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Psychiatry

Terminating the Treatment Relationship

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This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and onsite risk management audits, and other resources to healthcare providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers may provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney...

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About Schizophrenia and Psychosis

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About one in a hundred people have schizophrenia and can have a variety of ‘positive’ symptoms, such as hallucinations, delusions or disordered speech/behaviour, and ‘negative’ symptoms such as problems with fluency of language and thoughts or with expression of emotions.

As is the case with most mental illness, the cause of schizophrenia is not known. The conventional treatment for schizophrenia is usually long-term treatment with antipsychotic medication. A nutritional approach works alongside conventional treatment and may improve both positive and negative symptoms, and also reduce the side-effects of medication.

Below is an outline of nutrition approaches that may be relevant:

• Correcting blood sugar problems made worse by excess stimulant and drug use • Addressing essential fat imbalances • Increasing antioxidants; niacin (Vitamin B3) therapy • Addressing methylation problems helped by B12 and folic acid • Investigating pyroluria and the need for zinc and identifying any food allergies

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Niacin Skin Flush Test: A Research Tool for Studying Schizophrenia.

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Abstract

BACKGROUND:

A body of biochemical evidence suggests that abnormal phospholipid metabolism may play a role in the etiology of schizophrenia, and possibly, other psychiatric and neurological diseases. Niacin, a B-complex vitamin, induces prostaglandin synthesis, vasodilatation, and skin flushing when applied as a solution on the skin or taken orally. In schizophrenia, diminished or absent skin response to niacin represents a robust finding.

RESULTS:

Attenuated niacin skin-flush response has been analysed as a potential biochemical marker of impaired prostaglandin signaling in schizophrenia. Diminished skin redness after topical application of niacin might be caused by a reduced level of the precursor arachidonic acid in the peripheral membranes, increased activity of the enzyme phospholipase A2, abnormal expression of niacin or prostaglandin receptors, or poor vasomotor activity of cutaneous capillary walls. Heritability estimates established in several studies support niacin skin flush response as a vulnerability...

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Lies in the Doctor-Patient Relationship

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Have you ever lied to your patients or been surprised to learn that one of your patients lied to you? Have you considered it important to learn why lies emerge in the treatment relationship? Have you wondered whether (or how) you should confront such untruths? If you have, then the following discussion should provide the forum for answers to these and other questions related to the exploration, detection, and management of lies in the medical arena.

Clinicians realize that making an accurate diagnosis relies on the provision of reliable information by patients and their family members and that timely, astute, and compassionate care depends on effective bidirectional communications (between the patient and the physician). Unfortunately, both patients and physicians are often challenged by complicated communications; each group withholds, distorts, obfuscates, fabricates, or lies about information that is crucial to the doctor-patient relationship and to effective treatment....

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Are Psychiatric Diagnoses Defamatory Statements?

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Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To evaluate evidence from randomised controlled trials (RCTs) for the efficacy of different communication strategies used by clinicians to inform patients about the diagnosis and outcome of schizophrenia, compared with treatment as usual

To compare efficacy between different communication strategies.

Background

Description of the condition

Schizophrenia, a serious mental illness, is a group of heterogeneous disorders typically characterised by the presence of delusions, hallucinations, disorganised speech, disorganised behaviour, and negative symptoms (avolition, apathy, anhedonia, alogia, affective blunting). The two major classification systems, the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD-10), have different requirements of symptoms duration for the diagnosis of schizophrenia. While the DSM requires a total duration of a minimum of six months, the ICD-10 warrants a minimum duration of one month.

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Munchausen’s Syndrome and Other Factitious Disorders in Children

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Abstract

There has been increasing recognition in the pediatric literature for the past 20 years that illness falsification by caregivers must be included in the differential diagnosis of children presenting with persistent, unexplained symptoms or laboratory findings. However, there is considerably less awareness that pediatric symptoms can also be intentionally falsified by child and adolescent patients, and this unique group has remained virtually invisible. There have been reports that many children with factitious disorders also suffer from other mental disorders, particularly personality disorders. We report an unusual case of Munchausen's syndrome in a 15-year-old patient with sickle cell disease. We also review other reported pediatric factitious disorders in literature. Our purpose is to make clinicians aware of this less known disorder in children and to discuss the similarities and differences these disorders have in children compared to adults with the same disorders.

Introduction

Adult patients who present with symptoms of factitious disease are...

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What Is the Difference Between Malingering and Factitious Disorder?

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Factitious disorder is the term used to describe a pattern of behavior centered on the exaggeration or outright falsifications of one’s own health problems or the health problems of others. Some people with this disorder fake or exaggerate physical problems; others fake or exaggerate psychological problems or a combination of physical and psychological problems. Factitious disorder differs from a pattern of falsified or exaggerated behavior called malingering. While malingerers make their claims out of a motivation for personal gain, people with factitious disorder have no such motivation.

Factitious Disorder Basics

People with factitious disorder do several things that are unexpected for patients who present themselves for medical treatment, or for individuals seeking treatment for others in their care. First, they commonly exaggerate or lie about problems in their medical histories or the histories of others. They also present their doctors with symptoms that don’t legitimately ....

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Factitious Disorder Imposed on Another (Munchausen by proxy)

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Practice Essentials

Factitious disorder imposed on another (formerly factitious disorder by proxy) has as its cardinal characteristic the production or feigning of physical or psychological symptoms in another person, usually a child or adult under the care of the person with the disorder. It is currently understood as including the condition commonly known as Munchausen syndrome by proxy (MSBP). Signs and symptoms

Common presentations of factitious disorder imposed on another (including MSBP) include the following:

•Bleeding •Seizures •Recurrent apparent life-threatening events •Poisoning •Apnea •Central nervous system (CNS) depression •Diarrhea and vomiting •Fever, either feigned (via falsification of chart records) or actual •Rash •Hypoglycemia •Hyperglycemia •Hematuria or guaiac-positive stools •Multiple infections with varied and often unusual organisms

Warning signs that raise the possibility of this disorder include the following:

Unexplainable, persistent, or recurrent illnesses Discrepancies among the history, clinical findings, and child’s general health

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