Psychiatric Experience Research Articles

VII. Frieda Fromm-Reichmann, MD: Her Impact on American Psychiatry.

When Frieda Fromm-Reichmann left Germany in 1933, she characteristically went at first only across the border to Alsace in order to finish her therapy with her patients. She and Erich Fromm had established a private psychiatric sanitarium in Heidelberg in the late 1920s, and although they closed it after four years, she continued to practice as a psychoanalyst in Heidelberg for several years. She brought with her out ot Germany an especially varied and useful psychiatric experience--including her work during World War I with brain-injured soldiers, under Kurt Goldstein; the study of "relaxation training" as a treatment under Schulz; and work in 1923 in Kraepelin's Munich clinic, where she also continued to expand her reading of Freud, whom she had discovered only recently. After her psychoanalytic training in Munich and Berlin, she moved to Heidelberg, where she treated some schizophrenic patients. These various experiences later contributed to her fully developed belief before she emigrated that the personal relations of schizophrenic patients were the touchstone to therapy.

The effects of brief psychiatric training on the attitudes of general nursing students to psychiatric patients

The attitudes of an unselected sample of general nursing students to a series of matched medical and psychiatric case-examples were assessed before and after they received 9 weeks training in either a general hospital psychiatric unit or a geriatric unit. The major component in cluster analyses of construct ratings of case- descriptions by both groups before and after training was a factor of fear, or distrust, on which students differentiated clearly between medical and psychiatric cases, tending to expect the psychiatric patients to be more frightening, less likely to cooperate, more likely to be violent and dangerous and to need strict control. Psychiatric training, therefore, did not eliminate students' distrust of psychiatric patients. This highlights the importance, during training, of attending to issues of trust and responsibility, and the problems of fear and prejudice caused by psychiatric labels. The attitudes of permanent psychiatric staff are highly relevant in considering how students will be affected by psychiatric work experience. Some benefits of contact with psychiatric patients were found, and the implications of these are discussed. These benefits support the value of the training experience, overall, and it is suggested that students should work with psychiatric patients earlier in their course (in the first year). The scope of psychiatric training should be broadened and improved to make this a more attractive, worthwhile option.

Clinical teaching: an evaluation of a problem orientated approach to psychiatric nurse education.

In a recent paper by one of the authors (Cormack 1080) the use of the problem orientated approach to nursing, and a proposed framework for assessing nursing needs, were discussed. Subsequently one of the writers (W.R.) utilized the problem orientated approach during the psychiatric nursing experience made available to student nurses undergoing the comprehensive modular training at the Highland College of Nursing and Midwifery, Scotland. This paper presents an evaluation of the problem orientated approach which has now been developing for 2 years. This paper describes the experience of W.R. in using a problem orientated approach to nursing diagnosis and nursing care prescriptions. It is argued that such an approach, combined with patient-centred rather than classroom based nurse education, is essential to enable psychiatric nurse teachers to teach effectively. Such a patient-centred approach is also necessary to clarify the psychiatric nurses' role and to shift the emphasis of psychiatric nurse education away from psychomotor skills to interpersonal skills. While it is recognized that this evaluation does not comply with the scientific criteria of a formal research based project, it is suggested that the experience of the authors and the comments of the many students involved in the exercise accurately reflect the problems encountered and the progress achieved.

Traumatic war neurosis: Egyptian experience.

Over the last 24 years the Egyptian Military Forces have been involved in 5 wars. Each war had its own characteristics. The Yemen War, an overseas battle, the theatre of which was completely different from our Egyptian desert, being mountainous and not leading to a modern or even classical combat. The 1956 war, the 1967 war, the war of attrition lasting from 1968 to 1970 and lastly the war of October 1973, all in a relatively short period have enriched our psychiatric experience in handling the problem of war neurosis. The Egyptian military psychiatric team believes that traumatic war is a well defined nosological entity, a belief which is not yet shared by a group of Egyptian civilian psychiatrists. Traumatic war neurosis has its own precipitating factors, its own clinical picture, its own psychopathology as well as its own management. This paper is about war neurosis as an Egyptian experience, and is limited to two main items, namely, the various clinical pictures which we, as a military psychiatric team, have seen among Egyptian psychiatric casualties and secondly their management.

Multiple Sclerosis and Hysteria

To the Editor.— I wish to comment on the article by Caplan and Nadelson. First, I wish to add my emphasis to the necessity for recognizing the coexistence of organic and psychological disorders, especially with MS. Physicians often overlook the fact that organic disability represents a severe psychological trauma that may lead to responses that are ordinarily considered neurotic. Careful psychological history taking will generally uncover earlier psychological problems with any cooperative patient, but this does not define the extent to which the patient is trying to adapt to a disability. This is most important in differential diagnosis. In my psychiatric experience, I have had great difficulty in obtaining a thorough consultation once a diagnosis of hysteria is made. A psychoanalyst works constantly with history taking that often shows early, subtle evidence of organic disease that is camouflaged by the neurosis. This is particularly true with MS. It is frustrating

Medical Students Attitudinal Changes Associated with the Psychiatric Clerkship

This study explores the effects of the psychiatric clerkship on medical students’ attitudes toward mentally ill patients. Of 42 junior medical students in the study, 11 students were assigned to a primarily “Dispositional” unit and 11 to a “Treatment” unit. The control group consisted of 20 students with no psychiatric clerkship experience. All completed the Opinion about Mental Illness scale on the first and last days of the clerkship. The results demonstrate that the Dispositional Unit students experienced a decrease in Benevolence and an increase in Social Restrictiveness. The Treatment Unit students showed a decrease in Social Restrictiveness and an increase in Mental Hygiene Ideology.

Factors affecting the experience of the initial psychiatric consultation in outpatients with anxiety states

The experience of the first consultation was measured by a questionnaire in 42 outpatients with neurotic anxiety tension states. The correlation between this experience and the doctor's level of experience, the sex combinations of doctors and patients and the personality of the patient, as measured by an inventory 1-2 years after the end of the drug study (35 patients completed the inventory), was studied. Patients who had had a more favourable experience had more often been interviewed by doctors with longer psychiatric experience. Female patients tended to report a more favourable experience with male doctors than male patients did. Patients with a less favourable experience deviated more from the norms of the personality inventory with regard to, for instance, passive dependency than patients with a more favourable experience did, but the difference between the groups was not significant.

Psychiatrists' models of mental illness and their personal backgrounds

Seventy-nine junior psychiatrists at the Maudsley Hospital answered 16 biographical questions and a 68-item questionnaire measuring attitudes to the psychoanalytical, biological, social, behavioural, and anti-medical models of mental illness. The psychoanalytical model was the most clearly defined and its adherents the most dogmatic, while those supporting the social model were the most eclectic. Sex, social class, education and political sympathy proved a poor guide to the orientation of the respondent. Individuals who had decided on a career in psychiatry before entering medical school were the most critical of the biological model. Biologically minded psychiatrists were older and, in contrast to Kreitman's findings, there was a shift from a psychoanalytical to a biological preference with increasing psychiatric experience. The importance of scientific attitudes in psychiatry was endorsed by biologically and behaviourally inclined psychiatrists but denigrated by supporters of the analytical approach. Adherents of the psychoanalytical model had as many academic qualifications as the biologically inclined, but had fewer publications and were less active in research. It appears that interest in psychoanalysis is antipathetic to the development of scientific attitudes conducive to research.

Patients' comments on psychiatric inpatient treatment experiences: Patient-therapist relationships and their implications for treatment outcome

Only few researchers pay systematic attention to what patients may have to say about their treatment experience during psychiatric hospitalization. This study not only delineates the various therapeutic aspects of an open psychiatric inpatient unit based on the patients' comments, but also attempts to correlate the data with the objective outcome of treatment rated clinically by the therapists and independently by the author. Positive patient-therapist relationship has been found to be the most significant factor correlated closely with the treatment outcome. The correlation may support the relevance of the patients' comments regarding subjectively perceived therapeutic benefits vs. objective actual benefits.

Diagnostic errors in psychiatry

Although the importance of nosology has been derided as “pigeonholing” by some American psychiatrists, the science of diagnosis has lately enjoyed a renaissance. Actually, whether or not a psychiatrist possessed diagnostic acumen had little effect on the outcome of treatment until the past two decades, because so much of treatment was nonspecific. But the increasing use of drugs, particularly neuroleptics, antidepressants, and lithium, has made precise diagnosis a necessity. In recent years, several authors have commented upon the misdiagnosis of manic-depressive patients—particularly catatonics 1—as schizophrenics 2 and a multihospital cross-national study 3 has suggested that American psychiatrists overdiagnose schizophrenia and underdiagnose affective disorder. The Iowa group 4 has demonstrated that strict criteria result in a much lower rate of diagnosed schizophrenia than does the “agreement of experienced clinicians” so often set as the standard. With the compilation of diagnostic criteria for psychiatric disorder by Feighner et al., 5 it became clear that 80% or more of psychiatric patients can be definitely classified according to standards that permit accurate prediction of treatment and prognosis. But today, the vast majority of psychiatric diagnoses still are not made on the basis of scientific criteria, and the category of “undiagnosed psychiatric disorder,” at least as used by clinicians, is virtually an empty set. To what extent strict criteria are used no one knows, but from anecdotal case reports in the literature they are probably not overutilized. The resulting margin for disagreement and for downright error is probably enormous. We propose now to review the kinds of erroneous diagnoses commonly made, the reasons for these errors, and their possible consequences. This report, based upon the experience of psychiatrists in private practice, deals with the diagnostic pitfalls encountered despite, or in some cases because of, the use of scientific diagnostic criteria.

Teaching psychiatry to medical students on a consultation service.

Medical students experience psychiatric consultation as part of their undergraduate psychiatric clerkship experience. This allows further identification of the medical student with the psychiatrist in management of psychiatric problems in patient who are primarily non-psychiatric. Reaction has tended to be favourable from the medical students without a great loss of speed or efficiency in terms of the service committment.

Current problems in the diagnosis and treatment of psychological impotence

Abstract The recent psychiatric experience with sex therapy of impotent men has enabled clinicians to acquire extensive experience with this symptom, has reemphasized the need for careful differential diagnosis, and has increased awareness of our knowledge deficits. Important unanswered questions concerning the diagnosis or treatment of impotent men are the following: (1) What is the role of constitutional factors? (2) What mediates the loss of erectile capacity with age? (3) Which impotent men should have penile implants? (4) How effective is conjoint sex therapy for psychological impotence? (5) What should be the role of surrogate partners? Scientifically derived answers to these questions may revolutionize the therapeutic approach to impotence.

Children of imprisoned fathers.

John Bowlby's influential 1951 World Health Organization monograph, Maternal Care and Mental Health, pointed to a causal relationship between loss of maternal care and disturbed personality development, and had a profound effect on psychiatrists' thinking about antisocial behavior in particular, and character formation in general. More recently, psychiatric investigators have been increasingly interested in the effects of a child separation from his father. This has been stimulated by sociological concerns for one-parent, fatherless families (Adams, 1973) and by our realizing how historically neglected has been the paternal role in theories of child development. Herzog and Sudia (1971) have recently compiled an extensive bibliography of the fatherless family. Numerous clinical studies of loss of the father, through death (Nagera, 1970; Wolfenstein, 1966; Bonnard, 1964), suicide (Cain and Fast 1966), divorce (McDermott, 1970), military service (Crumley and Blumenthal, 1973), occupations (Rosenfeld et al., 1973), desertion (Thomes, 1968), and mental hospitalization (Schiff, 1965), have all reported various adverse effects, particularly on male children. It has been difficult, however, to sort out the effects of the loss itself from more general prevailing and prior family relationships. My interest in this subject was quickened when I began to see boys brought to a neighborhood clinic for aggressive and antisocial behavior soon after their fathers were imprisoned. I was impressed by the lack of reports in the literature on this form of father separation. I am presenting here my clinical observations of six families seen over a three-year period as part of a general child psychiatric experience at a comprehensive neighborhood health center sponsored by the Massachusetts General Hospital in Boston. Although there are obvious selection biases that limit generalization when families referred to psychiatrists are the only source of information, it seems a useful place to begin an examination of the consequences for children of father-separation as a result of imprisonment.

Labeling Theory and the Presumption of Mental Illness in Diagnosis: An Experimental Design

In this study, video-taped psychiatric interviews of a mental patient and a student were diagnosed by samples of psychiatrists (N=36) and students in an abnormal psychology class (N =77). Each sample was experimentally assigned to two groups. In one group it was suggested that both subjects were mental patients. In the other it was suggested that both were paid participants. It was hypothesized that the suggestion of illness and the increased clinical experience of psychiatrists would lead to an increase in diagnostic scores. The results partially support this hypothesis, in that suggestion and clinical experience led to significantly higher scores in all but one case. Also discussed are the effects of the appearances of the subjects in the tapes.

Psychopathologische Syndrome bei Epilepsien

Systematic presentation of psychopathological syndromes in epilepsy makes evident that the preoccupation with these phenomena is important to clarify essential problems in general psychiatry. There is a division into reversible and irreversible psycho-pathological syndromes. The different complexes of symptoms can nevertheless overlap. There is no nosologic specificity of psychopathological phenomena in epilepsy, which corresponds to general psychiatric experience. The division presented is to be understood as a coordinate system. The current state of development of pathological cerebral dysfunctions in an epileptic person is thus to be recorded in its course on the strength of psychopathological effects.

The amputee war casualty in a military hospital: observations on psychological management.

The psychological tasks facing the amputee war casualty change according to the phases of rehabilitation from wound healing through ambulation and the transition to civilian life. Psychiatric experience on the amputee ward in a military hospital over an eighteen month period, including individual and group psychotherapy, reveals that patient conflict over feelings of loss, guilt, dependency and anger are not uncommon. Impulsive behavior, social withdrawal, and lack of cooperation with recommended medical procedure may be symptomatic of earlier maladaptive responses to stress which have been exacerbated by the loss of a limb. Clinical examples are presented which highlight the importance of attachment to loved ones and magical wishful thinking in the experience of loss in the hospital setting. The psychiatric-orthopedic liaison helps to increase staff awareness of psychological processes so that the patient's emotional difficulties can be defined and minimized.

Epidemiological considerations of psychotic depression.

This study describes 568 individuals who had received a diagnosis of psychotic depression during 1961-1962 and examines their psychiatric experiences through 1966. The diagnosis of psychotic depression was given most frequently to an older, married, white female group, social class seemed unrelated to the diagnosis. Of these individuals, 54% had received psychiatric care prior to the psychotic depressive episode, and the majority had been hospitalized during the follow-up period. Psychiatric experiences after the initial psychotic depressive episode distinguishes four distinct groups: (1) a single isolated psychiatric contact; (2) a single psychotic depressive episode; (3) multiple psychotic depressive episodes; and (4) a single psychotic depressive episode with different diagnosed episodes. Of the sample, 16% died during the follow-up period with 14% of the deaths due to suicide.

Psychiatric experience of the Abortion Act (1967).

Public controversy surrounds the workings of the Abortion Act and will no doubt continue to do so, probably until such time as surgical operation is replaced by other methods. Recently the report has been published of the enquiry by the Royal College of Obstetricians and Gynaecologists which emphasises the difficulties involved in interpretation of the Act and the variations encountered in practice. There is a substantial body of psychiatric literature on the subject, e.g., Ekblad, 1955; Arkle, 1957; Kummer, 1963; Sim, 1963; Höök, 1963; Baird, 1967; Clark et al., 1968 and Kenyon, 1969, but results obtained in other countries and in this country some years ago are not necessarily applicable to this country now, since changes in public attitudes are likely to influence them. Little has been published by psychiatrists about their experience with cases since the Act came into operation. The recent follow-up series of Pare and Raven deals with cases seen in the years 1962 to 1968, i.e., mainly before the implementation of the Act.

Adjustment and fantasy in medical students.

In an effort to identify characteristics of a group of medical students who were conflicted about their identity, the authors investigated the value systems and attitudes of 46 graduating medical students. The 11 students characterized by imagining themselves in the field of arts and letters if they had not entered medicine differed significantly from their colleagues: they had a greater incidence of psychiatric treatment, suicidal ideation, depersonalization experiences, and dissatisfaction with their medical school training; they were more likely to attend concerts and to read nonmedical books than their fellow students; they were less likely to be members of an organized religion; and they were more likely to have smoked marijuana.

A Psychiatric Experience with Project 100,000

A Psychiatric Experience with Project 100,000