The Rapunzel syndrome: a hairy tale.

BACKGROUND: Trichobezoars are a rare medical condition, often requiring a surgical approach and commonly associated with an underlying psychiatric disorder. The Rapunzel syndrome is a rare variant of trichobezoar in the stomach extending from the stomach into the small intestine causing a bowel obstruction. CASE PRESENTATION: In this case report, the clinical presentation, diagnostic approach, and surgical removal of a large-size bezoar (Rapunzel syndrome) in a young and otherwise healthy female is described. Different surgical strategies are discussed. Psychiatric exploration gives an insight on development of trichophagia ultimately leading to the forming of the trichobezoar. CONCLUSIONS: This brief report sheds light on the importance of the collective mind of a multidisciplinary team preventing a potentially fatal outcome.

Compulsory Interventions in Severe and Persistent Mental Illness: A Survey on Attitudes Among Psychiatrists in Switzerland.

Background: Some psychiatric patients develop severe and persistent mental illness (SPMI), which, for a variety of reasons, can be therapy-refractory. Sometimes, treatment is not considered helpful by the patients themselves and does not improve their subjective quality of life. Furthermore, many SPMI patients experience compulsory interventions such as seclusion, restraint, or treatment against their will, which can cause harm. Methods: In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about the care of SPMI patients in general, and about their attitudes with regard to compulsory interventions in particular, using three case vignettes of patients with severe and persistent anorexia nervosa, schizophrenia and depression. Results: Out of 1,311 contacted psychiatrists, 457 (34.9%) returned the completed survey. In general, 91.0% found it important or very important to respect SPMI patients' autonomy in decision making. However, based on three different clinical case vignettes, 36.8% of psychiatrists would act against the wishes of the patient with severe and persistent schizophrenia, 34.1% against the wishes of the patient with severe and persistent depression, and 21.1% against the wishes of the patient with severe and persistent anorexia nervosa, although all patients were stated to have preserved decision-making capacity. With regard to the case vignettes, 41.1% considered compulsory interventions leading to a temporary reduction of quality of life acceptable in the patient with severe and persistent schizophrenia, 39.4% in the patient with severe and persistent depression, and 25.6% in the patient with severe and persistent anorexia nervosa, although it was stated in all three case vignettes that two independent experts ascribed the patients decision-making capacity regarding their illness and further treatment. Conclusions: Many psychiatrists in our sample found themselves in an ethical dilemma between autonomy and the provision of medical care. While most respondents respect the autonomy of SPMI patients, many saw the need to perform compulsory interventions even though it was clearly and prominently stated that two independent psychiatrists had ascribed the patients in the case vignettes decision-making capacity. Further examination of these conflicting views is warranted, perhaps along with the development of guidelines for such situations.

Risks and Benefits of Web-Based Patient Narratives: Systematic Review.

BACKGROUND: Patient narratives are illustrative, individual accounts of patients' experiences with certain health conditions. Web-based patient narratives have become widely available on the internet and in social media, as part of electronically available patient decision aids or Web-based databases. In recent years, the role of patient narratives as a source of information, insight, and support for both health care users and providers has increasingly been emphasized. Although the potential impact of patient stories has high immediate plausibility, it is of interest to know if this impact can be captured in quantitative studies. OBJECTIVE: This review aimed to evaluate whether research-generated Web-based patient narratives have quantifiable risks or benefits for (potential) patients, relatives, or health care professionals. METHODS: We searched the following databases from August 2017 to March 2019: Medical Literature Analysis and Retrieval System Online, PsycInfo, Sociological Abstracts, Web of Science, and EMBASE. Titles and abstracts of the retrieved studies were reviewed and assessed for the inclusion and exclusion criteria. Papers were included if they studied the following: (1) (potential) patients, relatives, or health care professionals; (2) the effects of Web-based patient narratives that were generated scientifically (eg, through qualitative research methods); and (3) were quantitative studies. Furthermore, 2 authors independently performed an assessment of the quality of the included studies using a validated checklist. RESULTS: Of 4226 documents, 17 studies met the inclusion criteria. The studies investigated 10 different sources of Web-based patient narratives. Sample sizes ranged from 23 to 2458. The mean score of the quality assessment was 82.6 (range 61-100). Effects regarding five different purposes were identified as follows: provide information, engage, model behavior, persuade, and comfort. We found positive effects in every category and negative effects in one category (persuade). Several of the reported effects are rather small or were identified under specific experimental conditions. CONCLUSIONS: Patient narratives seem to be a promising means to support users in improving their understanding of certain health conditions and possibly to provide emotional support and have an impact on behavioral changes. There is limited evidence for beneficial effects on some outcomes. However, narratives are characterized by considerable heterogeneity and the investigated outcomes are hardly comparable with each other, which makes the overall judgment difficult. As there are numerous possible measures and purposes of narratives, quantifying the impact of Web-based patient narratives remains a challenge. Future research is needed to define the optimal standards for quantitative approaches to narrative-based interventions.

Attitudes toward assisted suicide requests in the context of severe and persistent mental illness: A survey of psychiatrists in Switzerland.

OBJECTIVE: Switzerland is among the few countries worldwide where a request for assisted suicide (AS) can be granted on the basis of a primary psychiatric diagnosis. Psychiatrists play an increasingly important role in this regard, especially when the request for AS arises in the context of suffering caused by severe and persistent mental illness (SPMI). The objective of the survey was to assess general attitudes among psychiatrists in Switzerland regarding AS requests from patients with SPMI. METHOD: In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about their attitude to AS for patients with SPMI, based on three case vignettes of patients diagnosed with anorexia nervosa, treatment-refractory depression, or severe persistent schizophrenia. RESULT: From a final sample of 457 psychiatrists (a response rate of 34.9%) whose mean age was 57.8 years, 48.6% of respondents did not support access to AS for persons diagnosed with SPMI, 21.2% were neutral, and 29.3% indicated some degree of support for access. In relation to the case vignettes, a slightly higher percentage of respondents supported the patient's wish to seek AS: 35.4% for those diagnosed with anorexia nervosa, 32.1% for those diagnosed with depression, and 31.4% for those diagnosed with schizophrenia. SIGNIFICANCE OF RESULTS: Although a majority of the responding psychiatrists did not support AS for SPMI patients, about one-third would have supported the wishes of patients in the case vignettes. In light of the increasing number of psychiatric patients seeking AS and the continuing liberalization of AS practices, it is important to understand and take account of psychiatrists' perspectives.

Acceptability of palliative care approaches for patients with severe and persistent mental illness: a survey of psychiatrists in Switzerland.

BACKGROUND: Some patients develop severe and persistent mental illness (SPMI) which is therapy-refractory. The needs of these patients sometimes remain unmet by therapeutic interventions and they are at high risk of receiving care that is inconsistent with their life goals. Scholarly discourse has recently begun to address the suitability of palliative care approaches targeting at enhancing quality of life for these patients, but remains to be developed. METHOD: A cross-sectional survey asked 1311 German-speaking psychiatrists in Switzerland (the total number of German-speaking members of the Swiss Society for Psychiatry and Psychotherapy) about the care of SPMI patients in general, and about palliative care approaches in particular. 457 (34.9%) returned the completed survey. In addition, participants were asked to evaluate three case vignettes of patients with SPMI. RESULTS: The reduction of suffering and maintaining daily life functioning of the patient were rated as considerably more important in the treatment of SPMI than impeding suicide and curing the underlying illness. There was broad agreement that SPMI can be terminal (93.7%), and that curative approaches may sometimes be futile (e.g. 72.4% for the anorexia nervosa case vignette). Furthermore, more than 75% of the participating psychiatrists were in favour of palliative care approaches for SPMI. CONCLUSIONS: The results of the present study suggest that the participating psychiatrists in Switzerland regard certain forms of SPMI as posing high risk of death. Additionally, a majority of respondents consider palliative care approaches appropriate for this vulnerable group of patients. However, the generalizability of the results to all psychiatrists in Switzerland or other mental health professionals involved in the care of SPMI is limited. This limitation is important considering the reservations towards palliative care in the context of psychiatric illness, mainly because of the association with death and futility. Palliative care approaches, however, are applicable in conjunction with other therapies intended to prolong life. A next step could be to involve service users and develop a consensus of what palliative care might encompass in SPMI. A framework for identifying which patients might benefit from palliative care, should be explored for the future development of care for SPMI patients.

Self-regulation of the dopaminergic reward circuit in cocaine users with mental imagery and neurofeedback.

BACKGROUND: Enhanced drug-related reward sensitivity accompanied by impaired sensitivity to non-drug related rewards in the mesolimbic dopamine system are thought to underlie the broad motivational deficits and dysfunctional decision-making frequently observed in cocaine use disorder (CUD). Effective approaches to modify this imbalance and reinstate non-drug reward responsiveness are urgently needed. Here, we examined whether cocaine users (CU) can use mental imagery of non-drug rewards to self-regulate the ventral tegmental area and substantia nigra (VTA/SN). We expected that obsessive and compulsive thoughts about cocaine consumption would hamper the ability to self-regulate the VTA/SN activity and tested if real-time fMRI (rtfMRI) neurofeedback (NFB) can improve self-regulation of the VTA/SN. METHODS: Twenty-two CU and 28 healthy controls (HC) were asked to voluntarily up-regulate VTA/SN activity with non-drug reward imagery alone, or combined with rtfMRI NFB. RESULTS: On a group level, HC and CU were able to activate the dopaminergic midbrain and other reward regions with reward imagery. In CU, the individual ability to self-regulate the VTA/SN was reduced in those with more severe obsessive-compulsive drug use. NFB enhanced the effect of reward imagery but did not result in transfer effects at the end of the session. CONCLUSION: CU can voluntary activate their reward system with non-drug reward imagery and improve this ability with rtfMRI NFB. Combining mental imagery and rtFMRI NFB has great potential for modifying the maladapted reward sensitivity and reinstating non-drug reward responsiveness. This motivates further work to examine the use of rtfMRI NFB in the treatment of CUD.