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Starting clinical rotations in hospital can be a daunting prospect, and with each new specialty you are asked to master new skills, knowledge, and ways of working. To help guide you through your rotations we have illustrated some of the different medical specialties, with brief introductions on how to not just survive, but also thrive in each.
What happens in our relationships? This is the question that draws people into the profession of couple therapy. Therapists stand outside the couple in order to understand how their relationship systems and unconscious dynamics work. What is it that the couple have created between them? How can you restore the balance within that relationship?
Sigmund Karterud is a pioneer of group therapy for borderline personality disorders. He focuses on mentalization: our ability to understand ourselves and other people in terms of mental phenomena – beliefs, feelings, wishes, and hopes.
Sigmund Karterud is a pioneer of group therapy for borderline personality disorders. He focuses on mentalization: our ability to understand ourselves and other people in terms of mental phenomena – beliefs, feelings, wishes, and hopes. Marketing assistant Joe Hitchcock sat down with the Norwegian psychiatrist from Ulleval University Hospital to explore the concepts, history, and effectiveness of the treatment.
Despite progress in the care and treatment of mental health problems, violence directed at self or others remains high in many parts of the world. Subsequently, there is increasing attention to risk assessment in mental health. But it this doing more harm than good?
Each year in July, I greet a new group of post-doctoral psychiatric trainees ('residents,' 'registrars') for a year's work in our psychiatric outpatient clinic. One of the rewards of being a psychiatric educator is witnessing the professional growth of young clinicians as they mature into seasoned, competent, and humanistic psychiatrists.
An unacceptably large proportion of mentally ill individuals do not receive any care. Reasons vary but include the dearth of providers, the cost of treatment and stigma. Telemental health, which uses digital technology for the remote delivery of mental health services, may help toward finding a solution.
Sebastian Faulks’ new novel is quite simply superb. Tackling themes he has explored before Faulks delivers an original novel that is haunting, beautiful and profound that will resonate all the way through you. Dr Robert Hendricks is a veteran of the Second World War who lost his father in the First. These two wars have […]
I am constantly perplexed by the recurring tendency in western history to connect creativity with mental disability and illness. It cannot be denied that a number of well-known creative people, primarily in the arts, have been mentally ill—for example, Vincent Van Gogh, Virginia Woolf, Robert Schumann, Robert Lowell, and Sylvia Plath.
War. Of all human endeavours, perhaps none demonstrates the extremes of ingenuity and barbarity of which humanity is capable. The 21st century may be the century in which the threat of perpetual war is realised. Although many innovations have been brought about as a bi-product of the challenges war presents, the psychological and physical trauma wrought on the human body may prove too high a cost.
We are still in the longest war in our nation’s history. 2.7 million service members have served since 9/11 in the conflicts in Iraq and Afghanistan. Thousands have been killed, tens of thousands wounded, and approximately 20 to 30% have post-traumatic stress disorder and/or traumatic brain injury.
How are we to understand experiences of depression? First of all, it is important to be clear about what the problem consists of. If we don’t know what depression is like, why can’t we just ask someone who’s depressed? And, if we want others to know what our own experience of depression is like, why can’t we just tell them? In fact, most autobiographical accounts of depression state that the experience or some central aspect of it is difficult or even impossible to describe. Depression is not simply a matter of the intensification of certain familiar aspects of experience and the diminution of others, such as feeling more sad and less happy, or more tired and less energetic. First-person accounts of depression indicate that it involves something quite alien to what — for most people — is mundane, everyday experience. The depressed person finds herself in a ‘different world’, an isolated, alien realm, adrift from social reality. There is a radical departure from ‘everyday experience’, and this is not a localized experience that the person has within a pre-given world; it encompasses every aspect of her experience and thought – it is the shape of her world. It is the ‘world’ of depression that people so often struggle to convey.
My approach involves extracting insights from the phenomenological tradition of philosophy and applying them to the task of understanding depression experiences. That tradition includes philosophers such as Edmund Husserl, Edith Stein, Martin Heidegger, Maurice Merleau-Ponty and Jean-Paul Sartre, all of whom engage in ‘phenomenological’ reflection – that is, reflection upon the structure of human experience. Why turn to phenomenology? Well, these philosophers all claim that human experience incorporates something that is overlooked by most of those who have tried to describe it — what we might call a sense of ‘belonging to’ or ‘finding oneself in’ a world. This is something so deeply engrained, so fundamental to our lives, that it is generally overlooked. Whenever I reflect upon my experience of a chair, a table, a sound, an itch or a taste, and whenever I contrast my experience with yours, I continue to presuppose a world in which we are both situated, a shared realm in which it is possible to encounter things like chairs and to experience things like itches. This sense of being rooted in an interpersonal world does not involve perceiving a (very big) object or believing that some object exists. It’s something that is already in place when we do that, and therefore something that we seldom reflect upon.
Depression, I suggest, involves a shift in one’s sense of belonging to the world. We can further understand the nature of this once we acknowledge the role that possibilities play in our experience. When I get up in the morning, feel very tired, stop at a café on the way to work, and then look at a cup of coffee sitting in front of me, what do I ‘experience’? On one account, what I ‘see’ is just what is ‘present’, an object of a certain type. But it’s important to recognize that my experience of the cup is also permeated by possibilities of various kinds. I see it as something that I could drink from, as something that is practically accessible and practically significant. Indeed, it appears more than just significant – it is immediately enticing. Rather than, ‘you could drink me’, it says ‘drink me now’. Many aspects of our situation appear significant to us in some way or other, meaning that they harbor the potentiality for change of a kind that matters. We can better appreciate what experiences of depression consist of once we construe them in terms of shifts in the kinds of possibility that the person has access to. Whereas the non-depressed person might find one thing practically significant and another thing not significant, the depressed person might be unable to find anything practically significant. It is not that she doesn’t find anything significant, but that she cannot. And the absence is very much there, part of the experience – something is missing, painfully lacking, and nothing appears quite as it should do. In fact, many first-person accounts of depression explicitly refer to a loss of possibility. Here are some representative responses to a questionnaire study that I conducted with colleagues two years ago, with help from the mental health charity SANE:
“I remember a time when I was very young – 6 or less years old. The world seemed so large and full of possibilities. It seemed brighter and prettier. Now I feel that the world is small. That I could go anywhere and do anything and nothing for me would change.”
“It is impossible to feel that things will ever be different (even though I know I have been depressed before and come out of it). This feeling means I don’t care about anything. I feel like nothing is worth anything.”
“The world holds no possibilities for me when I’m depressed. Every avenue I consider exploring seems shut off.”
“When I’m not depressed, other possibilities exist. Maybe I won’t fail, maybe life isn’t completely pointless, maybe they do care about me, maybe I do have some good qualities. When depressed, these possibilities simply do not exist.”
By emphasizing the experience of possibility, we can understand a great deal. Suppose the depressed person inhabits an experiential world from which the possibility of anything ever changing for the better is absent; nothing offers the potential for positive change and nothing draws the person in, solicits action. This lack permeates every aspect of her experience. Her situation seems strangely timeless, as no future could differ from the present in any consequential way. Action seems difficult, impossible or futile, because there is no sense of any possibility for significant change. Her body feels somehow heavy and inert, as it is not drawn in by situations, solicited to act. She is cut off from other people, who no longer offer the possibility of significant kinds of interpersonal connection. Others might seem somehow elsewhere, far away, given that they are immersed in shared goal-directed activities that no longer appear as intelligible possibilities for the depressed person. We can thus see how the kind of ‘hopelessness’ or ‘despair’ that is central to so many experiences of depression differs in important respects from more mundane feelings that might be described in similar ways. I might lose hope in a certain project, but I retain the capacity for hope — I can still hope for other things. Some depression experiences, in contrast, involve erosion of the capacity for hope. There is no sense that anything of worth could be achieved or that anything good could ever happen — the attitude of hope has ceased to be intelligible; the person cannot hope.
Of course, it should also be conceded that depression is a heterogeneous, complicated, multi-faceted phenomenon; no single approach or perspective will yield a comprehensive understanding. Even so, I think phenomenological research has an important role to play in solving a major part of the puzzle, thus feeding into a broader understanding of depression and informing our response to it.
Heading image: Depression. Public Domain via Pixabay.
Over the last 15 years, research into various online addictions has greatly increased. Prior to the 2013 publication of the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there had been some debate as to whether ‘Internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has been debate as to whether those in the online addiction field should be researching generalized Internet use and/or the potentially addictive activities that can be engaged on the Internet (e.g. gambling, video gaming, sex, shopping, etc.).
It should also be noted that given the lack of consensus as to whether video game addiction exists and/or whether the term ‘addiction’ is the most appropriate to use, some researchers have instead used terminology such as ‘excessive’ or ‘problematic’ to denote the harmful use of video games. Terminology for what appears to be for the same disorder and/or its consequences include problem video game playing, problematic online game use, video game addiction, online gaming addiction, Internet gaming addiction, and compulsive Internet use.
Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic Internet use (i.e. Internet gaming disorder (IGD)) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien, IGD will not be included as a separate mental disorder until the
(i) defining features of IGD have been identified,
(ii) reliability and validity of specific IGD criteria have been obtained cross-culturally,
(iii) prevalence rates have been determined in representative epidemiological samples across the world, and
(iv) etiology and associated biological features have been evaluated.
Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that Internet gaming disorder was not included in the main text of the DSM-5 was that the Substance Use Disorder Work Group concluded that no standard diagnostic criteria were used to assess gaming addiction across these studies. In 2013, some of my colleagues and I published a paper in Clinical Psychology Review examining all instruments assessing problematic, pathological, and/or addictive gaming. We reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. The prevalence rates for problematic gaming were highly variable depending on age (e.g. children, adolescents, young adults, older adults) and sample (e.g. college students, Internet users, gamers, etc.). Most studies’ prevalence rates of problematic gaming ranged between 1% and 10%, but higher figures have been reported (particularly amongst self-selected samples of video gamers). In our review, we also identified both strengths and weaknesses of these instruments.
The main strengths of the instrumentation included the:
(i) the brevity and ease of scoring,
(ii) excellent psychometric properties such as convergent validity and internal consistency, and
(iii) robust data that will aid the development of standardized norms for adolescent populations.
However, the main weaknesses identified in the instrumentation included:
(i) core addiction indicators being inconsistent across studies,
(ii) a general lack of any temporal dimension,
(iii) inconsistent cut-off scores relating to clinical status,
(iv) poor and/or inadequate inter-rater reliability and predictive validity, and
(v) inconsistent and/or dimensionality.
It has also been noted by many researchers (including me) that the criteria for Internet gaming disorder assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioral addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used, as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental, and neurobiological research settings.
Video gaming that is problematic, pathological, and/or addictive lacks a widely accepted definition. Some researchers in the field consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the Internet as the main platform that unites different addictive Internet activities, including online games. My colleagues and I have begun to make an effort to integrate both approaches, i.e., classifying online gaming addiction as a sub-type of video game addiction but acknowledging that some situational and structural characteristics of the Internet may facilitate addictive tendencies (e.g. accessibility, anonymity, affordability, disinhibition, etc.).
Throughout my career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e. salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behavior. When I started research Internet addiction in the mid-1990s, I came to the view that there is a fundamental difference between addiction to the Internet, and addictions on the Internet. However, many online games (such as Massively Multiplayer Online Role Playing Games) differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.
Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the Internet gaming disorder criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically:
preoccupation with Internet games [salience];
withdrawal symptoms when Internet gaming is taken away [withdrawal];
the need to spend increasing amounts of time engaged in Internet gaming [tolerance],
unsuccessful attempts to control participation in Internet gaming [relapse/loss of control];
loss of interest in hobbies and entertainment as a result of, and with the exception of, Internet gaming [conflict];
continued excessive use of Internet games despite knowledge of psychosocial problems [conflict];
deception of family members, therapists, or others regarding the amount of Internet gaming [conflict];
use of the Internet gaming to escape or relieve a negative mood [mood modification]; and
loss of a significant relationship, job, or educational or career opportunity because of participation in Internet games [conflict].
The fact that Internet gaming disorder was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.
For epidemiological purposes, my research colleagues and I have asserted that the most appropriate measures in assessing problematic online use (including Internet gaming) should meet six requirements. Such an instrument should have:
(i) brevity (to make surveys as short as possible and help overcome question fatigue);
(ii) comprehensiveness (to examine all core aspects of problematic gaming as possible);
(iii) reliability and validity across age groups (e.g. adolescents vs. adults);
(iv) reliability and validity across data collection methods (e.g. online, face-to-face interview, paper-and-pencil);
(v) cross-cultural reliability and validity; and
(vi) clinical validation.
We also reached the conclusion that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity.
The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. There have also been over 20 studies using neuroimaging techniques (such as functional magnetic resonance imaging) indicating that generalized Internet addiction and online gaming addiction share neurobiological similarities with more traditional addictions. However, it is critical that a unified approach to assessment of Internet gaming disorder is urgently needed as this is the only way that there will be a strong empirical and scientific basis for IGD to be included in the next DSM.
How rapidly does medical knowledge advance? Very quickly if you read modern newspapers, but rather slowly if you study history. Nowhere is this more true than in the fields of neurology and psychiatry.
It was believed that studies of common disorders of the nervous system began with Greco-Roman Medicine, for example, epilepsy, “The sacred disease” (Hippocrates) or “melancholia”, now called depression. Our studies have now revealed remarkable Babylonian descriptions of common neuropsychiatric disorders a millennium earlier.
There were several Babylonian Dynasties with their capital at Babylon on the River Euphrates. Best known is the Neo-Babylonian Dynasty (626-539 BC) associated with King Nebuchadnezzar II (604-562 BC) and the capture of Jerusalem (586 BC). But the neuropsychiatric sources we have studied nearly all derive from the Old Babylonian Dynasty of the first half of the second millennium BC, united under King Hammurabi (1792-1750 BC).
The Babylonians made important contributions to mathematics, astronomy, law and medicine conveyed in the cuneiform script, impressed into clay tablets with reeds, the earliest form of writing which began in Mesopotamia in the late 4th millennium BC. When Babylon was absorbed into the Persian Empire cuneiform writing was replaced by Aramaic and simpler alphabetic scripts and was only revived (translated) by European scholars in the 19th century AD.
The Babylonians were remarkably acute and objective observers of medical disorders and human behaviour. In texts located in museums in London, Paris, Berlin and Istanbul we have studied surprisingly detailed accounts of what we recognise today as epilepsy, stroke, psychoses, obsessive compulsive disorder (OCD), psychopathic behaviour, depression and anxiety. For example they described most of the common seizure types we know today e.g. tonic clonic, absence, focal motor, etc, as well as auras, post-ictal phenomena, provocative factors (such as sleep or emotion) and even a comprehensive account of schizophrenia-like psychoses of epilepsy.
Epilepsy Tablet and the Dying Lioness, reproduced with kind permission of The British Museum.
Early attempts at prognosis included a recognition that numerous seizures in one day (i.e. status epilepticus) could lead to death. They recognised the unilateral nature of stroke involving limbs, face, speech and consciousness, and distinguished the facial weakness of stroke from the isolated facial paralysis we call Bell’s palsy. The modern psychiatrist will recognise an accurate description of an agitated depression, with biological features including insomnia, anorexia, weakness, impaired concentration and memory. The obsessive behaviour described by the Babylonians included such modern categories as contamination, orderliness of objects, aggression, sex, and religion. Accounts of psychopathic behaviour include the liar, the thief, the troublemaker, the sexual offender, the immature delinquent and social misfit, the violent, and the murderer.
The Babylonians had only a superficial knowledge of anatomy and no knowledge of brain, spinal cord or psychological function. They had no systematic classifications of their own and would not have understood our modern diagnostic categories. Some neuropsychiatric disorders e.g. stroke or facial palsy had a physical basis requiring the attention of the physician or asû, using a plant and mineral based pharmacology. Most disorders, such as epilepsy, psychoses and depression were regarded as supernatural due to evil demons and spirits, or the anger of personal gods, and thus required the intervention of the priest or ašipu. Other disorders, such as OCD, phobias and psychopathic behaviour were viewed as a mystery, yet to be resolved, revealing a surprisingly open-minded approach.
From the perspective of a modern neurologist or psychiatrist these ancient descriptions of neuropsychiatric phenomenology suggest that the Babylonians were observing many of the common neurological and psychiatric disorders that we recognise today. There is nothing comparable in the ancient Egyptian medical writings and the Babylonians therefore were the first to describe the clinical foundations of modern neurology and psychiatry.
A major and intriguing omission from these entirely objective Babylonian descriptions of neuropsychiatric disorders is the absence of any account of subjective thoughts or feelings, such as obsessional thoughts or ruminations in OCD, or suicidal thoughts or sadness in depression. The latter subjective phenomena only became a relatively modern field of description and enquiry in the 17th and 18th centuries AD. This raises interesting questions about the possibly slow evolution of human self awareness, which is central to the concept of “mental illness”, which only became the province of a professional medical discipline, i.e. psychiatry, in the last 200 years.
Why are people afraid to get old? Research shows that having a bad attitude toward aging at a young age is only detrimental to the young person’s health and well-being in the long-run. Contrary to common wisdom, our sense of well-being actually increases with our age–often even in the presence of illness or disability. Mindy Greenstein, PhD, and Jimmie Holland, MD, debunk the myth that growing older is something to fear in their new book Lighter as We Go: Virtues, Character Strengths, and Aging. In the following videos, Dr. Greenstein and Dr. Holland are joined by Holland’s granddaughter Madeline in a thought-provoking discussion about their different perspectives on aging in correlation to well-being.
The Relationship between Wisdom and Age
The Bridge between Older People and Younger Generations
On Fluctuations in Well-Being throughout Life
The Vintage Readers Book Club
Headline image credit: Cloud Sky over Brest. Photo by Luca Lorenzi. CC BY-SA 3.0 via Wikimedia Commons
Rated by the British Medical Journal as one of the top 15 breakthroughs in medicine over the last 150 years evidence-based medicine (EBM) is an idea that has become highly influential in both clinical practice and health policy-making. EBM promotes a seemingly irrefutable principle: that decision-making in medical practice should be based, as much as possible, on the most up-to-date research findings. Nowhere has this idea been more welcome than in psychiatry, a field that continues to be dogged by a legacy of controversial clinical interventions. Many mental health experts believe that following the rules of EBM is the best way of safeguarding patients from unproven fads or dangerous interventions. If something is effective or ineffective, EBM will tell us.
But it turns out that ensuring medical practice is based on solid evidence is not as straightforward as it sounds. After all, evidence does not emerge from thin air. There are finite resources for research, which means that there is always someone deciding what topics should be researched, whose studies merit funding, and which results will be published. These kinds of decisions are not neutral. They reflect the beliefs and values of policymakers, funders, researchers, and journal editors about what is important. And determining what is important depends on one’s goals: improving clinical practice to be sure, but also reaping profits, promoting one’s preferred hypotheses, and advancing one’s career. In other words, what counts as evidence is partly determined by values and interests.
Let’s take a concrete example from psychiatry. The two most common types of psychiatric interventions are medications and psychotherapy. As in all areas of medicine, manufacturers of psychiatric drugs play a very significant role in the funding of clinical research, more significant in dollar amount than government funding bodies. Pharmaceutical companies develop drugs in order to sell them and make profits and they want to do so in such a manner that maximizes revenue. Research into drug treatments has a natural sponsor — the companies who stand to profit from their sales. Meanwhile, psychotherapy has no such natural sponsor. There are researchers who are interested in psychotherapy and do obtain funding in order to study it. However, the body of research data supporting the use of pharmaceuticals is simply much larger and continues to grow faster than the body of data concerning psychotherapy. If one were to prioritize treatments that were evidence-based, one would have no choice but to privilege medications. In this way the values of the marketplace become incorporated into research, into evidence, and eventually into clinical practice.
The idea that values effect what counts as evidence is a particularly challenging problem for psychiatry because it has always suffered from the criticism that it is not sufficiently scientific. A broken leg is a fact, but whether someone is normal or abnormal is seen as a value judgement. There is a hope amongst proponents of evidence-based psychiatry that EBM can take this subjective component out of psychiatry but it cannot. Showing that a drug, like an antidepressant, can make a person feel less sad does not take away the judgement that there is something wrong with being sad in the first place. The thorniest ethical problems in psychiatry surround clinical cases in which psychiatrists and/or families want to impose treatment on mentally ill persons in hopes of achieving a certain mental state that the patient himself does not want. At the heart of this dispute is whose version of a good life ought to prevail. Evidence doesn’t resolve this debate. Even worse, it might end up hiding it. After all, evidence that a treatment works for certain symptoms — like hallucinations — focuses our attention on getting rid of those symptoms rather than helping people in other ways such as finding ways to learn to live with them.
The original authors of EBM worried that clinicians’ values and their exercise of judgment in clinical decision-making actually led to bad decisions and harmed patients. They wanted to get rid of judgment and values as much as possible and let scientific data guide practice instead. But this is not possible. No research is done without values, no data becomes evidence without judgments. The challenge for psychiatry is to be as open as possible about how values are intertwined with evidence. Frank discussion of the many ethical, cultural, and economic factors that inform psychiatry enriches rather than diminishes the field.
Heading image: Lexapro pills by Tom Varco. CC-BY-SA-3.0 via Wikimedia Commons.
In 1987, Esmin Green, a patient on the psychiatry ER floor of Kings County Hospital Center, died. International news coverage, lawsuits, and a US Department of Justice investigation ensued. The Behavioral Health department was to ensure the full and timely compliance with the resultant court decrees for drastic improvements in the care of the mentally ill at the hospital.
Our “initial state” was described as a mental health system operating in crisis mode, focused on putting out “fire” after “fire.” We were operating our numerous services in seven old buildings spread over a 44-acre campus. We were short-staffed; a good number of staff had been transferred to our service from other parts of the hospital and unfamiliar with work with psychiatric patients. Morale was low given the seemingly unending onslaught of negative publicity.
The prevailing culture was largely complacent and dispirited. Staff could be described as exhibiting signs of learned helplessness or hopelessness. They were largely not patient-centered or looking to empower patients, and not functioning as a coordinated interdisciplinary team. We lacked a leadership infrastructure and operated with an antiquated care delivery model. Inpatient units operated without “unit chiefs” and records were kept on paper without a system of chart review for quality and compliance. There were no interdisciplinary training programs in place that brought clinicians together with a unified vision of care delivery. There was no model or hunger for change as a result of this learned helplessness that overtook many.
Kings County Behavioral Health needed to dramatically transform all services at Kings County Hospital Center’s behavioral health programs. We envisioned a totally transformed psychiatric ER as well as an inpatient and outpatient infrastructure adequately staffed by caring, competent professionals. We wanted our new building to both symbolize as well as actualize a true transformation from the “snake pit” featured in the New York tabloids to the city’s “flagship” public hospital. Quality and safety processes had to change, and outcomes had to be radically improved with leadership and line staff trained in the profession’s best practices for assessment, diagnosis, treatment, and aftercare. The use of technology and data was seen as a tool to help us lead, manage, and deliver the needed improvement in quality care.
Looking east along Winthrop at Kings County Hospital Center on a sunny late afternoon. Downstate Medical Center is south (right) of this building. Photo by Jim Henderson. Public domain via Wikimedia Commons.
How were we to accomplish this? Where should be begin? How were we to proceed? To guide us along this seemingly impossible journey, it was decided to adopt the principles and practices embodied by lean.
No, “lean” isn’t a euphemism for managed care. Lean refers to a philosophy of management involving the process of identifying value vs. waste in what is delivered to the customer – our patient. Lean empowers the staff that directly does the work to identify waste and inefficiencies and to create solutions to the problems identified. The results are put into effect very quickly, usually within days not months or years later.
We assembled a leadership team, who in turn needed to recruit adequate numbers of competent staff to join our ranks. Then we had to ensure their training so they both understood what was required by the court and had the competencies to deliver what was required by the many policies and procedures that were produced or reviewed and revised to attain compliance. As the senior team was assembled, every former clinical discipline director eventually was replaced with new leaders. Surprisingly, the negative publicity about Kings County seemed to attract, not deter, exceptional leaders and staff, especially when during interviews the senior team displayed openness and a lack of defensiveness about the past, the current challenges and the vast potential for the Behavioral Health Service’s future. It was gratifying to hear the newly recruited leadership speak passionately about their desire to join the challenge of redefining the mental health care system for a population as large as central Brooklyn, seeing it as a once-in-a-career opportunity. Most of our new leadership came from other inner-city hospitals and were familiar both with our community culture and with the many challenges presented in such settings.
We have learned that even if you invest in the right number of sufficient staff, if your processes are faulty your people will fail. Ultimately, we needed to integrate each of the many fragmented services into one seamless continuum that improved access to care and delivered state of the art care in a timely and cost-effective way: better health, better quality care, and reduced overall cost.
Kings County Hospital Center Behavioral Health Services now has the tools, experience, and mentoring to achieve and sustain our gains, utilizing the philosophy and methodology of lean. We will continue to add value, decrease waste, improve performance, and become a center of excellence for our community.
Joseph P. Merlino, MD, MPA is the chief executive for behavioral health services and Director of Psychiatry at Kings County Hospital Center, where he leads the transformation efforts of one of the largest public hospitals in New York. He is the co-editor of Lean Behavioral Health: The Kings County Hospital Story with Joanna Omi and Jill Bowen.
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It is easy to delineate what clinical decision-making is not. It is not evidence-based medicine; it is not critical thinking; it is not eminence-based medicine; it is not one of many other of its many attributes; and it stands alone, with many contributions from all these fields. It is far more difficult to characterize what clinical reasoning is and very difficult to define.
But the clinicians among us deal with it every day and, I think, recognize it when we do it and observe it.
Evidence-based medicine is a mantra. But it is a difficult mantra. No one wants to say, “I reject evidence: I am a quack.” But it is complex and difficult. Evidence from the research in psychiatry comes from clinical trials, neural imaging, genetics, and other fields. Clinical trials can be read and understood. They are viewed as the sine qua non of evidence-based medicine. But the trials are conducted on patients without any other clinical conditions and are usually of very brief duration. The clinician, on the other hand, is often dealing with patients with many other syndromes and a great deal of chronicity. It is hard to make a claim, based on evidence, that the excellent clinical trial of Drug X applies to such a patient.
Neural imaging is far more difficult. It is a very complex methodology, and psychiatric studies which use it include as investigators physicists, neuroradiologists, psychiatrists, psychologists, and others. The work is so interdisciplinary that, usually, none of the authors understands the entire paper. This is a huge question, I believe, for philosophy of science. Most of these studies are conducted on a small N, with very complex statistics, and few have been replicated. What is the clinician to do with them? Many clinicians make the assumption that the spectroscopic findings somehow translate to clinical “facts”, but that is generally not a safe assumption, nor one on which to base treatment decisions as yet.
Similarly, genetics studies are also very difficult, especially because of the completely central statistical analyses which are necessary to understanding the papers — and which few clinicians have time to read or sufficient training to understand.
Many clinicians try hard to be “evidence-based”, but it is very difficult for anyone to truly sort through the evidence in order to make an on-the-spot clinical decision which will affect the health of a patient. Some journals and digests attempt to do this in order to assist clinicians, but reliance on them implies a trust in their employees which may or may not be justified.
For all these reasons, “eminence-based” reasoning has some attraction. The clinician should base his decisions on recommendations of experts rather than her or his own scrutiny of the literature. But many of the experts are quite old and have been removed from day-to-day clinical interactions for many years.
A couple of years ago I encountered a young patient with a severe, atypical depression. My immediate response was, “This patient reminds me of another patient, who had a superb response to a monoamine oxidase inhibitor, so perhaps I should try one.” This is a poor rationale for a clinical decision until it is parsed, but, in fact, the young man’s depression was categorically similar to that of the other patient, neither had responded to more traditional treatment, and there was a supportive literature for the use of a monoamine oxidase inhibitor in this type of clinical situation. The patient in fact responded well to this treatment. I believe that this type of clinical decision-making is common and that it is based on science and evidence, though sometimes the science and evidence are not immediately apparent unless the clinician thinks about it.
Clinical reasoning requires consideration of the evidence and efforts to assess it, good critical thinking, and also, in my view, the experience of interacting with and treating many patients over time. It is not a laboratory exercise but one which involves a doctor, a patient, and the world around them.
Lloyd A. Wells, Ph.D., M.D., is Consultant Emeritus at the Mayo Clinic in Rochester, Minnesota, USA. While there, he chaired the Division of Child and Adolescent Psychiatry for nineteen years and was the Department of Psychiatry’s Education Chair for twelve years. He is co-editor, with Christian Perring, of Diagnostic Dilemmas in Child and Adolescent Psychiatry.
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Depression in old age occurs frequently, places a severe burden on patients and relatives, and increases the utilization of medical services and health care costs. Although the association between age and depression has received considerable attention, very little is known about the incidence of depression among those 75 years of age and older. Studies that treat the group 65+ as one entity are often heavily weighted towards the age group 65-75. Therefore, the prediction of depression in the very old is uncertain, since many community-based studies lack adequate samples over the age of 75.
With the demographic change in the forthcoming decades, more emphasis should be put on epidemiological studies of the older old, since in many countries the increase in this age group will be particularly high. To study the older old is also important, since some crucial risk factors such as bereavement, social isolation, somatic diseases, and functional impairment become more common with increasing age. These factors may exert different effects in the younger old compared to the older old. Knowledge of risk factors is a prerequisite to designing tailored interventions, either to tackle the factors themselves or to define high-risk groups, since depression is treatable in most cases.
In our recent study, over 3,000 patients recruited by GPs in Germany were assessed by means of structured clinical interviews conducted by trained physicians and psychologists during visits to the participants’ homes. Inclusion criteria for GP patients were an age of 75 years and over, the absence of dementia in the GP’s view, and at least one contact with the GP within the last 12 months. The two follow-up examinations were done, on average, one and a half and then three years after the initial interview.
Depressive symptoms were ascertained using the 15-item version of the Geriatric Depression Scale (GDS). We found that the risk for incident depression was significantly higher for subjects
85 years and older
with mobility impairment and vision impairment
with mild cognitive impairment and subjective memory impairment
who were current smokers.
It revealed that the incidence of late-life depression in Germany and other industrialized countries is substantial, and neither educational level, marital status, living situation nor presence of chronic diseases contributed to the incidence of depression. Impairments of mobility and vision are much more likely to cause incidents of depression than individual somatic illnesses such as diabetes mellitus and coronary heart disease. As such, it is vital that more attention is paid to the oldest old, functional impairment, cognitive impairment, and smoking, when designing depression prevention programs.
GP practices offers ample opportunity to treat mental health problems such as depression occurring in relation to physical disability. If functional impairment causes greater likelihood of depression, GPs should focus on encouraging older patients to maintain physical health, whether by changing in personal health habits, advocating exercise, correcting or compensating functional deficits by means of medical and surgical treatments, or encouraging use of walking aids. Additionally, cognitive and memory training could prevent the onset of depressive symptoms, as could smoking cessation. If these steps are taken, the burden of old age depression could be significantly reduced.
Siegfried Weyerer is professor of epidemiology at the Central Institute of Mental Health in Mannheim, Germany. He has conducted several national and international studies on the epidemiology of dementia, depression and substance use disorders at different care levels. He is also an expert in health/nursing services research. He is one of the authors of the paper ‘Incidence and predictors of depression in non-demented primary care attenders aged 75 years and older: results from a 3-year follow-up study’, which appears in the journal Age and Ageing. You can read the paper in full here.
Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.
For many years I have pondered the mental state and motivations of mass shooters. The tragic events in Newtown, CT this past week have brought this to the fore. Mass shootings have become everyday occurrences in the United States, and for that reason tend not to attract much attention unless the circumstances are especially heinous, such as this instance in which the victims were young children. We are all left wondering what can be done. While the attention span of the general public and the media is usually a matter of nanoseconds, this mass shooting seems different, and I hope will lead to positive policy changes. This tragedy presents an opportunity for our leaders to step up to the plate and lead and, one hopes, implement rational gun control legislation most of us agree is necessary.
But back to the shooters. As a psychiatrist with an intense interest in bad behavior, I expect that discussions will center on mental health issues which many believe motivate the shooters. I am intensely interested in these “issues” because, to me, the main issue that keeps coming up is that of psychiatric diagnosis. Everyone seems interested in the possibility of a psychiatric diagnosis, because it suggests that we might “understand” the shooter, and this may lead to better identification of future shooters, and both improved treatment and prevention.
But will the presence of a psychiatric diagnosis improve our understanding? Probably not, because — at least in the cases we know about — the apparent psychiatric diagnosis runs the gamut. Some shooters appear to have schizophrenia, others a depressive disorder, and still others a personality disorder, as has been alleged in the case of Adam Lanza. While we seem able to understand that a “crazy” person out of touch with reality might carry out an otherwise senseless act, the thought that someone who is not psychotic carrying out such an act is very unsettling. How could a person who is not psychotic behave this way? For example, depressed persons are by and large not psychotic, yet some will — in the context of being hopeless and suicidal — want to take others with them: spouses, children, etc. More typically, while planning to harm themselves, most depressed persons have no desire to hurt anyone else.
What about the non-psychotic people with a personality disorder? The Diagnostic and Statistical Manual of Mental Disorders — a compendium of psychiatry’s officially recognized disorders (about to come out in its 5th edition) — lists ten personality disorders; the most relevant to our discussion is antisocial personality disorder. This disorder is quite common (up to 4.5% of the population) and causes all manner of problems because the antisocial person always seems to be in trouble with the law, their spouses and families, or their employers.
The term antisocial is almost always misunderstood and is often construed to mean ”shy” or “inhibited,” yet in a psychiatric sense the term suggests rebellion against society. My profession has done a poor job in educating the general public about the disorder and for that reason it remains under the radar screen. (An older term that seems more entrenched is sociopathy.) In the DSM, the diagnosis rests on the person having three or more of seven symptoms (such as deceitfulness, impulsivity, irritability and aggressiveness, etc). Perhaps the most important is “lack of remorse,” which occurs in about half of those diagnosed antisocial. This is what allows the antisocial person to hurt, to mistreat, or even to kill others. These are the “psychopaths” we read about and fear. (Psychopathy is at the extreme end of the antisocial spectrum of behavior.) Few antisocials are killers, but many of today’s mass shooters would fit the description of antisocial personality disorder. I don’t know if Adam Lanza would, but as we peel back the layers of his personal history, we might find that he does.
We don’t know what causes antisocial personality disorder, but like many disorders it probably results from a combination of genetic and environmental factors. I have argued for many years that the federal government needs to direct more funds to investigating its causes and developing effective treatments. Despite its high prevalence and the fact that it contributes to so much of society’s ills, the government has shown little interest in funding research on the disorder. The National Institutes of Health RePORTER website lists only two projects in which the term “antisocial” appears in the title and only five in which the terms “psychopathy” or “psychopathy” are used. Considering that NIH funds literally thousands of projects, this can only be considered hopelessly inadequate. Overcoming this resistance to research on antisocial personality disorder and related conditions must be a priority.
We need wide-ranging projects to explore the origins of antisocial behavior and search for methods to change its course. Geneticists should investigate the mechanisms underlying antisocial behavior, locating genes that might predispose individuals to antisocial behavior and determining how these genes function. Neuroscientists should pinpoint brain regions or networks linked to antisocial behavior and identify biochemical and physiological pathways that influence its expression. A range of treatments — both drugs and therapy — need to be developed, tested, and refined.
Will these steps help us understand the conundrum of the mass shooter? Will they allow us to treat antisocial persons and prevent youth with antisocial tendencies from developing a full-blown disorder? We can certainly hope.
Ben Carey’s thought-provoking article in the New York Times about the treatment of personality disorders in the forthcoming fifth edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association raises two questions:
1. Do disorders of “personality” really exist as natural phenomena, comparable to mania or dementia?
2. If they do exist, do they belong to the clinical specialty of psychiatry, or are they better considered characteristics of the human condition that have little to do with illness? Psychosis and melancholia are real illnesses, comparable to tuberculosis and mumps. Do personality disorders have that status?
Psychiatry’s involvement with personality disorders goes back to the early nineteenth century and the diagnosis of “hysteria”: the female character was considered weak and vulnerable. Women by virtue of their very personalities were deemed more vulnerable than men to feelings and emotional changability. Viennese psychiatry professor Ernst von Feuchtersleben wrote in 1845, “[The causes of] hysteria include everything that increases sensitivity, weakens spontaneity, gives predominance to the sexual sphere, and validates the feelings and drives associated with sexuality.”
In terms of the scientific assessment of personality and its breakdowns, this was not a promising beginning.
Things got worse. In 1888 German psychiatrist Julius Koch said there was such a thing as a personality that was “psychopathically inferior,” a product of genetic degeneration. Such degenerates were not exactly mentally ill, he said, merely unable to get their act together, and also showed “a pathological lack of reproductive drive.”
So psychiatry has always thought there were people who had something really wrong with their characters without being necessarily depressed or psychotic. But how to classify them?
Classification is obsessing the current debate. The struggle over what disorders to identify began with the great German classifier of disease (nosologist) Emil Kraepelin who, in the eighth edition of his Psychiatry textbook in 1915 expanded to seven types the list of “psychopathic personalities” with which he and his colleagues had been working. The list is interesting because it is very different from our own: the “excitable”; the irresolute; those driven by pleasure to seek out alochol, gambling, and who generally become wastrels; the eccentric; the liars and swindlers; and the quarrelsome, sometimes called the querulants.
Doesn’t sound very familiar, does it? That’s because each culture compiles a list of the personality traits it dislikes, or that are harmful to the further flourishing of things; and in Imperial Germany being querulous by challenging authority or being irresolute by not seeing France as the enemy were viewed as disorders.
There was lots yet to come, that I’m going to skip over. But what has most greatly influenced the current debate is the concept of personality disorders laid down by the psychoanalysts, the followers of Freud. Their list is quite different from Kraepelin’s because they were not interested in making war on France but on inner conflicts within the psyche. In 1908 Freud suggested the existence of an “anal” character, poeple who were orderly, tidy and meticulous and who in childhood had somehow come to dwell upon the anal region.
Freud’s followers came up with a whole list of character pathologies: Fritz Wittels’ “hysterical character,” Wilhelm Reich’s notion of “character armor” and its various guises, such as the “compulsive character,” the “phallic-narcissitic character,” and so forth.
We’re getting hot now. The modern concept of personality disorder comes directly to us from the psychoanalysts and from their current desperate desire to stay relevant. In 1938 Adolph Stern laid out a kind of personality disorder that was unresponsive to psychoanalysis, calling it “borderline personality disorder.”
Fourteen years later, in 1952, the American Psychiatric Association took a first cut at personality disorders, in its new DSM series, assigning them to three groups: (1) Those that were constitutional (inborn) in nature and unresponsive to change though psychotherapy, including “inadequate personality” and “paranoid personality”; (2) Those individuals with emotionally “unstable” and “passive aggressive” personalities; and (3) the sociopaths, such as the homosexuals, fetishists and other deviants.
American society in the early 1950s did not like those who deviated from the missionary position, who were inadequate to the challenges of empire-building, and who accepted authority but badmouthed it at the water-cooler.
Wilhelm Reich had laid out the concept of “narcicism” in 1933 and New York psychiatrist Heinz Kohut gave it pride of place in 1971. We are totally mired in the swamp of psychoanalysis here, a swamp that DSM-II in 1968 and DSM-III in 1980 failed to pull us out of, though DSM-III constructed an “axis II,” along which personality disorders could be arrayed, in addition to axis I for the real psychiatric disorders.
So this brings us to the current scene. The most recent edition of the DSM series, DSM-IV in 1994, had a whole slew of personality disorders, including histrionic, narcissistic, borderline, and so forth. The editor of DSM-IV, Allen Frances, was a psychoanalyst, and the list is a kind of last gasp. The problem is that patients who qualified for one, tended to qualify for almost all of them. The individual “disorders” were quite incapable of identifying individuals who had something psychiatrically wrong with them; the “disorders” had become labels for personality characteristics that are found in abundance in the population.
Moreover, who needed labels? Psychiatrists had a seat-of-the pants definition of a PD: “If your first impression of your patient is that he is an asshole, then he probably has a personality disorder.”
And what kind of disorder was this anyway, an illness in which the identified patient thinks he personally is fine but is making everyone around him unhappy? This is not like psychosis.
You can see why the drafters of DSM-V, due this May, have despaired. They wanted something clinically relevant and that also would sound vaguely like science (which psychoanalysis certainly didn’t). It will be interesting to see how the APA sorts this out. Personality disorders exist not as natural phenomena but as cultural phenomena: We as a society need some way of identifying people who can’t quite get it all together. But is this an illness that psychiatrists can treat? In the way that they treat schizophrenia with Zyprexa and depression with Prozac? What do we, as a society in 2012, do with people who can’t quite get it all together? I’m asking you.
Edward Shorter is an internationally-recognized historian of psychiatry and the author of numerous books, including A History of Psychiatry from the Era of the Asylum to the Age of Prozac (1997), Before Prozac (2009), and the forthcoming How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown. Shorter is the Jason A. Hannah Professor in the History of Medicine and a Professor of Psychiatry in the Faculty of Medicine, University of Toronto. Read his previous OUPblog posts.
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Robert Freedman, MD, is Professor and Chair of Psychiatry at the University of Colorado and the Editor-in-Chief of the American Journal of Psychiatry. His new book, The Madness Within Us: Schizophrenia as a Neuronal Process, is a discussion of these two aspects of the illness. Freedman outlines the emerging understanding of schizophrenia as a neurobiological illness. In the excerpt below we learn about the basic brain dysfunction in schizophrenia.
The earliest observers of how people with schizophrenia seemed to react to their environment noted a peculiarity in the ability of persons with schizophrenia to appear unaware of the environment and yet overly responsive to it. Eugen Bleuler first developed the concept of an attentional dysfunction in schizophrenia in his essay on attention in schizophrenia…
Rachel not only hears voices but she hears noises as well, noises that her family members also hear but have learned to ignore. She hears screaming all the time, and she sometimes wanders the neighborhood to find out who is screaming. When my colleague Merilyn Waldo suggested to her that it might be traffic, she told us that her mother had said the same thing. There is a busy corner near the front of her house, and there are always cars stopping and then accelerating away. My wife and I experienced the very same perceptual abnormality ourselves on the night we brought our first son home from the hospital. We put the baby to bed and tried to sleep ourselves, but I heard screaming. I checked on the baby, and he was asleep. Then my wife heard it too. We checked again. Then we listened at the door. The screaming must be coming from another apartment, and we wondered if we should call the police to alert them to child abuse, but we knew that no other couples with babies lived in the building. Finally, when the traffic on the highway in front of the building stopped at 2 a.m., we understood how two very anxious, hypervigilant new parents can misinterpret the world around them.
For Rachel, the problem is not a single stressful night. It is a lifelong problem, which she has struggled with since she was a teenager, long before the onset of her illness at 28. She could never concentrate at school. The least noise captured her attention. As she put it, “My mind has to be here, it has to be there, I can’t concentrate on anything.” Unlike a typical child with attention-deficit disorder (ADD), whose attention is rarely captured, her attention was captured by everything, from the traffic squeaking to the refrigerator cycling on and off, to the neighbor’s ongoing argument next door. As a result, she could concentrate on very little.
Paul, on the other hand, seems to be aloof in his environment. When he was first ill and worried about snakes, I wondered if their voices arose out of noises around him in the dormitory. He acknowledged that the noise of the dormitory was exquisitely painful, but he could not connect it to the snakes. Now he seems withdrawn. When I walk out to get him in the waiting room, he seems oblivious to the people around him. He has constructed a psychological shell around himself, a solution many patients use to shield themselves from their otherwise overwhelming environment.
The most dramatic experience of the phenomenon of seeming to ignore the environment is catatonia, a rarely seen syndrome in schizophrenia today. The patient gradually stops responding to environmental stimuli and then eventually stops moving altogether. In the most advanced cases, the person suddenly freezes. If he is moved passively, then he may retain the position into which he is moved, a symptom termed “waxy flexibility.” These patients can often be drawn back to awa
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Edward Shorter is the Jason A. Hannah Professor of the History of Medicine endowed chair at the University of Toronto School of Medicine as well as a Professor of Psychiatry. Max Fink has exensively contributed to the psychiatric community’s understanding of electroconvulsive therapy (ECT), pharmaco-electroencephalography (pharmaco-EEG), cannabis and the psychopathologies of catatonia, melancholia and mania. Together they wrote, Endocrine Psychiatry: Solving the Riddle of Melancholia, which traces the enthusiasm of biological efforts to solve the mystery of melancholia and proposes that a useful, and a potentially life-saving, connection between medicine and psychiatry has been lost. Below we have excerpted the preface which explains why endocrine psychiatry deserves a second look.
In the past hundred years, medicine has tried to acquire a scientific basis. Age-old prejudices and pointless procedures have been discarded in controlled study after study. Today, we take it for granted that the practice of medicine is evidence-based.
Yet in psychiatry the penetration of science has been imperfect. The discipline has swung wildly from fashion to fashion – from asylum care to psychoanalysis to lobotomy to psychopharmacology -without having an underlying scientific rationale for doing so. More than any other medical field, psychiatry has been guided by cultural preferences and political persuasions. We vaguely dislike the notion of “locking up” people or of shooting volts of electricity through their brains; we have a natural enlightened tropism toward psychotherapy and the enhancement of human reason and against the madness of unreason. None of these prejudices and preferences is in itself reprehensible, and all flow from a praiseworthy humanism. But prejudices and beliefs are not science. In a great disjunction, science and psychiatry have passed each other like two ships in the night.
Yet psychiatry cries out for science. To be sure, we can gauge the neurochemistry of the brain and assess its structures with the devices of neuroimaging. But the questions of clinical psychiatry are more complex than fluctuations in neurotransmitters or glucose uptake in the basal ganglia, where the brain gives up a few of its secrets. Is there no other way to gain a window to the brain and gauge is activity in psychiatric illness? Yes, there is. Another system, the endocrine system, sets the biological rhythms of the brain and body. Psychiatry was once fascinated with the endocrine system. Today, the adrenal and pituitary glands, and the hypothalamus within the brain, have lost their charm and arouse little interest.
Simultaneously, psychiatry also said adieu to another familiar historical concept, melancholia, as a diagnosis of severe depression. After the introduction of a new system of disease classification in 1980, the diagnosis of “major depression” – a heterogeneous assortment of varied illness entities and unhappiness states – swept in the field. This is very interesting: At the same time that psychiatric interest in neurotransmitters such as serotonin quickened, the discipline embraced such new illnesses as “major depression” and “bipolar disorder.” In understanding the seat of illness, there was a shift from the endocrine periphery to the neurotransmitter central, and in classification, there was a shift from such sturdy historical concepts as “melancholia” to the more faddish notions of “major depression” and “bipolar disorder.” These two shifts are related. In b
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Carol S. North and Sean H. Yutzy edited the sixth edition of Goodwin and Guze’s Psychiatric Diagnosis, which provides an overview of major psychiatric disorders, covering the definition, historical background, epidemiology, clinical picture, natural history, complications, family studies, differential diagnosis, and clinical management of each disorder.The excerpts bellow recount the place in history of panic disorders and phobias, and hysteria —what’s fascinating about both histories is the cultural emphasis in women as bearers of these disorders. In both cases, earliest observations (even in their most primitive, often inaccurate form) dealt almost exclusively with women and were constantly paired with superstitions of the time. The trend articulates the phenomenon of sexism in early psychological research.
Panic Disorder and Phobias
My cheek is cold and white, alas!
O lift me from the grass!
I die! I faint! I fall!
…
My check is cold and white, alas!
My heart beats loud and fast.
Percy Bysshe Shelley,
The Indian Serenade
It has been suggested that Shelly was having a panic attack when he wrote these lines. If so, he probably would have called it something else. In the nineteenth century, “anxiety reactions’ referring to fainting—which was fashionable among women in the era—were called “vapors.” Modern patients with panic disorder also sometimes faint—probably from hyperventilating. In Victorian times the prototype of a refined young woman was a “sooner, pale and trembling, who responded to unpleasant or unusual situations by taking to the floor in a graceful and delirious maneuver, in no way resembling the crash of an epileptic”… A Jane Austen heroine found one social situation “too pathetic for the feelings of Sophie and myself. We fainted alternately on a sofa.” Overly tight corsets may have been responsible for some of the fainting. A nineteenth-century physician, Dr. John Brown, cured fainting by “cutting the stay laces, which ran before the knife and cracked like a bow string”…
One of the first medical terms to describe anxiety disorders was “neurasthenia,” defined by an American physician, G.M. Beard, in 1869… Neurasthenia broadly included patients with hysteria, obsessional illness, and anxiety disorders, as well as hypochondriacs and swooners… The term “anxiety neurosis” was first used by Freud in 1895. It was not until 1980 that the concept of neurosis was dropped form American Psychiatric Association general nomenclature, and the term “panic disorder” replaced the older term “anxiety neurosis” as the disorder’s official name… Panic disorder was later subdivided into two types, with and without agoraphobia…, a distinction that still holds today.
The term phobia originates from the name of a Greek god, Phobos, whose likeness was painted on masks and shields for the purposes of frightening the enemy… The word phobia first appeared in medical terminology in Rome 2,000 years ago, when hydrophobia was used to describe a symptom of rabies. Hippocrates also described cases of phobic fears.
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Eugene H. Rubin, MD, PhD is Professor and Vice-Chair for Education in the Department of Psychiatry at Washington University in St. Louis – School of Medicine. Charles F. Zorumski MD is the Samuel B. Guze Professor and Head of the Department of Psychiatry at Washington University in St. Louis – School of Medicine, where he is also Professor of Neurobiology. In addition, he is Psychiatrist-in-Chief at Barnes-Jewish Hospital and Director of the Washington University McDonnell Center for Cellular and Molecular Neurobiology. Together they wrote, Demystifying Psychiatry: A Resource for Patients and Families, which offers a straightforward description of the specialty and the work of its practitioners. In the excerpt below we learn about the prevalence of psychiatric disorders. In the original article below they argue for funds to support drug prevention rather than for research for the resulting medical problems.
Heart disease, cancer, and stroke are the leading causes of death in the US. This is well known. What is less well known is that cigarette smoking (nicotine dependence) is the most important preventable contributor to these causes of death and alcohol abuse is the third most important contributor. These two legal substances have substantial addiction potential and together account for more than 400,000 deaths per year in the US. Once a young person smokes more than about 100 cigarettes, his or her chances of becoming addicted are substantial. Long term risky drinking predisposes a person to many health consequences in addition to enhancing the risk of becoming alcohol dependent. Risky alcohol use is defined as drinking 5 or more alcoholic beverages (12 oz beer equivalents) over a few hours on repeated occasions (actually, it is 5 drinks for men and 4 for women).
When misused, alcohol can lead to job loss, destruction of relationships, and a myriad of physical ailments not to mention its contribution to increased rates of traffic accidents, violence, and suicides. Alcohol-related disorders are major reasons why our emergency rooms (ERs) are so busy.
Cocaine, methamphetamine, and heroin are illegal drugs that with repeated use can take over a person’s ability to behave rationally. These addictive drugs have severe physical and psychiatric consequences. They destroy relationships as well and harm society in obvious ways. They also increase our health care costs and tie up our ERs.
All of these drugs, including nicotine and alcohol, hijack the brain’s motivational system and hamper its executive system (the part of the brain that helps us think, plan, and learn). Each drug interacts with the “wiring” of these brain systems in different, but related, ways. The cigarette smoker who reaches for a smoke before getting out of bed in the morning, the alcoholic who needs an eye-opener to start the day, and the woman who prostitutes herself in order to get her next injection of heroin – all are responding to the control of an abused substance.
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So psychiatry has always thought there were people who had something really wrong with their characters without being necessarily depressed or psychotic. But how to classify them?
history, complications, family studies, differential diagnosis, and clinical management of each disorder.The excerpts bellow recount the place in history of panic disorders and phobias, and hysteria —what’s fascinating about both histories is the cultural emphasis in women as bearers of these disorders. In both cases, earliest observations (even in their most primitive, often inaccurate form) dealt almost exclusively with women and were constantly paired with superstitions of the time. The trend articulates the phenomenon of sexism in early psychological research.
Department of Psychiatry at Washington University in St. Louis – School of Medicine, where he is also Professor of Neurobiology. In addition, he is Psychiatrist-in-Chief at Barnes-Jewish Hospital and Director of the Washington University McDonnell Center for Cellular and Molecular Neurobiology. Together they wrote,