Article

Mr. B, age 37, presents to a community mental health center for an appointment following a recent emergency department visit. He is diagnosed with schizophrenia, and has been treated for approximately 1 year. Six months ago, Mr. B stopped taking his antipsychotic due to its adverse effects. Despite compliance with another agent, he has become increasingly disorganized and paranoid.

He now believes that his mother, with whom he has lived all his life and who serves as his guardian, is poisoning his food and trying to kill him. She is an employee at a local grocery store, and Mr. B has expressed concern that her coworkers are assisting her in the plot to kill him.

Following a home visit, Mr. B’s case manager indicates that the patient showed them the collection of weapons he is amassing to “defend” himself. This leads to a concern for the safety of the patient, his mother, and others.

Although parricide—killing one’s parent—is a relatively rare event, its sensationalistic nature has long captured the attention of headline writers and the general public. This article discusses the diagnostic and demographic factors that may be seen among individuals who kill their parents, with an emphasis on those who commit matricide (murder of one’s mother) and associated spree killings, where an individual kills multiple people within a single brief but contiguous time period. Understanding these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents in addition to others.

Characteristics of perpetrators of parricide

Worldwide, approximately 2% to 4% of homicides involve parricide, or killing one’s parent.^1,2 Most offenders are men in early adulthood, though a proportion are adolescents and some are women.^1,3 They are often single, unemployed, and live with the parent prior to the killing.¹ Patricide occurs more frequently than matricide.⁴ In the United States, approximately 150 fathers and 100 mothers are killed by their child each year.⁵

In a study of all homicides in England and Wales between 1997 and 2014, two-thirds of parricide offenders had previously been diagnosed with a mental disorder.¹ One-third were diagnosed with schizophrenia.¹ In a Canadian study focusing on 43 adult perpetrators found not criminally responsible,⁶ most were experiencing psychotic symptoms at the time of parricide; symptoms of a personality disorder were the second-most prevalent symptoms. Similarly, Bourget et al⁴ studied Canadian coroner records for 64 parents killed by their children. Of the children involved in those parricides, 15% attempted suicide after the killing. Two-thirds of the male offenders evidenced delusional thinking, and/or excessive violence (overkill) was common. Some cases (16%) followed an argument, and some of those perpetrators were intoxicated or psychotic. From our clinical experience, when there are identifiable nonpsychotic triggers, they often can be small things such as an argument over food, smoking, or video games. Often, the perpetrator was financially dependent on their parents and were “trapped in a difficult/hostile/dependence/love relationship” with that parent.⁶ Adolescent males who kill their parents may not have psychosis⁷; however, they may be victims of longstanding serious abuse at the hands of their parents. These perpetrators often express relief rather than remorse after committing murder.

Three categories to classify the perpetrators of parricide have been proposed: severely abused, severely mentally ill, and “dangerously antisocial.”³ While severe mental illness was most common in adult defendants, severe abuse was most common in adolescent offenders. There may be significant commonalities between adolescent and adult perpetrators. A more recent latent class analysis by Bojanic et al¹ indicated 3 unique types of parricide offenders (Table 1).

Continue to: Matricide: A closer look...

 

 

Matricide: A closer look

Though multiple studies have found a higher rate of psychosis among perpetrators of matricide, it is important to note that most people with psychotic disorders would never kill their mother. These events, however, tend to grab headlines and may be highly focused upon by the general population. In addition, matricide may be part of a larger crime that draws additional attention. For example, the 1966 University of Texas Bell Tower shooter and the 2012 Sandy Hook Elementary school shooter both killed their mothers before engaging in mass homicide. Often in cases of matricide, a longer-term dysfunctional relationship existed between the mother and the child. The mother is frequently described as controlling and intrusive and the (often adult) child as overly dependent, while the father may be absent or ineffectual. Hostility and mutual dependence are usual hallmarks of these relationships.⁸

However, in some cases where an individual with a psychotic disorder kills their mother, there may have been a traditional nurturing relationship.⁸ Alternative motivations unrelated to psychosis must be considered, including crimes motivated by money/inheritance or those perpetrated out of nonpsychotic anger. Green⁸ described motive categories for matricide that include paranoid and persecutory, altruistic, and other. In the “paranoid and persecutory” group, delusional beliefs about the mother occur; for example, the perpetrator may believe their mother was the devil. Sexual elements are found in some cases.⁸ Alternatively, the “altruistic” group demonstrated rather selfless reasons for killing, such as altruistic infanticide cases, or killing out of love.⁹ The altruistic matricide perpetrator may believe their mother is unwell, which may be a delusion or actually true. Finally, the “other” category contains cases related to jealousy, rage, and impulsivity.

In a study of 15 matricidal men in New York conducted by Campion et al,¹⁰ individuals seen by forensic psychiatric services for the crime of matricide included those with schizophrenia, substance-induced psychosis, and impulse control disorders. The authors noted there was often “a serious chronic derangement in the relationships of most matricidal men and their mothers.” Psychometric testing in these cases indicated feelings of dependency, weakness, and difficulty accepting an adult role separate from their mother. Some had conceptualized their mothers as a threat to their masculinity, while others had become enraged at their mothers.

Prevention requires addressing underlying issues

As described above, several factors are common among individuals who commit parricide, and these can be used to develop prevention strategies that focus on addressing underlying issues (Table 2). It is important to consider the relationship dynamics between the potential victim and perpetrator, as well as the motive, rather than focusing solely on mental illness or substance misuse.²

Spree killings that start as parricide

Although spree killing is a relatively rare event, a subset of spree killings involve parricide. One infamous recent event occurred in 2012 at Sandy Hook Elementary School, where the gunman killed his mother before going to the school and killing 26 additional people, many of whom were children.^11,12 Because such events are rare, and because in these cases there is a high likelihood that the perpetrator is deceased (eg, died by suicide or killed by the police), much remains unknown about specific motivations and causative factors.

Information is often pieced together from postmortem reviews, which can be hampered by hindsight/recall bias and lack of contemporaneous documentation. Even worse, when these events occur, they may lead to a bias that all parricides or mass murders follow the pattern of the most recent case. This can result in overgeneralization of an individual’s history as being actionable risk violence factors for all potential parricide cases both by the public (eg, “My sister’s son has autism, and the Sandy Hook shooter was reported to have autism—should I be worried for my sister?”) and professionals (eg, “Will I be blamed for the next Sandy Hook by not taking more aggressive action even though I am not sure it is clinically warranted?”).

To identify trends for individuals committing parricide who engage in mass murder events (such as spree killing), we reviewed the 2000-2019 FBI active shooter list.¹² Of the 333 events identified, 46 could be classified as domestic violence situations (eg, the perpetrator was in a romantic or familial relationship/former relationship and engaged in an active shooting incident involving at least 1 person from that relationship). We classified 11 of those 46 cases as parricide. Ten of those 11 parricides involved a child killing a parent (Table 3), and the other involved a grandchild killing a grandfather who served as their primary caregiver. Of the 11 incidents, mothers were involved (killed or wounded) in 4, and father figures (including the grandfather serving as a father and a stepfather) were killed in 9, with 2 incidents involving both parents. In 4 of the 11 parricides, other family members were killed in addition to the parent (including siblings, grandparents, or extended family). When considering spree shooters who committed parricide, 4 alleged perpetrators died by suicide, 1 was killed at the scene, and the rest were apprehended. The most common active shooting site endangering the public was an educational location (5), followed by commerce locations (4), with 2 involving open spaces. Eight of the 11 parricides occurred before the event was designated as an active shooting. The mean age for a parricide plus spree shooter was 23, once the oldest (age 61) and youngest (age 14) were removed from the calculation. The majority of the cases fell into the age range of 16 to 25 (n = 6), followed by 3 individuals who were age 26 to 31 (n = 3). All suspected individuals were male.

Continue to: Parricide and society...

Parricide and society

For centuries, mothers and fathers have been honored and revered. Therefore, it is not surprising that killing of one’s mother or father attracts a great deal of macabre interest. Examples of parricide are present throughout popular culture, in mythology, comic books, movies, and television. As all psychiatrists know, Oedipus killed his father and married his mother. Other popular culture examples include: Grant Morrison’s Arkham Asylum: A Serious House on Serious Earth, Alfred Hitchcock’s Psycho, Oliver Stone’s Natural Born Killers, Peter Jackson’s Heavenly Creatures, The Affair drama series, and Star Wars: The Force Awakens.^13,14

CASE CONTINUED

In Mr. B’s case, it is imperative for the treatment team to inquire about his history of violence, paying particular attention to prior violent acts towards his mother. His clinicians should consider hospitalization with the guardian’s consent if the danger appears imminent, especially considering the presence of weapons at home. They should attempt to stabilize Mr. B on effective, tolerable medications to ameliorate his psychosis, and to refer him for long-term psychotherapy to address difficult dynamic issues in the family relationship and encourage compliance with treatment. These steps may help avert a tragedy.

Bottom Line

Individuals who commit parricide often have a history of psychosis, a mood disorder, childhood abuse, and/or difficult relationship dynamics with the parent they kill. Some go on a spree killing in the community. Through careful consideration of individual risk factors, psychiatrists may help prevent some cases of parent murder by a child and possibly more tragedy in the community.

Mr. B, age 37, presents to a community mental health center for an appointment following a recent emergency department visit. He is diagnosed with schizophrenia, and has been treated for approximately 1 year. Six months ago, Mr. B stopped taking his antipsychotic due to its adverse effects. Despite compliance with another agent, he has become increasingly disorganized and paranoid.

He now believes that his mother, with whom he has lived all his life and who serves as his guardian, is poisoning his food and trying to kill him. She is an employee at a local grocery store, and Mr. B has expressed concern that her coworkers are assisting her in the plot to kill him.

Following a home visit, Mr. B’s case manager indicates that the patient showed them the collection of weapons he is amassing to “defend” himself. This leads to a concern for the safety of the patient, his mother, and others.

Although parricide—killing one’s parent—is a relatively rare event, its sensationalistic nature has long captured the attention of headline writers and the general public. This article discusses the diagnostic and demographic factors that may be seen among individuals who kill their parents, with an emphasis on those who commit matricide (murder of one’s mother) and associated spree killings, where an individual kills multiple people within a single brief but contiguous time period. Understanding these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents in addition to others.

Characteristics of perpetrators of parricide

Worldwide, approximately 2% to 4% of homicides involve parricide, or killing one’s parent.^1,2 Most offenders are men in early adulthood, though a proportion are adolescents and some are women.^1,3 They are often single, unemployed, and live with the parent prior to the killing.¹ Patricide occurs more frequently than matricide.⁴ In the United States, approximately 150 fathers and 100 mothers are killed by their child each year.⁵

In a study of all homicides in England and Wales between 1997 and 2014, two-thirds of parricide offenders had previously been diagnosed with a mental disorder.¹ One-third were diagnosed with schizophrenia.¹ In a Canadian study focusing on 43 adult perpetrators found not criminally responsible,⁶ most were experiencing psychotic symptoms at the time of parricide; symptoms of a personality disorder were the second-most prevalent symptoms. Similarly, Bourget et al⁴ studied Canadian coroner records for 64 parents killed by their children. Of the children involved in those parricides, 15% attempted suicide after the killing. Two-thirds of the male offenders evidenced delusional thinking, and/or excessive violence (overkill) was common. Some cases (16%) followed an argument, and some of those perpetrators were intoxicated or psychotic. From our clinical experience, when there are identifiable nonpsychotic triggers, they often can be small things such as an argument over food, smoking, or video games. Often, the perpetrator was financially dependent on their parents and were “trapped in a difficult/hostile/dependence/love relationship” with that parent.⁶ Adolescent males who kill their parents may not have psychosis⁷; however, they may be victims of longstanding serious abuse at the hands of their parents. These perpetrators often express relief rather than remorse after committing murder.

Three categories to classify the perpetrators of parricide have been proposed: severely abused, severely mentally ill, and “dangerously antisocial.”³ While severe mental illness was most common in adult defendants, severe abuse was most common in adolescent offenders. There may be significant commonalities between adolescent and adult perpetrators. A more recent latent class analysis by Bojanic et al¹ indicated 3 unique types of parricide offenders (Table 1).

Continue to: Matricide: A closer look...

 

 

Matricide: A closer look

Though multiple studies have found a higher rate of psychosis among perpetrators of matricide, it is important to note that most people with psychotic disorders would never kill their mother. These events, however, tend to grab headlines and may be highly focused upon by the general population. In addition, matricide may be part of a larger crime that draws additional attention. For example, the 1966 University of Texas Bell Tower shooter and the 2012 Sandy Hook Elementary school shooter both killed their mothers before engaging in mass homicide. Often in cases of matricide, a longer-term dysfunctional relationship existed between the mother and the child. The mother is frequently described as controlling and intrusive and the (often adult) child as overly dependent, while the father may be absent or ineffectual. Hostility and mutual dependence are usual hallmarks of these relationships.⁸

However, in some cases where an individual with a psychotic disorder kills their mother, there may have been a traditional nurturing relationship.⁸ Alternative motivations unrelated to psychosis must be considered, including crimes motivated by money/inheritance or those perpetrated out of nonpsychotic anger. Green⁸ described motive categories for matricide that include paranoid and persecutory, altruistic, and other. In the “paranoid and persecutory” group, delusional beliefs about the mother occur; for example, the perpetrator may believe their mother was the devil. Sexual elements are found in some cases.⁸ Alternatively, the “altruistic” group demonstrated rather selfless reasons for killing, such as altruistic infanticide cases, or killing out of love.⁹ The altruistic matricide perpetrator may believe their mother is unwell, which may be a delusion or actually true. Finally, the “other” category contains cases related to jealousy, rage, and impulsivity.

In a study of 15 matricidal men in New York conducted by Campion et al,¹⁰ individuals seen by forensic psychiatric services for the crime of matricide included those with schizophrenia, substance-induced psychosis, and impulse control disorders. The authors noted there was often “a serious chronic derangement in the relationships of most matricidal men and their mothers.” Psychometric testing in these cases indicated feelings of dependency, weakness, and difficulty accepting an adult role separate from their mother. Some had conceptualized their mothers as a threat to their masculinity, while others had become enraged at their mothers.

Prevention requires addressing underlying issues

As described above, several factors are common among individuals who commit parricide, and these can be used to develop prevention strategies that focus on addressing underlying issues (Table 2). It is important to consider the relationship dynamics between the potential victim and perpetrator, as well as the motive, rather than focusing solely on mental illness or substance misuse.²

Spree killings that start as parricide

Although spree killing is a relatively rare event, a subset of spree killings involve parricide. One infamous recent event occurred in 2012 at Sandy Hook Elementary School, where the gunman killed his mother before going to the school and killing 26 additional people, many of whom were children.^11,12 Because such events are rare, and because in these cases there is a high likelihood that the perpetrator is deceased (eg, died by suicide or killed by the police), much remains unknown about specific motivations and causative factors.

Information is often pieced together from postmortem reviews, which can be hampered by hindsight/recall bias and lack of contemporaneous documentation. Even worse, when these events occur, they may lead to a bias that all parricides or mass murders follow the pattern of the most recent case. This can result in overgeneralization of an individual’s history as being actionable risk violence factors for all potential parricide cases both by the public (eg, “My sister’s son has autism, and the Sandy Hook shooter was reported to have autism—should I be worried for my sister?”) and professionals (eg, “Will I be blamed for the next Sandy Hook by not taking more aggressive action even though I am not sure it is clinically warranted?”).

To identify trends for individuals committing parricide who engage in mass murder events (such as spree killing), we reviewed the 2000-2019 FBI active shooter list.¹² Of the 333 events identified, 46 could be classified as domestic violence situations (eg, the perpetrator was in a romantic or familial relationship/former relationship and engaged in an active shooting incident involving at least 1 person from that relationship). We classified 11 of those 46 cases as parricide. Ten of those 11 parricides involved a child killing a parent (Table 3), and the other involved a grandchild killing a grandfather who served as their primary caregiver. Of the 11 incidents, mothers were involved (killed or wounded) in 4, and father figures (including the grandfather serving as a father and a stepfather) were killed in 9, with 2 incidents involving both parents. In 4 of the 11 parricides, other family members were killed in addition to the parent (including siblings, grandparents, or extended family). When considering spree shooters who committed parricide, 4 alleged perpetrators died by suicide, 1 was killed at the scene, and the rest were apprehended. The most common active shooting site endangering the public was an educational location (5), followed by commerce locations (4), with 2 involving open spaces. Eight of the 11 parricides occurred before the event was designated as an active shooting. The mean age for a parricide plus spree shooter was 23, once the oldest (age 61) and youngest (age 14) were removed from the calculation. The majority of the cases fell into the age range of 16 to 25 (n = 6), followed by 3 individuals who were age 26 to 31 (n = 3). All suspected individuals were male.

Continue to: Parricide and society...

Parricide and society

For centuries, mothers and fathers have been honored and revered. Therefore, it is not surprising that killing of one’s mother or father attracts a great deal of macabre interest. Examples of parricide are present throughout popular culture, in mythology, comic books, movies, and television. As all psychiatrists know, Oedipus killed his father and married his mother. Other popular culture examples include: Grant Morrison’s Arkham Asylum: A Serious House on Serious Earth, Alfred Hitchcock’s Psycho, Oliver Stone’s Natural Born Killers, Peter Jackson’s Heavenly Creatures, The Affair drama series, and Star Wars: The Force Awakens.^13,14

CASE CONTINUED

In Mr. B’s case, it is imperative for the treatment team to inquire about his history of violence, paying particular attention to prior violent acts towards his mother. His clinicians should consider hospitalization with the guardian’s consent if the danger appears imminent, especially considering the presence of weapons at home. They should attempt to stabilize Mr. B on effective, tolerable medications to ameliorate his psychosis, and to refer him for long-term psychotherapy to address difficult dynamic issues in the family relationship and encourage compliance with treatment. These steps may help avert a tragedy.

Bottom Line

Individuals who commit parricide often have a history of psychosis, a mood disorder, childhood abuse, and/or difficult relationship dynamics with the parent they kill. Some go on a spree killing in the community. Through careful consideration of individual risk factors, psychiatrists may help prevent some cases of parent murder by a child and possibly more tragedy in the community.

Mr. B, age 37, presents to a community mental health center for an appointment following a recent emergency department visit. He is diagnosed with schizophrenia, and has been treated for approximately 1 year. Six months ago, Mr. B stopped taking his antipsychotic due to its adverse effects. Despite compliance with another agent, he has become increasingly disorganized and paranoid.

He now believes that his mother, with whom he has lived all his life and who serves as his guardian, is poisoning his food and trying to kill him. She is an employee at a local grocery store, and Mr. B has expressed concern that her coworkers are assisting her in the plot to kill him.

Following a home visit, Mr. B’s case manager indicates that the patient showed them the collection of weapons he is amassing to “defend” himself. This leads to a concern for the safety of the patient, his mother, and others.

Although parricide—killing one’s parent—is a relatively rare event, its sensationalistic nature has long captured the attention of headline writers and the general public. This article discusses the diagnostic and demographic factors that may be seen among individuals who kill their parents, with an emphasis on those who commit matricide (murder of one’s mother) and associated spree killings, where an individual kills multiple people within a single brief but contiguous time period. Understanding these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents in addition to others.

Characteristics of perpetrators of parricide

Worldwide, approximately 2% to 4% of homicides involve parricide, or killing one’s parent.^1,2 Most offenders are men in early adulthood, though a proportion are adolescents and some are women.^1,3 They are often single, unemployed, and live with the parent prior to the killing.¹ Patricide occurs more frequently than matricide.⁴ In the United States, approximately 150 fathers and 100 mothers are killed by their child each year.⁵

In a study of all homicides in England and Wales between 1997 and 2014, two-thirds of parricide offenders had previously been diagnosed with a mental disorder.¹ One-third were diagnosed with schizophrenia.¹ In a Canadian study focusing on 43 adult perpetrators found not criminally responsible,⁶ most were experiencing psychotic symptoms at the time of parricide; symptoms of a personality disorder were the second-most prevalent symptoms. Similarly, Bourget et al⁴ studied Canadian coroner records for 64 parents killed by their children. Of the children involved in those parricides, 15% attempted suicide after the killing. Two-thirds of the male offenders evidenced delusional thinking, and/or excessive violence (overkill) was common. Some cases (16%) followed an argument, and some of those perpetrators were intoxicated or psychotic. From our clinical experience, when there are identifiable nonpsychotic triggers, they often can be small things such as an argument over food, smoking, or video games. Often, the perpetrator was financially dependent on their parents and were “trapped in a difficult/hostile/dependence/love relationship” with that parent.⁶ Adolescent males who kill their parents may not have psychosis⁷; however, they may be victims of longstanding serious abuse at the hands of their parents. These perpetrators often express relief rather than remorse after committing murder.

Three categories to classify the perpetrators of parricide have been proposed: severely abused, severely mentally ill, and “dangerously antisocial.”³ While severe mental illness was most common in adult defendants, severe abuse was most common in adolescent offenders. There may be significant commonalities between adolescent and adult perpetrators. A more recent latent class analysis by Bojanic et al¹ indicated 3 unique types of parricide offenders (Table 1).

Continue to: Matricide: A closer look...

 

 

Matricide: A closer look

Though multiple studies have found a higher rate of psychosis among perpetrators of matricide, it is important to note that most people with psychotic disorders would never kill their mother. These events, however, tend to grab headlines and may be highly focused upon by the general population. In addition, matricide may be part of a larger crime that draws additional attention. For example, the 1966 University of Texas Bell Tower shooter and the 2012 Sandy Hook Elementary school shooter both killed their mothers before engaging in mass homicide. Often in cases of matricide, a longer-term dysfunctional relationship existed between the mother and the child. The mother is frequently described as controlling and intrusive and the (often adult) child as overly dependent, while the father may be absent or ineffectual. Hostility and mutual dependence are usual hallmarks of these relationships.⁸

However, in some cases where an individual with a psychotic disorder kills their mother, there may have been a traditional nurturing relationship.⁸ Alternative motivations unrelated to psychosis must be considered, including crimes motivated by money/inheritance or those perpetrated out of nonpsychotic anger. Green⁸ described motive categories for matricide that include paranoid and persecutory, altruistic, and other. In the “paranoid and persecutory” group, delusional beliefs about the mother occur; for example, the perpetrator may believe their mother was the devil. Sexual elements are found in some cases.⁸ Alternatively, the “altruistic” group demonstrated rather selfless reasons for killing, such as altruistic infanticide cases, or killing out of love.⁹ The altruistic matricide perpetrator may believe their mother is unwell, which may be a delusion or actually true. Finally, the “other” category contains cases related to jealousy, rage, and impulsivity.

In a study of 15 matricidal men in New York conducted by Campion et al,¹⁰ individuals seen by forensic psychiatric services for the crime of matricide included those with schizophrenia, substance-induced psychosis, and impulse control disorders. The authors noted there was often “a serious chronic derangement in the relationships of most matricidal men and their mothers.” Psychometric testing in these cases indicated feelings of dependency, weakness, and difficulty accepting an adult role separate from their mother. Some had conceptualized their mothers as a threat to their masculinity, while others had become enraged at their mothers.

Prevention requires addressing underlying issues

As described above, several factors are common among individuals who commit parricide, and these can be used to develop prevention strategies that focus on addressing underlying issues (Table 2). It is important to consider the relationship dynamics between the potential victim and perpetrator, as well as the motive, rather than focusing solely on mental illness or substance misuse.²

Spree killings that start as parricide

Although spree killing is a relatively rare event, a subset of spree killings involve parricide. One infamous recent event occurred in 2012 at Sandy Hook Elementary School, where the gunman killed his mother before going to the school and killing 26 additional people, many of whom were children.^11,12 Because such events are rare, and because in these cases there is a high likelihood that the perpetrator is deceased (eg, died by suicide or killed by the police), much remains unknown about specific motivations and causative factors.

Information is often pieced together from postmortem reviews, which can be hampered by hindsight/recall bias and lack of contemporaneous documentation. Even worse, when these events occur, they may lead to a bias that all parricides or mass murders follow the pattern of the most recent case. This can result in overgeneralization of an individual’s history as being actionable risk violence factors for all potential parricide cases both by the public (eg, “My sister’s son has autism, and the Sandy Hook shooter was reported to have autism—should I be worried for my sister?”) and professionals (eg, “Will I be blamed for the next Sandy Hook by not taking more aggressive action even though I am not sure it is clinically warranted?”).

To identify trends for individuals committing parricide who engage in mass murder events (such as spree killing), we reviewed the 2000-2019 FBI active shooter list.¹² Of the 333 events identified, 46 could be classified as domestic violence situations (eg, the perpetrator was in a romantic or familial relationship/former relationship and engaged in an active shooting incident involving at least 1 person from that relationship). We classified 11 of those 46 cases as parricide. Ten of those 11 parricides involved a child killing a parent (Table 3), and the other involved a grandchild killing a grandfather who served as their primary caregiver. Of the 11 incidents, mothers were involved (killed or wounded) in 4, and father figures (including the grandfather serving as a father and a stepfather) were killed in 9, with 2 incidents involving both parents. In 4 of the 11 parricides, other family members were killed in addition to the parent (including siblings, grandparents, or extended family). When considering spree shooters who committed parricide, 4 alleged perpetrators died by suicide, 1 was killed at the scene, and the rest were apprehended. The most common active shooting site endangering the public was an educational location (5), followed by commerce locations (4), with 2 involving open spaces. Eight of the 11 parricides occurred before the event was designated as an active shooting. The mean age for a parricide plus spree shooter was 23, once the oldest (age 61) and youngest (age 14) were removed from the calculation. The majority of the cases fell into the age range of 16 to 25 (n = 6), followed by 3 individuals who were age 26 to 31 (n = 3). All suspected individuals were male.

Continue to: Parricide and society...

Parricide and society

For centuries, mothers and fathers have been honored and revered. Therefore, it is not surprising that killing of one’s mother or father attracts a great deal of macabre interest. Examples of parricide are present throughout popular culture, in mythology, comic books, movies, and television. As all psychiatrists know, Oedipus killed his father and married his mother. Other popular culture examples include: Grant Morrison’s Arkham Asylum: A Serious House on Serious Earth, Alfred Hitchcock’s Psycho, Oliver Stone’s Natural Born Killers, Peter Jackson’s Heavenly Creatures, The Affair drama series, and Star Wars: The Force Awakens.^13,14

CASE CONTINUED

In Mr. B’s case, it is imperative for the treatment team to inquire about his history of violence, paying particular attention to prior violent acts towards his mother. His clinicians should consider hospitalization with the guardian’s consent if the danger appears imminent, especially considering the presence of weapons at home. They should attempt to stabilize Mr. B on effective, tolerable medications to ameliorate his psychosis, and to refer him for long-term psychotherapy to address difficult dynamic issues in the family relationship and encourage compliance with treatment. These steps may help avert a tragedy.

Bottom Line

Individuals who commit parricide often have a history of psychosis, a mood disorder, childhood abuse, and/or difficult relationship dynamics with the parent they kill. Some go on a spree killing in the community. Through careful consideration of individual risk factors, psychiatrists may help prevent some cases of parent murder by a child and possibly more tragedy in the community.

Mr. J, age 35, is brought to the hospital from prison due to priapism that does not improve with treatment. He says he has had priapism 5 times previously, with the first incidence occurring “years ago” due to trazodone.

Recently, he has been receiving risperidone, which the treatment team believes is the cause of his current priapism. His medical history includes asthma, schizophrenia, hypertension, seizures, and sickle cell trait. Mr. J is experiencing auditory hallucinations, which he describes as “continuous, neutral voices that are annoying.” He would like relief from his auditory hallucinations and is willing to change his antipsychotic, but does not want additional treatment for his priapism. His present medications include risperidone, 1 mg twice a day, escitalopram, 10 mg/d, benztropine, 1 mg twice a day, and phenytoin, 500 mg/d at bedtime.

Priapism is a prolonged, persistent, and often painful erection that occurs without sexual stimulation. Although relatively rare, it can result in potentially serious long-term complications, including impotence and gangrene, and requires immediate evaluation and management.

There are 2 types of priapism: nonischemic, or “high-flow,” priapism, and ischemic, or “low-flow,” priapism (Table 1). While nonischemic priapism is typically caused by penile or perineal trauma, ischemic priapism can occur as a result of medications, including antipsychotics, antidepressants, anxiolytics, and antihypertensives, or hematological conditions such as sickle cell disease.¹ Other risk factors associated with priapism include substance abuse, hyperprolactinemia, diabetes, and liver disease.⁴

Antipsychotic-induced priapism

Medication-induced priapism is a rare adverse drug reaction (ADR). Of the medication classes associated with priapism, antipsychotics have the highest incidence and account for approximately 20% of all cases.¹

The mechanism of priapism associated with antipsychotics is thought to be related to alpha-1 blockade in the corpora cavernosa of the penis. Although antipsychotics within each class share common characteristics, each agent has a unique profile of receptor affinities. As such, antipsychotics have varying affinities for the alpha-adrenergic receptor (Table 2). Agents such as ziprasidone, chlorpromazine, and risperidone—which have the highest affinity for the alpha-1 adrenoceptors—may be more likely to cause priapism compared with agents with lower affinity, such as olanzapine. Priapism may occur at any time during antipsychotic treatment, and does not appear to be dose-related.

Continue to: Antipsychotic drug interactions and priapism...

 

 

Antipsychotic drug interactions and priapism

Patients who are receiving multiple medications as treatment for chronic medical or psychiatric conditions have an increased likelihood of experiencing drug-drug interactions (DDIs) that lead to adverse effects.

Various case reports have described priapism as a result of DDIs related to antipsychotic agents combined with other psychotropic or nonpsychotropic medications.³ Most of these DDIs have been attributed to the cytochrome P450 (CYP) family of enzymes, including CYP2D6, CYP1A2, and CYP3A4/5, which are major enzymes implicated in the metabolism of antipsychotics (Table 3).

Mitigating the risk of priapism

Although there are associated risk factors for priapism, there are no concrete indicators to predict the onset or development of the condition. The best predictor may be a history of prolonged and painless erections.³

As such, when choosing an antipsychotic, it is critical to screen the patient for the previously mentioned risk factors, including the presence of medications with strong alpha-1 receptor affinity and CYP interactions, especially to minimize the risk of recurrence of priapism in those with prior or similar episodes. Management of patients with priapism due to antipsychotics has involved reducing the dose of the offending agent and/or changing the medication to one with a lower alpha-adrenergic affinity (Table 2²).

Similar to most situations, management is patient-specific and depends on several factors, including the severity of the patient’s psychiatric disease, history/severity of priapism and treatment, concurrent medication list, etc. For example, although clozapine is considered to have relatively high affinity for the alpha-1 receptor, it is also the agent of choice for treatment-refractory schizophrenia. Risks and benefits must be weighed on a individualized basis. Case reports have described symptom improvement via lowering the dose of clozapine and adding on or switching to an antipsychotic agent with minimal alpha-1 receptor affinity.⁴

After considering Mr. J’s history, risk factors, and preferences, the treatment team discontinues risperidone and initiates haloperidol, 5 mg twice a day. Soon after, Mr. J no longer experiences priapism.

Mr. J, age 35, is brought to the hospital from prison due to priapism that does not improve with treatment. He says he has had priapism 5 times previously, with the first incidence occurring “years ago” due to trazodone.

Recently, he has been receiving risperidone, which the treatment team believes is the cause of his current priapism. His medical history includes asthma, schizophrenia, hypertension, seizures, and sickle cell trait. Mr. J is experiencing auditory hallucinations, which he describes as “continuous, neutral voices that are annoying.” He would like relief from his auditory hallucinations and is willing to change his antipsychotic, but does not want additional treatment for his priapism. His present medications include risperidone, 1 mg twice a day, escitalopram, 10 mg/d, benztropine, 1 mg twice a day, and phenytoin, 500 mg/d at bedtime.

Priapism is a prolonged, persistent, and often painful erection that occurs without sexual stimulation. Although relatively rare, it can result in potentially serious long-term complications, including impotence and gangrene, and requires immediate evaluation and management.

There are 2 types of priapism: nonischemic, or “high-flow,” priapism, and ischemic, or “low-flow,” priapism (Table 1). While nonischemic priapism is typically caused by penile or perineal trauma, ischemic priapism can occur as a result of medications, including antipsychotics, antidepressants, anxiolytics, and antihypertensives, or hematological conditions such as sickle cell disease.¹ Other risk factors associated with priapism include substance abuse, hyperprolactinemia, diabetes, and liver disease.⁴

Antipsychotic-induced priapism

Medication-induced priapism is a rare adverse drug reaction (ADR). Of the medication classes associated with priapism, antipsychotics have the highest incidence and account for approximately 20% of all cases.¹

The mechanism of priapism associated with antipsychotics is thought to be related to alpha-1 blockade in the corpora cavernosa of the penis. Although antipsychotics within each class share common characteristics, each agent has a unique profile of receptor affinities. As such, antipsychotics have varying affinities for the alpha-adrenergic receptor (Table 2). Agents such as ziprasidone, chlorpromazine, and risperidone—which have the highest affinity for the alpha-1 adrenoceptors—may be more likely to cause priapism compared with agents with lower affinity, such as olanzapine. Priapism may occur at any time during antipsychotic treatment, and does not appear to be dose-related.

Continue to: Antipsychotic drug interactions and priapism...

 

 

Antipsychotic drug interactions and priapism

Patients who are receiving multiple medications as treatment for chronic medical or psychiatric conditions have an increased likelihood of experiencing drug-drug interactions (DDIs) that lead to adverse effects.

Various case reports have described priapism as a result of DDIs related to antipsychotic agents combined with other psychotropic or nonpsychotropic medications.³ Most of these DDIs have been attributed to the cytochrome P450 (CYP) family of enzymes, including CYP2D6, CYP1A2, and CYP3A4/5, which are major enzymes implicated in the metabolism of antipsychotics (Table 3).

Mitigating the risk of priapism

Although there are associated risk factors for priapism, there are no concrete indicators to predict the onset or development of the condition. The best predictor may be a history of prolonged and painless erections.³

As such, when choosing an antipsychotic, it is critical to screen the patient for the previously mentioned risk factors, including the presence of medications with strong alpha-1 receptor affinity and CYP interactions, especially to minimize the risk of recurrence of priapism in those with prior or similar episodes. Management of patients with priapism due to antipsychotics has involved reducing the dose of the offending agent and/or changing the medication to one with a lower alpha-adrenergic affinity (Table 2²).

Similar to most situations, management is patient-specific and depends on several factors, including the severity of the patient’s psychiatric disease, history/severity of priapism and treatment, concurrent medication list, etc. For example, although clozapine is considered to have relatively high affinity for the alpha-1 receptor, it is also the agent of choice for treatment-refractory schizophrenia. Risks and benefits must be weighed on a individualized basis. Case reports have described symptom improvement via lowering the dose of clozapine and adding on or switching to an antipsychotic agent with minimal alpha-1 receptor affinity.⁴

After considering Mr. J’s history, risk factors, and preferences, the treatment team discontinues risperidone and initiates haloperidol, 5 mg twice a day. Soon after, Mr. J no longer experiences priapism.

Mr. J, age 35, is brought to the hospital from prison due to priapism that does not improve with treatment. He says he has had priapism 5 times previously, with the first incidence occurring “years ago” due to trazodone.

Recently, he has been receiving risperidone, which the treatment team believes is the cause of his current priapism. His medical history includes asthma, schizophrenia, hypertension, seizures, and sickle cell trait. Mr. J is experiencing auditory hallucinations, which he describes as “continuous, neutral voices that are annoying.” He would like relief from his auditory hallucinations and is willing to change his antipsychotic, but does not want additional treatment for his priapism. His present medications include risperidone, 1 mg twice a day, escitalopram, 10 mg/d, benztropine, 1 mg twice a day, and phenytoin, 500 mg/d at bedtime.

Priapism is a prolonged, persistent, and often painful erection that occurs without sexual stimulation. Although relatively rare, it can result in potentially serious long-term complications, including impotence and gangrene, and requires immediate evaluation and management.

There are 2 types of priapism: nonischemic, or “high-flow,” priapism, and ischemic, or “low-flow,” priapism (Table 1). While nonischemic priapism is typically caused by penile or perineal trauma, ischemic priapism can occur as a result of medications, including antipsychotics, antidepressants, anxiolytics, and antihypertensives, or hematological conditions such as sickle cell disease.¹ Other risk factors associated with priapism include substance abuse, hyperprolactinemia, diabetes, and liver disease.⁴

Antipsychotic-induced priapism

Medication-induced priapism is a rare adverse drug reaction (ADR). Of the medication classes associated with priapism, antipsychotics have the highest incidence and account for approximately 20% of all cases.¹

The mechanism of priapism associated with antipsychotics is thought to be related to alpha-1 blockade in the corpora cavernosa of the penis. Although antipsychotics within each class share common characteristics, each agent has a unique profile of receptor affinities. As such, antipsychotics have varying affinities for the alpha-adrenergic receptor (Table 2). Agents such as ziprasidone, chlorpromazine, and risperidone—which have the highest affinity for the alpha-1 adrenoceptors—may be more likely to cause priapism compared with agents with lower affinity, such as olanzapine. Priapism may occur at any time during antipsychotic treatment, and does not appear to be dose-related.

Continue to: Antipsychotic drug interactions and priapism...

 

 

Antipsychotic drug interactions and priapism

Patients who are receiving multiple medications as treatment for chronic medical or psychiatric conditions have an increased likelihood of experiencing drug-drug interactions (DDIs) that lead to adverse effects.

Various case reports have described priapism as a result of DDIs related to antipsychotic agents combined with other psychotropic or nonpsychotropic medications.³ Most of these DDIs have been attributed to the cytochrome P450 (CYP) family of enzymes, including CYP2D6, CYP1A2, and CYP3A4/5, which are major enzymes implicated in the metabolism of antipsychotics (Table 3).

Mitigating the risk of priapism

Although there are associated risk factors for priapism, there are no concrete indicators to predict the onset or development of the condition. The best predictor may be a history of prolonged and painless erections.³

As such, when choosing an antipsychotic, it is critical to screen the patient for the previously mentioned risk factors, including the presence of medications with strong alpha-1 receptor affinity and CYP interactions, especially to minimize the risk of recurrence of priapism in those with prior or similar episodes. Management of patients with priapism due to antipsychotics has involved reducing the dose of the offending agent and/or changing the medication to one with a lower alpha-adrenergic affinity (Table 2²).

Similar to most situations, management is patient-specific and depends on several factors, including the severity of the patient’s psychiatric disease, history/severity of priapism and treatment, concurrent medication list, etc. For example, although clozapine is considered to have relatively high affinity for the alpha-1 receptor, it is also the agent of choice for treatment-refractory schizophrenia. Risks and benefits must be weighed on a individualized basis. Case reports have described symptom improvement via lowering the dose of clozapine and adding on or switching to an antipsychotic agent with minimal alpha-1 receptor affinity.⁴

After considering Mr. J’s history, risk factors, and preferences, the treatment team discontinues risperidone and initiates haloperidol, 5 mg twice a day. Soon after, Mr. J no longer experiences priapism.

CASE Treatment-resistant MDD

Ms. P, age 21, presents to the outpatient clinic. She has diagnoses of treatment-resistant major depressive disorder (MDD) and schizoid personality disorder (SPD). Ms. P was diagnosed with MDD 3 years ago after reporting symptoms of prevailing sadness for approximately 8 years, described as feelings of worthlessness, anhedonia, social withdrawal, and decreased hygiene and self-care behaviors, as well as suicidal ideation and self-harm. SPD was diagnosed 1 year earlier based on her “odd” behaviors and disheveled appearance following observation and in collateral with her family. Her odd behaviors are described as spending most of her time alone, preferring solitary activities, and having little contact with people other than her parents.

Ms. P reports that she was previously treated with citalopram, 20 mg/d, bupropion, 150 mg/d, aripiprazole, 3.75 mg/d, topiramate, 100 mg twice daily, and melatonin, 9 mg/d at bedtime, but discontinued follow-up appointments and medications after no significant improvement in symptoms.

[polldaddy:11027942]

The authors’ observations

The term “schizoid” first made its debut in the medical community to describe the prodromal social withdrawal and isolation observed in schizophrenia.¹ The use of schizoid to describe a personality type first occurred in DSM-III in 1980.² SPD is a Cluster A personality disorder that groups personalities characterized by common traits that are “odd” or “eccentric” and may resemble the positive and/or negative symptoms of schizophrenia.^3,4 Relatively uncommon in clinical settings, SPD includes individuals who do not desire or enjoy close relationships. Those afflicted with SPD will be described as isolated, aloof, and detached from social relationships with others, even immediate family members. Individuals with SPD may appear indifferent to criticism and praise, and may take pleasure in only a few activities. They may exhibit a general absence of affective range, which contributes to their characterization as flat, blunted, or emotionally vacant. SPD is more commonly diagnosed in males and may be present in childhood and adolescence. These children are typified by solitariness, poor peer relationships, and underachievement in school. SPD impacts 3.1% to 4.9% of the United States population and approximately 1% of community populations.^5,6

EVALUATION Persistent depressive symptoms

Ms. P is accompanied by her parents for the examination. She reports a chronic, persistent sad mood, hopelessness, anergia, insomnia, anhedonia, and decreased concentration and appetite. She says she experiences episodes of intense worry, along with tension, restlessness, feelings of being on the edge, irritability, and difficulty relaxing. Socially, she is withdrawn, preferring to stay alone in her room most of the day watching YouTube or trying to write stories. She has 2 friends with whom she does not interact with in person, but rather through digital means. Ms. P has never enjoyed attending school and feels “nervous” when she is around people. She has difficulty expressing her thoughts and often looks to her parents for help. Her parents add that getting Ms. P to attend school was a struggle, which resulted in periods of home schooling throughout high school.

The treating team prescribes citalopram, 10 mg/d, and aripiprazole, 2 mg/d. On subsequent follow-up visits, Ms. P’s depression improves with an increase in citalopram to 40 mg/d. Psychotherapy is added to her treatment plan to help address the persistent social deficits, odd behavior, and anxieties.

Continue to: Evaluation Psychological assessment...

 

 

EVALUATION Psychological assessment

At her psychotherapy intake appointment with the clinical neuropsychologist, Ms. P is dressed in purple from head to toe and sits clutching her purse and looking at the ground. She is overweight with clean, fitting clothing. Ms. P takes a secondary role during most of the interview, allowing her parents to answer most questions. When asked why she is starting therapy, Ms. P replies, “Well, I’ve been using the bathroom a lot.” She describes a feeling of comfort and calmness while in the restroom. Suddenly, she asks her parents to exit the exam room for a moment. Once they leave, she leans in and whispers, “Have you ever heard of self-sabotage? I think that’s what I’m doing.”

Her mood is euthymic, with a blunted affect. She scores 2 on the Patient Health Questionnaire-9 (PHQ-9) and 10 on the Generalized Anxiety Disorder 7-item scale (GAD-7), which indicates the positive impact of medication on her depressive symptoms but continuing moderate anxious distress. She endorses fear of the night, insomnia, and suicidal ideation. She reports an unusual “constant itching sensation,” resulting in hours of repetitive excoriation. Physical examination reveals several significant scars and scabs covering her bilateral upper and lower extremities. Her vocational history is brief; she had held 2 entry-level customer service positions that lasted <1 year. She was fired due to excessive bathroom use.

As the interview progresses, the intake clinician’s background in neuropsychological assessment facilitates screening for possible developmental disorders. Given the nature of the referral and psychotherapy intake, a full neuropsychological assessment is not conducted. The clinician emphasizes verbal abstraction and theory of mind. Ms. P’s IQ was estimated to be average by Wide Range Achievement Test 4 word reading and interview questions about her academic history. Questions are abstracted from the Autism Diagnostic Observation Schedule, Module 4, to assess for conversation ability, emotional insight, awareness and expression, relationships, and areas of functioning in daily living. Developmental history questions, such as those found on the Adaptive Behavior Assessment System, 3rd edition, help guide developmental information provided by parents in the areas of communication, emotion and eye-gaze, gestures, sensory function, language, social functioning, hygiene behavior, and specific interests.

Ms. P’s mother describes a normal pregnancy and delivery; however, she states that Ms. P was “born with problems,” including difficulty with rooting and sucking, and required gastrointestinal intubation until age 3. Cyclical vomiting followed normal food consumption. Ambulation, language acquisition, toilet training, and hygiene behavior were delayed. Ms. P experienced improvements with early intervention in intensive physical and occupational therapy.

Ms. P’s hygiene is well below average, and she requires cueing from her parents. She attended general education until she reached high school, when she began special education. She was sensitive to sensory stimulation from infancy, with sensory sensitivity to textures. Ms. P continues to report sensory sensitivity and lapses in hygiene.

She has difficulty establishing and maintaining relationships with her peers, and prefers solitary activities. Ms. P has no history of romantic relationships, although she does desire one. When asked about her understanding of various relationships, Ms. P’s responses are stereotyped, such as “I know someone is my friend because they are nice to me” and “People get married because they love each other.” She struggles to offer greater insight into the nuances that form lasting relationships and bonds. Ms. P struggles to imitate and describe the physical and internal cues of several basic emotions (eg, fear, joy, anger).

Her conversational and social skills are assessed by asking her to engage in a conversation with the examiner as if meeting for the first time. Her speech is reciprocal, aprosodic, and delayed. The conversation is one-sided, and the examiner fills in several awkward pauses. Ms. P’s gaze at times is intense and prolonged, especially when responding to questions. She tends to use descriptive statements (eg, “I like your purple pen, I like your shirt”) to engage in conversation, rather than gathering more information through reflective statements, questions, or expressing a shared interest.

Ms. P’s verbal abstraction is screened using questions from the Wechsler Adult Intelligence Scale, 4th edition Similarities subtest, to which she provides several responses within normal limits. Her understanding of colloquial speech is assessed by asking her the meaning of common phrases (eg, “Get knocked down 9 times, get up 10,” “Jack and Jill are 2 peas in a pod”). On many occasions, she is able to limit her response to 1 word, (eg, “resiliency”), demonstrating intact ability to decipher idioms.

[polldaddy:11027971]

The authors’ observations

Upon reflection of Ms. P’s clinical presentation and history of developmental delays, social deficits, sensory sensitivity since infancy, and repetitive behaviors (all which continue to impact her), the clinical team concluded that the diagnosis of autism spectrum disorder (ASD) helps explain the patient’s “odd” behaviors, more so than SPD.

ASD is a heterogenous, complex neuropsychiatric disorder characterized by a persistent deficit in social reciprocity, verbal, and nonverbal communication, and includes a pattern of restricted, repetitive and/or stereotyped behaviors and/or interests.⁵ The term “autismus” is Greek meaning “self,” and was first used to classify the qualities of “morbid self-admiration” observed in prodromal schizophrenia.⁷Due to disorganized, odd behaviors and speech, adults with ASD are sometimes misdiagnosed with schizophrenia and schizophrenia-related disorders, such as SPD.⁸ Ms. P is an example of this phenomenon. In a prospective study looking at the continuity of ASD and SPD traits, Cook et al⁹ found that higher severity levels of ASD symptoms in childhood were associated with a higher level of reported SPD traits in adolescence. Although ASD and SPD are usually diagnosed at opposite ends of the age spectrum, they do have characteristics that overlap, such as limited range of affect and tendency to be described as loners. Table 1^5,8,9 highlights some of these similarities.

Continue to: Treatment...

TREATMENT Adding CBT

At an interdisciplinary session several weeks later that includes Ms. P and her parents, the treatment team discusses the revised diagnoses of ASD and MDD, a treatment recommendation for cognitive-behavioral therapy (CBT), and continued use of medication. At this session, Ms. P discloses that she has not been consistent with her medication regimen since her last appointment, which helps explain the increase in her PHQ-9 score from 2 to 14 and GAD-7 score from 10 to 15 as noted at this interdisciplinary session.

[polldaddy:11027990]

The authors’ observations

CBT can be helpful in improving medication adherence, developing coping skills, and modifying maladaptive behaviors.^16,17Table 2^16,17 provides examples of behavioral interventions that CBT can implement. The evidence for the benefits of psychosocial interventions for adults with ASD is growing. A small systemic review of psychosocial interventions for adults with ASD found that social cognition training, social skills training, and applied behavior analysis had positive benefits.¹⁸

OUTCOME Improvement with psychotherapy

Ms. P and family agree with the team’s recommendations. The aims of Ms. P’s psychotherapy are to maintain medication compliance; implement behavioral modification, vocational rehabilitation, and community engagement; develop social skills; increase functional independence; and develop coping skills for depression and anxiety.

Once her medication is augmented with psychotherapy, Ms. P exhibits a steady decline in PHQ-9 and GAD-7 scores, consistent with an overall reduction of subjective anxiety and depression. In 5 months, her PHQ-9 score decreases from 14 to 2 and her GAD-7 score decreases from 15 to 3. Ms. P is treatment-compliant, more active around the home, and spends more time engaging with friends face-to-face. Overall, the psychotherapy interventions most helpful to her are the development of social skills and coping skills. She reports improved mood, energy levels, concentration, interests, and appetite. Suicidal ideation lessens, and she has not engaged in self-harm since beginning treatment. Worries, tension, and difficulty relaxing also have lessened, though restlessness persists. Excoriation has also decreased significantly, and Ms. P spends less time in the bathroom. Sheenrolls in college courses, plans to start a volleyball team, and is excited about the future.

Bottom Line

The prevalence of schizoid personality disorder (SPD) is low, and its symptoms overlap with those of autism spectrum disorder. Therefore, before diagnosing SPD in an adult patient, it is important to obtain a detailed developmental history and include an interdisciplinary team to assess for autism spectrum disorder.

CASE Treatment-resistant MDD

Ms. P, age 21, presents to the outpatient clinic. She has diagnoses of treatment-resistant major depressive disorder (MDD) and schizoid personality disorder (SPD). Ms. P was diagnosed with MDD 3 years ago after reporting symptoms of prevailing sadness for approximately 8 years, described as feelings of worthlessness, anhedonia, social withdrawal, and decreased hygiene and self-care behaviors, as well as suicidal ideation and self-harm. SPD was diagnosed 1 year earlier based on her “odd” behaviors and disheveled appearance following observation and in collateral with her family. Her odd behaviors are described as spending most of her time alone, preferring solitary activities, and having little contact with people other than her parents.

Ms. P reports that she was previously treated with citalopram, 20 mg/d, bupropion, 150 mg/d, aripiprazole, 3.75 mg/d, topiramate, 100 mg twice daily, and melatonin, 9 mg/d at bedtime, but discontinued follow-up appointments and medications after no significant improvement in symptoms.

[polldaddy:11027942]

The authors’ observations

The term “schizoid” first made its debut in the medical community to describe the prodromal social withdrawal and isolation observed in schizophrenia.¹ The use of schizoid to describe a personality type first occurred in DSM-III in 1980.² SPD is a Cluster A personality disorder that groups personalities characterized by common traits that are “odd” or “eccentric” and may resemble the positive and/or negative symptoms of schizophrenia.^3,4 Relatively uncommon in clinical settings, SPD includes individuals who do not desire or enjoy close relationships. Those afflicted with SPD will be described as isolated, aloof, and detached from social relationships with others, even immediate family members. Individuals with SPD may appear indifferent to criticism and praise, and may take pleasure in only a few activities. They may exhibit a general absence of affective range, which contributes to their characterization as flat, blunted, or emotionally vacant. SPD is more commonly diagnosed in males and may be present in childhood and adolescence. These children are typified by solitariness, poor peer relationships, and underachievement in school. SPD impacts 3.1% to 4.9% of the United States population and approximately 1% of community populations.^5,6

EVALUATION Persistent depressive symptoms

Ms. P is accompanied by her parents for the examination. She reports a chronic, persistent sad mood, hopelessness, anergia, insomnia, anhedonia, and decreased concentration and appetite. She says she experiences episodes of intense worry, along with tension, restlessness, feelings of being on the edge, irritability, and difficulty relaxing. Socially, she is withdrawn, preferring to stay alone in her room most of the day watching YouTube or trying to write stories. She has 2 friends with whom she does not interact with in person, but rather through digital means. Ms. P has never enjoyed attending school and feels “nervous” when she is around people. She has difficulty expressing her thoughts and often looks to her parents for help. Her parents add that getting Ms. P to attend school was a struggle, which resulted in periods of home schooling throughout high school.

The treating team prescribes citalopram, 10 mg/d, and aripiprazole, 2 mg/d. On subsequent follow-up visits, Ms. P’s depression improves with an increase in citalopram to 40 mg/d. Psychotherapy is added to her treatment plan to help address the persistent social deficits, odd behavior, and anxieties.

Continue to: Evaluation Psychological assessment...

 

 

EVALUATION Psychological assessment

At her psychotherapy intake appointment with the clinical neuropsychologist, Ms. P is dressed in purple from head to toe and sits clutching her purse and looking at the ground. She is overweight with clean, fitting clothing. Ms. P takes a secondary role during most of the interview, allowing her parents to answer most questions. When asked why she is starting therapy, Ms. P replies, “Well, I’ve been using the bathroom a lot.” She describes a feeling of comfort and calmness while in the restroom. Suddenly, she asks her parents to exit the exam room for a moment. Once they leave, she leans in and whispers, “Have you ever heard of self-sabotage? I think that’s what I’m doing.”

Her mood is euthymic, with a blunted affect. She scores 2 on the Patient Health Questionnaire-9 (PHQ-9) and 10 on the Generalized Anxiety Disorder 7-item scale (GAD-7), which indicates the positive impact of medication on her depressive symptoms but continuing moderate anxious distress. She endorses fear of the night, insomnia, and suicidal ideation. She reports an unusual “constant itching sensation,” resulting in hours of repetitive excoriation. Physical examination reveals several significant scars and scabs covering her bilateral upper and lower extremities. Her vocational history is brief; she had held 2 entry-level customer service positions that lasted <1 year. She was fired due to excessive bathroom use.

As the interview progresses, the intake clinician’s background in neuropsychological assessment facilitates screening for possible developmental disorders. Given the nature of the referral and psychotherapy intake, a full neuropsychological assessment is not conducted. The clinician emphasizes verbal abstraction and theory of mind. Ms. P’s IQ was estimated to be average by Wide Range Achievement Test 4 word reading and interview questions about her academic history. Questions are abstracted from the Autism Diagnostic Observation Schedule, Module 4, to assess for conversation ability, emotional insight, awareness and expression, relationships, and areas of functioning in daily living. Developmental history questions, such as those found on the Adaptive Behavior Assessment System, 3rd edition, help guide developmental information provided by parents in the areas of communication, emotion and eye-gaze, gestures, sensory function, language, social functioning, hygiene behavior, and specific interests.

Ms. P’s mother describes a normal pregnancy and delivery; however, she states that Ms. P was “born with problems,” including difficulty with rooting and sucking, and required gastrointestinal intubation until age 3. Cyclical vomiting followed normal food consumption. Ambulation, language acquisition, toilet training, and hygiene behavior were delayed. Ms. P experienced improvements with early intervention in intensive physical and occupational therapy.

Ms. P’s hygiene is well below average, and she requires cueing from her parents. She attended general education until she reached high school, when she began special education. She was sensitive to sensory stimulation from infancy, with sensory sensitivity to textures. Ms. P continues to report sensory sensitivity and lapses in hygiene.

She has difficulty establishing and maintaining relationships with her peers, and prefers solitary activities. Ms. P has no history of romantic relationships, although she does desire one. When asked about her understanding of various relationships, Ms. P’s responses are stereotyped, such as “I know someone is my friend because they are nice to me” and “People get married because they love each other.” She struggles to offer greater insight into the nuances that form lasting relationships and bonds. Ms. P struggles to imitate and describe the physical and internal cues of several basic emotions (eg, fear, joy, anger).

Her conversational and social skills are assessed by asking her to engage in a conversation with the examiner as if meeting for the first time. Her speech is reciprocal, aprosodic, and delayed. The conversation is one-sided, and the examiner fills in several awkward pauses. Ms. P’s gaze at times is intense and prolonged, especially when responding to questions. She tends to use descriptive statements (eg, “I like your purple pen, I like your shirt”) to engage in conversation, rather than gathering more information through reflective statements, questions, or expressing a shared interest.

Ms. P’s verbal abstraction is screened using questions from the Wechsler Adult Intelligence Scale, 4th edition Similarities subtest, to which she provides several responses within normal limits. Her understanding of colloquial speech is assessed by asking her the meaning of common phrases (eg, “Get knocked down 9 times, get up 10,” “Jack and Jill are 2 peas in a pod”). On many occasions, she is able to limit her response to 1 word, (eg, “resiliency”), demonstrating intact ability to decipher idioms.

[polldaddy:11027971]

The authors’ observations

Upon reflection of Ms. P’s clinical presentation and history of developmental delays, social deficits, sensory sensitivity since infancy, and repetitive behaviors (all which continue to impact her), the clinical team concluded that the diagnosis of autism spectrum disorder (ASD) helps explain the patient’s “odd” behaviors, more so than SPD.

ASD is a heterogenous, complex neuropsychiatric disorder characterized by a persistent deficit in social reciprocity, verbal, and nonverbal communication, and includes a pattern of restricted, repetitive and/or stereotyped behaviors and/or interests.⁵ The term “autismus” is Greek meaning “self,” and was first used to classify the qualities of “morbid self-admiration” observed in prodromal schizophrenia.⁷Due to disorganized, odd behaviors and speech, adults with ASD are sometimes misdiagnosed with schizophrenia and schizophrenia-related disorders, such as SPD.⁸ Ms. P is an example of this phenomenon. In a prospective study looking at the continuity of ASD and SPD traits, Cook et al⁹ found that higher severity levels of ASD symptoms in childhood were associated with a higher level of reported SPD traits in adolescence. Although ASD and SPD are usually diagnosed at opposite ends of the age spectrum, they do have characteristics that overlap, such as limited range of affect and tendency to be described as loners. Table 1^5,8,9 highlights some of these similarities.

Continue to: Treatment...

TREATMENT Adding CBT

At an interdisciplinary session several weeks later that includes Ms. P and her parents, the treatment team discusses the revised diagnoses of ASD and MDD, a treatment recommendation for cognitive-behavioral therapy (CBT), and continued use of medication. At this session, Ms. P discloses that she has not been consistent with her medication regimen since her last appointment, which helps explain the increase in her PHQ-9 score from 2 to 14 and GAD-7 score from 10 to 15 as noted at this interdisciplinary session.

[polldaddy:11027990]

The authors’ observations

CBT can be helpful in improving medication adherence, developing coping skills, and modifying maladaptive behaviors.^16,17Table 2^16,17 provides examples of behavioral interventions that CBT can implement. The evidence for the benefits of psychosocial interventions for adults with ASD is growing. A small systemic review of psychosocial interventions for adults with ASD found that social cognition training, social skills training, and applied behavior analysis had positive benefits.¹⁸

OUTCOME Improvement with psychotherapy

Ms. P and family agree with the team’s recommendations. The aims of Ms. P’s psychotherapy are to maintain medication compliance; implement behavioral modification, vocational rehabilitation, and community engagement; develop social skills; increase functional independence; and develop coping skills for depression and anxiety.

Once her medication is augmented with psychotherapy, Ms. P exhibits a steady decline in PHQ-9 and GAD-7 scores, consistent with an overall reduction of subjective anxiety and depression. In 5 months, her PHQ-9 score decreases from 14 to 2 and her GAD-7 score decreases from 15 to 3. Ms. P is treatment-compliant, more active around the home, and spends more time engaging with friends face-to-face. Overall, the psychotherapy interventions most helpful to her are the development of social skills and coping skills. She reports improved mood, energy levels, concentration, interests, and appetite. Suicidal ideation lessens, and she has not engaged in self-harm since beginning treatment. Worries, tension, and difficulty relaxing also have lessened, though restlessness persists. Excoriation has also decreased significantly, and Ms. P spends less time in the bathroom. Sheenrolls in college courses, plans to start a volleyball team, and is excited about the future.

Bottom Line

The prevalence of schizoid personality disorder (SPD) is low, and its symptoms overlap with those of autism spectrum disorder. Therefore, before diagnosing SPD in an adult patient, it is important to obtain a detailed developmental history and include an interdisciplinary team to assess for autism spectrum disorder.

CASE Treatment-resistant MDD

Ms. P, age 21, presents to the outpatient clinic. She has diagnoses of treatment-resistant major depressive disorder (MDD) and schizoid personality disorder (SPD). Ms. P was diagnosed with MDD 3 years ago after reporting symptoms of prevailing sadness for approximately 8 years, described as feelings of worthlessness, anhedonia, social withdrawal, and decreased hygiene and self-care behaviors, as well as suicidal ideation and self-harm. SPD was diagnosed 1 year earlier based on her “odd” behaviors and disheveled appearance following observation and in collateral with her family. Her odd behaviors are described as spending most of her time alone, preferring solitary activities, and having little contact with people other than her parents.

Ms. P reports that she was previously treated with citalopram, 20 mg/d, bupropion, 150 mg/d, aripiprazole, 3.75 mg/d, topiramate, 100 mg twice daily, and melatonin, 9 mg/d at bedtime, but discontinued follow-up appointments and medications after no significant improvement in symptoms.

[polldaddy:11027942]

The authors’ observations

The term “schizoid” first made its debut in the medical community to describe the prodromal social withdrawal and isolation observed in schizophrenia.¹ The use of schizoid to describe a personality type first occurred in DSM-III in 1980.² SPD is a Cluster A personality disorder that groups personalities characterized by common traits that are “odd” or “eccentric” and may resemble the positive and/or negative symptoms of schizophrenia.^3,4 Relatively uncommon in clinical settings, SPD includes individuals who do not desire or enjoy close relationships. Those afflicted with SPD will be described as isolated, aloof, and detached from social relationships with others, even immediate family members. Individuals with SPD may appear indifferent to criticism and praise, and may take pleasure in only a few activities. They may exhibit a general absence of affective range, which contributes to their characterization as flat, blunted, or emotionally vacant. SPD is more commonly diagnosed in males and may be present in childhood and adolescence. These children are typified by solitariness, poor peer relationships, and underachievement in school. SPD impacts 3.1% to 4.9% of the United States population and approximately 1% of community populations.^5,6

EVALUATION Persistent depressive symptoms

Ms. P is accompanied by her parents for the examination. She reports a chronic, persistent sad mood, hopelessness, anergia, insomnia, anhedonia, and decreased concentration and appetite. She says she experiences episodes of intense worry, along with tension, restlessness, feelings of being on the edge, irritability, and difficulty relaxing. Socially, she is withdrawn, preferring to stay alone in her room most of the day watching YouTube or trying to write stories. She has 2 friends with whom she does not interact with in person, but rather through digital means. Ms. P has never enjoyed attending school and feels “nervous” when she is around people. She has difficulty expressing her thoughts and often looks to her parents for help. Her parents add that getting Ms. P to attend school was a struggle, which resulted in periods of home schooling throughout high school.

The treating team prescribes citalopram, 10 mg/d, and aripiprazole, 2 mg/d. On subsequent follow-up visits, Ms. P’s depression improves with an increase in citalopram to 40 mg/d. Psychotherapy is added to her treatment plan to help address the persistent social deficits, odd behavior, and anxieties.

Continue to: Evaluation Psychological assessment...

 

 

EVALUATION Psychological assessment

At her psychotherapy intake appointment with the clinical neuropsychologist, Ms. P is dressed in purple from head to toe and sits clutching her purse and looking at the ground. She is overweight with clean, fitting clothing. Ms. P takes a secondary role during most of the interview, allowing her parents to answer most questions. When asked why she is starting therapy, Ms. P replies, “Well, I’ve been using the bathroom a lot.” She describes a feeling of comfort and calmness while in the restroom. Suddenly, she asks her parents to exit the exam room for a moment. Once they leave, she leans in and whispers, “Have you ever heard of self-sabotage? I think that’s what I’m doing.”

Her mood is euthymic, with a blunted affect. She scores 2 on the Patient Health Questionnaire-9 (PHQ-9) and 10 on the Generalized Anxiety Disorder 7-item scale (GAD-7), which indicates the positive impact of medication on her depressive symptoms but continuing moderate anxious distress. She endorses fear of the night, insomnia, and suicidal ideation. She reports an unusual “constant itching sensation,” resulting in hours of repetitive excoriation. Physical examination reveals several significant scars and scabs covering her bilateral upper and lower extremities. Her vocational history is brief; she had held 2 entry-level customer service positions that lasted <1 year. She was fired due to excessive bathroom use.

As the interview progresses, the intake clinician’s background in neuropsychological assessment facilitates screening for possible developmental disorders. Given the nature of the referral and psychotherapy intake, a full neuropsychological assessment is not conducted. The clinician emphasizes verbal abstraction and theory of mind. Ms. P’s IQ was estimated to be average by Wide Range Achievement Test 4 word reading and interview questions about her academic history. Questions are abstracted from the Autism Diagnostic Observation Schedule, Module 4, to assess for conversation ability, emotional insight, awareness and expression, relationships, and areas of functioning in daily living. Developmental history questions, such as those found on the Adaptive Behavior Assessment System, 3rd edition, help guide developmental information provided by parents in the areas of communication, emotion and eye-gaze, gestures, sensory function, language, social functioning, hygiene behavior, and specific interests.

Ms. P’s mother describes a normal pregnancy and delivery; however, she states that Ms. P was “born with problems,” including difficulty with rooting and sucking, and required gastrointestinal intubation until age 3. Cyclical vomiting followed normal food consumption. Ambulation, language acquisition, toilet training, and hygiene behavior were delayed. Ms. P experienced improvements with early intervention in intensive physical and occupational therapy.

Ms. P’s hygiene is well below average, and she requires cueing from her parents. She attended general education until she reached high school, when she began special education. She was sensitive to sensory stimulation from infancy, with sensory sensitivity to textures. Ms. P continues to report sensory sensitivity and lapses in hygiene.

She has difficulty establishing and maintaining relationships with her peers, and prefers solitary activities. Ms. P has no history of romantic relationships, although she does desire one. When asked about her understanding of various relationships, Ms. P’s responses are stereotyped, such as “I know someone is my friend because they are nice to me” and “People get married because they love each other.” She struggles to offer greater insight into the nuances that form lasting relationships and bonds. Ms. P struggles to imitate and describe the physical and internal cues of several basic emotions (eg, fear, joy, anger).

Her conversational and social skills are assessed by asking her to engage in a conversation with the examiner as if meeting for the first time. Her speech is reciprocal, aprosodic, and delayed. The conversation is one-sided, and the examiner fills in several awkward pauses. Ms. P’s gaze at times is intense and prolonged, especially when responding to questions. She tends to use descriptive statements (eg, “I like your purple pen, I like your shirt”) to engage in conversation, rather than gathering more information through reflective statements, questions, or expressing a shared interest.

Ms. P’s verbal abstraction is screened using questions from the Wechsler Adult Intelligence Scale, 4th edition Similarities subtest, to which she provides several responses within normal limits. Her understanding of colloquial speech is assessed by asking her the meaning of common phrases (eg, “Get knocked down 9 times, get up 10,” “Jack and Jill are 2 peas in a pod”). On many occasions, she is able to limit her response to 1 word, (eg, “resiliency”), demonstrating intact ability to decipher idioms.

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The authors’ observations

Upon reflection of Ms. P’s clinical presentation and history of developmental delays, social deficits, sensory sensitivity since infancy, and repetitive behaviors (all which continue to impact her), the clinical team concluded that the diagnosis of autism spectrum disorder (ASD) helps explain the patient’s “odd” behaviors, more so than SPD.

ASD is a heterogenous, complex neuropsychiatric disorder characterized by a persistent deficit in social reciprocity, verbal, and nonverbal communication, and includes a pattern of restricted, repetitive and/or stereotyped behaviors and/or interests.⁵ The term “autismus” is Greek meaning “self,” and was first used to classify the qualities of “morbid self-admiration” observed in prodromal schizophrenia.⁷Due to disorganized, odd behaviors and speech, adults with ASD are sometimes misdiagnosed with schizophrenia and schizophrenia-related disorders, such as SPD.⁸ Ms. P is an example of this phenomenon. In a prospective study looking at the continuity of ASD and SPD traits, Cook et al⁹ found that higher severity levels of ASD symptoms in childhood were associated with a higher level of reported SPD traits in adolescence. Although ASD and SPD are usually diagnosed at opposite ends of the age spectrum, they do have characteristics that overlap, such as limited range of affect and tendency to be described as loners. Table 1^5,8,9 highlights some of these similarities.

Continue to: Treatment...

TREATMENT Adding CBT

At an interdisciplinary session several weeks later that includes Ms. P and her parents, the treatment team discusses the revised diagnoses of ASD and MDD, a treatment recommendation for cognitive-behavioral therapy (CBT), and continued use of medication. At this session, Ms. P discloses that she has not been consistent with her medication regimen since her last appointment, which helps explain the increase in her PHQ-9 score from 2 to 14 and GAD-7 score from 10 to 15 as noted at this interdisciplinary session.

[polldaddy:11027990]

The authors’ observations

CBT can be helpful in improving medication adherence, developing coping skills, and modifying maladaptive behaviors.^16,17Table 2^16,17 provides examples of behavioral interventions that CBT can implement. The evidence for the benefits of psychosocial interventions for adults with ASD is growing. A small systemic review of psychosocial interventions for adults with ASD found that social cognition training, social skills training, and applied behavior analysis had positive benefits.¹⁸

OUTCOME Improvement with psychotherapy

Ms. P and family agree with the team’s recommendations. The aims of Ms. P’s psychotherapy are to maintain medication compliance; implement behavioral modification, vocational rehabilitation, and community engagement; develop social skills; increase functional independence; and develop coping skills for depression and anxiety.

Once her medication is augmented with psychotherapy, Ms. P exhibits a steady decline in PHQ-9 and GAD-7 scores, consistent with an overall reduction of subjective anxiety and depression. In 5 months, her PHQ-9 score decreases from 14 to 2 and her GAD-7 score decreases from 15 to 3. Ms. P is treatment-compliant, more active around the home, and spends more time engaging with friends face-to-face. Overall, the psychotherapy interventions most helpful to her are the development of social skills and coping skills. She reports improved mood, energy levels, concentration, interests, and appetite. Suicidal ideation lessens, and she has not engaged in self-harm since beginning treatment. Worries, tension, and difficulty relaxing also have lessened, though restlessness persists. Excoriation has also decreased significantly, and Ms. P spends less time in the bathroom. Sheenrolls in college courses, plans to start a volleyball team, and is excited about the future.

Bottom Line

The prevalence of schizoid personality disorder (SPD) is low, and its symptoms overlap with those of autism spectrum disorder. Therefore, before diagnosing SPD in an adult patient, it is important to obtain a detailed developmental history and include an interdisciplinary team to assess for autism spectrum disorder.

The intramuscular (IM) route is commonly used to administer medication in various clinical settings. Even when an IM medication is administered appropriately, patient factors such as high subcutaneous tissue, greater body mass index, and gender can lower the success rate of injections.¹ A key but infrequently discussed issue is the skill of the individual administering the IM medication. Incorrectly administering an IM medication can lead to complications, such as abscesses, nerve injury, and skeletal muscle fibrosis.² Poor IM injection technique can impact patient care and safety.¹ For example, a poorly administered antipsychotic medication might lead to the patient receiving a subtherapeutic dose, and could prompt a clinician to ask, “Does this agitated patient need more emergent medication because the medication being given is not effective, or because the medication is not being administered properly?”

This article offers 3 questions to ask when clinicians are evaluating how IM medications are being administered in their clinical setting.

1. Who is administering the medication?

Is the person a registered nurse, licensed psychiatric technician, certified nursing assistant, licensed vocational nurse, or medical assistant? What a specific clinician is permitted to do in one state may not be permitted in another state. For example, in the state of Washington, under certain conditions a medical assistant is allowed to administer an IM medication.³

2. What is the individual’s training in administering IM medications?

Has the person been trained in the proper technique, depending on the body location? Is the injection being properly prepared? Is the correct needle gauge being used?

3. What is the individual’s comfort level with administering IM medications?

Is the person comfortable administering medication only when a patient is calm? Or are they comfortable administering medication when a patient is agitated and being physically held or in 4-point restraints, such as in inpatient psychiatric units or emergency departments?

The intramuscular (IM) route is commonly used to administer medication in various clinical settings. Even when an IM medication is administered appropriately, patient factors such as high subcutaneous tissue, greater body mass index, and gender can lower the success rate of injections.¹ A key but infrequently discussed issue is the skill of the individual administering the IM medication. Incorrectly administering an IM medication can lead to complications, such as abscesses, nerve injury, and skeletal muscle fibrosis.² Poor IM injection technique can impact patient care and safety.¹ For example, a poorly administered antipsychotic medication might lead to the patient receiving a subtherapeutic dose, and could prompt a clinician to ask, “Does this agitated patient need more emergent medication because the medication being given is not effective, or because the medication is not being administered properly?”

This article offers 3 questions to ask when clinicians are evaluating how IM medications are being administered in their clinical setting.

1. Who is administering the medication?

Is the person a registered nurse, licensed psychiatric technician, certified nursing assistant, licensed vocational nurse, or medical assistant? What a specific clinician is permitted to do in one state may not be permitted in another state. For example, in the state of Washington, under certain conditions a medical assistant is allowed to administer an IM medication.³

2. What is the individual’s training in administering IM medications?

Has the person been trained in the proper technique, depending on the body location? Is the injection being properly prepared? Is the correct needle gauge being used?

3. What is the individual’s comfort level with administering IM medications?

Is the person comfortable administering medication only when a patient is calm? Or are they comfortable administering medication when a patient is agitated and being physically held or in 4-point restraints, such as in inpatient psychiatric units or emergency departments?

The intramuscular (IM) route is commonly used to administer medication in various clinical settings. Even when an IM medication is administered appropriately, patient factors such as high subcutaneous tissue, greater body mass index, and gender can lower the success rate of injections.¹ A key but infrequently discussed issue is the skill of the individual administering the IM medication. Incorrectly administering an IM medication can lead to complications, such as abscesses, nerve injury, and skeletal muscle fibrosis.² Poor IM injection technique can impact patient care and safety.¹ For example, a poorly administered antipsychotic medication might lead to the patient receiving a subtherapeutic dose, and could prompt a clinician to ask, “Does this agitated patient need more emergent medication because the medication being given is not effective, or because the medication is not being administered properly?”

This article offers 3 questions to ask when clinicians are evaluating how IM medications are being administered in their clinical setting.

1. Who is administering the medication?

Is the person a registered nurse, licensed psychiatric technician, certified nursing assistant, licensed vocational nurse, or medical assistant? What a specific clinician is permitted to do in one state may not be permitted in another state. For example, in the state of Washington, under certain conditions a medical assistant is allowed to administer an IM medication.³

2. What is the individual’s training in administering IM medications?

Has the person been trained in the proper technique, depending on the body location? Is the injection being properly prepared? Is the correct needle gauge being used?

3. What is the individual’s comfort level with administering IM medications?

Is the person comfortable administering medication only when a patient is calm? Or are they comfortable administering medication when a patient is agitated and being physically held or in 4-point restraints, such as in inpatient psychiatric units or emergency departments?

Intermittent fasting is the purposeful, restricted intake of food (and sometimes water), usually for health or religious reasons. Common forms are alternative-day fasting or time-restricted fasting, with variable ratios of days or hours for fasting and eating/drinking.¹ For example, fasting during Ramadan, the ninth month of the Islamic calendar, occurs from dawn to sunset, for a variable duration due to latitude and seasonal shifts.² Clinicians are likely to care for a patient who occasionally fasts. While there are potential benefits of fasting, clinicians need to consider the implications for patients who fast, particularly those receiving psychotropic medications.

Potential benefits for weight loss, mood

Some research suggests fasting is popular and may have benefits for an individual’s physical and mental health. In a 2020 online poll (N = 1,241), 24% of respondents said they had tried intermittent fasting, and 87% said the practice was very effective (50%) or somewhat effective (37%) in helping them lose weight.³ While more randomized control trials are needed to examine the practice’s effectiveness in promoting and maintaining weight loss, fasting has been linked to better glucose control in both humans and animals, and patients may have better adherence with fasting compared to caloric restriction alone.¹ Improved mood, alertness, tranquility, and sometimes euphoria have been documented among individuals who fast, but these benefits may not be sustained.⁴ A prospective study of 462 participants who fasted during Ramadan found the practice reduced depression in patients with diabetes, possibly due to mindfulness, decreased inflammation from improved insulin sensitivity, and/or social cohesion.⁵

Be aware of the potential risks

Fasting may either improve or destabilize mood in people with bipolar disorder by disrupting circadian rhythm and sleep.² Fasting might exacerbate underlying eating disorders.² Increased dehydration escalates the risk for orthostatic hypotension, which might require discontinuing clozapine.⁶ Hypotension and toxicity might arise during lithium pharmacotherapy. The Table⁴ summarizes things to consider when caring for a patient who fasts while receiving pharmacotherapy.

Provide patients with guidance

Advise patients not to fast if you believe it might exacerbate their mental illness, and encourage them to discuss with their primary care physicians any potential worsening of physical illnesses.² When caring for a patient who fasts for religious reasons, consider consulting with the patient’s religious leaders.² If patients choose to fast, monitor them for mood destabilization and/or medication adverse effects. If possible, avoid altering drug treatment regimens during fasting, and carefully monitor whenever a pharmaceutical change is necessary. When appropriate, the use of long-acting injectable medications may minimize adverse effects while maintaining mood stability. Encourage patients who fast to ensure they remain hydrated and practice sleep hygiene while they fast.⁷

Intermittent fasting is the purposeful, restricted intake of food (and sometimes water), usually for health or religious reasons. Common forms are alternative-day fasting or time-restricted fasting, with variable ratios of days or hours for fasting and eating/drinking.¹ For example, fasting during Ramadan, the ninth month of the Islamic calendar, occurs from dawn to sunset, for a variable duration due to latitude and seasonal shifts.² Clinicians are likely to care for a patient who occasionally fasts. While there are potential benefits of fasting, clinicians need to consider the implications for patients who fast, particularly those receiving psychotropic medications.

Potential benefits for weight loss, mood

Some research suggests fasting is popular and may have benefits for an individual’s physical and mental health. In a 2020 online poll (N = 1,241), 24% of respondents said they had tried intermittent fasting, and 87% said the practice was very effective (50%) or somewhat effective (37%) in helping them lose weight.³ While more randomized control trials are needed to examine the practice’s effectiveness in promoting and maintaining weight loss, fasting has been linked to better glucose control in both humans and animals, and patients may have better adherence with fasting compared to caloric restriction alone.¹ Improved mood, alertness, tranquility, and sometimes euphoria have been documented among individuals who fast, but these benefits may not be sustained.⁴ A prospective study of 462 participants who fasted during Ramadan found the practice reduced depression in patients with diabetes, possibly due to mindfulness, decreased inflammation from improved insulin sensitivity, and/or social cohesion.⁵

Be aware of the potential risks

Fasting may either improve or destabilize mood in people with bipolar disorder by disrupting circadian rhythm and sleep.² Fasting might exacerbate underlying eating disorders.² Increased dehydration escalates the risk for orthostatic hypotension, which might require discontinuing clozapine.⁶ Hypotension and toxicity might arise during lithium pharmacotherapy. The Table⁴ summarizes things to consider when caring for a patient who fasts while receiving pharmacotherapy.

Provide patients with guidance

Advise patients not to fast if you believe it might exacerbate their mental illness, and encourage them to discuss with their primary care physicians any potential worsening of physical illnesses.² When caring for a patient who fasts for religious reasons, consider consulting with the patient’s religious leaders.² If patients choose to fast, monitor them for mood destabilization and/or medication adverse effects. If possible, avoid altering drug treatment regimens during fasting, and carefully monitor whenever a pharmaceutical change is necessary. When appropriate, the use of long-acting injectable medications may minimize adverse effects while maintaining mood stability. Encourage patients who fast to ensure they remain hydrated and practice sleep hygiene while they fast.⁷

Intermittent fasting is the purposeful, restricted intake of food (and sometimes water), usually for health or religious reasons. Common forms are alternative-day fasting or time-restricted fasting, with variable ratios of days or hours for fasting and eating/drinking.¹ For example, fasting during Ramadan, the ninth month of the Islamic calendar, occurs from dawn to sunset, for a variable duration due to latitude and seasonal shifts.² Clinicians are likely to care for a patient who occasionally fasts. While there are potential benefits of fasting, clinicians need to consider the implications for patients who fast, particularly those receiving psychotropic medications.

Potential benefits for weight loss, mood

Some research suggests fasting is popular and may have benefits for an individual’s physical and mental health. In a 2020 online poll (N = 1,241), 24% of respondents said they had tried intermittent fasting, and 87% said the practice was very effective (50%) or somewhat effective (37%) in helping them lose weight.³ While more randomized control trials are needed to examine the practice’s effectiveness in promoting and maintaining weight loss, fasting has been linked to better glucose control in both humans and animals, and patients may have better adherence with fasting compared to caloric restriction alone.¹ Improved mood, alertness, tranquility, and sometimes euphoria have been documented among individuals who fast, but these benefits may not be sustained.⁴ A prospective study of 462 participants who fasted during Ramadan found the practice reduced depression in patients with diabetes, possibly due to mindfulness, decreased inflammation from improved insulin sensitivity, and/or social cohesion.⁵

Be aware of the potential risks

Fasting may either improve or destabilize mood in people with bipolar disorder by disrupting circadian rhythm and sleep.² Fasting might exacerbate underlying eating disorders.² Increased dehydration escalates the risk for orthostatic hypotension, which might require discontinuing clozapine.⁶ Hypotension and toxicity might arise during lithium pharmacotherapy. The Table⁴ summarizes things to consider when caring for a patient who fasts while receiving pharmacotherapy.

Provide patients with guidance

Advise patients not to fast if you believe it might exacerbate their mental illness, and encourage them to discuss with their primary care physicians any potential worsening of physical illnesses.² When caring for a patient who fasts for religious reasons, consider consulting with the patient’s religious leaders.² If patients choose to fast, monitor them for mood destabilization and/or medication adverse effects. If possible, avoid altering drug treatment regimens during fasting, and carefully monitor whenever a pharmaceutical change is necessary. When appropriate, the use of long-acting injectable medications may minimize adverse effects while maintaining mood stability. Encourage patients who fast to ensure they remain hydrated and practice sleep hygiene while they fast.⁷

Q2. Correct answer: B. He should undergo surveillance colonoscopy now and annually thereafter. 
 
Rationale  
PSC diagnosis is the most consistent risk factor for colorectal cancer (CRC) in patients with inflammatory bowel disease. Other identified risk factors include endoscopic extent of the disease (pancolitis), duration of the disease (more than 8 years), age at diagnosis (young), presence of pseudopolyps, and family history of CRC. The current guidelines recommend first surveillance colonoscopy 8-10 years after the diagnosis of ulcerative colitis or Crohn's disease that involves more than one-third of the colon with subsequent surveillance intervals at 1-3 years. However, for patients with a concomitant diagnosis of PSC, the recommendation is to initiate surveillance as soon as the coexisting diagnosis is established, with annual surveillance colonoscopy thereafter.  
High-dose UDCA (more than 28 mg/kg/day) is not recommended in patients with PSC because it was linked to adverse outcomes in this population including decompensated cirrhosis, death, and increased risk of colorectal neoplasia. On the other hand, low-dose UDCA may improve laboratory markers of cholestasis, but with no clear impact on survival or long-term outcomes, its role for chemoprophylaxis in colorectal cancer is still controversial.  
Yearly MRCP is recommended to screen for cholangiocarcinoma.  
 
References  
Lindor KD et al. Am J Gastroenterol. 2015 May;110(5):646-59; quiz 660.  
Lopez A et al. Best Pract Res Clin Gastroenterol. Feb-Apr 2018;32-33:103-109.

Q2. Correct answer: B. He should undergo surveillance colonoscopy now and annually thereafter. 
 
Rationale  
PSC diagnosis is the most consistent risk factor for colorectal cancer (CRC) in patients with inflammatory bowel disease. Other identified risk factors include endoscopic extent of the disease (pancolitis), duration of the disease (more than 8 years), age at diagnosis (young), presence of pseudopolyps, and family history of CRC. The current guidelines recommend first surveillance colonoscopy 8-10 years after the diagnosis of ulcerative colitis or Crohn's disease that involves more than one-third of the colon with subsequent surveillance intervals at 1-3 years. However, for patients with a concomitant diagnosis of PSC, the recommendation is to initiate surveillance as soon as the coexisting diagnosis is established, with annual surveillance colonoscopy thereafter.  
High-dose UDCA (more than 28 mg/kg/day) is not recommended in patients with PSC because it was linked to adverse outcomes in this population including decompensated cirrhosis, death, and increased risk of colorectal neoplasia. On the other hand, low-dose UDCA may improve laboratory markers of cholestasis, but with no clear impact on survival or long-term outcomes, its role for chemoprophylaxis in colorectal cancer is still controversial.  
Yearly MRCP is recommended to screen for cholangiocarcinoma.  
 
References  
Lindor KD et al. Am J Gastroenterol. 2015 May;110(5):646-59; quiz 660.  
Lopez A et al. Best Pract Res Clin Gastroenterol. Feb-Apr 2018;32-33:103-109.

Q2. Correct answer: B. He should undergo surveillance colonoscopy now and annually thereafter. 
 
Rationale  
PSC diagnosis is the most consistent risk factor for colorectal cancer (CRC) in patients with inflammatory bowel disease. Other identified risk factors include endoscopic extent of the disease (pancolitis), duration of the disease (more than 8 years), age at diagnosis (young), presence of pseudopolyps, and family history of CRC. The current guidelines recommend first surveillance colonoscopy 8-10 years after the diagnosis of ulcerative colitis or Crohn's disease that involves more than one-third of the colon with subsequent surveillance intervals at 1-3 years. However, for patients with a concomitant diagnosis of PSC, the recommendation is to initiate surveillance as soon as the coexisting diagnosis is established, with annual surveillance colonoscopy thereafter.  
High-dose UDCA (more than 28 mg/kg/day) is not recommended in patients with PSC because it was linked to adverse outcomes in this population including decompensated cirrhosis, death, and increased risk of colorectal neoplasia. On the other hand, low-dose UDCA may improve laboratory markers of cholestasis, but with no clear impact on survival or long-term outcomes, its role for chemoprophylaxis in colorectal cancer is still controversial.  
Yearly MRCP is recommended to screen for cholangiocarcinoma.  
 
References  
Lindor KD et al. Am J Gastroenterol. 2015 May;110(5):646-59; quiz 660.  
Lopez A et al. Best Pract Res Clin Gastroenterol. Feb-Apr 2018;32-33:103-109.

Q1. Correct answer: E. Emergent angiography 
 
Rationale  
This patient presents with a massive lower GI hemorrhage. After a brisk upper GI bleed was ruled-out with esophagogastroduodenoscopy, the patient continued to hemorrhage and remained hemodynamically unstable. In the setting of a patient with ongoing massive lower GI bleeding who has been ruled out for an upper GI bleed (negative upper endoscopy) and who continues to have hemodynamic instability despite resuscitation, emergent angiography should be pursued in an effort localize and control bleeding.  
Answer A is incorrect because an INR less than 2.5 does not require reversal prior to attempts at hemostasis. Answers B and C are incorrect because, given the patient's altered mental status and hemodynamic changes, she is unlikely to tolerate a bowel preparation and urgent colonoscopy. Also, there is no role for an unprepped colonoscopy in lower GI bleeding due to low yield and poor visualization. Answer D is incorrect because a nuclear-tagged red blood cell scan should be reserved for a patient who is hemodynamically stable.  
 
Reference  
Strate LL, Gralnek IM. Am J Gastroenterol. 2016 Apr;111(4):459-74.

Q1. Correct answer: E. Emergent angiography 
 
Rationale  
This patient presents with a massive lower GI hemorrhage. After a brisk upper GI bleed was ruled-out with esophagogastroduodenoscopy, the patient continued to hemorrhage and remained hemodynamically unstable. In the setting of a patient with ongoing massive lower GI bleeding who has been ruled out for an upper GI bleed (negative upper endoscopy) and who continues to have hemodynamic instability despite resuscitation, emergent angiography should be pursued in an effort localize and control bleeding.  
Answer A is incorrect because an INR less than 2.5 does not require reversal prior to attempts at hemostasis. Answers B and C are incorrect because, given the patient's altered mental status and hemodynamic changes, she is unlikely to tolerate a bowel preparation and urgent colonoscopy. Also, there is no role for an unprepped colonoscopy in lower GI bleeding due to low yield and poor visualization. Answer D is incorrect because a nuclear-tagged red blood cell scan should be reserved for a patient who is hemodynamically stable.  
 
Reference  
Strate LL, Gralnek IM. Am J Gastroenterol. 2016 Apr;111(4):459-74.

Q1. Correct answer: E. Emergent angiography 
 
Rationale  
This patient presents with a massive lower GI hemorrhage. After a brisk upper GI bleed was ruled-out with esophagogastroduodenoscopy, the patient continued to hemorrhage and remained hemodynamically unstable. In the setting of a patient with ongoing massive lower GI bleeding who has been ruled out for an upper GI bleed (negative upper endoscopy) and who continues to have hemodynamic instability despite resuscitation, emergent angiography should be pursued in an effort localize and control bleeding.  
Answer A is incorrect because an INR less than 2.5 does not require reversal prior to attempts at hemostasis. Answers B and C are incorrect because, given the patient's altered mental status and hemodynamic changes, she is unlikely to tolerate a bowel preparation and urgent colonoscopy. Also, there is no role for an unprepped colonoscopy in lower GI bleeding due to low yield and poor visualization. Answer D is incorrect because a nuclear-tagged red blood cell scan should be reserved for a patient who is hemodynamically stable.  
 
Reference  
Strate LL, Gralnek IM. Am J Gastroenterol. 2016 Apr;111(4):459-74.

Takayama et al evaluated 301 Japanese HCC patients who had a Child-Pugh score ≤ 7, no more than 3 HCC nodules (none more than 3 cm in greatest diameter), who were then randomly assigned to undergo either surgery (n=150) or RFA (n=151). The authors reported that though the median procedure duration was longer in the surgery group than in the RFA group (274 versus 40 minutes, P < 0.01) as was the median duration of hospital stay (17 days versus 10 days, P < 0.01), recurrence free survival (RFS) did not differ significantly between the groups. The median RFS was 3.5 years (95% confidence interval [CI], 2.6–5.1) in the surgery group and 3.0 years (95% CI, 2.4–5.6) in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P = 0.58). The overall survival (OS) data for this study are not yet mature.

Cao et al looked at outcomes of patients with periportal HCCs who were treated with RFA. They evaluated 233 patients who had a single nodular HCC that was ≤ 5 cm in greatest diameter who underwent RFA with or without transarterial chemoembolization (TACE) as first-line therapy. In that group, 56 patients had a periportal HCC. The authors reported that patients with periportal HCCs had worse outcomes. Local recurrence rates at 1, 3, and 5 years were significantly higher with periportal HCCs than with nonperiportal HCCs (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year OS rates with periportal HCCs were significantly worse than with nonperiportal HCCs (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P < 0.0001). In the subgroup of HCC ≤ 3 cm, patients with periportal HCCs showed significantly higher local recurrence rates (P = 0.0006) and OS (P < 0.0001) after RFA than patients with single nonperiportal HCCs. Subgroup analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. The authors concluded that periportal HCCs have a worse prognosis, and need better treatment options than are currently available.

Lee at al report a retrospective evaluation of Korean patients with HCC who were either treated with RFA or microwave ablation (MWA). Of 150 HCC patients (100 in the RFA group and 50 in the MWA group), the complete response rate, two-year survival rate, and complication rate were similar between the two groups. However, the MWA group had better one- and two-year disease-free survival than the RFA group (P = 0.035 and P = 0.032, respectively). In addition, there were fewer major complications in the MWA group (P = 0.043). In a subgroup analysis, patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. The authors concluded that in patients with HCC, initial treatment with microwave ablation leads to better 1- and 2-year disease-free survival and a lower risk of major complications than RFA.

Takayama et al evaluated 301 Japanese HCC patients who had a Child-Pugh score ≤ 7, no more than 3 HCC nodules (none more than 3 cm in greatest diameter), who were then randomly assigned to undergo either surgery (n=150) or RFA (n=151). The authors reported that though the median procedure duration was longer in the surgery group than in the RFA group (274 versus 40 minutes, P < 0.01) as was the median duration of hospital stay (17 days versus 10 days, P < 0.01), recurrence free survival (RFS) did not differ significantly between the groups. The median RFS was 3.5 years (95% confidence interval [CI], 2.6–5.1) in the surgery group and 3.0 years (95% CI, 2.4–5.6) in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P = 0.58). The overall survival (OS) data for this study are not yet mature.

Cao et al looked at outcomes of patients with periportal HCCs who were treated with RFA. They evaluated 233 patients who had a single nodular HCC that was ≤ 5 cm in greatest diameter who underwent RFA with or without transarterial chemoembolization (TACE) as first-line therapy. In that group, 56 patients had a periportal HCC. The authors reported that patients with periportal HCCs had worse outcomes. Local recurrence rates at 1, 3, and 5 years were significantly higher with periportal HCCs than with nonperiportal HCCs (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year OS rates with periportal HCCs were significantly worse than with nonperiportal HCCs (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P < 0.0001). In the subgroup of HCC ≤ 3 cm, patients with periportal HCCs showed significantly higher local recurrence rates (P = 0.0006) and OS (P < 0.0001) after RFA than patients with single nonperiportal HCCs. Subgroup analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. The authors concluded that periportal HCCs have a worse prognosis, and need better treatment options than are currently available.

Lee at al report a retrospective evaluation of Korean patients with HCC who were either treated with RFA or microwave ablation (MWA). Of 150 HCC patients (100 in the RFA group and 50 in the MWA group), the complete response rate, two-year survival rate, and complication rate were similar between the two groups. However, the MWA group had better one- and two-year disease-free survival than the RFA group (P = 0.035 and P = 0.032, respectively). In addition, there were fewer major complications in the MWA group (P = 0.043). In a subgroup analysis, patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. The authors concluded that in patients with HCC, initial treatment with microwave ablation leads to better 1- and 2-year disease-free survival and a lower risk of major complications than RFA.

Takayama et al evaluated 301 Japanese HCC patients who had a Child-Pugh score ≤ 7, no more than 3 HCC nodules (none more than 3 cm in greatest diameter), who were then randomly assigned to undergo either surgery (n=150) or RFA (n=151). The authors reported that though the median procedure duration was longer in the surgery group than in the RFA group (274 versus 40 minutes, P < 0.01) as was the median duration of hospital stay (17 days versus 10 days, P < 0.01), recurrence free survival (RFS) did not differ significantly between the groups. The median RFS was 3.5 years (95% confidence interval [CI], 2.6–5.1) in the surgery group and 3.0 years (95% CI, 2.4–5.6) in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P = 0.58). The overall survival (OS) data for this study are not yet mature.

Cao et al looked at outcomes of patients with periportal HCCs who were treated with RFA. They evaluated 233 patients who had a single nodular HCC that was ≤ 5 cm in greatest diameter who underwent RFA with or without transarterial chemoembolization (TACE) as first-line therapy. In that group, 56 patients had a periportal HCC. The authors reported that patients with periportal HCCs had worse outcomes. Local recurrence rates at 1, 3, and 5 years were significantly higher with periportal HCCs than with nonperiportal HCCs (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year OS rates with periportal HCCs were significantly worse than with nonperiportal HCCs (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P < 0.0001). In the subgroup of HCC ≤ 3 cm, patients with periportal HCCs showed significantly higher local recurrence rates (P = 0.0006) and OS (P < 0.0001) after RFA than patients with single nonperiportal HCCs. Subgroup analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. The authors concluded that periportal HCCs have a worse prognosis, and need better treatment options than are currently available.

Lee at al report a retrospective evaluation of Korean patients with HCC who were either treated with RFA or microwave ablation (MWA). Of 150 HCC patients (100 in the RFA group and 50 in the MWA group), the complete response rate, two-year survival rate, and complication rate were similar between the two groups. However, the MWA group had better one- and two-year disease-free survival than the RFA group (P = 0.035 and P = 0.032, respectively). In addition, there were fewer major complications in the MWA group (P = 0.043). In a subgroup analysis, patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. The authors concluded that in patients with HCC, initial treatment with microwave ablation leads to better 1- and 2-year disease-free survival and a lower risk of major complications than RFA.

Takayama et al evaluated 301 Japanese HCC patients who had a Child-Pugh score ≤ 7, no more than 3 HCC nodules (none more than 3 cm in greatest diameter), who were then randomly assigned to undergo either surgery (n=150) or RFA (n=151). The authors reported that though the median procedure duration was longer in the surgery group than in the RFA group (274 versus 40 minutes, P < 0.01) as was the median duration of hospital stay (17 days versus 10 days, P < 0.01), recurrence free survival (RFS) did not differ significantly between the groups. The median RFS was 3.5 years (95% confidence interval [CI], 2.6–5.1) in the surgery group and 3.0 years (95% CI, 2.4–5.6) in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P = 0.58). The overall survival (OS) data for this study are not yet mature.

Cao et al looked at outcomes of patients with periportal HCCs who were treated with RFA. They evaluated 233 patients who had a single nodular HCC that was ≤ 5 cm in greatest diameter who underwent RFA with or without transarterial chemoembolization (TACE) as first-line therapy. In that group, 56 patients had a periportal HCC. The authors reported that patients with periportal HCCs had worse outcomes. Local recurrence rates at 1, 3, and 5 years were significantly higher with periportal HCCs than with nonperiportal HCCs (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year OS rates with periportal HCCs were significantly worse than with nonperiportal HCCs (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P < 0.0001). In the subgroup of HCC ≤ 3 cm, patients with periportal HCCs showed significantly higher local recurrence rates (P = 0.0006) and OS (P < 0.0001) after RFA than patients with single nonperiportal HCCs. Subgroup analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. The authors concluded that periportal HCCs have a worse prognosis, and need better treatment options than are currently available.

Lee at al report a retrospective evaluation of Korean patients with HCC who were either treated with RFA or microwave ablation (MWA). Of 150 HCC patients (100 in the RFA group and 50 in the MWA group), the complete response rate, two-year survival rate, and complication rate were similar between the two groups. However, the MWA group had better one- and two-year disease-free survival than the RFA group (P = 0.035 and P = 0.032, respectively). In addition, there were fewer major complications in the MWA group (P = 0.043). In a subgroup analysis, patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. The authors concluded that in patients with HCC, initial treatment with microwave ablation leads to better 1- and 2-year disease-free survival and a lower risk of major complications than RFA.

Takayama et al evaluated 301 Japanese HCC patients who had a Child-Pugh score ≤ 7, no more than 3 HCC nodules (none more than 3 cm in greatest diameter), who were then randomly assigned to undergo either surgery (n=150) or RFA (n=151). The authors reported that though the median procedure duration was longer in the surgery group than in the RFA group (274 versus 40 minutes, P < 0.01) as was the median duration of hospital stay (17 days versus 10 days, P < 0.01), recurrence free survival (RFS) did not differ significantly between the groups. The median RFS was 3.5 years (95% confidence interval [CI], 2.6–5.1) in the surgery group and 3.0 years (95% CI, 2.4–5.6) in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P = 0.58). The overall survival (OS) data for this study are not yet mature.

Cao et al looked at outcomes of patients with periportal HCCs who were treated with RFA. They evaluated 233 patients who had a single nodular HCC that was ≤ 5 cm in greatest diameter who underwent RFA with or without transarterial chemoembolization (TACE) as first-line therapy. In that group, 56 patients had a periportal HCC. The authors reported that patients with periportal HCCs had worse outcomes. Local recurrence rates at 1, 3, and 5 years were significantly higher with periportal HCCs than with nonperiportal HCCs (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year OS rates with periportal HCCs were significantly worse than with nonperiportal HCCs (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P < 0.0001). In the subgroup of HCC ≤ 3 cm, patients with periportal HCCs showed significantly higher local recurrence rates (P = 0.0006) and OS (P < 0.0001) after RFA than patients with single nonperiportal HCCs. Subgroup analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. The authors concluded that periportal HCCs have a worse prognosis, and need better treatment options than are currently available.

Lee at al report a retrospective evaluation of Korean patients with HCC who were either treated with RFA or microwave ablation (MWA). Of 150 HCC patients (100 in the RFA group and 50 in the MWA group), the complete response rate, two-year survival rate, and complication rate were similar between the two groups. However, the MWA group had better one- and two-year disease-free survival than the RFA group (P = 0.035 and P = 0.032, respectively). In addition, there were fewer major complications in the MWA group (P = 0.043). In a subgroup analysis, patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. The authors concluded that in patients with HCC, initial treatment with microwave ablation leads to better 1- and 2-year disease-free survival and a lower risk of major complications than RFA.

Takayama et al evaluated 301 Japanese HCC patients who had a Child-Pugh score ≤ 7, no more than 3 HCC nodules (none more than 3 cm in greatest diameter), who were then randomly assigned to undergo either surgery (n=150) or RFA (n=151). The authors reported that though the median procedure duration was longer in the surgery group than in the RFA group (274 versus 40 minutes, P < 0.01) as was the median duration of hospital stay (17 days versus 10 days, P < 0.01), recurrence free survival (RFS) did not differ significantly between the groups. The median RFS was 3.5 years (95% confidence interval [CI], 2.6–5.1) in the surgery group and 3.0 years (95% CI, 2.4–5.6) in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P = 0.58). The overall survival (OS) data for this study are not yet mature.

Cao et al looked at outcomes of patients with periportal HCCs who were treated with RFA. They evaluated 233 patients who had a single nodular HCC that was ≤ 5 cm in greatest diameter who underwent RFA with or without transarterial chemoembolization (TACE) as first-line therapy. In that group, 56 patients had a periportal HCC. The authors reported that patients with periportal HCCs had worse outcomes. Local recurrence rates at 1, 3, and 5 years were significantly higher with periportal HCCs than with nonperiportal HCCs (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year OS rates with periportal HCCs were significantly worse than with nonperiportal HCCs (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P < 0.0001). In the subgroup of HCC ≤ 3 cm, patients with periportal HCCs showed significantly higher local recurrence rates (P = 0.0006) and OS (P < 0.0001) after RFA than patients with single nonperiportal HCCs. Subgroup analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. The authors concluded that periportal HCCs have a worse prognosis, and need better treatment options than are currently available.

Lee at al report a retrospective evaluation of Korean patients with HCC who were either treated with RFA or microwave ablation (MWA). Of 150 HCC patients (100 in the RFA group and 50 in the MWA group), the complete response rate, two-year survival rate, and complication rate were similar between the two groups. However, the MWA group had better one- and two-year disease-free survival than the RFA group (P = 0.035 and P = 0.032, respectively). In addition, there were fewer major complications in the MWA group (P = 0.043). In a subgroup analysis, patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. The authors concluded that in patients with HCC, initial treatment with microwave ablation leads to better 1- and 2-year disease-free survival and a lower risk of major complications than RFA.

The STAMPEDE platform included a multiple arm and multiple stage protocol to evaluate abiraterone and enzalutamide in high risk non-metastatic and metastatic disease in separate trials. In the accompanying article by Attard et. al, a meta-analysis of two separate trials conducted as part of the STAMPEDE platform was undertaken. In the first trial, patients with high-risk localized prostate cancer were randomized to androgen deprivation therapy (ADT) with or without abiraterone. In the second trial, similar patients were randomized to ADT versus ADT plus abiraterone plus enzalutamide. The primary outcome of metastasis-free survival and secondary outcome of overall survival [OS] were significantly longer for the treatment arms over ADT; however, the addition of enzalutamide to abiraterone did not result in additional benefit. In appropriately selected patients with high risk localized prostate cancer, abiraterone is a reasonable option to consider in appropriately selected patients.

While bone is the most frequent site of metastasis in men with prostate cancer, visceral metastases (predominantly liver or lung) has been associated with worse outcomes. However, lower incidence of visceral metastases makes conduct of studies focused on visceral disease challenging. Baciarello et al conducted a post-hoc analysis of the LATITUDE study (where men with metastatic castrate-sensitive disease were treated with ADT plus abiraterone or ADT alone) in participants with visceral disease. Overall, patients with visceral metastases derived OS benefit (55.4 versus 33 months). Patients with lung metastases had similar OS to the entire cohort; however, those with liver metastases still derived benefit but had lower OS (36.8 versus 25.6 months). These post-hoc findings suggest that liver metastases present unique challenges compare to other metastatic disease sites, but further study is needed.

In the ENZAMET trial, enzalutamide plus ADT was compared to ADT alone in patients with metastatic castrate-sensitive disease, and enzalutamide treatment was associated with improved OS. In the report by Stockler et al, quality of life metrics as assessed by periodic evaluation utilizing standard questionnaires were reported. Patients who received enzalutamide reported more fatigue and lower cognitive and physical function than those receiving placebo. However, the overall quality of life did not decrease. These important quality of life findings, which are increasingly being reported in similar studies, support the overall net benefit of utilization of enzalutamide in patients with metastatic castrate-sensitive disease.

The STAMPEDE platform included a multiple arm and multiple stage protocol to evaluate abiraterone and enzalutamide in high risk non-metastatic and metastatic disease in separate trials. In the accompanying article by Attard et. al, a meta-analysis of two separate trials conducted as part of the STAMPEDE platform was undertaken. In the first trial, patients with high-risk localized prostate cancer were randomized to androgen deprivation therapy (ADT) with or without abiraterone. In the second trial, similar patients were randomized to ADT versus ADT plus abiraterone plus enzalutamide. The primary outcome of metastasis-free survival and secondary outcome of overall survival [OS] were significantly longer for the treatment arms over ADT; however, the addition of enzalutamide to abiraterone did not result in additional benefit. In appropriately selected patients with high risk localized prostate cancer, abiraterone is a reasonable option to consider in appropriately selected patients.

While bone is the most frequent site of metastasis in men with prostate cancer, visceral metastases (predominantly liver or lung) has been associated with worse outcomes. However, lower incidence of visceral metastases makes conduct of studies focused on visceral disease challenging. Baciarello et al conducted a post-hoc analysis of the LATITUDE study (where men with metastatic castrate-sensitive disease were treated with ADT plus abiraterone or ADT alone) in participants with visceral disease. Overall, patients with visceral metastases derived OS benefit (55.4 versus 33 months). Patients with lung metastases had similar OS to the entire cohort; however, those with liver metastases still derived benefit but had lower OS (36.8 versus 25.6 months). These post-hoc findings suggest that liver metastases present unique challenges compare to other metastatic disease sites, but further study is needed.

In the ENZAMET trial, enzalutamide plus ADT was compared to ADT alone in patients with metastatic castrate-sensitive disease, and enzalutamide treatment was associated with improved OS. In the report by Stockler et al, quality of life metrics as assessed by periodic evaluation utilizing standard questionnaires were reported. Patients who received enzalutamide reported more fatigue and lower cognitive and physical function than those receiving placebo. However, the overall quality of life did not decrease. These important quality of life findings, which are increasingly being reported in similar studies, support the overall net benefit of utilization of enzalutamide in patients with metastatic castrate-sensitive disease.

The STAMPEDE platform included a multiple arm and multiple stage protocol to evaluate abiraterone and enzalutamide in high risk non-metastatic and metastatic disease in separate trials. In the accompanying article by Attard et. al, a meta-analysis of two separate trials conducted as part of the STAMPEDE platform was undertaken. In the first trial, patients with high-risk localized prostate cancer were randomized to androgen deprivation therapy (ADT) with or without abiraterone. In the second trial, similar patients were randomized to ADT versus ADT plus abiraterone plus enzalutamide. The primary outcome of metastasis-free survival and secondary outcome of overall survival [OS] were significantly longer for the treatment arms over ADT; however, the addition of enzalutamide to abiraterone did not result in additional benefit. In appropriately selected patients with high risk localized prostate cancer, abiraterone is a reasonable option to consider in appropriately selected patients.

While bone is the most frequent site of metastasis in men with prostate cancer, visceral metastases (predominantly liver or lung) has been associated with worse outcomes. However, lower incidence of visceral metastases makes conduct of studies focused on visceral disease challenging. Baciarello et al conducted a post-hoc analysis of the LATITUDE study (where men with metastatic castrate-sensitive disease were treated with ADT plus abiraterone or ADT alone) in participants with visceral disease. Overall, patients with visceral metastases derived OS benefit (55.4 versus 33 months). Patients with lung metastases had similar OS to the entire cohort; however, those with liver metastases still derived benefit but had lower OS (36.8 versus 25.6 months). These post-hoc findings suggest that liver metastases present unique challenges compare to other metastatic disease sites, but further study is needed.

In the ENZAMET trial, enzalutamide plus ADT was compared to ADT alone in patients with metastatic castrate-sensitive disease, and enzalutamide treatment was associated with improved OS. In the report by Stockler et al, quality of life metrics as assessed by periodic evaluation utilizing standard questionnaires were reported. Patients who received enzalutamide reported more fatigue and lower cognitive and physical function than those receiving placebo. However, the overall quality of life did not decrease. These important quality of life findings, which are increasingly being reported in similar studies, support the overall net benefit of utilization of enzalutamide in patients with metastatic castrate-sensitive disease.