César A. Alfonso

Caring for Persons with Early Childhood Trauma, PTSD, and HIV: a Curriculum for Clinicians

Access and adherence to medical care enable persons with HIV to live longer and healthier lives. Adherence to care improves quality of life, prevents progression to AIDS, and also has significant public health implications. Early childhood trauma-induced posttraumatic stress disorder (PTSD) is one factor that has been identified as an obstacle to adherence to both risk reduction and HIV care. The authors developed a 4-h curriculum to provide clinicians with more confidence in their ability to elicit a trauma history, diagnose PTSD, and address trauma and its sequelae in persons with HIV to improve adherence to medical care, antiretroviral medications, and risk reduction. The curriculum was designed to address the educational needs of primary care physicians, infectious disease specialists, psychiatrists, other specialists, psychologists, social workers, nurses, residents, medical students, and other trainees who provide care for persons infected with and affected by HIV.

An Integrative Approach to Treatment-Resistant Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder that often runs a chronic unremitting course. Treatment outcomes can be unsatisfactory despite the availability of various somatic and psychological therapies. Psychodynamic psychotherapy in combination with cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) could help patients with treatment-resistant OCD achieve better outcomes. An integrative approach can help patients gain insight, strengthen the therapeutic alliance, improve treatment adherence, and provide symptomatic relief when other treatments seem insufficient or have failed. We describe the treatment process of a person with treatment-resistant OCD who received pharmacotherapy, concurrent CBT/ERP, and a brief course of psychodynamic psychotherapy. Case formulations from cognitive behavioral and psychodynamic perspectives are presented. The authors discuss the advantages of doing a psychodynamic assessment and formulation in treatment refractory cases and the wisdom of integrating psychotherapy interventions for OCD, as well as the unique clinical features of cases that warrant a multimodal treatment approach.

Editorial: Contemporary Psychodynamic Psychiatry

Richard D. Chessick presents a somber view of contemporary psychoanalysis and dynamic psychotherapy. He attributes the decline of psychoanalysis in the U.S. (in large degree) to the deterioration of American culture and sees American society as dissolute and violent. He suggests that psychoanalysis has been victimized and presents it as an oasis of civilization barely afloat in a sea of barbarism. Our view is less nihilistic, more integrative of extra-analytic research and scholarship, and has broader clinical applications. moDErn PSyCHoDynamIC PSyCHIatry Chessick refers to psychodynamic psychotherapy (and by implication, psychodynamic psychiatry) as the “child” of psychoanalysis. This may have been so years ago but no longer. Times have changed although the model of the mind that classical psychoanalysts advocate has not. Free association by the patient and evenly hovering attention by the analyst initially advanced knowledge of the mind and the treatment of patients. One would be hard put to argue that this method has led to progress in knowledge or in improved therapeutic results in the past four or five decades (Kandel, 1999). In fact, major theoretical advances have primarily come from reactions of psychoanalysts to extra-psychoanalytic research. In a previous editorial we listed a partial list of important topics and areas including: Harlow’s studies of primates, Kinsey and colleagues’ research on human sexual behavior, Masters and Johnson’s research on the human sexual response cycle, epidemiological studies of the incidence, prevalence, and onset of mental illnesses in the general population, studies of childhood and adult trauma, behavioral genetics, the field of evolutionary psychology, the field of attachment

What is "psychodynamic psychiatry"?

Forrest, David V. Response to Michael H. Stone’s Article, “Disorder in the Domain of the Personality Disorders”: Invisible and Innominate Borderline Dynamics 677 Friedman, Richard C. and Downey, Jennifer I. About the Editors 1 Friedman, Richard C. and Downey, Jennifer I. Editorial: The Biopsychosocial Model 371 Friedman, Richard C. and Downey, Jennifer I. Psychodynamic Psychiatry and Psychoanalysis 5 Friedman, Richard C. Editor’s Introduction 543

Training community-based primary care physicians in the screening and management of mental health disorders among Latino primary care patients

OBJECTIVE To evaluate a quality improvement intervention to improve the screening and management (e.g., referral to psychiatric care) of common mental disorders in small independent Latino primary care practices serving patient populations of predominantly low-income Latino immigrants. METHODS In seven practices, academic detailing and consultation/liaison psychiatry were first implemented (Stage 1) and then supplemented with appointment scheduling and reminders to primary care physicians (PCPs) by clinic staff (Stage 2). Acceptability and feasibility were assessed with independent patient samples during each stage. RESULTS Participating PCP found the interventions acceptable and noted that referrals to language-matched specialty care and case-by-case consultation on medication management were particularly beneficial. The academic detailing and consultation/liaison intervention (Stage 1) did not significantly affect PCP screening, management or patient satisfaction with care. When support for appointment scheduling and reminders (Stage 2) was added, however, PCP referral to psychiatric services increased (P=.04), and referred patients were significantly more likely to follow through and have more visits to mental health professionals (P=.04). CONCLUSION Improving the quality of mental health care in low-resourced primary care settings may require academic detailing and consultation/liaison psychiatric intervention supplemented with staff outreach to achieve meaningful improvement in the processes of care.

HIV as the Great Magnifier of Maladies: Challenges for Prevention and Compassionate Care

Many persons in the world do not believe that there is still a human immunodeficiency virus (HIV) pandemic and that epidemics of acquired immune deficiency syndrome (AIDS), HIV stigma, and AIDSism still exist. However, throughout the world there is evidence of an HIV pandemic: 36.9 million persons are living with HIV despite the fact that HIV and AIDS are entirely preventable. Although HIV is easy to diagnose with rapid HIV testing, 19 million or 54% of persons with HIV are unaware that they are infected. Once diagnosed, persons who were previously unaware of the HIV infection can be referred for medical care and treatment with antiretroviral medication that will enable persons with HIV to live relatively healthy lives. Psychiatric factors play an important role in the transmission of HIV. Psychiatric illnesses are vectors of HIV, and psychiatrists can prevent transmission and decrease suffering, morbidity, and mortality in persons with HIV. If lupus, multiple sclerosis, malaria, Lyme disease, and syphilis can be thought of as “The Great Masqueraders of Maladies” because many of their symptoms are similar to those of other illnesses, HIV/AIDS is “The Great Magnifier of Maladies” of both illness and aspects of health care. HIV magnifies disparities, stigma, and discrimination in health care and leads to both transmission and lack of access to care. An integrated approach to medical and mental health is needed to prevent transmission of HIV and improve care for persons affected by and infected with HIV.

The Phosphodiasterase 5-Inhibitors (PDE-5i) for Erectile Dysfunction (ED): A Therapeutic Challenge For Psychiatrists

Erectile function (EF) is a prerequisite for satisfactory sexual intercourse (SI) and central to male sexual functioning. Satisfactory SI eventually initiates orgasm - a biopsychophysiological state of euphoria - leading to a sense of bliss, enjoyment and positive mental well being. For a psychiatrist, treating ED is self-propelled to harmonize these pleasurable experiences alongside with encouragement of physical wellness and sensuality. Hence, the role of PDE-5i is pivotal in this context and constitutes a therapeutic challenge. PDE-5i work via the dopaminergic-oxytocin-nitric oxide pathway by increasing the availability of endothelials guanosine monophosphate (GMP), immediately causing relaxation of the penile smooth muscle and an erection. The PDE-5i, like sildenafil, vardenafil and tadalafil, are effective in the treatment of ED with some benefits/ flexibilities and disadvantages compared to other treatment modalities. Prescribed PDE-5i exclusively improve EF, fostering males self-confidence and self-esteem. Treatment failures are associated with factors such as absent (or insufficient) sexual stimulation, psychosexual conflicts and the co-existence of medical disorders. Managing ED requires dealing with underlying medical diseases, addressing other co-morbid sexual dysfunctions like premature ejaculation (PE), and educating the patient on healthy life-styles. Furthermore, by dealing with interpersonal dynamics within the couple and embracing adequate lifestyles (managing stress and revising ones sexual scripts), PDE-5i treatment benefits may be enhanced. In this review, we propose a holistic conceptual framework approach for psychiatric management of patients with ED.