The medical care of patients with psychiatric illness

A survey of psychiatric inpatient, outpatients, and consultation services of a large general hospital showed a high incidence of undiagnosed physical illnesses in psychiatric patients. The finding is consistent with that of other researchers and highlights the need for a comprehensive medical examination of all psychiatric patients. The authors discuss the clinical diagnostic interface between physical and psychiatric disorders, as well as medical complications of psychiatric treatment and the reaction of psychiatric patients to physical illness. One recommendation for improving the delivery of medical care to this population is to equip psychiatric services to give complete medical work-ups as part of the standard psychiatric evaluation of entering patients.

VIth axis for DSM-III: psychodynamic evaluation

DSM-III has raised questions among mental health professionals about the relationship of diagnosis to treatment. Practicing psychotherapists have been reluctant to endorse the revised classification, arguing that diagnostic discriminations needed to plan psychotherapy treatment are absent from DSM-III's multiaxial system. The clinical usefulness of a diagnostic classification is a major measure of its validity. The authors illustrate with three patients from psychotherapy practice, all with long-standing problems of depressed mood, the limits of DSM-III in planning psychotherapy treatment, and they make suggestions for the development of a treatment-oriented "axis" to complement the current multiaxial evaluation system.

Expectations of hospital treatment. Conflicting views of patients and staff

A 40-item therapeutic community questionnaire, developed from a survey of experts, was used to assess the treatment needs and expectations of a group of 30 hospitalized psychiatric patients. The patients' attitudes regarding an ideal ward atmosphere were compared to those, as measured previously by the identical instrument, of the treating staff. The results indicated that psychiatric inpatients found the therapeutic community modality consistent with their needs and expectations. However, staff and patients were divided in attitude toward the therapeutic community concept. The staff's definition of therapeutic community was broad and exceeded the principles of the therapeutic community experts. The patients desired a more conservative approach which combined respect and responsibility with a ward structure that was unambiguous and less democratic. Studies of ward atmosphere as well as premature termination in psychotherapy indicate that such conflicts in viewpoint between patients and staff might have detrimental effects on hospital outcome. A negotiated approach to inpatient treatment is suggested as a means to establish greater autonomy, growth in self-esteem, sense of responsibility, and increased trust on the part of hospitalized patients.

Common mistakes in psychotherapy

To better monitor the psychotherapy training of psychiatric residents and to understand therapist factors involved in a negative outcome to psychotherapy, the authors surveyed 20 supervisors on the frequency of mistakes made by resident therapists. Among the mistakes most commonly made were wanting to be liked by patients, premature interpretations, overuse of intellectualization, inability to tolerate patients' aggression, and avoidance of fee setting. The authors conclude that the mitigation of the most common errors requires open discussion of countertransference issues.

Measurement of thinking dysfunction. An empirical study

This investigation is concerned with the development of a practical method for assessment of thought disorders. A review of eight major textbooks and four review articles revealed 37 different terms used to describe the components of thought disorders. Because of overlap of meanings or ambiguous usage, these terms were reduced to 17 discrete terms that could be operationally defined. Twenty-five psychiatrist were surveyed on the appropriateness of the definitions and their relevance to the concept of thought disorder. An average of 83 per cent agreement was obtained, and some of the definitions were modified as a result of the survey. Eight psychiatrists then applied this scale, titled the Thinking Dysfunction Rating Scale, to the evaluation of five videotaped patient interviews. Based on observation of all five patients, interjudge agreement was over 90 per cent for all items of the scale. Analysis of variance showed that the scale significantly discriminated among schizophrenics, patients with organic brain syndromes, psychotic depressives, geriatric depressives, and outpatients. The patterns of scores were found to vary among these five groups. The scale should be helpful for teaching purposes and as a checklist for routine clinical diagnosis.

Toward unification of psychotherapies: a complementary model

The emergence of different models of psychological healing from Freud to the present, and specific features which characterize "new" psychotherapies in contrast to psychoanalysis are examined. The author maintains that these represent a chronological evolution of therapeutic forms which are complementary and which portend the unification of the psychotherapies.

Psychotherapy of the psychosomatic patient

The role of psychotherapy for psychosomatic patients is reviewed. Barriers to treatment, including special characteristics of these patients that make them poor candidates for traditional psychodynamic interventions, are discussed with implications for practice. Clinical recommendations encompass two broad preparatory phases: I, the health alliance, and II, the life alliance.

Appearance of new symptoms in hospitalized patients: an instance of institutional iatrogenesis?

Data from the admission and termination forms of 100 consecutively discharged psychiatric inpatients were analyzed to determine the changes that occurred in the symptom profile of each patient during hospitalization. In general, patients entered the hospitalization. In general, patients entered the hospital with severe, chronic symptoms some of which were relieved and some of which remained unchanged. A number of symptoms, however, were reported present on the termination forms that had not been noted at admission. The results of this study offer evidence that a possible effect of the therapeutic process is the occasional appearance of new symptoms in some patients.

Age factors in patient-therapist relationship

This paper reports on the effects of therapist and patient age as factors in the evaluation and treatment of adult psychiatric outpatients. Therapist ratings and patient self-ratings are contrasted in three age groups. Rating scales include symptomatology, motivation, insight, and prognosis. In addition, a chart review follow-up of 68 patients includes disposition and drop-out. The data suggest that older patients are perceived as sicker, but less treatable than younger patients or patients of the same age group as the therapist. Residents express a strong preference for treating younger patients, but more readily develop a treatment relationship with same age patients. Both older and younger patients were significantly less likely to remain in treatment. Age of therapist and patient as a significant, frequent unrecognized factor in psychotherapeutic intervention is discussed and modifications in psychiatric training programs are suggested.

Psychotherapy of the medically ill

The author assesses the current status of psychotherapy with medically ill patients. He reviews the special problems of psychological treatment for this population; the respective rationales for the utilization of various psychotherapeutic approaches including psychoanalysis, dynamic psychotherapy, and family and group therapy; and the results of case reports and research studies. The author identifies specific areas of future investigation and research, elucidates some specific implications for clinical practice, and recommends more critical exploration of the role of psychotherapy in the treatment of the medically ill.

Emergency room patients in concurrent therapy: a neglected clinical phenomenon

The authors found that more than one-third of emergency room patients were participating in concurrent psychiatric treatment. Exploration of the relationship between patient and therapist proved to be a valuable tool in formulating consultation and in ensuring continuity of care.

"No-commitment week": a feasibility study

To determine the extent to which involuntary hospitalization is overused, a "No-Commitment Week" was set aside, during which emergency room psychiatrists committed only patients in absolute need of hospitalization. Compared with the week before and the week after, there was no significant difference in the number of patients committed during No-Commitment Week. The authors propose replication of the study on a larger scale but suggest that decisions about involuntary hospitalization in public mental hospitals are the result of societal attitudes, which will be subject to change as long as society itself continues to change.

A three-year follow-up study of the elimination of the internship. A comparative study of internship- and noninternship-trained residents in a psychiatric outpatient setting

The American Board of Psychiatry and Neurology eliminated the internship as a requirement for certification in psychiatry in 1970. Preliminary study on a psychiatric inpatient service of internship-trained first-year residents with that of a matched group of residents who entered the same program without the internship disclosed differences in patient care practices. The same group of residents in their subsequent years of training in a psychiatric outpatient service were compared. A chart review comparison disclosed differences in areas of management in psychiatric outpatient treatment, referral patterns, and use of medication. Supervisory ratings of the residents were found to differ substantially in nine of the 15 measured categories.

Toward a rationale for the seclusion process

The present paper summarizes three studies focusing on different aspects of seclusion room practices. The first study involved chart review to collect empirical data on reasons for seclusion, length of seclusion, and characteristics of secluded patients. The second study focused on staff attitudes toward seclusion; the third dealt with the attitudes of both secluded and nonsecluded patients. The average time of seclusion was approximately 4 hours and in most cases aggressive behaviors of various types were cited as the precipitating event. In addition, patient and staff attitudes implied that a major function of the seclusion process was to isolate patients from disturbing interactions and to maintain the smooth functioning of the ward minisociety. Two models of seclusion, an ethological model and a behavioristic "time out" model, were developed in order to integrate the results of these studies. Implications of the findings and models are presented for changes in seclusion room procedures.

Mid-adult development and psychopathology

The authors studied a group of 193 psychiatric outpatients with varying diagnoses and a comparison group of 136 nonpatients across nine measures: sense of self; feelings about marriage, sex, career, and leisure time; relationship to parents, friends, and children; and sense of time passing. They found significant differences between the groups at specific ages in the areas of sense of self, feelings about career and sex, and relationship to parents, children, and friends. They discuss these results with a view toward identifying and elucidating normal and pathological factors in the adult life cycle.

Emergency psychiatry and the assaultive patient

The authors studied 62 emergency room patients with violent ideation or action to assess the feasibility of predicting assaultive behavior. Although the likelihood of future violent acts could not be predicted accurately, they discovered that a significant majority of violent patients were potentially treatable within the setting of emergency psychiatry practice.

Clinical utility of a rapid diagnostic test series for elderly psychiatric outpatients

Psychiatric evaluation of the elderly is especially difficult for several reasons, e.g., the presence of organic impairment, the effects of multiple drug therapy, and the tendency to confuse the normal concomitants of aging with neurotic symptoms. The authors have developed and evaluated a brief series of self-report assessment tests (GRDB) designed to assist the psychiatrist in the process of diagnosis. Coefficients of the internal consistency of the seven scales are presented. A comparison was make between 28 psychiatric patients attending a geriatric clinic and 48 well-functioning elderly persons matched for age and sex, and living in the same community. Results showed that the geriatric outpatients functioned at a lower level of adaptation than did the control group, on all seven scales - depression, daily living skills, social interaction, cognitive skills, number of illnesses, number of life problems, and the use of drugs and alcohol. These findings provide a measure of discriminant validity. The advantages of this brief assessment instrument are discussed.

[Formation of new American psychiatrist and the future of psychiatry in the U. S.--A reference for France?]

A Ballad on the future of american psychiatry. Since the publication of Johann Reil's, Rhapsodies About the Application of Psychotherapy to Mental Disturbances (1803), variations upon this theme of extravagant discourse have received enthusiastic welcomes from the ever enlarging psychiatric audience for whom they are performed... Although the soloists change, the basic orchestration continues creating an uncanny sense of déjà entendu. While there as been longstanding recognition of the contributions of biological, psychological and social forces to the etiology of mental illness, actual efforts at a synthesis of their roles have been infrequent. Rather, we have experienced ideological clustering around each with the formation of schools and movements which have tended to over-value their own viewpoint at the expense of the others and to the detriment of progress in psychiatry. The authors describe a periodicity of one to two decades in which one of the schools achieves preeminence over the others, consolidates its position in medical education and with the community at large, comes under fire for failing to provide solutions to the problems of the mentally ill, and finally experiences a decline of its influence and prestige. Since World War II, both psychoanalytic and social and community psychiatry have experienced these vicissitudes, and, as the influence of the latter diminishes, voices are already raised promoting the succession of biological psychiatry of the seat of power. We believe another cycle of hopeful expectance in the quest for psychiatric omniscience and the following period of disillusionment can be avoided. The stunning advances in biological research in the past, and the prospect of even more exciting revelations to come should not lead us to devalue those techniques and institutions which have proved effective, while in pursuit of new approaches. Experience informs us that no one discipline in psychiatry can answer all the questions confronting us, and the time is ripe for a reassessment of the appropriate contributions of each subspecialty to the field as a whole. The authors propose the establishment of fellowships in biological psychiatry to promote this subspecialty, just as fellowships have been created to train child psychiatrists, administrative psychiatrists, etc. We believe such action could insure a more active role for biological psychiatry without repeating the cycle of disruption already described. The outlines of such a fellowship are sketched.

Psychotherapies: an overview

The author schematically describes the three predominating themes in the development of the psychotherapies: dynamic, behavioral, and experiential. These themes represent different conceptualizations of the fundamental nature of man and his ills, therapeutic processes or change agents, the basic nature of the physician-patient relationship, and the primary techniques and methods used. Although there appears to be some unifying thread connecting the four different areas within each theme, a comparable bond does not exist across the three themes. The author questions the potential unification of the psychotherapies and poses specific dimensions for further exploration.

The therapeutic community in theory and practice

To obtain an operational description of the therapeutic community, the authors reviewed recent literature and composed a 40-item questionnaire describing aspects of the therapeutic community. The questionnaire was mailed to authors of recently published articles or books on the subject, 27 of whom responded with ratings of the degree to which each item was characteristic of a therapeutic community. The validated questionnaire was then completed by 22 staff members on four psychiatric wards of a university-affiliated municipal hospital, who rated the items in terms of real and ideal conditions on the ward. Comparisons of the real and ideal ratings are discussed.

Patterns of psychiatric consultation in a general hospital

The authors conducted a study of the rate of utilization of psychiatric consultation by various services at two general hospitals. The study found that the rehabilitation and plastic surgery services had the highest ratio of consultations to admissions. Depression was the most frequent reason cited in staff requests for psychiatric consultation. Male patients were overrepresented among the consultees in proportion to their number in the total general hospital census. The authors conclude that appropriate psychiatric consultation can enable the majority of patients with psychiatric problems to be maintained on the wards to which they were admitted, and that psychiatric liaison staff should be trained in a variety of consulting roles.

[Ideas and theories in the new psychotherapies in the U.S.A]

A primary concern with man's fragmentation and alienation from himself and others. A concept of pathology which reflects the loss of self or congruence with one's experiences and the resultant blocking and diminution of one's potentialities. A concept of cure which means authenticity, spontaneity and self-actualization. A primary mode of change via immediate experiencing i.e. intense feeling of one's sensory, bodily and/or spiritual dimensions. A primary therapeutic task of providing an authentic and permissive atmosphere for mutual interaction or dialogue. A primary focus upon the phenomenological moment. A treatment model of therapist to client within the egalitarian framework of a "human alliance". A doctor/patient relationship which is a real, here-and-now encounter. A primary therapist role of mutual interactor and acceptor. A primary therapist stance which is involved and real. A primary tool or technique of encounter (and/or intensification of feelings via methods of emotional flooding for intense abreaction, or methods of meditation for profound rest). A primary treatment length which is shortterm and intense.

Psychotherapy with the dying patient

This paper develops and describes encounters with dying patients and their families and looks for consesus of patterns and responses of possible help in confronting this situation. It offers positive suggestions for those providing care for dying patients but also acknowledges that only an intellectual grasp of the situation is not sufficient qualification for caring for the dying.

Medical and nonmedical models in clinical practice and training

Dealing with the range of events encountered by mental health professionals requires both anatomic/physiologic and psychologic/behavioral viewpoints. These viewpoints belong to two different universes of discourse, and their languages are not mutually translatable. For responsible clinical practice, both medical and nonmedical models are necessary and neither model is sufficient.

Thioridazine stimulates prolactin secretion in man

Thioridazine, unlike most other effective antipsychotic drugs, appears to be only a weak dopamine antagonist in various regions of the brain. We decided to test, indirectly, thioridazine's effects on another brain dopaminergic system, the tuberoinfundibular tract, which regulates prolactin secretion by stimulating hypothalamic secretion of prolactin-inhibiting factor. Chlorpromazine and several other phenothiazines have been shown to stimulate prolactin secretion. Five healthy men ingested 50 mg of chlorpromazine concentrate on one occasion, and 50 mg of thioridazine concentrate on another. Both drugs noticeably stimulated prolactin secretion within two hours. It is concluded that thioridazine is a potent dopamine antagonist in the tuberoinfundibular system, and it is suggested that this system's regulation of prolactin secretion may provide a useful method for studying antipsychotic drug effects in man.

Attitudes of psychiatric residents toward the necessity of internship

The authors note that the elimination of the internship requirement for board certification has engendered much discussion and has called attention to the need for further study of training in psychiatry. To help clarify the issue, they investigated demographic and career choice factors, individual internship decisions, and perceptions and feelings about these decisions in 57 psychiatric residents. The results indicate that the career plans of students have a strong influence on their training choices--those who are oriented toward inpatient psychiatry and psychosomatic medicine view the internship as more relevant than those who plan to concentrate in other areas. The authors suggest further research on the relation between career choice and training preferences.

Supervision of the initial interview. A study of two methods

Two methods of supervision of the initial evaluation of outpatients by psychiatric residents were compared. In condition 1, residents evaluated patients and then presented the case material to a supervisor in the traditional manner. In condition 2, the supervisor observed the interview directly. Supervisor and residents then independently completed ratings of psychopathology, motivation, insight, and prognosis of the patients. Significant differences in several variables between the two conditions were noted. Resident and supervisor ratings of patients were in clear agreement when both observed the interview.