Eric M. Plakun

14-year follow-up of borderline and schizotypal personality disorders.

Abstract Admission and mean 14-year follow-up functioning were studied in inpatients meeting DSM-III criteria for borderline (BPD) or schizotypal (SPD) personality disorders and compared to schizophrenia, major affective disorder (MAD) and other diagnoses. Findings include the following: (1) BPD without MAD functioned better at admission and follow-up than schizophrenia, but was comparable to MAD; (2) SPD functioned better than schizophrenia, but not MAD at admission only; (3) BPD with MAD at follow-up functioned more poorly than BPD without MAD, contrary to a previous report; and (4) BPD with SPD patients were as impaired as schizophrenics at admission but significantly better at follow-up.

Treatment-refractory mood disorders: a psychodynamic perspective.

Abstract Treatment‐refractory mood disorders pose a significant problem for clinicians. Although biological approaches are usually emphasized in the treatment of patients with these disorders, preliminary findings from an ongoing, naturalistic, longitudinal study of treatment outcome support the notion that a subset of patients with treatment‐refractory mood disorders may respond to careful integration of a psychodynamic therapeutic approach into the customary biological approaches. Ten psychodynamic principles that appear to be useful in work with patients with treatment‐refractory mood disorders were identified based on a review of the records of 28 patients who were treated using this approach. These principles are presented, discussed, and illustrated by material from a representative case study.

Distinguishing narcissistic and borderline personality disorders using DSM-III criteria

Abstract Sixty-three former inpatients met criteria for borderline personality disorders (BPD) (N = 44) or narcissistic personality disorders (NPD) (N = 19), both scored using DSM-III criteria in a fully polythetic model. The frequency distribution of BPD criteria in BPD and NPD and of NPD criteria in NPD and BPD is reported. Phi coefficients of correlation are reported for each BPD and NPD criterion with each diagnosis and, where appropriate, with other criteria. Sixteen and five variable stepwise regressions assessing the relative predictive power of the 16 BPD and NPD criteria for each diagnosis are offered. The implications for changing BPD and NPD criteria as proposed in DSM-IIIR are assessed.

Obstacles to Early Career Psychiatrists Practicing Psychotherapy

Though psychiatric residents are expected to be competent psychotherapists on graduation, further growth in skill and versatility requires continued experience in their ongoing career. Maturity as a psychotherapist is essential because a psychiatrist is the only mental health provider who, as a physician, can assume full responsibility for biopsychosocial patient care and roles as supervisor, consultant, and team leader. Graduating residents face an environment in which surveys show a steady and alarming decline in practice of psychotherapy by psychiatrists, along with a decline in job satisfaction. High educational debts, practice structures, intrusive management, and reimbursement policies that devalue psychotherapy discourage early career psychiatrists from a practice style that enables providing it. For the early-career psychiatrist there is thus the serious risk of being unable to develop a critical mass of experience or a secure identity as a psychiatric psychotherapist. Implementation of parity laws and the Affordable Care Act (ACA) will affect the situation in unpredictable ways that call for vigilance and active response. Additional service and administrative demands may result from the ACA, creating ethical dilemmas about meeting urgent patient needs versus biopsychosocial standards of care. The authors recommend 1) vigorous advocacy for better payment levels for psychotherapy and freedom from disruptive management; 2) aggressive action against violations of the parity act, 3) active preparation of psychiatric residents for dealing with career choices and the environment for providing psychotherapy in their practice, and 4) post-graduate training in psychotherapy through supervision/consultation, continuing education courses, computer instruction, and distance learning.

Important medical decisions: Using brief motivational interviewing to enhance patients' autonomous decision-making.

Goals. The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. Background. As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. Method. A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. Discussion. The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient’s best interests by psychotherapeutically addressing his anxious, fear-based ambivalence. (Journal of Psychiatric Practice 2013;19:98–108)

Psychotherapy and Psychosocial Treatment: Recent Advances and Future Directions

Psychotherapy and psychosocial treatment have been shown to be effective forms of treatment of a range of individual and complex comorbid disorders. The future role of psychotherapy and psychosocial treatment depends on several factors, including full implementation of mental health parity, correction of underlying false assumptions that shape treatment, payment priorities and research, identification and teaching of common factors or elements shared by effective psychosocial therapies, and adequate teaching of psychotherapy and psychosocial treatment.

Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research.The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient’s responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

Psychotherapy, Parity, and Ethical Utilization Management.

Managed care has long functioned with the assumption of a split in clinical and ethical responsibility for treatment. The insurance company clinician has been seen as owing a primary obligation to the insurance company and its utilization management standards, while the treating clinician is seen as holding primary clinical and ethical responsibility for the patient and the treatment. This article explores the potential impact of mental health parity mandates and recent clarifications of the American Psychiatric Associations ethical code on this split for psychiatrists and other clinicians who develop utilization management standards or serve as utilization reviewers.

Psychodynamic Systems of Residential Treatment: Another View From Riggs

Many patients lack the capacity to manage intense affects between therapy sessions, and as a result are caught in impasses as treatment becomes organized around fending off the next crisis or recovering from the last. Risk of suicide is often part of this presentation. Among the range of interventions that may help such patients emerge from impasse and treatment resistance is residential treatment, particularly psychodynamic residential treatment. We describe the role of residential treatment for such patients and offer an illustrative case example.

Politics in the Consulting Room

The recent presidential campaign and election have had a strong impact on many patients and clinicians. This guest column and its introduction by Dr Eric Plakun, who edits the psychotherapy section of the journal, note the inevitability that we will all self-disclose, while describing some of the pros and cons and impacts of self-disclosure of a clinicians political perspectives.