Timothy L. Bayer

Situational and psychophysiological factors in psychologically induced pain

&NA; To investigate pain that occurs in the absence of painful stimulation, normal subjects were connected to a sham stimulator and were told that a headache could occur as a result of the electrical current they would receive. Half of the subjects who received this suggestion reported pain. The frequency and intensity of pain reports in a group which was given prior pain experience as a reference point in reporting pain and in a group which was exposed to a manipulation designed to reduce intentional deception were not significantly different from the pain reports of a group not exposed to these manipulations. The frequency of pain reports in subjects not connected to the sham stimulator but still asked to report pain was 25% which was significantly less than the frequency for subjects who were told there would be stimulation to the head. Pain ratings increased as the settings of the sham stimulator were increased. Subjects who reported pain had significantly fewer electrodermal responses to tones signaling them to prepare for a reaction time task. The results suggest that pain can be produced in the absence of peripheral stimulation. The pain does not appear to be due to intentional deception or the lack of a standard for comparison, but is strongly influenced by environmental cues. Psychophysiologically, pain responders were less attentive to signal stimuli.

Ethically justified clinically comprehensive guidelines for the management of the depressed pregnant patient

OBJECTIVE This article proposes ethically justified clinical guidelines for managing depressed patients during pregnancy. STUDY DESIGN We reviewed literature on depression and its consequences for pregnancy and related that literature to ethical principles. RESULTS The health effects of depression on the pregnant woman and her fetus cannot be managed without consideration of the chronic and variable impairment of autonomy that may result from the effects of depression on the pregnant womans decision-making capacity. CONCLUSION When the fetus is previable, recommendations concerning the disposition and prenatal diagnosis of the pregnancy should be nondirective, whereas strong treatment recommendations are justifiable if the pregnant woman has decided to continue her pregnancy and is severely depressed. After viability, directive counseling for fetal benefit is ethically justified. The guidelines focus on preventive ethics strategies to enhance the decision-making capacity of the depressed pregnant patient.

Ethically justified guidelines for family planning interventions to prevent pregnancy in female patients with chronic mental illness

OBJECTIVE: This article proposes ethically justified clinical guidelines for family planning interventions to prevent pregnancy in female patients. STUDY DESIGN: We reviewed literature on family planning and consequences of pregnancy in patients with chronic mental illness and related that literature to ethical principles. RESULTS: Patients with chronic mental illness are ethically unique because they have chronically and variably impaired autonomy. Existing guidelines and proposals for family planning interventions for mentally retarded patients are shown not to apply to such patients. CONCLUSION: Three sets of guidelines for three groups of patients, representing the continuum of chronically and variably impaired autonomy, are proposed: (1) a set of guidelines for patients who can achieve thresholds of autonomy, (2) a set of guidelines for patients irreversibly near thresholds of autonomy, and (3) a set of guidelines for patients irreversibly below thresholds of autonomy. These guidelines should contribute significantly to the quality of obstetric and gynecologic care for female patients with chronic mental illness.

The role of prior pain experience and expectancy in psychologically and physically induced pain

&NA; Cognitive theories regarding symptom formation suggest that environmental factors such as warnings of impending pain and earlier experiences with pain can lead to a cognitive schema in which pain is selectively monitored. This study evaluated the role of prior experience with pain in the development of expectancy induced somatoform pain. Subjects from two experimental groups were connected to a sham stimulator and told to expect a headache. One of these groups, the physical stimulation first group, was exposed to pain induction by ice water and by pressure prior to the sham stimulation. A second group, the sham stimulation first group, received the sham stimulation followed by the cold water and pressure pain induction techniques. Subjects in the physical stimulation first group showed significant increases in their pain reports as settings on the sham stimulator were increased. Significant increases were not noted in the sham stimulation first group. The two groups did not differ in the number of subjects reporting pain or the mean maximal pain reported during the sham stimulation. Duration of cold water tolerance and the time until the analgesic threshold level for cold water were significantly shorter in subjects who had the sham stimulation first. This study suggests that prior pain can influence the reactivity to external suggestion for pain but does not increase the frequency of pain reports. It does suggest that the selective monitoring induced during the sham stimulation may influence later pain behaviours as was seen during the cold water tolerance testing.

Weaving a tangled web: The psychology of deception and self deception in psychogenic pain

Accounting for the unusual economy of secondary gain or reinforcement, understanding abnormal illness behavior and evaluating for the role of the unconscious and primary gain are three important problems which complicate the understanding of psychogenic pain. These problems might be addressed in part by an examination of the experimental studies of the social psychology of deception of self and others. The forced compliance situation, in which subjects who lie for a certain level of compensation persist in telling the lie in other settings, is one of the best studied of these experimental situations. Ways in which this experimental work might apply to problems in understanding pain patients are explored. Possible applications of this research to treatment are discussed along with areas for further research.

Are We Teaching Psychiatrists to Be Ethical

The authors conducted a nationwide survey of ethics education during psychiatry residency. Of the 136 program directors and 95 chief residents responding, nearly all agreed that ethics should be a part of the core curriculum. Program directors reported that most programs (60%) did offer a formal seminar series or course. However, 26 programs (19%) had no planned discussion of ethics in any seminar and fewer than 30% of all programs held seminars on the issues considered most worthy of formal attention, including psychiatrist-patient sexual contact, confidentiality, and forced treatment. The discrepancy between what program directors and chief residents believe should be taught and what is actually being taught indicates a need to focus attention on the teaching of psychiatric ethics.

Clinical Implications and Management Strategies When Depression Occurs During Pregnancy

John H. Coverdale, MB ChB, Lauence B. McCullough, PhD, Frank A. Chervenak, MD and Timothy Bayer, MD Dr Coverdale is senior lecturer in the Department of Psychiatry and Behavioural Science at The University of AucWand, New Zealand. Dr McCullough is professor of medicine, community medicine, and medical ethics at Baylor College of Medicine, Houston, Texas and adjunct professor of ethics in Obstetrics and Gynecology at Cornell University Medical College, New York. Dr Chervenak is professor in the Department of Obstetrics and Gynecology ar Cornell University Medical College, New York, and Dr Bayer is assistant pmfessor in the D e p a m n t of Psychiatry and Behavioural Sciences at Baylor College of Medicine, Houston, Texas

Family planning needs of male chronic mental patients in the general hospital psychiatry clinic

We investigated the parenting history, contraceptive behavior, and contraceptive needs of 35 male chronic mental patients seen at an urban outpatient psychiatric clinic. Most patients had fathered children, but 60% of the children less than 16 years of age were not being reared by their biological father. Forty-one percent of the patients who had sexual intercourse during the preceding year and had not wanted children reported that they or their sexual partner had not used contraception at the time of last intercourse. Patients were reportedly at significant risk of fathering unwanted children and sexually transmitted diseases. Strategies for preventing unwanted pregnancies within this population are discussed.

Medical Students’ Attitudes on Specialist Physicians’ Social and Sexual Contact With Patients

To assess medical students’ attitudes toward social and sexual contact with patients by physicians from three medical specialties (internal medicine, obstetrics-gynecology, and psychiatry), 326 students were surveyed at one medical school and 239 students responded (response rate = 73.3%). Most students perceived that arranging to date and/or dating and genital sexual contact were not appropriate either during a patient visit or concurrent with ongoing treatment. However, as many as 20% of the male students and 3.5% of the female students said that genital sexual contact with patients concurrent with treatment was (sometimes or usually) appropriate, depending on the specialty. Significant gender differences were found in attitudes about physician-patient sexual contact. Genital sexual contact was also significantly less likely to be perceived as appropriate for psychiatrists, as might be expected, than for obstetrician-gynecologists and internal medicine specialists. These results are discussed in relation to current codes of ethics.

Evaluating the Evaluations of Psychiatry Residents

This survey assessed the perceptions of psychiatry residents and faculty about resident evaluations. Current residents, former residents, and faculty of a psychiatry residency program were asked about the value and effect of feedback in 15 specific areas and rated their preferences for evaluation methods. Residents and faculty most valued feedback that addressed practical clinical skills. Evaluations reportedly improved skills in half of the areas surveyed. Most respondents preferred face-to-face evaluations from individual faculty. This study confirms the value of resident evaluations addressing clinical skills, but it highlights discrepancies in expectations and merits of several methods of evaluation.