Good-Enough Therapy: A Review of the Empirical Basis of Good Psychiatric Management.

In this review, the question of whether good psychiatric management (GPM) has a sufficient, or good-enough, evidence base is examined from two complementary perspectives. First, the author reviews research that has investigated whether GPM reduces symptoms of borderline personality disorder. Analyses at the group and individual levels have indicated that symptoms may decrease among patients receiving GPM. Second, the author reviews research that has investigated the processes through which change occurs in GPM. Studies that have shown process changes toward emotional balance, interpersonally effective functioning, and a more coherent and reality-based autobiographical narrative are discussed. To fully answer the question of whether GPM is good enough, more controlled trials are needed to demonstrate effectiveness, mechanisms of change, and broad implementation in culturally diverse populations.

Navigating the Complexity of a Bipolar Pregnant Patient With Multiple Comorbidities.

Bipolar disorder I (BDI) is a psychiatric disorder characterized by the occurrence of at least one manic episode. Within the scope of neurological disorders, epilepsy and psychogenic nonepileptic seizures (PNES) share clinical features and can be differentiated using electroencephalogram (EEG). Substance use disorder is a condition defined by impaired control, risky use, social impairment, and addictive behaviors. We present the case of a 20-year-old pregnant woman with BDI associated with a history of epilepsy, PNES, and polyvalent substance use. The patient presented to the emergency department via the Baker Act involuntary hold multiple times throughout her pregnancy. Recognizing that the welfare of the mother and child was at risk, the court ordered a two-month commitment of inpatient psychiatric treatment at 30 weeks' gestation to ensure safe delivery. Comprehensive inpatient treatment, including risperidone, levetiracetam, lacosamide, haloperidol, diphenhydramine, lorazepam, and later clozapine, and a discharge plan for both the mother and the child are described in detail. Our goal is to contribute to the growing body of knowledge on the management of complex pregnant patients with psychiatric conditions in order to optimize outcomes for maternal and fetal health.

Corrective Experiences to Enhance Trust: Clinical Wisdom From Good (Enough) Psychiatric Management.

Unstable trust within social interchange underlies the symptom constellation of borderline personality disorder (BPD), resulting in preoccupation with intense dyadic relationships, limited capacity for social collaboration, and constricted social networks. Good Psychiatric Management (GPM) provides a distilled formulation of how interpersonal hypersensitivities drive the engine of BPD's symptomatic oscillations in both affect and attachment. The authors summarize clinically relevant conclusions from the empirical literature on trust in BPD, synthesize it with selected ideas from other empirically supported interventions, and distill a formulation of how the GPM approach can address problems of trust in BPD with strategies most clinicians can use to improve their work with patients. GPM's clinical management approach utilizes common factors in psychotherapy to structure collaboration with patients to be accountable partners in treatment, rely on themselves more to diminish unrealistic demands on others, and function more effectively in arenas that expand and stabilize their social network.

Case reports: Using Good Psychiatric Management (GPM) conceptualizations in the dimensional assessment and treatment of personality disorders.

Good Psychiatric Management (GPM) is a generalist clinical management approach for borderline personality disorder that incorporates common ingredients of good standard care for any psychiatric diagnosis with what works from prevailing specialist psychotherapies. Similar to all validated therapies for BPD, it relies on a specified formulation of the disorder' symptoms as arising from interpersonal hypersensitivity, to dynamically describe typical patterns of daily self- and interpersonal issues that drive the instability that defines the general personality dysfunction characteristic of the disorder. Recent adaptations of GPM have been proposed for narcissistic personality disorder and obsessive-compulsive personality disorder, with development of similar dynamic models for both (intrapsychic coherence model and model of overcontrol). New dimensional models of personality disorder diagnosis have been developed to address limitations of categorical approach, but the incorporation of these models into usage in the delivery of clinical services (where categorical approach remains the most used) is limited. This paper describes an adaptation of GPM to two cases of personality disorder that illustrate the usefulness of GPM models for dynamic representation of complex daily fluctuations in internal psychic coherence and interpersonal functioning. Specialist psychotherapies will never meet the demands of public health needs to treat personality dysfunction, and incorporation of new dimensional models of diagnosis are needed for treatments that can provide a minimal standard of care for providers and patients.

Case report: Dermatosis neglecta mimicking pemphigus foliaceus in association with obsessive-compulsive disorder.

Dermatosis neglecta (DN) is a frequently underrecognized skin disorder that occurs due to unconscious or conscious neglect of self-cleaning, causing the accumulation of keratin, sweat, sebum, and impurities. It is characterized by asymptomatic yellowish-to-brownish, waxy, adherent papules or plaques with cornflake-like scales that mimic several dermatological conditions. DN awareness is crucial for avoiding unnecessary invasive diagnostic procedures. Its lesions can be removed with some difficulty by ordinary cleansing and efficiently cleared with ethyl or isopropyl alcohol. Individuals with underlying physical or mental disabilities or psychiatric conditions are highly associated with DN. Nevertheless, supportive evidence for the coexistence of DN and psychological conditions is sparse, and most individuals with mental problems usually deny having psychiatric issues. Here, we present a case of DN resembling pemphigus foliaceus on the face with obsessive-compulsive disorder in a 16-years old male. The definitive diagnosis of DN in this patient was confirmed via histopathological examination. The lesions completely disappeared after appropriate facial cleansing and psychiatric management. DN may reveal underlying psychiatric disorders in patients.

Identifying risk factors to predict violent behaviour in community patients with severe mental disorders: A retrospective study of 5277 patients in China.

BACKGROUND: Patients with Severe Mental Disorders (SMD) have a higher risk of violent behaviour than the general population. The study aimed to investigate the predictive factors for the occurrence of violent behaviour in community SMD patients. METHODS: The cases and follow-up data were collected from SMD patient Information Management system in Jiangning District, Jiangsu Province. The incidence of violent behaviours was described and analyzed. Logistic regression model was used to examine the influencing factors for violent behaviours in those patients. RESULTS: Among 5277 community patients with SMD in Jiangning District, 42.4% (2236/5277) had violent behaviours. The stepwise logistic regression analysis revealed that the disease-related factors (including disease type, disease course, times of hospitalization, medication adherence, past violent behaviours), the demographic factors (age, male sex, educational level, economic and social living status), and the policy-related factors (like free treatment, annual physical check, disability certificate, family physician services, and community interviews) were significantly related to the violent behaviours in community SMD patients. After gender stratification, we found that male patients with unmarried status and with a longer course of disease were more likely to violent. However, we found that female patients with lower economic status and educational experience were more likely to violent. CONCLUSION: Our results suggest that community SMD patients had a high incidence of violent behaviour. The findings may provide valuable information for policymakers and mental health professionals worldwide taking a number of measures to reduce the incidence of violence in community SMD patients and to better maintain social security.

The first session matters: Therapist responsiveness and the therapeutic alliance in the treatment of borderline personality disorder.

OBJECTIVES: The focus of the present research is to investigate the impact of therapist responsiveness at the very first session of therapy on the evaluation of therapeutic alliance from the therapist's perspective and from patient's perspective in the context of guideline-based treatment for borderline personality disorder. DESIGN: The study has a correlational and longitudinal design applied to a 10-session therapy in a naturalistic setting. METHODS: A total of four trained raters evaluated therapist responsiveness during the first session of therapy. After each therapy session, therapists and patients filled out the short form of the Working Alliance Inventory measuring working alliance; the sample included 13 therapists and 47 patients. Correlational analysis as well as hierarchical linear modelling exploring the relationship between first session therapist responsiveness and working alliance were performed. RESULTS: The global evaluation of responsiveness revealed a significant relationship with the temporal evolution of the alliance rated from the therapists' perspective. DISCUSSION: There is the necessity to further explore therapist appropriate responsiveness which could potentially explain several psychotherapy research results. Moreover, it could help in finding alternatives in order to facilitate patients' early engagement in therapy as well as facilitating the building process of therapeutic alliance. Finally, an effort should be made in order to study more individualized operationalization of responsiveness.

C-L Case Conference: Applying Good Psychiatric Management for Borderline Personality Disorder in Hospitalized Patients With Co-occurring Substance Use Disorders.

We present a case illustrating common challenges in the hospital management and treatment of comorbid borderline personality disorder and substance use disorders. Experts in the field of personality disorders and substance use disorders discuss various topics and strategies for patient-centered management. Key learning points include evaluation and diagnosis of borderline personality disorder, good psychiatric management, withdrawal and pharmacologic management, harm reduction, team dynamics, and behavior planning all in the hospital setting. This paper provides actionable considerations with elements common to many clinical encounters that present challenges to the consultation-liaison psychiatrist in the general hospital setting.

The State of Overmedication in Borderline Personality Disorder: Interpersonal and Structural Factors.

Purpose of review: a)This review paper describes the state of prescribing practice in Borderline Personality Disorder (BPD), wherein medications are prescribed far more than either evidence or practice guideline would recommend. First, we describe the frequencies of medication use and polypharmacy in people with BPD. Recent findings: b)In subsequent sections, we elaborate two main categories of factors that lead to overmedication of people with BPD: the interpersonally mediated and the structural. We consider interpersonally mediated factors to arise from communications of patients in distress and the well-meaning efforts of their prescribers to provide relief for certain overwhelming affective states. We are particularly focused on patterns of countertransference in prescribing that are directly linked to specific aspects of BPD pathology. We consider structural factors to arise from the complexities of medical and medicolegal systems and the contemporary patterns of financing medical care; we postulate that these complexities often compel prescribers to start medications, with associated disincentives for decreasing or discontinuing those medications over time. Summary: c)More research is needed to understand how to best use medications in BPD, for example in targeted combination with psychotherapeutic and psychosocial interventions. However, current practice often departs markedly from the evidence. We recommend the dissemination of accessible, generalist BPD-treatment models in outpatient and inpatient practice; increased early detection of BPD; and increased diagnostic disclosure. We also recommend for individual providers and systems to implement prospective treatment plans that draw from BPD-specific psychosocial models. This approach can employ tiers of interventions to minimize reactive prescribing by anticipating high affect and offering BPD patients steadily empathic evidence-supported care.

Management of Psychosis in the Setting of Binge Eating, Mania, and Extrapyramidal Side Effects.

Psychosis is a mental disorder in which an individual exhibits a loss of contact with reality; this definition, however, often fails to convey the broadness and complexity behind the diagnosis. While studies agree that it is best practice to address psychosis by treating its underlying cause, manifestations of psychosis do vary widely and may be challenging to identify in some clinical scenarios, such as the one presented here. Binge eating in the setting of psychosis has been observed in instances where alterations of the gut microbiota in response to an eating disorder trigger psychotic episodes. However, instances in which the manifestation of psychosis itself is the catalytic factor for the presentation of a binge-eating event with aggression and delusions are seldom observed in the current medical literature. Of note, many of the drugs used to treat mental illness have been associated with regulating food intake. We aim to further expand on the association between psychosis, eating disorders, and management thereof in the setting of polypharmacy and undesired side effects. Here, we present the case and management of a 71-year-old male Hispanic patient with a significant history of mental illness who was admitted to the hospital due to acute gastroenteritis precipitated by binge eating during a psychotic episode.

The Utility of Research Domain Criteria in Diagnosis and Management of Dual Disorders: A Mini-Review.

The Research Domain Criteria (RDoC) initiative has been considered a comprehensive alternative classification framework for understanding neuropsychiatric ailments, as opposed to the longstanding, traditional DSM framework. Where the DSM categorizes neuropsychiatric disorders as each being distinct and diagnostically defined by the presence of specified symptoms, RDoC provides a multidimensional conceptualization of psychiatric disorders with neurobiological roots. By taking a multidimensional approach, RDoC overcomes two major constraints of the DSM framework: that is, that the DSM is categorical in its approach to psychiatric disorders to the point of understating the intersectionality between concomitant disorders, and that the DSM focuses mainly on clinical features. RDoC seems to better account for the intersection between dual disorders and considers a range of factors, from the more microscopic (e.g., genetics or molecular functions) to the more macroscopic (e.g., environmental influences). The multidimensional approach of RDoC is particularly appealing in the context of dual disorders. Dual disorders refers to a concurrent psychiatric disorder with an addiction disorder. RDoC accounts for the fact that there is often overlap in symptoms across and bidirectional influence between various disorders. However, to date, there is limited research into the clinical utility of RDoC, and less so in the context of the clinical management of dual disorders. In this Mini-Review, we discuss how RDoC differs from the DSM, what outcomes have been reported in utilizing RDoC clinically, the utility of RDoC for the diagnosis, management, and monitoring of psychopathology, and the limitations of RDoC as well as avenues for future research.

Interview and treatment of a case with gender dysphoria / 四川精神卫生

This paper interviewed a case of patient with gender dysphoria via a bio-psycho-social approach. The client， a 21-year-old college student of male sex， had been into female dressing since the age of ten. As an adult， he became increasingly convinced that he should become a woman and began taking hormone therapy in secret and on an irregular basis. He felt himself trapped in a cycle of anxiety and distress， due to the concerns about the side effects of hormone therapy， and the practical problems regarding the impact on his academic and career arrangements， as well as the ways to explain himself to his parents. Through a remote psychiatric consultation， therapists provided targeted interventions based on the bio-psycho-social model.

The Willingness of Community Psychiatric Management Physicians to Preferentially Recommend Long-Acting Injections in Beijing.

Background: Severe mental disorders (SMD) impose a heavy burden on individuals, society, and the country. Under the background of deinstitutionalization, more and more patients return to the community, and the community psychiatric management physicians (CPMP) play an essential role in this process. Long-acting injection (LAI) is an important way to improve compliance and reduce re-hospitalization. Some districts in Beijing have implemented the policy of free LAI. This article aims to find out the willingness of CPMP to preferentially recommend LAI and provide suggestions for follow-up promotion. Methods: All CPMP in 16 districts of Beijing were surveyed. A self-made electronic questionnaire was used to investigate the willingness to recommend LAI in priority. Descriptive statistics, Chi-square test, and logistic regression were used to analyze the data. Results: The willingness of CPMP to preferentially recommend LAI is up to 80%. Participants aged 40-49, female, with higher self-evaluation of psychiatric management knowledge, managing patients who have used LAI in the past, and working in communities with the free LAI policy have higher willingness to recommend LAI in priority. Conclusion: CPMP in Beijing have a positive attitude toward LAI, and most of them have the willingness to recommend LAI to the patients in priority. The recommendation willingness is the basis of prescription decision-making. Therefore, the coverage of free LAI policy should be further expanded in the future to improve the recommendation willingness and thus improve the injection rate of LAI.

Good Psychiatric Management and Transference-Focused Psychotherapy for Borderline Personality Disorder: A Spectrum of Psychodynamically Informed Treatments.

Good psychiatric management for borderline personality disorder (GPM) and transference-focused psychotherapy (TFP) are evidence-supported treatments that may be used in a complementary, flexible manner to provide a spectrum of psychodynamically informed care. In this article, we provide overviews of TFP and GPM, describing GPM's eclectic approach that includes psychodynamically informed supportive psychotherapy, case management, and medication management, informed by a model of hypersensitivity to rejection, comparing it with TFP's focus on identity integration and modification of standard psychodynamic techniques for use in treating patients with borderline personality disorder. We outline convergences and divergences between TFP and GPM in assessment, establishment of treatment goals and a treatment agreement, family involvement, and moment-to-moment psychotherapeutic interventions. The options for integration of TFP and GPM theoretical principles, as well as for models of treatment sequencing, are explored. Clinical vignettes are provided that illustrate sequential uses of GPM and TFP as part of psychodynamically informed long-term clinical management.

The Therapeutic Alliance Over 10 Sessions of Therapy for Borderline Personality Disorder: Agreement and Congruence Analysis and Relation to Outcome.

The authors examined whether alliance dynamics are affected by tailoring the therapeutic relationship to the individual patient in brief psychotherapy of borderline personality disorder. Sixty patients were randomized to 10-session Good Psychiatric Management (GPM-BV) or GPM combined with Motive-Oriented Therapeutic Relationship techniques (MOTR+GPM-BV). Patient- and therapist-rated alliance was assessed weekly. Self-reported symptomatic distress was assessed pre-, mid-, and posttreatment. In MOTR+GPM-BV, stronger therapist-rated alliance predicted lower symptomatic distress in the same timepoint, but not in a lag, whereas symptomatic distress predicted therapist-rated alliance in a lag. Therapist-rated alliance was lower than patient-rated alliance in GPM-BV but not in MOTR+GPM-BV. In MOTR+GPM-BV, higher agreement on strong alliance tended to predict lower symptomatic distress. Patient- and therapist-rated alliances were temporally congruent, but congruence did not predict outcome. Addressing the relationship needs of patients may partly exert its salutary effect by increasing agreement between patients' and therapists' experience of the alliance.

The Phosphodiasterase 5-Inhibitors (PDE-5i) for Erectile Dysfunction (ED): A Therapeutic Challenge For Psychiatrists.

Erectile function (EF) is a prerequisite for satisfactory sexual intercourse (SI) and central to male sexual functioning. Satisfactory SI eventually initiates orgasm - a biopsychophysiological state of euphoria - leading to a sense of bliss, enjoyment and positive mental well being. For a psychiatrist, treating ED is self-propelled to harmonize these pleasurable experiences alongside with encouragement of physical wellness and sensuality. Hence, the role of PDE-5i is pivotal in this context and constitutes a therapeutic challenge. PDE-5i work via the dopaminergic-oxytocin-nitric oxide pathway by increasing the availability of endothelial's guanosine monophosphate (GMP), immediately causing relaxation of the penile smooth muscle and an erection. The PDE-5i, like sildenafil, vardenafil and tadalafil, are effective in the treatment of ED with some benefits/ flexibilities and disadvantages compared to other treatment modalities. Prescribed PDE-5i exclusively improve EF, fostering male's self-confidence and self-esteem. Treatment failures are associated with factors such as absent (or insufficient) sexual stimulation, psychosexual conflicts and the co-existence of medical disorders. Managing ED requires dealing with underlying medical diseases, addressing other co-morbid sexual dysfunctions like premature ejaculation (PE), and educating the patient on healthy life-styles. Furthermore, by dealing with interpersonal dynamics within the couple and embracing adequate lifestyles (managing stress and revising one's sexual scripts), PDE-5i treatment benefits may be enhanced. In this review, we propose a holistic conceptual framework approach for psychiatric management of patients with ED.

What Works in the Treatment of Borderline Personality Disorder.

PURPOSE OF THE REVIEW: This review summarizes advances in treatments for adults with borderline personality disorder (BPD) in the last 5 years. RECENT FINDINGS: Evidence-based advances in the treatment of BPD include a delineation of generalist models of care in contrast to specialist treatments, identification of essential effective elements of dialectical behavioral therapy (DBT), and the adaptation of DBT treatment to manage post-traumatic stress disorder (PTSD) and BPD. Studies on pharmacological interventions remain limited and have not provided evidence that any specific medications can provide stand-alone treatment. SUMMARY: The research on treatment in BPD is leading to a distillation of intensive packages of treatment to be more broadly and practically implemented in most treatment environments through generalist care models and pared down forms of intensive treatments (e.g., informed case management plus DBT skills training groups). Evidence-based integrations of DBT and exposure therapy for PTSD provide support for changing practices to simultaneously treat PTSD and BPD.

Paradigms lost and gained: has psychiatry in Australasia lost its voice?

OBJECTIVE: The evolution of views about causes and management models in psychiatry is of keen interest to those who respect the field's history. The objective of this study was to identify international paradigm shifts since 1950 in psychiatric theorising and management models. METHOD: Multiple methods were used, including citation analysis, qualitative judgments by highly cited researchers and obtaining the views of historians of psychiatry. RESULTS: The quantitative citation analysis was of low yield, seemingly reflecting limitations intrinsic to such an approach, but it did identify some 'signals' to broader domain shifts, such as the progressive loss of salience of psychoanalysis and a contrasting emphasis on a science-weighted model. Also, the highly cited researchers tend to nominate narrow exemplars. Nominations by the historians were more panoramic and, while capturing the domains identified by the two other strategies, went further in proposing a wide set of additional candidates for consideration. CONCLUSION: Of the three strategies employed, the qualitative approach (canvassing the views of historians and of highly cited authors) captured the paradigm changes, or at least theoretical or research trends, more accurately than the quantitative citation analysis. Changes in Australasian psychiatry would appear to generally mirror such international changes, rather than evidence a distinctive voice.

Psychiatric care for patients with breast cancer

Psychiatric management of patients with breast cancer, as well as women's emotional reactions to all phases of breast cancer, were reviewed. These patients face two major losses; one is the physical loss of part of the body and a threat to life, and the other is the loss of femininity. The patients are also likely to suffer from various psychiatric problems including anxiety and depression. Oncologists should be alert to each patient's emotional reactions and potential psychiatric problems, and if necessary, should refer them to a psychiatrist. A combination of psychotherapeutic, behavioural, and pharmacologic techniques is available for the care of patients with breast cancer. Psychotherapeutic modalities include individual therapy, family therapy, group therapy, and self-help treatment. The author divided individual therapy into general and specific treatment. General treatment deals with a crisis-intervention and cognitive-behavioral approach, whereas specific treatment deals with issues relevant to patients with breast cancer. Some of the therapeutic processes were illustrated in a case report. These guidelines will contribute to the relief and prevention of emotional suffering stemming from an encounter with the most common form of cancer in women. Also, proper and effective care for patients with breast cancer requires combined use of a variety of therapeutic modalities as well as a multi-disciplinary approach including psychiatric care.