Journal of Psychiatric Practice最新文献

Background: The aim of this study was to examine various dimensions of insight among elderly and nonelderly patients with schizophrenia.

Materials and methods: Disease insight was assessed in 105 patients using the Self-Appraisal of Illness Questionnaire (SAIQ), while disease severity was assessed using the Positive and Negative Syndrome Scale (PANSS). Results were compared among 3 age groups: 20 to 39 years (young), 40 to 59 years (middle-aged), and 60 years or above (older), using the Kruskal-Wallis test. Factors associated with insight were identified by constructing a multiple linear regression model.

Results: Total PANSS scores did not differ significantly among the age groups. The total SAIQ score was significantly higher in the young and middle-aged groups compared with the older group (P = 0.011 and 0.024). The SAIQ Worry subscale score was significantly higher in the young group than in the older group (P = 0.021), while the Presence of Illness subscale scores were higher in both the young and middle-aged groups than in the older group (P = 0.017 and 0.041). Multiple linear regression identified older age (P = 0.024) and higher PANSS negative symptom scores (P = 0.041) as significantly associated with lower SAIQ scores.

Conclusions: Among those with a similar severity of disease, individuals with schizophrenia aged 60 years and older displayed the lowest levels of insight. This older cohort exhibited reduced concern regarding the impact of the illness on their social and occupational functioning and tended to underestimate the severity of their condition. In addition to age, negative symptoms of schizophrenia may also play a significant role in the relationship with deficits in insight.

This second column on psychotherapy and AI offers an update on progress in domains identified in the first column, including (1) provision of a private, secure, psychologically safe space for the patient to do the work, (2) mastery of a set of techniques grounded in the theoretical underpinnings of a given form of psychotherapy, and (3) addressing issues relevant to the therapeutic relationship and therapeutic alliance in AI psychotherapy. The column reviews several recent studies of AI psychotherapy and summarizes 5 sets of "threes" for categorizing and evaluating AI psychotherapy.

Patients with a personality disorder are frequently encountered in clinical settings, and their treatment often poses unique clinical dilemmas given specific features of the illness and treatment landscapes that are commonly austere. The past few decades have seen the emergence of new models for conceptualizing personality disorders and several new evidence-based treatments. However, the question of which patient should be matched to which treatment, and when, is a significantly under-investigated topic. We propose that one important component of answering this question is considering readiness for treatment, which has not received the same degree of attention as it has in other areas of mental health treatment. While there are currently no empirically validated tools to reliably quantify readiness for treatment, here we argue that it is still an important topic to consider when working with this patient population. We present 3 different case-based discussions where different features of personality disorders and different features of readiness are highlighted, along with several potential elements that could be included in clinical education curricula. In addition to benefiting patients, a more direct consideration of readiness for treatment may also benefit providers by reducing moral distress and the health care system more broadly by improving resource allocation.

Objective: Misophonia elicits strong negative emotional, behavioral, and physiological reactions to auditory stimuli. Despite its significant impact, misophonia remains underrecognized by health care providers. There is a lack of evidence-based treatment guidelines, creating challenges for affected individuals and their families in accessing appropriate care. The goal of this study was to examine the experiences of youth with misophonia and their caregivers in navigating the health care system and seeking treatment for the condition.

Materials and methods: Twenty parent-child dyads participated in focused interviews concerning their experiences seeking treatment for misophonia. Thematic analysis was used to analyze interviews, involving 2 rounds of inductive abstractions.

Results: Several themes emerged, primarily reflecting negative experiences, including: "Minimal Awareness," "Few Knowledgeable Professionals," "Limited General Resources," "Lack of Standard Treatment," "Misdiagnosis," and "Lack of Official Misophonia Diagnosis." Participants described substantial emotional impacts from these experiences, including frequent descriptions of hopelessness, frustration, and defeat. The primary positive experience described was by families who experienced "Validation from Providers."

Conclusions: The emotional burden associated with limited access to credible resources and knowledgeable professionals highlights the need for improved support. Families who were able to connect with empathetic providers reported considerable relief. The absence of a standardized treatment prompts individuals into a prolonged trial-and-error process in search of an approach that can provide even minimal relief from their symptoms.

The Alternative DSM-5 Model for Personality Disorders (AMPD) was introduced in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders as a dimensional alternative to the traditional categorical model. Despite considerable research, systematic implementation in clinical practice has remained limited. This article reports on the implementation of the AMPD in an institution that specializes in the assessment and treatment of personality disorders to offer guidance for other teams considering the adoption of the AMPD. Implementation involved developing a multimethod assessment procedure and a training and supervision program, reformulating treatment inclusion criteria in AMPD terms, and developing communication strategies for internal and external stakeholders. Both barriers to and benefits of implementing the AMPD are discussed. Surveys conducted 2 and 4 months after implementation showed that clinicians were increasingly positive, reported growing competence, and generally favored AMPD-based assessments over the traditional assessments. These first experiences suggest that transitioning to the AMPD model is feasible and clinically meaningful.

Background and objectives: Clonidine is a commonly prescribed medication with various indications that has abuse potential. This brief report outlines a case of clonidine misuse that led to clonidine withdrawal.

Methods: A 50-year-old male with a psychiatric history of Sedative-Hypnotic-Anxiolytic Use Disorder and Opioid Use Disorder in remission presented to the emergency department with a 1-day history of disorientation, slurred speech, word-finding difficulty, and altered mental status (AMS). Differential diagnoses included alcohol, benzodiazepine, and/or other substance intoxication versus withdrawal. The patient was placed on a lorazepam taper; however, his mental status worsened with further agitation, tachypnea, fever, tachycardia, hypertension, and myoclonus.

Results: The patient was ultimately transferred to the intensive care unit, where he was placed on a dexmedetomidine infusion and steadily improved. Collateral information from the family revealed that the patient had been abusing clonidine. As the patient's mental status cleared, he too admitted to his clonidine addiction. During his admission, he was observed drinking large amounts of water and was also diagnosed with polygenic polydipsia. He was placed on fluid restriction, dexmedetomidine was eventually tapered, and he was ultimately discharged and referred to a dual diagnosis psychiatry unit for further treatment of his addiction.

Discussion and conclusions: This case demonstrates the importance of understanding the multiple etiologies of AMS, including drug intoxication and withdrawal, particularly with commonly prescribed medications. Clonidine has abuse potential, and clonidine withdrawal must be considered in the differential diagnosis of a patient with a hypertensive crisis and AMS.

This column, like the previous 2 columns in this series, shows how placebo is a control for the natural course of an illness. In the study presented in this column, the use of placebo enabled the investigators to detect that active treatment was deleterious to the patient. In the second column in the series, the use of placebo showed that adding a usually effective antibiotic for an infection did not alter the outcome because of the nature of the infection and the value of treatment as usual (TAU). The first column in the series described TAU in a double-blind randomized controlled trial (RCT). Parenthetically, that column also discussed how different TAU is in such studies versus TAU in clinical practice. Those differences likely contribute to why TAU in such trials can be quite effective and why they are frequently negative. That first paper also discussed how the Heisenberg Uncertainty Principle from physics can be applied to psychiatric clinical trials, further emphasizing the difference in care received in an RTC versus clinical practice. Thus, investigators need to take the Heisenberg Principle into account when designing their studies and readers need to consider it when assessing the results. In the studies described in the second and third columns in the series, the focus was on objective and clinically meaningful endpoints (ie, resolution of a localized infection in the second column and death in this third column) in contrast to the often subjective endpoints in many psychiatric clinical trials (eg, improvement on a rating scale of symptoms that are reported by a participant/patient). The field of psychiatry needs to aim to develop such objective and clinically meaningful endpoints for its clinical trials. Finally, all 3 columns in this series emphasize that placebo does not mean nothing but rather involves all the treatment that a patient receives during the trial, except for the investigational treatment being tested, as well as the natural history of the illness, which includes the natural fluctuation in symptoms.

As advances in critical care medicine improve survival outcomes, attention has been increasingly directed toward long-term management of patients recovering from critical illness. In 2010, the term "post-intensive care syndrome" (PICS) was proposed at a meeting of stakeholders at the Society of Critical Care Medicine's headquarters to highlight the physical, psychological, cognitive, and social impairments faced by many survivors of critical illness. PICS offers a holistic conceptualization of the long and challenging recovery process these patients may face in the months following a course of intensive care. In particular, psychiatric morbidity following critical illness is associated with worsened physical functioning, increased mortality, and lower quality of life. Thus, psychiatrists occupy a key role in the multidisciplinary management of PICS. This article provides a narrative review of the literature encompassing PICS, with a focus on post-intensive care psychiatric morbidity, to assist general psychiatrists and primary care clinicians in providing well-informed, comprehensive care to this patient population. Core aspects of psychiatric evaluation and management are reviewed, including the components of a comprehensive medical history, the use of screening instruments, pharmacologic and nonpharmacologic interventions, and the importance of a multidisciplinary, coordinated approach to care.