Diagnosing demoralization in consultation psychiatry.

Demoralization, a normal response to adversity, is commonly seen in medical and surgical patients referred for psychiatric consultation. Demoralization should be distinguished from adjustment disorders and other pathological conditions--a process that would be facilitated if demoralization, like grief, were given a V code in DSM. Although the primary responsibility for treating demoralization rests with the patient's physician, the consulting psychiatrist must make an accurate diagnosis and begin the process of supportive psychotherapy.

When does Huntington's disease begin?

Recent studies have detected basal ganglia atrophy in clinically asymptomatic persons with the genetic mutation that causes Huntington's disease (HD). Whether reductions in caudate and putamen volume on MRI scans are associated with changes in cognitive and neurologic functioning was examined in 13 healthy adults with the IT-15 mutation. Reduced striatal volume was found to correlate with greater neurologic (largely motor) impairment, slower mental processing speed, and poorer verbal learning, although none of the participants met even liberal criteria for clinical diagnosis of HD. These correlations are strikingly similar to those observed in symptomatic HD patients, possibly reflecting the earliest manifestations of disease.

Predictors of psychological adjustment to genetic testing for Huntington's disease.

In the present study the authors assessed predictors of adjustment to genetic testing for Huntington's disease. Fifty-two genetically positive and 108 genetically negative persons were studied for 1 year following testing. Adjustment, defined by hopelessness and depressive symptoms, was measured at 3, 6, 9, and 12 months after disclosure and was within normal limits for both groups. Those less well adjusted had tested positive, were married, had no children, or were closer to their estimated ages of onset. The study delineated risk factors for psychological distress that should be considered by people contemplating testing for Huntington's disease.

Pseudoseizures, sexual abuse, and hermeneutic reasoning.

It has been proposed that pseudoseizures are a symbolic expression of having been sexually abused. Such reasoning is hermeneutic in nature and potentially damaging if uncritically used. Sexual abuse is one of several risk factors for pseudoseizures, but it should not be deduced simply from the occurrence or form of the conversion disorder.

In defense of Pseudoseizure.

There continues to be disagreement over the best term for behavior that simulates an epileptic seizure. In the author's view, pseudoseizure is the most accurate of the expressions currently in use, and fears about its potentially damaging effects are unfounded. Even pseudoseizure, however, fails to convey the behavioral nature of the phenomenon in question, for it identifies what the problem is not, rather than what it is.

The mind-brain problem, epistemology, and psychiatric education.

The mind-brain problem is the fundamental mystery in psychiatry and the chief obstacle to a coherent curriculum for its students. Rather than acknowledge the problem as a source of ambiguity and discord, some educators have attempted to abolish, finesse, or ignore it. An alternative to these tactics is found in the epistemological approach taken by Karl Jaspers and others, which seeks to determine what we know and how we know it. Educational programs based on such an approach seem more likely than others to produce students who are broad-minded, tough-minded, and fair-minded.

Belief and behavior: the role of "folk psychology" in psychiatry.

Most psychiatrists assume that belief is a basis for behavior. The validity of this assumption has been challenged by certain philosophers who assign the concept belief to the domain of "folk psychology." These philosophers contend that the discoveries of neuroscience will eliminate the ideas of folk psychology from scientific discourse and that behavior will eventually be accounted for in terms of brain states. In order to examine the relationship of belief and behavior, examples of self-mutilation by normal and abnormal individuals are reviewed. It is concluded that belief is a basis for behavior and that neuroscience, like folk psychology, is valid only within certain limits.

Affective disorder: the new imperium.

Eugen Bleuler formulated schizophrenia as a disjunctive category based on universal, dimensional phenomena that were regarded as pathognomonic of the disorder. In consequence, schizophrenia came to dominate diagnostic practice in American psychiatry. This report suggests that affective disorder has been formulated in a similar way, and with a similar result. The nature of disjunctive categories is examined and their replacement by conjunctive categories for schizophrenia and affective disorder is anticipated.

Presymptomatic diagnosis of delayed-onset disease with linked DNA markers. The experience in Huntington's disease.

Clinical medicine in the 21st century is almost certain to include wide-scale use of molecular genetic diagnostic tests. In September 1986, The Johns Hopkins University School of Medicine initiated a voluntary program of presymptomatic genetic testing for Huntington's disease for persons at 50% risk. DNA analyses using the D4S10 (G8), D4S43, and D4S95 locus probes have been performed for 55 people. Twelve of the tests have yielded positive results, 30 were negative, and 13 were uninformative. Initial reactions ranged from joy and relief to disappointment, sadness, and demoralization. Thus far, there have been no severe depressive reactions. Although the sample size is small, our data suggest that people who receive genetic test results cope well, at least over the short term, when the testing is performed in a clinical context that includes education, pretest counseling, psychological support, and regular follow-up.

Clinical judgements of self-dramatisation. A test of the sexist hypothesis.

It has been claimed that the diagnosis of histrionic personality disorder is inherently sexist. To estimate the extent to which psychiatrists are influenced by sexist prejudice in their judgements about self-dramatization (the central trait in the histrionic cluster), we conducted a study in which male and female subjects rated the degree of self-dramatization portrayed in videotaped vignettes. The results did not support the sexist hypothesis that dramatic behaviour would more often be attributed to a woman than to a man, especially by male raters.

Patients with medically unexplained symptoms: DSM-III diagnoses and demographic characteristics.

This study reports DSM-III diagnoses and demographic characteristics of 100 patients consecutively referred to a university hospital consultation-liaison service for evaluation of medically unexplained symptoms suggesting physical disorders. Thirty-seven percent of patients received diagnoses of somatoform, dissociative, or factitious disorders, and 14% were felt to have psychologic factors affecting physical conditions. Although black and male patients were less often referred for medically unexplained symptoms, once referred they were more likely than white and female patients to receive diagnoses of somatoform, dissociative, or factitious disorders. Among patients with somatoform disorders, those with conversion disorder and somatization disorder tended to be young women, whereas those with psychogenic pain disorder were older and equally likely to be male or female.

The life-story method in psychotherapy and psychiatric education: the development of confidence.

The disease concept and the life-story method are perspectives of psychiatry that have different consequences for the education and practice of house officers. The premises of the disease concept are taught in medical school, and provide a familiar basis for the explanation of certain psychiatric conditions. As the house officer sees how the disease concept is applied to such problems, he rapidly becomes confident in his abilities to diagnose and treat them. For other conditions, however, the disease concept is inappropriate, and the life-story method should be chosen. The premises of this way of understanding suffering are rarely taught in a formal manner before residency training begins, and thus, when confronted with a patient for whom psychotherapy is the treatment of choice, the fledgling psychiatrist is often bewildered. An understanding of the life-story method and its implications for the process of psychotherapy should help give confidence to the practice of beginners.