THE PSYCHOTHERAPEUTIC APPROACH TO EMOTIONAL PROBLEMS

Physicians are confronted with more and more psychological problems in their daily practice. Not only must a physician be able to recognize the problems, he must also be prepared to treat a certain number of them. Some of the patients will improve just because of a good relationship with the physician. Others will require more definitive, yet comparatively simple, psychotherapy. On the other hand, some patients with clear-cut emotional problems are best treated by the physician''s traditional medical approach rather than by some type of “formal” psychotherapy. In some circumstances psychotherapeutic efforts may be damaging.     

THE CHALLENGE OF THE “WELL CHILD”

Upon general practitioners and pediatricians falls the responsibility of recognizing and treating most emotional problems in young children. This may be best carried out by the anticipation of expected problems, and the advance guidance or counseling of parents. That such problems are of high incidence was indicated in experience at a pediatric clinic where approximately 40 per cent of 7,000 children observed had psychosomatic symptoms.In order to utilize effectively the limited time available in office practice for Well Child care, a physician must have at hand certain basic information on personality development. Many of the normal behavior patterns in children which frequently are misinterpreted as “behavior problems” by parents are presented herein in chart form, divided into critical age periods, to help physicians quickly recognize what is normal and what abnormal in various periods of maximal crisis. Most of the problems of conflict within a child and of conflict between parents and child, it is felt, could be and should be handled at the pediatric level. Some seriously disturbed children need to be referred for psychiatric care. When this is necessary, skillful preparation of the parent and the child by the family physician for referral is most important to successful psychotherapy.     

The Troubled Adolescent Patient—How the General Practitioner May Be Helpful

The disturbed adolescent is psychologically isolated from the worlds of childhood and adulthood. His sense of alienation results from both the upsurge of instinctual drives and his uneasy attempts to master changing physical attributes and new freedoms and responsibilities. The former result in conformity and in concerns about “normality.” The latter lead to confusion and to alternating rebellion and over-dependence.The general practitioner may be the first person consulted by the troubled adolescent or his parents. The physician''s sensitivity can be crucial in helping the family work together toward a solution. Persistent anxiety in either parent or child is in itself a problem. An understanding of those factors inherent in the adolescent experience may provide the physician with a recognition of disturbance denied by the adolescent with a facade of bravado or indifference.The physician must be prepared to help the adolescent accept a protracted period of stress, usually with only partial resolution of distressing problems.     

IS IT NEUROSIS?

So-called “minor psychiatry,” the treatment of neurosis in persons who are not psychotic, may well be undertaken by the general practitioner.The first duty of the physician in dealing with a neurotic person is to determine whether psychosis may develop. He must be patient and thorough in hearing the history of the case and should have full information on the patient''s life and family.A recent classification of the neuroses is given and the more generally recognized symptoms of these conditions are described.     

From Chattel to Consenter: Adolescents and Informed Consent: 2009 Grover Powers Lecture

Angela Holder was to give the Grover Powers Memorial Lecture at the weekly Grand Rounds conducted by the Yale Department of Pediatrics on Wednesday, May 27, 2009, but unfortunately, she died one month earlier, on April 22, leaving behind her prepared address, “From Chattel to Consenter: Adolescents and Informed Consent,” which she had regarded as the pinnacle of a remarkable career, much of it spent at Yale. As the Grover Powers honoree, the department’s highest honor, Ms. Holder was only the fourth woman of 46 recipients and the first who was not a physician. On the date scheduled for her address, tributes were presented by her son, John Holder, and her longtime colleague, Dr. Robert Levine, co-founder of Yale’s Interdisciplinary Bioethics Center. Their comments follow Angela Holder’s completed but undelivered Grover Powers address. — Myron Genel, MD, Professor Emeritus of PediatricsUnder the common law of England and in the early years of the United States, a minor (defined as anyone under 21) was a chattel or possession of his or her father [1-4]. A father had the right to sue a physician who treated his son or daughter perfectly properly but without the father’s permission because such an intervention contravened the father’s right to control the child. Beginning in the early years of the 20th century, by the end of World War II and into the 1950s, the notion that a 16-year-old was a legally different entity from a 6-year-old gradually became law in all states.¹ The first hospital unit for adolescents was created in 1951 at Boston Children’s Hospital, and the concept of “adolescent medicine” was born [5].As the law in this area currently defines “adolescent,” we are discussing someone 14 or older who may be (1) living at home with his or her parents; (2) Not living at home but still dependent on parents (i.e., a 16-year-old college freshman living in a dorm); (3) an “emancipated minor” who is married, emancipated by a court order, or a parent (other than in North Carolina), living away from home and self-supporting; or (4) a runaway or throwaway. At any time in this country, there are about 200,000 adolescents living on the streets with no adult supervision or involvement [6].Regardless of the age of the patient, informed consent consists of five elements: (1) An explanation of what will happen; (2) explanation of the risks; (3) explanation of the projected benefits; (4) alternatives (including doing nothing); and (5) why the physician thinks it should be done, which I interpret as a right to know one’s diagnosis. While the doctrine of “therapeutic privilege” means that in rare cases a physician may withhold some information from an adult patient if she or he believes the patient cannot “deal with the information,” there can never be any withholding of information from an adolescent. If the patient can’t deal with the information to be presented, then parents have to be involved and give permission to treat the adolescent.In some cases, when parents are involved, they do not want their adolescent to know his or her diagnosis. While this is usually not a good idea, it normally falls under the rubric of “professional judgment,” and the physician has every right to decide to follow the parents’ instruction if she agrees with it. In some situations, however, the adolescent must be told what his or her illness is, whether parents like it or not. For example, if a teenager is HIV positive, he or she must be told, must be instructed about safe sex, and must be asked to divulge the names of any sex partners. Parents who say, “Oh, no, don’t tell him, he would never do anything like that, so it doesn’t matter,” should be tactfully but firmly led to accept the fact that he may well have and if he hasn’t yet, he will certainly in the future. There has been at least one successful malpractice case in which the physician did not, at the request of the parents, tell his adolescent patient that he had HIV. The patient’s girlfriend caught it and sued the physician [7]. I feel sure there are many more cases like this that have been quietly settled and no one will ever hear about.Usually, questions about adolescents giving consent to treatments that their parents don’t know about involve outpatient treatment. In the first place, hospital administrators, who are much more interested in getting paid than they are in advancing the rights of autonomous adolescents, are not going to admit for a non-emergency problem a minor whose parent has not made some sort of financial arrangement to pay for it. Secondly, in most households, if Little Herman doesn’t show up for supper or throughout the evening, someone notices and a few telephone calls later discovers that Little Herman is in the hospital.     

Etiology of breast cancer III. Opportunities for prevention

Breast cancer, or its effects, may be preventable. Childbearing at an early age will confer some protection. Until there are other methods of primary prevention the physician must concentrate on secondary prevention, including screening. In presenting risk factors as criteria for screening we have attempted to make rational the use of screening technology. We should not easily accept screening for breast cancer as of proved value. Rather we must encourage clinical trials of various screening methods. In the meantime, while we engage in a moderate amount of screening we do so under the Scottish verdict of “not proven”.     

NONVERBAL TREATMENT OF NEUROSIS—Techniques for General Practice

“Psychosomatic medicine” does not demand that the general practitioner function as a psychiatrist; rather, it is a psychiatric orientation that can increase the effectiveness of purely medical treatment for such conditions as neuroses. The general practitioner to whom the patient turns may achieve permanent results with nonverbal techniques where formal psychotherapy would be impracticable or unacceptable.The first aim is to relieve pressure so that the patient can regain his mental balance and thereby his self-confidence. Arts, hobbies, sports, and the like can be prescribed rather specifically according to the patient''s personality and needs. Nutrition can be improved simply at first by prescribing needed additions to diet rather than imposing restrictions. Vitamin deficiency may by itself be the cause of neurosis or more serious mental disease, whereas psychic stress by itself may create a need for additional vitamin intake. Hormone therapy may be extremely helpful but must be based on clear indication and limited to specific purposes.Since lack of sleep and rest quickly impairs mental function, it is important for neurotic persons to learn relaxation as a necessity for sleep. Sedatives may be used in a crisis but should be abandoned as soon as possible.With all drugs there are problems of excess and habituation. The least, the mildest, the shortest dosage is the ideal.The initial steps of psychotherapy are available to any physician: Establishing rapport, noting how complaints are stated, encouraging ventilation, winning confidence rather than immediate results.     

The Medical Investigation of Alleged Rape

The web of human entanglement resulting from the cry “rape” may twist and disrupt the lives of the persons involved. The physician who is prepared and able to deal with the forensic medical aspects of the problem can play a vital role in the determination of innocence or guilt. And, if he is prepared to recognize and deal with the psychologic problems, the emotional distress and the anxiety, the physician can provide invaluable help.     

MANDIBULAR HERPES ZOSTER—With Report on the Use of Cortisone in a Case with Geniculate Ganglion Symptoms

Herpes zoster, an acute specific viral infection, occurs more commonly than is generally supposed. It should be differentiated from other diseases involving the ear and skin; it must be considered as a possible etiologic agent in some palsies of the facial, glossopharyngeal or vagal nerves.The type of cephalic herpes zoster should be carefully differentiated; cases involving the “geniculate zone” may be other than “Ramsay Hunt''s syndrome.” This syndrome is now defined as a herpes zoster eruption of the external ear at the “geniculate zone” with involvement of the seventh or seventh and eighth nerves.The “topognostic” method is the best for determining the level at which the facial nerve has been affected.It is questioned whether there is a single outstanding therapeutic agent for this disease. Cortisone had no apparent therapeutic effect in a case reported herein.     

NUTRITIONAL ASPECTS OF ANASTOMOTIC OPERATIONS—With Special Reference to the Sprue Syndrome

Necessary but radical operation which results in short-circuits between various levels of the digestive tract, with or without resections of portions of the esophagus, stomach or intestine, frequently cures the condition for which the operation was done, but leaves the patient with difficult nutritional problems. These nutritional disturbances are usually associated with inability to maintain or gain weight as a result of badly regulated movement of food material through the altered digestive tract, and by the removal or diversion of important digestive secretions, such as those elaborated by the stomach, pancreas, duodenum and small bowel.Increased intestinal rate and diminished specific gastrointestinal secretions reduce the ability of the small bowel to properly absorb food, with resulting malnutrition, deficiency disease, and at times specific avitaminosis. Inability to absorb fat and fat-soluble substances is a constant feature of these conditions. Successful treatment of the nutritional problems involves constant, prolonged overfeeding of nonbulky foods, usually given in regular, frequently administered meals of small volume. Vitamin concentrates may occasionally be of some temporary assistance but are not needed if a balanced diet is given and may cause undesirable and sometimes dangerous symptoms. The use of supplemental substances, such as liver extract and a wetting agent, such as “Tween 80,” to improve fat absorption have been demonstrated to be of value.The postoperative conditions described are fairly similar to the condition known as sprue, and it is possible that the general principles underlying the treatment of this disease apply to the entire group of post-operative nutritional disturbances alluded to.     

Nucleosome Remodeling and Epigenetics

Eukaryotic chromatin is kept flexible and dynamic to respond to environmental, metabolic, and developmental cues through the action of a family of so-called “nucleosome remodeling” ATPases. Consistent with their helicase ancestry, these enzymes experience conformation changes as they bind and hydrolyze ATP. At the same time they interact with DNA and histones, which alters histone–DNA interactions in target nucleosomes. Their action may lead to complete or partial disassembly of nucleosomes, the exchange of histones for variants, the assembly of nucleosomes, or the movement of histone octamers on DNA. “Remodeling” may render DNA sequences accessible to interacting proteins or, conversely, promote packing into tightly folded structures. Remodeling processes participate in every aspect of genome function. Remodeling activities are commonly integrated with other mechanisms such as histone modifications or RNA metabolism to assemble stable, epigenetic states.     

WORK INJURY—A Second Look at the Doctor's First Report

Injured employees require medical care and, if disabled, compensation payments for subsistence. The law requires that the employer or insurance carrier supply these benefits promptly. In the absence of prompt and adequate information from the attending physician, these benefits are withheld. The necessary information required to process employee''s claim is that called for on the standard accident report form, commonly called the “pink slip.” Not to supply this minimum information may constitute a hardship on the employee. By supplying more elaborate information than that called for, the physician may be increasing his load of “paper work” immeasurably.     

Project Head Start—An Evaluation of the Medical Components in California

Half of 1,135 children medically examined as a part of Project Head Start in California had one or more conditions that warranted referral to a physician or dentist, and only one-fifth of these were under care. In the judgment of the examining physicians, one-third of the referable medical conditions were described as “major.” Follow-up procedures were variable and not very successful.Increased local medical society participation in planning the health services for these children is recommended as an especially important step in securing care for the problems that are identified.     

Unusual Non-Occupational Exposure to Metals

Exposure to metals at workplaces is well known and in many cases occupational studies led to an adoption of limit values. For airborne concentrations of substances as metals refer to the “Maximaleo Arbeitsplatz-Konzentration” (MAK) in Germany or the “Threshold Limit Value” (TLV) in USA. Biological monitoring consists of an assessment of overall exposure to chemicals at the workplace and in the environment. The “Biologischer Arbeitsstoff Toleranzwert” (BAT) in Germany and the “Biological Exposure Index” in the USA serve as reference values. Besides these occupational limit values, reference values exist in Germany for the background exposure of the non occupationally exposed general population. In some cases the reference values are exceeded without any occupational exposure. Several cases of unusual environmental exposure to cobalt, mercury and manganese are reported. In such cases, it is often difficult to evaluate the measured concentration. In Germany, therefore, the “Human-Biomonitoring-Werte” (HBMValues) have been adopted in order to evaluate such high background exposures. The HBM-concept is presented. Environmental exposure to metals is usual within some limits. Reference values are helpful for an assessment. Unusual exposure occurs and the physician should be alert to symptoms of poisoning.     

The Organically Handicapped Child—How Can the Family Physician Help?

The better his understanding of some of the ways in which an organic deficit might affect normal development of the handicapped child, the more able the family physician will be to offer guidance to the family aimed at preventing the development of secondary problems. He can thus be instrumental in helping a child achieve his maximal potential.First, it is important to take into account how the parents'' emotional and intellectual responses to having a defective child may interfere markedly in normal parent-child relationship. Second, ways in which each deficit will limit a child''s exposure to stimuli must not be over-looked. Third, one must consider how a deficit may indirectly distort the normal learning patterns when parents do not make age appropriate demands. Fourth, it is important to understand how specific interference in the area of language skills may cause further developmental retardation. Fifth, one must be aware of special problems that an organically handicapped child must face in the society outside of the family. Last of all, in an older child, one must consider the need for a full scale evaluation to sort out primary and secondary factors in the picture.     

Resuscitation of the terminally ill

The CMA believes that there are conditions of ill health and inevitable death for which a “no resuscitation” order, signed by the attending physician, is appropriate and ethically acceptable. The association encourages physicians who are faced with the decision of writing a “no resuscitation” or “do not resuscitate” order to consider the clinical criteria and procedural guidelines in the Joint Statement on Terminal Illness. This protocol is intended as a basic, national guideline for those involved in the care of the terminally ill. Individual institutions may wish to develop their own directives as an adjunct to the national statement.     

ANALYSIS OF ABSENTEEISM IN INDUSTRY

There are many nonmedical factors that contribute to employee absenteeism in industry. An employee''s total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.The role of a private physician in determining and certifying the true state of a patient''s health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners.     

“INGROWN” NAILS AND OTHER TOENAIL PROBLEMS—Surgical Treatment

Appropriate office treatment for “ingrown” or deformed toenails can bring quick and lasting relief. The principle is the removal of the portion of the nail that irritates. For mild problems, a buried nail corner or spur may be successfully trimmed away without anesthesia. More extensive infection requires a nerve block anesthetic of the toe and removal of a wide triangle of deformity with nail edge and the mass of heaped up granulations.Chronic or recurrent infection is often associated with some abnormality of the nail. It usually saves time and suffering in the long run to remove a third or so of the width of the nail together with its matrix or “root.” Sharp dissection is relatively easy and far more dependable than other methods of removal or destruction of the matrix. The matrix of the entire nail can be removed just as easily to eliminate such problems as the grossly thickened nail of onychogryphosis.