Richard Balon, MD

The use of complementary and alternative medicine treatments by children and adults with ADHD is the rule rather than the exception…more than half of parents who have children with ADHD treat their child’s symptoms with vitamins, dietary changes, and expressive therapies-but only a small minority tell their doctor. And roughly 8 out of 10 patients who use these treatments regard them as their primary therapy.

That’s the premise of an 

And it’s that article that that editorial board member, Dr Richard Balon, has nominated as his “Top Paper” of the year.

Listen to Dr Balon discuss why he thinks this article is important to psychiatrists-and hear him summarize the teaching points he thinks could affect the way patients with ADHD are treated.

Dr Balon is Professor, Associate Residency Training Director, and Director of the Master of Science in Psychiatry Program at Wayne State University School of Medicine.  He has served as Director of Medical Student Education in Psychiatry and is a Graduate Faculty member at Wayne State University. Dr Balon has published and lectured widely in the areas of psychiatric education, sexual dysfunction, mood and anxiety disorders, and clinical psychopharmacology. 

Dr Balon's Top Paper of the Year: Integrative Management of ADHD

Podcasts

More than half of parents who have children with ADHD treat their child’s symptoms with vitamins, dietary changes, and expressive therapies-but only a small minority tell their doctor. More in this podcast.

Top Paper of the Year-Integrative Management of ADHD: What the Evidence Suggests

This 3-part manual on sexual disorders is edited by 2 psychiatrists who have been engaged for more than 20 years in clinical treatment of patients with sexual problems. Drs Balon and Segraves bring their rich experience to this field. Patients with sexual disorders need extra time to present their questions of doubt, confusion, misunderstanding, and perhaps guilt and shame. They also need clarification and understanding-and possible answers and reassurance.

Sex education in the home remains a wonderful rarity. In the past 2 to 4 decades, accurate sex education has finally become readily available in the United States-a result of sexual research. However, few physicians can say they received adequate sex education as children from parents comfortable enough to sit them down and say, “Sex is good. Let me tell you about the positives and negatives.”

Sexual silence at home and in most classrooms continues to allow much misinformation to remain. Early sexual experiences-while secret and exciting-can inevitably develop into fears, guilt, doubts, and ignorance. Some patients may require inquiry and discussion of sexual matters in individual therapeutic settings.

Therefore, many physicians will benefit from this interesting and readable paperback. It is well organized, and it includes contributions by clinical specialists and an indexed section to assist in rapid reference. 

is of great benefit to any patient, either gender, single or partnered. I highly recommend it for every physician’s bookshelf and for personal reading.

Articles

This 3-part manual on sexual disorders is edited by 2 psychiatrists who have been engaged for more than 20 years in clinical treatment of patients with sexual problems. 

Clinical Manual of Sexual Disorders

on sexual disorders is edited by 2 psychiatrists who have been engaged for more than 20 years in the clinical treatment of patients with sexual problems. Drs Balon and Segraves bring their rich experience to this field. Patients who have sexual disorders need extra time to present their questions of doubt, confusion, misunderstanding, and perhaps guilt and shame. They also need clarification and understanding-and possible answers and reassurance.

This 3-part manual on sexual disorders is edited by 2 psychiatrists who have been engaged for more than 20 years in the clinical treatment of patients with sexual problems. Drs Balon and Segraves bring their rich experience to this field. Patients who have sexual disorders need extra time to present their questions of doubt, confusion, misunderstanding, and perhaps guilt and shame. They also need clarification and understanding-and possible answers and reassurance.

Everyone would probably agree that the practice of clinical psychiatry has changed profoundly over the second half of the past century. One of the most remarkable changes has been the rapid development and expansion of clinical psychopharmacology, which has become, like it or not, a dominant part of the clinical practice of most psychiatrists. Available treatments for mental disorders changed and our armamentarium broadened. We have numerous medications for psychiatric disorders. We even use medications for disorders traditionally considered only amenable to and suitable for psychotherapy.

Clinical psychopharmacology, after its growing pains, has become a full-fledged, complicated discipline. New medications appear all the time that have various, at times complicated and serious, adverse-effect profiles. Drug-drug interactions have become an important issue. Clinical studies comparing psychotropic medications and reports on their benefits or dangers appear each month in psychiatric journals. The evidence base of clinical psychopharmacology keeps growing at an amazing rate. Pharmacoeconomics is already changing our practice, and new pharmacogenetic technologies seem to be on the verge of changing it even more.




The knowledge base of clinical psychopharmacology is clearly growing and becoming increasingly complex. It is obvious that because of information overload, any one person's expertise in all aspects of clinical psychopharmacology has to be decreasing. Nevertheless, clinical psychiatrists need to be educated and skilled in all aspects of clinical psychopharmacology. Thus, because of the growing complexity of psychopharmacology there is a need for creating some kind of "collective expertise and wisdom" by the experts in the field, which needs to be taught to physicians by using innovative teaching methods.

As Glick and colleagues noted, "psychopharmacology was taught using an apprenticeship model, with trainees expected to learn about medications by shadowing their mentors, reading in libraries, and applying that knowledge to the cases they saw."

 While using the apprenticeship model in clinical psychopharmacology may be practical and useful, this educational practice cannot embrace all the intricacies and complexities of the field. Furthermore, this model raises the important issue of whether the mentors themselves are keeping up with the developments in the field and, if so, how they do it. The "amount of material needing to be taught has expanded, [while] the resources available to do the job have contracted."



The 2 traditional sources of information for clinicians and experts, journals and psychopharmacology textbooks, have their own strengths and weaknesses. The number of journal articles and the complexity of their interpretation are increasing. Publication bias may be difficult to untangle at times. Textbooks usually bring a huge, comprehensive volume of information that may be somewhat difficult to digest, and they may be somewhat outdated because of the publication delay of books. Thus, there is a great need for a summary of information that:

• Is generated by experts.
• Is up-to-date.
• Is comprehensive yet relatively easy to understand.
• Is easy to use for teaching purposes by those who may not be experts in every aspect of the field. 
• Is easy to update, revise, and adapt to local needs ("portable").
• Uses new technologies.
• Is unbiased and not influenced by the pharmaceutical industry.




These criteria certainly represent an ideal that may be difficult to achieve completely. The information provided in such a format would be enormously helpful to teachers in psychiatry residency training programs, physicians in the field, teachers of medical students, and possibly physicians in other fields and disciplines. Some persons may argue that some of the distributed newsletters and digests (free or not-so-free of charge) fulfill at least some of the criteria. Perhaps they do, however, we believe that the best teaching tool or format that would fulfill all these criteria is a model psychopharmacology curriculum.

As Goldberg

 has pointed out, model curricula have a checkered history in psychiatric education. They have a static feel to them and can make otherwise seasoned educators feel like substitute teachers. Yet, the ideas behind them are compelling. In addition to the expertise, comprehensiveness, and easy understanding that such a curriciulum would provide, a model curriculum could be used at multiple sites and levels and could provide standardized educational materials across the field throughout the country.

A

merican Society of Clinical Psychopharmacology curriculum


About a decade ago, the curriculum committee of the American Society of Clinical Psychopharmacology (ASCP) developed the first edition of its model psychopharmacology curriculum.

 This curriculum was developed from an earlier version of a psychopharmacology curriculum prepared in the early 1980s under the auspices of the American College of Neuropsychopharmacology (ACNP).

 The ACNP curriculum, although well received and translated into several languages, has never become widely used.



The newer ASCP version has undergone several revisions during the past decade (the fifth revision is under way). It has outgrown its originally relatively primitive format (eg, slides available only as printed hard copy) and has become fairly sophisticated. In a small survey following the distribution of its first edition, 62% of the responders from the training programs surveyed found that the ASCP curriculum was, to varying degrees, satisfying, and it improved their psychopharmacology teaching.

 The results of this survey and other feedback have been used in the development of the subsequent editions of the model curriculum.

The ASCP model psychopharmacology curriculum consists of lectures by experts in the field, selected by the members of the ASCP Curriculum Committee (for the fourth edition: Drs Glick, Balon, Ellison, Janowsky, Lydiard, Oesterheld, Osser, Thompson, Walton, and Zisook).

The contributors were asked to provide the committee with an expert lecture on a certain topic (eg, a well-known expert on the psychopharmacology of generalized anxiety disorder is asked for her or his lecture on that topic). They were also given some specifications regarding the format of the lectures (eg, pretest and posttest questions, major teaching points, outline, length, and making sure that the slides are free of bias).

It is important to note that the initial version of the curriculum was supported by an unrestricted grant from Eli Lilly to cover the administrative costs, although Lilly did not influence the content. However, the newer editions of the curriculum were developed without any outside support-committee members gave their time voluntarily and without any compensation, and the administrative costs were covered by the ASCP (partially by the sale of the curriculum to residency programs). We have to emphasize that the existence of the model curriculum would not be possible without 

the incredible generosity of the psychopharmacology experts 

around the country who donated their lectures (either lectures in existence or newly created lectures) and their time in creating, refining, and revising them.

Curriculum description and content The key issue seems to be providing psychopharmacology teachers with a core group of slides that can be used to present the lecture as it stands or from which each local teacher can build a lecture.

 Thus, the main part of the curriculum consists of slides of 60-plus lectures by experts in their field. 

However, lectures alone would not be enough for comprehensive teaching. Therefore, the curriculum (fourth edition) consists of 3 printed spiral-bound volumes that, in addition to hard copies of all slides, include various materials important for teaching psychopharmacology. The slides of all the lectures also are provided on a CD in PowerPoint format. 

The curriculum consists of 3 volumes (

 stressed that clinical education is best developed when conceptualized as sequential and linked to the rest of the teaching program; thus, all the lecture modules are organized as follows.

• The "crash course" is presented first. This is to be used in PGY-1 and PGY-2 because it stresses the basics of inpatient and emergency department psychiatry and emphasizes safety and drug-drug interactions.
• The next module includes a PGY-2 basic or introductory course.
• The following module includes the PGY-3 and PGY-4 advanced psychopharmacology course.
• Finally, child and adolescent psychopharmacology and geriatric psychopharmacology courses are included.

The complete list of lecture topics is beyond the scope of this article, but the curriculum covers psychopharmacology of all mental disorders for which evidence exists. Lectures on topics such as evidence-based psychopharmacology; combining psycho pharmacology and psychotherapy; electroconvulsive therapy; other biological therapies; and drug-drug interactions are included.




As the instructions for the model curriculum note, this curriculum should not be considered a textbook or handbook of psychopharmacology. It is not a reference book. It is a sophisticated teaching tool that provides a clinically oriented overview of the field aimed at teachers, residency directors, and others responsible for physician education and for ensuring standards of knowledge and practice (competencies) within an organization. Because of its flexibility, the persons using the curriculum can add, delete, change, reorder, or combine slides from different modules and build their own lectures based on the chosen slides.

Hard copies of the slides (included in Volumes 2 and 3) may be distributed to the audience to allow note writing. Some lectures consist of "key" slides marked by asterisks and slides considered to be "extra," which allows the lecturer to use either the "key" slides by themselves or the entire lecture series, depending on time availability. The lectures do not usually provide references; rather, the user is referred to the recommended list of journals and texts for the appropriate text, chapter, or article. Each lecture includes a pretest and posttest that may be useful to gauge the effectiveness of the teaching.

Because the ASCP Curriculum Committee recognized the difficulties in introducing such a curriculum and the anxieties associated with it, names and contact information of its members are provided in case consultation is needed or users wish to provide feedback or to suggest improvements.



Usefulness of the curriculum beyond residency training


The ASCP curriculum is intended primarily for teaching clinical psycho-pharmacology in residency training programs and fellowships (child and adolescent, and geriatric). However, the expert-based knowledge, comprehensiveness of the program, and that the curriculum is regularly and frequently updated may suit physicians in the field who would like to update their knowledge base and skills (especially if they are unable to attend the many continuing medical education programs around the country or if they would like to avoid industry-sponsored educational activities).




The future of any curriculum depends on its use by educators in the field. Because we believe the model psychopharmacology curriculum meets most if not all the criteria for a modern educational tool, we hope that more and more residency training programs in psychiatry will use the curriculum in their programs. We believe that each program should identify, if possible, a coordinator or director of psychopharmacology training who can introduce and implement this curriculum.

The curriculum will be regularly and frequently updated, and we hope to continue to use experts in the field to provide top-notch psychopharmacology education to our trainees. The ASCP Curriculum Committee is planning to include another subspecialty track on the psychopharmacology of substance abuse disorders (in addition to the child/adolescent and geriatric psychopharmacology tracks) in the curriculum. Other ideas entertained as part of the curriculum expansion include possible developments of psychopharmacology curricula for medical students and primary care physicians, or making parts or modules of the curriculum available to interested physicians.

We hope that the ASCP model psychopharmacology curriculum will help improve the quality of clinical psychopharmacology education, and that it will ultimately benefit our patients.

 

 Glick ID, Zisook S, Shader RI. The challenge of teaching psychopharmacology and improving clinical practice

 Goldberg DA. Model curricula. The way we teach, the way we learn. 

 Glick ID, Janowsky DS, Zisook S, et al. How should we teach psychopharmacology to residents? Results of the initial experience with the ASCP model curriculum. 

 Glick ID, Zisook S. The challenges of teaching psychopharmacology in the new millennium: the role of curricula. 

 Glick ID, Janowsky DS, Salzman S, Shader RI. A proposal for a model psychopharmacology curriculum for psychiatric residents. 

Everyone would probably agree that the practice of clinical psychiatry has changed profoundly over the second half of the past century. One of the most remarkable changes has been the rapid development and expansion of clinical psychopharmacology, which has become, like it or not, a dominant part of the clinical practice of most psychiatrists. Available treatments for mental disorders changed  and our armamentarium broadened. We have numerous medications for psychiatric disorders. We even use medications for disorders traditionally considered only amenable to and suitable for psychotherapy.

A New Tool for Teaching Psychopharmacology

Sexual dysfunctions as distinct syndromes were first identified in 

 in 1980. At that time, sets of criteria were specified for inhibited sexual desire, inhibited sexual excitement, inhibited female orgasm, inhibited male orgasm, premature ejaculation, dyspareunia, and functional vaginismus. The sexual dysfunctions roughly corresponded to the phases of the sexual response cycle introduced by Masters and Johnson

 with the exception of disorders of sexual desire. The concept of inhibited sexual desire was separately introduced by Lief

 in 1977. It is important to note that some have questioned the wisdom of anchoring the diagnoses of sexual dysfunction in the phases of sexual response cycle, since 

-defined sexual dysfunctions frequently overlap, especially in the area of female sexual dysfunction.

Subsequent revisions of these categories have consisted of name changes (eg, inhibited sexual desire being changed to hypoactive sexual desire disorder), the addition of sexual aversion disorder (a diagnosis rarely used), the addition of subtypes (lifelong vs acquired, generalized vs situational, due to psychological factors vs due to combined factors) and minor modification of criteria sets. In 

 2 additional categories were added, namely substance-induced sexual dysfunction (eg, SSRI-induced anorgasmia) and sexual dysfunction due to a general medical disorder (eg, erectile dysfunction due to multiple sclerosis or due to diabetes mellitus). The diagnostic criteria for each sexual dysfunction are operationally defined in a similar way.

Criterion A defines the specific psychophysiological impairment (for example, lack of orgasm or erectile dysfunction).

Criterion B requires that the disturbance causes marked distress or interpersonal difficulty.

Criterion C requires that the dysfunction is not better accounted for by another Axis I disorder or general medical condition and is not solely due to a substance effect (medication use or abuse).

The requirement of exclusion of sexual dysfunction due to another Axis I disorder is an interesting and puzzling concept. The association of sexual dysfunctions with various physical illnesses is well known and is basically acknowledged by the creation of the "sexual dysfunction due to general medical condition" diagnostic category. Lately, we have increasingly appreciated the association of sexual dysfunctions with various psychiatric disorders, eg, major depression (well known for a long time) or schizophrenia. It is a bit puzzling and inconsistent not to establish the diagnostic category of "sexual dysfunction due to mental disorder" (especially because sexual dysfunction due to substance abuse could be classified as such, and even subclassified as "with onset during intoxication").

 the category of sexual disorder not otherwise specified is included at the end for those problems/behaviors that do not meet criteria for any specific sexual disorder, eg, marked feelings of inadequacy concerning sexual performance or other traits related to self-imposed standards of masculinity or femininity.

 new research on sexual disorders has shed additional light on issues such as distress and duration. Research results will no doubt be reflected in the upcom- ing 

. In this article, we briefly review the limitations of the current criteria for sexual disorders and suggest revisions that might be made in 

 and other criteria of sexual dysfunction are widely used, their validity and reliability have not been properly tested. 

 criteria also differ slightly from another set of sexual dysfunction diagnostic criteria-those of the 

ICD-10 Classification of Mental and Behavioural Disorders

 criteria include the duration criterion [6 months for most], which is not included in the 

 classification of sexual dysfunctions, several pervasive problems have remained. One major issue is the absence of operational criteria for the disorders. For example, premature ejaculation is defined as "persistent or recurrent ejaculation before, on, or shortly after penetration and before the person wishes it." From this definition, it is unclear exactly what constitutes "shortly after penetration." At this point, data regarding the average ejaculatory latency of men in multiple countries including the United States exist and, thus, we should be able to set specific times from penetration to ejaculation for the diagnosis of premature ejaculation.

 Similar lack of specificity plagues the other diagnoses.

 have specific duration criteria before a diagnosis can be made (eg, a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting for at least 1 week for the diagnosis of a manic episode). Such duration criteria might help the clinician to distinguish between transient alterations in sexual behavior related to partner relational problems and transient stress from more persistent problems, which might require medical intervention.

 For example, findings from population studies undertaken by Oberg and colleagues

 show that most sexual problems last less than 6 months. The problems lasting 6 months or longer may represent a different group of individuals and constitute a more homogeneous group for study of the efficacy of treatment interventions. Similarly, population studies suggest that more severe sexual problems may be less frequent than less severe ones, again suggesting that severity might be a logical way to define homogeneous groups.

As suggested above, operational criteria specifying frequency and duration of complaints are necessary to define homogeneous groups with a clear separation of severe, persistent sexual dysfunction from transient disturbances that may resolve without professional attention.

There are numerous other issues that need to be remedied in 

 requires that the diagnosis of hypoactive sexual desire disorder be based on absent or deficient sexual fantasies and the desire for sexual activity. Studies indicate that many women who are sexually responsive do not report having sexual fantasies. Also, some women report responding to partner advances yet not being aware of desire for sexual activity before partner initiation. This controversy and lack of clarity has led some to propose adding the "lack of responsive desire" criterion to the diagnostic criteria for femalehypoactive sexual desire disorder.

 is based on "recurrent or persistent involuntary spasm of the outer third of the vagina." However, recent research suggests that involutary contraction of the musculature of the vaginal wall may be present in only a subgroup of women with vaginismus. Phobic avoidance of penetration may be the defining aspect of this syndrome.

 is subtyping by causation. As we acquire more information about sexual disorders, it is clear that some disorders-especially hypoactive sexual desire disorder-are idiopathic.

 Requiring a distinction between sexual disorders that are due to psychological factors and those due to combined factors implies a knowledge regarding causation that is often absent.

In addition, the question of whether classifying dyspareunia as a sexual dysfunction is appropriate has been raised and the suggestion made that it be classified instead as a pain disorder.

 The area of female sexual dysfunction is perhaps the most problematic and confusing. Some experts have even questioned the existence of female sexual dysfunction and/or separate female sexual dysfunction entities and have suggested that the entire area of female sexual dysfunction diagnoses is at least in part created by the pharmaceutical industry.

 This viewpoint, although valid to some degree, is clearly an oversimplification of the issues. 

Pharmaceutical companies, driven by the profit motive, discover interventions for conditions that previously were untreatable. Subsequently, the marketing arm of these companies tries to increase the population for whom a treatment may be given in order to expand the market for their products. It is the health care professional's role to be certain that any given interven- tion is indeed appropriate for each patient.

 subgroup on sexual disorders should be convening in the near future. The group faces an exciting challenge because considerable information on the sexual disorders regarding issues such as distress and duration of sexual dysfunction has been reported since the publication of 

. We now may be able to adapt meaningful operational criteria for these diagnoses and  correct previous misconceptions about diagnostic criteria. It will also be especially challenging to address the biopsychosocial concept of sexual dysfunction, to face off demands of special interest groups, and to avoid both biological and psychological reductionism.

Hopefully, more precise criteria sets will facilitate clinical research and permit the development of meaningful treatment algorithms.

. Boston: Little Brown and Company; 1970.


 Segraves R, Balon R, Clayton A. Proposal for changes in diagnostic criteria for sexual dysfunctions. 

 Waldinger MD, Schweitzer DH. Changing paradigms from a historical 

 view toward an evidence based definition of premature ejaculation. Part II--proposals for 

 Moore D, Heiman J. Women's sexuality in context: relationship factors and female sexual dysfucntion. In: Goldstein I, Meston C, Davis S, Traish A, eds. 

 Oberg K, Fugl-Meyer A, Fugl-Meyer K. On categorization and quantification of women's sexual dysfunction: an epidemiological approach. 

 Mercer CH, Fenton KA, Johnson AM, et al. Sexual function problems and help seeking behavior in Britain: national probability sample survey. 

 Reising E, Binik Y, Khalife S, et al. Vaginal spasm, pain and behavior: an empirical investigation of the diagnosis of vaginismus. 

 Segraves R, Woodard T. Female hypoactive sexual desire disorder: history and current status. 

 Binik Y. Should dyspareunia be retained as a sexual dysfunction in 

 A painful classification decision. Arch Sex Behav. 2005;34:11-21.


 Tiefer L. Sexual behavior and its medicalisation. Many (especially economic) forces promote medicalisation. 

Sexual dysfunctions as distinct syndromes were first identified in DSM-III in 1980. At that time, sets of criteria were specified for inhibited sexual desire, inhibited sexual excitement, inhibited female orgasm, inhibited male orgasm, premature ejaculation, dyspareunia, and functional vaginismus.

Toward an Improved Nosology of Sexual Dysfunctions in DSM-V

The focus of this Special Report on anxiety disorders is not accidental. Anxiety disorders are, probably next to substance abuse, the most common mental disorders in the general population, and definitely the most common mental disorders among children and adolescents. Over the last several decades, we have seen tremendous developments in conceptualization, classification and treatment of these disorders. The time when benzodiazepines occupied the central stage in the treatment of these disorders is gone. Selective serotonin reuptake inhibitors and various forms of therapy, especially cognitive-behavioral therapy (CBT) are now considered first-line treatments in many, if not all, anxiety disorders. As child and adolescent psychopharmacology is coming of age, a large body of research data is emerging, and we are approaching treatment of children and adolescents more systematically. Research into anxiety disorders is focusing on the role of serotonin, amygdala, early experiences and many other issues.

The articles in this Special Report illustrate these developments, covering important problems such as: treating anxiety disorders during various stages of life; the relationship between pediatric anxiety disorders and adult psychopathology; differences between childhood and adolescent anxiety presentation from that in adults; issues associated with risk of relapse in panic disorder; the rational treatment for pediatric obsessive-compulsive disorder; tools for assessing severity of generalized anxiety disorder; and treatment options and considerations for late-life anxiety. The articles present a wealth of clinical material and lot of food for thought.

Nonetheless, brooding over the articles evokes more questions. Where does the universal experience of normal anxiety end and pathological anxiety begin? How does one decide whether to use CBT or medication in children and adolescents (especially since no medication is approved by the U.S. Food and Drug Administration for pediatric anxiety disorders)? Do benzodiazepines, especially the old ones, deserve the bad name they have received? What is the role of anxiety in healthy development? What is the social function of anxiety? How much does personality makeup contribute to the experience of and coping with anxiety? And there are certainly many others.

Hopefully, this Special Report will help the reader address some of the important decisions in the management of anxiety disorders. It may also help in finding answers to some of the aforementioned questions raised. It reminds us how little we know, how much still has to be done, and how much more our approach to treatment selection still reflects art rather than science.

The focus of this Special Report on anxiety disorders is not accidental. Anxiety disorders are, probably next to substance abuse, the most common mental disorders in the general population, and definitely the most common mental disorders among children and adolescents.

Richard Balon, MD

Articles

Top Paper of the Year-Integrative Management of ADHD: What the Evidence Suggests

Clinical Manual of Sexual Disorders

Clinical Manual of Sexual Disorders

A New Tool for Teaching Psychopharmacology

Toward an Improved Nosology of Sexual Dysfunctions in DSM-V

Special Report: Anxiety Disorders Across the Life Span