Focus (American Psychiatric Publishing)最新文献

Previous studies of physical assaults in hospitals focused primarily on inpatient psychiatric units, leaving unanswered questions about the extent to which findings generalize to psychiatric emergency rooms. Assault incident reports and electronic medical records from one psychiatric emergency room and two inpatient psychiatric units were reviewed. Qualitative methods were used to identify precipitants. Quantitative methods were used to describe characteristics of each event, as well as demographic and symptom profiles associated with incidents. During the five-year study period, there were 60 incidents in the psychiatric emergency room and 124 incidents on the inpatient units. Precipitating factors, incident severity, means of assault, and interventions were similar in both settings. Among patients in the psychiatric emergency room, a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder with manic symptoms (Adjusted Odds Ratio (AOR) 27.86) and presenting with thoughts to harm others (AOR 10.94) were associated with an increased likelihood of having an assault incident report. Similarities between assaults in the psychiatric emergency room and inpatient psychiatric units suggest that the broader literature from inpatient psychiatry can be generalized to the psychiatric emergency room setting, although some differences exist. Reprinted from J Am Acad Psychiatry Law 2020; 48:484-495, with permission from The American Academy of Psychiatry and the Law. Copyright © 2020.

The evaluation of a patient's competency to consent to treatment, regardless of the test of competency used, can be substantially affected by a number of clinical factors. The authors point out that, in assessing competency, the clinician must consider 1) psychodynamic elements of the patient's personality, 2) the accuracy of the historical information conveyed by the patient, 3) the accuracy and completeness of the information disclosed to the patient, 4) the stability of the patient's mental status over time, and 5) the effect of the setting in which consent is obtained. Inattention to these factors can lead to errors in assessment of competency that can have important implications for patient care. Reprinted from Am J Psychiatry 1981; 138:1462-1467, with permission from American Psychiatric Association Publishing. Copyright © 1981.

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

This review summarizes current knowledge about narcissistic personality disorder (NPD). Each section brings the reader up to date on advances in our knowledge during the last decade. In terms of NPD diagnosis, this review describes the addition of the dimensional model to the categorical model. The accumulating knowledge has led to the description of grandiose and vulnerable narcissism as well as their complex interrelationship. Strong support exists for co-occurrence of these presentations among people with high levels of grandiose narcissism. Studies have identified mechanisms, in domains such as self-esteem dysregulation, emotion dysregulation, cognitive style, interpersonal relations, and empathy, and possible developmental and temperamental antecedents of the disorder. Thus, it appears that NPD has a multifactorial etiology and pathogenesis, with numerous mechanisms associated with each area of dysfunction. Longitudinal studies support the view that these patients can improve, but such improvement is gradual and slow. Several treatments have been developed for the disorder, and a majority share commonalities, including clear goals, attention to treatment frame, attention to relationships and self-esteem, alliance building, and monitoring of countertransference.

Standard psychiatric risk management challenges are routinely amplified in the treatment of patients with primary or co-occurring borderline personality disorder diagnosis. Most psychiatrists receive limited guidance during training or as part of continuing medical education about specific risk management concerns in work with this patient population; nevertheless, these concerns can occupy a disproportionate amount of time and energy in clinical practice. The goal of this article is to review the frequently observed risk management quandaries encountered in work with this patient population. The more familiar risk management dilemmas related to management of suicidality, potential boundary violations, and patient abandonment, are considered. In addition, salient contemporary trends in prescribing, hospitalization, training, diagnostic classification, models of psychotherapeutic treatment, and use of emerging technologies in provision of care, are explored in terms of their impact on risk management.

Transient stress-related paranoia is the descriptive definition of psychotic phenomena associated with borderline personality disorder. Although psychotic symptoms usually do not qualify patients for a separate diagnosis in the psychotic spectrum, statistical probabilities predict the co-occurrence of cases with comorbid borderline personality disorder and major psychotic disorder. This article presents three perspectives on a complex case of borderline personality disorder and psychotic disorder: one from a medication prescribing psychiatrist who is a transference-focused psychotherapist responsible for care, one from the anonymous patient, and one from a specialist in psychotic disorder. A discussion of clinical implications concludes this multidimensional presentation of borderline personality disorder and psychosis.

This 21st-Century Psychiatrist column reflects the authors' perceptions of the importance of addressing patient-centered care through mindful listening and mentalizing in psychiatry. The authors maintain that adopting a mentalizing stance is a promising approach for clinicians with diverse backgrounds to humanize clinical practice, especially in today's dynamic high-speed, high-paced, and high-technology environment. Mindful listening and mentalizing are particularly consequential for the field of psychiatry since the COVID-19 pandemic prompted an abrupt transition from in-person to virtual platforms for education and clinical care.

Obsessive-compulsive personality disorder (OCPD) is a chronic condition that involves a maladaptive pattern of excessive perfectionism, preoccupation with orderliness and details, and the need for control over one's environment. It is one of the most common personality disorders in the general population, with an estimated prevalence ranging from 1.9% to 7.8%. Despite the fact that patients with OCPD often present for treatment, there is little empirical research on treatments for OCPD, and there is no definitive empirically supported treatment for the condition. This review provides an overview of OCPD, its core features, its common presentation style types, and its impact on functioning. We review the limited treatment research to date and focus on cognitive-behavioral approaches targeting core aspects of OCPD that directly affect functioning in these patients, emphasizing take-home points for clinicians. We also address questions and controversies related to OCPD and its treatment.