Current Psychiatry

A recent book contends that psychiatry has transformed normal sadness and sorrow into a depressive disorder,¹ which would be akin to saying primary care physicians diagnose every mild cough as pneumonia. The book’s premise is not true, of course, but it’s a perfect example of how misunderstood serious mental illness is.

Psychiatric disorders deal with extreme, pathologic changes in behavior, thoughts and emotions, perception, or will. Psychiatrists do not pathologize normal sadness over a missed opportunity nor noticeable grief over the death of a loved one. We do, however, recognize the substantial disruption that clinical depression brings to a person’s life and the potential for suicidal acts during major depressive illness.

Similarly, being happy about a minor achievement does not affect one’s life as much as the giddiness of infatuation and certainly is not as serious as the grandiose euphoria of a manic episode. Psychiatrists would intervene with a diagnosis and treatment plan only if the condition were severe enough to impair social and vocational functioning.

Cataloging human flaws

Let’s assume, just for fun, that psychiatrists did decide to pathologize common human traits. Consider the many categories we would need to add to DSM-V!

Take the worldwide financial meltdown triggered by questionable practices of banking executives who thought they would never fail or be caught on their way to accumulating obscene wealth. They certainly left a lot of wreckage in their wake, so perhaps psychiatry should create new diagnostic entities of “Horrendous Hubris” and “Gargantuan Greed.”

But why stop there? How about “Verbal Diarrhea” for folks who chatter incessantly at a cocktail party or committee meeting, or “Intellectual Constipation” for our friends with exasperating narrow-mindedness. And for the painfully irritating person, “Social Hemorrhoid” might be apropos.

Let’s not forget those who throw temper tantrums when they can’t have their way: they may suffer from “Temperamental Arrhythmia.” And for chronic complainers who never stop whining, let’s go with “Emotive Angina.” I’d better stop here and not go into the garden variety of human flaws: gluttony, sloth, fanaticism, indecisiveness, cowardice, chicanery, snobbishness, rudeness, and plain old stupidity.

Normal vs pathologic

My point is that the social retina of psychiatry does not perceive ordinary human traits and emotions such as normal sadness as pathologic behavior. But psychiatrists certainly are willing to intervene when people seek help on their own for problems such as depressive episodes that are disrupting their lives or are referred by physicians or brought in by family or friends who recognize the potential gravity of their afflictions.

A recent book contends that psychiatry has transformed normal sadness and sorrow into a depressive disorder,¹ which would be akin to saying primary care physicians diagnose every mild cough as pneumonia. The book’s premise is not true, of course, but it’s a perfect example of how misunderstood serious mental illness is.

Psychiatric disorders deal with extreme, pathologic changes in behavior, thoughts and emotions, perception, or will. Psychiatrists do not pathologize normal sadness over a missed opportunity nor noticeable grief over the death of a loved one. We do, however, recognize the substantial disruption that clinical depression brings to a person’s life and the potential for suicidal acts during major depressive illness.

Similarly, being happy about a minor achievement does not affect one’s life as much as the giddiness of infatuation and certainly is not as serious as the grandiose euphoria of a manic episode. Psychiatrists would intervene with a diagnosis and treatment plan only if the condition were severe enough to impair social and vocational functioning.

Cataloging human flaws

Let’s assume, just for fun, that psychiatrists did decide to pathologize common human traits. Consider the many categories we would need to add to DSM-V!

Take the worldwide financial meltdown triggered by questionable practices of banking executives who thought they would never fail or be caught on their way to accumulating obscene wealth. They certainly left a lot of wreckage in their wake, so perhaps psychiatry should create new diagnostic entities of “Horrendous Hubris” and “Gargantuan Greed.”

But why stop there? How about “Verbal Diarrhea” for folks who chatter incessantly at a cocktail party or committee meeting, or “Intellectual Constipation” for our friends with exasperating narrow-mindedness. And for the painfully irritating person, “Social Hemorrhoid” might be apropos.

Let’s not forget those who throw temper tantrums when they can’t have their way: they may suffer from “Temperamental Arrhythmia.” And for chronic complainers who never stop whining, let’s go with “Emotive Angina.” I’d better stop here and not go into the garden variety of human flaws: gluttony, sloth, fanaticism, indecisiveness, cowardice, chicanery, snobbishness, rudeness, and plain old stupidity.

Normal vs pathologic

My point is that the social retina of psychiatry does not perceive ordinary human traits and emotions such as normal sadness as pathologic behavior. But psychiatrists certainly are willing to intervene when people seek help on their own for problems such as depressive episodes that are disrupting their lives or are referred by physicians or brought in by family or friends who recognize the potential gravity of their afflictions.

A recent book contends that psychiatry has transformed normal sadness and sorrow into a depressive disorder,¹ which would be akin to saying primary care physicians diagnose every mild cough as pneumonia. The book’s premise is not true, of course, but it’s a perfect example of how misunderstood serious mental illness is.

Psychiatric disorders deal with extreme, pathologic changes in behavior, thoughts and emotions, perception, or will. Psychiatrists do not pathologize normal sadness over a missed opportunity nor noticeable grief over the death of a loved one. We do, however, recognize the substantial disruption that clinical depression brings to a person’s life and the potential for suicidal acts during major depressive illness.

Similarly, being happy about a minor achievement does not affect one’s life as much as the giddiness of infatuation and certainly is not as serious as the grandiose euphoria of a manic episode. Psychiatrists would intervene with a diagnosis and treatment plan only if the condition were severe enough to impair social and vocational functioning.

Cataloging human flaws

Let’s assume, just for fun, that psychiatrists did decide to pathologize common human traits. Consider the many categories we would need to add to DSM-V!

Take the worldwide financial meltdown triggered by questionable practices of banking executives who thought they would never fail or be caught on their way to accumulating obscene wealth. They certainly left a lot of wreckage in their wake, so perhaps psychiatry should create new diagnostic entities of “Horrendous Hubris” and “Gargantuan Greed.”

But why stop there? How about “Verbal Diarrhea” for folks who chatter incessantly at a cocktail party or committee meeting, or “Intellectual Constipation” for our friends with exasperating narrow-mindedness. And for the painfully irritating person, “Social Hemorrhoid” might be apropos.

Let’s not forget those who throw temper tantrums when they can’t have their way: they may suffer from “Temperamental Arrhythmia.” And for chronic complainers who never stop whining, let’s go with “Emotive Angina.” I’d better stop here and not go into the garden variety of human flaws: gluttony, sloth, fanaticism, indecisiveness, cowardice, chicanery, snobbishness, rudeness, and plain old stupidity.

Normal vs pathologic

My point is that the social retina of psychiatry does not perceive ordinary human traits and emotions such as normal sadness as pathologic behavior. But psychiatrists certainly are willing to intervene when people seek help on their own for problems such as depressive episodes that are disrupting their lives or are referred by physicians or brought in by family or friends who recognize the potential gravity of their afflictions.

HISTORY: ‘Not himself’

Mr. C, age 69, presents to the emergency department complaining of intermittent fever of about 100°F, hematuria, headache, weakness, fatigue, and decreased appetite over 2 months. Testing shows acute renal failure, elevated C-reactive protein, and increased sedimentation rate. The attending internist admits Mr. C with a working diagnosis of temporal arteritis and acute renal failure, administers corticosteroids for headache, and orders a right temporal artery biopsy, which shows no signs of vasculitis.

Family members report that Mr. C has not been himself—he has become increasingly withdrawn and “emotionless.” Mr. C’s wife says her husband has needed help with dressing and eating because of short-term memory loss over 9 months. She says he has lost 20 to 30 lb.

The patient’s cognitive function appears to have worsened since he developed these physical symptoms. Mrs. C also reports that he has had weakness and fatigue for 8 months.

One month earlier, the patient was admitted to a different hospital and treated for 2 weeks with IV antibiotics for fever of unknown origin. Results of lumbar puncture and extensive rheumatologic, infectious disease, urologic, and gastroenterologic evaluations were normal.

The internal medicine physician requests a psychiatric consultation. During our interview, Mr. C is cooperative, shows no signs of acute distress, is well groomed and dressed appropriately, and maintains eye contact. Speech rate and volume are low, with normal articulation and coherence, diminished spontaneity, and paucity of language. Mrs. C tells us her husband was lively and talkative before his recent illness. His mood is euthymic, and he is pleasant and cheerful during the evaluation.

The authors’ observations

Initially, we suspect an underlying medical condition is causing Mr. C’s psychiatric symptoms.

Mr. C’s wife reports that her husband stopped drinking 2 years ago after his family expressed concern about his health. Mr. C’s past alcohol use could not be quantified. He has not abused illicit drugs and has no personal or family history of dementia, trauma, or psychiatric or neurologic disorders.

EVALUATION: Impaired memory

Mr. C is afebrile during the initial physical examination, but fever returns within several days. Neurologic examination is normal, and negative rapid plasma reagin rules out syphilis. Vitamin B₁₂ and folate levels are normal, as is thyroid function. Other laboratory findings are outside normal limits (Table).

Urine is cloudy with 2+ protein, 3+ blood, and trace leukocyte esterase. The presence of protein and blood suggests a glomerular disease such as a glomerulonephritis.

A positive leukocyte esterase test results from the presence of white blood cells, either as whole cells or as lysed cells. An abnormal number of leukocytes may appear with upper or lower urinary tract infection or in acute glomerulonephritis.

Chest radiography shows increased bilateral pulmonary vasculature, which can indicate pulmonary hypertension.

Mr. C has fair attention and concentration but impaired recent memory. He cannot recall yesterday’s events without help.

Mr. C’s Mini-Mental State Examination score of 21/30 suggests markedly impaired executive functioning and cognitive deficits. The attending psychiatrist recommends brain MRI.

Table

Mr. C’s laboratory findings

The authors’ observations

Mr. C shows markedly impaired cognitive function without significant impairment of attention and concentration despite his progressive deterioration and increasing disability. Urine toxicology shows no illicit substances. Given his lack of a previous mood disorder and his family’s description of him as formerly vibrant and cheerful, he likely does not have a mood disorder.

Based on the history of events, including the symptom pattern, we rule out delirium. We suspect that Mr. C has dementia secondary to a general medical condition. His symptoms seem to be directly related to his medical complaints and do not have a waxing and waning course. The internal medicine physician orders additional laboratory tests.

TESTING: Kidney, lung damage

Over 5 days, Mr. C’s intermittent low-grade fevers continue. Laboratory tests are negative for HIV antibody, hepatitis panel, and antinuclear antibodies (ANA). C-reactive protein is elevated at 27.8 mg/dL (normal range,

Renal ultrasound is normal, but preliminary renal biopsy shows rapidly progressive glomerulonephritis. The internist immediately starts dialysis, cyclophosphamide at 1.5 mg/kg, and prednisone, 1 mg/kg. The pathology report on the renal biopsy describes extensive crescentic glomerular destruction, with inflammatory cells present.

Ten days after admission, Mr. C develops hemoptysis, and chest radiography shows increasing alveolar infiltrates. The attending internist consults pulmonary and critical care services.

The consultant suspects a pulmonary-renal syndrome because of bilateral alveolar infiltrates (diffuse alveolar hemorrhage). The internal medicine team continues high-dose corticosteroids, followed by plasmapheresis.

Brain MRI shows subacute to chronic infarcts involving the right basal ganglia and corona radiate and mild to moderate small vessel ischemic changes. Old areas of hemorrhage are noted within both cerebellar lobes, left temporal lobe, right basal ganglia, right parietal lobe, and right frontal lobe.

During follow-up interviews, Mr. C often cannot recall recent dialysis or plasmapheresis and reports no physical symptoms. His short-term memory continues to deteriorate; he would forget to eat if not cued by family or nursing staff. He shows global cognitive deficits and is increasingly withdrawn and flat.

The authors’ observations

Although few case reports have associated Goodpasture’s syndrome with neurobehavioral changes, the apparent relationship of Mr. C’s medical symptoms with the worsening of his cognitive impairment suggests a link.

Mr. C’s MRI findings also might suggest CNS vasculitis, which affects small arteries of the cerebral and spinal cord leptomeninges and parenchyma, leading to CNS dys-function.^6-8 CNS vasculitis can result from primary nervous system involvement or from a secondary systemic process such as Goodpasture’s syndrome.⁹

We rule out lupus because Mr. C is ANA-negative; this test has 99% sensitivity for lupus.¹⁰

Box

OUTCOME: Ongoing disability

Mr. C is hospitalized for 6 weeks. He receives cyclophosphamide, prednisone, and 10 sessions of plasmapheresis. We prescribe mirtazapine, 15 mg at bedtime, to treat mood symptoms. We chose mirtazapine because of the drug’s sleep-restoring and appetite-stimulating properties.

Mr. C’s fever resolves and pulmonary function soon improves, but his cognitive impairment persists. He has difficulties preparing meals, taking medications, and managing his money.

Mr. C is discharged with a referral to a psychiatrist. He continues taking mirtazapine and a lower dose of prednisone. He requires ongoing hemodialysis and assistance with activities of daily living.

The authors’ observations

Prompt multidisciplinary intervention is critical when patients present with concurrent cognitive and medical symptoms. A thorough psychiatric evaluation can help piece together the illness’ course. The psychiatrist’s role in a multidisciplinary assessment is to:

• document neurocognitive changes
  
• verify them through collateral information
  
• correlate these changes with the timing of medical symptoms.
  

An underlying psychiatric condition can complicate the diagnosis. In these cases, careful interviewing and collateral information can help you discern the chronology of events.

HISTORY: ‘Not himself’

Mr. C, age 69, presents to the emergency department complaining of intermittent fever of about 100°F, hematuria, headache, weakness, fatigue, and decreased appetite over 2 months. Testing shows acute renal failure, elevated C-reactive protein, and increased sedimentation rate. The attending internist admits Mr. C with a working diagnosis of temporal arteritis and acute renal failure, administers corticosteroids for headache, and orders a right temporal artery biopsy, which shows no signs of vasculitis.

Family members report that Mr. C has not been himself—he has become increasingly withdrawn and “emotionless.” Mr. C’s wife says her husband has needed help with dressing and eating because of short-term memory loss over 9 months. She says he has lost 20 to 30 lb.

The patient’s cognitive function appears to have worsened since he developed these physical symptoms. Mrs. C also reports that he has had weakness and fatigue for 8 months.

One month earlier, the patient was admitted to a different hospital and treated for 2 weeks with IV antibiotics for fever of unknown origin. Results of lumbar puncture and extensive rheumatologic, infectious disease, urologic, and gastroenterologic evaluations were normal.

The internal medicine physician requests a psychiatric consultation. During our interview, Mr. C is cooperative, shows no signs of acute distress, is well groomed and dressed appropriately, and maintains eye contact. Speech rate and volume are low, with normal articulation and coherence, diminished spontaneity, and paucity of language. Mrs. C tells us her husband was lively and talkative before his recent illness. His mood is euthymic, and he is pleasant and cheerful during the evaluation.

The authors’ observations

Initially, we suspect an underlying medical condition is causing Mr. C’s psychiatric symptoms.

Mr. C’s wife reports that her husband stopped drinking 2 years ago after his family expressed concern about his health. Mr. C’s past alcohol use could not be quantified. He has not abused illicit drugs and has no personal or family history of dementia, trauma, or psychiatric or neurologic disorders.

EVALUATION: Impaired memory

Mr. C is afebrile during the initial physical examination, but fever returns within several days. Neurologic examination is normal, and negative rapid plasma reagin rules out syphilis. Vitamin B₁₂ and folate levels are normal, as is thyroid function. Other laboratory findings are outside normal limits (Table).

Urine is cloudy with 2+ protein, 3+ blood, and trace leukocyte esterase. The presence of protein and blood suggests a glomerular disease such as a glomerulonephritis.

A positive leukocyte esterase test results from the presence of white blood cells, either as whole cells or as lysed cells. An abnormal number of leukocytes may appear with upper or lower urinary tract infection or in acute glomerulonephritis.

Chest radiography shows increased bilateral pulmonary vasculature, which can indicate pulmonary hypertension.

Mr. C has fair attention and concentration but impaired recent memory. He cannot recall yesterday’s events without help.

Mr. C’s Mini-Mental State Examination score of 21/30 suggests markedly impaired executive functioning and cognitive deficits. The attending psychiatrist recommends brain MRI.

Table

Mr. C’s laboratory findings

The authors’ observations

Mr. C shows markedly impaired cognitive function without significant impairment of attention and concentration despite his progressive deterioration and increasing disability. Urine toxicology shows no illicit substances. Given his lack of a previous mood disorder and his family’s description of him as formerly vibrant and cheerful, he likely does not have a mood disorder.

Based on the history of events, including the symptom pattern, we rule out delirium. We suspect that Mr. C has dementia secondary to a general medical condition. His symptoms seem to be directly related to his medical complaints and do not have a waxing and waning course. The internal medicine physician orders additional laboratory tests.

TESTING: Kidney, lung damage

Over 5 days, Mr. C’s intermittent low-grade fevers continue. Laboratory tests are negative for HIV antibody, hepatitis panel, and antinuclear antibodies (ANA). C-reactive protein is elevated at 27.8 mg/dL (normal range,

Renal ultrasound is normal, but preliminary renal biopsy shows rapidly progressive glomerulonephritis. The internist immediately starts dialysis, cyclophosphamide at 1.5 mg/kg, and prednisone, 1 mg/kg. The pathology report on the renal biopsy describes extensive crescentic glomerular destruction, with inflammatory cells present.

Ten days after admission, Mr. C develops hemoptysis, and chest radiography shows increasing alveolar infiltrates. The attending internist consults pulmonary and critical care services.

The consultant suspects a pulmonary-renal syndrome because of bilateral alveolar infiltrates (diffuse alveolar hemorrhage). The internal medicine team continues high-dose corticosteroids, followed by plasmapheresis.

Brain MRI shows subacute to chronic infarcts involving the right basal ganglia and corona radiate and mild to moderate small vessel ischemic changes. Old areas of hemorrhage are noted within both cerebellar lobes, left temporal lobe, right basal ganglia, right parietal lobe, and right frontal lobe.

During follow-up interviews, Mr. C often cannot recall recent dialysis or plasmapheresis and reports no physical symptoms. His short-term memory continues to deteriorate; he would forget to eat if not cued by family or nursing staff. He shows global cognitive deficits and is increasingly withdrawn and flat.

The authors’ observations

Although few case reports have associated Goodpasture’s syndrome with neurobehavioral changes, the apparent relationship of Mr. C’s medical symptoms with the worsening of his cognitive impairment suggests a link.

Mr. C’s MRI findings also might suggest CNS vasculitis, which affects small arteries of the cerebral and spinal cord leptomeninges and parenchyma, leading to CNS dys-function.^6-8 CNS vasculitis can result from primary nervous system involvement or from a secondary systemic process such as Goodpasture’s syndrome.⁹

We rule out lupus because Mr. C is ANA-negative; this test has 99% sensitivity for lupus.¹⁰

Box

OUTCOME: Ongoing disability

Mr. C is hospitalized for 6 weeks. He receives cyclophosphamide, prednisone, and 10 sessions of plasmapheresis. We prescribe mirtazapine, 15 mg at bedtime, to treat mood symptoms. We chose mirtazapine because of the drug’s sleep-restoring and appetite-stimulating properties.

Mr. C’s fever resolves and pulmonary function soon improves, but his cognitive impairment persists. He has difficulties preparing meals, taking medications, and managing his money.

Mr. C is discharged with a referral to a psychiatrist. He continues taking mirtazapine and a lower dose of prednisone. He requires ongoing hemodialysis and assistance with activities of daily living.

The authors’ observations

Prompt multidisciplinary intervention is critical when patients present with concurrent cognitive and medical symptoms. A thorough psychiatric evaluation can help piece together the illness’ course. The psychiatrist’s role in a multidisciplinary assessment is to:

• document neurocognitive changes
  
• verify them through collateral information
  
• correlate these changes with the timing of medical symptoms.
  

An underlying psychiatric condition can complicate the diagnosis. In these cases, careful interviewing and collateral information can help you discern the chronology of events.

HISTORY: ‘Not himself’

Mr. C, age 69, presents to the emergency department complaining of intermittent fever of about 100°F, hematuria, headache, weakness, fatigue, and decreased appetite over 2 months. Testing shows acute renal failure, elevated C-reactive protein, and increased sedimentation rate. The attending internist admits Mr. C with a working diagnosis of temporal arteritis and acute renal failure, administers corticosteroids for headache, and orders a right temporal artery biopsy, which shows no signs of vasculitis.

Family members report that Mr. C has not been himself—he has become increasingly withdrawn and “emotionless.” Mr. C’s wife says her husband has needed help with dressing and eating because of short-term memory loss over 9 months. She says he has lost 20 to 30 lb.

The patient’s cognitive function appears to have worsened since he developed these physical symptoms. Mrs. C also reports that he has had weakness and fatigue for 8 months.

One month earlier, the patient was admitted to a different hospital and treated for 2 weeks with IV antibiotics for fever of unknown origin. Results of lumbar puncture and extensive rheumatologic, infectious disease, urologic, and gastroenterologic evaluations were normal.

The internal medicine physician requests a psychiatric consultation. During our interview, Mr. C is cooperative, shows no signs of acute distress, is well groomed and dressed appropriately, and maintains eye contact. Speech rate and volume are low, with normal articulation and coherence, diminished spontaneity, and paucity of language. Mrs. C tells us her husband was lively and talkative before his recent illness. His mood is euthymic, and he is pleasant and cheerful during the evaluation.

The authors’ observations

Initially, we suspect an underlying medical condition is causing Mr. C’s psychiatric symptoms.

Mr. C’s wife reports that her husband stopped drinking 2 years ago after his family expressed concern about his health. Mr. C’s past alcohol use could not be quantified. He has not abused illicit drugs and has no personal or family history of dementia, trauma, or psychiatric or neurologic disorders.

EVALUATION: Impaired memory

Mr. C is afebrile during the initial physical examination, but fever returns within several days. Neurologic examination is normal, and negative rapid plasma reagin rules out syphilis. Vitamin B₁₂ and folate levels are normal, as is thyroid function. Other laboratory findings are outside normal limits (Table).

Urine is cloudy with 2+ protein, 3+ blood, and trace leukocyte esterase. The presence of protein and blood suggests a glomerular disease such as a glomerulonephritis.

A positive leukocyte esterase test results from the presence of white blood cells, either as whole cells or as lysed cells. An abnormal number of leukocytes may appear with upper or lower urinary tract infection or in acute glomerulonephritis.

Chest radiography shows increased bilateral pulmonary vasculature, which can indicate pulmonary hypertension.

Mr. C has fair attention and concentration but impaired recent memory. He cannot recall yesterday’s events without help.

Mr. C’s Mini-Mental State Examination score of 21/30 suggests markedly impaired executive functioning and cognitive deficits. The attending psychiatrist recommends brain MRI.

Table

Mr. C’s laboratory findings

The authors’ observations

Mr. C shows markedly impaired cognitive function without significant impairment of attention and concentration despite his progressive deterioration and increasing disability. Urine toxicology shows no illicit substances. Given his lack of a previous mood disorder and his family’s description of him as formerly vibrant and cheerful, he likely does not have a mood disorder.

Based on the history of events, including the symptom pattern, we rule out delirium. We suspect that Mr. C has dementia secondary to a general medical condition. His symptoms seem to be directly related to his medical complaints and do not have a waxing and waning course. The internal medicine physician orders additional laboratory tests.

TESTING: Kidney, lung damage

Over 5 days, Mr. C’s intermittent low-grade fevers continue. Laboratory tests are negative for HIV antibody, hepatitis panel, and antinuclear antibodies (ANA). C-reactive protein is elevated at 27.8 mg/dL (normal range,

Renal ultrasound is normal, but preliminary renal biopsy shows rapidly progressive glomerulonephritis. The internist immediately starts dialysis, cyclophosphamide at 1.5 mg/kg, and prednisone, 1 mg/kg. The pathology report on the renal biopsy describes extensive crescentic glomerular destruction, with inflammatory cells present.

Ten days after admission, Mr. C develops hemoptysis, and chest radiography shows increasing alveolar infiltrates. The attending internist consults pulmonary and critical care services.

The consultant suspects a pulmonary-renal syndrome because of bilateral alveolar infiltrates (diffuse alveolar hemorrhage). The internal medicine team continues high-dose corticosteroids, followed by plasmapheresis.

Brain MRI shows subacute to chronic infarcts involving the right basal ganglia and corona radiate and mild to moderate small vessel ischemic changes. Old areas of hemorrhage are noted within both cerebellar lobes, left temporal lobe, right basal ganglia, right parietal lobe, and right frontal lobe.

During follow-up interviews, Mr. C often cannot recall recent dialysis or plasmapheresis and reports no physical symptoms. His short-term memory continues to deteriorate; he would forget to eat if not cued by family or nursing staff. He shows global cognitive deficits and is increasingly withdrawn and flat.

The authors’ observations

Although few case reports have associated Goodpasture’s syndrome with neurobehavioral changes, the apparent relationship of Mr. C’s medical symptoms with the worsening of his cognitive impairment suggests a link.

Mr. C’s MRI findings also might suggest CNS vasculitis, which affects small arteries of the cerebral and spinal cord leptomeninges and parenchyma, leading to CNS dys-function.^6-8 CNS vasculitis can result from primary nervous system involvement or from a secondary systemic process such as Goodpasture’s syndrome.⁹

We rule out lupus because Mr. C is ANA-negative; this test has 99% sensitivity for lupus.¹⁰

Box

OUTCOME: Ongoing disability

Mr. C is hospitalized for 6 weeks. He receives cyclophosphamide, prednisone, and 10 sessions of plasmapheresis. We prescribe mirtazapine, 15 mg at bedtime, to treat mood symptoms. We chose mirtazapine because of the drug’s sleep-restoring and appetite-stimulating properties.

Mr. C’s fever resolves and pulmonary function soon improves, but his cognitive impairment persists. He has difficulties preparing meals, taking medications, and managing his money.

Mr. C is discharged with a referral to a psychiatrist. He continues taking mirtazapine and a lower dose of prednisone. He requires ongoing hemodialysis and assistance with activities of daily living.

The authors’ observations

Prompt multidisciplinary intervention is critical when patients present with concurrent cognitive and medical symptoms. A thorough psychiatric evaluation can help piece together the illness’ course. The psychiatrist’s role in a multidisciplinary assessment is to:

• document neurocognitive changes
  
• verify them through collateral information
  
• correlate these changes with the timing of medical symptoms.
  

An underlying psychiatric condition can complicate the diagnosis. In these cases, careful interviewing and collateral information can help you discern the chronology of events.

Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).^1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.

Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:

• Know what the treatment involves.
• Consider the evidence for the treatment in patients similar to yours.
• Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
• Communicate to the patient your reasons for the referral.

Box 1

Step 1. What does DBT involve?

Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.¹ Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.

Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:

• indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
• punishes emotional displays, then intermittently reinforces emotional escalation
• oversimplifies the ease of problem solving or coping.¹

As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.

Team treatment. The standard DBT treatment package is an outpatient program run by a team.¹ Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.

In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:

• Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
• Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
• Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).

Additional priorities include skills deficits and secondary targets.¹ Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.

Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:

• mindfulness (paying attention to the experience of the present moment)
• emotion regulation (regulating or managing distressing emotions)
• distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
• interpersonal effectiveness (maintaining relationships and asserting needs or wishes).

Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.

Step 2. Consider the evidence

Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”^3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.^2,4-13

Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).^3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.

DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).³

Table 1

Candidates for DBT: An evidence-based referral priority list*

	Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not.
	Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment)
	Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2).
	Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12
	Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder
	Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings
	Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship
* Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list.
BPD: borderline personality disorder; DBT: dialectical behavior therapy
Source: References 3,12,13

Table 2

When not to refer a patient for DBT: Evidence is stronger for alternate treatments

Step 3: Would this patient benefit?

Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.

DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,^15,16 you might consider DBT for patients who self-injure even if they do not have BPD.

DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.

Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.

Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.

DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:

• views his or her problems as resulting primarily from childhood experiences or relationships with parents
• would prefer insight-oriented therapy.

If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.

DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.

DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.

Step 4: Communicate reasons for referral to your patient

Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.

A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:

• my diagnosis or conceptualization of the patient’s clinical problems
• a brief description of DBT
• a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.

Box 2

Related Resources

• Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
• National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
• Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
• Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.

Disclosure

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

Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).^1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.

Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:

• Know what the treatment involves.
• Consider the evidence for the treatment in patients similar to yours.
• Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
• Communicate to the patient your reasons for the referral.

Box 1

Step 1. What does DBT involve?

Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.¹ Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.

Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:

• indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
• punishes emotional displays, then intermittently reinforces emotional escalation
• oversimplifies the ease of problem solving or coping.¹

As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.

Team treatment. The standard DBT treatment package is an outpatient program run by a team.¹ Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.

In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:

• Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
• Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
• Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).

Additional priorities include skills deficits and secondary targets.¹ Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.

Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:

• mindfulness (paying attention to the experience of the present moment)
• emotion regulation (regulating or managing distressing emotions)
• distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
• interpersonal effectiveness (maintaining relationships and asserting needs or wishes).

Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.

Step 2. Consider the evidence

Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”^3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.^2,4-13

Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).^3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.

DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).³

Table 1

Candidates for DBT: An evidence-based referral priority list*

	Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not.
	Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment)
	Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2).
	Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12
	Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder
	Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings
	Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship
* Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list.
BPD: borderline personality disorder; DBT: dialectical behavior therapy
Source: References 3,12,13

Table 2

When not to refer a patient for DBT: Evidence is stronger for alternate treatments

Step 3: Would this patient benefit?

Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.

DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,^15,16 you might consider DBT for patients who self-injure even if they do not have BPD.

DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.

Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.

Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.

DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:

• views his or her problems as resulting primarily from childhood experiences or relationships with parents
• would prefer insight-oriented therapy.

If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.

DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.

DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.

Step 4: Communicate reasons for referral to your patient

Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.

A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:

• my diagnosis or conceptualization of the patient’s clinical problems
• a brief description of DBT
• a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.

Box 2

Related Resources

• Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
• National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
• Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
• Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.

Disclosure

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

Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).^1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.

Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:

• Know what the treatment involves.
• Consider the evidence for the treatment in patients similar to yours.
• Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
• Communicate to the patient your reasons for the referral.

Box 1

Step 1. What does DBT involve?

Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.¹ Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.

Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:

• indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
• punishes emotional displays, then intermittently reinforces emotional escalation
• oversimplifies the ease of problem solving or coping.¹

As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.

Team treatment. The standard DBT treatment package is an outpatient program run by a team.¹ Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.

In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:

• Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
• Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
• Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).

Additional priorities include skills deficits and secondary targets.¹ Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.

Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:

• mindfulness (paying attention to the experience of the present moment)
• emotion regulation (regulating or managing distressing emotions)
• distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
• interpersonal effectiveness (maintaining relationships and asserting needs or wishes).

Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.

Step 2. Consider the evidence

Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”^3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.^2,4-13

Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).^3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.

DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).³

Table 1

Candidates for DBT: An evidence-based referral priority list*

	Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not.
	Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment)
	Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2).
	Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12
	Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder
	Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings
	Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship
* Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list.
BPD: borderline personality disorder; DBT: dialectical behavior therapy
Source: References 3,12,13

Table 2

When not to refer a patient for DBT: Evidence is stronger for alternate treatments

Step 3: Would this patient benefit?

Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.

DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,^15,16 you might consider DBT for patients who self-injure even if they do not have BPD.

DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.

Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.

Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.

DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:

• views his or her problems as resulting primarily from childhood experiences or relationships with parents
• would prefer insight-oriented therapy.

If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.

DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.

DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.

Step 4: Communicate reasons for referral to your patient

Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.

A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:

• my diagnosis or conceptualization of the patient’s clinical problems
• a brief description of DBT
• a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.

Box 2

Related Resources

• Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
• National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
• Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
• Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.

Disclosure

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

Any medication’s therapeutic success depends on the interaction between its specific biochemical effects and nonspecific factors.¹ Thus, clinical trial designers may view the placebo effect as undesirable, but it can be a valuable response that improves treatment outcomes in clinical practice. As Freud stated, “Expectation colored by hope and faith is an effective force with which we have to reckon…in all our attempts at treatment and cure.”²

This article describes how experienced clinicians make use of the placebo effect and 3 other powerful, nonspecific elements of successful pharmacotherapy.

The placebo effect

The placebo effect is any effect attributable to a pill or potion that does not originate from its specific pharmacologic properties.³ Its clinical value has been trivialized, in part because of misconceptions (Table 1). For example, the placebo effect is commonly believed to be short-lived, whereas in fact it can last a long time.⁴

In clinical practice, our goal is to enhance the placebo effect to maximize a desirable therapeutic outcome (Table 2).⁵ Therefore, before I prescribe a medication, I tell my patient that I have selected a particular medication because I have had good results with it in many other patients and I believe it will work well for him or her, too.

Too often, doctors feel pessimistic about a medication’s potential therapeutic result and communicate this pessimism. What the patient hears is, “There’s nothing else I can do for you; why not try this medication, even though I don’t believe it’s going to work.” This may create a negative placebo effect⁶—termed the “nocebo” effect—which gives the patient a negative expectation about the treatment’s outcome. The patient internalizes the doctor’s words and lives out this negative expectation.

Table 1

Correcting misconceptions about the placebo effect

Clinical strategies to enhance the placebo effect

CASE REPORT: Predicting positive results

Mr. B, age 42, has a history of recurrent depression associated with severe insomnia, poor appetite, significant weight loss, and psychosocial withdrawal with feelings of hopelessness. After I take a detailed history and do a mental status examination, I suggest that he be treated with cognitive-behavioral therapy (CBT) and mirtazapine.

Even though studies of antidepressants rarely show mood improvements within the first 7 days, it is not unusual to hear patients report feeling less depressed within days after they start a new antidepressant. Although the drug’s specific chemical effects on the brain may not be sufficient to explain this phenomenon, the explanation probably lies in nonspecific effects—such as the patient expecting that this medication will make him feel better.

The placebo effect can occur as soon as a patient starts a medication. Experienced clinicians understand the placebo effect’s power and harness it to benefit their patients.

Conditioned responses

Many biological responses can be associated with visual, auditory, tactile, olfactory, or gustatory stimuli. Nonconditioned physiologic responses paired with conditioned stimuli induce the same biological effects of a drug. Evidence supporting this phenomenon includes successful conditioning of the immune system.^7-10 Conditioned responses—as demonstrated in glycemia regulation¹⁰ and with psychopharmacology¹¹—also can enhance the desirable results of pharmacotherapy.

CASE REPORT: A soothing drink

Ms. L, a 22-year-old college student, suffers from obsessive-compulsive disorder associated with anxiety and depression. She arrives at the appointment hurried and worried that she might be late. She is short of breath and looks stressed. The nurse offers Ms. L a cup of tea or water. She chooses a glass of water and is asked to bring it into her session.

Following a comprehensive interview and mental status examination, I recommend CBT plus medication. Considering Ms. L’s medication history, we agree to start treatment with sertraline. We review its potential benefits and expectations that it will reduce her anxiety, alleviate her ruminating obsessive worries, and improve her mood. I give her a 50-mg sample and inform her that some patients experience positive effects soon after taking the medication. I then ask her to take the first pill, using her glass of water. She does so and thanks me for being attentive to her needs.

I instruct her to call within 1 week and report on her condition, even if she feels better. Seven days later she reports that she is feeling better and is looking forward to her next appointment. She reports no side effects.

Often patients come to my office feeling thirsty. My staff or I offer them a glass of water or a cup of tea. As patients sip from the cup, they swallow and incorporate the liquid into their bodies. At the same time, I use verbal interventions to make them feel listened to and understood. They internalize this emotional experience in connection with swallowing the liquid.

Later, when swallowing the new medication as instructed, the patient re-experiences the positive therapeutic effect that was internalized in the doctor’s office.

The power of suggestion

The power of suggestion has been shown to positively or negatively affect treatment outcomes.^12,13 In practice, most clinicians give unintentional suggestions by how and what they communicate to the patient.

CASE REPORT: Predicting improvement

Mrs. J, age 48, has had dysthymic disorder and fibromyalgia for many years. She describes how various specialists have tried to alleviate her depression and chronic pain. Follow-up questions reveal that whenever she received a new prescription the physician would alert her to all the possible side effects and instruct her to call the office if she developed a problem with the new medication.

Invariably, Mrs. J would call as instructed and describe side effects she developed with the new medication. Often the doctor would discontinue the medication, depriving Mrs. J of benefits she might have derived later.

When Mrs. J calls to report on her status, she mentions that she is sleeping better and has begun to feel better during the day. She says that her husband told her she has started to smile again.

This vignette illustrates the importance of suggesting to the patient a positive outcome of pharmacotherapy associated with a particular action (calling the doctor’s office to report results). When the patient promised to call, she internalized the suggestion that calling would be associated with feeling better—and that is what happened. This intervention contrasts with saying to the patient, “Call me if you have a problem with any of these side effects,” which gives the patient a suggestion to call and report a problem.

The suggestion effect also can be used to reframe a predictable side effect as a positive sign that indicates the beginning of change leading to recovery (Box).

Box

Participatory pharmacotherapy

Many patients seek ownership in making decisions about their treatment and medications. In participatory pharmacotherapy, patients provide you with data and valuable information—such as family history, personal medical history, and experience with treatment—and inform you about which medications worked best and which did not work. You invite patients to predict how they see themselves getting better and into recovery.

CASE REPORT: All in the family

Mr. A, age 28 and single, has been diagnosed with a bipolar mood disorder. As part of a detailed family history, he reports that his maternal grandfather, mother, and a maternal uncle were diagnosed with mood swings and were successfully treated with medications, specifically lithium. He states that he believes he has the same condition.

I compliment Mr. A for being so well informed about his grandfather and uncle and educate him about mood stabilizers’ benefits in bipolar disorder. I tell him about the finding that if lithium has helped his relatives, it will probably help him as well.

I also reassure Mr. A that, in deciding what medications to avoid and what medications to use, I will consider his experience with specific antidepressants that did not help him. He thanks me for considering his suggestion about what medication to use for him.

• a successful therapeutic alliance
  
• adherence with prescribed medications
  
• the best possible outcome with pharmacotherapy.
  

In patients with a defiant-oppositional personality, consider framing the treatment decision as a choice between 2 equally efficacious medications. This gives the patient the sense of control in choosing his or her own medication, which is jointly monitored.

Table 3

Choosing patients for participatory pharmacotherapy

• Brody H. The placebo response: how you can release the body’s inner pharmacy for better health. New York, NY: HarperCollins Publishers; 2000.
  
• Spiro H. The power of hope: a doctor’s perspective. New Haven, CT: Yale University Press; 1998.
  
• Ernst E. Placebo: new insights into an old enigma. Drug Discov Today 2007;12:413-8.
  

• Lithium • Eskalith, Lithobid
  
• Mirtazapine • Remeron
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Any medication’s therapeutic success depends on the interaction between its specific biochemical effects and nonspecific factors.¹ Thus, clinical trial designers may view the placebo effect as undesirable, but it can be a valuable response that improves treatment outcomes in clinical practice. As Freud stated, “Expectation colored by hope and faith is an effective force with which we have to reckon…in all our attempts at treatment and cure.”²

This article describes how experienced clinicians make use of the placebo effect and 3 other powerful, nonspecific elements of successful pharmacotherapy.

The placebo effect

The placebo effect is any effect attributable to a pill or potion that does not originate from its specific pharmacologic properties.³ Its clinical value has been trivialized, in part because of misconceptions (Table 1). For example, the placebo effect is commonly believed to be short-lived, whereas in fact it can last a long time.⁴

In clinical practice, our goal is to enhance the placebo effect to maximize a desirable therapeutic outcome (Table 2).⁵ Therefore, before I prescribe a medication, I tell my patient that I have selected a particular medication because I have had good results with it in many other patients and I believe it will work well for him or her, too.

Too often, doctors feel pessimistic about a medication’s potential therapeutic result and communicate this pessimism. What the patient hears is, “There’s nothing else I can do for you; why not try this medication, even though I don’t believe it’s going to work.” This may create a negative placebo effect⁶—termed the “nocebo” effect—which gives the patient a negative expectation about the treatment’s outcome. The patient internalizes the doctor’s words and lives out this negative expectation.

Table 1

Correcting misconceptions about the placebo effect

Clinical strategies to enhance the placebo effect

CASE REPORT: Predicting positive results

Mr. B, age 42, has a history of recurrent depression associated with severe insomnia, poor appetite, significant weight loss, and psychosocial withdrawal with feelings of hopelessness. After I take a detailed history and do a mental status examination, I suggest that he be treated with cognitive-behavioral therapy (CBT) and mirtazapine.

Even though studies of antidepressants rarely show mood improvements within the first 7 days, it is not unusual to hear patients report feeling less depressed within days after they start a new antidepressant. Although the drug’s specific chemical effects on the brain may not be sufficient to explain this phenomenon, the explanation probably lies in nonspecific effects—such as the patient expecting that this medication will make him feel better.

The placebo effect can occur as soon as a patient starts a medication. Experienced clinicians understand the placebo effect’s power and harness it to benefit their patients.

Conditioned responses

Many biological responses can be associated with visual, auditory, tactile, olfactory, or gustatory stimuli. Nonconditioned physiologic responses paired with conditioned stimuli induce the same biological effects of a drug. Evidence supporting this phenomenon includes successful conditioning of the immune system.^7-10 Conditioned responses—as demonstrated in glycemia regulation¹⁰ and with psychopharmacology¹¹—also can enhance the desirable results of pharmacotherapy.

CASE REPORT: A soothing drink

Ms. L, a 22-year-old college student, suffers from obsessive-compulsive disorder associated with anxiety and depression. She arrives at the appointment hurried and worried that she might be late. She is short of breath and looks stressed. The nurse offers Ms. L a cup of tea or water. She chooses a glass of water and is asked to bring it into her session.

Following a comprehensive interview and mental status examination, I recommend CBT plus medication. Considering Ms. L’s medication history, we agree to start treatment with sertraline. We review its potential benefits and expectations that it will reduce her anxiety, alleviate her ruminating obsessive worries, and improve her mood. I give her a 50-mg sample and inform her that some patients experience positive effects soon after taking the medication. I then ask her to take the first pill, using her glass of water. She does so and thanks me for being attentive to her needs.

I instruct her to call within 1 week and report on her condition, even if she feels better. Seven days later she reports that she is feeling better and is looking forward to her next appointment. She reports no side effects.

Often patients come to my office feeling thirsty. My staff or I offer them a glass of water or a cup of tea. As patients sip from the cup, they swallow and incorporate the liquid into their bodies. At the same time, I use verbal interventions to make them feel listened to and understood. They internalize this emotional experience in connection with swallowing the liquid.

Later, when swallowing the new medication as instructed, the patient re-experiences the positive therapeutic effect that was internalized in the doctor’s office.

The power of suggestion

The power of suggestion has been shown to positively or negatively affect treatment outcomes.^12,13 In practice, most clinicians give unintentional suggestions by how and what they communicate to the patient.

CASE REPORT: Predicting improvement

Mrs. J, age 48, has had dysthymic disorder and fibromyalgia for many years. She describes how various specialists have tried to alleviate her depression and chronic pain. Follow-up questions reveal that whenever she received a new prescription the physician would alert her to all the possible side effects and instruct her to call the office if she developed a problem with the new medication.

Invariably, Mrs. J would call as instructed and describe side effects she developed with the new medication. Often the doctor would discontinue the medication, depriving Mrs. J of benefits she might have derived later.

When Mrs. J calls to report on her status, she mentions that she is sleeping better and has begun to feel better during the day. She says that her husband told her she has started to smile again.

This vignette illustrates the importance of suggesting to the patient a positive outcome of pharmacotherapy associated with a particular action (calling the doctor’s office to report results). When the patient promised to call, she internalized the suggestion that calling would be associated with feeling better—and that is what happened. This intervention contrasts with saying to the patient, “Call me if you have a problem with any of these side effects,” which gives the patient a suggestion to call and report a problem.

The suggestion effect also can be used to reframe a predictable side effect as a positive sign that indicates the beginning of change leading to recovery (Box).

Box

Participatory pharmacotherapy

Many patients seek ownership in making decisions about their treatment and medications. In participatory pharmacotherapy, patients provide you with data and valuable information—such as family history, personal medical history, and experience with treatment—and inform you about which medications worked best and which did not work. You invite patients to predict how they see themselves getting better and into recovery.

CASE REPORT: All in the family

Mr. A, age 28 and single, has been diagnosed with a bipolar mood disorder. As part of a detailed family history, he reports that his maternal grandfather, mother, and a maternal uncle were diagnosed with mood swings and were successfully treated with medications, specifically lithium. He states that he believes he has the same condition.

I compliment Mr. A for being so well informed about his grandfather and uncle and educate him about mood stabilizers’ benefits in bipolar disorder. I tell him about the finding that if lithium has helped his relatives, it will probably help him as well.

I also reassure Mr. A that, in deciding what medications to avoid and what medications to use, I will consider his experience with specific antidepressants that did not help him. He thanks me for considering his suggestion about what medication to use for him.

• a successful therapeutic alliance
  
• adherence with prescribed medications
  
• the best possible outcome with pharmacotherapy.
  

In patients with a defiant-oppositional personality, consider framing the treatment decision as a choice between 2 equally efficacious medications. This gives the patient the sense of control in choosing his or her own medication, which is jointly monitored.

Table 3

Choosing patients for participatory pharmacotherapy

• Brody H. The placebo response: how you can release the body’s inner pharmacy for better health. New York, NY: HarperCollins Publishers; 2000.
  
• Spiro H. The power of hope: a doctor’s perspective. New Haven, CT: Yale University Press; 1998.
  
• Ernst E. Placebo: new insights into an old enigma. Drug Discov Today 2007;12:413-8.
  

• Lithium • Eskalith, Lithobid
  
• Mirtazapine • Remeron
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Any medication’s therapeutic success depends on the interaction between its specific biochemical effects and nonspecific factors.¹ Thus, clinical trial designers may view the placebo effect as undesirable, but it can be a valuable response that improves treatment outcomes in clinical practice. As Freud stated, “Expectation colored by hope and faith is an effective force with which we have to reckon…in all our attempts at treatment and cure.”²

This article describes how experienced clinicians make use of the placebo effect and 3 other powerful, nonspecific elements of successful pharmacotherapy.

The placebo effect

The placebo effect is any effect attributable to a pill or potion that does not originate from its specific pharmacologic properties.³ Its clinical value has been trivialized, in part because of misconceptions (Table 1). For example, the placebo effect is commonly believed to be short-lived, whereas in fact it can last a long time.⁴

In clinical practice, our goal is to enhance the placebo effect to maximize a desirable therapeutic outcome (Table 2).⁵ Therefore, before I prescribe a medication, I tell my patient that I have selected a particular medication because I have had good results with it in many other patients and I believe it will work well for him or her, too.

Too often, doctors feel pessimistic about a medication’s potential therapeutic result and communicate this pessimism. What the patient hears is, “There’s nothing else I can do for you; why not try this medication, even though I don’t believe it’s going to work.” This may create a negative placebo effect⁶—termed the “nocebo” effect—which gives the patient a negative expectation about the treatment’s outcome. The patient internalizes the doctor’s words and lives out this negative expectation.

Table 1

Correcting misconceptions about the placebo effect

Clinical strategies to enhance the placebo effect

CASE REPORT: Predicting positive results

Mr. B, age 42, has a history of recurrent depression associated with severe insomnia, poor appetite, significant weight loss, and psychosocial withdrawal with feelings of hopelessness. After I take a detailed history and do a mental status examination, I suggest that he be treated with cognitive-behavioral therapy (CBT) and mirtazapine.

Even though studies of antidepressants rarely show mood improvements within the first 7 days, it is not unusual to hear patients report feeling less depressed within days after they start a new antidepressant. Although the drug’s specific chemical effects on the brain may not be sufficient to explain this phenomenon, the explanation probably lies in nonspecific effects—such as the patient expecting that this medication will make him feel better.

The placebo effect can occur as soon as a patient starts a medication. Experienced clinicians understand the placebo effect’s power and harness it to benefit their patients.

Conditioned responses

Many biological responses can be associated with visual, auditory, tactile, olfactory, or gustatory stimuli. Nonconditioned physiologic responses paired with conditioned stimuli induce the same biological effects of a drug. Evidence supporting this phenomenon includes successful conditioning of the immune system.^7-10 Conditioned responses—as demonstrated in glycemia regulation¹⁰ and with psychopharmacology¹¹—also can enhance the desirable results of pharmacotherapy.

CASE REPORT: A soothing drink

Ms. L, a 22-year-old college student, suffers from obsessive-compulsive disorder associated with anxiety and depression. She arrives at the appointment hurried and worried that she might be late. She is short of breath and looks stressed. The nurse offers Ms. L a cup of tea or water. She chooses a glass of water and is asked to bring it into her session.

Following a comprehensive interview and mental status examination, I recommend CBT plus medication. Considering Ms. L’s medication history, we agree to start treatment with sertraline. We review its potential benefits and expectations that it will reduce her anxiety, alleviate her ruminating obsessive worries, and improve her mood. I give her a 50-mg sample and inform her that some patients experience positive effects soon after taking the medication. I then ask her to take the first pill, using her glass of water. She does so and thanks me for being attentive to her needs.

I instruct her to call within 1 week and report on her condition, even if she feels better. Seven days later she reports that she is feeling better and is looking forward to her next appointment. She reports no side effects.

Often patients come to my office feeling thirsty. My staff or I offer them a glass of water or a cup of tea. As patients sip from the cup, they swallow and incorporate the liquid into their bodies. At the same time, I use verbal interventions to make them feel listened to and understood. They internalize this emotional experience in connection with swallowing the liquid.

Later, when swallowing the new medication as instructed, the patient re-experiences the positive therapeutic effect that was internalized in the doctor’s office.

The power of suggestion

The power of suggestion has been shown to positively or negatively affect treatment outcomes.^12,13 In practice, most clinicians give unintentional suggestions by how and what they communicate to the patient.

CASE REPORT: Predicting improvement

Mrs. J, age 48, has had dysthymic disorder and fibromyalgia for many years. She describes how various specialists have tried to alleviate her depression and chronic pain. Follow-up questions reveal that whenever she received a new prescription the physician would alert her to all the possible side effects and instruct her to call the office if she developed a problem with the new medication.

Invariably, Mrs. J would call as instructed and describe side effects she developed with the new medication. Often the doctor would discontinue the medication, depriving Mrs. J of benefits she might have derived later.

When Mrs. J calls to report on her status, she mentions that she is sleeping better and has begun to feel better during the day. She says that her husband told her she has started to smile again.

This vignette illustrates the importance of suggesting to the patient a positive outcome of pharmacotherapy associated with a particular action (calling the doctor’s office to report results). When the patient promised to call, she internalized the suggestion that calling would be associated with feeling better—and that is what happened. This intervention contrasts with saying to the patient, “Call me if you have a problem with any of these side effects,” which gives the patient a suggestion to call and report a problem.

The suggestion effect also can be used to reframe a predictable side effect as a positive sign that indicates the beginning of change leading to recovery (Box).

Box

Participatory pharmacotherapy

Many patients seek ownership in making decisions about their treatment and medications. In participatory pharmacotherapy, patients provide you with data and valuable information—such as family history, personal medical history, and experience with treatment—and inform you about which medications worked best and which did not work. You invite patients to predict how they see themselves getting better and into recovery.

CASE REPORT: All in the family

Mr. A, age 28 and single, has been diagnosed with a bipolar mood disorder. As part of a detailed family history, he reports that his maternal grandfather, mother, and a maternal uncle were diagnosed with mood swings and were successfully treated with medications, specifically lithium. He states that he believes he has the same condition.

I compliment Mr. A for being so well informed about his grandfather and uncle and educate him about mood stabilizers’ benefits in bipolar disorder. I tell him about the finding that if lithium has helped his relatives, it will probably help him as well.

I also reassure Mr. A that, in deciding what medications to avoid and what medications to use, I will consider his experience with specific antidepressants that did not help him. He thanks me for considering his suggestion about what medication to use for him.

• a successful therapeutic alliance
  
• adherence with prescribed medications
  
• the best possible outcome with pharmacotherapy.
  

In patients with a defiant-oppositional personality, consider framing the treatment decision as a choice between 2 equally efficacious medications. This gives the patient the sense of control in choosing his or her own medication, which is jointly monitored.

Table 3

Choosing patients for participatory pharmacotherapy

• Brody H. The placebo response: how you can release the body’s inner pharmacy for better health. New York, NY: HarperCollins Publishers; 2000.
  
• Spiro H. The power of hope: a doctor’s perspective. New Haven, CT: Yale University Press; 1998.
  
• Ernst E. Placebo: new insights into an old enigma. Drug Discov Today 2007;12:413-8.
  

• Lithium • Eskalith, Lithobid
  
• Mirtazapine • Remeron
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI), with nearly 3 million new cases diagnosed annually in the United States.¹ In July 2007 the U.S. Preventive Services Task Force (USPSTF) updated its recommendation on Chlamydia screening of sexually active female adolescents and adults ( Table 1 ).² Routine screening is not recommended for men because there is not enough data to determine the benefits and risks of screening.

Although the USPSTF recommendation targets the general population, it is important to assess each patient’s sexual behavior. Women exhibiting impulsivity caused by bipolar mania, substance abuse, or personality disorders or who exchange sex for food, shelter, substances, or money are at high risk of infection ( Table 2 ).^1,2

The new guideline introduces a screening cutoff at age 25 because women age <25 years are 5 times more likely than women age >30 to have chlamydial infection.² In women age ≥25, yearly screening is recommended only for those at high risk as indicated by:

• previous chlamydial infection or other STIs
• new or multiple sexual partners
• inconsistent condom use
• being a sex worker ( Table 2 ).²

Chlamydia screening reduces the incidence of pelvic inflammatory disease (PID) in nonpregnant adolescent and adult women, which can cause infertility, ectopic pregnancy, and chronic pelvic pain.² If untreated, the risk of PID approaches 40%.¹ In pregnant women, Chlamydia treatment significantly improves birth outcomes. Pregnant women should be screened during the first prenatal visit and in the third trimester if at continued risk.

Psychological implications of screening. Address possible themes of guilt and shame with patients to clarify and alleviate the burden they may feel about STI screening and treatment. Compared with men, women experience more stigmatization, blame, and denial about the source of infection. Women also report being more concerned about potential threats to their relationships.¹

Table 1

U.S. Preventive Services Task Force
screening recommendations for chlamydial infection

Table 2

Risks for chlamydial infection

Screening test. The Centers for Disease Control and Prevention (CDC) recommends screening with nucleic acid amplification tests (NAATs), which have high specificity (>95%) and sensitivity (80% to 93%) for chlamydial infections. Urine specimens are comparable to cervical and urethral specimens and avert the cost and patient discomfort associated with speculum exams.³ NAATs do not exclude other infections, such as trichomonas, however, and are not sufficient in patients with active urinary or vaginal symptoms.

Clinical presentation and treatment. Most persons with Chlamydia are asymptomatic and may infect new sexual partners. In women, chlamydial infection may cause cervicitis, urethritis, PID, chronic pelvic pain, ectopic pregnancy, miscarriage, preterm labor, and infertility. In men, chlamydial infection may cause urethritis, urethral strictures, and epididymis. In both genders, chlamydial infection increases the risk of acquiring other STIs, such as human immunodeficiency virus.⁴

The CDC recommends treating chlamydial infection with azithromycin, 1 g/d PO for pregnant and nonpregnant women. Alternatives include amoxicillin, 500 mg tid for 7 days for pregnant women, or doxycycline, 100 mg bid for 7 days for nonpregnant women. Sexual partners of an infected individual should be treated presumptively or tested and then treated. Because Chlamydia NAAT is highly sensitive, patients with a negative test do not need treatment. Patients who test positive for gonorrhea and receive a negative non-NAAT (antigen-based tests that are less sensitive than NAATs) for Chlamydia should be treated for both.⁵

Related resources

• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. www.cdc.gov/std/treatment.
• U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Preventive Services. www.preventiveservices.ahrq.gov.

Drug brand names

• Amoxicillin • Amoxil, others
• Azithromycin • Zithromax
• Doxycycline • Vibramycin

Disclosure

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI), with nearly 3 million new cases diagnosed annually in the United States.¹ In July 2007 the U.S. Preventive Services Task Force (USPSTF) updated its recommendation on Chlamydia screening of sexually active female adolescents and adults ( Table 1 ).² Routine screening is not recommended for men because there is not enough data to determine the benefits and risks of screening.

Although the USPSTF recommendation targets the general population, it is important to assess each patient’s sexual behavior. Women exhibiting impulsivity caused by bipolar mania, substance abuse, or personality disorders or who exchange sex for food, shelter, substances, or money are at high risk of infection ( Table 2 ).^1,2

The new guideline introduces a screening cutoff at age 25 because women age <25 years are 5 times more likely than women age >30 to have chlamydial infection.² In women age ≥25, yearly screening is recommended only for those at high risk as indicated by:

• previous chlamydial infection or other STIs
• new or multiple sexual partners
• inconsistent condom use
• being a sex worker ( Table 2 ).²

Chlamydia screening reduces the incidence of pelvic inflammatory disease (PID) in nonpregnant adolescent and adult women, which can cause infertility, ectopic pregnancy, and chronic pelvic pain.² If untreated, the risk of PID approaches 40%.¹ In pregnant women, Chlamydia treatment significantly improves birth outcomes. Pregnant women should be screened during the first prenatal visit and in the third trimester if at continued risk.

Psychological implications of screening. Address possible themes of guilt and shame with patients to clarify and alleviate the burden they may feel about STI screening and treatment. Compared with men, women experience more stigmatization, blame, and denial about the source of infection. Women also report being more concerned about potential threats to their relationships.¹

Table 1

U.S. Preventive Services Task Force
screening recommendations for chlamydial infection

Table 2

Risks for chlamydial infection

Screening test. The Centers for Disease Control and Prevention (CDC) recommends screening with nucleic acid amplification tests (NAATs), which have high specificity (>95%) and sensitivity (80% to 93%) for chlamydial infections. Urine specimens are comparable to cervical and urethral specimens and avert the cost and patient discomfort associated with speculum exams.³ NAATs do not exclude other infections, such as trichomonas, however, and are not sufficient in patients with active urinary or vaginal symptoms.

Clinical presentation and treatment. Most persons with Chlamydia are asymptomatic and may infect new sexual partners. In women, chlamydial infection may cause cervicitis, urethritis, PID, chronic pelvic pain, ectopic pregnancy, miscarriage, preterm labor, and infertility. In men, chlamydial infection may cause urethritis, urethral strictures, and epididymis. In both genders, chlamydial infection increases the risk of acquiring other STIs, such as human immunodeficiency virus.⁴

The CDC recommends treating chlamydial infection with azithromycin, 1 g/d PO for pregnant and nonpregnant women. Alternatives include amoxicillin, 500 mg tid for 7 days for pregnant women, or doxycycline, 100 mg bid for 7 days for nonpregnant women. Sexual partners of an infected individual should be treated presumptively or tested and then treated. Because Chlamydia NAAT is highly sensitive, patients with a negative test do not need treatment. Patients who test positive for gonorrhea and receive a negative non-NAAT (antigen-based tests that are less sensitive than NAATs) for Chlamydia should be treated for both.⁵

Related resources

• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. www.cdc.gov/std/treatment.
• U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Preventive Services. www.preventiveservices.ahrq.gov.

Drug brand names

• Amoxicillin • Amoxil, others
• Azithromycin • Zithromax
• Doxycycline • Vibramycin

Disclosure

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI), with nearly 3 million new cases diagnosed annually in the United States.¹ In July 2007 the U.S. Preventive Services Task Force (USPSTF) updated its recommendation on Chlamydia screening of sexually active female adolescents and adults ( Table 1 ).² Routine screening is not recommended for men because there is not enough data to determine the benefits and risks of screening.

Although the USPSTF recommendation targets the general population, it is important to assess each patient’s sexual behavior. Women exhibiting impulsivity caused by bipolar mania, substance abuse, or personality disorders or who exchange sex for food, shelter, substances, or money are at high risk of infection ( Table 2 ).^1,2

The new guideline introduces a screening cutoff at age 25 because women age <25 years are 5 times more likely than women age >30 to have chlamydial infection.² In women age ≥25, yearly screening is recommended only for those at high risk as indicated by:

• previous chlamydial infection or other STIs
• new or multiple sexual partners
• inconsistent condom use
• being a sex worker ( Table 2 ).²

Chlamydia screening reduces the incidence of pelvic inflammatory disease (PID) in nonpregnant adolescent and adult women, which can cause infertility, ectopic pregnancy, and chronic pelvic pain.² If untreated, the risk of PID approaches 40%.¹ In pregnant women, Chlamydia treatment significantly improves birth outcomes. Pregnant women should be screened during the first prenatal visit and in the third trimester if at continued risk.

Psychological implications of screening. Address possible themes of guilt and shame with patients to clarify and alleviate the burden they may feel about STI screening and treatment. Compared with men, women experience more stigmatization, blame, and denial about the source of infection. Women also report being more concerned about potential threats to their relationships.¹

Table 1

U.S. Preventive Services Task Force
screening recommendations for chlamydial infection

Table 2

Risks for chlamydial infection

Screening test. The Centers for Disease Control and Prevention (CDC) recommends screening with nucleic acid amplification tests (NAATs), which have high specificity (>95%) and sensitivity (80% to 93%) for chlamydial infections. Urine specimens are comparable to cervical and urethral specimens and avert the cost and patient discomfort associated with speculum exams.³ NAATs do not exclude other infections, such as trichomonas, however, and are not sufficient in patients with active urinary or vaginal symptoms.

Clinical presentation and treatment. Most persons with Chlamydia are asymptomatic and may infect new sexual partners. In women, chlamydial infection may cause cervicitis, urethritis, PID, chronic pelvic pain, ectopic pregnancy, miscarriage, preterm labor, and infertility. In men, chlamydial infection may cause urethritis, urethral strictures, and epididymis. In both genders, chlamydial infection increases the risk of acquiring other STIs, such as human immunodeficiency virus.⁴

The CDC recommends treating chlamydial infection with azithromycin, 1 g/d PO for pregnant and nonpregnant women. Alternatives include amoxicillin, 500 mg tid for 7 days for pregnant women, or doxycycline, 100 mg bid for 7 days for nonpregnant women. Sexual partners of an infected individual should be treated presumptively or tested and then treated. Because Chlamydia NAAT is highly sensitive, patients with a negative test do not need treatment. Patients who test positive for gonorrhea and receive a negative non-NAAT (antigen-based tests that are less sensitive than NAATs) for Chlamydia should be treated for both.⁵

Related resources

• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. www.cdc.gov/std/treatment.
• U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Preventive Services. www.preventiveservices.ahrq.gov.

Drug brand names

• Amoxicillin • Amoxil, others
• Azithromycin • Zithromax
• Doxycycline • Vibramycin

Disclosure

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

When planning your outpatient, office-based practice, you might have overlooked the design of your waiting room while you negotiated a lease, ensured Health Insurance Portability and Accountability Act (HIPAA) compliance, and procured adequate liability insurance. The waiting room is important, however, because it provides a patient’s first impression of you. Aim to make your waiting room as comfortable as possible while avoiding unintended negative meanings.

Privacy

Maintaining privacy and confidentiality is many patients’ primary concern when they see a psychiatrist, given the sensitive nature of their presenting problems and the lingering stigma surrounding mental illness.

Some outpatient psychiatrists provide separate entrances and exits to ensure that successive patients will not see one another. Although this setup depends on the office’s layout, it may be an important factor to consider, especially when choosing new space.

Design

Whether you are a minimalist or favor a more eclectic style, give thought to the waiting room décor. Many physicians decorate their waiting rooms—as they do their offices—with personal works of art. Avoid overly personal pieces, however, such as family pictures, or provocative works of art, such as those with explicit sexual or aggressive content.

Providing magazines on an array of topics is a simple but thoughtful way to make your patient feel at ease. Choose comfortable furniture arranged to ensure adequate personal space and avoid crowding. Some physicians allow pharmaceutical representatives to leave literature in the waiting room, whereas others believe such advertisements are inappropriate.

Etiquette

A busy or shared waiting room can exacerbate the anxiety a patient may feel when meeting you for the first session. One way to maintain confidentiality when you meet a patient is to identify yourself and ask who in the room is waiting to meet with you.

Although some doctors wonder whether to use a patient’s first or last name, we initially refer to patients as Mr., Ms., or Mrs. Inside the office, we ask the patient how he or she would like to be addressed to establish openness and avoid awkwardness.

Body language

Establish eye contact when meeting the patient. A smile and maintaining 1 to 2 arm-lengths of personal space indicates appropriate intimacy without appearing threatening.

Even extending your hand may seem too forward or uncomfortable to some patients. Because some may refuse to shake hands out of religious or cultural observance, wait a moment when in doubt to see if the patient offers his or her hand first.

When planning your outpatient, office-based practice, you might have overlooked the design of your waiting room while you negotiated a lease, ensured Health Insurance Portability and Accountability Act (HIPAA) compliance, and procured adequate liability insurance. The waiting room is important, however, because it provides a patient’s first impression of you. Aim to make your waiting room as comfortable as possible while avoiding unintended negative meanings.

Privacy

Maintaining privacy and confidentiality is many patients’ primary concern when they see a psychiatrist, given the sensitive nature of their presenting problems and the lingering stigma surrounding mental illness.

Some outpatient psychiatrists provide separate entrances and exits to ensure that successive patients will not see one another. Although this setup depends on the office’s layout, it may be an important factor to consider, especially when choosing new space.

Design

Whether you are a minimalist or favor a more eclectic style, give thought to the waiting room décor. Many physicians decorate their waiting rooms—as they do their offices—with personal works of art. Avoid overly personal pieces, however, such as family pictures, or provocative works of art, such as those with explicit sexual or aggressive content.

Providing magazines on an array of topics is a simple but thoughtful way to make your patient feel at ease. Choose comfortable furniture arranged to ensure adequate personal space and avoid crowding. Some physicians allow pharmaceutical representatives to leave literature in the waiting room, whereas others believe such advertisements are inappropriate.

Etiquette

A busy or shared waiting room can exacerbate the anxiety a patient may feel when meeting you for the first session. One way to maintain confidentiality when you meet a patient is to identify yourself and ask who in the room is waiting to meet with you.

Although some doctors wonder whether to use a patient’s first or last name, we initially refer to patients as Mr., Ms., or Mrs. Inside the office, we ask the patient how he or she would like to be addressed to establish openness and avoid awkwardness.

Body language

Establish eye contact when meeting the patient. A smile and maintaining 1 to 2 arm-lengths of personal space indicates appropriate intimacy without appearing threatening.

Even extending your hand may seem too forward or uncomfortable to some patients. Because some may refuse to shake hands out of religious or cultural observance, wait a moment when in doubt to see if the patient offers his or her hand first.

When planning your outpatient, office-based practice, you might have overlooked the design of your waiting room while you negotiated a lease, ensured Health Insurance Portability and Accountability Act (HIPAA) compliance, and procured adequate liability insurance. The waiting room is important, however, because it provides a patient’s first impression of you. Aim to make your waiting room as comfortable as possible while avoiding unintended negative meanings.

Privacy

Maintaining privacy and confidentiality is many patients’ primary concern when they see a psychiatrist, given the sensitive nature of their presenting problems and the lingering stigma surrounding mental illness.

Some outpatient psychiatrists provide separate entrances and exits to ensure that successive patients will not see one another. Although this setup depends on the office’s layout, it may be an important factor to consider, especially when choosing new space.

Design

Whether you are a minimalist or favor a more eclectic style, give thought to the waiting room décor. Many physicians decorate their waiting rooms—as they do their offices—with personal works of art. Avoid overly personal pieces, however, such as family pictures, or provocative works of art, such as those with explicit sexual or aggressive content.

Providing magazines on an array of topics is a simple but thoughtful way to make your patient feel at ease. Choose comfortable furniture arranged to ensure adequate personal space and avoid crowding. Some physicians allow pharmaceutical representatives to leave literature in the waiting room, whereas others believe such advertisements are inappropriate.

Etiquette

A busy or shared waiting room can exacerbate the anxiety a patient may feel when meeting you for the first session. One way to maintain confidentiality when you meet a patient is to identify yourself and ask who in the room is waiting to meet with you.

Although some doctors wonder whether to use a patient’s first or last name, we initially refer to patients as Mr., Ms., or Mrs. Inside the office, we ask the patient how he or she would like to be addressed to establish openness and avoid awkwardness.

Body language

Establish eye contact when meeting the patient. A smile and maintaining 1 to 2 arm-lengths of personal space indicates appropriate intimacy without appearing threatening.

Even extending your hand may seem too forward or uncomfortable to some patients. Because some may refuse to shake hands out of religious or cultural observance, wait a moment when in doubt to see if the patient offers his or her hand first.

Nearly 1 in 4 Internet users has searched the Web for mental health information,¹ but finding reliable sources is challenging. Wading through poorly organized, variable quality sites to find information you need can be time-consuming and frustrating.² Also, without your guidance, patients may consult disreputable Web sites and follow advice that is contrary to standard psychiatric care.³

Because less is more when using the Internet, we recommend 1 good Web site for each of the following clinical needs. Each may be useful to you and to recommend to your patients.

Patient education

Medlineplus.gov from the National Library of Medicine and the National Institutes of Health (NIH) is an authoritative source for reliable, unbiased information on medications and illnesses. You will find valuable information on all psychotropic and nonpsychotropic medications and most common psychiatric disorders, including information in Spanish.

You can print out medication information and give it to patients, though we recommend asking patients to visit the Web site to introduce them to this resource. Most important, Medlineplus.gov provides links to other trusted medical Web pages. For consumers, this site provides a variety of information including an illustrated medical encyclopedia and a guide to finding reputable health information on the Web. Medlineplus.gov is an enormous site that alone could satisfy most of your patient education needs.

Formulary information

When prescribing, you often need to know if a patient’s insurance will cover the cost of the drug or if preauthorization is necessary. Fingertipformulary.com, a free and user-friendly site, allows you to select a medication, your patient’s state, and insurance plan to find out if the drug will be covered. This site also tells you authorization requirements, quantity limits, and the medication’s “tier” classification, which specifies the patient’s copayment level.

Patient assistance programs

Needymeds.org is a nonprofit resource center of patient assistance programs (PAP) administered by pharmaceutical companies for individuals who cannot afford their medications. The site links to these programs’ Web sites, application forms, and groups that can help patients fill out necessary paperwork. With this Web site, patients no longer have to request or retain PAP paperwork.

Drug interactions

Enter a drug name into the search box at Epocrates.com to learn about possible drug interactions as well as dosing information, contraindications, black-box warnings, and adverse effects. This free, continually updated Web site is invaluable when treating patients who take a large number of medications.

Clinical trials

When you want to know what clinical trials are being conducted on a particular medication or disorder, visit clinicaltrials.gov. All federally and privately supported clinical trials now must be registered with the NIH and posted at clinicaltrials.gov. The site lists ongoing and completed trials, allows you to search by medication, disorder, and geographic area, and indicates which trials are recruiting volunteers.

Information on drug abuse

The National Institute on Drug Abuse’s Drugabuse.gov provides information about substance abuse for clinicians, patients, parents, and teachers. In addition, the site features new research findings, information in Spanish, and links related to substance abuse. Click on the link for parents and teachers to access a searchable index of substance abuse treatment facilities, with information about insurance plans accepted, available treatments, and contact information.

Medication pricing

When you pull out your prescription pad, patients may ask how much a drug costs or if there is a cheaper way to buy the medication. Visit the pharmacy section of Costco.com to quickly check prices and out-of-pocket expenses, even if the patient does not buy medications from this retailer. Search by drug name to find out how much a formulation of a drug costs and if generic alternatives are available. Often this exercise will help you prescribe tablet strengths or formulations that can save the patient money.

Searching MEDLINE

You can search the National Library of Medicine’s MEDLINE bibliographic database for free by visiting Pubmed.gov. You can read abstracts of all journal articles in the database and full-text of some articles. The number of free full-text articles will increase because all articles based on research funded by the NIH must now be posted on Pubmed.gov.

Support groups

We recommend support groups to most of our psychiatric patients and their families. To find support groups in your area visit:

• Depression and Bipolar Support Alliance (dbsalliance.org) for patients with mood disorders
  
• Alcoholics Anonymous (aa.org) and Narcotics Anonymous (na.org) for patients with alcohol and other substance abuse problems
  
• National Alliance on Mental Illness (nami.org) for general support related to severe mental illness.
  

Nearly 1 in 4 Internet users has searched the Web for mental health information,¹ but finding reliable sources is challenging. Wading through poorly organized, variable quality sites to find information you need can be time-consuming and frustrating.² Also, without your guidance, patients may consult disreputable Web sites and follow advice that is contrary to standard psychiatric care.³

Because less is more when using the Internet, we recommend 1 good Web site for each of the following clinical needs. Each may be useful to you and to recommend to your patients.

Patient education

Medlineplus.gov from the National Library of Medicine and the National Institutes of Health (NIH) is an authoritative source for reliable, unbiased information on medications and illnesses. You will find valuable information on all psychotropic and nonpsychotropic medications and most common psychiatric disorders, including information in Spanish.

You can print out medication information and give it to patients, though we recommend asking patients to visit the Web site to introduce them to this resource. Most important, Medlineplus.gov provides links to other trusted medical Web pages. For consumers, this site provides a variety of information including an illustrated medical encyclopedia and a guide to finding reputable health information on the Web. Medlineplus.gov is an enormous site that alone could satisfy most of your patient education needs.

Formulary information

When prescribing, you often need to know if a patient’s insurance will cover the cost of the drug or if preauthorization is necessary. Fingertipformulary.com, a free and user-friendly site, allows you to select a medication, your patient’s state, and insurance plan to find out if the drug will be covered. This site also tells you authorization requirements, quantity limits, and the medication’s “tier” classification, which specifies the patient’s copayment level.

Patient assistance programs

Needymeds.org is a nonprofit resource center of patient assistance programs (PAP) administered by pharmaceutical companies for individuals who cannot afford their medications. The site links to these programs’ Web sites, application forms, and groups that can help patients fill out necessary paperwork. With this Web site, patients no longer have to request or retain PAP paperwork.

Drug interactions

Enter a drug name into the search box at Epocrates.com to learn about possible drug interactions as well as dosing information, contraindications, black-box warnings, and adverse effects. This free, continually updated Web site is invaluable when treating patients who take a large number of medications.

Clinical trials

When you want to know what clinical trials are being conducted on a particular medication or disorder, visit clinicaltrials.gov. All federally and privately supported clinical trials now must be registered with the NIH and posted at clinicaltrials.gov. The site lists ongoing and completed trials, allows you to search by medication, disorder, and geographic area, and indicates which trials are recruiting volunteers.

Information on drug abuse

The National Institute on Drug Abuse’s Drugabuse.gov provides information about substance abuse for clinicians, patients, parents, and teachers. In addition, the site features new research findings, information in Spanish, and links related to substance abuse. Click on the link for parents and teachers to access a searchable index of substance abuse treatment facilities, with information about insurance plans accepted, available treatments, and contact information.

Medication pricing

When you pull out your prescription pad, patients may ask how much a drug costs or if there is a cheaper way to buy the medication. Visit the pharmacy section of Costco.com to quickly check prices and out-of-pocket expenses, even if the patient does not buy medications from this retailer. Search by drug name to find out how much a formulation of a drug costs and if generic alternatives are available. Often this exercise will help you prescribe tablet strengths or formulations that can save the patient money.

Searching MEDLINE

You can search the National Library of Medicine’s MEDLINE bibliographic database for free by visiting Pubmed.gov. You can read abstracts of all journal articles in the database and full-text of some articles. The number of free full-text articles will increase because all articles based on research funded by the NIH must now be posted on Pubmed.gov.

Support groups

We recommend support groups to most of our psychiatric patients and their families. To find support groups in your area visit:

• Depression and Bipolar Support Alliance (dbsalliance.org) for patients with mood disorders
  
• Alcoholics Anonymous (aa.org) and Narcotics Anonymous (na.org) for patients with alcohol and other substance abuse problems
  
• National Alliance on Mental Illness (nami.org) for general support related to severe mental illness.
  

Nearly 1 in 4 Internet users has searched the Web for mental health information,¹ but finding reliable sources is challenging. Wading through poorly organized, variable quality sites to find information you need can be time-consuming and frustrating.² Also, without your guidance, patients may consult disreputable Web sites and follow advice that is contrary to standard psychiatric care.³

Because less is more when using the Internet, we recommend 1 good Web site for each of the following clinical needs. Each may be useful to you and to recommend to your patients.

Patient education

Medlineplus.gov from the National Library of Medicine and the National Institutes of Health (NIH) is an authoritative source for reliable, unbiased information on medications and illnesses. You will find valuable information on all psychotropic and nonpsychotropic medications and most common psychiatric disorders, including information in Spanish.

You can print out medication information and give it to patients, though we recommend asking patients to visit the Web site to introduce them to this resource. Most important, Medlineplus.gov provides links to other trusted medical Web pages. For consumers, this site provides a variety of information including an illustrated medical encyclopedia and a guide to finding reputable health information on the Web. Medlineplus.gov is an enormous site that alone could satisfy most of your patient education needs.

Formulary information

When prescribing, you often need to know if a patient’s insurance will cover the cost of the drug or if preauthorization is necessary. Fingertipformulary.com, a free and user-friendly site, allows you to select a medication, your patient’s state, and insurance plan to find out if the drug will be covered. This site also tells you authorization requirements, quantity limits, and the medication’s “tier” classification, which specifies the patient’s copayment level.

Patient assistance programs

Needymeds.org is a nonprofit resource center of patient assistance programs (PAP) administered by pharmaceutical companies for individuals who cannot afford their medications. The site links to these programs’ Web sites, application forms, and groups that can help patients fill out necessary paperwork. With this Web site, patients no longer have to request or retain PAP paperwork.

Drug interactions

Enter a drug name into the search box at Epocrates.com to learn about possible drug interactions as well as dosing information, contraindications, black-box warnings, and adverse effects. This free, continually updated Web site is invaluable when treating patients who take a large number of medications.

Clinical trials

When you want to know what clinical trials are being conducted on a particular medication or disorder, visit clinicaltrials.gov. All federally and privately supported clinical trials now must be registered with the NIH and posted at clinicaltrials.gov. The site lists ongoing and completed trials, allows you to search by medication, disorder, and geographic area, and indicates which trials are recruiting volunteers.

Information on drug abuse

The National Institute on Drug Abuse’s Drugabuse.gov provides information about substance abuse for clinicians, patients, parents, and teachers. In addition, the site features new research findings, information in Spanish, and links related to substance abuse. Click on the link for parents and teachers to access a searchable index of substance abuse treatment facilities, with information about insurance plans accepted, available treatments, and contact information.

Medication pricing

When you pull out your prescription pad, patients may ask how much a drug costs or if there is a cheaper way to buy the medication. Visit the pharmacy section of Costco.com to quickly check prices and out-of-pocket expenses, even if the patient does not buy medications from this retailer. Search by drug name to find out how much a formulation of a drug costs and if generic alternatives are available. Often this exercise will help you prescribe tablet strengths or formulations that can save the patient money.

Searching MEDLINE

You can search the National Library of Medicine’s MEDLINE bibliographic database for free by visiting Pubmed.gov. You can read abstracts of all journal articles in the database and full-text of some articles. The number of free full-text articles will increase because all articles based on research funded by the NIH must now be posted on Pubmed.gov.

Support groups

We recommend support groups to most of our psychiatric patients and their families. To find support groups in your area visit:

• Depression and Bipolar Support Alliance (dbsalliance.org) for patients with mood disorders
  
• Alcoholics Anonymous (aa.org) and Narcotics Anonymous (na.org) for patients with alcohol and other substance abuse problems
  
• National Alliance on Mental Illness (nami.org) for general support related to severe mental illness.
  

The authors of “Psychiatrist/patient boundaries: When it’s OK to stretch the line” (Current Psychiatry, August 2008) cited the American Academy of Psychiatry and the Law’s recommendation that “psychiatrists avoid acting as expert witnesses for their patients or performing patient evaluations for legal purposes… The intrusion of another role into the doctor/patient relationship can alter the treatment process and permanently color future interactions… these situations create the appearance that you have conscripted a vulnerable individual into your practice.”

These statements raise several questions:

• Aren’t most individuals coming into psychiatric practices vulnerable?
  
• If psychiatrists avoid patient evaluations for legal purposes, who will do them?
  
• Which opinion carries more weight, that of a psychiatrist who has worked with a patient for years or that of an independent evaluator who has seen the patient for an hour or 2?
  
• Is it in the best interest of the patient or the therapeutic alliance if the treating psychiatrist declines the patient’s request to testify or write an evaluation because of possible mercenary motivations, particularly when the testimony might make a significant difference?
  

If the patient and psychiatrist are willing to forego confidentiality, the doctor should have the option to represent the patient’s psychiatric treatment as a witness, not as an independent medical examiner. Salaried psychiatrists testifying for patients treated in public agencies—from city to federal—do not receive fees for testimony. As far as I know, there is not a standard forensic fee for private practice psychiatrists, who can adjust their fees to reflect work done, perhaps applying their hourly office rate for time spent on preparation, travel, and testimony. These psychiatrists also can discuss the fee with patients to prevent undue financial strain.

Hope is a precious commodity that should not be denied to patients because of possible overinterpretation of boundary concepts.

Perhaps I have overinterpreted the authors’ points. Maybe forensic psychiatric testimony should be re-examined in light of its possible harmful effects on psychiatrist/patient relationships. However, I think the material cited by the authors could needlessly deprive patients of assistance. I thought our goal is to use our clinical judgment to serve the best interest of each patient, not merely avoid lawsuits or board complaints as we go.

S. Epstein, MD
Los Angeles, CA

Drs. Marshall, Teston, and Myers respond

Dr. Epstein’s questions imply that in some cases, the legal system might serve as an ally to the therapist. Our assumptions about the legal system are less charitable. Though there may be occasions when treatment goals and a legal ruling may align, risks multiply when therapy moves from the office to the courtroom. Although we agree that our decisions should not be driven by a desire to avoid lawsuits or board complaints, once a case goes to court the therapist surrenders control of the therapeutic process, opening a Pandora’s box of potentially negative consequences.

Although there are unusual circumstances—such as physicians practicing in rural areas—when a physician may assume dual roles, physicians under oath serve the court, not the patient, and litigation is not always driven by the patient’s best interests. Presumably, the treating psychiatrist possesses more information about the patient, but what if the patient has lied? Or what if the psychiatrist reveals sensitive information about the patient, which results in a patient losing a job, losing respect in the community, or getting divorced? In other cases, patients may not be sufficiently competent to “forego confidentiality,” or they might not fully appreciate the risks involved in granting the therapist permission to testify.