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Lee JS, Dean E, Jimenez XF. Cannabis use in delusional infestation with folie à deux. Journal of Substance Use 2020. [DOI: 10.1080/14659891.2020.1833094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jason S. Lee
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin Dean
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xavier F. Jimenez
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Tricyclic antidepressants (TCAs) were originally designed and marketed for treating depression, but over time they have been applied to a variety of conditions, mostly off-label. TCAs can serve as first-line or augmenting drugs for neuropathic pain, headache, migraine, gastrointestinal syndromes, fibromyalgia, pelvic pain, insomnia, and psychiatric conditions other than depression. This article reviews pharmacology, dosing, and safety considerations for these uses.
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Affiliation(s)
- Joanne Schneider
- Center for Comprehensive Pain Recovery, Neurological Institute, Cleveland Clinic
| | - Mary Patterson
- Center for Comprehensive Pain Recovery, Neurological Institute, Cleveland Clinic
| | - Xavier F Jimenez
- Center for Comprehensive Pain Recovery, Neurological Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Fayed AA, Aung NM, Manger KM, Jimenez XF. Improving Psychiatric and Complex Case Formulation: an Assessment of the Accuracy and Time to Complete the Biopsychosocial/Three Ps (BPS/PPP) Approach. Acad Psychiatry 2020; 44:64-67. [PMID: 31673956 DOI: 10.1007/s40596-019-01122-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/30/2019] [Accepted: 09/18/2019] [Indexed: 06/10/2023]
Affiliation(s)
| | - Ngu M Aung
- MetroHealth Medical Center, Cleveland, OH, USA
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Jimenez XF, Nkanginieme N, Dhand N, Karafa M, Salerno K. Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis. Gen Hosp Psychiatry 2020; 62:93-95. [PMID: 30777298 DOI: 10.1016/j.genhosppsych.2019.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 01/23/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Consultation psychiatrists are often asked to assess factitious disorder (FD), yet this is challenging as confirmation depends on rarely achieved direct evidence of illness-inducing behaviors. Diagnosis is thus based on other variables, such as atypical features of the medical presentation and certain patient behaviors. This study sought to assess a cohort of patients with FD for demographic and clinical variables, but also psychological and behavioral ones unexamined in previous studies. METHODS 49 previously-identified FD patients at a single site were reviewed retrospectively and variables collected included demographic, medical, psychiatric, social, behavioral, and treatment-related. Descriptive statistical analysis was used. RESULTS Patients were mostly: 1) under age 40 (82%), 2) female (90%), 3) with past psychiatric (92%), family psychiatric (78%), and traumatic (69%) histories; 4) direct intravenous access (67%); and 7) some exposure to healthcare training (67%). All (100%) subjects had an identifiable family dynamic issue, including household abuse, parental divorce, parental influence/enmeshment, grief, and/or significant other conflict. Financial, emotional, or social incentives were common, and most patients (88%) exhibited at least 4 FD-related behaviors. CONCLUSION FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables previously unexplored. Future investigational, educational, and quality improvement directions are considered.
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Affiliation(s)
- Xavier F Jimenez
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America; Quantitative Health Statistics, Cleveland Clinic, Cleveland, OH, United States of America.
| | - Ngozi Nkanginieme
- Massachusetts General Hospital, Boston, MA, United States of America
| | - Niyati Dhand
- Meridian Partners, Chicago, IL, United States of America
| | - Matt Karafa
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America
| | - Karen Salerno
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America
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Marek RJ, Anderson JL, Tarescavage AM, Martin-Fernandez K, Haugh S, Block AR, Heinberg LJ, Jimenez XF, Ben-Porath YS. Elucidating somatization in a dimensional model of psychopathology across medical settings. J Abnorm Psychol 2019; 129:162-176. [PMID: 31599632 DOI: 10.1037/abn0000475] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Research using a categorical-polythetic classification system for mental illness has raised concern regarding the validity of categorical classification systems. Recent efforts suggest psychopathology is better understood from a dimensional framework, though there has been varying evidence of a somatization factor. The current investigation seeks to produce and validate a dimensional model of psychopathology, with a particular emphasis on the placement of somatization, across three nonoverlapping medical samples. Using a bariatric surgery seeking sample (n = 1,268), a spine surgery/spinal cord stimulator seeking sample (n = 1,711), and a chronic pain treatment seeking sample (n = 1,388), a dimensional model of psychopathology was replicated across all three samples using a dimensional measure of psychopathology (the Minnesota Multiphasic Personality Inventory-2-Restructured Form [MMPI-2-RF]). Clear evidence of a separate somatization factor was found in addition to broad internalizing, externalizing, and social detachment factors. Constructs assessable with the model yielded good convergent and discriminant validity coefficients with external criteria, and further supported the presence of a higher-order somatization construct. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Ryan J Marek
- Department of Clinical, Health, and Applied Sciences
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Affiliation(s)
- Xavier F Jimenez
- Medical Director, Chronic Pain Rehabilitation Program, Cleveland Clinic, Cleveland, OH, USA. .,Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Jimenez XF. Parallel Pains and Dynamic Dilemmas: Psychodynamic Considerations in Approaching and Managing Chronic Physical Pain. Psychodyn Psychiatry 2019; 47:167-182. [PMID: 31107168 DOI: 10.1521/pdps.2019.47.2.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Chronic physical pain is prevalent condition and has gained considerable attention in the wake of the opioid crisis and epidemic. As a medical phenomenon, it has highlighted significant gaps in healthcare training, finances, clinical service, and administration. The psychodynamic determinants of pain symptoms or the need for analgesia are rarely considered in the medical management of this problem. The specific objective of this article is to offer a general psychodynamic understanding of chronic physical pain. As a psychodynamically oriented, medically informed psychiatrist practicing in a multidisciplinary pain management program, I propose a clinical construct of psychologically rich "parallel pains" to chronic physical pain, and that these pains inform important interpersonal issues dubbed "dynamic dilemmas." Chronic physical pain is defined, clinical examples are provided, and general implications are considered.
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Jimenez XF, Shirvani N, Hogue O, Karafa M, Tesar GE. Polyallergy (Multiple Chemical Sensitivity) is Associated with Excessive Healthcare Utilization, Greater Psychotropic Use, and Greater Mental Health/Functional Somatic Syndrome Disorder Diagnoses: A Large Cohort Retrospective Study. Psychosomatics 2019; 60:298-310. [DOI: 10.1016/j.psym.2018.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 11/26/2022]
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Jimenez XF. Severe Noncardiac Chest Pain Responds to Interdisciplinary Chronic Pain Rehabilitation. Psychosomatics 2018; 59:204-206. [PMID: 28800977 DOI: 10.1016/j.psym.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/05/2017] [Accepted: 07/06/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Xavier F Jimenez
- Psychiatry and Psychology, Cleveland Clinic Lerner College of Medicine, Neurological Institute, Center for Neurological Restoration, Chronic Pain Section Medical Director, Chronic Pain Rehabilitation Program, Cleveland Clinic, Cleveland, OH.
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Jimenez XF, Aboussssouan A, Mandell D, Huffman KL. Additional evidence supporting the central sensitization inventory (CSI) as an outcome measure among chronic pain patients in functional restoration program care. Spine J 2017; 17:1765. [PMID: 29150261 DOI: 10.1016/j.spinee.2017.08.225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Xavier F Jimenez
- Chronic Pain Rehabilitation Section, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195
| | - Alix Aboussssouan
- Chronic Pain Rehabilitation Section, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195
| | - Darcy Mandell
- Chronic Pain Rehabilitation Section, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195
| | - Kelly L Huffman
- Chronic Pain Rehabilitation Section, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195
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Pesanti S, Hamm B, Esplin B, Karafa M, Jimenez XF. Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors. Psychosomatics 2017; 58:483-489. [DOI: 10.1016/j.psym.2017.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/20/2017] [Accepted: 03/25/2017] [Indexed: 11/17/2022]
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Abstract
Objective Patient-physician interaction is continually examined in an era prioritizing patient-centered approaches, yet elaboration beyond aspects of communication and empathy is lacking. Major chronic conditions would benefit tremendously from understanding interpersonal aspects of patient-physician encounters. This review intends to provide a concise introduction to the interpersonal model of attachment theory and how it informs both the patient-physician interaction and medical outcomes in chronic care. Methods A narrative review of the theoretical, neurobiological, epidemiological, investigational, and clinical literature on attachment theory and its impact on medical outcomes was conducted, utilizing a variety of key words as searched on PubMed database. Studies and reviews included were of a variety of sources, including textbooks and peer-reviewed journals. Reports in languages other than English were excluded. Results Measurable, discrete attachment styles and behavioral patterns correlate with poor medical outcomes, including nonadherence in insecure dismissing attachment and care overutilization in insecure preoccupied attachment. Furthermore, insecure dismissing attachment is associated with significant mortality. These variables can be easily assessed, and their effects are reversible, as evidenced by collaborative care outcome data. Discussion Attachment theory is useful a model with application in clinical and investigational aspects of chronic illness care. Implications and guidelines are explored.
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Affiliation(s)
- Xavier F Jimenez
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA
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Hamm B, Khokhar N, Jimenez XF. Refractory Self-Injurious Behavior in Severe Intellectual Disability Responsive to Topiramate: A Case Report. Psychosomatics 2017; 58:209-212. [PMID: 28189287 DOI: 10.1016/j.psym.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Brandon Hamm
- Department of Psychiatry, A. Cleveland Clinic, Cleveland, OH.
| | - Naveed Khokhar
- Department of Psychiatry, A. Cleveland Clinic, Cleveland, OH
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Caro MA, Jimenez XF. Mesiotemporal Disconnection and Hypoactivity in Klüver-Bucy Syndrome: Case Series and Literature Review. J Clin Psychiatry 2016; 77:e982-8. [PMID: 27380585 DOI: 10.4088/jcp.14r09497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 08/18/2015] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Klüver-Bucy syndrome (KBS) is often perceived as rare and limited to cases with bilateral amygdala destruction. In fact, various alternate mechanisms may be involved, warranting exploration of the syndrome's presentation, pathophysiology, prognosis, and management. DATA SOURCES Clinical management and the electronic medical records were examined for 2 patients diagnosed with partial KBS (ICD-10 F07.0) after experiencing ≥ 3 of the following: placidity, indiscriminate dietary behavior, hyperorality, hypersexuality, visual agnosia, and hypermetamorphosis. A literature search was performed in April 2015 by using the keyword Kluver-Bucy in PubMed and Ovid databases for English language publications since inception. Additionally, the authors reviewed the reference list of these publications in order to identify additional reports. STUDY SELECTION Studies were included if they had information about presentation, pathophysiology, syndrome treatment or management, and course of KBS. DATA EXTRACTION Information about our KBS cases was obtained by reviewing electronic medical records and by direct observation of the patients. A total of 186 (PubMed) and 137 (Ovid) publications were identified in each database. We ultimately reviewed 109 articles containing information about KBS, finding 51 publications addressing relevant aspects of this syndrome. RESULTS The first case demonstrates KBS secondary to mesiotemporal structural atrophy, and the second illustrates transient KBS due to functional, postictal, hypoactivity within such structures. Literature review and discussion regarding both prognosis and treatment of KBS follows. CONCLUSIONS Klüver-Bucy syndrome may be underreported due to a limited understanding of the syndrome as one necessitating bilateral amygdaloid destruction. The syndrome can be seen with damage/hypofunction of the hippocampal-amygdaloid complex and its projections. The prognosis of KBS is variable, and its treatment is based on a combination of environmental and pharmacologic measures.
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Affiliation(s)
- Mario A Caro
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, 9500 Euclid Ave P57, Cleveland, OH, 44195. .,Neurological Institute, Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Ohio, USA
| | - Xavier F Jimenez
- Neurological Institute, Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Ohio, USA
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Jimenez XF, Tesar GE. Assessment Style in Psychogenic Nonepileptic Seizures: Bridging the Gap from Diagnosis to Care. Psychosomatics 2016; 57:440-2. [DOI: 10.1016/j.psym.2016.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 02/25/2016] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
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Abstract
Objective Psychosomatic medicine psychiatrists are often tasked with the evaluation and treatment of complex neuropsychiatric states which may be motoric in phenotype. Little energy has been dedicated to understanding acute movement disorders in the hospital environment. Method Recognizing the importance of frontal-subcortical (corticostriatothalamocortical) circuitry and basal ganglia structures, we present a case series of acute movement disorder phenotypes resulting from underlying medical conditions, commonly-administered medications, or the interaction of both. We organize these scenarios into neurodegenerative disorders, primary psychiatric disorders, neuroinflammation, and polypharmacy, demonstrating a clinical example of each followed by background references on a variety of clinical states and medications contributing to acute movement disorders. In addition, we offer visual illustration of implicated neurocircuitry as well as proposed neurotransmitter imbalances involving glutamate, gamma aminobutyric acid, and dopamine. Furthermore, we review the various clinical syndromes and medications involved in the development of acute movement disorders. Results Acute movement disorder's involve complex interactions between frontal-subcortical circuits and acute events. Given the complexity of interactions, psychopharmacological considerations become critical, as some treatments may alleviate acute movement disorders while others will exacerbate them. Conclusion Integrating underlying medical conditions and acutely administered (or discontinued) pharmacological agents offers an interactional, neuromedical approach to acute movement disorders that is critical to the work of psychosomatic medicine.
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Affiliation(s)
- Ifrah Zawar
- 1 Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mario A Caro
- 2 Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lara Feldman
- 2 Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xavier F Jimenez
- 2 Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, OH, USA.,3 Center for Neurological Restoration, Cleveland Clinic Foundation, Cleveland, OH, USA
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Kumari S, Sundararajan T, Caro MA, Oliver J, Wright CA, Prayson R, Havemann J, Jimenez XF. Argyrophilic Grain Disease Presenting as Excited Catatonia: A Case Report. Psychosomatics 2016; 57:431-8. [DOI: 10.1016/j.psym.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
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Jimenez XF, Bautista JF, Tilahun BS, Fan Y, Ford PJ, Tesar GE. Bridging a clinical gap in psychogenic nonepileptic seizures: Mental health provider preferences of biopsychosocial assessment approaches. Epilepsy Behav 2016; 56:149-52. [PMID: 26878459 DOI: 10.1016/j.yebeh.2015.12.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/02/2015] [Accepted: 12/24/2015] [Indexed: 11/28/2022]
Abstract
Management of psychogenic nonepileptic seizures (PNES) is complex, requiring multidisciplinary care. A standardized assessment and formulation approach to PNES is lacking, yet use of a comprehensive model may alleviate problems such as mental health aftercare noncompliance. Although a biopsychosocial (BPS) approach to PNES balancing predisposing, precipitating, and perpetuating (PPP) variables has been described and has been recently tested in pilot form, it is unclear how this assessment style is perceived among community mental health practitioners such as psychotherapists (including psychologists, counselors, and social workers). We predicted preference of a comprehensive "BPS/PPP" assessment style by those most involved in PNES care (i.e., community psychotherapists). One hundred and forty-three community-based social workers and counselors completed a survey featuring a fictional PNES case followed by assessment style options ("Multiaxial," "Narrative," and "BPS/PPP"). Respondents clearly preferred the robust BPS/PPP approach over less-comprehensive multiaxial and narrative assessments (p<0.0001). Reasons for choosing the BPS/PPP by respondents include ease of organization, clear therapeutic goals, and comprehensive nature. This assessment of acceptability of a BPS/PPP approach to PNES assessment among community mental health practitioners may provide a patient-centered mechanism to enhance referrals from the neurological to mental health setting. Implications and future directions are explored.
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Affiliation(s)
- Xavier F Jimenez
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA; NeuroEthics Program, Cleveland Clinic Foundation, USA.
| | - Jocelyn F Bautista
- Epilepsy Center, Cleveland Clinic Foundation, USA; Department of Neurology, Cleveland Clinic Foundation, USA
| | - Bikat S Tilahun
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA; Epilepsy Center, Cleveland Clinic Foundation, USA
| | - Youran Fan
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, USA
| | - Paul J Ford
- NeuroEthics Program, Cleveland Clinic Foundation, USA
| | - George E Tesar
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA; Epilepsy Center, Cleveland Clinic Foundation, USA
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Sundararajan T, Tesar GE, Jimenez XF. Biomarkers in the diagnosis and study of psychogenic nonepileptic seizures: A systematic review. Seizure 2015; 35:11-22. [PMID: 26774202 DOI: 10.1016/j.seizure.2015.12.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/22/2015] [Accepted: 12/24/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Video electroencephalography (vEEG) is the gold-standard method for diagnosing psychogenic nonepileptic seizures (PNES), but such assessment is expensive, unavailable in many centers, requires prolonged hospitalization, and many times is unable to capture an actual seizure episode. This paper systematically reviews other non-vEEG candidate biomarkers that may facilitate both diagnosis and study of PNES as differentiated from epileptic seizures (ES). METHODS PubMed database was searched to identify articles between 1980 and 2015 (inclusion: adult PNES population with or without controls, English language; exclusion: review articles, meta-analyses, single case reports). RESULTS A total of 49 studies were examined, including neuroimaging, autonomic nervous system, prolactin, other (non-prolactin) hormonal, enzyme, and miscellaneous marker studies. Functional MRI studies have shown PNES is hyperlinked with dissociation and emotional dysregulation centers in the brain, although conflicting findings are seen across studies and none used psychiatric comparators. Heart rate variability suggests increased vagal tone in PNES when compared to ES. Prolactin is elevated in ES but not PNES, although shows low diagnostic sensitivity. Postictal cortisol and creatine kinase are nonspecific. Other miscellaneous biomarkers (neuron specific enolase, brain derived neurotropic factor, ghrelin, leptin, leukocytosis) showed no conclusive evidence of utility. Many studies are limited by lack of psychiatric comparators, size, and other methodological issues. CONCLUSION No single biomarker successfully differentiates PNES from ES; in fact, PNES is only diagnosed via the negation of ES. Clinical assessment and rigorous investigation of psychosocial variables specific to PNES remain critical, and subtyping of PNES is warranted. Future investigational and clinical imperatives are discussed.
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Affiliation(s)
- T Sundararajan
- Cleveland Clinic Department of Psychiatry and Psychology, United States
| | - G E Tesar
- Cleveland Clinic Department of Psychiatry and Psychology, United States; Cleveland Clinic Epilepsy Center, United States
| | - X F Jimenez
- Cleveland Clinic Department of Psychiatry and Psychology, United States.
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Affiliation(s)
- Nicole Shirvani
- Department of Psychiatry and Psychology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Xavier F. Jimenez
- Department of Psychiatry and Psychology; Cleveland Clinic Foundation; Cleveland Ohio
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Jimenez XF, Esplin BS, Hernandez JO. Capacity Consultation and Contextual Complexities: Depression, Decisions, and Deliberation. Psychosomatics 2015; 56:592-7. [DOI: 10.1016/j.psym.2015.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
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Jimenez XF, Bautista JF, Tesar GE, Fan Y. Diagnostic assessment and case formulation in psychogenic nonepileptic seizures: A pilot comparison of approaches. Epilepsy Behav 2015; 45:164-8. [PMID: 25812942 DOI: 10.1016/j.yebeh.2015.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 01/29/2015] [Accepted: 02/01/2015] [Indexed: 11/30/2022]
Abstract
Management of psychogenic nonepileptic seizures (PNES) is complex, requiring multidisciplinary care. A standardized assessment approach to PNES is lacking, yet use of a comprehensive model may alleviate problems such as mental health aftercare noncompliance. Although a biopsychosocial (BPS) approach to PNES balancing predisposing, precipitating, and perpetuating (PPP) variables has been described, it is unclear how this formulation style is perceived amongst clinicians. We predicted preference of a comprehensive, "BPS/PPP" assessment style by those most involved in PNES diagnosis and care (i.e., neurologists and psychologists). Sixty epileptologists, psychiatrists, and psychologists completed a survey featuring a fictional PNES case followed by assessment style options ("Multiaxial," "Narrative," and "BPS/PPP"). Epileptologists and psychologists ("nonpsychiatrists") differed from psychiatrists in PNES case formulation choice, with nonpsychiatrists preferring the robust BPS/PPP approach and with psychiatrists opting for less comprehensive Multiaxial and Narrative assessments (p=0.0009). Reasons for choosing the BPS/PPP by nonpsychiatrists included ease of organization, clear therapeutic goals, and comprehensive nature. Alternatively, psychiatrists cited time constraints and familiarity as reasons to prefer briefer Multiaxial or Narrative approaches. This pilot assessment of acceptability of a BPS/PPP approach to PNES case formulation, thus, reveals important gaps in formulation priorities between neurologists and psychiatrists. Implications and future directions are explored.
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Affiliation(s)
- Xavier F Jimenez
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA.
| | | | - George E Tesar
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA
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Jimenez XF, Azzam PN, Gopalan P. Teaching a neuromedical-contextual approach to psychosomatic medicine. Acad Psychiatry 2015; 39:204-211. [PMID: 25026951 DOI: 10.1007/s40596-014-0193-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 06/20/2014] [Indexed: 06/03/2023]
Abstract
The practice of psychosomatic medicine in the general hospital setting can be challenging, particularly for the inexperienced trainee. Guidance for how to approach a psychiatric consultation can be nonspecific or lacking altogether. In response, we offer a pedagogical model that emphasizes patient-specific neurological, medical, and contextual variables. A stepwise, "ABC" approach to psychiatric consultation is elaborated, beginning with collection of critical history ("Admission, Background, Consultation Question"), followed by both patient encounter ("Appearance, Behavior, Context") and actual patient examination ("Arousal, Brain/Body, Cognitive Assessment"), ultimately informing any given case formulation. Multiple clinical vignettes illustrate this approach and are offered for educational purposes in dissemination to trainees.
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Jimenez XF, Tesar GE. Polyallergy as a Proxy: Premature Yet Promising. Psychosomatics 2015; 56:606-7. [PMID: 26362918 DOI: 10.1016/j.psym.2015.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Xavier F Jimenez
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH
| | - George E Tesar
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH
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Wang L, Holthaus EA, Jimenez XF, Tavee J, Li Y. MRI evolution of CLIPPERS syndrome following herpes zoster infection. J Neurol Sci 2015; 348:277-8. [DOI: 10.1016/j.jns.2014.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/22/2014] [Accepted: 11/17/2014] [Indexed: 12/11/2022]
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Jimenez XF, Hernandez JO, Robinson EM. When mediation fails: identifying and working with inappropriate surrogate decision makers. Progress in Palliative Care 2014. [DOI: 10.1179/1743291x14y.0000000115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Jimenez XF, Sharma JS, Dar SA. Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: a case report. Gen Hosp Psychiatry 2014; 36:761.e1-2. [PMID: 25103545 DOI: 10.1016/j.genhosppsych.2014.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 11/27/2022]
Abstract
Psychogenic nonepileptic seizures (PNES), a form of conversion disorder, are paroxysmal episodes resembling epilepsy while lacking electrographic correlation. The phenomenon has rarely been reported in elderly patients and has not been associated with a new-onset medical diagnosis. We present the case of an 81-year-old female with no past psychiatric or traumatic history who developed PNES within the context of a new, suspected cancer. To our knowledge, this is the first such reported case of a suspected cancer (or otherwise medical) diagnosis contributing directly and temporally to the development of PNES. Discussion of involved psychosocial variables follows the vignette, and a brief review of relevant literature is offered.
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Affiliation(s)
- Xavier F Jimenez
- Cleveland Clinic Foundation, Department of Psychiatry and Psychology, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA.
| | - Jennifer S Sharma
- Cleveland Clinic Foundation, Department of Psychiatry and Psychology, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA
| | - Syma A Dar
- Cleveland Clinic Foundation, Department of Psychiatry and Psychology, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA
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Abstract
Therapeutic work with patients who are chronically suicidal and have borderline personality disorder (BPD) is challenging, and clinicians often resort to setting firm limits or excessively cautious interventions in efforts to prevent manipulation, regression, or over-dependence. Litigation and malpractice fears reinforce these stances, and reduced compensation for additional time and energy devoted to patients adds further disincentives to sole providers. However, elements of the working alliance and therapeutic limits are within the therapist's control. A case vignette illustrates an individual therapist's modification of usual therapeutic limits while working with a chronically suicidal patient with BPD within a dialectical behavior therapy (DBT) framework over a 16-week period. Discussions regarding the case, interventions used, DBT, and legality concerns follow.
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Affiliation(s)
- Xavier F Jimenez
- Department of Psychiatry, Massachusetts General Hospital, Warren 605, 55 Fruit Street, Boston, MA 02114, USA.
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Simon CM, Zyzanski SJ, Durand E, Jimenez XF, Jimenez X, Kodish ED. Interpreter accuracy and informed consent among Spanish-speaking families with cancer. J Health Commun 2006; 11:509-22. [PMID: 16846951 DOI: 10.1080/10810730600752043] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Language interpreters mediate a growing number of health care communication events, including the informed consent process, which underlies the ethical conduct of clinical research. This article explores a key interpretive outcome, accuracy, in 21 Spanish/English informed consent consultations. Discussions were transcribed, translated, and coded according to established techniques. Most (74%) discussion was accurately interpreted (range: 47%-98%; std. deviation: .137). Accuracy was lower in the more technical portions of the discussion when compared with nontechnical portions such as discussion of coping and quality-of-life issues (p = .024). The concept of "randomization" often was poorly communicated and interpreted. These differences may be due in part to the use of long, uninterrupted, and jargon-filled sentences by clinicians explaining research, among other factors. The article concludes that accuracy may be promoted if clinicians used less technical language and shorter sentences, and are more "process driven." Interpreters may need to be better informed about research-related concepts such as randomization. Further research is needed to determine the effects of interpretive accuracy on the informed consent process, the decision to participate in research, and other outcomes.
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Affiliation(s)
- Christian M Simon
- Bioethics Department, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA.
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