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Based on powerful epidemiological data such as numbers afflicted, mortality rates from suicide, personal and familial consequences, and skyrocketing fiscal costs, major depressive disorder (MDD) has the sad and ignominious distinction of being a leader among disabling disorders worldwide.With lifetime prevalence risks of 13% for men and 21% for women, the magnitude of this crisis cannot be understated. This hard-hitting volume focuses on recurrences -- perhaps most important among the many factors (others include extreme underdiagnosis and undertreatment, genetic vulnerability, frequent recurrences, severe stigma and poor adherence with maintenance treatment, and brain tissue degenerative changes associated with recurrences and chronic depression) that contribute to MDD's high morbidity.Following an introduction by the editor detailing the overwhelming personal and societal burden created by MDD, the distinguished authors of this volume emphasize five critical topics:   The lifetime impact of gender on recurrent MDD in women, emphasizing the clinical features, treatment, and prevention strategies of the illness during three key periods of hormone transition (adolescence, childbearing years, and middle life) and including recommendations on where future research should focus. Treatment strategies for chronic and recurrent depression to help prevent acute episodes from developing into long-term depression, specifically addressing the continuing question of whether pharmacotherapy and psychotherapy combinations are superior to either alone. Prevention of recurrences in bipolar patients, updating the demonstrated benefits of several new anticonvulsant mood stabilizers and integrative treatment approaches and suggesting that treatment success depends on a multifaceted approach that combines old and new pharmacotherapy. Potential applications of new somatic treatment strategies involving minimally invasive brain stimulation that have greatly reduced the stigma but done little to advance the diagnosis and treatment of neuropsychiatric illnesses, with exciting data suggesting the efficacy of vagal nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (TMS). A "call to arms" with updated recommendations on how to ensure demonstrable, lasting progress in preventing recurrences of depression, which -- along with other chronic diseases such as diabetes, heart disease, and schizophrenia -- progresses throughout life unless actively treated. This highly informative volume, clearly written and exceptionally well referenced, is a "must-read" for every clinician, including specialists in depression and clinical neurosciences, primary care physicians and mental health clinicians interested in learning more about how to successfully treat what remains one of our most recalcitrant, debilitating illnesses.

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The Integrated Behavioral Health Continuum

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Until recently, behavioral health was defined within the strict dichotomy of inpatient and outpatient care -- a dichotomy that failed to mirror the range and complexity of human experience and clinical needs. Today's integrated system renders this dichotomy obsolete. Instead, service delivery integration processes offer an organized system of care rooted in a common vision and defined by processes intended to promote continuity and quality of care, coordination of efforts, efficiencies of operation, and seamless patient movement through an otherwise bewildering array of health care services. Unique in the literature, this volume brings together distinguished clinicians and policymakers who focus on the operational aspects of developing state-of-the-art integrated delivery systems.    History and concept -- Why we need integrated health care delivery systems, including a model of service delivery integration that incorporates current barriers (e.g., ambiguous roles and responsibilities and lack of strategic alignment; how to design integrated delivery systems improving clinical outcomes, achieving fiscal and operating efficiencies, and aligning clinical and fiscal incentives) Structural foundations -- Access to the system of care for patients, payors, and employers; how to design level-of-care criteria; eight strategies that help clients move along the continuum; how to define level of care in today's managed care world; and the process of following therapeutic processes (i.e., philosophies, procedures, and practices used to create or support recovery and wellness) across the continuum Administrative and management processes -- How to reorient staff toward minimizing barriers and making the patient central to the system; documentation/information management and reimbursement (rates and rate structures, risk assumption); current research and its enormous potential to improve every aspect of care; quality assessments based on examining the driving forces behind the needs for monitoring and evaluating quality and outcomes; and the relation of behavioral health care systems, which seek to fully integrate clients and families into the fabric of their community and culture, to other systems A case vignette that highlights -- from the consumer's viewpoint -- the vital role of self-help during an episode of hospitalization and a discussion of future directions in integrated behavioral health care round out this remarkable volume.With its wealth of strategic and "nuts and bolts" information -- useful for alliances and single entities alike -- on how to harness operational forces in establishing an effective integrated behavioral health continuum, this volume will be welcomed by those who deliver direct services (psychiatric professionals) and those who administer and manage the integrated financing and delivery of quality care from public (U.S. government agencies) and private (managed care and insurance providers) sectors alike.

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Laurel J. Kiser, Paul M. Lefkovitz, Lawrence L. Kennedy

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Negative Symptom and Cognitive Deficit Treatment Response in Schizophrenia

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For the first time in a single volume, distinguished experts address the complex issues -- issues rarely confronted in empirical studies of patients with schizophrenia -- and controversial research surrounding the assessment of negative symptoms and cognitive deficits in patients with schizophrenia. Despite recent advances in our understanding of schizophrenia, still notably absent is consensus in assessing negative symptom treatment response. What is the most effective assessment method -- given the varying methodologies and contradictory results to date? What constitutes an adequate response? Which medication -- none is specifically indicated and licensed for negative symptom treatment -- yields the best results? What are the indications for use of this medication? Which instrument best measures negative symptom treatment response (eight rating scales are analyzed here)? Reaching consensus among clinicians and researchers alike is even more difficult because assessment is often thwarted by extrapyramidal side effects of medications, similarities to depressive symptoms, and secondary effects of psychotic experiences.In addition to clarifying these pressing issues, Negative Symptom and Cognitive Deficit Treatment Response in Schizophrenia also discusses   The importance of measuring the experience of emotion versus the more traditional objectively measured symptoms in patients with schizophrenia, and how deficits in emotional experience may resist treatment -- even in treatment-responsive patients.  The family as an often overlooked source of information about negative symptom improvement or worsening, and the impact of negative symptoms on patients' relatives. How treatment affects social functioning and subjective experience of "quality of life," and the importance of neurocognitive dysfunction in the social deficits of schizophrenia, which often persist despite significant amelioration of other symptoms. Specific guidelines for assessing neurocognitive treatment response. Cognitive enhancement is a major factor in improving the quality of patients' lives. The latest research on the neurobiology of negative symptoms, including the role of various neurotransmitter systems and brain regions in mediating negative symptom pathology. Also discussed is single vs. multiple pathophysiological processes and single treatment modality vs. distinct treatments for different aspects of negative symptoms. How to distinguish "pure" negative symptoms from deficit symptoms (i.e., those that persist for at least 1 year and are not secondary to factors such as depression, medication side effects, anxiety, delusions, and hallucinations), and which treatment is indicated for each. Highlighted by patient vignettes, this in-depth guide will be welcomed by all clinicians who treat patients with schizophrenia and want to know and document whether their interventions ameliorate negative symptoms and cognitive dysfunction, and by all researchers who study schizophrenia, particularly those interested in clinical issues and treatment studies.

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Schizophrenia is one of the most difficult diagnoses to make. And, once made, it was once among the most limited, offering few options in the management of care for schizophrenia patients with comorbid conditions. It was not until 1994, with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), that diagnostic guidelines first permitted additional diagnoses on Axis I, such as anxiety disorder, in the presence of schizophrenia. Yet remnants of the old hierarchical diagnostic system remain, diverting attention from the pressing issue of managing what appear to be common -- and treatable -- disabling conditions, such as panic disorder and obsessive-compulsive disorder (OCD), that often occur with schizophrenia.Schizophrenia and Comorbid Conditions: Diagnosis and Treatment lays diagnostic oversimplification of schizophrenia to rest once and for all. All schizophrenia patients are not the same. The editors of this groundbreaking work criticize the reductionist view of schizophrenia as a single unitary disorder -- a view that has led many psychiatrists and mental health care professionals to overlook potentially important syndromes.Asserting that these patients should be managed on the basis of their individual clinical presentations, not just their categorical diagnosis, recognized experts in their specialties offer a fascinating array of topics. Chapter 1 goes straight to the heart of this assertion, beginning with epidemiology and showing how hierarchical diagnostic concepts keep associated psychiatric syndromes (APS) hidden from clinical and scientific attention. Also presented are the findings of the few treatment studies of APS in schizophrenia.Additional chapters feature the following topics:   Chapter 2 takes an indepth look at the extensive literature on depression in patients with schizophrenia, including a discussion on differential diagnosis and treatment approaches. Chapters 3 and 4 detail obsessive-compulsive disorder and panic symptoms, using case vignettes to illustrate the clinical management of schizophrenia with these two conditions. Chapters 5 and 6 discuss the recognition and management of medical and surgical illness and the management of pregnancy in patients with schizophrenia, respectively. Chapter 7 reviews cognitive impairment in older patients with schizophrenia, including etiology, assessment, and treatment approaches. Chapter 8 presents old and new approaches to the treatment of aggressive behaviors and violence in patients with schizophrenia. Chapter 9 extensively reviews substance abuse in schizophrenia, with suggested practical approaches to assessing and treating the "dual-diagnosis" schizophrenia patient. Intended to help practitioners enhance their recognition of and improve treatment for the large -- and often neglected and clinically challenging -- group of schizophrenia patients with comorbid conditions, this unique collection combines a wealth of clinical and research experience of enduring value to practitioners and researchers alike.

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PTSD is a recently named psychiatric condition that unknown before the publication of DSM-III in 1980. The creation of this diagnosis was intensely controversial, and there continued to be considerable reluctance to apply the term to children. The 1985 landmark volume, Posttraumatic Stress Disorder in Children, edited by Spencer Eth and Robert Pynoos, helped establish the validity of this condition during childhood. Now Spencer Eth has edited PTSD in Children and Adolescents, a work that brings the field of childhood trauma in to the new century by offering fresh insights on five major topic areas in child and adolescent PTSD:   Techniques for comprehensive evaluation -- details recently developed diagnostic instruments and rating scales that measure the variety and severity of traumatic symptoms in children and adolescents. Forensic aspects of traumatized children -- surveys legally pertinent issues, including abuse, reliability of traumatic memories, and credibility of child victims. Juvenile offenders and incarcerated youth -- examines the role of trauma in the lives of juvenile offenders, noting that the victimization of delinquents must be specifically addressed in order for an integrated approach to treatment to achieve effective rehabilitation. Biological treatment strategies -- systematically reviews the important role of medications for PTSD in clinical practice, including such topics as biological dysregulation, target symptoms, and the inclusion of drugs into the biopsychosocial treatment plan. The relationship between exposure to trauma in childhood and the development of psychiatric disorders in adulthood -- presents current research on the long-term prognosis of traumatized children and adolescents by analyzing the association between early traumatic exposure, biological substrates, and subsequent symptomatic morbidity. Mental health practitioners and trainees, as well as attorneys, pediatricians, and school personnel, will find this thoroughly annotated volume an invaluable roadmap in their journey toward understanding PTSD and discovering more effective treatments for traumatized children and adolescents. With its eclectic perspective and interdisciplinary format, this exceptional reference will also enhance courses in developmental psychology, social work, and education.

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Treatment of Suicidal Patients in Managed Care

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Suicide remains all too common in the United States. As the ninth leading cause of death -- responsible for 30,000 deaths annually -- it is also one of the more preventable causes of deathIncreasingly, mental health clinicians must care for suicidal patients within managed care systems. Managed care's cost-driven focus on rapid assessment and triage, narrowly restrictive hospital admission criteria, and abbreviated inpatient stays have resulted in poorer clinical care and increased opportunities both for adverse outcomes such as suicide and for clinician liability.Bringing together a unique mix of clinicians, authorities, and administrators from private practice and managed care, Treatment of Suicidal Patients in Managed Care offers practical guidance on how to improve care and reduce risk for suicidal patients. Contributors explore a wide range of topics:   Hospitalization -- Emphasizes the increased importance of the initial assessment when managed care systems shorten or deny hospitalization for suicidal patients and of knowing whom to call within the managed care system. Includes alternative programs from acute residential care to cognitive-behavioral strategies and dialectical behavior therapy for the suicidal patient in crisis Suicide risk among adolescents and the elderly -- For adolescents, emphasizes the value of multiple levels of care when admissions are too short and too often followed by distressing and costly readmissions. For the elderly, offers preventive interventions for primary care physicians who are uncomfortable discussing depression and suicidal ideation and intention with their elderly patients Suicide and substance abuse -- Details the role of case managers in providing continuity of care in a disorder known to be chronic and relapsing Pharmacotherapy of depression and suicidality -- Discusses the effects of managed care and raises questions about the expertise of the prescriber, especially relevant now that more primary care physicians are treating patients with uncomplicated unipolar depression Risk management issues -- To counter the perception that managed care companies profit from withholding care, emphasizes the crucial importance today of documenting the reasons for treatment decisions Helping those affected by the aftermath of a suicide -- A step-by-step process: 1) anticipating a suicide, 2) announcing or sharing the news of a suicide, 3) assessing those affected by a suicide, and 4) seeing what can be learned from reviewing the patient's treatment This clinical guide will aid understanding of clinical, administrative, and risk management issues relevant to the care of suicidal patients. Psychiatrists, psychologists, nurse clinical specialists, social workers, administrators, and primary care physicians will also rely on it as they cope with the mounting pressures of managed care while maintaining the quality of their care for these vulnerable and patients.

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The past decade has witnessed tremendous progress in psychiatric neuroimaging research. Investigators have developed, in tandem with significant advances in imaging technology, innovative strategies for exploiting the awesome potential of these new tools.This volume brings you up to date on the latest developments by providing insight into the methodology of experimental design of the numerous neuroimaging articles being published in today's peer-reviewed journals. Revealing the remarkable wealth of neuroimaging's potential contributions to psychiatry, 49 distinguished contributors use accounts of their own research to illustrate the power of particular paradigmatic techniques. These techniques hold promise not only for delineating pathophysiology and advancing neuroscience, but also for yielding discoveries of direct clinical significance, such as diagnostic testing, predictors of treatment response, and new medications. Focused specifically on applications in psychiatry, these chapters are uniquely organized around experimental paradigms rather than psychiatric disorders:   Using magnetic resonance imaging (MRI) to detect and characterize subtle, easily overlooked abnormalities in schizophrenia and schizotypal personality disorder. Testing specific hypotheses regarding the functional integrity of implicated neural systems within the brain as part of cognitive activation studies of schizophrenia and obsessive-compulsive disorder (OCD). Assessing the roles of the amygdala and striatum in anxiety disorders, including masked stimuli and other task manipulation methods to assay nonconscious brain activity.  Investigating the neural correlates of psychiatric symptoms in anxiety disorders, using script-driven imagery and in vivo exposure to experimentally manipulate study conditions. Capturing the often elusive symptoms of hallucinations and psychomotor tics using innovative imaging techniques. Using transcranial magnetic stimulation (TMS) to investigate how the brain regulates mood. Other fascinating topics include using positron emission tomography (PET) and single photon emission computed tomography (SPECT) to discern the therapeutic mechanisms of psychotropic medications and enhance the development of new medications; integrating structural and functional imaging to treat major depression; using magnetic resonance spectroscopy (MRS) to quantify brain concentrations of exogenous compounds; using MRI to visualize circuits implicated in developmental disorders such as attention-deficit/hyperactivity disorder (ADHD) and anxiety, including ground-breaking studies of children; using functional MRI in animals and its applications in psychiatric research; and exploring the use of neuroimaging methods to investigate genetic contributions to normal cognitive function. Specialists and general clinicians alike will find much of interest in this definitive look at the exciting developments in neuroimaging today and how they can enhance our understanding and treatment of psychiatric disorders. This comprehensive text with its extensive illustrations and annotations will also prove a welcome addition to any course in the neurosciences.

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Why do some psychiatric patients fail to get better, even when in the care of competent clinicians?Treatment-refractory conditions are all too common in everyday clinical practice. Treatment resistance occurs across the full spectrum of psychiatric disorders, incurring enormous emotional, economic, and social costs. In the United States, treatment of depression alone costs more than $40 billion annually, and as many as 40% of patients with depression have a treatment-refractory form of the illness.This groundbreaking clinical guide starts where standard textbooks end, focusing on clinical strategies to be used after all basic treatment options, such as medication and psychotherapy, have failed. In this book expert contributors address the sequential clinical steps in treating difficult-to-treat psychiatric patients by offering a blend of evidence-based clinical recommendations, detailed case vignettes, treatment algorithms, and -- when necessary to go beyond the reach of evidence -- the clinical wisdom of leaders in the field. The chapters in this user-friendly, practical guide are organized by major disorder. Each chapter offers concrete recommendations on what to do when the usual first steps in therapy are ineffective, including evidence for biopsychosocial treatments alone versus in combination, generic versus specific therapies, and literature reviews and the latest expert wisdom. A sampling includes   The management of the complex and often refractory bipolar disorder, which involves replacing or combining lithium treatment with anticonvulsants or atypical antipsychotic agents with adjuncts such as benzodiazepines, thyroid hormone, and electroconvulsive therapy, but also -- above all -- with careful attention to the therapeutic alliance. The importance of combined therapeutic modalities for patients with schizophrenia -- especially given managed care's cost-cutting strategies, which deprive many schizophrenic patients of effective treatment modalities such as family therapy or early use of an atypical antipsychotic. Combination treatments for anxiety, with medications adjusted over time as symptoms wax and wane, and early and appropriate interventions to mitigate internal and external environmental stressors. The emphasis on common sense, optimism, a sense of humor, and an iron constitution as the most important tools for clinicians wishing to work with the most severely ill patients with borderline personality disorder. The importance of individual differences in biological vulnerability, emotionality and expressiveness, cognitive schemas and beliefs, prior traumatic experience, resilience, and coping strategies for successful treatment of posttraumatic stress disorder. Packed with up-to-date information of immediate relevance, this volume will prove invaluable in both classroom and clinical practice, for everyone from beginning interns and residents to experienced psychiatric and medical practitioners and social workers.

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Treating Mental Illness and Behavior Disorders in Children and Adults With Mental Retardation

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Since the 1970s, the development of normalization philosophy and the implementation of community care policies have highlighted the nature and treatment of psychiatric and behavior disorders in people with mental retardation and rekindled the interest of scientists, psychiatric practitioners, and service providers. With these changes has grown a substantial body of new research and information on the phenomenology, epidemiology, classification, and clinical features of mental illness and behavior disorders in mentally retarded persons.In response to this growing interest and awareness, the editors, together with internationally renowned contributors from the United States and Europe, have compiled the first comprehensive handbook of the current theory and practice of mental health treatment and care in mentally retarded children and adults.Both contemporary and in-depth, this multidisciplinary, multidimensional volume covers all available therapeutic methods, including psychopharmacotherapy, psychotherapy, behavior therapies, cognitive therapy, and the systems approach for all the main diagnostic disorders in people with mental retardation.Parts I and II present an overview of epidemiology and clinical presentation, including research trends, and therapeutic methods, including psychotherapy, psychopharmacology, behavioral therapies, cognitive and social learning treatments, and working with families and caregivers.Parts III and IV focus on psychotherapeutic interventions, such as rational emotive group treatment with dually diagnosed adults, pre-therapy for persons with mental retardation who are also psychotic, and systemic therapy, and how to apply these methods to the treatment of specific mental illnesses, such as schizophrenia, epilepsy, and mood and anxiety disorders.Parts V and VI discuss how to treat behavior disorders such as aggression/self-aggression (pharmacotherapy and strategic behavioral interventions) and self-injurious behaviors (multimodal contextual approach), including group therapy for sex offenders and a pedagogical approach to behavior problems, and which treatment methods, such as psychodynamically oriented psychotherapy and pharmacotherapy, are most effective with children, including developmental-dynamic relationship therapy with more severely mentally retarded children.Parts VII and VIII provide guidance on mental health services and staff training, including psychiatric treatment in community care and a model for inpatient services for mentally ill persons with mental retardation, and the editors final chapter, which draws together all the various therapeutic approaches described in previous chapters to provide a practical framework for an integrative approach.Filling a major gap in the literature, this indispensable resource for psychiatrists, psychologists, and educators working with mentally retarded persons is also intended for general practitioners, doctors, social workers, and therapists working in the same or related fields.

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In sharp contrast to the prevailing belief during the past century that schizophrenia inevitably results in a progressive deteriorating clinical course, research since the early 1980s shows that early intervention can significantly improve the long-term outcome of this complex illness. With very early treatment, many affected individuals can achieve an excellent recovery.This research has set off an explosion of interest in -- and optimism about -- early intervention in what was once thought to be an intractable illness. The work of 19 top experts in the field of schizophrenia research is available in this single, powerful volume that introduces the concept of early intervention and describes the clinical approaches most likely to facilitate the fullest degree of recovery. Contributors review the clinical and epidemiological evidence that supports the importance of comprehensive and optimal treatment during the early stages of schizophrenia -- treatment that must encompass emotional, family, and vocational as well as pharmacological needs of affected individuals. This rich overview is organized into three major parts:   Early Intervention, Epidemiology, and Natural History of Schizophrenia, which presents an overview of important concepts in early intervention and reviews our current understanding of the outcome from a first episode of schizophrenia, including which features predict the onset of first-episode psychosis Management of the Early Stages of Schizophrenia, which reviews the critical management issues in providing specialized and optimal care to this complex patient group and their families, including meeting the patient's emotional needs Neurobiological Investigations of the Early Stages of Schizophrenia, which describes important specialized topics that contribute to our understanding of the first episode of schizophrenia, including schizophrenia in childhood and adolescence and cognitive dysfunction in the early stages of schizophrenia This ground-breaking volume provides reason for new optimism about the treatment and outcome of schizophrenia. With its dramatically different perspective on the potential long-term outcome of a still-baffling illness, this volume is a must-read for mental health practitioners and educators, psychiatry residents, and family members of affected individuals.

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Ethics Primer of the American Psychiatric Association

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In questions of psychiatric ethics, simple "yes" or "no" answers are rare, yet questions arise frequently in the clinical setting. "Should I accept a patient's invitation to a party?" "Is it OK to tell a patient that I, too, have had a depression?" "Can I release sensitive information about my patient without the patient's consent?" "Can I give a psychiatric opinion about someone I've never examined?"A shortage of ethics instruction from medical school through residency has left many psychiatrists facing the increasingly complex field of ethics without a clear guide to ethical decision making and conductuntil now.Informed by some of the formal proceedings of the APA Ethics Committee, Ethics Primer of the American Psychiatric Association presents today's ethical dilemmas in eleven informative chapters -- brought to life by the clinical vignettes based on actual cases seen by this primer's distinguished contributors.    Boundary violations between the doctor -- patient relationship and any other relationship (e.g., social, sexual/romantic, business) Issues such as informed consent, psychopharmacology, hospitalization, and psychotherapy with children, adolescents, and families Issues such as confidentiality, competence and consent, quality of life, abuse and neglect, and use of restraints with geriatric populations  Involuntary hospitalization rife with conflict and controversy where many ethical principles clash (e.g., beneficence, autonomy, informed consent) Reconciling ethical conduct (as delineated in guidelines of the AMA, APA, and Sabin) with managed care's cost containment and rationing of medical services Confidentiality, how this fundamental ethics principle can clash with the business ethics of managed care and insurance companies Gifts from patients and industry when and why they are or are not acceptable The often uncomfortable duty to report colleagues who engage in fraud or deception, from speaking privately with a colleague to referring a concern to a departmental committee, supervisor, or local APA ethics committee (and applicable legal mandates) Emergency care ethics how to ensure proper treatment for psychiatric patients who come to the emergency room with physical illnesses forensic psychiatry, including codes of ethics, boundary issues, and management of allegations of ethical misconduct When consultations and second opinions are needed Including an appendix with selected material from The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, this clinical guide and reference is sure to stimulate the discussion so integral to maintaining the dynamic tradition of ethics. As such, it is essential reading for every psychiatrist -- whether in training or in established clinical practice -- who aspires to a richer appreciation for the wisdom and subtleties of the guidelines and principles of medical ethics.

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In recent years, considerable research, as well as clinical guidelines based on study findings, has been published on the treatment of posttraumatic stress disorder (PTSD). A gap remains, however, between the controlled environments and protocols used in intervention research and the more complex and often imperfect settings and situations that clinicians must navigate in daily practice. Moreover, clinicians routinely see patients whose comorbid substance abuse, self-destructive behavior, or medical illness would likely exclude them from research studies. In short, although the extensive literature is certainly helpful in articulating the various treatment modalities available to clinicians, the strength of the evidence for the efficacy of the treatments, and the recommendations and personal preferences of experts, the literature does not address the real-life dilemmas that clinicians face in attempting to treat trauma survivors.What is needed is a way to bridge the gap between research and practice -- to "translate" study findings into everyday clinical realities. Treating Trauma Survivors With PTSD answers that need. Its authors, experienced researchers and clinicians who are at the forefront of conceptual discourse on trauma and PTSD, are uniquely qualified to offer guidance on these issues. Among the specific topics covered are the following:   Diagnosis and assessment of and treatment planning for trauma survivors with PTSD, including clinical presentations related to trauma exposure and PTSD and the implications of comorbid symptoms and disorders Treatment matching in clinical practice -- how treatment outcome findings can be used to develop profiles for predicting which patients are most likely to respond to which treatments Medications useful in the treatment of PTSD and the strength of the empirical evidence for their efficacy Trauma in children and the efficacy of various treatments, including a discussion of how treatment for children differs from that for adults Assessment and treatment of multiply traumatized patients -- those with both recent trauma and a history of childhood trauma or abuse Treatment of trauma survivors in the acute aftermath of traumatic events, including a review of some of the exciting developments in the field regarding risk factors (e.g., normal vs. pathological coping responses) that influence which individuals are most likely to develop PTSD after such events. These topics have never been more relevant than now, in the wake of the attacks that shook our country on September 11, 2001. It is the authors' hope that by reading this book, mental health practitioners will gain more confidence in applying the specialized techniques described in empirical studies to their own practices and clinical realities.

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Kader Abdolah, Rachel Yehuda, Nancy Forest Flier

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Handbook of Integrated Short-Term Psychotherapy

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In the past, short-term -- or brief -- treatment was practiced by few clinicians, its power relatively unknown. Today, the dual pressures of managed care and patient preference make it imperative to reconsider brief treatment, which has proven to be as effective as long-term therapy for many disorders and problems.This remarkable guide for conducting short-term psychotherapy details the tools and techniques of brief psychotherapy, addressing four main areas:   Understanding, conceptualizing, and formulating the patient's problems -- Brief psychotherapy requires a concise formulation of the patient's problems within the first hours of treatment to ensure that the therapist understands and can focus on the patient's core problems early in therapy. The authors describe a detailed method of patient assessment and case formulation as the first building block in learning the fundamentals of short-term treatment. Setting realistic treatment goals -- Brief psychotherapy sets explicit goals from the beginning, based on a thorough evaluation that incorporates the patient's wishes, desires, and dissatisfactions and an agreement about what the work of therapy will encompass. Knowing what to say to patients (i.e., technique) -- Brief psychotherapy requires focused, concrete techniques within clear guidelines for each stage of treatment. With numerous clinical examples, the authors define a unified treatment that emphasizes the differential use of therapeutic interventions, such as cognitive-behavioral and interpersonal techniques, encompassing the continuum of interpretative to supportive approaches. They also offer an in-depth look into the therapeutic process: they use patient-therapist dialogues -- including both patient and therapist comments and accompanying third-voice explanations -- to chronicle the progress of four patients through the initial, middle, and termination phases of psychotherapy. Maintaining a positive therapeutic alliance -- Although the quality of the therapeutic alliance is the best predictor of outcome in both traditional and brief psychotherapy, it is absolutely vital to the success of brief psychotherapy. The authors present a framework for maintaining and enhancing this alliance, including how to heal misunderstandings. Concluding with a collaborative model and summary of the past 20 years' research on integrated treatment, this volume is more than a valuable clinical guide for integrated evaluation and treatment; it is also a practical blueprint for promoting and maintaining a flexible, positive patient/therapist relationship. As such, it will prove indispensable not only to practitioners, but also to educators and students.

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Retrospective Assessment of Mental States in Litigation

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"Why did the defendant do it?"Mental health professionals are asked to help courts answer this question. To serve justice, the law calls for evidence of the mental state at the time a crime is committed, of suicide intent in civil litigation, and of mental capacity in contract litigation. The law asks psychiatrists and psychologists to retrospectively determine mental states -- a daunting task made even more difficult by the passage of time, the uncertain credibility of witnesses, the paucity of collateral sources of information, and often the death of the person in question.This is the first book dedicated entirely to the retrospective assessment of mental states. This fascinating book explores the role of the psychiatrist and psychologist, as an expert witness in litigation, in rendering a retrospective judgment of an individual's mental state. Distinguished contributors apply their expertise in psychiatry, psychology, and the law to address the problems of retrospective assessment. With the goal of developing guidelines for more accurate retrospective assessment of mental states, they present topics such as    Guidelines for conducting retrospective assessments in children and adults  Guidelines for the retrospective assessment without benefit of direct examination  Assessments of suicide cases in both civil and criminal litigation Psychological testing and interviewing techniques that may assist in retrospective assessment  Methods and analysis to help clinicians and attorneys critically evaluate the search for "truth" about the past. This remarkable book will prove indispensable for helping clinicians, lawyers, and judges better understand the complex and difficult process of retrospective reconstruction of mental states.

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Every clinician today needs a basic understanding of what causes violent behavior. The second edition of Neurobiology of Violence synthesizes current research on the origins of violence and reveals its implications for managing aggressive patients and minimizing risk.Author Jan Volavka, currently Chief of Clinical Research at the Nathan S. Kline Institute, spent time in a Nazi prison as a child and has devoted much of his career to studying violence in humans. In Neurobiology of Violence, Second Edition, he brought together research and clinical data from many diverse disciplines in a single-authored volume with a unified voice that is clearly written and interesting to read.Neurobiology of Violence, Second Edition, will give you a firm grounding in a complex subject that will help you diagnose, manage, and predict violent behavior. In the first part of the book you'll examine the basic science of the origins of violence in humans, such as   Factors in animal aggression that have parallels in human aggression, including the relationship between serotonin and aggression  The genetic and environmental factors that interplay from conception to adulthood to result in violence. In the latter part, you'll develop new insights and strategies for working with violent patients in discussions of the latest clinical science, including Major mental disorders and violent behaviors, including behaviors expressed in the community and those in psychiatric hospitals  Alcohol and various drugs and the tendencies of each type of abuse to predispose people to violence Current psychopharmacological approaches to managing violent behavior in patients. With more than 1000 updated references, the second edition of Neurobiology of Violence is a seminal resource for clinicians. It is an important tool for psychiatrists, neurologists, psychologists, and all other clinicians who struggle to understand and treat violent patients.

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Medical Complications of Psychiatric Illness

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Psychiatric patients have an increased rate of morbidity and mortality due to physical illnesses. Distressingly, psychiatrists fail to recognize these comorbid medical illnesses in nearly half of all cases. All too often, the physical illness may be causing or exacerbating the psychiatric symptoms. Furthermore, the psychiatric condition itself and iatrogenic complications of medication or other treatments can result in serious medical pathology.Until now, most psychiatrists have deferred the general medical care of their patients to other practitioners. Yet because psychiatrists are uniquely positioned to provide health care that bridges somatic and mental conditions, they are increasingly being called on to ensure that their patients also receive adequate medical care. This breakthrough text responds to that call to action from a perspective unique in the literature: It focuses on the medical complications of psychiatric illnesses, rather than the more typical psychiatric complications of medical illnesses.This concise yet comprehensive book is intended for practitioners who treat adult medical patients. It is divided into two main sections:    Health Care of Psychiatric Patients, organized by recommendations for routine medical management and reproductive health, focuses on the general health care maintenance of psychiatric patients with medical illnesses. Also discussed are the unique reproductive health needs of psychiatric patients, who are often at increased risk of coercive or abusive sexual relationships, rape and other sexual assaults, unplanned pregnancy, pregnancy complications, and sexually transmitted diseases. Psychiatric Disorders, organized by diagnostic groupings, focuses on those psychiatric disorders -- affective, anxiety, and somatoform disorders and dementia; schizophrenia and other psychotic disorders; Munchausen's syndrome and other factitious disorders; self-injurious behavior; eating disorders; and alcohol and drug abuse -- that most clearly can have medical complications. Using extensive notes and tables throughout, these distinguished contributors have created far more than just another compendium of medical illnesses that can present with psychiatric symptoms. Here you'll find a practical, detailed roadmap that will be welcomed not only by students, residents, and clinicians working with adult psychiatric patients who develop medical complications, but also by practitioners who manage psychiatric patients in a general medical practice.

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Scott J. Crow, James L. Roerig, Claire Pomeroy, James E. Mitchell

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The Many Faces of Depression in Children and Adolescents

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Although research on the diagnosis and treatment of depression in children and adolescents has lagged far behind that in adults, recent large-scale studies -- armed with operationalized criteria and validated assessment instruments -- have done much to close this gap. In The Many Faces of Depression in Children and Adolescents, Drs. Shaffer and Waslick lead a distinguished group of contributors in presenting an overview of the key findings and concepts emerging from recent empirical efforts to understand the cause of depressive illness in youth. Featured are the following:   Current findings regarding the epidemiology, diagnosis, and treatment of depression in childhood and adolescence Results of major clinical trials evaluating outpatient psychotherapeutic interventions for depressed and suicidal children and adolescents (e.g., cognitive-behavior therapy and interpersonal psychotherapy for depressed children and adolescents; dialectical behavior therapy for suicidal youth) State-of-the-art principles of pharmacotherapy for acute, continuation, and maintenance treatment phases of major depressive disorder in children and adolescents Dilemmas and challenges related to the diagnosis of bipolar disorder in children Current knowledge regarding the epidemiology and clinical manifestations of -- and the etiological risk factors for -- suicidal ideation, suicide attempts, and completed suicide Developments in the emerging field of youth suicide prevention An invaluable compendium of current thought on a disorder whose potential consequences can be nothing short of devastating, this volume belongs on the bookshelf of every clinician who treats children and adolescents.

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Models of Clinical Intervention With Infants and Their Families

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Countless studies have demonstrated the power of early intervention to permanently alter the course of a child's life. Yet -- heightened by the past decade's research breakthroughs in genetics -- the nature vs. nurture controversy rages on.This volume dispels some of the persistent myths surrounding this controversy. Unlike largely theoretical texts that describe infant behavioral and emotional difficulties and other psychosocial challenges affecting young children, this eminently practical guide illustrates what to do in numerous clinical situations with actual patients. Written by clinicians who work with infants and children and their families every day, this reality-based approach addresses the most common and important problems in infant psychopathology (e.g., trauma, sleep, feeding, excessive crying, attachment disruptions), covering models of intervention from pregnancy through infancy, attachment issues, and transgenerational themes. Here, you'll find topics rarely addressed elsewhere:   The theoretical and clinical implications of trauma during early childhood and its effects on emotional regulation, cognition, and attachment, including potential disruptions of attachment -- a topic widely overlooked in the life of young children, perhaps because of the distress it produces in adults to think that infants can be subject to violence, witness major traumatic events, and experience consequences from such events Techniques, such as multimodal parent-infant psychotherapy, for working effectively with families -- once considered "unreachable" -- who are under severe stress and have endured multiple disruptions, disappointments, and marginalization A timely discussion of a rarely addressed problem on the importance of early intervention and the effects of day care for infants, from the point of view of the infant exposed to multiple caretakers, addressing the very difficult questions of the effects on infants of changes in caretakers How young children use their bodies and its functions to manifest their difficulties, focusing on sleeping, crying, and eating with practical suggestions that can be widely applied by health care professionals Unique commentaries on two case examples by a diverse international panel of clinicians and researchers -- from countries such as Argentina, Canada, France, Japan, Mexico, Switzerland, the UK, and the U.S. -- illustrating the differences of opinion, approaches, and perspectives that together generate more effective assessment and treatment This thought-provoking clinical reference is a "must read" for developmental, child, and adolescent psychiatry educators and practitioners -- and nurses, pediatricians, occupational therapists, and clinical social workers -- as they help the youngest members of our community through theoretical understanding and practical intervention.

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For most of its history, medicine has been male oriented. Doctors, research subjects, and patients were nearly all men, and medication dosages were considered to be "one size fits all.That orientation has changed dramatically. The medical profession now recognizes that women's physiology is different and realizes that women's health is one of its leading issues. Our relatively recent efforts to understand sex differences in the onset, presentation, course, and treatment of mental illnesses are yielding sometimes striking results. Why is schizophrenia so much more common in men, and why does it have an earlier onset and a more malignant course? Do estrogens protect against schizophrenia? Why do women have higher rates of mood disorders and increasing rates of substance abuse? Representing the work of 60 distinguished contributors, this comprehensive summary answers these and many other questions concerning the psychological and pharmacological treatment of psychiatric illnesses in women, including useful information about recent developments in psychopharmacology, physiology, course and manifestation, and the interaction between social and biological factors. This eye-opening book is divided into five parts:   Anxiety disorders and other related disorders -- Panic, agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), and substance abuse disorder associated with PTSD, featuring research that continues to uncover promising hypotheses to explain gender differences in prevalence and treatment rates Major depressive disorder and related disorders -- The role of women's reproductive cycle in precipitating or exacerbating mood instability; psychopharmacology of antidepressants; effects of hormones (especially estrogen); sex differences in brain structure and function; and pharmacokinetic differences in rates of drug absorption, distribution, metabolism, and elimination Schizophrenia and related disorders -- Origins and progression; neurocognition and symptom expression, with the central role of gonadal hormones; the effect of estrogen (menopause coincides with worsening symptoms); neuroleptic-induced hyperprolactinemia; quality-of-life considerations and systems of care; and schizophrenia's impact on the family in our post-institutionalization age Dementia and related disorders -- Overview of Alzheimer's disease (AD) research from the National Institute on Aging, recent clinical trials that suggest the treatment efficacy of estrogen replacement, the central role of gonadal steroids in preventing and treating AD, and the challenges faced by women caregivers Other psychiatric illnesses and special topics -- Epidemiology of substance abuse disorders, victimization, and PTSD; dissociative disorders (by far more prevalent in women than men); factors in the pathogenesis of anorexia nervosa and bulimia nervosa; treatment challenges during pregnancy; and women, ethnicity, and psychopharmacology Clinicians and laypersons alike will welcome this clearly written, definitive guide on the most recent developments in our understanding of the major differences in the brain anatomy, physiology, and epidemiology of psychiatric illnesses between women and men.

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Teresa S. Williams, John M. Herrera, Freda Lewis-Hall, Jill A. Panetta

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Brain Circuitry and Signaling in Psychiatry

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The 1990s, appropriately termed "the decade of the brain," witnessed unprecedented advances in our knowledge of psychiatric neuroscience. Yet with every advance, we realized afresh that we were still in the beginning stages of a much longer journey.This text chronicles the next step of that journey. Structured around a proven teaching methodology that uniquely integrates the clinical aspects of psychiatric disorders with their neurobiology, this volume begins with two introductory chapters on functional neural circuitry and neural signaling pathways. The remaining six chapters present current knowledge on the neuroanatomic and neurochemical mechanisms underlying schizophrenia, addiction, anxiety, depression, bipolar disorder, and dementia/Alzheimer's disease. For clarity and consistency, each chapter features the same four divisions -- clinical presentation, neural circuitry, signaling pathways, and psychopharmacology -- as they relate to   Schizophrenia, which reviews studies of the neural basis of schizophrenia and describes how the cortex, the thalamus, the basal ganglia, and the medial temporal lobe work together during normal brain function and then how each is perturbed in psychosis.  Addiction, which focuses on the consequences of psychoactive substance use, including compulsive practices (e.g., eating, sex, Internet browsing) that might also involve the same brain circuits and signaling pathways. Of exceptional value are two unique illustrations that capture -- for the first time -- much of what we know about the anatomy and neurochemistry underlying the behavioral symptoms of addiction. Anxiety, which presents current hypotheses regarding neurocircuitry and signaling pathways for the three best-studied (from a neurobiologic perspective) anxiety disorders: panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. Depression, which offers evidence for the involvement of highly interconnected cortical and limbic structures such as the prefrontal cortex, medial thalamus, amygdala, ventral striatum, hippocampus, and the hypothalamic-pituitary-adrenal axis in unipolar major depression, and suggests target areas (such as the cAMP pathway) for study in the development of new antidepressants. Bipolar disorder, which shows that specific abnormalities in signal transduction pathways, including protein kinase activity, G protein levels, and gene expression, are unique to bipolar patients, concluding that the actions of lithium and anticonvulsants on intracellular signaling pathways provide a new paradigm for novel pharmacological interventions.  Dementia and Alzheimer's disease, which details current findings on neurofibrillary degeneration, relevant genes and proteins, pathogenesis (metabolic decline, defective cell repair, and A toxicity), and treatment strategies (neurotransmitter replacement, and neuroprotective and regenerative approaches). Discusses frontotemporal dementia, dementia with Lewy bodies, Parkinson's disease, and vascular dementia. Meticulously researched and clearly written by 15 contributors -- all recognized experts from leading research and teaching institutions in the United States -- this compact and extensively illustrated volume stands out in the literature because it combines readability and practicality with the breadth and depth typically found only in far lengthier works. Psychiatric practitioners, residents, and students alike will welcome this informative, easy-to-read text, which will also be of special interest to mental health and pharmaceutical industry professionals, and of general interest to anyone who wants to know more about the biology of psychiatric illness.