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PubMed2004

Disclosure of a diagnosis of borderline personality disorder.

OBJECTIVE: Borderline personality disorder (BPD) is a common psychiatric disorder with a prevalence of 1%-2% in the general population. BPD also has the potential to cause significant distress in the lives of patients with BPD and their families. The diagnosis of BPD, however, is often withheld from patients. The purpose of this article is to explore the history of diagnostic disclosure in medicine and psychiatry and then discuss reasons why clinicians may or may not disclose the diagnosis of BPD. METHODS: The authors review medical literature about diagnostic disclosure and other issues that may affect the decision to disclose a diagnosis of BPD. RESULTS: The authors discuss the historical precedents for diagnostic disclosure and reasons a clinician may not disclose the diagnosis of BPD to a patient: questions regarding the validity of BPD as a diagnosis, worries about the stigma of the diagnosis being harmful to the patient, and transference/countertransference issues common in the treatment of patients with BPD. The authors cite factors promoting disclosure, such as the ideal of patient autonomy, possibilities for psychoeducation and collaboration with the patient toward more specific and effective therapies, and the increasing availability of diagnostic information available to patients from sources other than their clinicians. CONCLUSIONS: There are compelling reasons to make the diagnosis the subject of open examination and discussion between clinician and patient, and reasons to believe that disclosure would serve to advance the patient in his or her recovery.

Borderline Personality Disorder↗

PubMed2004

Suicidal behavior and self-disclosure in adolescent psychiatric inpatients.

The inability to communicate feelings and thoughts to people close to oneself may be an important risk factor for suicidal behavior. This inability has been operationalized in the concept of self-disclosure. The purpose of this article was to evaluate the correlation of self-disclosure with suicidal behavior in adolescents. Eighty consecutive admissions to an adolescent psychiatric inpatient unit were evaluated. Thirty-four were suicide attempters, 18 were suicidal ideators, and 18 were nonsuicidal. Assessment measures included the Child Suicide Potential Scale, the Suicide Intent Scale, the Suicide Ideation Scale, and the Self-Disclosure Scale. The results show that low self-disclosure levels are associated with suicidal thinking, suicide attempts, and suicidal attitudes. Thus, low self-disclosure may well be a risk factor worthy of further evaluation in the attempt to understand adolescent suicidal behavior.

Adolescent↗

PubMed2003

Prevalence and correlates of HIV serostatus disclosure.

BACKGROUND AND OBJECTIVE: A study of HIV-positive individuals in New Orleans, Louisiana, found that the majority of patients disclosed to their main partners and family members, but less than one fourth disclosed to any casual sex partner. Older age and lower CD4 cell counts were associated with disclosure. GOAL: The goal was to describe patterns of HIV serostatus disclosure among a diverse sample of patients at an HIV outpatient clinic in New Orleans, Louisiana. STUDY DESIGN: A convenience sample of HIV-seropositive patients provided information about disclosure of seropositivity, demographics, date of HIV diagnosis, CD4 cell count, mode of HIV acquisition, and sexual activity since HIV diagnosis. RESULTS: The 269 persons disclosed their HIV status to people in the following categories: main sex partner (74.2%), casual sex partner (24.8%), immediate family member (69.8%), other relative (27.0%), or friend (26.4%). Adolescents were less likely than adults to disclose to a main partner, immediate family member, or a friend. Immunosuppressed persons were more likely than nonimmunosuppressed persons to disclose to a main partner, immediate family member, or another relative. CONCLUSION: Many HIV-infected individuals delay disclosure until their disease has progressed. Interventions such as partner notification and skill-building to facilitate appropriate HIV disclosure are needed.

Adolescent↗

PubMed2005

Respiratory sinus arrhythmia predicts written disclosure outcome.

Research has indicated that writing about traumatic experiences is associated with beneficial health effects compared with writing about emotionally neutral topics. What remains unclear are those factors that moderate the beneficial effects associated with written disclosure. This study examined respiratory sinus arrhythmia (RSA) as a moderator of written disclosure outcome. Findings indicated that individuals with the highest RSA during the first written disclosure session benefited most from written disclosure in terms of physical health complaints and depression symptoms. As expected, RSA did not impact outcome for participants assigned to a control condition. These findings indicate that individuals who display good emotion regulation skills are best served by written disclosure.

Adaptation, Psychological↗

PubMed2005

Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure.

An important element of how adverse events are handled is effective communication between health care providers and patients and their families. This review addresses the main questions: What do patients expect in the aftermath of an adverse event? What is known about the practice of open disclosure? How can organizations support health care providers in the aftermath of an adverse event, both professionally and personally? Patients clearly expect open disclosure to include an explanation of what happened, an apology for harm done, that appropriate remedial action will be taken and an explanation of what will be done to learn from the event and to prevent recurrence. Research has found that open disclosure is not very common although the ethical duty to disclose is widely acknowledged. Barriers to open disclosure include discomfort and a lack of training how to disclose, a fear of litigation, a culture of infallibility among health professionals, and inadequate systems for analysis, discussion and learning from mistakes. Significant commitment is required from health care organizations and managers to develop frameworks for open disclosure to occur, to assure its quality and to support health care providers in this process. Organizations also need to address the emotional needs of health care professionals in the aftermath of an adverse event. Last but not least, adequate systems for debriefing and incident analysis need to be in place to learn from adverse events and to avoid recurrence.

Anesthesia↗

PubMed2006

Disclosure of medical errors: what factors influence how patients respond?

BACKGROUND: Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited. OBJECTIVE: This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors. PARTICIPANTS: Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure. DESIGN: Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome. MEASURES: Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response. RESULTS: Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact. CONCLUSIONS: This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain.

Attitude to Health↗

PubMed1980

Neuroticism, social desirability and anticipations and attributions affecting self-disclosure.

The first part of this research, a questionnaire study on 260 single British males, found neuroticism to be inversely related to need for social approval, thus raising an issue about the validity of the EPI-N scale. From the second part, a laboratory study with 48 subjects selected by the questionnaire study, there were four main findings: (1) an earlier finding, that most subjects tended in the direction of a double standard in which they anticipated more risk stemming from their own than from their friend's negative self-disclosures, was replicated highly significantly; (2) neuroticism was not associated significantly with differences in anticipated reactions for either negative or positive self-disclosures; (3) there was a large and highly significant main effect for order, with those subjects who first rated their own reactions to their friend's negative self-disclosures anticipating being esteemed less negatively than those who first rated their friend's reactions to their own negative self-disclosures; and (4) there were significant differences for some characteristics between self-attribution and friend's attribution after negative self-disclosure. Practical implications of the above findings are explored.

Adult↗

PubMed2005

Disclosure preferences regarding cancer diagnosis and prognosis: to tell or not to tell?

Telling people that they have cancer has a great impact on their lives, so many doctors are concerned about how they should inform patients about a cancer diagnosis and its prognosis. We conducted a general population survey in Japan to investigate people's preferences on receiving this information. There were no significant differences in respondents' preferences according to the seriousness of the cancer. Full disclosure of the diagnosis was preferred by 86.1% of the respondents, while 2.7% wanted non-disclosure. As for the initial provision of information, the majority preferred partial disclosure concerning the prospects of complete recovery (64.5%) and the expected length of survival (64.1%). Those who responded negatively to the statement, "If I am close to the end of my life, I want to be informed of the fact so I can choose my own way of life", were more likely to want non-disclosure on diagnosis. The results suggest that, at the first opportunity of providing information, a disclosure policy of giving patients full details of their diagnosis and some information on prognosis can satisfy the preferences of most patients. Contrary to popular belief, the seriousness of the cancer and people's demographic characteristics displayed little impact in this study.

Adult↗

PubMed2002

A system of medical error disclosure.

External mandates for medical error disclosure are often justified by potential cost savings, the belief in individual moral obligations in health care, and the concept that patients have rights and providers have responsibilities. Such an approach does not recognise the systems nature of error and outcomes and the important quality role disclosure can play in a system of medical error disclosure. Systems concepts, the patient-provider partnership, and overall quality of care can be enhanced using a system of disclosure that provides for education about the systems nature of error, fulfills the delivery system philosophy of mutual respect, and integrates the patient and his/her family as a partner in the error reduction enterprise. Such a system can result using clear disclosure policies and procedures sensitive to patient and family needs, open communications with concerned, committed, and compassionate system representatives, and use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Although a system may also result in conflict resolution costs, more importantly it may foster and solidify a team approach to reducing errors and promoting patient safety.

Humans↗

PubMed2006

Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.

OBJECTIVE: To assess whether patients' perceptions of a hypothetical medical error are influenced by staff responsiveness, disclosure of error, and health consequences of the error. DESIGN: Hypothetical scenario describing a medication error submitted by mail. Three factors were manipulated at random: rapid v slow staff responsiveness to error; disclosure v non-disclosure of the error; and occurrence of serious v minor health consequences. PARTICIPANTS: Patients discharged from hospital. MEASURES: Assessment of care described in the scenario as bad or very bad, rating of care as unsafe, and intent to not recommend the hospital. RESULTS: Of 1274 participants who evaluated the scenario, 71.4% rated health care as bad or very bad, 60.2% rated healthcare conditions as unsafe, and 25.5% stated that they would not recommend the hospital. Rating health care as bad or very bad was associated with slow reaction to error (odds ratio (OR) 2.8, 95% CI 2.1 to 3.6), non-disclosure of error (OR 2.0, 95% CI 1.5 to 2.6), and serious health consequences (OR 3.4, 95% CI 2.6 to 4.5). Similar associations were observed for rating healthcare conditions as unsafe and the intent to not recommend the hospital. Younger patients were more sensitive to non-disclosure than older patients. CONCLUSIONS: Former patients view medical errors less favorably when hospital staff react slowly, when the error is not disclosed to the patient, and when the patient suffers serious health consequences.

Adolescent↗

PubMed2002

The problem of self-disclosure in psychoanalysis.

The problem of self-disclosure is explored in relation to currently shifting paradigms of the nature of the analytic relation and analytic interaction. Relational and intersubjective perspectives emphasize the role of self-disclosure as not merely allowable, but as an essential facilitating aspect of the analytic dialogue, in keeping with the role of the analyst as a contributing partner in the process. At the opposite extreme, advocates of classical anonymity stress the importance of neutrality and abstinence. The paper seeks to chart a course between unconstrained self-disclosure and absolute anonymity, both of which foster misalliances. Self-disclosure is seen as at times contributory to the analytic process, and at times deleterious. The decision whether to self-disclose, what to disclose, and when and how, should be guided by the analyst's perspective on neutrality, conceived as a mental stance in which the analyst assesses and decides what, at any given point, seems to contribute to the analytic process and the patient's therapeutic benefit. The major risk in self-disclosure is the tendency to draw the analytic interaction into the real relation between analyst and patient, thus diminishing or distorting the therapeutic alliance, mitigating transference expression, and compromising therapeutic effectiveness.

Countertransference↗

PubMed2005

Emotional disclosure and closeness toward offenders.

Two studies tested whether emotional disclosure increases feelings of closeness toward offenders. In Study 1, participants recalled either someone who had offended them or a neutral acquaintance. "Disclosure" participants then expressed their thoughts and feelings regarding their targets, and "suppression" participants described their targets nonemotionally. As predicted, disclosure increased closeness toward offenders but not toward acquaintances. Study 2 extended these results by including a good friend to test whether disclosure selectively increases closeness toward offenders, and not simply toward any person who evokes strong feelings. This prediction was confirmed. Furthermore, the disclosure effect remained reliable even after controlling for mood. Studies 1 and 2 also showed that closeness toward offenders, but not toward friends or acquaintances, was positively related to the proportion of emotion-related words disclosed. Collectively, these findings suggest that confronting the emotions associated with an offense may be an important first step toward forgiveness.

Analysis of Variance↗

PubMed2004

The impact of type of out-of-court disclosure in a child sexual assault trial.

This study investigated the impact of type of out-of-court disclosure in a child sexual assault case involving a 6-year-old alleged victim. Community participants read a fictional criminal trial summary of a child sexual assault case in which the alleged victim's out-of-court disclosure of the assault was: (a) complete on two occasions or (b) incomplete at first, but later included the full account of the incident. The results showed that there were more guilty verdicts, higher ratings of the defendant's guilt, and greater belief of the alleged victim when there was full disclosure on two occasions compared to when there was a delay in full disclosure. These results are discussed in terms of the impact the nature of out-of-court disclosure can have when a child testifies in a sexual assault case.

Adult↗

PubMed2005

Effects of emotional disclosure on psychological and physiological outcomes in patients with rheumatoid arthritis: an exploratory home-based study.

The effects of an exploratory, home-based emotional disclosure intervention on psychological and physiological outcomes were assessed in patients with rheumatoid arthritis. Patients were randomly assigned to a disclosure group (n = 19) in which they wrote/talked about traumatic personal experiences, or to a control group (n = 15) in which they wrote/talked about the events of a particular day. Participants undertook these tasks for periods of 20 minutes on 4 consecutive days. The disclosure group demonstrated increases in negative mood and objective markers of disease activity at 1 week post-intervention. However, there were significant trends for the disclosure group to demonstrate minor improvements in mood and stability in disease activity, compared with the control group. These group differences appeared to be due to deteriorations in the control group more than improvements in the disclosure group.

Activities of Daily Living↗

PubMed2005

When is public disclosure of HIV seropositivity acceptable?

HIV/AIDS is a major public health problem in Africa. Stigmatization, discrimination and lack of appropriate health care are among the commonest challenges that HIV infected persons and their families face. It has been suggested that among the tools available in the fight against stigmatization and discrimination is public disclosure of a person's HIV seropositive status. While public disclosure of HIV status has a place in the fight against HIV and AIDS, especially by resulting in behavioural change among people who know of an HIV infected person, we argue that such disclosure also has potential attendant harms. The posthumous disclosure of HIV status is particularly problematic. Public disclosure should be accompanied by appropriate individual counselling and preparation of the community to deal with the situation, and should have regard for cultural sensitivity after consideration of the risks and benefits to individuals, families and the community. Health practitioners should keep in mind that their main duty is to the best interest of the patient, the family and the community, in that order.

Africa↗

PubMed2006

Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

OBJECTIVES: To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. METHODS: A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. RESULTS: Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p < 0.01). Nurses were less likely to disclose an error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p < 0.01). For all provider and error types, identification, disclosure, and reporting increased with increasing severity. CONCLUSIONS: Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

Academic Medical Centers↗

PubMed2002

A double standard in bioethical reasoning for disclosure of advanced cancer diagnoses in Japan.

This article examines the Japanese double standard in bioethical reasoning with respect to disclosure of advanced cancer diagnoses. This article is devoted to the analysis of communication styles preferred among the Japanese across different hypothetical situations involving cancer as one's own illness as opposed to cancer as a family member's illness. Generally, the Japanese prefer the use of a direct communication style, involving disclosure of the true diagnosis for their own cancer. When cancer is a family member's illness, however, many Japanese perceive the use of an indirect communication style, involving no disclosure or ambiguous disclosure to the patient more ethical than direct communication of the diagnosis. This article explores how and why the Japanese use this double standard when making judgments about the morality of disclosing an advanced cancer diagnosis to the patient. Policy and educational implications for reconciling such a double standard in bioethical reasoning for cancer disclosure are discussed as conclusions.

Bioethics↗

PubMed1997

Women's disclosure of HIV status: experiences of mistreatment and violence in an urban setting.

Women represent an increasing proportion of AIDS cases and anecdotal reports suggest some face substantial risks when others learn they are HIV-positive. The purpose of this paper is to describe women's fears and experiences regarding disclosure of their HIV status. Fifty HIV-positive women, ages 16-45 from urban teaching hospital outpatient clinics, were interviewed using an in-depth, qualitative interview. Eighty-six percent of the women were African American and 56% were current or former IVDU. At the time of the interview, 88% of the women had known their HIV status for a year or more. All but one woman had disclosed her HIV status to at least one person and 82% had disclosed to multiple people. Although two-thirds of the women had been afraid to disclose to others because of concerns about rejection, discrimination or violence, three-quarters of the sample reported only supportive and understanding responses to their disclosure. One-quarter of the sample reported negative consequences of disclosure, including rejection, abandonment, verbal abuse and physical assault. Disclosure-related violence was discussed by nine women (18%): two who feared violence were relieved to find a supportive response; four chose not to disclose their status because they feared violence; and three women were verbally or physically assaulted. Fear of mistreatment figured prominently in decisions about disclosure among this sample. That many women found supportive and understanding responses is encouraging. However, there were sufficient examples of negative consequences, including violence, to suggest individualized approaches to post-test counseling, enhanced support services for HIV-positive women, and public education to destigmatize HIV-disease.

Adolescent↗