Addiction & Substance Use

The recently posted first draft of DSM-5 has suggested a whole new category of mental disorders called the "Behavioral Addictions." The category would begin life in DSM-5 nested alongside the substance addictions and it would start with just one disorder (gambling).

Insurance restrictions sometimes make for strange bedfellows. My story begins with a phone call from a man about to lose his job. He said that he had been placed on probation and was about to be fired. He asked if he could see me. We met the following day.

Sometimes you spot a serious problem and figure out a very well-intended solution, only to discover eventually that your solution created as much trouble as the original problem. The workers on DSM5 have spotted an enormously worrying problem-the wild overdiagnosis of childhood bipolar disorder (BD) which has led to a massive increase in the use of antipsychotic and mood stabilizing medications in children and teenagers.

Mark Twain observed that "the past may not repeat itself, but it sure does rhyme." An unfortunate rhyme in psychiatric history is the recurrence of fad diagnoses. Childhood Bipolar Disorder is the most dangerous current bubble, with a remarkable forty-fold inflation in just one decade.

Diagnostic Dilemmas-Effective Treatment Approaches

Epidemiological studies show that, 4% to 5% of the general population have severe ADHD. Of this number, half have a comorbid substance use disorder. The aim of this article is to help physicians understand and manage this challenging combination of comorbidities.

The impact of FDA alerts and label warnings was examined in 2 recently published studies of antipsychotic drug use. In one study, researchers gauged physician response to the 2005 warning of increased mortality with antipsychotic use in elderly patients with dementia, and in the other study, researchers determined whether recommended safeguards were implemented following the 2003 advisories on adverse metabolic effects of second-generation antipsychotics.

My parents lived in 2 different worlds together. One, the outside world, was where they sparkled. Their business was so successful, and they were urbane, sophisticated, and very smooth. At home, the inside world was very different. They were competitive with each other, more critical than affectionate; there was none of the togetherness they presented to the outside world.

Overly sensitive, aversive reactions to stress seem to run in families. The literature abounds with reports of relatives in these populations predisposed to depression, anxiety, and even suicide. Some family members present with glucocorticoid levels notched abnormally high, and in curiously deregulated concentrations. Behaviorally, they seem to exist at a permanent state of high alert.

Oregon’s legislature has passed the bill: should the governor sign it? Most opinions on this issue are strong, and many have reached the point of invective. Even such a cool mind as Ronald Pies' has weighed in with an emotionally charged editorial.1 To speak in favor when so many are opposed seems only to invite more affective discharge. On the other hand, editorial views thus far may be moving us toward extremes on an issue that is highly complex. Perhaps a dialectic approach -– what value can we find in an opposing view? -- would be wise at this point. In that spirit, here are 4 considerations that I hope will be useful.

In his recent David Letterman–like Top 19 list of DSM5 issues, Allen Frances1 targeted a proposed revision of the DSM-IV diagnosis of Pedophilia, and 2 proposed new diagnoses: Hypersexual Disorder (HD) and Paraphilic Coercive Disorder. He protests the inclusion of pubescent teenagers in the definition of the proposed revision of Pedophilia (including the renaming of it as Pedohebephilic Disorder) and criticizes the quality of writing of these criteria.1 As the chair of the DSM5 Work Group responsible for those draft criteria, I need to address his poorly reasoned claims.

DSM-IV provides separate categories for Substance Abuse and Substance Dependence. The typical substance abuser is someone who gets into recurrent, but intermittent, trouble as a consequence of recreational binges. This is in contrast to the continuous and compulsive pattern of use that is typical of DSM-IV Substance Dependence.

In a study of 3801 young adults that was just published in the Archives of General Psychiatry, Australian researchers have concluded that early and prolonged use of marijuana is associated with psychosis-related outcomes in young adults. They found a “dose-response” relationship: the longer marijuana was used, the higher the risk was out eventual psychosis.

There are currently several disturbing phenomena in the field of suicidology: •Many papers are describing risk assessment and suggesting the need for high-risk patients to be hospitalized. •Emergency department (ED) staff are complaining about spending much of their time trying to find beds for patients. •Programs are claiming “crisis intervention” when, in fact, they only provide triage.

A major general problem in the preparation of DSM5 is that the various Work Groups have been given far too little guidance and support. This explains why: 1)most of the criteria sets are written so obscurely and inconsistently; 2) the rationales for change vary so widely in depth and quality across Work Groups,and; 3) so many suggestions that should have no chance at all have made it this far without being tossed.

There are a lot of temperamental Jerome Kagan moments in my friend’s household-an observation that will require this entire column to explain. What exactly is a temperamental moment? And who exactly is Jerome Kagan?

Traumatic brain injury (TBI) affects approximately 2 of every 1000 persons per year. Persons vulnerable to mental illness (eg, persons with alcohol abuse or antisocial personality disorder) are particularly at risk.

Six months after the deadline for a final rule, 3 federal departments published an interim final rule that leaves a number of questions open about the application of the expanded mental health parity law passed by Congress in October 2008. But the penultimate version of the implementing regulations won mostly praise from psychiatrists and psychiatric hospitals.

Given the potential for a significant role in recognition of neurologically complex disorders, psychiatrists should become familiar with diagnostic criteria and appropriate therapeutic option.

New Insights Into Diagnosis, Comorbidities, and Treatment Approaches

On February 12, 2009, the US Court of Federal Claims issued a trio of long-awaited decisions in its Omnibus Autism Proceeding.1 The 3 were representative cases chosen from more than 5500 pending MMR/autism cases by the Plaintiffs’ Steering Committee. Each presented the theory that the measles-mumps-rubella (MMR) vaccine in combination with thimerosal, a mercury-based ingredient contained in some diphtheria-tetanus-pertussis (DTP), diphtheria-tetanus–acellular pertussis (DTaP), hepatitis B, and Haemophilus influenzae type B (Hib) vaccines, causes autism. In nearly 700 combined pages that reviewed the scientific and epidemiological evidence, all 3 opinions determined that the plaintiffs had not demonstrated a link between these vaccines and autism.

I remember as a child gathering wild greens with my Cherokee grandmothers, 2 generations of them, and hearing the lilt of spoken Cherokee. I can still see myself listening quietly in the corner of the room while others came to visit my great-grandmother, a respected traditional healer. We were poor. There is no other way to say it. My mother carried water from a well in the middle of the field, and I remember before going outside to play in the snow that we wrapped bread sacks around our feet to keep them dry. But as a child, while life was hard and even harsh at times, it felt safe and constant.

Arlington, VA, March 2 (compiled from AP reports)-Officials at the American Psychiatric Association (APA) confirmed today that their national headquarters had been taken over by “very, very large English and literature teachers,” according to a spokesperson for APA President, Dr Alan Schatzberg. Schatzberg himself was unavailable for comment and was reported to be in seclusion “…brushing up his Shakespeare.”

Treating Child and Adolescent Mental Illness: A Practical, All-in-One Guide is just what its title promises: a clinically relevant, encompassing yet concise guide to child and adolescent mental health care. Dr Shatkin’s book serves as a useful primer for medical and mental health clinicians who do not specialize in the treatment of children and adolescents but who find themselves faced with the growing demand to provide mental health services to this sector. It is also a handy refresher for child and adolescent clinicians called on to treat disorders seen less often in their practices, as well as a reference for nonphysicians less familiar with psychopharmacological interventions.

In his recent David Letterman-like Top-19 list of DSM5 issues, Dr Allen Frances targeted a proposed revision of the DSM-IV diagnosis of Pedophilia, and 2 proposed new diagnoses: Hypersexual Disorder and Paraphilic Coercive Disorder.

“The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.”1

It is generally held that the offspring of parents with bipolar disorder (BD) are at risk for BD. The degree of risk is an important question for both clinicians and parents. A recent study of bipolar offspring by Birmaher and colleagues1 sheds light on this issue.

Dr Elvin Semrad was a much-loved psychiatrist and psychotherapy supervisor who had a profound influence on hundreds of psychotherapists and psychoanalysts in the Boston area. One of his unique qualities was his ability to connect empathically with even the most psychotic patients. He supervised at Boston State Hospital and then for 4 decades at the Massachusetts Mental Health Center (MMHC) in Boston, where he conveyed his strong conviction that psychotic and other seriously men-tally ill patients could benefit from long-term psychoanalytically oriented psychotherapy.

Let’s say you’re in a crowded bar when somebody suddenly shoots at a patron. You clearly see a man carrying a firearm, but all hell breaks loose as you and everybody else scramble for the exits. In the terrifying seconds following the crime, you lose track of who discharged the firearm: it could have been 1 of 3 suspects. Afterward, the police interview you, but it is hopeless. Even bringing in the suspects for a lineup isn’t going to help you recall. There will be no “Perry Mason” moments, when the perpetrator breaks down under the weight of guilt and confesses to the crime. How can the authorities make an arrest?

“The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.” How many of us psychiatrists recognize this statement? Or, is it like the fine print that we often gloss over in our everyday contracts and hope it doesn’t cause us trouble at some later time?