PTSD and lower respiratory symptoms: A systematic review of longitudinal associations in early 9/11 World Trade Center responders.

OBJECTIVE: The objective of this systematic review is to examine longitudinal associations between post-traumatic stress disorder (PTSD) and lower respiratory symptoms (LRS) specifically among responders present at the World Trade Center (WTC) site on September 11, 2001 (9/11). This group, which we refer to as "9/11 early responders," appears to have particularly high rates of both mental and physical illness relative to other 9/11-exposed populations. METHODS: We performed a systematic literature review to examine associations between PTSD and LRS among 9/11 early responders in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. After a structured search of Pubmed and the Fire Department of New York (FDNY) WTC bibliography for relevant articles, we identified 4 articles commenting on associations between PTSD and LRS in this population; all 4 passed quality review and were included in our primary analysis. 10 other articles we found in our research discussed rates of PTSD and LRS, but not associations between them, in the population in question; we commented on these in a secondary analysis. RESULTS: The data demonstrate that there are significant associations between PTSD and LRS among 9/11 early responders. The data also suggest that both of these phenomena are more prevalent among 9/11 early responders relative to other 9/11-exposed populations. CONCLUSIONS: These findings are relevant for optimizing care for the population in question, as well as for other survivors of past and future disasters with both psychiatric and medical sequelae.

Psychosocial and Psychodynamic Considerations Informing Factitious Disorder.

Factitious disorder is a condition in which patients deceitfully present themselves as injured or ill in the absence of obvious external reward. It is difficult to diagnose and treat, and little rigorous evidence exists in the literature. While larger studies have revealed some clinical and sociodemographic patterns, there is a lack of consensus on psychosocial factors and mechanisms contributing to factitious disorder. This in turn has led to conflicting recommendations on management. In this article, we review major psychopathological theories of factitious disorder, including the role of early trauma and subsequent development of interpersonal dysfunction, as well as maladaptive gratification obtained from assuming the sick role. Common themes of interpersonal disruptions in this patient population include a pathologic need for attention and care, as well as aggression and desire for dominance. In addition to psychodynamic and psychosocial etiologic models of factitious disorder, we also review associated treatment approaches. Finally, we offer clinical implications, including countertransference considerations, as well as directions for future research.

Challenges and strategies in the psychiatric care of the ultra-Orthodox Jewish population: A thematic analysis of 18 psychiatrist interviews.

Despite the importance of accessible psychiatric care for the ultra-Orthodox Jewish community, prior research has characterized how stigma and suspicion of secular institutions limit mental healthcare utilization by this population. No study, however, has interviewed a cohort of psychiatrists to identify commonly encountered challenges or successfully employed strategies in the care of ultra-Orthodox Jewish psychiatric patients who have overcome these barriers to present for care. We recruited by snowball sampling from a sample of convenience 18 psychiatrists affiliated with the Weill Cornell Department of Psychiatry, experienced in the care of ultra-Orthodox Jewish patients. Each participant was engaged in a 20-45-min, semi-structured interview, which was subsequently transcribed, de-identified, and analyzed with combined deductive and inductive thematic analysis. We identified 12 challenges and 11 strategies as particularly significant in psychiatric work with ultra-Orthodox Jewish patients at every phase of treatment, including rapport-building, history-taking, diagnostic formulation, and achieving concordance with patient and family. These challenges and strategies revolved around themes of community stigma, an extended family-patient-community team, cross-cultural communication, culture-related diagnostic complexity, transference/countertransference, and conflicts between Jewish law /community norms and treatment protocol. Psychiatrists caring for ultra-Orthodox Jewish patients face a range of complex challenges stemming from factors unique to ultra-Orthodox Jewish religion, culture, and family/community structure. However, they have also identified strategies to manage these challenges and provide culturally sensitive care. Further research is necessary to directly elicit perspectives from within the ultra-Orthodox Jewish community and validate our initial findings.

A COVID-19 Patient's Request to Die and Ensuing Conflict: Psychodynamic Considerations.

The role of psychodynamic theory in consultation-liaison (C-L) work, and particularly the importance of countertransference, has been well established. The psychological impact of the COVID-19 pandemic on healthcare workers is a new factor that must now be taken into account as C-L psychiatrists traverse a changed healthcare landscape. In this article, we highlight the case of a critically ill COVID-19 patient who endorsed a desire for hastened death. This request generated significant conflict between the physicians and nurses caring for him, and it became challenging for the C-L team to perform our typical liaison function. We briefly review the existing literature on the psychological impact of the pandemic on healthcare workers, and examine how psychodynamic factors within this context impacted the events that unfolded. Themes under consideration include the effect of mass trauma on clinician defense mechanisms, and specifically the impact on countertransference toward patients who express a desire for hastened death. C-L psychiatrists themselves are not immune to such reactions and must be particularly attentive to emergent conflict in such cases. Interdisciplinary meetings to discuss and process these disagreements may be effective in repairing staff ruptures.

Coping strategies among colorectal cancer patients undergoing surgery and the role of the surgeon in mitigating distress: A qualitative study.

BACKGROUND: Distress is common among cancer patients and leads to worse postoperative outcomes. Surgeons are often the first physicians to have in-depth conversations with patients about a new colorectal cancer diagnosis; therefore, it is important that these surgeons understand how patients cope with the distress of a diagnosis and how they can help patients manage this distress. METHODS: Patients with colorectal cancer were recruited from an outpatient surgery clinic. Purposive sampling was used to recruit patients if they were either planning to undergo surgery or had undergone surgery within six months. In-depth, open-ended, individual qualitative interviews were performed. Grounded theory was used to develop themes regarding patients' coping strategies and beliefs regarding the role of the surgeon in helping them cope. RESULTS: Patients described their own internal coping strategies using problem-focused, emotion-focused, and meaning-focused techniques. Patients also reported the importance of their social support network for coping. Patients believed surgeons and their teams should help patients manage the emotional components of their cancer diagnosis and surgical experience, especially if patients were experiencing high levels of distress or had inadequate coping skills. They did not believe surgeons themselves should be primarily responsible for helping them cope. CONCLUSION: In order for surgeons to guide diagnosis and initial management of distress in colorectal cancer patients undergoing surgery, they should screen patients for distress, identify and strengthen patients' own coping strategies, facilitate a strong social support network, and provide patients with the option to obtain further support from the surgeon's office.

Sources of distress among patients undergoing surgery for colorectal cancer: a qualitative study.

BACKGROUND: Distress is common among cancer and surgical patients and can lead to worse outcomes if untreated. The objective of this study was to explore sources of distress among colorectal cancer patients undergoing surgery. MATERIALS AND METHODS: This was a qualitative study using in-depth, semistructured, one-on-one interviews in an academic setting. Patients were recruited if they had a pathologically confirmed diagnosis of colon or rectal cancer. Purposive sampling was used to recruit patients who were about to undergo (preoperative), or had recently undergone (postoperative), curative resection for colorectal cancer. RESULTS: All participants (n = 24) reported experiencing distress during treatment. Participants identified sources of distress preoperatively (negative emotional reaction to diagnosis, distress from preconception of cancer diagnosis, and distress interacting with healthcare system). Sources of distress during in-hospital recovery included negative emotional reaction to having a surgery and negative emotions experienced in the hospital. Postoperative sources of distress included mismatch of expectations and experience of recovery, dealing with distressing physical symptoms and complications after surgery, and distress worrying about recurrence. Participants identified other sources of distress that were not time-specific (distress related to social support network, from disruption of life, and worrying about death). CONCLUSIONS: Our results highlight a potential role for a comprehensive screening program to identify which patients require assistance with addressing sources of distress during the surgical experience. Understanding how sources of distress may vary by time will help us tailor interventions at different time points of the surgical experience.

Abnormal thyroid function tests in psychiatric patients: a red herring?

Thyroid abnormalities can induce mood, anxiety, psychotic, and cognitive disorders. Thus, thyroid function tests are routinely checked in psychiatric patients. However, up to one-third of psychiatric patients may demonstrate thyroid function test abnormalities that do not reflect true thyroid disease, but rather are a manifestation of secondary effects on one or more levels of the hypothalamic-pituitary-thyroid (HPT) axis. Originally termed the euthyroid sick syndrome, this phenomenon is now more commonly referred to as "non-thyroidal illness." In psychiatric patients with non-thyroidal illness, patterns of thyroid function test abnormalities may vary considerably based upon factors such as the underlying psychiatric disorder, the presence of substance abuse, or even the use of certain psychiatric medications. Thus, any abnormal thyroid function tests in psychiatric patients should be viewed with skepticism. Given the fact that thyroid function test abnormalities seen in non-thyroidal illness usually resolve spontaneously, treatment is generally unnecessary, and may even be potentially harmful.