The Psychiatric clinics of North America

Published by WB Saunders
Print ISSN: 0193-953X
Publications
I have presented two in-depth, clinical vignettes that illustrate basic issues from early sessions with DID patients in phase one therapy. In these examples, I show how themes that present in initial sessions, and work on their resolution, can set the framework for successful stabilization of the DID patient. Major themes have included unconscious posttraumatic responding, the therapeutic alliance, the patient's responsibility for safety, skill building and management of symptoms using imagery, and structuring the treatment frame to work on acute crises.
 
To some extent, the emotional experiences of the therapists whose stories the authors narrated above may be different from the reports of therapists in other US disasters. To some extent, they appear similar. Among the therapists, it was, first, the scale of the event, combined with the absence of warning and confusion as to understanding its cause that was pivotal. As for other Americans, this was a truly unique, tragic, and historic event. As a terrorist event on US soil it was unprecedented, an act of human malevolence against civilians. Comprehending such a catastrophe is overwhelming for victims, families, rescue workers, and therapists. Loss of a national fantasy of safety and the realistic threat of future attacks have changed Americans' view of themselves and their world. Therapists and patients alike experienced the same fear, helplessness, disbelief, confusion, sorrow, and anger. As a paradigmatic example of event countertransference, all were left wondering, what's next? But much countertransference to the particulars of 9/11 have their precedents in other disasters: loss and grief, dealing with perpetrators, exposure to paranoia and the grotesque, idealization and despair, and frustrations and traumas associated with rescue efforts. These all parallel other disasters.
 
Although dementia praecox or schizophrenia has been considered a unique disease entity for more than a century, definitions and boundaries have changed and its precise cause and pathophysiology remain elusive. Despite uncertain validity, the construct of schizophrenia conveys useful clinical and etiopathophysiologic information. Revisions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases seek to incorporate new information about schizophrenia and include elimination of subtypes, addition of psychopathological dimensions, elimination of special treatment of Schneiderian "first-rank" symptoms, better delineation of schizoaffective disorder, and addition of a new category of "attenuated psychosis syndrome".
 
The article describes the author's experiences with disaster research in the post-9/11 period, first in application of prior research findings to the new situation and later in consultation on the design and development of new research specific to 9/11. The article begins by reviewing the important role of the science of disaster mental health, which was reinforced by the many requests for information from prior research for application to the post-9/11 situation. Next, the article summarizes enduring principles of disaster research application that apply across disaster sites, including 9/11. Addressing unique aspects of the post-9/11 setting, novel considerations for the disaster mental health field are introduced with a new model for conceptualization of subpopulations based on exposure level. Experience in developing research in the post-9/11 setting encountered a number of issues, suggesting need for new policy recommendations that may facilitate research in future disaster settings.
 
Trauma in the young child is mediated and moderated by the primary caretaker's emotional reactions to the traumatizing event and to the child's emotional reactions to the event. Moreover, the child's symptoms in response to a traumatic event and the particular meaning of that event to that child will be, in large part, dependent on the child's developmental capabilities at the time of the trauma and during the subsequent working through of the traumatic experience. In the wake of a disaster, the guidelines for intervention with the child are to listen, clarify, support the child's attachment bonds, facilitate symbolic expression, and support the child's capacity to imagine repair. Simultaneously, it is essential to help parents contextualize their responses, understand their child's reaction, and facilitate communication between parents and children. In treating entrenched PTSD, controlled re-exposure to the traumatizing event should occur within the established safety of the treatment situation, and when feasible, with the parents present during these sessions. This will facilitate the development of a shared narrative about the trauma. Although desensitization and the coconstruction of a coherent narrative about the trauma are goals for the child, the restoration of the ability of the caregivers to step outside of the trauma-related dysregulation and to attempt to understand the child's emotional experience is the primary goal of intervention with the parents. Only in this way, can the healing caregiver sensitively provide for the child's needs, needs such as reestablishing a sense of safety in the world, in one's family, and in the self.
 
In the 2 plus years since the terrorist attacks of Sept. 11, 2001, a substantial number of children have developed psychiatric disorders, severe psychological distress, and functional impairment. Despite significant financial support, the availability of mental health services, and the presence of relatively sophisticated mental health providers, a surprisingly large gap has emerged between documented need and service use. This article identifies some of the factors that appear to have contributed to this situation and potential remedies for ongoing difficulties.
 
The authors review the existing literature on the mental health impact of the September 11th attacks and the implications for disaster mental health clinicians and policy makers. The authors discuss the demographic characteristics of those affected and the state of mental health needs and existing mental health delivery services; the nature of the disaster and primary impacts on lives, infrastructure, and socioeconomic factors; the acute aftermath in the days and weeks after the attacks; the persistent mental health impact and evolution of services of the postacute aftermath; and the implications for future disaster mental health practitioners and policy makers.
 
One can see that the history of the American Psychiatric Association is the history of psychiatry and vice-versa. The last 150 years have seen significant advances in the humane treatment of the mentally ill. Stigma has been reduced, and significant numbers of patients are now leading productive and useful lives. One hundred and fifty years of caring, while commemorating our heritage, also challenges us to prepare for our future in our neverending quest for a cure.
 
The neuropsychiatric manifestations of HIV disease include neurobiologic and psychobiologic phenomena. The former consist of primary CNS complications caused directly by HIV, and include cognitive disorders (mild neurocognitive disorder and HIV-associated dementia) and other CNS diseases such as myelopathy and the demyelinating neuropathies; and secondary disorders (principally deliria) occasioned by opportunistic infections, neoplasms, cerebrovascular events, and the effects of metabolic derangements and medications. The latter (psychobiologic) phenomena reflect efforts to cope with various nodal, or transition points, in HIV disease; such points of transition include time of serostatus determination, adaptation to asymptomatic seropositivity, response to early medical symptomatology, and later transition to frank AIDS. Anxiety symptoms and various efforts to cope with anxiety (e.g., denial, anger, withdrawal, hypochondriacal preoccupation) all can punctuate these transition points. Additionally, there may be reactivation of long-standing psychopathology (e.g., depression) in seropositive individuals who tend to belong to a group that has an elevated prevalence of pre-infection psychiatric disorder. These interacting neurobiologic and psychobiologic phenomena pose challenges to the psychiatrist who must develop a good understanding of the medical aspects of HIV infection, as well as the neuropsychiatry of AIDS. In this way psychiatric physicians can play an important role in early identification of neuropsychiatric complications, assist the medical team to anticipate emotional and behavioral disturbances, and develop treatment plans that maximize our ability to help those with HIV infection achieve the best possible quality of life.
 
Freud's concept of transference was not the discovery of a solitary genius, but was an inspired, creative synthesis deeply rooted in the prevailing discourses of his time. In the nineteenth century, transference started out as a neurologic term; Freud used that concept of displaceable energies in his neurologic writings as early as 1888. Then in Studies in Hysteria, Freud explicated the basis by which ideas dissociated and made for a mésalliance with the physician. False connections such as transference were conceptualized along lines drawn by Charcot's school, and the concept of auto-suggestion that they used to explain the inherent suggestibility of a hysteric. In developing this 1895 model of transference, Freud strove to tame disquieting concerns about the epistemologic status of hysteria and hypnosis. It is the epistemologic anxiety created by accusations of iatrogenic suggestion as much as the sexual anxiety Szasz pointed to that prodded Freud to focus exclusively on the intrapsychic. It also may be the legacy of this epistemologic anxiety that accounts for the fact that until recently, psychoanalytic theoreticians have been hesitant to explore the effect that the real person of the analyst might have on the manifestations of transference. In the last years of the nineteenth century, Freud modified his theory of transference and built a place for it in his topographic model of mind. In the Interpretation of Dreams, Freud integrated the biologic and psychologic possibilities inherent in prior usages of übertragung. By 1900, transference could theoretically refer to both a hypothesized displacement of quantifiable neuronal energies as well as the psychological phenomena Freud observed occurring between him and his patients. Perceptual theories of illusion like Helmholtz's provided Freud with a model that by analogy helped re-define transference as a central facet of irrational inner life. Transference in 1900 accounted for a patient's possible distortion of the person of the physician, but it also postulated a more general subjectification of consciousness and perception. In transference, a conscious perception could be as distorted by unconscious wishes as a day residue was in dreams. When Ida Bauer (a.k.a "Dora") stalked out of Freud's office, this newly empowered theory was in the metapsychological wings waiting to make meaning of her failed treatment. No longer was transference an unimportant mishap, a nuisance, or a theoretical aside. By 1900, transference was ready to stand, as it does today, at the core of psychoanalytic theory.
 
When faced with a patient having treatment-resistant depression, it is essential to maintain a systematic approach to diagnosis and treatment: 1. Consider the presence of comorbid medical or psychiatric illness that may contribute to or cause the refractory state 2. Determine the affective subtype of depression (e.g., unipolar vs. phenotypic variant of bipolar depression) 3. Ensure the presence of adequate antidepressant dosage, plasma concentrations (where applicable), and duration of treatment 4. Apply systematic treatment algorithms, which means (1) initiate the most efficacious "first-line" therapy for a specific depressive subtype (even if that is an MAOI) and (2) initiate augmentation strategies in a systematic fashion. Augmentation strategies should be initiated only after first reviewing prior therapy, considering available treatment alternatives, and examining the relative risk:benefit ratio for each treatment option in the current clinical context. Following these guidelines should prevent the development of "therapeutic nihilism" in both the patient and physician, as well as enhance the ultimate treatment outcome for patients with treatment-resistant depression.
 
In outline form, the major centers of European psychoanalysis have been described: from the first post-war meeting of the International Psychoanalytic Association in Budapest, 1918, when institutes for analytic training were proposed, to the Anschluss in March 1938, when Vienna was occupied by the Nazis and psychoanalysis on the Continent was extinguished for almost a decade. The emphasis has been on the organization and structure of institutes, chiefly Berlin, Vienna, and London, in that order. As an institutional history, both biographic details and theoretical issues have been kept to a minimum. The exceptions have been the controversies about lay analysis, Melanie Klein's developmental theories, and Ferenczi's innovations in technique. In these issues, some detail is necessary to understand how one institute differed from another within the analytic movement, although they were unified by the International Psychoanalytic Association (IPA). The history of the British analytic community, which survived World War II intact, is highly condensed, and Prague, Budapest, and Paris are briefly mentioned. A history of psychoanalysis in Russia has yet to be written, from its early flowering before and during the Bolshevik revolution (1918-1920) to its swift repression under Stalin in the later 1920s. Among the conclusions to be drawn from these data is the extent to which political events influenced the development of analysis, then in its most expansive phase. Even theory was affected by history, as in the evolution of Freud's repetition-compulsion from observations on the traumatic neuroses of war. Socioeconomic conditions influenced the propagation of analytic ideas, favorably in post-war Berlin, adversely in Vienna. Each country evolved the kind of analysis that suited it best, with a variety of institutions within the same international movement. The causes of these variations in psychoanalytic institutes are a matter for speculation. Some analytic historians have linked Freud's advocacy of lay analysis to his estrangement from the medical establishment of Vienna, or to his dread that analysis might become the "house-maid" of medicine and psychiatry, as in America. Others find the roots of Freud's attitudes toward medicine in his conflicts about becoming a doctor, his yearning for philosophic speculation, which he "sternly held in check." In contrast, psychoanalysis in the United States was always committed to medical education as a prerequisite for becoming an analyst, and, in 1926, there was a sharp break from Freud's defense of lay analysis. Hale, among others, has suggested that the American "medical fixation" was a reaction to the chaotic state of our nineteenth century medical education, with diploma mills and self-taught healers scattered over a vast continent.(ABSTRACT TRUNCATED AT 400 WORDS)
 
Thirty-five years ago, the Mount Sinai unit was considered the state of the art for inpatient psychiatry. Now, short-term hospitalization, active management techniques, and quick dispositions are the practice. At the rate at which neurophysiology and psychiatry are expanding, I have to anticipate that inpatient psychiatric care will again change radically, and long before another 35 years. I doubt that the psychiatric unit of today that I have described will still be recognizable in 10 years.
 
The background of psychotherapy is discussed along with fundamental theory and indications for dynamic therapy. Dynamic psychotherapy is defined, and steps for its implementation are described.
 
Electroconvulsive therapy (ECT) has generated more controversy and strong feelings than any other psychiatric modality in use today. This review presents the facts upon which each reader can make a rational decision as to the advantages and disadvantages of ECT.
 
Antidepressant therapy for panic attacks, exposure therapy for stimulus-dependent anxieties, and, to a lesser extent, clomipramine therapy for obsessive-compulsive symptoms have transformed the treatment of anxiety disorders and ushered in an era of rapid progress in research on anxiety and anxiety disorders. In most cases, these symptomatic treatments should be recommended first. After these approaches have produced maximal benefit, other treatments can be considered if indicated.
 
Recent research in the field of mental retardation has pointed to a better-defined population with exacting prevalence of the basic pathology and related disabilities. Advances in the areas of prevention and treatment have further reduced the prevalence and incidence of mental retardation. Current legislation and legislative procedures have led to a more equitable and fairer application of human rights to all citizens. However, discrepancies and ambiguities still remain with respect to interpretation of the spirit of the law as related to the retarded. Financial restraints and serious economic hardship have impacted on social and political attitudes and created two-tier systems of the rich and poor with the retarded referred to as "surplus population." This situation has, in turn, influenced the availability of resources, manpower, training, and research in this field. The future could be brighter if sociologic and philosophic changes parallel technologic advances. It is our duty and commitment to continue and further the developments in all spheres relevant to the retarded in order to maximize human potential whenever possible.
 
Managed behavioral health care approaches have significantly reduced inpatient utilization and related cost of care, but the relationship between decreased utilization and cost of care to changes in quality of care performance over time remains in question. The trends in utilization and quality of care performance measures over the course of 10 years of the Tufts Health Plan Designated Facility Program, a model health maintenance organization capitated program for inpatient behavioral health care, are presented. The results indicate that substantial decreases in inpatient utilization were sustained while quality of care measures improved over time. The data support the Tufts Health Plan Designated Facility Program as a successful means of balancing cost containment with quality of care.
 
In the 1990s, the Supreme Court has decided several cases that have had an impact on psychiatry and psychiatric patients in the criminal justice system, on psychiatric hospitalization, and on psychotherapist-patient privilege. Of the seven cases discussed in this article, Chief Justice Rehnquist and Justice Scalia voted similarly in all seven cases. Since joining the court, Justice Thomas has voted with them. Justice Scalia interprets the Constitution, using what has been termed "textualism": avoid reference to legislative history, and interpret the Constitution according to the plain language meaning of the relevant section. Chief Justice Rehnquist and Justices Scalia and Thomas are inclined to protect states' rights from court decisions that expand US Constitutional power in cases involving civil plaintiffs and criminal defendants. They seek to protect states from being sued in federal courts, and, if there is doubt, lean toward not interfering with state prerogatives. They tend to not find unenumerated rights and prefer clear-cut rules over amorphous standards. Justices Kennedy and O'Connor, at times joined by Justice Souter in the middle of the court, provide the deciding votes in many cases. They seem to prefer a case-by-case pragmatism over a global jurisprudential philosophy. Approaching cases one at a time, they usually avoid broad philosophic pronouncements when they join with Chief Justice Rehnquist. Justice Stevens, joined by Justices Breyer and Ginsburg since they have been appointed to the court, is more likely to favor a broader reading of the 14th Amendment's Due Process and Equal Protection clauses. Of the seven cases, Kennedy and O'Connor voted with the majority in five cases, the dissent in one case (Zinermon v Burch), and split their votes in one case (Foucha v Louisiana, with O'Connor siding with the Court and Kennedy with the dissent). Commager, a noted historian, believed that political issues can be explored, explained, and debated and that the people of the new American democracy, armed with knowledge and freedom to defend, argue, and choose, will make the right decisions for their common welfare. This theory applies equally to the court: Whenever questions involving psychiatry and psychiatric patients are brought to the court, American psychiatry must make its views known in that forum. To do so requires awareness and knowledge of the cases that involve psychiatry and psychiatric patients that the court has decided, including those decided in the 1990s. To participate effectively, psychiatrists must understand the political landscape in which the cases arrive at the court's doorstep and the composition and leanings of the court and examine carefully the fact patterns (understanding that some fact patterns are more sympathetic than others). This awareness should result in amicus briefs that are scholarly, rely on empiric data, and are scrupulously honest about the limitations of our knowledge. In this way, psychiatrists may fully participate in the debate and aid the court in its exploration and analysis of the issues involving psychiatry and psychiatric patients.
 
Cognitive behavioral treatment outcome studies published between 1995-2005 
Dropout rates and refractory cases persist, for reasons that remain unexplained. There are few predictor variables and few innovative approaches to deal with them. New treatment approaches must be developed to improve treatment response even for the responders. Studies show that symptoms are reduced minimally (30% 50%). No new ways of dealing with treatment-refractory cases have been developed. Studies now include more co-morbid cases, however, and their inclusion may account for some of the lack of progress in improvement rates. It needs to be seen whether patients who have one or more comorbid conditions do as well as patients who do not have comorbidity and whether the number or type of comorbid disorders accounts for treatment response. Perhaps better results would be seen with pure OCD cases. Certainly results now are more generalizable to clinical practice. Now it is important to look for alternative treatment approaches and to apply cognitive therapy to more specific problems. Cognitive therapy seems to be helpful with the disorders of the obsessive-compulsive spectrum. The attrition rate is lower when cognitive therapy is used in the treatment of hypochondriasis, and cognitive therapy also is helpful in reducing OVI , which is more severe in body dysmorphic disorder and hypochondriasis. The role of cognitive therapy in OVI needs further exploration.
 
Practice guidelines aspire to be authoritative statements regarding the state of the art in quality care for various clinical problems. The American Medical Association Partnership has set forth stringent parameters for guideline development by professional organizations, and these have been followed by the American Psychiatric Association in creating its practice guidelines for the treatment of patients with eating disorders. The revised edition, published in January 2000, benefitted from extensive input from a wide array of psychiatrists, psychologists, pediatricians, and other recognized experts who blended together available evidence-based practice with a considerable amount of clinical experience and consensus. These guidelines are useful for practitioners, students, and health-resource managers. Future research will continue to lead to constant upgrades.
 
This article presents an overview of the mental health response to the 2010 Haiti earthquake. Discussion includes consideration of complexities that relate to emergency response, mental health and psychosocial response in disasters, long-term planning of systems of care, and the development of safe, effective, and culturally sound mental health services in the Haitian context. This information will be of value to mental health professionals and policy specialists interested in mental health in Haiti, and in the delivery of mental health services in particularly resource-limited contexts in the setting of disasters.
 
Unipolar major depression is among the leading contributors to the global burden of illness-related disability, and is predicted to be the greatest contributor to illness burden by 2030. It is a matter of public health significance to identify people at high risk for depression and/or already mildly symptomatic, and to discover ways of implementing timely and rational risk reduction strategies to preempt major depression. In this article, the published literature is reviewed to summarize what is known about depression prevention in older adults, and, ultimately, to inform future research.
 
In 1980, the diagnosis of post-traumatic stress disorder (PTSD) was established to describe the long-lasting symptoms that can occur following exposure to extremely stressful life events. This article reviews the findings of neuroendocrinologic alterations in PTSD and summarizes the finding of hypothalamic-pituitary-adrenal (HPA), catecholamine, hypothalamic-pituitary-thyroid (HPT) and hypothalamic-pituitary-gonadal (HPG) systems. These are the neuroendocrine systems that have been studied in PTSD. Also included is a review of the basic facts about PTSD and biologic data.
 
Among the more consistent observations in patients with major depression is dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis presenting as elevation of basal cortisol, dexamethasone-mediated negative feedback resistance, increased cerebrospinal fluid levels of corticotropin-releasing factor (CRF), and a blunted adrenocorticotropic hormone (ACTH) response to challenge with exogenous CRF. These features appear to be state, rather than trait markers, and are normalized upon successful treatment. These pathophysiologic adaptations may arise from defects in central drive to the neuroendocrine hypothalamus, disruption of normal adrenocortical hormone receptor function or a modification of HPA axis function at any level. Functional assessment of the HPA axis is thought to provide a window into central nervous system operation that may be of diagnostic value in this and other affective disorders regardless of whether CRF and glucocorticoids are directly involved in the origin of major depression or merely exacerbate the consequences of other primary defects.
 
Psychiatric disease constructs represent social constructs and genuine states of distress that have biopsychosocial sources. As such, they have social uses peculiar to the social groups in which they are created and legitimized. This is as true in the United States as in the rest of the world. The DSM schema, for instance, is so organized that every possible mental condition is listed as a disease to legitimate remuneration to practitioners from private medical insurance and government programs. This particular social use may be irrelevant to other societies where health care is financed differently. The CCMD-3 system represents an attempt at global unification and preservation of features that are salient for local application. Compared with its previous editions, noticeable changes have been made to render it in tune with international usage. This remarkable speed of adaptation speaks to the global flows of information technology and China's openness under rapid economic reform. It also demonstrates that the middle-aged cohort of more pragmatic Chinese psychiatric leaders who headed the CCMD-3 task force are now less vulnerable to the domination of the most senior generation of Chinese psychiatrists. Having been trained in the Russian system of psychiatry and gone through the various periods of national shame that traumatized China, they used to be very cautious about adopting foreign technology in general. This is why much less harmonization with the ICD-10 occurred with the CCMD-2-R, when the responsible task force was, for better or worse, dominated by these senior psychiatrists. Nonetheless, as Stengel and Sartorius remarked, an international classification must not aim to oust or replace regional classifications that serve valuable functions in the local contexts. No single classificatory system, Kirmayer submits, will suffice for all purposes--the correct diagnostic scheme is the one that accomplishes its explicit pragmatic aim by addressing the relevant level of description. The particular additions (e.g., travelling psychosis, culture-related mental disorders), deletions (e.g., depressive neurosis, pathologic gambling, avoidant and borderline personality disorders), retentions (e.g., unipolar mania, neurosis, hysteria, homosexuality), and epistemologic variations (e.g., somatoform disorder, neurasthenia) of diagnostic categories reflect exactly this simultaneous need to globalize and to take account of the changing reality of illness in contemporary China. Stengel advised that "no psychiatric classification can help being partly etiological and partly symptomatological, because these are the criteria by which psychiatrists distinguish mental disorders from each other." To an extent, the CCMD-3 is a critique of certain nosologic assumptions of Western psychiatry, such as the feasibility of a neo-Kraepelinian taxonomy grounded exclusively in symptomatology across all diagnostic categories, and the validity of syndromic architectures based on a firm adherence to the mind-body dichotomy. From this angle of vision, local systems of classification such as the CCMD-3 may offer an opportunity for needed reflections by North American psychiatrists who have simply taken the DSM-IV schema for granted. Sartorius reckoned that a classification is a way of seeing the world at a point in time. A deep study of the CCMD-3 is thus an avenue for achieving an understanding of the contemporary Chinese mind and the social realities in China. The remarkable diversity of China at present, namely, a Communist Party dominated state socialist political structure but the most rapidly growing capitalist economy in the world, guarantees that Chinese people's social and moral experience of illness will continue to change. The study of such culture-specific categories as travelling psychosis, neurasthenia, qigong-induced mental disorder, and dysfunctional homosexuality sheds light on the larger sociomoral processes and destabilizing changes in subjectivity that are occurring in this most populous country in the world.
 
Despite the fact that the rate of substance abuse and dependence is higher among men than it is among women, the prevalence rates, especially the more recent ones, indicate that a diagnosis of substance abuse is not gender specific. From the emerging literature on gender differences over the past 25 years, male and female substance abusers are clearly not the same. Women typically begin using substances later than do men, are strongly influenced by spouses or boyfriends to use, report different reasons for maintaining the use of the substances, and enter treatment earlier in the course of their illnesses than do men. Importantly, women also have a significantly higher prevalence of comorbid psychiatric disorders, such as depression and anxiety, than do men, and these disorders typically predate the onset of substance-abuse problems. For women, substances such as alcohol may be used to self-medicate mood disturbances, whereas for men, this may not be true. Although these comorbid disorders might complicate treatment for women, women are, in fact, responsive to treatment and do as well as men in follow-up. Gender differences and similarities have significant treatment implications. This is especially true for the telescoping phenomenon, in which the window for intervention between progressive landmarks is shorter for women than for men. This is also true for the gender differences in physical and sexual abuse, as well as other psychiatric comorbidity that is evident in female substance abusers seeking treatment. The barriers to treatment for women are being addressed in many treatment settings to encourage more women to enter treatment, and family and couples therapy are standard therapeutic interventions. Negative consequences associated with substance abuse are different for men and women, and gender-sensitive rating instruments must be used to measure not only the severity of the problem but also to evaluate treatment efficacy. To determine whether gender differences observed over the past 25 years become less demarcated in comparisons of younger cohorts of substance abusers in the future will be interesting. Changing societal roles and attitudes toward women, the increase in women entering the workplace, in general, and into previously male-dominated sports and professions, in particular, may influence not only opportunities to drink but also drinking culture. Some gender differences likely will remain, but other gender differences will probably also emerge. The comparison of male and female substance abusers promises to be a fruitful one for researchers. The translation if the research findings to the treatment community to improve treatment outcome for both sexes will be an equally exciting challenge for the field.
 
One of the challenges facing modern psychiatry is to determine to what extent the diagnostic categories clinicians have represent valid constructs. Epidemiologic studies are helpful in this regard when their findings are consistent across various cultural or geographic settings or with those of clinical studies. The cross-national epidemiologic data on OCD reviewed in this article are remarkable for their consistency in rates, age at onset, and comorbidity across diverse countries, a fact which lends additional support to the validity of the diagnosis of OCD. The variability in symptom presentation across national sites suggests that cultural factors may affect the symptom expression; however, why the rates of OCD and other psychiatric disorders are so much lower in Taiwan than in other sites, including another Asian site, is unclear. Epidemiologic studies of adolescents and of adults have shown similar prevalence of OCD and substantial comorbidity with major depression and other anxiety disorders. Studies of adolescent populations indicate that OCD symptoms are fairly common among adolescents but not necessarily predictive of developing the full disorder within 1 year of follow-up. Family studies have suggested an association between OCD and TS and other CMT disorders. Clinical studies have suggested an association between Sydenham's chorea and OCD. These various studies provide a growing body of knowledge regarding the nature of OCD. Together with evidence of the substantial demand on mental health services by those afflicted with OCD, the epidemiologic data make a compelling case for additional efforts to improve the understanding and treatment of this troubling disorder.
 
Functional neuroimaging studies have advanced the understanding of the brain mediation of OCD by orbitofrontal-subcortical circuitry, but much is still unknown. Phenotypic heterogeneity could account for many of the inconsistencies among previous neuroimaging studies of OCD. Current studies are seeking to find the neurobiological basis of OCD symptom subtypes and predictors of treatment response. Future studies combining genetics and basic neuroanatomic research with neuroimaging may clarify the cause and pathophysiology of OCD. Although many lines of evidence point to dysfunction of orbitofrontal-subcortical circuitry in patients with OCD, many questions remain unanswered. Some have suggested that orbitofrontal-subcortical hyperactivity in OCD may be the result of abnormal neuroanatomic development of these structures or a failure of pruning of neuronal connections between them, as occurs in normal development, but no postmortem neuroanatomic studies of OCD exist to delineate its pathophysiology. Interventions that directly alter the indirect-direct pathway balance within frontal-subcortical circuits will allow for direct testing of the pathophysiologic hypotheses presented here. The roles of various neurochemical systems in OCD are similarly unclear. Although an abundance of indirect evidence suggests serotonergic abnormalities in patients with OCD, no direct evidence demonstrates what those abnormalities are or whether they are primary or secondary phenomena in patients with OCD. Ongoing studies of 5-HT synthesis in the brains of patients with OCD may shed light on this question.
 
Recent findings support and add to earlier findings of cognitive dysfunction in schizophrenia. Deficits across neurocognitive domains such as attention, working memory, language skills, and executive functioning tend to be moderate, with the most pronounced deficits found in verbal learning and memory. All these neurocognitive domains are related to adaptive and social skills, with executive functions and verbal learning and memory showing more variance across more domains than other neuro-cognitive variables. Negative symptoms and neurocognitive domains, although correlated, are distinct and have differential pathways of change with treatment. General psychopathology symptoms, such as depression and anxiety, may become important treatment targets as strategies are developed for translating cognitive enhancement to real-world functional performance.
 
This article describes treatment results in 33 patients with multiple personality disorder with respect to the major identifying characteristic of the condition: the presence of separate personalities within a single individual. The author discusses responsiveness to treatment, apparent and stable fusion, follow-up, and reassessment.
 
The authors detail their investigation into the positive relationship between borderline personality and multiple personality and present their finding that although borderline personality disorder is very prevalent in patients with multiple personality disorder, it is not universal and is a separate and distinct disorder.
 
This article summarizes findings of hypothalamic-pituitary-adrenal axis alterations in post-traumatic stress disorder (PTSD) and evaluates likely reasons for the lack of agreement among published studies. Sources of variance caused by methodologic and interpretative differences are highlighted, but the disparate findings are explained as illustrating a more complex neuroendocrinology of PTSD than has previously been described.
 
Antisocial behavior is a complex phenomenon that arises out of multiple causes involving biologic, psychological, and social forces. Moreover, different forms of violent antisocial behavior may each result from different biopsychosocial pathways. The overview of human psychophysiologic findings presented in this article provides some support for this notion. In particular, the finding of psychophysiologic underarousal (e.g., reduced resting HR and SC levels, increased slow-wave EEG, poor classical conditioning) is one of the most robust and best replicated findings in antisocial populations. The majority of these studies consist of populations exhibiting nonviolent antisocial behavior or milder forms of aggression. Findings of underarousal in institutionalized criminal samples are very few in number and are not well-replicated. The relationship of psychophysiologic underarousal to antisocial behavior, therefore, may be specific to covert forms of antisocial behavior and perhaps to some less severe forms of violent behavior. On the other hand, violence associated with anger and emotional aggression (which is often more impulsive, less controlled, and reactive to some perceived provocation) may have very different psychophysiologic underpinnings. It was suggested that risk factors for emotional aggression include a predisposition to negative affect/arousal and an inability to regulate that affect/arousal. It also was suggested that this effect will be most pronounced in individuals experiencing stressors or adverse social environments, where negative affect and arousal would be increased. Laboratory studies have suggested that overarousal may facilitate aggression in situations in which someone has been provoked. Clinical studies also have indicated a relationship between increased physiologic arousal, negative emotionality, and aggression/antisocial behavior in some populations, with increases in aggression in those also exposed to adverse home environments. Thus, the relationship of increased psychophysiologic arousal to antisocial behavior may be more specific to angry or emotional violence. It is important to note that these psychophysiologic distinctions are speculative for few studies actually have differentiated type of violence in their design. Pitts did group children according to proactive or reactive aggression and found reduced HR levels in both groups, but a substantial increase in HR only in the reactive aggressive group. Lakosina and Trunova found increased SC responsivity in psychopathic individuals characterized by affective violence. These studies provide some initial support for underarousal in proactive/instrumental aggression and overarousal in emotional aggression. It is important, however, that more studies be done with subtypes of violence to test the notion of such differential psychophysiologic patterns. Lastly, some definitional and methodologic considerations need to be mentioned. First, a distinction exists between physiologic arousal and reactivity. Typically, arousal refers to psychophysiologic activity that occurs during a resting state, whereas reactivity refers to activity that occurs in response to some stimulus. Although some studies did assess measures during a resting state, the majority of findings on over-arousal in relation to emotional aggression more accurately reflect psychophysiologic and emotional reactivity to a situation or stimulus. Second, arousal or reactivity are nonspecific terms that can refer to any psychophysiologic response system (e.g., electrodermal, cardiovascular, cortical, and so on). Responses from these systems typically do not correlate in the general population. Thus, it would be worthwhile for future studies to include more than one response system (as done by Raine et al) and see if the arousal/reactivity measures converge. If the measures converge, a general model of arousal or reactivity is supported. (ABSTRACT TRUNCATED)
 
During the past decade, there has been rapid growth in understanding the clinical features, pathophysiology, and treatment of obsessive compulsive disorder (OCD). This article reviews the current state of knowledge of the epidemiology and clinical features of OCD with a focus on the disorder's phenomenologic heterogeneity and its comorbidity with other Axis I and Axis II syndromes.
 
This article presents a neuropsychological perspective on obsessive compulsive disorder (OCD) and describes some of the cognitive strengths and weaknesses that characterize the disorder. Neuroanatomic findings and theories of the neurologic basis of OCD are reviewed as are studies that use neuropsychological assessments. Findings of frontal lobe and/or basal ganglia dysfunction as well as memory deficits are emphasized. This information is then discussed in the context of cognitive-behavioral and information processing perspectives that emphasize normal patterns in anxiety and worry. The goal is to provide an integrated conceptual model of OCD, identifying the normal and abnormal information processing patterns that characterize the disorder.
 
Over the past two decades, much has been learned about the evaluation and management of violent patients. This has been translated into clinical guidelines for the evaluation and management of violent persons with psychiatric disorders. New research on neurotransmitters and the use of technology that can explore neurophysiologic and chemical activity in the brain promises continued advances in this area of psychiatry.
 
Agitation and other noncognitive abnormalities in patients with Alzheimer's disease are present in at least 50% of patients and are a serious problem for caregivers. Agitation can be divided into aggressive agitation, physically nonaggressive agitation, and verbal agitation. Persecutory delusions of suspiciousness and stealing are the most common psychotic symptoms. Auditory and visual hallucinations are also associated with delusions. Similar to delusions are misidentifications, which are false beliefs probably secondary to agnosia. They occur in one third of patients with dementia of the Alzheimer type in the form of the belief that strangers are living in the home and misidentification of the patient's home and reflection in the mirror. Passive personality changes are present early in the disease, whereas agitation and psychotic symptoms occur with disease progression and predict a more rapid rate of cognitive decline. Agitation and wandering are related to more severe cognitive impairment and psychosocial variables, and neurochemical variables that may be related to behavior disturbance require further study. There are few systematic studies of behavioral or environmental interventions for behavioral symptoms in patients with Alzheimer's disease. Current treatment emphasizes education of families, the formation of Alzheimer units in the nursing home, and adjunctive psychotropic agents to treat well-defined target symptoms.
 
Grief following spontaneous abortion is a common occurrence that is often overlooked by clinicians until serious manifestations occur. Often patients report prolonged distress following this condition. This article defines symptoms and signs of normal and pathologic grief following spontaneous abortion. It discusses the types of psychological disability associated with this condition and makes specific suggestions for interventions. The variables affecting the onset and severity of the condition are further defined as are alternative approaches to treatment.
 
With roots in ancient religious practices of purification and cleansing and in ancient medicine's purgings, Plato evolved a verbal catharsis for diseases of the soul, and Aristotle developed a catharsis of the passions through tragic drama. Through the centuries, most cultures have had recognized contexts in which emotions were evoked, heightened in intensity, and ultimately released or discharged; and cathartic procedures can be detected in many cultures' healing practices. The late decades of the nineteenth century saw the emergence of numerous psychological healings with a cathartic basis. Catharsis came to mean the lively remembering of a traumatic experience in addition to the emotional release; and the term abreaction frequently was used to refer to the emotional release. Subsequently, the notion that the recovered traumatic memories needed to be integrated with the rest of the patient's mental life became a third significant element. The significance of these three factors has been debated vigorously; but, whether it has been some combination of them or merely the emotional discharge, there has been a cathartic element in many twentieth-century approaches to psychological healing.
 
The mortality rate from alcoholism and related comorbidities is high. Studies show multiple causes of premature death from alcoholism. Several studies showed that abstinence had a positive effective on the overall survival of alcoholics. Alcoholics who abstained from alcohol, particularly continuously, showed reduced mortality rates and increased years of longevity than alcoholics who relapsed to alcohol consumption. The sources of the findings tend to be derived from treatment populations, in which abstinence is expected to occur in higher rates than in the general population.
 
Psychiatrists have tended to be reluctant followers rather than leaders in the proliferation of concern for child abuse that has developed over the past 25 years. By discounting the relevance of child sexual trauma, psychiatric clinicians and theoreticians overlook not only the therapeutic needs of many survivors but the opportunity to reconceptualize the role of trauma in the etiology and treatment of conditions presumed to be incurable. Present controversies over child sexual abuse are mirrors of past misadventures with uncovering. Since 1860, child abuse has been discovered and then discredited every 35 years by the most visionary clinicians of the day, each faced with the alternative of denouncing the discovery or succumbing to scorn and disgrace. The history of child sexual abuse, whether viewed by parent via child, therapist via patient, or adult survivor via the child within, is one of unimaginable pain and betrayal masked by adult distancing, disavowal, victim blame, and identification with the aggressor. The lurid emotional imperatives of the trauma itself have no place in a just and fair society, and they resist translation into the rational, objective language and concepts of behavioral science. The subject of child sexual abuse is itself so passionate and so paradoxical that it provokes polarized dichotomies at every level, leaving indifference and avoidance as the only hope for serenity. The active nesciance, the determined insistence on not knowing, that pervades every aspect of child sexual abuse encourages the most authoritative scholars to be the most repressive of radical discovery, especially if authority has been achieved as a reaction against youthful vulnerability. Every clinician facing a survivor of childhood sexual trauma faces an assault on personal comfort and authority, just as each patient in that encounter risks intimidation and disgrace. The connections between childhood assault and adult adjustment will be missed unless the therapist can find an unprejudiced path toward mutual acceptance. The promise of genuine understanding and radical resolution of the effects of child sexual abuse is dimmed on both sides by a history of abandonment in the face of scornful, punishing authority. Freud's concept of the unconscious as the arena for successful psychotherapy, his sense of the patient as a normal, healthy individual incapacitated by the effects of buried trauma and his initial optimism for radical recovery from post-traumatic handicaps were soundly derived from his clinical confrontations with child sexual abuse, as were Ferenczi's parallel contributions 35 years later.(ABSTRACT TRUNCATED AT 400 WORDS)
 
Cost-effectiveness analysis, a technique for allocating resources, examines the relationship between the cost of providing treatment and resulting improvement in health measured in a single, numerical scale. In applying this concept to substance abuse services, the authors expressed effectiveness in terms of additional "abstinent years." To control for differences in clients across modalities, the authors used multivariate cost-effectiveness analysis, estimating results for a typical client at each of three alternative severity levels.
 
Twin studies have demonstrated that addictive disorders are genetically and environmentally influenced. Our knowledge of behavioral differences predisposing to addiction is advancing rapidly, particularly in alcoholism but also in the other addictions, through studies on animals and humans. Recently, linkage analyses in humans and rodents have pointed to genomic regions harboring genes which influence addiction or drug-associated behaviors. There is increasing evidence that the addictions have common as well as distinct neurobiological pathways. These advances in the understanding of the genetics of addictive disorders should facilitate the development of specific pharmacotherapies and the more accurate targeting of therapies using molecular diagnostic approaches.
 
Competence in treating the victims of sexual abuse and exploitation requires an understanding of shame, the complex and multilayered emotion triggered when we have been exposed or when our self-esteem has been reduced. The experience of shame is initially physiologic, involving a cortical shock momentarily halting higher cognitive function, but followed immediately by a host of associations to previous experiences of shame. Acutely, the affect itself impels hiding, while defenses against it include anger, humor, silence, and a wide range of behaviors. In our culture, all sexuality involves an interplay between exposure and privacy, between control and release. The sexual abuse of adults and the sexual exploitation of children must produce shame, study of the interaction between abuser and abused suggests that shame conflict figures prominently in the genesis of such activity. To the extent that psychotherapy itself involves exposure, it must trigger shame; thus, it is likely that the therapist unskilled in the recognition of shame in all its disguises will overlook or misunderstand many of the issues that should form the core of our treatment of those whose sexual selves have been abused or exploited.
 
The relationship between alcohol use and anxiety is complex. From a clinical standpoint, it is clear that psychiatrists caring for anxious patients must be aware of the possibility of secondary alcohol abuse. For the most part, anxiety disorders are highly treatable conditions, whereas alcoholism is less successfully treated. With this in mind, it is important for the clinician to accurately diagnose anxiety disorders in their patients. Failure to do so may lead a high percentage of patients to the major complication of substance abuse, which itself may be very difficult to treat. Further research to understand the relationship between anxiety and alcohol use is warranted. Future studies should focus on discovering which anxious patients are likely to abuse alcohol. Studies screening patients for the presence of alcoholic traits, such as antisocial behavior or a family history of alcoholism, may help identify anxiety disorder patients who are likely to go on to become alcohol abusers. Researchers interested in the treatment of substance abusers should become acutely interested in the recognition and treatment of anxiety disorder in their patients. Identifying patients with anxiety disorders would be a first step in individualizing treatment for a given alcoholic patient.
 
The relevance of hypnosis to the treatment of sexual assault derives from two sources: the fact that hypnotic phenomena are mobilized spontaneously as defenses during assault, becoming part of the syndrome of posttraumatic stress disorder (PTSD) and the usefulness of formal hypnosis in treating PTSD. The role of dissociative defenses during and after traumatic experiences is reviewed; an analogy between the major elements of formally-induced hypnosis--absorption, dissociation, and suggestibility, and the major elements of PTSD--is drawn. Special problems relevant to sexual assault in childhood are discussed, including extreme self-blame and a profound sense of personality fragmentation. Uses of hypnosis in the treatment of sexual assault victims are reviewed, with an emphasis on helping such patients restructure their memories of the experience, both by reviewing them with greater control over their physical sense of comfort and safety and by balancing painful memories with recognition of their efforts to protect themselves or someone else who was endangered. The use of a split-screen technique in hypnosis is described with a clinical example. Special considerations in such treatment, including the traumatic transference and forensic complications of such psychotherapeutic work, are enumerated.
 
Prescription drug abuse (PDA) accounts for much drug-related morbidity and mortality. The PDA issue contains several interrelated dimensions: regulatory, practical, and clinical. Historical and current governmental efforts to regulate prescribing practices are reviewed. The authors discuss the many ways that prescription drugs can be diverted for abuse purposes and how potential abuse situations can be identified in the clinical setting. Types of prescribers at risk for promoting PDA are discussed and remedies for PDA are offered in terms of physician and patient education.
 
This article reviews what is known about the relationships between recreational psychoactive substance use and HIV infection and sexual behaviors that can transmit HIV. The focus of this article is on nonparenterally used recreational substances and their relationship to HIV transmission behaviors, specifically high-risk sexual behaviors of one of the largest groups of persons at risk for infection--self-identified gay and bisexual men. Published and unpublished studies in this area are reviewed in terms of a hierarchy of epidemiologic evidence that ranges from global associations between substance use and high-risk sexual behaviors to prospective studies of substance use in the context of sexual encounters and incident rates of HIV infection. This article also discusses the secondary community impact of these associations and their intervention implications.
 
Despite controversy about the impact of sexual abuse on victims, accumulating evidence indicates that sexual abuse is a serious mental health problem. Rape falls under the larger category of sexual abuse, which includes molestation of children by adults in which overt coercion is not necessarily involved as it is in rape. The eradication of rape is contingent on educating our society to the meaning of the crime. Innovative and empathetic services to victims will serve as a deterrent by facilitating reporting, apprehension, and prosecution of assailants.
 
Top-cited authors
Maurizio Fava
  • Massachusetts General Hospital
Hagop Akiskal
  • University of California, San Diego
Jane L Eisen
  • Partners HealthCare
Harold A Sackeim
  • Columbia University
Michael J Owens
  • Emory University