Xavier F. Jimenez

Biomarkers in the diagnosis and study of psychogenic nonepileptic seizures: A systematic review

OBJECTIVE Video electroencephalography (vEEG) is the gold-standard method for diagnosing psychogenic nonepileptic seizures (PNES), but such assessment is expensive, unavailable in many centers, requires prolonged hospitalization, and many times is unable to capture an actual seizure episode. This paper systematically reviews other non-vEEG candidate biomarkers that may facilitate both diagnosis and study of PNES as differentiated from epileptic seizures (ES). METHODS PubMed database was searched to identify articles between 1980 and 2015 (inclusion: adult PNES population with or without controls, English language; exclusion: review articles, meta-analyses, single case reports). RESULTS A total of 49 studies were examined, including neuroimaging, autonomic nervous system, prolactin, other (non-prolactin) hormonal, enzyme, and miscellaneous marker studies. Functional MRI studies have shown PNES is hyperlinked with dissociation and emotional dysregulation centers in the brain, although conflicting findings are seen across studies and none used psychiatric comparators. Heart rate variability suggests increased vagal tone in PNES when compared to ES. Prolactin is elevated in ES but not PNES, although shows low diagnostic sensitivity. Postictal cortisol and creatine kinase are nonspecific. Other miscellaneous biomarkers (neuron specific enolase, brain derived neurotropic factor, ghrelin, leptin, leukocytosis) showed no conclusive evidence of utility. Many studies are limited by lack of psychiatric comparators, size, and other methodological issues. CONCLUSION No single biomarker successfully differentiates PNES from ES; in fact, PNES is only diagnosed via the negation of ES. Clinical assessment and rigorous investigation of psychosocial variables specific to PNES remain critical, and subtyping of PNES is warranted. Future investigational and clinical imperatives are discussed.

Attachment in medical care: A review of the interpersonal model in chronic disease management:

Objective Patient–physician interaction is continually examined in an era prioritizing patient-centered approaches, yet elaboration beyond aspects of communication and empathy is lacking. Major chronic conditions would benefit tremendously from understanding interpersonal aspects of patient–physician encounters. This review intends to provide a concise introduction to the interpersonal model of attachment theory and how it informs both the patient–physician interaction and medical outcomes in chronic care. Methods A narrative review of the theoretical, neurobiological, epidemiological, investigational, and clinical literature on attachment theory and its impact on medical outcomes was conducted, utilizing a variety of key words as searched on PubMed database. Studies and reviews included were of a variety of sources, including textbooks and peer-reviewed journals. Reports in languages other than English were excluded. Results Measurable, discrete attachment styles and behavioral patterns correlate with poor medical outcomes, including nonadherence in insecure dismissing attachment and care overutilization in insecure preoccupied attachment. Furthermore, insecure dismissing attachment is associated with significant mortality. These variables can be easily assessed, and their effects are reversible, as evidenced by collaborative care outcome data. Discussion Attachment theory is useful a model with application in clinical and investigational aspects of chronic illness care. Implications and guidelines are explored.

Capacity Consultation and Contextual Complexities: Depression, Decisions, and Deliberation.

Consultation psychiatrists are often thrust into complex ethical and psychosocial situations in the determination of patients’ decision-making capacity (DMC) to refuse vital interventions, including lifesustaining treatment (LST). Although some medical systems are equippedwith robust clinical ethics and palliative care services, often a consultation psychiatrist is tasked with weighing the totality of medical, ethical, social, familial, and economic circumstances affecting DMC. Herein, we present a layered case simultaneously informed by a host of competing factors, including but not limited to patients’ preferences, medical uncertainty, legal obligations, family concerns, physician discomfort, and psychiatric illness. A critique of both simplistic DMC assessment approaches and principlebased ethical analysis is articulated, and an alternative approach (the “four quadrants approach”) to such contextual complexities is offered.

Empathic failures from the patient perspective: validation in the acute setting

O ne widely accepted definition of empathy involves both an understanding of patients’ experiences, concerns and perspectives as well as an ability to communicate this understanding to patients.5 This implies that in order for a patient to experience the benefits of being cared for by an empathic physician, the physician must also be an effective communicator who successfully conveys understanding and validation. But communication breakdown is rampant in medicine; a recent study comparing a self-rated measure of empathy in medical students with a patient-rated empathy tool demonstrated consistently higher self-rating when compared with scores given by patients,1 indicating a gap between physician intention and patient perception.

Teaching a Neuromedical-Contextual Approach to Psychosomatic Medicine

The practice of psychosomatic medicine in the general hospital setting can be challenging, particularly for the inexperienced trainee. Guidance for how to approach a psychiatric consultation can be nonspecific or lacking altogether. In response, we offer a pedagogical model that emphasizes patient-specific neurological, medical, and contextual variables. A stepwise, “ABC” approach to psychiatric consultation is elaborated, beginning with collection of critical history (“Admission, Background, Consultation Question”), followed by both patient encounter (“Appearance, Behavior, Context”) and actual patient examination (“Arousal, Brain/Body, Cognitive Assessment”), ultimately informing any given case formulation. Multiple clinical vignettes illustrate this approach and are offered for educational purposes in dissemination to trainees.

Medical countertransference and the trainee: identifying a training gap.

Objective. Although consultation-liaison (CL) psychiatrists are implicitly expected to recognize and consider interpersonal dynamics in clinical settings when offering recommendations, few guiding principles have been established, strongly suggesting the presence of a training gap. Methods. Trainees in psychiatry residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) were invited to complete an Internet-based, 20-item, Likert scale questionnaire assessing practices and opinions concerning countertransference management and training. Results. Of 192 respondents, 162 (84%) reported having participated in a rotation on the CL service for at least some period of time and were eligible to complete the survey; 136 (71%) reported having completed at least 2 months of CL rotations. Approximately 80% identified a frequent need to address countertransference reactions when working with primary medical/surgical teams, but less than a quarter reported doing so regularly. The motivation for addressing such issues in over half of the respondents was the belief that it would be “clinically beneficial” to patients, although 40% of respondents also feared that this practice could “worsen the relationship between the CL consultant and the primary team.” Regarding training, 95% of respondents felt didactics addressing counter-transference would be “clinically beneficial”; however, three fifths of the respondents reported that “very few” to none of their didactics explored this issue. Conclusions. Results of this study suggest that discrepancies exist between trainee perceptions of the utility of countertransference management in CL psychiatry and actual training in this area. The authors discuss possible explanations for these discrepancies and advocate for the establishment of formal guidelines in training CL residents in such aptitudes. (Journal of Psychiatric Practice 2012;18:109–117).

Argyrophilic Grain Disease Presenting as Excited Catatonia: A Case Report

Received November 3, 2015; revised February 1, 2016; accepted February 1, 2016. From Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, OH (SK, TS,MAC, JO, CAW, JH, XFJ); Department of Pathology, Neurology, Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, OH (RP); Department of Ethics, Humanities, and Spiritual Care, Cleveland Introduction

Atypical Findings in Massive Bupropion Overdose: A Case Report and Discussion of Psychopharmacologic Issues.

Bupropion is an atypical antidepressant that is structurally similar to amphetamines. Its primary toxic effects include seizure, sinus tachycardia, hypertension, and agitation; however, at higher amounts of ingestion, paradoxical cardiac effects are seen. We report the case of a 21-year-old woman who ingested 13.5 g of bupropion, a dose higher than any other previously reported. The patient presented with seizure, sinus tachycardia with prolonged QTc and QRS intervals, dilated pupils, and agitation. Four days after overdose, the patient’s sinus tachycardia and prolonged QTc and QRS intervals resolved with symptomatic management, but she soon developed sinus bradycardia, hypotension, and mild transaminitis. With continued conservative management and close monitoring, her sinus bradycardia resolved 8 days after the overdose. The transaminitis resolved 12 days after the overdose. Our findings are consistent with previously reported toxic effects associated with common overdose amounts of bupropion. In addition, we have observed transient cardiotoxicity manifesting as sinus bradycardia associated with massive bupropion overdose. These findings are less frequently reported and must be considered when managing patients with massive bupropion overdose. We review the psychopharmacologic implications of this and comment on previous literature.

Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report

Psychogenic nonepileptic seizures (PNES), a form of conversion disorder, are paroxysmal episodes resembling epilepsy while lacking electrographic correlation. The phenomenon has rarely been reported in elderly patients and has not been associated with a new-onset medical diagnosis. We present the case of an 81-year-old female with no past psychiatric or traumatic history who developed PNES within the context of a new, suspected cancer. To our knowledge, this is the first such reported case of a suspected cancer (or otherwise medical) diagnosis contributing directly and temporally to the development of PNES. Discussion of involved psychosocial variables follows the vignette, and a brief review of relevant literature is offered.

Psychiatry Residency Education in Countries with Low- and Middle-Income Economies

Utilizing scarce resources creatively becomes challenging for psychiatrists in impoverished countries. Balancing academic duties with public health needs compounds economic hardship, having to face concomitant problems of low wages, personnel shortages, large-volume practices, societal stigma, and discrimination. This chapter reviews how economic disparities in most of Asia, Africa, and Latin America, combined with psychiatric workforce inequities, create resource deficiencies having to culturally adapt educational initiatives. We recommend a learning inclusive approach that incorporates meeting public health needs and highest standards of care educational models. Specific examples will be given of collaborative didactic programs that connect mentors and institutions from high-income countries with trainees and faculty in underserved areas.