The detection and management of mental health disorders in pediatric primary care

We reviewed the literature on the detection and management of mental health disorders within the context of pediatric primary care. Pediatricians have displayed a low sensitivity and high specificity in research investigating the detection of mental health impairment in children. Active management efforts characterize approaches to identified cases with more recently trained primary care pediatricians displaying a wider range of skills in managing mental health disorders. Few efforts have been made by pediatric psychologists to develop strategies for enhancing detection rates and management or to empirically evaluate the integration of pediatric psychology services into the primary care context. A conceptual model of factors influencing detection rates and ongoing management of mental health disorders within pediatric primary care is presented. Recommendations are made for more direct involvement of pediatric psychologists within the primary care context.     

Stress and family support as predictors of distress and rejection in people who care for a relative with schizophrenia

Relatives (N=121) of adult schizophrenia patients were interviewed to investigate predictors of their level of psychological distress and of rejecting attitudes toward the sufferer. The relatives' total stress, particularly that associated with poor communication skills in the sufferer, predicted several measures of their psychological distress, and the same variables plus turbulence of sufferer behavior (i.e., violence and disruptiveness) predicted rejection of the sufferer by the relative. In each case, adequacy of family support moderated the influence of the stressors, although this effect was more marked for distress outcomes than for rejection. The results have important implications for the sorts of professional and peer support which relatives may need to encourage their performance of this potentially burdensome role. In addition, the results fit a classic stress management model and provide a feasible alternative to the Expressed Emotion Model of the relationship between relatives' rejection and patients' illness severity.     

Electrodermal lability in anxiety disorders

Twenty-eight anxiety patients, aged below 50 years, were diagnosed according to DSM-III-R criteria (panic disorder with and without agoraphobia, generalised anxiety disorder, and anxiety disorder not otherwise specified). The patients were characterised by high levels of state and trait anxiety and neuroticism, compared with the controls. However, there were no differences between patients and controls in electrodermal habituation rate, non-specific activity, or skin resistance level. When the patients were divided into electrodermally labile and stable subjects, significant differences were found between patients and controls in both electrodermal activity and Eysenck's personality dimensions. The labile patients were more introverted and attained higher psychoticism scores than either the stable patients or controls. Duration of anxiety symptoms removed the difference found in extroversion, but not in any other variable. The results are discussed in relation to the utility of electrodermal measurements in validation of diagnostic entities. It is concluded, that from the psychophysiological point of view, anxiety disorders may be examined within a dimensional framework.     

Structural models of psychotherapy groups and their effect on inpatients with borderline personality disorders: Patients' perceptions

This research compares the way in which various group structural models affect self-understanding, interpersonal relationships and catharsis in hospitalized patients with borderline personality disorders. Each of the models is characterized by a different combination of group focus and leadership style. Three psychotherapy groups were chosen as paradigms: the dynamic psychotherapy group; the therapeutic games group, and psychodrama group. Sixty three inpatients with borderline personality disorders participated in the study. The one-way ANOVA yielded significant differences between the group models. Results of the post-hoc t-test showed that the dynamic and the games groups were perceived by the patients as more beneficial than psychodrama.     

Effects of differential reinforcement on the behavior and self-esteem of children with emotional and behavioral disorders

Students in a residential special school for children with emotional and behavioral disorders participated in a study designed to reduce their levels of inappropriate behavior. The residential care staff rated the students' behavioral problems and their class teachers rated their overt self-esteem pre and post intervention. In addition, the students completed self-ratings of their self-esteem. The students were divided into two groups, experimental and control. A multiple baseline across behaviors design was used to assess behavioral changes in the experimental group. Both groups received tangible rewards to the same level but only the experimental group received them contingent upon behaving appropriately. Results showed that the experimental group students made substantial reductions in their levels of inappropriate behavior, which were maintained at a three-month followup. Also, ratings of their behavioral problems by residential child care staff suggested that this improvement in behavior had generalized beyond the classroom to the residential setting. However, no significant differences were found between the pre- and post-intervention ratings of their self-esteem or teacher ratings of their overt self-esteem.     

The use of the psychological stress evaluator with stutterers

A lie detection instrument, the Psychological Stress Evaluator, has been reported by the manufacturer as being capable of quantifying changes in the degree of “stress” as reflected by a subject's voice. Speech pathologists might consider the use of the instrument in clinical and research activities concerning the stutterer's emotional (stress) reaction to stuttering.To test the validity of the instrument, four stutterers and four normal speakers were recorded while making consecutive telephone calls. Randomized recordings were analyzed by a company trained technical to determine the degree of stress for each speech sample.Results indicated that both groups had a significant reduction of stress from the first to the fourth telephone call. However, the groups did not differ in the degree of stress during the ordered series of calls. Due to the inability of the Psychological Stress Evaluator to differentiate between the groups, the validity of the instruments is questioned.     

Behavioral assessment and treatment of acquired visuoperceptual disorders

Visuoperceptual deficits are common sequelae of damage to either hemisphere of the brain, but are typically more pronounced following injuries involving the right cerebral hemisphere. Common visuoperceptual disorders include visual field cuts, hemi-inattention and hemi-spatial neglect, hemi-perceptual deficits, and gaze and visual pursuit disturbances. A number of behavioral interventions have been developed to teach patients to compensate for acquired visual deficits. Studies addressing assessment and treatment issues in this area are reviewed, and future directions for research are outlined.     

Thoughts and feelings and things: A new psychiatric epistemology

Epistemology — the study of knowledge — is a philosophical discipline with close ties to psychiatry. When epistemologists address specific questions about how knowledge is actually realized by human beings, their philosophy must be informed by empirical studies of the sort psychiatrists now take up in a variety of forms. As this paper describes, psychiatrists can likewise improve their understanding of human psychology through a deeper appreciation of philosophical analysis in epistemology.The aim of this article is to introduce a unifying framework within which the experience from different approaches to psychiatry — (1) the conceptual schemas of cognitive psychiatry, (2) the mental structures of psychoanalytic psychiatry, (3) the categorical forms of existential psychiatry, and (4) the neural pathways of biological psychiatry — can all be applied productively to the central question of epistemology. By establishing a broad understanding of the problem of knowledge, this new view of epistemology is developed within the idiom of each psychiatric approach. In addressing themselves to a unitary problem, these diverse psychiatric approaches are themselves revealed, not as competing points of view, but as complementary views of a single subject. The result is a new epistemology that can not only bring the insights of psychiatry to philosophy, but can also contribute to the care of patients when psychiatrists bring this broader view to their clinical work.     

Synapses,Schizophrenia, and Civilization: What Made Homo Sapient?

Progress in technology has allowed dynamic research on the development of the human brain that has revolutionized concepts. Particularly, the notions of plasticity, neuronal selection, and the effects of afferent stimuli have entered into thinking about brain development. Here I focus on development from the age of four years to early adulthood, during which a 30 percent reduction in some brain synapses occurs that is out of proportion to changes in neuronal numbers. This corresponds temporally with changes in normal child behavior from the loose‐associative, almost schizoid, thinking and art of the four‐year‐old to the more trained, or disciplined, or acculturated—and restrained—personality of the young adult. I propose that the synaptic changes can best be thought of as a winnowing process likely subject to environmental influences. Acquisition of language and the ability to link linguistic cognition to the plastic development of the brain provide a potentially powerful means of explaining the evolutionally explosive development of human cognition and culture. Schizophrenia, a disease that can be envisioned as representing a derangement of synaptic maturation, may provide an entry into the search for genes controlling the processes mediating the unprecedented development of Homo sapiens over the past 40,000 to 70,000 years. The recently completed mapping of the genome of the chimpanzee provides a new frame of reference that may speed the search.