Workplace mobbing: Are they really out to get your patient?

James Randolph Hillard, MD
Professor, Department of psychiatry, Associate provost for human health affairs, Michigan State University, East Lansing, MI

Initiated most often by a person in a position of power or influence, workplace mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.” This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

This article discusses how to recognize symptoms of workplace mobbing, using a case study to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

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Measurement-based psychiatric practice

Henry A. Nasrallah, MD, Editor-in-Chief

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications.

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Fibromyalgia: Psychiatric drugs target CNS-linked symptoms

Sharon B. (Shay) Stanford, MD
Assistant professor of psychiatry and family medicine, Assistant director, Women’s Health Research Program, University of Cincinnati College of Medicine, Cincinnati, OH

Patients with fibromyalgia are a heterogeneous group, yet many describe a common experience: seeing multiple physicians who seem unable or unwilling to provide a diagnosis or treat their symptoms. This situation may be changing with the recent FDA approval of an anticonvulsant and 2 antidepressants for managing fibromyalgia symptoms.

These medications—pregabalin, duloxetine, and milnacipran—reflect a revised understanding of fibromyalgia as a CNS condition, rather than an inflammatory process in the muscles or connective tissue. As a result, psychiatrists—because of our experience with CNS phenomena and managing antidepressant and anticonvulsant medications—are likely to play a larger role in treating fibromyalgia.

Listen to Dr. Stanford discuss "Is fibromyalgia a somatoform disorder?"

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‘Night owls’: Reset the physiologic clock in delayed sleep phase disorder

R. Robert Auger, MD
Assistant professor of psychiatry and medicine, Mayo Clinic College of Medicine Consultant, Mayo Center for Sleep Medicine, Rochester, MN

Delayed sleep phase disorder (DSPD)—characterized by a pathological “night owl” circadian preference—is seen most commonly in adolescents and is associated with psychiatric morbidity, psychosocial impairment, and poor academic performance. Proper identification of the condition can be enhanced with a variety of assessment tools, and successful treatment requires an awareness of potential endogenous and exogenous contributors.

This article describes what is known about DSPD and uses the case example to illustrate diagnostic assessment and treatment choices. Intriguing data support various pathophysiologic explanations for DSPD. Facilitating the adjustment of patients’ physiologic clocks is the overall goal in managing DSPD.

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Compulsive bruxism: How to protect your patients’ teeth

Bernard Friedland, BChD, MSc, JD
Assistant professor of oral medicine, infection, and immunity, Harvard School of Dental Medicine, Boston, MA

Theo C. Manschreck, MD, MPH
Professor of psychiatry, Harvard Medical School, Boston, MA

Oral habits such as bruxism—compulsive grinding or clenching of the teeth—can be a manifestation of obsessive-compulsive disorder (OCD) and other anxiety disorders. Bruxism also may be a side effect of selective serotonin reuptake inhibitors (SSRIs) used to treat OCD and depression. Other oral conditions can complicate treatment of these disorders.

Potentially serious sequelae of bruxism and similar behaviors include:

• wearing down of teeth (more common)

• necrosis of the pulpal tissues that results in non-vital teeth (less common).

The following case underlines the need for early referral to a dentist and close follow-up for patients who have tooth-related behaviors or are taking medications associated with a risk for such behaviors.

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Is Darwin still relevant? Advanced human brain breaks evolutionary rules

Henry A. Nasrallah, MD, Editor-in-Chief

You may have noticed the buzz about Charles Darwin in the news: 2009 marks the 200th anniversary of his birth and the 150th anniversary of his monumental description of evolution in On the Origin of Species. Celebrations are scheduled around the world to honor the scientist who coined the phrase “natural selection” to explain the heritable process by which adaptive evolution occurs.

But is Darwin’s theory of evolution still relevant? The “game-changer” that is transforming evolution is the genetic mutation that led to dramatic growth in the primate cortex—especially the frontal lobe—culminating in the emergence of Homo sapiens. The overdeveloped brain that has helped our species adapt and survive may be transforming us into predators of all other species and a hazard to our planet.

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Controversies in bipolar disorder: Trust evidence or experience?

Gary E. Miller, MD
Clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Richard L. Noel, MD
Assistant clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Today’s buzzword in health care is evidence-based medicine. Most clinicians would agree that evidence from clinical research should guide decisions about treating bipolar disorder. In theory, randomized controlled trials should tell us how to manage bipolar patients and achieve therapeutic success. But good theory does not always translate to good practice; many patients with bipolar disorder have poor outcomes, even when clinicians adhere to research-derived evidence.

The problem is that one well-designed study’s conclusions may contradict those of another equally well-designed study because of differences in subject selection, comorbidities, dosages, outcome criteria, and other variables. As a result, bipolar experts often disagree about issues as basic as antidepressants’ role in often disagree about issues as basic as antidepressants’ role in managing bipolar disorder and whether recurrent major depression should be considered a form of bipolar disorder. This leaves the clinician with the task of interpreting not only conflicting research findings but also conflicting expert opinion.

This article conveys clinical impressions gained from treating approximately 10,000 patients with bipolar disorder over 16 years. We do not claim to have resolved the issues in dispute, but we hope our experience will help practicing clinicians. We examine the evidence and address controversies in bipolar disorder—such as subthreshold hypomania, manic switches, use order—such as subthreshold hypomania, manic switches, use of antidepressants, juvenile depression/bipolar disorder, and atypical depression—together with our opinions on each.

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