Sherry Boschert

LOS ANGELES – For the first time, a pediatric stroke severity scale has been validated in a prospective clinical trial.

The study in 15 North American medical centers showed excellent interrater reliability when neurologists used a pediatric version of the National Institutes of Health Stroke Scale for adults to examine children aged 2–18 years with acute arterial ischemic stroke.

The neurologists used the Pediatric NIH Stroke Scale (PedNIHSS) on 113 patients examined daily from admission to discharge, or through day 7 of hospitalization. Interrater reliability was tested in a subset of 25 patients who were examined simultaneously by two pediatric neurologists. Characteristics of the subgroup were similar to those of the entire cohort, Dr. Rebecca N. Ichord reported.

The simultaneous raters' scores were identical in 60% of ratings and were within a 1-point difference in 84% of ratings (Stroke 2011;42:613–7).

Research into potential ways of preventing or treating childhood stroke has been stymied in the past by the lack of a validated and reliable pediatric stroke scale. The PedNIHSS provides a way to index the severity of a child's stroke, to make comparisons across treatment groups, and to get a baseline for predicting outcome, said Dr. Ichord, director of the pediatric stroke program at the Children's Hospital of Philadelphia.

Clinicians, too, have been hungering for such a scale. “I have been asked over and over again [for a pediatric stroke scale] by clinicians who want to have a method of describing the severity of a child's stroke,” she said at the meeting, which was sponsored by the American Heart Association. “It's absolutely needed and wanted right now by clinicians on the front line.”

Characteristics of the patients and the strokes in the study were similar to those reported in previous pediatric stroke cohort studies, which suggests the current findings are generalizable and the PedNIHSS should be applicable in other settings.

The PedNIHSS was drafted by a consensus panel of pediatric and adult stroke experts. Dr. Ichord and one of her associates in the study are on the clinical event committee for the Berlin Heart Trial for pediatric ventricular assist devices.

A pediatric stroke scale is 'absolutely needed and wanted right now by clinicians on the front line.'

Source DR. ICHORD

LOS ANGELES – For the first time, a pediatric stroke severity scale has been validated in a prospective clinical trial.

The study in 15 North American medical centers showed excellent interrater reliability when neurologists used a pediatric version of the National Institutes of Health Stroke Scale for adults to examine children aged 2–18 years with acute arterial ischemic stroke.

The neurologists used the Pediatric NIH Stroke Scale (PedNIHSS) on 113 patients examined daily from admission to discharge, or through day 7 of hospitalization. Interrater reliability was tested in a subset of 25 patients who were examined simultaneously by two pediatric neurologists. Characteristics of the subgroup were similar to those of the entire cohort, Dr. Rebecca N. Ichord reported.

The simultaneous raters' scores were identical in 60% of ratings and were within a 1-point difference in 84% of ratings (Stroke 2011;42:613–7).

Research into potential ways of preventing or treating childhood stroke has been stymied in the past by the lack of a validated and reliable pediatric stroke scale. The PedNIHSS provides a way to index the severity of a child's stroke, to make comparisons across treatment groups, and to get a baseline for predicting outcome, said Dr. Ichord, director of the pediatric stroke program at the Children's Hospital of Philadelphia.

Clinicians, too, have been hungering for such a scale. “I have been asked over and over again [for a pediatric stroke scale] by clinicians who want to have a method of describing the severity of a child's stroke,” she said at the meeting, which was sponsored by the American Heart Association. “It's absolutely needed and wanted right now by clinicians on the front line.”

Characteristics of the patients and the strokes in the study were similar to those reported in previous pediatric stroke cohort studies, which suggests the current findings are generalizable and the PedNIHSS should be applicable in other settings.

The PedNIHSS was drafted by a consensus panel of pediatric and adult stroke experts. Dr. Ichord and one of her associates in the study are on the clinical event committee for the Berlin Heart Trial for pediatric ventricular assist devices.

A pediatric stroke scale is 'absolutely needed and wanted right now by clinicians on the front line.'

Source DR. ICHORD

LOS ANGELES – For the first time, a pediatric stroke severity scale has been validated in a prospective clinical trial.

The study in 15 North American medical centers showed excellent interrater reliability when neurologists used a pediatric version of the National Institutes of Health Stroke Scale for adults to examine children aged 2–18 years with acute arterial ischemic stroke.

The neurologists used the Pediatric NIH Stroke Scale (PedNIHSS) on 113 patients examined daily from admission to discharge, or through day 7 of hospitalization. Interrater reliability was tested in a subset of 25 patients who were examined simultaneously by two pediatric neurologists. Characteristics of the subgroup were similar to those of the entire cohort, Dr. Rebecca N. Ichord reported.

The simultaneous raters' scores were identical in 60% of ratings and were within a 1-point difference in 84% of ratings (Stroke 2011;42:613–7).

Research into potential ways of preventing or treating childhood stroke has been stymied in the past by the lack of a validated and reliable pediatric stroke scale. The PedNIHSS provides a way to index the severity of a child's stroke, to make comparisons across treatment groups, and to get a baseline for predicting outcome, said Dr. Ichord, director of the pediatric stroke program at the Children's Hospital of Philadelphia.

Clinicians, too, have been hungering for such a scale. “I have been asked over and over again [for a pediatric stroke scale] by clinicians who want to have a method of describing the severity of a child's stroke,” she said at the meeting, which was sponsored by the American Heart Association. “It's absolutely needed and wanted right now by clinicians on the front line.”

Characteristics of the patients and the strokes in the study were similar to those reported in previous pediatric stroke cohort studies, which suggests the current findings are generalizable and the PedNIHSS should be applicable in other settings.

The PedNIHSS was drafted by a consensus panel of pediatric and adult stroke experts. Dr. Ichord and one of her associates in the study are on the clinical event committee for the Berlin Heart Trial for pediatric ventricular assist devices.

A pediatric stroke scale is 'absolutely needed and wanted right now by clinicians on the front line.'

Source DR. ICHORD

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one’s appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

Second, the person’s preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person’s functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it’s dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

People with this disorder commonly avoid other people and activities, including therapy appointments. "Often, the best outcome after an initial visit is to have the patient come back for another visit," she said.

In the first visit, it’s pointless to focus on a patient’s self-image. Focus instead on the patient’s suffering and dysfunction, and how these can be alleviated by treating the body dysmorphic disorder, though the time course for improvement is uncertain, Dr. Phillips advised. Try to find the fine line between "wanting to instill hope but not overpromising," she said.

At the first visit, always ask about suicidality, and develop a safety plan to help the patient cope if suicidal thoughts emerge.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one’s appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

Second, the person’s preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person’s functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it’s dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

People with this disorder commonly avoid other people and activities, including therapy appointments. "Often, the best outcome after an initial visit is to have the patient come back for another visit," she said.

In the first visit, it’s pointless to focus on a patient’s self-image. Focus instead on the patient’s suffering and dysfunction, and how these can be alleviated by treating the body dysmorphic disorder, though the time course for improvement is uncertain, Dr. Phillips advised. Try to find the fine line between "wanting to instill hope but not overpromising," she said.

At the first visit, always ask about suicidality, and develop a safety plan to help the patient cope if suicidal thoughts emerge.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one’s appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

Second, the person’s preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person’s functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it’s dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

People with this disorder commonly avoid other people and activities, including therapy appointments. "Often, the best outcome after an initial visit is to have the patient come back for another visit," she said.

In the first visit, it’s pointless to focus on a patient’s self-image. Focus instead on the patient’s suffering and dysfunction, and how these can be alleviated by treating the body dysmorphic disorder, though the time course for improvement is uncertain, Dr. Phillips advised. Try to find the fine line between "wanting to instill hope but not overpromising," she said.

At the first visit, always ask about suicidality, and develop a safety plan to help the patient cope if suicidal thoughts emerge.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one’s appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

Second, the person’s preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person’s functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it’s dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

People with this disorder commonly avoid other people and activities, including therapy appointments. "Often, the best outcome after an initial visit is to have the patient come back for another visit," she said.

In the first visit, it’s pointless to focus on a patient’s self-image. Focus instead on the patient’s suffering and dysfunction, and how these can be alleviated by treating the body dysmorphic disorder, though the time course for improvement is uncertain, Dr. Phillips advised. Try to find the fine line between "wanting to instill hope but not overpromising," she said.

At the first visit, always ask about suicidality, and develop a safety plan to help the patient cope if suicidal thoughts emerge.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one’s appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

Second, the person’s preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person’s functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it’s dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

People with this disorder commonly avoid other people and activities, including therapy appointments. "Often, the best outcome after an initial visit is to have the patient come back for another visit," she said.

In the first visit, it’s pointless to focus on a patient’s self-image. Focus instead on the patient’s suffering and dysfunction, and how these can be alleviated by treating the body dysmorphic disorder, though the time course for improvement is uncertain, Dr. Phillips advised. Try to find the fine line between "wanting to instill hope but not overpromising," she said.

At the first visit, always ask about suicidality, and develop a safety plan to help the patient cope if suicidal thoughts emerge.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one’s appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

Second, the person’s preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person’s functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it’s dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

People with this disorder commonly avoid other people and activities, including therapy appointments. "Often, the best outcome after an initial visit is to have the patient come back for another visit," she said.

In the first visit, it’s pointless to focus on a patient’s self-image. Focus instead on the patient’s suffering and dysfunction, and how these can be alleviated by treating the body dysmorphic disorder, though the time course for improvement is uncertain, Dr. Phillips advised. Try to find the fine line between "wanting to instill hope but not overpromising," she said.

At the first visit, always ask about suicidality, and develop a safety plan to help the patient cope if suicidal thoughts emerge.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one's appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

Second, the person's preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person's functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it's dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one's appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

Second, the person's preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person's functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it's dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one's appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

Second, the person's preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person's functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it's dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

As consumers buy up stocks of potassium iodide in stores, multiple physicians’ organizations and government health agencies issued statements advising U.S. residents not to take or hoard potassium iodide in response to radiation released from crippled Japanese nuclear power plants.

A joint statement from The Endocrine Society, the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Society of Nuclear Medicine emphasizes that potassium iodide (KI) should not be taken unless there is a clear risk of exposure to high levels of radioactive iodine. Ingesting pills or solution of KI (a stable salt of iodine) can potentially block uptake of radioactive iodine by the thyroid gland.

There is no radiation emergency in the United States at this time, the organizations emphasized. Current estimates suggest that the United States and its territories may be exposed to radiation amounts that are a little above baseline atmospheric levels at most and that by the time any radioactive particles are blown here, levels are unlikely to be harmful to the thyroid gland or general health, the statement said.

A powerful earthquake and tsunami on March 11 led to explosions at multiple nuclear reactors in northeast Japan and releases of some radioactive materials into the atmosphere. At press time, the crisis continued to evolve as workers there struggle to contain further radiation releases and stabilize the reactors.

The U.S. Environmental Protection Agency monitors for radioactivity through a network of stations, and the four medical organizations noted that they will continue to monitor the potential health risks from the Japanese power plants and will issue more advisories if warranted.

The statement pointed out that at the worst nuclear plant accident in history, at Chernobyl in 1986, people in nearby regions were exposed to radioactive iodine mainly from eating contaminated food and milk, not atmospheric exposure. The risk for thyroid cancer was highest in pregnant women, fetuses, infants, and children.

Dr. Kenneth A. Woeber, clinical chief of endocrinology at the University of California, San Francisco, said in an interview that he agrees with the organizations’ statement. He particularly worries about pregnant women in the United States taking KI unnecessarily, because it can cross the placenta and cause fetal goiter and hypothyroidism.

"I’ve had a lot of patients call me in a panic," he said. "One patient wanted me to write a prescription" for KI. "I told her, ‘No.’ "

Consumers have cleared stocks of KI from many stores and pharmacies, according to news accounts, especially panicked parents.

In addition, KI taken unnecessarily can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism, or hypothyroidism in a small percentage of people, the statement cautioned.

"People should not panic" and take KI, Dr. Woeber said. "The harm-to-benefit ratio is overwhelmingly in favor of harm" unless authorities declare a radiation emergency.

The Centers for Disease Control and Prevention (CDC) also advised against taking KI or iodine supplements in response to the power plant explosions in Japan on its Web site’s Emergency Preparedness and Response pages. The CDC added that KI does not protect other parts of the body from radioactive iodine, and does not protect the body from any radioactive elements other than iodine. No radioactive iodine has been detected so far in the United States or its territories, according to the CDC.

Both the CDC and the Food and Drug Administration (FDA) cautioned consumers especially to not take iodine supplements that have not been approved by the FDA, and to watch out for fake anti-radiation products such as dietary supplements, food items, or fraudulent drugs, devices, or vaccines. The FDA posted a Radiation Safety page at its Web site to offer information.

KI is prescribed to some patients in preparation for thyroid surgery because it makes the gland less vascular, thus making it easier for the surgeon to operate, Dr. Woeber said. KI also is used in rare instances of a patient presenting in thyroid storm. A shortage of KI supplies in stores shouldn’t be a problem, he said.

Dr. Woeber said he has no relevant conflicts of interest.

As consumers buy up stocks of potassium iodide in stores, multiple physicians’ organizations and government health agencies issued statements advising U.S. residents not to take or hoard potassium iodide in response to radiation released from crippled Japanese nuclear power plants.

A joint statement from The Endocrine Society, the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Society of Nuclear Medicine emphasizes that potassium iodide (KI) should not be taken unless there is a clear risk of exposure to high levels of radioactive iodine. Ingesting pills or solution of KI (a stable salt of iodine) can potentially block uptake of radioactive iodine by the thyroid gland.

There is no radiation emergency in the United States at this time, the organizations emphasized. Current estimates suggest that the United States and its territories may be exposed to radiation amounts that are a little above baseline atmospheric levels at most and that by the time any radioactive particles are blown here, levels are unlikely to be harmful to the thyroid gland or general health, the statement said.

A powerful earthquake and tsunami on March 11 led to explosions at multiple nuclear reactors in northeast Japan and releases of some radioactive materials into the atmosphere. At press time, the crisis continued to evolve as workers there struggle to contain further radiation releases and stabilize the reactors.

The U.S. Environmental Protection Agency monitors for radioactivity through a network of stations, and the four medical organizations noted that they will continue to monitor the potential health risks from the Japanese power plants and will issue more advisories if warranted.

The statement pointed out that at the worst nuclear plant accident in history, at Chernobyl in 1986, people in nearby regions were exposed to radioactive iodine mainly from eating contaminated food and milk, not atmospheric exposure. The risk for thyroid cancer was highest in pregnant women, fetuses, infants, and children.

Dr. Kenneth A. Woeber, clinical chief of endocrinology at the University of California, San Francisco, said in an interview that he agrees with the organizations’ statement. He particularly worries about pregnant women in the United States taking KI unnecessarily, because it can cross the placenta and cause fetal goiter and hypothyroidism.

"I’ve had a lot of patients call me in a panic," he said. "One patient wanted me to write a prescription" for KI. "I told her, ‘No.’ "

Consumers have cleared stocks of KI from many stores and pharmacies, according to news accounts, especially panicked parents.

In addition, KI taken unnecessarily can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism, or hypothyroidism in a small percentage of people, the statement cautioned.

"People should not panic" and take KI, Dr. Woeber said. "The harm-to-benefit ratio is overwhelmingly in favor of harm" unless authorities declare a radiation emergency.

The Centers for Disease Control and Prevention (CDC) also advised against taking KI or iodine supplements in response to the power plant explosions in Japan on its Web site’s Emergency Preparedness and Response pages. The CDC added that KI does not protect other parts of the body from radioactive iodine, and does not protect the body from any radioactive elements other than iodine. No radioactive iodine has been detected so far in the United States or its territories, according to the CDC.

Both the CDC and the Food and Drug Administration (FDA) cautioned consumers especially to not take iodine supplements that have not been approved by the FDA, and to watch out for fake anti-radiation products such as dietary supplements, food items, or fraudulent drugs, devices, or vaccines. The FDA posted a Radiation Safety page at its Web site to offer information.

KI is prescribed to some patients in preparation for thyroid surgery because it makes the gland less vascular, thus making it easier for the surgeon to operate, Dr. Woeber said. KI also is used in rare instances of a patient presenting in thyroid storm. A shortage of KI supplies in stores shouldn’t be a problem, he said.

Dr. Woeber said he has no relevant conflicts of interest.

As consumers buy up stocks of potassium iodide in stores, multiple physicians’ organizations and government health agencies issued statements advising U.S. residents not to take or hoard potassium iodide in response to radiation released from crippled Japanese nuclear power plants.

A joint statement from The Endocrine Society, the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Society of Nuclear Medicine emphasizes that potassium iodide (KI) should not be taken unless there is a clear risk of exposure to high levels of radioactive iodine. Ingesting pills or solution of KI (a stable salt of iodine) can potentially block uptake of radioactive iodine by the thyroid gland.

There is no radiation emergency in the United States at this time, the organizations emphasized. Current estimates suggest that the United States and its territories may be exposed to radiation amounts that are a little above baseline atmospheric levels at most and that by the time any radioactive particles are blown here, levels are unlikely to be harmful to the thyroid gland or general health, the statement said.

A powerful earthquake and tsunami on March 11 led to explosions at multiple nuclear reactors in northeast Japan and releases of some radioactive materials into the atmosphere. At press time, the crisis continued to evolve as workers there struggle to contain further radiation releases and stabilize the reactors.

The U.S. Environmental Protection Agency monitors for radioactivity through a network of stations, and the four medical organizations noted that they will continue to monitor the potential health risks from the Japanese power plants and will issue more advisories if warranted.

The statement pointed out that at the worst nuclear plant accident in history, at Chernobyl in 1986, people in nearby regions were exposed to radioactive iodine mainly from eating contaminated food and milk, not atmospheric exposure. The risk for thyroid cancer was highest in pregnant women, fetuses, infants, and children.

Dr. Kenneth A. Woeber, clinical chief of endocrinology at the University of California, San Francisco, said in an interview that he agrees with the organizations’ statement. He particularly worries about pregnant women in the United States taking KI unnecessarily, because it can cross the placenta and cause fetal goiter and hypothyroidism.

"I’ve had a lot of patients call me in a panic," he said. "One patient wanted me to write a prescription" for KI. "I told her, ‘No.’ "

Consumers have cleared stocks of KI from many stores and pharmacies, according to news accounts, especially panicked parents.

In addition, KI taken unnecessarily can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism, or hypothyroidism in a small percentage of people, the statement cautioned.

"People should not panic" and take KI, Dr. Woeber said. "The harm-to-benefit ratio is overwhelmingly in favor of harm" unless authorities declare a radiation emergency.

The Centers for Disease Control and Prevention (CDC) also advised against taking KI or iodine supplements in response to the power plant explosions in Japan on its Web site’s Emergency Preparedness and Response pages. The CDC added that KI does not protect other parts of the body from radioactive iodine, and does not protect the body from any radioactive elements other than iodine. No radioactive iodine has been detected so far in the United States or its territories, according to the CDC.

Both the CDC and the Food and Drug Administration (FDA) cautioned consumers especially to not take iodine supplements that have not been approved by the FDA, and to watch out for fake anti-radiation products such as dietary supplements, food items, or fraudulent drugs, devices, or vaccines. The FDA posted a Radiation Safety page at its Web site to offer information.

KI is prescribed to some patients in preparation for thyroid surgery because it makes the gland less vascular, thus making it easier for the surgeon to operate, Dr. Woeber said. KI also is used in rare instances of a patient presenting in thyroid storm. A shortage of KI supplies in stores shouldn’t be a problem, he said.

Dr. Woeber said he has no relevant conflicts of interest.

As consumers buy up stocks of potassium iodide in stores, multiple physicians’ organizations and government health agencies issued statements advising U.S. residents not to take or hoard potassium iodide in response to radiation released from crippled Japanese nuclear power plants.

A joint statement from The Endocrine Society, the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Society of Nuclear Medicine emphasizes that potassium iodide (KI) should not be taken unless there is a clear risk of exposure to high levels of radioactive iodine. Ingesting pills or solution of KI (a stable salt of iodine) can potentially block uptake of radioactive iodine by the thyroid gland.

There is no radiation emergency in the United States at this time, the organizations emphasized. Current estimates suggest that the United States and its territories may be exposed to radiation amounts that are a little above baseline atmospheric levels at most and that by the time any radioactive particles are blown here, levels are unlikely to be harmful to the thyroid gland or general health, the statement said.

A powerful earthquake and tsunami on March 11 led to explosions at multiple nuclear reactors in northeast Japan and releases of some radioactive materials into the atmosphere. At press time, the crisis continued to evolve as workers there struggle to contain further radiation releases and stabilize the reactors.

The U.S. Environmental Protection Agency monitors for radioactivity through a network of stations, and the four medical organizations noted that they will continue to monitor the potential health risks from the Japanese power plants and will issue more advisories if warranted.

The statement pointed out that at the worst nuclear plant accident in history, at Chernobyl in 1986, people in nearby regions were exposed to radioactive iodine mainly from eating contaminated food and milk, not atmospheric exposure. The risk for thyroid cancer was highest in pregnant women, fetuses, infants, and children.

Dr. Kenneth A. Woeber, clinical chief of endocrinology at the University of California, San Francisco, said in an interview that he agrees with the organizations’ statement. He particularly worries about pregnant women in the United States taking KI unnecessarily, because it can cross the placenta and cause fetal goiter and hypothyroidism.

"I’ve had a lot of patients call me in a panic," he said. "One patient wanted me to write a prescription" for KI. "I told her, ‘No.’ "

Consumers have cleared stocks of KI from many stores and pharmacies, according to news accounts, especially panicked parents.

In addition, KI taken unnecessarily can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism, or hypothyroidism in a small percentage of people, the statement cautioned.

"People should not panic" and take KI, Dr. Woeber said. "The harm-to-benefit ratio is overwhelmingly in favor of harm" unless authorities declare a radiation emergency.

The Centers for Disease Control and Prevention (CDC) also advised against taking KI or iodine supplements in response to the power plant explosions in Japan on its Web site’s Emergency Preparedness and Response pages. The CDC added that KI does not protect other parts of the body from radioactive iodine, and does not protect the body from any radioactive elements other than iodine. No radioactive iodine has been detected so far in the United States or its territories, according to the CDC.

Both the CDC and the Food and Drug Administration (FDA) cautioned consumers especially to not take iodine supplements that have not been approved by the FDA, and to watch out for fake anti-radiation products such as dietary supplements, food items, or fraudulent drugs, devices, or vaccines. The FDA posted a Radiation Safety page at its Web site to offer information.

KI is prescribed to some patients in preparation for thyroid surgery because it makes the gland less vascular, thus making it easier for the surgeon to operate, Dr. Woeber said. KI also is used in rare instances of a patient presenting in thyroid storm. A shortage of KI supplies in stores shouldn’t be a problem, he said.

Dr. Woeber said he has no relevant conflicts of interest.

As consumers buy up stocks of potassium iodide in stores, multiple physicians’ organizations and government health agencies issued statements advising U.S. residents not to take or hoard potassium iodide in response to radiation released from crippled Japanese nuclear power plants.

A joint statement from The Endocrine Society, the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Society of Nuclear Medicine emphasizes that potassium iodide (KI) should not be taken unless there is a clear risk of exposure to high levels of radioactive iodine. Ingesting pills or solution of KI (a stable salt of iodine) can potentially block uptake of radioactive iodine by the thyroid gland.

There is no radiation emergency in the United States at this time, the organizations emphasized. Current estimates suggest that the United States and its territories may be exposed to radiation amounts that are a little above baseline atmospheric levels at most and that by the time any radioactive particles are blown here, levels are unlikely to be harmful to the thyroid gland or general health, the statement said.

A powerful earthquake and tsunami on March 11 led to explosions at multiple nuclear reactors in northeast Japan and releases of some radioactive materials into the atmosphere. At press time, the crisis continued to evolve as workers there struggle to contain further radiation releases and stabilize the reactors.

The U.S. Environmental Protection Agency monitors for radioactivity through a network of stations, and the four medical organizations noted that they will continue to monitor the potential health risks from the Japanese power plants and will issue more advisories if warranted.

The statement pointed out that at the worst nuclear plant accident in history, at Chernobyl in 1986, people in nearby regions were exposed to radioactive iodine mainly from eating contaminated food and milk, not atmospheric exposure. The risk for thyroid cancer was highest in pregnant women, fetuses, infants, and children.

Dr. Kenneth A. Woeber, clinical chief of endocrinology at the University of California, San Francisco, said in an interview that he agrees with the organizations’ statement. He particularly worries about pregnant women in the United States taking KI unnecessarily, because it can cross the placenta and cause fetal goiter and hypothyroidism.

"I’ve had a lot of patients call me in a panic," he said. "One patient wanted me to write a prescription" for KI. "I told her, ‘No.’ "

Consumers have cleared stocks of KI from many stores and pharmacies, according to news accounts, especially panicked parents.

In addition, KI taken unnecessarily can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism, or hypothyroidism in a small percentage of people, the statement cautioned.

"People should not panic" and take KI, Dr. Woeber said. "The harm-to-benefit ratio is overwhelmingly in favor of harm" unless authorities declare a radiation emergency.

The Centers for Disease Control and Prevention (CDC) also advised against taking KI or iodine supplements in response to the power plant explosions in Japan on its Web site’s Emergency Preparedness and Response pages. The CDC added that KI does not protect other parts of the body from radioactive iodine, and does not protect the body from any radioactive elements other than iodine. No radioactive iodine has been detected so far in the United States or its territories, according to the CDC.

Both the CDC and the Food and Drug Administration (FDA) cautioned consumers especially to not take iodine supplements that have not been approved by the FDA, and to watch out for fake anti-radiation products such as dietary supplements, food items, or fraudulent drugs, devices, or vaccines. The FDA posted a Radiation Safety page at its Web site to offer information.

KI is prescribed to some patients in preparation for thyroid surgery because it makes the gland less vascular, thus making it easier for the surgeon to operate, Dr. Woeber said. KI also is used in rare instances of a patient presenting in thyroid storm. A shortage of KI supplies in stores shouldn’t be a problem, he said.

Dr. Woeber said he has no relevant conflicts of interest.

As consumers buy up stocks of potassium iodide in stores, multiple physicians’ organizations and government health agencies issued statements advising U.S. residents not to take or hoard potassium iodide in response to radiation released from crippled Japanese nuclear power plants.

A joint statement from The Endocrine Society, the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Society of Nuclear Medicine emphasizes that potassium iodide (KI) should not be taken unless there is a clear risk of exposure to high levels of radioactive iodine. Ingesting pills or solution of KI (a stable salt of iodine) can potentially block uptake of radioactive iodine by the thyroid gland.

There is no radiation emergency in the United States at this time, the organizations emphasized. Current estimates suggest that the United States and its territories may be exposed to radiation amounts that are a little above baseline atmospheric levels at most and that by the time any radioactive particles are blown here, levels are unlikely to be harmful to the thyroid gland or general health, the statement said.

A powerful earthquake and tsunami on March 11 led to explosions at multiple nuclear reactors in northeast Japan and releases of some radioactive materials into the atmosphere. At press time, the crisis continued to evolve as workers there struggle to contain further radiation releases and stabilize the reactors.

The U.S. Environmental Protection Agency monitors for radioactivity through a network of stations, and the four medical organizations noted that they will continue to monitor the potential health risks from the Japanese power plants and will issue more advisories if warranted.

The statement pointed out that at the worst nuclear plant accident in history, at Chernobyl in 1986, people in nearby regions were exposed to radioactive iodine mainly from eating contaminated food and milk, not atmospheric exposure. The risk for thyroid cancer was highest in pregnant women, fetuses, infants, and children.

Dr. Kenneth A. Woeber, clinical chief of endocrinology at the University of California, San Francisco, said in an interview that he agrees with the organizations’ statement. He particularly worries about pregnant women in the United States taking KI unnecessarily, because it can cross the placenta and cause fetal goiter and hypothyroidism.

"I’ve had a lot of patients call me in a panic," he said. "One patient wanted me to write a prescription" for KI. "I told her, ‘No.’ "

Consumers have cleared stocks of KI from many stores and pharmacies, according to news accounts, especially panicked parents.

In addition, KI taken unnecessarily can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism, or hypothyroidism in a small percentage of people, the statement cautioned.

"People should not panic" and take KI, Dr. Woeber said. "The harm-to-benefit ratio is overwhelmingly in favor of harm" unless authorities declare a radiation emergency.

The Centers for Disease Control and Prevention (CDC) also advised against taking KI or iodine supplements in response to the power plant explosions in Japan on its Web site’s Emergency Preparedness and Response pages. The CDC added that KI does not protect other parts of the body from radioactive iodine, and does not protect the body from any radioactive elements other than iodine. No radioactive iodine has been detected so far in the United States or its territories, according to the CDC.

Both the CDC and the Food and Drug Administration (FDA) cautioned consumers especially to not take iodine supplements that have not been approved by the FDA, and to watch out for fake anti-radiation products such as dietary supplements, food items, or fraudulent drugs, devices, or vaccines. The FDA posted a Radiation Safety page at its Web site to offer information.

KI is prescribed to some patients in preparation for thyroid surgery because it makes the gland less vascular, thus making it easier for the surgeon to operate, Dr. Woeber said. KI also is used in rare instances of a patient presenting in thyroid storm. A shortage of KI supplies in stores shouldn’t be a problem, he said.

Dr. Woeber said he has no relevant conflicts of interest.

SAN FRANCISCO – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

"For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients" with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) "can be useful," though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. "That’s emerging" and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are "nowhere near enough to fully support what these meta-analyses" suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. "The strongest impact was on decreased danger," he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. "I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder," he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

"I feel pretty passionately about this," Dr. Schulz said in an interview after the group discussion. "I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point."

Another problem is researchers’ preference in the past decade for enrolling "symptomatic volunteers" in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

"We have to look at some new methodology" to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. "Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview," he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

SAN FRANCISCO – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

"For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients" with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) "can be useful," though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. "That’s emerging" and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are "nowhere near enough to fully support what these meta-analyses" suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. "The strongest impact was on decreased danger," he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. "I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder," he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

"I feel pretty passionately about this," Dr. Schulz said in an interview after the group discussion. "I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point."

Another problem is researchers’ preference in the past decade for enrolling "symptomatic volunteers" in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

"We have to look at some new methodology" to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. "Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview," he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

SAN FRANCISCO – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

"For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients" with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) "can be useful," though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. "That’s emerging" and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are "nowhere near enough to fully support what these meta-analyses" suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. "The strongest impact was on decreased danger," he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. "I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder," he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

"I feel pretty passionately about this," Dr. Schulz said in an interview after the group discussion. "I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point."

Another problem is researchers’ preference in the past decade for enrolling "symptomatic volunteers" in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

"We have to look at some new methodology" to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. "Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview," he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

SAN FRANCISCO – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

"For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients" with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) "can be useful," though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. "That’s emerging" and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are "nowhere near enough to fully support what these meta-analyses" suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. "The strongest impact was on decreased danger," he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. "I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder," he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

"I feel pretty passionately about this," Dr. Schulz said in an interview after the group discussion. "I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point."

Another problem is researchers’ preference in the past decade for enrolling "symptomatic volunteers" in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

"We have to look at some new methodology" to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. "Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview," he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

SAN FRANCISCO – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

"For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients" with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) "can be useful," though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. "That’s emerging" and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are "nowhere near enough to fully support what these meta-analyses" suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. "The strongest impact was on decreased danger," he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. "I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder," he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

"I feel pretty passionately about this," Dr. Schulz said in an interview after the group discussion. "I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point."

Another problem is researchers’ preference in the past decade for enrolling "symptomatic volunteers" in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

"We have to look at some new methodology" to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. "Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview," he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

SAN FRANCISCO – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

"For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients" with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) "can be useful," though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. "That’s emerging" and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are "nowhere near enough to fully support what these meta-analyses" suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. "The strongest impact was on decreased danger," he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. "I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder," he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

"I feel pretty passionately about this," Dr. Schulz said in an interview after the group discussion. "I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point."

Another problem is researchers’ preference in the past decade for enrolling "symptomatic volunteers" in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

"We have to look at some new methodology" to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. "Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview," he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.

"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.

Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.

Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.

While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.

"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.

In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.

"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.

Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."

Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.

Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.

Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.

A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.

Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.

Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.

"I’m a child psychiatrist. We tend to have a lot of folks involved in the care of any individual patient. The efficiency with which we’re able as a treatment team to stay in touch with each other is much enhanced by the use of e-mail," she said.

She said she asks adolescent patients to show her their Facebook sites as part of the therapeutic session, or talk about what might be found if someone searched online for the patient’s name.

In many ways, boundary issues raised by e-mail are similar to boundary issues related to use of the telephone; they’re just in a different form, several participants noted. Psychiatrists have little control over Internet searches and the information they turn up, except for setting search engine alerts to be notified whenever their name is mentioned and perhaps hiring a company to scour erroneous information from the Web.

It’s the use of social networking sites like Facebook, LinkedIn, and others that seems to create the greatest ambiguity, some said. One doctor noted that even if you set the highest privacy settings and refuse to "friend" patients on Facebook, nonfriends can "see" you in other ways. "I have to caution family members about posting photos" that include him, he said.

New curricula are available from the American Association of Directors of Psychiatry Residency Training to inform trainees about the ramifications of electronic and social media.

One participant summed it up by saying, "We have to accept that this is the digital age."

Dr. Gray, Dr. Gabbard, and Dr. DeJong said they have no relevant financial disclosures. Dr. DeJong is a paid contributor to a nonprofit website, Children’s Emotional Health Link.

SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.

"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.

Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.

Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.

While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.

"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.

In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.

"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.

Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."

Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.

Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.

Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.

A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.

Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.

Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.

"I’m a child psychiatrist. We tend to have a lot of folks involved in the care of any individual patient. The efficiency with which we’re able as a treatment team to stay in touch with each other is much enhanced by the use of e-mail," she said.

She said she asks adolescent patients to show her their Facebook sites as part of the therapeutic session, or talk about what might be found if someone searched online for the patient’s name.

In many ways, boundary issues raised by e-mail are similar to boundary issues related to use of the telephone; they’re just in a different form, several participants noted. Psychiatrists have little control over Internet searches and the information they turn up, except for setting search engine alerts to be notified whenever their name is mentioned and perhaps hiring a company to scour erroneous information from the Web.

It’s the use of social networking sites like Facebook, LinkedIn, and others that seems to create the greatest ambiguity, some said. One doctor noted that even if you set the highest privacy settings and refuse to "friend" patients on Facebook, nonfriends can "see" you in other ways. "I have to caution family members about posting photos" that include him, he said.

New curricula are available from the American Association of Directors of Psychiatry Residency Training to inform trainees about the ramifications of electronic and social media.

One participant summed it up by saying, "We have to accept that this is the digital age."

Dr. Gray, Dr. Gabbard, and Dr. DeJong said they have no relevant financial disclosures. Dr. DeJong is a paid contributor to a nonprofit website, Children’s Emotional Health Link.

SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.

"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.

Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.

Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.

While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.

"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.

In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.

"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.

Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."

Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.

Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.

Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.

A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.

Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.

Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.

"I’m a child psychiatrist. We tend to have a lot of folks involved in the care of any individual patient. The efficiency with which we’re able as a treatment team to stay in touch with each other is much enhanced by the use of e-mail," she said.

She said she asks adolescent patients to show her their Facebook sites as part of the therapeutic session, or talk about what might be found if someone searched online for the patient’s name.

In many ways, boundary issues raised by e-mail are similar to boundary issues related to use of the telephone; they’re just in a different form, several participants noted. Psychiatrists have little control over Internet searches and the information they turn up, except for setting search engine alerts to be notified whenever their name is mentioned and perhaps hiring a company to scour erroneous information from the Web.

It’s the use of social networking sites like Facebook, LinkedIn, and others that seems to create the greatest ambiguity, some said. One doctor noted that even if you set the highest privacy settings and refuse to "friend" patients on Facebook, nonfriends can "see" you in other ways. "I have to caution family members about posting photos" that include him, he said.

New curricula are available from the American Association of Directors of Psychiatry Residency Training to inform trainees about the ramifications of electronic and social media.

One participant summed it up by saying, "We have to accept that this is the digital age."

Dr. Gray, Dr. Gabbard, and Dr. DeJong said they have no relevant financial disclosures. Dr. DeJong is a paid contributor to a nonprofit website, Children’s Emotional Health Link.

SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.

"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.

Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.

Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.

While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.

"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.

In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.

"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.

Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."

Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.

Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.

Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.

A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.

Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.

Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.

"I’m a child psychiatrist. We tend to have a lot of folks involved in the care of any individual patient. The efficiency with which we’re able as a treatment team to stay in touch with each other is much enhanced by the use of e-mail," she said.

She said she asks adolescent patients to show her their Facebook sites as part of the therapeutic session, or talk about what might be found if someone searched online for the patient’s name.

In many ways, boundary issues raised by e-mail are similar to boundary issues related to use of the telephone; they’re just in a different form, several participants noted. Psychiatrists have little control over Internet searches and the information they turn up, except for setting search engine alerts to be notified whenever their name is mentioned and perhaps hiring a company to scour erroneous information from the Web.

It’s the use of social networking sites like Facebook, LinkedIn, and others that seems to create the greatest ambiguity, some said. One doctor noted that even if you set the highest privacy settings and refuse to "friend" patients on Facebook, nonfriends can "see" you in other ways. "I have to caution family members about posting photos" that include him, he said.

New curricula are available from the American Association of Directors of Psychiatry Residency Training to inform trainees about the ramifications of electronic and social media.

One participant summed it up by saying, "We have to accept that this is the digital age."

Dr. Gray, Dr. Gabbard, and Dr. DeJong said they have no relevant financial disclosures. Dr. DeJong is a paid contributor to a nonprofit website, Children’s Emotional Health Link.

SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.

"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.

Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.

Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.

While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.

"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.

In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.

"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.

Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."

Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.

Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.

Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.

A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.

Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.

Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.

"I’m a child psychiatrist. We tend to have a lot of folks involved in the care of any individual patient. The efficiency with which we’re able as a treatment team to stay in touch with each other is much enhanced by the use of e-mail," she said.

She said she asks adolescent patients to show her their Facebook sites as part of the therapeutic session, or talk about what might be found if someone searched online for the patient’s name.

In many ways, boundary issues raised by e-mail are similar to boundary issues related to use of the telephone; they’re just in a different form, several participants noted. Psychiatrists have little control over Internet searches and the information they turn up, except for setting search engine alerts to be notified whenever their name is mentioned and perhaps hiring a company to scour erroneous information from the Web.

It’s the use of social networking sites like Facebook, LinkedIn, and others that seems to create the greatest ambiguity, some said. One doctor noted that even if you set the highest privacy settings and refuse to "friend" patients on Facebook, nonfriends can "see" you in other ways. "I have to caution family members about posting photos" that include him, he said.

New curricula are available from the American Association of Directors of Psychiatry Residency Training to inform trainees about the ramifications of electronic and social media.

One participant summed it up by saying, "We have to accept that this is the digital age."

Dr. Gray, Dr. Gabbard, and Dr. DeJong said they have no relevant financial disclosures. Dr. DeJong is a paid contributor to a nonprofit website, Children’s Emotional Health Link.

SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.

"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.

Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.

Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.

While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.

"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.

In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.

"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.

Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."

Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.

Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.

Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.

A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.

Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.

Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.

"I’m a child psychiatrist. We tend to have a lot of folks involved in the care of any individual patient. The efficiency with which we’re able as a treatment team to stay in touch with each other is much enhanced by the use of e-mail," she said.

She said she asks adolescent patients to show her their Facebook sites as part of the therapeutic session, or talk about what might be found if someone searched online for the patient’s name.

In many ways, boundary issues raised by e-mail are similar to boundary issues related to use of the telephone; they’re just in a different form, several participants noted. Psychiatrists have little control over Internet searches and the information they turn up, except for setting search engine alerts to be notified whenever their name is mentioned and perhaps hiring a company to scour erroneous information from the Web.

It’s the use of social networking sites like Facebook, LinkedIn, and others that seems to create the greatest ambiguity, some said. One doctor noted that even if you set the highest privacy settings and refuse to "friend" patients on Facebook, nonfriends can "see" you in other ways. "I have to caution family members about posting photos" that include him, he said.

New curricula are available from the American Association of Directors of Psychiatry Residency Training to inform trainees about the ramifications of electronic and social media.

One participant summed it up by saying, "We have to accept that this is the digital age."

Dr. Gray, Dr. Gabbard, and Dr. DeJong said they have no relevant financial disclosures. Dr. DeJong is a paid contributor to a nonprofit website, Children’s Emotional Health Link.