The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

Serum cholesterol concentration and structured individual psychoanalytic psychotherapy in suicidal and non-suicidal male patients suffering from borderline personality disorder

Findings from numerous studies suggest an association between low cholesterol levels and suicidal behavior in patients with different psychiatric diagnoses. The aims of this case-control study were to test whether cholesterol levels in male suicidal patients (N=20) with borderline personality disorder (BPD) are lower than in male non-suicidal patients (N=20) with BPD and male healthy control group (N=20), and to evaluate the influence of structured individual psychoanalytic psychotherapy on suicidal behavior. The groups were matched for age and body mass index (BMI). Results showed that serum cholesterol levels did not differ significantly between suicidal and non-suicidal BPD patients and healthy controls. The level of psychopathology (measured by Brief Psychiatric Rating Scale and Hamilton Depression Rating Scale) was significantly higher in the group of suicidal patients, which indicates the importance of evaluating particular clinical symptoms in BPD, in order to prevent suicidal behavior. Non-suicidal male patients suffering from BPD received more frequently structured individual psychoanalytic psychotherapy prior to the hospitalization than suicidal group. These results emphasized the role of this type of psychotherapy in preventing suicidal behavior in BPD patients.     

Persistence of Psychological Distress in Surgical Patients with Interest in Psychotherapy: Results of a 6-Month Follow-Up

Objectives

This prospective observational study investigated whether self-reported psychological distress and alcohol use problems of surgical patients change between preoperative baseline assessment and postoperative 6-month follow-up examination. Patients with preoperative interest in psychotherapy were compared with patients without interest in psychotherapy.

Methods

A total of 1,157 consecutive patients from various surgical fields completed a set of psychiatric questionnaires preoperatively and at 6 months postoperatively, including Patient Health Questionnaire-4 (PHQ-4), Brief Symptom Inventory (BSI), Center for Epidemiologic Studies Depression Scale (CES-D), World Health Organization 5-item Well-Being Index (WHO-5), and Alcohol Use Disorder Identification Test (AUDIT). Additionally, patients were asked for their interest in psychotherapy. Repeated measure ANCOVA was used for primary data analysis.

Results

16.7% of the patients were interested in psychotherapy. Compared to uninterested patients, they showed consistently higher distress at both baseline and month 6 regarding all of the assessed psychological measures (p’s between <0.001 and 0.003). At 6-month follow-up, neither substantial changes over time nor large time x group interactions were found. Results of ANCOVA’s controlling for demographic variables were confirmed by analyses of frequencies of clinically significant distress.

Conclusion

In surgical patients with interest in psychotherapy, there is a remarkable persistence of elevated self-reported general psychological distress, depression, anxiety, and alcohol use disorder symptoms over 6 months. This suggests high and chronic psychiatric comorbidity and a clear need for psychotherapeutic and psychiatric treatment rather than transient worries posed by facing surgery.     

Endothelial cells in blood smears

Selected prisoners, most of them with severe character disorders, are permitted to serve the remaining portion of their sentence on parole in the community on condition that they be patients in psychotherapy at a psychiatric clinic created in 1953 for this purpose. Nearly all the patients begin without personal motivation for such treatment. Attendance has been attained because parole officers are assigned to the task of enforcing attendance. Coercion can bring these reluctant patients to expose themselves to treatment, but staff members then have the task to overcome hostility, combat extensive rationalizations, and transform an initially poor rapport into patient participation in working through major personality change. This clinic provides an interesting laboratory for the development of a psychiatric treatment program for adults who have not responded well to a great variety of forms of correctional care.     

GROUP PSYCHOTHERAPY FOR CRIMINAL OFFENDERS—A Program for Parolees Under Social-Psychological Coercion

Selected prisoners, most of them with severe character disorders, are permitted to serve the remaining portion of their sentence on parole in the community on condition that they be patients in psychotherapy at a psychiatric clinic created in 1953 for this purpose. Nearly all the patients begin without personal motivation for such treatment. Attendance has been attained because parole officers are assigned to the task of enforcing attendance.Coercion can bring these reluctant patients to expose themselves to treatment, but staff members then have the task to overcome hostility, combat extensive rationalizations, and transform an initially poor rapport into patient participation in working through major personality change.This clinic provides an interesting laboratory for the development of a psychiatric treatment program for adults who have not responded well to a great variety of forms of correctional care.     

Guías de práctica clínica para la valoración y tratamiento de la transexualidad. Grupo de Identidad y Diferenciación Sexual de la SEEN (GIDSEEN)*(anexo 1)

Transsexual patients can only be diagnosed and treated at functional gender identity Units with provision of high quality care, development of clinical practice guidelines, and interdisciplinary working groups. The therapeutic process has three mainstays: initial psychological diagnostic evaluation and psychotherapy, endocrinological evaluation and hormone therapy, and sex reassignment surgery. Cross-sex hormone therapy is essential for the anatomical and psychological transition process in duly selected patients. Hormones help optimize real-life sex identity, improve quality of life, and limit psychiatric co-morbidities often associated to lack of treatment. Development of this clinical practice guideline addresses the need for implementing a coordinated action protocol for comprehensive health care for transgender people in the National Health System.     

The Use of Lysergic Acid Diethylamide (LSD) in Psychotherapy

One hundred of 150 patients with non-psychotic functional psychiatric disorders were benefited by the use of LSD psychotherapy. The dosage of LSD employed was 25 to 2000 micrograms intramuscularly per session for from one to 10 sessions. On this regimen four patients became psychotic and required electroconvulsive therapy. None were permanently harmed.Indications for and contraindications to this form of treatment and a procedure involving a doctor and a nurse as co-therapists are discussed. In particular, LSD is considered to permit “perceptualization of the transference”.LSD possibly extends the scope and value of the psychotherapeutic approach in such cases.     

Micturition and the mind: psychological factors in the aetiology and treatment of urinary symptoms in women.

The mental state of 211 women attending a urodynamic clinic was assessed using questionnaires. Patients with genuine stress incontinence had scores comparable with other patients with longstanding physical complaints. Patients with sensory urgency were more anxious than those with genuine stress incontinence. Patients with detrusor instability were as anxious as patients with sensory urgency and in addition had higher scores on the hysteria scale. A subset of patients (roughly a quarter of the total) was identified, comprising members of all three diagnostic groups, for whom urinary symptoms rendered life intolerable. These patients were as anxious, depressed, and phobic as psychiatric inpatients, emphasising the serious psychological morbidity experienced by patients with urinary symptoms. Fifty patients with detrusor instability or sensory urgency entered a randomised trial comparing psychotherapy, bladder drill, and propantheline. The psychotherapy group significantly improved on measures of urgency, incontinence, and nocturia, though not on frequency. Bladder training was an effective treatment for frequency and patients became less anxious and depressed. There was a modest improvement in frequency of micturition in patients given propantheline. Frequency may be a learnt disorder which responds to the direct symptom oriented approach of bladder training. Patients with urgency and nocturia predominating might derive more benefit from psychotherapy.     

NON-DIRECTIVE PSYCHOTHERAPY

Psychotherapy is a word to describe an age-old process. It would be better not to speak of psychotherapy, but of psychotherapies. Specialists are not the only ones who act as psychotherapists, since every human being fills this role at one time or another. Besides this, no two persons follow an identical approach. Finally, all therapists change technique constantly. The kinds of psychotherapy must therefore approach infinity.Some physicians appear to assume that only one type of psychotherapy may claim a scientific basis. Although Freud first put psychotherapy on a scientific path, there is no reason to say that Freud must be the last in this field.Over the past few years a new trend has started in psychotherapy which deserves close study. This new trend challenges some old beliefs and gives a new tool to help patients of some types. It is called non-directive or client-centered psychotherapy. This therapy does not try to solve the patient''s problems for him, but rather establishes the conditions under which a patient can work out his own salvation.Each year non-directive psychotherapy grows in importance. Much can be learned from the method.     

Non-directive psychotherapy

Psychotherapy is a word to describe an age-old process. It would be better not to speak of psychotherapy, but of psychotherapies. Specialists are not the only ones who act as psychotherapists, since every human being fills this role at one time or another. Besides this, no two persons follow an identical approach. Finally, all therapists change technique constantly. The kinds of psychotherapy must therefore approach infinity.Some physicians appear to assume that only one type of psychotherapy may claim a scientific basis. Although Freud first put psychotherapy on a scientific path, there is no reason to say that Freud must be the last in this field. Over the past few years a new trend has started in psychotherapy which deserves close study. This new trend challenges some old beliefs and gives a new tool to help patients of some types. It is called non-directive or client-centered psychotherapy. This therapy does not try to solve the patient's problems for him, but rather establishes the conditions under which a patient can work out his own salvation. Each year non-directive psychotherapy grows in importance. Much can be learned from the method.     

Attitudes of Ontario psychiatrists towards health insurance.

In 1979 the opinions of Ontario psychiatrists were sought regarding the influence of the Ontario Health Insurance Plan (OHIP) on the practice of their specialty. Full replies to a 44-item questionnaire were received from more than half the certified psychiatrists in Ontario, half of whom had been in practice before the introduction of OHIP. Both satisfaction and uneasiness were expressed about most aspects of health insurance. Many of the 416 psychiatrists stated that OHIP had improved access to psychiatric care, providing a more socially diverse practice, especially with respect to psychotherapy. Only one quarter believed that OHIP constituted a major intrusion on the doctor-patient relationship, and the majority reported that OHIP had been beneficial to themselves as psychiatrists (70%) and to their patients (86%). Almost half reported having raised their concern about the confidentiality of OHIP records with their patients; the patients less often brought up the issue. Although most psychiatrists in practice before the introduction of OHIP reported no change in their conduct of psychotherapy, a minority reported a decrease in the duration of treatment and an increase in the frequency of missed appointments. Also noted was an increase in the number of referrals for consultation, which led at times to overutilization of these specialists'' services.     

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM‐5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom‐defined disorders depends on factors extrinsic to those disorders, such as self‐efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.     

A network meta‐analysis of the effects of psychotherapies,pharmacotherapies and their combination in the treatment of adult depression

No network meta‐analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long‐term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop‐out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment‐resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random‐effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta‐analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14‐1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14‐1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92‐1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05‐1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02‐1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment‐resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long‐term effects of treatments (including cost‐effectiveness), on the impact of specific pharmacological and non‐pharmacological approaches, and on the effects in specific populations of patients.     

Ethology and psychotherapy

During the last 25 years, ethology has developed systematic and quantitative methods for studying psychiatric patients' behavior, especially nonverbal behavior. Both research results as well as theoretical considerations may be of interest and value for psychiatric interviews and psychotherapy. Direct observations of endogenously depressed patients on the ward show significant behavior changes from admission to discharge. The depressive phase is characterized by withdrawal, nonspecific gaze, looking down, little self-activity, little motor activity, and a substantial reduction of social interaction. The recovery phase is characterized by verbal and nonverbal communication, that is , nod, smile, laughter, gesticulation, help, and others. Such behaviors are primarily useful for the assessment of a patient's mental state in the ward environment. In addition, they may also contribute to the psychiatric interview and future psychotherapeutic situations. These elements are related to four basic motivation categories: relaxation, assertion, contact, and flight. The theoretical considerations include evolutionary theory, ethological theory, and regulation-deregulation theory.     

Konsiliardienste in den Fachgebieten „Psychiatrie und Psychotherapie“ und „Psychosomatische Medizin und Psychotherapie“ im Land Sachsen-Anhalt

Objective To assess the availability and the utilization of specialists for psychiatry, psychotherapy and psychosomatic medicine in somatic hospitals in the German state of Sachsen- Anhalt. Method The “Committee for Issues of Psychiatric Care in Sachsen- Anhalt” sent written questionnaires to the medical chairmen of the 46 hospitals with a somatic department; the return rate was 98% with some information about 48 of 55 hospital locations. Results 17 hospitals use specialists from their own clinical facilities (12 from their own psychiatric department for inpatient care and 4 from their own psychiatric day hospital as well as 9 from their own inpatient psychosomatic unit) for psychiatric consultations on somatic wards and were classified as hospitals with “internal” consultation services. 27 hospitals ask for visits from specialists from another psychiatric hospital (14) and/or call colleagues working in private practice (14) and were classified as “external consultation services”, even if they had psychologists among their own staff (3). In another 4 hospitals, no psychiatric services were offered. Only 16 houses had statistical data regarding the frequency of psychiatric consultations at hand; another 22 hospitals provided estimates. The availability of the consultation service was a strong predictor of its utilization: Hospitals with an “internal” service reported about five times more consultations than those hospitals whose consultation services depended on external specialists. Some formal psychotherapeutic qualification was available in nearly all hospitals with internal and in 37% of the hospitals with external services. Conclusions We were able to gather at least some information regarding psychiatric and/or psychosomatic consultation services in about nearly 90% of the local somatic hospitals of the whole state of Sachsen- Anhalt, which is one of the “new” federal states that emerged from the former “German Democratic Republic” and has to catch up to the standards of medical care of the Federal Republic of Germany. The quality of the data, however, left much room for improvement, as only 36% of the hospitals were able to provide the exact number of psychiatric consultations in the previous year or the last six months. The results, nevertheless, suggest considerable deficits in the care of patients with psychiatric disorders especially in those somatic hospitals with no internal psychiatric consultation service. A service “around the clock” was only available in hospitals with a psychiatric inpatient department of their own. We strongly recommend the implementation of regular reports about the utilization of psychiatric consultations in somatic hospitals as an addition to the current measures of quality assurance. Every somatic hospital should have at least one psychiatrist (with some psychotherapeutic training) on its own staff.     

Conjoint Psychotherapy of Marital Pairs

Many traditional concepts are being challenged in contemporary psychiatric practice, including the classical “one-to-one” relationship of individual psychotherapy. Where the patient''s presenting difficulties include significant inability to function or feel happy in the marital role, the technique of conjoint psychotherapy (having both partners treated simultaneously by the same doctor) may be indicated. Conjoint therapy is envisaged as a continuum, embracing a considerable range of situations where it is sound practice to see husband and wife together. The treatment plan has three stages: complaint, clarification, and compromise, each of which presents specific features and pitfalls. Emphasis is placed on dealing with individual psychopathology of each partner, both per se and in relation to the marital situation. Results to date suggest that conjoint treatment represents a promising therapeutic modality. Even in cases where individual psychopathology cannot fully be resolved, certain plateaus of satisfaction may be attained as communication improves.     

Psychiatry and Psychotherapy: Is a Divorce Imminent?

Despite the long tradition of psychiatrists practicing psychotherapy, many psychiatric and medical leaders are predicting and urging a reorientation of psychiatry toward the medical model. They would leave psychotherapy to psychologists, social workers and the like. Many social, governmental and institutional factors favor such a change. The marriage of psychiatry and psychotherapy has always been an uneasy one, and the push for divorce may be irresistible. The author cautions that a divorce could be detrimental to medicine by substituting, in the name of “science,” a dehumanized, technological psychiatry for the current “moral” treatment. One alternative to divorce is a broader approach to psychiatry, combining biological, neuromedical, socioenvironmental and psychodynamic factors. The divorce, though imminent, should be resisted.     

The concept of neurasthenia and its treatment in Japan

The term neurasthenia, which had been widely used in Japan before the Second World War, came to be replaced by the term neurosis thereafter. With this change in terminology, there seems to have been a shift in the popular ideas of minor psychiatric disorders towards a more psychological view. Unlike in the West where psychoanalysis was a major contributing factor, in Japan it was Shoma Morita who contributed to this change by questioning the somatic basis of conditions then diagnosed as neurasthenia and by developing the conceptshinkeishitsu in the early 1920's, rejecting the concept of neurasthenia. In his theory, the development of shinkeishitsu symptoms is explained in terms of certain psychic dispositions and as a vicious cycle of sensation and attention; he formulated a psychological treatment, Morita therapy, which has been very effective for that condition. With the advent of modernization in this country, doubts have been raised whether this form of psychotherapy with continue to be acceptable to modern Japanese. However, in reality many neurotic patients are still being treated with Morita therapy, although analytically oriented psychotherapy is coming to be practiced more and more in recent years. The indigenous psychotherapies represented by Morita therapy and Naikan therapy have deep-seated roots in Buddhist tradition: its values and ideas have been redefined and reformulated into forms of therapy acceptable to modern Japanese.This paper was translated by Ryu Suzuki.     

Toward a culture-bound syndrome-based insanity defense?

The American Psychiatric Association's recent inclusion of a Glossary of Culture-Bound Syndromes within DSM-IV draws upon decades of medical anthropological and cultural psychiatric research to afford culture-bound syndromes (CBSs) a newfound legitimacy within professional Western psychiatric nosology. While DSM-IV's recognition of the CBS concept as a category of psychosocial distress has important clinical implications for mental health care practitioners throughout the world, it also has significant legal implications. Given that several CBSs involve a degree of psychological impairment that may satisfy the standard for legal insanity under certain circumstances, this essay focuses on the potential emergence of an insanity defense based on the claim that an immigrant or minority defendant was suffering from a CBS at the time of his or her criminal act. Aimed at initiating interdisciplinary debate over the reification of the CBS concept, the essay discusses the theoretical ambiguity and status of CBSs within professional Western psychiatry, describes what a CBS-based insanity defense might look like, and considers the relevant challenges facing medical anthropologists and cultural psychiatrists, on the one hand, and legal practitioners, on the other. The essay identifies a pressing need for interdisciplinary debate concerning the validity, scope, and viability of CBS-based insanity defenses.