Economic anxiety: First aid for the recession’s casualties

Christopher Palmer, MD
Medical director, Continuing medical education, McLean Hospital, Belmont, MA, Harvard Medical School

Jeffrey Rediger, MD, MDiv
Medical director, Adult inpatient service, McLean Hospital, Belmont, MA, Harvard Medical School

Carol Kauffman, PhD, ABPP, PCC
Director, Institute of Coaching, McLean Hospital, Belmont, MA, Harvard Medical School

How is the recession affecting psychiatric practice? Christopher Palmer, MD, says, “We in psychiatry and psychology are well-equipped to help people who are unemployed, underemployed, and financially ruined. We do it all the time. The difference in this economy is that we’re going to be seeing a lot more people.”

Psychiatrists who read Current Psychiatry and were polled in March 2009 agree. Most were seeing an increase in patients experiencing psychological stress because of the recession, which by then had persisted 16 months. “All my patients are reporting increased stress as a result of the economic situation. The more successful my patient is, the more distress they seem to be feeling,” says a psychiatrist from Melbourne, FL.

This article on the psychological effects of the recession discusses the results of an online survey of Current Psychiatry readers, with analysis and recommendations from an interview with Dr. Palmer and colleagues Jeffrey Rediger, MD, MDiv, and Carol Kauffman, PhD, ABPP, PCC, from McLean Hospital, Belmont, MA, and the department of psychiatry, Harvard Medical School.

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Risk factors for suicide in borderline personality disorder

Michele S. Berk, PhD
Assistant professor of psychiatry, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA

Bernadette Grosjean, MD
Assistant professor of psychiatry, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA

Heather D. Warnick, PsyD
Postdoctoral Fellow, Harbor-UCLA Medical Center, Torrance, CA

Manipulative, “just threats,” or suicide gestures are terms you may have heard or used to label suicidal thoughts and behavior in individuals with borderline personality disorder (BPD). These terms imply that the risk of injury or death is low, but evidence shows that BPD patients are at high risk for completed suicide—and clinicians who use these labels may underestimate this risk and respond inadequately.

Based on the literature and our clinical experience, this article offers recommendations for assessing and treating suicidal behavior in BPD patients. We review risk factors for suicide and suicide attempts and suggest strategies for safety management, psychotherapy, and pharmacotherapy. Because of the high-risk nature of this population, we recommend that all clinicians working with suicidal BPD patients obtain consultation and supervision as needed when using these strategies.

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Listen to Dr. Berk discuss suicide risk in BPD

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What is your patient’s predicament?

Daniel D. Cowell, MD
Senior associate dean for graduate medical education, Professor of psychiatry, Department of psychiatry and behavioral medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

When a patient’s symptoms seem disproportionate to apparent stressors, I call this presentation a patient’s predicament: a unique, profoundly unsettling, but poorly understood misgiving that something is wrong—perhaps terribly so—and that life may never be the same again. Emotional flooding typically overwhelms these patients, and they are unable to express what they are experiencing.

For mental health professionals, the concept of a predicament is useful when working with patients who are moderately to severely ill or facing a life-diminishing or life-threatening illness.

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The hallucination portrait of psychosis: Probing the voices within

Henry A. Nasrallah, MD
Editor-in-Chief

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH.

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

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Clinical guide to countertransference: Help medical colleagues deal with ‘difficult’ patients

Philip R. Muskin, MD
Professor of clinical psychiatry, Columbia University College of Physicians and Surgeons, Chief, Consultation-liaison psychiatry, Columbia University Medical Center, Faculty, Columbia University Psychoanalytic Center for Training and Research, New York, NY

Lucy A. Epstein, MD
Postdoctoral clinical fellow in psychosomatic medicine, Columbia University College of Physicians and Surgeons, New York, NY

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

Listen to Dr. Muskin discuss "What to do when a patient makes you angry"

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Worried about high-dose prescribing? Manage risk for you and your patient

Neil S. Kaye, MD, DFAPA
Assistant clinical professor of psychiatry and human behavior, Assistant clinical professor of family medicine, Jefferson Medical College, Philadelphia, PA

Jacqueline M. Melonas, RN, MS, JD
Vice president, risk management, Professional Risk Management Services, Inc., Arlington, VA

Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts to control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package insert (PI). What do you do next?

Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

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Informed consent: Is your patient competent to refuse treatment?

Debra A. Pinals, MD
Associate professor of psychiatry, Director of forensic education, Department of psychiatry, University of Massachusetts Medical School, Worcester, MA

Informed consent in clinical settings is designed to allow patients to make rational choices about their treatment before it begins. When a psychiatric patient declines a treatment you recommend, how can you balance the 2 ethical principles in medicine: beneficence toward the patient and respect for individual autonomy?

Some authors have raised concerns that informed consent in physician-patient interactions are at times an empty exercise undertaken solely to satisfy a legal expectation. If executed properly, however, informed consent can enhance the therapeutic alliance and help improve treatment adherence.

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