Keep or trash delusional writings?

[Encephalopathy]

Not sure about this one.

An inpatient's mother found, among the patient's very limited belongings, stacks of papers that the patient filled with details of her persecutory delusion (strongly-held for several years). Mom asks me whether she should throw them away or not.

On one hand, if the delusion lifts even at least partially while she's in the hospital, mom wouldn't want anything to remind her of it. On the other hand, will it piss off the patient and make things worse?

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[BobA]

This is up to the patient.

 

[whopper]

I've never seen any evidenced based studies on this, however a former teacher of mine mentioned that in some cases, patients who write obsessively about "negative" topics may encourage the formation of memories concerning that in their brain. What I mean by "negative" are adverse symptoms of their mental illness, e.g. a depressed person focusing on their feelings of guilt, and in turn it may strengthen the brain's cognitive structure, making the person more likely to feel guilty.

This particular teacher I was very good, and almost everything he stated was evidence based. If it were opinion, and not evidence based, he'd state so & encourage us to look into it more (forgot if he said if this particular thing was evidenced based or not).

On this one, I'm not so sure. Those writings may help the person, family or therapist to obtain more insight into the illness.

If anyone does have any evidenced base data on something like this certainly post about it.

But aside from that, in this specific situation, I wouldn't advise the destruction of someone else's property without his/her permission. That I believe would be out of our professional bounds.

 

[BobA]

It doesn't matter. It's the patient's personal property. Just because she's delusional doesn't mean she doesn't have property rights. It's not appropriate to be so paternal/maternalistic.

 

[Still Kickin]

It doesn't matter. It's the patient's personal property. Just because she's delusional doesn't mean she doesn't have property rights. It's not appropriate to be so paternal/maternalistic.

I agree.

 

[dianamd]

...among the patient's very limited belongings, stacks of papers that the patient filled with details of her persecutory delusion (strongly-held for several years). Mom asks me whether she should throw them away or not....

I would imagine that this poor person would only feel more persecuted if someone trashed his or her detailed thoughts, especially when those writings are among this person's few belongings.

Fixed delusions can lift in the hospital but return in some form down the road. Either now or later this patient may be looking for the writings. And so either now or later, there is going to be cost paid for the mother's trashing of the patient's writings.

Tell the mother that if she wants to help the patient, to put the writings in a box and leave them for the patient after discharge. Some people....

 

[chameleonknight]

What if the patient's personal property included some crack and a sawed off shotgun? Put it in a box until discharge?

The OP has a very valid, if difficult question.

That being said, I'd lean towards leaving them alone for the time being.

 

[BobA]

nobody has property rights over crack and sawed off shotguns. both are illegal.

 

[Encephalopathy]

Appreciate the help, guys. So I basically advised the mother thats it is ultimately the patient's personal property, and she wouldn't want to risk being seen as a persecutor herself. Mother, who patient will live with, decided she is going to keep them and give them to the patient if she asks for them.

[Edit]:

What if it was a noose? Razor blades? If there are evidence-based studies of the kind Whopper brings up, would it not be unethical to withhold scientific information from the mother that could help her daughter? Yeah, it is maternalistic, because it's the mother who is deciding and acting, not me. You can't say there's no element of "ends justfies the means" in psychiatry. We're the specialty that locks people up against their will, right?

 

[whopper]

Psychiatrists only have paternal/maternal responsibility if its a case of parens patriae, and that person is an immediate danger to him/herself or others, or in some states, is at immediate risk of property damage--all as a result of mental illness, or in assigning a guardian to someone who is in need of one because that person doesn't have the capacity to make decisions for him/herself.

So in the case of the delusional writings, unless somehow, someone could link it to an immediate danger, (which is highly doubtful, e.g. the person is determined to kill themself, only by cutting their wrist using the paper its written on), then it can't be tampered with without the patient's permission.

Guns-now that's different. There is plenty of evidenced based medicine that taking away the person's guns will increase the odds that the person will not commit suicide.

As for a noose, well if they had one, I'd have it taken away, though someone could of course easily make another one. The only purpose to have a noose is to hang, and its not needed for daily living. If someone argued that they wanted to keep the noose, that'd be a signal to me that they're still suicidal. I would then ask the person to have a friend or family member keep it for the time being.

There of course is a grey area. There are plenty of items that can be used to hurt oneself that are needed in everyday living--kitchen knives, bleach, ammonia, car, etc. I have never seen a case where someone was kept because of these type of items unless the suicidality was severe--I'm talking GAF less than 30.

If however the person is no longer an immediate danger in the opinion of the psychiatrist, the person has to be released, and yes there's plenty of things that can happen on the outside with items that aren't considered dangerous. I'd do what I could to lessen the possibility of suicide, such as have the person discharged while in a supervised setting (E.g. family's home, with family there to see the person), but you have to let them go when they're not dangerous.

On a similar note, I came up with an idea (which I'm sure several else have) to video-record psychotic or manic patients when fully decompensated, and when cleared of their symptoms, to allow them a recording of what they looked like. My intent was to show patients with poor compliance &/or insight what they look like when fully decompensated to prove to them they have a mental illness in need of treatment, and what could happen to them if they become noncompliant. (I'm sure all of you have had plenty of patients, who when cleared with medications deny they are mentally ill). I have not seen any studies on this type of thing. I was told by a psychologist that he saw a paper perform this same procedure, and it didn't seem to help. I unfortunately cannot locate this paper. Anyone see a study like this? IF not, I might try to do one in the near future.

 

[Encephalopathy]

Whopper, thanks for another informative post. In this case, the patient's delusions led this upper-middle class young adult to live on inner city streets on the other side of the country without her parent's knowledge for the last 6 months, and she was in pretty bad shape once located. Your point of immediacy is well-taken, though. Do you make an ethical distinction between the psychiatrist ordering a patient's belongings removed/destroyed vs answering a patient's mother's request for information that may lead to removal/destruction?

I think I found a study like you mentioned:

www.ncbi.nlm.nih.gov/pubmed/9824172...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

J Nerv Ment Dis. 1998 Nov;186(11):697-700. Links

Effect of video self-observation on development of insight in psychotic disorders.

Davidoff SA, Forester BP, Ghaemi SN, Bodkin JA.
Department of Psychiatry, McLean Hospital, Belmont, Massachusetts 02178, USA.
Many patients with psychotic disorders lack awareness of being ill. This often presents a serious impediment to treatment compliance. We hypothesized that exposing partially remitted patients to videotapes of themselves, made while they were acutely psychotic, might increase their insight into the nature of their illness. Eighteen acutely psychotic inpatients were assigned randomly to a control or experimental group and interviewed on videotape 24 to 48 hours after admission, using scales that measure insight (Insight and Treatment Attitudes Questionnaire [ITAQ]) and psychopathology (Brief Psychiatric Rating Scale [BPRS]). One to six weeks later, when judged to be significantly improved, subjects were shown either a videotape of their initial interview (experimental group) or a placebo videotape (control group) and then reinterviewed 24 to 48 hours later on videotape, using the BPRS and ITAQ scales. Evaluation of initial and final ITAQ and BPRS scores revealed significantly greater improvement in insight scores and in delusionality in the experimental group. However, no significant difference in overall psychopathology was seen for the two groups. These results suggest that exposure of hospitalized patients to videotapes of their own psychotic behavior may be a cost-effective therapeutic tool for developing personal insight into psychotic illness.

 

[hippiedoc13]

On a similar note, I came up with an idea (which I'm sure several else have) to video-record psychotic or manic patients when fully decompensated, and when cleared of their symptoms, to allow them a recording of what they looked like. My intent was to show patients with poor compliance &/or insight what they look like when fully decompensated to prove to them they have a mental illness in need of treatment, and what could happen to them if they become noncompliant. (I'm sure all of you have had plenty of patients, who when cleared with medications deny they are mentally ill). I have not seen any studies on this type of thing. I was told by a psychologist that he saw a paper perform this same procedure, and it didn't seem to help. I unfortunately cannot locate this paper. Anyone see a study like this? IF not, I might try to do one in the near future.

We do this at my institution. We routinely videotape the intake interview for all inpatients and it effectively becomes a part of the medical record. A couple of times we've shown the admission video to the patient/family close to the time of discharge as an attempt at "insight-building." I have absolutely no data to comment on whether or not this is effective.

Incidentally, we are also using the videos for educational purposes--culling the best clips to make a library of classic and/or unusual examples of mental status exam findings.

 

[whopper]

Thanks for the post, & the info on the study. Its certainly contrary to what my psychologist collegue mentioned. He mentioned something to the effect that doing so with psychotic patient cleared of their illness was countertherapeutic, and could cause the patient to believe that the video was forged.

But with the above data, I still might do a similar study. I think one with just a few patients certainly invites the need to do more. I can't do it at the place I'm currently at because they forbid making videos of the patients, but maybe at some other institution.

I'm also not surprised where it was done. Often times I see some very good studies being done there (somewhat OT, but this is from the prestige thread, and Mclean & MGH have been making some very good progress in our field).

Just wanted to clarify this from my last post....

There of course is a grey area. There are plenty of items that can be used to hurt oneself that are needed in everyday living--kitchen knives, bleach, ammonia, car, etc. I have never seen a case where someone was kept because of these type of items unless the suicidality was severe--I'm talking GAF less than 30.

Well if a GAF is less than 30, you're pretty much going to keep them in the hospital anyway, since with a GAF under 30, they're still commitable.

Do you make an ethical distinction between the psychiatrist ordering a patient's belongings removed/destroyed vs answering a patient's mother's request for information that may lead to removal/destruction?

Yes, if I'm interpreting your question right. Are you asking that the mother is requesting for information that may lead to removal/destruction? I don't see how giving information to the mother can lead to destruction of the writings unless that information is a reccomendation for her to do so--which I would not do for the reasons mentioned above.

The mother could destroy the items on her own without your reccomendation. Parents have a tendency to for better or worse, do things the kids don't want, which the parents believe are in the best interests of their children.

I would not reccomend such destruction for the reasons mentioned above. The writings may also be helpful. For example you could request the mother to bring in the writings, once the patient's psychosis has cleared, and present them as proof of the person's psychosis, and the need for compliance with medications.

 

[michaelrack]

When I was a resident, family members would often bring in things an inpatient had written, and we would put it in the chart. However, this was usually just a few pages of manic ramblings and not a large stack.

 

[Encephalopathy]

Yes, if I'm interpreting your question right. Are you asking that the mother is requesting for information that may lead to removal/destruction? I don't see how giving information to the mother can lead to destruction of the writings unless that information is a reccomendation for her to do so--which I would not do for the reasons mentioned above.

I guess my question is pretty hypothetical: the general consensus so far is that it would be out of professional bounds to advise destruction...however, if significant evidence existed that destruction could be beneficial in diminishing the delusion, would it be "ethical" to reveal that to the mother (knowing the most likely result would be the destruction)?

 

[BobA]

I think we could go back to the basics of medical ethics to think about this dilemma: Autonomy, Justice, Benificence.

Autonomy: the patient has autonomy in decision-making, even if they make a bad decision. For example, your patient has the right to smoke cigarettes even if they could kill them.

Justice: The patient has property rights.

Beneficence: your action must benefit the patient.

Non-maleficence: do no harm.

Would you take away your patient's cigarettes?

 

[nancysinatra]

I think we could go back to the basics of medical ethics to think about this dilemma: Autonomy, Justice, Benificence.

Autonomy: the patient has autonomy in decision-making, even if they make a bad decision. For example, your patient has the right to smoke cigarettes even if they could kill them.

Justice: The patient has property rights.

Beneficence: your action must benefit the patient.

Non-maleficence: do no harm.

Would you take away your patient's cigarettes?

That's how we all learn it in US medical school (though I hadn't heard about justice in there), but it doesn't have to be written in stone. The "basics of medical ethics" could be understood in a different way somewhere else. For example, I think "autonomy" has gained more focus in recent decades in the US as compared to earlier in the 20th century. In some cultures patients are shielded from their diagnoses (cancer, say) and only the family is told. Plus, autonomy and beneficence are often in conflict with each other, and may be in this case, and you may not be able to accomplish both with any one decision. For example, the action that benefits the patient most may require taking away some of their autonomy.

Patients cannot smoke in many hospitals. And their personal property is often confiscated (and later returned) when they enter the hospital. So the real estate owners' rights can trump the rights of the personal property owners who enter that real estate. Were the papers IN the mother's house? Who owned the paper they were written on? In any case, it's not obvious whose property are they, legally. Or let's say that the mother had gotten the papers while recovering the patient's belongings from some place where they were threatened, and was holding on to them, but didn't have the space for them, and wanted to throw them out. It's not the mother's job to safeguard the papers if in fact the patient doesn't have a home or other place in which to keep them.

I'm thinking of a similar scenario where you could have an OCPD patient get thrown out of their apartment OR their parents' house, where they had collected a lot of stuff. The patient could get treatment and gain insight, and want to go back and see the conditions they were living in, but the landlord or parents for multiple reasons, got rid of the stuff. Is that ethical or not, and does it matter if it's a landlord or a parent?

However, it is helpful to break it down like you did. I personally kind of cringe every time a patient has to hand over their personal stuff when they enter the hospital. I know it is for their good but it encroaches upon their property "rights."

It would be very interesting to study whether a recovered, formerly delusional patient confronted with past evidence of their delusions in the form of videotaped interview vs. their own writings has a different reaction based on the format.

 

[Encephalopathy]

Would you take away your patient's cigarettes?

No, but if the patient's mother asked me for my professional opinion on smoking, I would have no problem telling her that there is a large body of evidence that shows her daughter's health would likely be adversely affected by continued use of cigarettes.

Nancy, the papers are the patient's. She was found by her mother at a shelter, and brought (willingly) to the hospital. I believe the patient chose to give them to her mother to hold for her.

 

[BobA]

I believe as long as the patient has capacity, autonomy trumps beneficence.

 

[nancysinatra]

I believe as long as the patient has capacity, autonomy trumps beneficence.

Why do you believe that?

 

[BobA]

Why do you believe that?

If a patient has capacity, they always have the right to refuse a treatment.

Don't want that colon cancer removed? Well, OK -that's your choice.

Don't want to stop smoking? OK. Let me know if you change your mind and maybe we can help you.

Don't want dialysis? That's your choice.

I can't think of an example where beneficence trumps autonomy - assuming the patient has capacity.

If you're asking why this is on a deeper level, I would guess that it's rooted in the individualism that's at the base of a good deal of American culture.

 

[Encephalopathy]

One example would be euthanasia (except in Oregon). Also, illicit drug use. Both highly controversial issues in our society, of course.

 

[whopper]

I've got 1 case right now where the family wants me to keep the patient committed against her will for the rest of her life, and she's clearly not commitable. They don't seem to understand that I can't do that. What is really bothering me about this case is the case manager is actively misinforming the family, telling them that I should keep the person committed even though she is clearly not commitable, and encouraging them to sue me if I do not do that. She's actually said some very inappropriate things such as "I'm going to treat this case as if its my own daughter". Very frustrating.

Paternalism (or should it be called Maternalism?) is actively practiced in other countries. For example in Eastern Asian countries such as Japan & Korea, it is the standard for the doctor to not tell a patient for example that the patient has cancer if the doctor feels it may be too hurtful to the patient. If the family tells the doctor to not tell a patient information and the doctor follows the family's advice, that too is done there and is considered still within ethical bounds.

I haven't read much about how this would affect psychiatric commitment in those countries.

 

[nancysinatra]

If you're asking why this is on a deeper level, I would guess that it's rooted in the individualism that's at the base of a good deal of American culture.

I am asking why on a deeper level. The practice wasn't always so much to favor autonomism in America. Things have changed greatly since as recently as the early 1970s. There's a movie called the Case of Dax which illustrates this pretty well.

40 years is not that long for a cultural sea change, so I'm curious why this has happened.

Personally, if I were in a horrible accident or were horribly sick, and had capacity and were in pain and were asking for treatment to be stopped, I very much hope that if you were my doctor, you WOULD NOT stop treatment. That's my wish. My most autonomous wish as a healthy person right now is for you to violate my autonomy when I'm sick and, while still having capacity, suffering and in pain. I realize others do differ. However, you won't know it's me when I come to the hospital. And you'll stop treatment, and I could die, even though overall, I don't want to. That's why I think autonomy is complicated.

Also I do not feel like an "autonomous" being really, most of the time. I have a lot of people I answer to! And I'm in America where, yeah, we're pretty individualistic. I can't imagine how people in other countries understand "autonomy." Anyway, I'm just curious where this concept came from and how it came to be so firmly ingrained over such a short time and how the pendulum went so far to one side.

Don't worry, I follow the rules in the hospital of course! And I think this patient's has their property rights regarding their papers.

 

[BobA]

One example would be euthanasia (except in Oregon). Also, illicit drug use. Both highly controversial issues in our society, of course.

I think we're on the same page here. Both euthanasia and illicit drug use are examples of patients exercising their autonomy.

the reason that euthanasia is not legal in other states has to do with nonmalficence, not beneficence.

Personally, I think euthanasia should be far more widely used.