Showing papers in "International Journal of Psychiatry in Medicine in 1971"

Variation in patients' compliance with doctors' orders: medical practice and doctor-patient interaction.

Abstract: Doctor-patient interactions were tape-recorded and coded according to a modified system of Interaction Process Analysis. These data, combined with a series of patient interviews and a self-administered questionnaire completed by physicians, were analyzed to determine the extent of patient compliance with doctors' orders and how variations in patient compliance are influenced by some selected patient characteristics and by the structure and process of the doctor-patient relationship.None of the demographic characteristics of patients investigated here was associated with compliance. However, the ways in which doctors and patients initially fit their activity into the presumably institutionalized patterns of behavior appropriate for doctor-patient interaction and the way they deviate over time from the institutionalized role expectations was found to be related to variations in patient compliance.

Suicide among physicians.

Abstract: A review of the international literature of the past 75 years of suicide among physicians indicates that (1) suicide among physicians is high, (2) suicide among female physicians is higher than amo...

Patterns of Psychiatric Consultation in Two General Hospitals

Abstract: The data presented in this paper reflect five years' experience of the Psychiatric Consultation-Liaison Service in two general hospitals of a large medical teaching center. The frequency of consultations shows that the more liaison time spent teaching on the wards, the more consultations generated. The decrease in consultations observed over the course of the academic year may indicate that the nonpsychiatric house staff which has a liaison with psychiatry becomes more competent in handling cases with psychiatric problems. Liaison psychiatry provides the most varied training experience possible for the psychiatric resident, making him more conscious of the interrelationships between psychiatry and other clinical specialties.

Conversion reactions and psychophysiologic disorders: a comparative study.

Abstract: A chart study of psychosomatic consultations was undertaken in order to compare characteristics of conversions and psychophysiologic diseases. One hundred nine charts were rated according to sixty descriptive, mental status, and psychodynamic factors. The subjectivity of many of these parameters is recognized, but was controlled by cross-checking scorings made by independent raters. Reliability, so measured, proved satisfactory in general but not for certain factors central to psychosomatic theory.Within these limitations, the results showed significant differences between the two classes of disorders in eighteen factors, including reason for referral, type of stress, intelligence, insight and depression. Among the traits traditionally considered distinctive, yet failing to differ in this study, were sex, religion, rural background, education, social class, and sexual adjustment.Psychosomatic theory has evolved from the unitary “unconscious symbolism” model through the very discrete distinctions postulate...

The nurse as a psychiatric consultation team member.

Abstract: A better understanding of the psychological aspects of illness and hospitalization necessitates increased attention to the patient's interpersonal transactions with care-givers in the general hospi...

Postcardiotomy psychosis in non-English-speaking patients.

Abstract: This paper presents another causative or additive factor in the production of post-cardiotomy delirium. Comparison of two matched groups of patients from the National Heart Institute reveals a marked difference in the incidence of psychosis between the group that is from the United States and speaks English and the group that is foreign and has no ability to communicate in English. The United States group had two patients with psychosis (3.9 percent), while the foreign group had fifteen (29.4 percent) (p<0.001). A higher incidence of delirium occurred in men than women, and there was suggestive evidence that the group with psychoses had more medical complications, with resulting delays in discharge. The importance of language and culture in the determination of this delirium are considered and methods of mitigating this reaction are presented.

Training in psychological medicine: an attempt to assess Tavistock Clinic seminars.

Abstract: In recent years there have been a number of attempts to evaluate the effects of postgraduate training seminars in psychological medicine for primary physicians. All of these studies agree in one respect–the enormously complex task of choosing meaningful criteria for assessment. This paper describes a pilot project in which twelve pre-seminar and twelve post-seminar doctors were interviewed. Analysis of the data suggests two general criteria which reflect a “limited though considerable change” in the personality of the doctor: (1) the doctor engages in work commensurate with his limits and he makes appropriate use of available consultant help; and (2) the interference by his own psychopathology in his work is minimal.The study also suggests that seminar work promotes this kind of limited personal change in the doctor, and that improvement on these criteria may be necessary for the maintenance of skills gained in seminars. Implications for training and for further research are discussed.

A study of psychiatric emergencies. 3. Findings on followup.

Abstract: Criteria to measure the effectiveness of a psychiatric emergency consultation service include (1) whether or not the recommendations made were followed, and (2) the rate of hospitalizations in the followup period.Negro females were identified as following outpatient recommendations least often of any group. With this finding, the suitability of the classical recommendations available is discussed.The hospitalization rate for the psychiatric emergency group in the followup period is significantly higher than the national rate. This finding is independent of (1) hospitalizations effected at the time of the emergency evaluations and (2) psychiatric hospitalizations in the followup period. This result suggests that a large fraction of the psychiatric emergency population presents with extensive pathology which is not or cannot be dealt with in the context of the emergency consultation.

Emotional interactions of patient and staff: a focus of psychiatric consultation.

Abstract: Factors in the relationship with the medical staff often precipitate a psychological crisis in a patient eventuating in a request for psychiatric consultation Such reactions and the part the medic

Interpersonal aspects of psychiatric consultations in a general hospital.

Abstract: Interactions between referring physicians and psychiatric consultants are crucial issues in the overall care of the patient in the general hospital. This presentation concerns itself with these issues, in particular the types of referrers and consultants involved in the consultation process. Psychiatrists are often ineffective as consultants if they are unable to communicate with referring physicians because of inflexibility and are unable to explain the patient's behavior in terms meaningful to the physician. Likewise the referrals are ineffective if the physician calls in the consultant only after all other diagnoses are considered and if emotional illness is presented in a disparaging manner. Because of the patient's unconscious use of somatic defenses and denial of emotional conflict, care must be taken not to reinforce resistances toward a psychosocial approach to his illness.

Patients with eye symptoms and no organic illness: an interdisciplinary study.

Abstract: The eyes and the visual functions receive great emotional investment. Ophthalmologists often overlook the emotional aspects of eye disease and overdiagnose hysteria in their patients. This project was a combined psychiatric and ophthalmologic study of patients without organic eye disease who presented with symptoms at an outpatient ophthalmology clinic. These patients differed from ordinary eye patients by age (younger), duration of symptoms (longer), and type of chief complaint (nonvisual). A large number of these patients were felt to have significant psychiatric illness, although the presence of organic eye illness did not protect against psychiatric difficulty. Tubular visual fields, like any conversion symptoms, are not diagnostic of hysteria. Greater use of the psychiatric consultant is urged.

How children live after disfiguring burns.

Abstract: At the Boston Shriners Burns Institute, where this study was undertaken, a great number of burned patients present a further complication: poor socioeconomic conditions, which often have a clear causal relationship with the injury. Because of this complex of relationships, not only the psychodynamics of the child and his family, but social conditions and the widely variant nature of the trauma itself, each case, in the end, is singular. Nevertheless, for each severely burned child and his family, it can be said that the psychological effects of injury are both of great magnitude and lifelong. This study, then, is particularly concerned with the individual patient, his family, their attempt to cope with their problem and—beyond that—what can be done to help keep them in the community somehow and out of the pale of despair.

Breast cancer: has the time come for a less mutilating treatment?

Abstract: The emotional turmoil which may be induced by the threat of mastectomy was forcefully brought to Dr. Cope's attention by a patient in 1958. He opens his article with the report of the patient; she was treated by irradiation instead of mastectomy. He then goes on to weigh the value of irradiation without mastectomy as a cancer therapy vis-a-vis that of the traditional radical mastectomy. He concludes from the evidence recorded in the literature and from his own experience that for the majority of patients modern high voltage irradiation is a reasonable alternative to surgery, that women should be informed of the alternative and that for psychological reasons “they don't need to be railroaded into having their breast removed.”

Maternal Influence on Child Behavior in the Dental Setting

Abstract: A significant relationship was observed between the behavior of 127 children (3 to 7 years old), 60 whose treatment involved a dental extraction and 67 a dental examination, and the anxiety level of their mothers as measured by scores on the Taylor Manifest Anxiety Scale. A significant relationship was also found between the mothers' answers to the first three questions on a short preoperative questionnaire and their children's behavior. These results indicated that, in this sample, maternal anxiety appears to be a major factor affecting the behavior of young children during early dental experiences. There is also some indication that a preoperative questionnaire could be substituted for a psychological anxiety test in a variety of clinical settings, thus aiding the clinician in predicting and managing the child's behavior.

Changing attitudes and patterns of behavior among emerging physicians.

Abstract: In an attempt to identify emergent trends in the value systems of graduating medical students, questionnaires investigating sexual, religious, and political attitudes and behavior as well as students' drug use, prejudices, attitudes toward the American Medical Association, and several social issues were sent to the graduating classes of Columbia (1968) and Yale (1970). Although physicians are frequently seen as the repositories of the morals of the nation, these graduating physicians had views quite distinct from the more traditionalistic views generally ascribed to physicians.

Psychiatric impairment versus adjustment in hemophilia: review and five case studies.

Abstract: The literature on psychiatric impairment and adjustment in hemophiliacs is reviewed with particular regard to types of psychiatric disorder and social maladjustment which have been found in adolescents and adults. A set of hypotheses is developed from the literature regarding factors which may interact with hemophilia to produce psychiatric impairment. The hypothetical factors relate to the age of onset and frequency of bleeding episodes; degree of gratification and restriction consequent to them; rejection by the father; and death of a sibling. Five cases are presented which are representative of the spectrum of psychiatric impairment in hemophilia. Some of the hypothesized factors are found to be significantly operative in the individual cases, and others are not.

The family doctor and patients' secrets.

Abstract: One of the most difficult decisions for the family physician is when and to what extent to inquire into his patients' private thoughts and emotions. Asking too many questions may be just as hazardo...

Early Clinical Responsibility for Medical Students

Abstract: Trends in medical education point to accelerated training in medical schools and postgraduate medical education. In a shortened curriculum, opportunities for major clinical responsibility may decrease, though it is generally acknowledged that medical students learn most effectively when given such responsibility. This paper presents the results of a questionnaire evaluating the experience of third- and fourth-year medical students who assumed major clinical responsibility on a short-term psychiatric inpatient service in a general hospital. An open-ended questionnaire was sent to the twenty-seven medical students who were on the service during the 1968–69 academic year. All but one student in each year described a positive experience in assuming major clinical responsibility. An important finding was that much anxiety and depression were present in both years, particularly in the third year. One of the implications of this study is the possibility that major patient responsibility for medical students can ...

Learning processes in physician education: integrating psyche and soma.

Abstract: There was a wide range of difference in the way fifty-five third-year medical students wrote about a hypothetical medical patient with abdominal complaints and mild schizophrenic traits. The written exercise served as a projective test. Twenty-five wrote from a singularly psychological orientation; eighteen mentioned possible somatic disease in terms of dichotomy, psychic vs. somatic; twelve wrote in terms that allowed for the possible coexistence of psychic and somatic diseases. In each of these groups there were a few who demonstrated a relatively extreme attitude. The latter tend to represent a type of learning problem involving compartmentalized thinking. The three such students who dichotomized also demonstrated a tendency for strong ambivalence, vigorous likes and dislikes.One of the students who made a strong dichotomy between psyche and soma is the subject of a more intensive study of his learning processes. Hypotheses are suggested to explain how the physician learns to regard the “whole man” in ...

Psychoactive drugs in outpatient therapy.

Abstract: A great many patients coming to a clinic for the first time are already using one or more drugs. The physician must be aware of this, not only for the purpose of prescription, but also in determining the validity of patient responses. He should be aware, too, of the correlation between demographic data and drug effect. If a drug is indicated, the therapist must consider, in addition to questions of potency, side effects and possible habituation, what he hopes to achieve through therapy. This paper provides a brief clinical evaluation of psychoactive drugs and their interaction with such non-drug variables as setting, expectation, placebo response, therapist attitude, and social class.

Bedlam in the Therapeutic Community: The Disruption of a Hospital Therapeutic Community as a Pattern of Social Conflict

Abstract: A difficult patient arouses staff feelings to the point where a hospital therapeutic community ceases to function and the patient is forced to leave. The events reveal that there are social forces ...

Teaching psychiatry to medical students: a lesson for the teacher.

Abstract: As in the clinical practice of medicine, crises are common events in the lives of those who teach. When these are viewed as episodes in the development and continuation of a teaching-learning situation, they serve to focus attention on the entire learning process. The refusal by a section of second year medical students to sign their psychiatry quiz papers is taken as such an event and is scrutinized to help define the task of a teacher of psychiatry in an era of confrontation. With a conceptual focus on the dyad of teacher and student, and a consideration of the collaborative definition of goals, content, methods and evaluation procedures, the author describes his delayed recognition of the full impact of the milieu on the students. Their perception of the evaluation process and the necessity to involve them in it is described. Such elements as work overload, a minimization of the relative importance of psychiatric learning, an understandable fear and mistrust of authority are considered, as are the students' wishes to be good physicians and to receive feedback. A solution to this problem which resolved the crisis and prevented its recurrence is outlined. Such post facto learning by the teacher fosters the activity of the intuitive and cognitive processes in him, and permits him to form new perceptions of the teaching process.

Behavioral biology in medicine.

Abstract: The continuing emergence of a clinically helpful behavioral biology is a basic scientific trend in contemporary psychiatry and medicine. Much of this new knowledge describes the genetic, maturational and learned developmental structure and physiology of the behaving brain and body. The dichotomy between the depersonalized body and the disembodied person is no longer very productive either for pragmatic or for heuristic purposes. The growing science of behavioral genetics indicates that man is never an “empty” or a “standard” organism. Specific motivational and capacity factors are genetically conditioned. Since medicine deals largely with the phenotypic individual, ordinary clinical assessment of symptoms and behavior may entirely miss the genotypic differences between persons who are labelled with the same but genetically non-differentiating diagnosis of schizophrenia, epilepsy and other diseases. The increasing knowledge of molecular biology coupled with the genetic study of animal behavior has given us an increasing awareness of our own evolved behavior. Some of this behavior originally “bred in” as adaptive to environments now remote in time, space and culture has now become maladaptive to the contemporary changing world. Animal research becomes, among other objectives, another method for studying our own behavioral past. Particularly useful to the clinician are the accumulating efforts of the central neurophysiologists in demonstrating the interrelationships among arousal, emotional and cognitive, information-processing behavioral states. Emotions are the labels for the resultant effects of many variables. What makes emotions “abnormal” are not “abnormal” causes but the differences in the frequency, intensity or duration of emotional responses. “Hung-up” emotional states may be modified by a person-centered reappraisal of the stimulus, by an actual environmental alteration, by a person-centered reappraisal of himself in the situation, by a change in the availability or content of the environmental resources for problem-seeing and solving, or by a pharmacologic, physiologic or structural alteration of appropriate regional or integrative brain anatomy and process. Clinically relevant advances are being made in the study of the operant learning of the autonomic nervous system in body-organ adaptation to the internal milieu. Increased clinical modification of psychosomatic distress can now be based upon the current investigations of biofeedback sensation and the learning of sensory discrimination and of sensory awareness from “inside the skin.”

The current situation in psychiatry and its effects on the delivery of mental health services in the next decade.

Abstract: As long as mental illness is regarded as primarily a behavioral disorder, current and foreseeable manpower shortages in psychiatry make it necessary to increase the participation of nonmedical personnel in the treatment process. The controversy between those advocating behavioral treatment and those favoring the medical model cannot be resolved due to the fact that our current knowledge of the biologic roots of mental illness is inadequate. A breakthrough in research in this area could resolve the argument and solve the manpower problem by transferring psychiatric disorders into physiologic disease susceptible to medical treatment. Alternative models for the delivery of mental health services can be developed to allow for different possibilities in the outcome of research. Additional data is needed, especially on the costs and effectiveness of future therapies, before an evaluation of programs can be carried out.

Congenital heart disease and childhood adjustment.

Abstract: This report deals with the findings from a study of twenty-eight children, all of whom had ventricular septal defects and were studied by the same cardiovascular team. One-half of the group had a surgical procedure for correction of the defect.The study investigated three problems in children with ventricular septal defect (VSD). (1) Do children with surgical intervention for VSD show greater impairment of intellectual functioning than non-operated children? (2) Do children with surgical intervention show greater emotional disturbance than non-operated children? (3) Do children with surgical intervention show greater alteration of body image than do non-operated children?Data were collected using questionnaires, family interviews, subject interviews, medical records, school reports, physicians' reports and Human Figure Drawings, both inside and outside the body.The findings conclude that (a) operated children do demonstrate significantly more impairment of intellectual functioning; (b) there was no signif...

Psychopharmacologic Management of Anxiety in the Cardiac Patient

Abstract: Of 253 patients who had suffered acute myocardial infarction (MI), 88 percent received daytime sedation while hospitalized. Sixty percent of all prescriptions were for phenobarbital, 30 percent for chlordiazepoxide, and 6 percent for meprobamate. In addition, 79 percent of patients received night time hypnotic medication. Sixty-six percent of such prescriptions were for short-acting barbiturates, 21 percent for chloral hydrate, and 7 percent for diphenhydramine. Multiple drug use was common.The barbiturates, while inexpensive sedative agents, are of questionable efficacy in reducing anxiety and probably produce only general CNS depression. A narrow margin of safety, liability to produce habituation, and antagonism of warfarin-type anticoagulants are other disadvantages. The benzodiazepine tranquilizers, whose antianxiety efficacy is more clearly established, do not produce general CNS depression, have a wide margin of safety, and do not interact with oral anticoagulants.Antidepressant agents, phenothiazin...

Psychiatry in Japan's general hospitals: a brief report.

Abstract: Although the Japanese Society of Neuropsychiatry advocated the development of psychiatric departments in general hospitals as long as thirty years ago, progress has been regrettably slow. While public health centers are legally the front-line mental health facilities in Japan, they have not fulfilled their function and perhaps have even impeded development of psychiatric services in general hospitals. In Tokyo City, only three outpatient psychiatry clinics and no inpatient services are available to 10,000,000 inhabitants in eight general city hospitals. The advantages of psychiatric services in general hospitals are apparent; further progress awaits public enlightenment, increased staff, and political and community support.

A field-work case in the teaching of clinical psychiatry.

Abstract: This paper describes the teaching program developed at the University of Virginia in which observation and treatment of a hospitalized mental patient provide the focus for the learning experience of residents without previous training in psychiatry. The performance of each resident vis-a-vis a patient is reviewed by the group, which also engages in learning as a group through preceptorship and didactic techniques. The dynamics of the group itself are put to use in elucidating psychiatric principles. The case of a young schizophrenic with the delusion of “an influencing machine” is described to indicate the manner in which a patient under treatment may exemplify phenomena with which the learner must become acquainted, the meaning of which he is encouraged to weigh with increasing insight, so that he will be guided into good therapeutic practices.

The dilemma of mental health services for the poor.

Abstract: The basic issue in mental health intervention is behavioral change. This is influenced by the family, the community and social institutions. In the long run, a major focus of activity must be in the area of education and prevention, the development of tools for self-help in the population served, and positive social and community change. Services must be accountable to the people of the community. The poor, as well as the well-to-do must have the right to exercise options in obtaining the best possible services in accord with their own perceptions of needs. Public facilities seem unable to adequately provide such services or to allow choices. New models must be developed. The mental health and other health programs must be viewed as important community institutions with their own set of perspectives and skills; the major focus must be on the integration of health behavior and those social influences and institutions which influence that behavior.

Septic shock: phenomenology.

Abstract: This is an autobiographical account of an episode of life-threatening endotoxin shock experienced in the intensive care unit of a university-affiliated V.A. hospital. It was written within a day of the event by a psychiatrist interested in sharing with other physicians and nurses his harrowing time as a patient. He has added some afterthoughts as his perspective has broadened. The account presents the moment-to-moment events as he perceived them as well as his thoughts, feelings and fantasies. The ambiguities of being a psychiatrist-patient with its passivity-control, intellectual defenses, denial and fears of death are prominent in his thoughts.