American Academy of Psychiatry and the Law (AAPL): Annual Meeting

BOSTON – Most people just get a mild buzz from their morning coffee, but an unfortunate few have reactions to caffeine ranging from severe agitation to paranoid delusions and psychosis, forensic psychiatrists reported in a poster presented at the annual meeting of the American Academy of Psychiatry in the Law.

Photo credit Lynda Banzi/Elsevier Global Medical News

Caffeine is known to act as an antagonist of the adenosine A2a receptor, thereby causing an increase in dopaminergic neurotransmission, especially in areas of the brain rich in D2 receptors. "This mechanism may cause or exacerbate psychotic symptoms, and is also triggered by modulation of transmission in the mesolimbic dopaminergic pathways," wrote Dr. Christopher M. Davidson of the University of South Dakota Sanford School of Medicine, Sioux Falls, and his associates.

Caffeine is metabolized by the cytochrome P450 1A2 enzyme. Polymorphisms in the enzyme might affect how individuals metabolize and respond to caffeine, the authors said.

They reported on a forensic case and two corrections cases of caffeine-induced mental and behavioral problems.

In the forensics case, a 24-year old man with no history of mental illness assaulted an emergency room nurse after he had driven all night and ingested the caffeine equivalent of about three cups of coffee, said coauthor Dr. James B. Reynolds of the Northwest Missouri Psychiatric Rehabilitation Center, St. Joseph, in an interview.

The patient had been brought to the emergency department by police whom he had sought out when he began experiencing confusion and paranoia. At one point, without apparent provocation, he jumped out of bed, grabbed the nurse, and shouted: "Why do you do that to me, why do you do that to me?" and cut her neck with a box cutter in his possession.

He was charged with first-degree assault, but was found to have no apparent motive for the assault, no criminal or mental health history, and no evidence of drug or alcohol abuse. He did, however, have a box of caffeine pills in his possession, leading to the conclusion that he was likely suffering from pathologic intoxication.

Dr. Reynolds said that if intoxication occurs because of unforeseeable circumstances, it might qualify as a valid defense against a criminal charge.

Given the circumstances, the prosecutor agreed with the defense, and the man was found not guilty by reason of insanity.

"He came into my hospital, and for nearly 3 years this man was under our observation, and never had one symptom of mental illness and no repeat episode," Dr. Reynolds said.

In the first of the two corrections cases, a 22-year-old man who had been diagnosed with schizophrenia of the catatonic type was living in a section for mentally ill prisoners. He developed new symptoms of activation, irritability, confrontation, restlessness, and high energy with little need for sleep. The episodes occurred at intervals of 1-2 weeks and lasted for 1-3 days.

The mental health staff suspected he had rapid-cycling bipolar-type schizoaffective disorder, and tried treating him with higher doses of olanzapine, augmented with fluphenazine, aripiprazole, and valproic acid, none of which seemed to work.

Through careful observation and documentation, staff noticed that the episodes corresponded to the prisoner’s visits to the commissary, where he bought caffeinated beverages. After he was forbidden to buy coffee or tea, the patient’s maniclike episodes vanished.

In the second case, prison staff saw that a 24-year-old man who had been diagnosed with schizophrenia, undifferentiated type, became agitated and spent most of the night pacing and yelling after he had visited the unit commissary.

"In the months following careful monitoring and restriction of caffeine use in the patient’s housing unit, he had such significant resolution of his symptoms that his doses of trifluophenazine and benzotropine were halved, and he was able to transition to the general population," the authors wrote.

They noted that caffeine is not necessary for the health and functioning of patients in correctional settings, and recommended that institutions either monitor and limit caffeine use, or eliminate it in some correctional settings. They also called for further investigation of highly variable responses to caffeine.

The authors did not disclose a funding source. Dr. Davidson, Dr. Reynolds, and their coauthors reported that they had no relevant financial disclosures.

BOSTON – Most people just get a mild buzz from their morning coffee, but an unfortunate few have reactions to caffeine ranging from severe agitation to paranoid delusions and psychosis, forensic psychiatrists reported in a poster presented at the annual meeting of the American Academy of Psychiatry in the Law.

Photo credit Lynda Banzi/Elsevier Global Medical News

Caffeine is known to act as an antagonist of the adenosine A2a receptor, thereby causing an increase in dopaminergic neurotransmission, especially in areas of the brain rich in D2 receptors. "This mechanism may cause or exacerbate psychotic symptoms, and is also triggered by modulation of transmission in the mesolimbic dopaminergic pathways," wrote Dr. Christopher M. Davidson of the University of South Dakota Sanford School of Medicine, Sioux Falls, and his associates.

Caffeine is metabolized by the cytochrome P450 1A2 enzyme. Polymorphisms in the enzyme might affect how individuals metabolize and respond to caffeine, the authors said.

They reported on a forensic case and two corrections cases of caffeine-induced mental and behavioral problems.

In the forensics case, a 24-year old man with no history of mental illness assaulted an emergency room nurse after he had driven all night and ingested the caffeine equivalent of about three cups of coffee, said coauthor Dr. James B. Reynolds of the Northwest Missouri Psychiatric Rehabilitation Center, St. Joseph, in an interview.

The patient had been brought to the emergency department by police whom he had sought out when he began experiencing confusion and paranoia. At one point, without apparent provocation, he jumped out of bed, grabbed the nurse, and shouted: "Why do you do that to me, why do you do that to me?" and cut her neck with a box cutter in his possession.

He was charged with first-degree assault, but was found to have no apparent motive for the assault, no criminal or mental health history, and no evidence of drug or alcohol abuse. He did, however, have a box of caffeine pills in his possession, leading to the conclusion that he was likely suffering from pathologic intoxication.

Dr. Reynolds said that if intoxication occurs because of unforeseeable circumstances, it might qualify as a valid defense against a criminal charge.

Given the circumstances, the prosecutor agreed with the defense, and the man was found not guilty by reason of insanity.

"He came into my hospital, and for nearly 3 years this man was under our observation, and never had one symptom of mental illness and no repeat episode," Dr. Reynolds said.

In the first of the two corrections cases, a 22-year-old man who had been diagnosed with schizophrenia of the catatonic type was living in a section for mentally ill prisoners. He developed new symptoms of activation, irritability, confrontation, restlessness, and high energy with little need for sleep. The episodes occurred at intervals of 1-2 weeks and lasted for 1-3 days.

The mental health staff suspected he had rapid-cycling bipolar-type schizoaffective disorder, and tried treating him with higher doses of olanzapine, augmented with fluphenazine, aripiprazole, and valproic acid, none of which seemed to work.

Through careful observation and documentation, staff noticed that the episodes corresponded to the prisoner’s visits to the commissary, where he bought caffeinated beverages. After he was forbidden to buy coffee or tea, the patient’s maniclike episodes vanished.

In the second case, prison staff saw that a 24-year-old man who had been diagnosed with schizophrenia, undifferentiated type, became agitated and spent most of the night pacing and yelling after he had visited the unit commissary.

"In the months following careful monitoring and restriction of caffeine use in the patient’s housing unit, he had such significant resolution of his symptoms that his doses of trifluophenazine and benzotropine were halved, and he was able to transition to the general population," the authors wrote.

They noted that caffeine is not necessary for the health and functioning of patients in correctional settings, and recommended that institutions either monitor and limit caffeine use, or eliminate it in some correctional settings. They also called for further investigation of highly variable responses to caffeine.

The authors did not disclose a funding source. Dr. Davidson, Dr. Reynolds, and their coauthors reported that they had no relevant financial disclosures.

BOSTON – Most people just get a mild buzz from their morning coffee, but an unfortunate few have reactions to caffeine ranging from severe agitation to paranoid delusions and psychosis, forensic psychiatrists reported in a poster presented at the annual meeting of the American Academy of Psychiatry in the Law.

Photo credit Lynda Banzi/Elsevier Global Medical News

Caffeine is known to act as an antagonist of the adenosine A2a receptor, thereby causing an increase in dopaminergic neurotransmission, especially in areas of the brain rich in D2 receptors. "This mechanism may cause or exacerbate psychotic symptoms, and is also triggered by modulation of transmission in the mesolimbic dopaminergic pathways," wrote Dr. Christopher M. Davidson of the University of South Dakota Sanford School of Medicine, Sioux Falls, and his associates.

Caffeine is metabolized by the cytochrome P450 1A2 enzyme. Polymorphisms in the enzyme might affect how individuals metabolize and respond to caffeine, the authors said.

They reported on a forensic case and two corrections cases of caffeine-induced mental and behavioral problems.

In the forensics case, a 24-year old man with no history of mental illness assaulted an emergency room nurse after he had driven all night and ingested the caffeine equivalent of about three cups of coffee, said coauthor Dr. James B. Reynolds of the Northwest Missouri Psychiatric Rehabilitation Center, St. Joseph, in an interview.

The patient had been brought to the emergency department by police whom he had sought out when he began experiencing confusion and paranoia. At one point, without apparent provocation, he jumped out of bed, grabbed the nurse, and shouted: "Why do you do that to me, why do you do that to me?" and cut her neck with a box cutter in his possession.

He was charged with first-degree assault, but was found to have no apparent motive for the assault, no criminal or mental health history, and no evidence of drug or alcohol abuse. He did, however, have a box of caffeine pills in his possession, leading to the conclusion that he was likely suffering from pathologic intoxication.

Dr. Reynolds said that if intoxication occurs because of unforeseeable circumstances, it might qualify as a valid defense against a criminal charge.

Given the circumstances, the prosecutor agreed with the defense, and the man was found not guilty by reason of insanity.

"He came into my hospital, and for nearly 3 years this man was under our observation, and never had one symptom of mental illness and no repeat episode," Dr. Reynolds said.

In the first of the two corrections cases, a 22-year-old man who had been diagnosed with schizophrenia of the catatonic type was living in a section for mentally ill prisoners. He developed new symptoms of activation, irritability, confrontation, restlessness, and high energy with little need for sleep. The episodes occurred at intervals of 1-2 weeks and lasted for 1-3 days.

The mental health staff suspected he had rapid-cycling bipolar-type schizoaffective disorder, and tried treating him with higher doses of olanzapine, augmented with fluphenazine, aripiprazole, and valproic acid, none of which seemed to work.

Through careful observation and documentation, staff noticed that the episodes corresponded to the prisoner’s visits to the commissary, where he bought caffeinated beverages. After he was forbidden to buy coffee or tea, the patient’s maniclike episodes vanished.

In the second case, prison staff saw that a 24-year-old man who had been diagnosed with schizophrenia, undifferentiated type, became agitated and spent most of the night pacing and yelling after he had visited the unit commissary.

"In the months following careful monitoring and restriction of caffeine use in the patient’s housing unit, he had such significant resolution of his symptoms that his doses of trifluophenazine and benzotropine were halved, and he was able to transition to the general population," the authors wrote.

They noted that caffeine is not necessary for the health and functioning of patients in correctional settings, and recommended that institutions either monitor and limit caffeine use, or eliminate it in some correctional settings. They also called for further investigation of highly variable responses to caffeine.

The authors did not disclose a funding source. Dr. Davidson, Dr. Reynolds, and their coauthors reported that they had no relevant financial disclosures.

BOSTON – Before hanging out a shingle on Facebook or other social networking sites, mental health providers should be aware of the pitfalls of TMI – too much information – warned a psychiatrist at the annual meeting of the American Academy of Psychiatry and the Law.

Roughly half of all medical students who posted on Facebook without thought to their privacy settings revealed personal information that did not reflect well on them, including profanity, intoxication, and discriminatory language, and more than a third posted sexually suggestive messages or images, reported Dr. Helen M. Farrell, a staff psychiatrist at Beth Israel Deaconess Medical Center in Boston.

In addition, indiscriminate postings can run afoul of HIPAA rules and leave clinicians liable to malpractice actions, Dr. Farrell cautioned.

Facebook can be useful for marketing a practice, but it can also be a professional and ethical minefield when used improperly, she noted in a poster presentation and an interview.

"If psychiatrists are contacted by patients on Facebook, they should not ‘friend’ the patients or establish any communication with them. They can also block patients from seeing their profiles and that would be recommended," she said.

She quoted a 2009 article in Entertainment Weekly which asked, "How on earth did we stalk our exes, remember our coworkers’ birthdays, bug our friends, and play a rousing game of Scrabulous before Facebook?"

Dr. Farrell did a PubMed search for articles on professionalism and Facebook, and found 12 studies that looked at how medical students and residents used the social medium.

"If psychiatrists are contacted by patients on Facebook, they should not ‘friend’ ... or establish any communication with them."

For example, a survey of Vanderbilt surgery residents and faculty found that 64% of the residents and 22% of the faculty had Facebook pages, and that 31% had publicly accessible sites with work-related comments posted (J. Surg. Educ. 2010;67:381-6). Of those comments, 14% made reference to patient care or to specific patient situations.

In a another study, investigators from the Wellington School of Medicine and Health Sciences in New Zealand, conducted a cross-sectional survey of Facebook use by recent medical graduates (Med. Educ. 2010;44:805-13).

They found that 37% of the 220 graduates who had Facebook accounts had publicly available profiles, more than one-third of which (37%) revealed the poster’s sexual orientation, 46% showed them using alcohol, and 10% showed them being intoxicated.

It’s also unwise for clinicians to accept "friending" requests from patients. The patient may be exposed to possible unprofessional or embarrassing content that could tarnish the doctor-patient relationship, and there are concerns about boundary issues and potential liability, Dr. Farrell said.

The flip side of the Facebook coin is its promotional value, which can be used to market a school’s curriculum and share information about clinical and academic departments, schedules, etc.

In addition, public profiles that patients post can provide clues about their mental states, such as histrionic or narcissistic personality traits, antisocial moods, or behaviors such as the use of hostile language, libel, or cyberbullying.

The way in which patients react to Facebook also might provide clues to their thought processes or content. For example, patients who frequently, repeatedly check their Facebook accounts might have obsessive/compulsive traits, whereas postings by the patient might reveal psychosis or homicidal or suicidal ideation. Postings also may provide clues to patients’ perceptual disturbances, insight, and judgment, Dr. Farrell noted.

She recommends that Facebook users choose the highest privacy settings allowed, and that "e-professionalism" become part of the formal curriculum at professional schools and organizations.

The study was internally funded. Dr. Farrell reported that she had no relevant conflicts of interests.

BOSTON – Before hanging out a shingle on Facebook or other social networking sites, mental health providers should be aware of the pitfalls of TMI – too much information – warned a psychiatrist at the annual meeting of the American Academy of Psychiatry and the Law.

Roughly half of all medical students who posted on Facebook without thought to their privacy settings revealed personal information that did not reflect well on them, including profanity, intoxication, and discriminatory language, and more than a third posted sexually suggestive messages or images, reported Dr. Helen M. Farrell, a staff psychiatrist at Beth Israel Deaconess Medical Center in Boston.

In addition, indiscriminate postings can run afoul of HIPAA rules and leave clinicians liable to malpractice actions, Dr. Farrell cautioned.

Facebook can be useful for marketing a practice, but it can also be a professional and ethical minefield when used improperly, she noted in a poster presentation and an interview.

"If psychiatrists are contacted by patients on Facebook, they should not ‘friend’ the patients or establish any communication with them. They can also block patients from seeing their profiles and that would be recommended," she said.

She quoted a 2009 article in Entertainment Weekly which asked, "How on earth did we stalk our exes, remember our coworkers’ birthdays, bug our friends, and play a rousing game of Scrabulous before Facebook?"

Dr. Farrell did a PubMed search for articles on professionalism and Facebook, and found 12 studies that looked at how medical students and residents used the social medium.

"If psychiatrists are contacted by patients on Facebook, they should not ‘friend’ ... or establish any communication with them."

For example, a survey of Vanderbilt surgery residents and faculty found that 64% of the residents and 22% of the faculty had Facebook pages, and that 31% had publicly accessible sites with work-related comments posted (J. Surg. Educ. 2010;67:381-6). Of those comments, 14% made reference to patient care or to specific patient situations.

In a another study, investigators from the Wellington School of Medicine and Health Sciences in New Zealand, conducted a cross-sectional survey of Facebook use by recent medical graduates (Med. Educ. 2010;44:805-13).

They found that 37% of the 220 graduates who had Facebook accounts had publicly available profiles, more than one-third of which (37%) revealed the poster’s sexual orientation, 46% showed them using alcohol, and 10% showed them being intoxicated.

It’s also unwise for clinicians to accept "friending" requests from patients. The patient may be exposed to possible unprofessional or embarrassing content that could tarnish the doctor-patient relationship, and there are concerns about boundary issues and potential liability, Dr. Farrell said.

The flip side of the Facebook coin is its promotional value, which can be used to market a school’s curriculum and share information about clinical and academic departments, schedules, etc.

In addition, public profiles that patients post can provide clues about their mental states, such as histrionic or narcissistic personality traits, antisocial moods, or behaviors such as the use of hostile language, libel, or cyberbullying.

The way in which patients react to Facebook also might provide clues to their thought processes or content. For example, patients who frequently, repeatedly check their Facebook accounts might have obsessive/compulsive traits, whereas postings by the patient might reveal psychosis or homicidal or suicidal ideation. Postings also may provide clues to patients’ perceptual disturbances, insight, and judgment, Dr. Farrell noted.

She recommends that Facebook users choose the highest privacy settings allowed, and that "e-professionalism" become part of the formal curriculum at professional schools and organizations.

The study was internally funded. Dr. Farrell reported that she had no relevant conflicts of interests.

BOSTON – Before hanging out a shingle on Facebook or other social networking sites, mental health providers should be aware of the pitfalls of TMI – too much information – warned a psychiatrist at the annual meeting of the American Academy of Psychiatry and the Law.

Roughly half of all medical students who posted on Facebook without thought to their privacy settings revealed personal information that did not reflect well on them, including profanity, intoxication, and discriminatory language, and more than a third posted sexually suggestive messages or images, reported Dr. Helen M. Farrell, a staff psychiatrist at Beth Israel Deaconess Medical Center in Boston.

In addition, indiscriminate postings can run afoul of HIPAA rules and leave clinicians liable to malpractice actions, Dr. Farrell cautioned.

Facebook can be useful for marketing a practice, but it can also be a professional and ethical minefield when used improperly, she noted in a poster presentation and an interview.

"If psychiatrists are contacted by patients on Facebook, they should not ‘friend’ the patients or establish any communication with them. They can also block patients from seeing their profiles and that would be recommended," she said.

She quoted a 2009 article in Entertainment Weekly which asked, "How on earth did we stalk our exes, remember our coworkers’ birthdays, bug our friends, and play a rousing game of Scrabulous before Facebook?"

Dr. Farrell did a PubMed search for articles on professionalism and Facebook, and found 12 studies that looked at how medical students and residents used the social medium.

"If psychiatrists are contacted by patients on Facebook, they should not ‘friend’ ... or establish any communication with them."

For example, a survey of Vanderbilt surgery residents and faculty found that 64% of the residents and 22% of the faculty had Facebook pages, and that 31% had publicly accessible sites with work-related comments posted (J. Surg. Educ. 2010;67:381-6). Of those comments, 14% made reference to patient care or to specific patient situations.

In a another study, investigators from the Wellington School of Medicine and Health Sciences in New Zealand, conducted a cross-sectional survey of Facebook use by recent medical graduates (Med. Educ. 2010;44:805-13).

They found that 37% of the 220 graduates who had Facebook accounts had publicly available profiles, more than one-third of which (37%) revealed the poster’s sexual orientation, 46% showed them using alcohol, and 10% showed them being intoxicated.

It’s also unwise for clinicians to accept "friending" requests from patients. The patient may be exposed to possible unprofessional or embarrassing content that could tarnish the doctor-patient relationship, and there are concerns about boundary issues and potential liability, Dr. Farrell said.

The flip side of the Facebook coin is its promotional value, which can be used to market a school’s curriculum and share information about clinical and academic departments, schedules, etc.

In addition, public profiles that patients post can provide clues about their mental states, such as histrionic or narcissistic personality traits, antisocial moods, or behaviors such as the use of hostile language, libel, or cyberbullying.

The way in which patients react to Facebook also might provide clues to their thought processes or content. For example, patients who frequently, repeatedly check their Facebook accounts might have obsessive/compulsive traits, whereas postings by the patient might reveal psychosis or homicidal or suicidal ideation. Postings also may provide clues to patients’ perceptual disturbances, insight, and judgment, Dr. Farrell noted.

She recommends that Facebook users choose the highest privacy settings allowed, and that "e-professionalism" become part of the formal curriculum at professional schools and organizations.

The study was internally funded. Dr. Farrell reported that she had no relevant conflicts of interests.