Maladaptive denial of physical illness: a proposal for DSM-IV.

Denial of physical illness is a commonly encountered problem in consultation-liaison psychiatry. Although there is an extensive literature on denial, it has virtually ignored the diagnostic issues raised by the individual whose denial of physical illness is clearly maladaptive. The authors propose that DSM-IV include a subtype of adjustment disorder called "with maladaptive denial of physical disorder." They discuss this new category, its differential diagnosis, and the benefits to clinical practice of this proposed addition to diagnostic classification.

The combined use of psychotherapy and pharmacotherapy in the medical setting.

A psychiatric consultation is a complex challenge that may require an evaluation across the full spectrum of possibilities, from the molecular level of neurotransmitters to the intricacy of large social systems. Many psychiatrists regularly perform consultations in the medical setting. This requires they pay attention to the special psychodynamic and psychopharmacologic issues involved in treating patients in the general hospital.

Panics, prolapse, and PVCs.

There is a group of patients who presents with intense anxiety and physical complaints suggestive of cardiac or gastrointestinal disease. These patients are more commonly women and complain of palpitations, lightheadedness, chest pains, and dyspnea. A work-up may reveal positive findings such as extrasystoles and mitral valve prolapse that appear to confirm the organic etiology of the symptoms. Evidence is presented that the positive findings serve to confuse the picture and are an impediment, rather than an aid, to the physician in making the correct diagnosis. Effective treatment using tricyclic antidepressants or monoamine oxidase inhibitors is suggested.

An AIDS educational program for third-year medical students.

Medical student training now involves an increasing number of patients with HIV infection and AIDS. Thus far educational efforts to change attitudes and behaviors toward AIDS patients have not been successful. Education that only involves the presentation of information appears to be insufficient to alter fearful and prejudicial attitudes toward such patients. Using four different teaching modules (open discussion, role play, and two videotapes) we demonstrated a positive change in students' anticipation of how they would respond to a question or a statement from a non-AIDS patient or a patient with AIDS. There were significant changes in the students' response to AIDS patients on the Understanding, Probing, Focusing, and Judgmental scales of the Medical Helping Relationship Inventory. This initial work suggests that educators can have a positive effect on students' attitudes. Techniques that traverse the emotional barriers students erect to protect themselves from the painful feelings stimulated by working with AIDS appear to be useful.

A "new" drug for treating agitation and psychosis in the general hospital: chlorpromazine.

Psychiatric residents on a consultation-liaison service consistently avoid chlorpromazine in favor of haloperidol for the treatment of psychotic, agitated patients. The residents' fears of chlorpromazine as a dangerous medication are presented and the literature about chlorpromazine's side effects is reviewed. Evidence was not found to support the contention that chlorpromazine is too dangerous to use in the medical setting. Case material illustrating the benefits of chlorpromazine is presented. A theoretical explanation for the observed prescribing practices is suggested.

Psychotherapy with a woman at high risk for developing breast cancer.

Women who are at high risk for developing breast cancer increasingly consult with psychiatrists about the psychological, social, and sexual consequences of genetic testing and risk-reducing surgeries such as bilateral mastectomy and oophorectomy. The 9-year psychotherapy with a woman who had bilateral mastectomy because of her family history of breast cancer and who later tested negative for BRCA1 is described and discussed.

The multisite field trial of the consultation-liaison psychiatry assessment instrument.

A multisite field trial was conducted at 11 institutions to test the clinical reliability of a 29-item consultation-liaison (C-L) psychiatry assessment instrument. Twenty-five raters viewed videotapes of two "trainees" conducting clinical interviews with a simulated patient. One trainee was a medical student, the other was a fellow in psychiatry. Raters completed the 29-item assessment instrument for each trainee. The mean value scores reflected the skill of each trainee. The medical student had a mean score of 1.93, whereas the C-L fellow had a mean score of 3.13 which parallels the expected level of skill for the two interviewers. Eighty-six percent of the items (25/29) had a standard deviation (SD) of less than 1.0. Each of the remaining four items (14%) had a SD minimally greater than 1.0. These results reflect clear wording of items with measurable parameters defined for assessing trainees' skills. The authors present different uses for the assessment instrument, including giving feedback to trainees regarding interviewing techniques and skills; setting "gold" and "lead" standards for clinical C-L interviewing skills; and training supervisors in evaluation using a standardized assessment instrument.

Techniques for reversing the failure of empathy towards AIDS patients.

Educating the general population and health care workers about the acquired immunodeficiency syndrome (AIDS) is of paramount importance. There is a need to address the many fears and anxieties concerning this dreaded illness. Experience has shown that simple information-giving alone does little to allay the panic in the general population and in hospital personnel. The paper offers a psychodynamic explanation of the origins of the irrational fear and anxieties around AIDS patients and why information alone does not help the anxieties hospital workers experience. We have suggested a training program using group process and videotape techniques which can address the underlying fears and concerns about AIDS patients. These sessions can help hospital staff to deliver more empathic care to this patient group.

The request to die: role for a psychodynamic perspective on physician-assisted suicide.

Published reports indicate that 2.5% of deaths in the Netherlands are the result of euthanasia or physician-assisted suicide. It is not known how many patients make these requests in the United States, but the issue has gained considerable attention, including that of the Supreme Court. The focus of the writing and discussion regarding the request to die has been on a patient's capacity. There has not been an adequate focus on the possible meanings contained within the request to die. A patient's request to die is a situation that requires the physician to engage in a dialogue to understand what the request means, including whether the request arises from a clinically significant depression or inadequately treated pain. This article outlines some of the thoughts and emotions that could underlie the patient's request to die. Recommendations are made regarding the role of the primary care physician and the role of the psychiatric consultant in the exploration of the meaning of the request.

Treatment of panic disorder.

In this article we present a 2-yr treatment experience of 14 patients with panic disorder. An approach that utilizes both psychopharmacological and psychodynamically oriented psychotherapy is described. Specific methods of using medication, types and structure of psychotherapeutic interventions, typical response patterns, and reasons for treatment successes and failures are discussed. Our intent is to provide a basis upon which other clinicians may formulate their own treatment approach.

Mood and behavioral disturbances in hospitalized AIDS patients.

A retrospective chart review of 127 patients with acquired immune deficiency syndrome (AIDS) was undertaken to determine the rate of requests for psychiatric consultation. Thirty-six patients (28.3%) had received psychiatric consultations. This is similar to the rate of consultations seen in other studies. Patients who were not intravenous (iv) drug abusers were more likely to be seen for mood disturbances; iv drug users were more likely to be seen for behavior disturbances. The implications of these findings for future demands on consultation-liaison services for AIDS patients are discussed.

Medical student experience with AIDS and needle disposal behaviour.

A survey of medical students at Columbia University, College of Physicians and Surgeons, was conducted to investigate needle-handling behaviour with HIV positive patients. Recapping a used needle increases the students' risk of a needle stick. There were 160 responses, yielding a response rate of 27.6%. Students placed used needles in the sharps container without recapping the needle significantly more often if they had experience with a patient with AIDS. There was no correlation between personal exposure to contaminated material (being stuck or exposure to other contaminated material) and correct needle disposal behaviour. Women students (single or married) only used increased precautions during sex about one-third of the time, a figure similar to women psychiatric patients. Single male students used increased precautions 41.5% of the time, while married male students used increased precautions 8.7% of the time.

Medical students' attitudes toward AIDS, homosexual, and intravenous drug-abusing patients: a re-evaluation in New York City.

After completing their clinical rotations, 69% of the third-year medical school class at Columbia University responded to a survey based on one originally used by Kelly et al. at the University of Mississippi, to determine their attitudes toward acquired immunodeficiency syndrome (AIDS) patients, homosexual men, and intravenous drug abusers (IVDAs). Results of this study were compared to the findings of Kelly et al. to determine how, if at all, geographic and environmental exposures affected student attitudes. Unlike the University of Mississippi students, who exhibited a highly negative and prejudiced view of homosexuals and patients with AIDS, Columbia students displayed no evidence of negative attitude toward homosexuals and a much less harsh judgment of AIDS patients. They, however, did have dramatically negative attitudes toward IVDAs; 78.4% stated that they strongly disliked and would avoid this group of patients. There is a complex multi-variable environmental effect on students' attitudes during medical school. It is not possible to generalize attitudes from one medical school to another. The necessity of incorporating activities into student education to evaluate and to reduce prejudice is discussed.

Lorazepam reduces cardiac vagal modulation in normal subjects.

Benzodiazepines are frequently administered postmyocardial infarction, but their effect on heart period variability (HPV), a prognostic index of sudden arrhythmogenic death, is unclear. In fact, in both humans and animals, previous studies utilizing acute intravenous doses yielded mixed results. We hypothesized that lorazepam (LZ), by potentiating gamma-aminobutyric acid-A-ergic inhibition of preganglionic vagal neurons projecting to the heart, would reduce cardiac vagal modulation. We therefore tested LZ's effect on HPV over 24 hours of normal physiologic activity in human volunteers in the presence of steady-state LZ. A double-blind, randomized, placebo-controlled study was conducted. Seven healthy subjects received LZ or placebo for 1 week, 1 week taper, then crossed over. Electrocardiogram recordings measured HPV after the administration of drug and placebo for 24 hours. LZ increased mean heart rate by 8% (p < 0.002), decreased the standard deviation of R-R intervals by 9% (p < 0.05), decreased the percent differences between adjacent normal R-R intervals > 50 msec by 30% (p < 0.002), decreased the root-mean-square successive difference by 17% (p < 0.02), and decreased the natural logarithm of high-frequency power by 6% (p < 0.03). The significant heart rate increase and HPV decreases demonstrate vagolytic effects of LZ in healthy subjects during 24 hours of normal physiologic activity.

Maladaptive denial of physical illness: a useful new "diagnosis".

OBJECTIVE: Denial of physical illness and/or refusal of treatment are critical issues in the practice of medicine. A previous article proposed DSM-IV consider a new diagnosis for a subgroup of patients who refuse treatment, i.e., maladaptive denial of physical illness [1]. It is necessary to be able to use this form of denial as a diagnosis rather than invoke the term denial as merely a mental mechanism. This is a report of a prospective descriptive study of psychiatric consultations for medical inpatients who deny that they are ill or who refuse treatment. METHOD: In order to investigate the utility of this proposed diagnosis we conducted a one year study of all psychiatric consultations at a community hospital in Manhattan, New York. RESULTS: The diagnosis of maladaptive denial of physical illness was made in 2.5 percent of 317 psychiatric consultations. The patients did not fit into other DSM-III-R or DSM-IV categories. CONCLUSIONS: We suggest a clarification of the concept of denial for use with medically ill patients. The findings in this study demonstrate that the current categories in DSM-IV do not provide physicians with a diagnosis that describes this particular type of pathological denial of illness.

What the general psychiatrist should know about herbal medicine.

The use of complementary and alternative medicine (CAM) has increased tremendously over the past 10 years. As a result of the increase physicians must understand both the factual information about CAM practices and the psychologic reasons patients seek out such treatments. A particular concern is the use of CAM by patients without the knowledge of their physicians, which may lead to complications resulting from interactions, or adverse effects from treatments of which the physician is unaware. This paper reviews research concerning the use of CAM by patients, explores some of the psychodynamic factors in CAM use, and suggests means of integrating that use into the patient's therapy. Specific information about herbal and other alternative products is provided.