Implications of increased dosage of neuroleptic medications during psychotherapy.

Unrecognized emotional reactions on the part of the psychiatric trainee may result in the inappropriate use of medications. To illustrate the possibility that increases in medication dosages may be related to the psychiatric clinician's lack of control, the authors present three clinical examples and discuss the concept of countertransference. A model of supervision is described in which the supervisor, trainee, and patient meet to correct these therapeutic distortions and reduce the amount of medication required.

Response of patients to participation in psychiatry board examinations.

The patient who volunteers to be a subject for Part II of the certifying examination in psychiatry and neurology is an indispensable but surprisingly invisible participant in a highly controversial process. A survey of the attitudes of 78 patients toward this experience revealed that although they experienced a significant degree of stress, the overwhelming majority viewed their participation in strongly positive terms. The patient's loyalty to the host institution and the manner in which the patient is prepared for the experience appear to be the major factors in determining a positive outcome.

The role of physical restraint in the treatment of psychiatric illness.

Although physical restraint is a widely used and possibly hazardous form of treatment, few guidelines for its use appear in the recent psychiatric literature. An approach is described in which physical restraint is considered to be a specific therapeutic technique with definable indications, "dosages", contra-indications, and side effects. A method of initiating and terminating this treatment modality is presented and the indications for its use are discussed. These include the presence of violent behavior during a psychotic illness; the presence of agitation or confusion when the use of antipsychotic medication is limited by physical illness; the presence of severe psychotic symptoms in conjunction with severely regressed, socially aversive behavior; the need to reduce excessive external stimuli; and the request for restraint by the patient. Possible side effects and contra-indications are also discussed and criteria for evaluating the duration and effectiveness of the treatment are proposed.

Three-way interviews and psychiatric training.

The three-way interview is a helpful and sometimes necessary adjunct to the supervision of psychiatric residents who are treating disturbed inpatients. Direct bedside observation of the interaction between therapist and patient can reveal evidence of previously unrecognized countertransference difficulties in the beginning therapist. It also maximizes patient care by allowing detection and correction of diagnostic errors that have resulted from either underlying medical illnesses or drug toxicity. This supervision model resembles that used in teaching internal medicine, in which the house staff and the consultant share their observations.

Management of hostile, suspicious patients. Trifluoperazine versus haloperidol.

In a population of hostile suspicious patients mostly fitting into the paranoid schizophrenic category, haloperidol and trifluoperazine when compared in double-blind fashion were equal in global clinical ratings. Haloperidol showed significantly more improvement on the Brief Psychiatric Rating Scale and on the Global Paranoia rating. On the Global Hostility rating and in speed of onset of activity, the effects of the two drugs were not significantly different. In a small sub-sample of extremely uncooperative patients haloperidol showed marked effects, but trifluoperazine showed only minimal or moderate effects.

The role of stress as a precipitating factor of psychiatric illness.

Fifty-six psychiatric patients were interviewed to obtain a record of life events preceding admission to hospital, using a modified version of the Schedule of Recent Experiences. Two control groups were studied for comparison: medical and surgical in-patients and a "normal" population studied independently by Myers. Psychiatric patients reported a significantly larger number of events than the medical-surgical patients, who, in turn, reported significantly more events than the "normal" population. There were no significant differences in the specific life event histories between groups.