Primary psychiatry最新文献

Epidemiologic studies indicate that co-occurring substance use disorders and psychiatric disorders are frequently found in clinical practice. From a neurobiologic perspective, what do these two seemingly different groups of disorders have in common? Currently, several hypotheses are postulated to explain the high rates of comorbidity. Chronic alcohol and drug use may lead to neuroadaptation in the biologic systems mediating psychiatric disorders. Conversely, co-occurring psychiatric and substance use disorders (SUDs) may represent phenotypic expressions of common premorbid neurobiologic abnormalities. Similar alterations in the dopamine-mediated reward system and various neurotransmitter systems including glutamate, γ-aminobutyric acid, and serotonin are found in both SUDs and numerous psychiatric disorders. Stress and chronic distress with the resultant activation of the hypothalamic-pituitary-adrenal axis and stress system has also been implicated in the pathophysiology of both psychiatric disorders and SUDs. Better understanding the commonalities between the two groups of disorders should lead to more efficacious treatments and targeted prevention strategies.

This article reviews the literature on the acute effects of Delta 9-tetrahydrocannabinol, the primary psychoactive component of marijuana, on working memory, and the implications for schizophrenia. Working memory deficits are a hallmark feature of schizophrenia, and have been implicated as an etiologic mechanism contributing to the onset of the disorder. Regular marijuana smokers may also exhibit subtle working memory impairment relative to healthy controls, and an association between marijuana abuse and subsequent development of schizophrenia, though controversial, has been reported in the literature. The causal role that marijuana plays in working memory impairment related to schizophrenia, however, remains unclear. Thus, this article specifically considers the acute effects of marijuana on working memory performance. The ecologic relevance and clinical significance of these findings will be examined, and directions for future research will be recommended.

The association between cannabis use and the initial development of psychotic symptoms has attracted increased interest over the past decade. In particular, researchers have attempted to elucidate whether cannabis use increases the risk of psychosis among vulnerable individuals or may just represent attempts to self-medicate distressing symptoms. While a growing literature suggests that cannabis use may contribute to the development of psychotic symptoms, these findings are based primarily on retrospective assessments that have limited ability to clarify the temporal link between cannabis use and psychotic symptoms. The authors review the literature regarding the link between cannabis use and psychotic symptoms; point out the limitations associated with retrospective assessments; and discuss advantages of incorporating daily diary methods, such as Experience Sampling Method (ESM), to study cannabis use and symptoms during daily functioning in "real world" environments. The authors also discuss potential future applications of ESM in research and clinical practice that may inform the identification of individuals vulnerable to develop psychotic symptoms, as well as the development of treatments that target this population.

Rapidly changing demographics in the United States and diverse cultural beliefs impact hospice utilization and end-of-life care. Healthcare professionals and clinicians need a connecting framework to understand patients' and their family's perspectives regarding utilization of those services. This framework will assist healthcare workers in providing culturally sensitive and appropriate information to patients nearing the end of life, so that they and their loved ones can make informed decisions for optimal care during this passage of life. Considering the variables in this framework may also help facilitate communication between healthcare professionals and patients and reduce misunderstanding among the surviving family members.

Suicide is one of the leading causes of death, and suicidal ideation and attempts are a major public health problem. However, little is known about the relationship between ethnicity and suicidal behaviors.The goal of this article is to provide an update on the relationship between ethnicity and suicidal ideation and attempts. We review the rates of suicide ideation/attempts across ethnic groups in the US, and the risk factors associated with suicide attempts in each ethnic group.The results of published studies have been inconsistent. Some studies have suggested that non-Hispanic Whites have significantly higher suicide attempt risk than other ethnic groups, while two studies using national data did not find any significant relationship between race/ethnicity and suicide ideation or attempts. From the epidemiological point of view, these findings underscore the need to conduct large studies in general population samples that include enough individuals from all ethnic groups and that are large enough to detect significant effects among those groups. From the clinical point of view, mental health professionals should focus on factors that have been consistently found to be strongly associated with suicide attempts across different populations, including major depression and other psychiatric disorders, female gender, and young age.

Suicidal ideation, suicide attempts, and completed suicide appear common in individuals with body dysmorphic disorder (BDD). Available evidence indicates that approximately 80% of individuals with BDD experience lifetime suicidal ideation and 24% to 28% have attempted suicide. Although data on completed suicide are limited and preliminary, the suicide rate appears markedly high. These findings underscore the importance of recognizing and effectively treating BDD. However, BDD is underrecognized in clinical settings even though it is relatively common and often presents to psychiatrists and other mental health practitioners, dermatologists, surgeons, and other physicians. This article reviews available evidence on suicidality in BDD and discusses how to recognize and diagnose this often secret disorder. Efficacious treatments for BDD, ie, serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy, are also discussed. Although data are limited, it appears that SRIs often diminish suicidality in these patients. Additional research is greatly needed on suicidality rates, characteristics, correlates, risk factors, treatment, and prevention of suicidality in BDD.

Body dysmorphic disorder (BDD) is a relatively common psychiatric illness that often presents to mental health professionals as well as nonpsychiatric physicians. However, BDD usually goes unrecognized and undiagnosed in clinical settings. It is important to recognize and accurately diagnose BDD because this often secret illness may be debilitating. Patients with BDD typically have markedly impaired functioning, notably poor quality of life, and a high rate of suicidal ideation and suicide attempts. Thus, it is important to screen patients for BDD and avoid misdiagnosing it as another illness. Nonpsychiatric treatments (eg, dermatologic, surgical), which most patients seek and receive, appear ineffective for BDD and can be risky for physicians to provide. This article provides a clinically focused overview of BDD, including its symptoms, morbidity, case examples, nonpsychiatric (ie, cosmetic) treatment, diagnostic "do's" and "don'ts," and suggestions for how to persuade patients to accept appropriate psychiatric care.

Schizophrenia is a chronic, debilitating psychiatric disorder that affects 0.2-2% of the population worldwide. Often striking without warning in the late teens or early twenties, its symptoms include auditory and visual hallucinations, psychotic outbreaks, bizarre or disordered thinking, depression and social withdrawal. To combat the disease, new antipsychotic drugs are emerging; these atypical neuroleptics target dopamine and serotonin pathways in the brain, offering increased therapeutic efficacy with fewer side effects. Despite their moderate success in controlling some patients' symptoms, little is known about the causes of schizophrenia, and what triggers the disease. Its peculiar age of onset raises key questions: What physical changes occur in the brain as a patient develops schizophrenia? Do these deficits spread in the brain, and can they be opposed? How do they relate to psychotic symptoms? As risk for the disease is genetically transmitted, do a patient's relatives exhibit similar brain changes? Recent advances in brain imaging and genetics provide exciting insight on these questions. Neuroimaging can now chart the emergence and progression of deficits in the brain, providing an exceptionally sharp scalpel to dissect the effects of genetic risk, environmental triggers, and susceptibility genes. Visualizing the dynamics of the disease, these techniques also offer new strategies to evaluate drugs that combat the unrelenting symptoms of schizophrenia.