A roadmap for observership programs in psychiatry for international medical graduates.

OBJECTIVE: International medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs. METHOD: This article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs. RESULTS: Authors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them. CONCLUSION: Observership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls.

Manifest Dream Content as a Predictor of Suicidality.

A number of behavioral, social, biological, and cultural factors are associated with suicide. However, the ability to predict an imminent suicide attempt remains problematic. Prior studies indicate that the manifest dream content of depressed, non-suicidal patients differs from that of depressed, suicidal patients. The dream imagery of depressed, suicidal patients contains themes of death, dying, violence, and departure. The dream imagery of depressed, non-suicidal patients contains themes of rejection, helplessness, hopelessness, humiliation, failure, and loss. In the present study, the dream reports of 52 depressed patients were collected and rated for various themes. Patients were divided into three groups: Depressed and non-suicidal; Depressed, with suicidal ideation; Depressed, with suicidal ideation and/or attempt(s). Themes of death and/or dying, and to a lesser extent, themes of violence, injury, and/or murder occurred with greater frequency in the dream reports of depressed patients with suicidal ideation and/or attempts, than in the dream reports of depressed patients without suicidal ideation or behavior. These observations correspond with the prevailing psychodynamic explanation of suicide; namely, that it is a murderous attack on the self that is identified with hated internalized objects.

Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report.

Insomnia is highly prevalent, has associated daytime consequences which impair job performance and quality of life, and is associated with increased risk of comorbidities including depression. These practice parameters provide recommendations regarding behavioral and psychological treatment approaches, which are often effective in primary and secondary insomnia. These recommendations replace or modify those published in the 1999 practice parameter paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature since 1999 and to grade the evidence regarding non-pharmacological treatments of insomnia. Recommendations were developed based on this review using evidence-based methods. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Psychological and behavioral interventions are effective in the treatment of both chronic primary insomnia (Standard) and secondary insomnia (Guideline). Stimulus control therapy, relaxation training, and cognitive behavior therapy are individually effective therapies in the treatment of chronic insomnia (Standard) and sleep restriction therapy, multicomponent therapy (without cognitive therapy), biofeedback and paradoxical intention are individually effective therapies in the treatment of chronic insomnia (Guideline). There was insufficient evidence to recommend sleep hygiene education, imagery training and cognitive therapy as single therapies or when added to other specific approaches. Psychological and behavioral interventions are effective in the treatment of insomnia in older adults and in the treatment of insomnia among chronic hypnotic users (Standard).

Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005.

These practice parameters are an update of the previously published recommendations regarding use of oral appliances in the treatment of snoring and Obstructive Sleep Apnea (OSA). Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. Until there is higher quality evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA before considering OAs. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures. Follow-up polysomnography or an attended cardiorespiratory (Type 3) sleep study is needed to verify efficacy, and may be needed when symptoms of OSA worsen or recur. Patients with OSA who are treated with oral appliances should return for follow-up office visits with the dental specialist at regular intervals to monitor patient adherence, evaluate device deterioration or maladjustment, and to evaluate the health of the oral structures and integrity of the occlusion. Regular follow up is also needed to assess the patient for signs and symptoms of worsening OSA. Research to define patient characteristics more clearly for OA acceptance, success, and adherence is needed.

Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders.

Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization. 8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.

Educational challenges of international medical graduates in psychiatric residencies.

Suggestions have been made on how to meet the educational challenges of international medical graduates (IMGs) such as learning to do psychodynamic psychotherapy. These suggestions include providing more structured instruction with explicit feedback. More demonstration of interviewing by faculty and more opportunity to do practice interviews are necessary. Language, slang, and accent reduction training needs to be incorporated into the training program. Courses in American culture are essential for IMGs. Focusing on board preparation with special courses might well improve pass rates. Including psychological theory from the start of the residency and discussing the psychological aspects of the doctor-patient and staff encounters in many clinical settings will place the psychological issues on a sounder footing. IMGs could benefit from having a mentor available to discuss both personal and professional issues.

Changes in manifest dream affect during psychoanalytic treatment.

Affect is central to our understanding of many processes, including dreams. The question has been raised as to whether it is the affective or narrative aspect of dreaming that is central to its development. The purpose of the study is to assess the frequency and valence of affect in the manifest content of dream reports of patients in analytic therapy and if affect is absent to assess the frequency and valence of affect in the associations to the dream reports without affect [MK1]. The presence and valence of affect was evaluated in the first and last manifest dream report of 24 patients who had completed psychoanalytic treatment. If no affect was found, the dream associations were examined for affect and valence. Affect was found in 58.3% of dream reports. The valence of affect in dream reports became more positive during the course of treatment from 19.2% in the first manifest dream report to 53.3% in the last. The associations to the dream reports without affect had affect 94.1% of the time. Affect was present in either the dream report or the associations to it 97.9% of the time. The positive change in affect is most likely the result of psychotherapeutic treatment, although the psychotropic medication 46% of the patients were on at the time of the last dream report and the passage of time may also be factors. The centrality of affect in dream formation and interpretation is supported if the view of the dream experience includes the associations to the dream report.

Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test.

Characterization of excessive sleepiness is an important task for the sleep clinician, and assessment requires a thorough history and in many cases, objective assessment in the sleep laboratory. These practice parameters were developed to guide the sleep clinician on appropriate clinical use of the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT). These recommendations replace those published in 1992 in a position paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature and grade the evidence regarding the clinical use of the MSLT and the MWT. Practice parameters were developed based on this review and in most cases evidence based methods were used to support recommendations. When data were insufficient or inconclusive, the collective opinion of experts was used to support recommendations. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The MSLT is indicated as part of the evaluation of patients with suspected narcolepsy and may be useful in the evaluation of patients with suspected idiopathic hypersomnia. The MSLT is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea syndrome, or in assessment of change following treatment with nasal continuous positive airway pressure (CPAP). The MSLT is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy), insomnia, or circadian rhythm disorders. The MWT may be indicated in assessment of individuals in whom the inability to remain awake constitutes a safety issue, or in patients with narcolepsy or idiopathic hypersomnia to assess response to treatment with medications. There is little evidence linking mean sleep latency on the MWT with risk of accidents in real world circumstances. For this reason, the sleep clinician should not rely solely on mean sleep latency as a single indicator of impairment or risk for accidents, but should also rely on clinical judgment. Assessment should involve integration of findings from the clinical history, compliance with treatment, and, in some cases, objective testing using the MWT. These practice parameters also include recommendations for the MSLT and MWT protocols, a discussion of the normative data available for both tests, and a description of issues that need further study.

Practice parameters for the indications for polysomnography and related procedures: an update for 2005.

These practice parameters are an update of the previously-published recommendations regarding the indications for polysomnography and related procedures in the diagnosis of sleep disorders. Diagnostic categories include the following: sleep related breathing disorders, other respiratory disorders, narcolepsy, parasomnias, sleep related seizure disorders, restless legs syndrome, periodic limb movement sleep disorder, depression with insomnia, and circadian rhythm sleep disorders. Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders; for continuous positive airway pressure (CPAP) titration in patients with sleep related breathing disorders; for the assessment of treatment results in some cases; with a multiple sleep latency test in the evaluation of suspected narcolepsy; in evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; and in certain atypical or unusual parasomnias. Polysomnography may be indicated in patients with neuromuscular disorders and sleep related symptoms; to assist in the diagnosis of paroxysmal arousals or other sleep disruptions thought to be seizure related; in a presumed parasomnia or sleep related seizure disorder that does not respond to conventional therapy; or when there is a strong clinical suspicion of periodic limb movement sleep disorder. Polysomnography is not routinely indicated to diagnose chronic lung disease; in cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated; for patients with seizures who have no specific complaints consistent with a sleep disorder; to diagnose or treat restless legs syndrome; for the diagnosis of circadian rhythm sleep disorders; or to establish a diagnosis of depression.

Practice parameters for the role of actigraphy in the study of sleep and circadian rhythms: an update for 2002.

Actigraphy is a method used to study sleep-wake patterns and circadian rhythms by assessing movement, most commonly of the wrist. These evidence-based practice parameters are an update to the Practice Parameters for the Use of Actigraphy in the Clinical Assessment of Sleep Disorders, published in 1995. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the role of actigraphy, which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of actigraphy. Actigraphy is reliable and valid for detecting sleep in normal, healthy populations, but less reliable for detecting disturbed sleep. Although actigraphy is not indicated for the routine diagnosis, assessment, or management of any of the sleep disorders, it may serve as a useful adjunct to routine clinical evaluation of insomnia, circadian-rhythm disorders, and excessive sleepiness, and may be helpful in the assessment of specific aspects of some disorders, such as insomnia and restless legs syndrome/periodic limb movement disorder. The assessment of daytime sleepiness, the demonstration of multiday human-rest activity patterns, and the estimation of sleep-wake patterns are potential uses of actigraphy in clinical situations where other techniques cannot provide similar information (e.g., psychiatric ward patients). Superiority of actigraphy placement on different parts of the body is not currently established. Actigraphy may be useful in characterizing and monitoring circadian rhythm patterns or disturbances in certain special populations (e.g., children, demented individuals), and appears useful as an outcome measure in certain applications and populations. Although actigraphy may be a useful adjunct to portable sleep apnea testing, the use of actigraphy alone in the detection of sleep apnea is not currently established. Specific technical recommendations are discussed, such as using concomitant completion of a sleep log for artifact rejection and timing of lights out and on; conducting actigraphy studies for a minimum of three consecutive 24-hour periods; requiring raw data inspection; permitting some preprocessing of movement counts; stating that epoch lengths up to 1 minute are usually sufficient, except for circadian rhythm assessment; requiring interpretation to be performed manually by visual inspection; and allowing automatic scoring in addition to manual scoring methods.

Practice parameters for using polysomnography to evaluate insomnia: an update.

Insomnia is a common and clinically important problem. It may arise directly from a sleep-wake regulatory dysfunction and/or indirectly result from comorbid psychiatric, behavioral, medical, or neurological conditions. As an important public-health problem, insomnia requires accurate diagnosis and effective treatment. Insomnia is primarily diagnosed clinically with a detailed medical, psychiatric, and sleep history. Polysomnography is indicated when a sleep-related breathing disorder or periodic limb movement disorder is suspected, initial diagnosis is uncertain, treatment fails, or precipitous arousals occur with violent or injurious behavior. However, polysomnography is not indicated for the routine evaluation of transient insomnia, chronic insomnia, or insomnia associated with psychiatric disorders.

Practice parameters for the dopaminergic treatment of restless legs syndrome and periodic limb movement disorder.

Dopaminergic agents, particularly dopamine agonists, have been used with increasing frequency in the treatment of restless legs syndrome and periodic limb movement disorder. These evidence-based practice parameters are complementary to the Practice Parameters for the Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder, published in 1999. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the dopaminergic treatment of restless legs syndrome (RLS) and periodic limb movement disorder (PLMD), which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of dopaminergic agents in the treatment of RLS and PLMD. Levodopa with decarboxylase inhibitor, and the dopaminergic agonists pergolide, pramipexole, and ropinirole are effective in the treatment of RLS and PLMD. Other dopamine agonists (talipexole, cabergoline, piribidel, and alpha-dihydroergocryptine) and the dopaminergic agents amantadine and selegiline may be effective in the treatment of RLS and PLMD, but the level of effectiveness of these medications is not currently established. Lastly, no specific recommendations can be made regarding dopaminergic treatment of children or pregnant women with RLS or PLMD.

Using dreams to assess clinical change during treatment.

This article describes several studies that examine the relationship between the manifest content of selected dreams reported by patients and their clinical progress during psychoanalytic and psychodynamically oriented treatment. There are a number of elements that dreaming and psychotherapy have in common: affect regulation; conflict resolution; problem-solving; self-awareness; mastery and adaptation. Four different studies examined the relationship between the manifest content of selected dreams and clinical progress during treatment. In each study, the ratings of manifest content and clinical progress by independent observers were rank-ordered and compared. In three of the four studies there was a significant correlation between the rankings of manifest content and the rankings of clinical progress. This finding suggests that the manifest content of dreams can be used as an independent variable to assess clinical progress during psychoanalytic and psychodynamically oriented treatment.

The biology of dream formation: a review and critique.

There is great interest in brain function as a result of the new laboratory and imaging techniques in the neurosciences. Psychoanalysis has embraced these contributions without adequate assessment of whether they bridge the mind/brain divide and provide answers to the questions psychoanalysts ask. A review and critique of the biological theories of dreaming highlights their limitations and points out they do not address the semantics, meaning, and content of dreaming nor the pragmatics of dreaming, its function. At best these theories attempt to provide the syntax of dreaming, the form dreaming takes. Brain biology cannot provide the transduction rules to go from neuronal firing to the psychological experience of dreaming or other mind states.

Initial and last manifest dream reports of patients in psychodynamic psychotherapy and combined psychotherapy/pharmacotherapy.

The initial and last manifest dream reports (MDRs) of 30 patients who had either successfully terminated, or continued to make satisfactory progress at an advanced stage of psychodynamic psychotherapy and combined psychotherapy/pharmacotherapy, were rated according to the following variables: Affect and Affect Valence; Affect Valence of Associations and Direction of Association Themes; Dream Narrative; Psychodynamic Formulation; Transference; and Dream Theme. Similar to previous studies, the initial MDRs contained more negative than positive affect. Conversely, the last MDRs contained more positive than negative affect. Associations to initial MDRs contained more negative affect; on the other hand, associations to last MDRs contained more positive affect. Direction of association themes were more negative in initial MDRs and more positive in last MDRs. Dream narratives were more negative in initial MDRs and more positive in last MDRs. Psychodynamic formulations were more negative in initial MDRs and more positive in last MDRs. Transference was more negative in initial MDRs and more positive in last MDRs. Relational and injury dream themes occurred more frequently than others in both initial and last MDRs. Initial MDRs contained more injury dream themes than last MDRs. The findings of this study demonstrate that there is a correlation between MDR variables and clinical improvement during treatment. The patients in this study were selected by MG, the treating therapist, on the basis of satisfactory progress. The MDRs of patients who failed to progress or did poorly were not discussed in this report. The findings, therefore, must be taken as preliminary and indicate the need for further research on manifest dreams during psychotherapy and combined psychotherapy/pharmacotherapy.

The clinical and predictive value of the initial dream of treatment.

The authors collected the initial dreams of treatment from 63 patients and independently evaluated the manifest dream report (MDR). Variables included: Affect and Valence of Affect; Associations; Psychodynamic Theme; Psychodynamic Theme as Predictor of Core Psychodynamic Issues; Transference; Gender; Psychodynamic Theme Categories; Clinical Progress in relation to Psychodynamic Theme Categories and Transference. The initial MDR invariably contains Affect that is frequently Negative. The Psychodynamic Themes of MDRs are dependable predictors of Core Psychodynamic Issues that emerge during treatment. Transference is evident in a significant number of MDRs and is often Negative. Gender of the majority of MDRs is predictable. The most frequent Psychodynamic Themes of initial MDRs fall into Relational and Injury Categories. Relational and Injury Themes, as well as Positive and Negative Transference, are associated with clinical progress. This study confirms that the initial MDR of treatment provides a significant amount of clinical and predictive information.

Sleep loss in resident physicians: the cause of medical errors?

This review begins with the history of the events starting with the death of Libby Zion that lead to the Bell Commission, that the studied her death and made recommendations for improvement that were codified into law in New York state as the 405 law that the ACGME essentially adopted in putting a cap on work hours and establishing the level of staff supervision that must be available to residents in clinical situations particularly the emergency room and acute care units. A summary is then provided of the findings of the laboratory effects of total sleep deprivation including acute total sleep loss and the consequent widespread physiologic alterations, and of the effects of selective and chronic sleep loss. Generally the sequence of responses to increasing sleep loss goes from mood changes to cognitive effects to performance deficits. In the laboratory situation, deficits resulting from sleep deprivation are clearly and definitively demonstrable. Sleep loss in the clinical situation is usually sleep deprivation superimposed on chronic sleep loss. An examination of questionnaire studies, the literature on reports of sleep loss, studies of the reduction of work hours on performance as well as observational and a few interventional studies have yielded contradictory and often equivocal results. The residents generally find they feel better working fewer hours but improvements in patient care are often not reported or do not occur. A change in the attitude of the resident toward his role and his patient has not been salutary. Decreasing sleep loss should have had a positive effect on patient care in reducing medical error, but this remains to be unequivocally demonstrated.