Terry McMahon

Spirituality and Religiousness and Alcohol/Other Drug Problems

SUMMARY Spirituality and religiousness are multidimensional concepts in their philosophical, theological and healthcare connotations. Both concepts have been discussed extensively in the literature describing the origins, diagnosis and treatment of alcohol and other drug problems. Recovery communities, especially Alcoholics Anonymous, have been studied in terms of their ongoing conversations about spirituality and religiousness in the process of recovery. The contributions of authors, such as James, Tiebout, Kurtz, Whitfield, Brown, Miller, Morgan and White to an understanding of those concepts are highlighted.

Radiation damage to the brain: Neuropsychiatric aspects

Although radiation necrosis of the brain is a recognized complication of irradiation of the central nervous system, the psychiatric aspects of this phenomenon are less well defined. Two cases of radiation necrosis in which psychiatric symptoms were a prominent part of the clinical picture are presented. Factors that determine the evolution and clinical presentation of radiation necrosis are reviewed. In particular, the role of the consultation psychiatrist in the diagnosis and management of such patients is discussed.

Obsessive-Compulsive Disorder with Suicide Obsessions in a First Responder without Previous Diagnosis of OCD or History of Suicide Attempts

Obsessive-compulsive disorder (OCD) is a distressing and often debilitating disorder characterized by obsessions, compulsions, or both that are time-consuming and cause impairment in social, occupational, or other areas of functioning. There are many published studies reporting higher risk of suicidality in OCD patients, as well as studies describing increased risk of suicidality in OCD patients with other comorbid psychiatric conditions such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Existing case reports on OCD with suicide as the obsessive component describe patients with long standing diagnosis of OCD with suicidal ideations or previous suicide attempts. This report describes the case of a 28-year-old male, who works as a first responder, who presented with new onset symptoms characteristic of MDD and PTSD, with no past history of OCD or suicidality who developed OCD with suicidal obsessions. Differentiating between suicidal ideation in the context of other psychiatric illnesses and suicidal obsessions in OCD is critical to ensuring accurate diagnosis and timely provision of most appropriate treatment. The combination of exposure and response prevention therapy and pharmacotherapy with sertraline and olanzapine was effective in helping the patient manage the anxiety and distress stemming from the patients OCD with suicidal obsession.

A Descriptive Study of a Spirituality Curriculum for General Psychiatry Residents

ObjectiveThe study collected data on the attitudes of residents toward religion and spirituality in their practice after taking part in a 3-year curriculum on spirituality during their residency.MethodsThis is a descriptive, single-site study with psychiatry residents as subjects. A questionnaire was given to the residents at the end of their third year of residency (N = 12).ResultsThe responses heavily endorsed the religiousness/spirituality curriculum to be helpful and meaningful. Residents consider addressing spiritual and religious needs of patients to be important (76.9%) and appropriate. For majority of the residents (69.2%), there is strong agreement in the management of addictions having spiritual dimensions. Residents also strongly agreed that treatment of suffering, depression, guilt, and complicated grief may require attention to spiritual concerns (92–100%).ConclusionRegardless of cultural or religious background, the residents endorsed the curriculum as a worthwhile experience and increased their appreciation of the place of spirituality in the holistic care of patients with psychiatric conditions.

Bipolar II Disorder Masked by Substance Use

To the Editor: According to the DSM-5,1 bipolar II disorder is a mood disorder characterized by at least 1 hypomanic episode and at least 1 major depressive episode. The patient with hypomania has elevated mood, or irritable mood, present nearly every day for at least 4 consecutive days.1 It is not uncommon for these patients to self-medicate with alcohol,2 and accurate diagnosis of bipolar II disorder is often delayed.3 Here we present a case of bipolar II disorder that was undiagnosed for an extended period of time. The patient was self-medicating with alcohol and relapsed every time after discharge until a mood stabilizer was added. Case report. Mr A is a 25-year-old graduate student who moved from his hometown to a university town to complete graduate school. He was doing well in school. He never used to drink alcohol but gradually started drinking heavily. Prior to his first admission to the hospital, he consumed 1.5 liters of whiskey and 12 beers in 3 days and then presented himself to the emergency room (ER) for detoxification (“detox”) with a blood alcohol concentration of 100 mg/dL. He denied any mood symptoms or suicidal or homicidal ideations. He was detoxed with lorazepam starting at 1.5 mg 3 times a day, gradually tapered down to 0.5 mg daily, then lorazepam was discontinued. He tolerated the detox well. Mr A reported no previous psychiatric diagnosis or hospitalizations. There was no family history of psychiatric illnesses, other than that his father abused alcohol occasionally. He reported trouble sleeping. He also reported some depression at the end of detox, but we thought it would be easier to assess this condition on an outpatient basis once he was sober for a period of time. Mr A was discharged with a DSM-5 diagnosis of substance-induced mood disorder with depressed mood and a prescription for trazodone 100 mg, his only psychiatric medication. After detox, Mr A was provided with resources to follow up at Alcoholics Anonymous (AA) meetings. Although Mr A had followed up with outpatient psychiatry, we saw him in the ER once again 3 months later with a similar presentation. Mr A’s blood alcohol concentration was 115 mg/dL. He reported that during outpatient follow-up, he was prescribed 150 mg of bupropion extended release for depression. After that initial appointment, however, he did not like how the medication made him feel as it did not address his depression. The bupropion was stopped after 1 week. He was then changed to citalopram that was initially started at 5 mg daily. He was on this dosage for 2 to 3 weeks and then titrated to 10 mg daily with a plan to titrate further to 20 mg and later to 40 mg daily. He thought it helped with his depression. He also took clonazepam on an as-needed basis, 0.5 mg tablet 2 or 3 times a week. He stated that his anxiety improved with clonazepam and citalopram. Gradually, he was tapered off the clonazepam. Mr A reported that he remained sober for 2 months and then relapsed by drinking 750 mL of whiskey per day at which time he again presented for detox, and his hospital course followed the same pattern as before. He had no withdrawal symptoms during this second admission, and we discharged him on citalopram 40 mg daily. No one in his graduate program was aware that he had been admitted twice now for alcohol detox and depressive symptoms. He continued to follow up on an outpatient basis. After 6 months, we saw the patient again in the ER. This time he was accompanied by his roommate, who was also a student in the same program. Mr A told us he had recently been diagnosed with leukemia and was feeling suicidal. He had never reported suicidal ideation before. His blood alcohol level was 400 mg/dL, and he continued to deny withdrawal symptoms from alcohol. He reported he had been sober for 1.5 months after his last discharge and then again relapsed. He reported going to the AA meetings. Prior to the ER visit, the Dean of Student Affairs visited him at his apartment because he was concerned that Mr A was not attending classes. The patient reported he was on an oral chemotherapeutic agent, cyclophosphamide, and recently had sporadic attendance at school. He had missed quite a bit of class and was behind in his studies; he stated he was considering a leave of absence or transferring to his hometown to seek treatment for the leukemia and to be nearer to his family. He reported anxiety since he had been in school, and this worry kept him up at night. Mr A told us citalopram was still helping. We asked for a release to speak to his oncologist, but he refused. He did however sign a release for us to speak with his parents and the Dean of Student Affairs. We noted this was the third presentation in a similar manner in 9 months. He again tolerated the detox well and again was ready to leave in 3 to 4 days. We obtained collateral information from the Dean of Student Affairs at the graduate program and from the parents and friends, who subsequently acknowledged that Mr A was never diagnosed with leukemia. Rather, it was a stepdad who was diagnosed with leukemia. The patient noted that he reported this as he thought it would facilitate his leaving school and returning home. Also, the family reported some anger outbursts and mood swings, which increased our suspicion index for a diagnosis of bipolar disorder. Mr A reported that he was bingeing on alcohol, most likely self-medicating. Thus, upon obtaining all this information, we decided to taper off his citalopram. He was taking 40 mg daily, which we gradually decreased and discontinued and started him on olanzapine 5 mg at bedtime. The patient throughout his stay in the hospital reported that he was feeling well and wanted to leave. However, eventually he decided to remain on a voluntary basis. Gradually, Mr A started sleeping better. He tolerated the medication well. He became more interactive with the staff and started going to group therapy. We also called his mother, and, before discharge, had a family meeting with the mother, the Dean of Student Affairs, and the patient together. We solidified the plans for him to take a leave of absence from school and return to his hometown for further care and follow-up in a chemical dependency rehabilitation program there. We discharged Mr A with a DSM-5 diagnosis of bipolar II disorder. The patient has not come back to the ER for the past 6 to 7 months, and he completed a chemical dependency rehabilitation program. We conclude that the medication regimen stabilized the patient. Our patient was a poor historian. He felt good and ready to leave the hospital every time alcohol detoxification was completed. Extensive collateral history from his dean and other students from his graduate program helped us arrive at the final diagnosis. Olanzapine is an atypical antipsychotic indicated for bipolar II disorder to control the irritability,4 to stabilize the disease course, and as an effective treatment for bipolar depression.5 Bupropion, a dopaminergic-noradrenergic reuptake inhibitor, and citalopram, a serotonergic reuptake inhibitor, are used for management of depression. Antidepressants can also cause mood elevation in bipolar II disorder, and monitoring is warranted if these agents are used.6 This case report demonstrates that often patients with bipolar disorder, especially bipolar II disorder, are undiagnosed. They may tend to self-medicate with alcohol and other substances. It is extremely important to get a good collateral history to understand these patients and monitor their status when sober. Addition of olanzapine in this case stabilized the patient and prevented further frequent visits for alcohol detoxification and depression.

Oral Hydrocodone Induced Acute Psychosis in an Adult Male: A CaseReport.

Hydrocodone is an opioid derived from codeine, which has been used for many years as a short-acting analgesic combined with acetaminophen (or less commonly ibuprofen). Common and severe psychiatric side effects included include mental depression, mood changes, hallucination, delirium, somnolence, agitation, and dysphoria. This is a report of a particular case that resulted in acute psychosis after immediately starting on Hydrocodone because of back pain in a 35 year old male, with no past psychiatrist history. The patient returned to his baseline mental status after the hydrocodone was discontinued. Earlier research was published about these symptoms are the ones where hydrocodone was used in combination with other drugs, but in this unique case the patient was not any other medication except the hydrocodone. This unique case showed an association between the short term use of hydrocodone and development of psychiatric symptoms. Recognition of these uncommon psychiatric side effects of hydrocodone usage will allow for early recognition of their etiology, symptoms and treatment. Psychotic symptoms induce by analgesics are not a common condition but they still remain under diagnosed and untreated.

A Case of Dissociative Amnesia With Dissociative Fugue and Treatment With Psychotherapy.

To the Editor: Dissociative fugue is a subtype of dissociative amnesia. Per the DSM-5, dissociative amnesia with dissociative fugue is the “purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information.”1(p156) As the name fugue implies, the condition involves psychological flight from an overwhelming situation.2 The onset is usually sudden and predicated by a traumatic or stressful life event.3 Severely traumatized patients with a history of sexual abuse are highly likely to use dissociation as a primary psychological defense.4 The prevalence of dissociative fugue disorder is very low, estimated at 0.2%.5 It becomes prudent for health care professionals to make themselves aware of this disorder to prevent misdiagnosis and unnecessary investigations. This case shows a need for early diagnosis and psychological support for these patients in a timely manner. Case report. Mr A, a 20-year-old man with no past medical and psychiatric history, was brought to the emergency department by his mother (Monday). He had difficulty remembering things for the past 2 days. According to his mother, he was doing fine until 2 days ago (Saturday). The next day (Sunday) when Mr A was at work, the mother got a call from Mr A’s supervisor at his office stating that he did not recognize his friends and that he was asking what he was supposed to do at work. Considering the situation, Mr A’s supervisor sent him home at 9:30 am. When he reached home, Mr A failed to recognize his mother, dog, siblings, and belongings. He slept until 1 pm on Sunday, woke up, and left the house without telling anybody. Later in the evening, his mom got concerned and started calling and sending him text messages, which went unanswered. She called his friends, and they were able to locate him in the parking lot of a convenience store. Mr A did not recall how or why he came to the parking lot. At admission to the inpatient psychiatry unit, Mr A’s urine drug screen tested negative for any illicit substances. Findings of a head computed tomography scan and magnetic resonance imaging were within normal limits. Results of other routine investigations including complete blood count, complete metabolic profile, ammonia level, B12 level, thyroid function tests, and liver function tests were also within normal limits. The human immunodeficiency virus and rapid plasma reagin tests were also negative. When asked how he was doing, Mr A said, “confused.” His mood was “okay,” and his affect seemed flat and somewhat guarded with no concern for his memory loss (la belle indifference). He was oriented in time, place, and person but had impaired attention and concentration at the time of the examination. The immediate recall was intact, but he was unable to provide important details pertaining to his life. He denied hallucinating and had no intentions to harm himself or anyone else. Mr A scored 27/30 on the Mini-Mental State Examination6; he lost 3 points in the attention domain. Mr A had slept a lot in the last 2 days. His mom denied symptoms of depression, anxiety, mania, and/or psychosis. He had no history of seizure or head trauma. When asked about any recent stressor, the mother recalled that about a week ago Mr A had broken up with his partner. They were in a relationship for about 1 year, but his mom did not notice emotional changes in Mr A after the breakup. The family was not opposed to Mr A’s sexual orientation. During hospitalization, the neurology department was consulted, and after complete neurologic workup, including electroencephalogram and brain imaging, the neurology team ruled out organic causes of transient amnesia. Malingering was also an important differential diagnosis; therefore, psychology consultation was requested. The results of the Miller Forensic Assessment of Symptoms7 and Coin-In-Hand test8 showed no evidence of feigned symptoms. The Personality Assessment Inventory9 showed no evidence of overreporting. During his psychiatric inpatient stay, Mr A continued to have no autobiographic memory. The treatment team did not force Mr A to recall the stressor that might have led to the dissociative amnesia and fugue. The family was allowed to have conversation with Mr A and show him the family photo album, but at his ease. Throughout the hospital course, Mr A was calm, and the memory loss did not seem to bother him. It was evident that he was forming fresh memories and could recall most events after he was found in the parking lot of the convenience store, which is an important feature of dissociative amnesia, in which the patient has no anterograde amnesia.10,11 After ruling out other causes of transient amnesia, Mr A was diagnosed with dissociative amnesia with dissociative fugue (DSM-5 criteria) and was discharged with close psychotherapy follow-up. Mr A was followed as a psychotherapy patient in our outpatient clinic. During the first few sessions, he continued to have difficulties remembering events from his past, stating, “I am a new person.” However, he did not have any problem with forming new memories (no anterograde amnesia). The psychotherapy team used persuasion and suggestive techniques and tried to provide a sense of safety and security. He was given a home assignment to look at his family photo album and review details of his job with his coworker. Simultaneously, the psychotherapy team continued supportive psychotherapy and empathic validation. Initially, Mr A felt good about being a “brand new person” so that he did not have to think about the painful aspect of the past. After multiple sessions, Mr A started to recall memories about his past. He talked about how “painful” his previous relationship was when he broke up with his partner because Mr A had been unfaithful. This incident happened 2 weeks prior to his admission to the inpatient unit. His partner refused to continue the relationship, even after several attempts at reconciliation by Mr A. He said he felt “numb” when he woke up on Sunday morning. Mr A said, “I lost everything, shame, guilt, being rejected and wished to be a new man,” so that he could be accepted by his ex-boyfriend. After a series of sessions over a period of 12–16 weeks, Mr A continued to show progress by returning to his job and started remembering details from his past. At present, the diagnosis of dissociative amnesia with dissociative fugue depends on the identification of severe retrograde amnesia in the absence of anterograde amnesia or other cognitive impairments, and the absence of a causative brain lesion.12 As depicted in this case, the most consistently successful treatment appears to be removal of the patient from threats; providing psychological support, gentle suggestion and cuing; and “reteaching.” Empathy rather than skepticism is essential to create a safe and effective environment for better therapeutic alliance.

WHO Global Strategy to Reduce the Harmful Use of Alcohol (2010)

The global harm associated with the use of alcohol is one of daunting proportions and a problem that has been addressed by the World Health Organization (WHO) over many years. The extent of the problem has been well documented and is supported by epidemiological and scientific data (WHO, 2004, 2007, 2010). In 2002, 2.3 million deaths, 3.7% of global mortality, were attributed to alcohol with a significant portion of the deaths being those of young people (WHO, 2004). Among the most modifiable and preventable risk factors for major noncommunicable diseases, including mental health, the misuse of alcohol ranks fourth. In addition, alcohol adds to the health burden already associated with communicable diseases, with the toll being especially heavy with tuberculosis and HIV/AIDS (WHO, 2010). The burden of disease associated with alcohol is global, but a growing burden in lower income and developing countries is of special concern. In these lower income countries consumption is increasing and the absence of effective public policy and treatment resources, together with intense and often underregulated promotion and advertising by the beverage industry, compounds the problem (Babor, 2010; Bakke & Endal, 2010). The WHO strategy, addressing the global harm caused by alcohol, embodies an overall concern together with objectives and identified target areas to address this concern (Babor, Zeigler, & Chun, 2010; WHO, 2010). In the past decade many professional organizations have expressed concern about

The Psychiatry Clerkship: Use of the “Split” Rotation in Clinical Training

Psychiatry clerkships traditionally place students on a single site for the duration of the rotation. This article describes an eight-week training model in which students rotate through two different sites during their clerkship. On one “track,” students spend four weeks each on an inpatient mental health unit and consultation-liaison service. On the other “track,” students spend four weeks each on an inpatient chemical dependency unit and an outpatient psychiatry service. The rationale for this split rotation is described and the “tracks” are compared via students’ performance on clinical evaluations, oral exams, and a written exam (NBME Subtest in Clinical Psychiatry). Based on these outcome variables, both tracks appear to provide comparable and effective clinical training for junior clerks.