Crawling in my skin | Clinical Correlation

In this segment of Clinical Correlation, Dr. Renee Kohanski completes part 2 of her review of the most effective treatments for patients with severe anxiety. She also announces that, after almost 200 episodes, the Psychcast is taking an indefinite pause. To reach Dr. Kohanski, email her at [email protected]. To reach Dr. Lorenzo Norris, host of the Psychcast, email him at [email protected]. Clinical Correlation was published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Craig Chepke, MD, speaks with Lorenzo Norris, MD, about changes he made to his practice during the COVID-19 pandemic, and plans to make some of those changes permanent. Dr. Chepke is a psychiatrist in Huntersville, N.C., and adjunct associate professor at Atrium Health and adjunct assistant professor at the University of North Carolina at Chapel Hill. He disclosed serving as a consultant and speaker for Otsuka and Janssen, and as a speaker for Alkermes. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Chepke discussed his strategies for adapting his practice to the restrictions of the pandemic. He engaged in shared decision-making with patients when modifying his practice, including starting a drive-through pharmacotherapy clinic. To ensure that patients continued to have access to treatments such as long-acting injectable antipsychotics and esketamine, Dr. Chepke created a system in which patients could drive up to his clinic to have the medication administered. Because esketamine requires a 2-hour monitoring period after administration, he adapted the safety protocol. After patients received their intranasal spray dosage, they would complete the monitoring period in their car in the parking lot outside of his office, which was close enough to the clinic for Dr. Chepke to physically observe the patient, and to monitor vital signs wirelessly via a Bluetooth-enabled blood pressure cuff. Throughout the pandemic, Dr. Chepke found ways to care for his patients’ physical and mental health. He also adopted technologies that help him monitor his patients' vital signs and glucose levels. Especially while focusing on treatment-resistant psychiatric illness, Dr. Chepke invites family members to participate in evaluation and treatment. He uses this approach because he realizes that effective treatment must involve the system in which the individual exists. Dr. Chepke and Dr. Norris discussed ways in which clinicians can extend hope to their patients through flexibility and innovation, especially throughout the pandemic. Providing hope to patients demonstrates belief in a better future. Reference Chepke C. Current Psychiatry. 2020 May;19(5):29-30. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]  

John “Jack” Rozel, MD, MSL, returns to the Psychcast to talk with Lorenzo Norris, MD, about American gun violence and steps clinicians can take to disrupt it. Dr. Rozel is medical director of the resolve Crisis Network. He also serves as associate professor of psychiatry and adjunct professor of law at the University of Pittsburgh. Dr. Rozel is also past president of the American Association for Emergency Psychiatry. He has no disclosures. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Mass violence with guns is occurring with greater frequency and severity in the United States, compared with other countries. Mass shootings have been on the rise. In 2020 there were nearly 200 more mass shootings, compared with 2019. The United States has a broad swath of firearm violence: Deaths by suicide account 60% of gun deaths, and the remaining 40% are deaths by homicide. Only 1%-2% of firearm homicides are completed in mass shootings – which are defined as an event in which four or more people are shot in an indiscriminate manner. It is also a distinctly American problem that we have so many guns in our country. The United States has more civilian-held firearms (393 million) than the next 39 countries combined. Being an adult in the United States means being 25 times more likely to be the victim of a firearm homicide, compared with adults in any other country. Dr. Norris and Dr. Rozel conclude that violence assessments must always cover suicide and homicide risk because they are related types of violence, especially when it comes to guns. Summary Suicide risk is increased by 100-fold when a new gun enters the home, and the risk peaks in the first days to weeks of ownership and then trails off. However, there is a measurable difference in risk of suicide in the 5 years after the purchase. Dr. Rozel emphasizes that it is essential to ask patients about acquisition of new guns, because as circumstances change as with the pandemic, people may feel the need to buy a gun. Dr. Rozel presented a model for possibly reducing gun violence: Grievance: All violence starts with feeling like a victim; some people feel aggrieved after a disagreement or even a threat. The Pivot: This is a transition from simply having a grievance to violent ideation and wanting vengeance through violence. Perpetrators of violence shift from fantasy into research about planning and preparing to attack. Preparation: This stage includes acquiring weapons and, in some cases, tactical clothing. It also could include probing into their targets’ vulnerabilities, a “test attack,” and eventually the final attack. Breach: This entails a change in the safety of the potential victim.  Attack: This stage encompasses perpetrating the attack. Identifying a person at the grievance stage is the most effective place to intervene and potentially diffuse a violent situation by using motivational interviewing to enhance protective factors. Psychiatry’s greatest strength is meeting the aggressor where they are and hearing out the grievance. References Victor D and Taylor DB. A partial list of mass shootings in the United States in 2021. New York Times. 2021 Apr 16. Kim NY. Gun violence spiked during pandemic, even as the deadliest mass shootings waned. Poynter.org. 2021 Mar 25. Rozel JS and Mulvey EP. Annu Rev Clin Psychol. 2017 May 8;13:445-69. Metzl JM et al. Har Rev Psychiatry. 2021 Jan-Feb 01;29(1):81-9. Firearm access is a risk factor for suicide. Harvard School of Public Health. National Council for Behavioral Health. Mass Violence in America: Causes, impacts, and solutions. 2019 Aug. Gun Violence Archive *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

In the first part of a two-part series on anxiety disorder, Dr. Kohanski shares what may be some surprising facts information about prescribing of the tried-and-true agents of anxiety, along with some clinical pearls. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Omar Sultan Haque, MD, PhD, talks with Lorenzo Norris, MD, about the need for medical schools to become responsive to physicians, medical students, and residents with mental disabilities. Dr. Haque is a physician, social scientist, and philosopher who is affiliated with the department of global health and social medicine at Harvard Medical School, Boston. He disclosed founding Dignity Brain Health, a clinic that seeks to provide clinical care for patients struggling with major depressive disorder. Dr. Haque also serves as medical director of Dignity Brain Health. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Haque and colleagues recently published a perspective piece in the New England Journal of Medicine about the “double stigma” against mental disabilities, which the authors define as “psychiatric, psychological, learning, and developmental disorders that impair functioning,” including common diagnoses, such as attention deficit disorder and major depressive disorder. Physicians and physicians-in-training, such as students and residents, face major challenges in disclosing mental disabilities, from fear of discrimination during the admissions process to stigma throughout training and licensure. Medical leave is often the only suggested solution to an exacerbation of a disability, and this response is likely to instill fear in trainees, because taking leave will require future disclosure and worsen the double stigma. Reasonable accommodations could improve functioning and allow trainees to remain enrolled and on their desired academic path. Dr. Haque recommends that medical schools and training programs have trained disability service providers (DSP) with specialized understanding of medical education and curricula who do not have conflicts of interest – as sometimes happens when they participate in other roles, such as serving as deans or professors within a medical school. A continued challenge to disability disclosures are questions on medical licensing applications and renewals about past or current diagnoses or treatment for mental disabilities. Dr. Haque reminds listeners that, according to the American Disabilities Act, these questions about past and current diagnoses are illegal if the answers to those questions do not affect physicians’ current functioning. Summary   Dr. Haque’s article offers several recommendations for medical schools, training programs, and licensing boards aimed at addressing the burden of the double stigma against mental disabilities within the culture of medical training and practice. Medical schools should clearly communicate that applicants with disabilities are welcome as part of a larger commitment to diversity, and individuals with mental disabilities should be admitted and allowed to complete training. Universities should hire medical school–specific disability service providers who understand medical education and are committed to parity for individuals with physical and mental disabilities. Policies related to mental disabilities should be clearly publicized so that students and trainees know what to expect if they disclose a disability, and should create reasonable accommodations for those with mental disabilities instead of promoting medical leave as the only option. Faculty members and administrators could publicly describe their own protected time for therapy and highlight the professional successes of people who were able to disclose their condition and get reasonable accommodations. The Federation of State Medical Boards should enforce the ADA-based legal standard that questions about mental disabilities should be asked and answered only if they address current functional impairments that affect a physician’s ability to practice medicine safely. References Haque OS et al. N Engl J Med. 2021 Mar 11;384:888-9. Wimsatt LA et al. Am J Prevent Med. 2015 Nov. 49(5):703-14. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Géraldine Fauville, PhD, joins Lorenzo Norris, MD, to discuss some of the causes of Zoom fatigue and strategies that can make videoconferences productive. Dr. Fauville is the lead researcher on the Zoom Exhaustion & Fatigue Scale project. She also is assistant professor in the department of education, communication, and learning at the University of Gothenburg (Sweden). Dr. Fauville has no disclosures. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Fauville started her research on Zoom fatigue in the Virtual Human Interaction Lab at Stanford (Calif.) University, founded by Jeremy N. Bailenson, PhD. The lab has pioneered research on the common but poorly understood phenomenon of Zoom fatigue.  Videoconferencing, often through Zoom, has allowed people to connect throughout the pandemic, but there are features of this modality that can contribute to stress, and for many, social anxiety. Dr. Fauville and Dr. Norris discuss Zoom fatigue and which dynamics of videoconferencing contribute to a sense of anxiety, fatigue, and affect our general wellness in a society that has come to rely on videoconferencing as a primary form of communication and central to parts of our economy during the pandemic.  Dr. Fauville discusses how the size of faces on the screen and feeling observed activate anxiety and stress. Constant mirroring from seeing yourself reflected from the camera onto a screen can lead to self-judgment and negative emotions. Loss of traditional nonverbal communication and being forced to pay attention to verbal cues or exaggerate gestures can increase the cognitive load associated with conversations that occur via videoconference. Videoconferencing also restricts mobility, because people feel tethered to a small area within their camera’s view where they can be seen.  Summary During an in-person meeting, people will stare at you while you’re speaking, but on videoconferencing it can feel as if all eyes are on you the whole time, which contributes to stress and social anxiety.  Dr. Fauville discusses the “large face” dynamic; if these conferences were real-life interactions, it would be like having a very large face just a few inches from ours,  which can feel like an invasion of privacy. For the brain, having a face in close proximity to yours signals either a desire for intimacy or conflict.  Recommendation: Minimize the videoconferencing application as much as possible and keep the size of the faces smaller.  Zoom and other platforms lead to “constant mirroring.” Seeing our own image can result in persistent self-evaluation and judgment, which can contribute to anxiety and negative emotions.  Recommendation: Keep your camera on but hide self-view; doing so can combat this constant mirroring. Videoconferencing has severely limited mobility during meetings, which make people feel trapped in the view of the camera.  Recommendation: Using a standing desk allows for more freedom from the view of the camera. You can stretch your legs, walk around in the view of the camera, and create distance, especially if you have an external keyboard.  Nonverbal communication and behaviors are essential cues between humans. Videoconferencing that focuses on head and shoulders diminishes a large portion of body language. Videoconferences are more taxing for the brain than audio-only communication because people have to be even more in tune to the cues in speakers' verbal tones, and some nonverbal cues, such as nodding, become exaggerated.  Recommendation: Organizations should create guidelines aimed at mitigating Zoom fatigue. Suggestions include allowing people to turn off their cameras for portions of meetings or didactics, having a mix of audio/telephone and video meetings, and assessing whether the information from some meetings can included in email messages or shared documents.  Dr. Fauville and colleagues created the Zoom Exhaustion & Fatigue Scale (ZEF Scale) to quantify the phenomenon. Fifteen items on the scale focus on five dimensions of Zoom fatigue, such as general, visual, emotional, social, and motivational fatigue.  Part of the evaluation of Zoom fatigue should include examining how many videoconferences you have per day, the amount of time between each, and how long the conferences last.  References Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes. Stanford News. 2020 Feb 23. Fauville G et al. Zoom Exhaustion & Fatigue Scale. SSRN.com. 2021 Feb 23. Bailenson JN. Nonverbal overload: A theoretical argument for the causes of Zoom fatigue. Technology, Mind & Behavior. 2021 Feb 23;2(1). doi: 10.1037/tmb0000030. Zoom Exhaustion & Fatigue Scale survey: https://vhil.stanford.edu/zef/ *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

In this week's installment of Clinical Correlation, Renee Kohanski, MD, unpacks the new Open Notes mandate. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Guest host Vicki L. Ellingrod, PharmD, talks with Kristen M. Ward, PharmD, and Amy Pasternak, PharmD, about integrating pharmacogenomic testing into psychiatric practice. Dr. Ellingrod is senior associate dean at the University of Michigan College of Pharmacy, Ann Arbor, and professor of psychiatry in the medical school. She is also section editor of the savvy psychopharmacology department in Current Psychiatry. Dr. Ellingrod has no relevant financial relationships to disclose. Dr. Ward and Dr. Pasternak are clinical assistant professors of pharmacy at the University of Michigan.  Dr. Ward and Dr. Pasternak report no relevant disclosures. Dr. Ward and Dr. Pasternak are team leads in the University of Michigan’s Precision Health Implementation Workgroup. Take-home points Pharmacogenomics is defined as the study of the relationship between genetic variations and how our body responds to medications. Two common reasons for ordering pharmacogenomic testing are that a patient or clinician wants testing completed before starting the trial of a psychotropic medication and that there are concerns about nonresponse or loss of response to medications. Common insurance criteria used to justify such testing include at least one failed medical trial; future use of a medication likely to be affected by genetic variants, such as metabolism through CYP2D6 or CYP2C19; or identification of human leukocyte antigen (HLA) variants before starting carbamazepine or oxcarbazepine. Quality improvement and usability campaigns around pharmacogenomic testing include ensuring that testing results are readily available in the medical record. Results should be searchable. Alerts can be created for prescribers when they order a medication for which a patient has a relevant genetic variant. After ordering testing, clinicians should document the patient’s medication response genotype and phenotype in the medical record so the information can be used for medications other than psychotropics. Summary Pharmacogenomic testing may be ordered for several reasons, including cases in which a patient or clinician wants information before switching to another medication or there are questions about failed medication trials. For approximately 50% of individuals who undergo pharmacogenomic testing, there may not be a change in treatment plans, or the results might not be conclusive enough to affect treatment. However, pharmacogenomic testing is useful in reassuring and improving adherence in patients who experience somatic adverse effects to psychotropic medications and want to know whether those effects are related to their metabolism. Getting insurance companies to cover pharmacogenetic testing can be tricky, and clinicians should be familiar with the criteria requested by insurers before ordering the tests. Many of the genetic-testing companies include a patient-assistance program to cover payment when insurance companies do not. In the medical record, it’s important to document the patient's genotype and phenotype. The patient’s genotype affects their metabolism of medications beyond psychotropics. Pharmacogenomic testing results can prevent serious adverse drug reactions. If testing comments on a patient’s carrier status for specific HLA subtypes implicated in drug metabolism, carbamazepine or other related medications should be added to the patient’s drug allergy list. States requirements about informed consent for genetic testing vary, so any clinicians who order such tests should be informed about their local laws. References Ellingrod VL. Current Psychiatry. 2019 Apr;18(4):29-33. Deardorff OG et al. Current Psychiatry. 2018 Jul;17(7):41-5. Ellingrod VL and Ward KM. Current Psychiatry. 2018 Jan;17(1):43-6. Bishop JR. Current Psychiatry. 2010 Sep;9(9):32-5. Maruf AA et al. Can J Psychiatry. 2020 Aug;65(8):521-30. National Institutes of Health. National Human Genome Research Institute. Genome Statute and Legislative Database. Clinical Pharmacogenetics Implementation Consortium. CPIC guidelines.. Pharmacogenetics Knowledge Base. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Lorenzo Norris, MD, speaks with Tonya Cross Hansel, PhD, about processing incidents such as the Jan. 6, 2021, siege on the Capitol, and determining how to foster recovery. Dr. Hansel is an associate professor with the Tulane University School of Social Work in New Orleans. She has no conflicts of interest. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Hansel’s research focuses on measuring traumatic experiences and implementing systematic recovery initiatives that address negative symptoms by emphasizing individual and community strengths. The tendency to come together in times of vulnerability is a human instinct. The Jan. 6 Capitol siege was a traumatic and polarizing event; in a Pew survey 1 week later, 37% of respondents expressed a strong negative emotion in response to the riot. The unpreparedness of the U.S. Capitol Police and other law enforcement agencies led to fear and shock as much of the nation watched the breach unfold in real time on television. A variety of groups attended the protest. Some groups were involved in domestic terrorism, and others were part of political groups who came protest their grievances against the government. Those who attended the event with the intent of engaging in violence and instilling fear are considered domestic terrorists. Dr. Hansel said an event such as the insurrection wears on society by causing chronic stress, and one-time events such as the insurrection can lead to a prolonged state of anxiety. Terrorism and violence are sometimes triggered by disenfranchisement when violence seems like the only way to make one’s voice heard. Disasters with an economic fallout, such as natural disasters or the ongoing COVID-19 pandemic, can result in greater disenfranchisement. Prevention of future attacks and domestic terrorism must balance people’s ability to speak out and protest with an effort to avoid disenfranchisement. The way forward must also include addressing chronic fear. Dr. Hansel suggests that building community over shared values is a powerful way to foster resilience after disaster. In the pandemic, we have all experienced sacrifice and hardship. When society moves beyond survival mode, efforts must be made to connect over our shared sense of loss. References Hartig H. In their own words: How Americans reacted to the rioting at the U.S. Capitol. Pew Research Center. 2021 Jan 15. Pape RA and Ruby K. The Capitol rioters aren’t like other extremists. The Atlantic. 2021 Feb 2. Ellis BH et al. Studies in Conflict & Terrorism. 2019 May 31. doi: 10.1080/1057610X.2019.1616929. Hansel T et al. Traumatology. 2020;26(3):278-84. Saltzman LY et al. Curr Psychiatry Rep. 2017 Jun 19. doi: 10.1007/s/1920-017-0786-6. Hall BJ et al. PLoS One. 2015 Apr 24. doi 10.1371/journal.pone.0124782. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

One wouldn't think autism spectrum disorder belonged in the same universe as narcissistic personality disorder. Yet sometimes emotional disconnection and seeming lack of empathy leads to miscommunication. There is one key difference, however. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.