Psychiatric Secrets (The Secrets Series) 2nd edition (January 15, 2001) by James L Jacobson (Editor), Alan Jacobson (Editor) By Hanley & Belfus; By OkDoKeY Frontmatter Title Page Copyright Page Contributors Dedication Preface to First Edition Preface to Second Edition Section One - APPROACH TO CLINICAL INTERVIEWING AND DIAGNOSIS Section Two - DIAGNOSTIC PROCEDURES Section Three - PRINCIPAL CLINICAL DISORDERS AND PROBLEMS Section Four - DEMENTIA, DELIRIUM, AND RELATED CONDITIONS Section Five - PERSONALITY DISORDERS Section Six - THERAPEUTIC APPROACHES IN PSYCHIATRY Section Seven - DIAGNOSIS AND TREATMENT OF PSYCHIATRIC DISORDERS IN CHILDHOOD AND ADOLESCENCE Section Eight - DISORDERS ASSOCIATED WITH PREGNANCY AND MENSTRUATION Section Nine - GERIATRIC PSYCHIATRY Section Ten - CONSULTATION-LIAISON PSYCHIATRY Section Eleven - SPECIAL TREATMENT POPULATIONS Section Twelve - ETHICAL AND LEGAL ISSUES IN PSYCHIATRY Section One - APPROACH TO CLINICAL INTERVIEWING AND DIAGNOSIS - THE INITIAL PSYCHIATRIC INTERVIEW - THE MENTAL STATUS EXAMINATION - ORGANIZATION AND PRESENTATION OF PSYCHIATRIC INFORMATION - INTRODUCTION TO DSM-IV Section Two - DIAGNOSTIC PROCEDURES - PROJECTIVE TESTING - NEUROPSYCHOLOGICAL TESTING - SELF-REPORT QUESTIONNAIRES - STANDARDIZED PSYCHIATRIC INTERVIEWS - BRAIN IMAGING IN PSYCHIATRY Section Three - PRINCIPAL CLINICAL DISORDERS AND PROBLEMS 10 - SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDERS 11 - PARANOID DISORDERS 12 - BIPOLAR DISORDERS 13 - DEPRESSIVE DISORDERS 14 - PANIC ATTACKS AND PANIC DISORDER 15 - SOCIAL PHOBIA AND SPECIFIC PHOBIAS 16 - GENERALIZED ANXIETY DISORDER 17 - OBSESSIVE-COMPULSIVE DISORDERS 18 - POSTTRAUMATIC STRESS DISORDER 19 - PSYCHOACTIVE SUBSTANCE USE DISORDERS 20 - ALCOHOL USE DISORDERS 21 - OPIOID USE DISORDERS 22 - SEDATIVE-HYPNOTIC USE DISORDERS 23 - COCAINE AND AMPHETAMINE USE DISORDERS 24 - MARIJUANA, HALLUCINOGENS, PHENCYCLIDINE, AND INHALANTS 25 - DUAL DIAGNOSIS: SUBSTANCE ABUSE AND PSYCHIATRIC ILLNESS 26 - DISSOCIATIVE DISORDERS INCLUDING DISSOCIATIVE IDENTITY DISORDER (FORMERLY MULTIPLE PERSONALITY DISORDER) 27 - SEXUAL DISORDERS AND SEXUALITY 28 - EATING DISORDERS 29 - SLEEP DISORDERS IN PSYCHIATRIC PRACTICE 30 - IMPULSE-CONTROL DISORDERS 31 - MEDICALLY UNEXPLAINED SYMPTOMS 32 - GRIEF AND MOURNING Section Four - DEMENTIA, DELIRIUM, AND RELATED CONDITIONS 33 - BEHAVIORAL PRESENTATIONS OF MEDICAL AND NEUROLOGIC DISORDERS 34 - DEMENTIA 35 - DELIRIUM 36 - PSYCHOSIS WITH NEUROLOGIC/SYSTEMIC DISORDERS Section Five - PERSONALITY DISORDERS 37 - PERSONALITY AND PERSONALITY DISORDERS 38 - BORDERLINE PERSONALITY DISORDER 39 - ANTISOCIAL PERSONALITY DISORDER Section Six - THERAPEUTIC APPROACHES IN PSYCHIATRY 40 - PSYCHOANALYTICALLY ORIENTED PSYCHOTHERAPIES 41 - COGNITIVE-BEHAVIORAL THERAPY 42 - BEHAVIOR THERAPY 43 - PLANNED BRIEF PSYCHOTHERAPY 44 - MARITAL AND FAMILY THERAPIES 45 - GROUP THERAPY 46 - RELAXATION TRAINING 47 - MEDICAL TREATMENT OF DEPRESSION 48 - ANTIPSYCHOTIC MEDICATIONS 49 - MOOD-STABILIZING AGENTS 50 - ANTIANXIETY AGENTS 51 - SEDATIVE-HYPNOTIC DRUGS 52 - THE USE OF STIMULANTS IN PSYCHIATRIC PRACTICE 53 - UNDERSTANDING MEDICATION INTERACTIONS 54 - ELECTROCONVULSIVE THERAPY Section Seven - DIAGNOSIS AND TREATMENT OF PSYCHIATRIC DISORDERS IN CHILDHOOD AND ADOLESCENCE 55 - AUTISM SPECTRUM DISORDERS 56 - ATTENTION DEFICIT-HYPERACTIVITY DISORDER 57 - CONDUCT DISORDER 58 - OBSESSIVE-COMPULSIVE DISORDER IN CHILDREN AND ADOLESCENTS 59 - ENCOPRESIS AND ENURESIS 60 - ADOLESCENT DRUG ABUSE 61 - PRINCIPLES OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY Section Eight - DISORDERS ASSOCIATED WITH PREGNANCY AND MENSTRUATION 62 - PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC DISORDER 63 - PSYCHIATRIC DISORDERS AND PREGNANCY 64 - POSTPARTUM PSYCHIATRIC DISORDERS ACKNOWLEDGMENTS Phillip J Resnick and Robert I Simon contributed highly detailed comments on this chapter, some of which were incorporated essentially verbatim into the text James C Beck, Thomas G Gutheil, Mark J Mills, Herbert C Modlin, Jonas R Rappeport, and Larry H Strasburger also contributed close readings that much improved the final draft Alan A Stone’s thought-provoking lectures on the aftermath of the Hinckley verdict and, more recently, Alan M Dershowitz’s exposition of the imperfect self-defense have been most useful Patricia M L Illingworth provided an invaluable perspective on an ethical framework for psychiatric and legal issues Buz Scherr illuminated with helpful clarity the distinction between “simple intent” and “specific intent” crimes None of these generous advisers, however, should be held responsible for anything with which readers may disagree BIBLIOGRAPHY Bursztajn HJ, Brodsky A: Captive patients, captive doctors: Clinical dilemmas and interventions in caring for patients in managed health care Gen Hosp Psychiatry 21:239–248, 1999 Bursztajn HJ, Brodsky A: Ethical and legal dimensions of benzodiazepine prescription: A commentary Psychiatr Annals 28:121–128, 1998 Bursztajn HJ, Brodsky A: A new resource for managing malpractice risks in managed care Arch Intern Med 156:2057–2063, 1996 Bursztajn HJ, Harding HP, Gutheil TG, Brodsky A: Beyond cognition: The role of disordered affective states in impairing competence to consent to treatment Bull Am Acad Psychiatry Law 19:383–388, 1991 Bursztajn HJ, Scherr AE, Brodsky A: The rebirth of forensic psychiatry in light of recent historical trends in criminal responsibility Psychiatr Clin North Am 17:611–635, 1994 Forensic Psychiatry & Medicine website: http://www.forensic-psych.com Grisso T, Appelbaum PS: Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals New York, Oxford University Press, 1998 Group for the Advancement of Psychiatry, Committee on Psychiatry and Law: The Mental Health Professional and the Legal System (Report No 131) New York, Brunner/Mazel, 1991 Parry J (ed): State Justice Institute Benchbook on Psychiatric and Psychological Evidence Chicago, American Bar Association, 1998 10 Perlin ML: Mental Disability Law: Civil and Criminal Charlottesville, VA, Michie, 1989–1993 11 Rosner R (ed): Principles and Practice of Forensic Psychiatry New York, Chapman & Hall, 1994 12 Stone AA: Law, Psychiatry, and Morality Washington, DC, American Psychiatric Press, 1984 499 Chapter 84 - ETHICS AND THE DOCTOR–PATIENT RELATIONSHIP Claire Zilber M.D The regimen I adopt shall be for the benefit of my patients according to my ability and judgment, and not for their hurt or any wrong… Whatsoever house I enter, there will I go for the benefit of the sick, refraining from all wrongdoing or corruption, and especially from any act of seduction, male or female.Oath of Hippocrates What is a fiduciary relationship? The Hippocratic oath expresses the essence of the fiduciary relationship between a physician and each of his patients The physician has a duty to act in the patient’s best interest and to refrain from exploiting the patient Respecting the fiduciary relationship and the trust of the patient is a cornerstone of the ethical physician’s practice What is a boundary violation? In the context of the physician–patient relationship, a boundary violation refers to any behavior on the part of a physician that transgresses the limits of the professional relationship Boundary violations have the potential to exploit or harm patients Boundary violations differ from boundary crossings, which occur whenever the patient–physician interaction goes beyond the usual therapeutic framework but is not necessarily harmful to a patient For example, if a therapist happens to encounter a patient in a social setting, that is a boundary crossing—but it is neither harmful nor unethical as long as the therapist does not violate confidentiality However, if the therapist plans to meet the patient for dinner, it is a boundary violation The potential areas of exploitation include personal or social boundary violations, business relationships, and sexual activity Examples of personal or social boundary violations include seeing patients in unorthodox settings for the convenience of the physician, loaning a patient money, or burdening the patient with personal information Business ventures with a patient or taking advantage of insider information revealed by the patient are examples of unethical business relationships Any form of sexual activity with a patient is a clear boundary violation A patient is looking for financial investors in a project that promises to be lucrative, and he invites the physician to invest in the project May the physician ethically participate? The same patient gives a hot stock tip Is it ethical to act on it? The ethical physician will not take advantage of either of these scenarios In the first scenario, participation in a business relationship with the patient may harm the patient’s treatment If the business fails, feelings of anger, guilt, or resentment may emerge between the physician and the patient The physician may lose the objectivity necessary to provide competent and compassionate treatment if he or she resents having lost money as a result of the business venture The patient may have similar negative feelings that make it difficult to seek help from the physician for medical problems Even if the business succeeds, the physician is no longer an impartial and objective person for the patient In the case of psychiatric treatment, the psychiatrist’s relative neutrality and abstinence, central to the healing nature of the therapeutic relationship, cannot be preserved if a business relationship exists between the patient and psychiatrist In the second scenario, the physician would be “exploiting information furnished by the patient.”[10] In addition, by acting on insider information, the physician may be breaking the law, which in itself is unethical behavior.[10] This applies equally to psychiatrists and other physicians 500 Why is sexual activity with a consenting adult patient considered unethical? Transference and countertransference are psychiatric concepts that help to explain why sexual activity, even with a consenting patient or former patient, is unethical Transference is a phenomenon of unconscious displacement of earlier relationship experiences and expectations onto the physician and may cause a wide range of feelings in the patient, from rage to love and sexual attraction Countertransference is the corresponding unconscious emotional reaction of the physician to the patient Transference and countertransference may continue even after the termination of treatment; for this reason, psychiatrists may not ethically enter into a sexual relationship with a former patient, no matter how long ago the treatment ended Many consider the same dynamics applicable to other medical specialists and would extend the prohibition to all physicians At present, the proscription against sexual activity with a former patient is unique to psychiatry, but sexual activity with a current patient is generally considered unethical in all fields of medicine Sexual activity with a patient damages the healing capacity of psychiatric treatment One survey of psychiatrists found that 65% of those who had been sexually involved with patients felt that they were in love with the patient, and 92% believed that the patient was in love with them.[4] In fact, such feelings may have had their origins in transference and countertransference; by acting on the feelings rather than working in therapy to understand them, the psychiatrist harms the treatment and the fiduciary relationship Freud observed that it is deleterious to the patient if countertransference is acted out: “If the patient’s advances were returned, it would be a great triumph for her, but a complete defeat of the treatment… The love relationship, in fact, destroys the patient’s susceptibility to influence from analytic treatment.” Are feelings of sexual attraction toward a patient unethical? No Sexual feelings toward a patient are quite common In one survey, 87% of psychotherapists (95% of men and 76% of women) acknowledged having been sexually attracted to one or more of their patients.[9] It is important not to act on such feelings It may be helpful to seek supervision in the treatment of these patients to ensure that the sexual countertransference does not impede the treatment As you discuss a case with a colleague, she tells you that she has been trying a new approach with an emotionally “needy” patient She has extended the session time beyond the customary 45 minutes, seeing him at the end of the day for 1½ hours She also begins and ends each session with a hug, which she feels is necessary to assure the patient of her care and concern Is this behavior ethical? This psychiatrist is sliding down the slippery slope of boundary crossings, but she probably has not yet behaved in an unethical manner Sexual transgressions frequently are preceded by such boundary crossings Although some may say that no sexual activity has occurred, others may see the hugs as sexual It is difficult to know whether the patient experiences the hugs as sexual Even without the hugs, the circumstances under which the physician is seeing the patient are unorthodox and may harm the treatment The psychiatrist is also at risk for a formal ethical complaint and a lawsuit Fifteen percent of lawsuits against psychiatrists involve sexual boundary violations.[11] A patient has just informed the physician of a plan to kill someone The physician wants to ensure the other person’s safety, but also is concerned about confidentiality What may the physician ethically do? The Principles of Medical Ethics direct physicians to “safeguard patient confidence within the constraints of the law.”[10] The law requires the physician to warn the person at risk or to intervene so that no harm may be done The ethical physician discloses only the information that is necessary and relevant to the situation Fantasy material, sexual orientation, or other sensitive information usually does not need to be disclosed The welfare and privacy of the patient should still be protected as much as possible Whenever possible, it is preferable to involve the patient in the ethical dilemma that the physician faces For example, by working with the homicidal patient, the physician may be able to obtain a release of information from the patient to warn the person at risk or to persuade the patient to accept hospitalization until the homicidal ideation subsides If the homicidal patient will not cooperate with 501 the physician’s efforts to ensure the safety of all involved, the physician is legally obligated to warn the person at risk A patient has been repeatedly resistant to treatment He has missed numerous appointments, has not been following treatment recommendations, and is abrasive when the physician raises concerns about such behavior Frustrated, the physician suggests that the patient seek treatment with someone else He retorts, “I hired you to be my doctor I can fire you, but you can’t fire me!” Is he right? No A physician may choose not to treat a patient provided that it is not an emergency and that the physician has provided suitable notice and referrals Generally, the ethical physician works with the patient to achieve as smooth a transition as possible The Principles of Medical Ethics states, “A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.[10] If a physician has strong and persistent negative feelings toward a patient, he or she will have difficulty providing objective treatment Likewise, if a physician feels obligated to treat someone regardless of the circumstances, problems with treatment may arise As an old maxim advises, you can’t treat someone who you can’t not treat A physician suspects that a colleague has been abusing alcohol One morning, while on hospital rounds, the physician smells alcohol on the colleague’s breath Is the physician obligated to take action? The physician is not obligated, but is strongly encouraged to report impairment in colleagues According to The Principles of Medical Ethics, “Special consideration should be given to those psychiatrists who, because of mental illness, jeopardize the welfare of their patients and their own reputations and practices It is ethical, even encouraged, for another psychiatrist to intercede in such situations.”[10] This ethical principle is easily extended to physicians and other specialties Furthermore, in some states physicians are mandated to report impaired colleagues to the medical licensing board The bylaws of most hospitals and health maintenance organizations also require reporting of suspected or proved impairments Once reported, impaired physicians are strongly encouraged to enter into treatment Every effort is made to assist the physician to get help so that he or she may retain medical license and practice Physicians are often reluctant to report their impaired colleagues because they not want to be responsible for jeopardizing another doctor’s professional practice; in fact, reporting is an excellent way to help impaired colleagues and to facilitate their entry into treatment 10 A 35-year-old man in the final stages of acquired immunodeficiency syndrome (AIDS) asks for the physician’s help He is in constant pain and homebound, with no appreciable quality of life He would like to overdose on medications to stop his suffering, but does not have enough of a stockpile to ensure a lethal overdose He informs the physician of his plan and asks the physician, who sympathizes with his plight, to write a prescription for a lethal dose of narcotics What may an ethical physician in this situation? The Principles of Medical Ethics explicitly states, “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of patients… It is conceivable that an individual could violate a law without being guilty of unethical behavior.”[10] At present it is illegal to assist in a suicide, although a few states have introduced legislation that would allow physician-assisted suicide In the above case, the physician may not legally prescribe a lethal dose of narcotics Many physicians feel strongly that their role is to treat illness and to save lives, not to assist in taking a life They also raise concerns about the limits of physician-assisted suicide: for whom is it appropriate, who decides it is appropriate, and how is it regulated? The possibility of abuse of the law raises many concerns for physicians who otherwise may have no moral objections to physician-assisted suicide Some physicians may disagree with the prohibition against physician-assisted suicide Such individuals may ethically organize to change the law The Principles of Medical Ethics allows for the possibility that a physician who assists a suicide may be acting ethically, even though the action is illegal 502 In fact, many doctors have quietly hastened death in some of their patients with terminal illness, acting on their belief that relieving hopeless suffering is consistent with their role as a physician Regardless of a particular physician’s stance on the issue of assisted suicide, he or she should everything else in his or her power to treat the patient’s pain and to improve the patient’s quality of life In many instances ameliorable conditions, such as chronic cancer pain, lead patients to seek death When the pain is treated and the patient feels comforted, suicidal wishes may be alleviated ACKNOWLEDGMENT The author is grateful to David Wahl, M.D., and Michael Weissberg, M.D., for reviewing this chapter BIBLIOGRAPHY Appelbaum PS: Statutes regulating patient-therapist sex Hosp Community Psychiatry 41:15–16, 1990 Carr M, Robinson GE: Fatal attraction: The ethical and clinical dilemma of patient-therapist sex Can J Psychiatry 35:122–127, 1990 Freud S: Observations on Transference Love (1914), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 12 Translated and edited by J Strachey, London, Hogarth Press, 1958, pp 157–171 Gartrell N, Herman J, Olarte S, et al: Psychiatrist-patient sexual contact: Results of a national survey: I Prevalence Am J Psych 143:1126–1131, 1986 Gutheil TG, Gabbard GO: The concept of boundaries in clinical practice: Theoretical and risk-management dimensions Am J Psychiatry 150:188–196, 1993 Lazarus JA: Sex with former patients almost always unethical Am J Psychiatry 149:855–857, 1992 Menninger WW, Gabbard GO (eds): Sexual boundary violations Psychol Am 21:644–680, 1991 Menninger WW: Inappropriate Doctor-patient Relationships Presented at the Menninger Winter Psychiatry Conference, Park City, Utah, 1993 Pope KS, Keith-Spiegel P, Tabachnick BG: Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system Am Psychol 41:147–158, 1986 The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry Washington, DC, American Psychiatric Association, 1998 10 11 Simon R: Clinical Psychiatry and the Law Washington, DC, American Psychiatric Press, 1987 Figure Modified from Goodwin F, Jamison K: Manic-Depressive Illness New York, Oxford University Press, 1990 Figure Stress-diathesis model of medical illness Figure Flow chart for approaching treatment-resistant depression Figure Multidimensional assessment of dangerousness in relation to competence to inform (From Gutheil TG, Bursztajn HJ, Brodsky A: The multidimensional assessment of dangerousness: Competence assessment in patient care and liability prevention Bull Am Acad Psychiatry Law 14:123–129, 1986; with permission.) [...]... who encouraged us to undertake this project, and the many unsung heroes who typed, re-typed, re-re-typed, critiqued, proofread, and helped us move the book to completion Without all of their efforts, this book would not have happened James L Jacobson M.D Alan M Jacobson M.D XV Preface to Second Edition Psychiatric Secrets presents an up-to-date approach to the assessment and treatment of psychiatric. .. Mental Disorders—therapy—Examination Questions WM 18.2 P9727 2000] RC457.P76 2001 616.89'0076—dc21 00-037043 PSYCHIATRIC SECRETS, 2nd ed ISBN 1-56053-418-4 © 2001 by Hanley & Belfus, Inc All rights reserved No part of this book may be reproduced, reused, republished, or transmitted in any form, or stored in a data base or retrieval system, without written permission of the publisher Last digit is the print... particular, those chapters devoted to psychopharmacology have been revised to reflect the rapid advances in treatment Because of the increasing complexity of the pharmacology of psychiatric disorders, we have added one new chapter that addresses the complex drug interactions now involved in treating patients, especially those with both psychiatric and medical problems This text is intended to reinforce concepts... health professional, yet is geared primarily for the medical student, house officer, and general practitioner The chapters are designed to be read independently; consequently, there is occasional overlap of information Each author was given complete freedom to utilize his or her expertise in expressing views about assessment and treatment Thus, Psychiatric Secrets, 2nd edition presents both basic information... of The Secrets Series® The questions raise central issues and provide the organizational structure for each chapter This process of question and answer yields a dialogue through which the expert clinicians who authored each chapter can provide their best “pearls of wisdom,” gained from years of experience as researchers, educators, and practicing clinicians This second edition of Psychiatric Secrets. .. the expert clinicians who authored each chapter can provide their best “pearls of wisdom” often gained from years of experience as researchers, educators, and practicing clinicians Psychiatric Secrets is divided into twelve sections that address in systematic fashion the steps in the treatment process The book has a heavy emphasis on diagnosis, for it is the belief of the editors that careful, thoughtful... recommendations, and other information pertinent to the safe and effective use of the product described Library of Congress Cataloging-in-Publication Data Psychiatric secrets / written [i.e edited] by James L Jacobson, Alan M Jacobson. 2nd ed p ; cm — (The Secrets Series ® ) Includes bibliographical references and index ISBN 1-56053-418-4 (alk paper) 1 Psychiatry—Examinations, questions, etc I Jacobson,... - INVOLUNTARY TREATMENT: HOSPITALIZATION AND MEDICATIONS 83 - COMPETENCE AND INSANITY 84 - ETHICS AND THE DOCTOR-PATIENT RELATIONSHIP I PSYCHIATRIC SECRETS Second Edition James L Jacobson MD Associate Professor Department of Psychiatry University of Vermont Medical School Burlington, Vermont Alan M Jacobson MD Professor Department of Psychiatry Harvard Medical School Senior Vice President Strategic... designed to be read independently, and thus there is occasional overlap of information Each author was given complete freedom to utilize his or her expertise in expressing views about assessment or treatment Thus, Psychiatric Secrets presents both basic information as well as the approach of experienced practitioners to specific topics We are grateful to the authors for contributing their knowledge,... Neither the publisher nor the editor makes any warranty, expressed or implied, with respect to the material contained herein Before prescribing any drug, the reader must review the manufacturer’s current product information (package inserts) for accepted indications, absolute dosage recommendations, and other information pertinent to the safe and effective use of the product described Library of Congress