Psychological Symptom Amplification: Are Psychological Symptoms Subject to "Somatization"-Like Processes?

Many patients demonstrate amplified somatic symptom experiences that are felt by providers to cause excessive distress and functional impairment, and that can be diagnostically misleading. Terms attached to these presentations include somatization, medically unexplained symptoms, and, most recently, somatic symptom disorder. The analogous amplification of psychological symptoms has not been considered. Accordingly, this column makes a case for discussion and investigation of psychological symptom amplification (PSA), a process made possible by the medical legitimization of certain types of human suffering. As various forms of psychological suffering gain greater medical legitimacy, PSA becomes increasingly relevant. Circumstantial evidence suggests that unrecognized PSA may distort research findings and clinical efficacy in psychiatry. The largely symptom-based nature of psychiatric diagnosis makes PSA a challenging, but necessary, object of further scientific and clinical scrutiny.

"Poor Insight": A Capacity Perspective on Treatment Refusal in Serious Mental Illness.

For several decades, a protection standard has prevailed in determining the conditions under which a mental health provider, in concert with state authority, might intrude upon the civil rights of a person with serious mental illness. This approach contrasts with a treatment standard that guides consideration and assessment of incapacity in all other branches of medicine. This Open Forum examines the rationale, goals, and limits associated with involuntary intervention in serious mental illness compared with the rest of medicine. The authors believe that reviving a treatment standard that focuses on capacity among persons with serious mental illness would help build bridges between psychiatry and general medicine, between patients and providers, and between illness and recovery.

Capable of more: some underemphasized aspects of capacity assessment.

BACKGROUND: The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching. OBJECTIVE: The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded. METHODS: Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making. RESULTS: Accessing patients' maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients' difficulties are important components of these assessments. DISCUSSION: The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.

Beyond capacity: identifying ethical dilemmas underlying capacity evaluation requests.

BACKGROUND: Psychiatric consultations involving the evaluation of patients' medical decision-making capacity often seem to have little to do with truly compromised patient autonomy. OBJECTIVE: The authors seek to examine hidden ethical dilemmas that lead to capacity evaluation requests. METHOD: The authors utilize the "principlism" approach to biomedical ethics to illustrate some common moral issues in patient care that are poorly captured by the "autonomy-versus-paternalism" paradigm. RESULTS: Patient autonomy sometimes comes into conflict with ethical imperatives to do "good," to avoid harm, and to deliver care fairly, as well as with the autonomy of others. Consultation psychiatrists are well positioned to unearth these dilemmas and begin to address them. DISCUSSION: Effective engagement of everyday ethics in clinical medicine is hindered by reflexive resort to capacity evaluations when moral problems arise. Greater attention to matters of values, aggressive urges, and obligations to others can enhance the negotiation of routine ethical dilemmas.

Psychiatric polypharmacy: a clinical approach based on etiology and differential diagnosis.

Polypharmacy is common clinical practice in the United States for many psychiatric conditions and for many reasons. In this article we encourage clinicians to use the familiar practice of differential diagnosis to systematically identify etiological factors contributing to polypharmacy. We offer a clinical approach based on (1) reviewing the four main factors responsible for polypharmacy (the disease, the patient, the physician, and society) and (2) answering two questions about optimizing medication regimens (What can I do without explicit permission from the patient or others? What can I do with permission from them?). We contend that all physicians share a professional responsibility for prescribing medications judiciously because unnecessary prescribing exposes patients to unwarranted risks and squanders valuable and scarce resources. Psychiatrists can ask themselves a Kantian question: would my way of prescribing lead to good, socially acceptable outcomes if followed by all physicians treating similar patients?

An approach to the patient with dysregulated mood: major depression and bipolar disorder.

Major depressive disorder (MDD) and bipolar disorder are chronic relapsing-remitting illnesses whose effects on mood, behavior, and thinking exact a heavy toll on patients' physical and mental health and on their capacity for satisfying relationships and employment. In the inpatient setting, these affective illnesses and their treatments can complicate the diagnosis, course, therapy, and prognosis of numerous medical conditions. In this article, the authors discuss a general approach for general internists, family practitioners, and other primary care providers to follow in caring for patients with suspected MDD or bipolar disorder.

The muddles of medicine: a practical, clinical addendum to the biopsychosocial model.

BACKGROUND: The commonly-accepted "biopsychosocial model" does not always lend itself to the kind of pragmatic decisions that many clinical situations demand of physicians. OBJECTIVE: The authors attempt to identify and close gaps in the biopsychosocial model that hinder its application in certain real-life clinical situations. METHOD: The authors review some of the current and historical literature on the development and application of the biopsychosocial model, and argue the shortcomings of this modality in various clinical situations. RESULTS: The authors present three dicta to guide clinicians toward relevant areas of inquiry: 1) Think neuroanatomically; 2) Think existentially; and 3) Think "dirty;" that is, understand that patients and physicians sometimes work toward different goals. DISCUSSION: These dicta form an addendum to the biopsychosocial model, identifying and filling three specific, commonly-encountered gaps in that paradigm, which, ironically, is usually considered all-inclusive.

Consultation, communication, and conflict management by out-of-operating room anesthesiologists: strangers in a strange land.

With anesthesiology increasingly practiced outside the operating room (OR) environment, it is important that anesthesiologists begin to identify and to teach the communication skills required for practice in non-OR general hospital settings. The "one back" position of the consultant, and the associated diminished sense of immediate control, can generate discomfort for many clinicians. This article discusses the literature regarding practice as a consultant and the navigation of conflict with an emphasis on how anesthesiologists might apply the findings to out-of-OR practice.