Showing papers in "American Journal of Psychiatry in 1981"

The diagnostic interview for borderline patients.

Abstract: The authors describe the content, administration, reliability, construct validity, and training requirements for a semistructured diagnostic interview for borderline patients. The interview is composed of operationally defined and scored variables that assess five areas of functioning considered most characteristic of borderline patients--social adaptation, impulse/action patterns, affects, psychosis, and interpersonal relations. Their results show that the interview provides a reasonably constructed and reliable method for researchers and clinicians interested in identifying the syndrome of borderline personality disorders. Although existing research supports the clinical utility of defining borderline patients with the diagnostic interview for borderline patients, both the diagnosis and the content of the interview may require revisions.

The symptoms of major depressive illness.

Abstract: The authors suggest that the common characteristics of various descriptions of major depressive illness--endogenous, endogenomorphic, psychotic, and melancholic--are an autonomous course, a need for biological treatment, and a presumed alteration in neurochemistry. The literature is reviewed to determine those symptoms which best characterize this syndrome. These symptoms may prove useful in developing valid diagnostic criteria for major depressive illness.

Overview: white norms and psychiatric diagnosis of black patients.

Abstract: Allegations of psychiatric misdiagnosis of black patients are supported by only a few examples of such errors, but there is a modest body of circumstantial evidence suggesting that black patients run a higher risk of being misdiagnosed than white patients. The author reviews the studies providing such evidence and concludes that greater awareness among clinicians and research into more appropriate diagnostic criteria for black patients are desirable.

Overview: Deinstitutionalization of psychiatric patients, a critical review of outcome studies.

Abstract: The authors performed a critical review of experimental studies on the outcomes for psychiatric patients of 1) alternatives to hospital admission, 2) modifications of conventional hospitalization, and 3) alternatives to continued long-term hospitalization. The internal validity of many of the studies was compromised by shortcomings in design and performance and generalizability limited by selection of patient populations. With these qualifications experimental alternatives to hospital care of patients have led to psychiatric outcomes not different from and occasionally superior to those of patients in control groups. This conclusion is best supported for alternatives to admission and for modifications of conventional hospitalization. The available studies do not permit firm conclusions regarding alternatives to continued long-term hospitalization of chronically ill patients or for a critical analysis of the optimal management of specific subpopulations of psychiatric patients. Satisfactory deinstitutionalization appears to depend on the availability of appropriate programs for care in the community.

Continuity of care for chronic mental patients: a conceptual analysis.

Abstract: The author discusses seven dimensions of continuity of care, a basic concept in planning services for chronic mental patients. Continuity of care in psychiatry is distinguished from that in other medical specialties by the unique needs of chronic mental patients. Different approaches to continuity must be used for chronic mental patients with different institutional histories and specialized service needs.

Mastery of stress: psychosocial aspects.

Abstract: Psychological stress may increase an individual's vulnerability to mental and physical illness. This may be prevented if the individual receives social support in mastering the stressful situation in the form of cognitive guidance that compensates for the inevitable reduction in his problem-solving capacity caused by stress-induced emotional arousal. This guidance should also help the individual or compensate for this arousal and enable him to come to terms with inescapable changes in his life produced by the experience. Empirical researches confirm that exposure to high stress by individuals receiving adequate support does not increase the risk of mental and physical illness.

Psychic trauma in children: observations following the Chowchilla school-bus kidnapping.

Abstract: Twenty-three children involved in a school-bus kidnapping were studied from 5 to 13 months following the event. Each child suffered posttraumatic emotional sequelae. The author found that the children suffered from initial misperceptions, early fears of further trauma, hallucinations, and "omen" formation. Later they experienced posttraumatic symptoms consisting of posttraumatic play, reenactment, personality change, repeated dreams (including predictive dreams and those in which they died), fears of being kidnapped again, and "fear of the mundane." Differences between child and adult response to psychic trauma are discussed.

CSF GABA in normal subjects and patients with depression, schizophrenia, mania, and anorexia nervosa.

Abstract: The authors examined the CSF GABA of 87 subjects: 29 normal control subjects, 11 patients with schizophrenia, 26 with depression, 6 with mania, and 15 with anorexia nervosa. Depressed patients had significantly lower CSF GABA levels than did normal subjects. This finding suggests that GABA may have a direct or indirect association with depressive affective disorders.

Delusional and nondelusional unipolar depression: further evidence for distinct subtypes.

Abstract: In a retrospective analysis, the course, symptoms, treatment response, and personality of 54 delusional and 66 nondelusional unipolar depressed patients were compared. The delusional patients had more guilt feelings and were more ruminative, agitated, and referential than the nondelusional patients. They had a poor response to a tricyclic antidepressant therapy but good treatment outcome with a tricyclic-antipsychotic combination or ECT. The form and content of prior episodes were remarkably similar to the index episode in both groups. The authors believe that these findings support the conception of unipolar delusional depression as a distinct subtype of depressive illness.

Clinical and cost benefits of liaison psychiatry.

Abstract: A liaison psychiatrist participated in the postoperative care of a group of elderly patients who underwent surgery for fractured femurs. Clinical outcomes for this group were compared with a control group of patients who were not treated by a liaison psychiatrist. Length of stay for the treatment group was 12 days shorter than for the control group, and twice as many patients in the treatment group returned home rather than being discharged to a nursing home or other health-related institution; therefore, a substantial reduction in the cost of their medical care was effected. The authors suggest that psychiatric liaison services should be viewed as a potential cost containment mechanism for general medical care. Language: en

Treatment of Sex Offenders with Antiandrogenic Medication: Conceptualization, Review of Treatment Modalities, and Preliminary Findings

Abstract: Sexual deviation disorders, or paraphilias, are diagnosable psychiatric syndromes manifested by 1) recurrent fantasies about deviant sex, 2) intense associated cravings, and 3) stereotypic behavioral responses. Pedophiles seek out children in response to their erotic thoughts and urges, whereas exhibitionists expose themselves. Paraphiliac syndromes ordinarily follow a chronic course and may be associated with biological pathology, but etiological factors are poorly understood. Treatment becomes a consideration when the well-being or rights of others are compromised. Proposed treatments have included psychotherapy, behavior therapy, surgery, and medication. Medroxyprogesterone acetate, which reduces testosterone, may diminish sexual preoccupation and urges, making self-control easier.

Personality Traits and Disorder in Depression

Abstract: The authors examined the relationship of personality traits and personality disorder to depressive subtype, descriptive characteristics, and outcome in 160 depressed inpatients. Personality disorder was significantly more common in unipolar nonmelancholic depressed patients (61%) than in unipolar melancholic (14%) or bipolar depressed patients (23%). Personality disorder did not affect symptom manifestation but was related to earlier onset of depressive illness and worse outcome within the unipolar nonmelancholic group. Obsessive traits were most common in the unipolar melancholic patients, while histrionic, hostile, and borderline traits predominated in the nonmelancholic patients. The authors discuss the usefulness of a multiaxial diagnostic system and the importance of separating trait and disorder in personality assessment.

Unrecognized physical illness prompting psychiatric admission: a prospective study.

Abstract: The authors studied 100 state hospital psychiatric patients consecutively admitted to a research ward who were screened to eliminate physical illness before admission They found an unusually high incidence of medical illness: 46% of these patients had an unrecognized medical illness that either caused or exacerbated their psychiatric illness, 80% had physical illnesses requiring treatment, and 4% had precancerous conditions or illnesses A workup consisting of psychiatric and physical examination, SMA-34, urinalysis, ECG, and EEG after sleep deprivation identified over 90% of medical illnesses present in this population The authors suggest that such a battery be part of the routine workup for all hospitalized psychiatric patients

Psychological sequelae of brain damage in children.

Abstract: The author reviews the empirical evidence on the psychological sequelae of brain damage in childhood, concluding that brain injury causes a markedly increased risk in both intellectual impairment and psychiatric disorder. The risk is related to the severity of the brain damage, but there is little indication of locus effects. Psychiatric disorder is probably most likely to occur when there is abnormal neurophysiological activity; to some extent it may be influenced by the nature of the basic medical condition. Psychiatric consequences of brain injury are also substantially affected by the child's pre-injury behavior, psychosocial circumstances, and cognitive level. However, there are few psychological sequelae that are specific to brain damage. Language: en

The diagnostic status of homosexuality in DSM-III: a reformulation of the issues

Abstract: In 1973 homosexuality per se was removed from the DSM-II classification of mental disorders and replaced by the category Sexual Orientation Disturbance. This represented a compromise between the view that preferential homosexuality is invariably a mental disorder and the view that it is merely a normal sexual variant. While the 1973 DSM-II controversy was highly public, more recently a related but less public controversy involved what became the DSM-III category of Ego-dystonic Homosexuality. The author presents the DSM-III controversy and a reformulation of the issues involved in the diagnostic status of homosexuality. He argues that what is at issue is a value judgment about heterosexuality, rather than a factual dispute about homosexuality.

Sleep and treatment prediction in endogenous depression.

Abstract: The prediction of clinical response in depression has been based primarily on clinical symptoms and history. Recently, psychobiologic measures have been used to increase the accuracy of clinical prediction. In 34 drug-free patients with primary endogenous depression treated with amitriptyline, the application of EEG-monitored sleep criteria alone was more significant than clinical status alone in the prediction of clinical response. Prolonged REM latency and reduced difficulty in sleep onset following the administration of amitriptyline were the main sleep variables contributing to this prediction equation. These data suggest a strong relationship between clinical outcome and psychobiologic profile in patients with endogenous depression after a "pharmacologic probe" with a tricyclic antidepressant.

Dopamine receptors, neuroleptics, and schizophrenia.

Abstract: The antipsychotic effects of neuroleptic drugs are mediated by dopamine DA-2 receptors, and dopamine DA-1 receptors, linked to cyclic AMP formation, are not involved. Dopamine receptor binding is enhanced in brain specimens of deceased schizophrenic patients, an increase which may relate to chronic neuroleptic treatment. The binding of 3H-butyrophenones to dopamine receptors can be used for a radioreceptor assay that detects blood levels of all clinically used neuroleptics and their pharmacologically active metabolites and may facilitate routine monitoring of blood levels.

REM sleep dreams and the activation-synthesis hypothesis.

Abstract: The authors studied 104 dreams obtained from 14 subjects and quantified the formal aspects of the subjects' dream experiences by the following categories: movement in dreams, sensation, affect, dream bizarreness, and dream lucidity. Their results are compared with the predictions of the activation-synthesis hypothesis, which postulates that the characteristic formal aspects of dreams correspond to characteristic aspects of physiological activation during REM sleep. Although further experimental work is needed, the authors show that their results are consistent with and supportive of the activation-synthesis hypothesis.

Abnormalities of dexamethasone suppression test and urinary MHPG in anorexia nervosa.

Abstract: Twenty-two patients with primary anorexia nervosa were assessed on variables of weight, mood, dexamethasone suppression test, and 24-hour urinary MHPG levels. Patients at less than 80% of their ideal weight had abnormally high cortisol levels after the test and low MHPG levels, regardless of their mood. The authors hypothesize that these abnormalities are not due to depression associated with anorexia nervosa and that decreased norepinephrine metabolism may be related to this illness.

Propranolol in the treatment of rage and violent behavior in patients with chronic brain syndromes.

Abstract: The authors successfully treated four patients who had irreversible CNS lesions and socially disabling aggressiveness and outbursts of rage, which had not been affected by high doses of major tranquilizers or anticonvulsants, with 320-520 mg/day of propranolol. Disorientation, memory impairment, and psychotic thought processes associated with the CNS lesions were not altered by the propranolol. Language: en

Clinical issues in the assessment of competency.

Abstract: The evaluation of a patient's competency to consent to treatment, regardless of the test of competency used, can be substantially affected by a number of clinical factors. The authors point out that, in assessing competency, the clinician must consider 1) psychodynamic elements of the patient's personality, 2) the accuracy of the historical information conveyed by the patient, 3) the accuracy and completeness of the information disclosed to the patient, 4) the stability of the patient's mental status over time, and 5) the effect of the setting in which consent is obtained. Inattention to these factors can lead to errors in assessment of competency that can have important implications for patient care.

Natural history of male psychological health, X: Work as a predictor of positive mental health.

Abstract: A sample of 456 inner city men was prospectively followed from age 14 until age 47. Rates blind to adult outcome assessed the men's childhood success at tasks reflecting Erikson's fourth developmental stage, industry versus inferiority. Childhood assessments were made on the parenting the men received and other psychosocial variables, including social class and IQ, and were compared with independent judgments of these men's mental health and career success at age 47. Capacity to work in childhood predicted the success of these underprivileged men at work in adult life and surpassed social class, multiproblem-family membership, and all other childhood variables in predicting adult mental health and capacity for interpersonal relationships.

Current perspectives on childhood depression: an overview.

Abstract: The rapidly increasing research interest in childhood depression indicates that it has become a recognized disorder. The authors review the literature on depression in children, focusing on epidemiology, various diagnostic criteria, classification schemes, assessment instruments, and intervention studies that have been applied to childhood depression. Given that there are many etiological factors, it will be important to study the disorder from various conceptual frameworks, including biochemical, genetic learned helplessness, life stresses, cognitive distortion, behavioral reinforcement, and sociological models.

Therapeutic alliance scales: development and relationship to psychotherapy outcome.

Abstract: The authors describe the development of patient and therapist alliance scales and their application to the therapies of selected patients with good and poor outcomes following brief psychodynamic psychotherapy. They focus on therapist and patient contributions to the attitudinal-affective climate of the therapy rather than on specific therapist techniques. The findings support the value of separating the contributions to the therapeutic alliance made individually by the therapist and the patient. Only the patient's contribution to the therapeutic alliance was predictive of outcome. Patients who developed and maintained positive attitudes toward the therapist and the work of therapy achieved the greatest gains.

Families at Risk for Father-Daughter Incest

Abstract: Sexual abuse of children within their families is a common problem that is only beginning to gain the attention of the mental health professions. As recently as 1975, the Comprehensive Textbook of Psychiatry 1 contained an estimated prevalence of all forms of incest of one case per million population. This estimate is most likely in error by four or five orders of magnitude. Several large surveys2–6 of predominantly white, middle-class women have indicated that between 20% and 35% of all women have had a childhood sexual encounter with an adult male, that 4%–12% of all women have had such an experience with a relative, and that about 1% of all women have been involved in father-daughter incest. The great majority of these sexual encounters are not disclosed at the time of occurrence and have never come to the attention of any social agency.

Changing epidemiology of tardive dyskinesia: an overview.

Abstract: Dyskinesia is found significantly more often among neuroleptic-treated psychiatric patients than among non-neuroleptic-treated patients. The epidemiology of tardive dyskinesia is changing; its reported prevalence among neuroleptic-treated psychiatric inpatients has been progressively rising and has reached 25% during the past five years. The prevalence of persistent tardive dyskinesia that may be attributable to neuroleptics is about 13%. Tardive dyskinesia is not restricted to old, brain-damaged inpatients but also occurs with a noticeable frequency among younger patients, including outpatients, treated neuroleptics. Yet neuroleptics are the most effective available treatment for schizophrenia; hence, any drastic curtailment of their use in the treatment of chronic schizophrenic patients may not be justified. Cautious use of these drugs, along with intensified research on tardive dyskinesia is warranted.

Treatment of sex offenders with medroxyprogesterone acetate.

Abstract: 48 male patients with longterm histories of deviant sexual behavior received medroxyprogesterone acetate (MPA) and milieu therapy for up to 12 months at the Sherbrooke Hospital in Quebec 39 of the 48 patients were referred to the hospital after having been arrested and charged with a criminal offense 20 had a history of psychiatric or psychological treatment and 21 had been convicted of sex offenses 28 had a diagnosis of paraphilia alone and 19 a diagnosis of paraphilia associated with another psychological disorder 7 used alcohol excessively 26 were single 19 married 2 divorced and 1 widowed The treatment objective was to maintain the subjects plasma testosterone levels at less than 250 ng/100 ml For the 1st 2 weeks patients received MPA 200 mg 2-3 times/week; for the next 4 weeks they received 200 mg once or twice/week; and for the next 12 weeks they were given 100 mg once a week or 200 mg every 2 weeks Most patients received 100 mg every 1-4 weeks during the last 7-8 months Plasma testosterone levels were measured biweekly for the 1st month and monthly thereafter Patients had daily psychiatric evaluations during hospitalization and bimonthly assessments after release Patients were followed up for 3 years after termination of hormonal therapy 40 patients showed a positive response to the treatment all within 3 weeks with diminished frequency of sexual fantasies and arousal increased control over sexual urges and improvement in psychosocial functioning Improvement was maintained after treatment ended and there was no evidence of permanent physiological changes All patients reported side effects including fatigue weight gain hot and cold flashes headaches insomnia nausea and 1 case of phlebitis 7 patients who had an associated diagnosis of antisocial personality showed no change in sexual behavior