Jeffrey P. Kahn

How Much Does Quality Mental Health Care Profit Employers

Objective:Employers provide most American mental health benefits and are increasingly cost conscious. However, commonplace anxiety and depressive disorders have enormous economic and workplace performance costs. Methods:We performed multiple literature searches on several areas of pertinent research (and on key articles) covering the past 5 years. Results:Substantial research exists about anxiety and depression costs, such as performance and productivity, absenteeism, presenteeism, disability, physical disability exacerbation, mental health treatment, increased medical care costs, exacerbating of physical illness, and studies of mental health care limitations and cost-offset. Research addressing the potential value of higher quality mental health care is limited. Conclusions:Commonplace anxiety and depressive disorders are costly in the workplace. Employers and researchers remain largely unaware of the value of quality care and psychiatric skills. Effective solutions involve the increased use of psychiatric skills and appropriate treatment.

Type A behavior and blood pressure during coronary artery bypass surgery.

&NA; Systemic hypertension has been reported as common during coronary artery bypass surgery. The coronary‐prone Type A behavior pattern has been associated with heightened reactivity of the sympathetic nervous system. Therefore, the possible relationships between the two was explored. Significant correlations were found between systolic blood pressure rise during surgery and interview ratings of overall Type A (p < 0.05), aggressive content (p < 0.01), and job commitment (p < 0.001). A statistically association was also found between diastolic pressure rise and the job commitment rating (p < 0.01). Significant correlations were still present after controlling for the role of physical predictors of blood pressure rise by statistical multiple regression analysis. The data suggest that patients with Type A behavior characteristics manifest an autonomic hyperactivity which is present under general anesthesia. This hyperactivity may contribute to the association of Type A behavior pattern and coronary heart disease.

Diagnosis and referral of workplace depression.

Objective: Effective treatment requires understanding of the many possible reasons for employees and patients to complain of “depression.” Methods: This process of differential diagnosis includes panic anxiety, thyroid and other medical conditions, as well as several distinct types of depression (including atypical depression and melancholia). Results: Much of workplace depression care can be delivered by occupational health and mental health professionals. Optimal treatment requires accurate and specific diagnosis, and focused care. And, some cases require urgent psychiatric referral, while less urgent referral is important for some others. Conclusions: Optimal diagnosis and specific treatment is a cost effective approach that saves money for employers, while helping employees.

Type A behavior and the thallium stress test

&NA; Several recent studies have examined the association between Type A personality and coronary artery disease (CAD) by coronary angiography. Most of these studies have reported a significant association. The present study is an attempt at further confirmation, using a new non‐invasive technique for measuring CAD. Subjects were 53 patients undergoing routine exercise stress tests with concomitant thallium‐201 myocardial perfusion studies. Five aspects of Type A behavior were assessed by the use of the Rosenman‐Friedman Semistructured Interview, and each was rated on a three‐point scale. Severity of CAD was independently estimated on a four‐point scale. Pearson correlation coefficients were separately computed for patients with and without reported history of myocardial infarction (MI). For 37 patients without reported MI, CAD severity was significantly correlated with Overall Type A (r = ‐0.53), Vocal Characteristics (r = ‐0.53), Job Involvement (r = ‐0.36) and Aggressiveness (r = ‐0.48), but not Time Urgency (r = ‐0.25). For 16 patients with reported MI, CAD severity was significantly correlated with Job Involvement only (r = +0.49). The data are consistent with the association of Type A personality and coronary atherogenesis, but may also reflect Type A psychological and physiological characteristics. Future studies may be able to examine these and other aspects of Type A behavior using this noninvasive technique in more diverse patient populations.

Carbon dioxide induction of panic anxiety in schizophrenia with auditory hallucinations

Panic is commonly co-morbid with schizophrenia. Panic may emerge prodromally, contribute to specific psychotic symptoms, and predict medication response. Panic is often missed due to agitation, impaired cognition, psychotic symptom overlap and limited clinician awareness. Carbon dioxide exposure has been used reliably to induce panic in non-psychotic panic subjects, but has not been systematically studied in schizophrenia. Eight inpatients with schizophrenia, recent auditory hallucinations, none preselected for panic, all on antipsychotic medication, received a structured Panic and Schizophrenia Interview (PaSI), assessing DSM-IV panic symptoms concurrent with paroxysmal auditory hallucinations. On that interview, all eight subjects reported panic concurrent with auditory hallucinations. At one sitting, subjects were exposed, in random order, to 35% carbon dioxide and to placebo room air, blinded to condition. All subjects experienced panic to carbon dioxide, one with limited symptoms. Only one subject panicked to placebo. One subject (one of only two without antipanic medication) had paroxysmal voices concurrent with induced panic. With added adjunctive clonazepam, that patient had marked clinical improvement and no response to carbon dioxide re-challenge. This first systematic examination offers preliminary evidence that carbon dioxide safely induces panic symptoms in schizophrenia. Panic may be prevalent and pathophysiologically significant in schizophrenia with auditory hallucinations.

Type A behavior and blood pressure during general surgery.

&NA; The Type A behavior pattern (TABP) has been demonstrated as a risk factor for the development of coronary heart disease (CHD). Psychophysiologic studies suggest that the TABP may be associated with autonomic hyperreactivity to a variety of stressors. Recent studies report an association of TABP with autonomic hyperreactivity in patients under general anesthesia for coronary artery bypass surgery. The present study did not find a significant correlation between the TABP and intraoperative rise in blood pressure for 44 noncardiac patients undergoing anesthesia for elective general surgical procedures. Suggestive associations were found in sub‐samples with family history of CHD or age greater than 60 years. Thus, the TABP may be correlated with heightened physiologic response under anesthesia only in selected populations.

Workplace mental health consultation: A primer of organizational and occupational psychiatry

Though there are only a few hundred psychiatrists who identify themselves as specialists in organizational and occupational issues, the need for psychiatric skills in the workplace has increased dramatically in recent years. Crucial issues include distressed employees, the effects of organizational structure and change, job stress, psychiatric disability, substance abuse, and violence in the workplace. It is important for general psychiatrists to become more conversant in work and workplace-related mental health issues. Use of an occupational history with all patients, and knowledge of organizational structures and function, are just two ways to become more aware of these matters. With business and government increasingly attentive to mental health benefits and systems, appropriate psychiatric focus on organizational and occupational concerns becomes ever more important.

Paranoid delusional disorder follows social anxiety disorder in a long-term case series: evolutionary perspective.

Social anxiety disorder (SAD) patients may have self-referential ideas and share other cognitive processes with paranoid delusional disorder (PDD) patients. From an evolutionary perspective, SAD may derive from biologically instinctive social hierarchy ranking, thus causing an assumption of inferior social rank, and thus prompting concerns about mistreatment from those of perceived higher rank. This naturalistic longitudinal study followed four patients with initial SAD and later onset of PDD. These four patients show the same sequence of diagnosed SAD followed by diagnosed PDD, as is often retrospectively described by other PDD patients. Although antipsychotic medication improved psychotic symptoms in all patients, those who also had adjunctive serotonin-specific reuptake inhibitors for SAD had much more improvement in both psychosis and social functioning. From an evolutionary perspective, it can be conjectured that when conscious modulation of the SAD social rank instinct is diminished due to hypofrontality (common to many psychotic disorders), then unmodulated SAD can lead to paranoid delusional disorder, with prominent ideas of reference. Non-psychotic SAD may be prodromal or causal for PDD.

Attachment and self-consciousness: A dynamic connection between schizophrenia and panic

INTRODUCTION Attachment theory offers an evolutionary explanation for the occurrence of panic states. The distance between a mother and child causes the sensation of fear. The experience of feared annihilation, an intense fear reaction (panic), is presented as a threat to the individuals cohesiveness, disrupting the mental representation of self-consciousness, specifically self-unity. Alterations in self-consciousness in schizophrenia are so important that they are mostly included among Kurt Schneiders first-ranked symptoms. HYPOTHESES Based on clinical trials, case reports, and brain imaging and pharmacological studies, a paradigm is proposed to explain the relationship between panic anxiety and psychosis. CONCLUSION The psychosis-anxiety pathophysiology explanation needs further investigation into the brain areas that integrate self-monitoring with fear areas, but it seems possible to note the importance of the anterior cingulate cortex.

Panic psychosis: paroxysmal panic anxiety concomitant with auditory hallucinations in schizophrenia

Kahn & Meyers has pointed to a link between classic paranoid schizophrenia and panic, suggesting a ‘‘panic psychosis’’ that is distinct from other schizophrenic diagnoses, much as psychotic depression is also distinct from schizophrenia. Veras et al. described a cognitiveaffective link between panic attacks and psychosis, pointing to the influence of the experience of helplessness on the symptoms of psychotic patients who experience highly intense auditory hallucinations and panic attacks. Freeman & Fowler and Ruby et al. described the importance of traumatic events as a common etiological element and connector between anxiety and psychosis. An important psychological contribution to psychiatric disorders is impaired psychological development during childhood. Infants and young children who experienced physical or psychological traumas during early development may be more susceptible to psychosis and panic anxiety in later life. In this case report, we highlight the importance of lifeime anxiogenic events as a trigger of paroxysmal psychotic episodes and an influence on hallucinatory content in a patient with schizophrenia and panic attacks. A 53-year-old woman had her life marked by reported difficulties in her family relationship. Her mother was strict, and frequently required religious ‘‘conversion’’ to her own practices as a price for her daughter’s wishes. Her father abused her mother in her presence, and she herself was sexually abused by him on one occasion. At 17, she developed physical and psychological symptoms of anxiety, consisting mainly of severe headaches. At 21, she was hospitalized due to worsening of those symptoms, retrospectively characterized as panic disorder according to DSM-5, characterized by short-term episodes of symptoms such as palpitation, derealization, and feeling of imminent death, despite absence of characteristic symptoms of agoraphobia. The patient was referred for psychiatric care and started on psychotropic medications. Since adolescence, the patient used alcohol and marijuana, typically in the company of men who sexually abused her when she was intoxicated. Her relationships have never been stable, and she started to believe that men only approached her to take advantage of her. At 33, she experienced her first hallucinations, voices that accused her of being ‘‘crazy, problematic, neurasthenic’’; worsening of these symptoms caused repeated hospitalizations. She was given a DSM-5 diagnosis of schizophrenia due to persistent hallucinations and religious delusions and development of marked negative symptoms such as blunted affect, apathy, social isolation, and cognitive impairments on memory and attention. Initially, her panic attacks were characterized by recurrent episodes of severe anxiety, even with no psychotic symptoms. With progression of the disorder, the patient started to experience paroxysmal anxiety followed by hallucinations with persecutory and punitive content. Her present crises are characterized by subtle, offensive voices that curse and voices that threaten her through ‘‘witchcraft,’’ accompanied by physical symptoms such as palpitations, shortness of breath, tremors, feeling of impending doom, and derealization. Such crises, for which she often resorts to self-injurious behaviors, are usually triggered on Fridays and weekends, when ‘‘everybody goes home’’ while she remains in the hospital, anguished by the realization that she is an abandoned hospital resident without any close family contact. The patient became more anxious and irritable when she learned she was pregnant by rape, although her harmful use of alcohol and drugs was also an influential factor in triggering anxiety symptoms. She was not able to raise the child, which was raised by her mother; this child, in turn, also became addicted to drugs during adolescence and began to live on the streets. The patient was often hospitalized intermittently, but ultimately became a full-time resident of the hospital after her mother’s death 3 years ago, when other family members could not take over her care. Since then, the subtle auditory hallucinations became frequent, to the point that the patient has pierced her eardrum by introducing multiple foreign objects into her ears during crises. Her punitive auditory hallucinations have made her focus on the traumatic framework of her life, and have been triggered by the revival of situations of aggression, invasion, and abandonment. A correlation between anxiogenic memories revived in crisis and onset of the break can be observed, highlighting that a multifactorial understanding of psychotic phenomena is required for their better management. It is clinically useful to examine the characteristics of these experiences, providing that some types of delusions or hallucinations may be a more severe manifestation of anxiety symptoms. Indeed, these patients may do far better when anti-panic medication is added to their antipsychotic and combined with optimal psychotherapy. In the reported case, although the patient did not tolerate augmentation with more than 1 mg/daily of clonazepam, after 12 weeks on psychotherapy and sertraline (increased from 50 to 150 mg/day), panic-hallucinatory episodes decreased and partial insight into psychotic symptoms developed. The antipsychotic dosage remained stable during the period.