The functional-organic dichotomy in new patient evaluations by residents in family practice

The interface of psychosocial and organic medicine is increasingly represented in primary care training programs. The intent of such programs is a comprehensive model for patient evaluation, yet current medical education may foster an artificial division in the diagnostic process. The initial interview of 60 depressed or hypertensive patients revealed a functional organic dichotomy in patient evaluations. Such a reductionistic approach neglected the role of psychosocial variables on the course of organic disease, drug compliance, or patient-physician attitudes. Alternatively, somatopsychic factors or concurrent physical disease amongst depressed patients may have gone undetected. Psychiatric patients were also scheduled for follow-up visits significantly less than their hypertensive counterparts. This may reflect resident physician attitudes toward the psychiatric patient.     

Is the distinction between situational and nonsituational primary depression valid?

Fifty-one patients with situational major depression were compared to 75 nonsituational depressives, using multiple clinical variables. Very few differences were found between the two groups for the 75 tested variables. The study data is most consistent with the postulate that the division of depressives into situational and nonsituational categories may not be valid.     

Suicide attempts in antisocial personality disorder

Previous studies that have examined suicide attempts and the diagnosis of antisocial personalities are somewhat difficult to compare because of variable diagnostic criteria. The diagnosis of antisocial personality disorder does not include past suicide attempts as a criterion.^1–4 Previous investigations have revealed antisocial personality disorder or criminal behavior to be a predictor of subsequent suicide attempts.^5,6 These findings of suicide attempts contrast to those of completed suicides.Sociopaths completed suicides infrequently when compared to patients with other psychiatric disorders.^7,8 A follow-up study of sociopaths and nonpsychiatrically ill controls revealed no difference in completed suicides.⁹Previous investigations^9,10 revealed suicide attempt rates in sociopaths of 23%–11%. Our experience has been that sociopaths frequently had past histories of nonserious suicide attempts. This investigation was undertaken to explore the incidence of previous suicide attempts in sociopaths.     

Behavioral treatment of hysterical dysphagia in a hospital setting: A case report

A behavior therapy procedure was implemented to increase oral caloric intake in a patient with hysterical dysphagia, following esophagectomy and cervical esophagogastrostomy reconstruction. A marked increase in caloric consumption occurred in response to the behavioral intervention during hospitalization and follow-up, while the complaint of dysphagia followed a more persistent course leading to further psychiatric care. The etiology of the hysterical symptom and the factors contributing to its maintenance and treatment are discussed.     

The medication seminar and primary care education

This paper defines the need to provide postgraduate psychiatric education to primary care physicians, as well as the need to provide psychiatrists with teaching experiences in the primary care setting. Two psychiatrists in rural New England developed and administered, over an eight-month period, a Balint-type seminar on psychotropic medications, designed to emphasize experiential and two-way learning. The process of the seminar reflected the special problems encountered in postgraduate education of physicians in a rural area. The impact on the instructors and participants has implications for the design and development of future educational programs in both psychiatry and primary care.     

Psychiatry and primary care: Can a working relationship develop?

This article explores the relationship between psychiatrists and primary care physicians. Expectations and results of attempts to train nonpsychiatric physicians in the care of the mentally ill are reviewed. The failure of this effort, along with the stigma against psychiatry has led to poor treatment of disturbed patients by primary care physicians. Using other mental health professionals as both educators and clinicians in primary care training programs over the past 20 years has resulted in a different referral pattern system for the mentally ill than for any other group of patients. Although the gap between psychiatry and the rest of medicine has widened, there are models of interaction and cooperation that are explored. The development of consultation-liaison programs has been a most important effort. The need for all of medicine to recognize the relationship between mind and body is stressed.     

Psychosocial care in a medical genetics clinic

In the process of genetic counseling, many patients and their families need psychosocial evaluation and care to help them cope with the genetic information and its implications. Such psychosocial work may be routine or extended. For two years we assessed the actual psychosocial evaluation and care provided by us in a medical genetics clinic, using six categories to classify the nature of a patient's need for extended psychosocial work. Of 138 new patients, 82 (59%) required extended psychosocial evaluation and care. In particular, young patients, seen with many family members, and requiring multiple medical consultations, were found to need the most extensive psychosocial care. Ongoing clinic patients (N=35) referred for psychosocial care were used as a comparison group. We concluded that a significant number of patients and their families receiving genetic counseling also require extended psychosocial evaluation and care, and that these patients may be identifiable early in the counseling procedure.     

Bipolar disorders in a forensic setting

The authors studied 187 men found not guilty by reason of insanity and committed to a forensic hospital for treatment. The bipolar disorder accounted for 34% of all diagnoses and was the most frequent diagnosis. Those men diagnosed as bipolar disorder had the lowest rate of a violent crime, a very low rate of murder and of a sexual crime, but a higher than expected rate of being a “White House Case”.     

The prevalence of somatization in primary care

The authors define somatization as an idiom of distress in which patients with psychosocial and emotional problems articulate their distress primarily through physical symptomatology. Studies are then reviewed to demonstrate the inordinate amount of time and energy these patients cost the health care practitioner as well as the frequency of misdiagnosis. Iatrogenic harm is a common problem in somatizing patients due to unnecessary tests, hospitalizations, surgeries as well as the development of chronic illness behavior. It is essential that psychiatrists working in consultationliaison begin to develop research in the area of somatization especially at the primary care level.     

Marital disputes and treatment outcome in depressed women

This study assesses the relationship between improvement of marital disputes and other treatment outcomes. The subjects are 76 women who received 8 months of individual psychotherapy as part of a controlled clinical trial testing the efficacy of various outpatient maintenance treatments for depression. The presence or absence of marital disputes was rated at the beginning of treatment, and improvement or failure to improve was noted at the end of treatment. Three marital groups (no marital disputes, marital improvement, and no marital improvement) were compared in terms of symptom status and overall social adjustment at the beginning and end of treatment. The results reveal that depressed women with marital disputes at the onset of treatment have a generally poorer treatment outcome than women who are single or in supportive relationships. Only a minority of women with marital disputes effected an improvement in the relationship during the course of treatment. Those who improved their marriages also experienced an improvement in depressive symptoms, while those whose marriages did not improve experienced less improvement or a worsening of symptoms.     

The implications of OX3

In current practice and in the medical literature the term “oriented to person” has diverse definitions. This situation has persisted for at least 50 years without causing problems in communication because clinical decisions are based upon evidence of disorientation to time and place; disorientation to person, no matter how defined, is not the basis for treatment decisions. The phrase “oriented times three” is recognizable as jargon, but it implies a specific examination that is often omitted. The phrase is uttered in a ritualistic manner, occupying space in clinical notes even though it may be of little salience to the case. The emphasis in medicine upon completeness encourages phrases or abbreviations that imply this completeness, when in fact, medical writing would be enhanced by attention to the salience of every word in a brief report. Although the meaning of words may change over the years, the meaning of a medical abbreviation should be fixed and precise, not permitted to evolve.     

Briquet's syndrome (somatization disorder) and primary depression: Comparison of background and outcome

The authors screened the charts of consecutive past admissions to select 49 cases meeting research criteria for Briquet's Syndrome. These were matched to 49 primary depression cases and to a group with a discharge diagnosis of hysteria without a research diagnosis of Briquet's Syndrome. The nondiagnostic historical variables assessed did not distinguish the groups. Briquet's Syndrome patients were less likely than the other groups to eventually experience complete recovery according to follow-up information in the charts. Differences in outcome between groups were consistent with previously reported difference in illness patterns among the first degree relatives.     

Continuity of care: A patient-centered model

A patient-centered model for the delivery of mental health services to acute psychiatric patients is described. This model may also be applicable to more comprehensive delivery systems. Mental health systems usually are centered around separate staff and physical locations of various units. The psychiatric patient's sensitivity to disruptions of the environment may respond favorably to a system of patient-staff continuity, which avoids fragmentation of care.The patient-centered care model allows the treatment staff to follow patients throughout the entire course of their treatment program. Impressions are that this model results in a marked decrease in acting out, suicide gestures, and other regressive manifestations at the time of transfer from one phase of the program to another. Specific issues of patient care account-ability, patient follow-through, and compliance with treatment recomendations, and cost-effectiveness are also discussed. In addition, staff satisfaction and professional growth are enhanced by the ability to follow patients and families through all phases of their treatment. Decreased staff turnover and increased interdisciplinary communication can enhance staff growth as well as patient care.     

Correlates of lithium response in psychotic-affective syndromes

We examined clinical and biochemical predictors of lithium response in 17 schizoaffective patients as well as the effect of lithium treatment upon several aminergic systems in this group. Ten patients were rated improved by the addition of lithium to the treatment regimen. No clinical predictors reached significance although DSM-III diagnosis and family history showed trends. Pretreatment plasma GABA was higher in the responders to lithium as compared to the nonresponders. Lithium tended to increase CSF HVA, CSF GABA, and plasma cAMP and to decrease plasma GABA. Lithium had little effect upon CSF 5HIAA, CSF cAMP, or plasma HVA.     

Phobic symptoms in an elderly woman: a multidisciplinary case conference.

A 67-year-old woman, previously self-sufficient, became housebound by phobic symptoms. During the patient's hospitalization for treatment of these disabling symptoms, a multidisciplinary case conference served to identify the underlying psychodynamic issues, which were related to separation anxiety. Treatment included helping the patient understand her relationships with her daughter and her own mother, and behavior modification to reduce the secondary gains of her symptoms. After treatment, the patient successfully returned to self-care.