Comments & Controversies

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Coming to Ask more questions APA? suspected to be at risk for workplace MAY 2009 Visit us at booth The list of interview questions Dr. #1624 violence and for fi tness for duty. Mob- Henry Nasrallah suggested in “The bing seems to be more prevalent and hallucination portrait of psychosis: the consequences more dire for a vic- Probing the voices within” (From the A DOWDEN PUBLICATION • VOL. 8, NO. 5 Beyond threats tim who is feeling pressured to leave Editor, Current Psychiatry, May Risk factors for suicide his or her job when there is little hope in borderline personality 2009, p. 10-12) is a much-needed re- disorder of getting another one or is taking on

] SPECIAL REPORT minder of the clinical importance of Economic anxiety: First aid responsibilities previously held by oth- for the recession’s casualties patients’ verbal auditory hallucina- What is your patient’s ers who have been laid off. predicament? Knowing can tions. In 15 years of practice—much Mr. S experiences recurrent hypothermia inform clinical practice This brings to the forefront a very during treatment for multiple medical PLUS Editorial: Dr. Nasrallah problems and psychotic symptoms. of that inpatient psychiatry—I have Hallucination portrait of psychosis: important consideration for individu- Could antipsychotics be the cause? Probing the voices within

Malpractice Rx cared for many patients with hallu- Smoking allowed: als who confront such assessment Is hospital policy a liability risk?

Pearls cinations, and until recently I confess \DRiNK TWO 6 PACK challenges. Gathering collateral infor- clarifi es substance use ONLINE ONLY my interview was not as thorough as SEE PAGE 9 mation is critical for diagnostic accura-

Dr. Nasrallah advises. Then after at- May 2009 cy and well-articulated interventions 0C1_r2_CPSY0509 0C1 4/21/09 9:30:53 AM tending a workshop in January 2009, I that may be recommended. Evalua- modifi ed my usual clinical interview when he says “I am hearing voices.” tors who do such assessments at the when a patient reported religious, How® Dowden can we really understandHealth what Media behest of corporate clients should in- paranoid, persecutory, and/or com- our patient is experiencing if we don’t sist that they have access to employee mand verbal auditory hallucinations. attempt to grasp the specifi cs of some- fi les investigative reports, and—if ap- The results have been startling.Copyright Forthing personal as remarkable as use a hallucination? only propriate—permission to interview Anne M. Stoline, MD Unfortunately, there are patients supervisors, employee assistance Perryville, MD who use statements such as “I am program representatives, and human hearing voices telling me to kill myself resources personnel familiar with the and others” in order to be admitted to case. Mobbing is real and deserves 'What do the voices tell you?' hospitals or for secondary gain. Get- much greater attention by researchers I would like to thank Dr. Nasrallah ting or attempting to get details about and clinicians in the United States. for his wonderful editorial about as- these “voices” and documenting what Scott Bresler, PhD sessing auditory hallucinations (“The we are told can be an invaluable part Clinical director Center for Threat Assessment hallucination portrait of psychosis: of a patient’s records. Inconsistencies Institute for Psychiatry and Law Probing the voices within,” From the arise that can be taken into consider- University of Cincinnati Editor, Current Psychiatry, May ation during subsequent encounters. Cincinnati, OH 2009, p. 10-12). He has eloquently ad- Bennett Cohen, MD dressed many of the concerns I have New York, NY Don’t 'teach to the test' had regarding how psychiatrists re- I was disappointed to read Dr. Henry spond when a patient says “I am hear- Nasrallah’s editorial calling for the ing voices.” In my experience many Workplace mobbing is real use of clinician measurement tools in psychiatrists simply leave it at that and I found Dr. James Randolph Hillard’s the management of psychiatric illness don’t even attempt the briefest charac- article on workplace mobbing timely (“Long overdue: Measurement-based terization of these hallucinations, let and extremely interesting (“Workplace psychiatric practice,” From the Editor, alone the rigorous elucidation that Dr. mobbing: Are they really out to get Current Psychiatry, April 2009, p. Nasrallah suggests. your patient?” Current Psychiatry, 14-16). I agree that general and vague We are doing a disservice to our April 2009, p. 45-51). As clinical direc- comments such as “doing better” are patients by not performing a thorough tor of a consultation service for corpo- of limited value. I would further argue evaluation of what a patient means rations, I am asked to assess employees continued on page 17

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05_CPSY0709 05 6/17/09 10:38:10 AM Comments & Controversies

continued from page 5 that such documentation is the psy- these. Each test takes 30 to 40 minutes To summarize, until scientifi c re- chiatric equivalent of “WNL”—which to administer and requires skilled and search leads to actual lab tests for psy- stands for “we never looked”—in a trained clinicians, if not psychiatrists chiatric disorders—and I believe that day medical review of systems. But I do themselves. That at least doubles will come—psychiatrists should quantify not believe the answer is to further the length of the visit with no evi- their patients’ clinical distress and impair- dumb down the practice of psychiatry dence-based benefi t. A recovery focus ment with the same objective measures by generating quantifi able, 1-dimen- requires that we—as does the DSM— used in evidence-based FDA trials, even if sional scores that purport to measure focus on our patients’ perceived im- the scales' reliability and validity are not how well our patient is doing. pairments, not their test scores. perfect. In the past, when these psycho- Lyle B. Forehand, Jr, MD Henry A. Nasrallah, MD metric tools were developed (approx- Modesto, CA Editor-In-Chief imately from 1960 to 1987), 2 primary Dr. Nasrallah responds concerns were voiced. I thank Dr. Forehand for his comments. I Scales are worth the time First, there was limited data to agree that psychiatric diagnoses at this Thank you for bringing the issue of support their validity and reliability, time are purely syndromal and require measurement-based psychiatric prac- although that concern is somewhat “clinically signifi cant distress or impair- tice to light (“Long overdue: Mea- less now, at least with some of the tests ment.” What I am calling for is to quan- surement-based psychiatric practice,” Dr. Nasrallah recommended. These tify the various signs and symptoms of From the Editor, Current Psychia- tests still lack criterion-related validity. the distress and impairment before and try, April 2009, p. 14-16). As nurse For example, IQ as measured by an IQ after treatment with a standard scale practitioners, we were strictly taught test predicts performance on an IQ test, widely used by all researchers and some to elaborate on psychiatric symptoms so it’s reliable. But to use that number clinicians. and progress, which is why the notes to predict fi tness for a job or even aca- The defi nition of remission, which is are called “progress notes” and not demic success ends up discriminating the phase that precedes recovery, actu- “shorthand notes.” I use blank forms against some individuals or groups ally is based on standard rating scales’ of various modifi ed scales—such as who are more than just a number. severity score for a given psychiatric ill- the Hamilton Rating Scale for Depres- Second, there was the concern ness. Therefore, clinicians must rate their sion and Positive and Negative Syn- that, similar to schoolteachers who patients on the scale corresponding to drome Scale—and I checkmark and end up teaching to a normative test, that illness to recognize when their pa- write all 4 axis and global assessment we could end up treating a patient’s tients have met the offi cial criteria for of functioning scores. These objective test score rather than the discomfort remission. fi ndings include a short version of with his or her life. I believe this also Practitioners do not have to use the mental status exam. On the top of remains true. Unlike diabetes mel- a scale to rate the patient’s symptoms the chart, I note subjective symptoms. litus, which is defi ned by increased separate from the standard interviewing I never use general syntax such as blood sugars, psychiatric diagnoses process. Rather, once clinicians become “Pt. is improving, doing well.” Also, are purely syndromal and require familiar with these scales, they could I utilize a 0-to-10 scale for overall im- “clinically signifi cant distress or im- conduct their usual interview and then provement, with 0 being the worst pairment” or they are not a disease ac- take a moment when writing their note and 10 being no symptoms. cording to DSM-IV-TR. It’s the distress in the chart to circle the score of each In my treatment plan, I state and the impairment that we treat. symptom they assessed during their which symptoms have resolved and Today, I see 2 positive trends in clinical interaction, and cite the total which have not. My psychiatrist our fi eld: to fi nd increasingly effi - score in the admission or progress note. friends object to that because it is cient methods to appropriately tailor A copy of the scale can be included as time-consuming. The fact is it takes and effectively deliver care and to a supplement to the progress note and only approximately 5 minutes. be recovery-focused. It seems to me will ensure that all signs and symptoms Khalid Hussain that routine and indiscriminate use related to an illness are assessed, rather Board-certifi ed psychiatric nurse practitioner of psychometrics obstructs both of than just some of them. Kingman, AZ

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