Category: Mental Health

What is Child and Adolescent Psychiatry?

Published on by Andrew Marshall1 Comment

Introduction

Child and adolescent psychiatry (or paediatric psychiatry) is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families.

It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the paediatric population.

Brief History

When psychiatrists and paediatricians first began to recognise and discuss childhood psychiatric disorders in the 19th century, they were largely influenced by literary works of the Victorian era. Authors like the Brontë sisters, George Eliot, and Charles Dickens, introduced new ways of thinking about the child mind and the potential influence early childhood experiences could have on child development and the subsequent adult mind. When the Journal of Psychological Medicine and Mental Pathology, the first psychiatric journal in English, was published in 1848, child psychiatry didn’t exist as its own field yet. However, some of the earliest works on the possibility of nervous disorders and “insanity” in children were published in the Journal and several medical writers directly referenced works such as Jane Eyre (1847), Wuthering Heights (1847), Dombey and Son (1848), and David Copperfield (1850), to illustrate this new conceptualisation of the child mind. Until that time, it was generally accepted that children were free from nervous disorders and the “passions” that affected the adult mind.

As early as 1899, the term “child psychiatry” (in French) was used as a subtitle in Manheimer’s monograph Les Troubles Mentaux de l’Enfance. However, the Swiss psychiatrist Moritz Tramer (1882-1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria. The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894-1981), an Austrian émigré and medical graduate of the University of Berlin, under the direction of Adolf Meyer at the Johns Hopkins Hospital in Baltimore. Kanner was the very first physician to be identified as a child psychiatrist in the US and his textbook, Child Psychiatry (1935), is credited with introducing both the specialty and the term to the anglophone academic community. In 1936, Kanner established the first formal elective course in child psychiatry at the Johns Hopkins Hospital. In 1944 he provided the first clinical description of early infantile autism, otherwise known as Kanner Syndrome.

Maria Montessori together with It:Giuseppe Ferruccio Montesano and Clodomiro Bonfigli, two distinguished child psychiatrists, created in 1901 in Italy the “Lega Nazionale per la Protezione del Fanciullo” (National League for the Protection of Children). She gradually developed her own pedagogic method, initially based on the “intuition that the question of the ‘mentally deficient’ was more pedagogic than medical”. In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world’s first child guidance clinic. Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent’s biological aspects of brain functioning and IQ, but also the delinquent’s social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.

From its establishment in February 1923, the Maudsley Hospital, a South London-based postgraduate teaching and research psychiatric hospital, contained a small children’s department. Similar overall early developments took place in many other countries during the late 1920s and 1930s. In the United States, child and adolescent psychiatry was established as a recognised medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.

The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children. But it was not until the 1960s that the first NIH grant to study paediatric psychopharmacology was awarded. It went to one of Kanner’s students, Leon Eisenberg, the second director of the division.

The discipline has relatively flourished since the 1980s, in large part, because of contributions made in the 1970s, even if the outcomes for patients have been disappointing at times. It was a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by, Eva Frommer, Douglas Haldane, Michael Rutter, Robin Skynner and Sula Wolff, among others. The first comprehensive population survey of 9- to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children’s adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time, and the influence of social and contextual factors in children’s mental health, in their subsequent re-evaluation of the original cohort of children. These studies described the prevalence of ADHD (relatively low as compared to the US), identified the onset and prevalence of depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievement.

It was paralleled similarly by work on the epidemiology of autism that was to enormously increase the number of children diagnosed with autism in future years. Although attention had been given in the 1960s and ’70s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability. Since then, the DSM-IV and DSM-IVR have altered some of the parsing of psychiatric disorders into “childhood” and “adult” disorders, on the basis that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV). The American Psychiatric Association’s DSM is now on its fifth edition (DSM-5).

People in the field are sometimes referred to as “neurodevelopmentalists”. As of 2005 there was debate in the field as to whether “neurodevelopmentalist” should be made a new speciality.

In terms of patient outcomes, there is evidence that, in the United Kingdom at least on the 70th anniversary of the NHS, mental health remains a medical “Cinderella” (low priority) and the more so Child and Adolescent Health services which have been through repeated reorganisations and underinvestment all of which leads to disruption and loss of adequate provision.

“Modern neuroscience, genetics, epigenetics, and public health research has presented the tantalizing possibility that it can now be said with relative certainty that much (certainly not all) is understood about why some children struggle and others soar. Although it is an oversimplification, it can now be suggested that it is possible to understand how environmental factors, both negative and positive, influence the genome or epigenome, which in turn influence the structure and function of the brain and thus human thoughts, actions, and behaviors.”

Classification of Disorders

Not an exhaustive list:

  • Developmental disorders:
    • Autism spectrum disorder.
    • Learning disorders.
  • Disorders of attention and behaviour:
    • Attention deficit hyperactivity disorder.
    • Oppositional defiant disorder.
    • Conduct disorder.
  • Psychotic disorders:
    • Childhood schizophrenia.
  • Mood disorders:
    • Major depressive disorder.
    • Bipolar disorder.
    • Persistent Depressive Disorder.
    • Disruptive Mood Dysregulation Disorder.
  • Anxiety disorders:
    • Panic disorder.
    • Phobias.
  • Eating disorders:
    • Anorexia nervosa.
    • Bulimia nervosa.
  • Gender identity disorder:
    • Gender identity disorder in children.

Disorders are often comorbid. For example, an adolescent can be diagnosed with both major depressive disorder and generalised anxiety disorder. The incidence of psychiatric comorbidities during adolescence may vary by race, ethnicity and socioeconomic status, among other variables.

Clinical Practice

Assessment

The psychiatric assessment of a child or adolescent starts with obtaining a psychiatric history by interviewing the young person and their parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child’s emotional or behavioural problems, the child’s physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child’s problems. Collateral information is usually obtained from the child’s school with regards to academic performance, peer relationships, and behaviour in the school environment.

Psychiatric assessment always includes a mental state examination of the child or adolescent which consists of a careful behavioural observation and a first-hand account of the young person’s subjective experiences. The assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.

The assessment may be supplemented by the use of behaviour or symptom rating scales such as the Achenbach Child Behaviour Checklist or CBCL, the Behavioural Assessment System for Children or BASC, Connors Rating Scales (used for diagnosis of ADHD), Millon Adolescent Clinical Inventory or MACI, and the Strengths and Difficulties Questionnaire or SDQ. These instruments bring a degree of objectivity and consistency to the clinical assessment. More specialised psychometric testing may be carried out by a psychologist, for example using the Wechsler Intelligence Scale for Children, to detect intellectual impairment or other cognitive problems which may be contributing to the child’s difficulties.

Diagnosis and Formulation

The child and adolescent psychiatrist makes a diagnosis based on the pattern of behaviour and emotional symptoms, using a standardized set of diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV-TR) or the International Classification of Diseases (ICD-10). While the DSM system is widely used, it may not adequately take into account social, cultural and contextual factors and it has been suggested that an individualized clinical formulation may be more useful. A case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarising all the relevant factors implicated in the development of the patient’s problem, including biological, psychological, social and cultural perspectives (the “biopsychosocial model”). The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.

The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.

Treatment

Treatment will usually involve one or more of the following elements: behaviour therapy, cognitive behaviour therapy (CBT), problem-solving therapies, psychodynamic therapy, parent training programmes, family therapy, and/or the use of medication. The intervention can also include consultation with paediatricians, primary care physicians or professionals from schools, juvenile courts, social agencies or other community organisations.

In a review of existing meta-analyses and disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder), only for ADHD was the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders.

Training

In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 4 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialised training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry. Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.

Certification and Continuing Education

In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP). Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.

Shortage of Child and Adolescent Psychiatrists in the United States

The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. As of 2016, there are 7991 child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Centre for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. In 1999, however, the Surgeon General reported that “there is a dearth of child psychiatrists.” Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.

Cross-Cultural Considerations

Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.

Criticisms

Subjective Diagnoses

One criticism against psychiatry is that psychiatric diagnoses lack complete “objectivity,” particularly when compared with diagnoses in other medical specialties. However, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties. In 2013, Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgements rather than objective biological tests.”

Traditional deficit and disease models of child psychiatry have been criticised as rooted in the medical model which conceptualises adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterise problematic behaviour as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behaviour has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession: it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behaviour and symptoms, to promote a view of the “patient” as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behaviour, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability.

Prescription of Psychotropic Medications

Since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. In 2004 the US Food and Drug Administration (FDA) issued the Black Box Warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in paediatric patients. The most common diagnoses for which children receive psychiatric medication are ADHD, ODD, and conduct disorder.

Some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioural issues other than a psychotic disorder. In the United States, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families. More research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in paediatric populations. Because of the risk of metabolic syndrome and cardiovascular events with long-term antipsychotic use, use in paediatric populations is highly scrutinized and recommended in combination with psychotherapy and effective parent-training interventions.

Electroconvulsive Therapy

In 1947, child neuropsychiatrist Lauretta Bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ECT). These children received ECT daily for a typical course of approximately twenty treatments. This formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ECT, which is also known as either regressive ECT or annihilation therapy. In the 1950s Bender abandoned ECT as a therapeutic practice for the treatment of children. In the same decade the results of her published work on the use of ECT in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated. Commenting on his experience as part of Bender’s therapeutic program, Ted Chabasinski said that, “It really made a mess of me … I went from being a shy kid who read a lot to a terrified kid who cried all the time.” Following his treatment, he spent ten years as an inmate of Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Centre.

What is the Canadian Psychological Association?

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Introduction

The Canadian Psychological Association (CPA) is the primary organisation representing psychologists throughout Canada. It was organised in 1939 and incorporated under the Canada Corporations Act, Part II, in May 1950.

Its objectives are to improve the health and welfare of all Canadians; to promote excellence and innovation in psychological research, education, and practice; to promote the advancement, development, dissemination, and application of psychological knowledge; and to provide high-quality services to members.

Brief History

The CPA was founded in a University of Ottawa psychology lab in 1938, although it was not formally organised until 1939. Initially, the CPA’s purpose was to help with Canada’s contribution to World War II; indeed, the CPA was heavily involved with test construction for the Department of National Defence.

Organisational Structure

CPA’s head office is located in Ottawa, ON. The CPA has a directorate for each of its three pillars:

  1. The Science Directorate’s mandate is to lobby government for increased funding for psychological research, promote and support the work of Canadian researchers in psychology, and educate the public about important findings from psychological science.
  2. The Practice Directorate’s mandate is to support and facilitate advocacy for the practice of psychology across Canada.
  3. The Education Directorate’s mandate is to oversee the accreditation of doctoral and internship programmes in professional psychology.

The Board of Directors sets policies that guide the CPA. It is made up of Presidential Officers, Directors, and Executive Officers.

Policy and Position Statements

The CPA publishes the Canadian Code of Ethics for Psychologists which articulates ethical principles, values, and standards to guide all members of the Canadian Psychological Association. This Code is reviewed regularly with the most recent version published in January 2017. The ethical standards are built on four principles which form cornerstone guidelines for making ethical decision. Those principles are: Respect for the Dignity of Persons and Peoples; Responsible Caring; Integrity in Relationships; and Responsibility to Society.

The CPA publishes policy and positions statements which are based on psychological evidence and ethical standards on given issues of importance. Below are some issues in which the CPA has issued public statements on:

Policy Statements

  • Conversion/Reparative Therapy for Sexual Orientation.
  • Gender Identity in Adolescents and Adults.
  • Violence against Women.
  • Bullying in Children and Youth.
  • The Presence of Involved Third Party Observer in Neuropsychological Assessments.
  • Public Statements.
  • Physical Punishment of Children and Youth.
  • Ethical Use and Reporting of Psychological Assessment Results for Student Placement.
  • Convictions based Solely on Recovered Memories.
  • Public Statement by Paul Cameron on Homosexuality.
  • Equality for Lesbians, Gay Men, their Relationships and their Families.
  • Inclusion of Unpaid Household Activities in 1996 Census.
  • CPA Response to Canadian Panel on Violence Against Women.
  • Child Care.
  • The Death Penalty in Canada.
  • Prejudicial Discrimination.
  • Minority Groups.
  • Discrimination in the Employment Areas.
  • Psychology of Women.
  • Female Role Models.
  • Education of Graduate Students.
  • Autonomous Profession.
  • Psychology in Hospitals.
  • Prepaid Health Schemes.
  • Psychologists Providers of Health Care.

Position Statements

  • Addressing Climate Change in Canada: The Importance of Psychological Science.
  • Inappropriate Psychological Test Use: A Public Safety Concern.
  • Recommendations for Addressing the Opioid Crisis in Canada.
  • Health and Well-Being Needs of LGBTQI People.
  • Recommendations for the Legalization of Cannabis in Canada.
  • Psychologists Practicing to Scope: The Role of Psychologists in Canada’s Public Institutions.
  • Neuropsychological Services in Canada.
  • Issues and Recommendations about Advertising and Children’s Health Behaviour.
  • Same Sex Marriage.

The CPA board of directors convenes working groups to explore various issues affecting the science, practice and education of psychology. Some of those working group reports are as follows:

  • E-Psychology Working Group.
  • CPA Task Force on Title: Model Language Suggestions.
  • Recommendations for Addressing the Opioid Crisis in Canada.
  • Psychology’s Response to the Truth and Reconciliation Commission of Canada’s Report.
  • Medical Assistance in Dying and End-of-Life Care.
  • Fitness to Stand Trial and Criminal Responsibility Assessments in Canada.
  • Supply and Demand for Accredited Doctoral Internship/Residency Positions in Clinical, Counselling, and School Psychology in Canada.
  • Evidence-Based Practice of Psychological Treatments: A Canadian Perspective.
  • CPA Task Force on the Supply of Psychologists in Canada.
  • CPA Task Force of Prescriptive Authority for Psychologists in Canada.

Sections

Members of the CPA with interests in specific areas of psychology are able to form and join sections. Sections have official status under the By-laws of the CPA, which give them power to:

  • Initiate and undertake activities of relevance to its members.
  • Draft position papers on topics of relevance to the Section.
  • Initiate policy statements in areas of expertise.
  • Organize meetings within CPA.
  • Make specific representation to external agencies or organisations, if it has received the approval of the Board of Directors to do so.
  • Recommend that CPA make specific representations to external organisations or agencies.

List of CPA Sections

  • Addiction Psychology.
  • Adult Development and Ageing.
  • Brain and Cognitive Sciences.
  • Clinical Psychology.
  • Clinical Neuropsychology.
  • Community Psychology.
  • Counselling Psychology.
  • Criminal Justice Psychology.
  • Developmental Psychology.
  • Educational and School Psychology.
  • Environmental Psychology.
  • Extremism and Terrorism.
  • Family Psychology.
  • Health Psychology and Behavioural Medicine.
  • History and Philosophy Section.
  • Indigenous Peoples’ Psychology.
  • Industrial/Organisational Psychology.
  • International and Cross-Cultural Psychology.
  • Psychologists in Hospitals and Health Centres.
  • Psychology in the Military.
  • Psychologists and Retirement.
  • Psychopharmacology.
  • Quantitative Methods.
  • Quantitative Electrophysiology.
  • Rural and Northern Psychology.
  • Sexual Orientation and Gender Identity.
  • Social and Personality Section.
  • Sport and Exercise Psychology.
  • Students.
  • Teaching of Psychology.
  • Traumatic Stress Section.
  • Section for Women And Psychology (SWAP).

Membership and Affiliation

The CPA offers 5 types of membership to individuals residing in Canada or the United States.

  • Full member: One has to have a Masters or Doctoral degree in psychology (or its academic equivalent) to become a full member.
  • Early Career Year 1: One has to have graduated with a Masters, or PhD in Psychology (or a related field), and are not returning to school, or those working on the first year of their Post Doc. Applicants must have graduated University the previous year (e.g. 2020) to be eligible for Early Career Year 1 in the year they are applying for membership (e.g. 2021).
  • Early Career Year 2: Available to members who were Early Career Year 1 in the previous membership year (e.g. 2020) OR recent graduates who have graduated with a Masters, or PhD in Psychology (or a related field) in the previous 2 years and are not returning to school or those working on the second year of their Post Docs.
  • Retired member: One has to be a full member or fellow who has retired.
  • Honorary life fellow/Honorary life member: Offered to individuals who are 70 years old and have been full members of the CPA for at least 25 years.

The CPA offers 2 types of affiliation to individuals residing in Canada or the United States.

  • Student affiliate: One has to be an undergraduate or graduate student at a recognised university.
  • Special affiliate: Open to those who have an active interest in psychology.

The CPA offers two types of affiliation to individuals residing outside of Canada or the United States.

  • International affiliate: Open to international psychologists.
  • International student affiliate: Open to international undergraduate and graduate students in psychology.

The CPA now offers a section associate category for individuals who do not qualify for membership or are interested in joining only one section and receiving their section communication.

The CPA has approximately 7,000 members and affiliates.

Public Outreach and Partnerships

The CPA produces a series of informative brochures for the public called “Psychology Works Fact Sheets”. Each brochure is reviewed by psychologists who are knowledgeable on that subject before being published online. Topics range from information on psychological disorders, parenting challenges, pain, stress, perfectionism, and much more. Along with these informative brochures, the CPA website contains many resources for individuals interested in psychology or receiving psychological services in Canada.

Every year, the CPA promotes February as Psychology Month and encourages Canadian psychologists to reach out to the public to raise awareness of what psychology is, what psychologists do, and how psychology benefits everyone.

The CPA is engaged in numerous emergency preparedness activities. Following national and international emergencies and disasters, the CPA provides the general public with timely resources on effective coping and information about stress and the indicators of psychological distress. The CPA is also involved in the National Emergency Psychosocial Advisory Consortium (NEPAC), the Mental Health Support Network, and the Council of Emergency Voluntary Sector Directors.

The CPA is also involved in partnerships with the following:

  • Canadian Alliance on Mental Illness and Mental Health (CAMIMH).
  • Canadian Association for School Health Communities of Practice.
  • Canadian Coalition for Public Health in the 21st Century (CCPH21).
  • Canadian Consortium for Research (CCR).
  • Canadian Federation for the Humanities and Social Sciences (CFHSS).
  • Canadian Primary Health Care Research and Innovation Network (CPHCRIN).
  • Chronic Disease Prevention Alliance of Canada (CDPAC).
  • G7.
  • Mental Health Table.
  • Promoting Relationships and Eliminating Violence Network (PREVNet).
  • Science Media Centre of Canada.
  • The Health Action Lobby (HEAL).

Publications

The CPA, in partnership with the American Psychological Association, quarterly publishes the following three academic journals:

  • Canadian Journal of Behavioural Science.
  • Canadian Journal of Experimental Psychology.
  • Canadian Psychology.

The CPA also publishes a quarterly magazine called Psynopsis. Issues contain brief articles on specific themes relating to psychology, as well as updates from the head office of CPA, committee news, information about the annual convention, and much more.

Mind Pad is a professional newsletter that is written and reviewed by student affiliates of the Canadian Psychological Association. The newsletter is published biannually online.

Convention

CPA hosts a convention annually. The conventions usually include pre-convention workshops, keynote and invited speakers, poster presentations, symposiums, award presentations, and various social events. The location varies each year from city to city across Canada.

Awards

Each year at the annual convention, CPA honours individuals who have made distinguished contributions to psychology in Canada with the following awards:

  • CPA Gold Medal Award For Distinguished Lifetime Contributions to Canadian Psychology.
  • CPA John C. Service Member the Year Award.
  • CPA Donald O. Hebb Award for Distinguished Contributions to Psychology as a Science.
  • CPA Award for Distinguished Contributions to Education and Training in Psychology.
  • CPA Award for Distinguished Contributions to Psychology as a Profession.
  • CPA Award for Distinguished Contributions to the International Advancement of Psychology.
  • CPA Award for Distinguished Contributions to Public or Community Service.
  • Distinguished Practitioner Award.
  • CPA Award for Distinguished Lifetime Service to the Canadian Psychological Association.
  • CPA Humanitarian Award.
  • President’s New Researcher Award.

The CPA has numerous student awards. As an example, the CPA gives out Certificates of Academic Excellence to students in each Canadian psychology department for the best undergraduate, masters, and doctoral thesis. The sections of CPA also award students for exceptional papers, presentations, and posters at the annual convention.

Fellowships are awarded to members of the CPA who have made distinguished contributions to the advancement of the science or profession of psychology or who have given exceptional service to their national or provincial associations. The Committee on Fellows and Awards review nominations and make recommendations to the Board of Directors who appoint fellows.

What is Depersonalisation?

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Introduction

Depersonalisation can consist of a detachment within the self, regarding one’s mind or body, or being a detached observer of oneself.

Subjects feel they have changed and that the world has become vague, dreamlike, less real, lacking in significance or being outside reality while looking in. Chronic depersonalisation refers to depersonalisation/derealisation disorder, which is classified by the DSM-5 as a dissociative disorder, based on the findings that depersonalisation and derealisation are prevalent in other dissociative disorders including dissociative identity disorder.

Though degrees of depersonalisation and derealisation can happen to anyone who is subject to temporary anxiety or stress, chronic depersonalisation is more related to individuals who have experienced a severe trauma or prolonged stress/anxiety. Depersonalisation-derealisation is the single most important symptom in the spectrum of dissociative disorders, including dissociative identity disorder and “dissociative disorder not otherwise specified” (DD-NOS). It is also a prominent symptom in some other non-dissociative disorders, such as anxiety disorders, clinical depression, bipolar disorder, schizophrenia, schizoid personality disorder, hypothyroidism or endocrine disorders, schizotypal personality disorder, borderline personality disorder, obsessive compulsive disorder, migraines, and sleep deprivation; it can also be a symptom of some types of neurological seizure.

In social psychology, and in particular self-categorisation theory, the term depersonalisation has a different meaning and refers to “the stereotypical perception of the self as an example of some defining social category”.

Description

Individuals who experience depersonalisation feel divorced from their own personal self by sensing their body sensations, feelings, emotions, behaviours etc. as not belonging to the same person or identity. Often a person who has experienced depersonalisation claims that things seem unreal or hazy. Also, a recognition of a self breaks down (hence the name). Depersonalisation can result in very high anxiety levels, which further increase these perceptions.

Depersonalisation is a subjective experience of unreality in one’s self, while derealisation is unreality of the outside world. Although most authors currently regard depersonalisation (self) and derealisation (surroundings) as independent constructs, many do not want to separate derealisation from depersonalisation.

Prevalence

Depersonalisation is a symptom of anxiety disorders, such as panic disorder. It can also accompany sleep deprivation (often occurring when suffering from jet lag), migraine, epilepsy (especially temporal lobe epilepsy, complex-partial seizure, both as part of the aura and during the seizure), obsessive compulsive disorder, severe stress or trauma, anxiety, the use of recreational drugs – especially cannabis, hallucinogens, ketamine, and MDMA, certain types of meditation, deep hypnosis, extended mirror or crystal gazing, sensory deprivation, and mild-to-moderate head injury with little or full loss of consciousness (less likely if unconscious for more than 30 mins). Interoceptive exposure is a non-pharmacological method that can be used to induce depersonalisation.

In the general population, transient depersonalisation/derealisation are common, having a lifetime prevalence between 26-74%. A random community-based survey of 1,000 adults in the US rural south found a 1-year depersonalisation prevalence rate at 19%. Several studies, but not all, found age to be a significant factor: adolescents and young adults in the normal population reported the highest rate. In a study, 46% of college students reported at least one significant episode in the previous year. In another study, 20% of patients with minor head injury experience significant depersonalisation and derealisation. Several studies found that up to 66% of individuals in life-threatening accidents report transient depersonalisation at minimum during or immediately after the accidents. Depersonalisation occurs 2-4 times more in women than in men.

A similar and overlapping concept called ipseity disturbance (ipse is Latin for “self” or “itself”) may be part of the core process of schizophrenia spectrum disorders. However, specific to the schizophrenia spectrum seems to be “a dislocation of first-person perspective such that self and other or self and world may seem to be non-distinguishable, or in which the individual self or field of consciousness takes on an inordinate significance in relation to the objective or intersubjective world” (emphasis in original).

For the purposes of evaluation and measurement depersonalisation can be conceived of as a construct and scales are now available to map its dimensions in time and space. A study of undergraduate students found that individuals high on the depersonalisation/derealisation subscale of the Dissociative Experiences Scale exhibited a more pronounced cortisol response in stress. Individuals high on the absorption subscale, which measures a subject’s experiences of concentration to the exclusion of awareness of other events, showed weaker cortisol responses.

In general infantry and special forces soldiers, measures of depersonalisation and derealisation increased significantly after training that includes experiences of uncontrollable stress, semi-starvation, sleep deprivation, as well as lack of control over hygiene, movement, communications, and social interactions.

Pharmacological and Situational Causes

Depersonalisation has been described by some as a desirable state, particularly by those that have experienced it under the influence of mood-altering recreational drugs. It is an effect of dissociatives and psychedelics, as well as a possible side effect of caffeine, alcohol, amphetamine, cannabis, and antidepressants. It is a classic withdrawal symptom from many drugs.

Benzodiazepine dependence, which can occur with long-term use of benzodiazepines, can induce chronic depersonalisation symptomatology and perceptual disturbances in some people, even in those who are taking a stable daily dosage, and it can also become a protracted feature of the benzodiazepine withdrawal syndrome.

Lieutenant Colonel Dave Grossman, in his book On Killing, suggests that military training artificially creates depersonalisation in soldiers, suppressing empathy and making it easier for them to kill other human beings.

Graham Reed (1974) claimed that depersonalisation occurs in relation to the experience of falling in love.

Depersonalisation as a Psychobiological Mechanism

Depersonalisation is a classic response to acute trauma, and may be highly prevalent in individuals involved in different traumatic situations including motor vehicle accident, and imprisonment.

Psychologically depersonalisation can, just like dissociation in general, be considered a type of coping mechanism. Depersonalisation is in that case unconsciously used to decrease the intensity of unpleasant experience, whether that is something as mild as stress or something as severe as chronically high anxiety and post-traumatic stress disorder. The decrease in anxiety and psychobiological hyperarousal helps preserving adaptive behaviours and resources under threat or danger. Depersonalisation is an overgeneralised reaction in that it does not diminish just the unpleasant experience, but more or less all experience – leading to a feeling of being detached from the world and experiencing it in a more bland way. An important distinction must be made between depersonalisation as a mild, short term reaction to unpleasant experience and depersonalisation as a chronic symptom stemming from a severe mental disorder such as PTSD or Dissociative Identity Disorder. Chronic symptoms may represent persistence of depersonalization beyond the situations under threat.

Treatment

Treatment is dependent on the underlying cause, whether it is organic or psychological in origin. If depersonalisation is a symptom of neurological disease, then diagnosis and treatment of the specific disease is the first approach. Depersonalisation can be a cognitive symptom of such diseases as amyotrophic lateral sclerosis, Alzheimer’s, multiple sclerosis (MS), or any other neurological disease affecting the brain. For those suffering from depersonalisation with migraine, tricyclic antidepressants are often prescribed.

If depersonalization is a symptom of psychological causes such as developmental trauma, treatment depends on the diagnosis. In case of dissociative identity disorder or DD-NOS as a developmental disorder, in which extreme developmental trauma interferes with formation of a single cohesive identity, treatment requires proper psychotherapy, and – in the case of additional (co-morbid) disorders such as eating disorders – a team of specialists treating such an individual. It can also be a symptom of borderline personality disorder, which can be treated in the long term with proper psychotherapy and psychopharmacology.

The treatment of chronic depersonalisation is considered in depersonalisation disorder.

A recently completed study at Columbia University in New York City has shown positive effects from transcranial magnetic stimulation (TMS) to treat depersonalisation disorder. Currently, however, the FDA has not approved TMS to treat DP.

A 2001 Russian study showed that naloxone, a drug used to reverse the intoxicating effects of opioid drugs, can successfully treat depersonalization disorder. According to the study: “In three of 14 patients, depersonalization symptoms disappeared entirely and seven patients showed a marked improvement. The therapeutic effect of naloxone provides evidence for the role of the endogenous opioid system in the pathogenesis of depersonalization.” The anti convulsion drug Lamotrigine has shown some success in treating symptoms of depersonalisation, often in combination with a Selective serotonin reuptake inhibitor and is the first drug of choice at the depersonalisation research unit at King’s College London.

Research

The Depersonalisation Research Unit at the Institute of Psychiatry in London conducts research into depersonalization disorder. Researchers there use the acronym DPAFU (Depersonalisation and Feelings of Unreality) as a shortened label for the disorder. In a 2020 article in the journal Nature, Vesuna, et al. describe experimental findings which show that layer 5 of the retrosplenial cortex is likely responsible for dissociative states of consciousness in mammals.

What is Dependent Personality Disorder?

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Introduction

Dependent personality disorder (DPD) is a personality disorder that is characterised by a pervasive psychological dependence on other people.

This personality disorder is a long-term condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. Dependent personality disorder is a Cluster C personality disorder, characterised by excessive fear and anxiety. It begins by early adulthood, and it is present in a variety of contexts and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation or helplessness when relationships end, avoidance of responsibilities and severe submission.

Brief History

The conceptualisation of dependency, within classical psychoanalytic theory, is directly related to Freud’s oral psychosexual stage of development. Frustration or over-gratification was said to result in an oral fixation and in an oral type of character, characterised by feeling dependent on others for nurturance and by behaviours representative of the oral stage. Later psychoanalytic theories shifted the focus from a drive-based approach of dependency to the recognition of the importance of early relationships and establishing separation from these early caregivers, in which the exchanges between the caregiver and the child become internalised, and the nature of these interactions becomes part of the concepts of the self and of others.

Signs and Symptoms

People who have dependent personality disorder are overdependent on other people when it comes to making decisions. They cannot make a decision on their own as they need constant approval from other people. Consequently, individuals diagnosed with DPD tend to place needs and opinions of others above their own as they do not have the confidence to trust their decisions. This kind of behaviour can explain why people with DPD tend to show passive and clingy behaviour. These individuals display a fear of separation and cannot stand being alone. When alone, they experience feelings of isolation and loneliness due to their overwhelming dependence on other people. Generally people with DPD are also pessimistic: they expect the worst out of situations or believe that the worst will happen. They tend to be more introverted and are more sensitive to criticism and fear rejection.

Risk Factors

People with a history of neglect and an abusive upbringing are more susceptible to develop DPD, specifically those involved in long-term abusive relationships. Those with overprotective or authoritarian parents are also more at risk to develop DPD. Having a family history of anxiety disorder can play a role in the development of DPD as a 2004 twin study found a 0.81 heritability for personality disorders collectively.

Causes

The exact cause of dependent personality disorder is unknown. A study in 2012 estimated that between 55% and 72% of the risk of the condition is inherited from one’s parents. The difference between a “dependent personality” and a “dependent personality disorder” is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.

Dependent traits in children tended to increase with parenting behaviours and attitudes characterized by overprotectiveness and authoritarianism. Thus the likelihood of developing dependent personality disorder increased, since these parenting traits can limit them from developing a sense of autonomy, rather teaching them that others are powerful and competent.

Traumatic or adverse experiences early in an individual’s life, such as neglect and abuse or serious illness, can increase the likelihood of developing personality disorders, including dependent personality disorder, later on in life. This is especially prevalent for those individuals who also experience high interpersonal stress and poor social support.

There is a higher frequency of the disorder seen in women than men, hence expectations relating to gender role may contribute to some extent.

Diagnosis

Clinicians and clinical researchers conceptualise dependent personality disorder in terms of four related components:

  • Cognitive: a perception of oneself as powerless and ineffectual, coupled with the belief that other people are comparatively powerful and potent.
  • Motivational: a desire to obtain and maintain relationships with protectors and caregivers.
  • Behavioural: a pattern of relationship-facilitating behaviour designed to strengthen interpersonal ties and minimise the possibility of abandonment and rejection.
  • Emotional: fear of abandonment, fear of rejection, and anxiety regarding evaluation by figures of authority.

American Psychiatric Association and DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains a dependent personality disorder diagnosis. It refers to a pervasive and excessive need to be taken care of which leads to submissive and clinging behaviour and fears of separation. This begins by early adulthood and can be present in a variety of contexts.

In the DSM Fifth Edition (DSM-5), there is one criterion by which there are eight features of dependent personality disorder. The disorder is indicated by at least five of the following factors:

  1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
  2. Needs others to assume responsibility for most major areas of their life.
  3. Has difficulty expressing disagreement with others because of fear of loss of support or approval.
  4. Has difficulty initiating projects or doing things on their own (because of a lack of self confidence in judgement or abilities rather than a lack of motivation or energy).
  5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
  6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themselves.
  7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
  8. Is unrealistically preoccupied with fears of being left to take care of themselves.

The diagnosis of personality disorders in the fourth edition the DSM, including dependent personality disorder, was found to be problematic due to reasons such as excessive diagnostic comorbidity, inadequate coverage, arbitrary boundaries with normal psychological functioning, and heterogeneity among individuals within the same categorial diagnosis.

World Health Organisation

The World Health Organisation’s (WHO) ICD-10 lists dependent personality disorder as F60.7 Dependent personality disorder:

  • It is characterised by at least 4 of the following:
    1. Encouraging or allowing others to make most of one’s important life decisions;
    2. Subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with their wishes;
    3. Unwillingness to make even reasonable demands on the people one depends on;
    4. Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself;
    5. Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
    6. Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.
  • Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina.
  • Includes:
    • Asthenic, inadequate, passive, and self-defeating personality (disorder).

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

SWAP-200

The SWAP-200 is a diagnostic tool that was proposed with the goal of overcoming limitations, such as limited external validity for the diagnostic criteria for dependent personality disorder, to the DSM. It serves as a possible alternative nosological system that emerged from the efforts to create an empirically based approach to personality disorders – while also preserving the complexity of clinical reality. Dependent personality disorder is considered a clinical prototype in the context of the SWAP-200. Rather than discrete symptoms, it provides composite description characteristic criteria – such as personality tendencies.

Based on the Q-Sort method and prototype matching, the SWAP-200 is a personality assessment procedure relying on an external observer’s judgment. It provides:

  • A personality diagnosis expressed as the matching with ten prototypical descriptions of DSM-IV personality disorders.
  • A personality diagnosis based on the matching of the patient with 11 Q-factors of personality derived empirically.
  • A dimensional profile of healthy and adaptive functioning.

The traits that define dependent personality disorder according to SWAP-200 are:

  1. They tend to become attached quickly and/or intensely, developing feelings and expectations that are not warranted by the history or context of the relationship.
  2. Since they tend to be ingratiating and submissive, people with DPD tend to be in relationships in which they are emotionally or physically abused.
  3. They tend to feel ashamed, inadequate, and depressed.
  4. They also feel powerless and tend to be suggestible.
  5. They are often anxious and tend to feel guilty.
  6. These people have difficulty acknowledging and expressing anger and struggle to get their own needs and goals met.
  7. Unable to soothe or comfort themselves when distressed, they require involvement of another person to help regulate their emotions.

Psychodynamic Diagnostic Manual

The Psychodynamic Diagnostic Manual (PDM) approaches dependent personality disorder in a descriptive, rather than prescriptive sense and has received empirical support. The Psychodynamic Diagnostic Manual includes two different types of dependent personality disorder:

  • Passive-aggressive.
  • Counter-dependent.

The PDM-2 adopts and applies a prototypic approach, using empirical measures like the SWAP-200. It was influenced by a developmental and empirically grounded perspective, as proposed by Sidney Blatt. This model is of particular interest when focusing on dependent personality disorder, claiming that psychopathology comes from distortions of two main coordinates of psychological development:

  • The anaclitic/introjective dimension.
  • The relatedness/self-definition dimension.

The anaclitic personality organization in individuals exhibits difficulties in interpersonal relatedness, exhibiting the following behaviours:

  • Preoccupation with relationships.
  • Fear of abandonment and of rejection.
  • Seeking closeness and intimacy.
  • Difficulty managing interpersonal boundaries.
  • Tend to have an anxious-preoccupied attachment style.

Introjective personality style is associated with problems in self-definition.

Differential Diagnosis

There are similarities between individuals with dependent personality disorder and individuals with borderline personality disorder, in that they both have a fear of abandonment. Those with dependent personality disorder do not exhibit impulsive behaviour, unstable affect, and poor self-image experienced by those with borderline personality disorder, differentiating the two disorders.

The following conditions commonly coexist (comorbid) with dependent personality disorder:

Treatment

People who have DPD are generally treated with psychotherapy. The main goal of this therapy is to make the individual more independent and help them form healthy relationships with the people around them. This is done by improving their self-esteem and confidence.

Medication can be used to treat patients who suffer from depression or anxiety because of their DPD, but this does not treat the core problems caused by DPD. Individuals who take these prescription drugs are susceptible to addiction and substance abuse and therefore may require monitoring.

Epidemiology

Based on a recent survey of 43,093 Americans, 0.49% of adults meet diagnostic criteria for DPD (National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Grant et al., 2004). Traits related to DPD, like most personality disorders emerge in childhood or early adulthood. Findings from the NESArC study found that 18 to 29 year olds have a greater chance of developing DPD. DPD is more common among women compared to men as 0.6% of women have DPD compared to 0.4% of men.

A 2004 twin study suggests a heritability of 0.81 for developing dependent personality disorder. Because of this, there is significant evidence that this disorder runs in families.

Children and adolescents with a history of anxiety disorders and physical illnesses are more susceptible to acquiring this disorder.

What is Dementia Praecox?

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Introduction

Dementia praecox (meaning a “premature dementia” or “precocious madness”) is a disused psychiatric diagnosis that originally designated a chronic, deteriorating psychotic disorder characterised by rapid cognitive disintegration, usually beginning in the late teens or early adulthood. Over the years, the term dementia praecox was gradually replaced by schizophrenia, which remains in current diagnostic use.

The term dementia praecox was first used in 1891 by Arnold Pick (1851-1924), a professor of psychiatry at Charles University in Prague. In a brief clinical report, he described a person with a psychotic disorder resembling “hebephrenia” (schizophrenia). German psychiatrist Emil Kraepelin (1856-1926) popularised the term dementia praecox in his first detailed textbook descriptions of a condition that eventually became a different disease concept and relabelled as schizophrenia. Kraepelin reduced the complex psychiatric taxonomies of the nineteenth century by dividing them into two classes: manic-depressive psychosis and dementia praecox. This division, commonly referred to as the Kraepelinian dichotomy, had a fundamental impact on twentieth-century psychiatry, though it has also been questioned.

The primary disturbance in dementia praecox was seen to be a disruption in cognitive or mental functioning in attention, memory, and goal-directed behaviour. Kraepelin contrasted this with manic-depressive psychosis, now termed bipolar disorder, and also with other forms of mood disorder, including major depressive disorder. He eventually concluded that it was not possible to distinguish his categories on the basis of cross-sectional symptoms.

Kraepelin viewed dementia praecox as a progressively deteriorating disease from which no one recovered. However, by 1913, and more explicitly by 1920, Kraepelin admitted that while there may be a residual cognitive defect in most cases, the prognosis was not as uniformly dire as he had stated in the 1890s. Still, he regarded it as a specific disease concept that implied incurable, inexplicable madness.

Brief History

“[T]he history of dementia praecox is really that of psychiatry as a whole.” Adolf Meyer.

First Use of the Term

Dementia is an ancient term which has been in use since at least the time of Lucretius in 50 B.C.E. where it meant “being out of one’s mind”. Until the seventeenth century, dementia referred to states of cognitive and behavioural deterioration leading to psychosocial incompetence. This condition could be innate or acquired, and the concept had no reference to a necessarily irreversible condition. It is the concept in this popular notion of psychosocial incapacity that forms the basis for the idea of legal incapacity. By the eighteenth century, at the period when the term entered into European medical discourse, clinical concepts were added to the vernacular understanding such that dementia was now associated with intellectual deficits arising from any cause and at any age. By the end of the nineteenth century, the modern ‘cognitive paradigm’ of dementia was taking root. This holds that dementia is understood in terms of criteria relating to aetiology, age and course which excludes former members of the family of the demented such as adults with acquired head trauma or children with cognitive deficits. Moreover, it was now understood as an irreversible condition and a particular emphasis was placed on memory loss in regard to the deterioration of intellectual functions.

The term démence précoce was used in passing to describe the characteristics of a subset of young mental patients by the French physician Bénédict Augustin Morel in 1852 in the first volume of his Études cliniques. and the term is used more frequently in his textbook Traité des maladies mentales which was published in 1860. Morel, whose name will be forever associated with religiously inspired concept of degeneration theory in psychiatry, used the term in a descriptive sense and not to define a specific and novel diagnostic category. It was applied as a means of setting apart a group of young men and women who were suffering from “stupor.” As such their condition was characterised by a certain torpor, enervation, and disorder of the will and was related to the diagnostic category of melancholia. He did not conceptualise their state as irreversible and thus his use of the term dementia was equivalent to that formed in the eighteenth century as outlined above.

While some have sought to interpret, if in a qualified fashion, the use by Morel of the term démence précoce as amounting to the “discovery” of schizophrenia, others have argued convincingly that Morel’s descriptive use of the term should not be considered in any sense as a precursor to Kraepelin’s dementia praecox disease concept. This is due to the fact that their concepts of dementia differed significantly from each other, with Kraepelin employing the more modern sense of the word and that Morel was not describing a diagnostic category. Indeed, until the advent of Pick and Kraepelin, Morel’s term had vanished without a trace and there is little evidence to suggest that either Pick or indeed Kraepelin were even aware of Morel’s use of the term until long after they had published their own disease concepts bearing the same name. As Eugène Minkowski succinctly stated, ‘An abyss separates Morel’s démence précoce from that of Kraepelin.’

Morel described several psychotic disorders that ended in dementia, and as a result he may be regarded as the first alienist or psychiatrist to develop a diagnostic system based on presumed outcome rather than on the current presentation of signs and symptoms. Morel, however, did not conduct any long-term or quantitative research on the course and outcome of dementia praecox (Kraepelin would be the first in history to do that) so this prognosis was based on speculation. It is impossible to discern whether the condition briefly described by Morel was equivalent to the disorder later called dementia praecox by Pick and Kraepelin.

Time Component

Psychiatric nosology in the nineteenth-century was chaotic and characterised by a conflicting mosaic of contradictory systems. Psychiatric disease categories were based upon short-term and cross-sectional observations of patients from which were derived the putative characteristic signs and symptoms of a given disease concept. The dominant psychiatric paradigms which gave a semblance of order to this fragmentary picture were Morelian degeneration theory and the concept of “unitary psychosis” (Einheitspsychose). This latter notion, derived from the Belgian psychiatrist Joseph Guislain (1797-1860), held that the variety of symptoms attributed to mental illness were manifestations of a single underlying disease process. While these approaches had a diachronic aspect they lacked a conception of mental illness that encompassed a coherent notion of change over time in terms of the natural course of the illness and based upon an empirical observation of changing symptomatology.

In 1863, the Danzig-based psychiatrist Karl Ludwig Kahlbaum (1828-1899) published his text on psychiatric nosology Die Gruppierung der psychischen Krankheiten (The Classification of Psychiatric Diseases). Although with the passage of time this work would prove profoundly influential, when it was published it was almost completely ignored by German academia despite the sophisticated and intelligent disease classification system which it proposed. In this book Kahlbaum categorised certain typical forms of psychosis (vesania typica) as a single coherent type based upon their shared progressive nature which betrayed, he argued, an ongoing degenerative disease process. For Kahlbaum the disease process of vesania typica was distinguished by the passage of the sufferer through clearly defined disease phases: a melancholic stage; a manic stage; a confusional stage; and finally a demented stage.

In 1866 Kahlbaum became the director of a private psychiatric clinic in Görlitz (Prussia, today Saxony, a small town near Dresden). He was accompanied by his younger assistant, Ewald Hecker (1843-1909), and during a ten-year collaboration they conducted a series of research studies on young psychotic patients that would become a major influence on the development of modern psychiatry.

Together Kahlbaum and Hecker were the first to describe and name such syndromes as dysthymia, cyclothymia, paranoia, catatonia, and hebephrenia. Perhaps their most lasting contribution to psychiatry was the introduction of the “clinical method” from medicine to the study of mental diseases, a method which is now known as psychopathology.

When the element of time was added to the concept of diagnosis, a diagnosis became more than just a description of a collection of symptoms: diagnosis now also defined by prognosis (course and outcome). An additional feature of the clinical method was that the characteristic symptoms that define syndromes should be described without any prior assumption of brain pathology (although such links would be made later as scientific knowledge progressed). Karl Kahlbaum made an appeal for the adoption of the clinical method in psychiatry in his 1874 book on catatonia. Without Kahlbaum and Hecker there would be no dementia praecox.

Upon his appointment to a full professorship in psychiatry at the University of Dorpat (now Tartu, Estonia) in 1886, Kraepelin gave an inaugural address to the faculty outlining his research programme for the years ahead. Attacking the “brain mythology” of Meynert and the positions of Griesinger and Gudden, Kraepelin advocated that the ideas of Kahlbaum, who was then a marginal and little known figure in psychiatry, should be followed. Therefore, he argued, a research programme into the nature of psychiatric illness should look at a large number of patients over time to discover the course which mental disease could take. It has also been suggested that Kraepelin’s decision to accept the Dorpat post was informed by the fact that there he could hope to gain experience with chronic patients and this, it was presumed, would facilitate the longitudinal study of mental illness.

Quantitative Component

Understanding that objective diagnostic methods must be based on scientific practice, Kraepelin had been conducting psychological and drug experiments on patients and normal subjects for some time when, in 1891, he left Dorpat and took up a position as professor and director of the psychiatric clinic at Heidelberg University. There he established a research programme based on Kahlbaum’s proposal for a more exact qualitative clinical approach, and his own innovation: a quantitative approach involving meticulous collection of data over time on each new patient admitted to the clinic (rather than only the interesting cases, as had been the habit until then).

Kraepelin believed that by thoroughly describing all of the clinic’s new patients on index cards, which he had been using since 1887, researcher bias could be eliminated from the investigation process. He described the method in his posthumously published memoir:

… after the first thorough examination of a new patient, each of us had to throw in a note [in a “diagnosis box”] with his diagnosis written on it. After a while, the notes were taken out of the box, the diagnoses were listed, and the case was closed, the final interpretation of the disease was added to the original diagnosis. In this way, we were able to see what kind of mistakes had been made and were able to follow-up the reasons for the wrong original diagnosis.

The fourth edition of his textbook, Psychiatrie, published in 1893, two years after his arrival at Heidelberg, contained some impressions of the patterns Kraepelin had begun to find in his index cards. Prognosis (course and outcome) began to feature alongside signs and symptoms in the description of syndromes, and he added a class of psychotic disorders designated “psychic degenerative processes”, three of which were borrowed from Kahlbaum and Hecker: dementia paranoides (a degenerative type of Kahlbaum’s paranoia, with sudden onset), catatonia (per Kahlbaum, 1874) and dementia praecox, (Hecker’s hebephrenia of 1871). Kraepelin continued to equate dementia praecox with hebephrenia for the next six years.

In the March 1896 fifth edition of Psychiatrie, Kraepelin expressed confidence that his clinical method, involving analysis of both qualitative and quantitative data derived from long term observation of patients, would produce reliable diagnoses including prognosis:

What convinced me of the superiority of the clinical method of diagnosis (followed here) over the traditional one, was the certainty with which we could predict (in conjunction with our new concept of disease) the future course of events. Thanks to it the student can now find his way more easily in the difficult subject of psychiatry.

In this edition dementia praecox is still essentially hebephrenia, and it, dementia paranoides and catatonia are described as distinct psychotic disorders among the “metabolic disorders leading to dementia”.

Kraepelin’s Influence on The Next Century

In the 1899 (6th) edition of Psychiatrie, Kraepelin established a paradigm for psychiatry that would dominate the following century, sorting most of the recognized forms of insanity into two major categories: dementia praecox and manic-depressive illness. Dementia praecox was characterised by disordered intellectual functioning, whereas manic-depressive illness was principally a disorder of affect or mood; and the former featured constant deterioration, virtually no recoveries and a poor outcome, while the latter featured periods of exacerbation followed by periods of remission, and many complete recoveries. The class, dementia praecox, comprised the paranoid, catatonic and hebephrenic psychotic disorders, and these forms were found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until the fifth edition was released, in May 2013. These terms, however, are still found in general psychiatric nomenclature.

Change in Prognosis

In the seventh, 1904, edition of Psychiatrie, Kraepelin accepted the possibility that a small number of patients may recover from dementia praecox. Eugen Bleuler reported in 1908 that in many cases there was no inevitable progressive decline, there was temporary remission in some cases, and there were even cases of near recovery with the retention of some residual defect. In the eighth edition of Kraepelin’s textbook, published in four volumes between 1909 and 1915, he described eleven forms of dementia, and dementia praecox was classed as one of the “endogenous dementias”. Modifying his previous more gloomy prognosis in line with Bleuler’s observations, Kraepelin reported that about 26% of his patients experienced partial remission of symptoms. Kraepelin died while working on the ninth edition of Psychiatrie with Johannes Lange (1891-1938), who finished it and brought it to publication in 1927.

Cause

Though his work and that of his research associates had revealed a role for heredity, Kraepelin realized nothing could be said with certainty about the aetiology of dementia praecox, and he left out speculation regarding brain disease or neuropathology in his diagnostic descriptions. Nevertheless, from the 1896 edition onwards Kraepelin made clear his belief that poisoning of the brain, “auto-intoxication,” probably by sex hormones, may underlie dementia praecox – a theory also entertained by Eugen Bleuler. Both theorists insisted dementia praecox is a biological disorder, not the product of psychological trauma. Thus, rather than a disease of hereditary degeneration or of structural brain pathology, Kraepelin believed dementia praecox was due to a systemic or “whole body” disease process, probably metabolic, which gradually affected many of the tissues and organs of the body before affecting the brain in a final, decisive cascade. Kraepelin, recognising dementia praecox in Chinese, Japanese, Tamil and Malay patients, suggested in the eighth edition of Psychiatrie that, “we must therefore seek the real cause of dementia praecox in conditions which are spread all over the world, which thus do not lie in race or in climate, in food or in any other general circumstance of life…”

Treatment

Kraepelin had experimented with hypnosis but found it wanting, and disapproved of Freud’s and Jung’s introduction, based on no evidence, of psychogenic assumptions to the interpretation and treatment of mental illness. He argued that, without knowing the underlying cause of dementia praecox or manic-depressive illness, there could be no disease-specific treatment, and recommended the use of long baths and the occasional use of drugs such as opiates and barbiturates for the amelioration of distress, as well as occupational activities, where suitable, for all institutionalised patients. Based on his theory that dementia praecox is the product of autointoxication emanating from the sex glands, Kraepelin experimented, without success, with injections of thyroid, gonad and other glandular extracts.

Use of Term Spreads

Kraepelin noted the dissemination of his new disease concept when in 1899 he enumerated the term’s appearance in almost twenty articles in the German-language medical press. In the early years of the twentieth century the twin pillars of the Kraepelinian dichotomy, dementia praecox and manic depressive psychosis, were assiduously adopted in clinical and research contexts among the Germanic psychiatric community. German-language psychiatric concepts were always introduced much faster in America (than, say, Britain) where émigré German, Swiss and Austrian physicians essentially created American psychiatry. Swiss-émigré Adolf Meyer (1866-1950), arguably the most influential psychiatrist in America for the first half of the 20th century, published the first critique of dementia praecox in an 1896 book review of the 5th edition of Kraepelin’s textbook. But it was not until 1900 and 1901 that the first three American publications regarding dementia praecox appeared, one of which was a translation of a few sections of Kraepelin’s 6th edition of 1899 on dementia praecox.

Adolf Meyer was the first to apply the new diagnostic term in America. He used it at the Worcester Lunatic Hospital in Massachusetts in the fall of 1896. He was also the first to apply Eugen Bleuler’s term “schizophrenia” (in the form of “schizophrenic reaction”) in 1913 at the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital.

The dissemination of Kraepelin’s disease concept to the Anglophone world was facilitated in 1902 when Ross Diefendorf, a lecturer in psychiatry at Yale, published an adapted version of the sixth edition of the Lehrbuch der Psychiatrie. This was republished in 1904 and with a new version, based on the seventh edition of Kraepelin’s Lehrbuch appearing in 1907 and reissued in 1912. Both dementia praecox (in its three classic forms) and “manic-depressive psychosis” gained wider popularity in the larger institutions in the eastern United States after being included in the official nomenclature of diseases and conditions for record-keeping at Bellevue Hospital in New York City in 1903. The term lived on due to its promotion in the publications of the National Committee on Mental Hygiene (founded in 1909) and the Eugenics Records Office (1910). But perhaps the most important reason for the longevity of Kraepelin’s term was its inclusion in 1918 as an official diagnostic category in the uniform system adopted for comparative statistical record-keeping in all American mental institutions, The Statistical Manual for the Use of Institutions for the Insane. Its many revisions served as the official diagnostic classification scheme in America until 1952 when the first edition of the Diagnostic and Statistical Manual: Mental Disorders, or DSM-I, appeared. Dementia praecox disappeared from official psychiatry with the publication of DSM-I, replaced by the Bleuler/Meyer hybridization, “schizophrenic reaction”.

Schizophrenia was mentioned as an alternate term for dementia praecox in the 1918 Statistical Manual. In both clinical work as well as research, between 1918 and 1952 five different terms were used interchangeably: dementia praecox, schizophrenia, dementia praecox (schizophrenia), schizophrenia (dementia praecox) and schizophrenic reaction. This made the psychiatric literature of the time confusing since, in a strict sense, Kraepelin’s disease was not Bleuler’s disease. They were defined differently, had different population parameters, and different concepts of prognosis.

The reception of dementia praecox as an accepted diagnosis in British psychiatry came more slowly, perhaps only taking hold around the time of World War I. There was substantial opposition to the use of the term “dementia” as misleading, partly due to findings of remission and recovery. Some argued that existing diagnoses such as “delusional insanity” or “adolescent insanity” were better or more clearly defined. In France a psychiatric tradition regarding the psychotic disorders predated Kraepelin, and the French never fully adopted Kraepelin’s classification system. Instead the French maintained an independent classification system throughout the 20th century. From 1980, when DSM-III totally reshaped psychiatric diagnosis, French psychiatry began to finally alter its views of diagnosis to converge with the North American system. Kraepelin thus finally conquered France via America.

From Dementia Praecox to Schizophrenia

Due to the influence of alienists such as Adolf Meyer, August Hoch, George Kirby, Charles Macphie Campbell, Smith Ely Jelliffe and William Alanson White, psychogenic theories of dementia praecox dominated the American scene by 1911. In 1925 Bleuler’s schizophrenia rose in prominence as an alternative to Kraepelin’s dementia praecox. When Freudian perspectives became influential in American psychiatry in the 1920s schizophrenia became an attractive alternative concept. Bleuler corresponded with Freud and was connected to Freud’s psychoanalytic movement, and the inclusion of Freudian interpretations of the symptoms of schizophrenia in his publications on the subject, as well as those of C.G. Jung, eased the adoption of his broader version of dementia praecox (schizophrenia) in America over Kraepelin’s narrower and prognostically more negative one.

The term “schizophrenia” was first applied by American alienists and neurologists in private practice by 1909 and officially in institutional settings in 1913, but it took many years to catch on. It is first mentioned in The New York Times in 1925. Until 1952 the terms dementia praecox and schizophrenia were used interchangeably in American psychiatry, with occasional use of the hybrid terms “dementia praecox (schizophrenia)” or “schizophrenia (dementia praecox)”.

Diagnostic Manuals

Editions of the Diagnostic and Statistical Manual of Mental Disorders since the first in 1952 had reflected views of schizophrenia as “reactions” or “psychogenic” (DSM-I), or as manifesting Freudian notions of “defence mechanisms” (as in DSM-II of 1969 in which the symptoms of schizophrenia were interpreted as “psychologically self-protected”). The diagnostic criteria were vague, minimal and wide, including either concepts that no longer exist or that are now labelled as personality disorders (for example, schizotypal personality disorder). There was also no mention of the dire prognosis Kraepelin had made. Schizophrenia seemed to be more prevalent and more psychogenic and more treatable than either Kraepelin or Bleuler would have allowed.

Summary

As a direct result of the effort to construct Research Diagnostic Criteria (RDC) in the 1970s that were independent of any clinical diagnostic manual, Kraepelin’s idea that categories of mental disorder should reflect discrete and specific disease entities with a biological basis began to return to prominence. Vague dimensional approaches based on symptoms – so highly favoured by the Meyerians and psychoanalysts – were overthrown. For research purposes, the definition of schizophrenia returned to the narrow range allowed by Kraepelin’s dementia praecox concept. Furthermore, after 1980 the disorder was a progressively deteriorating one once again, with the notion that recovery, if it happened at all, was rare. This revision of schizophrenia became the basis of the diagnostic criteria in DSM-III (1980). Some of the psychiatrists who worked to bring about this revision referred to themselves as the “neo-Kraepelinians”.

What is Emergency Psychiatry?

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Introduction

Emergency psychiatry is the clinical application of psychiatry in emergency settings.

Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behaviour. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work. The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas. Care for patients in situations involving emergency psychiatry is complex.

Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment. Care of patients requiring psychiatric intervention usually encompasses crisis stabilisation of many serious and potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions.

Definition

Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behaviour. Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. A physician’s or a nurse’s ability to identify and intervene with these and other medical conditions is critical.

Delivery of Services

The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centres, or Comprehensive Psychiatric Emergency Programs. Mental health professionals from a wide area of disciplines, including medicine, nursing, psychology, and social work in these settings alongside psychiatrists and emergency physicians. The facilities, sometimes housed in a psychiatric hospital, psychiatric ward, or emergency department, provide immediate treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week.

Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalisation for the patient, and to treat those patients whose symptoms can be improved within that brief period of time. Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting. The functions of psychiatric emergency services are to assess patients’ problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilise teams to carry out interventions at patients’ residences, utilise emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counselling.

Brief History

Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalisation both in Europe and the United States. Deinstitutionalisation, in some locations, has resulted in a larger number of severely mentally ill people living in the community. There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication. The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency service settings located in urban areas.

Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity. While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile. The individualised care needed for patients utilising psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach.

Scope

Suicide Attempts and Suicidal Thoughts

As of 2000, the World Health Organisation (WHO) estimated one million suicides in the world each year. There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of completed suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.

Violent Behaviour


Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide. Violence is also associated with many conditions such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. Additional risk factors have also been identified which may lead to violent behaviour. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological impairment, being uneducated, unmarried, etc. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient.

Psychosis

Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient suffering from a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan.

An individual could also be suffering from an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention. The lack of identification and treatment can result in suicide, homicide, or other violence.

Substance Dependence, Abuse and Intoxication

Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition. Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterised by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short term memory loss which could result in behavioural change causing injury or death, levels of alcohol below 60 milligrams per decilitre of blood are usually considered non-lethal. However, individuals at 200 milligrams per decilitre of blood are considered grossly intoxicated and concentration levels at 400 milligrams per decilitre of blood are lethal, causing complete anaesthesia of the respiratory system.

Beyond the dangerous behavioural changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation and violence. Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms.

Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants. Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centres, or hospitals. Both the immediate and long term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse.

Hazardous Drug Reactions and Interactions

Overdoses, drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics. If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death. Serotonin syndrome can result when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone. Severe symptoms of serotonin syndrome include hyperthermia, delirium, and tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency department or medicine service for increased monitoring.

Personality Disorders

Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning and impulse control can be considered personality disorders. Patients suffering from a personality disorder will usually not complain about symptoms resulting from their disorder. Patients suffering an emergency phase of a personality disorder may showcase combative or suspicious behaviour, suffer from brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals suffering from personality disorders in inpatient psychiatric settings is usually 7-25% higher. Clinicians working with such patients attempt to stabilise the individual to their baseline level of function.

Anxiety

Patients suffering from an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalised anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually attempt to first provide a “safe harbour” for the patient so that assessment processes and treatments can be adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients suffering from anxiety disorders have a higher risk of premature death.

Disasters

Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria.

Due to the typically disorganised and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may suffer from both chronic or acute post-traumatic stress disorder. Patients suffering severely from this disorder often are admitted to psychiatric hospitals to stabilise the individual.

Abuse

Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may suffer from extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination, collection of medicolegal evidence, and determination of the risk of pregnancy, if applicable.

Treatment

Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilise life-threatening conditions. Once stabilised, patients suffering chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation. Prescribed treatments within the emergency service setting vary dependent upon the patient’s condition. Different forms of psychiatric medication, psychotherapy, or electroconvulsive therapy may be used in the emergency setting. The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced the utilisation of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication.

Medications

With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration. Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration, absorption, distribution and metabolism of the medication. A common route of administration is oral administration, however if this method is to work the drug must be able to get to the stomach and stay there. In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead. Medication can also be administered through intramuscular injection, or through intravenous injection.

The amount of time required for absorption varies dependent upon many factors including drug solubility, gastrointestinal motility and pH. If a medication is administered orally the amount of food in the stomach may also affect the rate of absorption. Once absorbed medications must be distributed throughout the body, or usually with the case of psychiatric medication, past the blood-brain barrier to the brain. With all of these factors affecting the rapidity of effect, the time until the effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol, an antipsychotic, is administered intramuscularly. Antipsychotics, especially Haloperidol, as well as assorted benzodiazepines are the most frequently used drugs in emergency psychiatry, especially agitation.

Psychotherapy

Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected. The process of brief therapy under emergency psychiatric conditions includes the establishment of a primary complaint from the patient, realising psychosocial factors, formulating an accurate representation of the problem, coming up with ways to solve the problem, and setting specific goals. The information gathering aspect of brief psychotherapy is therapeutic because it helps the patient place their problem in the proper perspective. If the physician determines that deeper psychotherapy sessions are required, they can transition the patient out of the emergency setting and into an appropriate clinic or centre.

ECT

Electroconvulsive therapy (ECT) is a controversial form of treatment which cannot be involuntarily applied in psychiatric emergency service settings. Instances wherein a patient is depressed to such a severe degree that the patient cannot be stopped from hurting themselves or when a patient refuses to swallow, eat or drink medication, electroconvulsive therapy could be suggested as a therapeutic alternative. While preliminary research suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to occur.

Observation and Collateral Information

There are other essential aspects of emergency psychiatry: observation and collateral information. The observation of the patient’s behaviour is an important aspect of emergency psychiatry inasmuch as it allows the clinicians working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base involuntary commitment on dangerousness or the inability to care for one’s basic needs. Observation for a period of time may help determine this. For example, if a patient who is committed for violent behaviour in the community, continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission may be needed.

Collateral information or parallel information is information obtained from family, friends or treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information while others do not. For example, with a patient who is thought to be paranoid about people following him or spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in reality. Past episodes of suicide attempts or violent behaviour can be confirmed or disproven.

Disposition

Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as disposition. This is one of the essential features of emergency psychiatry.

Hospital Admission

The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment. Initial emergency psychiatric evaluations usually involve patients who are acutely agitated, paranoid, or who are suicidal. Initial evaluations to determine admission and interventions are designed to be as therapeutic as possible.

Involuntary Commitment

Involuntary commitment, or sectioning, refers to situations where police officers, health officers, or health professionals classify an individual as dangerous to themselves, others, gravely disabled, or mentally ill according to the applicable government law for the region. After an individual is transported to a psychiatric emergency service setting, a preliminary professional assessment is completed which may or may not result in involuntary treatment. Some patients may be discharged shortly after being brought to psychiatric emergency services while others will require longer observation and the need for continued involuntary commitment will exist. While some patients may initially come voluntarily, it may be realised that they pose a risk to themselves or others and involuntary commitment may be initiated at that point.

Referrals and Voluntary Hospitalisation

In some locations, such as the United States, voluntary hospitalisations are outnumbered by involuntary commitments partly due to the fact that insurance tends not to pay for hospitalisation unless an imminent danger exists to the individual or community. In addition, psychiatric emergency service settings admit approximately one third of patients from assertive community treatment centres. Therefore, patients who are not admitted will be referred to services in the community.

What is an Eating Disorder Inventory?

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Introduction

The Eating Disorder Inventory (EDI) is a self-report questionnaire used to assess the presence of eating disorders:

  • Anorexia nervosa both restricting and binge-eating/purging type;
  • Bulimia nervosa; and
  • Eating disorder not otherwise specified including binge eating disorder.

The original questionnaire consisted of 64 questions, divided into eight subscales. It was created in 1984 by David M. Garner and others. There have been two subsequent revisions by Garner:

  • The Eating Disorder Inventory-2 (EDI-2); and
  • The Eating Disorder Inventory-3 (EDI-3).

Diagnostic Use

The Eating Disorder Inventory is a diagnostic tool designed for use in a clinical setting to assess the presence of an eating disorder. It is generally used in conjunction with other psychological tests such as the Beck Depression Inventory. Depression has been shown to yield higher scores on the EDI-3.

Eating Disorder Inventory

The Eating Disorder Inventory (EDI) comprises 64 questions, divided into eight subscales. Each question is on a 6-point scale (ranging from “always” to “never”), rated 0-3. The score for each sub-scale is then summed. The 8 subscale scores on the EDI are:

  • Drive for thinness: an excessive concern with dieting, preoccupation with weight, and fear of weight gain.
  • Bulimia: episodes of binge eating and purging.
  • Body dissatisfaction: not being satisfied with one’s physical appearance.
  • Ineffectiveness: assesses feelings of inadequacy, insecurity, worthlessness and having no control over their lives.
  • Perfectionism: not being satisfied with anything less than perfect.
  • Interpersonal distrust: reluctance to form close relationships.
  • Interoceptive awareness: “measures the ability of an individual to discriminate between sensations and feelings, and between the sensations of hunger and satiety”.
  • Maturity fears: The fear of facing the demands of adult life.

Eating Disorder Inventory-2

The first revision of the EDI was in 1991. The 1991 version, Eating Disorder Inventory-2 (EDI-2) is used for both males and females over age 12. The EDI-2 retains the original format of the EDI with the inclusion of 27 new items divided into three additional subscales:

  • Asceticism: reflects the avoidance of sexual relationships.
  • Impulse regulation: shows the ability to regulate impulsive behaviour, especially the binge behaviour.
  • Social insecurity: estimates social fears and insecurity.

Eating Disorder Inventory-3

The latest revision to the Eating Disorder Inventory was released in 2004. It contains the original items of the first version as well as EDI-2, and was also enhanced to reflect more modern theories related to the diagnosis of eating disorders. It was designed for use with females ages 13-53 years, and can be administered in 20 minutes. It contains 91 items divided into twelve subscales rated on a 0-4 point scoring system. Three items on the EDI-3 are specific to eating disorders, and 9 are general psychological scales that are relevant to eating disorders. The inventory yields six composite scores: eating disorder risk, ineffectiveness, interpersonal problems, affective problems, overcontrol, and general psychological maladjustment.

Eating Disorder Symptom Checklist

The Eating Disorder Symptom Checklist is a separate self-report form used to measure the frequency of symptoms (i.e., binge eating; the use of laxatives, diet pills; exercise patterns). The information provided by the checklist aids in determining whether patients meets the diagnostic criteria as set forth in the Diagnostic and Statistical Manual of Mental Disorders IV-TR for an eating disorder.

Eating Disorder Referral Form

The Eating Disorder Referral Form is an abbreviated form of the EDI-3 for use in non-clinical settings such as the allied health professions. It contains 25 questions from the EDI-3 that are specific to eating disorder risk. It also includes questions specific to the behavioural patterns of someone with or at risk of developing an eating disorder. The referral form utilizes indexes based on body mass index in identifying at risk patients.

What is an Eating Disorder Examination Interview?

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Introduction

The Eating Disorder Examination Interview (EDE) devised by Cooper & Fairburn (1987) is a semi-structured interview conducted by a clinician in the assessment of an eating disorder.

Outline

The EDE is a semi-structured interview conducted by a trained clinician to assess the psychopathology associated with the diagnosis of an eating disorder. The EDE is rated through the use of four subscales and a global score. The four subscales are:

  1. Restraint.
  2. Eating concern.
  3. Shape concern.
  4. Weight concern.

The questions concern the frequency in which the patient engages in behaviours indicative of an eating disorder over a 28-day period. The test is secured on a 7-point scale from 0-6. With a zero score indicating not having engaged in the questioned behaviour.

EDE-Q

The Eating Disorders Examination Questionnaire (EDE-Q) was adapted from the EDE. The EDE-Q is a 41 item self-report questionnaire. It retains the format of the EDE including the 4 subscales and global score. It also concerns behaviours over a 28-day time period and retains the scoring system of 0-6, with:

  • 0 indicating no days;
  • 1 = 1-5 days;
  • 2 = 6-12 days;
  • 3 = 13-15 days;
  • 4 = 16-22 days;
  • 5 = 23-27 days; and
  • 6 = every day.

Reference

Cooper, Z. & Fairburn, CG (1987). The Eating Disorder Examination: A Semistructured Interview for the Assessment of the Specific Psychopathology of Eating Disorders”. International Journal of Eating Disorders. 6, pp.1-8. doi:10.1002/1098-108x(198701)6:1<1::aid-eat2260060102>3.0.co;2-9.

What is Histrionic Personality Disorder?

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Introduction

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterised by a pattern of excessive attention-seeking behaviours, usually beginning in early childhood, including inappropriate seduction and an excessive desire for approval.

Individuals diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, and flirtatious. Women are diagnosed with HPD roughly 4 times as often as men. It affects 2-3% of the general population and 10-15% in inpatient and outpatient mental health institutions.

HPD lies in the dramatic cluster of personality disorders. People with HPD have a high desire for attention, make loud and inappropriate appearances, exaggerate their behaviours and emotions, and crave stimulation. They may exhibit sexually provocative behaviour, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behaviour to achieve their own needs.

Signs and Symptoms

People with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to manipulate others into making them the centre of attention. HPD may also affect a person’s social and romantic relationships, as well as their ability to cope with losses or failures. They may seek treatment for clinical depression when romantic (or other close personal) relationships end.

Individuals with HPD often fail to see their own personal situation realistically, instead dramatising and exaggerating their difficulties. They may go through frequent job changes, as they become easily bored and may prefer withdrawing from frustration (instead of facing it). Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression.

Additional characteristics may include:

  • Exhibitionist behaviour.
  • Constant seeking of reassurance or approval.
  • Excessive sensitivity to criticism or disapproval.
  • Pride of own personality and unwillingness to change, viewing any change as a threat.
  • Inappropriately seductive appearance or behaviour of a sexual nature.
  • Using factitious somatic symptoms (of physical illness) or psychological disorders to garner attention.
  • Craving attention.
  • Low tolerance for frustration or delayed gratification.
  • Rapidly shifting emotional states that may appear superficial or exaggerated to others.
  • Tendency to believe that relationships are more intimate than they actually are.
  • Making rash decisions.
  • Blaming personal failures or disappointments on others.
  • Being easily influenced by others, especially those who treat them approvingly.
  • Being overly dramatic and emotional.
  • Influenced by the suggestions of others.

Some people with histrionic traits or personality disorder change their seduction technique into a more maternal or paternal style as they age.

Mnemonic

A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as “PRAISE ME”:

  • Provocative (or seductive) behaviour.
  • Relationships are considered more intimate than they actually are.
  • Attention-seeking.
  • Influenced easily by others or circumstances.
  • Speech (style) wants to impress; lacks detail.
  • Emotional lability; shallowness.
  • Make-up; physical appearance is used to draw attention to self.
  • Exaggerated emotions; theatrical.

Causes

Little research has been done to find evidence of what causes histrionic personality disorder. Although direct causes are inconclusive, various theories and studies suggest multiple possible causes, of a neurochemical, genetic, psychoanalytic, or environmental nature. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD. HPD symptoms typically do not fully develop until the age of 15, while the onset of treatment only occurs, on average, at approximately 40 years of age.

Neurochemical/Physiological

Studies have shown that there is a strong correlation between the function of neurotransmitters and the Cluster B personality disorders such as HPD. Individuals diagnosed with HPD have highly responsive noradrenergic systems which is responsible for the synthesis, storage, and release of the neurotransmitter, norepinephrine. High levels of norepinephrine leads to anxiety-proneness, dependency, and high sociability.

Genetic

Twin studies have aided in breaking down the genetic vs. environment debate. A twin study conducted by the Department of Psychology at Oslo University attempted to establish a correlation between genetic and Cluster B personality disorders. With a test sample of 221 twins, 92 monozygotic and 129 dizygotic, researchers interviewed the subjects using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that there was a correlation of 0.67 that histrionic personality disorder is hereditary.

Psychoanalytic Theory

Though criticised as being unsupported by scientific evidence, psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet. Using psychoanalysis, Freud believed that lustfulness was a projection of the patient’s lack of ability to love unconditionally and develop cognitively to maturity, and that such patients were overall emotionally shallow. He believed the reason for being unable to love could have resulted from a traumatic experience, such as the death of a close relative during childhood or divorce of one’s parents, which gave the wrong impression of committed relationships. Exposure to one or multiple traumatic occurrences of a close friend or family member’s leaving (via abandonment or mortality) would make the person unable to form true and affectionate attachments towards other people.

HPD and Antisocial Personality Disorder

Another theory suggests a possible relationship between histrionic personality disorder and antisocial personality disorder. Research has found 2/3 of patients diagnosed with histrionic personality disorder also meet criteria similar to those of the antisocial personality disorder, which suggests both disorders based towards sex-type expressions may have the same underlying cause. Women are hypersexualised in the media consistently, ingraining thoughts that the only way women are to get attention is by exploiting themselves, and when seductiveness is not enough, theatrics are the next step in achieving attention. Men can just as well be flirtatious towards multiple women yet feel no empathy or sense of compassion towards them. They may also become the centre of attention by exhibiting the “Don Juan” macho figure as a role-play.

Some family history studies have found that histrionic personality disorder, as well as borderline and antisocial personality disorders, tend to run in families, but it is unclear if this is due to genetic or environmental factors. Both examples suggest that predisposition could be a factor as to why certain people are diagnosed with histrionic personality disorder, however little is known about whether or not the disorder is influenced by any biological compound or is genetically inheritable. Little research has been conducted to determine the biological sources, if any, of this disorder.

Diagnosis

The person’s appearance, behaviour and history, along with a psychological evaluation, are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed.

DSM 5

The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) defines histrionic personality disorder (in Cluster B) as:

A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  • Is uncomfortable in situations in which he or she is not the centre of attention.
  • Interaction with others is often characterised by inappropriate sexually seductive or provocative behaviour.
  • Displays rapidly shifting and shallow expression of emotions.
  • Consistently uses physical appearance to draw attention to self.
  • Has a style of speech that is excessively impressionistic and lacking in detail.
  • Shows self-dramatisation, theatricality, and exaggerated expression of emotion.
  • Is suggestible, i.e. easily influenced by others or circumstances.
  • Considers relationships to be more intimate than they actually are.

The DSM 5 requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.

ICD-10

The World Health Organization’s ICD-10 lists histrionic personality disorder as:

A personality disorder characterised by:

  • Shallow and labile affectivity.
  • Self-dramatisation.
  • Theatricality.
  • Exaggerated expression of emotions.
  • Suggestibility.
  • Egocentricity.
  • Self-indulgence.
  • Lack of consideration for others.
  • Easily hurt feelings.
  • Continuous seeking for appreciation, excitement and attention.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Comorbidity

Most histrionics also have other mental disorders. Comorbid conditions include: antisocial, dependent, borderline, and narcissistic personality disorders, as well as depression, anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder and attachment disorders, including reactive attachment disorder.

Millon’s Subtypes

Theodore Millon identified six subtypes of histrionic personality disorder. Any individual histrionic may exhibit none or one of the following (as outlined in the table below).

SubtypeDescriptionPersonality Traits
Appeasing histrionicIncluding dependent and compulsive features.Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
Vivacious histrionicThe seductiveness of the histrionic mixed with the energy typical of hypomania.
Some narcissistic features can also be present.		Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionicIncluding negativistic features.Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous histrionicIncluding antisocial features.Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionicVariant of “pure” pattern.Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Infantile histrionicIncluding borderline features.Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.

Treatment

Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. The only successful method studied and proven to succeed is to fully break contact with their lovers in order to gain a sense of stability and independence once again. Treatment for HPD itself involves psychotherapy, including cognitive therapy.

Interviews and Self-Report Methods

In general clinical practice with assessment of personality disorders, one form of interview is the most popular; an unstructured interview. The actual preferred method is a semi-structured interview but there is reluctance to use this type of interview because they can seem impractical or superficial. The reason that a semi-structured interview is preferred over an unstructured interview is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the client.

One of the single most successful methods for assessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. There are some disadvantages with the self-report inventory method that with histrionic personality disorder there is a distortion in character, self-presentation, and self-image. This cannot be assessed simply by asking most clients if they match the criteria for the disorder. Most projective testing depend less on the ability or willingness of the person to provide an accurate description of the self, but there is currently limited empirical evidence on projective testing to assess histrionic personality disorder.

Functional Analytic Psychotherapy

Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. Initial goals of functional analytic psychotherapy are set by the therapist and include behaviours that fit the client’s needs for improvement. Functional analytic psychotherapy differs from the traditional psychotherapy due to the fact that the therapist directly addresses the patterns of behaviour as they occur in-session.

The in-session behaviours of the patient or client are considered to be examples of their patterns of poor interpersonal communication and to adjust their neurotic defences. To do this, the therapist must act on the client’s behaviour as it happens in real time and give feedback on how the client’s behaviour is affecting their relationship during therapy. The therapist also helps the client with histrionic personality disorder by denoting behaviours that happen outside of treatment; these behaviours are termed “Outside Problems” and “Outside Improvements”. This allows the therapist to assist in problems and improvements outside of session and to verbally support the client and condition optimal patterns of behaviour. This then can reflect on how they are advancing in-session and outside of session by generalising their behaviours over time for changes or improvement.

Coding Client and Therapist Behaviours

This is called coding client and therapist behaviour. In these sessions there is a certain set of dialogue or script that can be forced by the therapist for the client to give insight on their behaviours and reasoning. Here is an example a hypothetical conversation. T = therapist C = Client. This coded dialogue can be transcribed as:

  • ECRB – Evoking clinically relevant behaviour:
    • T: Tell me how you feel coming in here today (CRB2).
    • C: Well, to be honest, I was nervous. Sometimes I feel worried about how things will go, but I am really glad I am here.
  • CRB1 – In-session problems:
    • C: Whatever, you always say that. (becomes quiet). I don’t know what I am doing talking so much.
  • CRB2 – In-session improvements.
  • TCRB1 – Clinically relevant response to client problems.
    • T: Now you seem to be withdrawing from me. That makes it hard for me to give you what you might need from me right now. What do you think you want from me as we are talking right now?”.
  • TCRB2 – Responses to client improvement:
    • T: That’s great. I am glad you’re here, too. I look forward to talking to you.

Functional Ideographic Assessment Template

Another example of treatment besides coding is functional ideographic assessment template. The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy. The template was made by a combined effort of therapists and can be used to represent the behaviours that are a focus for this treatment. Using the FIAT therapists can create a common language to get stable and accurate communication results through functional analytic psychotherapy at the ease of the client; as well as the therapist.

Epidemiology

The survey data from the National epidemiological survey from 2001-2002 suggests a prevalence of HPD of 1.84%. Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences. This personality is seen more often in women than in men. Approximately 65% of HPD diagnoses are women while 35% are men. In Marcie Kaplan’s A Women’s View of DSM-III, she argues that women are overdiagnosed due to potential biases and expresses that even healthy women are often automatically diagnosed with HPD.

Many symptoms representing HPD in the DSM are exaggerations of traditional feminine behaviours. In a peer and self-review study, it showed that femininity was correlated with histrionic, dependent and narcissistic personality disorders. Although two thirds of HPD diagnoses are female, there have been a few exceptions. Whether or not the rate will be significantly higher than the rate of women within a particular clinical setting depends upon many factors that are mostly independent of the differential sex prevalence for HPD. Those with HPD are more likely to look for multiple people for attention, which leads to marital problems due to jealousy and lack of trust from the other party. This makes them more likely to become divorced or separated once married. With few studies done to find direct causations between HPD and culture, cultural and social aspects play a role in inhibiting and exhibiting HPD behaviours.

Brief History

Histrionic personality disorder stems from Etruscan histrio which means “an actor”. Hysteria can be described as an exaggerated or uncontrollable emotion that people, especially in groups, experience. Beliefs about hysteria have varied throughout time. It wasn’t until Sigmund Freud who studied histrionic personality disorder in a psychological manner. “The roots of histrionic personality can be traced to cases of hysterical neurosis described by Freud.” He developed the psychoanalytic theory in the late 19th century and the results from his development led to split concepts of hysteria. One concept labelled as hysterical neurosis (also known as conversion disorder) and the other concept labelled as hysterical character (currently known as histrionic personality disorder). These two concepts must not be confused with each other, as they are two separate and different ideas.

Histrionic personality disorder is also known as hysterical personality. Hysterical personality has evolved in the past 400 years and it first appeared in the DSM II (Diagnostic and Statistical Manual of Mental Disorders, 2nd edition) under the name hysterical personality disorder. The name we know today as histrionic personality disorder is due to the name change in DSM III, third edition. Renaming hysterical personality to histrionic personality disorder is believed to be because of possible negative connotations to the roots of hysteria, such as intense sexual expressions, demon possessions, etc.

Histrionic personality disorder has gone through many changes. From hysteria, to hysterical character, to hysterical personality disorder, to what it is listed as in the most current DSM, DSM-5.[clarification needed] “Hysteria is one of the oldest documented medical disorders.” Hysteria dates back to both ancient Greek and Egyptian writings. Most of the writings related hysteria and women together, similar to today where the epidemiology of histrionic personality disorder is generally more prevalent in women and also frequently diagnosed in women.

Ancient Times

  • Ancient Egypt:
    • First description of the mental disorder, hysteria, dates back to 1900 BC in Ancient Egypt. Biological issues, such as the uterus movement in the female body, were seen as the cause of hysteria.
    • Traditional symptoms and descriptions of hysteria can be found in the Ebers Papyrus, the oldest medical document.
  • Ancient Greece:
    • Similar to ancient Egyptians, the ancient Greeks saw hysteria being related to the uterus.
    • Hippocrates (5th century BC) is the first to use the term hysteria.
    • Hippocrates believed hysteria was a disease that lies in the movement of uterus (from the Greek ὑστέρα hystera “uterus”).
    • Hippocrates’s theory was that since a woman’s body is cold and wet compared to a man’s body which is warm and dry, the uterus is prone to illness, especially if deprived from sex.
    • He saw sex as the cleansing of the body so that being overemotional was due to sex deprivation.
  • According to History Channel’s Ancients Behaving Badly, Cleopatra and Nero had histrionic personality disorder.

Middle Ages

  • The Trotula:
    • A group of three texts from the 12th century, discusses women’s diseases and disorders as understood during this time period, including hysteria.
    • Trota of Salerno, a female medical practitioner from 12th-century Italy, is an authoritative figure behind one of the texts of the Trotula.
    • Authoritative in that it is her treatments and theories that are presented in the text.
    • Some people believe Trota’s teachings resonated with those of Hippocrates.

Renaissance

  • The uterus was still the explanation of hysteria, the concept of women being inferior to men was still present, and hysteria was still the symbol for femininity.

Modern Age

  • Thomas Willis (17th century) introduces a new concept of hysteria.
    • Thomas Willis believed that the causes of hysteria was not linked to the uterus of the female, but to the brain and nervous system.
  • Hysteria was consequence of social conflicts during the Salem witch trials.
  • Witchcraft and sorcery was later considered absurd during the Age of Enlightenment in the late 17th century and 18th century.
    • Hysteria starts to form in a more scientific way, especially neurologically.
    • New ideas formed during this time and one of them was that if hysteria is connected to the brain, men could possess it too, not just women.
  • Franz Mesmer (18th century) treated patients suffering from hysteria with his method called mesmerism, or animal magnetism.
  • Jean-Martin Charcot (19th century) studied effects of hypnosis in hysteria.
    • Charcot states that hysteria is a neurological disorder and that it is actually very common in men.

Contemporary Age

  • Sigmund Freud’s work with Josef Breuer, Studies on Hysteria, contributes to a psychoanalytic theory of hysteria.
  • Freud believed that hysteria was caused by a lack of libidinal evolution.

Social Implications

The prevalence of histrionic personality disorder in women is apparent and urges a re-evaluation of cultural notions of normal emotional behaviour. The diagnostic approach classifies histrionic personality disorder behaviour as “excessive”, considering it in reference to a social understanding of normal emotionality.

What was the Kirkbride Plan?

Published on by Andrew Marshall1 Comment

Introduction

The Kirkbride Plan was a system of mental asylum design advocated by Philadelphia psychiatrist Thomas Story Kirkbride (1809-1883) in the mid-19th century.

The asylums built in the Kirkbride design, often referred to as Kirkbride Buildings (or simply Kirkbrides), were constructed during the mid-to-late-19th century in the United States. The structural features of the hospitals as designated by Dr. Kirkbride were contingent on his theories regarding the healing of the mentally ill, in which environment and exposure to natural light and air circulation were crucial. The hospitals built according to the Kirkbride Plan would adopt various architectural styles, but had in common the “bat wing” style floor plan, housing numerous wings that sprawl outward from the centre.

1848 lithograph of the Kirkbride design of the Trenton State Hospital.

The first hospital designed under the Kirkbride Plan was the Trenton State Hospital in Trenton, New Jersey, constructed in 1848. Throughout the remainder of the nineteenth century, numerous psychiatric hospitals were designed under the Kirkbride Plan across the United States. By the twentieth century, popularity of the design had waned, largely due to the economic pressures of maintaining the immense facilities, as well as contestation of Dr. Kirkbride’s theories amongst the medical community.

Numerous Kirkbride structures still exist today, though many have been demolished or partially-demolished and repurposed. At least 30 of the original Kirkbride buildings have been registered with the National Register of Historic Places in the United States, either directly or through their location on hospital campuses or in historic districts.

Background

Basis and Philosophy

The establishment of state mental hospitals in the US is partly due to reformer Dorothea Dix, who testified to the New Jersey legislature in 1844, vividly describing the state’s treatment of lunatics; they were being housed in county jails, private homes, and the basements of public buildings. Dix’s effort led to the construction of the New Jersey State Lunatic Asylum, the first complete asylum built on the Kirkbride Plan.

Thomas Story Kirkbride (1809-1883), a psychiatrist from Philadelphia, Pennsylvania, developed his requirements of asylum design based on a philosophy of Moral Treatment and environmental determinism. The typical floor plan, with long rambling wings arranged en echelon (staggered, so each connected wing received sunlight and fresh air), was meant to promote privacy and comfort for patients. The building form itself was meant to have a curative effect, “a special apparatus for the care of lunacy, [whose grounds should be] highly improved and tastefully ornamented.” The idea of institutionalisation was thus central to Kirkbride’s plan for effectively treating the insane.

Design and Architectural Features

The Kirkbride Plan asylums tended to be large, imposing institutional buildings, with the defining feature being their “narrow, stepped, linear building footprint” featuring staggered wings extending outward from the centre, resembling the wingspan of a bat. The standard number of wings for a Kirkbride Plan hospital was eight, with an accommodation of 250 patients. Kirkbride’s philosophy behind the staggered wings was to allow individual corridors open to sunlight and air ventilation through both ends, which he believed aided in healing the mentally ill. Each wing, according to Kirkbride’s original guidelines, would house a separate ward, which would contain its own “comfortably furnished” parlour, bathroom, clothes room, and infirmary, as well as a speaking tube and dumbwaiter to allow open communication and movement of materials between floors. The furthest wings from the centre complex of the building were reserved for the “most excitable,” or most physically dangerous and volatile patients. Patient rooms were suggested to be spacious, with ceilings “at least 12 feet (3.7 m) high,” but only large enough to room a single person. The centre complexes of the Kirkbride Plan buildings were designed to house administration, kitchens, public and reception areas, and apartments for the superintendent’s family. Architectural styles of Kirkbride Plan buildings varied depending on the appointed architect, and ranged from Richardsonian Romanesque to Neo-Gothic.

In addition to the intricate building design, Dr. Kirkbride also advocated the importance of “fertile” and spacious landscapes on which the hospitals would be built, with views that “if possible, should exhibit life in its active forms.” Kirkbride also suggested the hospital grounds be a minimum of 100 acres (40 ha) in size. The foliage and farmlands on the hospital grounds were sometimes maintained by patients as part of physical exercise and/or therapy. Over the course of the nineteenth and twentieth centuries, the campuses of these hospitals often evolved into sprawling, expansive grounds with numerous buildings.

Operations and Staffing

In his proposal, Dr. Kirkbride outlined specific guidelines as to how a Kirkbride Plan hospital should be staffed and operate on a daily basis. Dr. Kirkbride suggested a total of 71, all of whom were required to live within, or in the immediate vicinity of, the hospital. The superintending physician, or physician-in-chief, was required to live in the main hospital or in a building contiguous to it, while his family had the option of residing at the hospital or seeking private lodging. The staff was also to have a balanced gender distribution, with approximately 36 female and 35 male staff members.

Among the staff of a Kirkbride Plan hospital were the superintending physician, an assisting physician and nurses, supervisors and teachers of each sex, a chaplain, matron, and a nightwatchman. Kirkbride urged that at least two attendants be working in each ward at any given time, and stressed the importance of the superintendent’s “proper selection” of attendants, given the extent of their management responsibilities: “The duties of attendants, when faithfully performed, are often harassing, and in many wards, among excited patients, are peculiarly so. On this account pains should always be taken to give them a reasonable amount of relaxation and their position should, in every respect, be made as comfortable as possible.” For general labour at the hospital, he suggested that the able-minded patients help maintain the hospital grounds and assist in duties in their respective wards.

Dr. Kirkbride’s estimation of the number of staff as well as their respective compensations was outlined in an 1854 publication on the Kirkbride Plan design. He proposed a living wage for all employees of the hospital, noting that “although in a few institutions a liberal compensation is given, in many, the salaries are quite too low, and entirely inadequate to be depended on, to secure and retain the best kind of talent for the different positions. The services required about the insane, when faithfully performed, are peculiarly trying to the mental and physical powers of any individual, and ought to be liberally paid for.” Salary for the superintending physician according to the 1854 guideline was to be USD$1,500 (equivalent to $43,206 in 2020) if the physician’s family resided at the hospital, and $2,500 (equivalent to $72,009 in 2020) if they found lodging at a private residence. In addition to the medical staff and attendants, the Kirkbride Plan hospitals also employed labourers of various trades, including resident engineers, carpenters, cooks and dairymaids, gardeners, seamstresses, ironworkers, clothing launderers, and a carriage driver.

Decline and Phasing Out

By the late-nineteenth century, the Kirkbride design had begun to wane in popularity, largely because the hospitals (which were state-funded), had received significant budget cuts that rendered them difficult to maintain. General psychiatric and medical opinion of Kirkbride’s theories regarding the “curability” of mental illness were also questioned by the medical community.

Future

Status

A total of 73 known Kirkbride Plan hospitals were constructed throughout the United States between 1845 and 1910. As of 2016, approximately 33 of these identified Kirkbride Plan hospital buildings still exist in their original form to some degree: 24 have been preserved indicating that the building is still standing and still in use, at least, in part. 11 of the 24 preserved properties received secondary condition codes of deteriorating, vacant, partial demolition or a combination, while the remaining nine have been adaptively reused. Of the 40 hospital buildings that no longer exist (either via demolition or destruction from natural occurrences, such as earthquakes), 26 were demolished to be replaced with new facilities.

The highest concentrations of Kirkbride Plan hospitals were in the Northeast and Midwestern states. Fewer Kirkbride Plan hospitals were constructed on the West Coast: In California, the Napa State Hospital was a notable Kirkbride Plan hospital, though the original structure was severely damaged during the 1906 San Francisco earthquake, and was ultimately demolished. The two surviving Kirkbride structures on the West Coast are both located in the state of Oregon, at the Oregon State Hospital, and the Eastern Oregon State Hospital, the latter of which now houses the Eastern Oregon Correctional Institution. While the vast majority of Kirkbride hospitals were located in the United States, similar facilities were built in Canada, and the Callan Park Hospital for the Insane in Sydney, Australia (constructed in 1885) was also influenced by Kirkbride’s design.

Preservation Efforts

Due to their intricate architectural features and historical significance, Kirkbride Plan hospitals have attracted conservation efforts from local and national groups, and (as of 2016) approximately 30 of the buildings have been registered with National Register of Historic Places. Local conservation groups and historical societies have made attempts to save numerous Kirkbrides from demolition: The Danvers State Hospital in Danvers, Massachusetts is one example, in which a local historical society filed a lawsuit in 2005 to stall demolition of the building. The majority of the Danvers State Hospital was demolished in 2007 in spite of the lawsuit, with only the centre portion of the building receiving restoration and conversion into apartments. The Northampton State Hospital in Northampton, Massachusetts, was demolished in 2006.

Many of the surviving Kirkbride Plan buildings in the United States have undergone at least partial demolition and have been repurposed, often with the centre portions of the buildings being most commonly preserved. The centre complexes of the Hudson River State Hospital in Poughkeepsie, New York, and the Oregon State Hospital in Salem, Oregon, for example, have been retained in spite of the majority of the outermost wings being demolished. One such Kirkbride Plan facility that has survived in its entirety is the Trans-Allegheny Lunatic Asylum, though does not contemporarily function as an active hospital. As of 2017, Trans-Allegheny Lunatic Asylum has not undergone demolition.

Several facilities originally established as Kirkbride Plan hospitals are still active in the 21st century, though not all have retained the original Kirkbride buildings on their campuses. The Oregon State Hospital, the longest continuously-operated psychiatric hospital on the West Coast, retained the majority of its original Kirkbride building during a 2008 demolition, seismically retrofitting and repurposing it as a mental health museum in 2013.

In Popular Culture

Numerous Kirkbride Plan hospitals and buildings have been featured in the arts: the Danvers State Hospital in Danvers, Massachusetts was both the setting and primary filming location for the 2001 psychological horror film Session 9. It has also been suggested by historians as an inspiration on H.P. Lovecraft, and in turn an inspiration for the fictional setting Arkham Asylum in the various Batman series. The Oregon State Hospital was also featured as the primary filming location for the film One Flew Over the Cuckoo’s Nest (1975), and was also the setting of “Ward 81,” a 1976 series of photographs by photographer Mary Ellen Mark.

The Trans-Allegheny Lunatic Asylum in West Virginia was featured on the Travel Channel reality series Ghost Adventures.