New onset of body dysmorphic disorder following frontotemporal lesion.

The etiology and pathophysiology of body dysmorphic disorder (BDD) have not been delineated. The authors report a 24-year-old man who developed BDD at age 21 after an inflammatory brain process. Neuroimaging studies showed new atrophy in the frontotemporal region. The authors review cases from the literature with similar clinical features and neuroimaging findings as well as discuss the possible correlation between the neuroanatomic lesion and the clinical presentation of BDD in the patient.

Psychotherapy in consultation-liaison psychiatry.

Psychotherapy in the Consultation-Liaison (C-L) setting is shaped by the realities of the patient's situation, since all patients referred are dealing with physical illness. The patient's state of physical and mental health will determine both the type of therapeutic work possible and the focus of such work. Tailoring the therapeutic intervention to the patient's specific needs and flexibility in altering and adapting therapeutic strategies over time in line with the patient's changing needs are essential. Although periods of treatment may range from single session to long term, supportive, insight oriented, group, family, cognitive and behavioral techniques have all been used successfully in a C-L setting, with measurable impact on well-being. Psychotherapeutic work in C-L is unique in that the focus of the therapist extends beyond the patient and family to include all caregivers, including other health care professionals, in line with the biopsychosocial model.

Delivering mental health care to HIV-positive individuals. A comparison of two models.

Data on initial psychiatric evaluations performed in 1995 were compared to assess whether psychiatric consultation for human immunodeficiency virus (HIV)-positive/acquired immunodeficiency syndrome (AIDS) patients provided on-site in an infectious disease (ID) clinic improved compliance and were preferred by staff to evaluations performed in a specialized AIDS psychiatric program. Compliance with initial appointments remained below 50% in both settings, but more patients seen in the ID clinic had received prior psychiatric treatment and medication and they were more likely to receive a psychotropic prescription at this initial visit. The ID clinic staff preferred on-site consultations. Stationing psychiatric consultants in the ID clinic may reach a more impaired population but did not improve compliance with the initial visit.

A noncompliant patient with fluctuating capacity.

Because of intermittent refusal of both dialysis and medications, serial capacity assessments were made on a 38-year-old male on hemodialysis and receiving TB treatment. His capacity to make an informed treatment decision appeared to fluctuate and despite multidisciplinary involvement and a court determination that treatment should take place, questions remained as to how such a case should be managed in the patient's best interest. The process of making a capacity determination was reviewed from both a psychiatric and legal viewpoint and alternative strategies presented.

What, why, and how of consultation-liaison psychiatry. An analysis of the consultation process in the 1990s at five urban teaching hospitals.

There is controversy about the role and function of a consultation-liaison (C-L) psychiatrist, as reflected in the ongoing debate about what to call ourselves. To clarify the essential elements of our function, the authors analyzed the process and content of the entire consultation experience from the time of initial consultation to the time of discharge in 50 patients across 5 urban teaching hospitals. The common components of the C-L process, in this pilot study, were identified to be facilitative, consensus-seeking, and interpretative. Implications of these findings for the C-L psychiatrist's role in the general hospital are discussed.

A comparison of Japanese and American psychiatrists' attitudes towards patients wishing to die in the general hospital.

BACKGROUND: The attitudes of the psychiatrists in Japan and the US were compared in order to investigate their ideas on whether patients in general medical hospitals who have a desire to die should be allowed to do so or be assisted in this regard, and whether they require psychiatric evaluation and intervention, and the cultural influences on these attitudes. METHODS: Japanese and American general hospital psychiatrists' attitudes towards the reasonability of suicide, physician-assisted suicide, and removal of life supports under various medical and psychosocial situations were compared. Seventy-two American and 62 Japanese psychiatrists' data were collected using the Suicidal Attitudes Inventory. RESULTS: The majority of both American and Japanese psychiatrists agreed that there may be times when suicidal ideation or completed suicide in med-surg patients could be reasonable. Significantly more Japanese psychiatrists responded with some agreement to the reasonability of suicide when one is unable to fulfill social role expectations, and had more concern about causing suicidal ideation by informing terminal patients of their diagnosis. CONCLUSIONS: The results indicate that psychiatrists' attitudes towards the relationship of psychopathology with suicidal ideation, the effect of depression, and other cultural factors on the desire to die in the medically ill are issues that need better clarification among both the medical profession as well as within society. Looking at how other societies handle these matters may help to understand one's own approach to them.

Managing diazepam abuse in an AIDS-related psychiatric clinic with a high percentage of substance abusers.

Controversy over using benzodiazepines in a human immunodeficiency virus (HIV)-positive population to relieve sleep and anxiety has not been addressed in the literature. Serious problems with diazepam abuse emerged in a psychiatric outpatient clinic for a predominately HIV-positive and illicit drug-using population, which led to a review of patient characteristics and prescribing policies and to a systematic problem-solving effort. The patients originally prescribed diazepam were significantly more likely to be on methadone and have histories of intravenous drug use compared with the patients not on benzodiazepines. Thus, the patients asking for diazepam are likely to have histories of substance abuse and have a high potential for abusing the medication. The authors found that diazepam can be discontinued without causing a significantly greater drop-out rate in that group.

Psychopathology and psychotherapy in the dying AIDS patient.

AIDS is not yet the problem in Japan that it is in North American, Europe and Africa, but at the recent 10th International AIDS Conference held in Japan, it was estimated that more Asians will become infected with HIV in the coming year than any other population worldwide. Although the majority of these infections will occur in Thailand and India, it was estimated that there may be as many as 15,000 HIV positive individuals in Japan, a number expected to rise to 26,000 over the next 3 years. Although AIDS is arriving in Japan later, this may give society in general and the medical profession in particular, time to learn from the experiences and mistakes of those who had a head start in dealing with the epidemic. Although this paper deals with the dying AIDS patient, some of the issues faced by the therapist working with any population of dying patients will be reviewed before focusing more specifically, on some of the particular issues seen in working with AIDS patients.

Depression, HIV dementia, delirium, posttraumatic stress disorder (or all of the above)

A 29-year-old single Puerto Rican woman with AIDS was admitted to the Medical Service for pneumonia, seen by the Psychiatric Consultation Service, an eventually transferred to the Inpatient Psychiatric Unit with several possible psychiatric diagnoses including major depression, HIV dementia, delirium, and posttraumatic stress disorder. These possibly coexisting and interacting syndromes are discussed by three psychiatrists, one of whom is also a board-certified neurologist. This case illustrates the combined contribution of organic and psychological factor to complex behavioral disorders, which are increasingly common in HIV infection.

Association of baseline neuropsychological function and progression of illness over 4 years in HIV-seropositive individuals.

The authors conducted a study to examine the association between neuropsychological markers of central nervous system impairment and systemic human immunodeficiency virus (HIV) disease progression in a sample of 64 HIV-positive asymptomatic patients who were followed for a median of 45.6 months. Patients with poorer baseline scores on the Halstead-Reitan Trail-Making A neuropsychological test developed HIV-related systemic symptoms earlier over the study period than patients with the higher scores on the same test (P < 0.05). Subclinical neuropsychological dysfunction in otherwise asymptomatic HIV-infected individuals may be a harbinger of progressive HIV-related immunologic dysfunction.

A prospective four-year follow-up of neuropsychological function in HIV seropositive and seronegative methadone-maintained patients.

The evolution of central nervous system (CNS) impairments associated with human immunodeficiency virus (HIV) infection was assessed by a prospective, longitudinal study of patients in a methadone maintenance clinic. At a mean of 47 months after baseline testing, which included physical exams, HIV antibody testing and a neuropsychological (NP) screening battery, 121 subjects received a second NP assessment. Forty subjects (33%) who were seropositive at baseline showed statistically significant declines in NP function over the 4 years compared with 81 seronegatives, on the Finger Tapping and Trail Making B tests. This relatively long-term follow-up suggests that subtle cognitive deficits develop over time and can be identified early, but their course is slow and appears generally to parallel that of non-CNS symptoms/signs of HIV infection.

Incidence of suicidality in AIDS and HIV-positive patients attending a psychiatry outpatient program.

Current suicidality and many other characteristics were assessed in 183-patients in the various stages of HIV infection who were referred to a specialized HIV-related psychiatric clinic. Intravenous drug use was the most common HIV risk factor. Patients with AIDS had significantly less current suicidal ideation than patients with AIDS-related complex and asymptomatic HIV positivity. The lower suicidality in AIDS patients was independent of age, gender, HIV risk group, and source of referral. Possible explanations of this association include denial, refocusing of life goals in AIDS patients, and psychological changes related to central nervous system impairment.

Suicidality and HIV status.

Among psychiatric consultation patients, 322 AIDS patients were significantly less suicidal than 82 other HIV-positive patients and were comparable in suicidality to 1,086 patients with negative or unknown HIV status. AIDS patients had significantly more organic mental disorders. Organicity, denial, acceptance, and/or preoccupation with a fatal illness may reduce suicidality in AIDS patients.

The baron has AIDS: a case of factitious human immunodeficiency virus infection and review.

A 31-year-old cachectic intravenous drug user received treatment at in- and outpatient AIDS care facilities for almost one year before the diagnosis of Munchausen syndrome was established. Cases of factitious AIDS have been reported with increasing frequency since the onset of the AIDS epidemic. Patients typically give a complex history of opportunistic infections and present with acute neurological or psychiatric complaints. Few of these patients have a history of Munchausen syndrome. Most are members of groups at high risk for human immunodeficiency virus (HIV) infection and are thus at risk for actually developing the conditions they feign. As multidisciplinary care of HIV-infected patients becomes increasingly broad-based, technical, and expensive, health care providers should be aware of the phenomenon of factitious AIDS. Judicious confirmation of medical history and HIV serologic test results should not be overlooked in clinical facilities that are oriented toward treatment of HIV-infected patients.

Reducing unnecessary psychiatric consultations for informed consent by liaison with administration.

The frequency of a psychiatric consultation being requested to assess a patients' capacity to give informed consent varies among institutions, with most recent surveys reporting a frequency of between 3% and 8% of all consultations. At Montefiore Medical Center, a hospital policy was interpreted as mandating such consultations for all patients with possible or even definite lack of decisional capacity. From 1987 to 1988, 55% of all psychiatric consultations in the institution were for consent. Only 9% of the consent patients seen had an Axis I diagnosis other than organic mental syndrome (OMS). Because many of these consultations were believed to be unnecessary, with patient clearly able or unable to give consent, the consultation service worked first with administration to modify the guidelines, and then educated the medical and nursing staff as to when consultation was indicated. With this program, the number of consent consultations fell from 958 in 1988 to 177 in 1990, representing a major saving of staff time and third-party billings. In this era of cost containment and outside review of professional practices, psychiatrists must take responsibility for identifying areas where patient services and billings for them are not justified by clinical indications.

Characteristics of patients attending an HIV-related psychiatric clinic.

Demographic and clinical data were recorded for 324 patients who visited an AIDS-related psychiatric outpatient clinic over a three-year period. Seventy-five percent of the patients had a diagnosis of AIDS, AIDS-related complex, or asymptomatic HIV seropositivity. Intravenous drug use and heterosexual relations were the most common HIV transmission risk factors. Seventy-three percent of the patients were black or Hispanic; 51 percent were female. In all stages of HIV infection, adjustment disorder was the most common diagnosis; one third to one half of the patients had substance abuse diagnoses. Only 5 percent were diagnosed with dementia, with the incidence highest (12 percent) in patients with AIDS. On the basis of their experience with the clinic, the authors discuss issues that have proved important in the treatment of patients with the triple diagnoses of medical illness, mental illness, and substance abuse.