Allen. The title is “When Physicians Reach Their ‘Use By Date.’ At the time I didn’t make a link to his post because the web site was not listed as secure.

Since that time, the web site has become secure, and you can read the post here. Dr. Allen lists anecdotes about physicians who ran close to or past their “use by” date.

Dr. Allen’s point is that we often don’t realize when we are past our “use by” date. That applies to a lot of professions, not just medicine.

There’s been a shortage of psychiatrists for a long time and it’s not getting better, the last I heard. All in all, I’m OK with the timing of my retirement.

I note for the record that I have not seen any mention in the news that the Rolling Stones have ever been required to take a cognitive test to continue working. I also want to point out that they are around 80 years old and their 2024 tour is sponsored by the AARP, the organization formerly known as the American Association of Retired Persons. I heard that the Rolling Stones new song, “Angry” is up for a Grammy.

I doubt anyone is angry about the obvious fact they’re not even thinking about retiring.

On Retiring from Psychiatry

I found this very uplifting and thought-provoking article on retiring from psychiatry by Juan C. Corvalan.

He sounds like he’s successfully navigating his retirement. On the few occasions I’ve felt compelled to make a remark about my own retirement, I typically say something like “It’s a mixed blessing.”

My retirement is a process, unfolding as time passes. It was difficult in the beginning, which was only a little over 3 years ago. It’s not what I would call easy even now.

What gave me joy since I retired were getting messages from the learners I was privileged to teach. Some of them I’d not heard from in many years. Someone from my department said, “We miss you.” I answered that, in some ways, I never left.

Time itself feels different. The days go by so quickly that I want time to slow down.

I like Corvalan’s way of expressing himself. He’s a writer and likes to talk about words and their meaning. He talked about the definition of the Spanish word for retirement, which is jubilacion, which reminds me of the English word “jubilation.”

Retirement has been, at times (perhaps often), anything but cause for jubilation.

On the other hand, I can think of several things I will never miss about being a psychiatrist. I don’t write about them, as a rule. In fact, I tend to write about anything but psychiatry: cribbage, juggling, making wisecracks about extraterrestrials.

I really appreciate colleagues like George Dawson, MD (who writes the blog Real Psychiatry), H. Steven Moffic, MD (who writes the articles “Psychiatric Views on the Daily News”), Ronald Pies, MD, Editor in Chief Emeritus of Psychiatric Times, and Jenna, the psychiatry resident who writes the blog “The Good Enough Psychiatrist,” who is very far from retirement, unlike me and the other writers just mentioned.

And I appreciate Dr. Corvalan’s excellent essay on retirement from psychiatry.

Reference:

Corvalan JC. A Retired Psychiatrist on Retirement: Rejoicing Jubilatio. Mo Med. 2022 Sep-Oct;119(5):408-410. PMID: 36338006; PMCID: PMC9616447.

Food for Thought

I’m giving a shout-out to a couple of child psychiatrists, one I know only from a blog, The Good Enough Psychiatrist. The other is an assistant professor in the University of Iowa Child Psychiatry Dept. I’ve never met her.

Since Jenna gives her name in the About Me section of her blog, I’m going to call her that because it’s easier. Jenna writes many thought-provoking posts, but I really admire the one titled “Amae.”

Dr. Ashmita Banerjee, MD wrote an essay titled “The Power of Reflection and Self-Awareness.” It’s published on line in the Mental Health at Iowa section of The University of Iowa web site.

As a relatively recently retired consultation-liaison psychiatrist who is also a writer, I feel a strong connection to them. In addition to being very glad that extremely talented persons are filling the ranks of a specialty which suffers from a serious manpower shortage, I get a big kick out of reading what really smart people write.

Here’s where a geezer retired psychiatrist starts kidding around. Jenna, a fellow blogger, is used to my habit of deploying humor, admittedly often as a defense. Dr. Banerjee doesn’t know me.

What is it about these essays that reminds me of the X-Files episode “Hungry”? It’s a Monster of the Week episode from the monster’s perspective. This monster looks like a human but sucks brains out of people’s skulls. He’s conflicted about it and even sees a therapist. But in the end his dying words were, as Agent Mulder shoots him down, “I can’t be something I’m not.”

If you read Dr. Banerjee’s essay and followed one of the links, you would have caught the clue that I actually read it because I consciously substituted the word “What” for “Why” in the previous paragraph. I could have as easily asked why instead of what—but it’s less helpful in gaining self-awareness.

And I haven’t sucked anybody’s brains out of their skulls in, what, over two weeks now! Upon reflection, I’m very aware of being incorrigible. Food for thought.

Jenna’s description of the Japanese concept of the word “amae” and Dr. Banerjee’s examination of the Japanese word “kintsukuroi” fascinated me. What made both writers consider human emotions using a language which captures the nuances so deftly?

I was a first-generation college student. There was a time in my life that a path to medical school seemed impossible. At times I probably thought I was trying to be something I’m not.

I’m just grateful for the new generation.

Dr. Igor Galynker and The Suicidal Crisis Syndrome

I was looking at my bookshelves and found the copy of the book, “The Suicidal Crisis: Clinical Guide to the Assessment of Imminent Suicide Risk.” It was written by Dr. Igor Galynker. It’s a fit topic for this month because September is National Suicide Prevention Month.

This brings back memories. I still have a gift from Dr. Galynker. It’s a stuffed animal called Bumpy the Bipolar Bear.

It arrived at my office at The University of Iowa Hospitals & Clinics in 2011. It was in a box addressed to:

WordPress

Attn: James Amos

200 Hawkins Drive

Iowa City, IA 52242

 I’m still not entirely sure why he sent me Bumpy. There was no letter of explanation. I was writing a blog at the time called “The Practical Psychosomaticist” and I might have posted something about some research he published on suicide risk assessment.

I bought a copy of his book a few years ago. I barely had time to skim a few of the chapters because I was too busy conducting suicide risk assessments in the emergency room, the general hospital, and the clinics in my role as a psychiatric consultant. In fact, I think it’s an excellent resource.

I also found a YouTube video (posted about a month ago) in which he describes his suicide crisis syndrome assessment. You can find the actual set of questions for the assessment here and in a link posted in the description below the YouTube.