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Delirium

Key Points Incidence Delirium is a syndrome caused by an underlying physiological disturbance. Of patients admitted to intensive care units, delirium may develop in more than half. Pathophysiology The pathophysiology of delirium remains unclear, but the current leading theory cites an excess release of endogenous dopamine and loss of acetylcholine due to conditions of oxidative stress. Clinical Findings Delirium is marked by a fluctuating course of…

The DSM-5: A System for Psychiatric Diagnosis

Key Points Background A useful psychiatric diagnostic system allows clinical and research endeavors to flourish. The DSM-5, the most common diagnostic system used in the United States, encourages evaluation and description of multiple kinds of information: psychiatric, medical, and psychosocial. Careful use of the DSM-5 can promote rigorous conceptualization of psychiatric issues and enhance clinical communication. History DSM-5, released in May 2013, is the most recent…

Cognitive-behavioral Therapy, Behavioral Therapy, and Cognitive Therapy

Key Points Background Cognitive-behavioral therapy (CBT) is one of the most extensively researched forms of psychotherapy that is increasingly recognized as the treatment of choice for many disorders. History Cognitive-behavioral therapies represent an integration of two strong traditions within psychology: behavioral therapy (BT) and cognitive therapy (CT). BT employs principles of learning to change human behavior. BT techniques include exposure, relaxation, assertion training, social skills training,…

Hypnosis

Key Points Hypnosis has been used successfully for healing under various names and in varied forms for thousands of years. Hypnosis is most effective in the control of pain and discomfort and in the treatment of stress-related illnesses. Individuals differ in their responsiveness to hypnotic interventions. Several reliable physiological and functional neural differences have been found between individuals with high and low levels of hypnotizability. Multiple…

Group Psychotherapy

Key Points Background Throughout history people have gathered in groups to survive and to accomplish challenging tasks. It is natural that they can heal best in groups. Group psychotherapy rests on the assumption that people need to move from a state of isolation to one involving contact with others who share common interests. Groups can vary in their length, membership, goals, techniques, and frequency of meetings.…

Family Therapy

Key Points Modern family therapy represents a diverse collection of innovative theories and creative techniques that have materialized into several distinct schools. Important distinctions among schools include the following: their characterizations of the locus of power for change; expected schedule of progress; relative importance of affect, insight, or behavior as the focus of change; use of a team; different emphases on the past, present, and future;…

Couples Therapy

Key Points Like family therapy, couples therapy is founded on systemic ideas. A couple's evaluation should include exploration of the presenting problem, as well as challenging and re-framing of the couple's problems. “The relationship” takes the role of the patient for couples therapists, who also must take into account each individual's family of origin, history of previous relationships, current stressors, and medical and psychiatric history. A…

Brief Psychotherapy: An Overview

Key Points Short-term therapies typically last 12 to 36 sessions and focus on a single problem or symptom (called the focus or sector) by actively excluding less pivotal issues. Brief therapies differ from each other in how the focus is chosen and approached, how the therapist–patient relationship is leveraged, and whether the field of action is intrapsychic or interpersonal. Interpersonal psychotherapy (IPT) avoids intrapsychic interpretations and…

An Overview of the Psychotherapies

Key Points Research evidence supports the effectiveness of most psychotherapies. Psychotherapy training during residency includes competency in five basic psychotherapies. Child and adolescent psychotherapy includes more integrative strategies than does adult psychotherapy. All psychotherapies will require greater accountability under proposed accountable care plans. Background Clinicians half-jokingly assert that the number of psychotherapies in existence might exceed the number of psychotherapists in practice. Each session, even of…

Coping with Medical Illness and Psychotherapy of the Medically Ill

Key Points Physicians are constantly appraising the coping styles of their patients, and these appraisals dictate both diagnosis and treatment. Though there are multiple definitions of coping, coping with chronic illness is best defined as the behavioral style that patients use to bring quiescence and peace of mind to their medical predicament. There are consistent characteristics of effective and less effective coping styles, and it is…

Neuropsychological Assessment

Key Points Neuropsychological assessment is a method of evaluating behavior that relies on administration of norm-referenced, standardized tests. A major goal of neuropsychological assessment is to determine whether, and to what extent, a patient's cognitive status has been altered. This information can provide important diagnostic information, and helps guide clinical management. Neuropsychological evaluations assess a broad range of cognitive functions, including intelligence, and attention, as well…

Understanding and Applying Psychological Assessment

Key Points Background Psychological assessment is a professional consultation service aimed at providing clinicians with a more complex and empirically-based picture of their patients across a number of relevant clinical domains (e.g., intellectual and neurocognitive functioning, psychopathology and clinical diagnosis, personality style). The evolution of psychological assessment over the last century has resulted in improved reliability and clinical validity, which in turn has enhanced patient care…

Diagnostic Rating Scales and Psychiatric Instruments

Key Points Background Diagnostic rating scales provide validated measures of symptom severity in psychiatric disorders. Rating scales may be employed in both clinical and research settings. History The format of psychiatric rating scales varies widely in content, length, and administration. Ratings can supply either global assessments of function or disorder-specific measurements. Clinical and Research Challenges Clinician-rated and patient-rated scales each have advantages and disadvantages. It is…

Child, Adolescent, and Adult Development

Key Points Development is not a linear process; it proceeds unevenly throughout the life cycle with periods of great activity and periods of relative quiescence in particular areas. Development is a process of complex interactions between genes and the environment and between a child and his or her caregivers. In general, development follows a fairly predictable course, particularly in early life; however, there can be a…

Treatment Adherence

Key Points Background Among patients with a psychiatric illness, treatment adherence is associated with better treatment outcomes, a lower risk of relapse and hospitalization, and better adherence to treatments for co-morbid medical illnesses. However, barriers to adherence are common and rates of suboptimal adherence remain critically high. History Over the past several decades, approaches have evolved to help patients continue treatment for chronic health problems. The…

Laboratory Tests and Diagnostic Procedures

Key Points The mainstay of psychiatric diagnosis involves a thorough history, mental status examination, and focused physical examination; however, laboratory tests and diagnostic studies are important adjuncts. Laboratory tests and diagnostic studies are especially useful in the diagnostic work-up of high-risk populations. Laboratory tests provide a clinically useful tool to monitor levels of many psychotropic drugs by guiding medication titration, preventing toxicity, and checking for compliance.…

The Psychiatric Interview

Key Points The purpose of the psychiatric interview is to establish a therapeutic relationship with the patient in order to collect, organize, and synthesize data that can become the basis for a formulation, differential diagnosis, and treatment plan. A fundamental part of establishing this relationship is fostering a secure attachment between doctor and patient, in order to facilitate mutual and open communication, to correct misunderstandings, and…

The Doctor–Patient Relationship

Key Points Background The doctor–patient relationship is a key driver of clinical outcomes—both in promoting desired results and in avoiding calamities. Clinical and Research Challenges Especially in psychiatry, the physician must understand and relate to the patient as a whole person, requiring both accurate diagnosis and formulation, blending biological, social, psychological, and spiritual perspectives. History Conflict is an inevitable aspect of all important relationships, and, properly…

Maintaining motivation and preserving the therapeutic alliance as tools to overcome treatment-resistant depression

Thus far, this text has focused on the understanding and application of a broad range of interventions to improve outcomes in treatment-resistant depression. Understanding the breadth of psychopharmacologic and psychotherapeutic interventions permits tailoring treatment to specific patient characteristics to ensure the greatest response. However, there is another dimension to treatment-resistant depression that must be considered. In this age of biological psychiatry the rapid expansion of understanding…

Managing the risk of suicide in people with treatment-resistant depression

Introduction The management of suicide risk is often integral to the care of people with treatment-resistant depression (TRD). Suicide is a major public health concern worldwide, and yet it is a problem that remains poorly understood. Suicide occurs across a wide range of clinical presentations, including TRD, but the mechanisms accounting for suicide risk in TRD are not fully understood. Nevertheless, treatment guidelines for suicide risk…