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The Psychiatric Interview

Overview The purpose of the initial psychiatric interview is to build a relationship and a therapeutic alliance with an individual or a family, and to collect, organize, and synthesize information about present and past thoughts, feelings, and behaviors. The relevant data derive from several sources: observing the patient's behavior with the examiner and with others present (including medical staff); attending to the emotional responses of the…

The Doctor–Patient Relationship

Overview The doctor–patient relationship—despite all the pressures of accountable care, complex and demanding electronic health records, and other systemic complications—remains one of the most profound partnerships in the human experience; in it, one person reveals to another his or her innermost concerns, in hope of healing. In this deeply intimate relationship, when we earn our patients' trust, we are privileged to learn about fears and worries…

Approach to Psychiatric Consultations in the General Hospital

This chapter provides a practical approach to the assessment of affective, behavioral, and cognitive problems of patients in the general hospital. We first survey the landscape of consultation psychiatry and then identify six broad domains of psychiatric problems commonly encountered in the medical setting. Next, we describe the differences in clinical approach, environment, interactive style, and use of language that distinguish psychiatry in the general hospital…

Beginnings: Psychosomatic Medicine and Consultation Psychiatry in the General Hospital

Psychosomatic Medicine A keen interest in the relationship between the psyche and the soma has been maintained in medicine since early times, and certain ancient physicians (such as Hippocrates) have been eloquent on the subject. A search for the precise origins of psychosomatic medicine is, however, a difficult undertaking unless one chooses to focus on the first use of the term itself. Johann Heinroth appears to…

Global Mental Health in the Twenty-first Century

Key Points Mental health is essential to general health around the world; however, there is a continuous need to educate psychiatrists in the developed world about global mental health and to build psychiatric and mental health resources to meet an expanding need. Mental illnesses (which are typically high-prevalence, early-onset disorders) account for 13% of the global burden of disease; yet health resources devoted to mental health…

Psychiatry and the Media

Key Points Background Portrayals of mental illness in news and entertainment media can educate the public and promote help-seeking efforts, or they can create and perpetuate stigma. Clinical and Research Challenges Mass media reports of suicide can trigger imitation; following new guidelines for reporting on suicide can reduce this risk. Practical Pointers Violence on television (including news programs) and in video games may promote fear or…

Coping with the Rigors of Psychiatric Practice

Key Points Psychiatrists are particularly vulnerable to workplace stress and to burnout. Especially challenging aspects of psychiatry include patient suicide, malpractice litigation, and residency training. Diverse coping strategies can be used to prevent and to manage difficult situations. Overview The practice of medicine is focused on disease, not health, and on treatment, not primary prevention. Therefore, it should not be surprising that physicians have difficulty minimizing…

Disaster Psychiatry

Key Points Disaster psychiatry is an evolving field that has developed in response to severe and usually unpredictable events. A psychiatrist has multiple potential roles in a disaster, ranging from advocating for appropriate preparation and policy to treatment of long-term effects that emerge in individuals and communities; the functions of psychiatrists shift according to the phase of the disaster. Disaster psychiatry involves interfacing with multiple systems.…

Military Psychiatry

Key Points Background The discipline of military psychiatry extends psychiatric practice beyond the boundaries of traditional environments of care. Though resiliency is the norm, negative effects of combat exposure can persist for decades. Psychological casualties in chemical and biological threat scenarios may outnumber and prove more costly in terms of personnel losses than physical casualties. History During World War I “gas hysteria” was common and threatened…

Rehabilitation Psychiatry

Key Points Background Many patients receiving rehabilitation services have psychiatric conditions that may adversely affect the rate, quality, and durability of their recovery. Losses or changes in functional status, disfiguring trauma or disease, and displacement far away from loved ones for long periods of time may lead to depression, fear, or anxiety. In addition, thoughts of suicide and suicidal behaviors are not uncommon in patients undergoing…

Emergency Psychiatry

Key Points The safety assessment is crucial in emergency evaluations. Assessment and management of acute agitation are of particular importance. It is critical to consider and to diagnose acute medical problems during the evaluation of a psychiatric emergency. Signs of intoxication and withdrawal that may herald a psychiatric emergency should be identified and treated. Psychiatric care plays an important role in responses to disasters. Overview Over…

Legal and Ethical Issues in Psychiatry II: Malpractice and Boundary Violations

Key Points Malpractice litigation has a significant impact on the professional and personal lives of sued psychiatrists, but the evidence does not support perceptions that it is out of control. Liability of psychiatrists is normally limited to acts of negligence and a limited number of intentional acts that occur in the course of treatment. Sexual involvement with current patients and former patients is considered unethical by…

The Role of Psychiatrists in the Criminal Justice System

Key Points Psychiatric evaluations within the criminal justice system include assessment of criminal responsibility, competency to stand trial, competency to plead, competency to waive counsel, and competency to be executed. Each of the above evaluations serves the purpose of upholding the fairness, accuracy, and integrity of the criminal justice system. In none of these evaluations is the presence of a mental illness, in and of itself,…

Legal and Ethical Issues in Psychiatry I: Informed Consent, Competency, Treatment Refusal, and Civil Commitment

Key Points Litigation is divided into two general categories: civil and criminal. Civil matters involve claims of injury or some other transgression that can be remedied by the payment of money (damages) or performance or cessation of certain activities (injunctive relief). Criminal matters involve acts committed in violation of a statute, for which the penalty may be a monetary fine, incarceration, or both. To qualify as…

Psychiatric Correlates and Consequences of Abuse and Neglect

Key Points Every state in the US has passed legislation that makes physicians and other health professionals mandatory reporters for child and elder abuse and neglect. Abused children are at serious risk for behavioral, emotional, and learning disorders. Mental injury to a child can have pervasive and long-term effects on a child's development. Neglect is the most common form of child maltreatment reported to state protective…

Intimate Partner Violence

Key Points Background Intimate partner violence (IPV) is a common, under-reported, and life-threatening public health problem that affects all segments of society. Societal implications of IPV include the cost of medical and psychiatric injury, chronicity and disability, as well as lost productivity, legal system costs, and generational effects and repetition. History Legal systems that equate women and children with property, sociocultural and religious systems that abhor…

Psychiatric Manifestations of Traumatic Brain Disorder

Key Points Complex deficits and disorders result from brain injuries and may evolve over time. Most of the recovery that occurs following traumatic brain injury (TBI) is seen within the first 2 years; however, there is high interpersonal variation in the rate of recovery and some people improve even 3–5 years after TBI; rehabilitation at any time after injury can lead to further improvement. Assessment and…

Movement Disorders

Key Points Movement disorders result from dysfunction of neural circuits that typically include the basal ganglia. Dopamine, the best-understood basal ganglia neurotransmitter, affects the drive for movements, cognitions, and emotions. Hypokinetic disorders, such as Parkinson's disease, may include depression and slowed cognitions. Hyperkinetic disorders, such as Huntington's disease or levodopa toxicity, can trigger impulse-control problems or hallucinations. Of movement disorders associated with psychiatric drugs, neuroleptic malignant…

Psychiatric Aspects of Stroke Syndromes

Key Points Clinical Findings Stroke is defined as the acute onset of a neurological deficit that is due to a cerebrovascular cause; a stroke has occurred if symptoms persist for longer than 24 hours or if a permanent lesion is detected by neuroimaging techniques. Strokes may be broadly described as ischemic or hemorrhagic. Neuropsychiatric sequelae of stroke include affective and cognitive disorders. Prognosis Early intervention may…

Pathophysiology, Psychiatric Co-morbidity, and Treatment of Pain

Key Points There is a high rate of psychiatric co-morbidity in patients with pain syndromes. Specific terminology is used to characterize pain and pain syndromes. Pain is transmitted in pathways involving the peripheral and central nervous systems. Psychiatric treatment can be effective for pain and the psychiatric co-morbidities of pain. Multimodal and multidisciplinary treatment facilitates provision of the highest-quality care for chronic pain. Overview Pain, as…