The psychodynamics of transference--a virtual reality model.

OBJECTIVE: Virtual reality is not only being utilized increasingly as an enhancement for diagnosis and treatment of psychiatric illness, but it also can be used to model theories, generate hypotheses, and provide a new context for teaching psychodynamic therapy. Here we describe the use of an online virtual world--Second Life--as a heuristic tool for understanding and teaching a key psychoanalytic concept, transference. METHODS: Using an extended vignette to illustrate the results of the modeling process, we explore teaching the vicissitudes of object relationships by means of analogs in virtual reality. RESULTS: Simple reframing operations demonstrate how traditional dynamic theories of psychiatric treatment can be brought to life in simulations using modern computer technology. CONCLUSIONS: Virtual worlds offer a helpful analogy in teaching complex psychoanalytic concepts, such as transference.

Medical professionalism: a tale of two doctors.

The AMA's social media guidelines provide physicians with some basic rules for maintaining professional boundaries when engaging in online activities. Left unanswered are questions about how these guidelines are to be implemented by physicians of different generations. By examining the issues of privacy and technological skill through the eyes of digital natives and digital immigrants, the challenges associated with medical e-professionalism become clear.

Crime and hate in virtual worlds: a new playground for the ID?

Virtual worlds offer the potential for friendship, compassionate listening and support, and even love for 15 million users worldwide. But virtual analogs of crimes such as rape, murder, and pedophilia also exist within these worlds. The writings of Freud and Winnicott provide one model for understanding what may motivate these virtual crimes and how to think about them clinically. Psychiatric treatment can potentially benefit if therapists discuss virtual world use with patients as a way of understanding their inner lives.

The Role of Psychiatry in the Management of Acute Trauma Surgery Patients.

BACKGROUND: Trauma is a leading cause of death and disability in the United States, with high prevalence and recidivism in individuals with psychiatric and substance abuse disorders. Half of these disorders go undiagnosed by the trauma team, resulting in adverse public health and economic consequences. METHOD: In a 16-week pilot study in the emergency department of an inner-city tertiary care hospital, a psychiatrist was integrated into the trauma surgery team by responding to all traumas and rounding with the staff 1 shift per week (March 1, 2000, through June 31, 2000). During this 16-week period, 375 patients passed through the trauma surgery service. Data on the frequency of psychiatric consultations were compared with those for a retrospectively selected control group consisting of all 360 patients passing through the trauma surgery service during the corresponding 16 weeks of the previous year (March 1, 1999, through June 31, 1999). To determine the prevalence of psychopathology, eligible patients seen during the psychiatrist's shift (N = 28) were assessed with a semistructured interview, and charts for eligible patients seen in the corresponding shift during the previous year (N = 18) were assessed according to the same criteria. Before the study, a 10-item, self-report questionnaire was completed by 16 (73%) of the 22 emergency medicine physicians who serve as front-line staff members. The survey assessed physicians' attitudes toward psychiatric consultation for psychopathology and addictions in trauma patients. RESULTS: Based on DSM-IV screening criteria, the prevalence of preexisting psychopathology was 68% (19/28), but before the psychiatrist's involvement, only 12% (2/16) of physicians surveyed had considered consulting psychiatry, even for patients with gross psychopathology. Before the psychiatrist's integration into the 16-week study period, 75% (9/12) of trauma patients were discharged without psychiatric consultation despite the fact that more than half had documented substance abuse. After the psychiatrist joined the team, staff awareness of psychopathology sharpened. The number of patients treated for a psychiatric disorder that was often the proximal cause of the traumatic event nearly doubled, even on shifts not covered in the study. CONCLUSIONS: The ability to identify and treat coexisting psychopathology requires trauma surgeons to routinely incorporate a psychiatrist into their evaluation and treatment algorithm. Such a change in physician awareness and motivation hinges on a psychiatrist's visible presence (even if brief) and regular, active participation in the emergency department.

Celebrity Patients, VIPs, and Potentates.

BACKGROUND: During the second half of the 20th century, the literature on the doctor-patient relationship mainly dealt with the management of "difficult" (personality-disordered) patients. Similar problems, however, surround other types of "special" patients. METHOD: An overview and analysis of the literature were conducted. As a result, such patients can be subcategorized by their main presentations; each requires a specific management strategy. RESULTS: Three types of "special" patients stir up irrational feelings in their caregivers. Sick celebrities threaten to focus public scrutiny on the private world of medical caregivers. VIPs generate awe in caregivers, with loss of the objectivity essential to the practice of scientific medicine. Potentates unearth narcissism in the caregiver-patient relationship, which triggers a struggle between power and shame. Pride, privacy, and the staff's need to be in control are all threatened by introduction of the special patient into medicine's closed culture. CONCLUSION: The privacy that is owed to sick celebrities should be extended to protect overexposed staff. The awe and loss of medical objectivity that VIPs generate are counteracted by team leadership dedicated to avoiding any deviation from standard clinical procedure. Moreover, the collective ill will surrounding potentates can be neutralized by reassuring them that they are "special"-and by caregivers mending their own vulnerable self-esteem.