Current Psychiatry

In some patients, symptoms of depres­sion, psychosis, delirium, or dementia exist concomitantly with, or as a result of, an abnormal (elevated or low) serum cal­cium concentration that has been precipi­tated by an unrecognized endocrinopathy. The apparent psychiatric presentations of such patients might reflect parathyroid pathology—not psychopathology.

Hypercalcemia and hypocalcemia often are related to a distinct spectrum of condi­tions, such as diseases of the parathyroid glands, kidneys, and various neoplasms including malignancies. Be alert to the pos­sibility of parathyroid disease in patients whose presentation suggests mental ill­ness concurrent with, or as a direct conse­quence of, an abnormal calcium level, and investigate appropriately.

The Table^1-9 illustrates how 3 clini­cal laboratory tests—serum calcium, serum parathyroid hormone (PTH), and phosphate—can narrow the differen­tial diagnosis when the clinical impres­sion is parathyroid-related illness. Seek endocrinology consultation whenever a parathyroid-associated ailment is discov­ered or suspected. Serum calcium is rou­tinely assayed in hospitalized patients; when managing a patient with treatment-refractory psychiatric illness, (1) always check the reported result of that test and (2) consider measuring PTH.

Case reports¹
Case 1: Woman with chronic depression. The patient was hospitalized while suicidal. Serial serum calcium levels were 12.5 mg/dL and 15.8 mg/dL (reference range, 8.2–10.2 mg/dL). The PTH level was elevated at 287 pg/mL (refer­ence range, 10–65 pg/mL).

After thyroid imaging, surgery revealed a parathyroid mass, which was resected. Histologic examination confirmed an adenoma.

The calcium concentration declined to 8.6 mg/dL postoperatively and stabilized at 9.2 mg/dL. Psychiatric symptoms resolved fully; she experienced a complete recovery.

Case 2: Man on long-term lithium mainte­nance. The patient was admitted in a delusional psychotic state. The serum calcium level was 14.3 mg/dL initially, decreasing to 11.5 mg/dL after lithium was discontinued. The PTH level was elevated at 97 pg/mL at admission, consis­tent with hyperparathyroidism.

A parathyroid adenoma was resected. Serum calcium level normalized at 10.7 mg/dL; psycho­sis resolved with striking, sustained improve­ment in mental status.

Full return to mental, physical health

The diagnosis of parathyroid adenoma in these 2 patients, which began with a psy­chiatric presentation, was properly made after an abnormal serum calcium level was documented. Surgical treatment of the endocrinopathy produced full remission and a return to normal mental and physi­cal health.

Although psychiatric manifestations are associated with an abnormal serum calcium concentration, the severity of those presen­tations does not correlate with the degree of abnormality of the calcium level.¹⁰

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

In some patients, symptoms of depres­sion, psychosis, delirium, or dementia exist concomitantly with, or as a result of, an abnormal (elevated or low) serum cal­cium concentration that has been precipi­tated by an unrecognized endocrinopathy. The apparent psychiatric presentations of such patients might reflect parathyroid pathology—not psychopathology.

Hypercalcemia and hypocalcemia often are related to a distinct spectrum of condi­tions, such as diseases of the parathyroid glands, kidneys, and various neoplasms including malignancies. Be alert to the pos­sibility of parathyroid disease in patients whose presentation suggests mental ill­ness concurrent with, or as a direct conse­quence of, an abnormal calcium level, and investigate appropriately.

The Table^1-9 illustrates how 3 clini­cal laboratory tests—serum calcium, serum parathyroid hormone (PTH), and phosphate—can narrow the differen­tial diagnosis when the clinical impres­sion is parathyroid-related illness. Seek endocrinology consultation whenever a parathyroid-associated ailment is discov­ered or suspected. Serum calcium is rou­tinely assayed in hospitalized patients; when managing a patient with treatment-refractory psychiatric illness, (1) always check the reported result of that test and (2) consider measuring PTH.

Case reports¹
Case 1: Woman with chronic depression. The patient was hospitalized while suicidal. Serial serum calcium levels were 12.5 mg/dL and 15.8 mg/dL (reference range, 8.2–10.2 mg/dL). The PTH level was elevated at 287 pg/mL (refer­ence range, 10–65 pg/mL).

After thyroid imaging, surgery revealed a parathyroid mass, which was resected. Histologic examination confirmed an adenoma.

The calcium concentration declined to 8.6 mg/dL postoperatively and stabilized at 9.2 mg/dL. Psychiatric symptoms resolved fully; she experienced a complete recovery.

Case 2: Man on long-term lithium mainte­nance. The patient was admitted in a delusional psychotic state. The serum calcium level was 14.3 mg/dL initially, decreasing to 11.5 mg/dL after lithium was discontinued. The PTH level was elevated at 97 pg/mL at admission, consis­tent with hyperparathyroidism.

A parathyroid adenoma was resected. Serum calcium level normalized at 10.7 mg/dL; psycho­sis resolved with striking, sustained improve­ment in mental status.

Full return to mental, physical health

The diagnosis of parathyroid adenoma in these 2 patients, which began with a psy­chiatric presentation, was properly made after an abnormal serum calcium level was documented. Surgical treatment of the endocrinopathy produced full remission and a return to normal mental and physi­cal health.

Although psychiatric manifestations are associated with an abnormal serum calcium concentration, the severity of those presen­tations does not correlate with the degree of abnormality of the calcium level.¹⁰

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

In some patients, symptoms of depres­sion, psychosis, delirium, or dementia exist concomitantly with, or as a result of, an abnormal (elevated or low) serum cal­cium concentration that has been precipi­tated by an unrecognized endocrinopathy. The apparent psychiatric presentations of such patients might reflect parathyroid pathology—not psychopathology.

Hypercalcemia and hypocalcemia often are related to a distinct spectrum of condi­tions, such as diseases of the parathyroid glands, kidneys, and various neoplasms including malignancies. Be alert to the pos­sibility of parathyroid disease in patients whose presentation suggests mental ill­ness concurrent with, or as a direct conse­quence of, an abnormal calcium level, and investigate appropriately.

The Table^1-9 illustrates how 3 clini­cal laboratory tests—serum calcium, serum parathyroid hormone (PTH), and phosphate—can narrow the differen­tial diagnosis when the clinical impres­sion is parathyroid-related illness. Seek endocrinology consultation whenever a parathyroid-associated ailment is discov­ered or suspected. Serum calcium is rou­tinely assayed in hospitalized patients; when managing a patient with treatment-refractory psychiatric illness, (1) always check the reported result of that test and (2) consider measuring PTH.

Case reports¹
Case 1: Woman with chronic depression. The patient was hospitalized while suicidal. Serial serum calcium levels were 12.5 mg/dL and 15.8 mg/dL (reference range, 8.2–10.2 mg/dL). The PTH level was elevated at 287 pg/mL (refer­ence range, 10–65 pg/mL).

After thyroid imaging, surgery revealed a parathyroid mass, which was resected. Histologic examination confirmed an adenoma.

The calcium concentration declined to 8.6 mg/dL postoperatively and stabilized at 9.2 mg/dL. Psychiatric symptoms resolved fully; she experienced a complete recovery.

Case 2: Man on long-term lithium mainte­nance. The patient was admitted in a delusional psychotic state. The serum calcium level was 14.3 mg/dL initially, decreasing to 11.5 mg/dL after lithium was discontinued. The PTH level was elevated at 97 pg/mL at admission, consis­tent with hyperparathyroidism.

A parathyroid adenoma was resected. Serum calcium level normalized at 10.7 mg/dL; psycho­sis resolved with striking, sustained improve­ment in mental status.

Full return to mental, physical health

The diagnosis of parathyroid adenoma in these 2 patients, which began with a psy­chiatric presentation, was properly made after an abnormal serum calcium level was documented. Surgical treatment of the endocrinopathy produced full remission and a return to normal mental and physi­cal health.

Although psychiatric manifestations are associated with an abnormal serum calcium concentration, the severity of those presen­tations does not correlate with the degree of abnormality of the calcium level.¹⁰

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
   • Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
   • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
   • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.


Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
   • Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
   • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
   • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.


Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
   • Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
   • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
   • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.


Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.

CASE Seizures, amnesia
Ms. A, age 13, who has a history of seizures, presents to the emergency department (ED) with sudden onset of memory loss. Her family reports that she had been spend­ing a normal evening at home with family and friends. After going to the bathroom, Ms. A became acutely confused and extremely upset, had slurred speech, and did not recognize anyone in the room except her mother.

Initial neurologic examination in the ED reports that Ms. A does not remember recent or remote past events. Her family denies any recent stressors.

Vital signs are within normal range. She has mild muscle soreness and gait instability, which is attributed to a presumed postictal phase. Her medication regimen includes: leve­tiracetam, 500 mg, 3 times a day; valproic acid, 1,000 mg/d; and oxcarbazepine, 2,400 mg/d, for seizure management.

Complete blood count and comprehen­sive metabolic panel are within normal limits. Pregnancy test is negative. Urine toxicology report is negative. Serum valproic acid level is 71 μg/mL; oxcarbazepine level, <2 μg/mL; ammonia level, 71 μg/dL (reference range, 15 to 45 μg/dL). Other than the aforementioned deficits, she is neurologically intact. The team thinks that her symptoms are part of a postic­tal phase of an unwitnessed seizure.

Ms. A is admitted to the inpatient medi­cal unit for further work up. Along with the memory loss and seizures, she reports visual hallucinations.

What could be causing Ms. A’s amnesia?
   a) a seizure disorder
   b) malingering
   c) posttraumatic stress disorder
   d) traumatic brain injury

HISTORY Repeat ED visits
Ms. A’s mother reports that 3 years ago her daughter was treated for tics with quetiapine and aripiprazole, prescribed by a primary care physician. She received a short course of coun­seling 6 years ago after her sister was sexually abused by her grandfather. Approximately 6 months ago, Ms. A engaged in self-injurious behavior by cutting herself, and she briefly received counseling. There is no history of sui­cide attempts, psychiatric hospitalization, or a psychiatric diagnosis.

Medical and surgical history include viral meningitis at age 6 months. Medical records show a visit to the ED for abdominal pain after a classmate punched her in the abdomen, which resolved with supportive care. She was given a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections 6 years ago.

Ms. A developed multiple recurrent methicillin-resistant Staphylococcus aureus abscesses a year ago, which lasted for 4 months; it was noted that she was self-inoculating by scratching eczema. She had a possible syncopal episode 5 months ago, but the medical work-up was normal. The pediat­ric neurology service diagnosed and treated seizures 4 months ago.

Levetiracetam was prescribed after a pos­sible syncopal episode followed by a tonic-clonic seizure. Because she was still having seizure-like episodes with a single antiepilep­tic drug (AED), oxcarbazepine, then valproic acid were added. Whether her seizures were generalized or partial was inconclusive. The seizures were followed by a postictal phase lasting 3 minutes to 1 hour. Her last general­ized tonic-clonic seizure was 1 month before admission.

Ms. A had 3 MRI studies of the brain over the past 3 years, which showed consistent and unchanged multifocal punctate white matter lesions. The findings represented gliosis from an old perivascular inflammation, trauma, or ischemic damage. There is no history of trau­matic brain injury.

Her perinatal history is unremarkable, with normal vaginal delivery at 36 weeks (pre-term birth). All developmental milestones were on target.

Ms. A lives at home with her mother, 6-year-old brother, and stepfather. Her par­ents are divorced, but her biological father has been involved in her upbringing. She is in seventh grade, but is home schooled after she withdrew from school because of mul­tiple seizure episodes. Ms. A denied bullying at school although she had been punched by a peer. It was unclear if it was a single incident or bullying continued and she was hesitant to disclose it.

The authors’ observations
We focus on the amnesia because it has an acute onset and it seems this is the first time Ms. A presented with this symptom. There is no need to wait for neurology consultation, even though organic causes of amnesia need to be ruled out. Our plan is to develop rapport with Ms. A, and then administer a mental status examina­tion focusing on memory assessment. We understand that, because Ms. A’s chief concern is amnesia, she might not be able to provide many details. We start the initial interview with the family in the patient’s room to understand family dynamics, and then interview Ms. A alone.

EVALUATION Memory problems
On initial psychiatric interview, Ms. A can rec­ognize some of her family members. She is seen in clean attire, with short hair, lying in the bed with good eye contact and a calm demeanor. She seems to be difficult to engage because of her reserved nature.

Ms. A displays some psychomotor retarda­tion. She reports her mood as tired, and her affect is flat and mood incongruent. She is alert and oriented to person only; not to place, time, or situation. She can do a simple spell­ing task, perform 5-minute recall of 3 words, complete serial 3 subtractions, repeat phrases, read aloud, focus on a coin task, and name simple objects. She does not compare similar objects or answer simple historical or factual questions.

Ms. A replies “I don’t know” to most his­torical questions, such as her birthday, favor­ite color, and family members; she does not answer when asked how many legs a dog has, who is the current or past president, what month the Fourth of July is in, or when Christmas is. She can complete some memory tasks on the Mini-Mental State Examination, but does not attempt many others. Ms. A says she is upset about her memory deficit, but her affect was flat. Her mood and her affect were incongruent. She describes a vision of a “girl with black holes [for eyes]” in the corner of her hospital room telling her not to believe any­one and that the interviewers are lying to her. Also, she reports that “the girl” tells her to hurt herself and others, but she is not going to act on the commands because she knows it is not the right thing to do. When we ask Ms. A about a history of substance abuse, she says she has never heard of drugs or alcohol.

Overall, she displays multiple apparent deficits in declarative memory, both episodic and semantic. Regarding non-declarative or procedural memory, she can dress herself, use the bathroom independently, order meals off the menu, and feed herself, among other rou­tine tasks, without difficulty.

According to Ms. A’s mother, Ms. A has shown a decline in overall functioning and personality changes during the past 5 months. She started to cut herself superficially on her forearms 6 months ago and also tried to change her appearance with a new hairstyle when school started. She displayed noticeably intense and disturbing writings, artwork, and conversations with others over 3 to 4 months.

She started experiencing seizures, with 3 to 4 seizures a day; however, she could attend sleepovers seizure-free. She had prolonged periods of seizures lasting up to an hour, much longer than would be expected clinically. She also had requested to go to the cemetery for unclear reasons (because the spirit wanted her to visit), and was observed mumbling under her breath.

Six years ago, Ms. A’s 6-year-old sister tried to suffocate her infant brother. Child protec­tive services was involved and the sister was hospitalized in a psychiatric facility, where she was given a diagnosis of bipolar disorder; she was then transferred to foster care, and later placed in residential treatment. Her mother relinquished her parental rights and gave cus­tody of Ms. A’s sister to the state.

Ms. A’s mother has a history of depression, but her younger brother is healthy. There is no history of autism, attention problems, tics, substance abuse, brain tumor, or intellectual disabilities in the family.

Which diagnosis does Ms. A’s presentation and history suggest?
   a) dissociative amnesia
   b) factitious disorder imposed on self
   c) conversion disorder (neurological symp­tom disorder)
   d) psychosis not otherwise specified
   e) malingering

The authors’ observations
The history of unwitnessed seizures, sud­den onset of visual hallucinations, and transient amnesia points to a possible post­ictal cause. Selective amnesia brings up the question of whether psychological compo­nents are driving the symptoms.

Her psychotic symptoms appear to be mediated by anxiety and possibly related to the trauma of losing her only sister when her mother relinquished custody to the state; the circumstances might have aroused feelings of insecurity or fear of abandonment and raised questions about her mother’s love toward her. Her sis­ter’s abuse by a family member might have created reticence to trust others. These background experiences could be intensely conflicting at this age when the second separation individuation process commences, especially in an emotionally immature adolescent.

OUTCOME Medication change
The neurology team recommends discontinuing levetiracetam because the visual hallucinations, mood disturbance, and personality change could be adverse effects of the drug. Because of generalized uncontrolled body movements with staring episodes and unresponsiveness, an EEG is ordered to rule out ongoing seizures.

Ms. A recognizes the psychosomatic medi­cine team members when they interview her again. The team employs consistent reassur­ance and a non-confrontational approach. She spends 3 days in the medical unit during which she reports that the frequency of visual and auditory hallucinations decreases and her memory symptoms resolve. Her 24-hour EEG is negative for seizure activity, and the 24-hour video EEG does not show any signs of epilepto­genic foci. Ms. A’s family declines inpatient psy­chiatric hospitalization.

Because of gradual improvement in Ms. A’s symptoms and no imminent safety concerns, she is discharged home with valproic acid, 1,000 mg/d, and oxcarbazepine, 1,200 mg/d, and follow-up appointments with her primary care physician, a neurologist, and a psychiatrist.

The authors’ observations
Dissociative amnesia
Generalized dissociative amnesia is dif­ficult to differentiate from factitious disorder or malingering. According to DSM-5, there is loss of episodic memory in dissociative amnesia, in which the person is unable to recall the stressful event after trauma (Table 1).¹ Although there have been case reports of dissocia­tive amnesia with loss of semantic and procedural memory, episodic memory is the last to return.² In Ms. A’s case, there was no immediate basis to explain amne­sia onset, although she had experienced the trauma of losing her sister. She had episodic and mostly semantic memory loss.

Although organic causes can pre­cipitate amnesia,³ Ms. A’s EEG and MRI results did not reflect that. Patients with a dissociative disorder often report some physical, sexual, or emotional abuse.⁴ Although Ms. A did not report any abuse, it cannot be completely ruled out because of her sister’s history of abuse.

Suicidality or self-injurious behavior is common among adults with dissociative amnesia, although it is not well studied in children.^4,5 Generally, the constella­tion of primary dissociative symptoms that patients develop are forgetfulness, fragmentation, and emotional numbing. Ms. A presented with some of these fea­tures; did she, in fact, have dissociative amnesia?

Factitious amnesia
Factious amnesia (Table 2)⁶ is a symptom of factious disorder in which amnesia appears with the motivation to assume a sick role.³ Ms. A’s amnesia garnered sig­nificant attention from her mother and other family members; this may have been related to insecurity in her family relationships because her sister was given up to the state. She also could be afraid of entering adolescence and leaving her sister behind. Did she want more time to bond with her mother? Did she experi­ence emotional benefit from being cared for by medical professionals?⁷ Her affect during interviews was blunted and her attitude was nonchalant, and her multiple visits to the hospital since childhood for abdominal pain, abscesses (it isn’t clear whether the abscesses were related to self-injury and scratching), tics, seizures, and, recently, amnesia and hallucinations indi­cated some desire to occupy a sick role. Furthermore, the severity of her symp­toms seemed to be increasing over time, from somatic to neurologic (seizure-like episodes) to significant and less frequent psychiatric symptoms (amnesia and hal­lucinations). One could speculate that her symptoms were escalating because she was not receiving the attention she needed.

Malingered amnesia
Although malingering is not a psychi­atric diagnosis, it can be a focus of clini­cal attention. It is challenging to identify malingered cognitive impairments.⁸ Children often have difficulty malinger­ing symptoms because they have limited understanding of the illness they are try­ing to simulate.⁹ Many malingerers do not want to participate in their medical work up and might exhibit a hostile attitude toward examiners (Table 2⁶). Clinicians could rely on family to provide informa­tion regarding history and inconsistencies in clinical deficits.⁹ The clinical interview, mental status examination, and collateral information are crucial for identifying malingering.

Most of Ms. A’s seizure-like episodes happened in specific contexts, such as in school, but not at friends’ houses, raising the question of whether she is aware of her episodes. Ms. A’s grades are consis­tently good; because she is being home schooled, there is no secondary gain from not going to school. There is no other reason to speculate that she was malingering.

The inconsistency of Ms. A’s symptoms and her compliance with assessment and treatment did not reflect malingering. Interestingly, Ms. A’s amnesia was retrograde in nature. There have been more studies on malingered anterograde amne­sia⁸ than on retrograde amnesia, making her presentation even more unusual.

Amnesia presenting as conversion disorder
Amnesia as a symptom of conversion disorder is referred as psychogenic amne­sia; the memory loss mostly is isolated retrograde amnesia.¹⁰ Ms. A likely had unconsciously produced symptoms of non-epileptic seizures, followed by audi­tory and visual hallucinations not related to her seizures, and then later developed selective transient amnesia. Conversion disorder seemed to be the diagnosis most consistent with her indifference (“la belle indifference”) and the significant atten­tion she gained from the acute memory loss (Table 3).¹ It seemed that she devel­oped multiple symptoms in progression leading toward a conversion disorder diagnosis. The question arises whether Ms. A’s presentation is a gradually increasing cry for help or reflects depres­sive or anxiety symptoms, which often are comorbid with conversion disorder.

FOLLOW-UP Suicide attempt
Ms. A has frequent visits to the ED with symp­toms of syncope and seizures and undergoes medical work-up and multiple EEGs. A pro­longed 5-day video EEG is performed to assess seizure episodes after AEDs were withdrawn, but no seizure activity is elicited. She also has an ED visit for recurrent tic emergence.

The last visit in the ED is for a suicide attempt with overdose of an unknown quantity of unspecified pills. Ms. A talks to a social worker, who reports that Ms. A needed answers to such questions as why her grandfather abused her sister? Could she have stopped them and made a difference for the family?

The authors’ observations
Conversion disorder arises from uncon­scious psychological conflicts, needs, or responses to trauma. Ms. A’s consistent conflict about her sister and grandfather’s relationship was evident from occasions when she tried to confide in hospital staff. During an ED visit, she reported her sis­ter’s abuse to a staff member. Another time, while recovering from sedation, she spontaneously spoke about her sister’s abuse. When asked again, she said she did not remember saying it.

Freud said that patients develop conver­sion disorder to avoid unacceptable conflict­ing thoughts and feelings.¹⁰ It appeared that Ms. A was struggling with these questions because she brought them up again when she visited the ED after the suicide attempt.

Dissociative symptoms arise from unsta­ble parenting and disciplining styles with variable family dynamics. Patients show extreme detachment and emotional unre­sponsiveness akin to attachment disorder.¹¹ Ms. A had inconsistent parenting because both her stepfather and biological father were involved with her care. Her mother had relinquished her parental rights to her sister, which indicated some attachment issues.

Ms. A’s idea that her mother was indifferent stemmed from her uncaring approach toward her sister and not able to understand her emotionally. Her amnesia could be thought of as “I don’t know you because I don’t remember that I am related to you.” The traumas of infancy (referred to as hidden traumas) that were a result of par­ent-child mismatch of needs and availabil­ity at times of distress might not be obvious to the examiner.¹¹

Although Ms. A’s infancy was reported to be unremarkable, there always is a question, especially in a consultation-liaison setting, of whether conversion disorder might be mask­ing an attachment problem. Perhaps with long-term psychotherapy, an attachment issue would be revealed.

Excluding an organic cause or a neuro­logic disorder is important when diagnosing conversion disorder¹⁰; Ms. A’s negative neu­rologic tests favored a diagnosis of amnesia due to conversion disorder. It appears that, although Ms. A presented with “transient amnesia,” she had underlying psychiatric symptoms, likely depression or anxiety. We were concerned about possible psychiatric comorbidity and recommended inpatient hospitalization to clarify the diagnosis and provide intensive therapy, but her family declined. She may have received outpatient services, but that was not documented.


Bottom Line
Psychogenic amnesia can be a form of conversion disorder or a symptom of
malingering; can occur in dissociative disorder; and can be factitious in nature.
Regardless of the cause, the condition requires continuous close follow up. Although organic causes of amnesia should be ruled out, mental health care can help address comorbid psychiatric symptoms and might change the course of the illness.

Related Resources
• Byatt N, Toor R. Young, pregnant, ataxic—and jilted. Current Psychiatry. 2015;14(1):44-49.
• Leipsic J. A teen who is wasting away. Current Psychiatry. 2013;12(6):40-45.

Drug Brand Names
Aripiprazole • Abilify              Quetiapine • Seroquel
Levetiracetam • Keppra         Valproic acid • Depakote
Oxcarbazepine • Trileptal

 Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Seizures, amnesia
Ms. A, age 13, who has a history of seizures, presents to the emergency department (ED) with sudden onset of memory loss. Her family reports that she had been spend­ing a normal evening at home with family and friends. After going to the bathroom, Ms. A became acutely confused and extremely upset, had slurred speech, and did not recognize anyone in the room except her mother.

Initial neurologic examination in the ED reports that Ms. A does not remember recent or remote past events. Her family denies any recent stressors.

Vital signs are within normal range. She has mild muscle soreness and gait instability, which is attributed to a presumed postictal phase. Her medication regimen includes: leve­tiracetam, 500 mg, 3 times a day; valproic acid, 1,000 mg/d; and oxcarbazepine, 2,400 mg/d, for seizure management.

Complete blood count and comprehen­sive metabolic panel are within normal limits. Pregnancy test is negative. Urine toxicology report is negative. Serum valproic acid level is 71 μg/mL; oxcarbazepine level, <2 μg/mL; ammonia level, 71 μg/dL (reference range, 15 to 45 μg/dL). Other than the aforementioned deficits, she is neurologically intact. The team thinks that her symptoms are part of a postic­tal phase of an unwitnessed seizure.

Ms. A is admitted to the inpatient medi­cal unit for further work up. Along with the memory loss and seizures, she reports visual hallucinations.

What could be causing Ms. A’s amnesia?
   a) a seizure disorder
   b) malingering
   c) posttraumatic stress disorder
   d) traumatic brain injury

HISTORY Repeat ED visits
Ms. A’s mother reports that 3 years ago her daughter was treated for tics with quetiapine and aripiprazole, prescribed by a primary care physician. She received a short course of coun­seling 6 years ago after her sister was sexually abused by her grandfather. Approximately 6 months ago, Ms. A engaged in self-injurious behavior by cutting herself, and she briefly received counseling. There is no history of sui­cide attempts, psychiatric hospitalization, or a psychiatric diagnosis.

Medical and surgical history include viral meningitis at age 6 months. Medical records show a visit to the ED for abdominal pain after a classmate punched her in the abdomen, which resolved with supportive care. She was given a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections 6 years ago.

Ms. A developed multiple recurrent methicillin-resistant Staphylococcus aureus abscesses a year ago, which lasted for 4 months; it was noted that she was self-inoculating by scratching eczema. She had a possible syncopal episode 5 months ago, but the medical work-up was normal. The pediat­ric neurology service diagnosed and treated seizures 4 months ago.

Levetiracetam was prescribed after a pos­sible syncopal episode followed by a tonic-clonic seizure. Because she was still having seizure-like episodes with a single antiepilep­tic drug (AED), oxcarbazepine, then valproic acid were added. Whether her seizures were generalized or partial was inconclusive. The seizures were followed by a postictal phase lasting 3 minutes to 1 hour. Her last general­ized tonic-clonic seizure was 1 month before admission.

Ms. A had 3 MRI studies of the brain over the past 3 years, which showed consistent and unchanged multifocal punctate white matter lesions. The findings represented gliosis from an old perivascular inflammation, trauma, or ischemic damage. There is no history of trau­matic brain injury.

Her perinatal history is unremarkable, with normal vaginal delivery at 36 weeks (pre-term birth). All developmental milestones were on target.

Ms. A lives at home with her mother, 6-year-old brother, and stepfather. Her par­ents are divorced, but her biological father has been involved in her upbringing. She is in seventh grade, but is home schooled after she withdrew from school because of mul­tiple seizure episodes. Ms. A denied bullying at school although she had been punched by a peer. It was unclear if it was a single incident or bullying continued and she was hesitant to disclose it.

The authors’ observations
We focus on the amnesia because it has an acute onset and it seems this is the first time Ms. A presented with this symptom. There is no need to wait for neurology consultation, even though organic causes of amnesia need to be ruled out. Our plan is to develop rapport with Ms. A, and then administer a mental status examina­tion focusing on memory assessment. We understand that, because Ms. A’s chief concern is amnesia, she might not be able to provide many details. We start the initial interview with the family in the patient’s room to understand family dynamics, and then interview Ms. A alone.

EVALUATION Memory problems
On initial psychiatric interview, Ms. A can rec­ognize some of her family members. She is seen in clean attire, with short hair, lying in the bed with good eye contact and a calm demeanor. She seems to be difficult to engage because of her reserved nature.

Ms. A displays some psychomotor retarda­tion. She reports her mood as tired, and her affect is flat and mood incongruent. She is alert and oriented to person only; not to place, time, or situation. She can do a simple spell­ing task, perform 5-minute recall of 3 words, complete serial 3 subtractions, repeat phrases, read aloud, focus on a coin task, and name simple objects. She does not compare similar objects or answer simple historical or factual questions.

Ms. A replies “I don’t know” to most his­torical questions, such as her birthday, favor­ite color, and family members; she does not answer when asked how many legs a dog has, who is the current or past president, what month the Fourth of July is in, or when Christmas is. She can complete some memory tasks on the Mini-Mental State Examination, but does not attempt many others. Ms. A says she is upset about her memory deficit, but her affect was flat. Her mood and her affect were incongruent. She describes a vision of a “girl with black holes [for eyes]” in the corner of her hospital room telling her not to believe any­one and that the interviewers are lying to her. Also, she reports that “the girl” tells her to hurt herself and others, but she is not going to act on the commands because she knows it is not the right thing to do. When we ask Ms. A about a history of substance abuse, she says she has never heard of drugs or alcohol.

Overall, she displays multiple apparent deficits in declarative memory, both episodic and semantic. Regarding non-declarative or procedural memory, she can dress herself, use the bathroom independently, order meals off the menu, and feed herself, among other rou­tine tasks, without difficulty.

According to Ms. A’s mother, Ms. A has shown a decline in overall functioning and personality changes during the past 5 months. She started to cut herself superficially on her forearms 6 months ago and also tried to change her appearance with a new hairstyle when school started. She displayed noticeably intense and disturbing writings, artwork, and conversations with others over 3 to 4 months.

She started experiencing seizures, with 3 to 4 seizures a day; however, she could attend sleepovers seizure-free. She had prolonged periods of seizures lasting up to an hour, much longer than would be expected clinically. She also had requested to go to the cemetery for unclear reasons (because the spirit wanted her to visit), and was observed mumbling under her breath.

Six years ago, Ms. A’s 6-year-old sister tried to suffocate her infant brother. Child protec­tive services was involved and the sister was hospitalized in a psychiatric facility, where she was given a diagnosis of bipolar disorder; she was then transferred to foster care, and later placed in residential treatment. Her mother relinquished her parental rights and gave cus­tody of Ms. A’s sister to the state.

Ms. A’s mother has a history of depression, but her younger brother is healthy. There is no history of autism, attention problems, tics, substance abuse, brain tumor, or intellectual disabilities in the family.

Which diagnosis does Ms. A’s presentation and history suggest?
   a) dissociative amnesia
   b) factitious disorder imposed on self
   c) conversion disorder (neurological symp­tom disorder)
   d) psychosis not otherwise specified
   e) malingering

The authors’ observations
The history of unwitnessed seizures, sud­den onset of visual hallucinations, and transient amnesia points to a possible post­ictal cause. Selective amnesia brings up the question of whether psychological compo­nents are driving the symptoms.

Her psychotic symptoms appear to be mediated by anxiety and possibly related to the trauma of losing her only sister when her mother relinquished custody to the state; the circumstances might have aroused feelings of insecurity or fear of abandonment and raised questions about her mother’s love toward her. Her sis­ter’s abuse by a family member might have created reticence to trust others. These background experiences could be intensely conflicting at this age when the second separation individuation process commences, especially in an emotionally immature adolescent.

OUTCOME Medication change
The neurology team recommends discontinuing levetiracetam because the visual hallucinations, mood disturbance, and personality change could be adverse effects of the drug. Because of generalized uncontrolled body movements with staring episodes and unresponsiveness, an EEG is ordered to rule out ongoing seizures.

Ms. A recognizes the psychosomatic medi­cine team members when they interview her again. The team employs consistent reassur­ance and a non-confrontational approach. She spends 3 days in the medical unit during which she reports that the frequency of visual and auditory hallucinations decreases and her memory symptoms resolve. Her 24-hour EEG is negative for seizure activity, and the 24-hour video EEG does not show any signs of epilepto­genic foci. Ms. A’s family declines inpatient psy­chiatric hospitalization.

Because of gradual improvement in Ms. A’s symptoms and no imminent safety concerns, she is discharged home with valproic acid, 1,000 mg/d, and oxcarbazepine, 1,200 mg/d, and follow-up appointments with her primary care physician, a neurologist, and a psychiatrist.

The authors’ observations
Dissociative amnesia
Generalized dissociative amnesia is dif­ficult to differentiate from factitious disorder or malingering. According to DSM-5, there is loss of episodic memory in dissociative amnesia, in which the person is unable to recall the stressful event after trauma (Table 1).¹ Although there have been case reports of dissocia­tive amnesia with loss of semantic and procedural memory, episodic memory is the last to return.² In Ms. A’s case, there was no immediate basis to explain amne­sia onset, although she had experienced the trauma of losing her sister. She had episodic and mostly semantic memory loss.

Although organic causes can pre­cipitate amnesia,³ Ms. A’s EEG and MRI results did not reflect that. Patients with a dissociative disorder often report some physical, sexual, or emotional abuse.⁴ Although Ms. A did not report any abuse, it cannot be completely ruled out because of her sister’s history of abuse.

Suicidality or self-injurious behavior is common among adults with dissociative amnesia, although it is not well studied in children.^4,5 Generally, the constella­tion of primary dissociative symptoms that patients develop are forgetfulness, fragmentation, and emotional numbing. Ms. A presented with some of these fea­tures; did she, in fact, have dissociative amnesia?

Factitious amnesia
Factious amnesia (Table 2)⁶ is a symptom of factious disorder in which amnesia appears with the motivation to assume a sick role.³ Ms. A’s amnesia garnered sig­nificant attention from her mother and other family members; this may have been related to insecurity in her family relationships because her sister was given up to the state. She also could be afraid of entering adolescence and leaving her sister behind. Did she want more time to bond with her mother? Did she experi­ence emotional benefit from being cared for by medical professionals?⁷ Her affect during interviews was blunted and her attitude was nonchalant, and her multiple visits to the hospital since childhood for abdominal pain, abscesses (it isn’t clear whether the abscesses were related to self-injury and scratching), tics, seizures, and, recently, amnesia and hallucinations indi­cated some desire to occupy a sick role. Furthermore, the severity of her symp­toms seemed to be increasing over time, from somatic to neurologic (seizure-like episodes) to significant and less frequent psychiatric symptoms (amnesia and hal­lucinations). One could speculate that her symptoms were escalating because she was not receiving the attention she needed.

Malingered amnesia
Although malingering is not a psychi­atric diagnosis, it can be a focus of clini­cal attention. It is challenging to identify malingered cognitive impairments.⁸ Children often have difficulty malinger­ing symptoms because they have limited understanding of the illness they are try­ing to simulate.⁹ Many malingerers do not want to participate in their medical work up and might exhibit a hostile attitude toward examiners (Table 2⁶). Clinicians could rely on family to provide informa­tion regarding history and inconsistencies in clinical deficits.⁹ The clinical interview, mental status examination, and collateral information are crucial for identifying malingering.

Most of Ms. A’s seizure-like episodes happened in specific contexts, such as in school, but not at friends’ houses, raising the question of whether she is aware of her episodes. Ms. A’s grades are consis­tently good; because she is being home schooled, there is no secondary gain from not going to school. There is no other reason to speculate that she was malingering.

The inconsistency of Ms. A’s symptoms and her compliance with assessment and treatment did not reflect malingering. Interestingly, Ms. A’s amnesia was retrograde in nature. There have been more studies on malingered anterograde amne­sia⁸ than on retrograde amnesia, making her presentation even more unusual.

Amnesia presenting as conversion disorder
Amnesia as a symptom of conversion disorder is referred as psychogenic amne­sia; the memory loss mostly is isolated retrograde amnesia.¹⁰ Ms. A likely had unconsciously produced symptoms of non-epileptic seizures, followed by audi­tory and visual hallucinations not related to her seizures, and then later developed selective transient amnesia. Conversion disorder seemed to be the diagnosis most consistent with her indifference (“la belle indifference”) and the significant atten­tion she gained from the acute memory loss (Table 3).¹ It seemed that she devel­oped multiple symptoms in progression leading toward a conversion disorder diagnosis. The question arises whether Ms. A’s presentation is a gradually increasing cry for help or reflects depres­sive or anxiety symptoms, which often are comorbid with conversion disorder.

FOLLOW-UP Suicide attempt
Ms. A has frequent visits to the ED with symp­toms of syncope and seizures and undergoes medical work-up and multiple EEGs. A pro­longed 5-day video EEG is performed to assess seizure episodes after AEDs were withdrawn, but no seizure activity is elicited. She also has an ED visit for recurrent tic emergence.

The last visit in the ED is for a suicide attempt with overdose of an unknown quantity of unspecified pills. Ms. A talks to a social worker, who reports that Ms. A needed answers to such questions as why her grandfather abused her sister? Could she have stopped them and made a difference for the family?

The authors’ observations
Conversion disorder arises from uncon­scious psychological conflicts, needs, or responses to trauma. Ms. A’s consistent conflict about her sister and grandfather’s relationship was evident from occasions when she tried to confide in hospital staff. During an ED visit, she reported her sis­ter’s abuse to a staff member. Another time, while recovering from sedation, she spontaneously spoke about her sister’s abuse. When asked again, she said she did not remember saying it.

Freud said that patients develop conver­sion disorder to avoid unacceptable conflict­ing thoughts and feelings.¹⁰ It appeared that Ms. A was struggling with these questions because she brought them up again when she visited the ED after the suicide attempt.

Dissociative symptoms arise from unsta­ble parenting and disciplining styles with variable family dynamics. Patients show extreme detachment and emotional unre­sponsiveness akin to attachment disorder.¹¹ Ms. A had inconsistent parenting because both her stepfather and biological father were involved with her care. Her mother had relinquished her parental rights to her sister, which indicated some attachment issues.

Ms. A’s idea that her mother was indifferent stemmed from her uncaring approach toward her sister and not able to understand her emotionally. Her amnesia could be thought of as “I don’t know you because I don’t remember that I am related to you.” The traumas of infancy (referred to as hidden traumas) that were a result of par­ent-child mismatch of needs and availabil­ity at times of distress might not be obvious to the examiner.¹¹

Although Ms. A’s infancy was reported to be unremarkable, there always is a question, especially in a consultation-liaison setting, of whether conversion disorder might be mask­ing an attachment problem. Perhaps with long-term psychotherapy, an attachment issue would be revealed.

Excluding an organic cause or a neuro­logic disorder is important when diagnosing conversion disorder¹⁰; Ms. A’s negative neu­rologic tests favored a diagnosis of amnesia due to conversion disorder. It appears that, although Ms. A presented with “transient amnesia,” she had underlying psychiatric symptoms, likely depression or anxiety. We were concerned about possible psychiatric comorbidity and recommended inpatient hospitalization to clarify the diagnosis and provide intensive therapy, but her family declined. She may have received outpatient services, but that was not documented.


Bottom Line
Psychogenic amnesia can be a form of conversion disorder or a symptom of
malingering; can occur in dissociative disorder; and can be factitious in nature.
Regardless of the cause, the condition requires continuous close follow up. Although organic causes of amnesia should be ruled out, mental health care can help address comorbid psychiatric symptoms and might change the course of the illness.

Related Resources
• Byatt N, Toor R. Young, pregnant, ataxic—and jilted. Current Psychiatry. 2015;14(1):44-49.
• Leipsic J. A teen who is wasting away. Current Psychiatry. 2013;12(6):40-45.

Drug Brand Names
Aripiprazole • Abilify              Quetiapine • Seroquel
Levetiracetam • Keppra         Valproic acid • Depakote
Oxcarbazepine • Trileptal

 Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Seizures, amnesia
Ms. A, age 13, who has a history of seizures, presents to the emergency department (ED) with sudden onset of memory loss. Her family reports that she had been spend­ing a normal evening at home with family and friends. After going to the bathroom, Ms. A became acutely confused and extremely upset, had slurred speech, and did not recognize anyone in the room except her mother.

Initial neurologic examination in the ED reports that Ms. A does not remember recent or remote past events. Her family denies any recent stressors.

Vital signs are within normal range. She has mild muscle soreness and gait instability, which is attributed to a presumed postictal phase. Her medication regimen includes: leve­tiracetam, 500 mg, 3 times a day; valproic acid, 1,000 mg/d; and oxcarbazepine, 2,400 mg/d, for seizure management.

Complete blood count and comprehen­sive metabolic panel are within normal limits. Pregnancy test is negative. Urine toxicology report is negative. Serum valproic acid level is 71 μg/mL; oxcarbazepine level, <2 μg/mL; ammonia level, 71 μg/dL (reference range, 15 to 45 μg/dL). Other than the aforementioned deficits, she is neurologically intact. The team thinks that her symptoms are part of a postic­tal phase of an unwitnessed seizure.

Ms. A is admitted to the inpatient medi­cal unit for further work up. Along with the memory loss and seizures, she reports visual hallucinations.

What could be causing Ms. A’s amnesia?
   a) a seizure disorder
   b) malingering
   c) posttraumatic stress disorder
   d) traumatic brain injury

HISTORY Repeat ED visits
Ms. A’s mother reports that 3 years ago her daughter was treated for tics with quetiapine and aripiprazole, prescribed by a primary care physician. She received a short course of coun­seling 6 years ago after her sister was sexually abused by her grandfather. Approximately 6 months ago, Ms. A engaged in self-injurious behavior by cutting herself, and she briefly received counseling. There is no history of sui­cide attempts, psychiatric hospitalization, or a psychiatric diagnosis.

Medical and surgical history include viral meningitis at age 6 months. Medical records show a visit to the ED for abdominal pain after a classmate punched her in the abdomen, which resolved with supportive care. She was given a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections 6 years ago.

Ms. A developed multiple recurrent methicillin-resistant Staphylococcus aureus abscesses a year ago, which lasted for 4 months; it was noted that she was self-inoculating by scratching eczema. She had a possible syncopal episode 5 months ago, but the medical work-up was normal. The pediat­ric neurology service diagnosed and treated seizures 4 months ago.

Levetiracetam was prescribed after a pos­sible syncopal episode followed by a tonic-clonic seizure. Because she was still having seizure-like episodes with a single antiepilep­tic drug (AED), oxcarbazepine, then valproic acid were added. Whether her seizures were generalized or partial was inconclusive. The seizures were followed by a postictal phase lasting 3 minutes to 1 hour. Her last general­ized tonic-clonic seizure was 1 month before admission.

Ms. A had 3 MRI studies of the brain over the past 3 years, which showed consistent and unchanged multifocal punctate white matter lesions. The findings represented gliosis from an old perivascular inflammation, trauma, or ischemic damage. There is no history of trau­matic brain injury.

Her perinatal history is unremarkable, with normal vaginal delivery at 36 weeks (pre-term birth). All developmental milestones were on target.

Ms. A lives at home with her mother, 6-year-old brother, and stepfather. Her par­ents are divorced, but her biological father has been involved in her upbringing. She is in seventh grade, but is home schooled after she withdrew from school because of mul­tiple seizure episodes. Ms. A denied bullying at school although she had been punched by a peer. It was unclear if it was a single incident or bullying continued and she was hesitant to disclose it.

The authors’ observations
We focus on the amnesia because it has an acute onset and it seems this is the first time Ms. A presented with this symptom. There is no need to wait for neurology consultation, even though organic causes of amnesia need to be ruled out. Our plan is to develop rapport with Ms. A, and then administer a mental status examina­tion focusing on memory assessment. We understand that, because Ms. A’s chief concern is amnesia, she might not be able to provide many details. We start the initial interview with the family in the patient’s room to understand family dynamics, and then interview Ms. A alone.

EVALUATION Memory problems
On initial psychiatric interview, Ms. A can rec­ognize some of her family members. She is seen in clean attire, with short hair, lying in the bed with good eye contact and a calm demeanor. She seems to be difficult to engage because of her reserved nature.

Ms. A displays some psychomotor retarda­tion. She reports her mood as tired, and her affect is flat and mood incongruent. She is alert and oriented to person only; not to place, time, or situation. She can do a simple spell­ing task, perform 5-minute recall of 3 words, complete serial 3 subtractions, repeat phrases, read aloud, focus on a coin task, and name simple objects. She does not compare similar objects or answer simple historical or factual questions.

Ms. A replies “I don’t know” to most his­torical questions, such as her birthday, favor­ite color, and family members; she does not answer when asked how many legs a dog has, who is the current or past president, what month the Fourth of July is in, or when Christmas is. She can complete some memory tasks on the Mini-Mental State Examination, but does not attempt many others. Ms. A says she is upset about her memory deficit, but her affect was flat. Her mood and her affect were incongruent. She describes a vision of a “girl with black holes [for eyes]” in the corner of her hospital room telling her not to believe any­one and that the interviewers are lying to her. Also, she reports that “the girl” tells her to hurt herself and others, but she is not going to act on the commands because she knows it is not the right thing to do. When we ask Ms. A about a history of substance abuse, she says she has never heard of drugs or alcohol.

Overall, she displays multiple apparent deficits in declarative memory, both episodic and semantic. Regarding non-declarative or procedural memory, she can dress herself, use the bathroom independently, order meals off the menu, and feed herself, among other rou­tine tasks, without difficulty.

According to Ms. A’s mother, Ms. A has shown a decline in overall functioning and personality changes during the past 5 months. She started to cut herself superficially on her forearms 6 months ago and also tried to change her appearance with a new hairstyle when school started. She displayed noticeably intense and disturbing writings, artwork, and conversations with others over 3 to 4 months.

She started experiencing seizures, with 3 to 4 seizures a day; however, she could attend sleepovers seizure-free. She had prolonged periods of seizures lasting up to an hour, much longer than would be expected clinically. She also had requested to go to the cemetery for unclear reasons (because the spirit wanted her to visit), and was observed mumbling under her breath.

Six years ago, Ms. A’s 6-year-old sister tried to suffocate her infant brother. Child protec­tive services was involved and the sister was hospitalized in a psychiatric facility, where she was given a diagnosis of bipolar disorder; she was then transferred to foster care, and later placed in residential treatment. Her mother relinquished her parental rights and gave cus­tody of Ms. A’s sister to the state.

Ms. A’s mother has a history of depression, but her younger brother is healthy. There is no history of autism, attention problems, tics, substance abuse, brain tumor, or intellectual disabilities in the family.

Which diagnosis does Ms. A’s presentation and history suggest?
   a) dissociative amnesia
   b) factitious disorder imposed on self
   c) conversion disorder (neurological symp­tom disorder)
   d) psychosis not otherwise specified
   e) malingering

The authors’ observations
The history of unwitnessed seizures, sud­den onset of visual hallucinations, and transient amnesia points to a possible post­ictal cause. Selective amnesia brings up the question of whether psychological compo­nents are driving the symptoms.

Her psychotic symptoms appear to be mediated by anxiety and possibly related to the trauma of losing her only sister when her mother relinquished custody to the state; the circumstances might have aroused feelings of insecurity or fear of abandonment and raised questions about her mother’s love toward her. Her sis­ter’s abuse by a family member might have created reticence to trust others. These background experiences could be intensely conflicting at this age when the second separation individuation process commences, especially in an emotionally immature adolescent.

OUTCOME Medication change
The neurology team recommends discontinuing levetiracetam because the visual hallucinations, mood disturbance, and personality change could be adverse effects of the drug. Because of generalized uncontrolled body movements with staring episodes and unresponsiveness, an EEG is ordered to rule out ongoing seizures.

Ms. A recognizes the psychosomatic medi­cine team members when they interview her again. The team employs consistent reassur­ance and a non-confrontational approach. She spends 3 days in the medical unit during which she reports that the frequency of visual and auditory hallucinations decreases and her memory symptoms resolve. Her 24-hour EEG is negative for seizure activity, and the 24-hour video EEG does not show any signs of epilepto­genic foci. Ms. A’s family declines inpatient psy­chiatric hospitalization.

Because of gradual improvement in Ms. A’s symptoms and no imminent safety concerns, she is discharged home with valproic acid, 1,000 mg/d, and oxcarbazepine, 1,200 mg/d, and follow-up appointments with her primary care physician, a neurologist, and a psychiatrist.

The authors’ observations
Dissociative amnesia
Generalized dissociative amnesia is dif­ficult to differentiate from factitious disorder or malingering. According to DSM-5, there is loss of episodic memory in dissociative amnesia, in which the person is unable to recall the stressful event after trauma (Table 1).¹ Although there have been case reports of dissocia­tive amnesia with loss of semantic and procedural memory, episodic memory is the last to return.² In Ms. A’s case, there was no immediate basis to explain amne­sia onset, although she had experienced the trauma of losing her sister. She had episodic and mostly semantic memory loss.

Although organic causes can pre­cipitate amnesia,³ Ms. A’s EEG and MRI results did not reflect that. Patients with a dissociative disorder often report some physical, sexual, or emotional abuse.⁴ Although Ms. A did not report any abuse, it cannot be completely ruled out because of her sister’s history of abuse.

Suicidality or self-injurious behavior is common among adults with dissociative amnesia, although it is not well studied in children.^4,5 Generally, the constella­tion of primary dissociative symptoms that patients develop are forgetfulness, fragmentation, and emotional numbing. Ms. A presented with some of these fea­tures; did she, in fact, have dissociative amnesia?

Factitious amnesia
Factious amnesia (Table 2)⁶ is a symptom of factious disorder in which amnesia appears with the motivation to assume a sick role.³ Ms. A’s amnesia garnered sig­nificant attention from her mother and other family members; this may have been related to insecurity in her family relationships because her sister was given up to the state. She also could be afraid of entering adolescence and leaving her sister behind. Did she want more time to bond with her mother? Did she experi­ence emotional benefit from being cared for by medical professionals?⁷ Her affect during interviews was blunted and her attitude was nonchalant, and her multiple visits to the hospital since childhood for abdominal pain, abscesses (it isn’t clear whether the abscesses were related to self-injury and scratching), tics, seizures, and, recently, amnesia and hallucinations indi­cated some desire to occupy a sick role. Furthermore, the severity of her symp­toms seemed to be increasing over time, from somatic to neurologic (seizure-like episodes) to significant and less frequent psychiatric symptoms (amnesia and hal­lucinations). One could speculate that her symptoms were escalating because she was not receiving the attention she needed.

Malingered amnesia
Although malingering is not a psychi­atric diagnosis, it can be a focus of clini­cal attention. It is challenging to identify malingered cognitive impairments.⁸ Children often have difficulty malinger­ing symptoms because they have limited understanding of the illness they are try­ing to simulate.⁹ Many malingerers do not want to participate in their medical work up and might exhibit a hostile attitude toward examiners (Table 2⁶). Clinicians could rely on family to provide informa­tion regarding history and inconsistencies in clinical deficits.⁹ The clinical interview, mental status examination, and collateral information are crucial for identifying malingering.

Most of Ms. A’s seizure-like episodes happened in specific contexts, such as in school, but not at friends’ houses, raising the question of whether she is aware of her episodes. Ms. A’s grades are consis­tently good; because she is being home schooled, there is no secondary gain from not going to school. There is no other reason to speculate that she was malingering.

The inconsistency of Ms. A’s symptoms and her compliance with assessment and treatment did not reflect malingering. Interestingly, Ms. A’s amnesia was retrograde in nature. There have been more studies on malingered anterograde amne­sia⁸ than on retrograde amnesia, making her presentation even more unusual.

Amnesia presenting as conversion disorder
Amnesia as a symptom of conversion disorder is referred as psychogenic amne­sia; the memory loss mostly is isolated retrograde amnesia.¹⁰ Ms. A likely had unconsciously produced symptoms of non-epileptic seizures, followed by audi­tory and visual hallucinations not related to her seizures, and then later developed selective transient amnesia. Conversion disorder seemed to be the diagnosis most consistent with her indifference (“la belle indifference”) and the significant atten­tion she gained from the acute memory loss (Table 3).¹ It seemed that she devel­oped multiple symptoms in progression leading toward a conversion disorder diagnosis. The question arises whether Ms. A’s presentation is a gradually increasing cry for help or reflects depres­sive or anxiety symptoms, which often are comorbid with conversion disorder.

FOLLOW-UP Suicide attempt
Ms. A has frequent visits to the ED with symp­toms of syncope and seizures and undergoes medical work-up and multiple EEGs. A pro­longed 5-day video EEG is performed to assess seizure episodes after AEDs were withdrawn, but no seizure activity is elicited. She also has an ED visit for recurrent tic emergence.

The last visit in the ED is for a suicide attempt with overdose of an unknown quantity of unspecified pills. Ms. A talks to a social worker, who reports that Ms. A needed answers to such questions as why her grandfather abused her sister? Could she have stopped them and made a difference for the family?

The authors’ observations
Conversion disorder arises from uncon­scious psychological conflicts, needs, or responses to trauma. Ms. A’s consistent conflict about her sister and grandfather’s relationship was evident from occasions when she tried to confide in hospital staff. During an ED visit, she reported her sis­ter’s abuse to a staff member. Another time, while recovering from sedation, she spontaneously spoke about her sister’s abuse. When asked again, she said she did not remember saying it.

Freud said that patients develop conver­sion disorder to avoid unacceptable conflict­ing thoughts and feelings.¹⁰ It appeared that Ms. A was struggling with these questions because she brought them up again when she visited the ED after the suicide attempt.

Dissociative symptoms arise from unsta­ble parenting and disciplining styles with variable family dynamics. Patients show extreme detachment and emotional unre­sponsiveness akin to attachment disorder.¹¹ Ms. A had inconsistent parenting because both her stepfather and biological father were involved with her care. Her mother had relinquished her parental rights to her sister, which indicated some attachment issues.

Ms. A’s idea that her mother was indifferent stemmed from her uncaring approach toward her sister and not able to understand her emotionally. Her amnesia could be thought of as “I don’t know you because I don’t remember that I am related to you.” The traumas of infancy (referred to as hidden traumas) that were a result of par­ent-child mismatch of needs and availabil­ity at times of distress might not be obvious to the examiner.¹¹

Although Ms. A’s infancy was reported to be unremarkable, there always is a question, especially in a consultation-liaison setting, of whether conversion disorder might be mask­ing an attachment problem. Perhaps with long-term psychotherapy, an attachment issue would be revealed.

Excluding an organic cause or a neuro­logic disorder is important when diagnosing conversion disorder¹⁰; Ms. A’s negative neu­rologic tests favored a diagnosis of amnesia due to conversion disorder. It appears that, although Ms. A presented with “transient amnesia,” she had underlying psychiatric symptoms, likely depression or anxiety. We were concerned about possible psychiatric comorbidity and recommended inpatient hospitalization to clarify the diagnosis and provide intensive therapy, but her family declined. She may have received outpatient services, but that was not documented.


Bottom Line
Psychogenic amnesia can be a form of conversion disorder or a symptom of
malingering; can occur in dissociative disorder; and can be factitious in nature.
Regardless of the cause, the condition requires continuous close follow up. Although organic causes of amnesia should be ruled out, mental health care can help address comorbid psychiatric symptoms and might change the course of the illness.

Related Resources
• Byatt N, Toor R. Young, pregnant, ataxic—and jilted. Current Psychiatry. 2015;14(1):44-49.
• Leipsic J. A teen who is wasting away. Current Psychiatry. 2013;12(6):40-45.

Drug Brand Names
Aripiprazole • Abilify              Quetiapine • Seroquel
Levetiracetam • Keppra         Valproic acid • Depakote
Oxcarbazepine • Trileptal

 Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Lisdexamfetamine, approved by the FDA in 2007 for attention-deficit/hyperactivity disorder (ADHD), has a new indication: binge eating disorder (BED) (Table 1). BED is characterized by recurrent episodes of consuming a large amount of food in a short time. A prodrug of amphet­amine, lisdexamfetamine is a Schedule-II controlled substance, with a high potential for abuse and the risk of severe psychologi­cal or physical dependence.

Lisdexamfetamine is not indicated for weight loss or obesity.

Dosage
For BED, the initial dosage of lisdexamfet­amine is 30 mg/d in the morning, titrated by 20 mg/d per week to the target dos­age of 50 to 70 mg/d. Maximum dosage is 70 mg/d. Morning dosing is recommended to avoid sleep disturbance.

Efficacy
The clinical efficacy of lisdexamfetamine was assessed in two 12-week parallel group, flexible-dose, placebo-controlled trials in adults with BED (age 18 to 55). Primary efficacy measure was the num­ber of binge days per week. Both studies had a 4-week dose-optimization period and an 8-week dose-maintenance period and followed the same dosage protocol. Patients began treatment at 30 mg/d and after 1 week were titrated to 50 mg/d; increases to 70 mg/d were made if clini­cally necessary and well tolerated. Patients were maintained on the optimized dos­age during the 8-week dose-maintenance period. A dosage of 30 mg/d did not produce a statistically significant effect, but 50 mg/d and 70 mg/d dosages were statistically superior to placebo. Patients taking lisdexamfetamine also had greater improvement on the Clinical Global Impression—Improvement scores, 4-week binge cessation, and greater reduction in the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating score.

The prescribing information does not state if lisdexamfetamine should be con­tinued long-term for treating BED.

Adverse reactions
In controlled trials, 5.1% of patients receiv­ing lisdexamfetamine for BED discontin­ued the drug because of an adverse event, compared with 2.4% of patients receiv­ing placebo. The most common adverse reactions in BED studies were dry mouth (36%), insomnia (20%), decreased appetite (8%), increased heart rate (8%), constipation (6%), and feeling jittery (6%). In trials of children, adolescents, and adults with ADHD, decreased appetite was more com­mon (39%, 34%, and 27%, respectively) than in BED trials (Table 2). Anaphylactic reac­tions, Stevens-Johnson syndrome, angio­edema, and urticaria have been described in postmarketing reports.

The safety of lisdexamfetamine for BED has not been studied in patients age <18, but has been studied in patients with ADHD.

Contraindications
Do not give lisdexamfetamine to patients who have a known hypersensitivity to amphetamine products or other ingredi­ents in lisdexamfetamine capsules.

Lisdexamfetamine is contraindicated in patients who are taking a monoamine oxi­dase inhibitor, because of a risk of hyper­tensive crisis.
 

Related Resources
• Wilens TE. Lisdexamfetamine for ADHD. Current Psychiatry. 2007;6(6):96-98,105.
• Peat CM, Brownley KA, Berkman ND, et al. Binge eating dis­order: evidence-based treatments. Current Psychiatry. 2012; 11(5):32-39.

Lisdexamfetamine, approved by the FDA in 2007 for attention-deficit/hyperactivity disorder (ADHD), has a new indication: binge eating disorder (BED) (Table 1). BED is characterized by recurrent episodes of consuming a large amount of food in a short time. A prodrug of amphet­amine, lisdexamfetamine is a Schedule-II controlled substance, with a high potential for abuse and the risk of severe psychologi­cal or physical dependence.

Lisdexamfetamine is not indicated for weight loss or obesity.

Dosage
For BED, the initial dosage of lisdexamfet­amine is 30 mg/d in the morning, titrated by 20 mg/d per week to the target dos­age of 50 to 70 mg/d. Maximum dosage is 70 mg/d. Morning dosing is recommended to avoid sleep disturbance.

Efficacy
The clinical efficacy of lisdexamfetamine was assessed in two 12-week parallel group, flexible-dose, placebo-controlled trials in adults with BED (age 18 to 55). Primary efficacy measure was the num­ber of binge days per week. Both studies had a 4-week dose-optimization period and an 8-week dose-maintenance period and followed the same dosage protocol. Patients began treatment at 30 mg/d and after 1 week were titrated to 50 mg/d; increases to 70 mg/d were made if clini­cally necessary and well tolerated. Patients were maintained on the optimized dos­age during the 8-week dose-maintenance period. A dosage of 30 mg/d did not produce a statistically significant effect, but 50 mg/d and 70 mg/d dosages were statistically superior to placebo. Patients taking lisdexamfetamine also had greater improvement on the Clinical Global Impression—Improvement scores, 4-week binge cessation, and greater reduction in the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating score.

The prescribing information does not state if lisdexamfetamine should be con­tinued long-term for treating BED.

Adverse reactions
In controlled trials, 5.1% of patients receiv­ing lisdexamfetamine for BED discontin­ued the drug because of an adverse event, compared with 2.4% of patients receiv­ing placebo. The most common adverse reactions in BED studies were dry mouth (36%), insomnia (20%), decreased appetite (8%), increased heart rate (8%), constipation (6%), and feeling jittery (6%). In trials of children, adolescents, and adults with ADHD, decreased appetite was more com­mon (39%, 34%, and 27%, respectively) than in BED trials (Table 2). Anaphylactic reac­tions, Stevens-Johnson syndrome, angio­edema, and urticaria have been described in postmarketing reports.

The safety of lisdexamfetamine for BED has not been studied in patients age <18, but has been studied in patients with ADHD.

Contraindications
Do not give lisdexamfetamine to patients who have a known hypersensitivity to amphetamine products or other ingredi­ents in lisdexamfetamine capsules.

Lisdexamfetamine is contraindicated in patients who are taking a monoamine oxi­dase inhibitor, because of a risk of hyper­tensive crisis.
 

Related Resources
• Wilens TE. Lisdexamfetamine for ADHD. Current Psychiatry. 2007;6(6):96-98,105.
• Peat CM, Brownley KA, Berkman ND, et al. Binge eating dis­order: evidence-based treatments. Current Psychiatry. 2012; 11(5):32-39.

Lisdexamfetamine, approved by the FDA in 2007 for attention-deficit/hyperactivity disorder (ADHD), has a new indication: binge eating disorder (BED) (Table 1). BED is characterized by recurrent episodes of consuming a large amount of food in a short time. A prodrug of amphet­amine, lisdexamfetamine is a Schedule-II controlled substance, with a high potential for abuse and the risk of severe psychologi­cal or physical dependence.

Lisdexamfetamine is not indicated for weight loss or obesity.

Dosage
For BED, the initial dosage of lisdexamfet­amine is 30 mg/d in the morning, titrated by 20 mg/d per week to the target dos­age of 50 to 70 mg/d. Maximum dosage is 70 mg/d. Morning dosing is recommended to avoid sleep disturbance.

Efficacy
The clinical efficacy of lisdexamfetamine was assessed in two 12-week parallel group, flexible-dose, placebo-controlled trials in adults with BED (age 18 to 55). Primary efficacy measure was the num­ber of binge days per week. Both studies had a 4-week dose-optimization period and an 8-week dose-maintenance period and followed the same dosage protocol. Patients began treatment at 30 mg/d and after 1 week were titrated to 50 mg/d; increases to 70 mg/d were made if clini­cally necessary and well tolerated. Patients were maintained on the optimized dos­age during the 8-week dose-maintenance period. A dosage of 30 mg/d did not produce a statistically significant effect, but 50 mg/d and 70 mg/d dosages were statistically superior to placebo. Patients taking lisdexamfetamine also had greater improvement on the Clinical Global Impression—Improvement scores, 4-week binge cessation, and greater reduction in the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating score.

The prescribing information does not state if lisdexamfetamine should be con­tinued long-term for treating BED.

Adverse reactions
In controlled trials, 5.1% of patients receiv­ing lisdexamfetamine for BED discontin­ued the drug because of an adverse event, compared with 2.4% of patients receiv­ing placebo. The most common adverse reactions in BED studies were dry mouth (36%), insomnia (20%), decreased appetite (8%), increased heart rate (8%), constipation (6%), and feeling jittery (6%). In trials of children, adolescents, and adults with ADHD, decreased appetite was more com­mon (39%, 34%, and 27%, respectively) than in BED trials (Table 2). Anaphylactic reac­tions, Stevens-Johnson syndrome, angio­edema, and urticaria have been described in postmarketing reports.

The safety of lisdexamfetamine for BED has not been studied in patients age <18, but has been studied in patients with ADHD.

Contraindications
Do not give lisdexamfetamine to patients who have a known hypersensitivity to amphetamine products or other ingredi­ents in lisdexamfetamine capsules.

Lisdexamfetamine is contraindicated in patients who are taking a monoamine oxi­dase inhibitor, because of a risk of hyper­tensive crisis.
 

Related Resources
• Wilens TE. Lisdexamfetamine for ADHD. Current Psychiatry. 2007;6(6):96-98,105.
• Peat CM, Brownley KA, Berkman ND, et al. Binge eating dis­order: evidence-based treatments. Current Psychiatry. 2012; 11(5):32-39.

Dear Dr. Mossman,

At the hospital where I serve as the psychi­atric consultant, a medical team asked me to evaluate a patient’s capacity to designate a new power of attorney (POA) for health care. The patient’s relatives want the change because they think the current POA—also a relative—is stealing the patient’s funds. The contentious family situation made me wonder: What legal risks might I face after I assess the patient’s capacity to choose a new POA?

Submitted by “Dr. P”

As America’s population ages, situa­tions like the one Dr. P has encoun­tered will become more common. Many variables—time constraints, patients’ cognitive impairments, lack of prior rela­tionships with patients, complex medical situations, and strained family dynamics— can make these clinical situations complex and daunting.

Dr. P realizes that feuding relatives can redirect their anger toward a well-meaning physician who might appear to take sides in a dispute. Yet staying silent isn’t a good option, either: If the patient is being mis­treated or abused, Dr. P may have a duty to initiate appropriate protective action.

In this article, we’ll respond to Dr. P’s question by examining these topics:
   • what a POA is and the rationale for having one
   • standards for capacity to choose a POA
   • characteristics and dynamics of poten­tial surrogates
   • responding to possible elder abuse.

Surrogate decision-makers
People can lose their decision-making capacity because of dementia, acute or chronic illness, or sudden injury. Although autonomy and respecting decisions of mentally capable people are paramount American values, our legal system has several mechanisms that can be activated on behalf of people who have lost their decision-making capabilities.

When a careful evaluation suggests that a patient cannot make informed medical decisions, one solution is to turn to a sur­rogate decision-maker whom the patient previously has designated to act on his (her) behalf, should he (she) become inca­pacitated. A surrogate can make decisions based on the incapacitated person’s cur­rent utterances (eg, expressions of pain), previously expressed wishes about what should happen under certain circum­stances, or the surrogate’s judgment of the person’s best interest.¹

States have varied legal frameworks for establishing surrogacy and refer to a sur­rogate using terms such as proxy, agent, attorney-in-fact, and power of attorney.² POA responsibilities can encompass a broad array of decision-making tasks or can be limited, for example, to handling banking transactions or managing estate planning.^3,4 A POA can be “durable” and grant lasting power regardless of disability, or “spring­ing” and operational only when the desig­nator has lost capacity.

A health care POA designates a substi­tute decision-maker for medical care. The Patient Self-Determination Act and the Joint Commission obligate health care pro­fessionals to follow the decisions made by a legally valid POA. Generally, providers who follow a surrogate’s decision in good faith have legal immunity, but they must challenge a surrogate’s decision if it devi­ates widely from usual protocol.²

Legal standards
Dr. P received a consultation request that asked whether a patient with compro­mised medical decision-making powers nonetheless had the current capacity to choose a new POA.

To evaluate the patient’s capacity to des­ignate a new POA, Dr. P must know what having this capacity means. What deter­mines if someone has the capacity to des­ignate a POA is a legal matter, and unless Dr. P is sure what the laws in her state say about this, she should consult a lawyer who can explain the jurisdiction’s applicable legal standards to her.⁵

The law generally presumes that adults are competent to make health care decisions, including decisions about appointing a POA.⁵ The law also recognizes that people with cog­nitive impairments or mental illnesses still can be competent to appoint POAs.⁴

Most states don’t have statutes that define the capacity to appoint a health care POA. In these jurisdictions, courts may apply standards similar to those concerning competence to enter into a contract.⁶Table 1 describes criteria in 4 states that do have statutory provisions concerning compe­tence to designate a health care POA.

Approaching the evaluation
Before evaluating a person’s capacity to designate a POA, you should first under­stand the person’s medical condition and learn what powers the surrogate would have. A detailed description of the evalu­ation process lies beyond the scope of this article. For more information, please con­sult the structured interviews described by Moye et al⁴ and Soliman’s guide to the evaluation process.⁷

In addition to examining the patient’s psychological status and cognitive capacity, you also might have to consider contextual variables, such as:
   • potential risks of not allowing the appointment of POA, including a delay in needed care
   • the person’s relationship to the pro­posed POA
   • possible power imbalances or evi­dence of coercion
   • how the person would benefit from having the POA.⁸

People who have good marital or parent-child relationships are more likely to select loved ones as their POAs.⁹ Family mem­bers who have not previously served as surrogates or have not had talked with their loved ones about their preferences feel less confident exercising the duties of a POA.¹⁰ An evaluation, therefore, should consider the prior relationship between the designator and proposed surrogate, and particularly whether these parties have dis­cussed the designator’s health care prefer­ences. Table 2 lists potential pitfalls in POA evaluations.^{2,4,5,8,11-13,16}

Many variables—the stress of the situation,⁸ pre-existing relationship dynamics,¹⁸ and caregiver psychopathology¹¹—lead POAs to exploit their designator. Sometimes, family members believe that they are enti­tled to a relative’s money because of real or imagined transgressions¹⁹ or because they regard themselves as eventual heirs to their relative’s estate.¹⁶ Some desig­nated POAs use designators’ funds sim­ply because they need money. Kemp and Mosqueda²⁰ have developed an evaluation framework for assessing possible financial abuse (Table 3).

Although reporting financial abuse can strain alliances between patients and their families, psychiatrists bear a responsibil­ity to look out for the welfare of their older patients.⁸ Indeed, all 50 states have elder abuse statutes, most of which mandate reporting by physicians.²¹

Suspicion of financial abuse could indi­cate the need to evaluate the susceptible person’s capacity to make financial deci­sions.¹² Depending on the patient’s circum­stances and medical problems, further steps might include:
   • contacting proper authorities, such as Adult Protective Services or the Department of Human Services
   • contacting local law enforcement
   • instituting procedures for emergency guardianship
   • arranging for more in-home services for the patient or recommending a higher level of care
   • developing a treatment plan for the patient’s medical and psychiatric problems
   • communicating with other trusted family members.^12,18

Bottom Line
Evaluating the capacity to appoint a power of attorney (POA) often requires awareness of social systems, family dynamics, and legal requirements, combined with the psychiatric data from a systematic individual assessment. Evaluating psychiatrists should understand what type of POA is being considered and the applicable legal standards in the jurisdictions where they work.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman,

At the hospital where I serve as the psychi­atric consultant, a medical team asked me to evaluate a patient’s capacity to designate a new power of attorney (POA) for health care. The patient’s relatives want the change because they think the current POA—also a relative—is stealing the patient’s funds. The contentious family situation made me wonder: What legal risks might I face after I assess the patient’s capacity to choose a new POA?

Submitted by “Dr. P”

As America’s population ages, situa­tions like the one Dr. P has encoun­tered will become more common. Many variables—time constraints, patients’ cognitive impairments, lack of prior rela­tionships with patients, complex medical situations, and strained family dynamics— can make these clinical situations complex and daunting.

Dr. P realizes that feuding relatives can redirect their anger toward a well-meaning physician who might appear to take sides in a dispute. Yet staying silent isn’t a good option, either: If the patient is being mis­treated or abused, Dr. P may have a duty to initiate appropriate protective action.

In this article, we’ll respond to Dr. P’s question by examining these topics:
   • what a POA is and the rationale for having one
   • standards for capacity to choose a POA
   • characteristics and dynamics of poten­tial surrogates
   • responding to possible elder abuse.

Surrogate decision-makers
People can lose their decision-making capacity because of dementia, acute or chronic illness, or sudden injury. Although autonomy and respecting decisions of mentally capable people are paramount American values, our legal system has several mechanisms that can be activated on behalf of people who have lost their decision-making capabilities.

When a careful evaluation suggests that a patient cannot make informed medical decisions, one solution is to turn to a sur­rogate decision-maker whom the patient previously has designated to act on his (her) behalf, should he (she) become inca­pacitated. A surrogate can make decisions based on the incapacitated person’s cur­rent utterances (eg, expressions of pain), previously expressed wishes about what should happen under certain circum­stances, or the surrogate’s judgment of the person’s best interest.¹

States have varied legal frameworks for establishing surrogacy and refer to a sur­rogate using terms such as proxy, agent, attorney-in-fact, and power of attorney.² POA responsibilities can encompass a broad array of decision-making tasks or can be limited, for example, to handling banking transactions or managing estate planning.^3,4 A POA can be “durable” and grant lasting power regardless of disability, or “spring­ing” and operational only when the desig­nator has lost capacity.

A health care POA designates a substi­tute decision-maker for medical care. The Patient Self-Determination Act and the Joint Commission obligate health care pro­fessionals to follow the decisions made by a legally valid POA. Generally, providers who follow a surrogate’s decision in good faith have legal immunity, but they must challenge a surrogate’s decision if it devi­ates widely from usual protocol.²

Legal standards
Dr. P received a consultation request that asked whether a patient with compro­mised medical decision-making powers nonetheless had the current capacity to choose a new POA.

To evaluate the patient’s capacity to des­ignate a new POA, Dr. P must know what having this capacity means. What deter­mines if someone has the capacity to des­ignate a POA is a legal matter, and unless Dr. P is sure what the laws in her state say about this, she should consult a lawyer who can explain the jurisdiction’s applicable legal standards to her.⁵

The law generally presumes that adults are competent to make health care decisions, including decisions about appointing a POA.⁵ The law also recognizes that people with cog­nitive impairments or mental illnesses still can be competent to appoint POAs.⁴

Most states don’t have statutes that define the capacity to appoint a health care POA. In these jurisdictions, courts may apply standards similar to those concerning competence to enter into a contract.⁶Table 1 describes criteria in 4 states that do have statutory provisions concerning compe­tence to designate a health care POA.

Approaching the evaluation
Before evaluating a person’s capacity to designate a POA, you should first under­stand the person’s medical condition and learn what powers the surrogate would have. A detailed description of the evalu­ation process lies beyond the scope of this article. For more information, please con­sult the structured interviews described by Moye et al⁴ and Soliman’s guide to the evaluation process.⁷

In addition to examining the patient’s psychological status and cognitive capacity, you also might have to consider contextual variables, such as:
   • potential risks of not allowing the appointment of POA, including a delay in needed care
   • the person’s relationship to the pro­posed POA
   • possible power imbalances or evi­dence of coercion
   • how the person would benefit from having the POA.⁸

People who have good marital or parent-child relationships are more likely to select loved ones as their POAs.⁹ Family mem­bers who have not previously served as surrogates or have not had talked with their loved ones about their preferences feel less confident exercising the duties of a POA.¹⁰ An evaluation, therefore, should consider the prior relationship between the designator and proposed surrogate, and particularly whether these parties have dis­cussed the designator’s health care prefer­ences. Table 2 lists potential pitfalls in POA evaluations.^{2,4,5,8,11-13,16}

Many variables—the stress of the situation,⁸ pre-existing relationship dynamics,¹⁸ and caregiver psychopathology¹¹—lead POAs to exploit their designator. Sometimes, family members believe that they are enti­tled to a relative’s money because of real or imagined transgressions¹⁹ or because they regard themselves as eventual heirs to their relative’s estate.¹⁶ Some desig­nated POAs use designators’ funds sim­ply because they need money. Kemp and Mosqueda²⁰ have developed an evaluation framework for assessing possible financial abuse (Table 3).

Although reporting financial abuse can strain alliances between patients and their families, psychiatrists bear a responsibil­ity to look out for the welfare of their older patients.⁸ Indeed, all 50 states have elder abuse statutes, most of which mandate reporting by physicians.²¹

Suspicion of financial abuse could indi­cate the need to evaluate the susceptible person’s capacity to make financial deci­sions.¹² Depending on the patient’s circum­stances and medical problems, further steps might include:
   • contacting proper authorities, such as Adult Protective Services or the Department of Human Services
   • contacting local law enforcement
   • instituting procedures for emergency guardianship
   • arranging for more in-home services for the patient or recommending a higher level of care
   • developing a treatment plan for the patient’s medical and psychiatric problems
   • communicating with other trusted family members.^12,18

Bottom Line
Evaluating the capacity to appoint a power of attorney (POA) often requires awareness of social systems, family dynamics, and legal requirements, combined with the psychiatric data from a systematic individual assessment. Evaluating psychiatrists should understand what type of POA is being considered and the applicable legal standards in the jurisdictions where they work.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman,

At the hospital where I serve as the psychi­atric consultant, a medical team asked me to evaluate a patient’s capacity to designate a new power of attorney (POA) for health care. The patient’s relatives want the change because they think the current POA—also a relative—is stealing the patient’s funds. The contentious family situation made me wonder: What legal risks might I face after I assess the patient’s capacity to choose a new POA?

Submitted by “Dr. P”

As America’s population ages, situa­tions like the one Dr. P has encoun­tered will become more common. Many variables—time constraints, patients’ cognitive impairments, lack of prior rela­tionships with patients, complex medical situations, and strained family dynamics— can make these clinical situations complex and daunting.

Dr. P realizes that feuding relatives can redirect their anger toward a well-meaning physician who might appear to take sides in a dispute. Yet staying silent isn’t a good option, either: If the patient is being mis­treated or abused, Dr. P may have a duty to initiate appropriate protective action.

In this article, we’ll respond to Dr. P’s question by examining these topics:
   • what a POA is and the rationale for having one
   • standards for capacity to choose a POA
   • characteristics and dynamics of poten­tial surrogates
   • responding to possible elder abuse.

Surrogate decision-makers
People can lose their decision-making capacity because of dementia, acute or chronic illness, or sudden injury. Although autonomy and respecting decisions of mentally capable people are paramount American values, our legal system has several mechanisms that can be activated on behalf of people who have lost their decision-making capabilities.

When a careful evaluation suggests that a patient cannot make informed medical decisions, one solution is to turn to a sur­rogate decision-maker whom the patient previously has designated to act on his (her) behalf, should he (she) become inca­pacitated. A surrogate can make decisions based on the incapacitated person’s cur­rent utterances (eg, expressions of pain), previously expressed wishes about what should happen under certain circum­stances, or the surrogate’s judgment of the person’s best interest.¹

States have varied legal frameworks for establishing surrogacy and refer to a sur­rogate using terms such as proxy, agent, attorney-in-fact, and power of attorney.² POA responsibilities can encompass a broad array of decision-making tasks or can be limited, for example, to handling banking transactions or managing estate planning.^3,4 A POA can be “durable” and grant lasting power regardless of disability, or “spring­ing” and operational only when the desig­nator has lost capacity.

A health care POA designates a substi­tute decision-maker for medical care. The Patient Self-Determination Act and the Joint Commission obligate health care pro­fessionals to follow the decisions made by a legally valid POA. Generally, providers who follow a surrogate’s decision in good faith have legal immunity, but they must challenge a surrogate’s decision if it devi­ates widely from usual protocol.²

Legal standards
Dr. P received a consultation request that asked whether a patient with compro­mised medical decision-making powers nonetheless had the current capacity to choose a new POA.

To evaluate the patient’s capacity to des­ignate a new POA, Dr. P must know what having this capacity means. What deter­mines if someone has the capacity to des­ignate a POA is a legal matter, and unless Dr. P is sure what the laws in her state say about this, she should consult a lawyer who can explain the jurisdiction’s applicable legal standards to her.⁵

The law generally presumes that adults are competent to make health care decisions, including decisions about appointing a POA.⁵ The law also recognizes that people with cog­nitive impairments or mental illnesses still can be competent to appoint POAs.⁴

Most states don’t have statutes that define the capacity to appoint a health care POA. In these jurisdictions, courts may apply standards similar to those concerning competence to enter into a contract.⁶Table 1 describes criteria in 4 states that do have statutory provisions concerning compe­tence to designate a health care POA.

Approaching the evaluation
Before evaluating a person’s capacity to designate a POA, you should first under­stand the person’s medical condition and learn what powers the surrogate would have. A detailed description of the evalu­ation process lies beyond the scope of this article. For more information, please con­sult the structured interviews described by Moye et al⁴ and Soliman’s guide to the evaluation process.⁷

In addition to examining the patient’s psychological status and cognitive capacity, you also might have to consider contextual variables, such as:
   • potential risks of not allowing the appointment of POA, including a delay in needed care
   • the person’s relationship to the pro­posed POA
   • possible power imbalances or evi­dence of coercion
   • how the person would benefit from having the POA.⁸

People who have good marital or parent-child relationships are more likely to select loved ones as their POAs.⁹ Family mem­bers who have not previously served as surrogates or have not had talked with their loved ones about their preferences feel less confident exercising the duties of a POA.¹⁰ An evaluation, therefore, should consider the prior relationship between the designator and proposed surrogate, and particularly whether these parties have dis­cussed the designator’s health care prefer­ences. Table 2 lists potential pitfalls in POA evaluations.^{2,4,5,8,11-13,16}

Many variables—the stress of the situation,⁸ pre-existing relationship dynamics,¹⁸ and caregiver psychopathology¹¹—lead POAs to exploit their designator. Sometimes, family members believe that they are enti­tled to a relative’s money because of real or imagined transgressions¹⁹ or because they regard themselves as eventual heirs to their relative’s estate.¹⁶ Some desig­nated POAs use designators’ funds sim­ply because they need money. Kemp and Mosqueda²⁰ have developed an evaluation framework for assessing possible financial abuse (Table 3).

Although reporting financial abuse can strain alliances between patients and their families, psychiatrists bear a responsibil­ity to look out for the welfare of their older patients.⁸ Indeed, all 50 states have elder abuse statutes, most of which mandate reporting by physicians.²¹

Suspicion of financial abuse could indi­cate the need to evaluate the susceptible person’s capacity to make financial deci­sions.¹² Depending on the patient’s circum­stances and medical problems, further steps might include:
   • contacting proper authorities, such as Adult Protective Services or the Department of Human Services
   • contacting local law enforcement
   • instituting procedures for emergency guardianship
   • arranging for more in-home services for the patient or recommending a higher level of care
   • developing a treatment plan for the patient’s medical and psychiatric problems
   • communicating with other trusted family members.^12,18

Bottom Line
Evaluating the capacity to appoint a power of attorney (POA) often requires awareness of social systems, family dynamics, and legal requirements, combined with the psychiatric data from a systematic individual assessment. Evaluating psychiatrists should understand what type of POA is being considered and the applicable legal standards in the jurisdictions where they work.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Too few psychiatrists. A growing number of patients. A new federal law, technological advances, and a genera­tional shift in the way people communicate. Add them together and you have the perfect environment for telepsy­chiatry—the remote practice of psychiatry by means of tele­medicine—to take root (Box 1). Although telepsychiatry has, in various forms, been around since the 1950s,¹ only recently has it expanded into almost all areas of psychiatric practice.

Here are some observations from my daily work on why I see this method of delivering mental health care is poised to expand in 2015 and beyond. Does telepsychiatry make sense for you?

Lack of supply is a big driver
There are simply not enough psychiatrists where they are needed, which is the primary driver of the expansion of telepsychiatry. With 77% of counties in the United States reporting a shortage of psychiatrists² and the “graying” of the psychiatric workforce,³ a more efficient way to make use of a psychiatrist’s time is needed. Telepsychiatry elimi­nates travel time and allows psychiatrists to visit distant sites virtually.

The shortage of psychiatric practitioners that we see today is only going to become worse. The Patient Protection and Affordable Care Act of 2010 includes mental health care and substance abuse treatment among its 10 essential benefits; just as important, new rules arising from the Mental Health Parity and Addiction Equity Act of 2008 limit restrictions on access to mental health care when insurance provides such cover­age.⁴ These legislative initiatives likely will lead to increased demand for psychiatrists in all care settings—from outpatient consults to acute inpatient admissions.


Why so attractive an option?
The shortage of psychiatrists creates limita­tions on access to care. Fortunately, telemed­icine has entered a new age, ushered in by widely available teleconferencing technol­ogy. Specialists from dermatology to surgery currently are using telemedicine; psychia­try is a good fit for telemedicine because of (1) the limited amount of “touch” required to make a psychiatric assessment, (2) signifi­cant improvements in video quality in recent years, and (3) a decrease in the stigma associ­ated with visiting a psychiatrist.

A generation raised on the Internet is entering the health care marketplace. These consumers and clinicians are accustomed to using video for many daily activities, and they seek health information from the Web. Visiting a psychiatrist through teleconferenc­ing isn’t strange or alienating to this genera­tion; their comfort with technology allows them to have intimate exchanges on video.

Subspecialty particulars
The earliest adopters, not surprisingly, are in areas where the strain of shortage has been felt most, with pediatric, geriatric, and correctional psychiatrists leading the way. In these fields, a substantial literature supports the use of telepsychiatry from a number of practice perspectives.

Pediatric psychiatry. The literature shows that children, families, and clinicians are, on the whole, satisfied with telepsychia­try.⁵ Children and adolescents who have been shown to benefit from telepsychia­try include those with depression,⁶ post­traumatic stress disorder, and eating disorders.⁷ Based on a case series, some authors have asserted that telepsychiatry might be preferable to in-person treatment (Box 2).⁸

Correctional psychiatry. Clinicians work­ing in correctional psychiatry have been at the forefront of experimentation with tele­psychiatry. The technology is a natural fit for this setting:  
   • Prisons often are located in remote locations.  
   • Psychiatrists can be reluctant to pro­vide on-site services because of safety concerns.

With correctional telepsychiatry, not only are patient outcomes comparable with in-person psychiatry, but the cost of delivering care can be significantly lower.¹¹ With the U.S. Department of Justice reporting that 50% of inmates have a diagnosable mental disorder, including substance abuse,¹² the need for access to a psychiatrist in the cor­rectional system is acute.

Telepsychiatry can confidently be pro­vided in a number of settings:  
   • emergency rooms  
   • nursing homes  
   • offices of primary care physicians  
   • in-home care.

Clinical services in these settings have been offered, studied, and reviewed.¹³

Can confidentiality and security be assured?
As with any new medical tool, the risk and benefits must be weighed care­ fully. The most obvious risk is to privacy. Telepsychiatry visits, like all patient encounters, must be secure and confiden­tial. Given the growing suspicion among the public and professionals who use com­puters that all data are at risk, clinicians must take appropriate cautions and, at the same time, warn patients of the risks. Readily available videoconferencing soft­ware, such as Skype, does not provide the level of security that patients expect from health care providers.¹⁴

Other common concerns about telepsy­chiatry are stable access to videoconferenc­ing and the safety from hackers of necessary hardware. Medical device companies have created hardware and software for use in telepsychiatry that provide a Health Insurance Portability and Accountability Act-compliant high-quality, stable, video­conferencing visit.

Do patients benefit?
Clinically, patients have fared well when they receive care through telepsychiatry. In some studies, however, clinicians have expressed some dissatisfaction with the technology¹³— understandable, given the value that psychi­atry traditionally has put on sitting with the patient. As Knoedler¹⁵ described it, making the switch to telepsychiatry from in-person contact can engender loneliness in some phy­sicians; not only is patient contact shifted to videoconferencing, but the psychiatrist loses the supportive environment of a busy clinical practice. Knoedler also pointed out that, on the other hand, telepsychiatry offers practi­tioners the opportunity to evaluate and treat people who otherwise would not have men­tal health care.

Obstacles—practical, knotty ones
Reimbursement and licensing. These are 2 pressing problems of telepsychiatry, although recent policy developments will help expand telepsychiatry and make it more appealing to physicians:
   • Medicare reimburses for telepsychiatry in non-metropolitan areas.
   • In 41 states, Medicaid has included tele­psychiatry as a benefit.¹⁶
   • Nine states offer a specific medical license for practicing telepsychiatry¹⁷ (in the remaining states, a full medical license must be obtained before one can provide telemedi­cine services).
   • The Joint Commission has included lan­guage in its regulations that could expedite privileging of telepsychiatrists.¹⁸

Even with such advancements, problems with licensure, credentialing, privacy, secu­rity, confidentiality, informed consent, and professional liability remain.¹⁹ I urge you to do your research on these key areas before plunging in.

Changes to models of care. The risk that telepsychiatry poses to various models of care has to be considered. Telepsychiatry is a dramatic innovation, but it should be used to support only high-quality, evidence-based care to which patients are entitled.²⁰ With new technology—as with new medi­cations—use must be carefully monitored and scrutinized.

Although evidence of the value of telepsy­chiatry is growing, many methods of long-distance practice are still in their infancy. Data must be collected and poor outcomes assessed honestly to ensure that the “more-good-than-harm” mandate is met.
 

Good reasons to call this shift ‘inevitable’
The future of telepsychiatry includes expansion into new areas of practice. The move to providing services to patients where they happen to be—at work or home— seems inevitable:
   • In rural areas, practitioners can com­municate with patients so that they are cared for in their homes, without the expense of transportation.
   • Employers can invest in workplace health clinics that use telemedicine ser­vices to reduce absenteeism.
   • For psychiatrists, the ability to provide services to patients across a wide region, from a single convenient location, and at lower cost is an attractive prospect.

To conclude: telepsychiatry holds potential to provide greater reimburse­ment and improved quality of life for psy­chiatrists and patients: It allows physicians to choose where they live and work, and limits the number of unreimbursed com­mutes, and gives patients access to psychi­atric care locally, without disruptive travel and delays.

Bottom Line
The exchange of medical information from 1 site to another by means of electronic communication has great potential to improve the health of patients and to alleviate the shortage of psychiatric practitioners across regions and settings. Pediatric, geriatric, and correctional psychiatry stand to benefit because of the nature of the patients and locations.

Related Resources
• American Telemedicine Association. Practice guidelines for video-based online mental health services. http://www. americantelemed.org/docs/default-source/standards/practice-guidelines-for-video-based-online-mental-health-services. pdf?sfvrsn=6. Published May 2013. Accessed February 10, 2015.
• Freudenberg N, Yellowlees PM. Telepsychiatry as part of a com­prehensive care plan. Virtual Mentor. 2014;16(12):964-968.
• Kornbluh R. Telepsychiatry is a tool that we must exploit. Clinical Psychiatry News. August 7, 2014. http://www. clinicalpsychiatrynews.com/home/article/telepsychiatry-is-a-tool-that-we-must-exploit/28c87bec298e0aa208309fa 9bc48dedc.html.
• University of Colorado Denver. Telemental Health Guide. http:// www.tmhguide.org.

Disclosure
Dr. Kornbluh reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Too few psychiatrists. A growing number of patients. A new federal law, technological advances, and a genera­tional shift in the way people communicate. Add them together and you have the perfect environment for telepsy­chiatry—the remote practice of psychiatry by means of tele­medicine—to take root (Box 1). Although telepsychiatry has, in various forms, been around since the 1950s,¹ only recently has it expanded into almost all areas of psychiatric practice.

Here are some observations from my daily work on why I see this method of delivering mental health care is poised to expand in 2015 and beyond. Does telepsychiatry make sense for you?

Lack of supply is a big driver
There are simply not enough psychiatrists where they are needed, which is the primary driver of the expansion of telepsychiatry. With 77% of counties in the United States reporting a shortage of psychiatrists² and the “graying” of the psychiatric workforce,³ a more efficient way to make use of a psychiatrist’s time is needed. Telepsychiatry elimi­nates travel time and allows psychiatrists to visit distant sites virtually.

The shortage of psychiatric practitioners that we see today is only going to become worse. The Patient Protection and Affordable Care Act of 2010 includes mental health care and substance abuse treatment among its 10 essential benefits; just as important, new rules arising from the Mental Health Parity and Addiction Equity Act of 2008 limit restrictions on access to mental health care when insurance provides such cover­age.⁴ These legislative initiatives likely will lead to increased demand for psychiatrists in all care settings—from outpatient consults to acute inpatient admissions.


Why so attractive an option?
The shortage of psychiatrists creates limita­tions on access to care. Fortunately, telemed­icine has entered a new age, ushered in by widely available teleconferencing technol­ogy. Specialists from dermatology to surgery currently are using telemedicine; psychia­try is a good fit for telemedicine because of (1) the limited amount of “touch” required to make a psychiatric assessment, (2) signifi­cant improvements in video quality in recent years, and (3) a decrease in the stigma associ­ated with visiting a psychiatrist.

A generation raised on the Internet is entering the health care marketplace. These consumers and clinicians are accustomed to using video for many daily activities, and they seek health information from the Web. Visiting a psychiatrist through teleconferenc­ing isn’t strange or alienating to this genera­tion; their comfort with technology allows them to have intimate exchanges on video.

Subspecialty particulars
The earliest adopters, not surprisingly, are in areas where the strain of shortage has been felt most, with pediatric, geriatric, and correctional psychiatrists leading the way. In these fields, a substantial literature supports the use of telepsychiatry from a number of practice perspectives.

Pediatric psychiatry. The literature shows that children, families, and clinicians are, on the whole, satisfied with telepsychia­try.⁵ Children and adolescents who have been shown to benefit from telepsychia­try include those with depression,⁶ post­traumatic stress disorder, and eating disorders.⁷ Based on a case series, some authors have asserted that telepsychiatry might be preferable to in-person treatment (Box 2).⁸

Correctional psychiatry. Clinicians work­ing in correctional psychiatry have been at the forefront of experimentation with tele­psychiatry. The technology is a natural fit for this setting:  
   • Prisons often are located in remote locations.  
   • Psychiatrists can be reluctant to pro­vide on-site services because of safety concerns.

With correctional telepsychiatry, not only are patient outcomes comparable with in-person psychiatry, but the cost of delivering care can be significantly lower.¹¹ With the U.S. Department of Justice reporting that 50% of inmates have a diagnosable mental disorder, including substance abuse,¹² the need for access to a psychiatrist in the cor­rectional system is acute.

Telepsychiatry can confidently be pro­vided in a number of settings:  
   • emergency rooms  
   • nursing homes  
   • offices of primary care physicians  
   • in-home care.

Clinical services in these settings have been offered, studied, and reviewed.¹³

Can confidentiality and security be assured?
As with any new medical tool, the risk and benefits must be weighed care­ fully. The most obvious risk is to privacy. Telepsychiatry visits, like all patient encounters, must be secure and confiden­tial. Given the growing suspicion among the public and professionals who use com­puters that all data are at risk, clinicians must take appropriate cautions and, at the same time, warn patients of the risks. Readily available videoconferencing soft­ware, such as Skype, does not provide the level of security that patients expect from health care providers.¹⁴

Other common concerns about telepsy­chiatry are stable access to videoconferenc­ing and the safety from hackers of necessary hardware. Medical device companies have created hardware and software for use in telepsychiatry that provide a Health Insurance Portability and Accountability Act-compliant high-quality, stable, video­conferencing visit.

Do patients benefit?
Clinically, patients have fared well when they receive care through telepsychiatry. In some studies, however, clinicians have expressed some dissatisfaction with the technology¹³— understandable, given the value that psychi­atry traditionally has put on sitting with the patient. As Knoedler¹⁵ described it, making the switch to telepsychiatry from in-person contact can engender loneliness in some phy­sicians; not only is patient contact shifted to videoconferencing, but the psychiatrist loses the supportive environment of a busy clinical practice. Knoedler also pointed out that, on the other hand, telepsychiatry offers practi­tioners the opportunity to evaluate and treat people who otherwise would not have men­tal health care.

Obstacles—practical, knotty ones
Reimbursement and licensing. These are 2 pressing problems of telepsychiatry, although recent policy developments will help expand telepsychiatry and make it more appealing to physicians:
   • Medicare reimburses for telepsychiatry in non-metropolitan areas.
   • In 41 states, Medicaid has included tele­psychiatry as a benefit.¹⁶
   • Nine states offer a specific medical license for practicing telepsychiatry¹⁷ (in the remaining states, a full medical license must be obtained before one can provide telemedi­cine services).
   • The Joint Commission has included lan­guage in its regulations that could expedite privileging of telepsychiatrists.¹⁸

Even with such advancements, problems with licensure, credentialing, privacy, secu­rity, confidentiality, informed consent, and professional liability remain.¹⁹ I urge you to do your research on these key areas before plunging in.

Changes to models of care. The risk that telepsychiatry poses to various models of care has to be considered. Telepsychiatry is a dramatic innovation, but it should be used to support only high-quality, evidence-based care to which patients are entitled.²⁰ With new technology—as with new medi­cations—use must be carefully monitored and scrutinized.

Although evidence of the value of telepsy­chiatry is growing, many methods of long-distance practice are still in their infancy. Data must be collected and poor outcomes assessed honestly to ensure that the “more-good-than-harm” mandate is met.
 

Good reasons to call this shift ‘inevitable’
The future of telepsychiatry includes expansion into new areas of practice. The move to providing services to patients where they happen to be—at work or home— seems inevitable:
   • In rural areas, practitioners can com­municate with patients so that they are cared for in their homes, without the expense of transportation.
   • Employers can invest in workplace health clinics that use telemedicine ser­vices to reduce absenteeism.
   • For psychiatrists, the ability to provide services to patients across a wide region, from a single convenient location, and at lower cost is an attractive prospect.

To conclude: telepsychiatry holds potential to provide greater reimburse­ment and improved quality of life for psy­chiatrists and patients: It allows physicians to choose where they live and work, and limits the number of unreimbursed com­mutes, and gives patients access to psychi­atric care locally, without disruptive travel and delays.

Bottom Line
The exchange of medical information from 1 site to another by means of electronic communication has great potential to improve the health of patients and to alleviate the shortage of psychiatric practitioners across regions and settings. Pediatric, geriatric, and correctional psychiatry stand to benefit because of the nature of the patients and locations.

Related Resources
• American Telemedicine Association. Practice guidelines for video-based online mental health services. http://www. americantelemed.org/docs/default-source/standards/practice-guidelines-for-video-based-online-mental-health-services. pdf?sfvrsn=6. Published May 2013. Accessed February 10, 2015.
• Freudenberg N, Yellowlees PM. Telepsychiatry as part of a com­prehensive care plan. Virtual Mentor. 2014;16(12):964-968.
• Kornbluh R. Telepsychiatry is a tool that we must exploit. Clinical Psychiatry News. August 7, 2014. http://www. clinicalpsychiatrynews.com/home/article/telepsychiatry-is-a-tool-that-we-must-exploit/28c87bec298e0aa208309fa 9bc48dedc.html.
• University of Colorado Denver. Telemental Health Guide. http:// www.tmhguide.org.

Disclosure
Dr. Kornbluh reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Too few psychiatrists. A growing number of patients. A new federal law, technological advances, and a genera­tional shift in the way people communicate. Add them together and you have the perfect environment for telepsy­chiatry—the remote practice of psychiatry by means of tele­medicine—to take root (Box 1). Although telepsychiatry has, in various forms, been around since the 1950s,¹ only recently has it expanded into almost all areas of psychiatric practice.

Here are some observations from my daily work on why I see this method of delivering mental health care is poised to expand in 2015 and beyond. Does telepsychiatry make sense for you?

Lack of supply is a big driver
There are simply not enough psychiatrists where they are needed, which is the primary driver of the expansion of telepsychiatry. With 77% of counties in the United States reporting a shortage of psychiatrists² and the “graying” of the psychiatric workforce,³ a more efficient way to make use of a psychiatrist’s time is needed. Telepsychiatry elimi­nates travel time and allows psychiatrists to visit distant sites virtually.

The shortage of psychiatric practitioners that we see today is only going to become worse. The Patient Protection and Affordable Care Act of 2010 includes mental health care and substance abuse treatment among its 10 essential benefits; just as important, new rules arising from the Mental Health Parity and Addiction Equity Act of 2008 limit restrictions on access to mental health care when insurance provides such cover­age.⁴ These legislative initiatives likely will lead to increased demand for psychiatrists in all care settings—from outpatient consults to acute inpatient admissions.


Why so attractive an option?
The shortage of psychiatrists creates limita­tions on access to care. Fortunately, telemed­icine has entered a new age, ushered in by widely available teleconferencing technol­ogy. Specialists from dermatology to surgery currently are using telemedicine; psychia­try is a good fit for telemedicine because of (1) the limited amount of “touch” required to make a psychiatric assessment, (2) signifi­cant improvements in video quality in recent years, and (3) a decrease in the stigma associ­ated with visiting a psychiatrist.

A generation raised on the Internet is entering the health care marketplace. These consumers and clinicians are accustomed to using video for many daily activities, and they seek health information from the Web. Visiting a psychiatrist through teleconferenc­ing isn’t strange or alienating to this genera­tion; their comfort with technology allows them to have intimate exchanges on video.

Subspecialty particulars
The earliest adopters, not surprisingly, are in areas where the strain of shortage has been felt most, with pediatric, geriatric, and correctional psychiatrists leading the way. In these fields, a substantial literature supports the use of telepsychiatry from a number of practice perspectives.

Pediatric psychiatry. The literature shows that children, families, and clinicians are, on the whole, satisfied with telepsychia­try.⁵ Children and adolescents who have been shown to benefit from telepsychia­try include those with depression,⁶ post­traumatic stress disorder, and eating disorders.⁷ Based on a case series, some authors have asserted that telepsychiatry might be preferable to in-person treatment (Box 2).⁸

Correctional psychiatry. Clinicians work­ing in correctional psychiatry have been at the forefront of experimentation with tele­psychiatry. The technology is a natural fit for this setting:  
   • Prisons often are located in remote locations.  
   • Psychiatrists can be reluctant to pro­vide on-site services because of safety concerns.

With correctional telepsychiatry, not only are patient outcomes comparable with in-person psychiatry, but the cost of delivering care can be significantly lower.¹¹ With the U.S. Department of Justice reporting that 50% of inmates have a diagnosable mental disorder, including substance abuse,¹² the need for access to a psychiatrist in the cor­rectional system is acute.

Telepsychiatry can confidently be pro­vided in a number of settings:  
   • emergency rooms  
   • nursing homes  
   • offices of primary care physicians  
   • in-home care.

Clinical services in these settings have been offered, studied, and reviewed.¹³

Can confidentiality and security be assured?
As with any new medical tool, the risk and benefits must be weighed care­ fully. The most obvious risk is to privacy. Telepsychiatry visits, like all patient encounters, must be secure and confiden­tial. Given the growing suspicion among the public and professionals who use com­puters that all data are at risk, clinicians must take appropriate cautions and, at the same time, warn patients of the risks. Readily available videoconferencing soft­ware, such as Skype, does not provide the level of security that patients expect from health care providers.¹⁴

Other common concerns about telepsy­chiatry are stable access to videoconferenc­ing and the safety from hackers of necessary hardware. Medical device companies have created hardware and software for use in telepsychiatry that provide a Health Insurance Portability and Accountability Act-compliant high-quality, stable, video­conferencing visit.

Do patients benefit?
Clinically, patients have fared well when they receive care through telepsychiatry. In some studies, however, clinicians have expressed some dissatisfaction with the technology¹³— understandable, given the value that psychi­atry traditionally has put on sitting with the patient. As Knoedler¹⁵ described it, making the switch to telepsychiatry from in-person contact can engender loneliness in some phy­sicians; not only is patient contact shifted to videoconferencing, but the psychiatrist loses the supportive environment of a busy clinical practice. Knoedler also pointed out that, on the other hand, telepsychiatry offers practi­tioners the opportunity to evaluate and treat people who otherwise would not have men­tal health care.

Obstacles—practical, knotty ones
Reimbursement and licensing. These are 2 pressing problems of telepsychiatry, although recent policy developments will help expand telepsychiatry and make it more appealing to physicians:
   • Medicare reimburses for telepsychiatry in non-metropolitan areas.
   • In 41 states, Medicaid has included tele­psychiatry as a benefit.¹⁶
   • Nine states offer a specific medical license for practicing telepsychiatry¹⁷ (in the remaining states, a full medical license must be obtained before one can provide telemedi­cine services).
   • The Joint Commission has included lan­guage in its regulations that could expedite privileging of telepsychiatrists.¹⁸

Even with such advancements, problems with licensure, credentialing, privacy, secu­rity, confidentiality, informed consent, and professional liability remain.¹⁹ I urge you to do your research on these key areas before plunging in.

Changes to models of care. The risk that telepsychiatry poses to various models of care has to be considered. Telepsychiatry is a dramatic innovation, but it should be used to support only high-quality, evidence-based care to which patients are entitled.²⁰ With new technology—as with new medi­cations—use must be carefully monitored and scrutinized.

Although evidence of the value of telepsy­chiatry is growing, many methods of long-distance practice are still in their infancy. Data must be collected and poor outcomes assessed honestly to ensure that the “more-good-than-harm” mandate is met.
 

Good reasons to call this shift ‘inevitable’
The future of telepsychiatry includes expansion into new areas of practice. The move to providing services to patients where they happen to be—at work or home— seems inevitable:
   • In rural areas, practitioners can com­municate with patients so that they are cared for in their homes, without the expense of transportation.
   • Employers can invest in workplace health clinics that use telemedicine ser­vices to reduce absenteeism.
   • For psychiatrists, the ability to provide services to patients across a wide region, from a single convenient location, and at lower cost is an attractive prospect.

To conclude: telepsychiatry holds potential to provide greater reimburse­ment and improved quality of life for psy­chiatrists and patients: It allows physicians to choose where they live and work, and limits the number of unreimbursed com­mutes, and gives patients access to psychi­atric care locally, without disruptive travel and delays.

Bottom Line
The exchange of medical information from 1 site to another by means of electronic communication has great potential to improve the health of patients and to alleviate the shortage of psychiatric practitioners across regions and settings. Pediatric, geriatric, and correctional psychiatry stand to benefit because of the nature of the patients and locations.

Related Resources
• American Telemedicine Association. Practice guidelines for video-based online mental health services. http://www. americantelemed.org/docs/default-source/standards/practice-guidelines-for-video-based-online-mental-health-services. pdf?sfvrsn=6. Published May 2013. Accessed February 10, 2015.
• Freudenberg N, Yellowlees PM. Telepsychiatry as part of a com­prehensive care plan. Virtual Mentor. 2014;16(12):964-968.
• Kornbluh R. Telepsychiatry is a tool that we must exploit. Clinical Psychiatry News. August 7, 2014. http://www. clinicalpsychiatrynews.com/home/article/telepsychiatry-is-a-tool-that-we-must-exploit/28c87bec298e0aa208309fa 9bc48dedc.html.
• University of Colorado Denver. Telemental Health Guide. http:// www.tmhguide.org.

Disclosure
Dr. Kornbluh reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.