Steven A. Cohen-Cole

The efficacy of intensive biopsychosocial teaching programs for residents: a review of the literature and guidelines for teaching.

Objective: To review research evaluations of intensive biopsychosocial training programs for nonpsychiatry residents, and determine whether this research showed sufficient rigor and consistent beneficial impact to allow initial research-based teaching guidelines.Data sources: An English-language literature search used MEDLINE (1966–93), Psychological Abstracts (1967–93), and Educational Resource Information Clearinghouse (1966–93) as well as bibliographic reviews from prominent peer-reviewed articles and consultation with an expert.Study selection: From among several hundred articles about biopsychosocial training, only 12 studies met the selection criteria: at least 100 contact hours of training for nonpsychiatry residents and an evaluation of efficacy.Data extraction: The three authors independently assessed these 12 studies and made a consensus decision based on explicit criteria. Successful and unsuccessful programs were distinguished from among those classified as quasi-experimental or experimental to identify programs of sufficient rigor to meet the study objective; success was defined as learning beyond knowledge and residents’ acceptance of teaching.Data synthesis: Four successful quasi-experimental or experimental programs showed the following uniquely beneficial features: 1) protected time for residents; 2) teaching that was required, structured, multidimensional, and balanced between learner-centered and teacher-centered approaches; 3) teaching methods that used normal as well as psychosocially disturbed patients, nonpsychiatrist teachers, and special teaching techniques; and 4) inclusion in the curriculum of interviewing, interpersonal skills, doctor-patient relationship, and patient education. Two unsuccessful quasi-experimental or experimental programs were unidimensional and unstructured, and used predominant or isolated teacher-centered approaches. Features found in both successful and unsuccessful programs were experiential teaching, psychiatrist and other mental health professional teachers, use of disturbed patients, training to manage patients’ psychosocial problems, teaching directed toward knowledge acquisition, teaching about treatment, and university affiliation.Conclusions: Four rigorously studied, successful programs showed a common pattern of intensive biopsychosocial teaching that produced, in aggregate, improvement in residents’ knowledge, attitudes, skills, and self-awareness. Although there is need for more definitive research, these data are sufficiently compelling and consistent to provide initial, research-based teaching guidelines.

Behavioral treatment of angina-like chest pain in patients with hyperventilation syndrome

The hyperventilation syndrome is present in as many as 50% of patients with non-cardiac chest pain. This study evaluated a behavioral treatment of this disorder in three adult females. They had long histories of chest pain and were documented to be free of coronary artery disease. Each subject met the DSM-III-R diagnostic criteria for an anxiety disorder. Following treatment, all subjects showed a marked decrease in the frequency and intensity of chest pain episodes and in the frequency of shortness of breath episodes. Two subjects maintained their progress at one-year follow-up. The results lend support to the efficacy of controlled breathing and relaxation training for the treatment of hyperventilation-related chest pain and to the inclusion of a hyperventilation provocation test in the diagnosis of the syndrome as well as its role in changing cognitions regarding cardiac status. Also discussed is the rationale for treating hyperventilation related chest pain in a medical care setting.

Adrenoleukodystrophy: frequency of presentation as a psychiatric disorder.

Adrenoleukodystrophy (ALD) is an inheritable clinical disorder in which very long chain fatty acids accumulate in several tissue types. ALD is underrepresented in the psychiatric literature, although the disorder may cause an organic brain syndrome, often misdiagnosed as another psychiatric problem. A survey of 109 reported cases of ALD revealed that 39% presented with some psychiatric sign or symptom, whereas 17% presented exclusively as a psychiatric problem. A computed axial tomogram (CAT) head scan is recommended to rule out ALD in psychiatric patients suspected of having organic brain disease, as a characteristic image may be found in ALD patients who have brain involvement.

Recent Research Developments in Consultation- Liaison Psychiatry

With the major changes in health care and general hospital practice in the last decade, practice and research in consultation and liaison psychiatry have also changed dramatically. The authors present a selected review of recent advances and implications for five important topics in consultation-liaison research: diagnosis, disease mechanisms, biologic treatments, health services, and psychosocial treatments for medical disorders.

Basic readings in consultation psychiatry.

Dr. Mohl is an associate professor ofpsychiatry at the University ofTexas Health Science Center. and Dr. Cohen-Cole is an associate professor ofpsychiatry at Emory University. Reprint requests to Dr. Mohl in the Department ofPsychiatry. University ofTexas Health Science Center at San Antonio. 7703 Floyd Curl Drive. San Antonio. TX. 78284. As tertiary care medicine has grown more specialized, the clinical need for and cost-effectiveness of psychiatric and psychosocial care for medical patients have increasingly been recognized. Similarly, the growth of primary care programs in medicine and family practice has led to parallel needs for psychiatric and psychosocial services for general medical patients, and for psychiatric training of medical housestaff. In recognition of these relatively new demands and opportunities for psychiatric services and training, the Consultation-Liaison (C-L) Section of the Association for Academic Psychiatry (AAP) has been working to develop a more thorough and intellectually coherent basis for C-L psychiatry. Under the chairmanship of Don Lipsitt, M.D., the C-L section has encouraged required C-L rotations in general psychiatry residencies and it has proposed a set of basic objectives for provision of competent consultation to medical colleagues. I These objectives, developed by a task force chaired by one of the authors (SC-C), were derived from recommendations of leading academic C-L psychiatrists concerning the basic knowledge and skills needed by general psychiatrists in consultation psychiatry. To increase the usefulness of these objectives, the Section then sought to develop a set of readings tied to each of them. It was thought that such a reading list would help the field of C-L psychiatry, as a relatively new area of practice and training, and would further define its distinct educational content and clinical approaches. In order to create this reading list, a task force, chaired by the two authors, solicited readings from AAP members as well as from several additional nationally prominent C-L programs (eg. at UCLA). In all, 617 different readings from 18 different programs were proposed for the final list. Evaluation forms were developed to rate each articles comprehensiveness, relevance, clarity. brevity, current content, and overall suitability for a basic reading list. All recommended readings were evaluated by at least one of 27 reviewers as well as by one of II task force members (see Appendix). Task force members then made final recommendations for the list based on these evaluations. When there was disagreement or lack of certainty, the two co-authors collaboratively made final decisions concerning which readings should be recommended for each objective. A draft reading list was presented to the C-L section of the AAP at its annual meeting in March 1984. This presentation led to additional modifications. The final choice of 86 recommended readings tied to 46 specific objectives is listed below. These are suggested as basic readings on material that the Section believed should be mastered by psychiatrists.

Psychiatric symptoms, type A behavior, and arrhythmias following coronary bypass

Abstract One hundred four patients undergoing coronary bypass surgery were evaluated for psychiatric symptoms and their association with postoperative arrhythmias occurring within 48 hours after surgery. Patients high in type A behavior had increased risk of ventricular arrhythmias, while those scoring relatively high in depression and anxiety had fewer atrial arrhythmias than patients low in these measures. No significant association was found between postoperative arrhythmias and obesity, heavy tobacco use, or number of bypasses. A history of arrhythmias correlated significantly with postoperative arrhythmias. Anxious or depressed patients who deny their symptoms may be at increased risk for postoperative atrial arrhythmias.

A pilot program for assigned reading by residents in consultation psychiatry

Abstract To increase the likelihood of their reading pertinent literature, the 27 residents in five consultation-liaison (C-L) training programs were required to present written responses to short-answer, examination-type questions derived from articles previously linked to a set of teaching objectives in C-L psychiatry. Questionnaire responses clearly indicated that all of the C-L service directors and about 75% of the residents found this approach to be of significant value in reading, remembering, and discussing assigned articles. This program is also recommended as a model for helping to train residents in other areas of psychiatry.

Terminal cardiomyopathy, splitting, and borderline personality organization

A 63-year-old married man with idiopathic terminal cardiomyopathy was admitted to the medical service for treatment of advanced heart failure. A psychiatric consultation was requested to assist the medical treatment team in dealing with the patients abusive behavior. The case is presented and discussed within the context of understanding the borderline personality in the medical setting.