Addiction & Substance Use

The fiscal year (FY) 1999 budget for National Institutes of Health funding totals more than $15 billion. This figure reflects an increase of 15% over the FY 1998 budget and is $320 million less than President Clinton's requested budget for FY 2000 (Varmus, 1999). The Foundation Center reports the funding from U.S. grant-making foundations in 1998 as $15.4 billion from independent foundations, $2.37 billion from corporate foundations and $1.48 billion from community foundations (Foundation Center, 1999). Additional funds are available from the National Science Foundation (NSF), which has a $3.95 billion budget request for FY 2000, up almost 6% from FY 1999 (NSF, 1999). With all of this available funding, how can medical clinicians and researchers increase their chances of obtaining a medical grant?

By the time I interviewed Robyn in the emergency room, her panic attack had all but passed. But this 21-year-old woman was still shaken and tearful. This was her first panic attack, and she did not know what hit her. She thought she was having a heart attack. She had a tight feeling in her chest, she was hyperventilating. Her fingers and feet were numb and tingling. She experienced what she called a "closing in feeling." Robyn thought she was going to die.

Among psychiatrists who treat patients with HIV/AIDS, the question of how psychosocial distress effects the progression of HIV disease is likely to arise. Even for healthy individuals, we are only beginning to clarify the complex pathways by which thoughts and emotions impact immune function. Due to the bidirectionality of the communications of the brain and the immune system, this is a complicated scenario. The fact that HIV alters the function of the immune system during the course of its progression creates greater confounds to the understanding of these systems. We will address the rationale that progression from HIV infection to AIDS may be modulated by psychosocial factors, discuss possible reasons for conflicting findings and posit some clinically relevant recommendations drawn from research findings.

In the 1950s and 1960s, researchers found that mice and rats subjected to stressful stimuli were more likely to develop viral infections and tumors than nonstressed animals (Miller, 1998). Today, that once-pioneering research in psychoneuroimmunology (PNI) has burgeoned into sophisticated clinical studies that look at, for example, how caregiving can affect the immune system, how stress may delay wound healing and how pretreatment with an antidepressant prevents cytokine-induced depression in therapy for cancer.

As chief of the division of sleep and chronobiology in the department of psychiatry at the University of Pennsylvania School of Medicine, David F. Dinges, Ph.D., focuses on ways sleep and the endogenous circadian pacemaker interact to control wakefulness and waking neurobehavioral functions such as physiological alertness, attention, cognitive performance, fatigue, mood, neuroendocrine profiles, immune responses and health. In an interview with Psychiatric Times, Dinges discussed neurobehavioral consequences of sleep loss, factors that impair sleeping, the pervasiveness of sleepiness and new ways to manage sleepiness.

Mood-stabilizing drugs slipped into the vocabulary of psychiatrists during the last 15 years without a proper discussion of their definition. Consequently, these medications have been used in ways that have no empirical justification.

Present-day psychiatry has fallen into crisis because of the severe limitations of its conception of the person and, as a result, its conception of the patient. It objectifies the patient in a number of ways. Because of this reductionism, psychiatry fails to distinguish between healthy and pathological features of human life. It fails to consider adequately the psychological and social factors that cause and maintain each patient's problems.

The most common psychiatric sequelae following trauma include major depressive disorder, somatoform pain disorder, adjustment disorder and posttraumatic stress disorder (PTSD). In law, trauma that precipitates PTSD is viewed as a tort, which stems from the root word "torquere" (to twist), as does the word torture. In a sense, plaintiffs do allege torture in personal injury cases. A tort constitutes a civil or private wrong, as opposed to a criminal wrong, and rests on the general principle that every act of a person causing damage to a legally protected interest of another obliges that person, if at fault, to repair the damage (Slovenko, 1973).

More than 430 psychiatrists, research donors and others gathered in late October for the National Alliance for Research on Schizophrenia and Depression (NARSAD)'s awards dinner in New York City. The black-tie fundraising event was held in conjunction with the organization's 10th annual scientific symposium at which 15 selected NARSAD grantees presented their ongoing research over two days of sessions devoted to basic science, schizophrenia and depression.

When do therapists legally owe a duty of care to persons other than their patients? It is an axiom that good medical care involves consideration not only of the patient but also of others. In law, the general principle is that the risk which may result from one's behavior, as reasonably perceived, determines the duty of care.

It is relatively recent that boundary issues in clinical practice have attained professional awareness, although some early concepts portended the issue. Several decades ago, for example, the term boundary violations referred almost exclusively to what we now term sexual misconduct.

Other Hormones on Behavior - Poetry of the Times

For her work in establishing the Dialectic Behavioral Therapy (DBT) model for use with chronically suicidal individuals suffering from borderline personality disorder (BPD), Marsha M. Linehan, Ph.D., is this year's recipient of the annual research award given by the New York City-based American Foundation for Suicide Prevention (AFSP).

The benefits of psychotherapy in treating the chronically suicidal patient, as well as strategies that can help the potential suicide patient imagine and reflect others' reactions to this most final of acts, was the subject of a conference by Glen O. Gabbard, M.D., at the 11th Annual U.S. Psychiatric & Mental Health Congress. Gabbard is the Bessie Callaway Distinguished Professor of Psychoanalysis and Education at the Karl Menninger School of Psychiatry and Mental Health Sciences.

Tina, a 35-year-old legal secretary, is admitted to the hospital hearing voices that demand she gouge out her own eyes as punishment for having lived a sinful life. She was seen in the local emergency room prior to admission, both for involuntary certification and treatment for corneal damage from having attempted to harm herself. She states to the admitting psychiatrist, "If thine eye offend thee, pluck it out!"

For her work in establishing the Dialectic Behavioral Therapy (DBT) model for use with chronically suicidal individuals suffering from borderline personality disorder (BPD), Marsha M. Linehan, Ph.D., is this year's recipient of the annual research award given by the New York City-based American Foundation for Suicide Prevention (AFSP). Linehan is professor of psychology and adjunct professor of psychiatry and behavioral sciences at the University of Washington.

Psychiatry residents want and need solid training in psychotherapy in order to best serve their patients and to remain competitive in the mental health marketplace, concluded a March conference sponsored by the American Psychiatric Association's Commission on Psychotherapy by Psychiatrists (COPP). The event, entitled "Integration and Specificity in Psychotherapy Education," drew 120 training directors, residents and faculty from around the country, and represented approximately 40% of U.S. residency training programs.

Until the last half of this century, there were few if any treatments that seemed consistently effective in responding to the clinical needs of individuals who were abusing or dependent upon alcohol. As a result, support or self-help groups emerged. Alcoholics Anonymous is an extraordinary example of these groups.

Only one month after the American Medical Association unveiled a major reorganization of its science and technology departments-one that included the dismantling of its department of mental health-the former director, psychiatrist Larry Goldman, M.D., was fired after he criticized the changes.

Recent advances in the treatment of mental and addictive disorders, along with research findings in basic neuroscience, molecular genetics and molecular biology that contribute to the understanding of such disorders, were discussed at the American College of Neuropsychopharmacology's 37th annual meeting in Puerto Rico. The following are brief reports from selected presentations.

Psychogenic excoriation (also called neurotic excoriation, pathologic or compulsive skin picking, and dermatotillomania) is not yet recognized as a symptom of a distinct DSM-IV disorder.

Marc Schuckit, M.D., professor of psychiatry at the University of California, San Diego, School of Medicine, examined recent developments in the treatments for alcohol and drug dependence, and examined important changes in DSM-IV's classification of substance use disorder at the 11th Annual U.S. Psychiatric & Mental Health Congress.

Myron Liptzin, M.D., is a respected psychiatrist who specialized in the treatment of university students. Liptzin retired last year as chief of psychiatry of student health at the University of North Carolina at Chapel Hill, where he had earned a reputation as a skillful clinician who was particularly adept at crisis intervention. If Liptzin had hoped to go on to a less hectic and stressful life, his expectations were shattered when he found himself accused of negligence in one of the most unusual cases of psychiatric malpractice of this century. A former patient went on a rampage-killing two people-and then blamed Liptzin. The verdict against the psychiatrist was front-page news, and CBS's "60 Minutes" went to North Carolina to do a story that aired mid-November 1998. Like a bolt out of the blue, Liptzin had gotten his 15 minutes of unwanted fame.

DeAndra's story: I came into the rooms and realized after a while that I had the attitudes and behaviors of an addict way before I ever picked up a drug. I remember growing up and being at my family's parties, [where] my aunts and uncles would give me and my brothers beer. There are pictures in our photo albums of us, all under 6 or 7, with cans of beer in our hands. At an early age I learned to manipulate to get what I wanted.

Psychiatrists, like the rest of America, continue to have trouble with alcoholic and other addicted patients. We are comfortable when patients want to get better, tell us the truth and come to treatment of their own free will, but alcoholics often don't fit this profile. We respond angrily when patients manipulate us. We are surprised when their sincere desire for help evaporates after we suggest a plan that will bring about real change.