As is common in psychiatric practice and on the board exam, you are likely to interview a patient who has a long history of psychiatric illness. When you ask the patient to expand on their chief complaint(s), the patient will often start at the beginning. What the patient conveys about their life and illness is often both interesting and valuable. And thus, the interviewing psychiatrist is lulled away from the realization that the history is NOT focusing on the most recent past.

It is the most recent past that minute for minute is the most valuable history because it conveys the patients current or recent stresses, triggers, nature and severity of illness, and treatment. It is the most valuable in identifying potential upcoming stresses and triggers that can lead to high-risk behaviors, such as suicide attempts, self-injurious behavior, violence towards others, or decompensation more generally.

So, one clear message to repeat in your mind as you are interview a patient on the oral boards is that you MUST focus on the HPI. Not exclusively, of course, but to much higher degree than many candidates do.

Before I go on to an organizing method for HPIs, let me define it first. For the purposes of the board exam, the HPI consists in the current or most recent episode or exacerbation of illness. Some patients are curently in the midst of a decompensation while others are in the phase of full or partial remission. So, the HPI starts with the start of the last episode or exacerbation. Note also that patients who have clear episodes of decompensation and remission, identifying the episode is straight-forward. Many persons with mental illness, however, do not have such on-off pattern. For many, it is a pattern of chronic symptoms and dysfunction. What do you do in these cases? Look for evidence of an exacerbation of illness, one that can be identified by a hospitalization or by an increased level of care or supervision.

Now let’s focus on how to organize your HPI as you interview the patient. It is helpful to divide it up into 4 sections: beginning, middle, end, future.

BEGINNING: Identify when and what triggered the patient’s episode or exacerbation. Triggers are extremely important to identify because past triggers will often be similar to future triggers. Thus, once identified, they can be addressed (eliminated, minimizes, inoculated against) in your treatment plan.

MIDDLE: Focus on the nature of symptoms and level of dysfunction at the height of this current or most recent episodes. This will permit you to develop a sensible differential diagnostic list as well as know about the patient’s recent or ongoing burden of psychopathology. This section would include an risk assessment focusing on the height of the illness.

END: Focus on the NOW! In the thousands of psychiatric interviews I’ve witnessed over the last 12 years, it is amazingly common for the interviewer to end up knowing very little about the patient’s current status. It’s understandable in a way: the interviewer has spent a considerable amount of time focusing on the symptoms at the height of the illness and now needs to revisit those same symptoms in regard to their CURRENT status. It certainly adds to the amount of time needed for the HPI.

This is the approach to assess the now.
* “How are you doing now?”
* “Do you have any suicidal thoughts now?” [If not}
* “When was the last time you had any?”

And work your way through the most serious symptoms in a similar manner. Why is this section so important? Because to a large degree your treatment will reflect the patient’s current status. The first question to ask yourself regarding treatment with most patients is “Is the response to current treatment optimal or not?” So, you clearly have to know the current level of symptoms and dysfunction as well as the current treatment to know if you have to change it, and if so, how. Given the state of treatment, in my experience over 90% of patients have less than optimal response and could use a reconsideration of their current treatment.

FUTURE: A usually brief but important section of the HPI is assessing the future. How do you do that, given the future hasn’t occurred yet? The answer is to query the patient, especially the patient with a history of high-risk behaviors, what could trigger a future episode or exacerbation. I’ve often impressed by how specific many patients are when describing the types of situations that could trigger them to decompensate. Why should you know about these future triggers? So you can pre-emptively address them, that’s why.

I hope this has given you insights into how you too can improve your assess of the HPI. Know that we will continue to run the Beat The Boards! Psychiatry Part 2 prep courses for as long as the ABPN continues to hold the exam.

Today’s Quote

“Data is not information, information is not knowledge, knowledge is not understanding, understanding is not wisdom.” – Clifford Stoll

Take care and …
Happy Studies

Jack Krasuski, MD
877-225-8384

For psychiatrists, the single most important reading material – because it is highest yield – is the DSM-IV. Many questions on all the various ABPN exams simply require you to recognize the diagnostic entity.

On the multiple choice question exams, the question is often presented as a clinical vignette of 5-6 lines of text. You are then asked the most likely diagnostic entity. On the oral board exams, both the general and the child and adolescent exams, the one page clinical vignettes frequently require you to present a differential diagnostic list. (From there, the examiner  often proceeds to ask you to present your work-up, that is, the evaluations you would conduct that would lead you to a more definitive diagnosis.)

My recommendation to review the DM-IV might seem like a no-brainer. But consider this: a clinical vignette presented in an exam is nothing more than words on a screen (or page). Therefore, it is just as easy for an ABPN writer to write up a case with an obscure DSM-IV diagnosis as as it is to write up a case of a common disorder. I can tell you with assurance that most psychiatrists are not able to identify, for instance, many of the sleep disorders.

Second, the next most important material to review is basic psychopharmacology. It is especially important to review meds you do not use frequently. Know starting and target doses, common side effects, important drug-drug interactions, warnings, and monitoring / testing requirements. Next, learn the basic treatment algorithms, that is, if a first line drug fails, know what second and third line treatments you would recommend. This immediately clues you into the fact that you need to know at least a little about clozapine, TCAs, MAOIs, and ECT.

Those are the two highest yield activities outside our board prep courses. The Beat The Boards! Courses that are designed for the multiple choice question exams incorporate all the highest yield info right in the course so you need not look elsewhere. For the oral board courses, however, our laser-focus is on performance, skill-building, and practice. So, we ask that you bring your DSM-IV pocketbook with you to the course to review as diagnostic questions come to your mind. (We do not formally review the DSM-IV as part of the oral board courses.)

An ancillary question I often recieve is my view on the need to read a big textbook as part of exam preparation. My response is that for most candidates trying to read a textbook from cover to cover is unrealistic. Most doctors start their exam prep no longer than 2-3 months ahead, and many only 2-3 weeks ahead. Within that timeframe, trying to read a textbook will usually lead to a feeling of overwhelm and frustration. Note that I keep writing “trying to read” rather than “reading” a textbook. The reason is that most doctors who set out to read the textbook will not get through very much of it.

Additionally, even if you had all the time in the world to read a textbook, the yield and benefit would not be as great as you might believe. These 2000 page behemoths contain an incredible amount of exam-irrelevant blah, blah, blah. Since I write many lectures myself, I often turn to textbooks for source material. It often astounds me how little useful information there is per page. In fact, I often say semi-jokingly, that our clients pay us not for what we teach them but for all the stuff we edit away. Our job is to turn one or two or three textbooks’ worth of information into a three to five day high yield course.

That’s it for today.

Happy Studies,

Jack Krasuski, MD
877-225-8384

    .

The concept is this: the end, or ultimate objective, has to direct everything that came before it. In psychiatric assessment, the ultimate objective is the treatment. That’s what we get paid for. Everything else before that is simply information gathering and thinking. Something in this world changes only when we implement the treatment. For the purposes of the psychiatry oral board exam, we have to revise our objective slightly. Since we do not actually implement treatment, our ultimate objective is the closest thing to treatment, that is, a treatment plan.

If you keep your objective, the need for a treatment plan clearly in mind during your assessment interview, you will conduct a much better interview. I heard several seemingly competent interviews at the course. During the candidates’ presentation of their treatment plan, it became apparent, however, that the assessment was grossly inadequate. You can spend 30 minutes asking relevant questions of a patient, and at the end, be left with next to no information to guide your treatment plan.

Here are the kinds of questions that get you the information you need for development of a coherent treatment plan. Pay attention to what they have in common. (I’ll assume I’m interviewing a patient with a severe depressive episode with psychosis, in partial remission.)

* How have you been since you were released from the hospital last month?
* On a scale of one to ten, with ten being the most severe depression you can imagine, how severe has your depression remained?
* Which depressive symptoms persist and are most troubling to you?
* You told me that you no longer have suicidal thoughts? When was the last time you had them?
* What situation triggered those suicidal thoughts when you last had them?
* What situation in the future can you imagine that might trigger those suicidal thoughts again?
* Do you still have the voices coming back?
* When was the last time you heard the voices?
* What messages were the voices giving you? Did they tell you to do anything? Hurt yourself? Or anyone else?
* Have you ever acted on the voices in the past?
* How is your function since you left the hospital? How active are you?
* How much has your function improved since you left the hospital?
* What would most keep you from returning to work or school?
* What else do you believe you need to get completely over the depression?
* What medications are you taking now? When were they changed last?
* How are these medications treating you? What is most problematic to you about them?
* How often do you take them?
* Etc.

That’s a lot of questions, isn’t it? And sure, I don’t have a lot of time in a board interview and may actually run out of time before I get through all of them. And that is OK with the examiner. I’ll tell you why in a moment. Now let me share with you what I think about these questions, and what they have in common.

* Taken as a whole, this series of questions demonstrates to a listener (examiner), that the interviewer is delving into detail, perhaps is even relentlessly drilling down.

* For the most part the questions focus on the recent time frame, the time since the hospitalization. This question series focused on the history of present illness.

* The questions ALL have implications for the treatment plan. They are asked to assess the nature and degree of the patient’s current symptoms and function. In addition, symptoms that can place the patient at particular risk of suicide are explicitly assessed. Also, the nature of the current treatment and barriers to full compliance are assessed. So, at the end of this series, the interviewer has a relatively good sense of where the patient is now and also WHAT NEEDS TO CHANGE to achieve full remission.

* ALL of the questions above come naturally to mind – you don’t have to try to memorize them – if you assume that you have to present a detailed, comprehensive, individualized, and justified treatment plan at the end of this exercise.

I think reading the questions above you get a sense that the interviewer has a specific focus – that never leaves his mind – and that is to get information that will help him develop an optimal treatment plan. Even if that interviewer was stopped in the middle due to time running out, the listener would still be left with the same impression, that of a competent, focused, effective and objective-driven interviewer.

How does this style of interviewing differ from interviewing that is much less effective? Less effective interviewing can be defined as an interview that does not provide sufficient information to develop an optimal treatment plan. What are the common errors that lead to one of these less effective interviews?

* Too little time spent on the history of present illness and too much time on remote history.
* Not enough detail / follow-through to know if the current treatment should be continued or changed.
* Not enough detail to know if the current treatment and level of care is sufficient for the patient’s level of risk.

In conclusion, when you conduct your own interviews or observe a colleague interview, keep in mind the interview’s objective – to provide enough information to develop an effective treatmetn plan. Keeping this single thought in mind will instantly tell you if the interview is good or not good enough. And that will tell you whether it is a passing or failing interview.

Take care and …
Happy Studies.

Jack Krasuski, MD
877-225-8384

   .

I usually start the substance assessment by asking about the nature of the drugs used and the amounts consumed. But then, before I start asking about the problems that the drugs lead to I swerve in another direction. I ask the patient to tell me what’s “the good side of using drugs?” This is a set-up for then proceeding to ask about “the bad side of the drug use.”  This focus on “the good side” has several beneficial effects.

1. The patient becomes less defensive. It is easier to then move into the “bad side” without appearing that it’s only the “bad” that you’re interested in. It let’s the patient know that you want the whole picture and are not biased against their drug use before even having learned anything about it. Such an approach is also more true to life because, unless you’re in end-stage alcoholism or running the streets for your next heroin dose, there probably are some positives for the patient in their contined use of the drug.

2. By asking about both the good and the bad of drug use, you are able to assess the patient’s insight into their drug use and the degree of denial. Here’s an example. A patient tells you about excessive use of alcohol, with frequent hangovers, missing work, and conflict with the family. Then he tells you how there is no bad side of drinking. The only problem is his wife “nagging” him about his drinking. In fact, he says, it’s her nagging that drives him to drink. That’s a confusion of cause and consequence, a classic cognitive distortion among persons with addictions.

3. Focusing on both the good and the bad allows you to assess the patient’s motivation for change. You are taking a balanced approach in your questioning, not limiting your questions to only the negative consequences of use. This gives the interview a neutral space in which the patient’s true motivations / commitment to change can be more accurately assessed. The patient does not feel the need to defend himself against a percieved judgmental attitude from you, thereby allowing the patient to be more open about the benefits and costs of the drug use. When once I asked a patient about the good that comes from her cocaine use, she got quiet and after a moment said, “You know there is no good side.” She paused again and said, “I think it’s time for me to stop.” Now, there is more to motivational interviewing than this, but this is a good start for an initial interview.

4. You need to know the good side of drug use for the patient in order to optimize their treatment plan. Why? Because you have to help them get the good stuff they’ve been getting from their drug use in some other way. For instance, I’ve heard versions of this several hundreds of times from patients, “If I didn’t use drugs, I’d have no friends because that’s all that my friends and I do.” In fact, a major shortcoming of drug rehab is not focusing on the need to develop less destructive alternatives to the percieved good the drugs bring the patient. Think about this: a person addicted to a drug could be spending 12 hours a day obtaining, injesting, feeling intoxicated, and recovering from drug use. If you take all that activity away, what do you have – a big black hole! You must help the patient get the friendship, love, camarederie, and purpose in their lives that they need in order to stay clean and sober. These social benefits associated with drug use may have been pale imitations of the real thing (or not) but they were something of importance and they need to be replaced. I had one patient tell me about his last relapse, “After 6 months sober, all I saw in my life was just grayness. At least when I was using I had some drama in my life.”

OK. Thanks for the opportunity to share. In closing, let me point out that you can ask about the good and the bad in ways most conducive to your style. You can ask it like this: the good and the bad, the good side and the bad side, the upside and the downside, or the benefits and costs.

Take care and until next time,

Happy studies.

Jack Krasuski, MD
877-225-8384

     .

FIghting means different things to different people. It ranges from name-calling, to pushing, to fisticuffs, to taking a bat to another person’s head. Out of the adolescents I observed at this course, that was the exact range of behaviors that the teens were referring to when they said they were “fighting.” Yes, bats to heads – you read that right – experiences shared by an ex-gangbanger being interviewed.

In one interview, a 16 year old boy spoke about how he and his older brother would fight while growing up. He mentioned this after stating that he did not have a good relationship with his brother. The interviewing psychiatrist smiled when the boy talked about fighting with his older brother and said something to the effect of, “So you were fighting until you got big enough to fight back” and made a small laugh. The boy agreed but was not smiling or laughing at all. It seemed that he had tried to convey something that could have been much more traumatizing to him than the “rough-housing” the psychiatrist assumed had occurred.

It’s easy to fall into this trap when you come from a stable family and have had the inevitable disagreements, tensions, and “fights” with your siblings. Many of our patients, however,  come from much different environments, from families in which violence and the threat of violence occurs on a daily basis. Remember that violence flows downhill: an older sib may be physically abused by a parent, who then physically abuses a younger sibling. The experiences can be much more than you expect based on your own experiences.

An additional tip: learn about Anger Management Therapy. I was amazed by how many of the interviewees said they had been in Anger Management at some point in their lives. So, it’s a therapy that is popular and, if your patient has received it, you can count on the examiner asking you to explain it.

Until next time.

Jack Krasuski, MD
877-225-8384

      .

Taking Notes Has a Cost

Very frequently (as in several times at each course) I hear board candidates tell me how they are taking a lot of notes during their practice interviews because they are afraid to miss something. Clearly, forgetting to report something the patient told you is a negative. However, writing notes during the interview has a cost and this cost is actually a high cost. Let me explain.

There are two approaches that candidates taking when writing down notes. In the first, the candidate writes as the patient speaks. Whether or not you realize it, if you do this, you are doing two things simultaneously: you are listening and you are writing. So what, you say? The risk is that you will not be a good listener when your attention is heavily geared towards what you are writing. One dramatic example occurred during one mock-exam when a patient stated he was having compelling thoughts of suicide. The candidate reported that the patient denied thoughts of suicide. How did this occur? It happened because the doctor was writing and either misheard the patient, or simply never registered what the patient said.

The second approach, the candidate does NOT write while the patient is speaking. The candidate listens intently and politely and only when the patient completes their answer does the doctor write it down. The cost here is in lost opportunity, in taking time to write down the answer when the candidate could be already asking the next question. I’ve estimated that some doctors spend about 20% of their interview time writing down the patient’s answers, while the patient sits silently waiting for the next question. That’s six minutes in a 30 minute interview! That six minutes could have been used to ask several high yield questions.

The Right Note Taking Approach for You

There is no single right answer on how to take notes during the board interview. To find the right note-taking approach for YOU, I recommend the following: use the way you take notes during your day-to-day practice as your starting point. Identify in what ways, if any, your current note-taking approach does not work. Make adjustments to your current approach only as much as you need to in order to fix its shortcomings. If your current approach works, then keep doing what you are doing. At the oral board course I go into a lot of detail in showing different note-taking techniques. I present them to give the course participants detailed models of how notes should be taken. But here is the important point: if your current note-taking works, do NOT change it just because I’m showing you different approaches.

One touchstone for success on the oral boards is that your performance should be second nature to you, that is, it should feel comfortable and stable. Given this, it is a good thing if you can incorporate your current approach into your oral board approach. Change ONLY what you need to, only the things that are NOT working. Here are two concrete examples.

Many psychiatrists have the following practice pattern. During a new patient eval, they interview the patient and jot down a few notes as memory jogs. As soon as the patient leaves their office, these doctors dictate their eval note. Here’s the beauty – these doctors’ day-to-day approach can be almost exactly replicated at the board exam: the doctor can interview the patient, jot down a few memory jogs and then -rather than dictate – orally present the case to the examiners.

If you practice in this way, I recommend you stick to this approach on the board exam. It is doctors in this category who most often come to believe that their current approach is inadequate. They change their approach for the board exam by taking copious notes. Guess what? The new approach doesn’t work for them because they are not used to interviewing in this way. If you fall into this category, trust yourself and your current approach. Take only the notes you need to to jog your memory. Remember that you will be presenting the case as soon as the patient leaves. Your memory can handle that!

Many other psychiatrists have the following practice pattern: they hand-write the entire eval note while interviewing the patient. This is so natural to these doctors, that they are able to write many, many words and not be distracted by their writing. They are able to maintain a strong focus on the patient and the patient’s story.

If you practice in this way, then stick to it for the board interview. The main thing to do is to make sure that all the information on a specific topic is written down in a contiguous area. For instance, a patient with depression is likely to touch on different aspects of their depression throughout the interview. You cannot have notes on different aspects of depression interspersed throughout your copious notes. You’ll never find all of the facts relevant to depression hidden among all the other facts you learned from the patient. So, consolidate all notes on a single topic in a single section of your notes. Then you will be able to present the entire topic – like the patient’s depression – without searching through scattered notes.

If You Are Unsure Of Your Note-Taking Approach

The only way to really know what note-taking approach works for you is to try different approaches. I have recommended to many candidates to do a practice interview without taking any notes whatsoever. Once you try this, only then will you truly find out how many notes, and on what particular topics, you have to take notes. Or you even may find that taking ZERO notes works very well for you. If it does, then don’t be afraid. Many candidates conduct the interview in exactly this way.

Now let me share with you what works for me. Before I do let me again stress that we all have our individual right way. Just because I focus on particular and limited topics in my note-taking, does not mean that mirroring me will work for you.  Having said that, here are the only things I write down when interiewing for the board or when doing new evals in my office.

1. Patient’s name – it’s discombobulating if you realize you don’t know the patient’s name
2. Demographics
3. Chief complaint – easier to forget than you imagine
4. Medications and allergies
5. Medical conditions

Notice what I don’t write down – the entire psychiatric history. I have found that listening carefully without writing results in much better presentations for me. Taking more notes distracts my single-minded focus on the patient. So, I have found the five topics that I have to write notes down on paper. I have discovered these particular weak points through doing actual interviews. I did not assume they were my weak points; I discovered they were my weak points.

That’s it for today. Thanks much. ‘Til next time.

Today’s Quote

“I do not think that there is any other quality so essential to success of any kind as the quality of perseverance. It overcomes almost everything, even nature.” – John D. Rockefeller

Jack Krasuski, MD
877-225-8384

     .

Here’s how I categorize the myriad assessment instruments.

- IQ tests
- Achievement tests
- Tests of adaptive function
- Tests of cognitive functions
     – Tests of individual cognitive function
     – Batteries: comprehensive series of tests
- Personality or psychological tests

IQ Tests

Background: David Wechsler, the neuropsychologist who developed several IQ tests described intelligence as “the global capacity of a person to act purposefully, to think rationally, and to deal effectively with his environment.” Note the word ‘global.’ Thus,  intelligence is hypothesized to be a measure of general mental ability.

When: order IQ tests in children, adolescents, and adults when a diminished intellectual capacity is suspected.

Examples of available IQ tests
- Wechsler Adult Intelligence Scale
- Stanford-Binet Intelligence Scale
- Wechsler Intelligence Scale for Children
- Wechsler Preschool & Performance Scale of Intelligence
- Bayley Scale for Infant & Toddler Development
- Leiter International Performance Scale (a specialized non-verbal test)

Achievement Tests

Background: Achievement tests measure a student’s acquired knowledge and skills in educational areas. The key word here is’acquired,’ which refers to measuring what the student actually has learned in school. The types of achievement measured includes reading, mathematics, and language skills.

When: order achievement tests when a student shows poor school performance. Order both an IQ test and an achievement test and look for a discrepancy between the IQ test and the achievement test results. A descrepancy (with normal or high IQ scores in the context of poor school performance) suggests a problem other than limited intellectual capacity as an explanation for the poor school performance. It should trigger a careful exploration for the presence of depression, anxiety, PTSD, ADHD, substance use, and other psychiatric disorders and psychosocial stressors.

Examples of available achievement tests
- Wechsler Individual Achievement Test
- Peabody Individual Achievement Test
- Woodcock Johnson III Test of Achievement
- Wide-range Achievement Test

Tests of Adaptive Function

Background: When diagnosing mental retardation or dementia, the diagnosis requires more than just an assessment of intellectual or cognitive function. It also requires an assessment of adaptive function. Note that irrespective of IQ score, if a person meets the standards for adaptive ability for their age and cultural group, then they do NOT have mental retardation. Analogously, if someone retains good career and and social function, then they do not meet criteria for a dementia.

When: Conduct an assessment of adaptive function for patients with suspected mental retardation, cognitive impairment, and autism spectrum disorders.

Common Example
- Vineland Adaptive Function Scale

Tests of Cognitive Functions

Background: the main divisions of cognitive function are these

- Attention
- Language: receptive, expressive, word finding
- Memory: verbal, visual
- Motor: gross, fine, procedural memory (praxis)
- Construction
- Perception (agnosia)
- Executive function

Myriad cognitive assessments exist for assessing each cognitive sphere. You will usually recognize the focus of an assessment instrument because their titles will make clear what they are for. For example, the Peabody Picture Vocabulary Test assesses vocabulary by showing a card of four pictures to the subject who has to point to the picture showing an object named by the examiner. Recognition of vocabulary words is obviously a test of langauge in general and of receptive language more specifically.  

In addition, there exists neuropsychological batteries, which are bundled series of cognitive tests that assess a broad range of cognitive function.

Examples of Neuropsychological Batteries
- Halstead-Reitan
- Luria-Nebraska

Personality or Psychological Tests

Background: Some tests shed light on a patient’s personality and emotional function and can help identify some forms of psychopathology more clearly than can be identified through clinical interviewing. For instance, the MMPI, TAT, and Rorschach can identify psychotic beliefs or thoughts that the patient otherwise may be too guarded to share during a diagnostic interview.

When: When personality and emotional function needs to be further assessed, or when suspected psychopathology is suspected but cannot be delineated through interview. Types of psychopathology include psychosis, depression, and anxiety.

Examples of Personality or Psychological Tests
- Thematic Apperception Test
- Minnesotta Multiphasic Personality Inventory
- Rorschach Test

I hope this overview allows you to recognize the area of focus of many neuropsychological tests and to know when they should be ordered. (Detailed descriptions of instruments are included in my manuscript “Lightning Review of Neuropsychological Assessments” which  is included with the neurology and psychiatry board review courses.)

Today’s Quote

“Success is not final, failure is not fatal: it is the courage to continue that counts.” – Winston Churchill

 Jack Krasuski, MD
877-225-8384

  .

Guardianship and Conservatorship

Guardianship, or in some states, Conservatorship, is a legal process. A guardian or conservator is a person appointed by a court to decide financial, personal or medical matters for another person who is unable to manage his or her own affairs. The court takes care to remove only those rights that the proposed ward (that is, the impaired individual) is incapable of exercising.

The following rights of the ward may be removed and decision-making given to the guardian. The right to:
*      Determine residence 
*      Consent to medical treatment 
*      Make end-of-life decisions 
*      Possess a driver’s license 
*      Manage, buy, or sell property
*      Own or possess a firearm or weapon 
*      Contract or file lawsuits 
*      Marry 
*      Vote

The guardian can be a family member or friend, or it may be a public or private entity appointed by the court.

A guardian should strive to take into account the ward’s wishes as much as possible. This is called the “substituted judgment” standard. It means the guardian makes decisions that are the decisions that the ward would make if he or she were able to.

If the ward’s wishes are unknown, then the “best interest” standard can be followed. Under this standard the guardian makes decisions based on the best interests of the ward.

Because a Guardianship or Conservatorship limits or removes a person’s right to make his or her own decisions, it should be considered after alternative methods of protecting the person fail. Alternative methods of protecting an individual include:

Durable Power of Attorney

This method permits an individual to appoint another person, someone the individual trusts, to make decisions for the individual and manage his or her affairs. The person who signs the power of attorney, called the principal, must be competent to do so and have the capacity to do so. For the Power of Attorney to remain in effect during times the principal loses decision-making capacity, the Power of Attorney must include a clause that specifically states this. Such an agreement is called a Durable Power of Attorney. Note that the Power of Attorney can be made to be as specific or broad as the principal wishes. It can restrict the types of decisions that the person given Power of Attorney is permitted to make. Also, the Power of Attorney may take effect upon signing or at a future date.

Representative Payee

Another protective tool is the Representative Payee. Individuals receiving disability income from the Social Security Administration may request that another person be appointed to receive their monthly checks and to use that money to pay the requesting individual’s bills. The payee must open a separate bank account in which the checks are electronically deposited. Note that the representative payee does not have the right to control the person’s other sources of income or wealth.

Today’s Quote

“The purpose of life is to live it, to taste experience to the utmost, to reach out eagerly and without fear for newer and richer experiences.” -Eleanor Roosevelt

Take care and Happy Studies
Jack Krasuski, MD
877-225-8384

   .

Since this is the first article in a series on DDIs, let me start with the big picture. DDIs can be divided into two categories, the pharmacokinetic DDIs and the pharmacodynamic DDIs. Understanding this distinction will better allow you to recognize when a potential DDI exists.

Pharmacokinetics refers to what the body does to a drug which is, in short, to try to get rid of it once it enters the body. The components of pharmacokinetics includes absorption, distribution, metabolism, and elimination – ADME is the mnemonic. One drug (the perpetrator) can effect another drug (the victim) by changing any of the above parameters. Today’s post specifically covers the metabolic DDI seen with carbamazepine.

Pharmacodynamics refers to what the drug does to the body. It includes all of the intended effects as well as the unintended and unwanted effects caused by the drug-induced changes occurring at its site of action (SOA), using its mechanism of action (MOA). As an example, tramadol, an opiate analgesic, has monoamine oxidase inhibition effects, thus potentiating the neurotransmission of, among other neurotransmitters, serotonin. Thus, tramadol can lead to a pharmacodynamic DDI (serotonin syndrome) when coadministered with an SSRI, SNRI, TCA, or MAOI antidepressant. Tramadol is, by the way, also a common focus of exam questions.

Carbamazepine

Now to our main focus – carbamazepine. Carbamazepine is a substrate for (meaning it is metabolized by) as well as an inducer of (meaning it speeds up the metabolic efficiency) the CYP 3A4 enzyme and also the CYP 2C9 enzyme. Thus, it speeds up its own metabolism (referred to as autoinduction) and the metabolism of other drugs (referred to as heteroinduction) metabolized through the CYP 3A4 and / or the CYP 2C9 isoenzymes.

Carbamazepine lowers levels of the following drugs. Thus, doses of these medicines may need to be increased when co-administered with carbamazepine.
* Mood stabilizers / AEDs: carbamazepine, oxcarbazepine, valproate +, lamotrigine, ethosuximide, tiagabine, topirimate, phenytoin
* Oral contraceptive pills (OCPs)
* Antipsychotics: haloperidol, clozapine, olanzapine, risperidone, ziprasidone
* Antidepressants: bupropion, citalopram, TCAs (nortriptyline, imipramine, amitriptyline)
* Benzo’s: clonazepam, midazolam
* Protease inhibitors
* Opiates: tramadol, methadone
* Others: warfarin, theophylline, levothyroxine

Carbamazepine levels may be increased due to co-administration of these CYP 3A4 and / or CYP 2C9 inhibitors.
* Erythromycin
* Grapefruit juice
* Ketoconazole
* Valproate+
* Antidepressants: fluoxetine, fluvoxamine, nefazadone, trazodone
* Antipsychotics: loxapine, olanzapine, quetiapine

Carbamazepine levels may be decreased due to co-administration of these CYP 3A4 and / or CYP 2C9 inducers.
* Rifampin
* Phenobarbital
* Phenytoin
* Primidone
* Theophylline and aminophylline

Two-sided Effects

Note that levels of carbamazepine and the medications used concurrently with it can both be effected, in the same or opposite ways. Notice the following.
* Carbamazepine lowers valproate levels, while valproate increases carbamazepine levels.
+ Note that the metabolic DDI’s between carbamazepine and valproate occur primarily through phase II enzymatic interactions (i.e., glucuronosyltransferases), and not through phase I CYP450 enzymatic interactions.
* Carbamazepine lowers phenytoin levels and phenytoin lowers carbamazepine levels.

Sample Exam Questions

Here are the ways that the ABPN may test your knowledge of the above DDIs. I am not providing the right answer because if you can’t figure it out, it means you have to reread this post. These were questions on recent exams.

* 24 year old woman with bipolar disorder using oral contraceptives is started on carbamazepine. She tolerates it well and achieves mood stability. What would you advise her.
A. Stop carbamazepine
B. Add valproate
C. Begin using a barrier anti-contraceptive (condoms)
D. Continue to use carbamazepine without additional precautions

* 55 year old man with Bipolar Disorder remains stable on carbamazepine. He develops bronchitis. Since he is allergic to penicillin, he is started on erithromycin by his primary care physician. The next day he becomes lethargic and speaks incoherently. What is the most likely cause of his change in mental state?

A. Hyponatremia related to erithromycin use
B. Carbamazepine toxicity
C. Fulminant bronchitis
D. Alcohol intoxication
E. Comorbid somatoform disorder

Look for upcoming posts on other exam DDI favorites. Also, please send your advice on additional DDIs I should cover.

Jack Krasuski, MD
877-225-8384

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The bottom line is this: some violent behaviors, whether they are directed at self or others, are premeditated and intentional, while others are impulsive and triggered by immediate circumstances. If you wish to conduct an adequate assessment of suicidal and homicidal risk, you MUST evaluate for both types of behaviors. Often, only the first type of violence is considered.

Let’s begin by reviewing intentional violence towards self or others. Intentional means that the behavior is ’intended’ to achieve some goal. Often,when asked, the patient can indeed identify a goal. You may disagree with the patient’s goal, or you may view the patient’s planned behavior as not particularly effective in helping the patient reach their goal – not everyone is a systematic thinker, after all. Nevertheless, the behavior in this type of violence is seen as a means to a particular end.

Further, this type of behavior usually connotes that the patient has been thinking about both their goal and about the behavior to achieve it – thus it is premeditated. Also, it connotes that the patient has given some thought to how they can best achieve their goal – thus some planning is usually evident.

The straight-forward way to assess for the potential for this type of violence is to ask questions such as the following.
*   “Do you have any thoughts of hurting yourself or others?”
*   “Do you have a plan on how you might do this?”
*   “If you are having these types of thoughts, how likely are you to carry them out?
*   “Why do you want to hurt / kill yourself / another person?”

Notice how these questions ask about the goal (the intention), the desire or likelihood of acting to reach that goal, and the plan for reaching that goal. Of course, the more thought out the plan and the stronger the intention, the higher is the risk that the patient will act in a violent way.

But now, let’s consider the impulsive type of violent behavior. Consider what it is not: it is not necessarily focused on achieving a goal, although it could be. It is not premeditated. A person does wake up and say to themselves, ‘I think I’ll engage in some impulsive violence today.’

Impulsive behavior is triggered by certain situations. What those triggering situations are is particular to each individual – and this last point is important because it leads to a line of questioning that you can and should carry out. 

Here are the types of statements made by individuals who have engaged in impulsive violence. You can identify this as being impulsive behavior by the fact that the statement focus on the triggering situations rather than on achieving any particular goal.
*   “I almost killed the guy in the bar when he looked at me the wrong way.”
*   “I took the pills after I had a big fight with my boyfriend.”

Notice that intential, predmeditated behaviors are guided or controlled by what follows, which is, the goal. Impulsive behaviors, on the other hand, are guided or controlled by what precedes them, that is, the triggers. Take a moment to consider how utterly ineffective it is to evaluate a patient’s propensity to act with impulsive violence by evaluating them regarding their current thoughts, plans and intentions for suicide or homicide. They usually do not exist! Why? Because when the patient is sitting there being interviewed by you, they are not facing a likely triggering situation. Impulsive violence is situationally determined.

Again, to highlight this point: the patient at risk of impulsive suicide or violence towards others is highly likely to truthfully deny any current or recent suicidal ideation, intent or plan- even though they are in fact at high risk of such violent behavior. And yet, this is the exact point where the assessment for violent risk ends for many board candidates who are, thus, likely to fail their exam.

So, please stop and think what sorts of questions or other information about the patient can actually lead you to a better understanding for the potential for impulsive violence. (And in my clinical experience as a psychiatrist, this is the more common type of violent behavior that patients engage in.)

Here is the answer. To assess risk for impulsive violence assess these three areas:
*   A history of previous episodes of suicidal or homicidal behavior. The best predictor of the future is the past.
*   The presence of vulnerability factors that make impulsive violence more likely.
*  The presence and types of situations that in the past have triggered the impulsive violence.

For the patient who almost killed a man in a bar, his vulnerability factors were a history of severe childhood abuse. He had untreated and uncontrolled PTSD that continued to greatly elevate his homicidal risk and make him a walking time-bomb. His main triggering factor was being in situations that put him into contact with men who were likely to engage him in a provacative, threatening, or disrespectful way. And where was this patient likely to encounter such men? The patient was very clear on this point. In bars and when sleeping in shelters. He was not nearly as at high risk when walking down the street, attending clinic, or when doing odd jobs for people he knew and had worked with in the past.

This man was actually interviewed at one of our Part 2 courses. The candidate asked this man if he had any thoughts, plans, or intentions to hurt himself or others. This man responded – truthfully, I believe, that he did not. The candidate then blightly reported that this patient was not at high risk of suicide or homicide.

He was so wrong! What was the candidate’s error? He assessed only for intentional violence and did not consider this patient’s potential for impulsive violence. And this man’s history of frequent and serious suicide attempts and near-lethal attacks on others, belied the candidate’s impression.

Let me know what you think or what else I can tell you to shed further light on assessing potential for violence. Thanks.

Today’s Quotes

” Nonviolence means avoiding not only external physical violence but also internal violence of spirit. You not only refuse to shoot a man, but you refuse to hate him.” – Martin Luther King, Jr.

” I hate to advocate drugs, alcohol, violence, or insanity to anyone, but they’ve always worked for me.” – Hunter S. Thompson

Thanks and …
Happy Studies!

Jack Krasuski, MD
877-225-8384

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