Hero

Videos

Slideshows

Articles

Podcasts

Poll

Delusional disorder is a major psychotic illness that is enigmatic and poorly understood. It is often difficult to treat because of the individual’s denial of a problem, difficulties in establishing a therapeutic alliance, and interpersonal and social conflicts. Unfortunately, many individuals with this disorder refuse treatment altogether. Available research suggests that 50% of patients who are adequately treated achieve a symptom-free recovery, while 90% of patients demonstrate at least some improvement.

 It has been found that persecutory delusions respond least well to treatment, with 50% improvement rates and 

 Only a handful of studies have used objective outcome measures to evaluate patient improvement during treatment for delusional disorder.

 The best objective measure of adult psychopathology in the world is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). There have been hundreds of 

 on the MMPI-2 and the treatment of psychiatric disorders.

 Up until now, there has been nothing in the literature that addresses the utility of the MMPI-2 in tracking or documenting treatment effects in delusional disorder.

This case illustrates the effectiveness of the MMPI-2 in documenting patient recovery during treatment for delusional disorder. Practical implications for psychiatrists and other mental health professionals are discussed.

“Mary,” a 42-year-old white female, temporarily lost custody of her 3 children to her ex-husband 18 months ago due to apparent psychotic-level functioning. I was appointed by the court to arrive at a definitive diagnosis and to provide appropriate guidance about her parenting abilities and custody status. (Mary, a pseudonym, has given written informed consent for her case to be included in this presentation. Identifying information about her has been altered to protect her privacy.)

Mary’s primary symptoms included both persecutory delusions and somatic delusions. Her delusions had been present for about 2 years. She believed that her colleagues at work were concocting a scheme to have her fired. She believed that her mother was not her biological parent. Mary also believed that drones were hovering over her home and that someone had installed a camera in her car to follow her. She reported unrelenting somatic symptoms that she attributed to an alien virus that had been planted in her water at home. Because of her delusional thinking, Mary had recently quit her job and was residing with her parents.

Prior to the onset of her delusions, Mary had obtained 2 master’s degrees and had a full-time position. She had a boyfriend, many friends, and her family relationships were intact. She was described as a smart and sweet person. She had been given primary custody of her 3 children at the time of her divorce 4 years earlier; it was not a highly adversarial divorce proceeding. She had no medical problems. She had no family history of psychosis or other psychiatric disorder.

Mary had been seeing a psychiatrist for several months prior to my involvement in the case; I obtained her records from him. Mary was described as having depression and anxiety. Psychosis was not noted. She was being treated with fluoxetine 20 mg and bupropion hydrochloride extended-release tablets 150 mg, but she was not improving. Mary had not divulged any delusional material to her psychiatrist.

Clinically, Mary was appropriately attired and well-groomed for her sessions with me. She wore make-up and jewelry. She was pleasant with me and made good eye contact. Mary’s cognitive abilities were intact. Her affect was slightly dysphoric but within normal limits. She was not manic or hypomanic. Mary’s delusions were prominent, and she had little or no insight into their nature and severity. She was also suspicious of me; she thought I might be involved in the conspiracy with her colleagues at work.

I asked Mary to provide a urine screen to rule out substance abuse. Her urine screen the same day was negative for illicit drugs.

Mary completed the MMPI-2, answering all 567 questions in 90 minutes. Her responses were scored on 3 validity scales, 10 basic clinical scales, and the PSY-5 supplementary scales.

Mary showed considerable distress but in the context of normal validity scales. She approached the test in an open and honest fashion. She did not exaggerate her symptoms. She was not defensive or guarded. Her responses were considered valid. She was to be believed.

Ten basic clinical scales were developed to assess different psychiatric conditions and symptoms. See 

 below for a description of the 10 scales. Mary’s 10 basic clinical scales showed significant elevations on scales 6-8-1-3. Scales 6 and 8 were considerably higher than scales 1 and 3.While this profile often indicates schizophrenia, Mary’s history and clinical presentation were not consistent with that illness. In my view, Mary’s MMPI-2 profile was reflective of her persecutory delusions (scales 6 and 8) and her somatic delusions (scales 1 and 3), both components in her psychotic illness.

Supplementary scales are available on the MMPI-2 as well. Mary’s PSY-5 scales showed a significant elevation on the scale having to do with psychosis. This was corroborative data to Mary’s 10 basic clinical scales.

Based on her history, clinical observations, and MMPI-2 test data, I diagnosed Mary with delusional disorder. Her delusional disorder was primary. She did not have a comorbid condition, such as bipolar disorder or schizophrenia. Mary did not have major depressive disorder or an anxiety disorder nor was she abusing alcohol or drugs.

No specific stressors were identified that contributed to the onset of Mary’s delusional disorder. However, she was feeling “pressure” from juggling a full-time job with raising 3 children.

Interestingly, Mary’s psychiatrist and I independently but simultaneously came to the conclusion that she had delusional disorder. Mary was started on ziprasidone 20 mg. Fluoxetine 20 mg was continued. A brain MRI at that time was negative. Bupropion was stopped because it enhances dopamine levels and can 

I re-evaluated Mary 4 months later in preparation for her upcoming court appearance. The court would want to hear about my findings and conclusions as well as any progress in her condition since her last court hearing. I interviewed Mary on 2 occasions. She completed the MMPI-2 again, and I obtained updated records from her psychiatrist.

After 4 months on ziprasidone, Mary was remarkably improved. She was tolerating it well, and her delusions had remitted. She had developed important insight about her resolved delusions. They now seemed foreign and distant to her; they did not make sense to her. She could not even recall her suspiciousness about me. Mary’s affect was bright. She was talkative and expressive. She was appreciative of everyone’s concerns. Mary was looking for a full-time job and planned to get her own apartment.

Mary’s MMPI-2 after 4 months of treatment was remarkable as well. It was completely normal. Her validity scales were normal. All 10 basic clinical scales were normal; there were no significant elevations. In fact, there were no near-significant elevations. Her PSY-5 scales were normal as well. All signs of psychosis had dissipated.

Mary will be maintained on ziprasidone for the foreseeable future. She will have monthly to quarterly visits with her psychiatrist. Cognitive behavior therapy has been added to her treatment regimen, since it is regarded as a 

 Mary’s legal case is close to resolution. With her regained parenting abilities, the parties are approaching a compromised settlement.

This case study illustrates many important clinical and practical points.

Mary’s persecutory delusions and somatic delusions both abated with treatment. This result is consistent with the literature that reports that 50% of patients treated adequately achieve a symptom-free recovery.

 Delusional disorder in this case was treated successfully with antipsychotic medication (ziprasidone 20 mg). This finding is contrary to the data that suggest that persecutory delusions are recalcitrant.

condition, and the absence of comorbid conditions may make successful treatment of delusional disorder more attainable.

Overall, Mary’s recovery was likely due to a combination of the relatively short duration of her delusions (about 2 years), the lack of a comorbid condition, the use of an antipsychotic medication, the discontinuance of bupropion, and her high level of premorbid functioning.

The MMPI-2 proved to be a sensitive outcome measure in evaluating this patient’s improvement. Using the MMPI-2 at the time of diagnosis and later during treatment is an objective, data-driven way to assess a patient’s response to treatment. The MMPI-2 can be administered easily and is not overly intrusive.

Lessons learned from this case study are clinically interesting, but only suggestive. Well-designed research is needed to study the proposition that the MMPI-2 is a highly effective instrument for evaluating treatment outcome in delusional disorder.

Mary’s psychiatrist and I worked independently but in a cooperative fashion. This was quite helpful in facilitating Mary’s evaluation and treatment with minimal delays and roadblocks. The sharing of findings and conclusions between us led to an excellent result after much initial confusion.

Mary was fully adherent with her evaluation and treatment, whereas many patients with delusional disorder refuse treatment. Mary’s successful treatment was largely attributable to her therapeutic alliance with her psychiatrist and me. Her motivation to get well superseded any desire to resist intervention. 

 is a critical building block in adequate treatment.

Whether Mary will have a recurrence in her delusional disorder is unclear. Longitudinal research is needed to address the question of incidence recurrence in this specific illness. With other types of psychotic disorders, 

 As such, maintenance treatment in delusional disorder becomes extremely important. Treatment should include a combination of psychiatric medication and individual therapy.

The impact of psychotic disorders on child custody cases is a delicate matter. It should be recognized by all parties that a parent’s recovery from a psychotic disorder may be less than permanent. Child custody decisions need to be made with that psychiatric reality in mind. Maintenance treatment for the parent with a psychotic disorder is the vehicle by which parenting abilities can be regained and sustained.

is a clinical psychologist in private practice in Birmingham, Alabama. He is clinical associate professor, department of psychology, University of Alabama at Birmingham. Much of his clinical practice is devoted to forensic cases, including child custody, personal injury, and criminal cases.

1. Bourgeois JA. Delusional disorder: Overview, diagnosis, epidemiology. 2017. 

Acute and transient psychotic disorders versus persistent delusional disorders: a comparative longitudinal study

3. O’Connor K, Stip E, Pélissier MC, et al. Treating delusional disorder: a comparison of cognitive-behavioural therapy and attention placebo control. 

4. Butcher JN. Significant contributions for use of the MMPI/MMPI-2 in treatment. 2016. 

https://pdfs.semanticscholar.org/cd97/a44d879d3db42721556ca74588543aa68227.pdf

5. Kesby, JP, Eyler, DW, McGrath, JJ, Scott, JG. 

Dopamine, psychosis and schizophrenia: the widening gap between basic and clinical neuroscience

Current treatments for delusional disorder

7. González-Rodríguez A, Molina-Andreu O, Odriozola VN, Ferrer CG, Penadés R, Catalan R. Delusional disorder: An overview of affective symptoms and antidepressant use. 

Recurrent acute and transient psychotic disorder: A pilot study

9. Deutsch RM, Clyman J. Impact of mental illness on parenting capacity in a child custody matter. 

10. Engur B. Parents with psychosis: Impact on parenting and parent-child relationship. 

Journal of Child and Adolescent Behavior. 

This case illustrates the practical implications and effectiveness of the Minnesota Multiphasic Personality Inventory-2 in documenting patient recovery during treatment for delusional disorder.

Documenting Recovery in Delusional Disorder With the MMPI-2

A 59-year-old man with a history of multiple concussions has been having a series of neurocognitive symptoms for the past several years. Discover more in this case.

4 Stages of Chronic Traumatic Encephalopathy

Lack of empathy is a commonly known feature of narcissistic personality disorder. Relationships are typically shallow and difficult to maintain. What are some other features of NPD? More in this case presentation.

10 Things to Know About Narcissistic Personality Disorder

Despite advances in addiction research, substance use disorders continue to tighten their grip on society. Forensic psychiatrist and Editor in Chief Emeritus of 

 James L. Knoll IV, MD, weighs in on a case report.

A Rock and A Hard Place, by Eduardo Constantino, MD

Dr Constantino has our gratitude and sincere respect for submitting his case which is both real world and timely. Upon consulting with many respected addiction psychiatrists to formulate my response, all of them added that they were grateful that these difficult issues were being raised for discussion. I must imagine that such cases will be seen with greater frequency, particularly as the specialty of addiction psychiatry advances and substance use disorders tighten their grip on society.

In my view, Dr Constantino’s case is not so much a case about malpractice, but an extremely rich case highlighting the ethical and legal duties of a practicing addiction psychiatrist. There do not appear to be any clear deviations from the standard of care, nor are we made aware of any damages-effectively removing two of the 

that a plaintiff must prove in a malpractice case.

 Nevertheless, the learning value from this case is substantial. Dr Constantino’s “awkward quandary” involved the frustrating dilemma between preserving a patient’s right to confidentiality-and an ethical/clinical duty to act beneficently and preserve life. Yet as with many clinical dilemmas, the resolution often lies along the path of engagement and dialogue with the patient.

All physicians are presumed to have some awareness of confidentiality, given that it is required by professional ethics, hospital policy, and federal and state law. The exceptions to confidentiality are relatively small in number and include: medical emergencies, statutory reporting requirements (suspected child or elder abuse) and an individual state’s legal requirements regarding patients’ credible threats to third parties (Tarasoff statutes). From a legal standpoint, actions for breaching confidentiality may include: breach of contract, breach of statutory duty and professional misconduct. Confidentiality and privacy of psychiatric records is especially important in the field of addiction psychiatry. In fact, this issue is stressed by federal law, which requires that documentation in addiction treatment be held to even higher standards of confidentiality than general psychiatric and medical encounters.

 (AAAP), a “basic principle of confidentiality of personal health information is that, to the greatest extent possible, control of personal medical information should be in the hands of the patient. Nonetheless, when patients receive . . . substance use disorder services, their agreement to begin treatment should include their written consent that certain identifiable health information will be shared with other health professionals.”

A major concern of patients and addiction psychiatrists is that failure to maintain strict confidentiality in the setting of substance use treatment can potentially result in a cascade of highly adverse consequences.

 For example, it is not uncommon for disclosure of substance use treatment to result in: loss of employment, loss of child custody, discrimination by insurers and other health care professionals. Of course, the possibilities of arrest and incarceration are ever-present. Unsurprisingly, such concerns may lead individuals in need of treatment to avoid seeking the help they need-often until it is too late. Keeping this in mind, let us turn to Dr Constantino’s first question: “

Even though his probation officer was allowed to speak to any and all medical staff, could we legally call the probation officer against the patient’s specific instructions?”

Based on the case description, the treatment team’s decision to not call the probation officer seems appropriate, as doing otherwise would be a violation of consent and breach of confidentiality. It is recommended that psychiatrists obtain specific signed consents “for release of any personal health information to entities outside of the health-care delivery system, such as . . . judges, prosecutors, police or other legal investigators, or institutional or community corrections officials, even in response to subpoenas, as stipulated in 42 CFR Part 2.”

 Absent patient consent, requests for information from law enforcement or other government agencies seeking information without patient consent should be denied. One exception to this may be a specific court order (per 42 CFR Part 2). However, such court orders are typically reserved for patients who have been involved in serious crimes.

Addiction specialists know that parole and probation officers play a critical role in the lives of their patients. A positive relationship with a parole officer can mean the difference between recidivism-and continued wellness in the community.

 Because of their central role, it is important to have a clear understanding, from the beginning of treatment, about the precise conditions of probation that were ordered by the court. A meeting with the probation officer may be helpful to establish rapport, ground rules, limits of confidentiality and to review any legal documentation from the court. A reliable understanding of the probation officers’ “marching orders” will put the treatment team in a better position to understand any concerns the probation officer may have, as well as what information may be communicated between parties.

Turning to Dr Constantino’s second and third questions regarding notifying the patient’s IOP, and concerns about providing appropriate care-it is noted that the patient refused to give consent to speak to his IOP substance use treatment center. From a clinical standpoint, effective coordination of care is assumed to be in the best interests of the patient. Yet in this case, it can be argued that the same legal restrictions apply to informing the patient’s IOP. This is highly unfortunate, but there appear to be at least two barriers. First, the patient refused to give consent. Second, there is no mention that consent was legally applied by the court to the patient’s original terms of probation, which would allow for communication of health information with the IOP and vice versa.

There are several important points to consider regarding this impasse. The AAAP notes that when patients opt to not allow health information to be shared among other providers, they “should be educated about the implications for the quality of the health care services they may receive, and thus the potential detriments to their own health care outcomes and health status, when they decline to sign the consent.”

 Therefore, an open and serious discussion with the patient regarding the potentially life-threatening consequences of refusing to allow communication between mental health and substance use treatment providers should be undertaken and documented. However, the patient is noted to have poor insight into his dilemma and so we proceed to other options for now, while recognizing that improving insight will remain a continuing goal.

Arguably, the ideal resolution occurs prior to any treatment plan implementation, and involves a clear agreement between patient and treatment team from the outset regarding coordination and communication of care with the IOP. The patient’s signed informed consent for communication with other health care providers is one of the goals of this discussion. Some addiction specialists would advise going no further with a treatment agreement if the patient refuses to allow communication between key health care providers. In contrast, other addiction psychiatrists may view their ethical and clinical duty to the patient as transcending this impasse and would not refuse treatment to a patient who refused to give consent to communicate with other health care providers.

Finally, a third option involves investigating, with legal counsel, the possibility of returning to court to amend the patient’s probation conditions to allow for such communications. This last option would be less preferable, of course, to the patient agreeing with his treatment team to give consent. In other words, a solid and agreed upon plan from outset is superior to one that must confront repeated barriers to coordinated treatment. Nevertheless, there may be no simple or clear-cut answers, as obtaining consent in advance does not preclude a patient from later deciding to rescind consent. What are some possible adverse outcomes if a psychiatrist decides (in good faith) that a duty to the patient necessitates contact with a key health care provider, despite the patient refusing to give consent? A medical malpractice suit brought forth by the patient for breach of confidentiality is one possibility. In such a case, the patient would need to show that the breach of confidentiality directly caused some untoward event (eg, loss of employment, loss of custody, psychological damages.). Another possibility is that an aggrieved patient may lodge a formal complaint with the local medical board, prompting a review and possible sanctions.

This case highlights the growing importance of addiction psychiatry, as well as appropriate legal arrangements 

 of treatment to ensure proper coordination of care. Addiction psychiatrists know well that substance use and criminal recidivism are irrevocably linked,

 and that relapse prevention is necessary to prevent a return to jail or prison.

 For justice-involved individuals with substance use disorders, continued illicit drug use likely inhibits the ability to “mature out” of a criminal lifestyle in young adults.

 The stakes are extremely high for this population of patients. Release from prison is associated with significant mortality rates and a leading cause is drug overdose.

 The first two weeks after release appears to be a particularly vulnerable time of high risk for opioid overdose.

Dr Constantino is appropriately concerned about the challenge involved when a prolonged period without opioid use can simultaneously be a sign of recovery, as well as a risk factor for fatal overdose.

 I would add that the patient’s focus on getting through his “five months” of probation and refusal of long acting naltrexone would reasonably make a treatment provider nervous. There is now some data supporting extended-release naltrexone being associated with a decreased risk of overdose. Thus, naltrexone is currently an option for patients who decline or are unable to obtain opioid agonist treatment.

 This can become critical in that opioid use disorder treatment remains quite limited in US correctional facilities.

 Looking towards the future, it is hoped that concerted efforts are made to implement programs across the criminal justice continuum to address this deadly public health issue.

Dr Constantino and his team seek consultation from their risk management department-always a sound decision that follows the dictum of the great Tom Gutheil, MD: “Never worry alone.” Finally, I would add that Dr Constantino’s team appeared to exert due diligence with “repeated” follow up calls and a letter. This is particularly important in that proper termination with patients involves such efforts, along with documentation they occurred and that some other potential providers in the community were offered to the patient. In this case, a follow-up communication letter letting the patient know you are willing to arrange communication of important health care information with his new provider would be ideal.

I conclude again with a thanks to Dr Constantino, as well as a supportive proclamation that competent and evidence-based substance use disorder treatment “is a more appropriate intervention than incarceration for non-violent drug offenders,” and “non-violent drug offenders should be diverted to treatment programs while being monitored through intensive probation drug courts, or other means, instead of expensive and less effective incarceration.”

 Further, treatment and monitoring following incarceration should be available, and likely court mandated, for those on probation to prevent relapse, deadly overdose and recidivism.

Dr Knoll would like to thank Professor Andrew J. Saxon, MD, Director, Center of Excellence in Substance Abuse Treatment and Education, University of Washington School of Medicine, for his helpful review and comments.

Dr Knoll is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of

This article was originally published on July 1, 2019, and has since been updated. The print version of this article is titled 

2. Chapter 42 of the Code of Federal Regulations, Part 2, (42 CFR Part 2)

3. Confidentiality of Patient Records and Protections Against Discrimination: A Joint Statement by American Society of Addiction Medicine, American Academy of Addiction Psychiatry, American Osteopathic Academy of Addiction Medicine and the Association for Medical Education and Research in Substance Abuse https://www.aaap.org/wp-content/uploads/2018/07/confidentiality-2018-final.pdf. Accessed June 28, 2019.

4. Dept. of Health and Human Services. Confidentiality of Substance Use Disorder Patient Records. 42 CFR Part 2; 2017: 82(11). 

https://www.govinfo.gov/content/pkg/FR-2017-01-18/pdf/2017-00719.pdf

5. Chamberlain A, et al.: Parolee-Parole Officer Rapport: Does It Impact Recidivism? 

6. Fearn NE, Vaughn MG, Nelson EJ, et al. Trends and correlates of substance use disorders among probationers and parolees in the United States 2002–2014. 

7. Kopak A, Haugh S, Hoffman N. The entanglement between relapse and posttreatment criminal justice involvement. 

8. Walters G. Does Drug Use Inhibit Crime Deceleration or Does Crime Inhibit Drug Use Deceleration? A Test of the Reciprocal Risk Postulate of the Worst of Both Worlds Hypothesis. 

9. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison--a high risk of death for former inmates. 

10. Babu K, Brent J, Juurlink D. Prevention of Opioid Overdose. 

11. Friedmann PD, Wilson D, Hoskinson R Jr, et al. Initiation of extended release naltrexone (XR-NTX) for opioid use disorder prior to release from prison. 

12. Csete J. Criminal Justice Barriers to Treatment of Opioid Use Disorders in the United States: The Need for Public Health Advocacy. 

13. Brinkley-Rubinstein L, Zaller N, Martino S, et al.: 

Criminal justice continuum for opioid users at risk of overdose

14. Criminal Justice System and Substance Use Disorder Treatment Policy. 

https://www.aaap.org/wp-content/uploads/2018/07/AAAP-FINAL-Criminal-Justice-System-and-SUD-Treatment-Policy-HC_rr.pdf

James L. Knoll IV, MD, analyzes the ethical and legal duties of psychiatrists treating substance use disorders.

Psychiatric Malpractice Grand Rounds: Addiction Psychiatry 

The costs, risks, and considerations involved in treating addiction have upped the ante, as illustrated in this case about the ethical and legal duties of practicing psychiatrists. Forensic analysis of the case 

I have worked in university health centers for many years and treated psychiatric disorders in adult patients, often with concomitant substance use disorders (SUDs). Despite a background in addiction psychiatry, I have found that the current opioid crisis has led to difficult ethical and legal scenarios that are different from past “epidemics.” The risk of sudden death from overdose with opioids (whether intentional or not) has added a new level of complexity and risk to my day-to-day work. Particularly troubling is that when I successfully help patients stay off opioids for an extended period of time, I am effectively increasing their risk for death if they relapse. This increased risk is due both to their loss of tolerance to narcotic medications and to recent changes in 

preparations that include the potential mix of high-potency agents (eg, fentanyl, carfentanil).

Psychiatric Malpractice Grand Rounds: Addiction Psychiatry

“Mr L,” a divorced man in his 30s with 

 (BD), presented to our outpatient department after completing a 14-day court-mandated inpatient rehabilitation program. He had a long history of daily alcohol and IV heroin use, intermittent use of intranasal cocaine and oral (PO) amphetamines, and brief treatments at multiple substance programs with no extended periods of sobriety. Before his recent admission, he had been hospitalized medically for respiratory depression after an inadvertent heroin overdose that required four doses of naloxone. This episode was considered a violation of his probation, and he was mandated to the inpatient program where he was successfully detoxified and treated. His BD symptoms were well controlled on his psychiatric medication regimen, and he presented to our clinic after discharge for his initial evaluation with no evident mood symptoms.

At that time, he was also mandated to an 

(IOP) where he was subject to random urine toxicology. He refused our offer for naltrexone (whether PO or by long-acting injection) citing his relative stability. However, three months later, he had another serious overdose of IV heroin use that resulted in a brief ICU admission. The admitting hospital contacted us for aftercare but did not contact the patient’s substance IOP or his probation officer. The hospital staff assumed that the patient’s probation officer was aware of this new violation of probation.

When he presented to our clinic one week after this overdose, Mr L was calm and psychiatrically stable, reporting full sobriety since he had left the hospital. He refused our recommendation to start monthly long-acting injectable naltrexone, but he agreed to take PO 

daily. He also told us that he was attending his substance IOP three times per week as court ordered. However, he rescinded his consent for us to speak to that program and also asked us not to speak to his probation officer about his recent heroin relapse and overdose. His reasons for this change were simple and clearly stated: he needed only five more months to “graduate” from his outpatient substance program and shortly thereafter, his probation period would be over. He told us that if we notified either party (who were both unaware of his most recent overdose), his probation would be extended and he would likely face jail time.

This put our treatment team in an awkward quandary. We knew that clinically, it was very important that his substance program know about the relapse so they could adjust his treatment accordingly and that all parties needed to be alerted to Mr L’s high risk for relapse and overdose. Our treatment team felt that the Mr L showed limited insight and that informing his IOP and probation staff was ethically the right thing to do. Nonetheless, this disclosure would be against his specific stated wishes. Even though his probation officer was allowed to speak to any and all medical staff, could we legally call the probation officer against the patient’s specific instructions? Would notifying his substance IOP be a violation of consent? And would 

 notifying all parties of Mr L’s recent overdose and near-death be considered a failure to provide appropriate care for Mr L?

Before we took any action, we sought the advice of our risk management department. They focused on the fact that in emergency situations, clinicians are allowed to speak to any provider and that the inpatient hospital should have contacted the substance IOP and probation officer after his most recent overdose admission. However, since there was no emergent situation currently, they recommended that we should not initiate contact, but could respond and share information that would be in the best interest of the patient if the IOP reached out to us. They felt that the situation was similar for probation and that we should not initiate the call to Mr L’s probation officer. Our treatment team followed these specific recommendations. We did not reach out and inform the IOP or probation of Mr L’s most recent relapse and overdose and regrettably, no party ever reached out to us.

Thereafter, Mr L consistently returned for his monthly appointments to receive his prescriptions for PO naltrexone and medications for BD. After five months, he informed us that he had complied with all requirements of his outpatient substance program and that his probation had ended. He planned to attend Narcotic Anonymous meetings moving forward and he agreed to provide random urine samples at our clinic. He also agreed to change to monthly injectable naltrexone which we arranged to start at his next scheduled appointment two weeks later.

One week after this visit, Mr L presented to our hospital medical emergency department after injuring his hand while heavily intoxicated. His blood alcohol level on arrival was 270 mg/dL and his urine toxicology was positive for opiates and cocaine. He was discharged the same day with instructions to keep his follow-up appointment at our clinic the next week. Mr L did not show up for that appointment and did not respond to repeated phone calls and a letter over the ensuing days. He eventually left a message that he had found treatment elsewhere. He was never subsequently seen in our health system and was lost to follow-up.

Dr Constantino is Vice-Chair for Education and Clinical Associate Professor of Psychiatry in the Department of Psychiatry, 

Editor's note: This article was originally posted on July 1, 2019, and has since been updated.

The author reports no conflicts of interest concerning the subject matter of this article.

The costs, risks, and considerations involved in treating addiction have upped the ante, as illustrated in this case.

A Rock and a Hard Place

As Gilbert and Sullivan wrote, “Things are seldom what they seem, skim milk masquerades as cream.” Medical disorders may also masquerade, not as cream but as psychiatric disorders, as occurred in Maureen’s case.

Maureen had every reason to be depressed. Her live-in boyfriend left after 5 fitful years. Since then, her energy waned. She rarely slept through the night and couldn’t make it to morning team meetings.

Not surprisingly, her job was in jeopardy. Worse yet, her company was also in jeopardy, for the fashion industry had been floundering ever since “fast fashion” priced out their designer dresses. Her once-prestigious brand would be “cutting the fat” to stay afloat. They hinted at lay-offs to come.

Even when she was in time for the morning meetings, Maureen couldn’t concentrate. She made careless and costly errors. She received a formal warning from her boss, who said that her “presenteeism” was worse than her absenteeism. He referred her to HR, expecting them to do the dirty work of dismissing her.

Maureen left a voice message for me, saying that she had explained her situation to Eileen, the head of HR, who suggested a medical leave of absence, rather than the immediate termination recommended by her supervisor. She received my name from the company’s Employee Assistance Program (EAP). To me, this sounded like a generous offer, especially since it came with short-term disability benefits; however, there was one caveat. Maureen needed to seek psychiatric treatment while on leave. Maureen was told in no uncertain terms that she needed a psychiatrist to “sign off” on the disability and to prescribe medications as needed. HR would not accept a note from the texting therapist whom Maureen had found through a subway ad.

I knew from the get-go that there would be plenty of papers to sign, and annoying insurance forms to complete, along with regular clinical care, should I schedule her appointment. The EAP staff knew that I would not endorse questionable disability papers, and I made sure that Maureen knew that I could promise her an evaluation but could not promise anything more before completing that evaluation.

Maureen arrived at her appointment, looking pale and haggard for someone so young. She had neglected her grooming, which didn’t go unnoticed in the fashion industry. Her nails were chipped. Three inches of dark roots told me that her self-care had lapsed 6 months earlier, since hair grows half an inch a month.

Her speech was slow and monotone. Luckily, she was not and never had been suicidal. I could count on the EAP to catch those serious symptoms before referring patients to an office setting.

Maureen’s psychiatric history was straightforward. She had one previous depressive episode in college, also after a break-up. Symptoms were milder and remitted with therapy that she received from student health services. Her family history included uncles with alcohol use disorders and early deaths from cirrhosis but no other serious psychiatric disease. Maureen had the good sense to avoid alcohol because of this family history.

It would have been easy enough to diagnose MDD, recurrent, fill out her forms, start an SSRI, set up follow-up appointments, touch bases with her therapist, and leave it at that. But there was no way that she would leave my office without reviewing her medical history as much as her psychiatric and social history. A “review of systems” is a standard part of any initial evaluation. Obliging psychiatrists to apply the same “E & M” (“evaluation and management”) codes used by all other physicians (rather than unique behavioral health codes of the past) drives that point home even more.

On her intake forms, Maureen noted that she had anemia back in college-which remitted 5 years ago. In the section about exercise she wrote that she had stopped exercising when she felt too weak to walk to the gym. As always, intake questions included LMP (last menstrual period), since it is imperative to avoid certain medications in potentially pregnant patients. She scribbled a series of question marks after that question. I asked her to elaborate.

Upon questioning, Maureen mentioned that her periods often lasted so long that she wasn’t sure when they began or ended. She recalled that her college gynecologist attributed her anemia to heavy periods but did not recommend treatment or further work-up. Maureen added that her previously mild menstrual pain had become major pain. When asked about her last primary care or gynecology visit or recent laboratory tests, she looked up sheepishly and said that she hadn’t seen a doctor for 2 or 3 years.

I needed more data about Maureen’s medical status, since any number of medical conditions can affect mood and cognition, even when someone has obvious social stressors that can precipitate depressive symptoms. So, I bargained with Maureen and told her that I would sign her disability papers a week at a time, with the proviso that she consult a primary care physician and a gynecologist in the interim. Again, the ever-efficient EAP head had those doctors on direct-dial. To expedite matters, I handed Maureen a lab slip, knowing that basic lab results would return electronically the following day, but thyroid functions would follow in a few days. Those tests would be ready by the time she scheduled her PCP appointment.

Maureen was started on sertraline, but I emphasized that her unexplained medical problems could also cause lassitude. Her gynecology appointment was arranged quickly, and the gynecologist took the time to call and say that she felt large masses during the office examination. She suspected fibroids but needed imaging studies and a biopsy to support her suspicions and to rule out something more serious. In the meantime, Maureen’s lab tests returned with strikingly low hemoglobin levels. The repeat lab test ordered by the gynecologist later that week showed even lower levels. The gynecologist recommended iron supplements in the interim and explained the treatment options to Maureen.

The biopsy report came in. Luckily, there were no cancerous cells. Unwilling to wait for a response to medical treatment when her hemoglobin was dropping, the gynecologist scheduled a myomectomy. By then, Maureen’s stomach pain had increased and interfered with traveling to our appointments. We decided to make do with telepsychiatry appointments until she recovered from surgery.

It was late in the day when Maureen telephoned me to say that her surgery took far longer than expected. The gynecologist called in a GI surgeon to assist with dissection of a bowel loop wrapped around the 5-pound fibroid. Maureen wasn’t sure of the specifics. What was certain is that Maureen’s worsening stomach pains were something other than the vague aches and pains of depression. The gynecologist warned her that she could have developed gangrene that required a bowel resection, or might even have died from sepsis, had the mucosal membrane ruptured, and had they not acted so quickly.

While she recovered, Maureen’s surgeon assumed responsibility for documenting her disability and our telepsychiatry appointments revolved around titrating her dose of antidepressants. I half-expected her to transfer all treatment to her PCP, but a few months later, Maureen scheduled an office appointment.

She bounced into the room, looking like a different person. Her cheeks were rosy; she had “pep in her step” or so she said. There were no signs or symptoms of depression. She said that this near brush with death made her appreciate life. I asked about the insurance paperwork, since insurance paperwork prompted her first appointment with me. Maureen said it was moot: her company collapsed since she left on leave, and her disability benefits disappeared. Yet she seemed happy. She received a severance package and paid COBRA benefits and now had renewed energy and enthusiasm to seek new work.

I, too, had renewed enthusiasm about the importance of medical training to the practice of psychiatry. I confess that I cringe when I hear people say that “psychiatrists prescribe medications” without considering the need for a differential diagnosis and the significance of the “big picture.” Maureen’s life was at stake; this was more than a matter of mood. Doing a review of systems was a rather simple matter and putting those pieces together could be done by any doctor. It wasn’t “rocket science,” as they say-but it was a classic example of medical science and of why psychiatrists are physicians first.

That’s all well and good-but what happens when psychiatric physicians are not available? The supply is dwindling. There are some innovative solutions on the table, including “integrated care.” But that approach presupposes that patients already have PCPs in place-and many younger people consult urgent care for minor problems without forging relationships with PCPs. Curiously, as per Peggy Drexler’s 

 millennials are more comfortable with therapy, even texting therapy, and may bypass psychiatric assessment as well, as happened with Maureen.

Currently, pediatricians can fast-track into child psychiatry fellowships, but I don’t know of plans to fast-track PCPs into general psychiatry training. Perhaps that’s something to consider, especially for PCPs who miss the doctor-patient relationships that get lost in an increasingly impersonal and corporatized health care delivery system. Perhaps there is a solution in sight-but dismissing the value of medical training in providing psychiatric treatment is not the solution.

Drexler P. Millennials are the therapy generation. 

https://www.wsj.com/articles/millennials-are-the-therapy-generation-11551452286

Doing a review of systems wasn’t “rocket science,” as they say-but it was a classic example of medical science and of why psychiatrists are physicians first.

Things Are Seldom What They Seem

You are referred a patient with a 3-year history of multiple vague health and cognitive complaints including pain, nausea, memory and concentration difficulties, and fatigue. Despite an exhaustive battery of tests, 

 has been found for the patient's symptoms.

Additionally, the reported severity of her complaints appears grossly out of proportion given gathered information and your own clinical observations. She does appear genuinely and significantly distressed by her reported issues but otherwise denies depressive symptoms.

After meeting with the patient, reviewing medical records (which include valid performance on neuropsychological validity testing), and interviewing multiple collateral sources, you come to the opinion that the patient is not intentionally falsifying or exaggerating her symptoms.

The patient does claim that she is no longer able to work due to the severity of her difficulties and states that she intends to file for disability.

Given this information, which of the following would be the most appropriate diagnosis for this patient?

The reported severity of the complaints in this patient appears grossly out of proportion given gathered information and clinical observations. What's your diagnosis?

Mini Quiz: Assessment of Malingering

Prior to 1990, the psychiatric literature often contained detailed clinical case descriptions. These descriptions allowed us to communicate important and nuanced aspects of our psychotherapeutic work. Providing detailed descriptions of interactions that occurred between patient and therapist moved our field forward by both honing our technique and considering more effective ways to help our patients.

Today, the vast majority of professional publications are available to anyone with access to the internet. Perhaps as a result, the number of detailed descriptions in journal articles have decreased, and some have even stopped publishing case reports. In turn, this deprives our field of the opportunities to provide optimal stewardship of our unique and valuable knowledge base. (Of course, presentations to exclusively professional audiences continue; these seminars and conferences remain viable options that can offer this same rich clinical material.)

To maximize our continued progress, we need to retain our practice of presenting detailed clinical reports. Only detailed narratives provide the actual, in-the-moment, give and take of clinical work. Unfortunately, using composite or disguised cases, now a common practice, creates fiction that may fall short of guiding us to the answers, and even to the questions, about real psychotherapeutic process. For example, to achieve anonymity, we may consider changing a refugee from Sudanese to Armenian. That may seem a small detail with no obvious impact until we consider the huge difference between the trauma these two diverse cultures experienced.

There is an inherent dilemma when we publish detailed clinical material. On the one hand, we commit ourselves to providing confidentiality to our patients. On the other hand, we need to consider how to continue moving our field forward by publishing meaningful, detailed clinical material.

there were three generally accepted ways to accomplish this:

• Publish the material and hope the patient would never find it;

• Disguise the identity of patients and change the details of the case so the patient is not recognizable;

• Inform the patient of an intent to publish and obtain the patient’s consent.

Prior to the internet, journal articles were much less accessible to the public. Now, published material can be retrieved rapidly by anyone with internet access and the thought that patients will not find their therapist’s published work is simply naive.

Since clinicians who participate in educational activities are sworn to maintain the same confidentiality as the treating clinicians, teaching and professional presentations are not considered violations of patient confidentiality. Even in these situations, though, we customarily provide only de-identified material to reduce the chances of accidental disclosure.

When it comes to publishing detailed clinical case material, however, de-identification may not offer enough protection, but too much disguise may threaten to make the case a fiction that loses the specificity necessary to advance knowledge. Changing small details, as previously illustrated, can drastically alter the dynamics of a case.

The third option, to inform the patient, may be the safest and most effective approach at this time.

 In fact, most journals now require written consent from the patient. However, there are concerns with this approach, too. We begin our clinical work with each patient by promising them confidentiality. As we discover our patients’ secrets, how can we turn around and say, in essence, “Now I would like to tell the entire world about your thoughts and feelings.”

Similarly, can (and should) we ask the patient for consent, given the potential power differential between patient and therapist? Might the patient react negatively to the publication, even if we ask for and obtain consent in advance? Might what we publish have an adverse effect on the patient’s future life?

If we are to assure continuing advancement of our psychotherapies, we must find solutions to these dilemmas. With the intent of supporting continued stewardship of a progressive knowledge base, the Committee offers the following suggestions in hopes they will open a dialogue that leads to practical, effective solutions to these dilemmas.

To begin, let us consider psychotherapy as a field in medicine that is built on a tripartite model of practice, teaching and research. The knowledge base for this three-pronged endeavor must rest on a foundation of real, not fabricated, clinical observations.

We must also understand that we are not in full control of the clinical process. Neither are we omniscient. Instead, in psychotherapy, we listen with an open mind, stretching ourselves to be aware of the vast uncertainties that always lie before us when we work with our patients. With these perspectives in mind, we might begin our treatments with a consent that acknowledges these perspectives. An example is the following:

From time to time in our work, if and only if it is fully acceptable to you, it may be useful to share what we do here with my colleagues. I might do this to teach or to better understand what we are doing here. Of course, these other medical professionals will keep this material private, just as I do. It may also be useful to share this material with a wider audience, such as by publishing in a professional journal. I would speak with you about this possibility before pursuing it. Again, if you agree, I would work with you to make such a publication acceptable to you, and you will always have absolute veto power to say no to anything before it is submitted for publication.

This sort of consent lays the groundwork for helping the patient become aware of, and participate in, a collaborative process.

when working toward a publication of detailed clinical material and case reports. These guidelines lay out the details of this collaboration, and they further specify principles to considered in this process.

1 The work to be published should be a finished product, meaning the treatment has been completed or, at a minimum, that the therapeutic work has moved on to other areas and the area of interest has been settled.

2 The therapist should review the work with the patient. Together, they should consider if there is an agreement on the initial problem, the process by which the problem was addressed and settled, and the gains made. This can be a naturally flowing process of constructing a narrative over time. Optimally, the process should culminate in a summary created collaboratively by the therapist and the patient.

3 The therapist and the patient should discuss the importance of sharing this new understanding/narrative with the field, eg, its potential to benefit others. It is important to identify with the patient the patient’s own motivations for consenting.

4 There should be review and oversight of the detailed clinical material that is being considered for dissemination, similar to what an Institutional Review Board (IRB) does for research. Such oversight considers not only the patient’s perspective, but also the importance to the field.

The step should involve both the review of the clinical material as well as the venue of dissemination. At stake is the potential harm to the patient (both present and future) weighed against the benefit to the field.

This process has traditionally been completed by consulting a respected colleague. Ideally this oversight/review should be completed by persons sufficiently knowledgeable and impartial so they may offer objective reflections. The reviewer(s) should not be too close to the author or have any competing interests with respect to the author; these conditions will make it more difficult to render a contrasting view, as bias may be conscious or unconscious.

5 Input from the patient should be elicited during this process. The writing should be offered to the patient, who may want to read and even edit it. This is not to burden the patient, who may not want to participate in the process. Instead, the patient may wish to simply consent to disseminating the agreed upon and previously discussed material.

Providing detailed descriptions of interactions that occurred between patient and therapist moved our field forward by both honing our technique and considering more effective ways to help our patients. But is the sharing of cases ethical?

Case Discussions

Documenting Recovery in Delusional Disorder With the MMPI-2

4 Stages of Chronic Traumatic Encephalopathy

10 Things to Know About Narcissistic Personality Disorder

Psychiatric Malpractice Grand Rounds: Addiction Psychiatry

A Rock and a Hard Place

Things Are Seldom What They Seem

Mini Quiz: Assessment of Malingering

Sharing Patient Cases: Balancing Confidentiality and Educational Needs

Ethics case quiz | Food for Thought

8 Reasons a Psychotropic Medication May Be Discontinued