Attention deficit disorders persisting in adulthood: A review

The diagnostic term “minimal brain dysfunction” (MBD) has in the past been applied in child psychiatry to encompass a number of behavioral and learning problems with which children may present. Clements¹ cited, in order of frequency, an extended array of symptoms subsumed under this syndrome: (1) hyperactivity; (2) perceptual motor impairment; (3) emotional lability; (4) incoordination; (5) short attention span; (6) impulsivity; (7) disorders of memory and cognition; (8) specific learning disabilities; (9) deficits of speech and hearing; and (10) equivocal neurological findings.The construct validity of MBD and its congeners (Hyperactivity, Hyperkinetic Syndrome) has, however, come under general disrepute. Controversy has arisen over imprecise definitions, etiological speculations, pharmacological manipulations, and the moral and political implications of applying the term indiscriminately. Yet interest in such a distinct entity remains unabated, as may be surmised by the establishment of the Attention Deficit Disorders (ADD) in the recently revised psychiatric nomenclature.²The course of an MBD-like syndrome past childhood and adolescence seems to be extremely variable, probably a reflection of its etiological heterogeneity. While some children may adapt satisfactorily to the demands of adulthood, the literature suggests that residua such as learning difficulties and antisocial behavior tendencies may linger. These symptoms may provide clues to suspect the persistence of ADD in adults who might otherwise carry other psychiatric diagnoses. Therapeutic modalities are discussed, cautious conclusions are drawn, and suggestions are made for elaboration of further research.     

An oral examination of the psychiatric knowledge of medical housestaff: Assessment of needs and evaluation baseline

To assess the psychiatric knowledge of medical housestaff, the authors devised an oral examination based on two simulated clinical encounters and administered it to 26 medical residents. The case material embodied those psychiatric problems known to be common in medical populations, namely depression, delirium, dementia, and “psychogenic” pain. The stan-dardized simulations were punctuated by standardized “open” questions with followup probes. A panel of experienced clinicians developed rating criteria for each question such that responses could be categorized as “good,” “adequate,” “inadequate,” or “poor,” in terms of “what an internist needs to know,” Blind raters of the exam achieved an interrater reliability of 0.88. The results indicated major deficits in the knowledge needed for assessment and treatment of these common problems. Only 16% of answers were “good,” whereas 42% were “inadequate” or “poor.” For example, 88% of the doctors could not name three factors that help distinguish organic from “functional” psychosis, and 88% could not list three side-effects of tricyclic antidepressants. The doctors' level of experience was not correlated with test scores, either overall or question by question. These results, together with measures of attitude and skill, have been used to develop a needs-based liaison psychiatry curriculum and to evaluate the effectiveness of that curriculum.     

A study of the inpatient service of a Nigerian psychiatric hospital

Psychiatric hospitals and psychiatric units of teaching hospitals are gradually replacing the “civil asylums” in prisons, for the care of mentally ill patients in Nigeria.According to Boroffka,¹ 15 of such asylums still exist in addition to eight psychiatric hospitals and four psychiatric units situated in teaching hospitals. The phasing out of these asylums is due partly to the availability of more effective treatment for mental disorders and increasing numbers of psychiatrists in the country.Apart from Anumonye² and Jegede and Adaranijo,³ who have described the pattern of psychiatric practice in a psychiatric unit of a teaching hospital with four beds, no comprehensive information exists on the types of psychiatric patients requiring admission, either for a long- or a short-term stay and the management pattern and the relationship of such management to the underlying psychiatric illness. The present study is a preliminary report of a long-term longitudinal study, which aims at investigating both of the above problems, using the inpatients of a large psychiatric hospital.     

Biochemical correlates of schizophrenia

Schizophrenia is an ailment of the complex and diverse manifestations springing from evolution's most complicated product—the human mind. Despite the splendid formulation of schizophrenia by Bleuler in 1911, this disease has remained poorly defined.Szasz¹ is of the opinion that the term “schizophrenia” is a “panchreston.” In other words, schizophrenia is supposed to explain abnormal behavior in much the same way as “protoplasm” explains the nature of life. The term schizophrenia, he points out, interferes with better understanding of psychiatric entities, and without modifying psychiatric nosology, all these entities are no more than panchrestons.Along this line, Laing² views schizophrenia as a label which imposes consequences on the individual labeled schizophrenic. He points out that some individuals undergo unusual experiences and manifest unusual behavior which appears to be a natural sequence of their experiences. From laing's point of view, what we observe in some individuals whom we label schizophrenic is the behavioral expression of an experiential drama, and schizophrenia is an “abnormal way of dealing with an abnormal situation.”The American Psychiatric Association³ describes schizophrenia as “a group of disorders manifested by characteristic disturbances of thinking, mood and behavior. Disturbances in thinking are marked by alterations of concept formation which may lead to misinterpretation of reality and sometimes to delusions and hallucinations which frequently appear psychologically self-protective. Corollary mood changes include ambivalent, constricted and inappropriate emotional responsiveness and loss of empathy with others. Behavior may be withdrawn, regressive, and bizarre.”As an outcome of the National Conference on Schizophrenia held at the Menninger Foundation in 1969, it was suggested that one refer to a “schizophrenic syndrome” rather than “schizophrenia” with connotations of a disease state.     

Depressives syndromes in a primary care setting: Evaluation,classification, and outcome

Fifteen percent of the general population may experience a major disorder of mood during their lives.¹ Their care falls to the greatest degree upon the primary physician.² A general practitioner may be chosen for the first contact by an estimated 88% of individuals fearing an experiencing psychologic disturbance.³ As many as 63% of community based mentally ill (n = 490,000) may receive their psychiatric treatment from a general practitioner.⁴ This prevalence is further enhanced by the observation that psychiatric patients represents a high medical utilization group when contrasted with nonpsychiatric controls.⁵Since the depressive syndrome is of diverse etiology, and may present under the guise of a physical complaint, a comprehensive evaluation should include a personal and family history, physical and mental status examination, and appropriate laboratory tests. While family practitioners may spend from 17% to 27% of patients care time dealing with emotionally related problems,⁶ some 60% of the American Academy of Family Physicians reported “insufficient training in medical school” to deal with their patients' emotional problems. A comprehensive data base (Table 1) was contrasted with the practices of second and third year family practice residents by a prospective study of recently diagnosed “depression” at a community primary care center.     

Mental illness and mortality

For well over a century there have been studies^1–10 demonstrating that the mentally ill carry a greater than expected risk of early death. The observed to expected risk has ranged from fifty fold to two fold and has diminished over time. Organic brain disease usually has been found to have the worst prognosis. All types of physical disease, apart from cancer, have been found in excess, although in the earlier studies tuberculosis was the most noteworthy. The effect has been examined with differing methodologies on psychiatric populations in diverse clinical settings and in various countries in Europe and North America, but certain findings have been consistent. The excess mortality has been greatest in women, younger patients and within the first year after admission. The last result has led to the speculation that the patients, although diagnosed as being psychiatrically ill, were really suffering from physical disease.A confounding feature of this type of research has been that several psychiatric diagnoses are known to have an increased “unnatural” mortality risk. Thus, in comparison with the general population it is known that psychiatric patients are more likely to die by suicide¹¹ and accidents.¹² In order to examine the relationship between mental illness and death nowadays, when psychiatric patients spend only short intervals in hospital, it seems useful to look at “natural” and “unnatural” causes of death separately. Psychiatric patients, in general, are no longer subject to the ill effects of chronic institutionalization and should be receiving the health care provided for the general population. It was hypothesized that psychiatric patients would not show an excess mortality due to natural causes.     

Presenting problems and diagnosis.

As an object of widespread criticism, psychiatric diagnosis has amassed a voluminous body of literature, most of it being focused on questions of validity, reliability, and consistency. Even though germane to the issue, less attention has been directed to the process of diagnostic decision making, i.e., how such assessments are made, what identifiable factors they are based on, and so forth. The work of Gauron and Dickinson,⁶ Petzel and Gynther,⁴ Sandifer et al.,⁵ and Kendall⁷ are among the few studies addressed to these questions.This paper continues this line of inquiry by exploring psychiatric diagnosis in relation to presenting problems. At times a presenting problem is simply a short-hand verbal account of a person's “story”. Generally, however, it is a composite presentation that also includes accounts about his condition made by “significant others” acting as complainant and/or concerned party, as well as the clinician's gross observations.Except for the work of a few investigators,^8–10 presenting problems remain a relatively unexplored area. Taken at face value, without interpretation or inference, presenting problems provide a unique body of information. As such, they constitute one of the few variables that stand at the interfaces of demographic, psychosocial, and clinical data and can thus provide a fruitful, empirically-grounded research tool.Accordingly, data and findings are presented from a recent community-wide survey of psychiatric utilization,¹¹ i.e., specifically, the presenting problems of a 1-year adult population of applicants (unduplicated count) who sought psychiatric care from either a large urban mental health center or from the private sector (i.e., the office and hospital clientele of psychiatrists in private practice; 86% of the private psychiatrists cooperated and participated in the study).     

Diagnostic errors in psychiatry

Although the importance of nosology has been derided as “pigeonholing” by some American psychiatrists, the science of diagnosis has lately enjoyed a renaissance. Actually, whether or not a psychiatrist possessed diagnostic acumen had little effect on the outcome of treatment until the past two decades, because so much of treatment was nonspecific. But the increasing use of drugs, particularly neuroleptics, antidepressants, and lithium, has made precise diagnosis a necessity.In recent years, several authors have commented upon the misdiagnosis of manic-depressive patients—particularly catatonics¹—as schizophrenics² and a multihospital cross-national study³ has suggested that American psychiatrists overdiagnose schizophrenia and underdiagnose affective disorder. The Iowa group⁴ has demonstrated that strict criteria result in a much lower rate of diagnosed schizophrenia than does the “agreement of experienced clinicians” so often set as the standard. With the compilation of diagnostic criteria for psychiatric disorder by Feighner et al.,⁵ it became clear that 80% or more of psychiatric patients can be definitely classified according to standards that permit accurate prediction of treatment and prognosis. But today, the vast majority of psychiatric diagnoses still are not made on the basis of scientific criteria, and the category of “undiagnosed psychiatric disorder,” at least as used by clinicians, is virtually an empty set.To what extent strict criteria are used no one knows, but from anecdotal case reports in the literature they are probably not overutilized. The resulting margin for disagreement and for downright error is probably enormous. We propose now to review the kinds of erroneous diagnoses commonly made, the reasons for these errors, and their possible consequences. This report, based upon the experience of psychiatrists in private practice, deals with the diagnostic pitfalls encountered despite, or in some cases because of, the use of scientific diagnostic criteria.     

Psychiatric service planning: beds in perspective.

The origins and validity of the British national planning “norm” for psychiatric beds are discussed. Evidence of present and future use of psychiatric beds is drawn from a number of studies relating to the remnant of earlier long-stay cohorts, the current accumulation of new long-stay patients, and the present use of beds for short and medium stays.The use of “beds” in the context of a comprehensive psychiatric service and the dangers of planning beds in isolation are discussed. Suggestions are made for an alternative approach to “norms” and psychiatric service planning.     

Behavioral precipitants of restraint in the modern milieu

Physical restraint of the psychiatric patient is a persisting reality in the acute management of uncontrolled, disruptive, or violent behavior. Depite advances in pharmacologic and milieu management, the “quiet room”, locked seclusion, or mechanical restraint often remain the last resort in control of the acutely disturbed patient. In this era of nonrestraint, little is taught or written of the practice of restraint. The literature contains few systematic studies of its persistence in modern milieu wards. The practice of restraint is viewed in resident education as an embarrassing anachronism, yet persists in some form in most clinical settings. This incongruity between teaching and practice led us to systematically survey our own use of physical restraint in an acute inpatient milieu. The diagnosis of patients restrained and the behavioral precipitants of restraint are the focus of this report.The modern therapeutic milieu stands in philosophic opposition to physical restraint by virtue of widespread acceptance of dynamic management of violent patients and confidence in the efficacy of pharmacologic treatment. The clinical belief that dynamic understanding in experienced hands can render a potential combatant “quickly cooperative”¹ is widely held. Following Connolly's famous admonition that “restraint and neglect are synonymous,”² the milieu staff shares responsibility for the patient's disruptive behavior. Violence and impulsive behavior are not so much the product of autistic process as they are defensive responses to “ambiguous, confusing, belligerent or threatening treatment.”¹ A violent outcome and resort to physical restraint implies staff failure and a punitive response to fear of the threatening patient. In his study of factors sustaining the practice of locked seclusion at the Boston Psychopathic Hospital, Greenblatt identified the “evils” of “overroutinization of use, lack of knowledge concerning the patient's feelings, poor communication about these feelings among the staff and lack of adequate motivation for serving the basic psychologic needs of the patient.”³ Attention to these dynamic considerations in a therapeutic milieu augmented by the use of potent pharmacologic agents has greatly reduced but not eliminated the use of physical restraint. The question of who is restrained on the modern milieu ward and why must be asked in this dynamic context.     

Psychiatrie du sujet âgé en milieu pénitentiaire

ContextThe high prevalence of psychiatric disorders in prison and the aging of inmates should lead to the consideration of gerontopsychiatry in the prison environment.ObjectiveThis review aims to emphasize the clinical characteristics and associated comorbidities of elderly prisoners with psychiatric disorders. We examined the international literature in September 2013 and performed the literature search with PubMed electronic database using the following Mesh headings: “prisons”, “prisoners”, “geriatric psychiatry”, “geriatric assessment”, “geriatric nursing”.ResultsFourteen studies were retained by the literature search strategy and were included in the qualitative analysis. More than one out of two elderly prisoners (> 60 year-old) suffer from a psychiatric disorder. Major depressive disorder (MDD) is the first psychiatric disorder diagnosed among elderly prisoners, affecting 30 to 50% of them. Personality disorders are also very common demonstrating a prevalence of about 30%. Psychotic disorders concern 5% of the elderly prisoners and thus largely exceed the prevalence in the general population. Furthermore, stress events are frequent in prison and might precipitate or worsen psychiatric disorders. This review highlights the difficulties and complexities of care plans and management for the elderly in prison.ConclusionThe situation of elderly prisoners with psychiatric disorders is extremely worrying. In addition, both the aging of the population and the lengthening of incarcerations increase the number of elderly prisoners, widely exposed to psychiatric disorders, and thus will probably worsen these issues in the future.     

Social skills training for chronic psychiatric patients: Rationale,research findings,and future directions

In 1969 Gordon Paul stated that “the ‘hard core’ refractory group of chronic mental patients is clearly one of the most difficult problems facing the mental health field today.”¹ Although some progress has been achieved in this area since then,^2–7 this same hard-core group of patients (most of whom bear schizophrenic diagnoses) remains a persistent challenge to mental health practitioners. A variety of pharmacologic, socioenvironmental, and behavioral approaches (primarily the token economy) have been applied to this group of chronic psychiatric patients. We will very briefly examine the major contributions and limitations of each approach.     

Psychotherapist trainees’ professional self-doubt and negative personal reaction: Changes during cognitive behavioral therapy and association with patient progress

Objective: This study examined psychotherapist trainees’ experiences of “professional self-doubt” (PSD) and “negative personal reaction” (NPR) during cognitive behavioral therapy (CBT) and their associations with patients’ symptoms and interpersonal problems. Method: Forty therapists treating 621 patients were analyzed. Patients’ symptoms and interpersonal problems were collected repeatedly during therapy. Data about patients’ interpersonal problems were available only for 106 patients and 18 therapists. Therapists’ difficulties were assessed as trait-based (one assessment across all patients) and as state-based (repeated assessments for each individual patient) difficulties. Multilevel models were performed. Results: None of the trait-based difficulties correlated with the change of the patients’ symptoms. Yet, more NPR at the trait-level predicted a more favorable change, whereas higher PSD at the trait-level showed an opposite effect on change of patients’ interpersonal problems. Regarding state-based difficulties, PSD as well as NPR decreased significantly over the course of CBT. Patients whose therapists’ experienced PSD to increase during CBT were at risk of a less favorable patient progress regarding symptoms, whereas the change of interpersonal problems was not significantly associated with changes in therapists’ difficulties. Conclusion: Patients’ progress is associated with therapists’ experiences of difficulties. Yet, trait- and state-based difficulties lead to different results.     

Crisis and emergency on the psychiatric ward

The hospital psychiatric emergency is usually conceptualized as a single patient requiring immediate attention.^1–3 Ewalt defines an emergency as occurring “when an individual is faced with a situation beyond his particular adaptive capacity at a particular time.” Miller defines it as a “sudden or rapid disorganization in his capacity to control his behavior or to carry out his personal, vocational or social activities.” Although this restricted view is valuable in providing a guide to the immediate management of the emergency, it fails to take into account the relationship between the patient's social environment and his behavior. Usually there are intense group issues associated with the emergency that have been latently present prior to it and are of central importance to its development and resolution.⁴ An awareness of the group issues provides the opportunity for prevention and more successful therapeutic work, as opposed to emergency-centered management. In this paper we present a conceptual model that facilitates the recognition and evaluation of ward emergencies. The evolution of emergencies and their prevention and management are discussed.The term crisis will refer to persistent group behavior that threatens or prevents the psychiatric ward from accomplishing its work as a therapeutic agent. Thus a crisis may be chronic, may be not consciously perceived, and may not need emergency action. It may, however, evolve into an emergency. The term emergency will refer to ward behavior that is grossly disruptive and requires immediate management. It occurs when a crisis comes to focus in an individual or a small subgroup of individuals and usually consists of an imminent threat to physical safety via self-destructive or assaultive behavior. By so defining a psychiatric emergency—which is usually viewed as the end result of intrapsychic events—we wish to call attention to aspects of group structure and functioning that may precipitate the emergency.Concepts described in this paper follow from the ideas of group function espoused by Wilfred Bion.⁵ Bion observed that any work group has covert tasks as well as the overt, agreed-upon work tasks. For this article, the clinical staff and patients of a psychiatric unit comprise the work group, and the restoration to health of the patients is the work task.     

Hostility conflict and the effect of chlordiazepoxide on change in hostility level

Dimascio, Shader, Salzman and their colleagues^1–5 conducted a series of experiments providing evidence that chlordiazepoxide produced a significantly greater increment in self-reported and behaviorally expressed hostility over a 1-week interval than did placebo in groups of college age normal male volunteers. Rickels and Downing⁶ presented data indicating that a group of anxious, nonpsychotic outpatients treated with chlordiazepoxide in 4-week double-blind drug trials showed greater decrements in physician rated irritability and hostility and in self-assessed anger-hostility than did placebo treated patients. These latter findings were considered to strongly suggest that caution be exercised in generalizing results obtained in samples of asymptomatic volunteers to psychiatric patient groups.Kochansky et al.³ have suggested that the ratings employed by Rickels and Downing to assess clinical hostility may focus upon “manifest angry affects” rather than hostility as “inner motivational or arousal level;” Kochansky et al. employed the Buss Durkee Hostility Inventory (BDHI) to assess such arousal level. The present study examines 4-week changes in hostility in anxious neurotic outpatients treated with either chlordiazepoxide (CDZ) or placebo using four scales from the BHDI (verbal hostility, indirect hostility, irritability, and resentment) in an effort to assess hostility as an inner motivational level. An Hostility Conflict Scale⁷ intended to assess the level of conflict or guilt about the expression of hostility was also administered. It was felt that the potential for CDZ-facilitated hostility increase might be greater among patients with greater amounts of conflict associated with hostility expression since the drug might be expected to allay anxiety associated with such conflict.     

“Mental illness” and “disease”

Are the addict and alcoholic mentally ill? By traditional standards, yes. The validity of the “mental illness” concept and its associated psychiatric labeling process, however, is challenged. A synthesis of the human ecological systems and thirdforce frames of reference is presented as a viable alternative to the medical “disease” model of alcoholism and drug dependency. According to the proposed disease model, “alcoholism,” “addiction,” and “mental illness” are considered to be modes of coping with pain and anger associated with a person's participating in social systems that frustrate self-actualization and diminish self-esteem. Combined treatment of “alcoholics,” “addicts,” and “nonaddicted psychiatric patients” is supported with qualifications.     

The “least restrictive environment”: From Rhetoric to Practice

During the past 10 years, more and more general hospitals have opened psychiatric units, many of which represent the best of modern hospital psychiatry. Therapeutic success on these units is based on control of admissions as well as on clinical programs. Pressure from the State to admit involuntary patients, recently justified by the doctrine of the “least restrictive environment”, threatens to erode the quality of treatment now being provided. The concept of “least restrictive environment” is ambiguous and sometimes misleading. The treatment of involuntary psychiatric patients in general hospitals, in order to be safe and effective, requires the resolution of legal, clinical, financial, and architectural issues, as well as problems in the relationship between psychiatric units and other areas of the general hospital.     

The importance of body experience for psychiatry

The realm of subjective body experience in health and disease is an indispensable, although neglected, dimension of psychiatric knowledge and practice. By body experience I mean the perceptions of, attitudes towards, and beliefs about one's own body appearance and functions. Body experience is changed in all forms of psychopathology and it contributes one of the psychopathogenic factors in physical illness, injury, and disability. Paul Schilder, who pioneered the study of body experience, summed it up succinctly: “Organic disease and psychogenic disturbance lead in the same way to suffering. Suffering expresses itself necessarily in the postural model of the body. Mental suffering finds its way into a somatic expression, and somatic disease leads to mental suffering”.¹ The key theoretical concept in this area is that of the body image. Schilder defined it as the “tri-dimensional image everybody has about himself”. Recent writers, notably Fisher² and Shontz,³ have elaborated this concept and reviewed the massive literature on experimental work related to it. I shall describe examples of these studies and discuss the importance of this whole area for psychiatry.