Category: Patient

Simply, a placebo can be described as an inert substance which has no medically proven healing ability or positive physiological effect yet can improve the receivers symptoms of a condition. However, the definition of a placebo has become murky in recent times as we are becoming more aware of other aspects of healthcare which seem to contribute to the overall placebo effect.

Traditionally, the placebo effect was regarded as the positive effects experienced by a patient after receiving a placebo, which they believed to be an active drug. We now have wider understanding into healthcare psychology and the study/use of the placebo effect has become far more advanced to that of Henry Beechers. Studies today not only look at the deceptive power of the placebo but look more so towards how patient-practitioner engagement, healthcare set ups, treatment protocols, past experiences, culture, expectation, desire, optimism, trust and even how treatment delivery and communication can improve symptom relief in patients.

Some individuals can experience placebo effect without receiving a drug, injection, or procedure. Some may just simply feel better from visiting a practitioner or doing something they believe will help, like living a healthier lifestyle. However, this type of placebo effect seems most related to the degree of confidence and faith the patient has in the practitioner/treatment.

The most common way to test the effectiveness of a placebo is using a double-blind controlled study, where neither the individuals taking part in the study or doctors know who’s receiving which treatment. This helps avoid biases in measuring outcomes that can be caused by the researchers or the patients’ expectations about the treatment. This is not as big a problem in studies of cancer treatment, where objective outcome measures are most often used. It’s more likely in studies that require patient reporting for symptoms like depression, sleeplessness, or pain.

As placebos often have an effect, even if the effect doesn’t last long, some people think that the placebo produced a cure. However, we know that placebos do not cure, at least not cancer. And in studies looking at whether a tumor shrinks, placebos have very little effect, if any, on reducing tumor growth. Still, physical placebos clearly can help reduce certain symptoms such as pain, anxiety, and trouble sleeping. There is a theory that a placebo may help the brain remember a time before the symptoms and bring about certain chemical changes – A theory named remembered wellness.

It is imperative to consider the importance that cultural differences may have in the clinical setting, particularly in the identification of signs and cues within the patient–practitioner interaction, Although this adds a degree of complexity to the practitioner who is part of the bi-cultural patient–practitioner relationship.

Patients who already have some faith in a particular method are more likely to sign up for a study about that method. For example, people who have faith in their doctors methods are more likely to sign up for a study on medical treatment. Individuals who believe that meditation works are likely to volunteer for a study investigating meditation impacts. Likewise, those who don’t believe in a certain procedure probably won’t sign up to test it. This means that the group who volunteers for the study already has some expectation effect before the study starts. Many who take part will likely report at least a brief improvement in symptoms with the treatment, or even with a placebo, because they expect to be helped by the treatment. One particular study found that reward expectation accounted for 28% of the variance in the formation of placebo analgesia.

Many people feel better after they get medical treatments that they expect to work. The opposite can also happen, and this seems to support the idea of the expectation effect even more. For example, in one study, people with Alzheimer disease got less relief from pain medicines. These patients required higher doses – possibly because they had forgotten they were being administered the drugs, or they forgot that the pain medicines had worked for them before. This suggests that past experiences also play into the placebo effect and support the theory of remembered wellness mentioned earlier.

There has been numerous studies which have shown a direct correlation between an individuals belief and physiological change. According to one study of 84 hotel maids, those who were told that they meet sufficient exercise levels solely through their work showed a decrease in weight, blood pressure, body fat, waist-to-hip ratio, and body mass index. Perhaps if cancer patients focus more on the positive aspects and habits of their lifestyle which are conducive to improved health, they could experience better and faster recoveries.

In one study using the drug maxalt, different labelling of placebos and the actual drug found that by simply labelling the true drug container with “maxalt” symptoms significantly decreased as compared to a true drug container labelled “placebo”. If one word can have this much of an impact on patient belief in a drug, the effectiveness of a treatment plan could be massively increased by the way the radiation therapist communicates with the patient. If a practitioner personally believes in a treatment and communicates that the treatment will likely work – patients will be more likely to see an improvement.

Creating a positive doctor–patient relationship can help decrease the quantity of medication used, and therefore, experienced side effects. A recent review found that there is substantial evidence that positive therapeutic relationships between patients and practitioners are correlated with improvements in quality of life, anxiety and depression levels, as well as patient satisfaction and treatment adherence. Interactions that hold a business-like character and that create doubt and uncertainty around the practitioner’s skills and competencies could lead to nocebo effects or to a reduction of placebo effects.

Identifying patient mindsets may serve as an efficient way for evaluating a patient’s stance on different aspects of the clinical interaction and setting, including previous experiences and expectations regarding treatment plans and other outcomes. In addition to the practitioner’s expression of certain psychosocial characteristics within their role, other actions can be taken to enhance the placebo and prevent the placebo effect. For instance, a practitioner could avoid over-emphasising negative information regarding a treatment by balancing it with information about the positive effects in a truthful and ethical manner that preserves the right of patients to make decisions about their medical care without their health care provider trying to influence the decision – otherwise known as patient autonomy. Therefore, a radiation therapist should always have a positive and optimistic outlook when delivering information but should never try to deceive a patient. Information regarding treatments, success rates and possible issues should be presented in a truthful way but remain focussed on the positives. The first and last points discussed should not be negative.

Preventing interactions that are uncaring, judgmental and insensitive, which send a message of invalidation and lack of warmth, while at the same time creating a safe and positive environment for patients to begin internalising their own process of healing, can prevent the nocebo effect while promoting the activation of placebo effects.

Perhaps the largest benefit of the placebo effect for radiation therapy patients lies in the reduction of health risk factors which can reduce treatment effectiveness. Many studies have shown how negative lifestyle aspects can increase our health risks. However, there are less obvious lifestyle habits which could reduce treatment efficacy besides obesity, high blood sugar, alcohol consumption, smoking, CHD, stress, or poor diet. For example, in June of this year late night shift work was listed as a possible carcinogen. Perhaps a simple suggestion to change shift work may help with treatment success rates. Other studies have shown how losing just one hour of sleep through daylight savings time can increase our risk of heart attack by 24%, which shows just how important sleep is for our health and reducing illness. By using existing knowledge on the importance of diet, sleep, exercise, stress management etc radiation therapists could greatly increase patients overall health and the bodies ability to fight against cancer.

Conclusion

The placebo effect is more than just the effect that the administration of an inert substance, or “sugar pills” deceptively to a patient. It is a way in which we can quantify and measure everything that surrounds pills and procedures. Rituals, words,engagement, beliefs, diplomas, clothing, and anticipation of improvement are all aspects of the wider placebo effect when patients visit a healthcare practitioner. In radiation therapy, the placebo effect is more about how we can create a healthcare environment that can help alleviate patient symptoms, stress, anxiety and worries without the use of pharmaceuticals or treatments. By creating a favourable environment, the placebo effect can be increased and used to the advantage of patients as an aid to reduce health risk behaviours associated with negative impacts on treatment outcomes.

The placebo effect studies discussed above show how the effects of mindset, perception, and outlook of both the patient and practitioner can largely determine health improvement. Furthermore, the placebo effect shows us that sometimes the best way to fix what’s wrong with our health is by focusing on what’s right with our health. I still think that no matter how hard practitioners attempt to improve a patients outcome, ultimately it is the individuals choice to adopt a healthier lifestyle and believe in their treatment. When it comes to health, there is often not much choice involved, but fortunately this is an aspect of healthcare which the practitioner can play a pivotal role.

References

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When a patient is admitted to the hospital the issue to tackle is not necessarily only the immediate course of evaluation and treatment, but to also address what lies ahead of the initial admittance. The lack of follow-up care post hospital discharge is a matter of contention within the United States healthcare system and a direct causation of high readmittance rates (Jackson et al., 2015). Post hospital discharge, patients often encounter issues amidst recovery that cause them to be readmitted to the hospital. Statistically speaking, one in five patients with an initial admittance to a hospital make a repeat visit and around 30% of revisits are made over the course of a month (Van Walraven et al., 2004). Additionally, one-half of patients readmitted within 30 days of hospital discharge do not have nor have had follow-up care before their readmission to the hospital (Jackson et al., 2015).

Hospital readmissions are costly and increasingly common and the issues that patients encounter post discharge in most cases can be properly evaluated and minimized by an office visit to a primary care provider or by a follow up from the emergency room (ER) physician. High readmission rates has significant costs for both hospitals and the patients and continuity of care and mandated clinical follow up care are keys to preventing and narrowing unnecessary hospital readmissions in addition to improving the continuity and excellence of care each patient receives. Hospital readmissions are associated with unfavorable patient outcome however, it can also affect the financial health of the hospitals and the insurance companies. The Medicare beneficiaries which include the elderly have high rates of hospital readmissions and have the highest hospital spending on readmissions (Andreasen et al., 2015). Hospital readmissions cost Medicare $26 billion annually and about $17 billion is spent on preventable readmissions. These high costs can be easily avoided by a follow up from the ER physician or the primary care provider. However, the lack of follow up in the US health care system is due to lack of clarity on who is responsible for the follow up and there is no actual guideline for doctors to abide by in regards to follow up (Callen et al., 2015).

Lack of follow up can have major consequences for the quality of care and can have suboptimal patient outcomes. Patients do not have the adequate knowledge about their health and self-care. After hospital discharge, patients tend to fail to follow up and lack to adhere to post discharge instructions which subsequently leads to poor health outcomes and readmission. Many patients do not have a follow up appointment after discharge and have the confusion that whether the primary care provider or the ER physician is in charge for their follow up care. Another factor that leads to patients’ lack of follow up is not scheduling an appointment due to the patients’ limited knowledge about their health and many perceive returning to emergency department as an easier and more efficient way. There are also many barriers that are associated with patients’ lack of follow up and keeping their appointment. These barriers include transportations issues, lack of health insurance, commitment to work, not being able to get an appointment and co-payments (Misky et al., 2010). Due to patients’ limited knowledge about their health and the importance of follow up, the physicians and hospitals should be responsible to implement follow up care with the patients.

Hospitals and doctors ethically and professionally are devoted to provide the best care for the patients. However, they do not have any form of incentive to reduce readmission and consequently reduction in readmissions might cost them and lead to loss of revenue (revenue loss). Hospitals receive payments from insurances through inpatient prospective payment system, in which they receive a fixed payment per inpatient admission and diagnosis (James, 2013). Additionally, hospitals do not receive any reimbursements from the insurances for the costs of post-discharge follow up and interventions. Therefore, hospitals do not have any form of financial incentive to implement strategies to reduce the hospital readmissions. Moreover, the ER physicians do not have any form of obligation to follow up with the patients after discharge.

According to a survey conducted by myself, Ramina Bagheri, the results suggested that out of 25 individuals, 72% (18 out of 25) of the participants never received a follow up care after the discharge, but rather only received a recommendation from the ER physician to follow up with other primary care providers. Further questions from the survey provided insight that 44% (11 out of 25) individuals returned into ER after their initial visit.

The transition from inpatient to outpatient is a critical in stage of recovery and primary care providers play a significant role during this period. In emergency departments, patients are often treated by a physician other than their regular primary care provider and after their initial visit patients tend to lack timely follow up with their primary care provider. Without a consult with their primary care provider this can result in recurrent admissions to the hospital. According to a study done in 2010, the results showed that about 33% of the patients did not abide by the ER physician’s recommendations to follow up with their primary care provider (Misky, 2010).

Another issue that arises within healthcare and is linked to lack of follow up care is the lack of continuity and coordination of care between ER physicians and primary care providers. Poor transfer of information and delayed communication between the hospital physician and the primary doctor is prominent in the United States Healthcare system (Mageean, 1998). These limitations makes it difficult for the primary care provider to find access to patient’s records and information’s which can lead to misdiagnosis. Without sufficient communication between the initial ER physician and the primary care provider, illnesses are left to progressed and individuals are not fully treated for the medical condition they presented to the emergency department.

Reducing hospital readmissions is a current priority for the health care system in the United States, however, reducing hospital readmissions are complex and not straightforward. New interventions by both the policy makers and the hospitals are needed to tackle this issue and to reduce the costs and to improve the quality of care received by the patients. Policy makers should implement a new policy that imposes a financial penalty on hospitals with high rates of readmissions. Implementation of this policy, allows hospitals to employ new and clever strategies to reduce the preventable hospital readmissions and to provide a better care for the patient.

A study done by the Yale University, offers some strategies and suggestions that hospitals can employ to reduce the readmission rates. These strategies include “partnering with community physicians, partnering with local hospitals, having nurses reconcile medications, arranging follow-up appointments prior to discharge, sending discharge papers to patients’ primary care provider and assigning staff to follow up on test results after discharge” (Bradley et al., 2012). These strategies are relatively inexpensive and simple however they need greater collaboration from other parties as well.

According to Dr. Emily Rose, Emergency medicine doctor and chief resident at Los Angeles County/USC medical center, team approach and holistic care is the most effective way and much more is needed to implement which is beyond the hospitals boundaries. She also added that the focus of healthcare has never been on educating the patients and there are many factors that affect the patients well-being which are often overlooked. Interventions such as targeting health education, accessibility to resources, reducing barriers and educating about the consequences of the lack of follow up (Gust et al., 2011). These strategies are important to empower the patients to have responsibility for their care and are needed to improve adherence to follow up.

There are many modifiable factors that are associated with poor outcomes that keeps surfacing when the care is handed from the ER physician to the primary care provider. Coordination of care is one significant factor which can improve the quality of patient care. Direct coordination and management of care after discharge can improve continuity of care and information. To implement coordination of care, hospitals should immediately send the patient information and diagnosis to their primary care provider after discharge and require patients to make a follow up appointment with their primary care provider. However, the issue that arises is that patients tend to miss their follow up apportionments and statistically speaking only half of the patients show up to their follow-up appointment (Breathett et al., 2017). To mitigate this issue, hospitals and primary care providers should work as a team to reduce the barriers to follow up for the patients and by offering new strategies for follow up. These new strategies include, offering appointment at patient’s home, videocall appointments, telemedicine and providing transportation. Prioritization of follow up care after hospital discharge among hospitals and primary care providers is necessary.

There are many ways to tackle this multifaceted issue within the health care system, which not only include work done by ER physicians and primary care providers but insurance companies should be included as well. Insurance companies should have the authority to require essential follow up care appointments with the primary care provider post hospital discharge by mandating follow up appointments. Mandatory follow up appointments can impact the high readmittance rates significantly and can improve the quality of care received by the patient. Mandatory follow up appointments would be necessary in orders for insurance companies to insure and cover the costs of initial hospital visit. Criteria in regards to post discharge follow up appointment should be based on patients status and needs. The “one-size-fits-all” discharge protocol that is currently being implemented in the healthcare system should be removed and follow up should be based on patient’s needs and condition. However, mandated follow up appointment arises logistical issues concerning uninsured patients and their ability, or inability to access a primary care provider for follow-up care would undoubtedly arise (Jackson et al., 2015). Accordingly, the responsibility would then fall on the hospital itself to help such patients secure needed follow-up care. If patients are required to schedule follow-up appointments with a primary care provider concerning the reason(s) for their initial admittance and to follow-up on treatment progress, the number of hospital readmittances would greatly reduce in number. This reduction in remittances would be combined with increasingly efficient and thorough medical care and treatment.

Currently, some hospitals have initiated financial incentives for physicians to see patients within seven days of discharge, such as bonus payments and billing at the highest evaluation (Jackson et al., 2015). Such programs have garnered a great deal of success, but these incentives primarily lie on the physician and have little to do with the patient. If these already implemented financial incentives were coupled with mandated follow-up appointments required by insurance companies before payment and coverage is dispersed, there is a real possibility to improve lacking follow-up care and decrease correlated hospital readmittance rates.

Lack of follow up is an important issue that significantly affects the patient, the physicians and the hospitals. New strategies and interventions are required to tackle this issue and to reduce the high readmittance rates. New policies such as enforcing penalties on hospitals, improvement of continuity of care, and mandated follow up care can significantly lower the readmittance rates. However, regardless of enforcement of these new policies there will be inevitable readmittances to hospitals but the overall goal is to lower the rate of admittances, as the total elimination of them is circumstantially impossible. There will continue to be readmittances to hospitals post discharge, but the number would be significantly lower with optimal and mandated follow-up care. Having continuity of care and timely outpatient follow-up is a key component in not only successfully reducing high readmission rates post hospital discharge, but improving the commitment to and quality of care every member of society needs and merits.

Introduction

Assessing and treating patients who have been diagnosed with psychosis and schizophrenia often creates a challenge to the PMHNP, as one has to choose the most appropriate treatment approach that would not cause any harm to the patient. This study involves managing a 34-year-old Pakistani female who had earlier been diagnosed with psychotic disorder, based on her symptoms, but was later discovered that she had paranoid schizophrenia. Patients with schizophrenia usually experience debilitating social, as well as occupational challenges, but with proper treatment, most patients are able to function effectively. Antipsychotic therapy is considered as the cornerstone of managing patients with schizophrenia (Mustafa et al., 2019). The following is an explanation of three decisions that seemed to be the most appropriate for managing the client with paranoid schizophrenia.

The most effective way of managing the patient with paranoid schizophrenia was to begin with an injection of Invega Sustenna 234 mg, which was followed by another injection of 156 mg on the fourth day. Additionally, the injection of 156 mg should be done after every month. According to Stahl (2014), Invega Sustenna (paliperidone) belongs to a category of atypical antipsychotic drugs, which are normally prescribed for patient with schizophrenia and other psychotic disorders. However, I had an option of choosing Zyprexa 10 mg, which would be administered orally at bedtime, but Zyprexa is known for causing weight gain, which the patient was trying to avoid. Additionally, Abilify (aripiprazole) is also known to cause weight gain among some patients (Mustafa et al., 2019). My decision was guided by the idea that paliperidone has a few side effects, and offers instant relief to some symptoms of schizophrenia.

My expectations were that choosing Invega Sustenna would assist in eliminating positive symptoms, in addition to improving negative symptoms. Invega Sustenna is likely to demonstrate positive response to about 15% of patients with schizophrenia, who can experience a reduction of up to 60% of symptoms (Stahl, 2014). However, the results did not meet my expectations, as the client only experienced a decline of about 25% in PANSS score after four weeks and also gained 2 pounds in terms of weight. Some of the positive gains were that the client was tolerating to medication and was able to return for the monthly injection.

The second decision was to continue with the same medication at the same dosage, but I requested the administering nurse to shift the injection site to the deltoid during the second visit and subsequent visits. This decision was reached after the client’s complaint of pain when siting after the injection. Basically, Invega Sustenna starts to react after 4 to 6 weeks, thus, one can determine the efficacy of the drug after this period (Stahl, 2014). Besides, long-acting injectable antipsychotic therapy offers therapeutic plasma concentrations for weeks to months, which eliminates the need to have daily oral treatment administration (Bossie et al., 2017).

The expectations at this stage were that symptoms would reduce to about 50% and that the client would not complain of weight gain. The reasons why first-line antipsychotic drugs are preferred to the second-generation antipsychotics is because the latter causes weight gain and lipid abnormalities while their effects cannot be controlled through dosage (Holder, 2014). The results at this stage met my expectations, as the client reported 50% reduction of symptoms since he began taking Invega sustenna. Although most patients do not experience a total remission in terms of symptoms, they usually record a reduction of about a third of the symptoms (Stahl, 2014). The only challenge the client was facing after the second decision was gaining of weight, which could be dealt with through exercise and diet.

A major issue with the first and the second decisions is that the client has been gaining weight, which was affecting him psychologically. Hence, the third decision was to continue with the injection of Invega sustenna, in addition to convincing the client that gaining weight through using Invega sustenna was insignificant as compared to other antipsychotic medications. To ease the pressure of explaining on the use of Invega sustenna, I made an appointment with a dietician, as well as an exercise physiologist. According to Stanton et al. (2015), physical exercise may assist patients with psychosis and schizophrenia to reduce cardiometabolic symptoms while having proper diet helps in maintaining acceptable weight.

The expectations after making a connection with a physiologist and a dietician was to ensure that the client does not gain too much weight, which could lead to cardiovascular disorders. Understanding the client’s personal and family history is essential before administering atypical antipsychotics to avoid making him worse, as individuals with hypertension, obesity, dyslipidemia, and cardiovascular disease should be evaluated first before they receive such medication (Stahl, 2014).

The results meet my expectations because the client was able to respond effectively to Invega sustenna before the recommended 6 months were over, thus, there was no need for augmenting or switching to other antipsychotic drugs. While Abilify Maintena (aripiprazole) is a suitable option for individuals who respond well to abilify oral, it does not bind well to D2 receptor as Invega sustenna does; hence, it can only benefit certain individuals. Additionally, akathisia and weight gain are some of the adverse effects of Abilify Maintena (Lenze et al., 2015). Although Qsymia is known for managing weight, it is only appropriate for individuals with obesity.

Ethical Considerations on Treatment Plans and Communication with the Client

Treating clients with schizophrenia should be guided by ethics to avoid harming them through ineffective medications. Consequently, understanding the patient’s family and medical history is the first step towards effective diagnosis and treatment of clients with psychosis and schizophrenia. PMHNPs should ensure that they have chosen appropriate antipsychotic medications, based on their clients’ preferences. Most patients are unable to tolerate antipsychotic drugs, thus, the PMHNP should strive to convince patients to take the medications in order to improve their lives (Morrison, Meehan & Stomski, 2015). The PMHNP should demonstrate communicate with the client whenever there is a need to switch to a new medication. Additionally, any adverse effect coming from the new medication should be considered while patients should be informed of the risk of relapse in case medical therapy is discontinued after one or two years (Holder, 2014). Morrison, Meehan and Stomski (2015) encourage PMHNPs to understand how patients experience medication side effects so that they can assist them to manage adverse effects.

Conclusion

Although schizophrenia does not have a cure for now, it can be managed effectively using appropriate atypical antipsychotic medications. Patients who undergo both medical and psychosocial therapies tend to have better outcomes than those who receive medical therapy alone. However, ethics should be considered when developing treatment plans for schizophrenia, since adverse effects resulting from antipsychotic medications may be costly and painful to the patients, as well as family members.

We’ve all had that feeling some days. That feeling that, no matter what your friends and family will tell you, you look wrong. It might be the way your hair is flipping, or perhaps how your nose is turned up a little too much, or maybe just your physique. It is always unpleasant, but usually goes away within a few minutes or so, maybe an hour at most, and you go about your day. This disorder is not that. The DSM V “Characterizes BDD as a preoccupation with a perceived defect or markedly excessive concern where there is a slight physical anomaly, with associate significant distress and/or functional impairments” (Singh & Veale, 2019, p. S132). Body Dysmorphia is when an individual will hyper-focus on one or more aspects of their physical appearance for long periods of time, consuming sometimes hours trying to hide or fix the defect, convinced that they are horrendously ugly and deformed. These perceived defects can cause a great deal of social anxiety, to the point where, Liane, a patient seeking help for her BDD (Body Dysmorphic Disorder) reported spending 90% of her energy and attention on her appearance in social situations, and was somewhat shocked to find that wasn’t average. The therapist assured this patient that the reverse was very nearly true with people focusing 80% to 90% of their attention on the outside world and only 10% to 20% on their appearance (Waldron & Parker 2018). People with this disorder also have a very hard time getting treatment, either due to shame over their behavior, or misconceptions that what they see is what others see, and they are just abnormally ugly, rather than the possessors of a dangerous mental illness.

Body dysmorphia hasn’t always been known as such, though it has probably existed in one form or another since humans first noticed their reflections. It was first recognized nearly 130 years ago by an Italian psychologist. In 1891, Enrico Morelli used the term “dysmorphophobia”, characterizing it as more of a fear than a disorder. He took the term Dysmorphia from a myth about the ‘ugliest girl in Sparta’. He defined dysmorphophobia as the “fixation in the consciousness of the idea of one’s own deformity…”(History of Body Dysmorphic Disorder, 2013), then went on to describe how it can affect people who seem to be mentally stable, but it will cause this individual to think and worry about their appearance multiple times a day, leading to serious distress and frustration. Morelli may have described it as a phobia because it sometimes manifests as a fear of mirrors or going out in public or a fear of other people’s judgments. In the documentary Ugly Me: My Life with Body Dysmorphia, some sufferers report being terrified of looking in mirrors even while getting their hair done (Waldron & Parker, 2018).

French philosopher, psychologist, and psychotherapist, Pierre Janet referred to “dysmorphophobia” in the description of a patient who refused to leave her hours for 5 years as “I’obession de la honte du corps” (“obsessions of shame of the body”). The woman in question repeatedly attempted to take her own life, and she suffered immensely from the imagined fear that her neighbors were consistently judging and talking about her “hairy face”. Every time that she heard laughter, she imagined that it was directed at her (History of Body Dysmorphic Disorder, 2013).

Freud is still a highly recognized psychologist to this day, and at one point he and Brunswick dealt with the case of an aristocrat known as “the Wolf Man.” Brunswick writes, “he neglected his daily life and work because he was engrossed… in the state of his nose.” This is a classic example of BDD as an obsession over one particular aspect of one’s appearance, and ignoring things that give an individual happiness and meaning. The story has a happy ending, as the aristocrat realized that running to the mirror first thing in the morning (and scaring his servants) was maybe not a satisfying way to live one’s life, and he was able to modify his behavior and eventually was able to go back to his life (History of Body Dysmorphic Disorder, 2013). However, this is an unusual case; most victims of BDD are not able to self-treat and must go through years of therapy to alter their behavior and attitudes (Waldron & Parker, 2018).

Eventually, BDD was given recognition in the DSM III in 1980 under the name of “Dysmorphophobia”. It was characterized as “ an atypical somatoform disorder” (History of Body Dysmorphic Disorder, 2013). At that time, psychologists did not entirely understand BDD, and were cautious in labeling it as a disorder in the first place, despite not entirely fitting the classifications of a phobia. Phobias are irrational fears, and although BDD is indeed irrational, there is no concrete fear associated with it. Some people wilt before a mirror, others will obsess over them. There is no single body part people will fret over, varying from one’s hairline, lips, ears, or anything else to do with the body. It was “used as a diagnosis in DSM III-R in 1987.” Its term was changed to Body Dysmorphic Disorder. Currently, the DSM V has put BDD in a new section of “Obsessive Compulsive and related disorders.” (History of Body Dysmorphic Disorder, 2013). In the end, the classification of a disorder suits the symptoms and characteristics of the disorder much better than filing it with phobias.

As an obsessive-compulsive disorder, BDD affects both men and women fairly equally. Although the numbers for women diagnosed with BDD are slightly higher; over the years the number of men diagnosed with BDD has grown steadily whereas women’s numbers have remained fairly constant. Singh and Veale (2019) comment that overall it is vastly underdiagnosed. They estimated that 1.9% of adults suffer from BDD (p. S132), but due to the nature of the disorder and the deep personal feelings associated with thinking oneself ugly, many people do not believe that they have BDD when they first hear of it. Liane, the subject of Waldron and Parker’s documentary had trouble grasping the idea that she had BDD because, although her obsession with appearance had been causing trouble in her relationship and personal happiness, she did not believe she had the disorder because she believed deeply that she was truly ugly, and she couldn’t fathom that she was the victim of a disorder. The definition of BDD states directly that the subject’s view on their appearance is false, but she knew with 100% certainty that she was ugly, and despite numerous people in her life denying this claim, she insisted that they were lying to spare her feelings. There is also a stigma surrounding BDD (like many mental disorders) that keeps many people from talking about it openly. In fact, the feelings of ugliness are often accompanied by feelings of shame.

My theory on why men’s cases of BDD have spiked hinges on the idea that before now any man who was dealing with it was too ashamed to talk about it or seek the help they needed. This stigma is dangerous, as “Failure to recognize BDD can lead to poor physical and psychiatric outcomes for patients and without treatment BDD appears to have a chronic course” (Singh & Veale, 2019, p. S132). Men also often suffer from a growing trend in a subcategory of BDD called Muscle Dysphoria. This is experienced almost exclusively by men and is the obsession with appearing weak or scrawny, so they will push themselves to build muscle to an unhealthy degree. One man in the article Body Image Obsession in Men stated in regard to his muscle dysphoria, “Why should I be Clark Kent when I can be Superman” (Olivardia, 2002, p. 61).

There are a number of famous people who psychologists now suspect had body dysphoria. I would be surprised if anyone has not heard of the strange parade of people who have gone through tens of thousands of dollars in plastic surgeries to look like Barbie or Ken dolls, but there are many famous, more subtle examples of body dysphoria as well. Michael Jackson is a prime example of someone who had behaviors linked to BDD. He had ten different surgeries on his nose and appeared to be increasingly dissatisfied with his appearance with a continued reticence to discuss it (Meyerson, Mcfadden & Mccarthy, 2009). This is an example of someone with body dysmorphia obsessively trying to fix an aspect of their appearance but never getting the results they are looking for. According to the Body Dysmorphic Disorder Foundation, there are several other idols that showed BDD tendencies, including pop artist Andy Warhol who was reportedly obsessed with the redness of his nose. Also under this blanket of feeling awful about their appearance was the famous writer Frank Kafka who was afraid of mirrors and hated new clothes because he felt he was too ugly for them (Famous People with BDD, 2013).

Since people with BDD often have trouble self-diagnosing, there are several things people can look for to identify if a friend or family member is diagnosable. According to Singh and Veale:

The criteria for BDD also specify that at some point during the purse of illness, the individual will have performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, and reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to their appearance concerns and painful resulting emotions. Therese repetitive behaviors and mental acts are not pleasurable and are hard to control/resist. (p. S132)

Liane from Waldron and Parker’s documentary, even after being diagnosed and knowing that, despite her beliefs, the was not as ugly as she thought she was, discussed potentially getting a tattoo on her upper lip to make her lips look fuller as well as various other modifications she would like to make. She was dissuaded by her boyfriend who insisted she wait until she had been fully treated to do anything dramatic. Other people suffering from BDD have gone through various plastic surgeries and other body modifications. They have also reported being either repulsed by or obsessively drawn to mirrors. One patient reported fearing sitting alone in a cafe by himself. He suspected that everyone was looking at him and judging his appearance. Some people haven’t left their homes in years for fear of judgment and in the worst cases have considered and even attempted suicide.

Causes of BDD are difficult to nail down as there are multiple theories but still few studies to confirm them. Liane’s therapist took her back in a guided visualization to a family vacation when she was fourteen. She remembered noticing the other girls having fun and hanging out and suddenly feeling very unexceptional and ugly (Waldron & Parker, 2018). Other researchers have begun to point to problems in the visual cortex. They have noticed that subjects with BDD seem to hone in on specific details of images shown, whereas those without BDD focus on the broader image. However, the problem here is determining what comes first. Feusner says, “…we haven’t yet determined whether abnormal visual processing contributes as a cause to developing BDD or is the effect of having BDD. So it’s the chicken-or-the-egg phenomenon” (Pedersen, 2018, para.9). Nauert suggests “that individuals with body dysmorphic disorder (BDD) have, in essence, global ‘bad wiring’ in their brains” (para.1). Either way, it is important for those with BDD to seek treatment.

Treatment seems to focus on either drug therapies or CBT. Treatment in Liane’s case had less to do with pills, and more to do with her mindset. Her therapist suggested she spend less time worrying about her appearance and more time concentrating on what was going on around her. When her boyfriend was brought into a session, they discussed possible ways he could support her when she was feeling bad in social situations without her explicitly asking for comfort. She was also put in contact with another one of her therapist’s patients who had been struggling with BDD for years. This seemed to help Liane as she could talk with someone who really knew what she had been going through (Waldron & Parker, 2018). Singh and Veale discuss studies on the efficacy of antidepressants and cognitive behavioral therapy in treating BDD but concluded that further study is necessary (p. S134).

BDD is an immensely complicated disorder, full of subcategories and potential consequences that are difficult to pin down. The stigma surrounding it makes it hard for people who have BDD to understand, come to terms with their condition, and find treatments that will work for them. Body Dysmorphia has the nasty effect of turning people against themselves to the point of believing the world would be better without them. However, research does progress, and more and more people have been able to come out with their stories of BDD and tell others how, despite the difficulties and hardships, and despite their own judgement, they are beautiful.

References

1. Famous People with BDD (2013). Body Dysmorphic Disorder Foundation. https://bddfoundation.org/resources/famous-people-with-bdd/
2. History of Body Dysmorphic Disorder (2013). Body Dysmorphic Disorder Foundation. https://bddfoundation.org/resources/history-of-bdd/
3. Meyersohn J., Mcfadden C. & Mccarthy T. (July 2009). Why did Michael Jackson go so far as to alter his appearance? ABC News. https://abcnews.go.com/2020/MichaelJackson/story?id=7982236&page=1
4. Nauert PhD, R. (2018). Body Obsession Linked to Disordered Brain Wiring. Psych Central. Retrieved on November 10, 2019, from https://psychcentral.com/news/2013/04/30/body-obsession-linked-to-disordered-brain-wiring/54313.html
5. Olivardia, R. (2002). Body Image Obsession in Men. Healthy Weight Journal, 16(4), 59. Retrieved from http://search.ebscohost.com.lib.snow.edu:2048/login.aspx?direct=true&db=asn&AN=7085180&site=ehost-live
6. Pedersen, T. (2018). Body Dysmorphic Disorder Can Extend to Inanimate Objects. Psych Central. Retrieved on November 10, 2019, from https://psychcentral.com/news/2011/05/30/body-dysmorphic-disorder-can-extend-to-inanimate-objects/26554.html
7. Singh, A. R., & Veale, D. (2019). Understanding and treating body dysmorphic disorder. Indian Journal of Psychiatry, 61, S131–S135. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_528_18
8. Waldron, S. & Parker, M. (2018). Ugly Me: My Life with Body Dysmorphia [Documentary]. UK: BBC TV. https://www.dailymotion.com/video/x6lobqx

Informed consent is getting the voluntary acceptance or permission of the person after being informed about all the relevant information related to treatment, such as the purpose, outcome, possible risks involved, and the alternative options available. According to Irvine, Osborne, Shariff, and Sneiderman (2013), “The Supreme Court developed the legal framework for the development of informed consent in 1980, Reibl v. Hughes” (p.75). The physicians have the primary responsibility to make sure that the patient understands what he explains without any barriers such as language problems or emotional distress. The legal facts about informed consent are that it is an important structure that helps in the legal rights of patients and the proper practice of medicine. The legal problems for not getting informed consent are based on the failure of physicians’ duty to provide the information and the injury happened. The ethical fact related to informed consent is that it respects the autonomy of the patient. It helps to make sure that the treatment is chosen by the patient. Informed consent directs more toward patient-centered decision-making rather than the ‘traditional physician-centered’. The moral aspects of the informed concept are about religious or cultural belief, an example is the case of “blood transfusions in minor children of Jehovah’s Witnesses” (Fisher, 2013), in which case the legal aspect is to place the health of the child as the primary concern than the religious rights of parents.

Obtaining informed consent is important in the healthcare profession. Informed consent protects healthcare providers from legal problems if they get sued. For example, in India, I have seen several cases that occurred in which the physicians got attacked and injured severely by the patient’s relatives after unsuccessful surgery. If the doctor had to face any legal problems that continued after this attack, informed consent helps him to avoid punishment. There are certain limitations in getting informed consent, such as age, education, mental ability, language barriers, emotions, etc. Sometimes giving more explanation about the side effects of a procedure or treatment can have a negative effect like making the patient feel more scared and refuse the life-saving treatment. Informed consent also sometimes leads physicians or other healthcare providers into a dilemma as some patients refuse to undergo the investigation or treatment due to religious reasons or fear of the outcomes. In the case of handling minor children, certain procedures can create an ethical dilemma, like the Jehovah’ witnesses (Fisher, 2013).

When considering the informed consent, not only the consent form is considered valid but the communication between the involved persons is also important (Evans, 2016). Informed consent is not necessary in some cases such as an emergency in which the person is not in a state of giving consent because, during an emergency, the physician must do what is necessary to save the patient’s life. Informed consent helps the patient to avoid getting any unnecessary medical interventions or battery during the treatment. According to my view as a healthcare professional, informed consent is important, which not only helps the patient but also healthcare professionals as well. In the case of patients, there are several hospitals that charge the patient for unnecessary investigation procedure and makes them pay for unwanted treatment procedures. Informed consent helps patients get rid of these up to a certain level. Informed consent is important in the healthcare profession as it protects both the provider and the recipient. In the case of healthcare professionals, knowing about informed consent and following the procedures in their practice helps them to face the legal system if any unexpected problems happen.

According to my view, knowing about and practicing informed consent is important for healthcare professionals. The most important aspect of informed consent is the autonomy of the patient, which helps to involve the patient in the decision-making process, however, the drawback of the ethics related to the informed consent is also related to autonomy. Since informed consent gives more importance to the patient, the informed refusal of life-saving treatments by patients causes ethical issues for the physicians who want to provide the care the patient needs.

References

1. Evans, G.K. (2016). Consent: A Guide for Canadian Physicians. Fourth Edition. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/handbooks/consent-a-guide-for-canadian-physicians#informed%20consent
2. Fisher J. (2013). Biomedical Ethics: A Canadian Focus. Oxford University Press.
3. Irvine, J.C., Osborne, P.H., Shariff, M.J., & Sneiderman, B. (2013). Canadian Medical Law: An Introduction for Physicians, Nurses and Other Health Care Professionals. Toronto: Carswell.

This work is a reflective commentary on the factors that influence an individual’s health from the poster developed for Health, life, and social science unit by analyzing the presentation. The Gibbs reflective cycle will be used as this is a popular model of reflection for describing, and identifying feelings that could have influenced my practice, identifying strengths, and weaknesses of my performance as well as creating an action plan (Gibbs, 1988). For the purpose of this assignment a pseudonym, Jason Tots will be used to protect patient confidentiality, Amelia as the Health Care Assistant, and Janet as my mentor (Nurse in charge) in accordance with the Nursing and Midwifery Council (2018).

I was among the team members that received handover at the beginning of a morning shift under the supervision of Janet where I and Amelia were placed in a ward of four patients to monitor. Upon handover, Mr. Tots appeared to be confused, incontinent, sad, and sometimes agitated. Mr. Tots is a 75-year-old man who was among the four patients in the ward I was placed. He is a retired bank manager who has lived alone with his dog as he is divorced for a very long time. He had a son who is out of the country and calls him almost every day. The past medical record of Mr. Tots states that he has Type I diabetes mellitus as well as a History of Dementia in his family and High blood pressure. Mr. Tots is diagnosed with Dementia which is a syndrome that is usually of a chronic or progressive nature that leads to deterioration in cognitive function beyond what might be expected from the usual consequences of biological aging (Ballard et al., 2011; WHO, 2017). To ensure all staff and nurses are aware of Tot’s condition, the ‘Butterfly Scheme’ was used whereby the logo was placed at the top of his bed station to identify he had Dementia, circular red logo was implemented to show that he is also diabetic and also yellow triangular sign was used to show he is at risk of falling. Old age is a common risk factor for dementia according to Raphael Wittenberg et al., 2019 ‘Projections of older people with dementia and costs of dementia care (2019-2040)’, it was estimated that almost 885,000 older people had dementia in 2019 (Raphael et al., 2019). Vascular risk factors such as Hypertension, Diabetes mellitus, smoking, and heart disease have been associated with Dementia (Breteler, 2000). Smoking, physical inactivity, diabetes, and air pollution have been identified as potentially modifiable late-life dementia risk factors (Livingston et al., 2020). According to research conducted by Cacioppo in 2011 on the ‘effects of social isolation’, it was observed that Depression and social isolation are associated with accelerated brain and cardiovascular aging (Cacioppo et al., 2011).

I was worried witnessing how confused and agitated Mr. Tots was because that was my first time caring for a dementia patient. He wanted to come off the bed knowing that he was at risk of failure, I and Amelia were trying to communicate to calm him down but it seems not working out so she told me to call Janet (The nurse in charge) as Amelia could not leave because it was a cohort bay. Janet was able to understand him and I was amazed by Janet’s calm approach toward Mr. Tots, I felt confident and determined that I could learn from Janet to meet the needs of Mr. Tots.

The incident was challenging at first because I and Amelia were trying to communicate with Mr Tots and it was not working out as I don’t have enough experience on how to communicate and care for a dementia patient. The strength of this incident was that Janet had a lot of experience caring for a dementia patient who I was able to learn about and was able to meet the needs of Mr Tots afterward. Also, a strength of this incident was that all staff were made aware of the Butterfly symbol which was in accordance with the National Health Service improvement guidelines for Dementia (NHS, 2017), and also placed the symbol on the wall at the top of his bed to identify she has dementia.

According to the Nursing and Midwifery Council (2018), good communication helps to build therapeutic relationships and aids better understanding of people’s health needs which is important to nursing. The Egan ‘SOLER’ principles proved to be effective when trying to communicate with Mr. Tots as it supports the warm approach used by Janet to calm him down (Egan, 1975) and a therapeutic touch to enhance trust as he lies down on the bed (Stonehouse, 2017). Therefore, as a student nurse caring for Mr. Tots under the supervision of Janet, learning the effective way of communicating is important to build a therapeutic relationship.

From this experience, I can understand how effective communication is a core principle of nursing. I can also understand how important a warm approach and the use of therapeutic touch are when the patient is not calm. Also, adapting communication to suit patients’ needs is a crucial part of person-centered care.

I aim to learn more about understanding dementia, methods of communicating, and also developing more skills on how to approach and care for dementia patients.