Does diagnosing a patient with borderline personality disorder negatively impact patient satisfaction with the initial diagnostic evaluation?

BACKGROUND: Research has found that clinicians have less sympathetic attitudes and behave less empathically toward patients with borderline personality disorder (BPD). Anecdotal conversations with clinicians and trainees reveal that some have a reluctance to tell their patients that they have BPD due to a concern that these patients will react badly. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether diagnosing BPD resulted in lower satisfaction with the initial evaluation. METHODS: One thousand ninety-three patients presenting to the Rhode Island Hospital partial hospital program completed the Clinically Useful Patient Satisfaction Scale (CUPSS), a reliable and valid measure of satisfaction with the initial evaluation. The usual clinical practice in our program is to discuss with the patients their diagnoses. RESULTS: Approximately one-sixth of the patients were diagnosed with BPD (15.6%, n = 171). There were no significant differences in satisfaction ratings on the 16 items of the CUPSS between patients with and without BPD. CONCLUSIONS: There was no evidence that diagnosing BPD was associated with reduced satisfaction with the initial diagnostic evaluation. Approaches toward making the diagnosis of BPD also are discussed.

The impact of anonymity on psychiatric patients' ratings of satisfaction with the initial evaluation.

BACKGROUND: Preserving anonymity is believed to yield more honest appraisals of patient satisfaction, although the data addressing this issue are sparse. The goal of this study from the Rhode Island Methods to Improve Diagnostic Assessment and Services project was to determine the impact of anonymity on patient satisfaction ratings after the initial evaluation. METHODS: The Clinically Useful Patient Satisfaction Scale (CUPSS) is a brief, self-administered questionnaire assessing patients' satisfaction with the initial evaluation. Every 2 to 3 months, we switched from anonymous to non-anonymous completion of the CUPSS. More than 1,300 patients completed the scale (729 anonymous, 603 non-anonymous). RESULTS: Anonymity was not associated with scores on the scale. In both the anonymous and non-anonymous conditions, the CUPSS had high internal consistency, all item-scale correlations were significant, and all items were significantly correlated with global satisfaction ratings. There was sufficient variability in satisfaction ratings to detect differences among clinicians. CONCLUSIONS: Anonymity was not associated with patient satisfaction ratings, did not affect the psychometric properties of the scale, and did not compromise the scale's ability to discriminate among clinicians. That is, anonymity did not affect the reliability or validity of satisfaction ratings.

Augmentation of aripiprazole with low-dose clozapine.

An issue under much clinical debate is whether treatment with two antipsychotic agents simultaneously is advantageous for optimizing response in patients whose previous monotherapy with antipsychotic agents has failed. Minimal evidence supports treatment with multiple antipsychotics, even when the agents have different mechanisms of action. The standard of care for treating schizophrenia is to first use monotherapy of adequate dosage and duration, including a trial of clozapine before adding a second agent. We report the case of a 32-year-old man whose monotherapy with various antipsychotic agents failed. During attempted conversion from aripiprazole to clozapine, the patient experienced a significant reduction in psychiatric features. Despite this improvement, the patient became resistant to the clozapine titration schedule due to complaints of sedation. Aripiprazole combined with low-dose clozapine as maintenance therapy resulted in a positive clinical outcome despite a clozapine serum level that is generally considered subtherapeutic. This case emphasizes the importance of making interventions based on individual patient response.

Levetiracetam for mood stabilization and maintenance of seizure control following multiple treatment failures.

OBJECTIVE: To report the case of a patient who experienced adverse events in succession to antiepileptic medications being used for both antiepileptic and mood-stabilization benefit. CASE SUMMARY: A 46-year-old white woman developed hyponatremia with carbamazepine, hyperammonemia with divalproex, cognitive impairment with topiramate, and hyponatremia with oxcarbazepine. The patient was stabilized physically and psychiatrically on levetiracetam without any noted adverse events. DISCUSSION: The adverse events in this report have been associated with the medications in question. The patient's presentation is unique, as she developed adverse events in succession to antiepileptic drugs being used to treat both a seizure disorder and symptoms of mood instability. The Naranjo rankings for the reported adverse events indicated the associations were probable (carbamazepine, divalproex, oxcarbazepine) and possible (topiramate). After repeated incidences of intolerability to these drugs, levetiracetam was initiated and provided both seizure control and mood-stabilizing benefits, which eventually led to hospital discharge. CONCLUSIONS: Levetiracetam may provide mood-stabilizing qualities through a mechanism that is unique from that of other antiepileptic agents used for their mood-stabilizing properties. There are potential advantages with levetiracetam, as no specific therapeutic drug monitoring parameters need to be followed after its introduction. Additionally, this case emphasizes the importance of therapeutic drug monitoring and frequent assessments to prevent physical and psychiatric adverse reactions.

Quetiapine use in a patient with chronic schizophrenia and severe parkinsonism.

A 52-year-old patient with treatment-resistant paranoid schizophrenia developed severe parkinsonian features after more than 20 years of antipsychotic drug therapy. The role of this therapy was thought to have been a contributing factor to the patient's clinical presentation, although Parkinson's disease could not be ruled out. Originally, parkinsonian symptoms developed acutely and progressed to hand tremor, sialorrhea, upper body rigidity, masked facies, striatal hand, bradykinesia, and a severe, unsteady, shuffling gait. Tremor and rigidity were the only parkinsonian symptoms that responded to anticholinergic therapy. After converting from a first- to a second-generation antipsychotic drug, the patient maintained psychiatric stability, with some improvement in motor functioning-most notably decreased upper body rigidity. Our findings are consistent with the literature on quetiapine therapy in patients with Parkinson's disease in terms of adequately controlling psychosis without worsening motor symptoms. The difference, however, was that in most cases reported, psychotic features were the result of dopamine-enhancing treatments and not schizophrenia.