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Primary Psychiatry. 2010;17(3):16-17
Dr. Sussman is editor of Primary Psychiatry as well as Associate Dean for Post-Graduate Programs and professor of psychiatry at the New York University School of Medicine in New York City.
Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Email questions or comments to ns@mblcommunications.com
Most of the articles in this issue of Primary Psychiatry address different ways to diagnose mental disorders and their manifestations. Given the reliance on diagnostic criteria and rating scales, our understanding of what clinical entities represent are constantly evolving. It is important that we keep current about any data that improve our efforts to understand the disorder at hand.
It is well known that patients with panic disorder are frequent visitors to emergency departments, usually with fears they are having a heart attack. Geneviève Belleville, PhD, and colleagues describe how the characteristics of patients with panic disorder in an emergency room differ from patients seen in psychiatric settings with respect to panic symptoms, comorbid psychiatric disorders, and psychological correlates of panic disorder. They assessed >2,000 patients seen either in an emergency department or anxiety disorder clinics. The authors report that men were more likely than women to go to an emergency room. Those in the emergency room sample were also more likely to have recently experienced suicidal ideation. Of interest was the finding that patients from the emergency department had less severe panic symptoms, but had higher rates of psychiatric comorbidity, most notably other anxiety disorders and major depressive disorder. Other differences between the groups are discussed in the article.
As a reminder, the American Psychiatric Association (APA) has just released the draft disorders and disorder criteria that have been proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Work Groups.1 As part of the development process of the DSM-5, set for publication in May 2013, the preliminary draft revisions to the current diagnostic criteria for psychiatric diagnoses are now available for public review and comment. The draft criteria are listed in Table 1.
Another anxiety disorder addressed in this issue is obsessive-compulsive disorder (OCD). Ashish Aggarwal, MD, and colleagues provide a case report of obsessive-compulsive symptoms following administration of clozapine. There have been numerous reports of OCD emerging or becoming exacerbated during the treatment of schizophrenia with atypical antipsychotics. In the reported case, these symptoms were dose related. The authors discuss possible explanations for this phenomenon. Incidentally, the APA work group is recommending that this OCD be included under a grouping of anxiety and obsessive-compulsive spectrum disorders, with the diagnostic criteria listed in Table 2.
The common dilemma of how to treat anxiety and insomnia in patients with chronic alcohol use disorders is addressed by Aazaz U. Haq, MD. Using an evidence-based approach, he describes many pharmacologic strategies that rely on off-label use of various agents and advocates concurrent use of cognitive behavioral therapy.
David Goodman, MD, and colleagues report on interpreting attention-deficit/hyperactivity disorder rating scale scores. The article supports the evidence that improvement on a rating scale translates into clinically significant symptom reduction. Conversely, Leo Baestiaens, MD, notes that measurement-based approaches to patient care that rely on validated rating scales may in fact be less helpful than believed. Addressing the care of patients with schizoprenia, he argues that professionals interact more with their patients and spend more time with them. This, of course, would require higher reimbursement rates.
In a case report, Ravi C. Sharma, MD, and Rajeshwar S. Thakur, MS, offer a reminder that conversion symptoms do indeed still occur. They report the case of a woman with acute urinary retention manifesting as a conversion symptom.
Finally, I want to share with you a communication I received from one of our readers about a December 2009 article by Galit Ben-Amitay, and colleagues2 about the psychiatric assessment of children with poor verbal capacities using a sandplay technique. Erno Daniel, MD, PhD, at the Sansum Clinic in Santa Barbara, CA wrote:
“An interesting offshoot of the study you reported could be the following. When my children were young, we built a sandcastle on the beach. When we tired of playing with it, we sat away from it in the sand doing other things. A little child came by. As he approached the sandcastle, it occurred to me that he had several choices: 1. Sit and play with it. 2. Add on to the sandcastle and make it better to suit his own imagination. 3. Kick it to bits and walk away.
The latter is what happened. It occurred to me that the ‘sandcastle test’ may have predictive correlates with future behavior: fit-in personality versus creative/progressive personality versus destructive personality. I would welcome a study to see if such is true.” PP
References
1. Proposed Draft Revisions to DSM Disorders and Criteria. Available at: www.dsm5.org/Pages/Default.aspx. Accessed February 17, 2010.
2. Ben-Amitay G, Lahav R, Toren P. Psychiatric assessment of children with poor verbal capacities using a sandplay technique. Primary Psychiatry. 2009;16(12):38-44.
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