Histrionic Personality Disorder

I was asked three interesting questions by a psychologist with 15 years experience evaluating sexually violent predators. She has testified often--both for the prosecution and for the defense in the hearings that determine the legitimacy of involuntary psychiatric commitment under SVP statutes.

As I came closer, I could see Mr P more clearly. He was in his own world, wearing a Walkman with earphones on. I puzzled for a brief moment over this-was this to shut out attempts to talk him down? I could also see more clearly the rivulets of blood dripping from the incisions on his wrists to the concrete ground below.

Photography has been a part of the history of psychiatry and mental illness since at least the last quarter of the nineteenth century. French clinicians Henri Dagonet and Jean-Martin Charcot were among the first to use photography in the 1870s to aid in establishing reliable diagnostic criteria for particular maladies. Charcot especially was renowned for taking photographs of patients suffering from hysteria in order to analyze their hysterical episodes, breaking down their postures and gestures into discrete stages in order to enable a more accurate diagnosis.

I don’t believe in witches or ghosts or things that go bump in the night. I’ve always thought that the Salem witch trials were a result of mass hysteria (on the part of the persecutors) rather than a phenomenon of dark forces at work. And seeing Arthur Miller’s The Crucible a few years ago, only confirmed my suspicions. So I was gratified to see Dr Quintanilla’s poster at this year’s meeting of the American Psychiatric Association. As a physician and researcher, she factually explains the fallacy of witchcraft. Looking at historical documents dating back to the 15th century, Dr Quintanilla was able to match the symptoms of people condemned as witches with associated neurological and psychiatric disorders, such as epilepsy and hysteria. [Editor’s Note: Natalie Timoshin]

Dramatology approaches human encounters, events, and scenes as dramatic enactments of characters in conflict and crisis.

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

On October 19, 2009, the Office of the Deputy US Attorney General issued a memorandum, “Investigations and Prosecutions in States Authorizing the Medical Use of Marijuana.”1 The memo announced a federal policy to abstain from investigating or prosecuting “individuals whose actions are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana.” The memo made clear, however, that it did not “legalize marijuana or provide a legal defense to a violation of federal law.” Rather, it was “intended solely as a guide to the exercise of investigative and prosecutorial discretion.”

Psychiatry is eminently corruptible. Soviet psychiatrists of the 1950s disgracefully organized themselves into the medical arm of the Gulag state. Political dissidence became prima facie evidence of impaired reality testing, of “sluggish schizophrenia.” We like to believe in the benefits of scientific progress, but for Soviet inmates, progress was prefixed with a minus sign; every apparent advance in psychiatric technology left them more tightly controlled and worse off.

Brief psychotherapy is not the name of a specific model or theory of treatment. Rather, it describes an approach that attempts to make psychotherapy as efficient and practically helpful as possible within a limited time frame. The aim of brief therapy is to speed up the process of change, amplify patient involvement, and foster more focused psychotherapy sessions. Over the years, several approaches to brief psychotherapy have evolved. Some advocate a handful of sessions; others involve more than 20 sessions (eg, psychodynamic therapy).

Recent decades have seen an outpouring of publications about psychological trauma. With its formal diagnostic category of posttraumatic stress disorder (PTSD), Western psychiatric medicine has led the way in opening up this field of study. Many other disciplines of inquiry, including sociology, anthropology, legal studies, and literary studies, also have contributed their distinctive approaches and methodologies to the subject. Most recently, professional historians in Britain, Germany, Austria, Australia, Canada, and the United States have researched the origins of PTSD to great effect. These “new historical trauma studies” draw heavily on pioneering medical research from earlier places and periods. In addition, empirical findings from and analytical insights into humanity’s troubled, traumatic past provide ideas, observations, and insights that may be useful for mental health practitioners today.

My first job after residency involved working at a large Veterans Affairs hospital in an outpatient dual diagnosis treatment program that focused on the comorbidity of schizophrenia and cocaine dependence. Having recently completed a chief resident position at the same hospital’s inpatient unit that focused on schizophrenia without substance abuse, I was struck by how “unschizophrenic” my new patients were. They were organized and social. Their psychotic symptoms were usually limited to claims of “hearing voices,” for which insight was intact and pharmacotherapy was readily requested.

Book reviews have long been a first defense against scholastic overload. Generations of high school students have bypassed Wuthering Heights and The Scarlet Letter in favor of CliffsNotes, and now Wiki­pedia. Many people use the New York Times Book Review less to plot future reading than to pick up enough talking points about this week’s bestseller that they can skip it but still sound intelligent. Recently, litterateur and psychoanalyst Pierre Bayard anatomized this art of faked literary chat in his nearly serious study, How to Talk About a Book You Haven’t Read.

Diagnostic assessment of psychiatric disorders and their comorbidities is a challenge for many clinicians. In emergency settings, there is no time to conduct lengthy interviews, and collateralinformation is often unavailable.

he key manifestations of DSM-IV somatoform disorder are unexplained physical symptoms or complaints that tend to coexist with other psychiatric syndromes or are linked to psychological issues. These symptoms typically lead to repeated medical or emergency department visits; are associated with serious discomfort, dysfunction, and disability; and lead to significant health expenditures.

The mind-brain dichotomy has been on a roller-coaster ride over the past few hundred years. Clinically astute European neuropsychiatrists in the 18th and 19th centuries described various neuropsychiatric disorders based on observations of their patients.

Traumatology has become an increasingly multidisciplinary field. Originally the province of psychiatry and clinical psychology, the field has now been enriched by the contributions of epidemiologists, neuroscientists, anthropologists, and historians.

Since the revision of DSM-III, high rates of co-occurring psychiatric disorders have been observed, particularly in cases of moderate and severe psychiatric illness. The reason lies in the design of the diagnostic system itself: DSM-IV is a descriptive, categorical system that splits psychiatric behaviors and symptoms into numerous distinct disorders, and uses few exclusionary hierarchies to eliminate multiple diagnoses.

Voluntary informed consent is, with rare exceptions, a necessary, albeit not sufficient, defining precondition of ethical clinical treatment, and it is essential for enrollment in clinical research trials.

One day in 1946 while I was making neurology rounds, a crumpled piece of humanity was wheeled into the ward. When "Ora" came to the hospital for her annual epilepsy checkup, she had not been able to walk for more than a year.

Few phenomena in medicine aremore confounding than the diagnosesinvolving deception:malingering, Munchausen syndrome,Munchausen by proxy (MBP), and factitiousdisorder.

Freud

Poetry of the Times by Richard M. Berlin, MD.

The skin is the largest organ of the body and functions as a social, psychological, and metabolically active biologic interface between the individual and the environment.

The Reflex Sympathetic Dystrophy Syndrome Association estimates that the CRPS affects between 200,000 and 1.2 million Americans. The underlying causes of the syndrome have yet to be defined, and no definitive diagnostic test exists even though CRPS was first described in the late 19th century by the neurologist Silas Weir Mitchell. Mitchell referred to the cluster of symptoms he noticed in some of the Civil War soldiers who were under his care as "causalgia.

Complaints of persistent memory loss in otherwise well-functioning individuals after recovery from a psychiatric illness through electroconvulsive therapy (ECT) are best viewed as a conversion reaction or a somatoform disorder. The Camelford experience is a model for the complaints of ECT's profound personal memory losses.

Many highly regarded clinicians have built careers working with patients they believe to have dissociative identity disorder (DID). Other distinguished practitioners consider DID to be a bogus diagnostic tag.

The evidence showing a relationship between mental disorders in childhood and adulthood has increased in the last several decades.

Somatoform disorders (disorders that are not fully explained by a medical condition or mental disorder) may require psychiatrists to consult with physicians.

About 25% of patients seen in epilepsy clinics and monitoring units who do not respond to antiepileptic drugs (AEDs) have received a misdiagnosis.1-3 The eventual diagnosis for most of these patients will be psychogenic nonepileptic seizure (PNES)1,4-a somatoform conversion disorder. It is treatable, but diagnosis, delivery of the diagnosis, and management present significant challenges. A major barrier to care has been the stigma associated with the label "psychogenic."

Attempting litigation based on a claim of posttraumatic stress disorder can be difficult. What is the proper DSM definition of PTSD and in what ways can and can't it be used in court to properly defend a client? What should the role of the psychiatrist be in this process?