Allen R. Dyer

Informed consent and the psychiatric patient.

Informed consent is reviewed as it applies to psychiatric patients. Although new legislation, such as the Mental Health Act 1983, provides a useful safeguard for the protection of the civil rights of patients, it could actually reduce their humane care unless applied with sensitivity for the nature of their unique difficulties. In order to guard against this possibility, we suggest that legal requirements should be considered in light of the ethical principles which underlie them. Three principles are considered: those of autonomy (freedom); beneficence (paternalism); and the fiduciary principle (partnership). Psychotherapy is offered as a model for informed consent, which might be generalised to other clinical situations.

Ethics, advertising and the definition of a profession.

In the climate of concern about high medical costs, the relationship between the trade and professional aspects of medical practice is receiving close scrutiny. In the United Kingdom there is talk of increasing privatisation of health services, and in the United States the Federal Trade Commission (FTC) has attempted to define medicine as a trade for the purposes of commercial regulation. The Supreme Court recently upheld the FTC charge that the American Medical Association (AMA) has been in restraint of trade because of ethical strictures against advertising. The concept of profession, as it has been analyzed in sociological, legal, philosophical, and historical perspectives, reveals the importance of an ethic of service as well as technical expertise as defining characteristics of professions. It is suggested that the medical profession should pay more attention to its service ideal at this time when doctors are widely perceived to be technically preoccupied.

Long-term effects of antidepressants on balance, equilibrium, and postural reflexes

To assess the long-term effects of antidepressant medication on balance, equilibrium, and postural reflexes, we studied 30 patients, ages 20-76 years, who had a diagnosis of depressive disorder (as defined by DSM-III-R criteria) and had been treated with tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) for > or = 1 year. They were assessed by a Balance Master System. The assessment included three tasks: static balance, rhythmic weight shift, and limits of stability. When compared with 30 nonhospitalized healthy controls (of comparable age and the same sex), patients who took TCAs showed impaired balance function in all main indices. The results suggest that the impairment of balance function includes motor coordination, fine-motor control, postural reflexes, maintaining equilibrium, and reaction time. No obvious impairment of balance function was observed in patients who took SSRIs.

Perceptions and utilization of primary health care services in Iraq: findings from a national household survey

BackgroundAfter many years of sanctions and conflict, Iraq is rebuilding its health system, with a strong emphasis on the traditional hospital-based services. A network exists of public sector hospitals and clinics, as well as private clinics and a few private hospitals. Little data are available about the approximately 1400 Primary Health Care clinics (PHCCs) staffed with doctors. How do Iraqis utilize primary health care services? What are their preferences and perceptions of public primary health care clinics and private primary care services in general? How does household wealth affect choice of services?MethodsA 1256 household national survey was conducted in the catchment areas of randomly selected PHCCs in Iraq. A cluster of 10 households, beginning with a randomly selected start household, were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraqs 18 governorates. A questionnaire was developed using key informants. Teams of interviewers, including both males and females, were recruited and provided a week of training which included field practice. Teams then gathered data from households in the service areas of randomly selected clinics.ResultsIraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector. Private clinics are generally the most popular source of primary care, however the PHCCs are utilized more by poorer households. In spite of free services available at PHCCs many households expressed difficulty in affording health care, especially in the purchase of medications. There is no evidence of informal payments to secure health services in the public sector.ConclusionsThere is widespread satisfaction reported with primary health care services, and levels did not differ appreciably between public and private sectors. The public sector PHCCs are preferentially used by poorer populations where they are important providers. PHCC services are indeed free, with little evidence of informal payments to providers.

Cardiopathia fantastica: The cardiac variant of Munchausen syndrome

Munchausen syndrome is a rare condition in which the patient repeatedly seeks medical care for factitious illnesses. Cardiac Munchausen syndrome was first reported in 1953 and later referred to as cardiopathia fantastica. It is characterized by clinical manifestations of acute cardiac disease that are feigned and recurrent. Cardiopathia fantastica can have a variety of presentations similar to true cardiac disease. Most cases have presented with chest pain simulating acute coronary artery disease, but arrhythmias, hypertensive crises, abnormal biochemistry, and electrocardiographic findings have also been noted. These patients are willing to undergo expensive, invasive, and risky procedures to evaluate their simulated illness. This condition is likely to be significantly underreported. In some patients, the presence of abnormal findings that are clinically insignificant may complicate the investigative approach. Patients with this disorder consume a disproportionate amount of health care dollars and sometimes are left with residual deficits as complications of invasive procedures. In this review, we discuss the recognition, manifestations, and treatment of cardiopathia fantastica.

Ethics and Psychiatry

Psychiatry is a profession defined and guided by well-established norms dating back to the Hippocratic Oath and carefully delineated by the standards of modern biomedical ethics and professionalism. Key principles, such as beneficence (confidentiality), autonomy (informed consent), nonmaleficence, and justice provide bases for clinical judgment in specific contexts. Commercialism in health care introduces potential conflicts for the professional, whose primary allegiances are to the patient and those served. Several new challenges are faced by psychiatrists and other professionals in the twenty-first century. These include telemedicine, electronic health records, and social networks/social media.

Spirituality and cancer: an introduction.

Adiagnosis of cancer is likely to precipitate spiritual reflection, if not spiritual crisis. It may even precipitate theological questions, challenging the understanding of God or one’s relationship with ultimate considerations, certainly existential issues when confronted with the possibility of nonexistence. We know that death is inevitable, but for much of our lives, it remains a remote possibility. Cancer changes that. It forces us to contemplate our own mortality. When confronted with a diagnosis such as cancer, everything that was once familiar becomes unfamiliar and unbalanced; however, religious traditions offer us metaphors and rituals for understanding and coping with the possibility of death. As one seeks to regain balance, such metaphors offer the familiar while searching for equilibrium. One such familiar theme is that of the warrior. For the patient, as the warrior, though the battle with cancer may not be of one’s choosing, the battle must be fought. For the physician, the task may be more complicated. While it might be tempting to say that the analogy for the physician is to take the role of the counselor, one boundary necessitates caution: the physician cannot assume the omniscient role of a god, who knows the outcome of the battle. The physician must act, but act with devotional humility. For the physician, the task is how to have a conversation with the patient about ultimate concerns, recognizing that the patient may not speak the same metaphorical language. The patient may have a different set of beliefs, use different metaphors, or may be at a different stage of faith. Even familiar words may mean different things to different people at different times. ‘‘You survived cancer. What a miracle!’’ Do we understand miracle to mean ‘‘divine intervention’’ or ‘‘a highly improbable or extraordinary event’’? Ordinary language has layers of meaning. Likewise, cancer stories are difficult to tell and difficult to listen to, yet they are an important part of the shared narrative of doctor and patient, as they live their lives together. Cancer stories are the sources from which we learn and understand lives, experiences, feelings, meanings, choices, options. They are the basis for empathy as we try to understand the experience of another person, whose experiences may differ from our own. Patients have an almost obsessive need to be heard and understood. In disaster situations such as earthquakes, patients often repeat their stories again and again, describing what happened to them. For busy physicians and nurses, these stories may seem unnecessary intrusions in the urgent routine, but they too are part of the healing process. With each telling of the story, there can be a new outcome as they integrate the experience of loss into the new reality of healing and the new community of those who care. To be part of the community of caring, the health team must bear all these uncomfortable feelings. There is a growing body of literature documenting the health benefits of spirituality and religion in cancer and other medical treatments. The Handbook of Religion and Health has a table of published studies on religion and health, which covers 76 printed pages (more than 1000 references, listed by health outcome). The relationships are complex; causes and effects are difficult to establish. Correlation does not imply causation, but any factors that might make a difference in dealing with a complex, life-threatening illness are worthy of attention. Spiritual practices, religious rituals, and meditative practices can calm the mind, relax the body, and elevate the spirits. Depending on whether the impact of a life-threatening experience is viewed microscopically or macroscopically, cancer can impact spirituality and spirituality can impact cancer. Cancer can be a source of spiritual reflection, and spirituality can be an ally in the battle.

The need for a new "new medical model": a bio-psychosocial-spiritual model.

My experiences as a cancer patient have helped me understand the complexity of illness in ways which I could not fully appreciate as a physician trying to be attentive to my patients. My experiences with managed care helped me appreciate that our system of healthcare finance fundamentally misconstrues the nature of illness and what the healthcare system should be trying to accomplish. As a cancer patient, I was thankful for sophisticated technology such as bone marrow transplant, but it is a grim technology. Without the attentive care of the Duke staff and the love and support of friends and family, it would have been unbearable. I consider this the spiritual side of care, not necessarily in a supernatural sense, but certainly in a transcendent sense. In calling for a new ‘‘new medical model,’’ I am suggesting a model that encompasses such spirituality, such transcendence. George Engel identified the need for a ‘‘new medical model’’ more than 30 years ago. The model he proposed was the bio-psycho-social model intended to expand the bio-reductionistic model then in force. The bio-reductionistic model held that everything one needs to know about medicine could be explained by reducing illness to its biological components. That model was extremely successful up to a point. There had been many advances in biomedicine that supported the treat-the-body-as-a-machine approach. Even organs could be replaced like the worn out parts of an old automobile. Now, more than a quarter of a century after the publication of Engel’s article, we appreciate that the biological model did not explain enough. We realize how mind (and stress) affect the body-machine and how so many of the illnesses people suffer stem from behavioral causes with physiological correlates. The bio-psycho-social gets at least grudging recognition even as bio-reductionism holds sway. In defense of Engel’s originality and insight, I think it could be said that spirituality is implicit in his consideration of the psychosocial. But it must also be recognized that the discussion of spirituality in modern Western thought is strained and uncomfortable, perhaps because a failure to distinguish the spiritual from the religious has impeded a broader consideration of the spiritual. In opening up the possibility of a conversation about the role of spirituality in health care, I am aware that we would need to consider everything from the array of organized religions to the most unique forms of New Age individualism. And that is precisely the point. Each patient, each person comes to medicine with a unique experience and outlook and needs and may find a unique path to healing. The doctor and healthcare team do not need to share the same experience, but they need to understand the uniqueness of each person’s psychosocial and spiritual needs, as well as the biology of disease. Spiritual reflections were very much part of my experience with bone marrow transplant for multiple myeloma. Getting well was a consuming goal and the spirit of determination carried the day, day after day. My spiritual concerns, however, were never explicitly discussed with my physician, the responsibility of which was left to the chaplain. It strikes me as ironic that chaplains are often the ones who are called upon to do psychological counseling and that psychologists are offering spiritual affirmations and guided imagery. But I take such confusion merely as an indication that the role of spirituality in medicine has not been well thought out. Perhaps the chaplains’ role would be easier if they weren’t left to do their own introductions or if they were consulted when needed or requested, like other ‘‘specialists.’’ Better definition of roles and boundaries might clarify expectations for all involved. Indeed, the people I found most spiritual were the members of the treatment team, doctors and nurses and physicians’ associates, though nothing they did might be identified in a formally religious sense. Their presence and their attentive concern again and again transcended the mundane details of chemicals and lab values. This could be considered integration of the spiritual with the bio-psycho-social at its best. Each day, my cancer ritual consisted of taking blood counts and receiving treatments. Nurses changed bandages, and doctors reviewed the progress. The staff offered hope, and the community of friends gathered round to keep the focus on healing, wellness, and recovery. Special Section: Spirituality/Medicine Interface Project

Self psychology as an avenue to pre-oedipal experiences

Currently much attention is being devoted to narcissism and self psychology. The work of Kohut and his followers has allowed periously maligned aspects of personality such as narcissism to be viewed as part of the normal developmental process of achieving self. Self psychology has gained the attention of psychotherapists previously not enamored with classical psychoanalysis. The author views self psychology as a new twist in a highly viable tradition that has opened the doors to psychotherapeutic intervention in some of the more difficult aspects of personality development. Clinical vignettes are used to illustrate the interplay of psychosexual development and the development of self, the application of self psychology to the treatment of psychosomatic disorders, and the similarity of narcissistic and co-dependent issues. The vignettes reflect difficulties not only seen in those often referred to as mentally ill, but also in, those characterized as the “worried well”. Dyer warns that not responding to the suffering of the “worried-well” may be one of the great unmet health needs of our time.Currently much attention is being devoted to narcissism and self psychology. The work of Kohut and his followers has allowed periously maligned aspects of personality such as narcissism to be viewed as part of the normal developmental process of achieving self. Self psychology has gained the attention of psychotherapists previously not enamored with classical psychoanalysis. The author views self psychology as a new twist in a highly viable tradition that has opened the doors to psychotherapeutic intervention in some of the more difficult aspects of personality development. Clinical vignettes are used to illustrate the interplay of psychosexual development and the development of self, the application of self psychology to the treatment of psychosomatic disorders, and the similarity of narcissistic and co-dependent issues. The vignettes reflect difficulties not only seen in those often referred to as mentally ill, but also in, those characterized as the “worried well”. Dyer warns that not responding to the suffering of the “worried-well” may be one of the great unmet health needs of our time.

Utilization of private child and adolescent services: Ethical considerations

Any discussion of ethics is inherently a discussion of values and choices. The emergence of for-profit healthcare, especially in the field of mental health and substance abuse treatment for adolescents, has heightened this discussion as it relates to appropriate and necessary care. This paper traces the history of this conflict as it relates to the medical profession and through a case vignette, raises a variety of ethical issues and dilemmas presented by the growth of this rapidly expanding industry.