Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self.

We present the case of a young woman with an extensive medical history that most notably includes over 60 emergency-room visits for unfounded respiratory distress that often prompted intubations. Each presentation displays elements of deceitfulness or inappropriate demands that align with factitious disorder imposed on self. Top experts in the Consultation-Liaison field provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching topics include a review of risk factors for development of deceptive syndromes, distinguishing factitious disorder from malingering and conversion disorder, and the role of a consulting psychiatrist in such cases. Patients with factitious disorder often show signs of pathologic lying, obstinance, and erratic behavior. Such attributes frequently arouse negative countertransference in providers, causing frustration and dread with continuing care, rendering psychiatric involvement. We address the unique challenges in managing factitious disorder and how to effectively collaborate with an interdisciplinary inpatient team with these cases.

Ketamine: A Practical Review for the Consultation-Liaison Psychiatrist.

BACKGROUND: Ketamine is a noncompetitive N-methyl-D-aspartate-receptor antagonist often used for sedation and management of acute agitation in general hospital settings. Many hospitals now include ketamine as part of their standard agitation protocol, and consultation-liaison psychiatrists frequently find themselves treating patients who have received ketamine, despite lack of clear recommendations for management. OBJECTIVE: Conduct a nonsystematic narrative review regarding the use of ketamine for agitation and continuous sedation, including benefits and adverse psychiatric effects. Compare ketamine to more traditional agents of agitation control. Provide consultation-liaison psychiatrists with a summary of available knowledge and recommendations for managing patients receiving ketamine. METHODS: A literature review was performed using PubMed, querying published articles from inception to March 2023 for articles related to use of ketamine for agitation or continuous sedation and side effects including psychosis and catatonia. RESULTS: A total of 37 articles were included. Ketamine was found to have multiple benefits, including shorter time to adequate sedation for agitated patients when compared to haloperidol ± benzodiazepines and unique advantages for continuous sedation. However, ketamine carries significant medical risks including high rates of intubation. Ketamine appears to induce a syndrome that mimics schizophrenia in healthy controls, and such effects are more pronounced and longer-lasting in patients with schizophrenia. Evidence regarding rates of delirium with ketamine for continuous sedation is mixed and requires further investigation before the agent is widely adopted for this purpose. Finally, the diagnosis of "excited delirium syndrome" and use of ketamine to treat this controversial syndrome warrants critical evaluation. CONCLUSIONS: Ketamine carries many potential benefits and can be an appropriate medication for patients with profound undifferentiated agitation. However, intubation rates remain high, and ketamine may worsen underlying psychotic disorders. It is essential that consultation-liaison psychiatrists understand the advantages, disadvantages, biased administration, and areas of limited knowledge regarding ketamine.

The Diagnosis of Malingering in General Hospitals in the United States: A Retrospective Analysis of the National Inpatient Sample.

Objective: To characterize the socio-demographics and comorbid medical and psychiatric diagnoses of patients in the general hospital diagnosed with malingering. Method: We conducted a retrospective observational cohort study using data from the 2019 National Inpatient Sample, an all-payors database of acute care general hospital discharges in the United States, querying for patients aged 18 and older discharged with a diagnosis of "malingerer [conscious simulation]," ICD-10 code Z76.5. Results: 45,645 hospitalizations (95% CI: 43,503 to 47,787) during the study year included a discharge diagnosis of malingering. 56.1% were for male patients, and the median age was 43 years (IQR 33 to 54). Black patients represented 26.8% of the patients with a discharge diagnosis of malingering, compared to 14.9% of all patients sampled. Zip codes in the lowest household income quartile comprised 39.9% of malingering diagnoses. The top categories of primary discharge diagnoses of hospitalizations included medical ("Diabetes mellitus without complications"), psychiatric ("Depressive disorders"), and substance use ("Alcohol-related disorders") disorders. "Sepsis, unspecified organism," was the most common primary diagnosis. Conclusion: The striking overrepresentation of Black patients in hospitalizations with diagnosis of malingering raises concern about the roles of implicit and systemic biases in assigning this label. The disproportionate number of patients of low socioeconomic status is further suggestive of bias and disparity. Another potential contribution is that the lower health literacy in these populations results in a limited knowledge of traditional ways to meet one's needs and thus greater reliance on malingered behavior as an alternative means. Accurate description of these patients' socio-demographics and comorbid medical and psychiatric diagnoses with reliable data from large samples can lead to improved understanding of how the malingering label is applied and ultimately better patient care.

The effect of the rescue plans and the need for policies to increase economic growth.

This paper evaluates the economic impact of discretionary fiscal and monetary actions taken in the United States during 2020 and 2021. The fiscal actions are The Coronavirus Aid, Relief, and Economic Security Act, or the "CARES" Act, passed in March 2020; The Consolidated Appropriations Act, passed in December 2020; and The American Rescue Plan Act, passed in March 2021. The paper focuses on the impact of the "economic impact payments" that underlie these fiscal actions. The paper also examines discretionary monetary policy actions taken during the same period. The overall implication is that there is a need to return to policies that increase economic growth and stability, including rules-based fiscal and monetary policy, rather than to continue with these one-time discretionary actions.

Simple monetary rules: many strengths and few weaknesses.

This paper endeavors to examine the basic idea in Richard Epstein's book Simple Rules for a Complex World. It does so by considering a specific simple rule which was explicitly designed for complex world. A basic idea in Epstein's book is that the more complex is the world the better is the case for simple rules. To show this, he develops six simple rules pertaining to the rights of individuals, first possession, contracts, torts, government eminent domain and the power of taxation to provide public goods. This paper considers one rule rather than six rules, and it looks at monetary policy rather than policy in general. While the context is different, the case for simple rules made here provides a useful comparison with the case made by Epstein.

Intravenous haloperidol: A systematic review of side effects and recommendations for clinical use.

INTRODUCTION: Though not approved by the United States Food and Drug Administration, intravenous haloperidol (IVH) is widely used off-label to manage agitation and psychosis in patients with delirium in the hospital setting. Over the years, concerns have emerged regarding side effects of IVH, particularly its potential to cause QT prolongation, torsades de pointes (TdP), extrapyramidal symptoms and catatonia. METHODS: We conducted a systematic review of literature of published literature related to side effects of IVH in PubMed in accordance with PRISMA guidelines. RESULTS: 77 of 196 identified manuscripts met inclusion criteria, including 34 clinical trials and 34 case reports or series. DISCUSSION: Extrapyramidal symptoms, catatonia and neuroleptic malignant syndrome appears to be relatively rare with IVH. In most prospective studies, IVH did not cause greater QT prolongation than placebo, and rates of TdP with IVH appear to be low. There is not clear evidence to suggest that IVH carries greater risk for QT prolongation or TdP than other antipsychotics. CONCLUSIONS: Based on the available literature, we provide modified evidence-based monitoring recommendations for clinicians prescribing IVH in hospital settings. Specifically, we recommend electrocardiogram monitoring only when using doses >5 mg of IVH and telemetry only for high-risk patients receiving cumulative doses of at least 100 mg or with accurately corrected QTc >500 ms.

Psychiatry Resident Attitudes Toward Practice Habit Data.

OBJECTIVE: This descriptive study queries the attitudes of psychiatry residents regarding provision of practice habit data to trainees by residency programs, as required by the Accreditation Council for Graduate Medical Education (ACGME). Identifying trainee perspectives may assist program directors in tailoring practice habit data reporting to better engage residents and to increase resident-reported adherence to the ACGME requirement. METHODS: Residents at a large, hospital-based adult psychiatry training program completed an anonymous survey of attitudes regarding practice habit data, including perceptions of the residency program's current reporting, preferences toward mechanisms of delivering this data, and perceived relative utility of five hypothetical domains of practice habit data. RESULTS: Of 61 eligible residents, 52 (85%) completed surveys. Only 29 (56%) recalled receiving prior-year individual practice habit data, and only 10 (19%) recalled receiving team-based data. Seventy-five percent desired more practice habit data. Out of five hypothetical thematic domains for practice habit reporting, residents preferred patient-oriented domains as opposed to process-oriented domains. Resident concerns about dissemination of these data included confidentiality, effect on evaluations, and difficulty translating data to changes in clinical practice. CONCLUSIONS: Residents generally desire increased dissemination of practice habit data that focuses on patient-oriented measures such as adherence to disease-specific guidelines and is both individual and team-based. Residency programs may benefit their trainees and improve resident-reported adherence to the ACGME requirement both by taking resident preferences into account and by addressing concerns about confidentiality when providing practice habit data.

"Call Me, Maybe": Supervisor and Resident Comfort With Indirect Supervision in Psychiatry Training.

BACKGROUND: Resident supervision is critical for education and ensuring patient safety. After hours, communication with attendings is variable. OBJECTIVE: The objective was to identify differences among psychiatry residents and attendings regarding the desired level of supervision for issues that arise overnight in the psychiatric emergency department (ED). METHODS: In a single-site psychiatric ED, an electronic survey containing 30 hypothetical scenarios was administered. For each scenario, residents were asked if they would call attendings and attendings whether they would want to be called. RESULTS: 35/44 psychiatry residents and 15/17 faculty participated, yielding a response rate of 82%. For five scenarios, faculty preferred that residents call for supervision more frequently than residents indicated they would. These included staff or house staff injuries (60% vs. 22.9%, p = 0.011; 93.3% vs. 62.9%, p = 0.039), a patient using heroin in the ED (53.3% vs. 5.7%, p < 0.001), a conflict with the medical ED attending (100% vs. 65.7%, p = 0.010), and a decision about calling in a backup resident (60% vs. 28.6%, p = 0.036). CONCLUSIONS: In a psychiatric ED, attendings prefer greater involvement in cases relating to psychosocial issues, legal concerns, and conflicts with patients. More work is needed to fully understand these differences and their potential impact on patient care and training.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population.

OBJECTIVE: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Ultra-fast intramolecular vibronic coupling revealed by RIXS and RPES maps of an aromatic adsorbate on TiO2(110).

Two-dimensional resonant inelastic x-ray scattering (RIXS) and resonant photoelectron spectroscopy (RPES) maps are presented for multilayer and monolayer coverages of an aromatic molecule (bi-isonicotinic acid) on the rutile TiO2(110) single crystal surface. The data reveal ultra-fast intramolecular vibronic coupling upon core excitation from the N 1s orbital into the lowest unoccupied molecular orbital (LUMO) derived resonance. In the RIXS measurements, this results in the splitting of the participator decay channel into a purely elastic line which disperses linearly with excitation energy and a vibronic coupling channel at constant emission energy. In the RPES measurements, the vibronic coupling results in a linear shift in binding energy of the participator channel as the excitation is tuned over the LUMO-derived resonance. Localisation of the vibrations on the molecule on the femtosecond time scale results in predominantly inelastic scattering from the core-excited state in both the physisorbed multilayer and the chemisorbed monolayer.

The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation.

OBJECTIVE: The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is an inherently risk-assuming action. The rationale and conduct of the therapeutic discharge has been written on previously. Here, we propose a method of documenting the therapeutic discharge in a way that is useful and teachable. METHOD: After describing some other types of note-writing that can be needed in the care of deceptive patients, we describe an approach to each of the major sections of an initial consultation/encounter note as it applies to the therapeutic discharge. RESULTS: Each note section is handled slightly differently than ordinarily. The history of present illness follows the sequence, rather than the re-organization of the information obtained. The past medical history requires and reflects a more granular chart review than is usually warranted. The mental status exam is less cross-sectional than usual. The assessment and plan incorporates several components that reflect a reasoning process specific to the therapeutic discharge. CONCLUSION: While labor-intensive, the documentation approach advocated for and exemplified here reaffirms aspects of one's identity as a physician, ensures responsible execution of a risk-involving decision, and potentially simplifies subsequent patient encounters.

Predictors of Disruptions in Breast Cancer Care for Individuals with Schizophrenia.

BACKGROUND: Patients with schizophrenia experience markedly increased breast cancer mortality, yet reasons for this disparity are poorly understood. We sought to characterize disruptions in breast cancer care for patients with schizophrenia and identify modifiable predictors of those disruptions. MATERIALS AND METHODS: We performed a medical record review of 95 patients with schizophrenia and breast cancer treated at an academic cancer center between 1993 and 2015. We defined cancer care disruptions as processes that interfere with guideline-concordant cancer care, including delays to diagnosis or treatment, deviations from stage-appropriate treatment, and interruptions in treatment. We hypothesized that lack of psychiatric treatment at cancer diagnosis would be associated with care disruptions. RESULTS: Half of patients with schizophrenia experienced at least one breast cancer care disruption. Deviations in stage-appropriate treatment were associated with breast cancer recurrence at 5 years (p = .045). Patients without a documented psychiatrist experienced more delays (p = .016), without documented antipsychotic medication experienced more deviations (p = .007), and with psychiatric hospitalizations after cancer diagnosis experienced more interruptions (p < .0001). Independent of stage, age, and documented primary care physician, lack of documented antipsychotic medication (odds ratio [OR] = 4.97, 95% confidence interval [CI] = 1.90, 12.98) and psychiatric care (OR = 4.56, 95% CI = 1.37, 15.15) predicted cancer care disruptions. CONCLUSION: Disruptions in breast cancer care are common for patients with schizophrenia and are associated with adverse outcomes, including cancer recurrence. Access to psychiatric treatment at cancer diagnosis may protect against critical disruptions in cancer care for this underserved population. IMPLICATIONS FOR PRACTICE: Disruptions in breast cancer care are common for patients with schizophrenia, yet access to mental health treatment is rarely integrated into cancer care. When oncologists documented a treating psychiatrist and antipsychotic medication, patients had fewer disruptions in breast cancer care after adjusting for age, cancer stage, and access to primary care. Addressing psychiatric comorbidity at breast cancer diagnosis may increase the likelihood that patients with schizophrenia receive timely, stage-appropriate cancer treatment. Comanagement of schizophrenia and breast cancer at cancer diagnosis may be one key strategy to decrease inequities in cancer treatment and improve cancer survival in this underserved population.

Teaching Psychiatric Trainees to "Think Dirty": Uncovering Hidden Motivations and Deception.

BACKGROUND: Despite the prevalence with which trainees encounter patients who attempt to manipulate, deceive, or withhold information from them, trainees receive little formal training in "thinking dirty"-that is, incorporating elements of hidden patient motives into their interview, formulation, and plan. Lack of acknowledgment of these aspects of patient care can lead to resident dissatisfaction, negative countertransference reactions, and decreased empathy for patients. METHODS: In this article, the authors outline a multimodal approach used in a large psychiatry training program for teaching trainees to recognize hidden motivations and deception, which involves formal didactic teaching, process rounds, and clinical experience. RESULTS: This approach improves trainee understanding of patients' motivations, and it allows trainees to better regulate their emotional responses to patients withholding information or deceiving them. CONCLUSIONS: Formally addressing this topic in the curriculum can lead to improved patient outcomes and decreased resident burnout, particularly on high-intensity rotations.

The therapeutic discharge: An approach to dealing with deceptive patients.

OBJECTIVE: Patients with factitious disorder or malingering behaviors pose particular problems in acute care settings. We sought to describe a manner to effectively discharge these patients and keep further harm, iatrogenic or otherwise, from being inflicted. METHOD: Once an indication has been identified, the therapeutic discharge can be carried out in a stepwise fashion, resulting in a safe discharge. We outlined how to prepare for, and execute, the therapeutic discharge, along with preemptive consideration of complications that may arise. RESULTS: Consequences for the patient, physicians, and larger healthcare system are considered. CONCLUSION: The therapeutic discharge is a safe and effective procedure for patients with deception syndromes in acute care settings. Carrying it out is a necessary element of psychiatric residency and psychosomatic medicine fellowship training.

Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine?

BACKGROUND: The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE: As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS: We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS: In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS: Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.

Silver-catalysed trifluoromethylation of arenes at room temperature.

A variety of heteroarenes and electron rich arenes can be trifluoromethylated at room temperature with TMSCF3, catalytic silver and PhI(OAc)2.