Factitious AIDS in a psychiatric inpatient

This article reports the case of a 28 year-old female presenting to a psychiatric inpatient unit with depression and a history of acquired immune deficiency syndrome (AIDS). Although medical assessment was negative for AIDS, psychiatric evaluation and psychological testing were consistent with a presentation of factitious disorder. This case illustrates the need to be on the alert for individuals admitted to psychiatric units who report they have AIDS or its related conditions.     

Factitious disorder and factitious disorder by proxy

Similar to the adult patient, a child or adolescent may actively feign or produce artificial symptoms (synonymous: Munchausen syndrome). The more frequent case is that the child suffers from being an object of symptom fabrication induced by a close person caring for the child, regularly the mother (Munchausen syndrome by proxy). This review focuses on psychopathological aspects of the clinically more relevant factitious disorder by proxy. Typical behaviour and personality characteristics are presented that can be taken as clinical warning signs. Doctor-mother-interaction is affectively challenging due to conflicting tasks imposed on the physician. Complementary to pediatric exclusion of genuine disease, psychopathological assessment is required to exclude other sources of deviant illness behaviour. Factious disorder shares particular features (active violation of the child, false report of history, aggravated symptom presentation and increased doctor-hopping, difficulties in conforming maternal report in biomedical data) with other psychopathological entities (child abuse, simulation, dissociative disorders, somatoform disorders including hypochondria, variants of maternal overprotection and infantilization, psychosis or delusion in the mother). Criteria for differentiation are presented. Three concepts on the psychopathological etiology of factitious disorder by proxy are relevant: In some cases, it may be conceived as secondary manifestation of a primary psychopathological entity or personality disorder. Learning theory emphasises operant rewards received from vicarious sick role. Attachment theory provides possible explanations concerning the traumatic impact on the child, early sources of psychopathology in the fabricating mother and risks for intergenerational transmission of factitious disorders.     

Negative effects of a smoking ban on an inpatient psychiatry service

Although many psychiatric inpatient units have banned smoking, the authors suggest that problems associated with implementation of no-smoking policies in these settings have been underreported. Over a two-year period after implementation of a smoking ban on inpatient units at a Veterans Affairs medical center, an estimated 20 to 25 percent of patients who smoked had difficulty adjusting to the ban, and some patients experienced major disruption in their treatment. Four cases illustrating problems in treating highly disturbed, nicotine-dependent patients are presented. The authors recommend that inpatient settings where smoking is banned should accommodate patients who cannot tolerate abrupt smoking cessation by providing smoking areas or allowing off-unit smoking breaks.     

Identification and treatment of substance misuse on an inpatient psychiatry unit

This chart review study examined identification and treatment of substance misuse on an inpatient psychiatry ward before and after the hospital's administration made changes to increase attention to patients' substance misuse. Before the ward changes, 113 of 250 inpatients (45 percent) were identified as misusing substances. Misusers were significantly more likely to be younger, male, single, and cigarette smokers. After the ward changes, substance misuse was more than twice as likely to be addressed in treatment planning and discharge diagnoses, and referrals to substance abuse treatment were nearly twice as likely to be made. Changes in assessment of and treatment planning for psychiatric inpatients may increase attention to substance misuse.     

Experiences of a paraplegic psychiatry resident on an inpatient psychiatric unit

The author reviews the literature on disabled physicians and describes her own adjustment to paraplegia. While she was a medical student and practicing internist, she encountered few comments about her disability, but during her later psychiatry residency, hospitalized psychiatric patients discussed it frequently. The author presents examples and points out that patients' reactions often revealed much about their characteristic response patterns; reactions to her disability became a type of projective test. Her primary defenses against patients' remarks were intellectualization and isolation of affect. Supervisors who were able to discuss the impact of her disability on the doctor-patient relationship were considered most helpful.     

Preventing assaults on a psychiatric inpatient ward

Although appropriate evaluation, management, and treatment of violence-prone patients will tend to reduce the incidence of aggressive acts on a psychiatric ward, such measures are not enough to prevent eruptions of violence. The author discusses several specific preventive steps that staff of psychiatric units can take to reduce the likelihood that assaults will occur: forming and maintaining a social norm against violence, recognizing and managing countertransferential reactions among both staff and patients, ensuring responsible involvement by psychiatrists during violent incidents, thoroughly assessing a patient's potential for assault, and paying prompt attention to the significance of an assault for the involved patient, other patients, and staff.     

Legal problems in inpatient psychiatry

This paper has discussed broadly a panorama of legal issues which may arise in the practice of inpatient psychiatry. Such a discussion can only be general and may not apply in a specific jurisdiction. Psychiatrists in inpatient settings should be familiar with all the issues raised and with local practices. Psychiatry is a field of medicine with a multitude of legal problems, more so than other medical specialties. Psychiatrists therefore have the obligation to themselves, their hospitals, and their patients to be cognizant of the legal issues in psychiatric practice. Hopefully, the more that they know, the less likely they are to be confronted with claims that they did not pay attention to this essential aspect of inpatient psychiatric practice.     

Educational opportunities and inpatient psychiatry

Despite inpatient psychiatry's longstanding role as a mainstay of psychiatric training, very little attention has been directed toward the educational opportunities of inpatient work. Experience rather than research has been our guide. Together with a brief history of inpatient psychiatry, the educational aspects of this setting have been discussed. The results of an informal survey supplement the text. We conclude with several educational concerns currently developing as a natural result of the ever-changing face of our profession. Our aim has been to provide a serious consideration of the issues and we invite our readers to expand upon or disagree with any or all of our contentions. We trust our ultimate goals are the same: to provide our profession with a steady supply of competent teachers, researchers and clinicians. Our patients can only benefit from this endeavor.     

DRGs and reimbursement for inpatient psychiatry

The reimbursement methodology outlined in the DRG (diagnosis-related groups) system is in many ways inappropriate for mental disorders. Some of the potential difficulties in the use of this system are reviewed. These are partly due to the methods used to develop the DRG system and partly a result of the use of such system to measure resource consumption in psychiatry. Prognosis, rather than diagnosis, should determine prospective reimbursement for psychiatry. It is suggested that PRGs (prognosis-related groups) be developed for classes of treatment facilities in the same manner as the current DRGs were developed.     

Geriatric psychiatry versus general psychiatry inpatient treatment of the elderly

OBJECTIVE: The authors compared the clinical treatment given older psychiatric inpatients on a geriatric psychiatry unit and a general psychiatry unit. METHOD: The charts of 50 randomly selected general psychiatry inpatients over the age of 65 years and 50 inpatients from the geriatric psychiatry unit who were matched for age, gender, and primary diagnosis were reviewed. RESULTS: Significantly greater percentages of older inpatients treated on the geriatric psychiatry unit received complete organic medical workups, structured cognitive assessment, aging-sensitive aftercare referral, and monitoring of psychopharmacological side effects and blood levels than comparable patients on a general psychiatry unit. CONCLUSIONS: Geriatric psychiatry subspecialty inpatient care appears to be associated with distinct clinically relevant assessment and treatment advantages. Continuing geropsychiatric education of general psychiatrists is indicated.     

Short-term group CBT versus psycho-education on an inpatient eating disorder unit

The purpose of the current study was to compare, on an inpatient eating disorder unit, short-term cognitive behavior group therapy with a psycho-education group.     

Prevalence of tics and Tourette syndrome in an inpatient adult psychiatry setting

OBJECTIVE: Given the widely recognized genetic basis for Gilles de la Tourette syndrome (TS) and the suggestion that the putative TS gene(s) may be expressed as or associated with a variety of psychiatric illnesses, this study was undertaken to assess the prevalence of tics and TS in a psychiatric inpatient population. DESIGN: Cross-sectional study. SETTING AND PATIENTS: 200 consecutive adult patients who were admitted to the psychiatric wards of University College London Teaching Hospitals. OUTCOME MEASURES: TS and related behaviours, as assessed by the comprehensive semi-structured National Hospital Interview Schedule. RESULTS: None of the 200 patients had definite TS, but 2 were observed to have motor tics; 10 had a history of tics (present for less than a year), and 7 reported a family history of tics. Thus, 19 (9.5%) inpatients qualified for inclusion in a broadly defined TS diathesis. These rates are significantly lower than those reported in a similar community based epidemiological study of adolescents (p = 0.018). CONCLUSIONS: Our findings do not support the theory that TS and related behaviours are over-represented among adult inpatients with psychiatric illnesses.     

Factitious disorder by proxy: pediatric condition falsification

We present a comprehensive overview of the condition factitious disorder by proxy, also known as Munchausen syndrome by proxy. The review begins by highlighting essential definitions and the etiology and epidemiology of the disorder. It then analyzes relevant clinical issues such as assessment and diagnostic methods. The final section is a detailed discussion of the complex issues facing the clinician, including the process of confronting the perpetrator, relevant legal issues, and the treatment of the caretaker, child, and family through a multidisciplinary, team approach.     

Morale is high in acute inpatient psychiatry

Background  

Morale on acute psychiatric wards has been considered to be problematic, and is reported to contribute to low quality patient care. Aim: To assess the relationship of staff morale to patient, service environment, physical environment, patient routines, conflict, containment, staff demographics, and staff group variables.