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My first job after residency involved working at a large Veterans Affairs hospital in an outpatient dual diagnosis treatment program that focused on the comorbidity of schizophrenia and cocaine dependence. Having recently completed a chief resident position at the same hospital’s inpatient unit that focused on schizophrenia without substance abuse, I was struck by how “unschizophrenic” my new patients were. They were organized and social. Their psychotic symptoms were usually limited to claims of “hearing voices,” for which insight was intact and pharmacotherapy was readily requested.

It has been a relatively short time between clinical use of the term anxiety neurosis-which included worry, panic, and obsessions-and the advent of recent DSM-defined categorical diagnoses of panic disorder, generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. It seems that we have moved from a symptom-oriented approach in treating anxiety to a syndromal approach in which the patient has to accumulate enough symptoms and impairment to have a more definable illness or disorder.

The number of persons in the United States who take prescription opioids for pain is growing. Sullivan and colleagues2 found that from 2000 to 2005 there was a 19% increase in the number of patients who received prescriptions for opioids to manage chronic noncancer pain conditions. Based on a survey conducted from 1998 to 2006 with more than 19,000 subjects, Parsells Kelly and associates3 reported that 2% of the US population 18 years and older legally used opioids as analgesics at least 5 days per week for 4 or more weeks-and that another 2.9% used these drugs less frequently.

Book reviews have long been a first defense against scholastic overload. Generations of high school students have bypassed Wuthering Heights and The Scarlet Letter in favor of CliffsNotes, and now Wiki­pedia. Many people use the New York Times Book Review less to plot future reading than to pick up enough talking points about this week’s bestseller that they can skip it but still sound intelligent. Recently, litterateur and psychoanalyst Pierre Bayard anatomized this art of faked literary chat in his nearly serious study, How to Talk About a Book You Haven’t Read.

The words attributed to Socrates resonate with the perspectives of many contemporary parents and clinicians.1 The endurance of the concern suggests something fundamental about the psychopathology of deviant, disruptive behavior of youth. Yet clinicians struggle to understand its origins, to help parents control their children, and to help the children control themselves. Clinically, this manifests in failed pharmacological treatments, incompleted courses of individual therapy, problems in engaging families in treatment, and controversies over which therapy is most effective.

Almost midnight and pissed off at my partnerwho left early again to rescue her drunkdriving husband, leaving me to work upthe O.D. who wants to leave against my orders.

While ECT remains a remarkably safe and effective treatment for severe depression, its broad application has been hampered by concerns-both perceived and real-about its cognitive effects.5 Worries about memory loss make some patients reluctant to undergo this therapy and some practitioners reluctant to refer patients for it. Within the field of ECT itself, there has been tension for some years between the wish to maximize (the already excellent) antidepressant and antipsychotic efficacy of ECT and the competing wish to minimize any effects on memory.

Women with bulimia nervosa (BN) respond more impulsively during psychological testing than do women without eating disorders, according to a recent article in Archives of General Psychiatry.1 Functional MRI showed differences in brain areas responsible for regulating behavior in women with and without BN.

I am scared of heights. As a psychiatrist, it’s faintly embarrassing to have such a phobia-but given that I live in a Boston suburb, not the Rockies, it’s a problem that hardly ever comes up. Ski lifts and I don’t get along all that well, but other than that, I barely ever think of this as an issue in my life.

Because numerous diseases- infectious, endocrinological, metabolic, and neurological, as well as connective-tissue disease-can induce psychiatric and/or behavioral symptoms, clinicians need to distinguish these neuropsychiatric masquerades from primary psychiatric disorders, warned José Maldonado, MD, the director of Stanford University’s Psychosomatic Medicine Service.

Just the sight of someone smoking may be enough to trigger the desire to start smoking again among those who have kicked the habit. Researchers from Duke University Medical Center have been trying to determine what changes in the brain lead to the desire to start smoking again. They used functional MRI to visualize changes in brain activity of persons who were trying to quit.1 Eighteen adult smokers were scanned once before quitting and 24 hours after quitting. Participants were shown photographs of people smoking during the scanning.

The FDA is forcing manufacturers of all antiepileptic drugs to include new warnings of possible suicide ideation in the prescribing information and also to prepare a new Medication Guide to be distributed by pharmacies to consumers. In addition, the companies will have to produce a Risk Evaluation and Mitigation Strategy for each drug, which the FDA only requires for drugs with possible adverse effects it considers especially dangerous.

In a resolution that has been expected since October 2008, pharmaceutical company Eli Lilly pled guilty to a criminal charge and has agreed to pay $1.42 billion in a settlement for what federal prosecutors called the illegal promotion of the antipsychotic drug Zyprexa (olanzapine). The drug was found to increase the risk of severe adverse effects, including sudden cardiac death, heart failure, and life-threatening infections, in certain populations.

Fibromyalgia syndrome is a chronic condition that consists of a pervasive set of unexplained physical symptoms with widespread pain (involving at least 3 of 4 body quadrants and axials) of at least 3 months duration and point tenderness at 9 bilateral locations (Figure) as the cardinal features.1 Patients with FM report a set of symptoms, functional limitations, and psychological dysfunctions, including persistent fatigue (78.2%), sleep disturbance (75.6%), feelings of stiffness (76.2%), headaches (54.3%), depression and anxiety (44.9%), and irritable bowel disorders (35.7%).1 Patients also report cognitive impairment and general malaise, “fibro fog.” This pattern of symptoms has been reported under various names (such as tension myalgia, psychogenic rheumatism, and fibro­myositis) since the early 19th century.

The 2 most common anxiety disorders are generalized anxiety disorder (GAD) and panic disorder. Approximately 5.7% of people in community samples will meet diagnostic criteria for GAD in their lifetime; the rate is about 4.7% for panic disorder (with or without agoraphobia).1 GAD-which is characterized by excessive and uncontrollable worry about a variety of topics (along with associated features such as trouble sleeping and impaired concentration)-is often chronic and is associated with significant costs to the individual and to society.

Are serum concentrations of folate and vitamin B12 related to the onset of dementia? Can depression be prevented with folate, vitamin B12, and B6 supplementation? Two recent studies shed light on these questions.

Sildenafil (Viagra, Revatio) reduced antidepressant-associated sexual dysfunction in wom­en in a randomized controlled trial, which investigators characterize as the first conducted in women with this adverse drug effect.

Does adoption pose psychological risks? University of Minnesota researchers revisited this controversial issue recently and found that common DSM-IV childhood disorders are more prevalent in adoptees than nonadoptees.

An NIMH-sponsored study found that extending the duration of therapy for depressed adolescents increased the rate of response and decreased relapse rates relative to acute, short-term treatment.

Suicide risk assessment is a core competency that all psychiatrists must have.1 A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.2 Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide-and those who will.

I am a fan of the television show Deadliest Catch-a documentary series that follows the travails of deep-sea fishermen in the Bering Sea. (Actually, it is mostly about deep crab fishing.) Living in Seattle, I have actually seen some of the boats filmed on the show.

A new study is raising important questions about the brain’s ability to remain active and regenerate in later life and whether Web searching can stimulate brain activity in middle-aged and older adults.

A combination of cognitive-behavioral therapy (CBT) and antidepressants to treat anxiety disorders in youngsters has yielded positive results in a government-funded study that was published online by the New England Journal of Medicine.1

Imagine seeing a patient in your office and being able to test for dozens or even hundreds of diseases with just the swipe of a card that contains microscopic samples of the patient’s blood, saliva, or urine. This technology may not be far off.

Although most studies have focused on the risk of metabolic syndrome for patients with schizophrenia exposed to atypical antipsychotics, other psychiatric patients appear to be at risk for metabolic disturbances as well.7-9 Major depressive disorder (MDD) may be of particular interest because it is much more common than schizophrenia and is treated with a broad range of psychotropics.

Psychiatrists will average a 4% fee increase in 2009 from Medicare, which compares very favorably with many other subspecialties.

Identifying and Reducing Professional Liability When Treating Older Adults, by Jacqueline M. Melonas, RN, MS, JD and Charles D. Cash, JD, LLM, ARM

Identifying and Reducing Professional Liability When Treating Older Adults, by Jacqueline M. Melonas, RN, MS, JD and Charles D. Cash, JD, LLM, ARM

She paused for a few moments and then responded, "I don't know when children may begin to think their parents are unhappy with each other except, of course, if there are a lot of arguments and fights. My parents didn't argue or fight, but they were not openly affectionate either.

A recent letter to the American Psychiatric Association (APA) from Sen Chuck Grassley about the APA’s financial relationship with pharmaceutical companies raises concerns about undue industry influence.1 By instituting a disclosure policy for DSM-V, the APA took a halting first step in restoring public trust in the most influential text on psychiatric taxonomy in the world. Unfortunately, the APA’s efforts at creating a conflict of interest (COI) policy have failed to ensure that the process for revising diagnostic and therapeutic guidelines is one that the public can trust. The need for more safeguards was evidenced when the APA reported that of the 27 task force members of DSM-V, only 8 reported no industry relationships.2 The fact that 70% of the task force members have reported direct industry ties-an increase of almost 14% over the percentage of DSM-IV task force members who had industy ties-shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed.