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Dissociative identity disorder (DID), known as multiple personality disorder until renamed in the DSM-IV (American Psychiatric Association, 1994), is a controversial diagnosis.

The obvious sometimes bears repeating: Sick people have trouble thinking. They may be suffering from a delirium, a dementia or a more subtle disturbance of cognition caused by fever, drugs, infection, inflammation, trauma, hypoxemia, metabolic derangement, hypotension, tumor, intracranial pathology, pain and so forth.

Wallowing in $1.3 billion in debt, and after losing about a million dollars a day for the past year, the Allegheny health system-a conglomeration of hospitals, physician medical practices and academic institutions-went down for the count in July, leaving Philadelphia's health care system in a financial snarl that may take years to untangle.

Consultation-Liaison (C-L) psychiatric services are generally not profit-making enterprises. Indeed, they are hard-pressed to demonstrate that they break even. Some attention has been paid to this issue in the recent literature, and specific recommendations of a most helpful nature have been made. The C-L service at Lehigh Valley Hospital (LVH) in Allentown, Pa., is an example of recommendations that have been put in place for C-L.

Atypical antipsychotic treatment for borderline personality disorder (BPD) and augmentation therapy with olanzapine (Zyprexa) or estrogen replacement therapy (ERT) for patients with mood disorders were among the research questions addressed at the American Psychiatric Association's annual meeting in Toronto. Following are some brief reports of selected presentations.

The future is both bright and dark for consultation-liaison (C-L) psychiatry. It is a paradox created by a still-evolving health care system that affords unique opportunities for innovation, while simultaneously placing seemingly insurmountable obstacles in the way of access to quality care. Striving to navigate these systemic contradictions, C-L psychiatry can be seen as on the verge of either a breakthrough or a breakdown-only time will tell how things will work out for this as yet uncertified subspecialty.

William - Poetry of the Times

As health care continues to shift in the United States from fee-for-service to managed care, and away from specialist-driven care to the primary care gatekeeper, it is necessary to re-examine psychiatric training and the psychiatric services that are being provided.

When Sigmund Freud gave his epochal lectures at Worcester's Clark University in the early 20th century, a young Harvard student named Alan Gregg was in the audience. Upon completion of his medical education and training as an internist, he would become a great visionary of psychiatry's role in the practice of medicine.

New methods of conducting and evaluating research were as intriguing as their results at the National Institute of Mental Health (NIMH)-sponsored New Clinical Drug Evaluation Unit Program's (NCDEU) 38th annual meeting in Boca Raton, Fla., June 10-13. The meeting has grown from a forum of NIMH-funded researchers reporting on their progress into a convention of approximately 1,000 clinicians, industry and regulatory personnel, and investigators marking the progress in psychopharmacology.

The diagnostic criteria for sexual addiction are derived from the behaviorally nonspecific criteria for addictive disorder that were presented in Part 1 (Goodman, 1998b), by replacing "behavior" with "sexual behavior".

Because of the very prominent physical symptoms of panic disorder, many see their primary care doctor or a specialist, such as a pulmonologist, first.

A gene variant in the CYP2A6 enzyme may help protect some individuals from nicotine addiction, according to a new study funded in part by the National Institute on Drug Abuse of the National Institutes of Health.

Before Masters and Johnson came on the scene in the late 1950s, any sexual problem was thought to be the result of a deep-seated neurosis that needed to be unearthed. It is now recognized that an understanding of physiology and couples dynamics-along with a practical approach-are required interventions

Day in and day out, psychiatrists-especially those involved with couples therapy-counsel and treat patients experiencing relationship problems with their spouses or partners. But what about the psychiatrist having a similar problem in his or her own life? Who does a doctor turn to for guidance and insight regarding such intimate matters?

The George Washington Bridge - Poetry of the Times

Explaining the Realities of Mental Illnesses. The ongoing campaign against stigma and discrimination attempts to promote an attitudinal shift from misunderstanding and fear to knowledge and compassion. Unfortunately, mental illnesses only grab the public's attention when high-profile tragedies become front-page news.

Using positron emission tomography (PET) to examine the cause of cluster headaches, researchers found that the hypothalamic region in affected people consistently lit up, indicating activity in that part of the brain.

How much of the beneficial effects of anti-depressant medications can be ascribed to the placebo effect? Irving Kirsch, Ph.D., and Guy Sapirstein, Ph.D., addressed this important question in a recent study that appeared in the first volume of the American Psychological Association's online journal, Prevention and Treatment (June 26,1998). Although their methodology and conclusions have met with some controversy, it would be imprudent to invalidate the study and its hypothesis.

Results of a multicenter, open-label observational trial of DuPont Merck's REVIA (naltrexone) demonstrated that patients were able to decrease their alcohol consumption from 57 to four drinks per week when the medication was part of an overall treatment program.

With advances in the neurosciences, and especially in imaging techniques, we stand at the threshold of demonstrating that psychotherapy is a powerful intervention that affects the brain. While it has been intuitively obvious to most clinicians that psychotherapy must work by affecting the brain (how else could it work?), recent breakthroughs in technology demonstrate what kinds of changes occur with psychotherapy.

Recently, in reviewing a particularly complicated case with a representative of a managed care company, I was told that I was the only child psychiatrist in the country who could not come up with a diagnosis in one session.

A traditional medical chart is a varied collection of printed and handwritten notes, forms, letters and laboratory reports. As the chart grows, it becomes more and more difficult to keep track of the information it contains.

A new booklet released in April of this year provides, for the first time in modern medical history, a road map for ending life with physician assistance. Entitled The Oregon Death With Dignity Act: A Guidebook for Health Care Providers, the publication was the product of a two-year project sponsored by the Center for Ethics in Health Care at the Oregon Health Sciences University in Portland.

As her patient leaves the consulting room, Susan Roth, M.D., picks up her computer's microphone and begins dictating. "Wake up. Open template recurrent major depression. Patient identification: Mr. Johnson is a 64-year-old married white male. Chief complaint: difficulty sleeping, loss of appetite and depressed mood with suicidal ideation for the last three weeks."

The fact that the Health Care Financing Administration (HCFA) canceled the July 1 start date for implementation of the much-maligned new evaluation and management (E/M) documentation guidelines does not mean that Medicare is relaxing its efforts to root out erroneous physician billing of Medicare.

In more than two dozen programs throughout the United States, telepsychiatry is ushering in a new way of bringing mental health services to thousands of individuals who, in the past, may have gone without. More often than not, however, they are pilot projects or grant-supported endeavors, meaning that these prototypes of the psychiatrist's office of the future have yet to prove themselves in the medical marketplace.

Uncle Joe - Poetry of the Times

Despite threatening skies on a Sunday afternoon in late May, about 2,000 people gathered in New York City's Bryant Park for the fourth annual picnic given by National Picnic for Parity, a broad-based coalition of mental health providers, consumer groups, legislators and other advocates interested in achieving parity for mental illness.

Psychiatrists would fare considerably worse than anticipated if the Health Care Financing Administration (HCFA) sticks with its recently-announced intention to use a 'top-down' methodology in rearranging new practice expense relative value units (RVUs) for 1999. The new methodology would yield a 4% increase over the four years 1999 to 2003, compared with the 'bottom-up' methodology HCFA had previously chosen, where psychiatrists would have received a 19% increase.