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Diagnosing Demoralization in Consultation Psychiatry
Letters to the Editor tremely elevated triglyceride level of 846 mg/dl. Mr. A. denied physical complaints, describing having started an exercise program in the absence of weight gain. Alcohol use was still minimal without other routine medications. His triglyceride elevation was confirmed 9 days later with a fasting level of 877 mg/dl. The citalopram was discontinued over 3 days. At this time, pre-antidepressant lipid profiles from 1993 and 1994 were located. Respective triglyceride levels were 200 mg/dl and 211 mg/dl. Alprazolam (0.25 mg) was added as-needed for anxiety while continuing with intermittent mirtazapine (30 mg) for insomnia. No other medications were used over the 3-week interval until the fasting lipid profile was repeated (577 mg/dl). Another level was performed 24 days after (692 mg/dl), although at a different laboratory than the 1996–October 1999 tests. The primary care physician recommended gemfibrozil (600 mg daily) to treat hypertriglyceridemia, while fluoxetine (20 mg daily) was restarted for recurrent depression. Mr. A.’s last lipid profile, drawn within 1 week of these medications being started, reflected almost full triglyceride normalization (223 mg/dl).
TABLE 1.
DISCUSSION
References
There are no apparent variables outside of fluoxetine and citalopram use that explain the hypertriglyceridemia. Baseline levels were generally in a normal range. Elevation was seen only after administration of these medications. Significant elevation was seen with fluoxetine use, and severe elevation was seen with citalopram use. The triglyceride level decreased on discontinuation of citalopram, although in a nonlinear fashion. The third postcitalopram triglyceride level included newly introduced variables (fluoxetine was added 6 days and gemfibrozil 7 days prior) and reflected a return to baseline. It is unlikely that these medications significantly influenced the lipid levels in this time span.5 Of significance, Mr. A. had no complaints or risk factors to aid in the diagnostic process. There is no known etiology to explain the hypertriglyceridemia, which raises the importance of labwork with antidepressant use. Additional studies may be required for clarification of the risk for SSRI-induced hypertriglyceridemia. Marshall Teitelbaum, M.D. Palm Beach Gardens, FL
1. Scheen AJ: How I investigate hypertriglyceridemia. Rev Med Liege 1998; 53:103–105 2. Hozumia Y, Kawano M, Miyata M: Severe hypertriglyceridemia caused by tamoxifentreatment after breast cancer surgery. Endocr J 1997; 44:745–749 3. Suga S, Tamasawa N, Kinpara I, et al: Identification of homozygous lipoprotein lipase gene mutation in a woman with recurrent aggravation of hypertriglyceridemia induced by pregnancy. J Intern Med 1998; 243:317– 321 4. Muldoon C: The safety and tolerability of citalopram. Int Clin Psychopharmacol 1996; 11:35–40 5. Jeng J, Jeng C, Sheu W, et al: Gemfibrozil treatment of hypertriglyceridemia: improvement on fibrinolysis without change of insulin resistance. Am J Heart 1997; 134:565– 571
Diagnosing Demoralization in Consultation Psychiatry TO THE EDITOR: Dr. Slavney’s stimulating article, “Diagnosing Demoralization in Consultation Psychiatry,” is a valuable addition to the ongoing debate on demoralization.1 Dr. Slavney states that demoralization is a normal response to adversity and that he disagrees with my proposal to substitute “demoralization” for “severity of psychosocial stressors” as Axis IV in the DSM. Although demoralization may, at
Lipid profile progression
Test Date
Total Cholesterol Level(mg/dl)
Total Triglyceride Level(mg/dl)
HDL Cholesterol (mg/dl)
Antidepressant Used(mg/daily)
1993 1994 12/95 2/96 10/96 9/8/99 9/18/99 10/12/99 11/05/99 11/16/99
176 161 276 250 N/A 382 304 225 284 198
200 211 N/A 509 490 846 877 577 692 223
N/A N/A N/A 34 N/A 45 27 33 25 37
— — Fluoxetine(20) Fluoxetine(20) Fluoxetine(20) Citalopram(30) Citalopram(30) — — 11/10/99 Fluoxetine(20)*
Note: N/A⳱not applicable; *included gemfibrozil (600 mg/daily) starting 11/09/99.
Psychosomatics 41:5, September-October 2000
449
Letters to the Editor times, be understandable, as in the cases described by Dr. Slavney, the view I proposed is that demoralization is always abnormal. It is because demoralization is abnormal that it requires treatment (psychotherapy). I proposed that demoralization be conceptualized as involving two states: distress (which some other authors have called “demoralization,” incorrectly in my opinion) and subjective incompetence. Although each of these two states may be normal by itself, their overlap would constitute demoralization, which is always abnormal. Demoralization is thus viewed as a boundary phenomenon, that is, a state that occurs within the individual and at the boundary with the environment, something akin to inflammation. In psychiatry and other fields of medicine, diagnosis refers to events that occur within the individual. By contrast, Axis IV in the DSM refers to events that occur in settings outside the individual, such as the primary support group, the legal domain, social environment, housing, place of education, place of occupation, or source of income. It would seem more appropriate to conceptualize Axis IV as the demoralization axis, perhaps with separate ratings for distress and subjective incompetence. Because demoralization may lead to severe complications, including suicide, it would seem more meaningful to recognize it for a separate axis, rather than relegate it to a V code. John de Figueiredo, M.D., Sc.D. References
1. Slavney PR: Diagnosing demoralization in consultation psychiatry. Psychosomatics 1999; 40:325–329
Reply to Dr. de Figueiredo TO THE EDITOR: Dr. de Figueiredo proposes that demoralization is always ab450
normal and requires treatment. If this was the case, psychotherapy should be prescribed for many defeated soldiers, failing students, laid-off workers, and slumping batters. We usually do not think these individuals have psychiatric disorders when they are demoralized; only that they have been overmastered by their circumstances. I regard the medical and surgical patients I have described as no different. Like other demoralized people, they benefit from understanding and encouragement, but that does not mean their response to adversity is abnormal. I support Dr. de Figueiredo’s efforts to distinguish demoralization from depression,1 though I believe the difference is between a normal dysphoric state and a pathological one. Phillip Slavney, M.D.
References
1. de Figueiredo JM: Depression and demoralization: phenomenologic differences and research perspectives. Compr Psychiatry 1993; 34:308–311
Illusion or Hallucination? Cholecystitis Presenting as Pseudopregnancy in Schizophrenia TO THE EDITOR: Pseudopregnancy as the presenting sign of a medical illness is a rarely reported psychiatric condition. However, it has been reported in association with alcohol-induced liver failure,1 systemic lupus erythematosus,2 abdominal neoplasia,3 persistent corpus luteum,4 pituitary tumor,5 and hyponatremia.6 There is only one reference to pseudopregnancy as the presenting symptom of abdominal surgery—in that case, the patient swallowed open safety pins.7 A nonpregnant woman presenting with a fixed, false belief that she is pregnant is often diagnosed with pseudocy-
esis. However, in these cases the disorder of thought content is limited strictly to the insistence on being pregnant despite medical evidence to the contrary. As this patient’s disorder was likely an extension of her underlying schizophrenia, it would not correctly be categorized as pseudocyesis.8 I present here the case of a patient who presented with a false pregnancy and offer a discussion of the misinterpretation of physical symptoms by some psychiatric patients. Case Report Ms. W., a mildly obese African American woman in her late thirties, presented to the emergency room (ER) screaming with pain, stating she was 9 months pregnant and about to deliver. Both the ER physician and the obstetrics resident examined her. A quantitative B-HCG and an ultrasound were obtained. The results of both studies were negative. When Ms. W. was told she was not pregnant, she angrily cursed at the ER staff, claiming that they were colluding in a plot against her and her baby. On physical examination, she appeared of stated age with a significantly distended abdomen. Ms. W.’s umbilicus was inverted, and she had normal bowel sounds. No abdominal palpation was documented. Gynecologic exam revealed no other changes associated with pregnancy. The remainder of the physical examination was unremarkable. Psychiatry was consulted. Ms. W.’s medical records indicated a long history of schizophrenia treated with trifluoperazine (Stelazine), a typical antipsychotic. As she persisted in her belief of pregnancy, she was admitted to the inpatient psychiatry unit. On further interview, Ms. W. persisted in her belief of being pregnant. She stated she had been pregnant 10 or more times and that “doctors from
Psychosomatics 41:5, September-October 2000
TABLE 1.
DISCUSSION
References
There are no apparent variables outside of fluoxetine and citalopram use that explain the hypertriglyceridemia. Baseline levels were generally in a normal range. Elevation was seen only after administration of these medications. Significant elevation was seen with fluoxetine use, and severe elevation was seen with citalopram use. The triglyceride level decreased on discontinuation of citalopram, although in a nonlinear fashion. The third postcitalopram triglyceride level included newly introduced variables (fluoxetine was added 6 days and gemfibrozil 7 days prior) and reflected a return to baseline. It is unlikely that these medications significantly influenced the lipid levels in this time span.5 Of significance, Mr. A. had no complaints or risk factors to aid in the diagnostic process. There is no known etiology to explain the hypertriglyceridemia, which raises the importance of labwork with antidepressant use. Additional studies may be required for clarification of the risk for SSRI-induced hypertriglyceridemia. Marshall Teitelbaum, M.D. Palm Beach Gardens, FL
1. Scheen AJ: How I investigate hypertriglyceridemia. Rev Med Liege 1998; 53:103–105 2. Hozumia Y, Kawano M, Miyata M: Severe hypertriglyceridemia caused by tamoxifentreatment after breast cancer surgery. Endocr J 1997; 44:745–749 3. Suga S, Tamasawa N, Kinpara I, et al: Identification of homozygous lipoprotein lipase gene mutation in a woman with recurrent aggravation of hypertriglyceridemia induced by pregnancy. J Intern Med 1998; 243:317– 321 4. Muldoon C: The safety and tolerability of citalopram. Int Clin Psychopharmacol 1996; 11:35–40 5. Jeng J, Jeng C, Sheu W, et al: Gemfibrozil treatment of hypertriglyceridemia: improvement on fibrinolysis without change of insulin resistance. Am J Heart 1997; 134:565– 571
Diagnosing Demoralization in Consultation Psychiatry TO THE EDITOR: Dr. Slavney’s stimulating article, “Diagnosing Demoralization in Consultation Psychiatry,” is a valuable addition to the ongoing debate on demoralization.1 Dr. Slavney states that demoralization is a normal response to adversity and that he disagrees with my proposal to substitute “demoralization” for “severity of psychosocial stressors” as Axis IV in the DSM. Although demoralization may, at
Lipid profile progression
Test Date
Total Cholesterol Level(mg/dl)
Total Triglyceride Level(mg/dl)
HDL Cholesterol (mg/dl)
Antidepressant Used(mg/daily)
1993 1994 12/95 2/96 10/96 9/8/99 9/18/99 10/12/99 11/05/99 11/16/99
176 161 276 250 N/A 382 304 225 284 198
200 211 N/A 509 490 846 877 577 692 223
N/A N/A N/A 34 N/A 45 27 33 25 37
— — Fluoxetine(20) Fluoxetine(20) Fluoxetine(20) Citalopram(30) Citalopram(30) — — 11/10/99 Fluoxetine(20)*
Note: N/A⳱not applicable; *included gemfibrozil (600 mg/daily) starting 11/09/99.
Psychosomatics 41:5, September-October 2000
449
Letters to the Editor times, be understandable, as in the cases described by Dr. Slavney, the view I proposed is that demoralization is always abnormal. It is because demoralization is abnormal that it requires treatment (psychotherapy). I proposed that demoralization be conceptualized as involving two states: distress (which some other authors have called “demoralization,” incorrectly in my opinion) and subjective incompetence. Although each of these two states may be normal by itself, their overlap would constitute demoralization, which is always abnormal. Demoralization is thus viewed as a boundary phenomenon, that is, a state that occurs within the individual and at the boundary with the environment, something akin to inflammation. In psychiatry and other fields of medicine, diagnosis refers to events that occur within the individual. By contrast, Axis IV in the DSM refers to events that occur in settings outside the individual, such as the primary support group, the legal domain, social environment, housing, place of education, place of occupation, or source of income. It would seem more appropriate to conceptualize Axis IV as the demoralization axis, perhaps with separate ratings for distress and subjective incompetence. Because demoralization may lead to severe complications, including suicide, it would seem more meaningful to recognize it for a separate axis, rather than relegate it to a V code. John de Figueiredo, M.D., Sc.D. References
1. Slavney PR: Diagnosing demoralization in consultation psychiatry. Psychosomatics 1999; 40:325–329
Reply to Dr. de Figueiredo TO THE EDITOR: Dr. de Figueiredo proposes that demoralization is always ab450
normal and requires treatment. If this was the case, psychotherapy should be prescribed for many defeated soldiers, failing students, laid-off workers, and slumping batters. We usually do not think these individuals have psychiatric disorders when they are demoralized; only that they have been overmastered by their circumstances. I regard the medical and surgical patients I have described as no different. Like other demoralized people, they benefit from understanding and encouragement, but that does not mean their response to adversity is abnormal. I support Dr. de Figueiredo’s efforts to distinguish demoralization from depression,1 though I believe the difference is between a normal dysphoric state and a pathological one. Phillip Slavney, M.D.
References
1. de Figueiredo JM: Depression and demoralization: phenomenologic differences and research perspectives. Compr Psychiatry 1993; 34:308–311
Illusion or Hallucination? Cholecystitis Presenting as Pseudopregnancy in Schizophrenia TO THE EDITOR: Pseudopregnancy as the presenting sign of a medical illness is a rarely reported psychiatric condition. However, it has been reported in association with alcohol-induced liver failure,1 systemic lupus erythematosus,2 abdominal neoplasia,3 persistent corpus luteum,4 pituitary tumor,5 and hyponatremia.6 There is only one reference to pseudopregnancy as the presenting symptom of abdominal surgery—in that case, the patient swallowed open safety pins.7 A nonpregnant woman presenting with a fixed, false belief that she is pregnant is often diagnosed with pseudocy-
esis. However, in these cases the disorder of thought content is limited strictly to the insistence on being pregnant despite medical evidence to the contrary. As this patient’s disorder was likely an extension of her underlying schizophrenia, it would not correctly be categorized as pseudocyesis.8 I present here the case of a patient who presented with a false pregnancy and offer a discussion of the misinterpretation of physical symptoms by some psychiatric patients. Case Report Ms. W., a mildly obese African American woman in her late thirties, presented to the emergency room (ER) screaming with pain, stating she was 9 months pregnant and about to deliver. Both the ER physician and the obstetrics resident examined her. A quantitative B-HCG and an ultrasound were obtained. The results of both studies were negative. When Ms. W. was told she was not pregnant, she angrily cursed at the ER staff, claiming that they were colluding in a plot against her and her baby. On physical examination, she appeared of stated age with a significantly distended abdomen. Ms. W.’s umbilicus was inverted, and she had normal bowel sounds. No abdominal palpation was documented. Gynecologic exam revealed no other changes associated with pregnancy. The remainder of the physical examination was unremarkable. Psychiatry was consulted. Ms. W.’s medical records indicated a long history of schizophrenia treated with trifluoperazine (Stelazine), a typical antipsychotic. As she persisted in her belief of pregnancy, she was admitted to the inpatient psychiatry unit. On further interview, Ms. W. persisted in her belief of being pregnant. She stated she had been pregnant 10 or more times and that “doctors from
Psychosomatics 41:5, September-October 2000