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We are pleased that the concept of terminal anorexia nervosa is being considered in serious discussion. Our previous presentations were not intended to assess eating disorders care broadly, but solely to bring attention to the importance... more
We are pleased that the concept of terminal anorexia nervosa is being considered in serious discussion. Our previous presentations were not intended to assess eating disorders care broadly, but solely to bring attention to the importance of end-of-life care issues for patients with anorexia nervosa. Regardless of differences in ability to access or utilize health care resources, inescapably, individuals contending with end-stage malnutrition due to anorexia nervosa who refuse further nutrition will progressively decline, and some will die as a result. Our description of these patients’ last days and weeks as “terminal” and meriting thoughtful end-of-life care is consistent with how the term is used in other end-stage terminal conditions. We clearly acknowledged that precise definitions and guidelines for end-of-life care for these patients should be developed by the eating disorder and palliative care fields. Avoiding the phrase “terminal anorexia nervosa” will not make these phenom...
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T he author presents a case of possible “hikikomori,” a syndrome initially described in Japan and subsequently reported internationally, including in the United States. Hikikomori refers to a syndrome of severe social isolation, ranging... more
T he author presents a case of possible “hikikomori,” a syndrome initially described in Japan and subsequently reported internationally, including in the United States. Hikikomori refers to a syndrome of severe social isolation, ranging from rarely leaving home to never leaving one's room. It occurs primarily in male adolescents and young adults, many immersed in online gaming, often living with and supported by their parents. Studies in Japan andHongKong suggest lifetime prevalence rates of 1% to 2% for individuals socially withdrawn for at least 6 months. Full-blown Hikikomori's clinical features variably resemble disorders involving depression, social anxiety, autism, and schizophrenia spectra.With prolonged isolation, feelings of loneliness may be expressed. Contributing factors have putatively included family problems,
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Autotraumatic stress disorders (ATSD), variants of posttraumatic stress disorder PTSD, may develop in individuals after traumatic stressors for which they carry some responsibility, for example, serious self-injury and injury or death to... more
Autotraumatic stress disorders (ATSD), variants of posttraumatic stress disorder PTSD, may develop in individuals after traumatic stressors for which they carry some responsibility, for example, serious self-injury and injury or death to others after murderous rages or careless vehicular driving. In ATSD, the individual is both the causative actor and casualty. As a result, in ATSD, distinctive negative psychological sequelae are grafted onto the usual distressing symptoms of PTSD, differentiating them from both PTSD and complex-PTSD. Whether the actions were intentional or unintentional and regardless of complications by comorbid psychiatric disorders, individuals with ATSD additionally experience some or all of the following symptoms stemming from actions for which they were responsible, wholly or in part: severe and unrelenting reality-based guilt, shame, remorse, regret, bitterness, self-betrayal, inability to trust oneself, and moral injury. Empirical studies investigating trauma-associated guilt and moral injury provide evidence to support these formulations. Clinical vignettes illustrate a range of circumstances leading to ATSD, in each instance adding significantly to the individual's distress, impeding recovery, and often requiring specific psychotherapeutic attention over and above that required for PTSD or complex-PTSD. These psychotherapeutic strategies have included intense, prolonged, noninterruptive, open-minded listening; avoiding premature whitewashing of responsibility and guilt; facilitating grief over lost innocence; helping create personal narratives that permit self-acceptance despite permanently altered damaged self-image; and, for some individuals, guiding repentance and restorative actions. Systematic case series and additional studies are necessary to ascertain how intentionality, self-harm versus harming others, and various comorbidities shape ATSD presentations, and to better delineate effective treatment strategies.
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BACKGROUND While contemporary psychiatric assessments ordinarily focus on signs, symptoms, and impairments comprising formal diagnoses, these assessments sometimes minimize or ignore specific complaints and other contributing problems... more
BACKGROUND While contemporary psychiatric assessments ordinarily focus on signs, symptoms, and impairments comprising formal diagnoses, these assessments sometimes minimize or ignore specific complaints and other contributing problems that are the sources of patients' and families' greatest distress. Neglect of these problems may decrease patient satisfaction and reduce the quality of care. METHODS The author reviewed limitations of previous problem-oriented efforts in psychiatry and limitations of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders. This review provided the basis for reconceptualizing how problems might be identified and framed in clinical assessments. RESULTS A clinically practical 3-tier framework for psychiatric problems is suggested. The first tier encompasses diagnostic contents, including subjective symptoms, observable signs, and impairments. The second tier consists of additional specific complex subjective complaints in the patient's and family's own words, comprised of highly individualized distressing intrapsychic, interpersonal, and environmental situations and conflicts. The third tier consists of contributing meta-problems, comprised of significant additional patient-related or systems-related difficulties noted by clinicians that contribute substantially to complicated clinical problem sets. CONCLUSIONS Diagnostic or not, specific problems expressed by patients and families and contributing meta-problems should be integrated into initial formulations and tracked during treatment. Whereas only some of these problems may fall within a clinician's scope of responsibilities, all should fall within the scope of concern, some to be referred to others, and some exceeding caregivers' capacities. Periodic review of problem lists for patients' and families' most distressing concerns can contribute to the therapeutic alliance, increase patient satisfaction, and perhaps improve outcomes.
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Residency-related stresses were examined as a function of age or age-related factors in a group of 10 psychiatrists who started psychiatric training at age 32 or older (average age, 36.2). Commonly expressed stresses included feelings of... more
Residency-related stresses were examined as a function of age or age-related factors in a group of 10 psychiatrists who started psychiatric training at age 32 or older (average age, 36.2). Commonly expressed stresses included feelings of isolation from the group, inflated expectations, and conflicting role obligations. Addressing the stresses on older residents may diminish their anxiety and enhance their morale and overall gratification in the residency program.
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Mentorship relationships have the potential to impart numerous benefits to early- and middle-career academic physicians–scientists, clinicians, and administrators. These relationships not only influence the mentee’s decision to enter and... more
Mentorship relationships have the potential to impart numerous benefits to early- and middle-career academic physicians–scientists, clinicians, and administrators. These relationships not only influence the mentee’s decision to enter and remain in academic medicine, but they have been shown to increase self-confidence and productivity, improve overall career satisfaction, and enhance the mentee’s sense of professional community.
Research Interests: Psychology and Mentorship
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An academic directory and search engine.
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The number of psychotherapies classified as "empirically supported treatments" has increased significantly. As the number and scope of empirically supported treatments multiply, it has become impossible to train therapists in... more
The number of psychotherapies classified as "empirically supported treatments" has increased significantly. As the number and scope of empirically supported treatments multiply, it has become impossible to train therapists in all of these specific modalities. Although the current Accreditation Council for Graduate Medical Education requirements for psychiatric residents follow an approach based on specific schools of psychotherapy (emphasizing competency in cognitive-behavioral therapy, psychodynamic therapy, and supportive treatments), evidence suggests that we are failing even in these efforts. In developing a specialized Psychotherapy Scholars Track in the residency program at the University of Colorado School of Medicine, we opted to focus initially on teaching the common factors in psychotherapy that positively affect psychotherapy outcomes. This article reviews 6 such broad common factors.
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Research Interests: Health Care, Job Satisfaction, Medicine, Multivariate Analysis, Humans, and 15 moreUnited States, Female, Male, Personnel Management, Workload, Risk factors, Specialization, Academic Medicine, Middle Aged, Organizational Innovation, Curriculum and Pedagogy, Risk Factors, Occupational Diseases, Academic, and Psychological Stress
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Background Throughout life, individuals are bombarded by countless emotion-generating messages. Certain of these messages, for example, some insults, admonitions, rejections, challenges, or insightful declarations, can be viewed as... more
Background Throughout life, individuals are bombarded by countless emotion-generating messages. Certain of these messages, for example, some insults, admonitions, rejections, challenges, or insightful declarations, can be viewed as “infective.” Infective messages shock, puncture, adhere, disturb, and generate discernable host responses that assimilate, accommodate, or repel the intruding messages. Messages originating in one's own mind can stimulate psychological equivalents of autoimmune responses. Sometimes, these messages produce enduring psychological changes. Infective messages may traumatize, organize, or therapize. The aims of this article are to consider how infective messages a) relate to their messengers (vectors), structural characteristics, and recipient (host) factors; b) might contribute to trauma, personal identity formation, psychological conflicts, and emotional self-regulatory and cognitive heuristics; c) might inform the conduct of psychotherapy; and d) suggest future research. Methods Clinical observations were augmented with selective literature reviews. These sources contributed to perspectives regarding how certain messages might become infective; contribute to trauma, complex aspects of identity formation, and inner conflict; and inform the conduct of psychotherapy. Results Infective messages are commonly characterized by short, cogent communications emanating from credible sources that fall on vulnerable recipients' receptive, dispositional feeling states. These infective stimuli trigger reactive and defensive emotions and associated behaviors reflecting responses to significant threats or benefits relative to the individual's deepest needs, motivations, and values. Defensive overreactions may occur in response to messages to which individuals have been previously sensitized. Infective message contents appear to assimilate into constantly evolving, dynamic autobiographical brain maps consisting of highly specific neuronal networks that range from the brainstem through limbic structures to multiple cortical areas. Autobiographical maps built from message-injected contents may transform, akin to the incorporation of retroviruses or prions, to encode personal identities as aspects of the self. Contrasting maps may exist semi-independently of one another, continuously evolving, interacting, combining, dividing, conflicting, and contending with one another for attention. Achieving attentional awareness, such maps help structure how individuals conceptualize and communicate about their encoded traumas, diverse identities, and the conflicts among them. Conclusions and Implications During psychotherapy, aftereffects of traumatizing infective messages might be detoxified by deconstructing, desensitizing, and processing messages' precise words and emotional envelopes in relation to contexts in which they were delivered, and the individual's inner dispositions at moments of impact. Carefully crafted, timely interpretations can be therapeutically infective, generating enduring positive impacts. Future studies using an assortment of approaches can test these perspectives.
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In 1980, psychiatric practitioners and educators were surveyed to determine their concepts of the knowledge and skills that define a specialist in psychiatry. The authors repeated this survey, expanding the list of skill and knowledge... more
In 1980, psychiatric practitioners and educators were surveyed to determine their concepts of the knowledge and skills that define a specialist in psychiatry. The authors repeated this survey, expanding the list of skill and knowledge items and asking respondents to comment on whether particular skills or knowledge were important to a psychiatric subspecialty. Less importance was ascribed in the current survey than in the earlier survey to certain long-term and social psychotherapies, and more importance was ascribed to descriptive or biological psychiatry; brief or supportive therapies; psychopharmacological agents; consultation-liaison psychiatry; evaluation of children, the aged, and alcoholics; and certain desirable personal characteristics of the psychiatrist.
Research Interests: Psychology, Psychiatry, Psychotherapy, Medicine, Teaching, and 12 moreHumans, United States, Child Psychiatry, American Journal of Psychiatry, Specialization, Professional Practice, Questionnaires, Clinical Competence, Psychology and Cognitive Sciences, Administrative Personnel, Medical and Health Sciences, and Referral and consultation
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Medical records of 150 medical ambulatory care patients randomly assigned to groups in which screening for depression, physician sensitization about depression, and informational feedback to physicians were systemically varied were... more
Medical records of 150 medical ambulatory care patients randomly assigned to groups in which screening for depression, physician sensitization about depression, and informational feedback to physicians were systemically varied were reviewed for physician notations about depression and its treatment. Forty-two percent of the 100 patients screened with the Zung self-rating depression scale had scores outside the normal range. Chart notation about depression was effectively and appropriately increased by feedback and sensitization from 8 to 25 percent, but these procedures were less effective in increasing treatment interventions, which were noted for 12 percent of the entire sample. Physicians responded to patient information about depression presented to them in the format of a laboratory test, and such previsit screening devices may increase physician attention to psychological problems in general medical settings.
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Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for Academic Medicine. Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining ...
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Page 1. Masters of the Mind Exploring the Story of Mental Illness from Ancient Times to the New Millennium Theodore Millon, PhD, DSc With Contributions by Seth D. Grossman and Sarah E. Meagher Portraits by Theodore Millon and Carrie N.... more
Page 1. Masters of the Mind Exploring the Story of Mental Illness from Ancient Times to the New Millennium Theodore Millon, PhD, DSc With Contributions by Seth D. Grossman and Sarah E. Meagher Portraits by Theodore Millon and Carrie N. Millon John Wiley & Sons, Inc. ...
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1. J Am Coll Health. 1986 Jun;34(6):280-2. A case of abuse of syrup of ipecac resulting in death. Dawson JA, Yager J. PMID: 2875087 [PubMed - indexed for MEDLINE] Publication Types: Case Reports. MeSH Terms: Adult; Eating ...
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This article provides an overview of how trainees, faculty, and institutions use technology for acquiring knowledge, skills, and attitudes for practicing modern medicine. The authors reviewed the literature on medical education,... more
This article provides an overview of how trainees, faculty, and institutions use technology for acquiring knowledge, skills, and attitudes for practicing modern medicine. The authors reviewed the literature on medical education, technology, and change, and identify the key themes and make recommendations for implementing technology in medical education. Administrators and faculty should initially assess their own competencies with technology and then develop a variety of teaching methods that use technology to improve their curricula. Programs should decrease the general knowledge-based content of curricula and increase the use of technology for learning skills. For programs to be successful, they must address faculty development, change management, and funding. Willingness for change, collaboration, and leadership at all levels are essential factors for successfully implementing technology.
Research Interests: Information Science, Educational Technology, Informatics, Higher Education, Medical Education, and 15 moreFaculty Development, Forecasting, Computer Literacy, Change Management, Learning, Continuing Medical Education, Computers, Faculty, Medical Students, Humans, Advisory Committees, Academic Psychiatry, Curriculum and Pedagogy, Academic, and Automatic data processing
Necropsy findings and electrocardiograms from three women with anorexia nervosa were reviewed. Necropsy examination failed to establish an anatomic cause of death. Electrocardiograms recorded 7 days or less before death showed various... more
Necropsy findings and electrocardiograms from three women with anorexia nervosa were reviewed. Necropsy examination failed to establish an anatomic cause of death. Electrocardiograms recorded 7 days or less before death showed various degrees of QT interval ...
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Douglas M. Ziedonis co-authored this practice guideline as a member of the Work Group on Substance Abuse Disorders. See article for complete list of authors.
Research Interests: Psychotherapy, Treatment Outcome, Pregnancy, Humans, Substance Abuse, and 15 moreTobacco Use, Behavior Therapy, Female, Goals, Pregnancy Complication, Psychotropic Drugs, American Psychiatric Association, Substance Use Disorder, The American, Marijuana abuse, Combined Modality Therapy, Psychology and Cognitive Sciences, Tobacco use disorder, Pregnancy complications, and Medical and Health Sciences
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Violence in psychiatric outpatient settings is a ubiquitous concern. This article describes the development, implementation, and evaluation of a live threat violence simulation exercise, designed to reduce the risk of future outpatient... more
Violence in psychiatric outpatient settings is a ubiquitous concern. This article describes the development, implementation, and evaluation of a live threat violence simulation exercise, designed to reduce the risk of future outpatient clinic violence and minimize the effects of future incidents on staff. The psychiatric outpatient clinic at the University of Colorado Hospital developed, implemented, and evaluated a 4-hour live violence threat simulation exercise as a companion to a 7-hour violence prevention program. The simulation includes an orientation, two threat simulation scenarios, three debriefings, satisfaction surveys, problem identification, action plans, and annual safety and process improvements. The authors have conducted live violence simulation exercises from 2011-2016, and have collected survey data about our annual simulation exercise from 2014-2016. Each year ≥ 52% of participants responded, and each year ≥ 90% of respondents rated the simulation as "very he...
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The goal of this column is to assist readers in reflecting on their attitudes and responses toward clinical and nonclinical situations involving preplanned deaths by decisionally capable individuals. Such circumstances range from... more
The goal of this column is to assist readers in reflecting on their attitudes and responses toward clinical and nonclinical situations involving preplanned deaths by decisionally capable individuals. Such circumstances range from encountering individuals in one's personal and professional lives who desire and intend to end their lives under their own terms, to having such individuals request assistance with predeath and postdeath arrangements. Attending to pertinent literature, this essay uses Socratic inquiry to question conventional assumptions and attitudes, push readers' thoughts beyond typical comfort zones, and consider alternative modes of responding to challenges posed by preplanned death. Studies indicate that, for their own end-of-life circumstances, physicians would prefer a briefer, higher quality life to prolonged low-quality life, dignity in infirmity and death, and avoidance of terminal suffering. Lay people generally endorse similar preferences. Although contemporary society generally shuns contemplating preplanned death, cultural attitudes regarding preplanned death are rapidly evolving, and variations of "Death with Dignity" legislation have gained traction in increasing numbers of US states as well as internationally. As yet, no broad consensus exists as to how clinicians should manage circumstances involving preplanned death. Considerations regarding preplanned deaths merit greater professional and public discussion. Many options exist for improving how professionals address the quality of human experiences surrounding death.