Full Transcript Introduction and speaker background 0:09 Hi everyone. Um, thanks to the academy. 0:09 Hi everyone. Um, thanks to the academy. My name is Javier Jimenez. I'm the 0:11 My name is Javier Jimenez. I'm the 0:11 My name is Javier Jimenez. I'm the director of CL Psychiatry at Long Island 0:13 director of CL Psychiatry at Long Island 0:13 director of CL Psychiatry at Long Island Jewish Medical Center, part of Northwell 0:15 Jewish Medical Center, part of Northwell 0:15 Jewish Medical Center, part of Northwell Health. Um, I'm going to be speaking 0:18 Health. Um, I'm going to be speaking 0:18 Health. Um, I'm going to be speaking about something very related actually to 0:19 about something very related actually to 0:20 about something very related actually to what has already been presented on. So, 0:21 what has already been presented on. So, 0:21 what has already been presented on. So, it's a nice segue. um a a concept uh 0:25 it's a nice segue. um a a concept uh 0:25 it's a nice segue. um a a concept uh post-traumatic embitterment that is not 0:28 post-traumatic embitterment that is not 0:28 post-traumatic embitterment that is not um necessarily part of our lexicon maybe 0:31 um necessarily part of our lexicon maybe 0:31 um necessarily part of our lexicon maybe yet. Uh and I think it's helpful for us 0:34 yet. Uh and I think it's helpful for us 0:34 yet. Uh and I think it's helpful for us um when we're conceptualizing the 0:36 um when we're conceptualizing the 0:36 um when we're conceptualizing the so-called difficult patient which still 0:37 so-called difficult patient which still 0:37 so-called difficult patient which still is in our lexicon unfortunately. Um I 0:41 is in our lexicon unfortunately. Um I 0:41 is in our lexicon unfortunately. Um I have no disclosures related to this 0:43 have no disclosures related to this 0:43 have no disclosures related to this work. Um you might have seen another
Post-traumatic embitterment overview 0:46 work. Um you might have seen another 0:46 work. Um you might have seen another name on there under under mine. That's 0:48 name on there under under mine. That's 0:48 name on there under under mine. That's Dr. Chernish. Just go back for one 0:50 Dr. Chernish. Just go back for one 0:50 Dr. Chernish. Just go back for one second. I'm indebted to her. She's 0:52 second. I'm indebted to her. She's 0:52 second. I'm indebted to her. She's actually a former CL fellow in our 0:54 actually a former CL fellow in our 0:54 actually a former CL fellow in our program who is now an attending in 0:56 program who is now an attending in 0:56 program who is now an attending in Connecticut and she brought this concept 0:59 Connecticut and she brought this concept 0:59 Connecticut and she brought this concept to my attention when we were working 1:00 to my attention when we were working 1:00 to my attention when we were working clinically and I'll unpack it in a 1:02 clinically and I'll unpack it in a 1:02 clinically and I'll unpack it in a second. So um again to set the table we 1:06 second. So um again to set the table we 1:06 second. So um again to set the table we are tasked with some challenging 1:08 are tasked with some challenging 1:08 are tasked with some challenging situations in our line of work. It's no 1:11 situations in our line of work. It's no 1:11 situations in our line of work. It's no surprise actually 10 years ago I 1:12 surprise actually 10 years ago I 1:12 surprise actually 10 years ago I remember doing a pre-conference workshop 1:15 remember doing a pre-conference workshop 1:15 remember doing a pre-conference workshop at the academy with a number of other 1:18 at the academy with a number of other 1:18 at the academy with a number of other speakers on the difficult patient and it 1:20 speakers on the difficult patient and it 1:20 speakers on the difficult patient and it was a 4-hour session talking about all 1:22 was a 4-hour session talking about all 1:22 was a 4-hour session talking about all the different psychotherrapeutic 1:23 the different psychotherrapeutic 1:23 the different psychotherrapeutic modalities and diagnoses and all of 1:26 modalities and diagnoses and all of 1:26 modalities and diagnoses and all of that. Today I'm going to just focus on 1:28 that. Today I'm going to just focus on 1:28 that. Today I'm going to just focus on on one element that might be at play in 1:31 on one element that might be at play in 1:31 on one element that might be at play in the so-called difficult patient. Um much 1:33 the so-called difficult patient. Um much 1:33 the so-called difficult patient. Um much of the attention has been sort of 1:35 of the attention has been sort of 1:35 of the attention has been sort of directed at personality traits uh 1:38 directed at personality traits uh 1:38 directed at personality traits uh disorders, diagnoses, DSM categories, 1:40 disorders, diagnoses, DSM categories, 1:40 disorders, diagnoses, DSM categories, things like that. And then of course 1:42 things like that. And then of course 1:42 things like that. And then of course other frameworks like counter
Clinical cases of embittered patients 1:43 other frameworks like counter 1:43 other frameworks like counter transference, um of course other 1:45 transference, um of course other 1:46 transference, um of course other diagnoses. I'm not going to focus on 1:47 diagnoses. I'm not going to focus on 1:47 diagnoses. I'm not going to focus on that. The alternative view that I'm 1:49 that. The alternative view that I'm 1:49 that. The alternative view that I'm going to talk about today is not mine. 1:50 going to talk about today is not mine. 1:50 going to talk about today is not mine. It's something that um is is borrowed 1:54 It's something that um is is borrowed 1:54 It's something that um is is borrowed from other scholars actually from the 1:56 from other scholars actually from the 1:56 from other scholars actually from the old world in Europe. Um the idea that 2:00 old world in Europe. Um the idea that 2:00 old world in Europe. Um the idea that somebody may have longlasting 2:03 somebody may have longlasting 2:03 somebody may have longlasting embitterment which we'll unpack um 2:05 embitterment which we'll unpack um 2:05 embitterment which we'll unpack um secondary to either medical trauma or 2:07 secondary to either medical trauma or 2:07 secondary to either medical trauma or some other insult and that that is 2:09 some other insult and that that is 2:09 some other insult and that that is informing to a large part the so-called 2:12 informing to a large part the so-called 2:12 informing to a large part the so-called difficult behavior or um um you know 2:15 difficult behavior or um um you know 2:15 difficult behavior or um um you know experiences that were encountered. So 2:17 experiences that were encountered. So 2:17 experiences that were encountered. So one definition of embitterment is that 2:19 one definition of embitterment is that 2:19 one definition of embitterment is that this important feeling um sorry the 2:21 this important feeling um sorry the 2:21 this important feeling um sorry the definition is coming up but leading this 2:23 definition is coming up but leading this 2:23 definition is coming up but leading this all led to this development of a 2:25 all led to this development of a 2:25 all led to this development of a diagnostic construct not in the DSM of 2:28 diagnostic construct not in the DSM of 2:28 diagnostic construct not in the DSM of PTED we'll talk about so what is 2:31 PTED we'll talk about so what is 2:31 PTED we'll talk about so what is embitterment embitterment refers to of 2:34 embitterment embitterment refers to of 2:34 embitterment embitterment refers to of course this difficult angry um state um 2:37 course this difficult angry um state um 2:37 course this difficult angry um state um individuals may present phenotypically 2:39 individuals may present phenotypically 2:39 individuals may present phenotypically like we were just describing refusing 2:41 like we were just describing refusing 2:41 like we were just describing refusing help u communicating frustration 2:43 help u communicating frustration 2:43 help u communicating frustration hostility anger it can even of course uh 2:46 hostility anger it can even of course uh 2:46 hostility anger it can even of course uh feature suicidality, homicidality or at 2:48 feature suicidality, homicidality or at 2:48 feature suicidality, homicidality or at least the expressions of that the common 2:51 least the expressions of that the common 2:51 least the expressions of that the common theme described here is a loss of 2:53 theme described here is a loss of 2:54 theme described here is a loss of something right some deep injustice that 2:56 something right some deep injustice that 2:56 something right some deep injustice that has led to this um and that's important 2:59 has led to this um and that's important 2:59 has led to this um and that's important for us as seal psychiatrists I would 3:02 for us as seal psychiatrists I would 3:02 for us as seal psychiatrists I would argue to identify in given patients 3:07 argue to identify in given patients 3:07 argue to identify in given patients this uh phenomenon psychological 3:09 this uh phenomenon psychological 3:09 this uh phenomenon psychological construct whatever you want to describe 3:10 construct whatever you want to describe 3:10 construct whatever you want to describe has been uh seen in a number of 3:13 has been uh seen in a number of 3:13 has been uh seen in a number of populations not just medical um 3:15 populations not just medical um 3:15 populations not just medical um immigrant populations that have lost 3:17 immigrant populations that have lost 3:17 immigrant populations that have lost much. Um it's been studied formally in 3:20 much. Um it's been studied formally in 3:20 much. Um it's been studied formally in different ones. I have references for 3:21 different ones. I have references for 3:21 different ones. I have references for those who are interested. Um the 3:23 those who are interested. Um the 3:23 those who are interested. Um the adolescent certain actual DSM diagnoses. 3:25 adolescent certain actual DSM diagnoses. 3:25 adolescent certain actual DSM diagnoses. So you can see how it's being looked at 3:27 So you can see how it's being looked at 3:27 So you can see how it's being looked at across clinical and nonclinical 3:29 across clinical and nonclinical 3:29 across clinical and nonclinical populations. And even in the medical 3:31 populations. And even in the medical 3:31 populations. And even in the medical setting, we're we're starting to see 3:32 setting, we're we're starting to see 3:32 setting, we're we're starting to see literature describing this in certain u 3:36 literature describing this in certain u 3:36 literature describing this in certain u diseases that that we of course treat. 3:38 diseases that that we of course treat. 3:38 diseases that that we of course treat. I'm not going to read them all there, 3:39 I'm not going to read them all there, 3:39 I'm not going to read them all there, but um medically unexplained symptoms, 3:42 but um medically unexplained symptoms, 3:42 but um medically unexplained symptoms, etc. 3:44 etc. 3:44 etc. I want to share two clinical vignettes. 3:46 I want to share two clinical vignettes. 3:46 I want to share two clinical vignettes. These are real cases that my fellow and 3:49 These are real cases that my fellow and 3:49 These are real cases that my fellow and I had um seen. One on the outpatient 3:53 I had um seen. One on the outpatient 3:53 I had um seen. One on the outpatient side in an ambulatory CL space and then 3:55 side in an ambulatory CL space and then 3:55 side in an ambulatory CL space and then one in the inpatient side. It's it's a 3:57 one in the inpatient side. It's it's a 3:58 one in the inpatient side. It's it's a lot to read, but I think it's important 3:59 lot to read, but I think it's important 3:59 lot to read, but I think it's important for us to just quickly get through it. 4:01 for us to just quickly get through it. 4:01 for us to just quickly get through it. The first case is a 55-year-old woman 4:03 The first case is a 55-year-old woman 4:03 The first case is a 55-year-old woman with past medical history of intractable 4:05 with past medical history of intractable 4:05 with past medical history of intractable focal left epilepsy 10 years in duration 4:08 focal left epilepsy 10 years in duration 4:08 focal left epilepsy 10 years in duration referred to us by neurology. They were 4:10 referred to us by neurology. They were 4:10 referred to us by neurology. They were recommending surgical intervention that 4:12 recommending surgical intervention that 4:12 recommending surgical intervention that she kept delaying. Uh neurology 4:14 she kept delaying. Uh neurology 4:14 she kept delaying. Uh neurology characterized her as difficult at times, 4:16 characterized her as difficult at times, 4:16 characterized her as difficult at times, strong personality and she initially 4:19 strong personality and she initially 4:19 strong personality and she initially presented as very pleasant, cognitively 4:21 presented as very pleasant, cognitively 4:21 presented as very pleasant, cognitively intact though quickly transitioned into 4:23 intact though quickly transitioned into 4:23 intact though quickly transitioned into this very loud agitated demeanor while 4:25 this very loud agitated demeanor while 4:25 this very loud agitated demeanor while discussing her experience with her 4:27 discussing her experience with her 4:27 discussing her experience with her illness. uh she became intermittently 4:29 illness. uh she became intermittently 4:29 illness. uh she became intermittently pressured in speech that though she was 4:31 pressured in speech that though she was 4:32 pressured in speech that though she was always interruptible and she noted that 4:33 always interruptible and she noted that 4:33 always interruptible and she noted that seizures significantly affected her life 4:35 seizures significantly affected her life 4:35 seizures significantly affected her life losing her fulfilling job as a teacher 4:37 losing her fulfilling job as a teacher 4:37 losing her fulfilling job as a teacher and her abilities to drive and advocate 4:40 and her abilities to drive and advocate 4:40 and her abilities to drive and advocate for herself. She felt very resentful 4:43 for herself. She felt very resentful 4:43 for herself. She felt very resentful towards family and friends, providers 4:45 towards family and friends, providers 4:46 towards family and friends, providers and healthcare at large. So this very 4:47 and healthcare at large. So this very 4:47 and healthcare at large. So this very diffuse sort of resentment uh feeling 4:50 diffuse sort of resentment uh feeling 4:50 diffuse sort of resentment uh feeling misunderstood and even exploited. She 4:52 misunderstood and even exploited. She 4:52 misunderstood and even exploited. She added that she was actually abused um 4:55 added that she was actually abused um 4:55 added that she was actually abused um after having a seizure in public which 4:57 after having a seizure in public which 4:57 after having a seizure in public which led to uh some agorophobic responses. So 5:00 led to uh some agorophobic responses. So 5:00 led to uh some agorophobic responses. So we'll talk about differential diagnoses 5:01 we'll talk about differential diagnoses 5:01 we'll talk about differential diagnoses in a minute. Uh review of symptoms 5:03 in a minute. Uh review of symptoms 5:04 in a minute. Uh review of symptoms however revealed anxiety, insomnia, 5:05 however revealed anxiety, insomnia, 5:05 however revealed anxiety, insomnia, depression, loss of appetite, 5:06 depression, loss of appetite, 5:06 depression, loss of appetite, irritability or verbal aggression to 5:08 irritability or verbal aggression to 5:08 irritability or verbal aggression to others but no overt psychosis or mania 5:10 others but no overt psychosis or mania 5:10 others but no overt psychosis or mania and she also lacked some of the more 5:13 and she also lacked some of the more 5:13 and she also lacked some of the more cardinal features of PTSD which we'll 5:15 cardinal features of PTSD which we'll 5:15 cardinal features of PTSD which we'll talk about in a bit. So think about this
Defining PTED and related constructs 5:18 talk about in a bit. So think about this 5:18 talk about in a bit. So think about this case. Um ask yourself what you might do 5:21 case. Um ask yourself what you might do 5:21 case. Um ask yourself what you might do if you're encountering such um you know 5:24 if you're encountering such um you know 5:24 if you're encountering such um you know intense embitterment if you will or 5:26 intense embitterment if you will or 5:26 intense embitterment if you will or anger around illness and what it's done 5:29 anger around illness and what it's done 5:29 anger around illness and what it's done to somebody psycho behaviorally etc 5:32 to somebody psycho behaviorally etc 5:32 to somebody psycho behaviorally etc whether you would treat it differently 5:33 whether you would treat it differently 5:34 whether you would treat it differently refer to a colleague etc. The second 5:36 refer to a colleague etc. The second 5:36 refer to a colleague etc. The second case from the inpatient setting is a 5:38 case from the inpatient setting is a 5:38 case from the inpatient setting is a 61-year-old male with chronic uh uh COPD 5:43 61-year-old male with chronic uh uh COPD 5:43 61-year-old male with chronic uh uh COPD and asthma, congestive heart failure, 5:45 and asthma, congestive heart failure, 5:45 and asthma, congestive heart failure, chronic pain. So number of issues also 5:47 chronic pain. So number of issues also 5:48 chronic pain. So number of issues also history of poly substance use admitted 5:50 history of poly substance use admitted 5:50 history of poly substance use admitted after a suicide attempt involving an 5:51 after a suicide attempt involving an 5:51 after a suicide attempt involving an overdose with alprazil. After an initial 5:54 overdose with alprazil. After an initial 5:54 overdose with alprazil. After an initial period of delirium, he presented with 5:56 period of delirium, he presented with 5:56 period of delirium, he presented with high irritability, dysphoria, cited his 5:58 high irritability, dysphoria, cited his 5:58 high irritability, dysphoria, cited his chronic pain and estrangement from 6:00 chronic pain and estrangement from 6:00 chronic pain and estrangement from family as activating stressors and uh 6:03 family as activating stressors and uh 6:03 family as activating stressors and uh adding that he really had nothing else 6:05 adding that he really had nothing else 6:05 adding that he really had nothing else to live for. He lacked any formal 6:07 to live for. He lacked any formal 6:07 to live for. He lacked any formal psychiatric history despite all of this 6:09 psychiatric history despite all of this 6:09 psychiatric history despite all of this um and and you know except for anxiety 6:12 um and and you know except for anxiety 6:12 um and and you know except for anxiety basically and demanded that he be on his 6:15 basically and demanded that he be on his 6:15 basically and demanded that he be on his uh alprazilam you know 1 milligram four 6:17 uh alprazilam you know 1 milligram four 6:17 uh alprazilam you know 1 milligram four times a day right away even after having 6:19 times a day right away even after having 6:19 times a day right away even after having had this you know suicide attempt. He 6:22 had this you know suicide attempt. He 6:22 had this you know suicide attempt. He did not meet full criteria actually for 6:24 did not meet full criteria actually for 6:24 did not meet full criteria actually for MDD despite everything. Um and uh he 6:27 MDD despite everything. Um and uh he 6:27 MDD despite everything. Um and uh he also denied core PTSD, panic, um 6:31 also denied core PTSD, panic, um 6:31 also denied core PTSD, panic, um generalized anxiety symptoms when we 6:33 generalized anxiety symptoms when we 6:33 generalized anxiety symptoms when we really look closely, manic psychotic 6:34 really look closely, manic psychotic 6:34 really look closely, manic psychotic symptoms. So there probably more of a 6:36 symptoms. So there probably more of a 6:36 symptoms. So there probably more of a substance use disorder as described, but 6:38 substance use disorder as described, but 6:38 substance use disorder as described, but he spoke aidly about his experience as a 6:41 he spoke aidly about his experience as a 6:41 he spoke aidly about his experience as a veteran of some wars and about 6:42 veteran of some wars and about 6:42 veteran of some wars and about separation from family portraying each 6:45 separation from family portraying each 6:45 separation from family portraying each with a strong theme of victimization, 6:47 with a strong theme of victimization, 6:47 with a strong theme of victimization, externalizing a lot. He felt rather 6:49 externalizing a lot. He felt rather 6:49 externalizing a lot. He felt rather angry and embittered about these 6:51 angry and embittered about these 6:51 angry and embittered about these experiences as well as about his 6:53 experiences as well as about his 6:53 experiences as well as about his arthritis, chronic pain and as mentioned 6:56 arthritis, chronic pain and as mentioned 6:56 arthritis, chronic pain and as mentioned externalizing often. So these are two 6:58 externalizing often. So these are two 6:58 externalizing often. So these are two caricatures that might seem very 7:00 caricatures that might seem very 7:00 caricatures that might seem very familiar to you. Uh you might see this 7:02 familiar to you. Uh you might see this 7:02 familiar to you. Uh you might see this again ambulatory and uh inatient setting 7:06 again ambulatory and uh inatient setting 7:06 again ambulatory and uh inatient setting just to sort of cement the idea that 7:07 just to sort of cement the idea that 7:07 just to sort of cement the idea that embitterment is at least a component of 7:09 embitterment is at least a component of 7:09 embitterment is at least a component of this maybe not the full explanation but 7:11 this maybe not the full explanation but 7:11 this maybe not the full explanation but certainly a component. So what is PTE? 7:14 certainly a component. So what is PTE? 7:14 certainly a component. So what is PTE? PTED again not in the DSM and and I'm 7:17 PTED again not in the DSM and and I'm 7:17 PTED again not in the DSM and and I'm not even certain that it needs to be. 7:19 not even certain that it needs to be. 7:19 not even certain that it needs to be. I'm just sharing the construct is uh is 7:23 I'm just sharing the construct is uh is 7:23 I'm just sharing the construct is uh is characterized by these criteria. I'm not 7:25 characterized by these criteria. I'm not 7:25 characterized by these criteria. I'm not going to go over every single word, but 7:28 going to go over every single word, but 7:28 going to go over every single word, but um you see that uh some negative life 7:31 um you see that uh some negative life 7:31 um you see that uh some negative life event, it could be medical, it could be 7:33 event, it could be medical, it could be 7:33 event, it could be medical, it could be non-medical, has activated a cascade of 7:36 non-medical, has activated a cascade of 7:36 non-medical, has activated a cascade of these um you know uh embitterment 7:39 these um you know uh embitterment 7:39 these um you know uh embitterment feelings, unjust, you know, uh 7:41 feelings, unjust, you know, uh 7:41 feelings, unjust, you know, uh experiences, that residue, if you will. 7:44 experiences, that residue, if you will. 7:44 experiences, that residue, if you will. Um no other mental health disorder, you 7:46 Um no other mental health disorder, you 7:46 Um no other mental health disorder, you know, would explain it otherwise prior 7:48 know, would explain it otherwise prior 7:48 know, would explain it otherwise prior to that. And you do need six months uh 7:51 to that. And you do need six months uh 7:51 to that. And you do need six months uh duration of this kind of like with PTSD 7:54 duration of this kind of like with PTSD 7:54 duration of this kind of like with PTSD and other DSM categories. Again, this is 7:57 and other DSM categories. Again, this is 7:57 and other DSM categories. Again, this is what has been proposed, not necessarily 8:00 what has been proposed, not necessarily 8:00 what has been proposed, not necessarily advocating for it or anything of that 8:02 advocating for it or anything of that 8:02 advocating for it or anything of that sort. Um the scholars are right about 8:04 sort. Um the scholars are right about 8:04 sort. Um the scholars are right about this uh right that there are 8:06 this uh right that there are 8:06 this uh right that there are embitterment subtypes if you will. This 8:08 embitterment subtypes if you will. This 8:08 embitterment subtypes if you will. This might help us think phenotypically about 8:10 might help us think phenotypically about 8:10 might help us think phenotypically about what we're seeing. So PT is PTED 8:12 what we're seeing. So PT is PTED 8:12 what we're seeing. So PT is PTED reaction, you know, uh after one event, 8:15 reaction, you know, uh after one event, 8:15 reaction, you know, uh after one event, which is the previous definition. 8:17 which is the previous definition. 8:17 which is the previous definition. complex embitterment stemming from 8:19 complex embitterment stemming from 8:19 complex embitterment stemming from multiple situations of perceived 8:21 multiple situations of perceived 8:21 multiple situations of perceived injustice. This uh might rub a little 8:24 injustice. This uh might rub a little 8:24 injustice. This uh might rub a little bit, you know, up against demoralization 8:26 bit, you know, up against demoralization 8:26 bit, you know, up against demoralization as we were talking about with prolonged 8:27 as we were talking about with prolonged 8:27 as we were talking about with prolonged hospitalization, non-reactive 8:29 hospitalization, non-reactive 8:29 hospitalization, non-reactive embitterment in embitterment prone 8:31 embitterment in embitterment prone 8:31 embitterment in embitterment prone personality, which is interesting. Uh we 8:33 personality, which is interesting. Uh we 8:33 personality, which is interesting. Uh we don't have time today to unpack all of 8:35 don't have time today to unpack all of 8:35 don't have time today to unpack all of these different nuances, but maybe there 8:37 these different nuances, but maybe there 8:37 these different nuances, but maybe there is a personality subtype that is more 8:39 is a personality subtype that is more 8:39 is a personality subtype that is more prone to developing this. And then 8:42 prone to developing this. And then 8:42 prone to developing this. And then secondary and vitamin in the context of 8:44 secondary and vitamin in the context of 8:44 secondary and vitamin in the context of some other mental disorder. So you can 8:46 some other mental disorder. So you can 8:46 some other mental disorder. So you can see there's obviously a lot of dynamic 8:48 see there's obviously a lot of dynamic 8:48 see there's obviously a lot of dynamic interplay between between different 8:50 interplay between between different 8:50 interplay between between different factors that we consider this construct. 8:52 factors that we consider this construct. 8:52 factors that we consider this construct. And then of course there's diagnostic 8:54 And then of course there's diagnostic 8:54 And then of course there's diagnostic overlap as is often the case in our 8:57 overlap as is often the case in our 8:57 overlap as is often the case in our field. We see individuals with one two 8:59 field. We see individuals with one two 8:59 field. We see individuals with one two maybe three different diagnosis. Um here 9:02 maybe three different diagnosis. Um here 9:02 maybe three different diagnosis. Um here you have a ven diagram just reminding us 9:05 you have a ven diagram just reminding us 9:05 you have a ven diagram just reminding us that we have adjustment disorder PTSD 9:07 that we have adjustment disorder PTSD 9:07 that we have adjustment disorder PTSD and then this uh other construct of 9:10 and then this uh other construct of 9:10 and then this uh other construct of PTED. And I'm not going to review all of 9:13 PTED. And I'm not going to review all of 9:13 PTED. And I'm not going to review all of the elements, but you can see some of 9:15 the elements, but you can see some of 9:15 the elements, but you can see some of the differentiating factors, but some of 9:16 the differentiating factors, but some of 9:16 the differentiating factors, but some of the overlap as well. Obviously, they 9:19 the overlap as well. Obviously, they 9:19 the overlap as well. Obviously, they share a significant reaction to uh an
Validation and case-based intervention 9:22 share a significant reaction to uh an 9:22 share a significant reaction to uh an event. It's interesting that depression 9:24 event. It's interesting that depression 9:24 event. It's interesting that depression is in the middle there. I'm not 9:26 is in the middle there. I'm not 9:26 is in the middle there. I'm not convinced that you'll always have 9:28 convinced that you'll always have 9:28 convinced that you'll always have depression, but uh with these three, but 9:30 depression, but uh with these three, but 9:30 depression, but uh with these three, but that's okay. 9:32 that's okay. 9:32 that's okay. So um because this is a new construct 9:36 So um because this is a new construct 9:36 So um because this is a new construct because I'm really just sharing it with 9:38 because I'm really just sharing it with 9:38 because I'm really just sharing it with the academy and seal psychiatrist to add 9:40 the academy and seal psychiatrist to add 9:40 the academy and seal psychiatrist to add to the lexicon we really don't know much 9:42 to the lexicon we really don't know much 9:42 to the lexicon we really don't know much about how to manage this if you will um 9:45 about how to manage this if you will um 9:45 about how to manage this if you will um obviously there are many you know 9:47 obviously there are many you know 9:47 obviously there are many you know empirically validated psychotherrapeutic 9:49 empirically validated psychotherrapeutic 9:49 empirically validated psychotherrapeutic strategies for the person who has 9:51 strategies for the person who has 9:52 strategies for the person who has embitterment generally anger issues etc 9:54 embitterment generally anger issues etc 9:54 embitterment generally anger issues etc but um when thinking about this in our 9:57 but um when thinking about this in our 9:57 but um when thinking about this in our CL practice especially if we don't have 10:00 CL practice especially if we don't have 10:00 CL practice especially if we don't have other other resources is, you know, 10:02 other other resources is, you know, 10:02 other other resources is, you know, sometimes the MD is going to have to uh 10:04 sometimes the MD is going to have to uh 10:04 sometimes the MD is going to have to uh dip into their psychotherrapeutic 10:05 dip into their psychotherrapeutic 10:06 dip into their psychotherrapeutic toolbox. And I'm just reminding the 10:08 toolbox. And I'm just reminding the 10:08 toolbox. And I'm just reminding the audience with this image of um Glenn 10:10 audience with this image of um Glenn 10:10 audience with this image of um Glenn Gabard's contribution during many of our 10:13 Gabard's contribution during many of our 10:13 Gabard's contribution during many of our psychiatric residency training 10:15 psychiatric residency training 10:15 psychiatric residency training experiences of the of the continuum of 10:18 experiences of the of the continuum of 10:18 experiences of the of the continuum of of psychotherrapeutic interventions, 10:20 of psychotherrapeutic interventions, 10:20 of psychotherrapeutic interventions, right? On one end, expressive ones and 10:21 right? On one end, expressive ones and 10:22 right? On one end, expressive ones and on the other end, supportive ones. And 10:24 on the other end, supportive ones. And 10:24 on the other end, supportive ones. And if you can imagine somebody who's 10:25 if you can imagine somebody who's 10:25 if you can imagine somebody who's seething and embittered, you're going to 10:27 seething and embittered, you're going to 10:27 seething and embittered, you're going to probably want to have to hover over on 10:28 probably want to have to hover over on 10:28 probably want to have to hover over on the right side of this page uh with 10:31 the right side of this page uh with 10:31 the right side of this page uh with supportive uh statements actually very 10:34 supportive uh statements actually very 10:34 supportive uh statements actually very uh much in line with the previous 10:35 uh much in line with the previous 10:35 uh much in line with the previous presentation, the second case that you 10:37 presentation, the second case that you 10:37 presentation, the second case that you presented. You're going to have to u 10:39 presented. You're going to have to u 10:39 presented. You're going to have to u engage in some of that um you know 10:42 engage in some of that um you know 10:42 engage in some of that um you know validating all of that. So one position 10:45 validating all of that. So one position 10:45 validating all of that. So one position that I'm going to just propose is that 10:48 that I'm going to just propose is that 10:48 that I'm going to just propose is that we leverage empathic validation 10:51 we leverage empathic validation 10:51 we leverage empathic validation regularly obviously with quote difficult 10:53 regularly obviously with quote difficult 10:53 regularly obviously with quote difficult patients embittered or not in our 10:55 patients embittered or not in our 10:55 patients embittered or not in our clinical setting. Um I'm sharing an uh a 10:59 clinical setting. Um I'm sharing an uh a 10:59 clinical setting. Um I'm sharing an uh a case that I wrote once with a trainee um 11:02 case that I wrote once with a trainee um 11:02 case that I wrote once with a trainee um where we had an individual who was in 11:04 where we had an individual who was in 11:04 where we had an individual who was in the hospital for very long a couple of 11:06 the hospital for very long a couple of 11:06 the hospital for very long a couple of months after ARDS bout and um he was 11:10 months after ARDS bout and um he was 11:10 months after ARDS bout and um he was really sort of checked out not engaging 11:12 really sort of checked out not engaging 11:12 really sort of checked out not engaging with too many folks ruled out major 11:14 with too many folks ruled out major 11:14 with too many folks ruled out major depressive disorder ruled out uh 11:16 depressive disorder ruled out uh 11:16 depressive disorder ruled out uh inphylopathy 11:17 inphylopathy 11:17 inphylopathy u but we knew that behaviorally 11:19 u but we knew that behaviorally 11:19 u but we knew that behaviorally something was going on and we basically 11:23 something was going on and we basically 11:23 something was going on and we basically identified during this case that 11:25 identified during this case that 11:25 identified during this case that empathically valid validating. In other 11:27 empathically valid validating. In other 11:27 empathically valid validating. In other words, acknowledging, recognizing what 11:28 words, acknowledging, recognizing what 11:28 words, acknowledging, recognizing what the individual was going through was a 11:30 the individual was going through was a 11:30 the individual was going through was a key to to getting through that moment. 11:32 key to to getting through that moment. 11:32 key to to getting through that moment. And uh for those interested, I'm not 11:34 And uh for those interested, I'm not 11:34 And uh for those interested, I'm not going to read this this script, but in 11:36 going to read this this script, but in 11:36 going to read this this script, but in the article, we purposely included the 11:38 the article, we purposely included the 11:38 the article, we purposely included the actual language that we used with the 11:40 actual language that we used with the 11:40 actual language that we used with the patient because it unlocks maybe some 11:43 patient because it unlocks maybe some 11:43 patient because it unlocks maybe some tips as to what to do with future 11:45 tips as to what to do with future 11:45 tips as to what to do with future patients. I'm going to skip because we 11:47 patients. I'm going to skip because we 11:47 patients. I'm going to skip because we only have a minute, but essentially we 11:49 only have a minute, but essentially we 11:49 only have a minute, but essentially we started the script by coming in as wrote 11:52 started the script by coming in as wrote 11:52 started the script by coming in as wrote physicians and doing what we always do, 11:53 physicians and doing what we always do, 11:53 physicians and doing what we always do, the ano x times three dance and all of 11:55 the ano x times three dance and all of 11:56 the ano x times three dance and all of that. And we realized midway that the uh 12:00 that. And we realized midway that the uh 12:00 that. And we realized midway that the uh patient was very frustrated by us doing 12:02 patient was very frustrated by us doing 12:02 patient was very frustrated by us doing the same thing that everyone else does. 12:03 the same thing that everyone else does. 12:03 the same thing that everyone else does. And we caught ourselves and had to call 12:05 And we caught ourselves and had to call 12:05 And we caught ourselves and had to call that out. And he was very embittered by 12:07 that out. And he was very embittered by 12:07 that out. And he was very embittered by this process and feeling dehumanized. Um 12:10 this process and feeling dehumanized. Um 12:10 this process and feeling dehumanized. Um so again in the interest of time I'm 12:12 so again in the interest of time I'm 12:12 so again in the interest of time I'm only going to skip to a little bit of 12:13 only going to skip to a little bit of 12:13 only going to skip to a little bit of this but uh right in the second doctor 12:16 this but uh right in the second doctor 12:16 this but uh right in the second doctor there where you see um he's actually the 12:19 there where you see um he's actually the 12:20 there where you see um he's actually the patient is saying Mr. else saying it's 12:21 patient is saying Mr. else saying it's 12:21 patient is saying Mr. else saying it's not okay to do these tests, right? The 12:23 not okay to do these tests, right? The 12:23 not okay to do these tests, right? The same, you know, tests, you know, * 3 12:26 same, you know, tests, you know, * 3 12:26 same, you know, tests, you know, * 3 again. And we caught ourselves and said, 12:28 again. And we caught ourselves and said, 12:28 again. And we caught ourselves and said, you're absolutely right. It's not okay. 12:30 you're absolutely right. It's not okay. 12:30 you're absolutely right. It's not okay. I just realized we're doing what we said 12:32 I just realized we're doing what we said 12:32 I just realized we're doing what we said is a big problem here, the repetitive 12:33 is a big problem here, the repetitive 12:33 is a big problem here, the repetitive test. He says, "Yeah, we can't do that 12:35 test. He says, "Yeah, we can't do that 12:35 test. He says, "Yeah, we can't do that all the time." Whether it's the nurses 12:36 all the time." Whether it's the nurses 12:36 all the time." Whether it's the nurses or the doctors, they just keep doing the 12:38 or the doctors, they just keep doing the 12:38 or the doctors, they just keep doing the same thing, checking you here, examining 12:40 same thing, checking you here, examining 12:40 same thing, checking you here, examining you there, and and then he adds to that 12:43 you there, and and then he adds to that 12:43 you there, and and then he adds to that and pulling the sheets, the gowns, 12:44 and pulling the sheets, the gowns, 12:44 and pulling the sheets, the gowns, grabbing my arm, and we assist, right? 12:47 grabbing my arm, and we assist, right? 12:47 grabbing my arm, and we assist, right? Oh, the blood pressure thing. Yes. So 12:49 Oh, the blood pressure thing. Yes. So 12:49 Oh, the blood pressure thing. Yes. So you see how we're sort of in similar 12:50 you see how we're sort of in similar 12:50 you see how we're sort of in similar territory 12:52 territory 12:52 territory validating the experience and said right 12:55 validating the experience and said right 12:55 validating the experience and said right all of that enough is enough and then we 12:57 all of that enough is enough and then we 12:57 all of that enough is enough and then we said we did the same thing you've been 12:59 said we did the same thing you've been 12:59 said we did the same thing you've been sick and tired of and we we know from 13:01 sick and tired of and we we know from 13:01 sick and tired of and we we know from our demoralization definitions we love 13:03 our demoralization definitions we love 13:03 our demoralization definitions we love the terminology of being sick and tired 13:05 the terminology of being sick and tired 13:05 the terminology of being sick and tired of being sick and tired. That has to be 13:07 of being sick and tired. That has to be 13:07 of being sick and tired. That has to be extremely upsetting. That's the 13:08 extremely upsetting. That's the 13:08 extremely upsetting. That's the validation that it keeps happening. We 13:11 validation that it keeps happening. We 13:11 validation that it keeps happening. We don't need to do that exam and maybe we 13:12 don't need to do that exam and maybe we 13:12 don't need to do that exam and maybe we simply talk and that'll be best. And 13:15 simply talk and that'll be best. And 13:15 simply talk and that'll be best. And from here, since we're out of time, I 13:16 from here, since we're out of time, I 13:16 from here, since we're out of time, I can't tell you more. But what did 13:18 can't tell you more. But what did 13:18 can't tell you more. But what did happen, it was a turning point where he 13:20 happen, it was a turning point where he 13:20 happen, it was a turning point where he really started to embrace physical 13:21 really started to embrace physical 13:21 really started to embrace physical therapy and some other strategies to get 13:23 therapy and some other strategies to get 13:23 therapy and some other strategies to get out of the hospital. So, it's very akin 13:25 out of the hospital. So, it's very akin 13:25 out of the hospital. So, it's very akin actually to the previous presentation in 13:27 actually to the previous presentation in 13:27 actually to the previous presentation in terms of how we use our language, 13:29 terms of how we use our language, 13:29 terms of how we use our language, perhaps our virtue ethics and our 13:31 perhaps our virtue ethics and our 13:31 perhaps our virtue ethics and our behaviors, but also psychother 13:33 behaviors, but also psychother 13:33 behaviors, but also psychother psychotherrapeutic principles like
Wrap-up and future directions 13:34 psychotherrapeutic principles like 13:34 psychotherrapeutic principles like empathic validation to get through that 13:36 empathic validation to get through that 13:36 empathic validation to get through that embitterment and not necessarily 13:39 embitterment and not necessarily 13:39 embitterment and not necessarily characterize it as difficult, if you 13:40 characterize it as difficult, if you 13:40 characterize it as difficult, if you will. So, future directions, I'm 13:42 will. So, future directions, I'm 13:42 will. So, future directions, I'm wrapping up. I I do think this construct 13:45 wrapping up. I I do think this construct 13:45 wrapping up. I I do think this construct demands or deserves more research 13:48 demands or deserves more research 13:48 demands or deserves more research particularly in medical settings and we 13:50 particularly in medical settings and we 13:50 particularly in medical settings and we should despite whether you use the 13:52 should despite whether you use the 13:52 should despite whether you use the construct or not we should of course 13:54 construct or not we should of course 13:54 construct or not we should of course tailor our clinical interventions around 13:55 tailor our clinical interventions around 13:55 tailor our clinical interventions around the presence of embitterment identify it 13:57 the presence of embitterment identify it 13:57 the presence of embitterment identify it call it out uh the the sense of of you 14:00 call it out uh the the sense of of you 14:00 call it out uh the the sense of of you know injustice etc and consider that 14:02 know injustice etc and consider that 14:02 know injustice etc and consider that impact on medical populations and maybe 14:05 impact on medical populations and maybe 14:05 impact on medical populations and maybe reconceptualize our patients as 14:07 reconceptualize our patients as 14:07 reconceptualize our patients as embittered and not so much difficult if 14:09 embittered and not so much difficult if 14:09 embittered and not so much difficult if you will. Obviously training around this 14:11 you will. Obviously training around this 14:11 you will. Obviously training around this would be the the next step after that. 14:14 would be the the next step after that. 14:14 would be the the next step after that. Thank you for your attention and there's 14:15 Thank you for your attention and there's 14:15 Thank you for your attention and there's references here for those who are 14:16 references here for those who are 14:16 references here for those who are interested.
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