Jon E. Grant, JD, MD, MPH

Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment. Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it. CSB can involve fantasies and urges in addition to or in place of the behavior but must cause clinically significant distress and interference in daily life to qualify as a disorder.

Because of the lack of large-scale, population-based epidemiological studies assessing CSB, its true prevalence among adults is unknown. A study of 204 psychiatric inpatients found a current prevalence of 4.4%,¹ while a university-based survey estimated the prevalence of CSB at approximately 2%.² Others have estimated that the prevalence is between 3% to 6% of adults in the United States,^3,4 with males comprising the majority (≥80%) of affected individuals.⁵

CSB usually develops during late adolescence/early adulthood, and most who present for treatment are male.⁵ Mood states, including depression, happiness, and loneliness, may trigger CSB.⁶ Many individuals report feelings of dissociation while engaging in CSB-related behaviors, whereas others report feeling important, powerful, excited, or gratified.

Why CSB is difficult to diagnose

Although CSB may be common, it usually goes undiagnosed. This potentially problematic behavior often is not diagnosed because of:

• Shame and secrecy. Embarrassment and shame, which are fundamental to CSB, appear to explain, in part, why few patients volunteer information regarding this behavior unless specifically asked.¹
• Patient lack of knowledge. Patients often do not know that their behavior can be successfully treated.
• Clinician lack of knowledge. Few health care professionals have education or training in CSB. A lack of recognition of CSB also may be due to our limited understanding regarding the limits of sexual normality. In addition, the classification of CSB is unclear and not agreed upon (Box^7-9), and moral judgments often are involved in understanding sexual behaviors.¹⁰

Box
Classifying compulsive sexual behavior

No consensus on diagnostic criteria

Accurately diagnosing CSB is difficult because of a lack of consensus about the diagnostic criteria for the disorder. Christenson et al¹¹ developed an early set of criteria for CSB as part of a larger survey of impulse control disorders. They used the following 2 criteria to diagnose CSB: (1) excessive or uncontrolled sexual behavior(s) or sexual thoughts/urges to engage in behavior, and (2) these behaviors or thoughts/urges lead to significant distress, social or occupational impairment, or legal and financial consequences.^11,12

During the DSM-5 revision process, a second approach to the diagnostic criteria was proposed for hypersexuality disorder. Under the proposed criteria for hypersexuality, a person would meet the diagnosis if ≥3 of the following were endorsed over a 6-month period: (a) time consumed by sexual fantasies, urges, or behaviors repetitively interferes with other important (non-sexual) goals, activities, and obligations; (b) repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states; (c) repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events; (d) repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors; and (e) repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.⁹

These 2 proposed approaches to diagnosis are somewhat similar. Both suggest that the core underlying issues involve sexual urges or behaviors that are difficult to control and that lead to psychosocial dysfunction. Differences in the criteria, however, could result in different rates of CSB diagnosis; therefore, further research will need to determine which diagnostic approach reflects the neurobiology underlying CSB.

Avoid misdiagnosis

Before making a diagnosis of CSB, it is important for clinicians to consider whether they are stigmatizing “negative consequences,” distress, or social impairment based on unconscious bias toward certain sexual behaviors. In addition, we need to ensure that we are not holding sex to different standards than other behaviors (for example, there are many things in life we do that result in negative consequences and yet do not classify as a mental disorder, such as indulging in less healthy food choices). Furthermore, excessive sexual behaviors might be associated with the normal coming out process for LGBTQ individuals, partner relationship problems, or sexual/gender identity. Therefore, the behavior needs to be assessed in the context of these psychosocial environmental factors.

Differential diagnosis

Various psychiatric disorders also may include excessive sexual behavior as part of their clinical presentation, and it is important to differentiate that behavior from CSB.

Bipolar disorder. Excessive sexual behavior can occur as part of a manic episode in bipolar disorder. If the problematic sexual behavior also occurs when the person’s mood is stable, the individual may have CSB and bipolar disorder. This distinction is important because the treatment for bipolar disorder is often different for CSB, because anticonvulsants have only case reports attesting to their use in CSB.

Substance abuse. Excessive sexual behavior can occur when a person is abusing substances, particularly stimulants such as cocaine and amphetamines.¹³ If the sexual behavior does not occur when the person is not using drugs, then the appropriate diagnosis would not likely be CSB.

Obsessive-compulsive disorder (OCD). Individuals with OCD often are preoccupied with sexual themes and feel that they think about sex excessively.¹⁴ Although patients with OCD may be preoccupied with thoughts of sex, the key difference is that persons with CSB report feeling excited by these thoughts and derive pleasure from the behavior, whereas the sexual thoughts of OCD are perceived as unpleasant.

Other disorders that may give rise to hypersexual behavior include neurocognitive disorders, attention-deficit/hyperactivity disorder, autism spectrum disorders, and depressive disorders.

Adverse effects of medication. It is important to ask the patient whether he (she)developed CSB after starting a medication. Certain medications (eg, medications for Parkinson’s disease or restless leg syndrome, or aripiprazole to treat depression or psychosis) may cause patients to engage in problematic sexual behavior.^15,16 If the sexual behavior decreases or stops when the medication dosage is reduced or the medication is stopped, a diagnosis of CSB would not be appropriate.

Comorbidity is common

Research suggests that approximately one-half of adults with CSB meet criteria for at least 1 other psychiatric disorder, such as mood, anxiety, substance use, impulse control, or personality disorders. A study of men with CSB (N = 103) found that 71% met criteria for a mood disorder, 40% for an anxiety disorder, 41% for a substance use disorder, and 24% for an impulse control disorder such as gambling disorder.¹⁷ Therefore, to successfully treat CSB, clinicians also may need to focus on how and to what extent these co-occurring disorders drive the sexual behavior.

Co-occurring medical conditions also are common among individuals with CSB. Medical concerns may include unwanted pregnancy, sexually transmitted infections, and HIV/AIDS. Thus, treating psychiatric comorbidities and providing education about sexual health, with referrals to primary care specialists, often are part of CSB treatment.

Neuroimaging and cognition

One imaging study that compared participants with and without CSB found that participants with CSB had higher activity in the ventral striatum, anterior cingulate cortex, and amygdala relative to controls during a cue-reactivity functional MRI task.¹⁸ These findings show notable similarities to the patterns of activation seen in patients addicted to drugs when assessed using drug-craving paradigms. An additional neuroimaging study assessing patients with hypersexuality using diffusion tensor imaging noted that diffusivity in a prefrontal white matter tract within a superior frontal region was greater in patients with CSB.¹⁸ This study also indicated that there was a negative correlation between observed diffusion in the noted location and overall severity score for CSB symptoms such as frequency of urges or behaviors.

In terms of cognition, a preliminary assessment of young adults with CSB compared with healthy controls did not find any differences between groups across several tasks, although the previously mentioned diffusion tensor imaging study reported elevated impulsivity in CSB.¹⁸

Approaches to treatment

Most people with CSB are reluctant to mention it to their health care providers, and most physicians are generally uncomfortable talking about sex with their patients, in part, because of a lack of training.¹⁹ Patients are more likely to bring up the topic when they are receiving treatment for anxiety, depression, or substance abuse. Therefore, clinicians must consider that sexual behavior might be associated with a coping mechanism, distressing outcome, or comorbid condition in these patients.

Pharmacologic treatment

Evidence for the pharmacologic treatment of CSB consists primarily of small, open-label studies, case series, or retrospective analyses, except for 1 double-blind, placebo-controlled study. Based on this evidence, there may be several pharma­cologic treatment options for patients with CSB; however, there are no FDA-approved medications for CSB.

Antidepressants. One of the most thoroughly documented categories of pharmacologic treatment for CSB is selective serotonin reuptake inhibitors (SSRIs). Several retrospective analyses and case series have reported on the general efficacy of SSRIs in reducing symptoms of CSB.^20-23 Citalopram, the only treatment for CSB that has been assessed using a double-blind, placebo-controlled methodology, was associated with significant decreases in CSB symptoms, including sexual desire/drive, frequency of masturbation, and pornography use.²⁴

In addition to SSRIs, several additional case reports have suggested that other classes of antidepressants, such as serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants, or stimulants may be beneficial when treating CSB.²⁵ Several case reports have indicated significant improvement of CSB symptoms using clomipramine.²² A retrospective study of nefazodone also has suggested that it may be an option for treating CSB. Patients reported notable reductions in the frequency of sexual obsessions/compulsions while taking nefazodone and reported no notable sexual adverse effects.²⁶ One branded version of nefazodone, Serzone, was associated with rare but severe liver problems and was withdrawn from the U.S. market in 2004.

Although some initial evidence regarding antidepressant use, particularly SSRIs, to treat CSB has suggested that these medications may be potentially beneficial, the findings are far from conclusive, with only 1 controlled trial and only single-subject case reports for many of the medications studied.

Naltrexone, an opioid antagonist, has received support from available cases, open-label studies, and retrospective analyses.^17,27 Although evidence for the use of naltrexone in CSB is limited to case reports and retrospective analyses, results have been positive. Naltrexone has shown notable decreases in CSB symptom severity when used as monotherapy and when used in combination with other treatments.

Anticonvulsants. Several case reports have suggested that certain anticonvulsants may be beneficial for treating CSB. Topiramate may be a particularly useful option.²⁸ Other anticonvulsants showing benefit for CSB in case reports include valproic acid, lamotrigine, and levetiracetam.¹⁸

Psychotherapy

Evidence supporting specific types of psychotherapy for CSB is limited and largely drawn from uncontrolled studies and case reports.

Cognitive-behavioral therapy (CBT) is one of the more common psychotherapeutic options used for CSB. Several uncontrolled studies and case reports have found that CBT is beneficial for CSB, although methodologies have varied.

Several cases found that combining CBT with motivational interviewing was associated with significant reductions in sexual behaviors, such as frequency of sexual partners and amount of time spent online during work hours.^29,30 Group CBT also has been shown to be effective for CSB.³¹

Acceptance and commitment therapy (ACT) has received some initial support, with 1 uncontrolled study and 1 controlled study.^32,33 The controlled study used 12 sessions of individual ACT compared with a wait-list condition.³² Improvements in CSB symptoms were maintained for 3 months. The overall reduction in problematic Internet pornography use was reported as 92% immediately after the study ended, and 86% after 3 months.

Marital/relationship therapy has been used successfully in several case series and case reports, although no studies have assessed its efficacy in treating CSB using a randomized protocol. In 1 case report, the researcher found that participation in marital sex therapy elicited notable improvements over the course of 1 year and 20 sessions.³⁴

Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment. Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it. CSB can involve fantasies and urges in addition to or in place of the behavior but must cause clinically significant distress and interference in daily life to qualify as a disorder.

Because of the lack of large-scale, population-based epidemiological studies assessing CSB, its true prevalence among adults is unknown. A study of 204 psychiatric inpatients found a current prevalence of 4.4%,¹ while a university-based survey estimated the prevalence of CSB at approximately 2%.² Others have estimated that the prevalence is between 3% to 6% of adults in the United States,^3,4 with males comprising the majority (≥80%) of affected individuals.⁵

CSB usually develops during late adolescence/early adulthood, and most who present for treatment are male.⁵ Mood states, including depression, happiness, and loneliness, may trigger CSB.⁶ Many individuals report feelings of dissociation while engaging in CSB-related behaviors, whereas others report feeling important, powerful, excited, or gratified.

Why CSB is difficult to diagnose

Although CSB may be common, it usually goes undiagnosed. This potentially problematic behavior often is not diagnosed because of:

• Shame and secrecy. Embarrassment and shame, which are fundamental to CSB, appear to explain, in part, why few patients volunteer information regarding this behavior unless specifically asked.¹
• Patient lack of knowledge. Patients often do not know that their behavior can be successfully treated.
• Clinician lack of knowledge. Few health care professionals have education or training in CSB. A lack of recognition of CSB also may be due to our limited understanding regarding the limits of sexual normality. In addition, the classification of CSB is unclear and not agreed upon (Box^7-9), and moral judgments often are involved in understanding sexual behaviors.¹⁰

Box
Classifying compulsive sexual behavior

No consensus on diagnostic criteria

Accurately diagnosing CSB is difficult because of a lack of consensus about the diagnostic criteria for the disorder. Christenson et al¹¹ developed an early set of criteria for CSB as part of a larger survey of impulse control disorders. They used the following 2 criteria to diagnose CSB: (1) excessive or uncontrolled sexual behavior(s) or sexual thoughts/urges to engage in behavior, and (2) these behaviors or thoughts/urges lead to significant distress, social or occupational impairment, or legal and financial consequences.^11,12

During the DSM-5 revision process, a second approach to the diagnostic criteria was proposed for hypersexuality disorder. Under the proposed criteria for hypersexuality, a person would meet the diagnosis if ≥3 of the following were endorsed over a 6-month period: (a) time consumed by sexual fantasies, urges, or behaviors repetitively interferes with other important (non-sexual) goals, activities, and obligations; (b) repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states; (c) repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events; (d) repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors; and (e) repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.⁹

These 2 proposed approaches to diagnosis are somewhat similar. Both suggest that the core underlying issues involve sexual urges or behaviors that are difficult to control and that lead to psychosocial dysfunction. Differences in the criteria, however, could result in different rates of CSB diagnosis; therefore, further research will need to determine which diagnostic approach reflects the neurobiology underlying CSB.

Avoid misdiagnosis

Before making a diagnosis of CSB, it is important for clinicians to consider whether they are stigmatizing “negative consequences,” distress, or social impairment based on unconscious bias toward certain sexual behaviors. In addition, we need to ensure that we are not holding sex to different standards than other behaviors (for example, there are many things in life we do that result in negative consequences and yet do not classify as a mental disorder, such as indulging in less healthy food choices). Furthermore, excessive sexual behaviors might be associated with the normal coming out process for LGBTQ individuals, partner relationship problems, or sexual/gender identity. Therefore, the behavior needs to be assessed in the context of these psychosocial environmental factors.

Differential diagnosis

Various psychiatric disorders also may include excessive sexual behavior as part of their clinical presentation, and it is important to differentiate that behavior from CSB.

Bipolar disorder. Excessive sexual behavior can occur as part of a manic episode in bipolar disorder. If the problematic sexual behavior also occurs when the person’s mood is stable, the individual may have CSB and bipolar disorder. This distinction is important because the treatment for bipolar disorder is often different for CSB, because anticonvulsants have only case reports attesting to their use in CSB.

Substance abuse. Excessive sexual behavior can occur when a person is abusing substances, particularly stimulants such as cocaine and amphetamines.¹³ If the sexual behavior does not occur when the person is not using drugs, then the appropriate diagnosis would not likely be CSB.

Obsessive-compulsive disorder (OCD). Individuals with OCD often are preoccupied with sexual themes and feel that they think about sex excessively.¹⁴ Although patients with OCD may be preoccupied with thoughts of sex, the key difference is that persons with CSB report feeling excited by these thoughts and derive pleasure from the behavior, whereas the sexual thoughts of OCD are perceived as unpleasant.

Other disorders that may give rise to hypersexual behavior include neurocognitive disorders, attention-deficit/hyperactivity disorder, autism spectrum disorders, and depressive disorders.

Adverse effects of medication. It is important to ask the patient whether he (she)developed CSB after starting a medication. Certain medications (eg, medications for Parkinson’s disease or restless leg syndrome, or aripiprazole to treat depression or psychosis) may cause patients to engage in problematic sexual behavior.^15,16 If the sexual behavior decreases or stops when the medication dosage is reduced or the medication is stopped, a diagnosis of CSB would not be appropriate.

Comorbidity is common

Research suggests that approximately one-half of adults with CSB meet criteria for at least 1 other psychiatric disorder, such as mood, anxiety, substance use, impulse control, or personality disorders. A study of men with CSB (N = 103) found that 71% met criteria for a mood disorder, 40% for an anxiety disorder, 41% for a substance use disorder, and 24% for an impulse control disorder such as gambling disorder.¹⁷ Therefore, to successfully treat CSB, clinicians also may need to focus on how and to what extent these co-occurring disorders drive the sexual behavior.

Co-occurring medical conditions also are common among individuals with CSB. Medical concerns may include unwanted pregnancy, sexually transmitted infections, and HIV/AIDS. Thus, treating psychiatric comorbidities and providing education about sexual health, with referrals to primary care specialists, often are part of CSB treatment.

Neuroimaging and cognition

One imaging study that compared participants with and without CSB found that participants with CSB had higher activity in the ventral striatum, anterior cingulate cortex, and amygdala relative to controls during a cue-reactivity functional MRI task.¹⁸ These findings show notable similarities to the patterns of activation seen in patients addicted to drugs when assessed using drug-craving paradigms. An additional neuroimaging study assessing patients with hypersexuality using diffusion tensor imaging noted that diffusivity in a prefrontal white matter tract within a superior frontal region was greater in patients with CSB.¹⁸ This study also indicated that there was a negative correlation between observed diffusion in the noted location and overall severity score for CSB symptoms such as frequency of urges or behaviors.

In terms of cognition, a preliminary assessment of young adults with CSB compared with healthy controls did not find any differences between groups across several tasks, although the previously mentioned diffusion tensor imaging study reported elevated impulsivity in CSB.¹⁸

Approaches to treatment

Most people with CSB are reluctant to mention it to their health care providers, and most physicians are generally uncomfortable talking about sex with their patients, in part, because of a lack of training.¹⁹ Patients are more likely to bring up the topic when they are receiving treatment for anxiety, depression, or substance abuse. Therefore, clinicians must consider that sexual behavior might be associated with a coping mechanism, distressing outcome, or comorbid condition in these patients.

Pharmacologic treatment

Evidence for the pharmacologic treatment of CSB consists primarily of small, open-label studies, case series, or retrospective analyses, except for 1 double-blind, placebo-controlled study. Based on this evidence, there may be several pharma­cologic treatment options for patients with CSB; however, there are no FDA-approved medications for CSB.

Antidepressants. One of the most thoroughly documented categories of pharmacologic treatment for CSB is selective serotonin reuptake inhibitors (SSRIs). Several retrospective analyses and case series have reported on the general efficacy of SSRIs in reducing symptoms of CSB.^20-23 Citalopram, the only treatment for CSB that has been assessed using a double-blind, placebo-controlled methodology, was associated with significant decreases in CSB symptoms, including sexual desire/drive, frequency of masturbation, and pornography use.²⁴

In addition to SSRIs, several additional case reports have suggested that other classes of antidepressants, such as serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants, or stimulants may be beneficial when treating CSB.²⁵ Several case reports have indicated significant improvement of CSB symptoms using clomipramine.²² A retrospective study of nefazodone also has suggested that it may be an option for treating CSB. Patients reported notable reductions in the frequency of sexual obsessions/compulsions while taking nefazodone and reported no notable sexual adverse effects.²⁶ One branded version of nefazodone, Serzone, was associated with rare but severe liver problems and was withdrawn from the U.S. market in 2004.

Although some initial evidence regarding antidepressant use, particularly SSRIs, to treat CSB has suggested that these medications may be potentially beneficial, the findings are far from conclusive, with only 1 controlled trial and only single-subject case reports for many of the medications studied.

Naltrexone, an opioid antagonist, has received support from available cases, open-label studies, and retrospective analyses.^17,27 Although evidence for the use of naltrexone in CSB is limited to case reports and retrospective analyses, results have been positive. Naltrexone has shown notable decreases in CSB symptom severity when used as monotherapy and when used in combination with other treatments.

Anticonvulsants. Several case reports have suggested that certain anticonvulsants may be beneficial for treating CSB. Topiramate may be a particularly useful option.²⁸ Other anticonvulsants showing benefit for CSB in case reports include valproic acid, lamotrigine, and levetiracetam.¹⁸

Psychotherapy

Evidence supporting specific types of psychotherapy for CSB is limited and largely drawn from uncontrolled studies and case reports.

Cognitive-behavioral therapy (CBT) is one of the more common psychotherapeutic options used for CSB. Several uncontrolled studies and case reports have found that CBT is beneficial for CSB, although methodologies have varied.

Several cases found that combining CBT with motivational interviewing was associated with significant reductions in sexual behaviors, such as frequency of sexual partners and amount of time spent online during work hours.^29,30 Group CBT also has been shown to be effective for CSB.³¹

Acceptance and commitment therapy (ACT) has received some initial support, with 1 uncontrolled study and 1 controlled study.^32,33 The controlled study used 12 sessions of individual ACT compared with a wait-list condition.³² Improvements in CSB symptoms were maintained for 3 months. The overall reduction in problematic Internet pornography use was reported as 92% immediately after the study ended, and 86% after 3 months.

Marital/relationship therapy has been used successfully in several case series and case reports, although no studies have assessed its efficacy in treating CSB using a randomized protocol. In 1 case report, the researcher found that participation in marital sex therapy elicited notable improvements over the course of 1 year and 20 sessions.³⁴

Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment. Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it. CSB can involve fantasies and urges in addition to or in place of the behavior but must cause clinically significant distress and interference in daily life to qualify as a disorder.

Because of the lack of large-scale, population-based epidemiological studies assessing CSB, its true prevalence among adults is unknown. A study of 204 psychiatric inpatients found a current prevalence of 4.4%,¹ while a university-based survey estimated the prevalence of CSB at approximately 2%.² Others have estimated that the prevalence is between 3% to 6% of adults in the United States,^3,4 with males comprising the majority (≥80%) of affected individuals.⁵

CSB usually develops during late adolescence/early adulthood, and most who present for treatment are male.⁵ Mood states, including depression, happiness, and loneliness, may trigger CSB.⁶ Many individuals report feelings of dissociation while engaging in CSB-related behaviors, whereas others report feeling important, powerful, excited, or gratified.

Why CSB is difficult to diagnose

Although CSB may be common, it usually goes undiagnosed. This potentially problematic behavior often is not diagnosed because of:

• Shame and secrecy. Embarrassment and shame, which are fundamental to CSB, appear to explain, in part, why few patients volunteer information regarding this behavior unless specifically asked.¹
• Patient lack of knowledge. Patients often do not know that their behavior can be successfully treated.
• Clinician lack of knowledge. Few health care professionals have education or training in CSB. A lack of recognition of CSB also may be due to our limited understanding regarding the limits of sexual normality. In addition, the classification of CSB is unclear and not agreed upon (Box^7-9), and moral judgments often are involved in understanding sexual behaviors.¹⁰

Box
Classifying compulsive sexual behavior

No consensus on diagnostic criteria

Accurately diagnosing CSB is difficult because of a lack of consensus about the diagnostic criteria for the disorder. Christenson et al¹¹ developed an early set of criteria for CSB as part of a larger survey of impulse control disorders. They used the following 2 criteria to diagnose CSB: (1) excessive or uncontrolled sexual behavior(s) or sexual thoughts/urges to engage in behavior, and (2) these behaviors or thoughts/urges lead to significant distress, social or occupational impairment, or legal and financial consequences.^11,12

During the DSM-5 revision process, a second approach to the diagnostic criteria was proposed for hypersexuality disorder. Under the proposed criteria for hypersexuality, a person would meet the diagnosis if ≥3 of the following were endorsed over a 6-month period: (a) time consumed by sexual fantasies, urges, or behaviors repetitively interferes with other important (non-sexual) goals, activities, and obligations; (b) repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states; (c) repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events; (d) repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors; and (e) repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.⁹

These 2 proposed approaches to diagnosis are somewhat similar. Both suggest that the core underlying issues involve sexual urges or behaviors that are difficult to control and that lead to psychosocial dysfunction. Differences in the criteria, however, could result in different rates of CSB diagnosis; therefore, further research will need to determine which diagnostic approach reflects the neurobiology underlying CSB.

Avoid misdiagnosis

Before making a diagnosis of CSB, it is important for clinicians to consider whether they are stigmatizing “negative consequences,” distress, or social impairment based on unconscious bias toward certain sexual behaviors. In addition, we need to ensure that we are not holding sex to different standards than other behaviors (for example, there are many things in life we do that result in negative consequences and yet do not classify as a mental disorder, such as indulging in less healthy food choices). Furthermore, excessive sexual behaviors might be associated with the normal coming out process for LGBTQ individuals, partner relationship problems, or sexual/gender identity. Therefore, the behavior needs to be assessed in the context of these psychosocial environmental factors.

Differential diagnosis

Various psychiatric disorders also may include excessive sexual behavior as part of their clinical presentation, and it is important to differentiate that behavior from CSB.

Bipolar disorder. Excessive sexual behavior can occur as part of a manic episode in bipolar disorder. If the problematic sexual behavior also occurs when the person’s mood is stable, the individual may have CSB and bipolar disorder. This distinction is important because the treatment for bipolar disorder is often different for CSB, because anticonvulsants have only case reports attesting to their use in CSB.

Substance abuse. Excessive sexual behavior can occur when a person is abusing substances, particularly stimulants such as cocaine and amphetamines.¹³ If the sexual behavior does not occur when the person is not using drugs, then the appropriate diagnosis would not likely be CSB.

Obsessive-compulsive disorder (OCD). Individuals with OCD often are preoccupied with sexual themes and feel that they think about sex excessively.¹⁴ Although patients with OCD may be preoccupied with thoughts of sex, the key difference is that persons with CSB report feeling excited by these thoughts and derive pleasure from the behavior, whereas the sexual thoughts of OCD are perceived as unpleasant.

Other disorders that may give rise to hypersexual behavior include neurocognitive disorders, attention-deficit/hyperactivity disorder, autism spectrum disorders, and depressive disorders.

Adverse effects of medication. It is important to ask the patient whether he (she)developed CSB after starting a medication. Certain medications (eg, medications for Parkinson’s disease or restless leg syndrome, or aripiprazole to treat depression or psychosis) may cause patients to engage in problematic sexual behavior.^15,16 If the sexual behavior decreases or stops when the medication dosage is reduced or the medication is stopped, a diagnosis of CSB would not be appropriate.

Comorbidity is common

Research suggests that approximately one-half of adults with CSB meet criteria for at least 1 other psychiatric disorder, such as mood, anxiety, substance use, impulse control, or personality disorders. A study of men with CSB (N = 103) found that 71% met criteria for a mood disorder, 40% for an anxiety disorder, 41% for a substance use disorder, and 24% for an impulse control disorder such as gambling disorder.¹⁷ Therefore, to successfully treat CSB, clinicians also may need to focus on how and to what extent these co-occurring disorders drive the sexual behavior.

Co-occurring medical conditions also are common among individuals with CSB. Medical concerns may include unwanted pregnancy, sexually transmitted infections, and HIV/AIDS. Thus, treating psychiatric comorbidities and providing education about sexual health, with referrals to primary care specialists, often are part of CSB treatment.

Neuroimaging and cognition

One imaging study that compared participants with and without CSB found that participants with CSB had higher activity in the ventral striatum, anterior cingulate cortex, and amygdala relative to controls during a cue-reactivity functional MRI task.¹⁸ These findings show notable similarities to the patterns of activation seen in patients addicted to drugs when assessed using drug-craving paradigms. An additional neuroimaging study assessing patients with hypersexuality using diffusion tensor imaging noted that diffusivity in a prefrontal white matter tract within a superior frontal region was greater in patients with CSB.¹⁸ This study also indicated that there was a negative correlation between observed diffusion in the noted location and overall severity score for CSB symptoms such as frequency of urges or behaviors.

In terms of cognition, a preliminary assessment of young adults with CSB compared with healthy controls did not find any differences between groups across several tasks, although the previously mentioned diffusion tensor imaging study reported elevated impulsivity in CSB.¹⁸

Approaches to treatment

Most people with CSB are reluctant to mention it to their health care providers, and most physicians are generally uncomfortable talking about sex with their patients, in part, because of a lack of training.¹⁹ Patients are more likely to bring up the topic when they are receiving treatment for anxiety, depression, or substance abuse. Therefore, clinicians must consider that sexual behavior might be associated with a coping mechanism, distressing outcome, or comorbid condition in these patients.

Pharmacologic treatment

Evidence for the pharmacologic treatment of CSB consists primarily of small, open-label studies, case series, or retrospective analyses, except for 1 double-blind, placebo-controlled study. Based on this evidence, there may be several pharma­cologic treatment options for patients with CSB; however, there are no FDA-approved medications for CSB.

Antidepressants. One of the most thoroughly documented categories of pharmacologic treatment for CSB is selective serotonin reuptake inhibitors (SSRIs). Several retrospective analyses and case series have reported on the general efficacy of SSRIs in reducing symptoms of CSB.^20-23 Citalopram, the only treatment for CSB that has been assessed using a double-blind, placebo-controlled methodology, was associated with significant decreases in CSB symptoms, including sexual desire/drive, frequency of masturbation, and pornography use.²⁴

In addition to SSRIs, several additional case reports have suggested that other classes of antidepressants, such as serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants, or stimulants may be beneficial when treating CSB.²⁵ Several case reports have indicated significant improvement of CSB symptoms using clomipramine.²² A retrospective study of nefazodone also has suggested that it may be an option for treating CSB. Patients reported notable reductions in the frequency of sexual obsessions/compulsions while taking nefazodone and reported no notable sexual adverse effects.²⁶ One branded version of nefazodone, Serzone, was associated with rare but severe liver problems and was withdrawn from the U.S. market in 2004.

Although some initial evidence regarding antidepressant use, particularly SSRIs, to treat CSB has suggested that these medications may be potentially beneficial, the findings are far from conclusive, with only 1 controlled trial and only single-subject case reports for many of the medications studied.

Naltrexone, an opioid antagonist, has received support from available cases, open-label studies, and retrospective analyses.^17,27 Although evidence for the use of naltrexone in CSB is limited to case reports and retrospective analyses, results have been positive. Naltrexone has shown notable decreases in CSB symptom severity when used as monotherapy and when used in combination with other treatments.

Anticonvulsants. Several case reports have suggested that certain anticonvulsants may be beneficial for treating CSB. Topiramate may be a particularly useful option.²⁸ Other anticonvulsants showing benefit for CSB in case reports include valproic acid, lamotrigine, and levetiracetam.¹⁸

Psychotherapy

Evidence supporting specific types of psychotherapy for CSB is limited and largely drawn from uncontrolled studies and case reports.

Cognitive-behavioral therapy (CBT) is one of the more common psychotherapeutic options used for CSB. Several uncontrolled studies and case reports have found that CBT is beneficial for CSB, although methodologies have varied.

Several cases found that combining CBT with motivational interviewing was associated with significant reductions in sexual behaviors, such as frequency of sexual partners and amount of time spent online during work hours.^29,30 Group CBT also has been shown to be effective for CSB.³¹

Acceptance and commitment therapy (ACT) has received some initial support, with 1 uncontrolled study and 1 controlled study.^32,33 The controlled study used 12 sessions of individual ACT compared with a wait-list condition.³² Improvements in CSB symptoms were maintained for 3 months. The overall reduction in problematic Internet pornography use was reported as 92% immediately after the study ended, and 86% after 3 months.

Marital/relationship therapy has been used successfully in several case series and case reports, although no studies have assessed its efficacy in treating CSB using a randomized protocol. In 1 case report, the researcher found that participation in marital sex therapy elicited notable improvements over the course of 1 year and 20 sessions.³⁴

Chronic  disruptive and impulsive behaviors are significant concerns for psychiatric clinicians because of their persistence and potential legal ramifications. To date, few studies have assessed treatment options for pyromania, oppositional defiant disorder (ODD), intermittent explosive disorder (IED), kleptomania, and conduct disorder (CD).

This article reviews the literature on the treatment of these disorders, focusing primarily on randomized, controlled studies. Because of the lack of clinical studies for these disorders, however, case studies and open tri­als are mentioned for reference. Summaries of supported medication and psychological interventions are provided for each disorder.

Categorizing impulse-control disorders
The DSM-5 created a new chapter on disruptive, impulse control, and conduct disorders that brought together disorders previously classified as disorders usually first diagnosed in infancy, childhood, or adolescence (ODD, CD) and impulse-control disorders not elsewhere classified. These disorders are unified by the presence of difficult, disruptive, aggressive, or antisocial behavior. Disruptive, aggressive, or antisocial behavior usu­ally is a multifaceted behavior, often associated with physical or verbal injury to self, others, or objects or with violating the rights of others. These behaviors can appear in several forms and can be defensive, premedi­tated, or impulsive.

Despite a high prevalence in the general population¹ and in psychi­atric cohorts,² disruptive and impulse-control disorders have been rela­tively understudied. Controlled trials of treatments do not exist for many impulse-control disorders, and there are no FDA-approved medications for any of these disorders.
 

Oppositional defiant disorder
Irritability, anger, defiance, and temper are specific descriptors of ODD. ODD seems to be a developmental antecedent for some youth with CD, suggesting that these dis­orders could reflect different stages of a spectrum of disruptive behavior. Transient oppositional behavior is common among children and adolescents, but ODD occurs in 1% to 11% of youth.³ The disorder is more prevalent among boys before puberty and has an equal sex prevalence in young people after puberty.

Regrettably, most ODD research has included patients with comorbidities, most commonly attention-deficit/hyperactivity disorder (ADHD). Because of this limita­tion, the drugs and programs discussed below are drawn from meta-analyses and review articles.

Pharmacotherapy. No medications have been FDA-approved for ODD. Studies assess­ing ODD have employed a variety of meth­odologies, not all of which are double-blind. The meta-analyses and reviews cited in this section include both randomized and open trials, and should be interpreted as such.

Stimulants are commonly used to treat ODD because of a high comorbidity rate with ADHD, and these drugs have improved ODD symptoms in randomized trials.⁴ Methylphenidate and d-amphetamine have shown some efficacy in trials of ODD and CD.^5-7 These medications are most commonly used when ODD is complicated by ADHD symptoms.

Antipsychotics also have been used to treat ODD, with the largest body of research suggesting that risperidone has some effi­cacy. Risperidone usually is considered a second- or third-line option because it has been associated with adverse effects in chil­dren and adolescents and requires caution in younger populations, despite its potential efficacy.^4,8-10

Alpha-2 agonists—clonidine and guanfa­cine—have shown some efficacy in treating ODD but have not been studied extensively. Studies of clonidine, however, often have grouped ODD, CD, and ADHD, which lim­its our understanding of this medication for ODD alone.^4,5,11

Atomoxetine has been studied for ODD, but its efficacy is limited, with different meta-analyses finding distinct results regarding efficacy. One explanation for these dispa­rate findings is that improvements in oppo­sitional symptoms may be secondary to improvement in ADHD symptoms.^7,12-14

Psychological treatments. As noted for pharmacotherapy, this section provides gen­eral information on empirically studied ther­apies. A series of meta-analyses have been included for further review, but are not iso­lated to randomized, controlled studies.

Individual therapy has shown consistent improvements in ODD. Examples include behavior modification therapy and parent-child interaction therapy. These sessions emphasize skills to manage outbursts and erratic emotionality. Emotion regulation and behavior and social skills training have shown significant reductions in target mea­sures. Some of these programs incorporate both patient and parent components.^15-17

Family/teacher training programs such as “Helping the Noncompliant Child” and the “Triple P” have yielded significant improve­ments. These programs focus on ways to manage the child’s oppositional behavior at home and in the classroom, as well as strate­gies to limit positive reinforcement for prob­lem behaviors.^17-20

Group programs have shown some effi­cacy with ODD. These programs cover a wide number of needs and intents. Examples include the “Incredible Years” program and the Community Parent Education Program. Research has found that these programs show some efficacy as preemptive measures to reduce the rate of ODD among adolescents.

Conclusions. A number of treatment options for ODD have shown some efficacy. However, many of these options have only been studied in patients with comorbid ADHD, which limits current knowledge about ODD as a distinct disorder.

Intermittent explosive disorder
IED is defined by recurrent, significant out­bursts of aggression, often leading to assaul­tive acts against people or property, which are disproportionate to outside stressors and are not better explained by another psy­chiatric diagnosis. Research suggests IED is common, with 6.3% of a community sample meeting criteria for lifetime IED.²¹

IED symptoms tend to start in adolescence and appear to be chronic.^21,22 People with IED regard their behavior as distressing and prob­lematic.²² Outbursts generally are short-lived (usually <30 minutes) and frequent (multiple times a month²²). Legal and occupational dif­ficulties are common.²²

Pharmacotherapy. Data on drug treatment for IED comes for a small set of double-blind studies (Table). Although pharmacotherapies have been studied for treating aggression, impulsivity, and vio­lent behavior, only 5 controlled studies are specific to IED.

A double-blind, randomized, placebo-controlled trial of fluoxetine in 100 par­ticipants with IED found that fluoxetine produced a sustained reduction in aggression and irritability as early as the second week of treatment. Full or partial remission of impul­sive aggressive behaviors occurred in 46% of fluoxetine-treated subjects. These findings have been supported by studies assessing other samples of aggressive patients, but not specifically IED.^23,24 Another treatment study found that oxcarbazepine produced signifi­cant improvements in IED symptom severity, specifically on impulsive aggression.²⁵

In a randomized, double-blind, placebo-controlled study, 96 participants with Cluster B personality disorders, 116 with IED, and 34 with posttraumatic stress disorder were assigned to divalproex sodium or placebo for 12 weeks. Using an intent-to-treat analysis, divalproex had no significant influence on aggression in patients with IED.²⁶ Similarly, a study assessing levetiracetam for IED did not show any improvements to measures of impulsive aggression.²⁷

Psychological treatments. The only available study on psychological treatments for IED found that patients receiving active cognitive-behavioral therapy (CBT) or group therapy showed significant improvements compared with waitlist controls. These improvements spanned several target symptoms of IED.²⁸

Conclusions. Although there is a paucity of treatment studies for IED, fluoxetine may be an effective treatment based on available studies, and oxcarbazepine has shown some preliminary efficacy. CBT also has shown some initial efficacy in reducing symptom severity in IED.

Conduct disorder
The essential feature of CD is a repetitive and persistent pattern of behavior in which the basic rights of others or social norms are vio­lated.³ These behaviors can entail:
   • aggressive conduct that causes or threatens harm to others or to animals
   • nonaggressive behavior resulting in property damage
   • deceitfulness or theft
   • serious violation of rules.

Prevalence among the general population is 2% to 10%. The disorder is more common among boys than girls.³

Pharmacotherapy. No medication is FDA-approved to treat CD. Fifteen con­trolled studies have examined medica­tions in patients with CD (Table), although a number of these included a high rate of comorbid ADHD.

To date, 7 studies have shown efficacy with lithium for patients with CD.^29-35 A number of trials assessing lithium also included a treatment condition with halo­peridol, which showed significant improve­ment.^29,30,33,34 Both lithium and haloperidol were associated with select deficits on cog­nitive tests, suggesting that there may be risks associated with these medications.

Preliminary double-blind results have indicated that methylphenidate, risperi­done, quetiapine, molindone, thioridazine, and carbamazepine might be effective options for treating CD.^36-43 The evidence for these medications is limited and addi­tional studies are needed to replicate initial findings.

Three studies of divalproex sodium have shown some efficacy in randomized stud­ies comparing high and low dosages of the drug.^40-42 Because these studies did not include a placebo, additional studies are necessary to corroborate these findings.

Psychological treatments. Several forms of behavioral, family-based, and school-based therapies have been found effective in randomized trials. Specifically, behavioral therapy and parental skills training have shown consistent benefits for patients and their families. As with ODD, parental train­ing programs for CD focus on parents’ skill acquisition to help manage outbursts and aggressive behavior. These treatments often follow a similar course to those used for other externalizing and disruptive disorders.^44-46

Conclusions. Based on evidence, psychother­apy and some pharmacotherapies (eg, lith­ium) could be considered first-line treatment options for CD. Psychotherapy programs have shown efficacy in reducing aggression in high-risk groups.⁴⁴ Lithium or antipsychot­ics could be useful for patients who do not respond sufficiently to psychotherapy. The risk of cognitive deficits with lithium and antipsychotics should be weighed against potential benefits of these medications.^33,34

Kleptomania
Kleptomania is characterized by repetitive, poorly controlled stealing of items that are not needed for personal use. Kleptomania often begins in late adolescence or early adulthood.⁴⁷ The course of the illness gen­erally is chronic, with waxing and waning symptoms. Women are twice as likely as men to suffer from kleptomania.⁴⁸ People with kleptomania frequently hoard, discard, or return stolen items.⁴⁷

Most people with kleptomania try unsuc­cessfully to stop stealing, which often leads to feelings of shame and guilt.⁴⁸ Many (64% to 87%) have been arrested because of their stealing behavior⁴⁷; a smaller percentage (15% to 23%) have been incarcerated.⁴⁸ Suicide attempts are common among these patients.⁴⁹

Pharmacotherapy. There has been only 1 randomized, placebo-controlled study of pharmacotherapy for kleptomania (Table). An 8-week, double-blind, placebo-controlled trial was conducted to evaluate the safety and efficacy of oral naltrexone, 50 to 150 mg/d, in 25 patients with kleptomania. Those taking naltrexone had a significantly greater reduc­tion in total score than those taking placebo on the Yale-Brown Obsessive Compulsive Scale Modified for Kleptomania; in stealing urges; and in stealing behavior. The mean effective dosage of naltrexone was 116.7 (± 44.4) mg/d.⁵⁰

Naltrexone was well tolerated, with mini­mal nausea, and did not cause elevation of liver enzymes.

There is one available open-label study with a double-blind discontinuation phase assessing the efficacy of escitalopram for kleptomania. Continuation of escitalopram during the blinded discontinuation phase did produce lower relapse rates.⁵¹

Psychological treatments. There are no con­trolled studies of psychological treatments for kleptomania. Case reports suggest that cognitive and behavioral therapies might be effective:
   • A young man who underwent 7 ses­sions of covert sensitization, combined with exposure and response prevention, over a 4-month period was able to reduce his steal­ing frequency.⁵²
   • In another case, a young woman underwent 5 weekly sessions when she was instructed to practice covert sensitiza­tion whenever she had an urge to steal. She remained in remission for 14 months with only a single lapse in behavior and with no reported urges to steal.⁵³
   • In 2 patients, imaginal desensitization in fourteen 15-minutes sessions over 5 days resulted in complete remission of symptoms for a 2-year period.⁵⁴

Conclusions. The single controlled study of naltrexone for kleptomania suggests that naltrexone might be a beneficial treatment for this disorder. No controlled trials of psy­chosocial interventions have been reported. The current psychological research is based primarily on case reports.

This state of affairs likely is because of (1) the low prevalence of kleptomania and (2) clinical difficulties in treating patients involved in illegal activities. Nevertheless, there is a need for systematic studies of treat­ing this disorder; such studies could involve collaboration across multiple treatment cen­ters because of the disorder’s low prevalence.

Pyromania
Pyromania is characterized by (1) deliberate and purposeful fire setting on >1 occasion; (2) tension or affective arousal before the act; (3) fascination with, interest in, curiosity about, or attraction to fire and its situational con­texts; and (4) pleasure, gratification, or relief when setting fires or when witnessing or par­ticipating in their aftermath.³

Although pyromania is thought to be a disorder primarily affecting men, recent research suggests that the sex ratio is equal among adults and may be slightly higher among adolescent females. Mean age of onset usually is late adoles­cence. Pyromania appears to be chronic if untreated.⁵⁵

Urges to set fires are common and the fire setting is almost always pleasurable. Severe distress follows the fire setting, and persons with pyromania report significant functional impairment. High rates of co-occurring psy­chiatric disorders (depression, substance use disorders, other impulse-control dis­orders) are common among persons with pyromania.⁵⁵

Pharmacotherapy. There are no random­ized, controlled clinical trials examining pharmacotherapy for treating pyromania. There are no FDA-approved medications for pyromania.

In case reports, medications that have shown benefit in treating pyromania include topiramate, escitalopram, sertraline, fluox­etine, lithium, and a combination of olan­zapine and sodium valproate. An equal number of medications have shown no ben­efit: fluoxetine, valproic acid, lithium, sertra­line, olanzapine, escitalopram, citalopram, and clonazepam. A case report of an 18-year-old man with pyromania described success­fully using a combination of topiramate with 3 weeks of daily CBT to achieve significant symptom improvement.^56,57

Pyromania is a largely unrecognized dis­order that causes significant psychological, social, and legal repercussions. Because few persons with pyromania volunteer informa­tion regarding fire-setting, it is important that clinicians recognize the disorder and screen patients appropriately. Various treatments have been helpful in case studies, but more research on the etiology and treatment of the disorder is needed.^56,57

Conclusions based on the literature
In disruptive, impulse-control, and conduct disorders, the systematic study of treatment efficacy and tolerability is in its infancy. With few controlled studies published, it is not possible to make treatment recommendations with confidence. There are no FDA-approved drugs for treating any of these disorders.

Nonetheless, specific psychotherapies and drug therapies offer promising options, but often are based on small studies, often in patient populations with prominent comor­bidities, and have not been replicated by independent investigators. For all of these disorders, issues such as which psycho­therapy or medication to use and the ideal duration of treatment cannot be sufficiently addressed with the available data.

In conjunction with emerging epidemio­logical data supporting a relatively high prevalence of disruptive, impulse-control, and conduct disorders, the small amount of data regarding effective treatments highlights the clinical need for additional research.

Bottom Line
Empirically supported treatment options for impulse-control disorders currently are limited, because only select disorders have been studied across multiple trials. New research is needed to confirm possible treatment options and identify effective psychotherapeutic and pharmacological treatment alternatives.
 

Related Resources
• Grant JE. Impulse control disorders: a clinician’s guide to un­derstanding and treating behavioral addictions. New York, NY: W. W. Norton & Company; 2008.
• Grant JE, Kim SW. Stop me because I can’t stop myself: tak­ing control of impulsive behavior. New York, NY: McGraw- Hill; 2003.
• American Academy of Child and Adolescent Psychiatry. Conduct disorder resource center. http://www.aacap.org/AACAP/FamiliesandYouth/ResourceCenters/ConductDisorderResourceCenter/Home.aspx.

Drug Brand Names
Atomoxetine • Strattera                      Methylphenidate • Ritalin
Carbamazepine • Tegretol                  Molindone • Moban
Citalopram • Celexa                            Naltrexone • ReVia
Clonazepam • Klonopin                      Olanzapine • Zyprexa
Clonidine • Catapres                           Oxcarbazepine • Trileptal
D-amphetamine • Dexedrine               Quetiapine • Seroquel
Divalproex sodium • Depakote            Risperidone • Risperdal
Escitalopram • Lexapro                       Sertraline • Zoloft
Fluoxetine • Prozac                             Sodium valproate • Depacon
Guanfacine • Intuniv                           Thioridazine • Mellaril
Haloperidol • Haldol                             Topiramate • Topamax
Levetiracetam • Keppra                       Valproic acid • Depakote
Lithium • Eskalith, Lithobid  

Disclosures
Dr. Grant receives grant or research support from Brainsway, Forest Pharmaceuticals, and Roche Pharmaceuticals. Mr. Leppink reports no financial relationship with any company whose products are mentioned in this article or with competing products.

Chronic  disruptive and impulsive behaviors are significant concerns for psychiatric clinicians because of their persistence and potential legal ramifications. To date, few studies have assessed treatment options for pyromania, oppositional defiant disorder (ODD), intermittent explosive disorder (IED), kleptomania, and conduct disorder (CD).

This article reviews the literature on the treatment of these disorders, focusing primarily on randomized, controlled studies. Because of the lack of clinical studies for these disorders, however, case studies and open tri­als are mentioned for reference. Summaries of supported medication and psychological interventions are provided for each disorder.

Categorizing impulse-control disorders
The DSM-5 created a new chapter on disruptive, impulse control, and conduct disorders that brought together disorders previously classified as disorders usually first diagnosed in infancy, childhood, or adolescence (ODD, CD) and impulse-control disorders not elsewhere classified. These disorders are unified by the presence of difficult, disruptive, aggressive, or antisocial behavior. Disruptive, aggressive, or antisocial behavior usu­ally is a multifaceted behavior, often associated with physical or verbal injury to self, others, or objects or with violating the rights of others. These behaviors can appear in several forms and can be defensive, premedi­tated, or impulsive.

Despite a high prevalence in the general population¹ and in psychi­atric cohorts,² disruptive and impulse-control disorders have been rela­tively understudied. Controlled trials of treatments do not exist for many impulse-control disorders, and there are no FDA-approved medications for any of these disorders.
 

Oppositional defiant disorder
Irritability, anger, defiance, and temper are specific descriptors of ODD. ODD seems to be a developmental antecedent for some youth with CD, suggesting that these dis­orders could reflect different stages of a spectrum of disruptive behavior. Transient oppositional behavior is common among children and adolescents, but ODD occurs in 1% to 11% of youth.³ The disorder is more prevalent among boys before puberty and has an equal sex prevalence in young people after puberty.

Regrettably, most ODD research has included patients with comorbidities, most commonly attention-deficit/hyperactivity disorder (ADHD). Because of this limita­tion, the drugs and programs discussed below are drawn from meta-analyses and review articles.

Pharmacotherapy. No medications have been FDA-approved for ODD. Studies assess­ing ODD have employed a variety of meth­odologies, not all of which are double-blind. The meta-analyses and reviews cited in this section include both randomized and open trials, and should be interpreted as such.

Stimulants are commonly used to treat ODD because of a high comorbidity rate with ADHD, and these drugs have improved ODD symptoms in randomized trials.⁴ Methylphenidate and d-amphetamine have shown some efficacy in trials of ODD and CD.^5-7 These medications are most commonly used when ODD is complicated by ADHD symptoms.

Antipsychotics also have been used to treat ODD, with the largest body of research suggesting that risperidone has some effi­cacy. Risperidone usually is considered a second- or third-line option because it has been associated with adverse effects in chil­dren and adolescents and requires caution in younger populations, despite its potential efficacy.^4,8-10

Alpha-2 agonists—clonidine and guanfa­cine—have shown some efficacy in treating ODD but have not been studied extensively. Studies of clonidine, however, often have grouped ODD, CD, and ADHD, which lim­its our understanding of this medication for ODD alone.^4,5,11

Atomoxetine has been studied for ODD, but its efficacy is limited, with different meta-analyses finding distinct results regarding efficacy. One explanation for these dispa­rate findings is that improvements in oppo­sitional symptoms may be secondary to improvement in ADHD symptoms.^7,12-14

Psychological treatments. As noted for pharmacotherapy, this section provides gen­eral information on empirically studied ther­apies. A series of meta-analyses have been included for further review, but are not iso­lated to randomized, controlled studies.

Individual therapy has shown consistent improvements in ODD. Examples include behavior modification therapy and parent-child interaction therapy. These sessions emphasize skills to manage outbursts and erratic emotionality. Emotion regulation and behavior and social skills training have shown significant reductions in target mea­sures. Some of these programs incorporate both patient and parent components.^15-17

Family/teacher training programs such as “Helping the Noncompliant Child” and the “Triple P” have yielded significant improve­ments. These programs focus on ways to manage the child’s oppositional behavior at home and in the classroom, as well as strate­gies to limit positive reinforcement for prob­lem behaviors.^17-20

Group programs have shown some effi­cacy with ODD. These programs cover a wide number of needs and intents. Examples include the “Incredible Years” program and the Community Parent Education Program. Research has found that these programs show some efficacy as preemptive measures to reduce the rate of ODD among adolescents.

Conclusions. A number of treatment options for ODD have shown some efficacy. However, many of these options have only been studied in patients with comorbid ADHD, which limits current knowledge about ODD as a distinct disorder.

Intermittent explosive disorder
IED is defined by recurrent, significant out­bursts of aggression, often leading to assaul­tive acts against people or property, which are disproportionate to outside stressors and are not better explained by another psy­chiatric diagnosis. Research suggests IED is common, with 6.3% of a community sample meeting criteria for lifetime IED.²¹

IED symptoms tend to start in adolescence and appear to be chronic.^21,22 People with IED regard their behavior as distressing and prob­lematic.²² Outbursts generally are short-lived (usually <30 minutes) and frequent (multiple times a month²²). Legal and occupational dif­ficulties are common.²²

Pharmacotherapy. Data on drug treatment for IED comes for a small set of double-blind studies (Table). Although pharmacotherapies have been studied for treating aggression, impulsivity, and vio­lent behavior, only 5 controlled studies are specific to IED.

A double-blind, randomized, placebo-controlled trial of fluoxetine in 100 par­ticipants with IED found that fluoxetine produced a sustained reduction in aggression and irritability as early as the second week of treatment. Full or partial remission of impul­sive aggressive behaviors occurred in 46% of fluoxetine-treated subjects. These findings have been supported by studies assessing other samples of aggressive patients, but not specifically IED.^23,24 Another treatment study found that oxcarbazepine produced signifi­cant improvements in IED symptom severity, specifically on impulsive aggression.²⁵

In a randomized, double-blind, placebo-controlled study, 96 participants with Cluster B personality disorders, 116 with IED, and 34 with posttraumatic stress disorder were assigned to divalproex sodium or placebo for 12 weeks. Using an intent-to-treat analysis, divalproex had no significant influence on aggression in patients with IED.²⁶ Similarly, a study assessing levetiracetam for IED did not show any improvements to measures of impulsive aggression.²⁷

Psychological treatments. The only available study on psychological treatments for IED found that patients receiving active cognitive-behavioral therapy (CBT) or group therapy showed significant improvements compared with waitlist controls. These improvements spanned several target symptoms of IED.²⁸

Conclusions. Although there is a paucity of treatment studies for IED, fluoxetine may be an effective treatment based on available studies, and oxcarbazepine has shown some preliminary efficacy. CBT also has shown some initial efficacy in reducing symptom severity in IED.

Conduct disorder
The essential feature of CD is a repetitive and persistent pattern of behavior in which the basic rights of others or social norms are vio­lated.³ These behaviors can entail:
   • aggressive conduct that causes or threatens harm to others or to animals
   • nonaggressive behavior resulting in property damage
   • deceitfulness or theft
   • serious violation of rules.

Prevalence among the general population is 2% to 10%. The disorder is more common among boys than girls.³

Pharmacotherapy. No medication is FDA-approved to treat CD. Fifteen con­trolled studies have examined medica­tions in patients with CD (Table), although a number of these included a high rate of comorbid ADHD.

To date, 7 studies have shown efficacy with lithium for patients with CD.^29-35 A number of trials assessing lithium also included a treatment condition with halo­peridol, which showed significant improve­ment.^29,30,33,34 Both lithium and haloperidol were associated with select deficits on cog­nitive tests, suggesting that there may be risks associated with these medications.

Preliminary double-blind results have indicated that methylphenidate, risperi­done, quetiapine, molindone, thioridazine, and carbamazepine might be effective options for treating CD.^36-43 The evidence for these medications is limited and addi­tional studies are needed to replicate initial findings.

Three studies of divalproex sodium have shown some efficacy in randomized stud­ies comparing high and low dosages of the drug.^40-42 Because these studies did not include a placebo, additional studies are necessary to corroborate these findings.

Psychological treatments. Several forms of behavioral, family-based, and school-based therapies have been found effective in randomized trials. Specifically, behavioral therapy and parental skills training have shown consistent benefits for patients and their families. As with ODD, parental train­ing programs for CD focus on parents’ skill acquisition to help manage outbursts and aggressive behavior. These treatments often follow a similar course to those used for other externalizing and disruptive disorders.^44-46

Conclusions. Based on evidence, psychother­apy and some pharmacotherapies (eg, lith­ium) could be considered first-line treatment options for CD. Psychotherapy programs have shown efficacy in reducing aggression in high-risk groups.⁴⁴ Lithium or antipsychot­ics could be useful for patients who do not respond sufficiently to psychotherapy. The risk of cognitive deficits with lithium and antipsychotics should be weighed against potential benefits of these medications.^33,34

Kleptomania
Kleptomania is characterized by repetitive, poorly controlled stealing of items that are not needed for personal use. Kleptomania often begins in late adolescence or early adulthood.⁴⁷ The course of the illness gen­erally is chronic, with waxing and waning symptoms. Women are twice as likely as men to suffer from kleptomania.⁴⁸ People with kleptomania frequently hoard, discard, or return stolen items.⁴⁷

Most people with kleptomania try unsuc­cessfully to stop stealing, which often leads to feelings of shame and guilt.⁴⁸ Many (64% to 87%) have been arrested because of their stealing behavior⁴⁷; a smaller percentage (15% to 23%) have been incarcerated.⁴⁸ Suicide attempts are common among these patients.⁴⁹

Pharmacotherapy. There has been only 1 randomized, placebo-controlled study of pharmacotherapy for kleptomania (Table). An 8-week, double-blind, placebo-controlled trial was conducted to evaluate the safety and efficacy of oral naltrexone, 50 to 150 mg/d, in 25 patients with kleptomania. Those taking naltrexone had a significantly greater reduc­tion in total score than those taking placebo on the Yale-Brown Obsessive Compulsive Scale Modified for Kleptomania; in stealing urges; and in stealing behavior. The mean effective dosage of naltrexone was 116.7 (± 44.4) mg/d.⁵⁰

Naltrexone was well tolerated, with mini­mal nausea, and did not cause elevation of liver enzymes.

There is one available open-label study with a double-blind discontinuation phase assessing the efficacy of escitalopram for kleptomania. Continuation of escitalopram during the blinded discontinuation phase did produce lower relapse rates.⁵¹

Psychological treatments. There are no con­trolled studies of psychological treatments for kleptomania. Case reports suggest that cognitive and behavioral therapies might be effective:
   • A young man who underwent 7 ses­sions of covert sensitization, combined with exposure and response prevention, over a 4-month period was able to reduce his steal­ing frequency.⁵²
   • In another case, a young woman underwent 5 weekly sessions when she was instructed to practice covert sensitiza­tion whenever she had an urge to steal. She remained in remission for 14 months with only a single lapse in behavior and with no reported urges to steal.⁵³
   • In 2 patients, imaginal desensitization in fourteen 15-minutes sessions over 5 days resulted in complete remission of symptoms for a 2-year period.⁵⁴

Conclusions. The single controlled study of naltrexone for kleptomania suggests that naltrexone might be a beneficial treatment for this disorder. No controlled trials of psy­chosocial interventions have been reported. The current psychological research is based primarily on case reports.

This state of affairs likely is because of (1) the low prevalence of kleptomania and (2) clinical difficulties in treating patients involved in illegal activities. Nevertheless, there is a need for systematic studies of treat­ing this disorder; such studies could involve collaboration across multiple treatment cen­ters because of the disorder’s low prevalence.

Pyromania
Pyromania is characterized by (1) deliberate and purposeful fire setting on >1 occasion; (2) tension or affective arousal before the act; (3) fascination with, interest in, curiosity about, or attraction to fire and its situational con­texts; and (4) pleasure, gratification, or relief when setting fires or when witnessing or par­ticipating in their aftermath.³

Although pyromania is thought to be a disorder primarily affecting men, recent research suggests that the sex ratio is equal among adults and may be slightly higher among adolescent females. Mean age of onset usually is late adoles­cence. Pyromania appears to be chronic if untreated.⁵⁵

Urges to set fires are common and the fire setting is almost always pleasurable. Severe distress follows the fire setting, and persons with pyromania report significant functional impairment. High rates of co-occurring psy­chiatric disorders (depression, substance use disorders, other impulse-control dis­orders) are common among persons with pyromania.⁵⁵

Pharmacotherapy. There are no random­ized, controlled clinical trials examining pharmacotherapy for treating pyromania. There are no FDA-approved medications for pyromania.

In case reports, medications that have shown benefit in treating pyromania include topiramate, escitalopram, sertraline, fluox­etine, lithium, and a combination of olan­zapine and sodium valproate. An equal number of medications have shown no ben­efit: fluoxetine, valproic acid, lithium, sertra­line, olanzapine, escitalopram, citalopram, and clonazepam. A case report of an 18-year-old man with pyromania described success­fully using a combination of topiramate with 3 weeks of daily CBT to achieve significant symptom improvement.^56,57

Pyromania is a largely unrecognized dis­order that causes significant psychological, social, and legal repercussions. Because few persons with pyromania volunteer informa­tion regarding fire-setting, it is important that clinicians recognize the disorder and screen patients appropriately. Various treatments have been helpful in case studies, but more research on the etiology and treatment of the disorder is needed.^56,57

Conclusions based on the literature
In disruptive, impulse-control, and conduct disorders, the systematic study of treatment efficacy and tolerability is in its infancy. With few controlled studies published, it is not possible to make treatment recommendations with confidence. There are no FDA-approved drugs for treating any of these disorders.

Nonetheless, specific psychotherapies and drug therapies offer promising options, but often are based on small studies, often in patient populations with prominent comor­bidities, and have not been replicated by independent investigators. For all of these disorders, issues such as which psycho­therapy or medication to use and the ideal duration of treatment cannot be sufficiently addressed with the available data.

In conjunction with emerging epidemio­logical data supporting a relatively high prevalence of disruptive, impulse-control, and conduct disorders, the small amount of data regarding effective treatments highlights the clinical need for additional research.

Bottom Line
Empirically supported treatment options for impulse-control disorders currently are limited, because only select disorders have been studied across multiple trials. New research is needed to confirm possible treatment options and identify effective psychotherapeutic and pharmacological treatment alternatives.
 

Related Resources
• Grant JE. Impulse control disorders: a clinician’s guide to un­derstanding and treating behavioral addictions. New York, NY: W. W. Norton & Company; 2008.
• Grant JE, Kim SW. Stop me because I can’t stop myself: tak­ing control of impulsive behavior. New York, NY: McGraw- Hill; 2003.
• American Academy of Child and Adolescent Psychiatry. Conduct disorder resource center. http://www.aacap.org/AACAP/FamiliesandYouth/ResourceCenters/ConductDisorderResourceCenter/Home.aspx.

Drug Brand Names
Atomoxetine • Strattera                      Methylphenidate • Ritalin
Carbamazepine • Tegretol                  Molindone • Moban
Citalopram • Celexa                            Naltrexone • ReVia
Clonazepam • Klonopin                      Olanzapine • Zyprexa
Clonidine • Catapres                           Oxcarbazepine • Trileptal
D-amphetamine • Dexedrine               Quetiapine • Seroquel
Divalproex sodium • Depakote            Risperidone • Risperdal
Escitalopram • Lexapro                       Sertraline • Zoloft
Fluoxetine • Prozac                             Sodium valproate • Depacon
Guanfacine • Intuniv                           Thioridazine • Mellaril
Haloperidol • Haldol                             Topiramate • Topamax
Levetiracetam • Keppra                       Valproic acid • Depakote
Lithium • Eskalith, Lithobid  

Disclosures
Dr. Grant receives grant or research support from Brainsway, Forest Pharmaceuticals, and Roche Pharmaceuticals. Mr. Leppink reports no financial relationship with any company whose products are mentioned in this article or with competing products.

Chronic  disruptive and impulsive behaviors are significant concerns for psychiatric clinicians because of their persistence and potential legal ramifications. To date, few studies have assessed treatment options for pyromania, oppositional defiant disorder (ODD), intermittent explosive disorder (IED), kleptomania, and conduct disorder (CD).

This article reviews the literature on the treatment of these disorders, focusing primarily on randomized, controlled studies. Because of the lack of clinical studies for these disorders, however, case studies and open tri­als are mentioned for reference. Summaries of supported medication and psychological interventions are provided for each disorder.

Categorizing impulse-control disorders
The DSM-5 created a new chapter on disruptive, impulse control, and conduct disorders that brought together disorders previously classified as disorders usually first diagnosed in infancy, childhood, or adolescence (ODD, CD) and impulse-control disorders not elsewhere classified. These disorders are unified by the presence of difficult, disruptive, aggressive, or antisocial behavior. Disruptive, aggressive, or antisocial behavior usu­ally is a multifaceted behavior, often associated with physical or verbal injury to self, others, or objects or with violating the rights of others. These behaviors can appear in several forms and can be defensive, premedi­tated, or impulsive.

Despite a high prevalence in the general population¹ and in psychi­atric cohorts,² disruptive and impulse-control disorders have been rela­tively understudied. Controlled trials of treatments do not exist for many impulse-control disorders, and there are no FDA-approved medications for any of these disorders.
 

Oppositional defiant disorder
Irritability, anger, defiance, and temper are specific descriptors of ODD. ODD seems to be a developmental antecedent for some youth with CD, suggesting that these dis­orders could reflect different stages of a spectrum of disruptive behavior. Transient oppositional behavior is common among children and adolescents, but ODD occurs in 1% to 11% of youth.³ The disorder is more prevalent among boys before puberty and has an equal sex prevalence in young people after puberty.

Regrettably, most ODD research has included patients with comorbidities, most commonly attention-deficit/hyperactivity disorder (ADHD). Because of this limita­tion, the drugs and programs discussed below are drawn from meta-analyses and review articles.

Pharmacotherapy. No medications have been FDA-approved for ODD. Studies assess­ing ODD have employed a variety of meth­odologies, not all of which are double-blind. The meta-analyses and reviews cited in this section include both randomized and open trials, and should be interpreted as such.

Stimulants are commonly used to treat ODD because of a high comorbidity rate with ADHD, and these drugs have improved ODD symptoms in randomized trials.⁴ Methylphenidate and d-amphetamine have shown some efficacy in trials of ODD and CD.^5-7 These medications are most commonly used when ODD is complicated by ADHD symptoms.

Antipsychotics also have been used to treat ODD, with the largest body of research suggesting that risperidone has some effi­cacy. Risperidone usually is considered a second- or third-line option because it has been associated with adverse effects in chil­dren and adolescents and requires caution in younger populations, despite its potential efficacy.^4,8-10

Alpha-2 agonists—clonidine and guanfa­cine—have shown some efficacy in treating ODD but have not been studied extensively. Studies of clonidine, however, often have grouped ODD, CD, and ADHD, which lim­its our understanding of this medication for ODD alone.^4,5,11

Atomoxetine has been studied for ODD, but its efficacy is limited, with different meta-analyses finding distinct results regarding efficacy. One explanation for these dispa­rate findings is that improvements in oppo­sitional symptoms may be secondary to improvement in ADHD symptoms.^7,12-14

Psychological treatments. As noted for pharmacotherapy, this section provides gen­eral information on empirically studied ther­apies. A series of meta-analyses have been included for further review, but are not iso­lated to randomized, controlled studies.

Individual therapy has shown consistent improvements in ODD. Examples include behavior modification therapy and parent-child interaction therapy. These sessions emphasize skills to manage outbursts and erratic emotionality. Emotion regulation and behavior and social skills training have shown significant reductions in target mea­sures. Some of these programs incorporate both patient and parent components.^15-17

Family/teacher training programs such as “Helping the Noncompliant Child” and the “Triple P” have yielded significant improve­ments. These programs focus on ways to manage the child’s oppositional behavior at home and in the classroom, as well as strate­gies to limit positive reinforcement for prob­lem behaviors.^17-20

Group programs have shown some effi­cacy with ODD. These programs cover a wide number of needs and intents. Examples include the “Incredible Years” program and the Community Parent Education Program. Research has found that these programs show some efficacy as preemptive measures to reduce the rate of ODD among adolescents.

Conclusions. A number of treatment options for ODD have shown some efficacy. However, many of these options have only been studied in patients with comorbid ADHD, which limits current knowledge about ODD as a distinct disorder.

Intermittent explosive disorder
IED is defined by recurrent, significant out­bursts of aggression, often leading to assaul­tive acts against people or property, which are disproportionate to outside stressors and are not better explained by another psy­chiatric diagnosis. Research suggests IED is common, with 6.3% of a community sample meeting criteria for lifetime IED.²¹

IED symptoms tend to start in adolescence and appear to be chronic.^21,22 People with IED regard their behavior as distressing and prob­lematic.²² Outbursts generally are short-lived (usually <30 minutes) and frequent (multiple times a month²²). Legal and occupational dif­ficulties are common.²²

Pharmacotherapy. Data on drug treatment for IED comes for a small set of double-blind studies (Table). Although pharmacotherapies have been studied for treating aggression, impulsivity, and vio­lent behavior, only 5 controlled studies are specific to IED.

A double-blind, randomized, placebo-controlled trial of fluoxetine in 100 par­ticipants with IED found that fluoxetine produced a sustained reduction in aggression and irritability as early as the second week of treatment. Full or partial remission of impul­sive aggressive behaviors occurred in 46% of fluoxetine-treated subjects. These findings have been supported by studies assessing other samples of aggressive patients, but not specifically IED.^23,24 Another treatment study found that oxcarbazepine produced signifi­cant improvements in IED symptom severity, specifically on impulsive aggression.²⁵

In a randomized, double-blind, placebo-controlled study, 96 participants with Cluster B personality disorders, 116 with IED, and 34 with posttraumatic stress disorder were assigned to divalproex sodium or placebo for 12 weeks. Using an intent-to-treat analysis, divalproex had no significant influence on aggression in patients with IED.²⁶ Similarly, a study assessing levetiracetam for IED did not show any improvements to measures of impulsive aggression.²⁷

Psychological treatments. The only available study on psychological treatments for IED found that patients receiving active cognitive-behavioral therapy (CBT) or group therapy showed significant improvements compared with waitlist controls. These improvements spanned several target symptoms of IED.²⁸

Conclusions. Although there is a paucity of treatment studies for IED, fluoxetine may be an effective treatment based on available studies, and oxcarbazepine has shown some preliminary efficacy. CBT also has shown some initial efficacy in reducing symptom severity in IED.

Conduct disorder
The essential feature of CD is a repetitive and persistent pattern of behavior in which the basic rights of others or social norms are vio­lated.³ These behaviors can entail:
   • aggressive conduct that causes or threatens harm to others or to animals
   • nonaggressive behavior resulting in property damage
   • deceitfulness or theft
   • serious violation of rules.

Prevalence among the general population is 2% to 10%. The disorder is more common among boys than girls.³

Pharmacotherapy. No medication is FDA-approved to treat CD. Fifteen con­trolled studies have examined medica­tions in patients with CD (Table), although a number of these included a high rate of comorbid ADHD.

To date, 7 studies have shown efficacy with lithium for patients with CD.^29-35 A number of trials assessing lithium also included a treatment condition with halo­peridol, which showed significant improve­ment.^29,30,33,34 Both lithium and haloperidol were associated with select deficits on cog­nitive tests, suggesting that there may be risks associated with these medications.

Preliminary double-blind results have indicated that methylphenidate, risperi­done, quetiapine, molindone, thioridazine, and carbamazepine might be effective options for treating CD.^36-43 The evidence for these medications is limited and addi­tional studies are needed to replicate initial findings.

Three studies of divalproex sodium have shown some efficacy in randomized stud­ies comparing high and low dosages of the drug.^40-42 Because these studies did not include a placebo, additional studies are necessary to corroborate these findings.

Psychological treatments. Several forms of behavioral, family-based, and school-based therapies have been found effective in randomized trials. Specifically, behavioral therapy and parental skills training have shown consistent benefits for patients and their families. As with ODD, parental train­ing programs for CD focus on parents’ skill acquisition to help manage outbursts and aggressive behavior. These treatments often follow a similar course to those used for other externalizing and disruptive disorders.^44-46

Conclusions. Based on evidence, psychother­apy and some pharmacotherapies (eg, lith­ium) could be considered first-line treatment options for CD. Psychotherapy programs have shown efficacy in reducing aggression in high-risk groups.⁴⁴ Lithium or antipsychot­ics could be useful for patients who do not respond sufficiently to psychotherapy. The risk of cognitive deficits with lithium and antipsychotics should be weighed against potential benefits of these medications.^33,34

Kleptomania
Kleptomania is characterized by repetitive, poorly controlled stealing of items that are not needed for personal use. Kleptomania often begins in late adolescence or early adulthood.⁴⁷ The course of the illness gen­erally is chronic, with waxing and waning symptoms. Women are twice as likely as men to suffer from kleptomania.⁴⁸ People with kleptomania frequently hoard, discard, or return stolen items.⁴⁷

Most people with kleptomania try unsuc­cessfully to stop stealing, which often leads to feelings of shame and guilt.⁴⁸ Many (64% to 87%) have been arrested because of their stealing behavior⁴⁷; a smaller percentage (15% to 23%) have been incarcerated.⁴⁸ Suicide attempts are common among these patients.⁴⁹

Pharmacotherapy. There has been only 1 randomized, placebo-controlled study of pharmacotherapy for kleptomania (Table). An 8-week, double-blind, placebo-controlled trial was conducted to evaluate the safety and efficacy of oral naltrexone, 50 to 150 mg/d, in 25 patients with kleptomania. Those taking naltrexone had a significantly greater reduc­tion in total score than those taking placebo on the Yale-Brown Obsessive Compulsive Scale Modified for Kleptomania; in stealing urges; and in stealing behavior. The mean effective dosage of naltrexone was 116.7 (± 44.4) mg/d.⁵⁰

Naltrexone was well tolerated, with mini­mal nausea, and did not cause elevation of liver enzymes.

There is one available open-label study with a double-blind discontinuation phase assessing the efficacy of escitalopram for kleptomania. Continuation of escitalopram during the blinded discontinuation phase did produce lower relapse rates.⁵¹

Psychological treatments. There are no con­trolled studies of psychological treatments for kleptomania. Case reports suggest that cognitive and behavioral therapies might be effective:
   • A young man who underwent 7 ses­sions of covert sensitization, combined with exposure and response prevention, over a 4-month period was able to reduce his steal­ing frequency.⁵²
   • In another case, a young woman underwent 5 weekly sessions when she was instructed to practice covert sensitiza­tion whenever she had an urge to steal. She remained in remission for 14 months with only a single lapse in behavior and with no reported urges to steal.⁵³
   • In 2 patients, imaginal desensitization in fourteen 15-minutes sessions over 5 days resulted in complete remission of symptoms for a 2-year period.⁵⁴

Conclusions. The single controlled study of naltrexone for kleptomania suggests that naltrexone might be a beneficial treatment for this disorder. No controlled trials of psy­chosocial interventions have been reported. The current psychological research is based primarily on case reports.

This state of affairs likely is because of (1) the low prevalence of kleptomania and (2) clinical difficulties in treating patients involved in illegal activities. Nevertheless, there is a need for systematic studies of treat­ing this disorder; such studies could involve collaboration across multiple treatment cen­ters because of the disorder’s low prevalence.

Pyromania
Pyromania is characterized by (1) deliberate and purposeful fire setting on >1 occasion; (2) tension or affective arousal before the act; (3) fascination with, interest in, curiosity about, or attraction to fire and its situational con­texts; and (4) pleasure, gratification, or relief when setting fires or when witnessing or par­ticipating in their aftermath.³

Although pyromania is thought to be a disorder primarily affecting men, recent research suggests that the sex ratio is equal among adults and may be slightly higher among adolescent females. Mean age of onset usually is late adoles­cence. Pyromania appears to be chronic if untreated.⁵⁵

Urges to set fires are common and the fire setting is almost always pleasurable. Severe distress follows the fire setting, and persons with pyromania report significant functional impairment. High rates of co-occurring psy­chiatric disorders (depression, substance use disorders, other impulse-control dis­orders) are common among persons with pyromania.⁵⁵

Pharmacotherapy. There are no random­ized, controlled clinical trials examining pharmacotherapy for treating pyromania. There are no FDA-approved medications for pyromania.

In case reports, medications that have shown benefit in treating pyromania include topiramate, escitalopram, sertraline, fluox­etine, lithium, and a combination of olan­zapine and sodium valproate. An equal number of medications have shown no ben­efit: fluoxetine, valproic acid, lithium, sertra­line, olanzapine, escitalopram, citalopram, and clonazepam. A case report of an 18-year-old man with pyromania described success­fully using a combination of topiramate with 3 weeks of daily CBT to achieve significant symptom improvement.^56,57

Pyromania is a largely unrecognized dis­order that causes significant psychological, social, and legal repercussions. Because few persons with pyromania volunteer informa­tion regarding fire-setting, it is important that clinicians recognize the disorder and screen patients appropriately. Various treatments have been helpful in case studies, but more research on the etiology and treatment of the disorder is needed.^56,57

Conclusions based on the literature
In disruptive, impulse-control, and conduct disorders, the systematic study of treatment efficacy and tolerability is in its infancy. With few controlled studies published, it is not possible to make treatment recommendations with confidence. There are no FDA-approved drugs for treating any of these disorders.

Nonetheless, specific psychotherapies and drug therapies offer promising options, but often are based on small studies, often in patient populations with prominent comor­bidities, and have not been replicated by independent investigators. For all of these disorders, issues such as which psycho­therapy or medication to use and the ideal duration of treatment cannot be sufficiently addressed with the available data.

In conjunction with emerging epidemio­logical data supporting a relatively high prevalence of disruptive, impulse-control, and conduct disorders, the small amount of data regarding effective treatments highlights the clinical need for additional research.

Bottom Line
Empirically supported treatment options for impulse-control disorders currently are limited, because only select disorders have been studied across multiple trials. New research is needed to confirm possible treatment options and identify effective psychotherapeutic and pharmacological treatment alternatives.
 

Related Resources
• Grant JE. Impulse control disorders: a clinician’s guide to un­derstanding and treating behavioral addictions. New York, NY: W. W. Norton & Company; 2008.
• Grant JE, Kim SW. Stop me because I can’t stop myself: tak­ing control of impulsive behavior. New York, NY: McGraw- Hill; 2003.
• American Academy of Child and Adolescent Psychiatry. Conduct disorder resource center. http://www.aacap.org/AACAP/FamiliesandYouth/ResourceCenters/ConductDisorderResourceCenter/Home.aspx.

Drug Brand Names
Atomoxetine • Strattera                      Methylphenidate • Ritalin
Carbamazepine • Tegretol                  Molindone • Moban
Citalopram • Celexa                            Naltrexone • ReVia
Clonazepam • Klonopin                      Olanzapine • Zyprexa
Clonidine • Catapres                           Oxcarbazepine • Trileptal
D-amphetamine • Dexedrine               Quetiapine • Seroquel
Divalproex sodium • Depakote            Risperidone • Risperdal
Escitalopram • Lexapro                       Sertraline • Zoloft
Fluoxetine • Prozac                             Sodium valproate • Depacon
Guanfacine • Intuniv                           Thioridazine • Mellaril
Haloperidol • Haldol                             Topiramate • Topamax
Levetiracetam • Keppra                       Valproic acid • Depakote
Lithium • Eskalith, Lithobid  

Disclosures
Dr. Grant receives grant or research support from Brainsway, Forest Pharmaceuticals, and Roche Pharmaceuticals. Mr. Leppink reports no financial relationship with any company whose products are mentioned in this article or with competing products.

Psychiatrist reveals patients’ information to another patient

Alameda County (CA) Superior Court

For several years 2 female patients were treated by the same psychiatrist. Jane Doe, age 56, read a breach of confidentiality report alleging sexual abuse filed by another patient of the psychiatrist. Jane Doe contacted the alleged victim, who informed her that the psychiatrist had disclosed information to her (the victim) regarding Jane Doe’s treatment, emotional problems, sexual preferences, and medication regimen.

Susan Doe, age 64, learned of the sexual abuse accusations against the psychiatrist in the same way and also contacted the alleged victim. She told Susan Doe that the psychiatrist had disclosed to her Susan Doe’s personal information regarding her dificult relationship with her daughter, depression, and instances when she stormed out of counseling sessions.

The patients brought separate claims, and their cases were later consolidated. The psychiatrist denied that he told the alleged sexual abuse victim details of the 2 patients’ treatments. The patients claimed that the victim could not have known their personal details unless the psychiatrist had told her.

• A jury returned a verdict in favor of the 2 patients. Jane Doe was awarded $225,000, and Susan Doe was awarded $47,000.

Dr. Grant’s observations

In the case of Jane Doe and Susan Doe, disclosing a patient’s personal information to another patient violates confidentiality. Patients must consent to the disclosure of information to third parties, and in this case these 2 patients apparently did not provide consent.

Medical practice—and particularly psychiatric practice—is based on the principle that communications between clinicians and patients are private. The Hippocratic oath states, “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”¹

According to the American Psychiatric Association’s (APA) code of ethics, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment, in part because of the special nature of psychiatric therapy. A psychiatrist may release confidential information only with the patient’s authorization or under proper legal compulsion.”²

Doctor-patient confidentiality is rooted in the belief that potential disclosure of information communicated during psychiatric diagnosis and treatment would discourage patients from seeking medical and mental health care (Table)

Table

Underlying values of confidentiality

When to disclose

There are circumstances, however, that override the requirement to maintain confidentiality and do not need a patient’s consent. Examples include:³

Duty to protect third parties. In 1976 the California Supreme Court ruled in the landmark Tarasoff case⁴ that a psychiatrist has a duty to do what is reasonably necessary to protect third parties if a patient presents a serious risk of violence to another person. The specific applications of this principle are governed by other states’ laws, which have extended or limited this duty.⁵ Be familiar with the law in your jurisdiction before disclosing confidential information to third parties who may be at risk of violence.

The APA’s position on this exception is consistent with legal standards. Its code of ethics states, “When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”⁶

Emergency release of information. Psychiatrists can release confidential information during a medical emergency. Releasing the information must be in the patient’s best interests, and the patient’s inability to consent to the release should be the result of a potentially reversible condition that leads the clinician to question the patient’s capacity to consent.³

For example, if a patient in an emergency room is delirious because of ingesting an unknown substance and is unable to consent, a physician can call family members to ask about the patient’s medical problems. Notifying family that the patient is in the hospital could violate confidentiality, however.

Reporting abuse. All clinicians are obligated to report suspected child abuse or neglect. Some state laws also may require physicians to disclose abuse of vulnerable groups such as the elderly or the disabled and report to the local department of health diagnosis of communicable diseases such as HIV.³

Circle of confidentiality. Certain parties— including clinical staff on an inpatient unit or a psychiatrist supervising a resident— are considered to be within a circle of confidentiality.³ You do not need a patient’s consent to share clinical information with those within the circle of confidentiality. Do not release a patient’s information to parties who are not in the circle of confidentiality—such as family members, attorneys representing the patient, and law enforcement personnel—unless you’ve first obtained the patient’s consent.

Document the reasoning behind your decision to disclose your patient’s personal information without the patient’s consent. Show that you engaged in a reasonable clinical decision-making process.³ For example, record the risks and benefits of your decision and how you arrived at your conclusion.³

Other scenarios

Multidisciplinary teams. Members of a multidisciplinary treatment team—such as physicians, nurses, or social workers—should only receive confidential information that is relevant to the patient’s care. Other clinicians who are not involved in the case—although they may be seeing other patients on the same unit—should not have access to the patient’s confidential information. Discussions with these team members must be private so that others do not overhear confidential information.

Insurance companies generally are not party to the patient’s records unless the patient agrees to allow access by signing a release. If the patient’s refusal to allow disclosure results in the insurance company’s refusal to pay, then the patient is responsible for resolving the issue.⁷

Scientific publications and presentations. When you present a case report for a scientific publication or at a meeting, alter the patient’s biographical data so that someone who knows the patient would be unable to identify him or her based on the information in the case report. If the information is so specific that you cannot prevent patient identification, either do not publish the case or offer the patient the right to veto the manuscript’s distribution. If necessary, have the patient sign a consent form to allow publication or presentation of the case report.

Confidentiality violations

Breach of confidentiality may be intentional, such as disclosing a patient’s personal information to a third party as in this case, or unintentional, such as talking about a patient to a colleague and having someone overhear your discussion.⁸ Violating confidentiality may result in litigation for malpractice (negligence), invasion of privacy, or breach of contract, and ethical sanctions.⁸

Psychiatrist reveals patients’ information to another patient

Alameda County (CA) Superior Court

For several years 2 female patients were treated by the same psychiatrist. Jane Doe, age 56, read a breach of confidentiality report alleging sexual abuse filed by another patient of the psychiatrist. Jane Doe contacted the alleged victim, who informed her that the psychiatrist had disclosed information to her (the victim) regarding Jane Doe’s treatment, emotional problems, sexual preferences, and medication regimen.

Susan Doe, age 64, learned of the sexual abuse accusations against the psychiatrist in the same way and also contacted the alleged victim. She told Susan Doe that the psychiatrist had disclosed to her Susan Doe’s personal information regarding her dificult relationship with her daughter, depression, and instances when she stormed out of counseling sessions.

The patients brought separate claims, and their cases were later consolidated. The psychiatrist denied that he told the alleged sexual abuse victim details of the 2 patients’ treatments. The patients claimed that the victim could not have known their personal details unless the psychiatrist had told her.

• A jury returned a verdict in favor of the 2 patients. Jane Doe was awarded $225,000, and Susan Doe was awarded $47,000.

Dr. Grant’s observations

In the case of Jane Doe and Susan Doe, disclosing a patient’s personal information to another patient violates confidentiality. Patients must consent to the disclosure of information to third parties, and in this case these 2 patients apparently did not provide consent.

Medical practice—and particularly psychiatric practice—is based on the principle that communications between clinicians and patients are private. The Hippocratic oath states, “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”¹

According to the American Psychiatric Association’s (APA) code of ethics, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment, in part because of the special nature of psychiatric therapy. A psychiatrist may release confidential information only with the patient’s authorization or under proper legal compulsion.”²

Doctor-patient confidentiality is rooted in the belief that potential disclosure of information communicated during psychiatric diagnosis and treatment would discourage patients from seeking medical and mental health care (Table)

Table

Underlying values of confidentiality

When to disclose

There are circumstances, however, that override the requirement to maintain confidentiality and do not need a patient’s consent. Examples include:³

Duty to protect third parties. In 1976 the California Supreme Court ruled in the landmark Tarasoff case⁴ that a psychiatrist has a duty to do what is reasonably necessary to protect third parties if a patient presents a serious risk of violence to another person. The specific applications of this principle are governed by other states’ laws, which have extended or limited this duty.⁵ Be familiar with the law in your jurisdiction before disclosing confidential information to third parties who may be at risk of violence.

The APA’s position on this exception is consistent with legal standards. Its code of ethics states, “When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”⁶

Emergency release of information. Psychiatrists can release confidential information during a medical emergency. Releasing the information must be in the patient’s best interests, and the patient’s inability to consent to the release should be the result of a potentially reversible condition that leads the clinician to question the patient’s capacity to consent.³

For example, if a patient in an emergency room is delirious because of ingesting an unknown substance and is unable to consent, a physician can call family members to ask about the patient’s medical problems. Notifying family that the patient is in the hospital could violate confidentiality, however.

Reporting abuse. All clinicians are obligated to report suspected child abuse or neglect. Some state laws also may require physicians to disclose abuse of vulnerable groups such as the elderly or the disabled and report to the local department of health diagnosis of communicable diseases such as HIV.³

Circle of confidentiality. Certain parties— including clinical staff on an inpatient unit or a psychiatrist supervising a resident— are considered to be within a circle of confidentiality.³ You do not need a patient’s consent to share clinical information with those within the circle of confidentiality. Do not release a patient’s information to parties who are not in the circle of confidentiality—such as family members, attorneys representing the patient, and law enforcement personnel—unless you’ve first obtained the patient’s consent.

Document the reasoning behind your decision to disclose your patient’s personal information without the patient’s consent. Show that you engaged in a reasonable clinical decision-making process.³ For example, record the risks and benefits of your decision and how you arrived at your conclusion.³

Other scenarios

Multidisciplinary teams. Members of a multidisciplinary treatment team—such as physicians, nurses, or social workers—should only receive confidential information that is relevant to the patient’s care. Other clinicians who are not involved in the case—although they may be seeing other patients on the same unit—should not have access to the patient’s confidential information. Discussions with these team members must be private so that others do not overhear confidential information.

Insurance companies generally are not party to the patient’s records unless the patient agrees to allow access by signing a release. If the patient’s refusal to allow disclosure results in the insurance company’s refusal to pay, then the patient is responsible for resolving the issue.⁷

Scientific publications and presentations. When you present a case report for a scientific publication or at a meeting, alter the patient’s biographical data so that someone who knows the patient would be unable to identify him or her based on the information in the case report. If the information is so specific that you cannot prevent patient identification, either do not publish the case or offer the patient the right to veto the manuscript’s distribution. If necessary, have the patient sign a consent form to allow publication or presentation of the case report.

Confidentiality violations

Breach of confidentiality may be intentional, such as disclosing a patient’s personal information to a third party as in this case, or unintentional, such as talking about a patient to a colleague and having someone overhear your discussion.⁸ Violating confidentiality may result in litigation for malpractice (negligence), invasion of privacy, or breach of contract, and ethical sanctions.⁸

Psychiatrist reveals patients’ information to another patient

Alameda County (CA) Superior Court

For several years 2 female patients were treated by the same psychiatrist. Jane Doe, age 56, read a breach of confidentiality report alleging sexual abuse filed by another patient of the psychiatrist. Jane Doe contacted the alleged victim, who informed her that the psychiatrist had disclosed information to her (the victim) regarding Jane Doe’s treatment, emotional problems, sexual preferences, and medication regimen.

Susan Doe, age 64, learned of the sexual abuse accusations against the psychiatrist in the same way and also contacted the alleged victim. She told Susan Doe that the psychiatrist had disclosed to her Susan Doe’s personal information regarding her dificult relationship with her daughter, depression, and instances when she stormed out of counseling sessions.

The patients brought separate claims, and their cases were later consolidated. The psychiatrist denied that he told the alleged sexual abuse victim details of the 2 patients’ treatments. The patients claimed that the victim could not have known their personal details unless the psychiatrist had told her.

• A jury returned a verdict in favor of the 2 patients. Jane Doe was awarded $225,000, and Susan Doe was awarded $47,000.

Dr. Grant’s observations

In the case of Jane Doe and Susan Doe, disclosing a patient’s personal information to another patient violates confidentiality. Patients must consent to the disclosure of information to third parties, and in this case these 2 patients apparently did not provide consent.

Medical practice—and particularly psychiatric practice—is based on the principle that communications between clinicians and patients are private. The Hippocratic oath states, “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”¹

According to the American Psychiatric Association’s (APA) code of ethics, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment, in part because of the special nature of psychiatric therapy. A psychiatrist may release confidential information only with the patient’s authorization or under proper legal compulsion.”²

Doctor-patient confidentiality is rooted in the belief that potential disclosure of information communicated during psychiatric diagnosis and treatment would discourage patients from seeking medical and mental health care (Table)

Table

Underlying values of confidentiality

When to disclose

There are circumstances, however, that override the requirement to maintain confidentiality and do not need a patient’s consent. Examples include:³

Duty to protect third parties. In 1976 the California Supreme Court ruled in the landmark Tarasoff case⁴ that a psychiatrist has a duty to do what is reasonably necessary to protect third parties if a patient presents a serious risk of violence to another person. The specific applications of this principle are governed by other states’ laws, which have extended or limited this duty.⁵ Be familiar with the law in your jurisdiction before disclosing confidential information to third parties who may be at risk of violence.

The APA’s position on this exception is consistent with legal standards. Its code of ethics states, “When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”⁶

Emergency release of information. Psychiatrists can release confidential information during a medical emergency. Releasing the information must be in the patient’s best interests, and the patient’s inability to consent to the release should be the result of a potentially reversible condition that leads the clinician to question the patient’s capacity to consent.³

For example, if a patient in an emergency room is delirious because of ingesting an unknown substance and is unable to consent, a physician can call family members to ask about the patient’s medical problems. Notifying family that the patient is in the hospital could violate confidentiality, however.

Reporting abuse. All clinicians are obligated to report suspected child abuse or neglect. Some state laws also may require physicians to disclose abuse of vulnerable groups such as the elderly or the disabled and report to the local department of health diagnosis of communicable diseases such as HIV.³

Circle of confidentiality. Certain parties— including clinical staff on an inpatient unit or a psychiatrist supervising a resident— are considered to be within a circle of confidentiality.³ You do not need a patient’s consent to share clinical information with those within the circle of confidentiality. Do not release a patient’s information to parties who are not in the circle of confidentiality—such as family members, attorneys representing the patient, and law enforcement personnel—unless you’ve first obtained the patient’s consent.

Document the reasoning behind your decision to disclose your patient’s personal information without the patient’s consent. Show that you engaged in a reasonable clinical decision-making process.³ For example, record the risks and benefits of your decision and how you arrived at your conclusion.³

Other scenarios

Multidisciplinary teams. Members of a multidisciplinary treatment team—such as physicians, nurses, or social workers—should only receive confidential information that is relevant to the patient’s care. Other clinicians who are not involved in the case—although they may be seeing other patients on the same unit—should not have access to the patient’s confidential information. Discussions with these team members must be private so that others do not overhear confidential information.

Insurance companies generally are not party to the patient’s records unless the patient agrees to allow access by signing a release. If the patient’s refusal to allow disclosure results in the insurance company’s refusal to pay, then the patient is responsible for resolving the issue.⁷

Scientific publications and presentations. When you present a case report for a scientific publication or at a meeting, alter the patient’s biographical data so that someone who knows the patient would be unable to identify him or her based on the information in the case report. If the information is so specific that you cannot prevent patient identification, either do not publish the case or offer the patient the right to veto the manuscript’s distribution. If necessary, have the patient sign a consent form to allow publication or presentation of the case report.

Confidentiality violations

Breach of confidentiality may be intentional, such as disclosing a patient’s personal information to a third party as in this case, or unintentional, such as talking about a patient to a colleague and having someone overhear your discussion.⁸ Violating confidentiality may result in litigation for malpractice (negligence), invasion of privacy, or breach of contract, and ethical sanctions.⁸

Woman claims improper contact during treatment

Fairfax County (VA) Circuit Court

A 23-year-old woman who received treatment from a psychiatrist for approximately 2½ years claimed that he sexually abused her during that time. She alleged that the inappropriate sexual relationship included holding, hugging, kissing, fondling, and watching pornography. The patient claimed that the relationship led to emotional distress and caused her to attempt suicide.

The psychiatrist admitted that a sexual relationship occurred but contended that the patient suffered no harm.

A $400,000 verdict was returned

Did inappropriate contact cause agoraphobia, anorexia?

Suffolk County (MA) Superior Court

A patient in her 20s had a history of emotional problems and sexual assaults against her. A psychiatrist treated her for obsessive-compulsive disorder for 4 years. He acknowledged giving the patient stuffed animals, cards, and letters and visiting her home several times when she was unable to go to his office. During sessions he touched her hand for comfort and hugged her. The patient claimed they had regular sexual contact.

The patient alleged that the psychiatrist was negligent for engaging in inappropriate sexual conduct, which she claims caused ongoing emotional distress. She claimed she was unable to work and suffered from agoraphobia, intimate relationships difficulties, and anorexia as a result of his actions. The psychiatrist denied any inappropriate sexual conduct.

The psychiatrist’s license was suspended indefinitely, but the suspension was stayed under an agreement that he attend medical education courses.

A $750,000 settlement was reached

Dr. Grant’s observations

Although most physicians would agree that sexual relations with a patient are inappropriate,¹ the fact that cases continue to occur suggests a need to emphasize treatment boundaries. Establishing clear boundaries in the doctor-patient relationship creates an atmosphere of safety and predictability that allows treatment to thrive.²

Boundary problems are one of the most frequent reasons for malpractice actions against mental health providers.³ Although much of the literature discusses boundary violations during psychotherapy, issues may arise in all treatment settings, including psychopharmacologic management.

One-half of all psychiatrists will treat at least 1 victim of physician sexual misconduct during their careers.⁴ One study⁵ examining sex-related offenses committed by U.S. physicians in all specialties found:

• The number of physicians disciplined for sex-related offenses increased each year from 1989 to 1996.
• 22% of disciplined physicians had sexual intercourse with patients, 15% had sexual contact or touching, 37% committed other sexual abuse that did not fit in either of these 2 categories, and 25% involved nonpatients.
• 28% of disciplined physicians were psychiatrists, the most represented specialty in the study.

Box

In a 1986 survey of psychiatrists, 7% of male and 3% of female clinicians reported having sexual contact with their patients.⁶ A 1988 survey of fourth-year psychiatry residents found that 1% of respondents acknowledged having sexual relations with a patient.⁷ In a 1992 study, 9% of physicians across specialties reported engaging in sexual contact with 1 or more current or former patients.⁸ In that study, 19% of female physicians and 40% of male physicians reported that they did not think physician-patient sexual misconduct was always harmful to patients.⁸ These views and behaviors are in violation of medical codes of ethics (Box).⁹

How misconduct harms patients

Trust is essential to establishing a secure therapeutic relationship. Boundary violations may result in missed diagnoses, inappropriate treatment, and/or worsened psychiatric symptoms. Patients might develop complex posttraumatic stress disorder, depression, anxiety, dissociation, sexual dysfunction, somatoform disorders, eating disorders, sleep disorders, or substance use disorders.⁴ They could lose faith in their treatment providers, have difficulties expressing anger, feel guilty, develop poor self-concept, experience a loss of confidence, and develop problems establishing trusting relationships.⁴ For these reasons, clinicians can be sued for negligent treatment and sexual misconduct.¹⁰

Boundary violations

Although sexual activities with patients are clear boundary violations, what about the second case when the therapist gave the patient stuffed animals and cards and hugged her? Progressive boundary violations often precede and accompany sexual misconduct.¹⁰

Five risk factors have been associated with therapist boundary violations:³

• life crises—effects of aging, career disappointments, unfulfilled hopes, or marital conflicts
• transitions—job changes or job loss
• medical illness
• arrogance—the belief that a boundary violation couldn’t happen to him or her and not recognizing the need for consultation
• common stress points with the patient

Although the list is not exhaustive, these factors may be associated with a psychiatrist turning to the patient for solace, gratification, or excitement.

Drawing boundary lines

Not all boundary issues are the same, and Gutheil et al² suggest 2 categories:

• Boundary crossings—a benign variant where the deviation may advance therapy in a constructive way that does not harm the patient, such as discussion of countertransference.
• Boundary violations—the transgression harms or exploits the patient.

Although some boundary issues may appear benign, even theoretically harmless boundary crossings can be misrepresented or misconstrued by the patient.¹¹ Also, boundary transgressions that do not involve erotic touch might harm the treatment process and the patient.²

When examining “minor” boundary issues that may seem innocuous, ask yourself if the action is for your benefit rather than to advance the patient’s therapy. Also, determine if the intervention is part of a series of progressive boundary violations. If the answer to either question is “yes,” desist immediately and take corrective action.¹⁰

The psychiatrist has a professional code of ethics to follow and can be held responsible for failing to set or adhere to boundaries.¹¹ If a patient initiates a boundary violation, you must refuse and then explore the patient’s underlying psychological issues, perhaps aided by consultation with a peer or mentor (Table). Repeated patient demands to breach boundaries requires prompt consultation to determine if you can continue treating the patient or if you should transfer the patient to another clinician. Document the patient’s demands to breach boundaries and your actions when seeking consultation.³

Table 1

How to maintain integrity of the treatment process

Woman claims improper contact during treatment

Fairfax County (VA) Circuit Court

A 23-year-old woman who received treatment from a psychiatrist for approximately 2½ years claimed that he sexually abused her during that time. She alleged that the inappropriate sexual relationship included holding, hugging, kissing, fondling, and watching pornography. The patient claimed that the relationship led to emotional distress and caused her to attempt suicide.

The psychiatrist admitted that a sexual relationship occurred but contended that the patient suffered no harm.

A $400,000 verdict was returned

Did inappropriate contact cause agoraphobia, anorexia?

Suffolk County (MA) Superior Court

A patient in her 20s had a history of emotional problems and sexual assaults against her. A psychiatrist treated her for obsessive-compulsive disorder for 4 years. He acknowledged giving the patient stuffed animals, cards, and letters and visiting her home several times when she was unable to go to his office. During sessions he touched her hand for comfort and hugged her. The patient claimed they had regular sexual contact.

The patient alleged that the psychiatrist was negligent for engaging in inappropriate sexual conduct, which she claims caused ongoing emotional distress. She claimed she was unable to work and suffered from agoraphobia, intimate relationships difficulties, and anorexia as a result of his actions. The psychiatrist denied any inappropriate sexual conduct.

The psychiatrist’s license was suspended indefinitely, but the suspension was stayed under an agreement that he attend medical education courses.

A $750,000 settlement was reached

Dr. Grant’s observations

Although most physicians would agree that sexual relations with a patient are inappropriate,¹ the fact that cases continue to occur suggests a need to emphasize treatment boundaries. Establishing clear boundaries in the doctor-patient relationship creates an atmosphere of safety and predictability that allows treatment to thrive.²

Boundary problems are one of the most frequent reasons for malpractice actions against mental health providers.³ Although much of the literature discusses boundary violations during psychotherapy, issues may arise in all treatment settings, including psychopharmacologic management.

One-half of all psychiatrists will treat at least 1 victim of physician sexual misconduct during their careers.⁴ One study⁵ examining sex-related offenses committed by U.S. physicians in all specialties found:

• The number of physicians disciplined for sex-related offenses increased each year from 1989 to 1996.
• 22% of disciplined physicians had sexual intercourse with patients, 15% had sexual contact or touching, 37% committed other sexual abuse that did not fit in either of these 2 categories, and 25% involved nonpatients.
• 28% of disciplined physicians were psychiatrists, the most represented specialty in the study.

Box

In a 1986 survey of psychiatrists, 7% of male and 3% of female clinicians reported having sexual contact with their patients.⁶ A 1988 survey of fourth-year psychiatry residents found that 1% of respondents acknowledged having sexual relations with a patient.⁷ In a 1992 study, 9% of physicians across specialties reported engaging in sexual contact with 1 or more current or former patients.⁸ In that study, 19% of female physicians and 40% of male physicians reported that they did not think physician-patient sexual misconduct was always harmful to patients.⁸ These views and behaviors are in violation of medical codes of ethics (Box).⁹

How misconduct harms patients

Trust is essential to establishing a secure therapeutic relationship. Boundary violations may result in missed diagnoses, inappropriate treatment, and/or worsened psychiatric symptoms. Patients might develop complex posttraumatic stress disorder, depression, anxiety, dissociation, sexual dysfunction, somatoform disorders, eating disorders, sleep disorders, or substance use disorders.⁴ They could lose faith in their treatment providers, have difficulties expressing anger, feel guilty, develop poor self-concept, experience a loss of confidence, and develop problems establishing trusting relationships.⁴ For these reasons, clinicians can be sued for negligent treatment and sexual misconduct.¹⁰

Boundary violations

Although sexual activities with patients are clear boundary violations, what about the second case when the therapist gave the patient stuffed animals and cards and hugged her? Progressive boundary violations often precede and accompany sexual misconduct.¹⁰

Five risk factors have been associated with therapist boundary violations:³

• life crises—effects of aging, career disappointments, unfulfilled hopes, or marital conflicts
• transitions—job changes or job loss
• medical illness
• arrogance—the belief that a boundary violation couldn’t happen to him or her and not recognizing the need for consultation
• common stress points with the patient

Although the list is not exhaustive, these factors may be associated with a psychiatrist turning to the patient for solace, gratification, or excitement.

Drawing boundary lines

Not all boundary issues are the same, and Gutheil et al² suggest 2 categories:

• Boundary crossings—a benign variant where the deviation may advance therapy in a constructive way that does not harm the patient, such as discussion of countertransference.
• Boundary violations—the transgression harms or exploits the patient.

Although some boundary issues may appear benign, even theoretically harmless boundary crossings can be misrepresented or misconstrued by the patient.¹¹ Also, boundary transgressions that do not involve erotic touch might harm the treatment process and the patient.²

When examining “minor” boundary issues that may seem innocuous, ask yourself if the action is for your benefit rather than to advance the patient’s therapy. Also, determine if the intervention is part of a series of progressive boundary violations. If the answer to either question is “yes,” desist immediately and take corrective action.¹⁰

The psychiatrist has a professional code of ethics to follow and can be held responsible for failing to set or adhere to boundaries.¹¹ If a patient initiates a boundary violation, you must refuse and then explore the patient’s underlying psychological issues, perhaps aided by consultation with a peer or mentor (Table). Repeated patient demands to breach boundaries requires prompt consultation to determine if you can continue treating the patient or if you should transfer the patient to another clinician. Document the patient’s demands to breach boundaries and your actions when seeking consultation.³

Table 1

How to maintain integrity of the treatment process

Woman claims improper contact during treatment

Fairfax County (VA) Circuit Court

A 23-year-old woman who received treatment from a psychiatrist for approximately 2½ years claimed that he sexually abused her during that time. She alleged that the inappropriate sexual relationship included holding, hugging, kissing, fondling, and watching pornography. The patient claimed that the relationship led to emotional distress and caused her to attempt suicide.

The psychiatrist admitted that a sexual relationship occurred but contended that the patient suffered no harm.

A $400,000 verdict was returned

Did inappropriate contact cause agoraphobia, anorexia?

Suffolk County (MA) Superior Court

A patient in her 20s had a history of emotional problems and sexual assaults against her. A psychiatrist treated her for obsessive-compulsive disorder for 4 years. He acknowledged giving the patient stuffed animals, cards, and letters and visiting her home several times when she was unable to go to his office. During sessions he touched her hand for comfort and hugged her. The patient claimed they had regular sexual contact.

The patient alleged that the psychiatrist was negligent for engaging in inappropriate sexual conduct, which she claims caused ongoing emotional distress. She claimed she was unable to work and suffered from agoraphobia, intimate relationships difficulties, and anorexia as a result of his actions. The psychiatrist denied any inappropriate sexual conduct.

The psychiatrist’s license was suspended indefinitely, but the suspension was stayed under an agreement that he attend medical education courses.

A $750,000 settlement was reached

Dr. Grant’s observations

Although most physicians would agree that sexual relations with a patient are inappropriate,¹ the fact that cases continue to occur suggests a need to emphasize treatment boundaries. Establishing clear boundaries in the doctor-patient relationship creates an atmosphere of safety and predictability that allows treatment to thrive.²

Boundary problems are one of the most frequent reasons for malpractice actions against mental health providers.³ Although much of the literature discusses boundary violations during psychotherapy, issues may arise in all treatment settings, including psychopharmacologic management.

One-half of all psychiatrists will treat at least 1 victim of physician sexual misconduct during their careers.⁴ One study⁵ examining sex-related offenses committed by U.S. physicians in all specialties found:

• The number of physicians disciplined for sex-related offenses increased each year from 1989 to 1996.
• 22% of disciplined physicians had sexual intercourse with patients, 15% had sexual contact or touching, 37% committed other sexual abuse that did not fit in either of these 2 categories, and 25% involved nonpatients.
• 28% of disciplined physicians were psychiatrists, the most represented specialty in the study.

Box

In a 1986 survey of psychiatrists, 7% of male and 3% of female clinicians reported having sexual contact with their patients.⁶ A 1988 survey of fourth-year psychiatry residents found that 1% of respondents acknowledged having sexual relations with a patient.⁷ In a 1992 study, 9% of physicians across specialties reported engaging in sexual contact with 1 or more current or former patients.⁸ In that study, 19% of female physicians and 40% of male physicians reported that they did not think physician-patient sexual misconduct was always harmful to patients.⁸ These views and behaviors are in violation of medical codes of ethics (Box).⁹

How misconduct harms patients

Trust is essential to establishing a secure therapeutic relationship. Boundary violations may result in missed diagnoses, inappropriate treatment, and/or worsened psychiatric symptoms. Patients might develop complex posttraumatic stress disorder, depression, anxiety, dissociation, sexual dysfunction, somatoform disorders, eating disorders, sleep disorders, or substance use disorders.⁴ They could lose faith in their treatment providers, have difficulties expressing anger, feel guilty, develop poor self-concept, experience a loss of confidence, and develop problems establishing trusting relationships.⁴ For these reasons, clinicians can be sued for negligent treatment and sexual misconduct.¹⁰

Boundary violations

Although sexual activities with patients are clear boundary violations, what about the second case when the therapist gave the patient stuffed animals and cards and hugged her? Progressive boundary violations often precede and accompany sexual misconduct.¹⁰

Five risk factors have been associated with therapist boundary violations:³

• life crises—effects of aging, career disappointments, unfulfilled hopes, or marital conflicts
• transitions—job changes or job loss
• medical illness
• arrogance—the belief that a boundary violation couldn’t happen to him or her and not recognizing the need for consultation
• common stress points with the patient

Although the list is not exhaustive, these factors may be associated with a psychiatrist turning to the patient for solace, gratification, or excitement.

Drawing boundary lines

Not all boundary issues are the same, and Gutheil et al² suggest 2 categories:

• Boundary crossings—a benign variant where the deviation may advance therapy in a constructive way that does not harm the patient, such as discussion of countertransference.
• Boundary violations—the transgression harms or exploits the patient.

Although some boundary issues may appear benign, even theoretically harmless boundary crossings can be misrepresented or misconstrued by the patient.¹¹ Also, boundary transgressions that do not involve erotic touch might harm the treatment process and the patient.²

When examining “minor” boundary issues that may seem innocuous, ask yourself if the action is for your benefit rather than to advance the patient’s therapy. Also, determine if the intervention is part of a series of progressive boundary violations. If the answer to either question is “yes,” desist immediately and take corrective action.¹⁰

The psychiatrist has a professional code of ethics to follow and can be held responsible for failing to set or adhere to boundaries.¹¹ If a patient initiates a boundary violation, you must refuse and then explore the patient’s underlying psychological issues, perhaps aided by consultation with a peer or mentor (Table). Repeated patient demands to breach boundaries requires prompt consultation to determine if you can continue treating the patient or if you should transfer the patient to another clinician. Document the patient’s demands to breach boundaries and your actions when seeking consultation.³

Table 1

How to maintain integrity of the treatment process

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Patient commits suicide after 15-minute checks are stopped

Honolulu County (HI) Circuit Court

A patient was brought to a hospital and interviewed by a psychiatrist. She was found to be at moderate risk for suicide, was admitted, and ordered to be monitored every 15 minutes. The patient attempted suicide 2 days later by closing a drawer on her neck. She died from the injuries the following day.

The patient’s family claimed that a hospital nurse misread the psychiatrist’s instructions and stopped the 15-minute checks on the morning of the incident, believing that the order was limited to 15-minute checks for the first 24 hours, even though they had been done for almost 2 days. The patient refused medication on the first day of admission, and the psychiatrist had started the procedure to obtain a court order committing the patient and allowing injection of necessary medication. The claims against the hospital were settled for a confidential amount.

The patient’s family claimed the psychiatrist diagnosed the patient with major depression with recurrent suicide ideation but failed to properly assess her for suicide monitoring. The family also said the patient should have been determined to be at least at high risk and required to be within sight of staff.

The psychiatrist claimed to be unaware the 15-minute monitoring had ceased. The psychiatrist saw the patient 30 minutes before she was found collapsed with her head in the drawer. The hospital staff checked the patient approximately 15 to 30 minutes before she was found.

• A defense verdict was returned
  

Reduced observation blamed for suicide by hanging

Kings County (NY) Supreme Court

A 45-year-old police lieutenant who suffered from alcohol abuse and depression was admitted to a psychiatric care facility. He was classiffied “Q15,” a category assigned to patients who must be visually inspected every 15 minutes, cannot have access to sharp objects or any other material or object they can use to inflict bodily harm, and must request permission to use restrooms. The next day the psychiatrist examined the patient and moved him to a “Q30” status, which halved the frequency of visual inspections, gave him unrestricted access to restrooms, and allowed him to have a bathrobe with a belt. The patient hanged himself the next day, using a restroom door to support a noose he made from the bathrobe belt.

The patient’s family faulted the hospital and psychiatrist for prematurely advancing the patient to “Q30” status. The hospital and psychiatrist claimed the suicide could not have been predicted and argued that given his background as a police lieutenant, the patient would have interpreted more stringent restrictions as incarceration. The psychiatrist argued that such a perception would have impeded the patient’s progress.

• A $71,989 verdict was returned, apportioning fault 65% to the hospital and 35% to the psychiatrist
  

Dr. Grant’s observations

Constant patient observation—such as one-to-one staffing or 15-minute checks—is used to protect patients from harming themselves or others. One study of a psychiatric hospital¹ reported that 13% of psychiatric inpatients required constant observation.

Even 15 minutes is sufficient time to complete a suicide.³ Common methods of inpatient suicide include hanging, overdosing, and jumping from high places.^4,5 One study found that 73% of inpatient suicides in a psychiatric ward occurred after 28 days of admission.⁵

The cost of constant observation may account for as much as 20% of the total nursing budget at a psychiatric hospital and up to 10% at a long-term care facility or general hospital.⁶ The annual cost of constant observation can exceed $500,000, depending on the hospital’s size and monitoring frequency.⁶

Determining responsibility

The outcomes of these 2 cases may appear inconsistent. In the first, the psychiatrist who assessed the patient as a moderate suicide risk was not negligent, even though the family claimed the patient was at high risk. In the second case, the psychiatrist was found partly liable for not maintaining a higher vigilance of suicide risk assessment.

Physicians cannot put every patient on one-to-one monitoring or 15-minute checks because of fear of suicide and malpractice litigation. These 2 cases demonstrate that if a suicide occurs, the courts will look for clinical reasons for the level of observation. The level of suicide precautions—one-to-one vs 15-minute checks—should be based on the patient’s clinical presentation and supported by clinical rationale.⁷

Risk analysis

The courts look to see if the suicide assessment was “clinically reasonable”.⁸ To meet this standard, perform a “suicide risk-benefit analysis” each time you make a significant clinical decision, such as ordering 15-minute checks. The record should include information sources you used (such as family members or previous medical records), factors that entered the clinical decision, and how you balanced these factors in a risk-benefit assessment (Box 1).⁹

Document decisions. Mistakes in clinical judgment do not necessarily constitute negligence,⁸ but deviations in the standard of care cannot be adequately determined in a court of law unless the clinician had documented his or her thought processes at the time of the decision.

Predicting which patients will re-experience or deny suicidal ideation is impossible,⁷ but if the patient is determined to be at high risk for suicide, then implement and document a plan to address this risk. In addition, communicate information regarding the risk-benefit assessment to staff responsible for implementing these precautions.

Box 1

• a patient is admitted for inpatient treatment
  
• observation status changes
  
• a patient’s clinical condition changes substantially
  
• acute psychosocial stressors are discovered during the hospitalization.⁷
  

Patient commits suicide after 15-minute checks are stopped

Honolulu County (HI) Circuit Court

A patient was brought to a hospital and interviewed by a psychiatrist. She was found to be at moderate risk for suicide, was admitted, and ordered to be monitored every 15 minutes. The patient attempted suicide 2 days later by closing a drawer on her neck. She died from the injuries the following day.

The patient’s family claimed that a hospital nurse misread the psychiatrist’s instructions and stopped the 15-minute checks on the morning of the incident, believing that the order was limited to 15-minute checks for the first 24 hours, even though they had been done for almost 2 days. The patient refused medication on the first day of admission, and the psychiatrist had started the procedure to obtain a court order committing the patient and allowing injection of necessary medication. The claims against the hospital were settled for a confidential amount.

The patient’s family claimed the psychiatrist diagnosed the patient with major depression with recurrent suicide ideation but failed to properly assess her for suicide monitoring. The family also said the patient should have been determined to be at least at high risk and required to be within sight of staff.

The psychiatrist claimed to be unaware the 15-minute monitoring had ceased. The psychiatrist saw the patient 30 minutes before she was found collapsed with her head in the drawer. The hospital staff checked the patient approximately 15 to 30 minutes before she was found.

• A defense verdict was returned
  

Reduced observation blamed for suicide by hanging

Kings County (NY) Supreme Court

A 45-year-old police lieutenant who suffered from alcohol abuse and depression was admitted to a psychiatric care facility. He was classiffied “Q15,” a category assigned to patients who must be visually inspected every 15 minutes, cannot have access to sharp objects or any other material or object they can use to inflict bodily harm, and must request permission to use restrooms. The next day the psychiatrist examined the patient and moved him to a “Q30” status, which halved the frequency of visual inspections, gave him unrestricted access to restrooms, and allowed him to have a bathrobe with a belt. The patient hanged himself the next day, using a restroom door to support a noose he made from the bathrobe belt.

The patient’s family faulted the hospital and psychiatrist for prematurely advancing the patient to “Q30” status. The hospital and psychiatrist claimed the suicide could not have been predicted and argued that given his background as a police lieutenant, the patient would have interpreted more stringent restrictions as incarceration. The psychiatrist argued that such a perception would have impeded the patient’s progress.

• A $71,989 verdict was returned, apportioning fault 65% to the hospital and 35% to the psychiatrist
  

Dr. Grant’s observations

Constant patient observation—such as one-to-one staffing or 15-minute checks—is used to protect patients from harming themselves or others. One study of a psychiatric hospital¹ reported that 13% of psychiatric inpatients required constant observation.

Even 15 minutes is sufficient time to complete a suicide.³ Common methods of inpatient suicide include hanging, overdosing, and jumping from high places.^4,5 One study found that 73% of inpatient suicides in a psychiatric ward occurred after 28 days of admission.⁵

The cost of constant observation may account for as much as 20% of the total nursing budget at a psychiatric hospital and up to 10% at a long-term care facility or general hospital.⁶ The annual cost of constant observation can exceed $500,000, depending on the hospital’s size and monitoring frequency.⁶

Determining responsibility

The outcomes of these 2 cases may appear inconsistent. In the first, the psychiatrist who assessed the patient as a moderate suicide risk was not negligent, even though the family claimed the patient was at high risk. In the second case, the psychiatrist was found partly liable for not maintaining a higher vigilance of suicide risk assessment.

Physicians cannot put every patient on one-to-one monitoring or 15-minute checks because of fear of suicide and malpractice litigation. These 2 cases demonstrate that if a suicide occurs, the courts will look for clinical reasons for the level of observation. The level of suicide precautions—one-to-one vs 15-minute checks—should be based on the patient’s clinical presentation and supported by clinical rationale.⁷

Risk analysis

The courts look to see if the suicide assessment was “clinically reasonable”.⁸ To meet this standard, perform a “suicide risk-benefit analysis” each time you make a significant clinical decision, such as ordering 15-minute checks. The record should include information sources you used (such as family members or previous medical records), factors that entered the clinical decision, and how you balanced these factors in a risk-benefit assessment (Box 1).⁹

Document decisions. Mistakes in clinical judgment do not necessarily constitute negligence,⁸ but deviations in the standard of care cannot be adequately determined in a court of law unless the clinician had documented his or her thought processes at the time of the decision.

Predicting which patients will re-experience or deny suicidal ideation is impossible,⁷ but if the patient is determined to be at high risk for suicide, then implement and document a plan to address this risk. In addition, communicate information regarding the risk-benefit assessment to staff responsible for implementing these precautions.

Box 1

• a patient is admitted for inpatient treatment
  
• observation status changes
  
• a patient’s clinical condition changes substantially
  
• acute psychosocial stressors are discovered during the hospitalization.⁷
  

Patient commits suicide after 15-minute checks are stopped

Honolulu County (HI) Circuit Court

A patient was brought to a hospital and interviewed by a psychiatrist. She was found to be at moderate risk for suicide, was admitted, and ordered to be monitored every 15 minutes. The patient attempted suicide 2 days later by closing a drawer on her neck. She died from the injuries the following day.

The patient’s family claimed that a hospital nurse misread the psychiatrist’s instructions and stopped the 15-minute checks on the morning of the incident, believing that the order was limited to 15-minute checks for the first 24 hours, even though they had been done for almost 2 days. The patient refused medication on the first day of admission, and the psychiatrist had started the procedure to obtain a court order committing the patient and allowing injection of necessary medication. The claims against the hospital were settled for a confidential amount.

The patient’s family claimed the psychiatrist diagnosed the patient with major depression with recurrent suicide ideation but failed to properly assess her for suicide monitoring. The family also said the patient should have been determined to be at least at high risk and required to be within sight of staff.

The psychiatrist claimed to be unaware the 15-minute monitoring had ceased. The psychiatrist saw the patient 30 minutes before she was found collapsed with her head in the drawer. The hospital staff checked the patient approximately 15 to 30 minutes before she was found.

• A defense verdict was returned
  

Reduced observation blamed for suicide by hanging

Kings County (NY) Supreme Court

A 45-year-old police lieutenant who suffered from alcohol abuse and depression was admitted to a psychiatric care facility. He was classiffied “Q15,” a category assigned to patients who must be visually inspected every 15 minutes, cannot have access to sharp objects or any other material or object they can use to inflict bodily harm, and must request permission to use restrooms. The next day the psychiatrist examined the patient and moved him to a “Q30” status, which halved the frequency of visual inspections, gave him unrestricted access to restrooms, and allowed him to have a bathrobe with a belt. The patient hanged himself the next day, using a restroom door to support a noose he made from the bathrobe belt.

The patient’s family faulted the hospital and psychiatrist for prematurely advancing the patient to “Q30” status. The hospital and psychiatrist claimed the suicide could not have been predicted and argued that given his background as a police lieutenant, the patient would have interpreted more stringent restrictions as incarceration. The psychiatrist argued that such a perception would have impeded the patient’s progress.

• A $71,989 verdict was returned, apportioning fault 65% to the hospital and 35% to the psychiatrist
  

Dr. Grant’s observations

Constant patient observation—such as one-to-one staffing or 15-minute checks—is used to protect patients from harming themselves or others. One study of a psychiatric hospital¹ reported that 13% of psychiatric inpatients required constant observation.

Even 15 minutes is sufficient time to complete a suicide.³ Common methods of inpatient suicide include hanging, overdosing, and jumping from high places.^4,5 One study found that 73% of inpatient suicides in a psychiatric ward occurred after 28 days of admission.⁵

The cost of constant observation may account for as much as 20% of the total nursing budget at a psychiatric hospital and up to 10% at a long-term care facility or general hospital.⁶ The annual cost of constant observation can exceed $500,000, depending on the hospital’s size and monitoring frequency.⁶

Determining responsibility

The outcomes of these 2 cases may appear inconsistent. In the first, the psychiatrist who assessed the patient as a moderate suicide risk was not negligent, even though the family claimed the patient was at high risk. In the second case, the psychiatrist was found partly liable for not maintaining a higher vigilance of suicide risk assessment.

Physicians cannot put every patient on one-to-one monitoring or 15-minute checks because of fear of suicide and malpractice litigation. These 2 cases demonstrate that if a suicide occurs, the courts will look for clinical reasons for the level of observation. The level of suicide precautions—one-to-one vs 15-minute checks—should be based on the patient’s clinical presentation and supported by clinical rationale.⁷

Risk analysis

The courts look to see if the suicide assessment was “clinically reasonable”.⁸ To meet this standard, perform a “suicide risk-benefit analysis” each time you make a significant clinical decision, such as ordering 15-minute checks. The record should include information sources you used (such as family members or previous medical records), factors that entered the clinical decision, and how you balanced these factors in a risk-benefit assessment (Box 1).⁹

Document decisions. Mistakes in clinical judgment do not necessarily constitute negligence,⁸ but deviations in the standard of care cannot be adequately determined in a court of law unless the clinician had documented his or her thought processes at the time of the decision.

Predicting which patients will re-experience or deny suicidal ideation is impossible,⁷ but if the patient is determined to be at high risk for suicide, then implement and document a plan to address this risk. In addition, communicate information regarding the risk-benefit assessment to staff responsible for implementing these precautions.

Box 1

• a patient is admitted for inpatient treatment
  
• observation status changes
  
• a patient’s clinical condition changes substantially
  
• acute psychosocial stressors are discovered during the hospitalization.⁷
  

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Psychotic patient declines hospital admission, drives into an office building

Cook County (IL) Circuit Court

The patient, age 43, had been treated for mental illness for many years. He was voluntarily admitted to a hospital under the care of his psychiatrist, and was discharged at his own request a few days later. He had improved and was not considered a candidate for involuntary admission because he was not a danger to himself or others.

The patient then informed the psychiatrist that he did not want to continue treatment and said he had an appointment with a new psychiatrist within 2 weeks.

Five days later, the patient went to another hospital for voluntary admission. He was seen by an emergency room physician, who determined the patient was a candidate for voluntary admission. The patient, however, decided to leave the hospital while a bed was being arranged.

Two days later, the patient began having auditory and visual hallucinations. He then drove his car through the glass doors of an office building. No one was injured, but the patient was arrested and convicted of felony damage to property.

In his suit, the patient alleged his longtime psychiatrist was negligent and failed to properly treat him to avoid development of hallucinations. The psychiatrist argued that involuntary admission was not indicated and that the care given was appropriate.

• A defense verdict was returned
  

Patient commits suicide after discharge

Cook County (IL) Circuit Court

A patient, age 45, committed suicide by taking lethal doses of medication prescribed by her psychiatrist. The patient had suffered from severe depression, personality disorder, and substance abuse. The day before her death, she went to a hospital emergency room, where she was assessed for suicide and released without the psychiatrist having been notified.

The patient’s family claimed that the psychiatrist was negligent because he did not adequately assess or monitor the patient’s clinical condition at sufficient intervals over the 3 months preceding her suicide. The family also alleged that the psychiatrist prescribed oxycodone inappropriately.

The psychiatrist argued that proper care was given and that the patient failed to provide a complete, accurate medical history at the emergency room visit and did not to consent to admission.

• A defense verdict was returned
  

Could admission have prevented patient’s suicide?

Douglas County (NE) District Court

A patient in his mid-60s with a history of depression committed suicide with a gunshot wound to the head. Before his suicide, the patient was seeing a psychiatrist and psychologist for depression and emotional problems.

The patient’s family alleged the psychiatrist failed to diagnose the severity of the patient’s problems and admit him to a hospital for treatment and observation. The psychiatrist and psychologist denied negligence.

• A defense verdict was returned
  

Medical malpractice law is constantly evolving to determine what constitutes “negligent care.” The legal standard requires a patient who brings a negligence claim against a psychiatrist to prove:

• a relationship between patient and psychiatrist such that a duty of care exists
  
• the duty was breached—meaning the standard of care was not met
  
• the breach of duty caused the injury.
  

Relationship rules

The first case highlights issues surrounding the patient-psychiatrist relationship. In general, once you have agreed to treat a patient, a doctor-patient relationship and duty of care exists.

In the first case, the patient informed his longtime psychiatrist that he no longer wanted to continue care after discharge. A psychiatrist who terminates a doctor-patient relationship should provide written notice, an explanation of termination, and referrals and continue to care for the patient for a reasonable period.¹ No such duty exists, however, when the patient ends treatment. Courts have found that the patient has not been abandoned when he or she voluntarily and unilaterally terminates the relationship.^2,3

The relationship ends the moment the patient terminates care, unless the patient is not competent to make that unilateral decision. In that situation, your duty of care to the patient continues.² When a competent patient terminates care, document the date and time of termination and the patient’s competence.

When relationships begin

The patient in the first case had an appointment with a new psychiatrist within 2 weeks. Is the new psychiatrist liable for what happens in the intervening period or does the relationship begin when the patient has been examined or treated? The legal question of when a physician-patient relationship is created remains problematic. Standards vary from state to state, but general principles offer some guidance.

The physician-patient relationship is a contract. The court would examine parties’ actions to ascertain their intent to determine if the patient reasonably believed that the physician—by actions or words—agreed to provide necessary medical care. Additionally, whether a relationship exists depends on the specific facts and circumstances of each situation.

There is some authority, across many jurisdictions, that a physician-patient relationship is established only when a physician conducts the initial history and physical examination. In some cases, however, the relationship has been found to exist at an earlier point, such as when a physician gave a referred patient an appointment for a consultation. When in doubt, assume the relationship exists.⁴

Duty of care

These cases raise areas where possible duty of care was breached:

• negligent prescription of medication
  
• failure to assess suicidal thinking.
  

Assessing suicide risk. Negligence in the second and third cases is based upon failure to assess suicidal thoughts. The legal system recognizes that psychiatrists cannot predict suicide,⁶ and mistakes in clinical judgment are not the same as negligence. Psychiatrists, however, are required to assess suicide risk and intervene appropriately.

When defending a negligence claim, the profession’s custom—reflected by the standard of care common to others with the practitioner’s training—is the benchmark against which the courts measure negligence. Therefore, take steps determined appropriate by the profession and document this risk assessment.⁷ For example, ask the patient about:

• suicidal thoughts and intent
  
• stressors
  
• history of suicidal behavior/attempts
  
• substance use
  
• signs and symptoms of depression
  
• bipolar disorder
  
• psychosis.⁸
  

Prescriptions. No clear line defines negligence when potentially dangerous medications are prescribed to a suicidal patient. Some psychiatrists dispense limited quantities of medications and see the patient weekly to monitor mood and medication. But even then a psychiatrist cannot prevent suicide—for example, the patient may have multiple prescribers or hoard medications. The concept of “sufficient intervals” to see a patient is determined case-by-case.

Documentation. Make suicide assessments an ongoing process. Document all aspects of the patient’s care, stability, and suicide risk, and reasons for the visit intervals. Indicate in the records your risk-benefit assessment in making treatment decisions.

Cases are selected byfrom Medical Malpractice Verdicts, Settlements & Experts, with permission of its editor, Lewis Laska of Nashville, TN (www.verdictslaska.com). Information may be incomplete in some instances, but these cases represent clinical situations that typically result in litigation.

Drug brand name

• Oxycodone • Percocet
  

Psychotic patient declines hospital admission, drives into an office building

Cook County (IL) Circuit Court

The patient, age 43, had been treated for mental illness for many years. He was voluntarily admitted to a hospital under the care of his psychiatrist, and was discharged at his own request a few days later. He had improved and was not considered a candidate for involuntary admission because he was not a danger to himself or others.

The patient then informed the psychiatrist that he did not want to continue treatment and said he had an appointment with a new psychiatrist within 2 weeks.

Five days later, the patient went to another hospital for voluntary admission. He was seen by an emergency room physician, who determined the patient was a candidate for voluntary admission. The patient, however, decided to leave the hospital while a bed was being arranged.

Two days later, the patient began having auditory and visual hallucinations. He then drove his car through the glass doors of an office building. No one was injured, but the patient was arrested and convicted of felony damage to property.

In his suit, the patient alleged his longtime psychiatrist was negligent and failed to properly treat him to avoid development of hallucinations. The psychiatrist argued that involuntary admission was not indicated and that the care given was appropriate.

• A defense verdict was returned
  

Patient commits suicide after discharge

Cook County (IL) Circuit Court

A patient, age 45, committed suicide by taking lethal doses of medication prescribed by her psychiatrist. The patient had suffered from severe depression, personality disorder, and substance abuse. The day before her death, she went to a hospital emergency room, where she was assessed for suicide and released without the psychiatrist having been notified.

The patient’s family claimed that the psychiatrist was negligent because he did not adequately assess or monitor the patient’s clinical condition at sufficient intervals over the 3 months preceding her suicide. The family also alleged that the psychiatrist prescribed oxycodone inappropriately.

The psychiatrist argued that proper care was given and that the patient failed to provide a complete, accurate medical history at the emergency room visit and did not to consent to admission.

• A defense verdict was returned
  

Could admission have prevented patient’s suicide?

Douglas County (NE) District Court

A patient in his mid-60s with a history of depression committed suicide with a gunshot wound to the head. Before his suicide, the patient was seeing a psychiatrist and psychologist for depression and emotional problems.

The patient’s family alleged the psychiatrist failed to diagnose the severity of the patient’s problems and admit him to a hospital for treatment and observation. The psychiatrist and psychologist denied negligence.

• A defense verdict was returned
  

Medical malpractice law is constantly evolving to determine what constitutes “negligent care.” The legal standard requires a patient who brings a negligence claim against a psychiatrist to prove:

• a relationship between patient and psychiatrist such that a duty of care exists
  
• the duty was breached—meaning the standard of care was not met
  
• the breach of duty caused the injury.
  

Relationship rules

The first case highlights issues surrounding the patient-psychiatrist relationship. In general, once you have agreed to treat a patient, a doctor-patient relationship and duty of care exists.

In the first case, the patient informed his longtime psychiatrist that he no longer wanted to continue care after discharge. A psychiatrist who terminates a doctor-patient relationship should provide written notice, an explanation of termination, and referrals and continue to care for the patient for a reasonable period.¹ No such duty exists, however, when the patient ends treatment. Courts have found that the patient has not been abandoned when he or she voluntarily and unilaterally terminates the relationship.^2,3

The relationship ends the moment the patient terminates care, unless the patient is not competent to make that unilateral decision. In that situation, your duty of care to the patient continues.² When a competent patient terminates care, document the date and time of termination and the patient’s competence.

When relationships begin

The patient in the first case had an appointment with a new psychiatrist within 2 weeks. Is the new psychiatrist liable for what happens in the intervening period or does the relationship begin when the patient has been examined or treated? The legal question of when a physician-patient relationship is created remains problematic. Standards vary from state to state, but general principles offer some guidance.

The physician-patient relationship is a contract. The court would examine parties’ actions to ascertain their intent to determine if the patient reasonably believed that the physician—by actions or words—agreed to provide necessary medical care. Additionally, whether a relationship exists depends on the specific facts and circumstances of each situation.

There is some authority, across many jurisdictions, that a physician-patient relationship is established only when a physician conducts the initial history and physical examination. In some cases, however, the relationship has been found to exist at an earlier point, such as when a physician gave a referred patient an appointment for a consultation. When in doubt, assume the relationship exists.⁴

Duty of care

These cases raise areas where possible duty of care was breached:

• negligent prescription of medication
  
• failure to assess suicidal thinking.
  

Assessing suicide risk. Negligence in the second and third cases is based upon failure to assess suicidal thoughts. The legal system recognizes that psychiatrists cannot predict suicide,⁶ and mistakes in clinical judgment are not the same as negligence. Psychiatrists, however, are required to assess suicide risk and intervene appropriately.

When defending a negligence claim, the profession’s custom—reflected by the standard of care common to others with the practitioner’s training—is the benchmark against which the courts measure negligence. Therefore, take steps determined appropriate by the profession and document this risk assessment.⁷ For example, ask the patient about:

• suicidal thoughts and intent
  
• stressors
  
• history of suicidal behavior/attempts
  
• substance use
  
• signs and symptoms of depression
  
• bipolar disorder
  
• psychosis.⁸
  

Prescriptions. No clear line defines negligence when potentially dangerous medications are prescribed to a suicidal patient. Some psychiatrists dispense limited quantities of medications and see the patient weekly to monitor mood and medication. But even then a psychiatrist cannot prevent suicide—for example, the patient may have multiple prescribers or hoard medications. The concept of “sufficient intervals” to see a patient is determined case-by-case.

Documentation. Make suicide assessments an ongoing process. Document all aspects of the patient’s care, stability, and suicide risk, and reasons for the visit intervals. Indicate in the records your risk-benefit assessment in making treatment decisions.

Cases are selected byfrom Medical Malpractice Verdicts, Settlements & Experts, with permission of its editor, Lewis Laska of Nashville, TN (www.verdictslaska.com). Information may be incomplete in some instances, but these cases represent clinical situations that typically result in litigation.

Drug brand name

• Oxycodone • Percocet
  

Psychotic patient declines hospital admission, drives into an office building

Cook County (IL) Circuit Court

The patient, age 43, had been treated for mental illness for many years. He was voluntarily admitted to a hospital under the care of his psychiatrist, and was discharged at his own request a few days later. He had improved and was not considered a candidate for involuntary admission because he was not a danger to himself or others.

The patient then informed the psychiatrist that he did not want to continue treatment and said he had an appointment with a new psychiatrist within 2 weeks.

Five days later, the patient went to another hospital for voluntary admission. He was seen by an emergency room physician, who determined the patient was a candidate for voluntary admission. The patient, however, decided to leave the hospital while a bed was being arranged.

Two days later, the patient began having auditory and visual hallucinations. He then drove his car through the glass doors of an office building. No one was injured, but the patient was arrested and convicted of felony damage to property.

In his suit, the patient alleged his longtime psychiatrist was negligent and failed to properly treat him to avoid development of hallucinations. The psychiatrist argued that involuntary admission was not indicated and that the care given was appropriate.

• A defense verdict was returned
  

Patient commits suicide after discharge

Cook County (IL) Circuit Court

A patient, age 45, committed suicide by taking lethal doses of medication prescribed by her psychiatrist. The patient had suffered from severe depression, personality disorder, and substance abuse. The day before her death, she went to a hospital emergency room, where she was assessed for suicide and released without the psychiatrist having been notified.

The patient’s family claimed that the psychiatrist was negligent because he did not adequately assess or monitor the patient’s clinical condition at sufficient intervals over the 3 months preceding her suicide. The family also alleged that the psychiatrist prescribed oxycodone inappropriately.

The psychiatrist argued that proper care was given and that the patient failed to provide a complete, accurate medical history at the emergency room visit and did not to consent to admission.

• A defense verdict was returned
  

Could admission have prevented patient’s suicide?

Douglas County (NE) District Court

A patient in his mid-60s with a history of depression committed suicide with a gunshot wound to the head. Before his suicide, the patient was seeing a psychiatrist and psychologist for depression and emotional problems.

The patient’s family alleged the psychiatrist failed to diagnose the severity of the patient’s problems and admit him to a hospital for treatment and observation. The psychiatrist and psychologist denied negligence.

• A defense verdict was returned
  

Medical malpractice law is constantly evolving to determine what constitutes “negligent care.” The legal standard requires a patient who brings a negligence claim against a psychiatrist to prove:

• a relationship between patient and psychiatrist such that a duty of care exists
  
• the duty was breached—meaning the standard of care was not met
  
• the breach of duty caused the injury.
  

Relationship rules

The first case highlights issues surrounding the patient-psychiatrist relationship. In general, once you have agreed to treat a patient, a doctor-patient relationship and duty of care exists.

In the first case, the patient informed his longtime psychiatrist that he no longer wanted to continue care after discharge. A psychiatrist who terminates a doctor-patient relationship should provide written notice, an explanation of termination, and referrals and continue to care for the patient for a reasonable period.¹ No such duty exists, however, when the patient ends treatment. Courts have found that the patient has not been abandoned when he or she voluntarily and unilaterally terminates the relationship.^2,3

The relationship ends the moment the patient terminates care, unless the patient is not competent to make that unilateral decision. In that situation, your duty of care to the patient continues.² When a competent patient terminates care, document the date and time of termination and the patient’s competence.

When relationships begin

The patient in the first case had an appointment with a new psychiatrist within 2 weeks. Is the new psychiatrist liable for what happens in the intervening period or does the relationship begin when the patient has been examined or treated? The legal question of when a physician-patient relationship is created remains problematic. Standards vary from state to state, but general principles offer some guidance.

The physician-patient relationship is a contract. The court would examine parties’ actions to ascertain their intent to determine if the patient reasonably believed that the physician—by actions or words—agreed to provide necessary medical care. Additionally, whether a relationship exists depends on the specific facts and circumstances of each situation.

There is some authority, across many jurisdictions, that a physician-patient relationship is established only when a physician conducts the initial history and physical examination. In some cases, however, the relationship has been found to exist at an earlier point, such as when a physician gave a referred patient an appointment for a consultation. When in doubt, assume the relationship exists.⁴

Duty of care

These cases raise areas where possible duty of care was breached:

• negligent prescription of medication
  
• failure to assess suicidal thinking.
  

Assessing suicide risk. Negligence in the second and third cases is based upon failure to assess suicidal thoughts. The legal system recognizes that psychiatrists cannot predict suicide,⁶ and mistakes in clinical judgment are not the same as negligence. Psychiatrists, however, are required to assess suicide risk and intervene appropriately.

When defending a negligence claim, the profession’s custom—reflected by the standard of care common to others with the practitioner’s training—is the benchmark against which the courts measure negligence. Therefore, take steps determined appropriate by the profession and document this risk assessment.⁷ For example, ask the patient about:

• suicidal thoughts and intent
  
• stressors
  
• history of suicidal behavior/attempts
  
• substance use
  
• signs and symptoms of depression
  
• bipolar disorder
  
• psychosis.⁸
  

Prescriptions. No clear line defines negligence when potentially dangerous medications are prescribed to a suicidal patient. Some psychiatrists dispense limited quantities of medications and see the patient weekly to monitor mood and medication. But even then a psychiatrist cannot prevent suicide—for example, the patient may have multiple prescribers or hoard medications. The concept of “sufficient intervals” to see a patient is determined case-by-case.

Documentation. Make suicide assessments an ongoing process. Document all aspects of the patient’s care, stability, and suicide risk, and reasons for the visit intervals. Indicate in the records your risk-benefit assessment in making treatment decisions.

Cases are selected byfrom Medical Malpractice Verdicts, Settlements & Experts, with permission of its editor, Lewis Laska of Nashville, TN (www.verdictslaska.com). Information may be incomplete in some instances, but these cases represent clinical situations that typically result in litigation.

Drug brand name

• Oxycodone • Percocet
  

Patient discharged from group therapy kills psychiatrist, patient, and himself

Oakland County (MI) Circuit Court

The plaintiff, age 57, attended regular group therapy with a psychiatrist. Another patient, Mr. B, was dismissed from group therapy by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B shot and killed the psychiatrist then entered the group meeting room and discharged his gun, fatally injuring another patient and wounding the plaintiff. Mr. B then turned the gun on himself and committed suicide. The plaintiff suffered gunshot wounds to the lower leg, foot, and hand and was away from work for 6 weeks.

The plaintiff alleged that the psychiatrist, his associates, and his daughter—who is also a psychiatrist at the office—knew Mr. B was dangerous and should not have been included in group therapy. The plaintiff claimed that Mr. B had a history of questionable psychotic behavior and other patients should not have been exposed to him. The psychiatrist’s associates contended that they had no way to anticipate this event and had used due care and caution in their practice.

• A $2 million verdict was returned
  

Dr. Grant’s observations

Warn and protect

In this case, several unavailable facts may have supported the successful negligence claim. For example, why was Mr. B dismissed from the group? Did he threaten someone in the group? Did he tell the group or the group leader about thoughts of violence or homicide? If so, perhaps a violent event was foreseeable.

Was Mr. B dismissed because of delusional or paranoid thoughts? What was done to help him, and were appropriate referrals in place? Instituting the right interventions requires clinicians to walk a fine line between preserving doctor-patient confidentiality and protecting other patients and the general public.

Doctor-patient confidentiality is deeply rooted in medical ethics and protected by law—in various forms—in all jurisdictions. Directives requiring a physician to reveal information without a patient’s consent are either legislated—and tend to be clear—or are based on court precedent, which is more open to interpretation. These mandated exceptions are purpose-specific and intended to preserve overall doctor-patient confidentiality.^{“Is this patient dangerous?” by John Battaglia, MD, and “Protect yourself from patient assault”, an interview between Dr. Battaglia and Lois E. Krahn, MD.}

Patient discharged from group therapy kills psychiatrist, patient, and himself

Oakland County (MI) Circuit Court

The plaintiff, age 57, attended regular group therapy with a psychiatrist. Another patient, Mr. B, was dismissed from group therapy by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B shot and killed the psychiatrist then entered the group meeting room and discharged his gun, fatally injuring another patient and wounding the plaintiff. Mr. B then turned the gun on himself and committed suicide. The plaintiff suffered gunshot wounds to the lower leg, foot, and hand and was away from work for 6 weeks.

The plaintiff alleged that the psychiatrist, his associates, and his daughter—who is also a psychiatrist at the office—knew Mr. B was dangerous and should not have been included in group therapy. The plaintiff claimed that Mr. B had a history of questionable psychotic behavior and other patients should not have been exposed to him. The psychiatrist’s associates contended that they had no way to anticipate this event and had used due care and caution in their practice.

• A $2 million verdict was returned
  

Dr. Grant’s observations

Warn and protect

In this case, several unavailable facts may have supported the successful negligence claim. For example, why was Mr. B dismissed from the group? Did he threaten someone in the group? Did he tell the group or the group leader about thoughts of violence or homicide? If so, perhaps a violent event was foreseeable.

Was Mr. B dismissed because of delusional or paranoid thoughts? What was done to help him, and were appropriate referrals in place? Instituting the right interventions requires clinicians to walk a fine line between preserving doctor-patient confidentiality and protecting other patients and the general public.

Doctor-patient confidentiality is deeply rooted in medical ethics and protected by law—in various forms—in all jurisdictions. Directives requiring a physician to reveal information without a patient’s consent are either legislated—and tend to be clear—or are based on court precedent, which is more open to interpretation. These mandated exceptions are purpose-specific and intended to preserve overall doctor-patient confidentiality.^{“Is this patient dangerous?” by John Battaglia, MD, and “Protect yourself from patient assault”, an interview between Dr. Battaglia and Lois E. Krahn, MD.}

Patient discharged from group therapy kills psychiatrist, patient, and himself

Oakland County (MI) Circuit Court

The plaintiff, age 57, attended regular group therapy with a psychiatrist. Another patient, Mr. B, was dismissed from group therapy by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B shot and killed the psychiatrist then entered the group meeting room and discharged his gun, fatally injuring another patient and wounding the plaintiff. Mr. B then turned the gun on himself and committed suicide. The plaintiff suffered gunshot wounds to the lower leg, foot, and hand and was away from work for 6 weeks.

The plaintiff alleged that the psychiatrist, his associates, and his daughter—who is also a psychiatrist at the office—knew Mr. B was dangerous and should not have been included in group therapy. The plaintiff claimed that Mr. B had a history of questionable psychotic behavior and other patients should not have been exposed to him. The psychiatrist’s associates contended that they had no way to anticipate this event and had used due care and caution in their practice.

• A $2 million verdict was returned
  

Dr. Grant’s observations

Warn and protect

In this case, several unavailable facts may have supported the successful negligence claim. For example, why was Mr. B dismissed from the group? Did he threaten someone in the group? Did he tell the group or the group leader about thoughts of violence or homicide? If so, perhaps a violent event was foreseeable.

Was Mr. B dismissed because of delusional or paranoid thoughts? What was done to help him, and were appropriate referrals in place? Instituting the right interventions requires clinicians to walk a fine line between preserving doctor-patient confidentiality and protecting other patients and the general public.

Doctor-patient confidentiality is deeply rooted in medical ethics and protected by law—in various forms—in all jurisdictions. Directives requiring a physician to reveal information without a patient’s consent are either legislated—and tend to be clear—or are based on court precedent, which is more open to interpretation. These mandated exceptions are purpose-specific and intended to preserve overall doctor-patient confidentiality.^{“Is this patient dangerous?” by John Battaglia, MD, and “Protect yourself from patient assault”, an interview between Dr. Battaglia and Lois E. Krahn, MD.}

Did benzodiazepines prescribed to patient
with addiction cause delirium?

Maricopa County (AZ) Superior Court

A 40-year-old woman addicted to diazepam sought treatment from a psychiatric nurse who performed a psychological evaluation. The patient claimed that the nurse negligently prescribed benzodiazepines and other medications for anxiety, panic attacks, and depression.

The patient claimed that the prescriptions caused a drug-induced delirium, during which she put a nonlethal amount of the medication on her two minor daughters’ ice cream, then attempted suicide by overdosing with her prescriptions. The patient and her daughters survived.

The patient was charged with two counts of attempted murder and was incarcerated for 18 months while awaiting trail. She was acquitted of the charges but lost custody of her daughters.

The psychiatric nurse argued that the medication prescribed was appropriate and the patient was not in a drug-induced delirium when she tried to kill herself and her daughters. The defense alleged that other factors caused the patient to attempt suicide/homicide, including a pending divorce and financial problems.

• A defense verdict was returned
  

Woman claims she was prescribed narcotics
despite alprazolam addiction

Multnomah County (OR) Superior Court

The patient, age 57, began seeing a psychiatrist in March 1993 for anxiety and panic attacks. She had kicked a 10-year alprazolam addiction and had been drug-free for more than 6 months when she first visited the psychiatrist.

The patient claimed that over the next 11 years she developed an intimate friendship with the psychiatrist. The patient visited the psychiatrist’s office almost weekly—sometimes twice a week—and incurred almost $100,000 in fees. The patient says that the psychiatrist prescribed her narcotics, then sought the drugs from her for his personal use, and was negligent in his treatment.

• A $593,000 verdict was returned, which included $200,000 in punitive damages
  

Dr. Grant’s observations

Should benzodiazepines or other addictive substances be prescribed to a patient with a history of substance abuse? Little evidence guides clinicians,^1,2 and limited research has examined whether former substance abusers are more likely than other patients to abuse benzodiazepines or if these medications increase the risk of substance abuse relapse.²

A psychiatrist can prescribe medication whenever a medical basis exists. In the first case a patient with anxiety and panic attacks was given benzodiazepines, an appropriate treatment for anxiety disorder.³ But what if the patient has a history of substance abuse? When is prescribing these medications negligent?

The fiduciary relationship between psychiatrist and patient states that the therapist is the patient’s ally and should always act in the patient’s best interest. With limited data, clinicians have no clear rule for a standard of care.

On one hand, benzodiazepine misuse is a problem and these medications must be prescribed cautiously. In 2004 roughly 300,000 Americans reported using prescription sedatives for nonmedical purposes.⁴ Many addiction specialists believe benzodiazepines are contraindicated for patients with current alcohol or drug abuse problems and for those in recovery. In this scenario, the clinician could choose an appropriate alternative to a benzodiazepine such as an antidepressant, buspirone, beta blocker, or anticonvulsant. Explain to the patient that these medications’ clinical effect is slower than that of benzodiazepines. Also consider psychotherapy to address anxiety.

On the other hand, benzodiazepines might be underused because of fear of addiction.⁵ Clinicians must consider whether their prescribing practices are designed to protect themselves or are in the patients’ best interests (Box 1). Of course, when treating a patient with a benzodiazepine addiction, the risk-benefit analysis shifts and abuse concerns may be more appropriate.

In the first case, the patient attempted suicide by overdosing on the prescribed medication. This fact might support the patient’s argument that she was not an appropriate candidate for benzodiazepines and the psychiatric nurse could be held liable—even though in this case she was not. One court found that a psychiatrist writing prescriptions for large amounts of controlled substances to someone addicted to drugs could be held liable for the patient’s suicide.⁶

In the second case, a psychiatrist prescribed narcotics to a patient with a history of addiction. The code of medical ethics is clear: A psychiatrist who regularly practices outside his or her area of professional competence should be considered as having acted in an unethical manner.⁷ So if you wish to prescribe narcotics, you must follow internal medicine’s ethical standards (Box 2).

Responsibility of care

Although the nurse in the first case could be liable for her actions, the psychiatrist who supervised the nurse might also be partially responsible. The law assumes that those who work under a physician’s supervision act as his or her agents. Nurses working for a physician are the physician’s agents, and the physician is responsible for a nurse’s acts. This legal principle is respondeat superior, or “let the master reply.”

Generally, the physician’s lack of knowledge about what the nurse prescribes is not a defense for a malpractice claim. In fact, the law requires that the physician know whether his or her agents meet the profession’s standard of care. In cases where a nurse prescribes an inappropriate medication, the psychiatrist can be charged with negligent supervision—that is, failing to provide to the nurse proper guidance and instruction.

Ethical conduct

Relationships with patients. The second case raises several egregious issues in patient care. Although intimate relationships with patients are prohibited, the fact that these cases still come before licensing boards and courts suggests that physicians are not getting the message. Although the report of this case is vague about what “intimate” means, several points are raised:

• Sexual relationships with current or former patients are not allowed.⁷ A patient is vulnerable, and the power differential makes it difficult for the patient to resist the therapist’s requests.
  
• Nonsexual, intimate relationships likely would be seen as a boundary violation, akin to a sexual relationship. In the case presented, the boundary violation is obvious even though the relationship may not have been sexual.
  

Medical ethics prohibit this behavior and state that psychiatrists should not:⁷

• use the unique position afforded by the psychotherapeutic situation to influence the patient in any way that is not directly relevant to treatment goals
  
• exploit information furnished by patients.
  

State medical boards have varying procedures in place to handle a physician’s substance abuse.

These programs’ goal is to assist recovery, eliminate risk to the public, and allow the physician to return to work. Clinicians should be aware of such programs in their jurisdictions.

Drug brand names

• Alprazolam • Xanax
  
• Buspirone • BuSpar
  
• Diazepam • Valium
  

Did benzodiazepines prescribed to patient
with addiction cause delirium?

Maricopa County (AZ) Superior Court

A 40-year-old woman addicted to diazepam sought treatment from a psychiatric nurse who performed a psychological evaluation. The patient claimed that the nurse negligently prescribed benzodiazepines and other medications for anxiety, panic attacks, and depression.