History and Physical

Journal Article Summary

Article: Inflammatory markers and chronic exposure to fluoxetine, divalproex, and placebo in intermittent explosive disorder

Journal of Psychiatry Research, 2015

Authors: Coccaro et al.  

• This is a double-blind randomized placebo-controlled trial.
• They compared outcomes among patients with Intermittent Explosive Disorder with and without treatment with the drugs Fluoxetine and Divalproex and looked at the outcomes by measuring inflammatory markers, aggression, and irritability.
• Around 90 patients with Intermittent Explosive Disorder were studied for 12 weeks.
• Subjects were divided into the Fluoxetine treatment group (29 patients), the Divalproex treatment group (30 patients), or the placebo group (31 patients). 
• Inclusion criteria were patients with Intermittent Explosive Disorder.
• Exclusion criteria were patients with mania, hypomania, schizophrenia, delusional disorder, major depression, or patients dependent on alcohol/other drugs of abuse.
• The outcomes measured were inflammatory markers (CRP, IL 1β, IL-2, IL-6, IL-8, IL-10, Tumor Necrosis Factor alpha), Aggression via the Overt Aggression Scale Modified (OAS-M), and Irritability via the Clinical Global Impression of Improvement (CGI-I).
• The primary finding of this study is that inflammatory markers were unaffected by the treatment with Fluoxetine or Divalproex, compared with placebo.
• Fluoxetine and Divalproex compared to placebo, did not have a significant difference on decreasing aggression via OAS-M (F[2,26] = 0.17, p=0.850) or irritability via CGI-I (F[2,26]=0.25, p=0.780).
• In previous studies by Coccaro and Kavoussi (1997) and Coccaro et al. (2009) there was a relationship between Fluoxetine and decreasing aggression. In this study, that wasn’t the case and this was explained by having looser entry criteria in the OAS-M Aggression Score. An OAS-M Aggression score of 15 or more and an OAS-M Irritability score of 6 or more is needed to display a significant effect favoring fluoxetine over placebo. Only 1/3 of the subjects in this study fulfilled the stringent entry criteria of having had an OAS-M Aggression score of 15 or more. Another limitation of the study is the modest sample size. 
• While the article focuses on which pharmacological agents will decrease inflammatory markers, aggression, and irritation in patients with intermittent explosive disorder I believe there still needs to be higher quality RCT with studies on focusing on comparing pharmacological treatment for impulse control disorders (such as Phenytoin, Oxcarbazepine, Carbamazepine, Lamotrigine, Topiramate, Valproate, Lithium). Another important concept future studies can focus on is comparing CBT with pharmacotherapy to pharmacotherapy alone or to CBT alone.

Sources:

Coccaro, E. F., Lee, R., Breen, E. C., & Irwin, M. R. (2015). Inflammatory markers and chronic exposure to fluoxetine, divalproex, and placebo in intermittent explosive disorder. Psychiatry research, 229(3), 844–849. https://doi.org/10.1016/j.psychres.2015.07.078

Coccaro, E.F., Kavoussi, R.J., 1997. Fluoxetine and impulsive aggressive behavior in personality-disordered subjects. Arch. Gen. Psychiatry 54, 1081–1088.

Coccaro, E.F., Lee, R., Kavoussi, R., 2009. A double-blind, randomized, placebo- controlled trial of fluoxetine in patients with intermittent explosive disorder. J. Clin. Psychiatry 70, 653–662.

Site Evaluation Presentation Summary

My site evaluator for my fourth rotation was Dr. Saint Martin. During my site evaluation, I presented 3 H&Ps from my time in Psych ED at QHC. The 1st H&P was a case of a 23-year-old female who was brought in by EMS activated by a therapist for suicidal ideations. She recently broke up with her boyfriend of 2 years. Pt was later diagnosed with borderline personality disorder. Suicidal threats, gestures, and attempts are common manifestations of BPD. Pts with BPD view their friend/romantic partner as an ideal almost perfect person. However, if the support person leaves the pt can immediately become angry, depressed, demeaning, hopeless, or suicidal. After breaking up with her boyfriend who meant the world to her, pt became suicidal. Pt also shows impulsivity with recurrent suicidal behavior/gestures/threats (she has never successfully mutilated herself). My second H&P was a case on Impulse Control Disorder-Intermittent Explosive Disorder. And my third H&P was a case on Schizoaffective- Bipolar Type.

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

Typically in psychiatric ED, patients are bought in because of agitation, bizarre behavior, or risky behavior. I remember there was one case that left a huge impression on me and made me reevaluate any assumptions I had on any patient. It was a case of a 34-year-old man who was brought in because of agitation. He was kept in CPEP for 24 hours, and he was later discharged. He stated he was drugged at the party, and his drug screen came back positive. After contacting his collateral, it was confirmed he was at a party last night and he started acting bizarrely afterward. It was a good reminder for me, that not everyone brought into psychiatric ED is there because of psychiatric illnesses or intentional drug use. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

Sometimes I found it difficult to educate patients and their families on the importance of being consistent with their medications. Oftentimes, family members believe that the antipsychotic is making the patient worse and want the provider to discontinue it. It was difficult for me to perform a full complete physical exam on a lot of the patients since most were at moderate to high risk for assault. However, for patients to be admitted to psychiatric ED they must be medically cleared beforehand.  

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

The hardest patients I had to deal with were the ones that were known to malinger. Those patients had a specific goal in mind, which was often food or shelter. However, these patients often were uncooperative and hostile whenever I tried to take history. Some providers recommended letting the patient eat first and then obtaining their history later. 

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

For my following rotations, I want to get better at patient education, procedures, and physical exam. I was unable to perform full physical exams in the psychiatric ED, but I gained experience in performing mental status exams along with depression screening. I understand that each rotation focuses on specific procedures, and I plan on perfecting those procedures at those sites. My next rotation is Surgery, and I’ll gain opportunities in suturing, IVs, etc.