James L. Griffith

Pharmacological management of mood and anxiety disorders in headache patients.

There is emerging evidence that treatment of comorbid mood and anxiety disorders can improve headache treatment outcome when implemented within a comprehensive program. Effective treatment for comorbid mood and anxiety disorders requires screening headache patients and accurately diagnosing specific psychiatric disorders when present. Specific dual‐action antidepressant, anticonvulsant, and atypical antipsychotic medications can serve as dual agents that simultaneously treat both headaches and a mood or anxiety disorder. Serotonin reuptake inhibitors and most other antidepressant, anxiolytic, and mood‐stabilizing medications are generally ineffective for headache prophylaxis. However, they can be safely added to a headache regimen for treatment of a comorbid psychiatric disorder. Treatment of comorbid psychiatric disorders in headache patients requires patient education about the psychiatric disorder, its treatment, possible side‐effects, and expected benefits. Clinicians need to be sensitive to possible stigma that some patients fear from a psychiatric diagnosis or its treatment.

A family approach to severe mental illness in post-war Kosovo.

Abstract This study describes the effects of a psychoeducational multiple—family group program for families of people with severe mental illness in post—war Kosovo that was developed by a Kosovar—American professional collaborative. The subjects were 30 families of people with severe mental illnesses living in two cities in Kosovo. All subjects participated in multiple—family groups and received family home visits. The program documented medication compliance, number of psychiatric hospitalizations, family mental health services use, and several other characteristics, for the year prior to the groups and the first year of the groups. The families attended an average of 5.5 (out of 7) groups, and 93% of these families attended four or more meetings. The uncontrolled pre- to post—intervention comparison demonstrated decreases in medication non—compliance and hospitalizations, and increases in family mental health service use. The program provided training for mental health professionals, led to policy change in the Ministry of Health, and resulted in dissemination to other community mental health centers. This study provides preliminary evidence that a collaboratively designed and implemented psychoeducational, multiple—family program is a feasible and beneficial intervention for families of people with severe mental illness in impoverished post—war settings.

Managing Stigma Effectively: What Social Psychology and Social Neuroscience Can Teach Us

Psychiatric education is confronted with three barriers to managing stigma associated with mental health treatment. First, there are limited evidence-based practices for stigma reduction, and interventions to deal with stigma against mental health care providers are especially lacking. Second, there is a scarcity of training models for mental health professionals on how to reduce stigma in clinical services. Third, there is a lack of conceptual models for neuroscience approaches to stigma reduction, which are a requirement for high-tier competency in the ACGME Milestones for Psychiatry. The George Washington University (GWU) psychiatry residency program has developed an eight-week course on managing stigma that is based on social psychology and social neuroscience research. The course draws upon social neuroscience research demonstrating that stigma is a normal function of normal brains resulting from evolutionary processes in human group behavior. Based on these processes, stigma can be categorized according to different threats that include peril stigma, disruption stigma, empathy fatigue, moral stigma, and courtesy stigma. Grounded in social neuroscience mechanisms, residents are taught to develop interventions to manage stigma. Case examples illustrate application to common clinical challenges: (1) helping patients anticipate and manage stigma encountered in the family, community, or workplace; (2) ameliorating internalized stigma among patients; (3) conducting effective treatment from a stigmatized position due to prejudice from medical colleagues or patients family members; and (4) facilitating patient treatment plans when stigma precludes engagement with mental health professionals. This curriculum addresses the need for educating trainees to manage stigma in clinical settings. Future studies are needed to evaluate changes in clinical practices and patient outcomes as a result of social neuroscience-based training on managing stigma.

Training Psychiatrists for Global Mental Health: Cultural Psychiatry, Collaborative Inquiry, and Ethics of Alterity

Awareness of the global burden of disease from mental illnesses, insufficient funding for services, and paucity of mental health professionals for lowand middle-income countries (LMIC) has spurred development of global mental health (GMH) curricula in psychiatry residencies. According to a recent study, 17 psychiatry residencies offer research and clinical opportunities in GMH. Most were offered through institution-wide, externally administered initiatives in which psychiatry residents could participate [1]. Learning objectives were mostly limited to acquisition of cultural competencies for care of patients from different ethnicities. As Belkin et al. ([2] p. 403) noted: (Table 1).

Distinguishing spiritual, psychological, and psychiatric issues in palliative care: Their overlap and differences

Abstract It is often difficult to discern whether the suffering of a medical patient should be regarded as a spiritual, psychological, or psychiatric problem. A further challenge is to determine whether consulting a chaplain, psychotherapist, or psychiatrist will best aid the patient. We present a four-step assessment for determining which perspective and which clinician may best aid a patient: (1) distinguish whether suffering is due to a normal syndrome of distress or to a psychiatric disorder; (2) assess the potential efficacy of spiritual care, psychotherapy, or psychopharmacology for relieving distress of this type; (3) determine probable effectiveness for spiritual care, psychotherapy, or psychopharmacology given limitations of clinician availability, clinicians clinical competencies, and the treatment setting; and (4) learn whether the patient has a strong preference for a consultant with a secular (psychiatrist, psychotherapist) or religious (chaplain, clergy) professional identity. This assessment prioritizes patient preferences in its decision making, while evaluating the clinical problem, consultants capabilities, and treatment setting so that recommendations hold promise for effectiveness. Spirituality, psychology, and psychiatry are each richly developed traditions of healing. The aim of care should be to provide the best from each towards reducing a patients suffering.

How Can Community Religious Groups Aid Recovery for Individuals with Psychotic Illnesses

Ministries of churches, temples, mosques, and synagogues are a potential resource for individuals with chronic psychoses. Church attendance is highest in states with the least mental health funding, suggesting a role for community religious groups to aid over-extended mental health systems. The American Psychiatric Association has initiated new efforts to foster partnerships between psychiatrists and religious groups. Such partnerships should be informed by research evidence: (1) religious coping can have both beneficial and adverse effects upon psychosis illness severity; (2) psychosocial programs for persons with psychotic disorders should target specific psychobiological vulnerabilities, in addition to providing compassionate emotional support; (3) family psychoeducation is a well-validated model for reducing schizophrenia illness severity that could inform how religious groups provide activities, social gatherings, and social networks for persons with psychotic disorders. Positive impacts from such collaborations may be greatest in low- and middle-income countries where mental health services are largely absent.

Factitious psychogenic nonepileptic paroxysmal episodes

Mistaking psychogenic nonepileptic paroxysmal episodes (PNEPEs) for epileptic seizures (ES) is potentially dangerous, and certain features should alert physicians to a possible PNEPE diagnosis. Psychogenic nonepileptic paroxysmal episodes due to factitious seizures carry particularly high risks of morbidity or mortality from nonindicated emergency treatment and, often, high costs in wasted medical treatment expenditures. We report a case of a 28-year-old man with PNEPEs that were misdiagnosed as ES. The patient had been on four antiseizure medications (ASMs) with therapeutic serum levels and had had multiple intubations in the past for uncontrolled episodes. He had no episodes for two days of continuous video-EEG monitoring. He then disconnected his EEG cables and had an episode of generalized stiffening and cyanosis, followed by jerking and profuse bleeding from the mouth. The manifestations were unusually similar to those of ES, except that he was clearly startled by spraying water on his face, while he was stiff in all extremities and unresponsive. There were indications that he had sucked blood from his central venous catheter to expel through his mouth during his PNEPEs while consciously holding his breath. Normal video-EEG monitoring; the patients volitional and deceptive acts to fabricate the appearance of illness, despite pain and personal endangerment; and the absence of reward other than remaining in a sick role were all consistent with a diagnosis of factitious disorder.

Existential inquiry: Psychotherapy for crises of demoralization

Background and Objectives: Existential inquiry is a focal psychotherapyntailored to address crises of demoralization. Demoralization refers to the helplessness, despair,nand subjective incompetence that people feel when perceiving themselves to be failingntheir own or others� expectations for coping with adversity.nMethods: Existential inquiry revives a demoralized person�s capacity for coping byneliciting accounts for how the person has sustained hope, communion with others, purpose,nagency, commitment, courage, and gratitude when threatened by losses, traumas, orninsecurities. Existential questions reveal emotional postures of vulnerability and resilience.nThey ask both how a person has been impacted by adversities and how he or shenhas prevailed against them. Existential inquiry rebuilds morale by mobilizing emotionalnpostures of resilience that are grounded in core identities: What are my deep desires andncommitments? To whom am I accountable? Who do I know myself to be, or wish to be?nResults: Clinical vignettes illustrate how these questions can open conversations thatnrebuild morale.nConclusions: Existential inquiry can serve as an effective brief psychotherapy forncountering demoralization.

Posttraumatic Stress Disorder in Headache Patients: Implications for Treatment

Chronic headaches following traumatic life events have been routinely noted by clinicians who treat posttraumatic stress disorder (PTSD). However, headaches from posttraumatic stress have largely “fallen between the cracks” therapeutically, seldom a focus of treatment and little understood. Concern for 1.5 million American soldiers returning from wars in Iraq and Afghanistan – 13-18% with PTSD and up to 18% with traumatic brain injuries (TBI), often in combination – provides fresh impetus for learning about and treating PTSD-associated headaches. Thirty-two percent of Iraq veterans with PTSD have headaches as a physical complaint. Peterlin et al present their findings from the first large, multicenter study of comorbidity between migraine headaches and PTSD. It is only the third published study to examine this relationship. National participation by 6 major centers for headache treatment with expert diagnoses of headache types strengthens their findings. Peterlin et al have found PTSD rates to be 30.3% for chronic daily headache and 22.4% for episodic migraine patients, far higher than the typical 8% community lifetime prevalence, suggesting that PTSD could play a role either in initiating migraine headaches or in their chronification. The authors found that depressed migraine patients constitute a category of particular risk for PTSD comorbidity. However, the PTSD, rather than the depression, appeared to account for the high rates of chronic daily headaches. As the authors point out, PTSD treatment has reduced pain and disability in other studies with chronic pain patients. Patients with PTSD have high health care utilization, already a concern for chronic headache patients. This new study thus suggests addition of specific PTSD therapies to a migraine treatment program when comorbid PTSD has been diagnosed. Posttraumatic stress disorder is a chronic psychiatric disorder precipitated by life events that evoke intense terror, horror, helplessness, or humiliation. Although traumatic events were initially defined as life-threatening, it is now recognized that a greater breadth of aversive events can produce posttraumatic symptoms, and that traumatization can occur vicariously rather than as a threat to self, as this study similarly found. Symptoms fall into 3 clusters of reexperiencing (nightmares, daytime intrusive memories), avoidance (emotional numbing, behavioral avoidance of trauma reminders), and hyperarousal (fragmented sleep, irritability, exaggerated startle, intolerance of excess lights or sounds). The complexity of trauma as a human experience is not adequately captured by PTSD as a psychiatric syndrome, particularly in its impacts upon sense of self, relatedness with other people, and existential worldview. PTSD also has uncertain validity outside Western societies. The PTSD symptom clusters, however, do provide markers to identify cases and to monitor responses to treatment. Evidence-based psychotherapies and psychopharmacological treatments can provide substantial relief from PTSD symptoms. The neurobiology of PTSD has been perhaps the best elucidated of all psychiatric disorders, and this understanding guides both psychotherapeutic and pharmacological therapies. Functional brain-imaging of PTSD patients has consistently shown heightened activation of amygdala and related anterior paralimbic circuits that generate emotional responses to ISSN 0017-8748 doi: 10.1111/j.1526-4610.2009.01378.x Published by Wiley Periodicals, Inc. Headache

Chronic Pain, Chronic Demoralization, and the Role of Psychotherapy

AbstractnThis article discusses demoralization in patients with chronic pain and the role of psychotherapy at combating chronic demoralization associated with chronic pain. The advantages of the biopsychosocial conceptual framework for the understanding of chronic pain are highlighted. Demoralization may be viewed as a combination of distress and subjective incompetence. While the distress experienced by the patient may be understandable and commensurate to the predicament, the co-occurrence of subjective incompetence (the polar opposite of resilience) and its escalation to helplessness, and hopelessness may result in suicidal attempts, demands for euthanasia, or death by suicide. The complexity of chronic pain and its relationship to demoralization may be examined from multiple perspectives. Biological, psychological, social and cultural variables play varying roles depending on the observer’s perspective and the context of the observation. The role of psychotherapy in chronic pain may be viewed in terms of multiple pathways through which language, cognitive style, behavior, relationships, attitude towards pain, and awareness of the body modify the relative influences of top-down and bottom-up processing of information within the pain neuromatrix. Various psychotherapeutic interventions developed for patients with chronic pain are reviewed and recommendations are made for future research.