The Kvetch: Assessment, Pathogenesis, and Treatment of Patients Who Are Clinically Impaired by Chronic Complaining.

ABSTRACT: Clinicians often encounter patients whose presentations are characterized by long lists of complaints about their biological, psychological, interpersonal, and social conditions. The problems on which the complaints are based are variably reality-based and variably modifiable. Some of these patients display chronic complaining as a core, distinguishing feature. Accordingly, the aims of this article are to consider excesses of chronic complaining as psychiatric phenomena, explore possible pathogenetic contributions, describe approaches for treating conditions marked by clinically pertinent chronic complaining, and suggest areas for future research. Based on clinical observations enhanced by selective narrative literature review, we delineate and differentiate four groups of patients: 1) situational complainers; 2) chronic complainers due to unidentified medical problems; 3) mood-induced chronic complainers; and 4) personality-driven pan-dimensional chronic complainers. The last-mentioned group consists of help-seeking versus help-rejecting subtypes, the latter including a subset we designate as malignant chronic complainers. Strategies for managing these patients begin with detailed assessment of all complaints, ascertaining reality-based contributions to the complaints, including those initiated by patients themselves. Management approaches use specific biopsychosocial techniques based on patient-centered particulars. Psychotherapeutic strategies center on compassionate, empathic witnessing. Specific tactics include attending to unresolved grief and trauma, behavioral activation, cognitive and narrative restructuring and reframing methods, mentalizing and imaginal approaches, and psychodynamic methods including attention to attachment issues and transference. Sources of countertransference reactions to these patients should be identified and can be addressed. The many questions raised by these patients' presentations merit further research.

Adages, Aphorisms, and Proverbs in Psychiatry and Psychotherapy: Tools for Assessment and Treatment.

OBJECTIVE: This study aimed to examine how adages, aphorisms, and proverbs arise in psychiatric management and psychotherapy and how they might be used to assist assessment and treatment. METHODS: A selective narrative literature review was conducted to supplement clinical observations and case vignettes. RESULTS: Adages appear to act as heuristic cognitive structures that serve as shortcuts for assessing situations, educating, persuading, aiding emotional self-regulation, and influencing courses of action. Some types of psychotherapy-such as dialectical behavior therapy, rational emotive behavior therapy, and acceptance and commitment therapy-and self-help programs such as Alcoholics Anonymous routinely utilize adages. The extent to and contexts in which adages spontaneously arise during general psychiatric and psychotherapeutic interactions have not been systematically studied. Clinicians can ascertain patients' favorite adages and appraise how patients respond to other sayings through exploratory questioning and by evoking responses to stock series of adages. As therapeutic tools, adages may help patients more easily conceptualize clinicians' interpretations and insights and may serve as encouraging affirmations. CONCLUSIONS: Considering the potential utility of adages as therapeutic cognitive scaffolds, how patients and clinicians spontaneously use adages, how adages are used therapeutically, and the adages most suitable for particular patients in particular circumstances deserve further study. In psychiatric management and psychotherapy, clinicians' sensitivity to timing and patients' circumstances, culture, and receptivity may determine whether introducing a particular aphorism or proverb will have a positive impact or come across as a vapid and potentially harmful platitude.

Purpose in Life: Addressing Transdiagnostic Psychopathologies Concerning Patients' Sense of Purpose.

ABSTRACT: Having a purpose in life is strongly associated with well-being and quality of life. Some individuals develop their sense of purpose early in life and can sustain lifelong ideals. In contrast, we identify four transdiagnostic syndromes where purpose in life is impaired: 1) deficiencies in generating purpose; 2) loss of purpose due to traumatic events such as catastrophic illnesses or bereavements; 3) conflicts due to crossed purposes; and 4) maladaptive purposes, such as life-limiting single-minded goals, dominating others, or exacting revenge. Several psychotherapies associated with positive and existential psychologies help patients construct, reconstruct, or retain a sense of purpose. However, given the strong links between a sense of purpose and beneficial health and mental health outcomes, the authors suggest that many patients in psychiatric treatment including psychotherapies will benefit from attention to these issues. This article reviews approaches for assessing and addressing purpose in life in psychiatric treatment, to enhance patients' healthy sense of purpose where this characteristic is impaired.

Ambition and Its Psychopathologies.

ABSTRACT: Ambition is a uniquely human, complex personality trait. Although the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition mentions ambition only once, in a peripheral comment concerning narcissistic personality disorder, psychopathological states associated with ambition are commonly encountered in everyday life. Ambition has been linked to narcissism, power, and dominance, but it is distinct from each of these concepts. Although the development of ambition is most strongly influenced by social, cultural, and demographic factors, evidence suggests that genetic and biological factors also contribute.This article describes how ambition-related psychopathologies can manifest as 1) misalignment of ambitions and capabilities; 2) "blind ambition"; 3) distortions associated with bipolar and other mood disorders; 4) amalgams of ambition with Machiavellian traits, psychopathy, narcissism, and sadism (i.e., dark triad/tetrad traits); and 5) amotivation/apathy syndrome deficits associated with general medical and psychiatric conditions.The field requires more robust measures for assessing ambition, further delineation of ambition-related psychopathologies, and effective treatments for these conditions.

Money Matters in Psychiatric Assessment, Case Formulation, Treatment Planning, and Ongoing Psychotherapy: Clinical Psychoeconomics.

ABSTRACT: Trainees often receive little guidance concerning money matters in patients' lives and treatment, that is, clinical psycho-economics. Accordingly, this article considers: a) practical approaches to inquiring about intrapsychic and interpersonal influences of money matters pertinent to psychiatric assessment; b) how money matters should impact case formulation; c) how money matters realistically impact treatment planning; and d) money matters in ongoing psychotherapy affecting transference, countertransference, and clinical supervision. To supplement their clinical experiences, the authors conducted a limited narrative review via PubMed, followed by snowballing for articles of interest. Evidence suggests that money matters influencing intrapsychic and interpersonal lives commonly cause emotional distress, generating a range of dysfunctional behaviors. These reactions manifest as explicit conflicts, implicit issues, and unequivocal money-related pathologies. Clinical vignettes illustrate specific issues. By explicitly addressing money matters in patient's intrapsychic and interpersonal lives, trainees can enrich their assessments, case formulations, treatment planning, and ongoing psychotherapy.

Clinicians' Cognitive and Affective Biases and the Practice of Psychotherapy.

OBJECTIVE: Cognitive and affective biases are essentially connected to heuristic shortcuts in thinking. These biases ordinarily function outside of conscious awareness and potentially affect clinical assessment, reasoning, and decision making in general medicine. However, little consideration has been given to how they may affect clinicians in the conduct of psychotherapy. This article aims to illustrate how such biases may affect assessment, formulation, and conduct of psychotherapy; describe strategies to mitigate these influences; and draw attention to the need for systematic research in this area. METHODS: Cognitive and affective biases potentially influencing clinical assessment, reasoning, and decision making in medicine were identified in a selective literature review. The authors drew from their experiences as psychotherapists and psychotherapy supervisors to consider how key biases may influence psychotherapists' conduct of psychotherapy sessions. RESULTS: The authors reached consensus in selecting illustrative biases pertinent to psychotherapy. Included biases related to anchoring, ascertainment, availability, base-rate neglect, commission, confirmation, framing, fundamental attribution error, omission, overconfidence, premature closure, sunk costs, and visceral reactions. Vignettes based on the authors' combined experiences are provided to illustrate how these biases could influence the conduct of psychotherapy. CONCLUSIONS: Cognitive and affective biases are likely to play important roles in psychotherapy. Clinicians may reduce the potentially deleterious effects of biases by using a variety of mitigating strategies, including education about biases, reflective review, supervision, and feedback. How extensively these biases appear among psychotherapists and across types of psychotherapy and how their adverse effects may be most effectively alleviated to minimize harm deserve systematic study.

Autotraumatic Stress Disorders: Posttraumatic Stress Disorder Variants When the Victim Bears Responsibility for the Trauma.

Autotraumatic stress disorders (ATSD), variants of posttraumatic stress disorder PTSD, may develop in individuals after traumatic stressors for which they carry some responsibility, for example, serious self-injury and injury or death to others after murderous rages or careless vehicular driving. In ATSD, the individual is both the causative actor and casualty. As a result, in ATSD, distinctive negative psychological sequelae are grafted onto the usual distressing symptoms of PTSD, differentiating them from both PTSD and complex-PTSD. Whether the actions were intentional or unintentional and regardless of complications by comorbid psychiatric disorders, individuals with ATSD additionally experience some or all of the following symptoms stemming from actions for which they were responsible, wholly or in part: severe and unrelenting reality-based guilt, shame, remorse, regret, bitterness, self-betrayal, inability to trust oneself, and moral injury. Empirical studies investigating trauma-associated guilt and moral injury provide evidence to support these formulations. Clinical vignettes illustrate a range of circumstances leading to ATSD, in each instance adding significantly to the individual's distress, impeding recovery, and often requiring specific psychotherapeutic attention over and above that required for PTSD or complex-PTSD. These psychotherapeutic strategies have included intense, prolonged, noninterruptive, open-minded listening; avoiding premature whitewashing of responsibility and guilt; facilitating grief over lost innocence; helping create personal narratives that permit self-acceptance despite permanently altered damaged self-image; and, for some individuals, guiding repentance and restorative actions. Systematic case series and additional studies are necessary to ascertain how intentionality, self-harm versus harming others, and various comorbidities shape ATSD presentations, and to better delineate effective treatment strategies.

Current state of psychotherapy training: preparing for the future.

This article provides an overview of what is currently being taught in psychiatry residency programs about psychotherapy in general, and to evolving changes in the field related to mental health parity and the Affordable Care Act (ACA) in particular. Future psychiatrists must have a firm grasp of not only the principles of psychotherapy but also the development of increasingly effective and evidence-based psychotherapies if they are to be effective health care leaders. We review what attracts medical students to psychiatry and how much their decision to train in psychiatry is rooted in a desire to learn both dynamic psychiatry and psychotherapy in its various modalities. It is no secret that the quality of teaching and learning psychotherapy is variable in our training programs. One reason for this can be attributed to trainees who ascribe more to the biological dimensions of our field and have less interest and commitment to more than basic skills in psychotherapy. In addition, in some settings there is a dearth of teachers trained in the various forms of psychotherapy who are committed to this pedagogical imperative. We conclude with several recommendations to residency training programs and to residents themselves regarding what we deem essential in both the curricular and clinical exposure to the challenges and shortcomings of the mental health parity and Affordable Care Act. Tomorrow's psychiatrists have a fiduciary responsibility of advocating for their complex and chronically ill patients that must include providing psychotherapy.

Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies.

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient's responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.