Eugene V. Beresin

Delirium in the Elderly

Delirium is an organic psychiatric syndrome characterized by acute onset and impairment in cognition, perception, and behavior. The most common and serious mental disorder in old age, delirium heralds death in about 25% of afflicted elderly patients. Despite this high mortality rate, it is usually a transient disorder, resulting in full recovery without progressing to a chronic mental disorder. Almost any physical illness may cause delirium in an elderly person. Prompt assessment, differential diagnosis, and treatment are essential to reverse the medical disorder and control behavior that may be life threatening. This paper presents an approach to the diagnosis of delirium, reviewing descriptive features of the syndrome, biological, psychological, and environmental variables predisposing to delirium in geriatric patients, and the most common medical etiologies. It describes effective therapeutics, including ward management, supportive psychotherapy, and pharmacotherapy. (J Geriatr Psychiatry Neurol 1988;1:127-143)

Adolescent Psychological Development : A Review

1. Eric Hazen, MD* 2. Steven Schlozman, MD† 3. Eugene Beresin, MD‡ 1. *Instructor in Psychiatry, Harvard Medical School, Boston, Mass 2. †Assistant Professor of Psychiatry, Harvard Medical School, Boston, Mass 3. ‡Professor of Psychiatry, Harvard Medical School, Boston, Mass After reading this article, readers should be able to: 1. Discuss the processes of physical, emotional, social, cognitive, and moral development in adolescence. 2. Know the contributions of major developmental theorists, including Erik Erikson, Jean Piaget, and Lawrence Kohlberg, to the understanding of adolescent development. 3. Describe the relationship between adolescent behavior and recent findings from studies of brain development. 4. Identify the primary tasks of adolescent development. Adolescent patients present a unique set of challenges to pediatricians. A polite, compliant child can appear to transform into a surly, rebellious teen before a doctors eyes. Adolescence can be a tumultuous time, even when it is unfolding in a healthy manner. For this reason, and because there is so much individual variation in adolescent development, it can be particularly challenging to determine what is “normal” in adolescent development. Although previously believed to be uniformly a time of turmoil, this view has not been substantiated by large-scale studies. (1) Most teenagers progress through this period of life with few obvious behavioral problems. However, a sound and trusting doctor-patient relationship is required to appreciate the inner struggles many adolescents endure. A working understanding of the developmental tasks of adolescence and the processes through which they are achieved provides the best tool for a pediatrician in evaluating an adolescents development. Any discussion of adolescent development should include a definition of adolescence itself. Determining the exact onset and conclusion of adolescent development can be difficult, with complex biologic, psychological, and social paradigms all playing roles. Cultural factors also must be considered in determining the developmental norms of adolescence. Normal development from one cultural perspective may appear aberrant when viewed through the lens of another culture, and in an increasingly multicultural society, such considerations are especially important. For example, an Asian youth who begins to question his parents’ values may …

M-Rated Video Games and Aggressive or Problem Behavior Among Young Adolescents

This research examined the potential relationship between adolescent problem behaviors and amount of time spent with violent electronic games. Survey data were collected from 1,254 7th and 8th grade students in two states. A “dose” of exposure to Mature-rated games was calculated using Entertainment Software Rating Board ratings of titles children reported playing “a lot in the past six months,” and average days per week of video game play. Analyses were conducted using simultaneous logistic regression for binary outcome variables, and simultaneous multiple linear regression for continuous outcome variables, controlling for a series of potential confounders. M-rated game dose predicted greater risk for bullying (p < .01) and physical fights (p < .001), but not for delinquent behaviors or being a victim of bullies. When analyzed separately, these associations became weaker for boys and stronger for girls.

Pregnancy during graduate medical training.

In 1990, 30% of resident physicians were women, and by the year 2010 it is estimated that nearly one-third of all physicians will be women. With the increasing percentage of women residents, pregnancy during residency is a fact of life for most residency programs, yet it continues to provide problems for many programs. The authors comment on much of the literature and discuss the problems and issues surrounding pregnancy during residency, including the effects of pregnancy on the mother and infant as well as the effects of pregnancy on the residency program, the other residents, and the patients. The authors advocate that well-written, specific parental leave policies (for paternal as well as maternal leave) would help alleviate many of these problems. Data obtained from the 1991–92 annual survey of the American Association of Directors of Psychiatry Training indicate that 84% of responding U.S. adult and child psychiatry programs had maternity leave policies, an increase from what previous surveys have indicated. Further national studies, in other specialties, are needed to provide better data on the impact of pregnancy during residency and to help develop more effective parental leave policies.

Web-Based Simulation in Psychiatry Residency Training: A Pilot Study.

BackgroundMedical specialties, including surgery, obstetrics, anesthesia, critical care, and trauma, have adopted simulation technology for measuring clinical competency as a routine part of their residency training programs; yet, simulation technologies have rarely been adapted or used for psychiatry training.ObjectiveThe authors describe the development of a web-based computer simulation tool intended to assess physician competence in obtaining informed consent before prescribing antipsychotic medication to a simulated patient with symptoms of psychosis.MethodEighteen residents participated in a pilot study of the Computer Simulation Assessment Tool (CSAT). Outcome measures included physician performance on required elements, pre- and post-test measures of physician confidence in obtaining informed consent, and levels of system usability.ResultsData suggested that the CSAT increased physician confidence in obtaining informed consent and that it was easy to use.ConclusionsThe CSAT was an effective educational tool in simulating patient—physician interactions, and it may serve as a model for use of other web-based simulations to augment traditional teaching methods in residency education.

A Milestone in the Milestones Movement: the JGME Milestones Supplement

The definition of the current competencies as well as their optimal assessment has remained controversial.,14,15 The purpose of competency assessment will need to be clarified, beyond formative vs. summative. Multiple agendas derived from different stakeholders may need to give way to the few that directly impact the goal of producing high caliber, independent practitioners.16 Streamlining the various purposes for assessment will be an important issue for the embryonic milestones as well. The reality for most training programs is that the supply of time and money is decreasing. No matter how laudable the goals of valid, reliable, and national educational outcomes, their implementation must be feasible within this reality. Therefore cost-effectiveness will need to be considered in future assessment studies. We must ensure the competent performance of graduate physicians, in the right balance of specialties, at a reduced cost to the nation; the milestones project may well be measured by how well it contributes to these aims. Will milestones advance the field of assessment and mark a turning point in GME? We urge readers to continue to the national conversation that seeks answers to these questions.

Relationship between resident-in-training examination in psychiatry and subsequent certification examination performances

ObjectiveThis study analyzed the relationship between performance on The American College of Psychiatrists’ Psychiatry Resident-In-Training Examination (PRITE) and the ABPN Part 1 examination.MethodsPearson correlation coefficients were used to examine the relationship between performance on the 2002 PRITE and the 2003 Part 1 examination for 297 examinees.ResultsThe correlation between the PRITE global psychiatry and the Part 1 psychiatry scores was 0.59, and the correlation between the PRITE global neurology and the Part 1 neurology scores was 0.39.ConclusionAlthough the PRITE and the Part 1 examination have different purposes and are developed independently, the significant correlations between scores on the two tests support the use of PRITE results to guide preparation for the Part 1 examination. Guidelines for PRITE scores associated with poor performance on the Part 1 examination are provided.

Child and Adolescent Psychiatry Residency Training: Current Issues and Controversies

OBJECTIVE To examine major current influences on child and adolescent psychiatry (CAP) residency training, highlighting the most common problems. Potential solutions and unresolved dilemmas are presented. METHOD Data were gathered from empirical studies, review articles, national census data, and discussions over the past decade at national meetings on recruitment of residents and faculty; clinical, didactic, and research training; the impact of managed care and changes in graduate medical education funding; and the professional development of CAP residents. RESULTS Overall there are significant problems recruiting U.S. medical students and attracting faculty into CAP training programs. Economic forces, including decreased reimbursements from managed care and the federal government, are threatening the survival and vitality of training programs. Managed care is harmful for sound residency training and identity formation of the child and adolescent psychiatrist. CONCLUSIONS The integrity of CAP residency training in the future will depend on increased efforts of teaching hospitals and programs to develop fiscally viable systems of care integrated with residency training; seek new sources of training subsidies; modify traditional models of clinical and didactic curricula; and foster greater collaboration between training programs locally and nationally.

Writing for academia: Getting your research into print: AMEE Guide No. 74

The authors identify and describe strategies for success in writing for publication, including how to choose an educational research topic, define the question and choose the correct design, know the anatomy of a research paper, write each of the sections, optimize the writing before publication, choose a journal, and respond to editors and reviewers. The research question should be focused, modest, and achievable given the constraints of the setting, significant, and appropriately imbedded in the available literature. The choice of methods is determined by the nature of the educational research question and should conform to ethical standards. Specific strategies for writing include starting where it is easiest to do so, spontaneously and uncritically writing the first paragraphs through, minimizing external impediments to the work, and knowing how each section of a manuscript is routinely structured. All papers require a number of revisions with careful attention to accuracy and detail as well as to specific requirements of the target journal before submission. Authors should respond positively, not defensively, and in detail to all of the editors and reviewers’ suggestions for revision. Writing for success is therefore a disciplined and systematic process following prescribed steps, which, although hard work, is rewarding.

Media Violence and Youth

This column reviews the literature on violence in the media and its effects on youth. The author summarizes the findings of naturalistic, longitudinal, and population-based studies conducted over the last 30 years. The literature provides compelling evidence that exposure of media violence to children plays a major role in the etiology of aggressive behavior. Psychiatrists can facilitate primary prevention of violence in our society by discussing the problem of media violence with parents, medical students, residents, and allied health and school professionals.