Pearls

The concept of pathoplasticity—that the presentation of illness varies depending on a patient’s experiences, situation, and background—is not new to psychiatry. Pathoplastic effects of culture on the content manifestation of psychiatric disorders have been documented in the literature.¹ We present a patient with schizophrenia whose hallucinations and delusions incorporated the social networking website Facebook to highlight the role internet culture can play in shaping modern psychiatric phenomena.

Ms. P, age 49, presents to the emergency department with increasing psychosis. At age 20 she was diagnosed with schizophrenia in Puerto Rico, where she was born and raised. One month before her current admission, Ms. P began to have auditory hallucinations of her Facebook “friends,” most of whom live in Puerto Rico. She says she secludes herself in her bedroom with the door closed, but can still hear voices “coming from Facebook.” She describes the voices as emanating from outside her head, from her computer. Ms. P states the voices stop when the computer is off and return as soon as she knows it is back on. The voices sometimes talk to each other, do not provide commentary, and always are derogatory, often commenting on her sexual experiences, mental health, and success as a mother.

Social media and psychiatry

Since the public introduction of the internet in 1991, contemporary culture has become increasingly web-based. Facebook launched in 2004 and now has >1 billion active monthly users, or approximately 14% of the global population.² Previously, patients such as Ms. P would be described as having auditory hallucinations and a dense delusional framework. However, in the setting of Facebook, her story seems less bizarre. Ms. P’s case shows the pathoplastic effect of web-based social media on psychiatric phenomena.

Social media sites could introduce stressful exogenous information and ideas; sudden, intimate relationships with strangers; permeable personal boundaries; and self-exposure to a degree that until recently was unimaginable.³ For psychotic patients, this new form of “real” can multiply the number of imagined enemies and further a perceived conspiracy.

Recognizing pathoplastic changes

As society shifts to an increasingly web-based culture, the role of culturally informed pathoplasticity in psychiatric illness merits renewed focus. The ever-evolving pathoplastic features of mental illness make our work interesting and challenging. Because every patient has a unique life story, no 2 patients will look the same. Taking a history of a patient’s use of web-based technology—including Facebook and other social media—may help explain possible pathoplastic changes in presentation. Ask patients about their use of social networking sites, blogs, and microblogs (eg, Twitter).

Disclosure

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

The concept of pathoplasticity—that the presentation of illness varies depending on a patient’s experiences, situation, and background—is not new to psychiatry. Pathoplastic effects of culture on the content manifestation of psychiatric disorders have been documented in the literature.¹ We present a patient with schizophrenia whose hallucinations and delusions incorporated the social networking website Facebook to highlight the role internet culture can play in shaping modern psychiatric phenomena.

Ms. P, age 49, presents to the emergency department with increasing psychosis. At age 20 she was diagnosed with schizophrenia in Puerto Rico, where she was born and raised. One month before her current admission, Ms. P began to have auditory hallucinations of her Facebook “friends,” most of whom live in Puerto Rico. She says she secludes herself in her bedroom with the door closed, but can still hear voices “coming from Facebook.” She describes the voices as emanating from outside her head, from her computer. Ms. P states the voices stop when the computer is off and return as soon as she knows it is back on. The voices sometimes talk to each other, do not provide commentary, and always are derogatory, often commenting on her sexual experiences, mental health, and success as a mother.

Social media and psychiatry

Since the public introduction of the internet in 1991, contemporary culture has become increasingly web-based. Facebook launched in 2004 and now has >1 billion active monthly users, or approximately 14% of the global population.² Previously, patients such as Ms. P would be described as having auditory hallucinations and a dense delusional framework. However, in the setting of Facebook, her story seems less bizarre. Ms. P’s case shows the pathoplastic effect of web-based social media on psychiatric phenomena.

Social media sites could introduce stressful exogenous information and ideas; sudden, intimate relationships with strangers; permeable personal boundaries; and self-exposure to a degree that until recently was unimaginable.³ For psychotic patients, this new form of “real” can multiply the number of imagined enemies and further a perceived conspiracy.

Recognizing pathoplastic changes

As society shifts to an increasingly web-based culture, the role of culturally informed pathoplasticity in psychiatric illness merits renewed focus. The ever-evolving pathoplastic features of mental illness make our work interesting and challenging. Because every patient has a unique life story, no 2 patients will look the same. Taking a history of a patient’s use of web-based technology—including Facebook and other social media—may help explain possible pathoplastic changes in presentation. Ask patients about their use of social networking sites, blogs, and microblogs (eg, Twitter).

Disclosure

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

The concept of pathoplasticity—that the presentation of illness varies depending on a patient’s experiences, situation, and background—is not new to psychiatry. Pathoplastic effects of culture on the content manifestation of psychiatric disorders have been documented in the literature.¹ We present a patient with schizophrenia whose hallucinations and delusions incorporated the social networking website Facebook to highlight the role internet culture can play in shaping modern psychiatric phenomena.

Ms. P, age 49, presents to the emergency department with increasing psychosis. At age 20 she was diagnosed with schizophrenia in Puerto Rico, where she was born and raised. One month before her current admission, Ms. P began to have auditory hallucinations of her Facebook “friends,” most of whom live in Puerto Rico. She says she secludes herself in her bedroom with the door closed, but can still hear voices “coming from Facebook.” She describes the voices as emanating from outside her head, from her computer. Ms. P states the voices stop when the computer is off and return as soon as she knows it is back on. The voices sometimes talk to each other, do not provide commentary, and always are derogatory, often commenting on her sexual experiences, mental health, and success as a mother.

Social media and psychiatry

Since the public introduction of the internet in 1991, contemporary culture has become increasingly web-based. Facebook launched in 2004 and now has >1 billion active monthly users, or approximately 14% of the global population.² Previously, patients such as Ms. P would be described as having auditory hallucinations and a dense delusional framework. However, in the setting of Facebook, her story seems less bizarre. Ms. P’s case shows the pathoplastic effect of web-based social media on psychiatric phenomena.

Social media sites could introduce stressful exogenous information and ideas; sudden, intimate relationships with strangers; permeable personal boundaries; and self-exposure to a degree that until recently was unimaginable.³ For psychotic patients, this new form of “real” can multiply the number of imagined enemies and further a perceived conspiracy.

Recognizing pathoplastic changes

As society shifts to an increasingly web-based culture, the role of culturally informed pathoplasticity in psychiatric illness merits renewed focus. The ever-evolving pathoplastic features of mental illness make our work interesting and challenging. Because every patient has a unique life story, no 2 patients will look the same. Taking a history of a patient’s use of web-based technology—including Facebook and other social media—may help explain possible pathoplastic changes in presentation. Ask patients about their use of social networking sites, blogs, and microblogs (eg, Twitter).

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

The ever-increasing number of psychiatric visits to emergency room (ER) settings is a daunting clinical challenge.¹ As psychiatrists, we must be prepared for these visits. The mnemonic FIRST can help when you encounter a psychiatric patient in the ER.

Frank conversation about why the patient came to the ER for evaluation and the need for observation or treatment is essential to obtaining an accurate history and providing appropriate care. Address a possible sense of isolation a patient may feel when being in a new environment. Be aware of nonverbal cues because they may lead to an appropriate and well-tailored conversation with your patient.

Individualize care by emphasizing to patients that they have choices in their treatment plan now and after discharge. Listen and communicate with the patient in a manner that decreases stigma because he or she may feel out of control, fearful, angry, or betrayed by loved ones. Doing so will help create a safe environment, can help alleviate the need for chemical or physical restraints, and may enhance treatment adherence.

Reach out to the patient’s family and friends to gather support for him or her and to obtain collateral information to formulate an appropriate course of treatment. Ask about family medical history, financial status, and a social support system because these can aid in diagnosis and optimizing the patient’s short- and long-term prognosis.

Somatic complaints can be used as a springboard to build rapport with patients. Many patients find it easier to talk about physical symptoms than emotional ones, so acknowledge and validate these concerns and explain that many psychiatric symptoms can present as somatic symptoms, such as panic disorder presenting as tachycardia. This also may indicate a need for a prompt, thorough physical examination.

Tease out secondary causes of psychiatric symptoms. Many organic conditions can initially present as psychiatric symptoms; for example, brain tumors or seizures can present with olfactory, gustatory, visual, or auditory hallucinations. Drug toxicology and laboratory testing can rule out medical causes of psychiatric symptoms.¹ Geriatric patients or those with multiple, chronic medical illness can present with agitation, heavy sedation, or delusions. Keep a high index of suspicion to rule out medical conditions.

Discuss this article at www.facebook.com/CurrentPsychiatry

The ever-increasing number of psychiatric visits to emergency room (ER) settings is a daunting clinical challenge.¹ As psychiatrists, we must be prepared for these visits. The mnemonic FIRST can help when you encounter a psychiatric patient in the ER.

Frank conversation about why the patient came to the ER for evaluation and the need for observation or treatment is essential to obtaining an accurate history and providing appropriate care. Address a possible sense of isolation a patient may feel when being in a new environment. Be aware of nonverbal cues because they may lead to an appropriate and well-tailored conversation with your patient.

Individualize care by emphasizing to patients that they have choices in their treatment plan now and after discharge. Listen and communicate with the patient in a manner that decreases stigma because he or she may feel out of control, fearful, angry, or betrayed by loved ones. Doing so will help create a safe environment, can help alleviate the need for chemical or physical restraints, and may enhance treatment adherence.

Reach out to the patient’s family and friends to gather support for him or her and to obtain collateral information to formulate an appropriate course of treatment. Ask about family medical history, financial status, and a social support system because these can aid in diagnosis and optimizing the patient’s short- and long-term prognosis.

Somatic complaints can be used as a springboard to build rapport with patients. Many patients find it easier to talk about physical symptoms than emotional ones, so acknowledge and validate these concerns and explain that many psychiatric symptoms can present as somatic symptoms, such as panic disorder presenting as tachycardia. This also may indicate a need for a prompt, thorough physical examination.

Tease out secondary causes of psychiatric symptoms. Many organic conditions can initially present as psychiatric symptoms; for example, brain tumors or seizures can present with olfactory, gustatory, visual, or auditory hallucinations. Drug toxicology and laboratory testing can rule out medical causes of psychiatric symptoms.¹ Geriatric patients or those with multiple, chronic medical illness can present with agitation, heavy sedation, or delusions. Keep a high index of suspicion to rule out medical conditions.

Discuss this article at www.facebook.com/CurrentPsychiatry

The ever-increasing number of psychiatric visits to emergency room (ER) settings is a daunting clinical challenge.¹ As psychiatrists, we must be prepared for these visits. The mnemonic FIRST can help when you encounter a psychiatric patient in the ER.

Frank conversation about why the patient came to the ER for evaluation and the need for observation or treatment is essential to obtaining an accurate history and providing appropriate care. Address a possible sense of isolation a patient may feel when being in a new environment. Be aware of nonverbal cues because they may lead to an appropriate and well-tailored conversation with your patient.

Individualize care by emphasizing to patients that they have choices in their treatment plan now and after discharge. Listen and communicate with the patient in a manner that decreases stigma because he or she may feel out of control, fearful, angry, or betrayed by loved ones. Doing so will help create a safe environment, can help alleviate the need for chemical or physical restraints, and may enhance treatment adherence.

Reach out to the patient’s family and friends to gather support for him or her and to obtain collateral information to formulate an appropriate course of treatment. Ask about family medical history, financial status, and a social support system because these can aid in diagnosis and optimizing the patient’s short- and long-term prognosis.

Somatic complaints can be used as a springboard to build rapport with patients. Many patients find it easier to talk about physical symptoms than emotional ones, so acknowledge and validate these concerns and explain that many psychiatric symptoms can present as somatic symptoms, such as panic disorder presenting as tachycardia. This also may indicate a need for a prompt, thorough physical examination.

Tease out secondary causes of psychiatric symptoms. Many organic conditions can initially present as psychiatric symptoms; for example, brain tumors or seizures can present with olfactory, gustatory, visual, or auditory hallucinations. Drug toxicology and laboratory testing can rule out medical causes of psychiatric symptoms.¹ Geriatric patients or those with multiple, chronic medical illness can present with agitation, heavy sedation, or delusions. Keep a high index of suspicion to rule out medical conditions.

Discuss this article at www.facebook.com/CurrentPsychiatry

Visual hallucinations in children and adolescents can be caused by many conditions other than psychosis. To prevent misdiagnosis and unnecessary antipsychotic use, it is important to rule out other causes of visual hallucinations. The mnemonic VISUALS reminds us of common causes.

Visions that are culturally sanctioned occur in non-Western societies—eg, images of fairy-like spirits are accepted and reinforced as part of the Filipino culture—and in several Christian denominations in the United States. Positive cultural connotations may increase the frequency of visual hallucinations as well as produce varied attitudes and emotional reactions to them.¹

Imaginary friends often fulfill a child’s need for a relationship, although even social children may have these “friends.” Children often refer to imaginary friends in conversations and play with them. Usually they are also children. They may be extensions of people the child admires or be named after characters from stories, movies, or television. Children rarely are able to explain the imaginary friend’s appearance and more than half the time there is no trigger for the appearance of such friends.^2,3

Stress and anxiety in preschool children may precipitate the onset of visual or tactile hallucinations. They often happen at night but also can occur when the child is awake. Typical visual hallucinations may include monsters, bugs, pets, or toys.²

Urine drug screens should be conducted for all adolescents and children. Cocaine, methamphetamine, and amphetamines—including high doses of prescribed stimulants—can cause visual hallucinations. Lysergic acid diethylamide (“LSD”), phencyclidine (“PCP”), 3,4-methylenedioxymethamphetamine (“ecstasy”), marijuana, nitrous oxide, and mescaline often cause visual hallucinations, although these substances may not be identified in a routine urine toxicology. Other considerations are withdrawal from benzodiazepines, sedative-hypnotics, or alcohol, and rare adverse reactions to antidepressants, antibiotics, or anticonvulsants.^4,5

Age and developmental immaturity may make it difficult for children to distinguish between reality and non-reality, including dreams and shadows in the dark. Underdeveloped communication may make it difficult to interpret what the child is trying to communicate.²

Look into other medical explanations, such as migraines, seizures, tumors, ophthalmologic disease, delirium, or metabolic disorders (Table).^4,5

Table

Medical causes of visual hallucinations in children and adolescents

Sleep-onset visual hallucinations (hypnagogic) and hallucinations upon awakening (hypnopompic) often are bizarre and dream-like. They may consist of geometric patterns, landscapes, faces, or figures. They mainly occur with narcolepsy but can be seen in insomnia or excessive daytime sleepiness.^4,5

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Visual hallucinations in children and adolescents can be caused by many conditions other than psychosis. To prevent misdiagnosis and unnecessary antipsychotic use, it is important to rule out other causes of visual hallucinations. The mnemonic VISUALS reminds us of common causes.

Visions that are culturally sanctioned occur in non-Western societies—eg, images of fairy-like spirits are accepted and reinforced as part of the Filipino culture—and in several Christian denominations in the United States. Positive cultural connotations may increase the frequency of visual hallucinations as well as produce varied attitudes and emotional reactions to them.¹

Imaginary friends often fulfill a child’s need for a relationship, although even social children may have these “friends.” Children often refer to imaginary friends in conversations and play with them. Usually they are also children. They may be extensions of people the child admires or be named after characters from stories, movies, or television. Children rarely are able to explain the imaginary friend’s appearance and more than half the time there is no trigger for the appearance of such friends.^2,3

Stress and anxiety in preschool children may precipitate the onset of visual or tactile hallucinations. They often happen at night but also can occur when the child is awake. Typical visual hallucinations may include monsters, bugs, pets, or toys.²

Urine drug screens should be conducted for all adolescents and children. Cocaine, methamphetamine, and amphetamines—including high doses of prescribed stimulants—can cause visual hallucinations. Lysergic acid diethylamide (“LSD”), phencyclidine (“PCP”), 3,4-methylenedioxymethamphetamine (“ecstasy”), marijuana, nitrous oxide, and mescaline often cause visual hallucinations, although these substances may not be identified in a routine urine toxicology. Other considerations are withdrawal from benzodiazepines, sedative-hypnotics, or alcohol, and rare adverse reactions to antidepressants, antibiotics, or anticonvulsants.^4,5

Age and developmental immaturity may make it difficult for children to distinguish between reality and non-reality, including dreams and shadows in the dark. Underdeveloped communication may make it difficult to interpret what the child is trying to communicate.²

Look into other medical explanations, such as migraines, seizures, tumors, ophthalmologic disease, delirium, or metabolic disorders (Table).^4,5

Table

Medical causes of visual hallucinations in children and adolescents

Sleep-onset visual hallucinations (hypnagogic) and hallucinations upon awakening (hypnopompic) often are bizarre and dream-like. They may consist of geometric patterns, landscapes, faces, or figures. They mainly occur with narcolepsy but can be seen in insomnia or excessive daytime sleepiness.^4,5

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Visual hallucinations in children and adolescents can be caused by many conditions other than psychosis. To prevent misdiagnosis and unnecessary antipsychotic use, it is important to rule out other causes of visual hallucinations. The mnemonic VISUALS reminds us of common causes.

Visions that are culturally sanctioned occur in non-Western societies—eg, images of fairy-like spirits are accepted and reinforced as part of the Filipino culture—and in several Christian denominations in the United States. Positive cultural connotations may increase the frequency of visual hallucinations as well as produce varied attitudes and emotional reactions to them.¹

Imaginary friends often fulfill a child’s need for a relationship, although even social children may have these “friends.” Children often refer to imaginary friends in conversations and play with them. Usually they are also children. They may be extensions of people the child admires or be named after characters from stories, movies, or television. Children rarely are able to explain the imaginary friend’s appearance and more than half the time there is no trigger for the appearance of such friends.^2,3

Stress and anxiety in preschool children may precipitate the onset of visual or tactile hallucinations. They often happen at night but also can occur when the child is awake. Typical visual hallucinations may include monsters, bugs, pets, or toys.²

Urine drug screens should be conducted for all adolescents and children. Cocaine, methamphetamine, and amphetamines—including high doses of prescribed stimulants—can cause visual hallucinations. Lysergic acid diethylamide (“LSD”), phencyclidine (“PCP”), 3,4-methylenedioxymethamphetamine (“ecstasy”), marijuana, nitrous oxide, and mescaline often cause visual hallucinations, although these substances may not be identified in a routine urine toxicology. Other considerations are withdrawal from benzodiazepines, sedative-hypnotics, or alcohol, and rare adverse reactions to antidepressants, antibiotics, or anticonvulsants.^4,5

Age and developmental immaturity may make it difficult for children to distinguish between reality and non-reality, including dreams and shadows in the dark. Underdeveloped communication may make it difficult to interpret what the child is trying to communicate.²

Look into other medical explanations, such as migraines, seizures, tumors, ophthalmologic disease, delirium, or metabolic disorders (Table).^4,5

Table

Medical causes of visual hallucinations in children and adolescents

Sleep-onset visual hallucinations (hypnagogic) and hallucinations upon awakening (hypnopompic) often are bizarre and dream-like. They may consist of geometric patterns, landscapes, faces, or figures. They mainly occur with narcolepsy but can be seen in insomnia or excessive daytime sleepiness.^4,5

Disclosure

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

Excessive sweating—diaphoresis—affects up to 22% of patients who take antidepressants.¹ Diaphoresis may interfere with social and occupational activities, which can lead to medication discontinuation and prevent effective treatment. Stopping, decreasing, or changing antidepressants are options, but patients may be reluctant if the current dose has relieved their depressive symptoms. Adding a medication to reduce diaphoresis may be appropriate.

Sympathetic division of the peripheral nervous system signals cholinergic neurons to stimulate sweat gland secretion. In the CNS, thermoregulation occurs in the hypothalamus through a balanced and complex interaction among serotonergic and dopaminergic neurons.¹ Consequently, oral medications to decrease sweating target peripheral or CNS neurons. Although evidence is limited to case reports, consider cholinergic and serotonergic antagonists and dopamine partial agonists to relieve antidepressant-induced diaphoresis.

Pharmacologic options

Peripherally, the anticholinergic agent benztropine reduced or eliminated diaphoresis at doses ranging from 0.5 mg every other day to 1 mg/d.^2,3 Dry mouth was the only reported side effect.

Centrally acting serotonin antagonists may decrease diaphoresis through the 5-HT2A receptor, which signals the hypothalamus to raise body temperature. Cyproheptadine is an antihistamine with serotonin receptor antagonism. In case reports, it reduced or eliminated sweating in doses of 4 mg once or twice daily.⁴ Mild sedation was the only noted adverse effect. The norepinephrine and serotonin antagonist mirtazapine reduced diaphoresis within 2 weeks of initiation at 15 mg/d with no adverse effects.⁵ Sweating resolved after mirtazapine was titrated to 60 mg/d.

In addition to excess serotonin activity, diaphoresis may result from decreased dopaminergic tone in the hypothalamus. Centrally acting dopamine agonists—even partial agonists—may restore homeostasis and decrease sweating. Aripiprazole, 10 to 20 mg/d, reduced sweating in 2 patients; no adverse effects were reported.⁶

Agents to avoid

Antiadrenergic medications such as clonidine have decreased or exacerbated diaphoresis in studies.¹ Similarly, paroxetine may alleviate or cause sweating. It is difficult to attribute paroxetine’s occasional effectiveness in reducing sweating solely to its anticholinergic properties because improvement may be attributed to an initial anxiolytic effect or efficacy in treating the underlying anxiety disorder.¹

Disclosure

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

Excessive sweating—diaphoresis—affects up to 22% of patients who take antidepressants.¹ Diaphoresis may interfere with social and occupational activities, which can lead to medication discontinuation and prevent effective treatment. Stopping, decreasing, or changing antidepressants are options, but patients may be reluctant if the current dose has relieved their depressive symptoms. Adding a medication to reduce diaphoresis may be appropriate.

Sympathetic division of the peripheral nervous system signals cholinergic neurons to stimulate sweat gland secretion. In the CNS, thermoregulation occurs in the hypothalamus through a balanced and complex interaction among serotonergic and dopaminergic neurons.¹ Consequently, oral medications to decrease sweating target peripheral or CNS neurons. Although evidence is limited to case reports, consider cholinergic and serotonergic antagonists and dopamine partial agonists to relieve antidepressant-induced diaphoresis.

Pharmacologic options

Peripherally, the anticholinergic agent benztropine reduced or eliminated diaphoresis at doses ranging from 0.5 mg every other day to 1 mg/d.^2,3 Dry mouth was the only reported side effect.

Centrally acting serotonin antagonists may decrease diaphoresis through the 5-HT2A receptor, which signals the hypothalamus to raise body temperature. Cyproheptadine is an antihistamine with serotonin receptor antagonism. In case reports, it reduced or eliminated sweating in doses of 4 mg once or twice daily.⁴ Mild sedation was the only noted adverse effect. The norepinephrine and serotonin antagonist mirtazapine reduced diaphoresis within 2 weeks of initiation at 15 mg/d with no adverse effects.⁵ Sweating resolved after mirtazapine was titrated to 60 mg/d.

In addition to excess serotonin activity, diaphoresis may result from decreased dopaminergic tone in the hypothalamus. Centrally acting dopamine agonists—even partial agonists—may restore homeostasis and decrease sweating. Aripiprazole, 10 to 20 mg/d, reduced sweating in 2 patients; no adverse effects were reported.⁶

Agents to avoid

Antiadrenergic medications such as clonidine have decreased or exacerbated diaphoresis in studies.¹ Similarly, paroxetine may alleviate or cause sweating. It is difficult to attribute paroxetine’s occasional effectiveness in reducing sweating solely to its anticholinergic properties because improvement may be attributed to an initial anxiolytic effect or efficacy in treating the underlying anxiety disorder.¹

Disclosure

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

Excessive sweating—diaphoresis—affects up to 22% of patients who take antidepressants.¹ Diaphoresis may interfere with social and occupational activities, which can lead to medication discontinuation and prevent effective treatment. Stopping, decreasing, or changing antidepressants are options, but patients may be reluctant if the current dose has relieved their depressive symptoms. Adding a medication to reduce diaphoresis may be appropriate.

Sympathetic division of the peripheral nervous system signals cholinergic neurons to stimulate sweat gland secretion. In the CNS, thermoregulation occurs in the hypothalamus through a balanced and complex interaction among serotonergic and dopaminergic neurons.¹ Consequently, oral medications to decrease sweating target peripheral or CNS neurons. Although evidence is limited to case reports, consider cholinergic and serotonergic antagonists and dopamine partial agonists to relieve antidepressant-induced diaphoresis.

Pharmacologic options

Peripherally, the anticholinergic agent benztropine reduced or eliminated diaphoresis at doses ranging from 0.5 mg every other day to 1 mg/d.^2,3 Dry mouth was the only reported side effect.

Centrally acting serotonin antagonists may decrease diaphoresis through the 5-HT2A receptor, which signals the hypothalamus to raise body temperature. Cyproheptadine is an antihistamine with serotonin receptor antagonism. In case reports, it reduced or eliminated sweating in doses of 4 mg once or twice daily.⁴ Mild sedation was the only noted adverse effect. The norepinephrine and serotonin antagonist mirtazapine reduced diaphoresis within 2 weeks of initiation at 15 mg/d with no adverse effects.⁵ Sweating resolved after mirtazapine was titrated to 60 mg/d.

In addition to excess serotonin activity, diaphoresis may result from decreased dopaminergic tone in the hypothalamus. Centrally acting dopamine agonists—even partial agonists—may restore homeostasis and decrease sweating. Aripiprazole, 10 to 20 mg/d, reduced sweating in 2 patients; no adverse effects were reported.⁶

Agents to avoid

Antiadrenergic medications such as clonidine have decreased or exacerbated diaphoresis in studies.¹ Similarly, paroxetine may alleviate or cause sweating. It is difficult to attribute paroxetine’s occasional effectiveness in reducing sweating solely to its anticholinergic properties because improvement may be attributed to an initial anxiolytic effect or efficacy in treating the underlying anxiety disorder.¹

Disclosure

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

Stiff person syndrome (SPS) is a rare autoimmune condition characterized by stiffness and rigidity in the lower limb muscles. Because SPS often is misdiagnosed as a psychiatric illness and psychiatric comorbidities are common in patients with this disorder,¹ awareness and recognition of this unique condition is essential.

An insidious presentation

Patients with SPS present with:²

• axial muscle stiffness slowly progressing to proximal muscles
• unremarkable motor, sensory, and cranial nerve examinations with normal intellectual functioning
• normal muscle strength, although electromyography shows continuous motor activity
• spasms evoked by sudden movements, jarring noise, and emotional distress
• slow and cautious gait to avoid triggering spasms and falls.

Symptoms start slowly and insidiously. Axial muscle stiffness can result in spinal deformity. Involvement is asymmetrical, with a predilection for proximal lower limb and lumbar paraspinal muscles. Affected muscles reveal tight, hard, board-like rigidity. In later stages of SPS, mild atrophy and muscle weakness are likely.

Frequent misdiagnosis

Because facial muscle spasticity is prominent, SPS patients may be misdiagnosed with Parkinson’s disease, primary lateral sclerosis, or multiple sclerosis. Spasms affecting respiratory and thoracic paraspinal muscles (status spasticus) may be misdiagnosed as an anxiety-related condition. These spasms can be life-threatening and require IV diazepam and supportive measures.

More than 60% of SPS patients have a comorbid psychiatric disorder.³ Anxiety disorders—generalized anxiety disorder, agoraphobia, and panic disorder—major depression, and alcohol abuse are the most frequent psychiatric comorbidities seen in SPS patients.³

SPS patients who panic when in public may be misdiagnosed with agoraphobia.³ Emotional stimuli may cause muscle spasms leading to falls. Treating muscle spasticity with γ-aminobutyric acid (GABA) agonists and narcotics can lead to drug abuse and dependence. Muscle spasticity can fluctuate from hour to hour, abate with sleep, and get worse with emotional distress. These findings are why approximately 70% of SPS patients are initially misdiagnosed; conversion disorder is a frequent misdiagnosis.⁴ Mood disorder in SPS patients may be resistant to antidepressants until these patients are treated with immunotherapy.⁴

Treating SPS patients

Although early intervention can reduce long-term disability, approximately 50% of SPS patients eventually have to use a wheelchair as a result of pain and immobility.⁵

Antibodies to glutamic acid decarboxylase, which is the rate-limiting enzyme for GABA synthesis, are present in 85% of SPS patients.⁵ Therefore, treatment usually includes GABA-enhancing drugs, including sedative anxiolytics (clonazepam and diazepam), antiepileptics (gabapentin, levetiracetam, tiagabine, and vigabatrin), antispasticity drugs (baclofen, dantrolene, and tizanidine), and immunotherapy (corticosteroids, IV immunoglobulins, and rituximab).⁵ Antidepressants, biofeedback, and relaxation training also can offer relief. Psychotherapy and substance dependency interventions may be needed.

To achieve optimum outcomes in SPS patients, a close collaborative relationship among all treating clinicians—including primary care physicians, neurologists, anesthesiologists, and psychiatrists—is necessary.

Disclosure

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

Stiff person syndrome (SPS) is a rare autoimmune condition characterized by stiffness and rigidity in the lower limb muscles. Because SPS often is misdiagnosed as a psychiatric illness and psychiatric comorbidities are common in patients with this disorder,¹ awareness and recognition of this unique condition is essential.

An insidious presentation

Patients with SPS present with:²

• axial muscle stiffness slowly progressing to proximal muscles
• unremarkable motor, sensory, and cranial nerve examinations with normal intellectual functioning
• normal muscle strength, although electromyography shows continuous motor activity
• spasms evoked by sudden movements, jarring noise, and emotional distress
• slow and cautious gait to avoid triggering spasms and falls.

Symptoms start slowly and insidiously. Axial muscle stiffness can result in spinal deformity. Involvement is asymmetrical, with a predilection for proximal lower limb and lumbar paraspinal muscles. Affected muscles reveal tight, hard, board-like rigidity. In later stages of SPS, mild atrophy and muscle weakness are likely.

Frequent misdiagnosis

Because facial muscle spasticity is prominent, SPS patients may be misdiagnosed with Parkinson’s disease, primary lateral sclerosis, or multiple sclerosis. Spasms affecting respiratory and thoracic paraspinal muscles (status spasticus) may be misdiagnosed as an anxiety-related condition. These spasms can be life-threatening and require IV diazepam and supportive measures.

More than 60% of SPS patients have a comorbid psychiatric disorder.³ Anxiety disorders—generalized anxiety disorder, agoraphobia, and panic disorder—major depression, and alcohol abuse are the most frequent psychiatric comorbidities seen in SPS patients.³

SPS patients who panic when in public may be misdiagnosed with agoraphobia.³ Emotional stimuli may cause muscle spasms leading to falls. Treating muscle spasticity with γ-aminobutyric acid (GABA) agonists and narcotics can lead to drug abuse and dependence. Muscle spasticity can fluctuate from hour to hour, abate with sleep, and get worse with emotional distress. These findings are why approximately 70% of SPS patients are initially misdiagnosed; conversion disorder is a frequent misdiagnosis.⁴ Mood disorder in SPS patients may be resistant to antidepressants until these patients are treated with immunotherapy.⁴

Treating SPS patients

Although early intervention can reduce long-term disability, approximately 50% of SPS patients eventually have to use a wheelchair as a result of pain and immobility.⁵

Antibodies to glutamic acid decarboxylase, which is the rate-limiting enzyme for GABA synthesis, are present in 85% of SPS patients.⁵ Therefore, treatment usually includes GABA-enhancing drugs, including sedative anxiolytics (clonazepam and diazepam), antiepileptics (gabapentin, levetiracetam, tiagabine, and vigabatrin), antispasticity drugs (baclofen, dantrolene, and tizanidine), and immunotherapy (corticosteroids, IV immunoglobulins, and rituximab).⁵ Antidepressants, biofeedback, and relaxation training also can offer relief. Psychotherapy and substance dependency interventions may be needed.

To achieve optimum outcomes in SPS patients, a close collaborative relationship among all treating clinicians—including primary care physicians, neurologists, anesthesiologists, and psychiatrists—is necessary.

Disclosure

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

Stiff person syndrome (SPS) is a rare autoimmune condition characterized by stiffness and rigidity in the lower limb muscles. Because SPS often is misdiagnosed as a psychiatric illness and psychiatric comorbidities are common in patients with this disorder,¹ awareness and recognition of this unique condition is essential.

An insidious presentation

Patients with SPS present with:²

• axial muscle stiffness slowly progressing to proximal muscles
• unremarkable motor, sensory, and cranial nerve examinations with normal intellectual functioning
• normal muscle strength, although electromyography shows continuous motor activity
• spasms evoked by sudden movements, jarring noise, and emotional distress
• slow and cautious gait to avoid triggering spasms and falls.

Symptoms start slowly and insidiously. Axial muscle stiffness can result in spinal deformity. Involvement is asymmetrical, with a predilection for proximal lower limb and lumbar paraspinal muscles. Affected muscles reveal tight, hard, board-like rigidity. In later stages of SPS, mild atrophy and muscle weakness are likely.

Frequent misdiagnosis

Because facial muscle spasticity is prominent, SPS patients may be misdiagnosed with Parkinson’s disease, primary lateral sclerosis, or multiple sclerosis. Spasms affecting respiratory and thoracic paraspinal muscles (status spasticus) may be misdiagnosed as an anxiety-related condition. These spasms can be life-threatening and require IV diazepam and supportive measures.

More than 60% of SPS patients have a comorbid psychiatric disorder.³ Anxiety disorders—generalized anxiety disorder, agoraphobia, and panic disorder—major depression, and alcohol abuse are the most frequent psychiatric comorbidities seen in SPS patients.³

SPS patients who panic when in public may be misdiagnosed with agoraphobia.³ Emotional stimuli may cause muscle spasms leading to falls. Treating muscle spasticity with γ-aminobutyric acid (GABA) agonists and narcotics can lead to drug abuse and dependence. Muscle spasticity can fluctuate from hour to hour, abate with sleep, and get worse with emotional distress. These findings are why approximately 70% of SPS patients are initially misdiagnosed; conversion disorder is a frequent misdiagnosis.⁴ Mood disorder in SPS patients may be resistant to antidepressants until these patients are treated with immunotherapy.⁴

Treating SPS patients

Although early intervention can reduce long-term disability, approximately 50% of SPS patients eventually have to use a wheelchair as a result of pain and immobility.⁵

Antibodies to glutamic acid decarboxylase, which is the rate-limiting enzyme for GABA synthesis, are present in 85% of SPS patients.⁵ Therefore, treatment usually includes GABA-enhancing drugs, including sedative anxiolytics (clonazepam and diazepam), antiepileptics (gabapentin, levetiracetam, tiagabine, and vigabatrin), antispasticity drugs (baclofen, dantrolene, and tizanidine), and immunotherapy (corticosteroids, IV immunoglobulins, and rituximab).⁵ Antidepressants, biofeedback, and relaxation training also can offer relief. Psychotherapy and substance dependency interventions may be needed.

To achieve optimum outcomes in SPS patients, a close collaborative relationship among all treating clinicians—including primary care physicians, neurologists, anesthesiologists, and psychiatrists—is necessary.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Research indicates that even brief physician advice on a regular basis can increase quit rates for patients who smoke.¹ This is particularly important in mental health settings, where there are more smokers than in the general population (50% to 90% vs 25% to 27%, respectively) but quit rates are lower.²

There is no “one size fits all” solution to quitting smoking; there are many individual factors to take into account for each patient. In addition to environmental factors that can make quitting smoking more challenging—eg, the patient’s partner also smokes—a patient’s genetic makeup can make it easier or harder to become addicted or to quit smoking, and can make pharmacologic approaches to cessation more or less successful.^3,4 A patient’s failed attempt to quit in the past does not indicate that quitting is impossible.

Although we encourage the use of traditional mnemonics such as the “5 A’s”⁵ and the “5 R’s,”⁵ we introduce QUIT as an easy-to-remember, compassionate, realistic way of discussing smoking cessation with patients.

Question each patient to understand the pros and cons of quitting. Ask your patients about the “benefits” of smoking and understand what role cigarettes serve in their lives. Remind patients of immediate benefits that would make quitting smoking a “trade” rather than a loss—eg, how would they use the extra $200 a month they would save by giving up cigarettes?

If patients say they are not interested in quitting, find out why they are not motivated to quit and collaborate with them to try to address their concerns. Additionally, ask if they would be comfortable discussing smoking cessation at each visit, even if they are not expressing interest.

Understand the nature of addiction. The trajectory of tobacco dependence—similar to other addictions—involves a chronic and relapsing course. Most patients require multiple quit attempts using several strategies before they succeed. Find out what they have tried in the past and build on previous successes. Be persistent in offering evidence-based treatments to help patients quit, even when motivation is low and patients have multiple failed attempts.

Keep in mind that only 4% to 7% of unaided quit attempts are successful.⁶ Most patients require counseling and/or medication, as well as help from a caring physician. By understanding the nature of addiction, you can be optimistic and supportive of your patients as they face the often disheartening process of quitting.

Identify risk factors and triggers. Studies have demonstrated that stimuli related to smoking increase a patient’s craving to smoke; this response is stronger than triggers encountered by patients addicted to alcohol or opiates.⁷ A plan for handling cravings and avoiding triggers can empower your patients and help them stay on track.

Talk with—not to—your patient. Discussing smoking can help clarify your patient’s feelings rather than avoiding them. Although patients may aspire to eventually quit smoking, the unspoken concerns they harbor combined with the “benefits” of smoking may lead to a failure to act.

Talk is powerful and with training, physicians can move patients toward change. Motivational interviewing is evidence-based and offers techniques that enable physicians to use conversation with their patients as a way of overcoming ambivalence about unhealthy behaviors and eliciting talk about changing these behaviors, and eventually help them to change.

You can make an impact

Physicians need to recognize their potential impact on this life-threatening behavior. Through an active, conversational style, develop a big-picture understanding of your patient’s pros and cons of quitting smoking; strengths and weaknesses; past failures and successes; barriers to success; available supports; etc. This information, combined with encouragement, support, and knowledge of evidence-based practices, can yield a thorough plan for quitting.

Although quitting smoking can be extremely challenging for clinicians and patients, expanding your knowledge in this area will allow you to help your patients make life-saving changes. The best care comes from direct communication and unconditional support.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Research indicates that even brief physician advice on a regular basis can increase quit rates for patients who smoke.¹ This is particularly important in mental health settings, where there are more smokers than in the general population (50% to 90% vs 25% to 27%, respectively) but quit rates are lower.²

There is no “one size fits all” solution to quitting smoking; there are many individual factors to take into account for each patient. In addition to environmental factors that can make quitting smoking more challenging—eg, the patient’s partner also smokes—a patient’s genetic makeup can make it easier or harder to become addicted or to quit smoking, and can make pharmacologic approaches to cessation more or less successful.^3,4 A patient’s failed attempt to quit in the past does not indicate that quitting is impossible.

Although we encourage the use of traditional mnemonics such as the “5 A’s”⁵ and the “5 R’s,”⁵ we introduce QUIT as an easy-to-remember, compassionate, realistic way of discussing smoking cessation with patients.

Question each patient to understand the pros and cons of quitting. Ask your patients about the “benefits” of smoking and understand what role cigarettes serve in their lives. Remind patients of immediate benefits that would make quitting smoking a “trade” rather than a loss—eg, how would they use the extra $200 a month they would save by giving up cigarettes?

If patients say they are not interested in quitting, find out why they are not motivated to quit and collaborate with them to try to address their concerns. Additionally, ask if they would be comfortable discussing smoking cessation at each visit, even if they are not expressing interest.

Understand the nature of addiction. The trajectory of tobacco dependence—similar to other addictions—involves a chronic and relapsing course. Most patients require multiple quit attempts using several strategies before they succeed. Find out what they have tried in the past and build on previous successes. Be persistent in offering evidence-based treatments to help patients quit, even when motivation is low and patients have multiple failed attempts.

Keep in mind that only 4% to 7% of unaided quit attempts are successful.⁶ Most patients require counseling and/or medication, as well as help from a caring physician. By understanding the nature of addiction, you can be optimistic and supportive of your patients as they face the often disheartening process of quitting.

Identify risk factors and triggers. Studies have demonstrated that stimuli related to smoking increase a patient’s craving to smoke; this response is stronger than triggers encountered by patients addicted to alcohol or opiates.⁷ A plan for handling cravings and avoiding triggers can empower your patients and help them stay on track.

Talk with—not to—your patient. Discussing smoking can help clarify your patient’s feelings rather than avoiding them. Although patients may aspire to eventually quit smoking, the unspoken concerns they harbor combined with the “benefits” of smoking may lead to a failure to act.

Talk is powerful and with training, physicians can move patients toward change. Motivational interviewing is evidence-based and offers techniques that enable physicians to use conversation with their patients as a way of overcoming ambivalence about unhealthy behaviors and eliciting talk about changing these behaviors, and eventually help them to change.

You can make an impact

Physicians need to recognize their potential impact on this life-threatening behavior. Through an active, conversational style, develop a big-picture understanding of your patient’s pros and cons of quitting smoking; strengths and weaknesses; past failures and successes; barriers to success; available supports; etc. This information, combined with encouragement, support, and knowledge of evidence-based practices, can yield a thorough plan for quitting.

Although quitting smoking can be extremely challenging for clinicians and patients, expanding your knowledge in this area will allow you to help your patients make life-saving changes. The best care comes from direct communication and unconditional support.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Research indicates that even brief physician advice on a regular basis can increase quit rates for patients who smoke.¹ This is particularly important in mental health settings, where there are more smokers than in the general population (50% to 90% vs 25% to 27%, respectively) but quit rates are lower.²

There is no “one size fits all” solution to quitting smoking; there are many individual factors to take into account for each patient. In addition to environmental factors that can make quitting smoking more challenging—eg, the patient’s partner also smokes—a patient’s genetic makeup can make it easier or harder to become addicted or to quit smoking, and can make pharmacologic approaches to cessation more or less successful.^3,4 A patient’s failed attempt to quit in the past does not indicate that quitting is impossible.

Although we encourage the use of traditional mnemonics such as the “5 A’s”⁵ and the “5 R’s,”⁵ we introduce QUIT as an easy-to-remember, compassionate, realistic way of discussing smoking cessation with patients.

Question each patient to understand the pros and cons of quitting. Ask your patients about the “benefits” of smoking and understand what role cigarettes serve in their lives. Remind patients of immediate benefits that would make quitting smoking a “trade” rather than a loss—eg, how would they use the extra $200 a month they would save by giving up cigarettes?

If patients say they are not interested in quitting, find out why they are not motivated to quit and collaborate with them to try to address their concerns. Additionally, ask if they would be comfortable discussing smoking cessation at each visit, even if they are not expressing interest.

Understand the nature of addiction. The trajectory of tobacco dependence—similar to other addictions—involves a chronic and relapsing course. Most patients require multiple quit attempts using several strategies before they succeed. Find out what they have tried in the past and build on previous successes. Be persistent in offering evidence-based treatments to help patients quit, even when motivation is low and patients have multiple failed attempts.

Keep in mind that only 4% to 7% of unaided quit attempts are successful.⁶ Most patients require counseling and/or medication, as well as help from a caring physician. By understanding the nature of addiction, you can be optimistic and supportive of your patients as they face the often disheartening process of quitting.

Identify risk factors and triggers. Studies have demonstrated that stimuli related to smoking increase a patient’s craving to smoke; this response is stronger than triggers encountered by patients addicted to alcohol or opiates.⁷ A plan for handling cravings and avoiding triggers can empower your patients and help them stay on track.

Talk with—not to—your patient. Discussing smoking can help clarify your patient’s feelings rather than avoiding them. Although patients may aspire to eventually quit smoking, the unspoken concerns they harbor combined with the “benefits” of smoking may lead to a failure to act.

Talk is powerful and with training, physicians can move patients toward change. Motivational interviewing is evidence-based and offers techniques that enable physicians to use conversation with their patients as a way of overcoming ambivalence about unhealthy behaviors and eliciting talk about changing these behaviors, and eventually help them to change.

You can make an impact

Physicians need to recognize their potential impact on this life-threatening behavior. Through an active, conversational style, develop a big-picture understanding of your patient’s pros and cons of quitting smoking; strengths and weaknesses; past failures and successes; barriers to success; available supports; etc. This information, combined with encouragement, support, and knowledge of evidence-based practices, can yield a thorough plan for quitting.

Although quitting smoking can be extremely challenging for clinicians and patients, expanding your knowledge in this area will allow you to help your patients make life-saving changes. The best care comes from direct communication and unconditional support.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Children and adolescents who have unrestricted use of the internet and cell phones are at increased risk for being exposed to sexually explicit material. One study found almost 1 in 5 high school students have “sexted”—sending a text message with sexually explicit pictures—and almost twice as many reported that they had received a sexually explicit picture via cell phone.¹ More than 25% of students acknowledged forwarding a sexually explicit picture to others; >33% did so despite knowing the legal consequences, including being arrested and facing pornography charges.¹

Concerned parents may seek advice on how to prevent their child from receiving or sending sexually inappropriate material on the internet or on their cell phones. You can help parents keep their children safe by sharing the following tips from The American Academy of Pediatrics (AAP)²:

Keep up with technology. Advise parents to become familiar with popular social networking websites such as Facebook. Creating their own Facebook page and “friending” their child may help them facilitate a conversation about their individual online experiences.

Enable privacy features. Instruct parents to install parental controls on their child’s computer. Explain to parents that these monitoring systems can help them check their child’s e-mail, chat records, and instant messages. Many social networking sites have privacy features that can help block unwanted users from contacting a child.

Check up on your children. Parents should let children know they are aware of their online presence and will be keeping an eye on them. They should periodically check a child’s chat logs, messages, e-mails, and social networking profiles for inappropriate content, friends, messages, and images. Instruct parents to teach their children that nothing is private once it’s posted on the internet. Suggest keeping the child’s computer in a public location such as the family room or kitchen.

Limit time spent online. Explain to parents that they should limit their child’s internet and cell phone access.

Combating ‘sexting’

Suggest to parents that they explain to their child in an age-appropriate manner what sexting is before giving their child a cell phone. The AAP² recommends that parents make sure their children understand the legal ramifications of sexting. A child who is caught sexting could be arrested, which may hurt his or her chances of being accepted into college or getting a job. A simple way to reduce a child’s opportunities for sexting is to restrict his or her access to a cell phone during social situations where peer pressure could influence behavior.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Children and adolescents who have unrestricted use of the internet and cell phones are at increased risk for being exposed to sexually explicit material. One study found almost 1 in 5 high school students have “sexted”—sending a text message with sexually explicit pictures—and almost twice as many reported that they had received a sexually explicit picture via cell phone.¹ More than 25% of students acknowledged forwarding a sexually explicit picture to others; >33% did so despite knowing the legal consequences, including being arrested and facing pornography charges.¹

Concerned parents may seek advice on how to prevent their child from receiving or sending sexually inappropriate material on the internet or on their cell phones. You can help parents keep their children safe by sharing the following tips from The American Academy of Pediatrics (AAP)²:

Keep up with technology. Advise parents to become familiar with popular social networking websites such as Facebook. Creating their own Facebook page and “friending” their child may help them facilitate a conversation about their individual online experiences.

Enable privacy features. Instruct parents to install parental controls on their child’s computer. Explain to parents that these monitoring systems can help them check their child’s e-mail, chat records, and instant messages. Many social networking sites have privacy features that can help block unwanted users from contacting a child.

Check up on your children. Parents should let children know they are aware of their online presence and will be keeping an eye on them. They should periodically check a child’s chat logs, messages, e-mails, and social networking profiles for inappropriate content, friends, messages, and images. Instruct parents to teach their children that nothing is private once it’s posted on the internet. Suggest keeping the child’s computer in a public location such as the family room or kitchen.

Limit time spent online. Explain to parents that they should limit their child’s internet and cell phone access.

Combating ‘sexting’

Suggest to parents that they explain to their child in an age-appropriate manner what sexting is before giving their child a cell phone. The AAP² recommends that parents make sure their children understand the legal ramifications of sexting. A child who is caught sexting could be arrested, which may hurt his or her chances of being accepted into college or getting a job. A simple way to reduce a child’s opportunities for sexting is to restrict his or her access to a cell phone during social situations where peer pressure could influence behavior.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Children and adolescents who have unrestricted use of the internet and cell phones are at increased risk for being exposed to sexually explicit material. One study found almost 1 in 5 high school students have “sexted”—sending a text message with sexually explicit pictures—and almost twice as many reported that they had received a sexually explicit picture via cell phone.¹ More than 25% of students acknowledged forwarding a sexually explicit picture to others; >33% did so despite knowing the legal consequences, including being arrested and facing pornography charges.¹

Concerned parents may seek advice on how to prevent their child from receiving or sending sexually inappropriate material on the internet or on their cell phones. You can help parents keep their children safe by sharing the following tips from The American Academy of Pediatrics (AAP)²:

Keep up with technology. Advise parents to become familiar with popular social networking websites such as Facebook. Creating their own Facebook page and “friending” their child may help them facilitate a conversation about their individual online experiences.

Enable privacy features. Instruct parents to install parental controls on their child’s computer. Explain to parents that these monitoring systems can help them check their child’s e-mail, chat records, and instant messages. Many social networking sites have privacy features that can help block unwanted users from contacting a child.

Check up on your children. Parents should let children know they are aware of their online presence and will be keeping an eye on them. They should periodically check a child’s chat logs, messages, e-mails, and social networking profiles for inappropriate content, friends, messages, and images. Instruct parents to teach their children that nothing is private once it’s posted on the internet. Suggest keeping the child’s computer in a public location such as the family room or kitchen.

Limit time spent online. Explain to parents that they should limit their child’s internet and cell phone access.

Combating ‘sexting’

Suggest to parents that they explain to their child in an age-appropriate manner what sexting is before giving their child a cell phone. The AAP² recommends that parents make sure their children understand the legal ramifications of sexting. A child who is caught sexting could be arrested, which may hurt his or her chances of being accepted into college or getting a job. A simple way to reduce a child’s opportunities for sexting is to restrict his or her access to a cell phone during social situations where peer pressure could influence behavior.

Disclosure

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

Since September 11, 2001, many Arab Americans have faced increased discrimination, which puts them at greater risk for depression and low self-esteem.¹ Children and adolescents in particular have been the victims of teasing and taunts. Many Muslim Arab Americans turned to their imams—a mosque’s spiritual leader—rather than a mental health clinician to help them deal with the national tragedy and the fallout that followed.²

Arab Americans may struggle to bridge their personal identity with their cultural one. Traditional Arab values stress the importance of family—both immediate and extended—loyalty to parents, religious adherence, and respect for elders and authority. Adapting those values to typical American values can cause dissonance as Arab Americans grapple to find a balance between renouncing their Arab culture in hopes of fitting in and feeling like outcasts in the country they call home.

Understanding cultural nuances

Be aware of the stigma of mental illness within Arab American communities. Unlike diabetes or heart disease, psychiatric disorders can carry a negative connotation for many Arab Americans.³ They may view mental illness as a personal shortcoming or ascribe their symptoms to supernatural spirits. The fear of being discriminated against for being culturally different and mentally ill may delay or prevent individuals from seeking care.

Understanding these dynamics, as well as Arab American culture, is the first step to evaluating these patients. Being aware of cultural nuances also is important. Patients may say they don’t smoke, but some prodding may reveal that they use a tobacco water pipe, or hookah.

Be cognizant of any preconceived notions that can seep into an assessment. It’s easy to assume that Arab American patients fall into stereotypical gender roles or are unhappy with what may be perceived as inadequate assimilation. Conversely, a patient’s appearance, devotion to cultural and religious values, and family support may lead to an assumption that the patient does not abuse substances or engage in high-risk behavior.

In addition, note that Arab Americans tend to present their mental illness as somatic complaints, which may make them more comfortable seeing a primary care physician than a psychiatrist.

Adjusting treatment

Many Arab Americans’ first choice is to seek support from family, friends, and religious leaders.⁴ A patient may need to be convinced to take psychotropics the same as they would other medications. Therefore, it may be necessary to involve family members to ensure treatment compliance. Clinicians may need to spend more time with Arab American patients, which can help the clinician grasp the complexity of their issues and allow patients to feel that they’re being cared for by a clinician who respects their cultural and religious beliefs. In conjunction, these steps will help you provide culturally sensitive care that best addresses Arab Americans’ mental health needs.

Since September 11, 2001, many Arab Americans have faced increased discrimination, which puts them at greater risk for depression and low self-esteem.¹ Children and adolescents in particular have been the victims of teasing and taunts. Many Muslim Arab Americans turned to their imams—a mosque’s spiritual leader—rather than a mental health clinician to help them deal with the national tragedy and the fallout that followed.²

Arab Americans may struggle to bridge their personal identity with their cultural one. Traditional Arab values stress the importance of family—both immediate and extended—loyalty to parents, religious adherence, and respect for elders and authority. Adapting those values to typical American values can cause dissonance as Arab Americans grapple to find a balance between renouncing their Arab culture in hopes of fitting in and feeling like outcasts in the country they call home.

Understanding cultural nuances

Be aware of the stigma of mental illness within Arab American communities. Unlike diabetes or heart disease, psychiatric disorders can carry a negative connotation for many Arab Americans.³ They may view mental illness as a personal shortcoming or ascribe their symptoms to supernatural spirits. The fear of being discriminated against for being culturally different and mentally ill may delay or prevent individuals from seeking care.

Understanding these dynamics, as well as Arab American culture, is the first step to evaluating these patients. Being aware of cultural nuances also is important. Patients may say they don’t smoke, but some prodding may reveal that they use a tobacco water pipe, or hookah.

Be cognizant of any preconceived notions that can seep into an assessment. It’s easy to assume that Arab American patients fall into stereotypical gender roles or are unhappy with what may be perceived as inadequate assimilation. Conversely, a patient’s appearance, devotion to cultural and religious values, and family support may lead to an assumption that the patient does not abuse substances or engage in high-risk behavior.

In addition, note that Arab Americans tend to present their mental illness as somatic complaints, which may make them more comfortable seeing a primary care physician than a psychiatrist.

Adjusting treatment

Many Arab Americans’ first choice is to seek support from family, friends, and religious leaders.⁴ A patient may need to be convinced to take psychotropics the same as they would other medications. Therefore, it may be necessary to involve family members to ensure treatment compliance. Clinicians may need to spend more time with Arab American patients, which can help the clinician grasp the complexity of their issues and allow patients to feel that they’re being cared for by a clinician who respects their cultural and religious beliefs. In conjunction, these steps will help you provide culturally sensitive care that best addresses Arab Americans’ mental health needs.

Since September 11, 2001, many Arab Americans have faced increased discrimination, which puts them at greater risk for depression and low self-esteem.¹ Children and adolescents in particular have been the victims of teasing and taunts. Many Muslim Arab Americans turned to their imams—a mosque’s spiritual leader—rather than a mental health clinician to help them deal with the national tragedy and the fallout that followed.²

Arab Americans may struggle to bridge their personal identity with their cultural one. Traditional Arab values stress the importance of family—both immediate and extended—loyalty to parents, religious adherence, and respect for elders and authority. Adapting those values to typical American values can cause dissonance as Arab Americans grapple to find a balance between renouncing their Arab culture in hopes of fitting in and feeling like outcasts in the country they call home.

Understanding cultural nuances

Be aware of the stigma of mental illness within Arab American communities. Unlike diabetes or heart disease, psychiatric disorders can carry a negative connotation for many Arab Americans.³ They may view mental illness as a personal shortcoming or ascribe their symptoms to supernatural spirits. The fear of being discriminated against for being culturally different and mentally ill may delay or prevent individuals from seeking care.

Understanding these dynamics, as well as Arab American culture, is the first step to evaluating these patients. Being aware of cultural nuances also is important. Patients may say they don’t smoke, but some prodding may reveal that they use a tobacco water pipe, or hookah.

Be cognizant of any preconceived notions that can seep into an assessment. It’s easy to assume that Arab American patients fall into stereotypical gender roles or are unhappy with what may be perceived as inadequate assimilation. Conversely, a patient’s appearance, devotion to cultural and religious values, and family support may lead to an assumption that the patient does not abuse substances or engage in high-risk behavior.

In addition, note that Arab Americans tend to present their mental illness as somatic complaints, which may make them more comfortable seeing a primary care physician than a psychiatrist.

Adjusting treatment

Many Arab Americans’ first choice is to seek support from family, friends, and religious leaders.⁴ A patient may need to be convinced to take psychotropics the same as they would other medications. Therefore, it may be necessary to involve family members to ensure treatment compliance. Clinicians may need to spend more time with Arab American patients, which can help the clinician grasp the complexity of their issues and allow patients to feel that they’re being cared for by a clinician who respects their cultural and religious beliefs. In conjunction, these steps will help you provide culturally sensitive care that best addresses Arab Americans’ mental health needs.

Discuss this article at www.facebook.com/CurrentPsychiatry

Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.¹ However, an anticipated leave allows for advanced planning that can help ease transfer of care.

A smooth transition

Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.

It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.

Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.¹ However, an anticipated leave allows for advanced planning that can help ease transfer of care.

A smooth transition

Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.

It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.

Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.

Disclosure

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

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Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.¹ However, an anticipated leave allows for advanced planning that can help ease transfer of care.

A smooth transition

Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.

It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.

Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.

Disclosure

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