Please help us get a sense of the public sentiment towards psychiatry, psychiatrists, and psychiatric patients. We will be including this information in our presentation on The Public Face of Psychiatry at this year’s annual meeting of The American Psychiatric Association. Please read all of the answers for all of the questions, then choose all that apply. If you choose “other,” please type in a response. This survey is totally anonymous and does not collect an IP address or any other identifying information. Please do not take our poll more than once! Thank you for participating!
Medical students have to do a psychiatry clerkship during their training. At the end of their psychiatric clerkship they have to take their final examination on psychiatry for their medical degree. This exam consists of three parts. First they’ll have to interview a patient. This interview is being watched and rated by a psychiatrist on several competencies such as interpersonal and communicational skills, and professionalism. Next they have to discuss this patient with the same psychiatrist to test their clinical reasoning in psychiatry and usually they are being questioned in this same exam about psychiatry at large, as a kind of theoretical exam on psychiatry. Especially this last bit of the examination meets a lot of critique: most specialists asks questions about their own hobbyhorses and the objectivity is also questioned during this exam.
Since recent we’re creating an online exam. This could meet the critique about objectivity and the lack of broad theoretical questioning during oral examination. Online because medical students follow their psychiatric clerkship in several different locations, different hospitals and community setting.
That’s were the video above comes in. The video above is from the movie American Beauty. I used a fragment for a question about personality disorders. The medical students have to fill in the most probable personality disorder depicted in a short video clip of about 4 minutes. The scene was to big to upload but you probably have some idea. A lot of questions have to be made on all topics in psychiatry. During examination a random sample is selected from a large database consisting of almost 300 questions. Making these questions with short videos is also an excuse to watch old good movies again.
Besides video clips and pictures a lot of case presentations are used and multiple choice questions. Any additional sources, suggestions, examples are appreciated, let me know in the comments.
Each category includes a winner and up to two runners-up. To qualify as a runner-up, at least three nominations must have been received. If a category has one or no runner-up, that’s why.
Number one psychiatrist blogger according to this election is well earned by Lake Cocytus, also one of my favorites in GReader. Congratulations.
I’ve been busy today preparing education for third year medical students. It’s their first engagement with psychiatry. In preparing before psychiatric examination they have to watch several video’s and answer questions about the psychiatric examination. These video’s were made by actors and some of them are small parts of Hollywood movies.
For OCD or obsessive compulsive disorder I used a fragment of The Aviator. It’s the story of the life of Howard Hughes.
With The Aviator, director Martin Scorsese and star Leonardo DiCaprio breathe fresh life into this old story with a soaring and soulful portrait of the enigmatic, troubled millionaire Howard Hughes. They succeed by focusing on the triumph that preceded the tragedy and sustaining a deep sense of empathy and compassion for this misunderstood trail blazer
The movie itself has some nice scenes expressing symptoms of OCD. Further on in the movie the psychiatric symptoms become severe. In 1947 when Howard Hughes was 42 years he descended into one of the most bizarre episodes of his life. So bizarre that it almost puts to question the diagnosis of OCD. Especially with younger patients with bizarre OCD symptoms the diagnosis of schizophrenia should be considered. Was Howard Hughes suffering from OCD or was it more complicated than that. Probably, but we’re unable to do a thorough psychiatric examination. He died on April 5, 1976 in extremely poor physical condition.
A subsequent autopsy noted kidney failure as the cause of death. Hughes was in extremely poor physical condition at the time of his death; X-rays revealed broken-off hypodermic needles still embedded in his arms and severe malnutrition. While his kidneys were damaged, his other internal organs were deemed perfectly healthy.
Here is a short video with movies depicting some sort of mental illness.
According to this neurosurgeon, the strongest evidence exists for Broadman Area 25 in the subcallosal cingulate gyrus (SCG) as target for deep brain stimulation in treatment resistant depression.. This area in the brain is depicted in the figure above and is from the most important publication about DBS and depression in Neuron march 2005 by Helen Mayberg. Functional neuroimaging as well as antidepressant treatment effects suggest that this area plays an important role in modulating negative mood states. A decrease in activity is reported with clinical response to antidepressants and electroconvulsive therapy (ECT).
But depression is not a disease of a single brain region nor neurotransmitter system. It is now generally viewed as a systems-level disorder affecting integrated pathways linking select cortical, subcortical, and limbic brain regions with their related neurotransmitter systems.
In a recent study done by the “Mayberg group”, Toronto, Canada, the autors compared the location of the electrode contacts in responders and nonresponders to DBS of the subcallosal cingulate gyrus (SCG) and correlated the results with clinical outcome to help in identifying the optimal target within the region.
On postoperative MRI scans the researchers did complicated mapping procedures to pin point the locations of the active contacts on the implanted electrodes. There was no difference when the right and left electrodes were compared in patients. So both electrodes were exactly placed on each side (hemisphere). The only significant difference they found between responders and nonresponders was that electrodes in patients who responded were in a slightly more ventral position relative to the anatomical landmarks used in the medial prefrontal lobe. This difference between responders and nonresponders did not exceed 1,5 mm. The authors is not likely to be of clinical significance, according to the authors. This small difference is probably unimportant compared to the clinical features of the patient for the outcome of the DBS procedure in depression. Another limiting factor on this research is the small sample size, in larger groups these results might differ.
What we can conclude based on our findings is that within the small targeted region of the SCG, the location of the electrode contacts did not determine outcome.
This article also describes a detailed method for a more standardized method for targeting the SCG with DBS for depression. This is to technical to reproduce in this post but those working with DBS for depression should have a look at this procedure. From this study it is still not clear whether DBS of other brain areas might be more superior in efficacy. And is brain area more important than clinical features of the patient or do the areas differ for different types of depression? All very interesting questions and topic for more research on DBS.
Hamani, C., Mayberg, H., Snyder, B., Giacobbe, P., Kennedy, S., & Lozano, A. (2009). Deep brain stimulation of the subcallosal cingulate gyrus for depression: anatomical location of active contacts in clinical responders and a suggested guideline for targeting Journal of Neurosurgery, 111 (6), 1209-1215 DOI: 10.3171/2008.10.JNS08763
This post was inspired by two recent visits to jazz clubs in Paris. It’s the first in a series of three. The others are: Medical Dangers of Jazz and The neuroscience of Jazz.
What do we know about the relationship between mental illness and creativity, more specific about the relationship between mental illness and jazz. Other art forms and mental illness are discussed elsewhere on this blog.
It will be particularly valued by that group of psychiatrists who prefer to frequent jazz clubs rather than conference gala dinners (those who prefer gala dinners are advised to obtain a copy of the CD reissue of Kind of Blue by Miles Davis).
A review of biographical material of 40 famous jazz musicians of the period from 1945 to 1960 excluding those who were still alive, was studied and rated for psychiatric diagnoses according to the DSM IV classification.
The categories used were: heroin-related disorder, alcohol-related disorder, cocaine-related disorder, schizophrenia and other psychotic disorders, mood disorders and anxiety disorders. The categories of family background, sensation- seeking, late-life deteriorations and suicides also were added.
Results:
10% (4) had family psychiatric disorder
17,5% (7) had unhappy or unstable early lifes
52,5% (21) were addicted to heroin some time during their lives.
27,5 (11) were dependent on alcohol and 15% (6) abused alcohol
8% (3) were dependent on cocaine
8% (3) had psychotic disorder
28,5% (11) had mood disorders
5% (2) had anxiety disorders
17,5% (7) had sentsation seeking tendencies such as disinhibition and thrill and adventure seeking. This has been linked to borderline personality disorder
2 killed themselfs later in life
These results are comparable to the results in composers and musical performers, with the exception of a higher drug use in jazz musicians. The results were higher compared to general population as researched in the Epidemiological Catchment Area study in the beginning of the nineties. Much later than when these jazz musicians were living.
The trouble with this kind of research is the lack of prospective design and relying on probably biased information from non scientific information written by biographers. The selection of participants could also be biased. Those considered famous now would be judged otherwise in earlier days. The group of jazz musicians was small and there was no control group living in the same day and age. more discussion on the short comings of this kind of research can be read here and here.
Moreover,
To maintain a sense of perspective in the present study, it needs to be stated that many of the sample were exemplary, well-balanced human beings.
WILLS, G. (2003). Forty lives in the bebop business: mental health in a group of eminent jazz musicians The British Journal of Psychiatry, 183 (3), 255-259 DOI: 10.1192/bjp.183.3.255
Poole R (2003). ‘Kind of blue’: creativity, mental disorder and jazz. The British journal of psychiatry : the journal of mental science, 183, 193-4 PMID: 12948989
Art and psychiatry is always an interesting combination to me. It has so many perspectives. Does being an artist combine with psychiatric illness, how do they influence each other? To name just a few perspectives. On this blog I regularly post about artists and psychiatry and painters and psychiatry in a broad sense.
Can depression as one important psychiatric illness enhance creativity despite depressed mood, loss of interest not to mention a lack of concentration and all other symptoms? Art can be comforting or even a form of medication. Klaas Koopmans (1920-2006) a Dutch artist who during his admissions as an inpatient for depression drew his fellow patients in psychiatric hospitals on the back of his cigar boxes and note paper. Department rules didn’t permit him drawing or painting. He made these secretly. He had bipolar disorder. His last admission to a psychiatric hospital was in 1963.
With his keen eye and highly personal approach, he lays bare the hidden feelings and thoughts of his subjects. The aim is not to achieve any superficial or flattering likeness, but to reveal the essence of the subject’s inner being. The results are impressive and extremely private portraits of vulnerable individuals.
Tales of a Borderline is an exhibition of artwork by artists with Borderline Personality Disorder (BPD). This disorder affects a persons emotions, causing emotional instability. Tamar Whyte one of the artists has her own website with galleries and a lot of more information also on borderline personality disorder.
Wasily Kandinsky didn’t suffer from mental illness but he had synaesthesia. Kandinsky in whom musical tones elicited specific colours, was a tone-colour synaesthete. Kandinsky used his synaesthesia to inform the artisitic process – he tried to capture on canvass the visual equivalent of a symphony. An aerial view shows the market square of the southern Bavarian town of Weilheim, Germany painted with a copy of Russian-born French Expressionist Wasily Kandinsky’s painting ‘Weilheim-Maria’s square’. 500 mostly students have been working on it for three weeks.
Psychotherapy training in residency has lost much of it’s importance due to the increasing interest for biological psychiatry and biological treatments. Especially those using long term psychotherapy haven’t supplied the answers for the growing demand for evidence based treatment. In the US the residency review committee has reduced the number of psychotherapy schools back to three: supportive-, cognitive-behavioral- and psychodynamic psychotherapy.
For this the development of an integrated model for teaching psychotherapy competencies across the three forms of psychotherapy was recently published. It’s: The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies. This article offers the Y Model as a means of structuring the teaching of all the core psychotherapy competencies.
Your life before your eyes: What to expect from a past life regression reading. If you’ve tried everything to overcome these challenges and aren’t seeing improvements, you might want to consider past lives regression therapy. There are lots of benefits to this type of therapy. But, it can seem a bit scary to people who are unfamiliar with it. The Y model is based on three publications by two groups. Two reviews by authors from Harvard Medical School and one empirical study by a Dutch group.
This Y Model structure describes the core features, or factors, common to both CBT and psychodynamic psychotherapy and then describes those features that are particular to each school. The core features form the stem of the Y, while particular aspects of psychodynamic and cognitive-behavioral therapies form the branches of the Y.
The authors state that negotiating a therapeutic alliance is common to all therapies. But the way to achieve this is very different for different therapy forms. Nevertheless they encourage their model to teach the skills at the beginning combined with the underlying theoretical underpinnings that explain how a school of therapy works. Residents are also introduced to the differences between the
two major schools in a way that foreshadows the branches of the Y.
Why?
Teaching these common characteristics to residents first may help to decrease the confusion that often arises when residents are taught multiple therapeutic approaches as if each one requires very different basic assumptions.
Combining psychotherapy with medication and brief psychotherapy is also incorporated in the stem of the Y, since it is assumed that any school of therapy can modify its techniques and goals in relation to a limitation of time. The basics of supportive psychotherapy, one of the most difficult forms of psychotherapy is also educated during the stem of the Y but will be broadened during the teaching of the two branches: Cognitive behavioral therapy and psychodynamic therapy.
The authors next describe the discussions in the Commission on Psychotherapy by Psychiatrists (COPP). These discussions had to result in the differences between the psychodynamic and cognitive behavioral therapy as the heuristic elements located on the branches of the Y. These differences were based on the 7 core features of psychodynamic psychotherapy that differentiated it from CBT as described by the Harvard Medical school group. Members of the committee couldn’t decide whether the finding of repeating patterns in a patient’s life was considered a feature of psychodynamic therapy or CBT. The solution was to name it a core feature for both therapies, leaving 6 differences to be defined.
The therapies differed in:
Psychodynamic therapy focus more on affect and expression of emotion, they encourage the expression of feelings to expose unconscious issues. CBT uses these affects as an opportunity to identify automatic thoughts
Psychodynamic therapists explore the patient’s avoidance of topics and behaviors while in CBT it is a maladaptive coping style needed to be modified.
Psychodynamic therapy places more emphasis on past experiences than CBT, looking for unresolved past conflicts. CBT focusses on patients’ future experiences, patients are taught skills to use with future problems
Psychodynamic psychotherapists place more emphasis on the therapeutic relationship and the notion of transference in sessions than cognitive-behavioral therapists. In CBT the relationships is one of collaborators.
Psychodynamic therapists explore the patient’s wishes, dreams, and fantasies, which are seen as central opportunities for accessing the unconscious, while these are de-emphasized in CBT.
In CBT there is a focus on how the emotions and behavior of the patient is influenced by beliefs or thoughts about the world. In psychodynamic therapy the focus is on impulses, affects, conflicts, wishes and fantasies
CBT is more likely to assign homework as part of the treatment
Sessions during CBT are structured and use active guidance, discussions with the patient
CBT teaches skills to cope with symptoms much more than in psychodynamic psychotherapy.
CBT provides information about their ailment, therapy and symptoms more often than psychodynamic therapy
You can see a narrated PowerPoint presentation suitable for teaching an overview of the Y Model without charge on line at www.austenriggs.org in the Continuing Education section on the left margin of the home page. You will have to register first but that’s simple and easy.
I think this model is a deterioration of teaching psychotherapy to residents.
These differences between psychodynamic therapy and cognitive behavioral therapy. I don’t think that residents are often confused when they are taught multiple therapeutic approaches. I think we can improve the education of psychotherapy for residents when using modern insights of the different schools, loosing a lot of old theoretical education and using more active learning methods.
What I mean is that reading most of Freud’s work although very interesting does not contribute much to the understanding of psychodynamic psychotherapy. Active learning means e.g. the use of camera recordings.
The Y model is to simplistic obscuring the different frame works for different kind of therapies. Interpersonal therapy is lumped together with psychodynamic psychotherapy and family therapy is completely absent. For psychiatrists it is important to learn the differences between therapies, learn the indications for the different therapies. Psychiatrists are the ones to assign patients to suited forms of therapy and they should focus on the difficult forms of psychotherapy with the difficult to treat patients, for complex mental disorders. Our focus on teaching residents psychotherapy should be directed to learning them to indicate the right form of therapy and teach them the more difficult forms such as long term supportive psychodynamic psychotherapy for complex mental disorders.
Nevertheless I think the authors and those in the committees did a great job, it will improve the education of psychotherapy to psychiatric residents in the US but in The Netherlands the situation is different. The critique has not yet resulted in an almost disappearing education of psychotherapy to residents. Most patients are insured for most forms of psychotherapy. But we will have to come up with improvements for educating psychotherapy before it’s to late and we will also have to cope with faculty programs educating only 2 forms of psychotherapy.
Plakun, E., Sudak, D., & Goldberg, D. (2009). The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies Journal of Psychiatric Practice, 15 (1), 5-11 DOI: 10.1097/01.pra.0000344914.54082.eb
When we started blogging, we looked for the blogs of other psychiatrists, and even other non-shrink docs, and linked to them. It’s been a while (oh, nearly 3 years) and mental health blogs have come and gone. I thought I’d survey the scene again.
Flickr
Twitter
RSS
LinkedIn
GoodReads
Last