PTSD and lower respiratory symptoms: A systematic review of longitudinal associations in early 9/11 World Trade Center responders.

OBJECTIVE: The objective of this systematic review is to examine longitudinal associations between post-traumatic stress disorder (PTSD) and lower respiratory symptoms (LRS) specifically among responders present at the World Trade Center (WTC) site on September 11, 2001 (9/11). This group, which we refer to as "9/11 early responders," appears to have particularly high rates of both mental and physical illness relative to other 9/11-exposed populations. METHODS: We performed a systematic literature review to examine associations between PTSD and LRS among 9/11 early responders in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. After a structured search of Pubmed and the Fire Department of New York (FDNY) WTC bibliography for relevant articles, we identified 4 articles commenting on associations between PTSD and LRS in this population; all 4 passed quality review and were included in our primary analysis. 10 other articles we found in our research discussed rates of PTSD and LRS, but not associations between them, in the population in question; we commented on these in a secondary analysis. RESULTS: The data demonstrate that there are significant associations between PTSD and LRS among 9/11 early responders. The data also suggest that both of these phenomena are more prevalent among 9/11 early responders relative to other 9/11-exposed populations. CONCLUSIONS: These findings are relevant for optimizing care for the population in question, as well as for other survivors of past and future disasters with both psychiatric and medical sequelae.

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.

A COVID-19 Patient's Request to Die and Ensuing Conflict: Psychodynamic Considerations.

The role of psychodynamic theory in consultation-liaison (C-L) work, and particularly the importance of countertransference, has been well established. The psychological impact of the COVID-19 pandemic on healthcare workers is a new factor that must now be taken into account as C-L psychiatrists traverse a changed healthcare landscape. In this article, we highlight the case of a critically ill COVID-19 patient who endorsed a desire for hastened death. This request generated significant conflict between the physicians and nurses caring for him, and it became challenging for the C-L team to perform our typical liaison function. We briefly review the existing literature on the psychological impact of the pandemic on healthcare workers, and examine how psychodynamic factors within this context impacted the events that unfolded. Themes under consideration include the effect of mass trauma on clinician defense mechanisms, and specifically the impact on countertransference toward patients who express a desire for hastened death. C-L psychiatrists themselves are not immune to such reactions and must be particularly attentive to emergent conflict in such cases. Interdisciplinary meetings to discuss and process these disagreements may be effective in repairing staff ruptures.

Abnormal thyroid function tests in psychiatric patients: a red herring?

Thyroid abnormalities can induce mood, anxiety, psychotic, and cognitive disorders. Thus, thyroid function tests are routinely checked in psychiatric patients. However, up to one-third of psychiatric patients may demonstrate thyroid function test abnormalities that do not reflect true thyroid disease, but rather are a manifestation of secondary effects on one or more levels of the hypothalamic-pituitary-thyroid (HPT) axis. Originally termed the euthyroid sick syndrome, this phenomenon is now more commonly referred to as "non-thyroidal illness." In psychiatric patients with non-thyroidal illness, patterns of thyroid function test abnormalities may vary considerably based upon factors such as the underlying psychiatric disorder, the presence of substance abuse, or even the use of certain psychiatric medications. Thus, any abnormal thyroid function tests in psychiatric patients should be viewed with skepticism. Given the fact that thyroid function test abnormalities seen in non-thyroidal illness usually resolve spontaneously, treatment is generally unnecessary, and may even be potentially harmful.