Randy A. Sansone

Disruptive Behaviors in the Medical Setting and Borderline Personality

Objective: Borderline personality disorder (BPD) is characterized in the DSM by anger. While previous studies have examined various types of externalized aggression and violence among individuals with BPD, we are aware of no investigations of disruptive behaviors perpetrated by patients with BPD in medical settings—the focus of the present study. Method: Using a cross-sectional, consecutive sample of internal medicine outpatients from a resident provider clinic, we surveyed 397 participants regarding 17 disruptive behaviors related to medical personnel and assessed BPD using two self-report measures, the BPD scale of the Personality Diagnostic Questionnaire-4 (PDQ-4) and the Self-Harm Inventory (SHI). Results: A statistically significantly greater proportion of respondents who exceeded the clinical cut-off scores for BPD on both the PDQ-4 and SHI endorsed at least one form of disruptive behavior. However, there were no differences between participants with versus without BPD symptomatology regarding the number of different forms of disruptive behaviors after that initial threshold of one such behavior was reached. Several specific disruptive behaviors were reported more often in those with BPD symptomatology (i.e., yelling, screaming, verbally threatening, and refusing to talk with medical staff as well as talking badly about medical staff to the patients friends and family). Conclusions: BPD appears to be associated with a greater likelihood of disruptive behaviors in the medical setting, but not physical threat.

The abuse of prescription medications: borderline personality patients in psychiatric versus non-psychiatric settings.

Objective: In this study, the prevalence of prescription substance abuse among those with borderline personality symptomatology was examined in a large cohort of respondents who participated in one of 13 prior research projects. Method: The entire cohort (N = 1039) was divided into 3 sub-samples: a psychiatric sample (n = 440), a predominantly primary care sample (n = 599), and an internal medicine sample (n = 332; i.e., a well-defined subset of the predominantly primary care sample that consisted of only internal medicine outpatients seen at one location). The borderline personality scale of the Personality Diagnostic Questionnaire (PDQ), either the revised (PDQ-R) or fourth (PDQ-4) version, was used to diagnose all participants either with or without borderline personality. One item from the Self-Harm Inventory, “Have you ever intentionally, or on purpose, abused prescription medication?,” was then used in the subsequent analyses. Results: Among the psychiatric, predominantly primary care, and internal medicine subsamples, the prevalence rates of prescription medication abuse in those diagnosed with borderline personality according to the PDQ were 46.9%, 46.2%, and 11.5%, respectively. In all subsamples, those with borderline personality were statistically significantly more likely to abuse prescription medication than those without the disorder. For example, borderline patients in the psychiatric sample were twice as likely to abuse prescription medications, in the predominantly primary care sample 4 times as likely, and in the internal medicine only sample nearly 6 times as likely. Conclusions: Regardless of setting, patients with BPD are at great risk for the abuse of prescription medications.

Road rage: relationships with borderline personality and driving citations.

Objective: The objectives of this study were to determine: (1) the prevalence of self-reported road rage in a primary care sample; (2) the relationship, if any, between road rage and borderline personality disorder (BPD); and (3) whether those with road rage have a greater prevalence of different types of driving citations compared to those without road rage. Method: Using a consecutive, cross-sectional sample of primary care outpatients, we surveyed 419 individuals. Results: The prevalence of self-reported road rage in this sample was 35.3%. BPD was significantly more prevalent among participants with road rage (24.8% vs. 9.8%). Compared to those without road rage, those with road rage reported statistically significantly higher numbers of different types of driving citations, including moving and non-moving violations, as well as having had a drivers license suspended. There were no differences between the groups with regard to vehicular crashes or driving while intoxicated. Conclusions: About one-third of individuals reported road rage. The prevalence of BPD was significantly higher among those with road rage compared to those without road rage, and is likely to be one of the contributory variables to reckless driving. Individuals who reported road rage appear to be less disciplined drivers and are subject to more types of driving citations, although they do not report greater rates of vehicular crashes or driving while intoxicated.

QTc prolongation due to propranolol overdose.

Prolongation of the QTc interval (a QT interval that has been corrected for heart rate) increases the risk of cardiac arrhythmias, and is an important topic with regard to psychotropic medication. Several typical (e.g., pimozide, thioridazine, haloperidol) and atypical (e.g., sertindole, ziprasidone) antipsychotics may cause QTc prolongation [1] as well as some antidepressants in overdose (e.g., citalopram) [2]. We wish to present a case of QTc prolongation that was due to an overdose of propranolol (used in psychiatry for the treatment of akathisia, lithium-induced tremor, and performance anxiety; used in medicine for hypertension and congestive heart failure).

Concerns about Career Stigma by Military Parents of Children with Psychiatric Illness

Stigma is known to have deleterious effects on individuals with psychiatric disorders as well as their family members. In this study, we examined stigma with regard to career concerns among active duty members of the Air Force with children who have psychiatric disorders. Albeit a weak relationship, a bivariate correlation confirmed a significant relationship between the childs mental health utilization (i.e., severity of illness) and participants concerns about the potential effects on their military (r = 0.423, p < 0.01), as well as civilian (r = 0.353, p < 0.01), careers. These findings indicate that among military members with children who have psychiatric disorders, illness severity significantly relates to concerns about the impact of stigma on careers, particularly military careers.

Being bullied in childhood, and pain and pain perception in adulthood

Background and Aims: While a number of negative health outcomes have been associated with bullying in childhood, we are not aware of any studies examining relationships between bullying in childhood, and pain symptoms and pain perception in adulthood – the focus of the present study. Methods: Using a cross-sectional consecutive sample and a self-report survey methodology, we examined among 243 primary-care outpatients a history of being bullied in childhood (yes/no) in relationship to three pain ratings (now, past month, past year) and catastrophic thoughts and feelings about pain as assessed by the Pain Catastrophizing Scale (PCS). Results: Being bullied in childhood was statistically significantly associated with present pain ratings (p < .001) as well as pain ratings over the past month and the past year (p < .01), and with the total score on the PCS as well as each of its sub-scales (i.e. rumination, magnification, helplessness) (p < .001). Conclusions: Being bullied in childhood is associated with higher reported levels of pain at various time points as well as greater levels of self-reported catastrophic thoughts and feelings about pain. Importantly, the methodology of this study does not allow for the examination of a causal relationship.

BORDERLINE PERSONALITY AMONG OUTPATIENTS SEEN BY A PAIN MANAGEMENT SPECIALIST

Objective: We examined the prevalence of borderline personality disorder among a sample of outpatients who were being initially evaluated by a pain management specialist. Method: Using two self-report measures for borderline personality disorder, the borderline personality scale of the Personality Diagnostic Questionnaire-4 (PDQ-4) and the Self-Harm Inventory (SHI), we explored prevalence rates of this Axis II disorder in a sample of 117 participants. Results: According to the PDQ-4 and the SHI, 9.4% and 14.5% of participants, respectively, met the criteria for borderline personality, with 6.8% meeting criteria on both measures. Conclusions: In this insured population of pain patients, rates of borderline personality, as determined by both measures, were comparable to rates of borderline personality in the general population.

The relationship between childhood trauma and medically self-sabotaging behaviors among psychiatric inpatients

Objective: This study was designed to explore the relationship between five forms of childhood trauma and medically self-sabotaging behaviors (i.e., the intentional induction, exaggeration, and/or exacerbation of medical symptoms). Method: Using a cross-sectional sample of convenience, 120 psychiatric inpatients were surveyed about childhood sexual, physical, and emotional abuses, the witnessing of violence, and physical neglect, as well as 19 medically self-sabotaging behaviors (i.e., intentional behaviors that represent attempts to sabotage medical care). Results: As expected, in this sample there were high prevalence rates of trauma (62.5% emotional abuse, 58.3% witnessing of violence, 46.7% physical abuse, 37.5% sexual abuse, 28.3% physical neglect). Simple correlations demonstrated statistically significant relationships between sexual abuse and physical neglect and medically self-sabotaging behaviors. Using multiple regression analysis, only physical neglect remained a unique predictor of medically self-sabotaging behaviors. Conclusions: These findings indicate that among psychiatric inpatients there appears to be a relationship between physical neglect in childhood and the generation of medically self-sabotaging behaviors in adulthood. Perhaps physical neglect in childhood contributes to the generation of somatic behaviors in adulthood for the purpose of eliciting caring responses from others.

Physician compliance with colon cancer screening.

cm, and his symptoms had improved; 12 wk after that he was asymptomatic and a CT scan showed complete resolution of the peripancreatic fluid collection. Drug-induced pancreatitis has been associated with sulfonamide derivatives. Case reports of pancreatitis have been associated with celecoxib (1, 2), which also has a sulfa moiety, as well as traditional nonsteroidal anti-inflammatory drugs without sulfa moieties (3, 4). In this case, other likely causes of acute pancreatitis (alcohol ingestion, cholelithiasis) were excluded. To our knowledge there have been no reports of acute pancreatitis associated with cyclobenzaprine, diazepam, or drugs similar to them. Thus, given the temporal relationship, we suspect that this case of acute pancreatitis was associated with the ingestion of rofecoxib. Although rofecoxib does contain a sulfur atom in its structure, it does not have a sulfonamide moiety, excluding a sulfonamide allergic reaction. The role of prostaglandins in acute pancreatitis is still controversial (5). In one animal model of sodium toracholate– induced acute pancreatitis, indomethecin decreased levels of local prostaglandins and increased mortality (6). Although not conclusive, these and other data support the notion that selective and nonselective nonsteroidal anti-inflammatory drug– induced pancreatitis may be a physiological consequence of the mechanism of action of this drug class. The rarity of this complication of a widely used medication suggests that host genetic factors play an important role. Nevertheless, this case report, put into context of the medical literature, suggests rofecoxib should be added to a growing list of selective and nonselective cyclooxygenase inhibitors that have been associated with acute pancreatitis.

History of childhood trauma and disruptive behaviors in the medical setting.

Abstract Objective. In this study, we examined relationships between five types of childhood trauma and 17 disruptive behaviors in the medical setting. Methods. Using a cross-sectional consecutive sample of 394 internal medicine outpatients, we surveyed participants about five types of childhood trauma (i.e. witnessing of violence, physical neglect, emotional abuse, physical abuse, and sexual abuse) and 17 disruptive behaviors in the medical setting (e.g., yelling, cursing, threatening medical personnel). Results. Initial correlations indicated relationships between four of the five forms of childhood trauma and the number of different disruptive behaviors endorsed. However, using multiple regression analysis, only witnessing violence and physical abuse remained independent predictors of disruptive behaviors in the medical setting. Conclusions. Individuals with childhood histories of witnessing violence and/or physical abuse are at-risk for perpetrating various disruptive behaviors in the medical setting.