Psychosocial and Psychodynamic Considerations Informing Factitious Disorder.

Factitious disorder is a condition in which patients deceitfully present themselves as injured or ill in the absence of obvious external reward. It is difficult to diagnose and treat, and little rigorous evidence exists in the literature. While larger studies have revealed some clinical and sociodemographic patterns, there is a lack of consensus on psychosocial factors and mechanisms contributing to factitious disorder. This in turn has led to conflicting recommendations on management. In this article, we review major psychopathological theories of factitious disorder, including the role of early trauma and subsequent development of interpersonal dysfunction, as well as maladaptive gratification obtained from assuming the sick role. Common themes of interpersonal disruptions in this patient population include a pathologic need for attention and care, as well as aggression and desire for dominance. In addition to psychodynamic and psychosocial etiologic models of factitious disorder, we also review associated treatment approaches. Finally, we offer clinical implications, including countertransference considerations, as well as directions for future research.

Case Report: De Novo and Persistent Psychosis After Withdrawal From Chronic Opioid Therapy.

Psychiatric illness is associated with both chronic pain syndromes and opioid use disorder, further complicating how we care for patients with psychiatric issues. We report a unique case of a de novo and persistent psychotic disorder after complicated opioid withdrawal in a patient without any psychiatric history. The patient developed persistent auditory hallucinations after discontinuation of chronic opioid therapy that responded only to atypical antipsychotic (olanzapine) treatment. This case illustrates the neuropsychiatric effects of chronic opioid exposure, as well as layered clinical management dimensions related to opioid detoxification and psychosis treatment. Long-term opioid therapy may have lasting neuropsychiatric effects, including playing a role in the development and/or expression of psychotic disorders. Here we review the limited literature on the effects of opioids on psychosis. This complex case also demonstrates a clinical approach for effectively co-managing psychiatric symptoms in the context of chronic pain and chronic opioid therapy.

Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis.

BACKGROUND: Consultation psychiatrists are often asked to assess factitious disorder (FD), yet this is challenging as confirmation depends on rarely achieved direct evidence of illness-inducing behaviors. Diagnosis is thus based on other variables, such as atypical features of the medical presentation and certain patient behaviors. This study sought to assess a cohort of patients with FD for demographic and clinical variables, but also psychological and behavioral ones unexamined in previous studies. METHODS: 49 previously-identified FD patients at a single site were reviewed retrospectively and variables collected included demographic, medical, psychiatric, social, behavioral, and treatment-related. Descriptive statistical analysis was used. RESULTS: Patients were mostly: 1) under age 40 (82%), 2) female (90%), 3) with past psychiatric (92%), family psychiatric (78%), and traumatic (69%) histories; 4) direct intravenous access (67%); and 7) some exposure to healthcare training (67%). All (100%) subjects had an identifiable family dynamic issue, including household abuse, parental divorce, parental influence/enmeshment, grief, and/or significant other conflict. Financial, emotional, or social incentives were common, and most patients (88%) exhibited at least 4 FD-related behaviors. CONCLUSION: FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables previously unexplored. Future investigational, educational, and quality improvement directions are considered.

Elucidating somatization in a dimensional model of psychopathology across medical settings.

Research using a categorical-polythetic classification system for mental illness has raised concern regarding the validity of categorical classification systems. Recent efforts suggest psychopathology is better understood from a dimensional framework, though there has been varying evidence of a somatization factor. The current investigation seeks to produce and validate a dimensional model of psychopathology, with a particular emphasis on the placement of somatization, across three nonoverlapping medical samples. Using a bariatric surgery seeking sample (n = 1,268), a spine surgery/spinal cord stimulator seeking sample (n = 1,711), and a chronic pain treatment seeking sample (n = 1,388), a dimensional model of psychopathology was replicated across all three samples using a dimensional measure of psychopathology (the Minnesota Multiphasic Personality Inventory-2-Restructured Form [MMPI-2-RF]). Clear evidence of a separate somatization factor was found in addition to broad internalizing, externalizing, and social detachment factors. Constructs assessable with the model yielded good convergent and discriminant validity coefficients with external criteria, and further supported the presence of a higher-order somatization construct. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Beyond depression: Other uses for tricyclic antidepressants.

Tricyclic antidepressants (TCAs) were originally designed and marketed for treating depression, but over time they have been applied to a variety of conditions, mostly off-label. TCAs can serve as first-line or augmenting drugs for neuropathic pain, headache, migraine, gastrointestinal syndromes, fibromyalgia, pelvic pain, insomnia, and psychiatric conditions other than depression. This article reviews pharmacology, dosing, and safety considerations for these uses.

Functional Neurological Disorder Responds Favorably to Interdisciplinary Rehabilitation Models.

BACKGROUND: Functional neurological disorder (FND) is difficult to treat and costly. Interdisciplinary chronic pain rehabilitation programs (iCPRPs) are multidimensional functional restoration interventions for pain; their impact on FND specifically has not been assessed. OBJECTIVE: The purpose of this study was to assess iCPRP's impact on functioning in FND. METHODS: Data were examined retrospectively from an Institutional Review Board-approved registry capturing admission and discharge data from patients participating in an outpatient iCPRP. Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach. RESULTS: Forty-nine FND patients completed care and showed pre-measures and postmeasures. Statistically significant reductions in subjective measures of pain-related disability (46.40-20.91; P < 0.001, d = 1.92), depression (20.38-4.81; P < 0.001, d = 1.53), anxiety (15.09-6.29; P < 0.001, d = 1.18), and stress (21.96-9.70; P < 0.001, d = 1.21) scores were observed. Statistically significant changes in objective measures of mean timed up and go scores (decreased from 15.96 to 8.87 s), stair climbing test scores (increased from 40.98 to 71.93 steps), and mean 6-minute walk test scores (increased from 0.21 to 0.30 miles) were also observed across the group. CONCLUSIONS: While preliminary and based on a small patient sample, these findings support the use of interdisciplinary care models for FND treatment. Clinical and investigational implications are explored.

Clinical and Demographic Predictors of Interdisciplinary Chronic Pain Rehabilitation Program Treatment Response.

Patients treated in interdisciplinary chronic pain rehabilitation programs show long-term improvements in symptoms; however, outcomes may vary across heterogenous patient subpopulations. This longitudinal retrospective study characterizes the influence of opioids, mood, patient characteristics, and baseline symptoms on pain and functional impairment (FI) in 1,681 patients 6-months to 12-months post-treatment in an interdisciplinary chronic pain rehabilitation program incorporating opioid weaning. Linear mixed models showed immediate and durable treatment benefits with nonuniform worsening at follow up which slowed over time. Latent class growth analysis identified three post-treatment trajectories of pain and FI: mild symptoms and durable benefits, moderate symptoms and durable benefits, and intractable symptoms. A fourth pain trajectory showed immediate post-treatment improvement and worsening at follow up. Whether a patient was weaned from opioids was not predictive of treatment trajectory. Racial ethnic minority status, higher levels of post-treatment depression, and lower perceived treatment response were associated with less resolution (moderate symptoms) or intractable symptoms. Not having a college education was predictive of intractable or worsening pain and a moderate course of FI. Older age and male gender was associated with intractable FI. Treatment outcomes may be improved by the development of targeted interventions for patients at risk of poor recovery and/or deteriorating long-term course. PERSPECTIVE: This study examined predictors of treatment response in 1,681 patients treated in an interdisciplinary chronic pain rehabilitation program incorporating opioid weaning. Opioid weaning did not predict outcome. Higher levels of symptoms, lower levels of education, and being a racial-ethnic minority were associated with a less salubrious long-term treatment response.

Parallel Pains and Dynamic Dilemmas: Psychodynamic Considerations in Approaching and Managing Chronic Physical Pain.

Chronic physical pain is prevalent condition and has gained considerable attention in the wake of the opioid crisis and epidemic. As a medical phenomenon, it has highlighted significant gaps in healthcare training, finances, clinical service, and administration. The psychodynamic determinants of pain symptoms or the need for analgesia are rarely considered in the medical management of this problem. The specific objective of this article is to offer a general psychodynamic understanding of chronic physical pain. As a psychodynamically oriented, medically informed psychiatrist practicing in a multidisciplinary pain management program, I propose a clinical construct of psychologically rich "parallel pains" to chronic physical pain, and that these pains inform important interpersonal issues dubbed "dynamic dilemmas." Chronic physical pain is defined, clinical examples are provided, and general implications are considered.

Polyallergy (Multiple Chemical Sensitivity) is Associated with Excessive Healthcare Utilization, Greater Psychotropic Use, and Greater Mental Health/Functional Somatic Syndrome Disorder Diagnoses: A Large Cohort Retrospective Study.

BACKGROUND: Associations between the crude capture of polyallergy-also known as multiple chemical sensitivity or multiple drug intolerance syndrome-and mental health/functional somatic syndrome disorders, healthcare utilization, or other clinical phenomenon have not been examined extensively. METHODS: An IRB-approved retrospective chart review of all patients between age 18 and 70 who had a clinical encounter at a large medical center between 2009 and 2014. Patients were stratified into 4 categories based on the absolute number of chart-documented allergies: (1) no allergies; (2) normal allergy (1-4 allergies); (3) polyallergy (5-9 allergies); and (4) "ultrapolyallergy," (≥10 allergies), which were corroborated through a sensitivity analysis. Demographics, comorbidities, and medications were clustered per allergy grouping. Analysis of variance, chi-square, and multivariable logistic regression analyses were employed to test for associations. RESULTS: 2,007,434 patients were examined ("no allergy" group, n = 1,423,631, 70.9%; "normal allergy" group: n = 549,927, 27.4%; "polyallergy" group n = 29,453, 1.5%; "ultrapolyallergy" group, n = 4,423, 0.22%). Proportion of females increased from 51% in the "no allergy" group to 89.6% in the "ultrapolyallergy" group (p < 0.001). Rates of mental health and functional somatic syndrome disorder diagnoses increased significantly across allergy groups (p < 0.001). All psychotropic medication classes were increased significantly across allergy groups (p < 0.001). Healthcare utilization was also significantly elevated across allergy cohorts (p <0.001). CONCLUSIONS: This study demonstrates that polyallergy/multiple chemical sensitivity may serve as a crude yet meaningful indicator of comorbid psychopathology. Drug intolerance mechanisms are reviewed, and both clinical and investigational implications are examined.

A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine.

INTRODUCTION: Many psychopharmacologic agents are used as primary or adjuncts in pain management. Atypical antipsychotics (AAs) have also been used as adjuncts in pain management regimens in a variety of manners; however, their efficacy in this capacity is unclear. METHODS: A systematic review of all studies examining AA use for pain was conducted. Three literature databases were utilized to search for word combinations of "pain" and a variety of commonly prescribed AAs ie, (olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, clozapine, paliperidone, iloperidone, lurasidone). Articles chosen for review included retrospective analyses, randomized control trials, and case series/reports. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram illustrates the study selection process. RESULTS: Olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone are the only AAs with published studies in pain management. Among these, olanzapine and quetiapine have the most studies (11 and 6, respectively). Olanzapine shows preliminary and consistent efficacy in fibromyalgia and headache/migraine, although only 1 study was a randomized controlled trial with level I evidence of efficacy. Other AAs eg, (quetiapine) fail to demonstrate efficacy in pain syndromes and/or lack robust study designs. CONCLUSIONS: Few studies have been conducted to evaluate the analgesic effects of AAs. The collective findings of multiple studies evaluating olanzapine in pain syndromes suggest a high, yet preliminary level of evidence of efficacy, warranting prospective studies in various pain syndrome contexts. Pharmacological mechanisms of AA action are elaborated, and the findings of this review are discussed. Risk and benefits of using AAs in chronic pain are described, and investigational implications and future directions are explored.

Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors.

BACKGROUND: Psychosocial and ethical variables influence physicians in requesting decision-making capacity (DMC) evaluations. Previous authors have classified certain DMC evaluation requests as "unwarranted" when there is no explicit suspicion or evidence that the patient might lack DMC. OBJECTIVE: To explore psychosocial and ethical reasons motivating both "warranted" and "unwarranted" DMC evaluation requests by physicians in the medical setting. METHODS: A retrospective electronic health record review was approved by the institutional review board. All psychiatric consultation requests identified as DMC evaluation requests between January 1, 2012 and December 31, 2012 were assessed independently by 2 reviewers. Each reviewer identified each DMC evaluation request as "warranted" vs "unwarranted." Unwarranted DMC evaluation requests were defined as those lacking explicit suspicion that the patient might lack DMC or those with explicit evidence of a patient with blatantly impaired DMC. We hypothesized that most (over half) DMC evaluation requests would be deemed unwarranted. Descriptive statistics, chi-square/Fisher exact tests, and t-test/ANOVA were used. RESULTS: A total of 146 DMC evaluations were reviewed, and 83 (56.8%) of these were deemed unwarranted. Of these, most were likely driven by a previous neuropsychiatric disturbance (p < 0.001). Various other psychosocial and ethical patterns were identified (i.e., the practice of defensive medicine and guardianship concerns). CONCLUSION: Over half of DMC evaluation requests in a general medical setting were unwarranted. Many such requests were motivated by unarticulated psychosocial and ethical factors. DMC evaluation requests appear to serve as a means for indirectly resolving various psychosocial and ethical dilemmas beyond assessing DMC itself. Implications and future directions are discussed.

Attachment in medical care: A review of the interpersonal model in chronic disease management.

Objective Patient-physician interaction is continually examined in an era prioritizing patient-centered approaches, yet elaboration beyond aspects of communication and empathy is lacking. Major chronic conditions would benefit tremendously from understanding interpersonal aspects of patient-physician encounters. This review intends to provide a concise introduction to the interpersonal model of attachment theory and how it informs both the patient-physician interaction and medical outcomes in chronic care. Methods A narrative review of the theoretical, neurobiological, epidemiological, investigational, and clinical literature on attachment theory and its impact on medical outcomes was conducted, utilizing a variety of key words as searched on PubMed database. Studies and reviews included were of a variety of sources, including textbooks and peer-reviewed journals. Reports in languages other than English were excluded. Results Measurable, discrete attachment styles and behavioral patterns correlate with poor medical outcomes, including nonadherence in insecure dismissing attachment and care overutilization in insecure preoccupied attachment. Furthermore, insecure dismissing attachment is associated with significant mortality. These variables can be easily assessed, and their effects are reversible, as evidenced by collaborative care outcome data. Discussion Attachment theory is useful a model with application in clinical and investigational aspects of chronic illness care. Implications and guidelines are explored.

Atypical Findings in Massive Bupropion Overdose: A Case Report and Discussion of Psychopharmacologic Issues.

Bupropion is an atypical antidepressant that is structurally similar to amphetamines. Its primary toxic effects include seizure, sinus tachycardia, hypertension, and agitation; however, at higher amounts of ingestion, paradoxical cardiac effects are seen. We report the case of a 21-year-old woman who ingested 13.5 g of bupropion, a dose higher than any other previously reported. The patient presented with seizure, sinus tachycardia with prolonged QTc and QRS intervals, dilated pupils, and agitation. Four days after overdose, the patient's sinus tachycardia and prolonged QTc and QRS intervals resolved with symptomatic management, but she soon developed sinus bradycardia, hypotension, and mild transaminitis. With continued conservative management and close monitoring, her sinus bradycardia resolved 8 days after the overdose. The transaminitis resolved 12 days after the overdose. Our findings are consistent with previously reported toxic effects associated with common overdose amounts of bupropion. In addition, we have observed transient cardiotoxicity manifesting as sinus bradycardia associated with massive bupropion overdose. These findings are less frequently reported and must be considered when managing patients with massive bupropion overdose. We review the psychopharmacologic implications of this and comment on previous literature.

Mesiotemporal Disconnection and Hypoactivity in Klüver-Bucy Syndrome: Case Series and Literature Review.

OBJECTIVE: Klüver-Bucy syndrome (KBS) is often perceived as rare and limited to cases with bilateral amygdala destruction. In fact, various alternate mechanisms may be involved, warranting exploration of the syndrome's presentation, pathophysiology, prognosis, and management. DATA SOURCES: Clinical management and the electronic medical records were examined for 2 patients diagnosed with partial KBS (ICD-10 F07.0) after experiencing ≥ 3 of the following: placidity, indiscriminate dietary behavior, hyperorality, hypersexuality, visual agnosia, and hypermetamorphosis. A literature search was performed in April 2015 by using the keyword Kluver-Bucy in PubMed and Ovid databases for English language publications since inception. Additionally, the authors reviewed the reference list of these publications in order to identify additional reports. STUDY SELECTION: Studies were included if they had information about presentation, pathophysiology, syndrome treatment or management, and course of KBS. DATA EXTRACTION: Information about our KBS cases was obtained by reviewing electronic medical records and by direct observation of the patients. A total of 186 (PubMed) and 137 (Ovid) publications were identified in each database. We ultimately reviewed 109 articles containing information about KBS, finding 51 publications addressing relevant aspects of this syndrome. RESULTS: The first case demonstrates KBS secondary to mesiotemporal structural atrophy, and the second illustrates transient KBS due to functional, postictal, hypoactivity within such structures. Literature review and discussion regarding both prognosis and treatment of KBS follows. CONCLUSIONS: Klüver-Bucy syndrome may be underreported due to a limited understanding of the syndrome as one necessitating bilateral amygdaloid destruction. The syndrome can be seen with damage/hypofunction of the hippocampal-amygdaloid complex and its projections. The prognosis of KBS is variable, and its treatment is based on a combination of environmental and pharmacologic measures.