Psychiatric Annals

CME Article 

Challenges of VIP Treatment on Inpatient Psychiatry

Megan B. Schabbing, MD

Abstract

One of the oldest documented cases of a psychiatric VIP patient occurred in Bavaria in 1886.1 King Ludwig II was noted to have had a significant family history of “paranoid and depressive psychoses.” He was committed to Castle Berg after being given a diagnosis of “primary insanity” by an appointed commission of four psychiatrists who deemed him incapable of carrying out his royal obligations. On one of his permitted walks, King Ludwig attacked and drowned his attending psychiatrist in the nearby lake before drowning himself.

Abstract

One of the oldest documented cases of a psychiatric VIP patient occurred in Bavaria in 1886.1 King Ludwig II was noted to have had a significant family history of “paranoid and depressive psychoses.” He was committed to Castle Berg after being given a diagnosis of “primary insanity” by an appointed commission of four psychiatrists who deemed him incapable of carrying out his royal obligations. On one of his permitted walks, King Ludwig attacked and drowned his attending psychiatrist in the nearby lake before drowning himself.

Megan B. Schabbing, MD, is Assistant Professor, Department of Psychiatry, The Ohio State University.

Dr. Schabbing has disclosed no relevant financial relationships.

Address correspondence to: Megan B. Schabbing, MD, via email: megan.schabbing@osumc.edu.

One of the oldest documented cases of a psychiatric VIP patient occurred in Bavaria in 1886.1 King Ludwig II was noted to have had a significant family history of “paranoid and depressive psychoses.” He was committed to Castle Berg after being given a diagnosis of “primary insanity” by an appointed commission of four psychiatrists who deemed him incapable of carrying out his royal obligations. On one of his permitted walks, King Ludwig attacked and drowned his attending psychiatrist in the nearby lake before drowning himself.

Perhaps the first error on the part of his treating physicians was the failure to make a definitive and accurate diagnosis. They ignored numerous warning signs such as grandiosity, impulsive spending sprees, unpredictable mood swings, and social withdrawal.

Ludwig was diagnosed as “insane” only after he issued a command to skin alive and commit other atrocities to the psychiatrists and members of the commission who were responsible for his initial diagnosis and removal from power. While the diagnosis “primary insanity” would now be called “paranoid psychosis,” it is not clear that any potential mood component to the King’s illness was identified and addressed.

A second, and fatal, error was the choice to improvise his treatment environment: rather than admitting him to a staffed mental hospital, his physicians set up a one-patient hospital in a castle in a park located on a lake, ultimately the site where he committed suicide and murder.

Negative Outcomes

In 1964, Weintraub2 described 12 VIP cases admitted to the inpatient unit of a private psychiatric hospital in Baltimore. Five were “influential patients,” typically prominent members of the community; five were “private patients,” admitted due to pressure from their out-patient psychiatrists; and two were “professional colleagues” of the treaters.

Ten of these cases were considered therapeutic failures; two committed suicide and three left against medical advice. Perhaps the most notable finding was that, of the two cases in which the patient was considered to have met the goals of hospitalization, symptomatic improvement occurred only after loss of VIP status.

Most of the reports of VIP patients on inpatient psychiatric units were published more than 3 decades ago and involve only the physician-patient.3–6 In the most recent of these reports — a review of 100 physician inpatients comprising more than 200 admissions to a private psychiatric hospital7 — one pattern identified was the failure on the part of the treating psychiatrist to make a full and accurate diagnosis.

Although only 12 of 100 patients were given a primary diagnosis of alcohol or drug abuse, more than half were found to have a substantial drug or alcohol problem. Only seven had sought outpatient treatment before hospitalization, supporting the previously recognized resistance of physicians to seek psychiatric treatment.3,5 Of note, peer leverage, such as suspension of admitting privileges, was an effective mechanism for precipitating the psychiatric hospitalization of a physician. Nine patients left against medical advice, a rate substantially higher than the overall rate for the hospital studied, 1.1%.3,5

Treatment Challenges

Patients with VIP status appear to be at a higher risk for an inaccurate or missed diagnosis. In the case of King Ludwig II, a delayed diagnosis was attributed to the fear of those close to the patient that he would use his power to retaliate against them.1 In today’s world, potential reasons for diagnostic failure include concerns over insurance coverage, lack of knowledge regarding diagnosis and treatment, and countertransference issues such as overprotectiveness of the patient.7

Resistance to inpatient treatment is another common problem for the psychiatric VIP, particularly the physician-patient, which may be related to fears of the stigma still associated with mental illness, and the associated concerns over privacy. As with nonpsychiatric VIP patients, special treatment of the VIP actually appears to interfere with therapeutic success, which may be related to deviation from standard care practices and, again, failure to make an accurate diagnosis.

Strategies for Successful Treatment

Effective treatment of the VIP patient may require additional attention to privacy, and placing limitations on visitors. It also may be necessary to explain that the care provided will be identical to that given to other patients with the same condition — and why that is important.8

Any case in which numerous parties are involved can lead to distorted communication and “splitting” of the team, so clear communication between team members and explicit demarcation of authority are vital. The high profile of the VIP can also lead to increased threats to the patient’s confidentiality, so how to manage communication with parties outside of the hospital also needs to be addressed.

One strategy that may be useful in management of the psychiatric inpatient VIP is to obtain a second opinion. Unlike other clinicians, who have the luxury of relying upon standard blood tests or imaging to confirm diagnosis, psychiatrists must diagnose with some degree of subjectivity.

Of course, all efforts should be taken to make an accurate diagnosis; a thorough clinical evaluation, review of previous medical records, laboratory studies, neuroimaging, and neuropsychological testing when appropriate, and collateral information obtained from family members and friends to corroborate the longitudinal course of the illness should be considered before a diagnosis is made.

However, particularly if the diagnosis is one that is difficult for the patient or other involved parties to accept (and that may require vigorous treatment), a second opinion may strengthen the case and increase the likelihood that proper treatment will be accepted.

Additional suggestions for caring for VIP patients are listed in the Sidebar.

Sidebar.

  1. Don’t bend the rules.

  2. Work as a team — with an appointed leader.

  3. Communicate clearly with team members.

  4. Manage communication with media.

  5. Resist transferring to the most senior clinician (unless that person is the best for that clinical situation).

  6. Care for the patient where most appropriate, not where most desired.

  7. Protect the patient’s security.

  8. Treat gifts and favors with caution.

  9. Work collegially with personal physicians from outside the institution.

Conclusion

Treatment of the inpatient psychiatric VIP presents unique challenges. As with all patients, clinicians should assure that diagnoses are accurate and complete, including the presence of substance use disorders and personality disorders. Although special treatment should not be given in general, additional measures may be necessary to maintain privacy for the patient. A second opinion approach may be used to clarify the diagnostic formulation and support the recommended treatment plan.

References

  1. Alexander L. The commitment and suicide of King Ludwig II of Bavaria. Am J Psychiatry. 1954;111(2):100–107.
  2. Weintraub W. “The VIP Syndrome”: A Clinical Study In Hospital Psychiatry. J Nerv Ment Dis. 1964;138:181–193. doi:10.1097/00005053-196402000-00012 [CrossRef]
  3. Pearson MM, Strecker EA. Physicians as psychiatric patients: private practice experience. Am J Psychiatry. 1960;116:915–919.
  4. Duffy JC, Litin EM. Psychiatric morbidity of physicians. JAMA. 1964;189:989–992. doi:10.1001/jama.1964.03070130009002 [CrossRef]
  5. A’Brook MF, Hailstone JD, McLaughlan IE. Psychiatric illness in the medical profession. Br J Psychiatry. 1967;113(502):1013–1023. doi:10.1192/bjp.113.502.1013 [CrossRef]
  6. Simon W, Lumry GK. Suicide among physician-patients. J Nerv Ment Dis. 1968;147(2):105–112. doi:10.1097/00005053-196808000-00002 [CrossRef]
  7. Jones RE. A study of 100 physician psychiatric inpatients. Am J Psychiatry. 1977;134(10):1119–1123.
  8. Block AJ. Beware of the VIP syndrome. Chest. 1993;104(4):989. doi:10.1378/chest.104.4.989b [CrossRef]
  9. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011;78(2):90–94. doi:10.3949/ccjm.78a.10113 [CrossRef]

CME Educational Objectives

  1. Appreciate patterns in the management of the VIP on inpatient psychiatric units as supported by the literature.

  2. Understand the unique challenges presented by a VIP inpatient on the psychiatric unit.

  3. Identify at least three strategies for appropriate management of the inpatient psychiatric VIP.

Sidebar.

  1. Don’t bend the rules.

  2. Work as a team — with an appointed leader.

  3. Communicate clearly with team members.

  4. Manage communication with media.

  5. Resist transferring to the most senior clinician (unless that person is the best for that clinical situation).

  6. Care for the patient where most appropriate, not where most desired.

  7. Protect the patient’s security.

  8. Treat gifts and favors with caution.

  9. Work collegially with personal physicians from outside the institution.

Authors

Megan B. Schabbing, MD, is Assistant Professor, Department of Psychiatry, The Ohio State University.

Dr. Schabbing has disclosed no relevant financial relationships.

Address correspondence to: Megan B. Schabbing, MD, via email: .megan.schabbing@osumc.edu

10.3928/00485713-20111229-06

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