Psychopsychiatry: Can psychosocial factors cause psychiatric disorders?

It is a widely accepted view today that psychosocial factors can cause psychiatric disorders. However, this view has, as yet, no firm foundation of verifiable facts. This paper outlines some research strategies that can provide data in favor of or against this theory: (1) systematic analysis of life events preceding psychiatric disorders, covering both stable events and interactional events; (2) vulnerability research on three levels (biologic, psychological, and sociological), aimed at factors that could explain the increased vulnerability of some individuals to the detrimental effects of life events; (3) pathogenesis research, aimed at analyzing how psychosocial stress disrupts cerebral systems, and discovering which of these disruptions is responsible for disturbed behavior, and (4) research into the efficacy of combined biologic (mainly pharmacotherapeutic) and psycho(socio)therapeutic methods. Some results obtained in these areas of research are discussed.The central idea of this study is that psychosocial and biologic factors do not operate independently but in close interaction. This seems a cliché, but is not, as clearly indicated by the scantiness of relevant research so far carried out. This gap is to be filled if psychiatry is to maintain and reinforce its status as a medical discipline.     

Commentary: A response to Wortzel and Arciniegas about amnesia and crime

The review by Wortzel and Arciniegas of the phenomenology and neuroanatomy of memory is a welcome complement to our psychiatric clinical perspective on the concept of amnesia in relation to crime. The authors raise their concerns in noting that certain concepts referred to in the literature are inconsistent with the phenomenology and neurobiology of memory. In response, we clarify the DSM-IV-TR nomenclature and provide information on current research exploring various mechanisms outlining memory impairment and other neurocognitive deficits in schizophrenia and other psychoses. In relation to amnesia and crime, the practice of forensic psychiatry requires the expert to be able to consider the validity of amnesia claims in criminal proceedings, translate scientific knowledge into a language accessible to the court, and provide an opinion. As such, a psychiatric clinical approach to the concept of amnesia in relation to crime provides a useful framework.     

Kinder psychisch kranker Eltern Forschungsperspektiven am Beispiel von Kindern depressiver Eltern

Children of psychiatrically ill parents represent a risk group that has received growing attention during the last years. The risk for this group to develop a psychiatric illness is markedly increased due to genetic and psychosocial factors. The development of effective preventive concepts requires a thorough knowledge of the psychosocial factors. In this paper, deficits and problems of research in psychosocial transmission mechanism are discussed taking the example of children of depressive parents. Conclusions from this exemplary considerations may serve as guidelines for future research. The authors suggest that the focus be rather placed on coping strategies and developmental psychopathology. Further, research criteria are formulated that refer to theoretical models as well as to study design.     

Epidemiology and child psychiatry: Future prospects

Child psychiatric epidemiology is on the threshold of an important future in its capacity to investigate the psychologic health of large aggregates of children. Within the last decade this field of study has made notable contributions to the establishment of a scientific child psychiatry by emphasizing empirical and logical formulations, and by applying methods derived from such reasoning to the study of psychiatric disorder in different social and cultural contexts. This base of knowledge is certain to expand over the next few decades, a time when the relationship of child psychiatry to pediatrics and general psychiatry is very likely to evolve in new directions.Recent developments in child psychiatric epidemiology must be viewed in the context of changing pediatric priorities. Public health practices are well established to reduce the major causes of infant mortality and many types of acute infectious diseases which contribute to childhood mortality. The application of these methods is currently more likely to be limited by cultural and political barriers than by scientific knowledge. As infant and childhood mortality decline, higher rates of psychosocial and intellectual morbidity are undoubtedly developing.The purpose of this article, the last of three exploring the relationship between epidemiology and child psychiatry, is to examine research objectives that will be useful in understanding the social and emotional handicaps of populations of children in different parts of the world.^1.2 As is traditional in any epidemiological pursuit, the interest is in studying the distribution of psychiatric disorders and maladaptive behavior within and across societies in an effort to understand and ultimately control their causes. Topics to be discussed in this article relate to diagnosis and incidence of child psychiatric disorders, the definition of risk and protective factors, the importance of comparative and cohort studies, the integration of biologic and social variables in research designs, and the implications and possible consequences of epidemiological research on the practice of child psychiatry.     

Consortium-based consultation/liaison research: commentary and perspective

Although a consortium approach for clinical trials is a common research strategy which has made important contributions in other disciplines in medicine, to date it has not been employed for research efforts in the consultation/liaison setting. There are several reasons for this: the relative newness of the field, lack of administrative control over patient care, and the unavailability of a standard methodology that could be adapted to multiple sites. Four basic research strategies can be employed within the framework of a research consortium to advance scientific knowledge in consultation/liaison psychiatry: 1) prevalence studies of psychiatric morbidity in medical settings; 2) interrelationship among psychiatric and medical conditions; 3) the outcome of psychiatric interventions within medical milieu; and, 4) cost-benefit evaluation. A field-tested computerized database protocol and a software system usable on an office-based microcomputer were employed to obtain standardized data across multiple training sites. The advantages and disadvantages of consortium studies are described.     

Biologic tests in psychiatry

Neurobiologic research has discovered a number of abnormalities that might serve as biologic markers for specific psychiatric disorders. Tests for these markers could aid in differential diagnosis and in the choice and monitoring of treatment. Tests with potential clinical utility in affective illness (unipolar and bipolar depression and mania), panic disorder, and schizophrenia are discussed.     

Hallucinogen-induced psychological disorders

OBJECTIVE: The purpose of this article is to provide an overview of the current research on hallucinogen induced psychiatric disorders. In addition to LSD and psilocybin hallucinogens of biologic origin are increasingly used by adolescents and young adults. METHODS: Relevant literature and related articles were identified by means of a computerized MEDLINE search including the years 1997 - 2007. As keywords "hallucinogen induced psychosis", "hallucinogen induced flashback", "hallucinogen persisting perception disorder (HPPD)" were used. Finally, 64 journal articles and books out of 103 were included in the review. RESULTS: Acute psychotic syndromes in adolescents are rarely due to intoxications with hallucinogenic drugs. However, clinical relevance of flashback phenomena as post-hallucinogenic psychiatric disorder has to be disputed. Because of the high popularity of biogenic hallucinogens and LSD knowledge of intoxications and resulting psychiatric disorders as well as medical complications and therapeutical approaches are clinically important. Especially intoxications with drugs of herbal origin like tropanalcaloids play an important role in emergency situations.     

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.     

Emergency psychiatric management of borderline personality disorder: Towards an articulation of modalities for personalised integrative care

Building on existing literature, the authors draw the landscape of psychiatric emergencies, and focus on borderline personality disorder, frequently encountered, and strongly linked to death by suicide. A review of knowledge in terms of diagnosis, prognosis, etiology, and treatment, as well as their own experiences, lead them to propose areas of progress that would secure the patient's care pathway. The evolution of society has led psychiatric emergency departments to play the role of a safety net and an entry point to the mental health system. Borderline personality disorder is one of the most common pathologies encountered in psychiatric emergencies. It represents a major concern, long characterized by an often dramatic evolution, and by the human and economic stress it generates. However, since the 1990s, knowledge of this disorder has been refined, and today there are various means of evaluation, good clinical practices and psychotherapeutic treatments, thanks to which significant and lasting improvement is possible. Recent studies highlight the crucial role of hospital caregivers, and the benefit of consolidating their skills by providing them with the knowledge and tools specific to this disorder. They also converge on the interest of setting up specific emergency treatment modalities, particularly highly structured, safe and empowering for the patient, in order to improve their effectiveness. The authors suggest that a case formulation model for persons with borderline personality disorder in emergency would make it possible to activate these two levers of progress, while improving collaboration between hospital and outpatient care. This would also address their main concern of optimizing the patient's therapeutic pathway and reinforcing adherence to treatment that could bring remission, and should be supported by data from empirical research.     

The psychiatric significance of the personal self

Drawing upon literature reviews in psychiatry, the social sciences, and philosophy, this article defines the concept of the "personal self" and briefly describes its importance to the following areas of psychiatry: (1) mental illness, (2) psychiatric ethics, (3) diagnosis, (4) the clinician, (5) clinical research, (6) psychiatric pluralism, and (7) the goals of psychiatric treatment. The personal self is a Western common-sense concept which is characterized by five aspects: agency, identity, trajectory, history, and perspective. Because of the intimate and often ambiguous relationship between the personal self and mental illness, the personal self has considerable psychiatric significance in moral, professional, research, and existential realms.     

Familial concordance in schizophrenia: a comparative study of pairs of sibs.

Intrafamilial resemblance in psychiatric clinical features may provide a powerful tool to the search for an explanation of the distheis-stress duality. Family studies of schizophrenia have emphasized the role of familial concordance for subtype diagnosis,^1,2 symptomatology,^2,3,5 mode,² and age of onset,^2,5,7 outcome,⁸ and sex^9–14 in psychiatric research. Most of these studies have failed, however, to apply uniform criteria for the selection of patients and were based on retrospective and non-blind evaluation of family members.An attempt has been made in this study to apply updated research criteria for the diagnosis of schizophrenia and to evaluate probands in a blind fashion as regards their relatives. Combined variables have been analyzed in order to further elucidate the issue of familial homogeneity in schizophrenia. Efforts to correlate between the results of this study and certain biologic derangements are currently being made (Baron, et al.: Tissue-Serum Affinity in Schizophrenia: Clinical and Familial Determinants, in preparation), aimed at achieving a better understanding of the “nature-nurture” duality.     

Physical illness diagnosed as psychiatric: Patients at special risk

Recent research has further confirmed the significant incidence of undiagnosed physical illness in patients presenting psychiatric symptoms. Such research has generally involved psychiatric inpatient or outpatient populations. As a liaison psychiatrist in a general hospital, the author defines two especially high-risk groups for such missed diagnoses and emphasizes the fact that psychiatric symptoms are not illness specific. An approach to the clinical evaluation of such patients is discussed, mentioning the inherent medicolegal implications.     

Medication noncompliance: Systematic approaches to evaluation and intervention

Medication noncompliance is a significant problem in medical practice, but many intervention strategies developed for noncompliant patients (such as tangible rewards, contingency contracting) are not practical for the large numbers of patients seen by private practitioners on an ongoing basis. Based upon a review of the literature concerning the key determinants affecting compliance, the authors have developed a practical, rational, and systematic approach to assessing medication compliance that may serve as a guide for psychiatrists in formulating consultation recommendations, in liaison teaching activities, and in clinical psychiatric practice. Special emphasis is placed upon the identification of psychiatric syndromes that may negatively affect compliance. Implications for compliance-related research in consultation-liaison psychiatry are also discussed.     

The development,evolution and philosophy of a clinical research unit

OBJECTIVE: To describe the development,evolution and philosophy of a clinical research unit. METHOD: The 20-year history of clinical psychiatric research in Christchurch is described. The variety of influences which have impacted upon the studies undertaken is acknowledged,as are the personal histories of key staff. CONCLUSIONS: Clinical research is potentially endangered. The maintenance and development of clinical research requires a mix of individual inquisitiveness and determination,local opportunity and political will. Despite a political desire for evidence-based medicine; most political policies and practices impede the development of new knowledge and the collection of new evidence.     

End-of-Life Care and Mental Illness: A Model for Community Psychiatry and Beyond

End-of-life care is often influenced by the stereotyping of patients by age, diagnosis, or cultural identity. Two common stereotypes arise from the presumed incompetence of many patients to contribute to end-of-life decisions, and the fear that the discussions themselves will be de-stabilizing. We present a model for end-of-life discussions that combines competence assessment with healthcare preferences in a psychiatric population that faces identical stereotypes. The model, which draws on clinical research in competence and suicide risk assessment, has important implications for all patients in the community who are marginalized or stereotyped during discussions of end-of-life treatment.     

Attitudes towards electroconvulsive therapy among Hungarian psychiatrists

Participants of a postgraduate biologic psychiatric course were surveyed about their attitudes toward electroconvulsive therapy (ECT) with a self-administered questionnaire. Among the respondents, 65 persons were specialists in psychiatry, 32% of whom would not consider using ECT even if they were in a psychotic depressive state. According to the bias factor, which has been calculated based on the answers to the 11 questions regarding attitudes, those psychiatrists who worked in inpatient care showed a less negative attitude. Among the items concerning knowledge of ECT, incorrect answers were most frequent to questions about myocardial infarction as a contraindication, and about the identity of the person who had pioneered this treatment. The negative attitude of Hungarian psychiatrists, especially of those who work in outpatient care, may have an important role in the decrease of the application of ECT in the past decade in Hungary.     

Brain development and the onset of mood disorders

Research in mood disorder pathophysiology has stimulated considerable interest in clinical and biologic aspects of mood disorders among children and adolescents. From the clinical perspective, developmental aspects of psychiatric disorders have crystallized in the relatively new theoretical school known as developmental psychopathology. This school attempts to understand the nature of developmental changes in behavior, with the goal of differentiating normal from abnormal stage-related behavior. This perspective has exerted major impact on conceptualizations of psychiatric disorders. From the basic science perspective, biologic findings in emotion have stimulated an integration of basic and clinical approaches to mood disorders. The term emotion is often used to refer to brain states elicited by stimuli for which an organism will extend effort to obtain (rewards) or avoid (punishments). Imaging studies suggest that brain regions engaged by rewarding and punishing stimuli in lower mammals are also implicated in mood disorders. Other studies suggest that environmental factors exert profound effects on the development of these brain regions. The impact of 4 areas of research on our understanding of depression pathophysiology is reviewed: (1) mood disorder onset, (2) structural magnetic resonance imaging (MRI), (3) behavioral or cognitive correlates of major depression, and (4) functional MRI of brain regions engaged across development. This is a US government work. There are no restrictions on its use.     

Illness management and recovery: a review of the research

Illness management is a broad set of strategies designed to help individuals with serious mental illness collaborate with professionals, reduce their susceptibility to the illness, and cope effectively with their symptoms. Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness. The authors discuss the concept of recovery from psychiatric disorders and then review research on professional-based programs for helping people manage their mental illness. Research on illness management for persons with severe mental illness, including 40 randomized controlled studies, indicates that psychoeducation improves people's knowledge of mental illness; that behavioral tailoring helps people take medication as prescribed; that relapse prevention programs reduce symptom relapses and rehospitalizations; and that coping skills training using cognitive-behavioral techniques reduces the severity and distress of persistent symptoms. The authors discuss the implementation and dissemination of illness management programs from the perspectives of mental health administrators, program directors, people with a psychiatric illness, and family members.     

Dementia, mental retardation, and competency to make decisions

The psychiatric literature on competency indicates that a diagnosable psychiatric condition alone does not imply incompetency to make treatment decisions. Nonetheless, it is frequently assumed that individuals who are either mentally retarded or demented are incompetent to make decisions. The authors, focusing on the clinical assessment of judgment and decision making, describe two cases. In both, the patients' judgments were intact. The authors conclude: (1) Diagnosis is not the critical factor in determining competency. (2) The process of judgment and decision making has to be assessed on a case by case basis. (3) Further research is needed to develop clinical instruments to assess judgment.     

Research strategies at the interface of medicine and psychiatry

The rapid growth of the neurosciences in the past decade has served to blur the differences and enhance the similarities between research in medicine and in psychiatry. As the number of relevant biological variables and the questions asked in relation to them has expanded, so has the number of medical disorders of interest to the clinical researcher in psychiatry. In addition to these new areas of common interest, consultation-liaison psychiatry and clinical psychiatric research share a common conceptual foundation based upon model development and testing. It is proposed, therefore, that research at the interface between medicine and psychiatry represents a new frontier for both consultation-liaison psychiatry and clinical psychiatric research. Goals and strategies for research at the interface are discussed with specific reference to current research efforts at the National Institutes of Health.