Debra A. Katz

Adolescent oxycontin abuse

Journal of the American Academy of Child & Adolescent Psychiatry - Vol. 43 - N° 2 - p. 231-234

Can psychiatry residents be attracted to analytic training? A survey of five residency programs.

In the face of fewer psychiatrist applicants for psychoanalytic training, determining the interest of current psychiatric residents in psychoanalysis and psychodynamic psychiatry is a pressing concern. To gauge this interest, an anonymous online survey was sent to residents from five psychiatry residency programs in the Midwest and South. Seventy-five residents responded, for a return rate of 42%. The data suggest that residents value psychoanalytic concepts and most plan to incorporate the practice of psychodynamic psychotherapy into their careers after graduation; however, residents have little confidence in their level of skill and the adequacy of their training. While 46% express interest in further psychodynamic psychotherapy training, only 22% express interest in psychoanalytic training. Most cite the cost and time involved as reasons they would not pursue further training. This study demonstrates that psychiatric residents have strong interest in and respect for psychodynamic psychotherapy and psychoanalysis. The data suggest that psychiatric residents are a viable pool of applicants for psychoanalytic training, especially if barriers to training can be reduced and creative ways for psychoanalysts to engage residents can be fostered.

Allostatic Load: Considering the Burden of Cumulative Trauma on Children in Foster Care

In this article it is proposed that allostatic load may be a useful concept to describe the physiological dysregulation that occurs in maltreated children through repeated exposure to traumatic events, the chronic stress of inconsistent and inadequate caregiving, and the disruptions of attachments and instability caused by foster care placements. In order to counteract the deleterious effects of allostatic load, a trauma-informed approach to the assessment and treatment of children suffering from this condition is proposed. Using a case example to illustrate the application of concepts, this article offers five recommendations for clinical work with maltreated children, especially those in foster care. The principles are illustrated by a case study.

Allostatic Load and Child Maltreatment in Infancy

Allostatic load refers to the persistent dysregulation in physiologic systems that occurs in response to severe, frequent or chronic stressors. Childhood maltreatment has been associated with physical health problems, neurobiological changes and long-term emotional and behavioral difficulties. This article utilizes the framework of allostatic load to examine the impact of maltreatment in infancy through the case of an infant who experienced severe abuse and neglect by her biological mother and a traumatic separation from her foster mother. Children involved in the child welfare system are especially vulnerable to allostatic load because of disruptions in caretaking, frequent abuse or neglect and inadequate medical and mental health care. Allostatic load provides a way of conceptualizing the impact of severe maltreatment and disrupted attachment on neuroendocrine, cardiovascular and immune function and how these experiences may contribute to impaired physical health and premature death in very young children.

A national survey of candidates: I. demographics, practice patterns, and satisfaction with training.

To better focus efforts in recruiting psychoanalytic candidates, current candidates’ demographics, practice patterns, and satisfaction with psychoanalytic training were investigated. An anonymous web-based survey was distributed by e-mail to all candidates subscribing to the affiliate member e-mail list in 2009–2010. Surveys were completed by 226 of 565 affiliate members, for a return rate of 40%. The majority of respondents were women 45 to 64 years of age, married, with a doctoral degree, in private practice, with an annual household income of over

A national survey of candidates: II. Motivations, obstacles, and ideas on increasing interest in psychoanalytic training.

100,000. Most candidates devoted 11 to 30 hours a week to training and had no analysts or candidates in their workplace. Almost half had considered training for more than four years before matriculation, with financial issues cited most frequently as delaying entry. Over 80% of respondents were satisfied with their training. The most frequently cited reasons for dissatisfaction were a negative institute atmosphere, concerns about teaching or the curriculum, and difficulty finding cases. Candidates in training for eight years or more accounted for almost 20% of the group and were more often dissatisfied with training. This study demonstrates that the majority of current candidates are satisfied with training but suggests that recruitment may become increasingly difficult unless factors related to time, cost, case finding, graduation requirements, and institute atmosphere can be addressed.

Lower dosages of phentermine-fenfluramine given in the afternoon: five cases with significant weight loss.

A national survey of candidates was conducted to identify motivations for pursuing psychoanalytic training, obstacles that prevent progression or completion, and candidates’ ideas on how best to increase interest among potential trainees. In 2009–2010, 40 percent of candidates on the affiliate member e-mail list completed an anonymous web-based survey. Candidates strongly endorsed contact with a personal psychotherapist, psychoanalyst, or supervisor as the most important influence in discovering psychoanalysis and deciding to pursue training. They identified the total cost of analytic training as the greatest obstacle. This was followed by the cost of personal analysis, loss of income for low-fee cases, time away from family, and difficulty finding cases. To enhance training, local institutes should work to improve institute atmosphere and provide assistance with finding cases; national organizations should increase outreach activities and publicize psychoanalysis. Psychoanalytic institutes could recruit future candidates by working to increase personal contact with psychoanalysts, reducing the cost of training, improving institute atmosphere, assisting with case-finding, enhancing outreach activities, and widely publicizing psychoanalysis. Narrative comments from candidates and the implications of these findings regarding engagement of future trainees are discussed.

Marked Reduction in Serotonergic Activity in a Sexually Aggressive Adolescent Male

Phentermine and fenfluramine are widely used in the treatment of obesity. Despite the fact that primary pulmonary hypertension and mitral valve insufficiency have been associated with fenfluramine use, many of these patients need medication to achieve weight loss. Small degrees of weight loss have been shown to significantly improve obesity-related medical conditions such as hypertension, hypercholesterolemia, and noninsulin-dependent diabetes mellitus. Current practice is to give phentermine and fenfluramine in the morning and afternoon. Doses for phentermine have ranged from 15 to 37.5 mg and for fenfluramine from 20 to 120 mg per day. We report five cases of severely obese women with medical complications who were treated with phentermine 8 mg twice per day (at 1:00 p.m. and 4:00 p.m.) and fenfluramine 20 mg per day (at 4:00 p.m.). Because many obese patients skip breakfast and eat more in the afternoon and evening, medication was dosed in order to cover these high-risk eating periods. Overall, these patients lost a mean of 22.4% of their initial weight (range 18.6% to 32.8%) over an average of 8.4 months (range 3.5 to 16 months). These cases suggest that short-term weight loss can be achieved with a low dose of fenfluramine when both medications are given in the afternoon to better target the eating patterns of obese subjects.

The Cost of Chronic Stress in Childhood: Understanding and Applying the Concept of Allostatic Load

Serotonergic dysfunctions are implicated in conduct disorder, impulsivity, and aggression. Early adverse experiences increase the risk for these behaviors in adolescents. The authors investigated serotonergic activity in one adolescent male who experienced maternal abandonment and childhood abuse and exhibited severely aggressive sexual offenses. Platelet serotonin (5-HT) concentration, [14C]-5HT uptake kinetics, and plasma prolactin, cortisol response to D,L-fenfluramine (D,L-FEN) were measured. Results showed extremely low 5-HT concentration (2.9+/-0.7 ng/10⁸ platelets), [14C]-5HT uptake rate (0.5+/-0.04 mM/min/10⁷ platelets), undetectable Km and Vmax, and abnormally blunted prolactin, cortisol response to D,L-FEN. These abnormalities in this sexually aggressive adolescent may be a consequence of childhood abuse.