Publications by authors named "Xavier F Jimenez"

35 Publications

Beyond depression: Other uses for tricyclic antidepressants.

Cleve Clin J Med 2019 12;86(12):807-814

Center for Comprehensive Pain Recovery, Neurological Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

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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http://dx.doi.org/10.3949/ccjm.86a.19005DOI Listing
December 2019

Elucidating somatization in a dimensional model of psychopathology across medical settings.

J Abnorm Psychol 2020 Feb 10;129(2):162-176. Epub 2019 Oct 10.

Department of Psychological Sciences.

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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http://dx.doi.org/10.1037/abn0000475DOI Listing
February 2020

Functional Neurological Disorder Responds Favorably to Interdisciplinary Rehabilitation Models.

Psychosomatics 2019 Nov - Dec;60(6):556-562. Epub 2019 Jul 10.

Neurological Institute, Cleveland Clinic, Cleveland, OH.

Background: Functional neurological disorder (FND) is difficult to treat and costly. Interdisciplinary chronic pain rehabilitation programs (iCPRPs) are multidimensional functional restoration interventions for pain; their impact on FND specifically has not been assessed.

Objective: The purpose of this study was to assess iCPRP's impact on functioning in FND.

Methods: Data were examined retrospectively from an Institutional Review Board-approved registry capturing admission and discharge data from patients participating in an outpatient iCPRP. Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach.

Results: Forty-nine FND patients completed care and showed pre-measures and postmeasures. Statistically significant reductions in subjective measures of pain-related disability (46.40-20.91; P < 0.001, d = 1.92), depression (20.38-4.81; P < 0.001, d = 1.53), anxiety (15.09-6.29; P < 0.001, d = 1.18), and stress (21.96-9.70; P < 0.001, d = 1.21) scores were observed. Statistically significant changes in objective measures of mean timed up and go scores (decreased from 15.96 to 8.87 s), stair climbing test scores (increased from 40.98 to 71.93 steps), and mean 6-minute walk test scores (increased from 0.21 to 0.30 miles) were also observed across the group.

Conclusions: While preliminary and based on a small patient sample, these findings support the use of interdisciplinary care models for FND treatment. Clinical and investigational implications are explored.
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http://dx.doi.org/10.1016/j.psym.2019.07.002DOI Listing
August 2020

Clinical and Demographic Predictors of Interdisciplinary Chronic Pain Rehabilitation Program Treatment Response.

J Pain 2019 12 5;20(12):1470-1485. Epub 2019 Jun 5.

Cleveland Clinic Neurological Institute Center for Outcomes Research and Evaluation, Cleveland, Ohio; Cleveland Clinic Lerner Research Institute Department of Quantitative Health Science, Cleveland, Ohio.

Patients treated in interdisciplinary chronic pain rehabilitation programs show long-term improvements in symptoms; however, outcomes may vary across heterogenous patient subpopulations. This longitudinal retrospective study characterizes the influence of opioids, mood, patient characteristics, and baseline symptoms on pain and functional impairment (FI) in 1,681 patients 6-months to 12-months post-treatment in an interdisciplinary chronic pain rehabilitation program incorporating opioid weaning. Linear mixed models showed immediate and durable treatment benefits with nonuniform worsening at follow up which slowed over time. Latent class growth analysis identified three post-treatment trajectories of pain and FI: mild symptoms and durable benefits, moderate symptoms and durable benefits, and intractable symptoms. A fourth pain trajectory showed immediate post-treatment improvement and worsening at follow up. Whether a patient was weaned from opioids was not predictive of treatment trajectory. Racial ethnic minority status, higher levels of post-treatment depression, and lower perceived treatment response were associated with less resolution (moderate symptoms) or intractable symptoms. Not having a college education was predictive of intractable or worsening pain and a moderate course of FI. Older age and male gender was associated with intractable FI. Treatment outcomes may be improved by the development of targeted interventions for patients at risk of poor recovery and/or deteriorating long-term course. PERSPECTIVE: This study examined predictors of treatment response in 1,681 patients treated in an interdisciplinary chronic pain rehabilitation program incorporating opioid weaning. Opioid weaning did not predict outcome. Higher levels of symptoms, lower levels of education, and being a racial-ethnic minority were associated with a less salubrious long-term treatment response.
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http://dx.doi.org/10.1016/j.jpain.2019.05.014DOI Listing
December 2019

Parallel Pains and Dynamic Dilemmas: Psychodynamic Considerations in Approaching and Managing Chronic Physical Pain.

Authors:
Xavier F Jimenez

Psychodyn Psychiatry 2019 ;47(2):167-182

Chronic Pain Rehabilitation Program, Cleveland Clinic.

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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http://dx.doi.org/10.1521/pdps.2019.47.2.167DOI Listing
February 2020

Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis.

Gen Hosp Psychiatry 2020 Jan - Feb;62:93-95. Epub 2019 Jan 31.

Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America.

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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http://dx.doi.org/10.1016/j.genhosppsych.2019.01.009DOI Listing
November 2020

Cannabis for chronic pain: Not a simple solution.

Authors:
Xavier F Jimenez

Cleve Clin J Med 2018 12;85(12):950-952

Medical Director, Chronic Pain Rehabilitation Program, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.3949/ccjm.85a.18089DOI Listing
December 2018

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 May - Jun;60(3):298-310. Epub 2018 Aug 2.

Cleveland Clinic, Cleveland, OH.

Background: Associations between the crude capture of polyallergy-also known as multiple chemical sensitivity or multiple drug intolerance syndrome-and mental health/functional somatic syndrome disorders, healthcare utilization, or other clinical phenomenon have not been examined extensively.

Methods: An IRB-approved retrospective chart review of all patients between age 18 and 70 who had a clinical encounter at a large medical center between 2009 and 2014. Patients were stratified into 4 categories based on the absolute number of chart-documented allergies: (1) no allergies; (2) normal allergy (1-4 allergies); (3) polyallergy (5-9 allergies); and (4) "ultrapolyallergy," (≥10 allergies), which were corroborated through a sensitivity analysis. Demographics, comorbidities, and medications were clustered per allergy grouping. Analysis of variance, chi-square, and multivariable logistic regression analyses were employed to test for associations.

Results: 2,007,434 patients were examined ("no allergy" group, n = 1,423,631, 70.9%; "normal allergy" group: n = 549,927, 27.4%; "polyallergy" group n = 29,453, 1.5%; "ultrapolyallergy" group, n = 4,423, 0.22%). Proportion of females increased from 51% in the "no allergy" group to 89.6% in the "ultrapolyallergy" group (p < 0.001). Rates of mental health and functional somatic syndrome disorder diagnoses increased significantly across allergy groups (p < 0.001). All psychotropic medication classes were increased significantly across allergy groups (p < 0.001). Healthcare utilization was also significantly elevated across allergy cohorts (p <0.001).

Conclusions: This study demonstrates that polyallergy/multiple chemical sensitivity may serve as a crude yet meaningful indicator of comorbid psychopathology. Drug intolerance mechanisms are reviewed, and both clinical and investigational implications are examined.
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http://dx.doi.org/10.1016/j.psym.2018.07.016DOI Listing
March 2020

Additional evidence supporting the central sensitization inventory (CSI) as an outcome measure among chronic pain patients in functional restoration program care.

Spine J 2017 11;17(11):1765

Chronic Pain Rehabilitation Section, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195.

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http://dx.doi.org/10.1016/j.spinee.2017.08.225DOI Listing
November 2017

A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine.

Clin J Pain 2018 Jun;34(6):585-591

Cleveland Clinic, Center for Neurological Restoration, Chronic Pain Rehabilitation Program, Cleveland, OH.

Introduction: Many psychopharmacologic agents are used as primary or adjuncts in pain management. Atypical antipsychotics (AAs) have also been used as adjuncts in pain management regimens in a variety of manners; however, their efficacy in this capacity is unclear.

Methods: A systematic review of all studies examining AA use for pain was conducted. Three literature databases were utilized to search for word combinations of "pain" and a variety of commonly prescribed AAs ie, (olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, clozapine, paliperidone, iloperidone, lurasidone). Articles chosen for review included retrospective analyses, randomized control trials, and case series/reports. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram illustrates the study selection process.

Results: Olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone are the only AAs with published studies in pain management. Among these, olanzapine and quetiapine have the most studies (11 and 6, respectively). Olanzapine shows preliminary and consistent efficacy in fibromyalgia and headache/migraine, although only 1 study was a randomized controlled trial with level I evidence of efficacy. Other AAs eg, (quetiapine) fail to demonstrate efficacy in pain syndromes and/or lack robust study designs.

Conclusions: Few studies have been conducted to evaluate the analgesic effects of AAs. The collective findings of multiple studies evaluating olanzapine in pain syndromes suggest a high, yet preliminary level of evidence of efficacy, warranting prospective studies in various pain syndrome contexts. Pharmacological mechanisms of AA action are elaborated, and the findings of this review are discussed. Risk and benefits of using AAs in chronic pain are described, and investigational implications and future directions are explored.
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http://dx.doi.org/10.1097/AJP.0000000000000567DOI Listing
June 2018

Severe Noncardiac Chest Pain Responds to Interdisciplinary Chronic Pain Rehabilitation.

Authors:
Xavier F Jimenez

Psychosomatics 2018 Mar - Apr;59(2):204-206. Epub 2017 Jul 15.

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. Electronic address:

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http://dx.doi.org/10.1016/j.psym.2017.07.007DOI Listing
December 2018

Acute movement disorders in the medical setting.

Int J Psychiatry Med 2016 07;51(5):395-413

2 Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, OH, USA.

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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http://dx.doi.org/10.1177/0091217416680202DOI Listing
July 2016

Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors.

Psychosomatics 2017 Sep - Oct;58(5):483-489. Epub 2017 Mar 28.

Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH; Center for Ethics, Humanities, and Spiritual Care, Cleveland Clinic, Cleveland, OH. Electronic address:

Background: Psychosocial and ethical variables influence physicians in requesting decision-making capacity (DMC) evaluations. Previous authors have classified certain DMC evaluation requests as "unwarranted" when there is no explicit suspicion or evidence that the patient might lack DMC.

Objective: To explore psychosocial and ethical reasons motivating both "warranted" and "unwarranted" DMC evaluation requests by physicians in the medical setting.

Methods: A retrospective electronic health record review was approved by the institutional review board. All psychiatric consultation requests identified as DMC evaluation requests between January 1, 2012 and December 31, 2012 were assessed independently by 2 reviewers. Each reviewer identified each DMC evaluation request as "warranted" vs "unwarranted." Unwarranted DMC evaluation requests were defined as those lacking explicit suspicion that the patient might lack DMC or those with explicit evidence of a patient with blatantly impaired DMC. We hypothesized that most (over half) DMC evaluation requests would be deemed unwarranted. Descriptive statistics, chi-square/Fisher exact tests, and t-test/ANOVA were used.

Results: A total of 146 DMC evaluations were reviewed, and 83 (56.8%) of these were deemed unwarranted. Of these, most were likely driven by a previous neuropsychiatric disturbance (p < 0.001). Various other psychosocial and ethical patterns were identified (i.e., the practice of defensive medicine and guardianship concerns).

Conclusion: Over half of DMC evaluation requests in a general medical setting were unwarranted. Many such requests were motivated by unarticulated psychosocial and ethical factors. DMC evaluation requests appear to serve as a means for indirectly resolving various psychosocial and ethical dilemmas beyond assessing DMC itself. Implications and future directions are discussed.
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http://dx.doi.org/10.1016/j.psym.2017.03.013DOI Listing
June 2018

New-Onset Refractory Status Epilepticus Associated With the Use of Synthetic Cannabinoids.

Psychosomatics 2017 Mar - Apr;58(2):180-186. Epub 2016 Oct 21.

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH; Epilepsy Center, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.psym.2016.10.006DOI Listing
January 2019

Refractory Self-Injurious Behavior in Severe Intellectual Disability Responsive to Topiramate: A Case Report.

Psychosomatics 2017 Mar - Apr;58(2):209-212. Epub 2016 Nov 2.

Department of Psychiatry, A. Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.psym.2016.11.001DOI Listing
January 2019

Atypical Findings in Massive Bupropion Overdose: A Case Report and Discussion of Psychopharmacologic Issues.

J Psychiatr Pract 2016 09;22(5):405-9

ZHU: Cleveland Clinic Lerner College of Medicine, Cleveland, OH KOLAWOLE and JIMENEZ: Center for Behavioral Health, Cleveland Clinic, Cleveland, OH.

Bupropion is an atypical antidepressant that is structurally similar to amphetamines. Its primary toxic effects include seizure, sinus tachycardia, hypertension, and agitation; however, at higher amounts of ingestion, paradoxical cardiac effects are seen. We report the case of a 21-year-old woman who ingested 13.5 g of bupropion, a dose higher than any other previously reported. The patient presented with seizure, sinus tachycardia with prolonged QTc and QRS intervals, dilated pupils, and agitation. Four days after overdose, the patient's sinus tachycardia and prolonged QTc and QRS intervals resolved with symptomatic management, but she soon developed sinus bradycardia, hypotension, and mild transaminitis. With continued conservative management and close monitoring, her sinus bradycardia resolved 8 days after the overdose. The transaminitis resolved 12 days after the overdose. Our findings are consistent with previously reported toxic effects associated with common overdose amounts of bupropion. In addition, we have observed transient cardiotoxicity manifesting as sinus bradycardia associated with massive bupropion overdose. These findings are less frequently reported and must be considered when managing patients with massive bupropion overdose. We review the psychopharmacologic implications of this and comment on previous literature.
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http://dx.doi.org/10.1097/PRA.0000000000000179DOI Listing
September 2016

Mesiotemporal Disconnection and Hypoactivity in Klüver-Bucy Syndrome: Case Series and Literature Review.

J Clin Psychiatry 2016 08;77(8):e982-8

Neurological Institute, Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Ohio, USA.

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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http://dx.doi.org/10.4088/JCP.14r09497DOI Listing
August 2016

Assessment Style in Psychogenic Nonepileptic Seizures: Bridging the Gap from Diagnosis to Care.

Psychosomatics 2016 Jul-Aug;57(4):440-2. Epub 2016 Mar 2.

Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.psym.2016.02.014DOI Listing
April 2018

Attachment in medical care: A review of the interpersonal model in chronic disease management.

Authors:
Xavier F Jimenez

Chronic Illn 2017 03 22;13(1):14-27. Epub 2016 Jun 22.

Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA.

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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http://dx.doi.org/10.1177/1742395316653454DOI Listing
March 2017

Argyrophilic Grain Disease Presenting as Excited Catatonia: A Case Report.

Psychosomatics 2016 Jul-Aug;57(4):431-8. Epub 2016 Feb 5.

Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, OH; Department of Ethics, Humanities, and Spiritual Care, Cleveland Clinic Foundation, Cleveland, OH; Center for Neurological Restoration, Cleveland Clinic Foundation, Cleveland, OH.

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http://dx.doi.org/10.1016/j.psym.2016.02.003DOI Listing
April 2018

Bridging a clinical gap in psychogenic nonepileptic seizures: Mental health provider preferences of biopsychosocial assessment approaches.

Epilepsy Behav 2016 Mar 12;56:149-52. Epub 2016 Feb 12.

Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA; Epilepsy Center, Cleveland Clinic Foundation, USA.

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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http://dx.doi.org/10.1016/j.yebeh.2015.12.035DOI Listing
March 2016

Cystocerebral Syndrome: A Case Report and Review of Literature and Mechanisms.

J Am Geriatr Soc 2015 Dec;63(12):2645-2647

Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Cleveland, Ohio.

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http://dx.doi.org/10.1111/jgs.13851DOI Listing
December 2015

Trichotillomania and Trauma: Dissociation and Alexithymia in a Case of Pregnancy Denial.

J Nerv Ment Dis 2015 Dec;203(12):971-974

Department of Psychiatry and Psychology, Cleveland Clinic, OH.

Pregnancy denial is rare yet reported and is often the result of complex psychosocial circumstances. We present an unusual case of pregnancy denial associated directly with both remote and ongoing trauma. A woman suddenly gave birth to a child in a hospital while visiting her other daughter, resulting in emergent labor and delivery as well as social work and psychiatric evaluation. Various atypical findings were noted, including pathological hair-pulling, alexithymia, indifference, and pregnancy denial. We offer a biopsychosocial conceptualization of the case, commenting on various possible processes including dissociation. The case also explores current states of knowledge regarding the interaction between impulse control disorders such as trichotillomania, dissociation, and trauma, with a call for future clinical and investigational attention to these interactions.
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http://dx.doi.org/10.1097/NMD.0000000000000401DOI Listing
December 2015

A case of familial frontotemporal dementia presenting with malignant catatonia.

Neurol Clin Pract 2015 Dec;5(6):521-523

Departments of Neurology (LS, YL) and Psychiatry (XFJ), Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1212/CPJ.0000000000000173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802481PMC
December 2015

Polyallergy as a Proxy: Premature Yet Promising.

Psychosomatics 2015 Sep-Oct;56(5):606-7. Epub 2015 Jan 16.

Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.psym.2015.01.002DOI Listing
August 2016

Capacity Consultation and Contextual Complexities: Depression, Decisions, and Deliberation.

Psychosomatics 2015 Sep-Oct;56(5):592-7. Epub 2015 Jun 6.

Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.psym.2015.06.002DOI Listing
March 2016

Diagnostic assessment and case formulation in psychogenic nonepileptic seizures: A pilot comparison of approaches.

Epilepsy Behav 2015 Apr 23;45:164-8. Epub 2015 Mar 23.

Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA.

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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http://dx.doi.org/10.1016/j.yebeh.2015.02.001DOI Listing
April 2015

Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: a case report.

Gen Hosp Psychiatry 2014 Nov-Dec;36(6):761.e1-2. Epub 2014 Jul 9.

Cleveland Clinic Foundation, Department of Psychiatry and Psychology, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA.

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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http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012DOI Listing
September 2015
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