Persistent physical symptoms: definition, genesis, and management.

Persistent physical symptoms (synonymous with persistent somatic symptoms) is an umbrella term for distressing somatic complaints that last several months or more, regardless of their cause. These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society. Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo. As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging. Multiple biological and psychosocial risk factors and mechanisms contribute to the persistence of somatic symptoms, including persistent inflammation; epigenetic profiles; immune, metabolic and microbiome dysregulation; early adverse life experiences; depression; illness-related anxiety; dysfunctional symptom expectations; symptom focusing; symptom learning; and avoidance behaviours, with many factors being common across symptoms and diagnoses. Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation. If basic care is insufficient, targeted psychological and pharmacological interventions can be beneficial. A better understanding of the multifactorial persistence of somatic symptoms should lead to more specific, personalised, and mechanism-based treatment, and a reduction in the stigma patients commonly face.

Anomalies in the review process and interpretation of the evidence in the NICE guideline for chronic fatigue syndrome and myalgic encephalomyelitis.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability.

Physicians' Perception of Sickle-cell Disease Pain.

The aim of this study was to evaluate the physician's perception of pain experienced by patients with sickle-cell disease (SCD). Pain experiences reported by patients were compared with physicians' perception of the patient's pain, and the treatment decision-making process was evaluated. Fifty-two patient-physician pairs were assessed. Before the clinic visit, the patients completed a 3-item on pain experienced 24 h prior to the visit and the PHQ-9. After the patient visit, the physicians completed a questionnaire assessing their perception of the patient's pain and a questionnaire on the factors taken into consideration when evaluating the patient's pain experience. The physicians rated the patients' pain as more intense than did the patients themselves; and there was agreement between pain intensity measurements (p < 0.05). The physicians' perception was influenced by the pain intensity reported by the patient, results of blood count at the time of the patient visit, and medication availability in the public health services. However, these factors were not predictive of the patient's pain intensity perceived by the physician. Patients' depressive symptoms were not predictive factor of the physicians' perception. Biochemical, genetic and symptomatic characteristics of SCD influenced the physicians' perception of the patient's pain experience, while psychosocial aspects did not.

Readiness for behaviour change in non-alcoholic fatty liver disease: implications for multidisciplinary care models.

BACKGROUND & AIMS: Weight management is a cornerstone of treatment for overweight/obese persons with non-alcoholic fatty liver disease (NAFLD). This exploratory study sought to: (i) evaluate readiness to change weight-related behaviours; (ii) assess psychosocial characteristics that may interfere with weight loss; and (iii) evaluate how baseline psychosocial features associate with 6-month change in weight in persons with NAFLD receiving standard medical care. The purpose of this investigation was to develop hypotheses regarding relationships between psychosocial factors and weight for use in future fully powered studies and clinical interventions METHODS: Fifty-eight overweight/obese participants with NAFLD completed baseline measures of personality, psychiatric symptoms and readiness for behaviour change and were followed up for 6 months in standard care. RESULTS: One-third of participants (31.0%) were not interested in making weight-related behaviour changes; 58.6% were considering making a change, and 10.4% of individuals were actively working on or preparing to change. Six-month change in weight was non-significant and was not associated with baseline readiness for change. Depression, low conscientiousness and high neuroticism were associated with higher weight at 6-month follow-up with small to large effect sizes. CONCLUSIONS: Although participants received nutritional education and guidance, very few individuals presented in the active stage of change. Although readiness for change did not predict subsequent change in weight, personality factors and psychiatric symptoms were associated with weight outcomes. Integrated multidisciplinary approaches that address psychiatric needs and provide behavioural support for weight loss may help patients with NAFLD implement sustained lifestyle changes.

The milestones for psychosomatic medicine subspecialty training.

BACKGROUND: The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. METHODS: With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. RESULTS: This article represents a record of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. CONCLUSIONS: The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows.

Emergent use of mechanical circulatory support devices: ethical dilemmas.

PURPOSE OF REVIEW: Mechanical Circulatory Support (MCS) devices are 'life-sustaining devices' placed as a bridge to decision, either recovery, transplantation or a lifetime tether with the device. Cardiogenic shock may compromise patient autonomy, or the right for an individual patient to determine his own care. This review addresses an ethical dilemma in the context of complex clinical medical decision-making, during marked uncertainty for outcomes. RECENT FINDINGS: The language in an advanced directive is often imprecise and may not provide clear guidance, especially for emergent decisions related to MCS devices. Despite improving outcomes, application of MCS in critical illness is associated with excessive morbidity and quality of life-limiting adverse outcomes. Several cohort experiences now exist that define deactivation of Left Ventricular Assist Devices (LVADs) in futility as now deemed as morally and ethically appropriate. In contradistinction to euthanasia, deactivation of an LVAD does not introduce new intervention or an additional surgical injury, thereby allowing the patient to die from their original disorder. SUMMARY: Clinicians must maintain the principle of patient autonomy, ensure the viability of an appropriate informed consent process and facilitate surrogate judgment. An interdisciplinary team-based approach is required, and, in some cases, assisted by formal ethics consultations in vexing situations.

Somatic symptom burden in adults with sickle cell disease predicts pain, depression, anxiety, health care utilization, and quality of life: the PiSCES project.

OBJECTIVE: Somatic symptoms have been extensively studied in primary care, but infrequently in diseases causing pain in multiple sites. We therefore examined the impact of somatic symptom burden (SSB) on pain, depression, anxiety, health-care utilization, and quality-of-life in adults with sickle cell disease (SCD). METHODS: Subjects were 230 adults in the prospective Pain in Sickle Cell Epidemiology Study (PiSCES). Baseline data included demographics, genotype, Patient Health Questionnaire (PHQ), and SF-36 health-related quality of life (HRQOL). In daily diaries for 6 months, patients recorded SCD pain and SCD health-care utilization. To exclude common SCD pain sites, we abridged the PHQ's 15 somatic symptoms to 11 (PHQscd). We divided subjects into two groups: PHQscd≥11 (high SSB), and PHQscd<11 (low SSB). RESULTS: High SSB occurred in 18.3% of subjects and was more frequent in women than men (24.6% vs. 9.1%, p=0.0033). Sixty percent of subjects with anxiety and 37.5% of those with depression had comorbid high SSB. Percentage of pain days not in crisis pain was significantly higher in somatizers, but crisis pain did not differ between groups. The high SSB group's hospitalization, scheduled doctor visits, and overall utilization, particularly on non-crisis days were significantly higher than the low SSB group's (p values < 0.05). All SF-36 subscales were significantly negatively correlated with PHQscd (p<0.0001). CONCLUSIONS: Even after excluding common SCD pain complaints, high somatic symptom burden was 1.5 to 2 times more prevalent in SCD patients than in primary care. High SSB in SCD predicts more non-crisis pain and healthcare utilization for pain, and is associated with depression, anxiety, and poorer HRQOL.

Evaluation of intramuscular olanzapine and ziprasidone in the medically ill.

INTRODUCTION: Despite the paucity of studies evaluating short-acting parenteral second-generation antipsychotics in the medically ill, their use in this population has increased. The purpose of this study was to characterize the use of IM olanzapine and ziprasidone in the medically ill at an academic medical center. METHODS: This is a retrospective medical record review of all patients who received IM olanzapine or ziprasidone on nonpsychiatric inpatient units at a large academic medical center from August 1, 2015 to July 31, 2017. The primary endpoint characterized the indication for use. Secondary endpoints included safety, effectiveness, and prescribing patterns. RESULTS: After exclusion criteria, a total of 100 patients were included in this study, predominantly white males with a mean age of 56 years. Seventy-four percent of patients received IM ziprasidone and 26% received IM olanzapine. The most common indications for use were agitation of nonpsychotic origin (40%) and delirium (33%). Patients received IM olanzapine and ziprasidone when their use was contraindicated (26.9% vs 9.5%, respectively). DISCUSSION: Intramuscular second-generation antipsychotics are increasingly being used in the medically ill for delirium and agitation. Our study confirms these were the most common indications for IM second-generation antipsychotic use in this population. Additionally, their use appeared to be well-tolerated, and no patient developed Torsades de Pointes even when combined with other agents that putatively increase QTc. Given the retrospective, single-center, nonrandomized design of this study, the safety and effectiveness of these parenteral second-generation antipsychotics in common causes of acute agitation should continue to be further evaluated.

When is lack of scientific integrity a reason for retracting a paper? A case study.

OBJECTIVE: The journal received a request to retract a paper reporting the results of a triple-blind randomized placebo-controlled trial. The present and immmediate past editors expand on the journal's decision not to retract this paper in spite of undisputable evidence of scientific misconduct on behalf of one of the investigators. METHODS: The editors present an ethical reflection on the request to retract this randomized clinical trial with consideration of relevant guidelines from the Committee on Publication Ethics (COPE) and the International Committee of Medical Journal Editors (ICMJE) applied to the unique contextual issues of this case. RESULTS: In this case, scientific misconduct by a blinded provider of a homeopathy intervention attempted to undermine the study blind. As part of the study, the integrity of the study blind was assessed. Neither participants nor homeopaths were able to identify whether the participant was assigned to homeopathic medicine or placebo. Central to the decision not to retract the paper was the fact that the rigorous scientific design provided evidence that the outcome of the study was not affected by the misconduct. The misconduct itself was thought to be insufficient reason to retract the paper. CONCLUSION: Retracting a paper of which the outcome is still valid was in itself considered unethical, as it takes away the opportunity to benefit from its results, rendering the whole study useless. In such cases, scientific misconduct is better handled through other professional channels.

An anonymous survey of psychosomatic medicine fellowship directors regarding breaches of contracts and a proposal for prevention.

OBJECTIVE: The authors studied how often applicants accept positions at more than one program, or programs offer positions to applicants who have already signed contracts with other programs. METHODS: An anonymous survey was distributed to all psychosomatic medicine fellowship program directors. RESULTS: It is fairly common for applicants to sign contracts for fellowship positions and then back out of the contracts. Only one program reported ever knowingly offering a contract to an applicant who had accepted a position elsewhere. Programs are divided over whether there are extenuating circumstances under which it would be acceptable to offer a position to an applicant who has already signed a contract with another program. CONCLUSION: Guidelines for fellowship programs that do not use the National Resident Match Program can improve the recruitment process.

Children as living organ donors: current views and practice in the United States.

PURPOSE OF REVIEW: To summarize recent practices and views regarding children as living organ donors in the USA. RECENT FINDINGS: Living donors have become an increasingly important source of organs for transplantation. Concern for the rights of donors has resulted in reconsideration of the use of minors as living organ donors. Most commentators have voiced concerns that minors deserve extraordinary protection, but are unwilling to ban the practice of living donation by minors outright. Instead, factors to be considered in individual situations have been enumerated, and safeguards recommended. These same safeguards have also been recommended to be extended to adults, as attainment of legal age does not in itself confer immunity from exploitation. Developmental factors of importance include brain maturation affecting decision making, executive function and impulse control; the dependent status of minors, usually on the persons who may most want them to be donors; youthful idealism and sense of invulnerability; and incomplete identity formation. SUMMARY: Fewer children in the USA have become living donors in the past decade. Preadolescent children in particular should probably be considered as potential donors only in extraordinary circumstances. Safeguards protect not only children, but transplant physicians, programs and the image of the transplant endeavor.

Comparisons of high versus low emergency department utilizers in sickle cell disease.

STUDY OBJECTIVE: Patients with sickle cell disease often receive a substantial amount of their health care in the emergency department (ED) and some come to the ED frequently, seeking treatment for pain. As a result, patients with sickle cell disease are often stigmatized as opioid-seeking ED overutilizers. We describe the proportion of sickle cell disease patients who are high utilizers of the ED and compare them with other sickle cell disease patients on demographics, pain characteristics, health data, psychosocial characteristics, and quality of life. METHODS: Two hundred thirty-two patients completed baseline data and at least 30 days of daily diary data. Baseline data included demographics, health data, and quality of life (Medical Outcome Study 36 Item Short Form). Daily diary data included ED utilization for sickle cell pain and descriptors of pain and distress. RESULTS: Eighty-two (35.5%) patients were found to be high ED utilizers. Clinically important and statistically significant differences were found between high ED utilizers and all other sickle cell disease patients: lower hematocrit level, more transfusions, more pain days, more pain crises, higher mean pain and distress, and worse quality of life on Medical Outcome Study 36 Item Short Form physical function summary scales. After controlling for severity and frequency of pain, high ED utilizers did not use opioids more frequently than other sickle cell disease patients. CONCLUSION: A substantial minority of sickle cell disease patients are high ED utilizers. However, high ED utilizers with sickle cell disease are more severely ill as measured by laboratory variables, have more pain, more distress, and have a lower quality of life.

A forgotten diagnosis: simple schizophrenia in a patient with breast cancer.

BACKGROUND: Simple schizophrenia (SS) is a disorder unfamiliar to many psychiatrists, and it often goes unrecognized by providers as an underlying psychiatric disorder in general-medical settings. OBJECTIVE: The authors seek to increase recognition, as demonstrated in the case presented. METHOD: The authors report on a breast mass in a homeless 40-year-old woman who was lost to treatment for 2 years and then reappeared in the hospital at stage IV. RESULTS: Palliative treatment was begun; however, the patient summarily left the hospital and was again lost to follow-up. CONCLUSION: SS can have profound consequences for the patient, both in terms of self-care and medical treatment. Improved recognition of SS is important for both general-medical and mental health providers in order to achieve appropriate provision of clinical care and better medical outcomes.

Daily assessment of pain in adults with sickle cell disease.

BACKGROUND: Researchers of sickle cell disease have traditionally used health care utilization as a proxy for pain and underlying vaso-occlusion. However, utilization may not completely reflect the amount of self-reported pain or acute, painful episodes (crises). OBJECTIVE: To examine the prevalence of self-reported pain and the relationship among pain, crises, and utilization in adults with sickle cell disease. DESIGN: Prospective cohort study. SETTING: Academic and community practices in Virginia. PATIENTS: 232 patients age 16 years or older with sickle cell disease. MEASUREMENTS: Patients completed a daily diary for up to 6 months, recording their maximum pain (on a scale of 0 to 9); whether they were in a crisis (crisis day); and whether they used hospital, emergency, or unscheduled ambulatory care for pain on the previous day (utilization day). Summary measures included both simple proportions and adjusted probabilities (for repeated measures within patients) of pain days, crisis days, and utilization days, as well as mean pain intensity. RESULTS: Pain (with or without crisis or utilization of care) was reported on 54.5% of 31 017 analyzed patient-days (adjusted probability, 56%). Crises without utilization were reported on 12.7% of days and utilization on only 3.5% (unadjusted). In total, 29.3% of patients reported pain in greater than 95% of diary days, whereas only 14.2% reported pain in 5% or fewer diary days (adjusted). The frequency of home opiate use varied and independently predicted pain, crises, and utilization. Mean pain intensity on crisis days, noncrisis pain days, and total pain days increased as the percentage of pain days increased (P < 0.001). Intensity was significantly higher on utilization days (P < 0.001). However, utilization was not an independent predictor of crisis, after controlling for pain intensity. LIMITATIONS: The study was done in a single state. Patients did not always send in their diaries. CONCLUSION: Pain in adults with sickle cell disease is the rule rather than the exception and is far more prevalent and severe than previous large-scale studies have portrayed. It is mostly managed at home; therefore, its prevalence is probably underestimated by health care providers, resulting in misclassification, distorted communication, and undertreatment.

Depression and anxiety in adults with sickle cell disease: the PiSCES project.

OBJECTIVE: Depression and anxiety are common in sickle cell disease (SCD) but relatively little is known about their impact on SCD adults. This study measured prevalence of depression and anxiety in SCD adults, and their effects on crisis and noncrisis pain, quality-of-life, opioid usage, and healthcare utilization. METHODS: The Pain in Sickle Cell Epidemiology Study is a prospective cohort study in 308 SCD adults. Baseline variables included demographics, genotype, laboratory data, health-related quality-of-life, depression, and anxiety. Subjects completed daily diaries for up to 6 months, reporting sickle cell pain intensity, distress, interference, whether they were in a sickle cell crisis, as well as health care and opioid utilization. RESULTS: Two hundred thirty-two subjects who completed at least 1 month of diaries were studied; 27.6% were depressed and 6.5% had any anxiety disorder. Depressed subjects had pain on significantly more days than nondepressed subjects (mean pain days 71.1% versus 49.6%, p < .001). When in pain on noncrisis days, depressed subjects had higher mean pain, distress from pain, and interference from pain. Both depressed and anxious subjects had poorer functioning on all eight SF-36 subscales, even after controlling for demographics, hemoglobin type, and pain. The anxious subjects had more pain, distress from pain, and interference from pain, both on noncrisis pain days and on crisis days, and used opioids more often. CONCLUSIONS: Depression and anxiety predicted more daily pain and poorer physical and mental quality-of-life in adults with SCD, and accounted for more of the variance in all domains of quality-of-life than hemoglobin type.

Decision-making, emotional distress, and quality of life in patients affected by the recall of their implantable cardioverter defibrillator.

AIMS: We sought to investigate whether patients with implantable cardioverter defibrillators (ICDs) were suffering from emotional distress related to the recent United States Food and Drug Administration (FDA) recalls, to better understand their decision process related to device replacement, and to assess any impact of recall on quality of life (QOL). METHODS AND RESULTS: Thirty-one patients experiencing device recalls answered questions regarding their knowledge about the recall and their decision whether to replace the device. Fifty patients whose devices were not recalled reported demographic data. In both groups, psychological factors were assessed. No significant differences were found for psychological factors. Most patients reported being informed of their recall by their physician. Most estimated the risk of device failure to be low or very low, but they overestimated the fail rate. Thirty-six per cent of patients reported feeling anxious about the recall. CONCLUSION: No significant differences existed in psychological factors and QOL between patients whose ICDs were recalled compared with those whose devices were not. The majority of patients whose ICDs are the subject of an FDA advisory/recall have a realistic understanding of the risks of device failure. Prompt information, support, and reassurance provided by healthcare professionals may allay patient distress.

Factitious wound infections in an altruistic living liver donor.

We report a case of recurrent factitious wound infections in an altruistic living liver donor. Costs for the infections after donation were billed to the recipient, creating a threat to the recipient's lifetime benefits. This case illustrates the importance of obtaining previous medical records on living donors.

Use of psychotropic drugs in the dermatology patient: When to start and stop?

Dermatologists often find themselves treating patients with psychiatric disorders, most commonly anxiety and depression, in the context of skin disease. The psychiatric condition may either be present before the skin condition developed and exacerbate it or, in some cases, even create it (eg, delusions of parasitosis). Alternatively, the psychiatric condition may occur subsequent to the development of the dermatologic condition. The treatment of psychodermatogic disorders requires collaboration between psychiatrists and dermatologists. Dermatologists should be able to recognize primary psychiatric disorders and refer patients to psychiatrists for appropriate treatment; however, the patient may encounter delays in accessing psychiatric care, and dermatologists should be familiar with the basic use of psychotropic drugs. This review describes common psychiatric disorders encountered in a dermatology practice and their treatment with psychotropic drugs. For each commonly used drug, dose range, side effects, and how to initiate and terminate treatment are described. Although psychotherapy is an important part of the treatment of most psychiatric disorders, we have limited our focus to psychotropic drugs in this review.