Focus (American Psychiatric Publishing)最新文献

Awareness of potential aggression and violence is crucial when treating patients experiencing mental health crises in psychiatric emergency and inpatient settings. To provide a practical overview for health care workers in acute care psychiatry, the authors summarize relevant literature and clinical considerations on this important topic. Clinical contexts of violence in these settings, possible impact on patients and staff, and approaches to mitigating risk are reviewed. Considerations for early identification of at-risk patients and situations, and nonpharmacological and pharmacological interventions, are highlighted. The authors conclude with key points and future scholarly and practical directions that may further assist those entrusted with providing psychiatric care in these situations. Although working in these often high-paced, high-pressured settings can be challenging, effective violence-management strategies and tools can help staff optimize the focus on patient care while maintaining safety, their own well-being, and overall workplace satisfaction.

The treatment of severe mental illness has undergone a paradigm shift over the last fifty years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition. The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency department's (ED's) that are not designed for their needs. Increasingly, many of those individuals end up waiting in ED's for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent in ED's that it has been given a name: "boarding". This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and system-wide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic. Reprinted with permission from American Psychiatric Association. Copyright © 2019.

Introduction: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications.

Methods: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED.

Results: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use.

Conclusion: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.

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.

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.

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.

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.