Dependent Personality Disorder

Addressing the Underlying Causes of Treatment Resistance

New technologies pose challenges in the need to maintain boundaries and confidentiality. The same boundaries and ethical standards that existed in the 20th century must be thoughtfully applied with all new and developing technologies of the 21st century.

Excellence in psychopharmacology demands sensitivity to the associated ethical considerations. The key considerations of psychiatry are both complex and dynamic, and psychiatrists who develop and refine their ethics skill set will be in a better position to anticipate and respond to ethical dilemmas as they arise in their practice.

Antidrug vaccines represent an exciting area of development in the pharmacological treatment of chemical dependency. In addition to the clinical trials being conducted on vaccines for cocaine and nicotine dependence, preclinical development of vaccines for methamphetamine and heroin is ongoing.

The title of Gardiner Harris’s front-page story in the March 6 New York Times was blunt: “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.” For those of us who see our profession as a humanistic calling, this piece is likely to provoke a mixture of sadness and anger.

The goal of palliative care is to prevent and relieve suffering and to improve quality of life for people facing a serious, complex illness.

Opioid Dependence and XR Naltrexone

Almost the first memory I have of a physician is our family doctor at my bedside, leaning over to press his warm fingers against my neck and beneath my jaw. I’m 5, maybe 6 years old. I have a fever and a sore throat, and Dr Gerace is carefully palpating my cervical and submandibular lymph nodes.

Almost the first memory I have of a physician is our family doctor at my bedside, leaning over to press his warm fingers against my neck and beneath my jaw. I’m 5, maybe 6 years old. I have a fever and a sore throat, and Dr Gerace is carefully palpating my cervical and submandibular lymph nodes. In my family, Dr Gerace’s opinion carried a lot of weight. It was the 1950s, and my mother did not quite trust those new-fangled antibiotics. She usually tried to haggle with the doctor over the dose-“Can’t the boy take just half that much?”-but even my mother would ultimately bow to Dr Gerace’s considered opinion.

Until the early 19th century, psychiatry and religion were closely connected. Religious institutions were responsible for the care of the mentally ill. A major change occurred when Charcot1 and his pupil Freud2 associated religion with hysteria and neurosis. This created a divide between religion and mental health care, which has continued until recently. Psychiatry has a long tradition of dismissing and attacking religious experience. Religion has often been seen by mental health professionals in Western societies as irrational, outdated, and dependency forming and has been viewed to result in emotional instability.3

The empirical basis for the effectiveness of 12-step recovery and the psychotherapeutic benefits of opioid agonist maintenance were among the topics of several symposia with introspective views of time-tested treatments at the 40th Annual Medical-Scientific Conference of the American Society of Addiction Medicine (ASAM) in New Orleans.

The debate within the medical profession over “conflicts of interest” (COIs) has often been shrill, and sometimes seems to be based on misunderstandings or myths about what COIs entail. In this psychiatrist’s view, it is helpful to step back from confident proclamations, acknowledge that the issues involved are complex, and aspire to some semblance of humility. Nobody has cornered the market on “the right way” to deal with COI in the realms of medical research, publication, and education.1 At the same time, as Alan Stone, MD, has noted (personal communication, August 27, 2009), ethical considerations lie at the heart of any debate on COI-in particular, the ancient dictum, “Do no harm.” Indeed, ethicist James M. DuBois has pointed out a direct connection between some types of COI and harm to the general public: “Mental health consumers are at risk when studies that involve questionable scientific and publication practices are translated into therapeutic practice.”1(p205)

Smoking cessation services should be integrated into substance use disorder treatment programs, according to David Kalman, MD, Department of Psychiatry, University of Massachusetts, and colleagues, in their recent review of tobacco dependency among patients who sought treatment for alcoholism.1

Why do people get addicted? Of the countless books that have been published on this topic, this is the first that focuses on the self-medication hypothesis (SMH). Understanding Addiction as Self Medication is largely based on the experiences of the authors and other clinicians with individuals who struggle with addiction.

There is currently a small but impressive evidence base that shows that psychological and interpersonal factors play a pivotal role in pharmacological treatment responsiveness.

It is an ancient practice to state instructions for distributing one’s property after death. In Genesis 48, Jacob verbally bequeaths his property to Joseph, Joseph’s siblings, and Joseph’s 2 sons. Wills existed in ancient Greece and Rome, with restrictions.

Every life ends with death. For the elderly, death is the end of a long life that has been shaped by personal history and world events, various relationships, well-set personality characteristics and, of course, happenstance. Each of these, in addition to the specific circumstances that herald death, shapes the experience of dying in old age.

Ninety percent of patients with psychiatric disorders are seen in the general medical sector. Two-thirds of these patients receive no treatment for their psychiatric illness. Of the one-third that does, only one-tenth is provided minimally adequate treatment.1 Furthermore, nontreatment or nonevidence-based treatment of psychiatric disorders in the primary care setting is associated with at least double the total health care costs for patients, mainly from increased general medical care and nonpsychiatric prescriptions.2,3

This month I will examine the relationship between alcohol use disorder, stress, and a neuropeptide called substance P (SP). The data that led directly to research with human subjects came from the mouse-based genetic manipulation of a gene called neurokinin-1 receptor (NK1R), the receptor for SP. To understand this research thread, I will need to review some basic biology behind a class of biochemicals called tachykinins, of which SP is its most famous member. I begin, however, with an attempt to understand the relationship between the experience of stress, relapse rates in alcohol-dependent populations, and how mouse research ended up helping a cohort of stressed-out patients.

Prognostication is a major part of what physicians do in many fields of medicine, and it is particularly relevant when a treatment or procedure is controversial or anxiety-provoking. Being able to accurately tell a prospective ECT patient how likely he or she is to respond would be helpful.

Maintaining abstinence from alcohol "one day at a time" may be easier with appropriate treatment, but even with the best treatment it can become more difficult as the days add up.

In the historical context of American psychiatry, the concept of boundaries is a relatively recent development.1 Freud reportedly analyzed some patients while walking along the river Danube, gave patients gifts, and was known to share a meal with a patient.

It was opening night for the critically acclaimed Canadian independent film Away From Her. Based on a short story by Alice Munro, the film is about a retired literature professor, Grant (played by Gordon Pinsent), and his wife, Fiona (played by Julie Christie), whose idyllic golden years together end when she succumbs to the ravages of Alzheimer dementia.

Both cognitive-behavioral and pharmacological treatments for panic disorder have been found to be effective over the short term. Not all patients, however, can tolerate or fully respond to these approaches, and the effectiveness of these interventions over the long term remains unclear.

According to the National Institute on Drug Abuse, of all the illicit substances, marijuana is the most commonly abused among adolescents and young adults, and abuse during adolescence increases the likelihood of dependency in adulthood.

Epidemiological studies report a lifetime prevalence rate of 24.9% for (any) anxiety disorder. Feelings of anxiety can also be related to normal fear of pain, loneliness, ridicule, illness, injury, grief, or death. In both these types of situations, anxiety can be difficult to deal with. Consequently, benzodiazepines, which offer almost immediate symptomatic relief for anxiety, can be quite appealing to many persons.

Proper suicide assessment is probably the most important part of a clinician's job; appropriately, heavy emphasis is placed on this in our education. Unfortunately, psychiatrists receive comparatively little practical guidance in documenting the history and physical examination (H&P) of a suicidal patient.

"There must be some way out of here," said the joker to the thief."There's too much confusion, I can't get no relief. . . .""No reason to get excited," the thief, he kindly spoke,"There are many here among us who feel that life is but a joke.But you and I, we've been through that, and this is not our fate,So let us not talk falsely now, the hour is getting late."From "All Along the Watchtower," Bob Dylan

The following cases highlight some of the challenges clinicians face when treating patients in whom malingerling is suspected. One key aspect of these evaluations is not overlooking signs or symptoms that point to serious illness.

Physicians are often conflicted regarding prescription medications for pain, especially pain complicated by insomnia and anxiety. Concerns that patients may become addicted to medications, exacerbated by limited time available to get to know patients, can lead to underprescribing of needed medications, patient suffering, and needless surgery. At the other extreme, pressure to alleviate patients' distress can lead to overprescribing, needless side effects, and even addiction.