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Suicide remains all too common in the United States. As the ninth leading cause of death – responsible for 30,000 deaths annually – it is also one of the more preventable causes of deathIncreasingly, mental health clinicians must care for suicidal patients within managed care systems. Managed care's cost-driven focus on rapid assessment and triage, narrowly restrictive hospital admission criteria, and abbreviated inpatient stays have resulted in poorer clinical care and increased opportunities both for adverse outcomes such as suicide and for clinician liability.Bringing together a unique mix of clinicians, authorities, and administrators from private practice and managed care, Treatment of Suicidal Patients in Managed Care offers practical guidance on how to improve care and reduce risk for suicidal patients. Contributors explore a wide range of topics: Hospitalization – Emphasizes the increased importance of the initial assessment when managed care systems shorten or deny hospitalization for suicidal patients and of knowing whom to call within the managed care system. Includes alternative programs from acute residential care to cognitive-behavioral strategies and dialectical behavior therapy for the suicidal patient in crisis Suicide risk among adolescents and the elderly – For adolescents, emphasizes the value of multiple levels of care when admissions are too short and too often followed by distressing and costly readmissions. For the elderly, offers preventive interventions for primary care physicians who are uncomfortable discussing depression and suicidal ideation and intention with their elderly patients Suicide and substance abuse – Details the role of case managers in providing continuity of care in a disorder known to be chronic and relapsing Pharmacotherapy of depression and suicidality – Discusses the effects of managed care and raises questions about the expertise of the prescriber, especially relevant now that more primary care physicians are treating patients with uncomplicated unipolar depression Risk management issues – To counter the perception that managed care companies profit from withholding care, emphasizes the crucial importance today of documenting the reasons for treatment decisions Helping those affected by the aftermath of a suicide – A step-by-step process: 1) anticipating a suicide, 2) announcing or sharing the news of a suicide, 3) assessing those affected by a suicide, and 4) seeing what can be learned from reviewing the patient's treatment This clinical guide will aid understanding of clinical, administrative, and risk management issues relevant to the care of suicidal patients. Psychiatrists, psychologists, nurse clinical specialists, social workers, administrators, and primary care physicians will also rely on it as they cope with the mounting pressures of managed care while maintaining the quality of their care for these vulnerable and patients.
The Early Stages of Schizophrenia
In sharp contrast to the prevailing belief during the past century that schizophrenia inevitably results in a progressive deteriorating clinical course, research since the early 1980s shows that early intervention can significantly improve the long-term outcome of this complex illness. With very early treatment, many affected individuals can achieve an excellent recovery.This research has set off an explosion of interest in – and optimism about – early intervention in what was once thought to be an intractable illness. The work of 19 top experts in the field of schizophrenia research is available in this single, powerful volume that introduces the concept of early intervention and describes the clinical approaches most likely to facilitate the fullest degree of recovery. Contributors review the clinical and epidemiological evidence that supports the importance of comprehensive and optimal treatment during the early stages of schizophrenia – treatment that must encompass emotional, family, and vocational as well as pharmacological needs of affected individuals. This rich overview is organized into three major parts: Early Intervention, Epidemiology, and Natural History of Schizophrenia, which presents an overview of important concepts in early intervention and reviews our current understanding of the outcome from a first episode of schizophrenia, including which features predict the onset of first-episode psychosis Management of the Early Stages of Schizophrenia, which reviews the critical management issues in providing specialized and optimal care to this complex patient group and their families, including meeting the patient's emotional needs Neurobiological Investigations of the Early Stages of Schizophrenia, which describes important specialized topics that contribute to our understanding of the first episode of schizophrenia, including schizophrenia in childhood and adolescence and cognitive dysfunction in the early stages of schizophrenia This ground-breaking volume provides reason for new optimism about the treatment and outcome of schizophrenia. With its dramatically different perspective on the potential long-term outcome of a still-baffling illness, this volume is a must-read for mental health practitioners and educators, psychiatry residents, and family members of affected individuals.
Treating Trauma Survivors With PTSD
In recent years, considerable research, as well as clinical guidelines based on study findings, has been published on the treatment of posttraumatic stress disorder (PTSD). A gap remains, however, between the controlled environments and protocols used in intervention research and the more complex and often imperfect settings and situations that clinicians must navigate in daily practice. Moreover, clinicians routinely see patients whose comorbid substance abuse, self-destructive behavior, or medical illness would likely exclude them from research studies. In short, although the extensive literature is certainly helpful in articulating the various treatment modalities available to clinicians, the strength of the evidence for the efficacy of the treatments, and the recommendations and personal preferences of experts, the literature does not address the real-life dilemmas that clinicians face in attempting to treat trauma survivors.What is needed is a way to bridge the gap between research and practice – to «translate» study findings into everyday clinical realities. Treating Trauma Survivors With PTSD answers that need. Its authors, experienced researchers and clinicians who are at the forefront of conceptual discourse on trauma and PTSD, are uniquely qualified to offer guidance on these issues. Among the specific topics covered are the following: Diagnosis and assessment of and treatment planning for trauma survivors with PTSD, including clinical presentations related to trauma exposure and PTSD and the implications of comorbid symptoms and disorders Treatment matching in clinical practice – how treatment outcome findings can be used to develop profiles for predicting which patients are most likely to respond to which treatments Medications useful in the treatment of PTSD and the strength of the empirical evidence for their efficacy Trauma in children and the efficacy of various treatments, including a discussion of how treatment for children differs from that for adults Assessment and treatment of multiply traumatized patients – those with both recent trauma and a history of childhood trauma or abuse Treatment of trauma survivors in the acute aftermath of traumatic events, including a review of some of the exciting developments in the field regarding risk factors (e.g., normal vs. pathological coping responses) that influence which individuals are most likely to develop PTSD after such events. These topics have never been more relevant than now, in the wake of the attacks that shook our country on September 11, 2001. It is the authors' hope that by reading this book, mental health practitioners will gain more confidence in applying the specialized techniques described in empirical studies to their own practices and clinical realities.
Infant and Toddler Mental Health
Countless studies have demonstrated the power of early intervention to permanently alter the course of a child's life. Yet – heightened by the past decade's research breakthroughs in genetics – the nature vs. nurture controversy rages on.This volume dispels some of the persistent myths surrounding this controversy. Unlike largely theoretical texts that describe infant behavioral and emotional difficulties and other psychosocial challenges affecting young children, this eminently practical guide illustrates what to do in numerous clinical situations with actual patients. Written by clinicians who work with infants and children and their families every day, this reality-based approach addresses the most common and important problems in infant psychopathology (e.g., trauma, sleep, feeding, excessive crying, attachment disruptions), covering models of intervention from pregnancy through infancy, attachment issues, and transgenerational themes. Here, you'll find topics rarely addressed elsewhere: The theoretical and clinical implications of trauma during early childhood and its effects on emotional regulation, cognition, and attachment, including potential disruptions of attachment – a topic widely overlooked in the life of young children, perhaps because of the distress it produces in adults to think that infants can be subject to violence, witness major traumatic events, and experience consequences from such events Techniques, such as multimodal parent-infant psychotherapy, for working effectively with families – once considered «unreachable» – who are under severe stress and have endured multiple disruptions, disappointments, and marginalization A timely discussion of a rarely addressed problem on the importance of early intervention and the effects of day care for infants, from the point of view of the infant exposed to multiple caretakers, addressing the very difficult questions of the effects on infants of changes in caretakers How young children use their bodies and its functions to manifest their difficulties, focusing on sleeping, crying, and eating with practical suggestions that can be widely applied by health care professionals Unique commentaries on two case examples by a diverse international panel of clinicians and researchers – from countries such as Argentina, Canada, France, Japan, Mexico, Switzerland, the UK, and the U.S. – illustrating the differences of opinion, approaches, and perspectives that together generate more effective assessment and treatment This thought-provoking clinical reference is a «must read» for developmental, child, and adolescent psychiatry educators and practitioners – and nurses, pediatricians, occupational therapists, and clinical social workers – as they help the youngest members of our community through theoretical understanding and practical intervention.
Mental Health Issues in Lesbian, Gay, Bisexual, and Transgender Communities
Over the last three decades, the visibility – and public acceptance – of self-identified lesbian women and gay men and bisexual and transgender individuals has increased dramatically, making it more important than ever to understand the dynamics of their relationships.This timely work, part of Volume 21 in the Review of Psychiatry series, offers compelling facts and insights in a concise yet comprehensive format, bringing together the latest research and clinical practice in this rapidly evolving field. Chapter 1 details normal adolescent development and the extra challenges imposed by the development of a sexual identity that is different from that of most of their peers, including the lack of lesbian, gay, bisexual, and transgender role models. Chapter 2 presents a rare discussion about theoretical models (managing a concealable stigma, minority stress and resilience, and coping with multiple minority statuses) and empirical data on aging as a stigmatized sexual minority, including the similarities and differences of aging between the sexual minority communities and the heterosexual community and special issues in working with aging ethnic minority gay men, lesbians, and bisexual persons. Chapter 3 breaks new ground by detailing the expanding role of the psychiatrist or other mental health professional as forensic expert and therapist – requiring not only an in-depth understanding of lesbian and gay mental health issues, but also the often-daunting task of encouraging and teaching judges and juries to better understand these issues as they relate to discriminatory laws in child custody/visitation, workplace harassment/other discrimination, domestic violence, and immigration/asylum. Chapter 4 covers both the three types of etiological theories on homosexuality presented in the scientific literature and an historical overview of clinical attitudes toward homosexuality, from early modern theories (Karl Ulrichs, Krafft-Ebing, and Freud) to the present day, reporting on some adverse side effects of sexual conversion treatment that have been either overlooked or ignored in the reparative therapy literature and raising important clinical and ethical concerns. Chapter 5 examines the public and professional evolution of thinking toward U.S. African race and toward sexual orientation with regard to the reevaluation of the psychiatric diagnosis and treatment of gender identity disorder. Among other topics, the author presents a fascinating discussion of differences between sexual orientation and gender (e.g., anatomical, social, hormonal, psychological, legal, or political), and distinctions between transgenderism and homosexuality, including an illuminating case example. Thought-provoking and informative, this compact volume will be welcomed by residents, clinicians, and students alike as they continue to look for ways to better differentiate health from pathology and successfully treat these remarkably diverse individuals.
Molecular Genetics and the Human Personality
In the 1960's and 1970's, personality and mental illness were conceptualized in an intertwined psychodynamic model. Biological psychiatry for many un-weaved that model and took mental illness for psychiatry and left personality to psychology. This book brings personality back into biological psychiatry, not merely in the form of personality disorder but as part of a new intertwined molecular genetic model of personality and mental disorder. This is the beginning of a new conceptual paradigm!!This breakthrough volume marks the beginning of a new era, an era made possible by the electrifying pace of discovery and innovation in the field of molecular genetics. In fact, several types of genome maps have already been completed, and today's experts confidently predict that we will have a smooth version of the sequencing of the human genome – which contains some 3 billion base pairsSuch astounding progress helped fuel the development of this remarkable volume, the first ever to discuss the brand-new – and often controversial – field of molecular genetics and the human personality. Questioning, critical, and strong on methodological principles, this volume reflects the point of view of its 35 distinguished contributors – all pioneers in this burgeoning field and themselves world-class theoreticians, empiricists, clinicians, developmentalists, and statisticians.For students of psychopathology and others bold enough to hold in abeyance their understandable misgivings about the conjunction of «molecular genetics» and «human personality,» this work offers an authoritative and up-to-date introduction to the molecular genetics of human personality. The book, with its wealth of facts, conjectures, hopes, and misgivings, begins with a preface by world-renowned researcher and author Irving Gottesman. The authors masterfully guide us through Chapter 1, principles and methods; Chapter 4, animal models for personality; and Chapter 11, human intelligence as a model for personality, laying the groundwork for our appreciation of the remaining empirical findings of human personality qua personality. Many chapters (6, 7, 9, 11, and 13) emphasize the neurodevelopmental and ontogenetic aspects of personality, with a major emphasis on the receptors and transporters for the neurotransmitters dopamine and serotonin. Though these neurotransmitters are a rational starting point now, the future undoubtedly will bring many other candidate genes that today cannot even be imagined, given our ignorance of the genes involved in the prenatal development of the central nervous system. Chapter 3 provides an integrative overview of the broad autism phenotype, and as such will be of special interest to child psychiatrists. Chapters 5, 8, and 10 offer enlightening information on drug and alcohol abuse. Chapter 14 discusses variations in sexuality. Adding balance and mature perspectives on how all the chapters complement and sometimes challenge one another are Chapter 2, written by a major figure in the renaissance of the relevance to psychopathology of both genetics and personality; Chapters 15-17, informed critical appraisals citing concerns and cautions about premature applications of this information in the policy arena; and Chapter 18, a judicious contemplation by the editors themselves of this promising – and, to some, alarming – field. Clear and meticulously researched, this eminently satisfying work is written to introduce the subject to postgraduate students just beginning to develop their research skills, to interested psychiatric practitioners, and to informed laypersons with some scientific background.
Psychoneuroendocrinology
The mind-body connection is one of the hottest topics in medicine today, documented by enormous amounts of data regarding hormone effects on the brain and behavior.Yet it is only now – with the debut of this thought-provoking volume – that we find an up-to-date, sophisticated reference that focuses on the clinical relevance of behavioral endocrinology and is written for practicing clinicians and researchers.This wide-ranging volume shows how the principles and emerging findings of psychoneuroendocrinology can inform modern clinical practice and lead to new breakthroughs in future science and practice. Here, leading authorities – internationally respected researchers and practicing clinicians – review empirical findings in their areas of expertise, highlight the clinical significance of these findings, and provide, wherever appropriate, clinical guidelines for the management of patients.Beginning with a lively history of psychoneuroendocrinology (including its many false starts), this book continues on to discussions of the hypothalamic-pituitary-adrenal axis hormone system, the gonadal hormone system, and the thyroid hormone system from each of the three paths generally used for psychoneuroendocrinological investigation: Alterations in endogenous hormone levels observed in primary psychiatric illness Psychiatric concomitants or sequelae of hormonal dysregulation in primary endocrinologic illness Behavioral effects of exogenously administered hormones or hormone antagonists (both the study of the side effects of hormonal medications and the use of hormones and hormone antagonists as psychotropic medications) An unmatched diversity of topics reveals the full breadth and depth of this volume: diabetes mellitus, corticosteroid effects on mood and cognition, Cushing's syndrome and Addison's disease, oral contraceptives and estrogen replacement therapy, psychiatric illness associated with the menstrual cycle and perimenopause, postpartum behavioral changes, anabolic/androgenic steroid use, and a thorough review of thyroid function in psychiatric disorders.Particularly fascinating are sections on the role of neuropeptides and hypothalamic-releasing factors in psychiatric illness, the use of laboratory tests and imaging procedures in evaluating hormonal function in psychiatric patients, the place of newer «alternative» hormonal medications such as melatonin and DHEA in therapeutics, and a provocative and compelling final chapter on the role stress plays in precipitating illness.Designed for both clinician and researcher-scientist, this richly informative guide will also prove an invaluable addition to graduate courses in neuroscience, neuroendocrinology, the biological basis of behavior, and consultation psychiatry. Neuroscientists/neurologists, endocrinologists, obstetricians/gynecologists, internists, family practitioners, nurses, and interested laypersons round out the wide audience for this remarkable volume.
The Dementias
Confusion. Fear. Isolation. This is the human experience of dementing illness, and it is at the heart of this practical, informative volume by a broad range of clinically grounded experts.This book is designed to meet the needs of clinicians dealing with persons with dementing illness and to serve as an introduction to the pathophysiology of dementing illness and a resource for clinical investigators.The giant strides in dementia research since the publication of the first edition in 1991 have generated optimism that we will soon be able to delay onset and even prevent these diseases that devastate both patients and caregivers. This third edition has been revised, updated, and expanded to cover changes in the classification, management and treatment of dementing illnesses and to give a more extensive account of basic and clinical research findings. At the same time, this remarkable volume indicates the interaction of the patient's personality, the caregiver, and the environment with the pathophysiology of dementing illnesses that creates the variety of symptoms accompanying these illnesses and impacting their treatment.Like the second edition, this third edition has three sections, flowing from diagnosis through management/treatment to research. New to this edition are A world-class presentation on the molecular and genetic basis of Alzheimer's disease A beautifully illustrated chapter on contemporary neuroimaging Discussions of mild cognitive impairment, the frontotemporal dementias, and the dementias associated with Lewy bodies This third edition is exceptionally valuable for addressing the day-to-day challenges of dealing effectively and humanely with persons with dementing illness. Case examples are used in the chapters on psychological/behavioral and drug management to indicate practical approaches to maintaining patients at their optimal level of function. Unlike similar texts, this volume also reviews legal and ethical issues in the care of persons with dementing illness and shows how clinicians and caregivers how to mobilize community resources. Extensive reference lists round out each chapter. The book concludes with 11 assessment guides and rating scales and an index.Now more than ever, there is hope that advances in understanding dementing illnesses such as Alzheimer's disease will lead to their effective treatment, and ultimately to their prevention. Until then, clinicians, families, and society will continue to be faced with the challenges posed by these illnesses – making this book a «must read» for physicians and other health care professionals, whether in training, in practice, or engaged in clinical research.
Infanticide
Maternal infanticide, or the murder of a child in its first year of life by its mother, elicits sorrow, anger, horror, and outrage. But the perpetrator is often a victim, too.The editor of this revealing work asks us to reach beyond rage, stretch the limits of compassion, and enter the minds of mothers who kill their babies – with the hope that advancing the knowledge base and stimulating inquiry in this neglected area of maternal-infant research will save young lives. Written to help remedy today's dearth of up-to-date, research-based literature, this unique volume brings together a multidisciplinary group of 17 experts – scholars, clinicians, researchers, clinical and forensic psychiatrists, pediatric psychoanalysts, attorneys, and an epidemiologist – who focus on the psychiatric perspective of this tragic cause of infant death. This comprehensive, practical work is organized into four parts for easy reference: Part I presents historical and epidemiological data, including a compelling discussion of the contrasting legal views of infanticide in the United States, United Kingdom, and other Western countries, a review of the latest statistics on maternal infanticide, and a discussion of the problems of underreporting and the lack of available documentation. Part II covers the psychiatric, psychological, cultural, and biological underpinnings of infanticide, detailing how to identify, evaluate, and treat postpartum psychiatric disorders. The authors explore clinical diagnosis, symptom recognition, risk factors, biological precipitants, and alternative motives, such as cultural infanticide. Chapter 3, developed to assist the attorney or mental health professional in understanding the implications of postpartum psychiatric illness as they relate to infanticide, presents a sensitive and thorough inquiry into infanticidal ideation. Part III focuses on contemporary legislation, criminal defenses, and disparate treatment in U.S. law and compares U.S. law with the U.K.'s model of probation and treatment. Chapter 8 is an especially useful resource for the attorney or expert psychiatric witness preparing for an infanticide/neonaticide case in the criminal court system. Part IV discusses clinical experience with mothers as perpetrators and countertransference in therapy, the range of mother-infant interactions (from healthy to pathological), and methods of early intervention and prevention. This balanced perspective on a highly emotional issue will find a wide audience among psychiatric and medical professionals (child, clinical, and forensic psychiatrists and psychologists; social workers; obstetricians/gynecologists and midwives; nurses; and pediatricians), legal professionals (judges, attorneys, law students), public health professionals, and interested laypersons.
Clinical Manual for the Treatment of Autism
Reflecting tremendous gains over the past decade in our understanding of the causes of autism, Clinical Manual for the Treatment of Autism meets the increasing need for clear, up-to-date, and evidence-based treatment. Internationally known researchers – who are also skilled in treating patients with autism – share treatment approaches they have either developed or thoroughly tested for safety and efficacy.The book describes in a straightforward manner how to diagnose autism, recognizing that patients may vary greatly in intelligence, language ability, disruptive behavior, and presence of comorbid disorders. It outlines the appropriate instruments to use for particular patients, providing examples and guidelines for evaluation and testing of individuals of all ages and levels of functioning, with a focus on initial diagnostic evaluation. It also evaluates the appropriate role of various medications for specific target symptoms and individuals: SSRIs and antidepressants, focusing on the rationale for their use and clinical trials in autism; anticonvulsants and mood stabilizers used to treat disruptive behaviors and mood instability; conventional and atypical antipsychotics, emphasizing studies using random assignment to active and control treatments; cholinesterase inhibitors, focusing on cholinergic mechanisms and treatment experience in autism; and stimulants and nonstimulants for the treatment of pervasive developmental disorder accompanied by hyperactivity, distractibility, and impulsiveness. In addition to pharmacological approaches, the book presents psychosocial treatments and includes well-accepted psychoeducational models for which there is sufficient evidence to recommend their use. In these chapters, the book: Covers the use of applied behavior analysis, the DIR/Floortime approach, and peer relationship interventions. Presents educational approaches, based on the experience of the TEACCH program in North Carolina, describing how its fundamental principles are utilized across the age spectrum. Describes complementary and alternative treatments – such as therapies targeting gastrointestinal function or the immune system or the use of nutritional supplements – with an eye toward helping parents make informed choices. Explores promising new avenues of treatment to address issues related to cognition and social and language deficits, focusing particularly on the potential of medications that target the glutamate and oxytocin brain systems. Clinical Manual for the Treatment of Autism is an essential resource for a broad range of professionals, including psychiatrists, pediatricians, neurologists, psychologists, educators, and behavioral, speech, and occupational therapists. It is a state-of-the-art compendium of treatments that will help advance the care that people with autism receive.