1 - Introduction - A Perspective on Contemporary Psychiatry as a Background to Psychopharmacology

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

Copyright 2003 Lippincott Williams & Wilkins

> Table of Contents > 1 - Introduction: A Perspective on Contemporary Psychiatry as a Background to Psychopharmacology

1

Introduction: A Perspective on Contemporary Psychiatry as a Background to Psychopharmacology

Richard I. Shader

Psychiatry primarily focuses on the capacity for integration of mind, brain, behavior, experience, intellect, and emotion as they relate to human growth and development and the prevention and treatment of mental disorders. An expanding body of clinical experience and research has clarified the idea that, to treat patients with psychiatric disorders, frequently an understanding not only of the patient's symptoms and complaints but also of the developmental, cultural, and present contexts in which symptoms develop, the meanings these symptoms have to the patient, the patient's relevant past experiences, and their available support systems is necessary.

The older concepts of organic and functional have polarized thinking about mental diseases (disorders) in detrimental ways and have little, if any, current value. Contemporary psychiatry places a heavy emphasis on an integrative model that combines a vulnerability stress paradigm with a biopsychosocial perspective, including attention to neurobiologic substrates, subjective experiences, and sociocultural factors, and that assumes the following important elements:

  • Genetic predispositions underlie most, if not all, major psychiatric disorders;

  • Disturbances of the functions or faculties of the mind and brain are present in all major psychiatric disorders (e.g., cognition is impaired in dementias, affective control is impaired in bipolar disorder);

  • Protective genetic factors, mitigating interpersonal relationships, and phenotypic or temperamental variations (e.g., shyness versus extroversion, stimulus-seeking or harm avoidance traits, fantasy proneness, eidetic imagery) shape patients' presentations and experiences;

  • Considerable variation exists in the strengths and weaknesses of adaptive capacities arising from earlier experiences, especially, but not limited to, those in childhood;

  • Individualized stressful experiences often may trigger or may expose episodes of dysfunction or underlying pathology.

Notwithstanding these considerations, the actual pathophysiologic underpinnings of most psychiatric disorders typically remain unknown. Unfortunately, these gaps in knowledge are sometimes used to bolster the arguments of those who view psychiatric disorders as arising merely from a lack of moral fiber or willpower or simply as a result of bad parenting.

Although some controversy exists about the validity and importance of psychodynamic and psychologic explanatory concepts in understanding and treating certain major mental disorders, some descriptive concepts are useful for comprehensive approaches to these disorders. A full explanation of all relevant terminology is beyond the scope of this chapter, but a brief review of selected conceptually important terms may help clinicians in their efforts on behalf of their patients.

I. Selected Explanatory Concepts

The existence of unconscious mental activity or storage is a basic tenet of a psychologic perspective on mental functioning feelings, ideas, or memories of experiences not within conscious awareness or accessible by introspection exist in the human mind.

A. Repression

Repression is a process by which some feelings and memories may be actively kept from one's awareness. This is a type of selective, defensive, or self-protective not remembering. Repression conveys more than merely not remembering: usual strategies that promote recall are not effective in

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retrieving the repressed material, which is often related to conflictual, traumatic, embarrassing, or affect-laden experiences. An example of repression would be a failure to recognize an earlier experience of physical or sexual abuse that nevertheless unconsciously influences adult behavior and relationships (e.g., as inhibitions in normal assertiveness or in the experience of sexual pleasure). The idea that repression is self-protective bridges to other important terms and concepts.

B. Ego

The terms self and ego are often used interchangeably to refer to the awareness and sense of self or selfness, including a continuity of one's identity over time, a coherence of one's values and aims, a basis for moral integrity, and an experience of boundaries (self versus non-self or the outside world). Self is actually a broader concept than ego. Ego commonly implies the executive functions of the self that have to do with adaptation and conflict resolution. To survive and function in what the self experiences as a complex and sometimes hostile or overly stressful world, the ego uses protective strategies (sometimes called defense mechanisms1), often unconsciously, to reduce or to contain feelings or experiences that would otherwise be overwhelming (e.g., too much uncertainty or ambiguity, too little control, or betrayal by trusted persons). This concept is reminiscent of T.S. Eliot's statement, Humankind cannot bear very much reality. Animals, for instance, instinctively protect their young and their own bodies. People, without consciously choosing to do so, add to these basic behaviors a protection of the sense of intactness of self. The importance of this postulate is that some of the psychopathology seen in persons with mental disorders or reactions to physical illness may represent unconsciously or instinctively motivated behaviors that serve to protect the individual from knowing that his or her mind is malfunctioning an idea that might be too disorganizing for a putatively needed sense of intactness of the self.

Supportive psychotherapy generally focuses on examining patients' coping styles to promote behavioral change; it strengthens those that are productive for the patient at the present time. Efforts may also be made to modify those that are maladaptive. Validation, compassion, acceptance, and trust are important elements.

C. Denial, Projection, Rationalization, Displacement, Transference, and Regression

These are a few of several postulated reality-distorting but self-guarding coping styles or defense mechanisms. Each coping style influences a patient's behavior and ability to provide an accurate history. Coping styles are potentially important in all areas of medicine but particularly in psychiatry. In the absence of clinical tests or a definitive confirmation of a psychiatric diagnosis, observing the patient, obtaining cooperation in the mental status evaluation, noting a pattern of symptoms and complaints, continuing interaction with the physician, and knowing the course and history support making a reliable and accurate diagnosis. An essentially normal physical examination combined with normal-range laboratory tests does not establish a psychiatric diagnosis, except to rule out an etiology secondary to a primary pathology outside of the brain (e.g., depression and mental slowing secondary to hypothyroidism). One should note that, although cultural and other experiential factors may influence a patient's presentation, most major psychiatric disorders continue to be remarkably similar to their earliest descriptions in religious and medical texts, as well as across disparate cultures.

  • Denial, which is closely related to and is often confused with repression, is a coping style in which the affected person experiences a minimal awareness of appropriate feelings or information that would reasonably and ordinarily be expected to be felt or known; overt behavior, however, may be incongruent (e.g., while talking about being refused

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    life insurance, a patient tells the physician that he understands and that he is not angry, yet the doctor observes the patient's tense jaw and tight grip on the chair). Denial usually is an unconscious mechanism or process, the function of which is to circumvent distress or anxiety. In denial, one reduces the impact of serious matters through self-deception. Bad news (and occasionally good news) may then be experienced as irrelevant, nonexistent, exaggerated, or inconsequential. Denial may hide feelings, the impact of events, or the events per se from others or from oneself. As Johnny Mercer's popular admonition in song says, You've got to accentuate the positive, eliminate the negative, latch on to the affirmative, don't mess with Mister In Between, denial may, in some instances, be health promoting. For example, in a patient with a recently diagnosed myocardial infarction, denial may circumvent hopelessness and a lack of will to live and may thereby contribute to recovery. When appropriate, a treating clinician may choose not to challenge a patient's denial. In contrast, denial could undermine recovery in a chronically ill cardiac patient who, as a result of denial, will not make the needed health-promoting changes in lifestyle and habits. Denial can also lead to avoiding needed help or to delays in seeking diagnosis or treatment. This can be extremely dangerous in some disorders (e.g., breast carcinoma). Denial is particularly frequent among adolescents and young adults who appear to ignore the dangers of many of their behaviors (e.g., smoking, unprotected sexual activity, disregard for speed limits when driving), although counterphobic elements may also be present for some in many of these same behaviors. Denial may be prominent in addictions (e.g., to alcohol, cigarettes) and substance abuse. Addicted persons often deny both the fact and the seriousness of their addiction. The frequent denial by spouses, friends, and employers that a drug abuse problem exists (see Chapters 9, 10, and 11) is a remarkable revelation of the same kind of avoidance.

  • Projection is the externalization onto another person of one's own feelings, thoughts, or motives that are, for some reason, not acceptable to the self or ego at the time at which they are experienced (perhaps because they are related to shame or guilt), thereby allowing the person to feel less distressed or possibly more justified. For example, a patient who is annoyed at waiting to see her physician for over an hour tells the nurse that she is sure that the doctor who unbeknownst to the patient is dealing with an emergency must be angry with her. Another example is the patient who should feel guilty about his neglect of his wife but who is unaware and unaccepting of his guilt feelings; instead he blames the hospital and his doctor for inadequate care.

  • Rationalization is the creation of a specious justification or of a false explanation for one's own or another's behavior to make the behavior seem more palatable (e.g., the same waiting patient from before assumes the doctor must be angry with her because she has not been following her diet).

  • Displacement may also be linked to projection. In displacement, feelings are shifted from the person who evokes them onto another, perhaps safer, person, object, or institution. For example, a patient who is unaware of her anger toward her physician instead is inappropriately caustic toward her husband later that day. Another example of displacement is the patient who shifts his or her concerns and fears about being ill to an inappropriate preoccupation with the inadequacies of his or her room or care.

  • Transference refers to the unconscious attribution of feelings that were originally connected to someone or something in the patient's past to a current person, institution, or even a medication in one's life (e.g., a patient may be immediately trusting, dependent, or obedient with his or her physician because he or she unconsciously sees the physician as a

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    positively viewed parental figure understanding, knowledgeable, strong, and compassionate). Transference is a powerful determinant of a patient's expectations, both positive and negative, and it may contribute to compliance or noncompliance with the doctor's recommendations (see Chapter 13).

    Transference may sometimes underlie perceptions of cultural or racial bias that, in turn, may interfere with access to treatment or its effectiveness. Transference brings the past into the present, typically not for defensive purposes. One must also remember that the reciprocal concept, countertransference, may also influence patient care (e.g., the physician perceives the patient in an altered or distorted way because of past relationships, including prior patients, in his or her own life).

  • Regression is the last reality-distorting coping style to be reviewed. Over a lifetime, new skills and mechanisms evolve to help one cope with the external world. In health, this development forms a continuum of increasingly effective styles of coping and adaptation, as survival and integration into one's family and community require growth and change. Regression represents a return, at times of extreme stress and upheaval, to earlier ways of coping. Patients typically become regressed when they feel overwhelmed or anxious about an illness or life crisis; their regressed state may color both their presentations and their abilities to participate in their own care. They behave less autonomously, and they become more dependent, passive, and helpless. Regression and helplessness may, in turn, make them feel considerable distress and anxiety. Regressed patients may also be very distrustful. Extremely regressed patients may be so childlike that they take no responsibility for getting better. Their transference expectations cause them to view physicians and other helping persons as complete and total caretakers, and they feel no need to be self-reliant. Many clinicians have difficulty tolerating regression in their patients; the recognition by the clinician and other caregivers that the regressed behavior is neither conscious nor willful may help to improve tolerance. Regression may be normative in childhood as developmental changes occur.

    Some forms of expressive psychotherapy make use of the concept of regression. Through the facilitation of regression, the hope is that patients may be able to work through earlier conflicts, to rebuild their self-image, and to mature.

D. Cognitive-Behavioral Concepts

In addition to the selected psychologic concepts (e.g., regression, denial, transference) described above, an awareness of some of the principal constructs underlying certain behavioral treatment approaches might be useful for the concerned clinician. Specific approaches and more details are enumerated in later chapters of this manual.

  • Exposure. This is a concept central to all approaches derived from avoidance and stimulus response theories. Exposure assumes that repeated systematic contact with a feared idea, image, or object in a safe and supportive environment will lead to a reduction in fear or anxiety and avoidance. The reduction in anxiety also promotes a sense of mastery and confidence. Exposure works best when the stimulus is, in reality, a nondangerous or a neutral one (conditioned stimulus) that has become associated with or is linked unconsciously to a threatening one (unconditioned stimulus) by the patient. The resulting decrement in fear or anxiety is referred to as extinction. In this context, anxiety is distinguished from fear by defining anxiety as a dysphoric response that is out of proportion to the danger cue (see Chapter 14).

  • Systematic desensitization. Repeated gradual exposure using a progressive series of imagined fear stimuli when coupled with relaxation strategies is sometimes referred to as systematic desensitization. Many effective uses of exposure are carried out in vivo (i.e., an actual

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    graded confrontation of the feared or anxiety-evoking stimulus that has led to avoidance). Obviously, this type of therapy is time-consuming and demanding for both the therapist and patient.

  • Flooding. This term is used when the exposure is controlled and safe but, at the same time, intense and inescapable. Flooding is infrequently used because little evidence exists to suggest that this approach is more effective than the graded in vivo exposure.

E. Treatments Based on Social Learning Theory

These are derived from notions of faulty modeling at formative life stages that can be corrected by role playing or imitation. Social skills training for patients with schizophrenia is an effective example of this approach (see Chapter 20).

F. Cognitive-Behavioral Therapies

These therapies promote a questioning of or confrontation with one's assumptions, beliefs, or doctrines with the suggestion that they may be false or distorted (see Chapters 6 and 8). Such false or distorted assumptions may significantly impair an individual's self-esteem or trust in others. Examining and challenging negative assumptions or even grandiose or self-centered ones may facilitate better coping and may promote a sense of mastery and self-efficacy. Terms such as cognitive restructuring are based on this concept.

G. Operant Conditioning Theories

Some treatments are rooted in operant approaches derived from the notion that behavior can be modified through positive reinforcements (rewards) or punishments. An important element in this approach is the skill of the therapist in selecting effective contingencies. Negative reinforcement is a confusing term that is currently used by many practicing clinicians to denote the use of an aversive experience before an undesired behavior occurs to block it (e.g., administering disulfiram to alcohol-dependent patients) rather than after the behavior to reduce or to suppress it (i.e., punishment).

II. The Clinician Patient Relationship

A comprehensive understanding of a patient's illness and needs coupled with the patient's cooperation and adherence to the treatment plan should promote positive therapeutic outcomes. Cooperation is facilitated by a strong clinician patient relationship. The strength of this relationship is enabled by the provision of useful information and the development of trust. The evolution of trust is encouraged when the clinician is successful at therapeutic listening. The patient must believe that the treating clinician has a genuine interest in the patient's well-being, inner experiences, and assumptions about life and the world. Trust and the provision of useful clarifications and information are among the core components of a therapeutic or working alliance.

An element of the bond of trust created between patient and clinician is rooted in the concept of confidentiality. Although the legal aspects may vary somewhat among jurisdictions, the core of confidentiality is the patient's right to control access to the information he or she provides to clinicians. Third-party health insurance programs, managed care plans, computerized pharmacy records, and Internet-accessible databases are among the many factors that have eroded the sense of personal privacy that many patients have customarily felt when sharing personal or painful material or genetic testing results with their caregivers. Treating clinicians must understand the applicable privacy statutes in their states, and they should be apprised of current federal guidelines and regulations. Early in treatment, establishing with patients an understanding of the limits of their privacy protection and working with them and their clinicians to find ways to share important experiences and facts are essential.

When treating children and youth (see Chapters 7, 21, and 22), multiple alliances may be needed to work with the child, the family, the school, and other involved parties and institutions. Similar issues may be involved when treating older patients who are no longer independent. Achieving an optimal therapeutic

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collaboration is another goal that is not easily met by current patterns of health care delivery, especially in the setting of managed care.

Managed care emphasizes time management and cost containment, which are often accomplished by following treatment protocols or by parsing out elements of the treatment plan to different health care personnel (e.g., prescribing clinicians, case managers, psychotherapists); inherent in this arrangement may be difficulties in maintaining confidentiality. Treatment protocols and guidelines can ensure that consideration is given to systematic and comprehensive treatment planning or diagnostic assessment. However, for some patients, protocols (with their emphasis on the modal patient) and the parsing out of their components can be antithetical to an evolving treatment alliance, to continuity of care, or to their unique features and needs.

Alliance maintenance is also essential for optimal patient care. Clinicians need to ensure that a way is always available so that patients can reach them or a previously designated surrogate during emergencies or times of heightened distress. Answering machines do not substitute for contact with a person. E-mail contact is increasing in acceptability among some people, but this route also has obvious limitations. Anticipating patients' needs and providing them with workable options in advance is important; knowing that a clinician can be reached and is willing to be reached may be sufficiently reassuring to obviate some patients' urgencies and emergencies.

Therapy protocols and manuals are an additional element that can affect the clinician patient relationship. The recent increase in their use has had important benefits for psychotherapy research. Following outlined procedures enables standardization and the assessment of adherence by the clinician to the type of therapeutic intervention being provided. Unfortunately, although some features of this trend may be positive, a potential downside also exists; any standardization of treatment has the potential to downplay the uniqueness and unpredictability of each therapeutic encounter.

In any treatment relationship, interplay between the patient's appropriate need for autonomy and some amount of paternalism inherent in the clinician's care provider and healer role is almost always present. Although empowering patients has obvious merits, effective clinicians are always more than mere technologists or providers of information and choices. Few would dispute the value of the healing touch and a caring attitude. Emanuel and Emanuel (1992) described and advocated the so-called deliberative model of the clinician patient relationship, a view that integrates the provision of information with clinicians' teaching, technical, and caring healer skills and promotes the self-development of patients with regard to their use of medical care. This perspective, although persuasive and appealing, can be compromised when clinicians ignore the ever-present impacts of transference and countertransference. For many psychiatric patients, careful attention must be paid to their distortions of reality, the acuteness of their distress and turmoil, and any other factors unique to their illness and circumstances.

III. Genetic Factors

After decades of research, little support exists for the notion that specific cytogenetic abnormalities are the major causal factors for the psychiatric disorders covered in subsequent chapters of this manual. Many psychiatric patients appear to be at increased risk for having more than one comorbid disorder, probably because of shared risk factors. That genes regulate a spectrum of behaviors also seems likely; practically speaking, this means that the presence of a psychiatric disorder in one member of the family may provide clues into the nature and appropriate treatment of the problems of another family member, even when their manifest problems are not identical. A multifactorial causality model has both heuristic and pragmatic value for the understanding of psychiatric disorders. It acknowledges the role of gene-related dysregulation of behavior, but it does so in the context of contributing environmental circumstances that are developmental, historical, and current, and it points the way to the beneficial application of both psychopharmacologic and psychotherapeutic treatment interventions.

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The bottom line of the perspective is that genetic liabilities combine with environmental risk factors to create a vulnerability or predisposition to a given disorder or disorders. This is the central theme of the vulnerability stress and biopsychosocial models of psychiatric disorders.

IV. Additional Comments and Caveats

Epidemiologic data suggest that, in any 6-month period, between one in six and one in five adults in the United States will manifest some form of clinically significant and definable mental disturbance. Anxiety and depression are among the most common complaints mentioned by patients seeking medical attention. The annual economic burden associated with the diagnosis and treatment of mental disorders and substance abuse problems is estimated at over a quarter of a trillion dollars. Therefore, for clinicians, regardless of their specialty, to be able to recognize major psychiatric disorders and to understand basic elements of treatment is important.

Not all mental disorders and substance abuse problems reveal themselves through obvious or florid symptoms or bizarre behavior. Mental illness or a substance abuse disorder should be suspected, for example, whenever patients complain of or are observed to be having difficulty in (a) performing simple or sequential tasks or sticking to a reasonable pace of work, (b) following or understanding instructions, (c) planning their day or following through with responsibilities, (d) getting along with other people, or (e) asking others for guidance or assistance when needed.

Variations in phenotypic expression and cultural, experiential, and developmental factors contribute in some measure to the uniqueness of each human being. This uniqueness in turn contributes to difficulties in classifying forms of mental illness. Whenever a disorder does not have pathognomonic features or when a patient does not present the full expression of the disorder, individual variation may make the diagnosis less than straightforward. Patients, especially children, often suffer from more than one disorder at a time or in sequence. In an effort to establish descriptive and phenomenologic diagnostic criteria, the American Psychiatric Association issued the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. Various transmutations have culminated in the current edition, the DSM, 4th edition, 2000 (DSM-IV-2000). Readers familiar with the development of DSM-III through DSM-IV-text revision (DSM-IV-TR) iterations will recognize that many of the descriptions of diagnostic entities contained in the subsequent chapters of this manual are similar to some of the criteria sets contained in the DSM-IV-TR but that these are not always listed in the familiar tabular format. This choice is intentional this manual is not intended to serve as a diagnostic handbook. Moreover, DSM-IV-TR and the widely used International Statistical Classification of Diseases and Related Health Problems, tenth edition, (ICD-10) do not always use identical criteria. Therefore, emphasizing a perspective about psychiatric illness that will probably remain viable and practical even with changing and variable diagnostic concepts and criteria seems sensible.

This manual cannot substitute for a textbook or reference book on psychiatry. An attempt has been made instead to highlight specific disorders, treatments, and management strategies that are likely to be seen by a broad spectrum of clinicians in various practice settings and to illustrate some of the challenges facing those who work with psychiatric patients. Problems of the mind disquiet not only the affected persons but also those who care for them. For example, clinicians all too often fail to recognize depression, anxiety, and stress-related symptoms in their patients not only because they may need to deny these states in themselves but also because they are confused about what is pathologic and amenable to treatment. Progress in the neurosciences and in related and complementary disciplines continues to bring further clarity to the understanding both of self-protective mechanisms and of mental illness per se. To foster these efforts, the community of clinicians and others who are interested in psychiatric disorders and patients must do all that they can to reduce, and ultimately to remove, the stigma associated with having a psychiatric illness or a family

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member who suffers from a mental disorder. This is even more important than in many other areas of medicine, because the mentally ill generally cannot be advocates for themselves because of their symptoms, disabilities, and self-protective distortions. Fortunately, many advocacy groups that add and provide a much needed voice for the support of vulnerable patients and their families now exist.

ADDITIONAL READING

Alexander FM. The use of the self. New York: EP Dutton, 1932.

Bibring E. The development and problems of the theory of the instincts. Int J Psychoan 1941;22:102 131.

Department of Health and Human Services. Standards for the privacy of individually identifiable health information: final rules. Federal Register 2000;65:82461 82510. Available at: http://www.hhs.gov/ocr/regtext.html.

Dobson KS. Handbook of cognitive-behavioral therapies, 2nd ed. New York: Guilford Press, 2000.

Ellenberger HF. The discovery of the unconscious: the history and evolution of dynamic psychiatry. New York: Basic Books, 1970.

Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221 2226.

Fellous JM. Neuromodulatory basis of emotion. The Scientist 1999;5:283 294.

Freud A. The ego and the mechanisms of defense. New York: International University Press, 1946.

Hartmann H. Ego psychology and the problem of adaptation. New York: International University Press, 1958.

Lazarus RS. The costs and benefits of denial. In: Dohrenwend BS, Dohrenwend BP, eds. Stressful life events and their contexts. New York: Prodist, 1981:131 156.

Nestler EJ, Hyman SE, Malenka RC. Molecular neuropharmacology: a foundation for clinical neuroscience. New York: McGraw-Hill, 2001.

White RW. Ego and reality in psychoanalytic theory. New York: International University Press, 1963.

1The author prefers the term coping style.



Manual of Psychiatric Therapeutics Paperback
Manual of Psychiatric Therapeutics: Practical Psychopharmacology and Psychiatry (Little, Browns Paperback Book Series)
ISBN: 0316782203
EAN: 2147483647
Year: 2002
Pages: 37

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