User login
A PEARL of wisdom about writing ‘Pearls’
Since 2005, I’ve had the opportunity to review “Pearls” articles submitted for publication in Current Psychiatry. In that time, I have read many worthwhile papers written by authors who may not be entirely clear about what constitutes a “Pearl." The mnemonic PEARL could help authors:
- decide if their article or idea is appropriate for “Pearls”
- construct the article to conform to the “Pearls” format.
Easy to remember. Lengthy, highly detailed articles may be helpful and informative but are not consistent with the purpose of “Pearls.
Alert. A “Pearl” should alert a physician to identify a problem, diagnosis, or adverse effect that they might otherwise miss or take unnecessary time to identify. Classic examples are the “handshake diagnosis” of hyperthyroidism,1 or the “3 little words that can diagnose mild cognitive impairment.”2
References. A professional article of any length should include references. References add immediate credibility to the information presented. For a “Pearl,” even 1 reference is acceptable. A writer can easily search PubMed and the Internet to find references to confirm or support their ideas.
Less is more. Architect Mies van der Rohe’s minimalist concept applies to “Pearls.” A “Pearl”—like its namesake—is small, polished, and valuable. Simplicity is its essence.
I hope this mnemonic is useful for clinicians interested in sharing their ideas or experiences to help others in the field. I look forward to reviewing many more “Pearls.”
1. Bedell SE, Graboys TB. Hand to hand. J Gen Intern Med. 2002;17(8):653-656.
2. Steenland NK, Auman CM, Patel PM, et al. Development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia. J Alzheimers Dis. 2008;15(3):419-427.
Since 2005, I’ve had the opportunity to review “Pearls” articles submitted for publication in Current Psychiatry. In that time, I have read many worthwhile papers written by authors who may not be entirely clear about what constitutes a “Pearl." The mnemonic PEARL could help authors:
- decide if their article or idea is appropriate for “Pearls”
- construct the article to conform to the “Pearls” format.
Easy to remember. Lengthy, highly detailed articles may be helpful and informative but are not consistent with the purpose of “Pearls.
Alert. A “Pearl” should alert a physician to identify a problem, diagnosis, or adverse effect that they might otherwise miss or take unnecessary time to identify. Classic examples are the “handshake diagnosis” of hyperthyroidism,1 or the “3 little words that can diagnose mild cognitive impairment.”2
References. A professional article of any length should include references. References add immediate credibility to the information presented. For a “Pearl,” even 1 reference is acceptable. A writer can easily search PubMed and the Internet to find references to confirm or support their ideas.
Less is more. Architect Mies van der Rohe’s minimalist concept applies to “Pearls.” A “Pearl”—like its namesake—is small, polished, and valuable. Simplicity is its essence.
I hope this mnemonic is useful for clinicians interested in sharing their ideas or experiences to help others in the field. I look forward to reviewing many more “Pearls.”
Since 2005, I’ve had the opportunity to review “Pearls” articles submitted for publication in Current Psychiatry. In that time, I have read many worthwhile papers written by authors who may not be entirely clear about what constitutes a “Pearl." The mnemonic PEARL could help authors:
- decide if their article or idea is appropriate for “Pearls”
- construct the article to conform to the “Pearls” format.
Easy to remember. Lengthy, highly detailed articles may be helpful and informative but are not consistent with the purpose of “Pearls.
Alert. A “Pearl” should alert a physician to identify a problem, diagnosis, or adverse effect that they might otherwise miss or take unnecessary time to identify. Classic examples are the “handshake diagnosis” of hyperthyroidism,1 or the “3 little words that can diagnose mild cognitive impairment.”2
References. A professional article of any length should include references. References add immediate credibility to the information presented. For a “Pearl,” even 1 reference is acceptable. A writer can easily search PubMed and the Internet to find references to confirm or support their ideas.
Less is more. Architect Mies van der Rohe’s minimalist concept applies to “Pearls.” A “Pearl”—like its namesake—is small, polished, and valuable. Simplicity is its essence.
I hope this mnemonic is useful for clinicians interested in sharing their ideas or experiences to help others in the field. I look forward to reviewing many more “Pearls.”
1. Bedell SE, Graboys TB. Hand to hand. J Gen Intern Med. 2002;17(8):653-656.
2. Steenland NK, Auman CM, Patel PM, et al. Development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia. J Alzheimers Dis. 2008;15(3):419-427.
1. Bedell SE, Graboys TB. Hand to hand. J Gen Intern Med. 2002;17(8):653-656.
2. Steenland NK, Auman CM, Patel PM, et al. Development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia. J Alzheimers Dis. 2008;15(3):419-427.
Let’s eliminate these imprecisions in chart notes of psychiatric evaluations
In private practice, government, and (especially) academically affiliated settings, chart notations that are neither erroneous nor accurate but just imprecise are seen regularly. Academic supervisors may overlook these ambiguous notations by medical students and residents because of their regularity; others may be actively taught by supervisors who use ambiguous notations themselves.
In my experience, the most frequently seen imprecisions are in diagnoses of personality disorders: for example, the terms “clusters” and “deferred,” and the symptomatic overlap between antisocial personality disorder (APD) and substance abuse. Least helpful are qualifying phrases added to substance abuse diagnoses, along with an abundance of abbreviations. The latter occurs despite efforts by the U.S. Department of Veteran Affairs and other agencies to standardize acceptable lists of abbreviations. Many imprecisions could qualify for highlighting; here are 5 of the most unhelpful:
Clusters. Personality disorders are grouped into 3 “clusters,” according to similar characteristics (eg, Cluster A includes paranoid, schizoid, and schizotypal personality disorders and focuses on patients’ oddities and eccentricities). The need for identifying “clusters” could be debated, but a “cluster” is not a diagnosis. A psychiatric evaluation that notes “Cluster B traits” in lieu of a specific personality disorder is not informative, especially to a nonpsychiatric clinician. Which Cluster B traits apply? Is the patient unstable? Self-absorbed? Needy? Dramatic? Criminal? Assaultive?
In complicated or ambiguous cases, the diagnosis of a personality disorder not otherwise specified is appropriate, indicating that traits need to be clarified.
Deferred. This notation frequently is seen under axis II, and often is carried through the medical record for months or years. Psychiatrists are reluctant to diagnose a personality disorder because of the pejorative nature a diagnosis conveys. Nevertheless, by the second or third visit—after 2 or 3 hours of interview contact—it should be evident whether a personality disorder exists. If none does, “no diagnosis” should be documented. This notation can be adjusted if such evidence comes to light.
APD (or APD traits). This diagnosis often is made mistakenly when the root problem is in fact a substance abuse disorder. A multi-decade study of alcoholism and antisocial personality attributes in university students illustrated this phenomenon.1
To be a successful substance abuser—that is, to satisfy the overwhelming urge to drink or use drugs—it’s essential to lie, cheat, and steal. Substance abusers might become belligerent when intoxicated. They might be arrested in bar fights, drive while intoxicated, and buy illegal substances. The result is incarceration, a common consequence of substance abuse and of APD. The latter diagnosis should be made only if the patient has exhibited a pattern of criminal behavior—often starting in adolescence—irrespective of substance abuse, such as breaking and entering, robbery, or assault with a deadly weapon.
Substance abusers often feel guilt and self-loathing for their “weakness,” and cannot gain control over their addiction; the APD patient, on the other hand, feels entitled to plunder and often justifies his (her) actions by attributing fault to the victim.
Keep in mind that many APD patients also are substance abusers; both diagnoses should be listed in the chart when that is the determination. Recognize that substance abuse and APD are distinct entities that should not be confused by the common denominator of having spent time in jail.
Early, late, full remission. These qualifiers often are appended to substance abuse disorders, but they do not convey useful information. How early is “early”? How late is “late”? Perhaps the most misleading term is “full” or “partial” remission,
because there is no clear definition of either.
If one is referring to length of time sober or a reduction in volume consumed, noting the date of the last use is more helpful—eg, “alcohol abuse in remission since summer of 2012.” If “partial” remission means the patient has reduced his intake, then that is not remission. The reduction can be specified—eg, “alcohol abuse, reduced to 1 or 2 beers per weekend.”
Abbreviations. Psychiatric evaluations should contain only standard, well-known medical shorthand (such as MSE for mental status exam). The military may be the biggest offender, devising acronyms and abbreviations for everything.
Two examples of abbreviations that I see in military psychiatric progress notes are AEB (“as evidenced by”) and LLGD (“linear, logical, and goal-directed”). Psychiatrists have a leg up on deciphering abbreviations in psychiatric notes; other providers might be compelled to resort to consultation. That wastes more time than typing out the words and results in frustration and lost productivity.
Reference
1. Vaillant GE. The natural history of alcoholism. Cambridge, MA: Harvard University Press; 1983.
In private practice, government, and (especially) academically affiliated settings, chart notations that are neither erroneous nor accurate but just imprecise are seen regularly. Academic supervisors may overlook these ambiguous notations by medical students and residents because of their regularity; others may be actively taught by supervisors who use ambiguous notations themselves.
In my experience, the most frequently seen imprecisions are in diagnoses of personality disorders: for example, the terms “clusters” and “deferred,” and the symptomatic overlap between antisocial personality disorder (APD) and substance abuse. Least helpful are qualifying phrases added to substance abuse diagnoses, along with an abundance of abbreviations. The latter occurs despite efforts by the U.S. Department of Veteran Affairs and other agencies to standardize acceptable lists of abbreviations. Many imprecisions could qualify for highlighting; here are 5 of the most unhelpful:
Clusters. Personality disorders are grouped into 3 “clusters,” according to similar characteristics (eg, Cluster A includes paranoid, schizoid, and schizotypal personality disorders and focuses on patients’ oddities and eccentricities). The need for identifying “clusters” could be debated, but a “cluster” is not a diagnosis. A psychiatric evaluation that notes “Cluster B traits” in lieu of a specific personality disorder is not informative, especially to a nonpsychiatric clinician. Which Cluster B traits apply? Is the patient unstable? Self-absorbed? Needy? Dramatic? Criminal? Assaultive?
In complicated or ambiguous cases, the diagnosis of a personality disorder not otherwise specified is appropriate, indicating that traits need to be clarified.
Deferred. This notation frequently is seen under axis II, and often is carried through the medical record for months or years. Psychiatrists are reluctant to diagnose a personality disorder because of the pejorative nature a diagnosis conveys. Nevertheless, by the second or third visit—after 2 or 3 hours of interview contact—it should be evident whether a personality disorder exists. If none does, “no diagnosis” should be documented. This notation can be adjusted if such evidence comes to light.
APD (or APD traits). This diagnosis often is made mistakenly when the root problem is in fact a substance abuse disorder. A multi-decade study of alcoholism and antisocial personality attributes in university students illustrated this phenomenon.1
To be a successful substance abuser—that is, to satisfy the overwhelming urge to drink or use drugs—it’s essential to lie, cheat, and steal. Substance abusers might become belligerent when intoxicated. They might be arrested in bar fights, drive while intoxicated, and buy illegal substances. The result is incarceration, a common consequence of substance abuse and of APD. The latter diagnosis should be made only if the patient has exhibited a pattern of criminal behavior—often starting in adolescence—irrespective of substance abuse, such as breaking and entering, robbery, or assault with a deadly weapon.
Substance abusers often feel guilt and self-loathing for their “weakness,” and cannot gain control over their addiction; the APD patient, on the other hand, feels entitled to plunder and often justifies his (her) actions by attributing fault to the victim.
Keep in mind that many APD patients also are substance abusers; both diagnoses should be listed in the chart when that is the determination. Recognize that substance abuse and APD are distinct entities that should not be confused by the common denominator of having spent time in jail.
Early, late, full remission. These qualifiers often are appended to substance abuse disorders, but they do not convey useful information. How early is “early”? How late is “late”? Perhaps the most misleading term is “full” or “partial” remission,
because there is no clear definition of either.
If one is referring to length of time sober or a reduction in volume consumed, noting the date of the last use is more helpful—eg, “alcohol abuse in remission since summer of 2012.” If “partial” remission means the patient has reduced his intake, then that is not remission. The reduction can be specified—eg, “alcohol abuse, reduced to 1 or 2 beers per weekend.”
Abbreviations. Psychiatric evaluations should contain only standard, well-known medical shorthand (such as MSE for mental status exam). The military may be the biggest offender, devising acronyms and abbreviations for everything.
Two examples of abbreviations that I see in military psychiatric progress notes are AEB (“as evidenced by”) and LLGD (“linear, logical, and goal-directed”). Psychiatrists have a leg up on deciphering abbreviations in psychiatric notes; other providers might be compelled to resort to consultation. That wastes more time than typing out the words and results in frustration and lost productivity.
In private practice, government, and (especially) academically affiliated settings, chart notations that are neither erroneous nor accurate but just imprecise are seen regularly. Academic supervisors may overlook these ambiguous notations by medical students and residents because of their regularity; others may be actively taught by supervisors who use ambiguous notations themselves.
In my experience, the most frequently seen imprecisions are in diagnoses of personality disorders: for example, the terms “clusters” and “deferred,” and the symptomatic overlap between antisocial personality disorder (APD) and substance abuse. Least helpful are qualifying phrases added to substance abuse diagnoses, along with an abundance of abbreviations. The latter occurs despite efforts by the U.S. Department of Veteran Affairs and other agencies to standardize acceptable lists of abbreviations. Many imprecisions could qualify for highlighting; here are 5 of the most unhelpful:
Clusters. Personality disorders are grouped into 3 “clusters,” according to similar characteristics (eg, Cluster A includes paranoid, schizoid, and schizotypal personality disorders and focuses on patients’ oddities and eccentricities). The need for identifying “clusters” could be debated, but a “cluster” is not a diagnosis. A psychiatric evaluation that notes “Cluster B traits” in lieu of a specific personality disorder is not informative, especially to a nonpsychiatric clinician. Which Cluster B traits apply? Is the patient unstable? Self-absorbed? Needy? Dramatic? Criminal? Assaultive?
In complicated or ambiguous cases, the diagnosis of a personality disorder not otherwise specified is appropriate, indicating that traits need to be clarified.
Deferred. This notation frequently is seen under axis II, and often is carried through the medical record for months or years. Psychiatrists are reluctant to diagnose a personality disorder because of the pejorative nature a diagnosis conveys. Nevertheless, by the second or third visit—after 2 or 3 hours of interview contact—it should be evident whether a personality disorder exists. If none does, “no diagnosis” should be documented. This notation can be adjusted if such evidence comes to light.
APD (or APD traits). This diagnosis often is made mistakenly when the root problem is in fact a substance abuse disorder. A multi-decade study of alcoholism and antisocial personality attributes in university students illustrated this phenomenon.1
To be a successful substance abuser—that is, to satisfy the overwhelming urge to drink or use drugs—it’s essential to lie, cheat, and steal. Substance abusers might become belligerent when intoxicated. They might be arrested in bar fights, drive while intoxicated, and buy illegal substances. The result is incarceration, a common consequence of substance abuse and of APD. The latter diagnosis should be made only if the patient has exhibited a pattern of criminal behavior—often starting in adolescence—irrespective of substance abuse, such as breaking and entering, robbery, or assault with a deadly weapon.
Substance abusers often feel guilt and self-loathing for their “weakness,” and cannot gain control over their addiction; the APD patient, on the other hand, feels entitled to plunder and often justifies his (her) actions by attributing fault to the victim.
Keep in mind that many APD patients also are substance abusers; both diagnoses should be listed in the chart when that is the determination. Recognize that substance abuse and APD are distinct entities that should not be confused by the common denominator of having spent time in jail.
Early, late, full remission. These qualifiers often are appended to substance abuse disorders, but they do not convey useful information. How early is “early”? How late is “late”? Perhaps the most misleading term is “full” or “partial” remission,
because there is no clear definition of either.
If one is referring to length of time sober or a reduction in volume consumed, noting the date of the last use is more helpful—eg, “alcohol abuse in remission since summer of 2012.” If “partial” remission means the patient has reduced his intake, then that is not remission. The reduction can be specified—eg, “alcohol abuse, reduced to 1 or 2 beers per weekend.”
Abbreviations. Psychiatric evaluations should contain only standard, well-known medical shorthand (such as MSE for mental status exam). The military may be the biggest offender, devising acronyms and abbreviations for everything.
Two examples of abbreviations that I see in military psychiatric progress notes are AEB (“as evidenced by”) and LLGD (“linear, logical, and goal-directed”). Psychiatrists have a leg up on deciphering abbreviations in psychiatric notes; other providers might be compelled to resort to consultation. That wastes more time than typing out the words and results in frustration and lost productivity.
Reference
1. Vaillant GE. The natural history of alcoholism. Cambridge, MA: Harvard University Press; 1983.
Reference
1. Vaillant GE. The natural history of alcoholism. Cambridge, MA: Harvard University Press; 1983.
A PEARL of wisdom about ‘Pearls’
Since 2005, I’ve had the opportunity to peer review Pearls articles submitted for publication in Current Psychiatry. In that time, I have read many worthwhile papers written by authors who may not be entirely clear about what constitutes a Pearl. The mnemonic PEARL could help authors:
- decide if their article or idea is appropriate for Pearls
- construct the article to conform to the Pearls format.
Precise. A Pearls article should make an accurate and concise statement. It should not be an elaborate or generalized idea based on either limited or copious information.
Easy to remember. Lengthy, highly detailed articles may be helpful and informative but are not consistent with the purpose of Pearls.
Alert. A Pearl should alert a physician to identify a problem, diagnosis, or adverse effect that they might otherwise miss or take unnecessary time to identify. Classic examples are the “handshake diagnosis” of hyperthyroidism,1 or the “3 little words that can diagnose mild cognitive impairment.”2
References. A professional article of any length should include references. References add immediate credibility to the information presented. For a Pearl, even one reference is acceptable. A writer can easily search PubMed and the Internet to find references to confirm or support their ideas.
Less is more. Architect Mies van der Rohe’s minimalist concept applies to Pearls. A Pearl—like its namesake—is small, polished, and valuable. Simplicity is its essence.
I hope this mnemonic is useful for clinicians interested in sharing their ideas or experiences to help others in the field. I look forward to reviewing many more Pearls in the future.
Lorraine S. Roth, MD
Department editor for Current Psychiatry
Assistant professor of psychiatry
Rosalind Franklin University of Medicine and Science
Attending psychiatrist
Department of Veterans Affairs Medical Center
North Chicago, Illinois
Lorraine S. Roth, MD
Department editor for Current Psychiatry
Assistant professor of psychiatry
Rosalind Franklin University of Medicine and Science
Attending psychiatrist
Department of Veterans Affairs Medical Center
North Chicago, Illinois
Lorraine S. Roth, MD
Department editor for Current Psychiatry
Assistant professor of psychiatry
Rosalind Franklin University of Medicine and Science
Attending psychiatrist
Department of Veterans Affairs Medical Center
North Chicago, Illinois
Since 2005, I’ve had the opportunity to peer review Pearls articles submitted for publication in Current Psychiatry. In that time, I have read many worthwhile papers written by authors who may not be entirely clear about what constitutes a Pearl. The mnemonic PEARL could help authors:
- decide if their article or idea is appropriate for Pearls
- construct the article to conform to the Pearls format.
Precise. A Pearls article should make an accurate and concise statement. It should not be an elaborate or generalized idea based on either limited or copious information.
Easy to remember. Lengthy, highly detailed articles may be helpful and informative but are not consistent with the purpose of Pearls.
Alert. A Pearl should alert a physician to identify a problem, diagnosis, or adverse effect that they might otherwise miss or take unnecessary time to identify. Classic examples are the “handshake diagnosis” of hyperthyroidism,1 or the “3 little words that can diagnose mild cognitive impairment.”2
References. A professional article of any length should include references. References add immediate credibility to the information presented. For a Pearl, even one reference is acceptable. A writer can easily search PubMed and the Internet to find references to confirm or support their ideas.
Less is more. Architect Mies van der Rohe’s minimalist concept applies to Pearls. A Pearl—like its namesake—is small, polished, and valuable. Simplicity is its essence.
I hope this mnemonic is useful for clinicians interested in sharing their ideas or experiences to help others in the field. I look forward to reviewing many more Pearls in the future.
Since 2005, I’ve had the opportunity to peer review Pearls articles submitted for publication in Current Psychiatry. In that time, I have read many worthwhile papers written by authors who may not be entirely clear about what constitutes a Pearl. The mnemonic PEARL could help authors:
- decide if their article or idea is appropriate for Pearls
- construct the article to conform to the Pearls format.
Precise. A Pearls article should make an accurate and concise statement. It should not be an elaborate or generalized idea based on either limited or copious information.
Easy to remember. Lengthy, highly detailed articles may be helpful and informative but are not consistent with the purpose of Pearls.
Alert. A Pearl should alert a physician to identify a problem, diagnosis, or adverse effect that they might otherwise miss or take unnecessary time to identify. Classic examples are the “handshake diagnosis” of hyperthyroidism,1 or the “3 little words that can diagnose mild cognitive impairment.”2
References. A professional article of any length should include references. References add immediate credibility to the information presented. For a Pearl, even one reference is acceptable. A writer can easily search PubMed and the Internet to find references to confirm or support their ideas.
Less is more. Architect Mies van der Rohe’s minimalist concept applies to Pearls. A Pearl—like its namesake—is small, polished, and valuable. Simplicity is its essence.
I hope this mnemonic is useful for clinicians interested in sharing their ideas or experiences to help others in the field. I look forward to reviewing many more Pearls in the future.
Be wary when sociopaths turn on the charm
Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.
Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.
Table
DSM-IV-TR criteria for antisocial personality disorder
Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following:
|
| Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000 |
Remain skeptical
When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.
Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:
- continuing undetected
- has been temporarily checked (“laying low”)
- or if the patient’s personality truly has been transformed.
5 treatment caveats
When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.
- Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims2 and is so convinced that he can easily persuade and distract the therapist.
- Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
- Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
- Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
- Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.3
1. Delain SL, Stafford KP, Ben-Porath YS. Use of the TOMM in a criminal court forensic assessment setting. Assessment 2003;10(4):370-81
2. Feldman MD. Munchausen by Internet: detecting factitious illness and crisis on the Internet. South Med J 2000;93(7):669-72
3. Eisenberg L. Violence and the mentally ill: victims, not perpetrators. Arch Gen Psychiatry 2005;62(8):825-6
Dr. Roth is assistant professor of psychiatry, Rosalind Franklin University of Medicine and Science and attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.
Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.
Table
DSM-IV-TR criteria for antisocial personality disorder
Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following:
|
| Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000 |
Remain skeptical
When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.
Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:
- continuing undetected
- has been temporarily checked (“laying low”)
- or if the patient’s personality truly has been transformed.
5 treatment caveats
When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.
- Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims2 and is so convinced that he can easily persuade and distract the therapist.
- Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
- Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
- Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
- Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.3
Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.
Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.
Table
DSM-IV-TR criteria for antisocial personality disorder
Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following:
|
| Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000 |
Remain skeptical
When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.
Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:
- continuing undetected
- has been temporarily checked (“laying low”)
- or if the patient’s personality truly has been transformed.
5 treatment caveats
When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.
- Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims2 and is so convinced that he can easily persuade and distract the therapist.
- Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
- Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
- Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
- Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.3
1. Delain SL, Stafford KP, Ben-Porath YS. Use of the TOMM in a criminal court forensic assessment setting. Assessment 2003;10(4):370-81
2. Feldman MD. Munchausen by Internet: detecting factitious illness and crisis on the Internet. South Med J 2000;93(7):669-72
3. Eisenberg L. Violence and the mentally ill: victims, not perpetrators. Arch Gen Psychiatry 2005;62(8):825-6
Dr. Roth is assistant professor of psychiatry, Rosalind Franklin University of Medicine and Science and attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
1. Delain SL, Stafford KP, Ben-Porath YS. Use of the TOMM in a criminal court forensic assessment setting. Assessment 2003;10(4):370-81
2. Feldman MD. Munchausen by Internet: detecting factitious illness and crisis on the Internet. South Med J 2000;93(7):669-72
3. Eisenberg L. Violence and the mentally ill: victims, not perpetrators. Arch Gen Psychiatry 2005;62(8):825-6
Dr. Roth is assistant professor of psychiatry, Rosalind Franklin University of Medicine and Science and attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
‘DARE’ to spot borderline personality disorder
Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.
A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.
Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.
Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.
BPD patients’ histories often include physical or emotional abandonment or abuse.
Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.
Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.
Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.
A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.
Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.
Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.
BPD patients’ histories often include physical or emotional abandonment or abuse.
Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.
Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.
Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.
A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.
Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.
Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.
BPD patients’ histories often include physical or emotional abandonment or abuse.
Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.
Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.
Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Defuse patient demands and other difficult behaviors
Mishandling patients’ suicidal thoughts, delusions, medication demands, and other difficult behaviors can damage the therapeutic alliance, cause you unnecessary consternation, and even endanger patients’ lives.
The following strategies can help you overcome six of psychiatry’s clinical conundrums (Box).
Assessing suicidality
Dealing with insistent delusions
Defusing intimidation
Weighing medication demands
Protecting patient confidentiality
Documenting patient complaints
1. Assessing suicidality
Not having a suicide plan is not necessarily protective; a patient with unremitting depression can deteriorate rapidly from “no plan” to high risk.
Besides probing for plans, ask what is stopping a patient with suicidal thoughts from completing suicide. Suspect increased risk in patients who:
- say they have not tried suicide because they fear the attempt will fail
- cannot express a reason to live.
2. Dealing with insistent delusions
If a delusional patient complains that previous physicians thought he was “lying” or “crazy” and asks if you believe his delusional statements:
- reassure him that you feel he sincerely believes what he says is true.
- affirm that you believe he is accurately and truthfully reporting his feelings.
3. Defusing intimidation
When an intimidating patient demands that you prescribe a controlled substance, be calm, patient, and firm. If the patient stands up and leans toward you or shows other threatening postures, calmly ask him to “please sit down.”
Refuse the patient’s request for the controlled substance by gently informing him that:
- the substance is not medically indicated
- the substance could be “detrimental to your health”
- prescribing the substance would not be good medical care
- you are prescribing a safer substitute.
4. Weighing medication demands
Patients who demand specific medications—controlled or not—might in fact be asking for a reasonable choice. Weigh the request against the patient’s symptoms and history. Don’t be put off by obnoxious, demanding patients who complain about providers who deny their requests for medication.
Barring contraindications or side effects, respect a competent patient’s desire to take an older medication he prefers.
Judge medication requests from incompetent or psychotic patients on a case-by-case basis. In many cases they can remember what worked best in the past.
5. Protecting patient confidentiality
Information about your patients from collateral sources can be valuable. Remember that you are not breaching the patient’s confidentiality when you:
- listen to someone who offers unsolicited information
- do not disclose that you are treating the patient to someone who calls you about him or her.
6. Documenting patient complaints
View with skepticism any history that patients tell you about collateral sources until you confirm the information. All persons—delusional or competent—filter their experiences through their own beliefs.
Be cautious about documenting a patient’s report of abusive treatment as factual. Preface documentation of derogatory or accusatory statements with comments such as, “The patient claims…” or “The patient feels….”
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL
Mishandling patients’ suicidal thoughts, delusions, medication demands, and other difficult behaviors can damage the therapeutic alliance, cause you unnecessary consternation, and even endanger patients’ lives.
The following strategies can help you overcome six of psychiatry’s clinical conundrums (Box).
Assessing suicidality
Dealing with insistent delusions
Defusing intimidation
Weighing medication demands
Protecting patient confidentiality
Documenting patient complaints
1. Assessing suicidality
Not having a suicide plan is not necessarily protective; a patient with unremitting depression can deteriorate rapidly from “no plan” to high risk.
Besides probing for plans, ask what is stopping a patient with suicidal thoughts from completing suicide. Suspect increased risk in patients who:
- say they have not tried suicide because they fear the attempt will fail
- cannot express a reason to live.
2. Dealing with insistent delusions
If a delusional patient complains that previous physicians thought he was “lying” or “crazy” and asks if you believe his delusional statements:
- reassure him that you feel he sincerely believes what he says is true.
- affirm that you believe he is accurately and truthfully reporting his feelings.
3. Defusing intimidation
When an intimidating patient demands that you prescribe a controlled substance, be calm, patient, and firm. If the patient stands up and leans toward you or shows other threatening postures, calmly ask him to “please sit down.”
Refuse the patient’s request for the controlled substance by gently informing him that:
- the substance is not medically indicated
- the substance could be “detrimental to your health”
- prescribing the substance would not be good medical care
- you are prescribing a safer substitute.
4. Weighing medication demands
Patients who demand specific medications—controlled or not—might in fact be asking for a reasonable choice. Weigh the request against the patient’s symptoms and history. Don’t be put off by obnoxious, demanding patients who complain about providers who deny their requests for medication.
Barring contraindications or side effects, respect a competent patient’s desire to take an older medication he prefers.
Judge medication requests from incompetent or psychotic patients on a case-by-case basis. In many cases they can remember what worked best in the past.
5. Protecting patient confidentiality
Information about your patients from collateral sources can be valuable. Remember that you are not breaching the patient’s confidentiality when you:
- listen to someone who offers unsolicited information
- do not disclose that you are treating the patient to someone who calls you about him or her.
6. Documenting patient complaints
View with skepticism any history that patients tell you about collateral sources until you confirm the information. All persons—delusional or competent—filter their experiences through their own beliefs.
Be cautious about documenting a patient’s report of abusive treatment as factual. Preface documentation of derogatory or accusatory statements with comments such as, “The patient claims…” or “The patient feels….”
Mishandling patients’ suicidal thoughts, delusions, medication demands, and other difficult behaviors can damage the therapeutic alliance, cause you unnecessary consternation, and even endanger patients’ lives.
The following strategies can help you overcome six of psychiatry’s clinical conundrums (Box).
Assessing suicidality
Dealing with insistent delusions
Defusing intimidation
Weighing medication demands
Protecting patient confidentiality
Documenting patient complaints
1. Assessing suicidality
Not having a suicide plan is not necessarily protective; a patient with unremitting depression can deteriorate rapidly from “no plan” to high risk.
Besides probing for plans, ask what is stopping a patient with suicidal thoughts from completing suicide. Suspect increased risk in patients who:
- say they have not tried suicide because they fear the attempt will fail
- cannot express a reason to live.
2. Dealing with insistent delusions
If a delusional patient complains that previous physicians thought he was “lying” or “crazy” and asks if you believe his delusional statements:
- reassure him that you feel he sincerely believes what he says is true.
- affirm that you believe he is accurately and truthfully reporting his feelings.
3. Defusing intimidation
When an intimidating patient demands that you prescribe a controlled substance, be calm, patient, and firm. If the patient stands up and leans toward you or shows other threatening postures, calmly ask him to “please sit down.”
Refuse the patient’s request for the controlled substance by gently informing him that:
- the substance is not medically indicated
- the substance could be “detrimental to your health”
- prescribing the substance would not be good medical care
- you are prescribing a safer substitute.
4. Weighing medication demands
Patients who demand specific medications—controlled or not—might in fact be asking for a reasonable choice. Weigh the request against the patient’s symptoms and history. Don’t be put off by obnoxious, demanding patients who complain about providers who deny their requests for medication.
Barring contraindications or side effects, respect a competent patient’s desire to take an older medication he prefers.
Judge medication requests from incompetent or psychotic patients on a case-by-case basis. In many cases they can remember what worked best in the past.
5. Protecting patient confidentiality
Information about your patients from collateral sources can be valuable. Remember that you are not breaching the patient’s confidentiality when you:
- listen to someone who offers unsolicited information
- do not disclose that you are treating the patient to someone who calls you about him or her.
6. Documenting patient complaints
View with skepticism any history that patients tell you about collateral sources until you confirm the information. All persons—delusional or competent—filter their experiences through their own beliefs.
Be cautious about documenting a patient’s report of abusive treatment as factual. Preface documentation of derogatory or accusatory statements with comments such as, “The patient claims…” or “The patient feels….”
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL
Writing progress notes: 10 dos and don’ts
Progress notes must convey that the psychiatrist provided quality care and respected the patient’s condition and wishes. Knowing what information to include—and what to leave out—can help you and your colleagues avoid a malpractice judgment.
Follow these 10 dos and don’ts of writing progress notes:
1. Be concise. Document all necessary information but avoid extraneous details, such as in this example:
“Patient moved to Kansas at age 4. Her parents separated when she was 6 and they moved back to Chicago, then reunited and moved to Indiana, where father took a job as a shoe salesman. When he lost that job, they moved back to Chicago and divorced for good. Mother remarried a fireman, who was an alcoholic; they stayed together for 2 years until …”
Instead, simply write:
“Patient’s childhood was chaotic with many moves; her mother remarried x 3. No physical or sexual abuse …”
2. Include adequate details. Do not exclude information critical to explaining treatment decisions. Describe the symptoms the patient is reporting and the signs you see—or do not see.
This example offers insufficient detail:
“Patient’s parents told her that they just bought a new car. She recalled the first car they had gotten when she was little, and how that made her happy. She talked about the first car she owned. Plan: Add lithium …”
By contrast, the following example explicitly describes signs and symptoms. Also be sure to include a short explanation when changing, discontinuing, or adding a medication:
“Patient reports her mood is much improved. She cannot recall what made her feel so depressed last week. She is hyperverbal, talking rapidly, gesticulating as she talks—much more animated, as compared to psychomotor-retarded presentation of last week, when SSRI was started. Assess: Bipolar switch. Plan: Add lithium, 300 mg bid, and titrate.”
3. Be careful when describing treatment of a patient who is suicidal at presentation. Your notes must contain clear, well-reasoned explanations for:
- discontinuing suicide precautions
- not hospitalizing outpatients who express suicidal ideation.
If the patient attempts or commits suicide shortly after the visit, your progress note may be your best—and only—defense against a malpractice claim. This example offers no convincing argument that the patient will not attempt suicide:
“Patient reports that he feels better. He denies suicidal ideation. He thinks the antidepressant is working. Nursing notes indicate no problems. He would like to get dressed and take a walk outside …”
Instead, verbatim patient statements offer more-concrete proof that the patient wants to live:
“He said he is his family’s sole support and could never abandon them …”
“He said it would kill his mother if he took his own life …”
“She said suicide is against her religion …”
Simply writing “No evidence of suicidal/homicidal ideation” raises the question of whether you asked the patient if he or she has considered suicide or just looked for a sign indicating suicidality. Always ask and record the patient’s exact response.
4. Remember that other clinicians will view the chart to make decisions about your patient’s care. Consider this example:
“Patient just moved to this area and requests amitriptyline and chlorpromazine. The risks of combining these medications were explained to him, but he insisted, so will order.”
If another provider is to grant the patient’s request, more details are needed:
“Patient states that he has been on every antipsychotic and antidepressant on the market—including the newest drugs—over 20 years. He says nothing works for him except this combination. The potential anticholinergic and other severe adverse effects associated with this combination were explained to him, and his responses indicated that he clearly understands the risks. He states, ‘These are the only drugs that have kept me from hearing voices and being depressed and suicidal. I want to stay on this combination.’ ”
5. Write legibly. Many doctors are encouraged to write illegible notes as a defense against legal action. The reasoning: the defendant can testify to anything since no one can read the notes anyway.
Illegible notes annoy and frustrate the people who cannot read them and inspire a lack of trust and confidence in the doctor who wrote them. And they are not likely to fool a jury.
6. Respect patient privacy. Do not name or quote anyone who is not essential to the record. Identifying another patient by name or Social Security number—even the last 4 digits—is a breach of privacy. For example:
“Charlene claimed R2803 followed her into the rest room and raped her…”
Did patient R2803 actually do this? What if Charlene’s psychosis prompted her to make delusional claims about other patients and staff? If her case ends up in court, patient R2803 is named in connection with an unproven allegation. Naming R2803 in Charlene’s chart identifies him as a psychiatric patient at that facility, thus violating his privacy.
If your patient makes accusations toward another patient, describe the alleged encounter this way:
“Charlene was upset over an interaction she described with another patient. Staff allowed her time to ventilate, and (name/dose of sedative) was given. The incident was addressed with the other patient’s treatment team and staff … ”
7. Do not include complaints about other staff members, whether from the patient, staff, or a doctor.
Let’s say a resident pages his backup attending but receives no answer. Entering in the patient’s chart that “Dr. Smith was paged but did not answer” gives the impression that Dr. Smith is ignoring calls, when in fact any of the following may be true:
- the resident does not realize Dr. Smith traded on-call duty with another doctor
- the batteries in Dr. Smith’s pager died
- or Dr. Smith was home, available by telephone, with his pager tucked away in his briefcase.
If the doctor on call cannot be reached, call another doctor—a supervisor or department head—and document your conversation with him or her. Do not identify the doctor who was not available.
Supervisors should address doctor availability issues the following day. Such issues do not belong in a patient’s chart.
8. Document responses to and from other providers. When consulting another doctor for advice, describe the encounter and identify the doctor by name. For example:
“Dr. Mark Jones advised me to accommodate the patient’s request for discharge, because he has known the patient for many years and feels it is safe for the patient to come to see him at the clinic in the morning.”
9. When disregarding a consultant’s advice, clearly explain why. For example:
“Neurology consultant recommended stopping patient’s antipsychotic due to risk of tardive dyskinesia. This patient, however, has been on numerous antipsychotics over the years, and this is the only one that controls his schizophrenia. Patient is aware of the risk of tardive dyskinesia and does not find it problematic. Patient is competent and understands the need to weigh potential side effects against the medication’s benefits, and he prefers to continue the medication.”
10. Never enter derogatory or pejorative statements about a patient. As psychiatrists, we must convey a sense of concern and respect for the patient, regardless of diagnosis and presentation.
Rather than entering, “This patient is obviously lying about his history,” instead write, “This patient’s version of his history is at odds with that in previous hospital records.”
Related resources
- Selden BS, Schnitzer PG, Nolan FX. Medicolegal documentation of prehospital triage. Ann Emerg Med 1990;19:547-51.
- Bjorck JP, Brown J, Goodman M. Casebook for managing managed care: a self-study guide for treatment planning, documentation, and communication (1st ed). Washington, DC: American Psychiatric Association, 2000.
- Wiger DE. The clinical documentation sourcebook: a comprehensive collection of mental health practice forms, handouts, and records (2nd ed). New York: John Wiley &Sons, 1999.
Drug brand names
- Amitriptyline • Elavil
- Chlorpromazine • Thorazine
- Lithium • Eskalith, others
Progress notes must convey that the psychiatrist provided quality care and respected the patient’s condition and wishes. Knowing what information to include—and what to leave out—can help you and your colleagues avoid a malpractice judgment.
Follow these 10 dos and don’ts of writing progress notes:
1. Be concise. Document all necessary information but avoid extraneous details, such as in this example:
“Patient moved to Kansas at age 4. Her parents separated when she was 6 and they moved back to Chicago, then reunited and moved to Indiana, where father took a job as a shoe salesman. When he lost that job, they moved back to Chicago and divorced for good. Mother remarried a fireman, who was an alcoholic; they stayed together for 2 years until …”
Instead, simply write:
“Patient’s childhood was chaotic with many moves; her mother remarried x 3. No physical or sexual abuse …”
2. Include adequate details. Do not exclude information critical to explaining treatment decisions. Describe the symptoms the patient is reporting and the signs you see—or do not see.
This example offers insufficient detail:
“Patient’s parents told her that they just bought a new car. She recalled the first car they had gotten when she was little, and how that made her happy. She talked about the first car she owned. Plan: Add lithium …”
By contrast, the following example explicitly describes signs and symptoms. Also be sure to include a short explanation when changing, discontinuing, or adding a medication:
“Patient reports her mood is much improved. She cannot recall what made her feel so depressed last week. She is hyperverbal, talking rapidly, gesticulating as she talks—much more animated, as compared to psychomotor-retarded presentation of last week, when SSRI was started. Assess: Bipolar switch. Plan: Add lithium, 300 mg bid, and titrate.”
3. Be careful when describing treatment of a patient who is suicidal at presentation. Your notes must contain clear, well-reasoned explanations for:
- discontinuing suicide precautions
- not hospitalizing outpatients who express suicidal ideation.
If the patient attempts or commits suicide shortly after the visit, your progress note may be your best—and only—defense against a malpractice claim. This example offers no convincing argument that the patient will not attempt suicide:
“Patient reports that he feels better. He denies suicidal ideation. He thinks the antidepressant is working. Nursing notes indicate no problems. He would like to get dressed and take a walk outside …”
Instead, verbatim patient statements offer more-concrete proof that the patient wants to live:
“He said he is his family’s sole support and could never abandon them …”
“He said it would kill his mother if he took his own life …”
“She said suicide is against her religion …”
Simply writing “No evidence of suicidal/homicidal ideation” raises the question of whether you asked the patient if he or she has considered suicide or just looked for a sign indicating suicidality. Always ask and record the patient’s exact response.
4. Remember that other clinicians will view the chart to make decisions about your patient’s care. Consider this example:
“Patient just moved to this area and requests amitriptyline and chlorpromazine. The risks of combining these medications were explained to him, but he insisted, so will order.”
If another provider is to grant the patient’s request, more details are needed:
“Patient states that he has been on every antipsychotic and antidepressant on the market—including the newest drugs—over 20 years. He says nothing works for him except this combination. The potential anticholinergic and other severe adverse effects associated with this combination were explained to him, and his responses indicated that he clearly understands the risks. He states, ‘These are the only drugs that have kept me from hearing voices and being depressed and suicidal. I want to stay on this combination.’ ”
5. Write legibly. Many doctors are encouraged to write illegible notes as a defense against legal action. The reasoning: the defendant can testify to anything since no one can read the notes anyway.
Illegible notes annoy and frustrate the people who cannot read them and inspire a lack of trust and confidence in the doctor who wrote them. And they are not likely to fool a jury.
6. Respect patient privacy. Do not name or quote anyone who is not essential to the record. Identifying another patient by name or Social Security number—even the last 4 digits—is a breach of privacy. For example:
“Charlene claimed R2803 followed her into the rest room and raped her…”
Did patient R2803 actually do this? What if Charlene’s psychosis prompted her to make delusional claims about other patients and staff? If her case ends up in court, patient R2803 is named in connection with an unproven allegation. Naming R2803 in Charlene’s chart identifies him as a psychiatric patient at that facility, thus violating his privacy.
If your patient makes accusations toward another patient, describe the alleged encounter this way:
“Charlene was upset over an interaction she described with another patient. Staff allowed her time to ventilate, and (name/dose of sedative) was given. The incident was addressed with the other patient’s treatment team and staff … ”
7. Do not include complaints about other staff members, whether from the patient, staff, or a doctor.
Let’s say a resident pages his backup attending but receives no answer. Entering in the patient’s chart that “Dr. Smith was paged but did not answer” gives the impression that Dr. Smith is ignoring calls, when in fact any of the following may be true:
- the resident does not realize Dr. Smith traded on-call duty with another doctor
- the batteries in Dr. Smith’s pager died
- or Dr. Smith was home, available by telephone, with his pager tucked away in his briefcase.
If the doctor on call cannot be reached, call another doctor—a supervisor or department head—and document your conversation with him or her. Do not identify the doctor who was not available.
Supervisors should address doctor availability issues the following day. Such issues do not belong in a patient’s chart.
8. Document responses to and from other providers. When consulting another doctor for advice, describe the encounter and identify the doctor by name. For example:
“Dr. Mark Jones advised me to accommodate the patient’s request for discharge, because he has known the patient for many years and feels it is safe for the patient to come to see him at the clinic in the morning.”
9. When disregarding a consultant’s advice, clearly explain why. For example:
“Neurology consultant recommended stopping patient’s antipsychotic due to risk of tardive dyskinesia. This patient, however, has been on numerous antipsychotics over the years, and this is the only one that controls his schizophrenia. Patient is aware of the risk of tardive dyskinesia and does not find it problematic. Patient is competent and understands the need to weigh potential side effects against the medication’s benefits, and he prefers to continue the medication.”
10. Never enter derogatory or pejorative statements about a patient. As psychiatrists, we must convey a sense of concern and respect for the patient, regardless of diagnosis and presentation.
Rather than entering, “This patient is obviously lying about his history,” instead write, “This patient’s version of his history is at odds with that in previous hospital records.”
Related resources
- Selden BS, Schnitzer PG, Nolan FX. Medicolegal documentation of prehospital triage. Ann Emerg Med 1990;19:547-51.
- Bjorck JP, Brown J, Goodman M. Casebook for managing managed care: a self-study guide for treatment planning, documentation, and communication (1st ed). Washington, DC: American Psychiatric Association, 2000.
- Wiger DE. The clinical documentation sourcebook: a comprehensive collection of mental health practice forms, handouts, and records (2nd ed). New York: John Wiley &Sons, 1999.
Drug brand names
- Amitriptyline • Elavil
- Chlorpromazine • Thorazine
- Lithium • Eskalith, others
Progress notes must convey that the psychiatrist provided quality care and respected the patient’s condition and wishes. Knowing what information to include—and what to leave out—can help you and your colleagues avoid a malpractice judgment.
Follow these 10 dos and don’ts of writing progress notes:
1. Be concise. Document all necessary information but avoid extraneous details, such as in this example:
“Patient moved to Kansas at age 4. Her parents separated when she was 6 and they moved back to Chicago, then reunited and moved to Indiana, where father took a job as a shoe salesman. When he lost that job, they moved back to Chicago and divorced for good. Mother remarried a fireman, who was an alcoholic; they stayed together for 2 years until …”
Instead, simply write:
“Patient’s childhood was chaotic with many moves; her mother remarried x 3. No physical or sexual abuse …”
2. Include adequate details. Do not exclude information critical to explaining treatment decisions. Describe the symptoms the patient is reporting and the signs you see—or do not see.
This example offers insufficient detail:
“Patient’s parents told her that they just bought a new car. She recalled the first car they had gotten when she was little, and how that made her happy. She talked about the first car she owned. Plan: Add lithium …”
By contrast, the following example explicitly describes signs and symptoms. Also be sure to include a short explanation when changing, discontinuing, or adding a medication:
“Patient reports her mood is much improved. She cannot recall what made her feel so depressed last week. She is hyperverbal, talking rapidly, gesticulating as she talks—much more animated, as compared to psychomotor-retarded presentation of last week, when SSRI was started. Assess: Bipolar switch. Plan: Add lithium, 300 mg bid, and titrate.”
3. Be careful when describing treatment of a patient who is suicidal at presentation. Your notes must contain clear, well-reasoned explanations for:
- discontinuing suicide precautions
- not hospitalizing outpatients who express suicidal ideation.
If the patient attempts or commits suicide shortly after the visit, your progress note may be your best—and only—defense against a malpractice claim. This example offers no convincing argument that the patient will not attempt suicide:
“Patient reports that he feels better. He denies suicidal ideation. He thinks the antidepressant is working. Nursing notes indicate no problems. He would like to get dressed and take a walk outside …”
Instead, verbatim patient statements offer more-concrete proof that the patient wants to live:
“He said he is his family’s sole support and could never abandon them …”
“He said it would kill his mother if he took his own life …”
“She said suicide is against her religion …”
Simply writing “No evidence of suicidal/homicidal ideation” raises the question of whether you asked the patient if he or she has considered suicide or just looked for a sign indicating suicidality. Always ask and record the patient’s exact response.
4. Remember that other clinicians will view the chart to make decisions about your patient’s care. Consider this example:
“Patient just moved to this area and requests amitriptyline and chlorpromazine. The risks of combining these medications were explained to him, but he insisted, so will order.”
If another provider is to grant the patient’s request, more details are needed:
“Patient states that he has been on every antipsychotic and antidepressant on the market—including the newest drugs—over 20 years. He says nothing works for him except this combination. The potential anticholinergic and other severe adverse effects associated with this combination were explained to him, and his responses indicated that he clearly understands the risks. He states, ‘These are the only drugs that have kept me from hearing voices and being depressed and suicidal. I want to stay on this combination.’ ”
5. Write legibly. Many doctors are encouraged to write illegible notes as a defense against legal action. The reasoning: the defendant can testify to anything since no one can read the notes anyway.
Illegible notes annoy and frustrate the people who cannot read them and inspire a lack of trust and confidence in the doctor who wrote them. And they are not likely to fool a jury.
6. Respect patient privacy. Do not name or quote anyone who is not essential to the record. Identifying another patient by name or Social Security number—even the last 4 digits—is a breach of privacy. For example:
“Charlene claimed R2803 followed her into the rest room and raped her…”
Did patient R2803 actually do this? What if Charlene’s psychosis prompted her to make delusional claims about other patients and staff? If her case ends up in court, patient R2803 is named in connection with an unproven allegation. Naming R2803 in Charlene’s chart identifies him as a psychiatric patient at that facility, thus violating his privacy.
If your patient makes accusations toward another patient, describe the alleged encounter this way:
“Charlene was upset over an interaction she described with another patient. Staff allowed her time to ventilate, and (name/dose of sedative) was given. The incident was addressed with the other patient’s treatment team and staff … ”
7. Do not include complaints about other staff members, whether from the patient, staff, or a doctor.
Let’s say a resident pages his backup attending but receives no answer. Entering in the patient’s chart that “Dr. Smith was paged but did not answer” gives the impression that Dr. Smith is ignoring calls, when in fact any of the following may be true:
- the resident does not realize Dr. Smith traded on-call duty with another doctor
- the batteries in Dr. Smith’s pager died
- or Dr. Smith was home, available by telephone, with his pager tucked away in his briefcase.
If the doctor on call cannot be reached, call another doctor—a supervisor or department head—and document your conversation with him or her. Do not identify the doctor who was not available.
Supervisors should address doctor availability issues the following day. Such issues do not belong in a patient’s chart.
8. Document responses to and from other providers. When consulting another doctor for advice, describe the encounter and identify the doctor by name. For example:
“Dr. Mark Jones advised me to accommodate the patient’s request for discharge, because he has known the patient for many years and feels it is safe for the patient to come to see him at the clinic in the morning.”
9. When disregarding a consultant’s advice, clearly explain why. For example:
“Neurology consultant recommended stopping patient’s antipsychotic due to risk of tardive dyskinesia. This patient, however, has been on numerous antipsychotics over the years, and this is the only one that controls his schizophrenia. Patient is aware of the risk of tardive dyskinesia and does not find it problematic. Patient is competent and understands the need to weigh potential side effects against the medication’s benefits, and he prefers to continue the medication.”
10. Never enter derogatory or pejorative statements about a patient. As psychiatrists, we must convey a sense of concern and respect for the patient, regardless of diagnosis and presentation.
Rather than entering, “This patient is obviously lying about his history,” instead write, “This patient’s version of his history is at odds with that in previous hospital records.”
Related resources
- Selden BS, Schnitzer PG, Nolan FX. Medicolegal documentation of prehospital triage. Ann Emerg Med 1990;19:547-51.
- Bjorck JP, Brown J, Goodman M. Casebook for managing managed care: a self-study guide for treatment planning, documentation, and communication (1st ed). Washington, DC: American Psychiatric Association, 2000.
- Wiger DE. The clinical documentation sourcebook: a comprehensive collection of mental health practice forms, handouts, and records (2nd ed). New York: John Wiley &Sons, 1999.
Drug brand names
- Amitriptyline • Elavil
- Chlorpromazine • Thorazine
- Lithium • Eskalith, others