The dissociative disorders (DDs) are a disturbance in the organization of identity, memory, perception, or consciousness involving both restricted access of information to consciousness and disruptions of consciousness. One of the important developments in the modern understanding of DDs is the establishment of a clearer link between trauma and dissociation. Dissociative Identity Disorder (DID) is the most popular, widely discussed, and recognized of the DDs. Pathological possession has been included as a symptom of DID in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Dissociative amnesia represents the classical functional disorder of episodic memory. Depersonalization/Derealization Disorder (DPDRD) involves lack of integration of one or more components of perception and characterizes by “the presence of recurrent or persistent experiences of depersonalization, derealization, or both”. The symptoms of depersonalization and/or derealization frequently co-occur in a variety of other psychiatric disorders, primarily in patients with anxiety disorders.
This chapter focuses on the diagnoses of pediatric separation anxiety disorder, social anxiety disorder, and generalized anxiety disorder because of their symptom overlap and frequent comorbidity. The research cited here is largely based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-IV) and DSM-IV-TR criteria. The chapter considers the diagnostic features of the three specific disorders. Research and clinical reports have identified a developmental progression of anxiety disorders in childhood and adolescence. Childhood anxiety disorders develop as a result of a multitude of biological, psychological, and social/environmental influences. The development and maintenance of anxiety disorders is strongly influenced by learning and fear conditioning. Several studies have examined response to anxiety treatment for youth with comborbid diagnoses. Youth with Autism Spectrum Disorder (ASD) appear to respond well to cognitive behavioral therapy (CBT) for anxiety protocols that have been adapted to address the additional symptoms associated with ASD.
Clinical vignettes described throughout this chapter illustrate that the physician-patient relationship is composed of both the reality-based component (the working alliance or therapeutic alliance) and the fantasy-based component (the transference) derived from the patient's patterns of interpersonal behavior learned in childhood. Either or both of these may maximize or limit the patient's sense of reassurance, available information, feelings of comfort, and sense of hope. In this way, the nonspecific curative aspects of the physician–patient relationship may be enhanced or diminished. Managed care, broadly defined as any care of patients that is not determined solely by the provider, currently focuses on the economic aspects of delivering medical care, with little attention thus far to its potential effects on the physician-patient relationship. Establishing an effective physician-patient relationship with children, adolescents, and families is one of the most challenging and rewarding tasks in the practice of psychiatry.
Psychiatric emergency services (PESs) have been evolving since the beginning of community-based care. Early on, psychiatric patients overwhelmed emergency departments (EDs) that had few staff with appropriate training and little space for psychiatric emergencies. Teams began to form inside hospitals to include psychiatrists, psychologists, nurses, and social workers to work more specifically with the mentally ill population. Care has become more specialized for the treatment of psychiatric emergencies. When it comes to treating a psychiatric emergency, the first goal is basic evaluation and stabilization. Encephalitis, CNS depressant withdrawal, and alcohol intoxication can all present with seemingly psychotic behavior: delayed medical attention can be fatal. Mobile crisis services, which once focused on triage, now offer much more support and brief therapies. Crisis stabilization and larger respite facilities tend to have a more therapeutic focus, rather than warehousing of patients.
For longer than 40 years, the cognitive and behavioral therapies have evolved as alternatives to more traditional nondirective and insight-oriented modes of psychotherapy (1). The cognitive and behavioral therapies now include a diverse group of interventions that share several pragmatic and theoretical assumptions. First, there is an emphasis on psychoeducation: patients are assumed to be capable of learning about their disorder and the interventions they will need to treat it. Second, homework and self-help assignments are usually recommended to provide patients the opportunity to practice therapeutic skills and to generalize positive behaviors outside of the therapy hour. Third, treatment is based on the objective assessment of psychiatric symptoms and selection of therapeutic strategies derives logically from such assessments. Fourth, the therapeutic methods used are generally structured, directive, and characterized by a high level of therapist activity. Fifth, for most disorders, the cognitive and behavioral therapies are time-limited interventions. Sixth, these therapies are based on empirical evidence that validates and guides the choice of therapeutic techniques: learning theory (i.e., classical, operant, and observational models of learning) and the principles of cognitive psychology.
The management of geropsychiatric patients involves a variety of intersecting elements. These include the aging process itself, age-related medical illness, cognitive loss (dementia, delirium), and changes in the role of the patient in the family and society. Loss of independence involves adaptation not only for the patient, but also for the patient's family and community. Loss of cognition usually involves a reduction in function (activities of daily living) as well as significant behavioral disturbances. Both nonpharmacologic and pharmacologic management of these behavioral disturbances are challenging and increasingly controversial areas. Depression in the elderly may represent a continuation or recurrence of an existing illness, or the onset of a new disorder. Late life onset depression must be understood in the context of aging, loss, and grief as well as comorbid medical and neurological illness. Suicide in the elderly, especially in men, is more frequent than in most other population groups. Depression in the elderly should be viewed as a treatable condition rather than a normal response to aging. The full range of therapies can be utilized, including psychotherapy, pharmacotherapy, and electroconvulsive therapy.
Brain stimulation spans our oldest to our newest treatment modalities in psychiatry. From the introduction of convulsive therapy in the 1930s, to the growing list of novel investigational treatments (e.g., transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), transcranial direct current polarization (tDCS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and epidural cortical stimulation), brain stimulation now comprises a unique family of therapeutic interventions that act via electromagnetic stimulation of the brain. These interventions differ in their degree of invasiveness, focality, efficacy, side effects, and mechanisms of action. Two (electroconvulsive therapy (ECT) and VNS) are currently U.S. Food and Drug Administration (FDA) approved, while the others are at various stages of clinical testing and FDA review. Collectively, these modalities have provided valuable information regarding basic brain functions and the pathophysiology of psychiatric illness. They also offer hope to patients who are experiencing severe psychiatric disorders that have failed to respond to conventional psychotherapy or psychopharmcology. This chapter reviews each brain stimulation modality, discussing its history, mechanisms of action, side effects, role in basic studies of pathophysiology, evidence for clinical efficacy, current status in treatment algorithms, patient selection, dosing, and future directions. As new brain stimulation techniques gain FDA approval and enter the realm of clinical practice, the field will be in the position to assess the ultimate clinical role of these modalities, and their proper place in treatment algorithms with respect to the original brain stimulation treatment in psychiatry—ECT.
Psychiatrists and other mental health professionals require an understanding of the organization and financing of care for persons with mental illness. The organization and financing of care have evolved over time in different countries and different states within the United States. This chapter describes the history of how the "system" of care in the United States has developed over several hundred years and how current public policy issues are likely to affect the short-and long-term future. It emphasizes the organization and financing of care in the specialty mental health sector since that has been of primary interest to mental health professionals and public policy makers. In addition, the chapter describes emerging models of collaborative care for the large numbers of patients seen in the general healthcare sector.
Mental health advocacy, self-help services for psychiatric disorders, and client-operated services represent three distinct concepts with organizations and individuals engaging in one, two, or all three activities at the same time. Client-operated services are used in this chapter to refer to services that are provided by individuals living with mental illness. The two most prominent advocacy organizations in the United States have been Mental Health America (MHA) and the National Alliance on Mental Illness (NAMI), formerly known as the National Alliance for the Mentally Ill. Peer counselors employed within the medical treatment industry can provide a form of peer support in this more traditional setting. However, programs that have been designed and developed by clients have permitted the development of important models for peer-oriented services. One of the most influential models has been the clubhouse model for psychosocial rehabilitation that grew out of Fountain House in New York City.
Careful evaluation of the cultural context of psychiatric problems must form a central part of any clinical assessment. The outline for a cultural formulation in DSM-IV-TR provides a useful checklist of basic issues to address, including the cultural, ethnic, religious, and linguistic identity of the patient; illness explanations and healing practices; social stress, support, and functioning; and models of the roles and relationship of doctor and patient. Psychiatric theory and practice reflect cultural assumptions that patients and clinicians may not share. Lack of awareness of important differences between patients and clinicians on any of these dimensions can undermine the development of a therapeutic alliance and the negotiation and delivery of effective treatment. Mainstream care cannot respond adequately to the needs of a diverse population unless it gives explicit attention to cultural issues. The ethnocultural diversity of mental health professionals itself represents an invaluable resource. The training programs must recognize this, and make it safe for clinicians to explore their own ethnocultural background and assumptions as a path to more sensitive and responsive work with others. Ultimately, cultural competence involves knowing one's own assumptions, biases, and limitations, and working collaboratively with patients, their families, and community as well as with trained interpreters and culture-brokers, toward goals that have been negotiated through open dialogues.
Treatment-resistant depression (TRD) is a common and challenging problem facing the practicing psychiatrist. This chapter focuses primarily on unipolar TRD. In the case of lithium augmentation for unipolar depression, it is most prudent to initiate treatment in the lower range of the therapeutic window, and to increase levels gradually according to clinical judgment. In considering various treatment strategies for TRD, lithium augmentation may be considered preferentially for subjects who have a positive family history of bipolar disorder or soft signs/symptoms themselves of bipolarity. Personalized medicine technologies likely to find a role in clinical care of TRD include functional brain imaging including PET and functional MRI (fMRI). An ideal clinical trial for TRD requires a very large number of subjects, because the first step in treatment is effective for many of the entering subjects, dramatically reducing the relevant subject pool for the next step of the study.
Guangzhou Psychiatric Hospital is the oldest hospital in China that specializes in psychiatry. Guangzhou Psychiatric Hospital plays a crucial role in mental healthcare in southern China. This article briefly discusses the general characteristics of Guangzhou Psychiatric Hospital.
In this article, we investigated the current practice for treatment of schizophrenia. According to our data, physicians consider one-product regimens 53 percent of the time. Two-product regimens are considered 29 percent of the time, and regimens of three or more products are considered 18 percent of the time. At the point of the patient visit, antipsychotic medications comprise 97 percent of treatment regimens. Fifty-six percent of treatment regimens involve only antipsychotic medications. Classes used to supplement antipsychotic medications in the treatment of schizophrenia include antidepressants (20%), mood stabilizers (15%), anti-anxiety (7%) drugs, and drugs to treat extrapyramidal symptoms (6%). An expert commentary is also included with the data.
This article concludes the series on cranial nerves, with review of the final four (IX-XII). To summarize briefly, the most important and common syndrome caused by a disorder of the glossopharyngeal nerve (craniel nerve IX) is glossopharyngeal neuralgia. Also, swallowing function occasionally is compromised in a rare but disabling form of tardive dyskinesia called tardive dystonia, because the upper motor portion of the glossopharyngel nerve projects to the basal ganglia and can be affected by lesions in the basal ganglia. Vagus nerve funtion (craniel nerve X) can be compromised in schizophrenia, bulimia, obesity, and major depression. A cervical lesion to the nerve roots of the spinal accessory nerve (craniel nerve XI) can cause a cervical dystonia, which sometimes is misdiagnosed as a dyskinesia related to neuroleptic use. Finally, unilateral hypoglossal (craniel nerve XII) nerve palsy is one of the most common mononeuropathies caused by brain metastases. Supranuclear lesions of cranial nerve XII are involved in pseudobulbar palsy and ALS, and lower motor neuron lesions of cranial nerve XII can also be present in bulbar palsy and in ALS patients who also have lower motor neuron involvement. This article reviews these and other syndromes related to cranial nerves IX through XII that might be seen by psychiatry.
29 INTRODUCTION After medical school, most psychiatrists are not likely to think about treating phenylketonuria (PKU) in their practices. After all, PKU is a rare, genetic disorder of amino acid metabolism identified at birth by pediatricians and treated by geneticists. But, PKU is also a disorder that, if left untreated, leads to severe behavioral difficulties and ultimately mental retardation. The identification of PKU during routine newborn screening and management with a diet low in phenylalanine became standard practice in the early 1960s, thereby averting the severe complications of PKU. Nonetheless, cognitive and behavioral problems remain a significant cause of morbidity in the PKU population. Several studies have documented attentional deficits, school difficulties, and mood disorders among adolescents and adults with PKU. In addition, there remain the obvious psychosocial consequences for a young child or adolescent who has to deal with a chronic disease and special diet. Recently, with the advent of medication to help manage blood phenylalanine (phe) levels, there has been a greater effort to characterize the prevalent difficulties experienced by individuals with PKU. For this column, I interviewed William Lang, MD, FACP, Senior Medical Director, BioMarin Pharmaceutical Inc., Marin County, California. Dr. Lang and BioMarin are exploring the effects of a medication, sapropterin dihydrochloride, on neuropsychiatric symptoms in patients with PKU with a clinical trial that is being conducted at more than 30 sites in the United States and Canada (Clinicaltrials.gov NCT01114737: Safety and Therapeutic Effects of Sapropterin Dihydrochloride on Neuropsychiatric Symptoms in Phenylketonuria (PKU) Patients).
Objective. There exists uncertainty regarding the role of magnetic resonance imaging in the evaluation of intensive care unit delirious patients. This case series describes preliminary magnetic resonance imaging findings obtained because of delirium, subsequent in-hospital clinical decisions, and post-discharge neurocognitive outcomes in intensive care unit survivors.Design. Case series.Setting. Intensive care unit.Participants. Eight patients who underwent magnetic resonance imaging for delirium in the absence of focal neurological findings as part of their intensive care unit clinical care.Measurements. Magnetic resonance imaging findings, clinical decisions following magnetic resonance imaging, and three-month neuropsychological outcomes were obtained.Results. Of the eight patients, six (75%) demonstrated white matter hyperintensities, one (12%) had mild atrophy, and no patient had ischemic/hemorrhagic lesions. Magnetic resonance imaging did not lead to new diagnoses or immediate changes in therapy. All six patients who underwent neuropsychological testing had severe impairments in memory, executive function, and attention at three months, despite the absence of baseline cognitive impairment.Conclusion. Magnetic resonance imaging findings in these delirious intensive care unit patients did not alter the immediate treatment course and these patients had neuropsychological impairments at three months. Future research is warranted to define the role of current and newer magnetic resonance imaging techniques in assessing and managing delirious intensive care unit patients, and to examine relationships between in-hospital magnetic resonance imaging findings (i.e. white matter hyperintensities) and short- and long-term neurological outcomes.
OBJECTIVE To test the hypothesis that long-term maintenance with injectable risperidone long-acting therapy is superior to oral daily aripiprazole in stable patients with schizophrenia. DESIGN This two-year, rater-blinded, open-label, multicenter study (NCT00299702) randomized subjects to injectable risperidone long-acting therapy (25-50mg, injected every 2 weeks) or oral aripiprazole (5-30mg/day), with study visits every two weeks. Subjects who met relapse criteria or discontinued study drug could remain in the study. SETTING Clinical trial. PARTICIPANTS Stable subjects with schizophrenia not adequately benefiting from current treatment who experienced two or more relapses in the past two years. If recently relapsed, subjects were stabilized (per clinician judgment) for two or more months before entry. MEASUREMENTS Primary endpoints: time to relapse and time in remission. Safety assessments included adverse event reporting. RESULTS Of 355 subjects randomized, 349 were in the intent-to-treat analysis set. Data inspection revealed that 53 (14.9%) randomized subjects deviated from inclusion/exclusion criteria, most commonly not meeting stability requirements. At baseline, mean (standard deviation [SD]) Positive and Negative Syndrome Scale total score was 68.9 (14.6); 115 (33.0%) intent-to-treat subjects met remission criteria. Approximately 29 percent in each group discontinued the study before completing two years. No significant between-group differences were noted in time to relapse or time in remission. No new tolerability issues were identified. CONCLUSION RESULTS failed to demonstrate superiority with injectable risperidone long-acting therapy versus oral aripiprazole. The study design did not allow for valid conclusions of equivalence or noninferiority. Although this study attempted to mimic a real-world treatment setting for stable patients, the broad study population, the lack of patient selection for nonadherence, biweekly visits, regular assessments, and other design issues limited generalizability and interpretation relative to the study hypothesis.
Sudden cardiac death has become a significant clinical concern when prescribing antipsychotic drugs, especially to older people with dementia. Sudden death syndrome has been known for decades to occur in association with taking first-generation antipsychotic medications, but it has become more prominent recently due to safety reviews about the use of second-generation antipsychotic medications. In 2005, the United States Food and Drug Administration disseminated information about cardiac fatalities, which led to black box warnings in second-generation, antipsychotic, drug-prescribing literature about higher mortality when administering to elderly persons with dementia-related psychoses. In this population, treatment results in death rates of 4.5 percent, as compared to 2.6 percent in subjects taking a placebo. Actually, patients treated with both the first- and second-generation versions experienced an increased incidence of fatalities. Before utilizing these agents, a careful workup must be completed. The presence of a psychosis or mania should be the only conventional indication for prescribing first- and second-generation antipsychotic medications. Physicians should always evaluate patients for comorbid conditions, especially heart disease and metabolic abnormalities, and all currently used medications to assure a risk-to-benefit ratio favoring the application of an antipsychotic medication. An electrocardiogram is a part of the evaluation of the cardiac status and determines the base line QT interval. While prescribing these medications in elderly patients, physicians must provide individualized clinical, electrocardiographic, and pharmaceutical monitoring.
The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is anticipated in May 2013 with many new additions and changes. In this article, the author summarizes the phases of psychiatric classification from the turn of the 20th century until today. Psychiatry 2010 offers a DSM-V Scientific Forum and invites readers to submit comments, recommendations, and articles to Psychiatry 2010 and DSM-V Task Force.
