Current psychiatry 

About: Current psychiatry is an academic journal published by Frontline Medical Communications. The journal publishes majorly in the area(s): Population & Bipolar disorder. It has an ISSN identifier of 1537-8276. Over the lifetime, 959 publications have been published receiving 2445 citations.

Cannabis, Synthetic Cannabinoids, and Psychosis Risk: What the Evidence Says: Research Suggests Marijuana May Be a 'Component Cause' of Psychosis

Abstract: Over the past 50 years, anecdotal reports linking cannabis sativa (marijuana) and psychosis have been steadily accumulating, giving rise to the notion of "cannabis psychosis." Despite this historic connection, marijuana often is regarded as a "soft drug" with few harmful effects. However, this benign view is now being revised, along with mounting research demonstrating a clear association between cannabis and psychosis. In this article, I review evidence on marijuana's impact on the risk of developing psychotic disorders, as well as the potential contributions of "medical" marijuana and other legally available products containing synthetic cannabinoids to psychosis risk. Cannabis use and psychosis Cannabis use has a largely deleterious effect on patients with psychotic disorders, and typically is associated with relapse, poor treatment adherence, and worsening psychotic symptoms. (1), (2) There is, however, evidence that some patients with schizophrenia might benefit from treatment with cannabidiol, (3-5) another constituent of marijuana, as well as delta-9-tetrahydrocannabinol ([DELTA]-9-THC), the principle psychoactive constituent of cannabis. (6), (7) The acute psychotic potential of cannabis has been demonstrated by studies that documented psychotic symptoms (eg, hallucinations, paranoid delusions, derealization) in a dose-dependent manner among healthy volunteers administered [DELTA]-9-THC under experimental conditions. (8-10) Various cross-sectional epidemiologic studies also have revealed an association between cannabis use and acute or chronic psychosis. (11), (12) [ILLUSTRATION OMITTED] In the absence of definitive evidence from randomized, long-term, placebo-controlled trials, the strongest evidence of a connection between cannabis use and development of a psychotic disorder comes from prospective, longitudinal cohort studies. In the past 15 years, new evidence has emerged from 7 such studies that cumulatively provide strong support for an association between cannabis use as an adolescent or young adult and a greater risk for developing a psychotic disorder such as schizophrenia. (13-19) These longitudinal studies surveyed for self-reported cannabis use before psychosis onset and controlled for a variety of potential confounding factors (eg, other drug use and demographic, social, and psychological variables). Three meta-analyses of these and other studies concluded an increased risk of psychosis is associated with cannabis use, with an odds ratio of 1.4 to 2.9 (meaning the risk of developing psychosis with any history of cannabis use is up to 3-fold higher compared with those who did not use cannabis). (11), (20), (21) In addition, this association appears to be dose-related, with increasing amounts of cannabis use linked to greater risk--1 study found an odds ratio of 7 for psychosis among daily cannabis users. (16) There are several ways to explain the link between cannabis use and psychosis, and a causal relationship has not yet been firmly established (Table 1). (1-7), (11-19), (21-25) Current evidence supports that cannabis is a "component cause" of chronic psychosis, meaning although neither necessary nor sufficient, cannabis use at a young age increases the likelihood of developing schizophrenia or other psychotic disorders. (26) This risk may be greatest for young persons with some psychosis vulnerability (eg, those with attenuated psychotic symptoms). (16), (18) Table 1 Hypotheses linking cannabis and psychosis Hypothesis Strength Evidence for of evidence Cannabis does Weak * No randomized controlled not cause trials chronic * Other possible explanations psychosis (demographic/socioeconomic, trauma, other drug use) * Possible reverse causality (psychosis leads to cannabis use) * Possible publication bias (negative evidence not published) Cannabis can Equivocal Cannabis use precedes the cause onset of schizophrenia in schizophrenia longitudinal studies (13-19) Cannabis Strong * Cannabis is associated worsens with increased symptoms, existing relapse, and treatment psychotic nonadherence among those disorders with schizophrenia (1), (2) * Patients with schizophrenia are more vulnerable to cannabis-induced psychosis under experimental conditions (22) Cannabis Strong * For patients with increases the schizophrenia, a history of risk of cannabis use is associated chronic with illness onset 2 to 3 psychosis years earlier compared with among non-users (23) vulnerable * Cannabis use is a risk individuals factor for conversion to psychosis in some studies of prodromal schizophrenia (24) Hypothesis Evidence against Cannabis does * Controlled not cause (cross-sectional chronic and longitudinal psychosis cohort) studies consistently show an association (11-19) * Longitudinal studies include risk calculations adjusted for confounding variables (13-19) * Publication bias not found in meta-analyses (11), (21) Cannabis can The incidence of cause schizophrenia has schizophrenia not been clearly increasing as expected with increasing cannabis use (11), (21) Cannabis Cannabidiol and worsens [DELTA]-9-THC existing improve symptoms psychotic in some patients disorders with schizophrenia (3-7) Cannabis Cannabis use is increases the not always a risk risk of factor for chronic conversion to psychosis psychosis in among studies of vulnerable prodromal individuals schizophrenia (25) [DELTA]-9-THC: delta-9-tetrahydrocannabinol The overall magnitude of risk appears to be modest, and cannabis use is only 1 of myriad factors that increase the risk of psychosis. …

Depression and suicide among physicians

Abstract: Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism. [ILLUSTRATION OMITTED] Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and "weak" to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to "carry his load." Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence. Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment. Although the rate of depression among physicians is comparable to that of the general population, physicians' risk of suicide is markedly higher.1 Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might: * be reluctant to seek treatment * attempt to diagnose and treat themselves * seek and receive "VIP treatment" from other health care providers. This article examines physicians' risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles. Not immune to depression Rates of depression are higher in medical students and residents (15% to 30%) than in the general population. (2-4) A longitudinal study of medical students at the University of California, San Francisco showed that students' rates of depression when they enter medical school are similar to those of the general population, but students' depression scores rise over time; approximately one-fourth of first- and second-year students were depressed. (3) Fahrenkopf et al (5 ) reported that 20% of 123 pediatric residents at 3 U.S. children's hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers. (5) For more information on physicians-in-training, see "Treating depression in medical residents," page 96. After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women (6); these rates are comparable to those of the general population. Firth-Cozens (7) found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1) (7) Although these stressors increase depression risk, Vaillant et al (8) showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse. (8) Table 1 Predictors of depression in physicians Difficult relationships with senior doctors, staff, and/or patients Lack of sleep Dealing with death Making mistakes Loneliness 24-hour responsibility Self-criticism Source: Reference 7 A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. …

Self-criticism and self-compassion: risk and resilience: being compassionate to oneself is associated with emotional resilience and psychological well-being

Abstract: Once thought to only be associated with depression, self-criticism is a transdiagnostic risk factor for diverse forms of psychopathology. (1,2) However, research has shown that self-compassion is a robust resilience factor when faced with feelings of personal inadequacy. (3,4) Self-critical individuals experience feelings of unworthiness, inferiority, failure, and guilt. They engage in constant and harsh selfscrutiny and evaluation, and fear being disapproved and criticized and losing the approval and acceptance of others. (5) Self-compassion involves treating oneself with care and concern when confronted with personal inadequacies, mistakes, failures, and painful life situations. (6,7) Although self-criticism is the aspect of perfectionism most associated with maladjustment, (8) one can be harshly self-critical without being a perfectionist. Most studies of self-criticism have not measured shame; however, this self-conscious emotion has been implicated in diverse forms of psychopathology. (9) In contrast to guilt, which results from acknowledging bad behavior, shame results from seeing oneself as a bad or inadequate person. Although self-criticism is destructive across clinical disorders and interpersonal relationships, self-compassion is associated with healthy relationships, emotional well-being, and better treatment outcomes. Recent research shows how clinicians can teach their patients how to be less self-critical and more self-compassionate. Neff (6,7) proposes that self-compassion involves treating yourself with care and concern when being confronted with personal inadequacies, mistakes, failures, and painful life situations. It consists of 3 interacting components, each of which has a positive and negative pole: * self-kindness vs self-judgment * a sense of common humanity vs isolation * mindfulness vs over-identification. Self-kindness refers to being caring and understanding with oneself rather than harshly judgmental. Instead of attacking and berating oneself for personal shortcomings, the self is offered warmth and unconditional acceptance. Humanity involves recognizing that humans are imperfect, that all people fail, make mistakes, and have serious life challenges. By remembering that imperfection is part of life, we feel less isolated when we are in pain. Mindfulness in the context of self-compassion involves being aware of one's painful experiences in a balanced way that neither ignores and avoids nor exaggerates painful thoughts and emotions. Self-compassion is more than the absence of self-judgment, although a defining feature of self-compassion is the lack of self-judgment, and self-judgment overlaps with self-criticism. Rather, self-compassion provides several access points for reducing self-criticism. For example, being kind and understanding when confronting personal inadequacies (eg, "it's okay not to be perfect") can counter harsh self-talk (eg, "I'm not defective"). Mindfulness of emotional pain (eg, "this is hard") can facilitate a kind and warm response (eg, "what can I do to take care of myself right now?") and therefore lessen self-blame (eg, "blaming myself is just causing me more suffering"). Similarly, remembering that failure is part of the human experience (eg, "it's normal to mess up sometimes") can lessen egocentric feelings of isolation (eg, "it's not just me") and over-identification (eg, "it's not the end of the world"), resulting in lessened self-criticism (eg, "maybe it's not just because I'm a bad person"). Depression Several studies have found that self-criticism predicts depression. In 3 epidemiological studies, "feeling worthless" was among the top 2 symptoms predicting a depression diagnosis and later depressive episodes. (10) Self-criticism in fourth-year medical students predicted depression 2 years later, and--in males--10 years later in their medical careers better than a history of depression. …

When Does Conscientiousness Become Perfectionism? Traits, Self-Presentation Styles, and Cognitions Suggest a Persistent Psychopathology

Abstract: Mr. C is a 50-year-old professional writer who recently made a serious suicide attempt. At his initial session, Mr. C was hesitant to discuss his situation and reason for attending. He did, however, bring a copy of his resume so the therapist could "get to know him quickly." [ILLUSTRATION OMITTED] He said he had been depressed for a long time, especially since he found an error in one of his published works. His confidence and writing abilities seemed to decline after this discovery, his career took a downturn, and ultimately he was fired from his position. He described often being at odds with his supervisors at work, whom he saw as critical and condescending. He was mortified by his job loss and did not inform his wife or friends of his firing. Mr. C had always been a bit of a loner, and after losing his job he further distanced himself from others. He began drinking heavily to avoid the pain of "letting everyone down." His wife, family, and friends were shocked at the suicide attempt and expressed dismay that Mr. C had not confided in anyone. Mr. C describes himself as being perfectionistic throughout his life and never being quite good enough in any of his pursuits. This leads to self-recriminations and persistent feelings of shame. Far from being a positive attribute, perfectionism is a neurotic personality style that can result in serious psychopathology, including relationship problems, depression, anorexia nervosa, and suicide. Determining a patient's perfectionistic traits is essential when evaluating those who seek treatment specifically for this distressing behavior as well as patients in treatment for other issues who may have a perfectionistic personality. Accurately assessing perfectionism can help you predict and forestall noncompliance, assess suicide risk, determine appropriate treatment and identify circumstances under which a patient might be particularly vulnerable to relapse. This article describes: * 3 traits of perfectionism * 3 dimensions of perfectionistic self-presentation * perfectionistic cognitions * useful self-report tools for clinical practice * effective treatments. Characteristics of perfectionism Although perfectionism initially was viewed as self-related cognitions, recent models suggest it incorporates intrapersonal and interpersonal dimensions. (1) A person with perfectionism has a marked need for absolute perfection for the self and/or others in many--if not all--pursuits that is strongly rooted in his or her intrapersonal and interpersonal worlds. Other characteristics of perfectionism include: * equating self-worth or esteem with performance * self-punishment in failure and a lack of satisfaction in success * maintaining and needing to strive for unrealistic expectations * unrealistic criteria for success and broad criteria for failure. Some clinicians have suggested that perfectionism may be adaptive, (2) but "adaptive perfectionism" is more likely a reflection of conscientiousness or achievement striving (Table 1). Although perfectionism can involve rumination, it is much broader than simply having an obsessional cognitive style. We define perfectionism as a neurotic personality style involving perfectionist traits, self-presentation styles, and cognitions that is a core vulnerability factor for a variety of psychological, physical, achievement, and relationship problems (Table 2). (1,3) 3 traits. Three traits of perfectionism reflect the desire for the self or others to be perfect: * self-oriented perfectionism -- a requirement for the self to be perfect * other-oriented perfectionism -- a requirement for others to be perfect * socially prescribed perfectionism -- a perception that others require perfection of oneself. Each of these traits is associated with different Axis I and Axis II disorders, which we outline below. …