Friday Factoids: Recognition of Personhood Among Suicidal Women Admitted to Psychiatric Hospitals

Hargen et al., examined the experience of 11 women who were admitted to a psychiatric hospital and were struggling with suicide (2020). It was found that individuals struggling with suicidality and being in the position as a patient in a psychiatric acute ward can be understood as being in a liminal phase and place, with a weakened sense of personhood.

 

Some of the participants described being in the hospital as feeling as if they were in a waiting room or an in-between stage with a lack of meaning. It is important for staff to recognize that personhood is an important aspect of care. Experiencing recognition of personhood means that a patient feels recognized, both verbally and non-verbally, as an equal and valuable human being, and experiences being taking seriously, respected, and understood.

 

One example of non-verbal support described nurses coming all the way into the patients’ room when they checked upon them, and not only standing in the doorway. Participants stated that small things such as a staff member smiling at them, making eye contact, shaking their hand, or carefully touching or patting their shoulder made a world of difference.

 

Hagen, J., Loa Knizek, B., & Hjelmeland, H. (2020). “… I felt completely stranded”: liminality and recognition of personhood in the experiences of suicidal women admitted to psychiatric hospital. International journal of qualitative studies on health and well-being, 15(1).

 

James Bender, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids (Catch-Up): Navigating Political Differences in Supervision and Training

Dr. Tania Israel discusses tips for how to have productive conversations regarding hot-button political issues if they should arise in supervision and training. The first tip is that no matter what your motivation, the best thing you can do is promote understanding.

 

It is important to create an environment where people feel they are not being unfairly evaluated due to their political views. Instead of making assumptions about their views, explore with them how their views might play out in a clinical context. Next, allow uninterrupted speaking and reflect back what you hear using “I” statements. Be willing to ask open-ended questions during the conversation.

 

When asking questions, try to be curious and nonjudgmental. Focus on the other individual and assume they have positive intentions. Try to consider why they might hold their views and what values are important for them that reinforce these views. If a supervisee has had limited exposure regarding a specific topic, be willing to explore this with them during supervision and identify opportunities in their community that might help them become more exposed. It is important to give supervisees the opportunity to grow in their understanding.

 

References
Israel, T. (2020). Beyond your bubble: How to connect across the political divide, skills and strategies for conversations that work. APA LifeTools.

 

 

James Bender, MA
WKPIC Doctoral Intern

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Article Review: Cardiac Surgery and Psychosis

Individuals undergoing open heart surgery are at risk of experiencing both delirium and psychosis.  Rates of delirium after such surgery are estimated to fall between 8-23%, but rates of psychosis have not been as clearly identified.  In addition, the factors which make it more likely for individuals to experience psychosis have also not been explored in as much detail as risk factors for delirium.

 

This study (Giltay, et al., 2006) included more than 8000 patients from a Danish hospital over an 8 year period to identify how many patients experienced hallucinations or delusions following heart surgery, and what factors associated with their health, age or complications from the procedure increased the likelihood of experiencing psychosis. The mean age of participants was 65, though participants ranged in age from 9-91. 71% were men.

 

Results indicated that 2% of participants experienced psychosis following surgery.  Older age and a prior diagnosis of Chronic Obstructive Pulmonary Disease (COPD) were both associated with a higher likelihood of psychosis.  In addition, cardiac arrythmias prior to surgery and cardiovascular disease (narrow blood vessels leading to the heart) also put patients at higher risk of experiencing psychosis.  Finally, lab work or treatment suggesting other body systems were not functioning well, such as high creatine levels, a history of dialysis and low preoperative hemoglobulin levels also increased the likelihood of experiencing psychosis.

 

In addition, there were more complications from surgery for those who went on to experience psychosis than those who did not. For example, multiple organ failure and cardiopulmonary resuscitation rates for individuals who later experienced psychotic symptoms were much higher.  These patients stayed in intensive care longer and were more likely to pass away shortly after surgery.

 

The researchers conclude that overall health prior to cardiac surgery is important to predicting the likelihood of experiencing psychosis after surgery, and advanced age, which is often associated with other health problems is a very strong predictor of post-surgical psychosis.

 

References
Giltay, E. J., Huijskes, R. V., Kho, K. H., Blansjaar, B. A., & Rosseel, P. M. (2006). Psychotic symptoms in patients undergoing coronary artery bypass grafting and heart valve operation. European Journal of Cardio-Thoracic Surgery, 30(1), 140-147.

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Returning to Work During COVID

While there has been some research exploring the mental health effects of the COVID-19 pandemic broadly, limited research has specifically explored the effects of returning to a physical workplace during the COVID pandemic. In early 2020, a group of researchers in China asked approximately 1300 employees who had permission to return to a physical workplace to complete depression, anxiety and PTSD assessments. Some participants had been working in the workplace for weeks, some had just returned, and some had not yet begun working in the workplace, but were planning to begin.

 

Across the entire sample, researchers were surprised to find that while PTSD rates were higher than rates pre-COVID, anxiety and depression rates reflected rates found in the general population prior to COVID. However, depression, anxiety and PTSD symptoms varied between subgroups significantly, indicating some populations may be at increased risk for mental health challenges upon returning to work.

 

Findings indicate the following:

  • Divorced/widowed/separated and married participants reported higher levels of anxiety, depression and PTSD symptoms than single participants.
  • Participants who characterized their physical health as “normal” or “poor” reported a higher number of PTSD symptoms than those who characterized their health as “good”.
  • Participants who had not returned to work yet, or had been back in the workplace for less than 7 days reported a significantly higher number of PTSD symptoms than participants who had been working in the workplace for 15+ days.
  • Participants who had concerns about workplace hygiene also reported a significantly higher number of PTSD symptoms than participants who were confident in their workplace hygiene.

 

This study was conducted in China before effective vaccines were available, so the severity of the outbreak for the region may be higher than some parts of the US, and anxiety may be reduced for individuals who have access to the vaccine. However, for many non-healthcare workers under the age of 65, it may be months before they are fully vaccinated, indicating it may be helpful to consider the effects of returning to work when evaluating their mental health.

 

Tan, W., Hao, F., McIntyre, R. S., Jiang, L., Jiang, X., Zhang, L., Zhao, X., Zou, Y., Hu, Y., Luo, X., Zhang, Z., Lai, A., Ho, R., Tran, B., Ho, C., & Tam, W. (2020). Is returning to work during the COVID-19 pandemic stressful? A study on immediate mental health status and psychoneuroimmunity prevention measures of Chinese workforce. Brain, behavior, and immunity, 87, 84–92. https://doi.org/10.1016/j.bbi.2020.04.055

 

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Has COVID affected the kinds of psychiatric cases seen in the Emergency Department?

 

In an effort to better understand the influence the COVID pandemic had on reasons for psychiatric visits to the Emergency Department, researchers at a New York City hospital compared diagnoses and referral outcomes for children, adolescents and adults in January and February of 2020 (pre COVID) versus March and April of 2020 (after COVID started). Researchers identified a number of interesting patterns, including the following:

 

  • Fewer children and adolescents were seen once COVID began (65) compared to the same length of time prior to COVID (202).
    • However, the children and adolescents who were seen were more likely to exhibit psychotic symptoms and were more likely to be transferred to inpatient hospitalization than children and adolescents seen pre-COVID.
    • Similarly, adult patients were also more likely to be transferred to inpatient hospitalization during COVID than before COVID.
  • During COVID adult patients also reported difficulty obtaining outpatient services than pre-COVID patients.
  • Only a third of patients were tested for COVID, but those who tested positive were more likely to present with psychotic symptoms and less likely to present with depressive symptoms than COVID negative patients.
  • There was a 43% decline in patients seen in the emergency department during the first two months of COVID (mostly due to reduced child/adolescent patients).
  • 25% of ED visits were due to COVID-specific stressors (unemployment, death of a friend/family member, social isolation).

 

Researchers hypothesize that reduced child/adolescent patients were likely due to the fact that common referral sources (schools, mental health clinics) were closing down at that time, and some school-stressors (bullying) may have been less prevalent, though parent’s fear of contracting COVID was also likely a factor that reduced the number of patients presenting.  Vaccination rates are slowly climbing, but it could be months before the majority of physically healthy adults and children have access to a vaccine, therefore some of these patterns could still be affecting ED referrals.

 

 

 

Ferrando, S. J., Klepacz, L., Lynch, S., Shahar, S., Dornbush, R., Smiley, A., … & Bartell, A. (2020). Psychiatric emergencies during the height of the COVID-19 pandemic in the suburban New York City area. Journal of psychiatric research. Iin press)

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Article Review: Clinical Differentiation of Bipolar II Disorder from Borderline Personality Disorder

 

A common diagnostic dilemma among clinicians is differentiating between Borderline Personality Disorder (BPD) and Bipolar II Disorder (BP II) (Bayes et al., 2014). These two disorders share similar features including impulsivity and emotional dysregulation. Additionally, “affect storms” in individuals with BPD can resemble hypomanic episodes similar to ones seen in individuals with BP II. Bayes et al., discuss various distinctions between the two disorders to assist clinicians with differentiating between the two (2014).

 

Family history, age of onset, and illness course
The first three categories examined are family history, age of onset, and illness course. Individuals with BP II have a greater probability of having a first-degree relative with bipolar disorder or another mood disorder (Bayes et al., 2014). Individuals with BPD have an increased likelihood of having a family member with an impulse control disorder, such as antisocial or substance use disorder, or a unipolar mood condition. Symptoms of BP II usually appear in late adolescence or young adulthood and the onset represents a distinct change in the individual. There is no distinct onset period for BPD and many individuals with BPD report being depressed their whole lives. BP II tends not to remit with age and can worsen over time, whereas BPD has a more favorable prognosis, with many individuals no longer meeting criteria in middle age (Bayes et al., 2014).

 

Depressive Symptoms and Suicidality
Depressive symptoms among individuals with BP II are usually presented as melancholic features, agitation, and mixed symptoms of depression (Bayes et al., 2014). They experience “typical” depressive feature such as decreased self-esteem and self-criticism, and feel guilty about annoying others with irritable mood and are self-accusatory. Individuals with BPD has depressive symptoms represented by non-melancholic reactive depressive episodes. They are characterized by emptiness, shame, and “painful incoherence.” They also tend to project responsibility onto others, being accusatory, blaming, hostile, and more angry than depressed. Suicidality and self-harm occur in both BP II and BPD with similar frequencies (Bayes et al., 2014).

 

Hypomanic Symptoms, Impulsivity, and Mood State Context
Individuals with BP II usually report elated mood, increased energy, creativity, connectedness, grandiosity, and productivity (Bayes et al., 2014). These traits are viewed as uncharacteristic and only occur during a mood episode. There is usually also a reduction in anxiety symptoms when an individual with BP II is experiencing a hypomanic episode. Individuals with BPD report emotional dysregulation and elation is rarely present. There remains an ongoing poor self-image and increased anxiety symptoms during these periods. Episodes of impulsivity are more commonly associated with hypomanic mood states in individuals with BP II, where as impulsivity is a core diagnostic feature for an individual with BPD and tends to be more enduring. Individuals with BP II are more likely than those with BPD to have autonomous mood episodes and lacking an interpersonal context. Individuals with BPD are usually more reactive, generally triggered by a psychologically salient interpersonal event (Bayes et al., 2014).

 

Psychosis and Trauma
During depressive episodes, psychotic features are uncommon for individuals with BP II (Bayes et al., 2014). There is a lifetime prevalence ranging from 3 to 45% and when present they tend to be mood congruent. 75% of individuals with BPD will experience transient dissociative and paranoid symptoms, but rarely have a depressive theme. A history of childhood trauma is not a distinctly differentiating feature, as there are high rates associated with both disorders. 50% of individuals with BP II report experience childhood trauma and 60 to 80% among individuals with BPD (Bayes et al., 2014).

 

Self-Identity and Relationships
Individuals with BP II tend to experience self-deficits only when depressed and a grandiose self when hypomanic (Bayes et al., 2014). There is typically stability while euthymic and they are able to maintain stable relationships. Individuals with BPD generally experience a disruption to their sense of self and core elements of BPD include “painful incoherence” and “role absorption.” There is a tendency towards idealization and devaluations, as well as, fears of abandonment and ongoing interpersonal conflicts (Bayes et al., 2014).

 

Treatment Response
Therapy including cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) have shown to be effective for individuals with BP II (Bayes et al., 2014). Additionally, antidepressants, anticonvulsant mood stabilizers, and atypical antipsychotics are usually prescribed to treat symptoms of BP II. Symptoms of BPD rarely remit with the use of mood stabilizers. DBT is typically used with individuals with BPD, to work on disrupted sense of self and improving mutually satisfying relationships (Bayes et al., 2014).

 

References
Bayes, A., Parker, G., & Fletcher, K. (2014). Clinical differentiation of bipolar II disorder from borderline personality disorder. Current opinion in psychiatry, 27(1), 14-20.

 

James Bender, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Drinking to Cope with the Pandemic

 

Individuals around the world have faced significant stressors due to the COVID-19 pandemic, including stay-at-home orders, high rates of unemployment, and millions of deaths as of February 2021. Rodriguez et al. (2020) explored how perceived threat and psychological distress related to the COVID-19 pandemic are associated with drinking behavior among an American sample of adults. 754 participants were surveyed in the study, with 50% being men and 50% being women.

 

The study found that indices of COVID-19 related stress, particularly psychological distress, are associated with drinking behavior. It was also found that the use of alcohol to cope with distress is more relevant to women’s than men’s drinking. When levels of COVID-19 related distress was low, men displayed the usual pattern of drinking more than women. However, as distress related to COVID-19 increased, women’s drinking caught up with that of men. This is a concerning finding given that similar quantities of alcohol in women and men result in greater adverse effects for women, including liver and heart disease. Psychological distress related to COVID-19 was also related to increased drinking frequency and heavy drinking among both men and women. Finally, the study identified that the presence of children in the home during the pandemic was related to increased drinking behavior among American adults.

 

References
Rodriguez, L. M., Litt, D. M., & Stewart, S. H. (2020). Drinking to cope with the pandemic: The unique associations of COVID-19-related perceived threat and psychological distress to drinking behaviors in American men and women. Addictive behaviors, 110

 

James Bender, MA
WKPIC Doctoral Intern

 

 

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Article Review: Psychosocial Treatment of Schizophrenia

Canadian Treatment Guidelines for psychosocial treatments of schizophrenia were recently updated.  Each of the following treatments were supported by at least one randomized control study, though many were supported by metanalyses of randomized controlled studies.  The authors emphasize that psychosocial treatment should be provided in tandem with medical treatment.

 

  1. Family Interventions. The way family members respond to or interact with the patient can have a significant effect on clinical outcomes including reducing likelihood of hospitalization and reduction of symptoms.  Family intervention should be offered to all families once a diagnosis has been made.  This family intervention should include at least 10 sessions over the course of 3 months and topics that cover:
    1. Communication skills
    2. Problem solving
    3. Psychoeducation

 

  • Work opportunities. It is important to offer supported employment opportunities, volunteer or prevocational/educational opportunities to individuals with schizophrenia if possible.

 

  • CBT for psychosis. This treatment has been found to reduce anxiety and depressive symptoms in individuals with schizophrenia, a minimum dose of 16 sessions is recommended. Sessions should focus on raising awareness of the relationship between their thoughts, feelings, behaviors, and symptoms. In addition, therapists should encourage individuals to evaluate how their perceptions, beliefs, and thought processes that contribute to symptoms; and they should promote helpful ways of coping with symptoms and reducing stress.

 

Other treatments, including life skills, social skills and patient psychoeducation about schizophrenia don’t have sufficient empirical evidence to be recommended at this time, but they are currently being offered to many patients, and they may be beneficial. There is new interest in incorporating mindfulness and acceptance and commitment therapy into treatments for individuals with schizophrenia as well, but again, research on these interventions is limited.

 

 

References
Norman, R., Lecomte, T., Addington, D., & Anderson, E. (2017). Canadian treatment guidelines on psychosocial treatment of schizophrenia in adults. The Canadian Journal of Psychiatry, 62(9), 617-623.

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Transgender Patient Care on an Inpatient Psychiatric Unit

Special considerations may be needed for transgender patients who are admitted to a psychiatric unit, to better assist with their care. These considerations should begin prior to the patient’s arrival. It is recommended that patients share a room with others of the same affirmed gender, and if that is not possible, a private room should be assigned. Many institutions room transgender patients with patients of the same assigned (by society to the individual at birth), but not affirmed (to which the individual has transitioned or is in the process of transitioning), gender. When this happens, it can feel invalidating, traumatizing, and discriminatory to the patient, as well as confusing to the roommate.

 

Staff should be aware of the patient’s desired name and pronouns, particularly when these do not align with the patient’s medical record. It is also important to note that withholding an outpatient hormone regimen can acutely worsen dysphoria for patients. If possible, affirming devices, such as chest binders or breast prostheses should be permitted, unless they pose a significant safety concern.

 

During the intake interview, it is crucial to have a basic understanding of the patient’s gender journey. Questions about their relationships and response to their identify in their social environment can assess for risk and protective factors. When a patient volunteers information, clarifying questions about their medical transition process should be asked. It is important to frame such questions in a manner which will enable the patient to understand the rationale of the question. It is important to remember that it is never appropriate to ask patients directly about their genitals. It is also important to phrase questions in a manner that does not assume the patient desires further medical intervention. Some individuals undergo social transitioning, while others undergo medical transitioning. Missed issues can be identified at the end of the interview by asking patients whether there is anything that can be done to make their stay on the unit more comfortable.

 

Throughout the patient’s hospitalization, it is important to follow up on how the patient’s gender identity has been affirmed on the unit. Finally, it is important to consider the patient’s psychiatric course prior to hormone therapy and whether something else might be driving the psychiatric presentation before concluding that the hormones are responsible for the decompensation.

 

References
Saw, C. (2017). Transgender patient care on the inpatient psychiatric unit. American Journal of Psychiatry Residents’ Journal.

 

James Bender, MA
WKPIC Doctoral Intern

 

 

 

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Friday Factoids: Migraines and Epilepsy Olfactory Hallucinations

Olfactory hallucinations are said to be one of the less common forms of hallucinations associated with psychotic disorders. However, olfactory hallucinations are said to occur with several other neurological disorders, most commonly temporal lobe epilepsy in which the aura before the epileptic seizure sometimes includes an olfactory hallucination lasting up to 24 hours.

 

While more rare, olfactory hallucinations also occur with headache disorders at times but are less commonly recognized and studied. This makes it essential to rule out serious medical causes of olfactory hallucinations before resorting to a schizophrenia spectrum disorder diagnosis.

 

Monica Babaian, MA
WKPIC Doctoral Intern

 

 

 

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