Highlights of the 1999 Institute on Psychiatric Services : Integrating Research Advances With Clinical Wisdom

After Nancy C. Andreasen, M.D., Ph.D., was presented with the 1999 Adolph Meyer Award for contributions to the science and practice of psychiatry, she gave a lecture on "Schizophrenia: The Fundamental Questions." Dr. Andreasen, who is the Andrew H. Woods chair of psychiatry at the University of Iowa College of Medicine and editor-in-chief of the American Journal of Psychiatry, observed that after more than 30 years as a psychiatrist, she still ponders questions she asked when she first encountered the "fascinating illness" of schizophrenia: "How in the world can the human mind produce such complexly disordered thoughts? What could possibly be going on?"

To answer the fundamental question of "What is schizophrenia?" researchers and clinicians must first decide how to define the clinical presentation of the illness, Dr. Andreasen said. She was chair of the committee that in the 1970s and 1980s developed the DSM-III definition of schizophrenia. She explained that the disorder was overly diagnosed at that time, and to help clinicians better diagnose schizophrenia, the committee emphasized its highly recognizable psychotic features—delusions and hallucinations. However, Dr. Andreasen said that she now believes that the emphasis on psychotic symptoms, combined with the DSM's purely descriptive approach that ignores underlying mechanisms, may have distracted the attention of clinicians and researchers from the real illness.

Dr. Andreasen argued for a model of the disease with cognitive impairment as its defining feature rather than psychotic symptoms. In fact, she proposed that schizophrenia should not be defined by signs and symptoms but by its underlying mechanisms. Dr. Andreasen called the model neo-Bleulerian, because Eugen Bleuler, a contemporary of Freud, described the fundamental abnormality in schizophrenia as a "loosening of associations." Dr. Andreasen pointed out that current research shows that schizophrenia has no consistent neuropathology—no single lesion in the brain accounts for the disease. Rather, it arises from dysfunctions in neural circuitry, or disruptions in connections between regions of the brain that affect the cognitive processes of all patients with the disorder. These disruptions underlie what Bleuler recognized as a loosening of associations.

Dr. Andreasen said that a "fascinating fact" about schizophrenia is that it has a similar clinical presentation and prevalence rate, about 1 percent, worldwide. Also, the disease has persisted over centuries despite significantly decreased fertility among people with schizophrenia, a fact that makes no biological sense, she said. Plus, the disease is not transmitted in a classic Mendelian fashion. Concordance in monozygotic twins is only 40 percent. The inferences that can be made from such observations suggest how hard it will be to solve the puzzle of schizophrenia, Dr. Andreasen pointed out, because they indicate that its causes are multiple and cannot be linked to a particular time and place. She compared schizophrenia with cancer: both have many etiologies with genetic, environmental, and psychological risk factors. Multiple cumulative "hits" appear to be necessary before the disease appears.

The persistence of schizophrenia despite decreased fertility among those affected suggests that it confers some biological advantages, Dr. Andreasen noted. She briefly reviewed the lives of such acknowledged geniuses as Isaac Newton, Bertrand Russell, James Joyce, and Albert Einstein to show how the disease affected them or their family members. Geniuses, she said, often have their seminal ideas in flashes of insight that resemble the eruptions of psychotic ideas and would seem to come from the same place. She believes that the link with genius, which has been pursued for other disorders such as bipolar illness, needs to be more systematically investigated for schizophrenia, which seems more prevalent among abstract thinkers, such as mathematicians and physicists.

Dr. Andreasen ended her lecture by describing a model of "cognitive dysmetria," which she says best fits converging evidence from a number of brain-imaging studies. Patients with schizophrenia have a cognitive dysmetria that arises when a neurodevelopmental aberration disrupts the cortico-cerebellar-thalamic-cortical circuit, a crucial feedback loop in the brain that modulates both cognitive and motor coordination. A defect in the ability to relay information from the cerebellum to cortical regions and back to the cerebellum through pontine nuclei could lead to the loosening of associations identified by Bleuler and the cognitive impairments so evident in people with the disorder.

Charles H. Zeanah, Jr., M.D., of Tulane University School of Medicine in New Orleans described preliminary results from a comprehensive intervention program for maltreated infants (birth to 47 months) and their parents in the New Orleans metropolitan area. The program aims to reduce the length of time that children spend in foster care by working with their family of origin to return the child or by determining that the child should be permanently placed with an adoptive family. It also works to reduce rates of repeated maltreatment if the child is returned to the parents.

Faculty members and trainees from the medical school's division of child psychiatry staff the program. The team becomes involved in the child's case after the juvenile court has found the child in need of care. The case plan for the family always involves reunification, and the team assesses what it will take to place the child back with the family. The team reports back to the court, and the judge orders treatment.

The team provides the treatment, and the outcomes are reviewed periodically by the court. A comprehensive evaluation of the child with the biological and foster parents is conducted, and a determination is made of family strengths as well as risk factors that predict future maltreatment. The program team then develops specific recommendations about what would be required to return the child to the biological parents. The recommendations are presented to child protection personnel and the juvenile court. The team works collaboratively with a variety of systems affecting the lives of high-risk infants and toddlers, including legal, child welfare, health care, educational, and mental health care systems.

Interventions focus on the relationship of the child and primary caregivers. Home visits serve to introduce the program and clinicians to the biological and foster parents, establish rapport, and permit observation of the home environment. Initial clinic visits involve intake and working with the families to help them become used to being observed by the program clinicians. In later visits, staff assess the parent and child together in free play and structured tasks. Treatments include medication, individual and couple psychotherapy, family psychotherapy, therapeutic visitation, dyadic psychotherapy, interaction guidance, crisis intervention, substance abuse counseling, and substance abuse residential placement.

Since the program started in early 1995, about 100 children have been seen. In about 45 percent of those cases, parental rights have been terminated; in 10 percent of cases, the parents voluntarily surrendered parental rights; in 30 percent, the family was reunited; and in 15 percent, the child was formally placed with biological relatives. During a similar time period before the program began, parental rights were terminated in about 23 percent of cases, and children were returned to their family of origin in about 48 percent of cases.

In a separate session, Dr. Zeanah and his colleagues described advances in the assessment, diagnosis, and treatment of posttraumatic stress disorder and attachment disorders in young children.

Dr. Zeanah described the challenges of understanding psychopathology in infants, including the lack of specificity between risk conditions and outcomes. A single risk factor can increase the likelihood of several disorders, and a variety of risk factors may lead to a single outcome. Further, assessment of infants' symptoms is made more difficult due to lack of agreement among different observers of the child, such as the mother and the father. Parents and clinicians may have different concerns and focus on different aspects of the child's behavior. In addition, rapid developmental changes and differences in the way symptoms are expressed at different ages cloud the diagnostic picture. Although the power of babies to change injects a certain optimism that symptoms may be overcome, not all symptoms are transient, Dr. Zeanah said.

Michael S. Scheeringa, M.D., reviewed research on posttraumatic stress disorder (PTSD) in infants and toddlers and discussed treatment options. Events that may be traumatic for very young children include dog attacks, motor vehicle accidents, and witnessing a threat to their caregivers, he said.

A major issue in diagnosis of PTSD among young children is whether DSM-IV criteria are appropriate for this age group. Modifications may be needed to make the criteria more behaviorally anchored—for example, children may show signs of social withdrawal but may not have the verbal ability to articulate the feelings of detachment that are a criterion of the disorder in adults. The criteria may also need to be more developmentally sensitive. Loss of developmental skills such as toileting and speech or the development of separation anxiety may be signs of PTSD. Dr. Scheeringa reported that in studies using such modified criteria with young children, a three- to sixfold increase in diagnosis of posttraumatic stress disorder was noted, compared with the criteria used with adults.

In a presentation about assessment of reactive attachment disorder in young children, Neil W. Boris, M.D., pointed out that although no controlled studies of the disorder have been done, considerable descriptive research involving maltreated and institutionalized children has provided the basis for revised DSM-IV criteria for this disorder. Infants begin to show preferred attachment around age seven to nine months, and the internal working model of attachment that develops out of early experience creates a template for how the person reacts to others over the lifetime, Dr. Boris said.

Behaviors that are important in considering problems with attachment in young children include how the child seeks comfort and help from caregivers, shows affection and cooperation, explores his or her surroundings, reacts to reunion with the caregiver after separation, and attempts to control others, Dr. Boris said. A structured assessment of attachment disorder should include observation of the child's reaction to the clinician, free play between child and family, and the child's response to a brief separation from the caregiver.

An important issue in the diagnosis of attachment disorders is whether the disorder resides within the child or within the child's relationship with the caregiver. If attachment disorders are "disorders of relationships," the existing DSM framework, which assumes disorders reside in individuals, may not adequately capture the nature of the disorder, Dr. Boris said.

Julie A. Larrieu, Ph.D., discussed findings from assessment procedures used in the intervention program for maltreated infants. In the semistructured Working Model of the Child Interview, the child's biological parents and, separately, the child's foster parents are asked a series of questions to elicit details of their relationship with the child, including how they would describe the child's personality, developmental milestones, what is unique about the child, and what they think the child will be like as an adolescent and as an adult. Analysis of the parents' answers is based not only on the information they provide, but also on the narrative features and emotional tone of their answers and the richness of the perceptions they express.

Responses are classified as balanced, disengaged, or distorted. A balanced account gives a full, rich, differentiated impression of the child and conveys that the child is noticed and valued as an individual. A disengaged account conveys the caregiver's aloofness; the descriptions of the child lack detail, and the respondent tends to normalize the child's characteristics, saying, for example, that the child is "just like other children." A distorted narrative lacks consistency and does not convey a convincing connection to the child.

In their clinical work, the Tulane team has found significant differences in the percentages of biological and foster parents with balanced views of the child, Dr. Larrieu reported. Foster parents were more likely to describe the child with a balanced view than were the biological parents. This finding indicates that young children construct very different relationships with different caregivers, Dr. Larrieu said, and suggests that the first few years of life are prime time to intervene to address symptomatic behaviors and problematic aspects of relationships, she said.

A panel of three psychiatrists and a mental health advocate addressed the problem of incarceration of youths with mental illness in the juvenile justice system. The United States locks up more children and adolescents than any other country in the world, one presenter noted. On any given day, 100,000 youths are in juvenile correctional facilities. Conditions in some facilities have attracted the attention of Amnesty International and Human Rights Watch, which have issued strong criticisms and recommendations for change. Inadequate mental health and other services in the juvenile justice system have led advocacy groups to file class action lawsuits against several states in federal courts.

In South Carolina, a state that is under a court mandate to improve services, a study of a random sample of 75 incarcerated youths showed that nearly three-fourths had a diagnosable psychiatric disorder, and the mean number of diagnoses per youth was 2.4. These results were presented by Andrés J. Pumariega, M.D., of James H. Quillen College of Medicine at East Tennessee State University in Johnson City. His group found evidence that the youths with mental illness were being diverted away from mental health services into residential placements with no services.

A Los Angeles study of nearly 250 children and adolescents in the juvenile justice system found that rates of referral to mental health services were significantly lower among minority youths compared with white youths. Minority youths were twice as likely to be repeat offenders and to be reincarcerated. Kenneth M. Rogers, M.D., M.S.H.S., of the University of South Carolina in Columbia, who discussed the results of this study, said that the failure to identify and treat emotional and psychiatric problems among minority juvenile offenders has a severe long-term impact on minority communities.

Given the high rates of mental illness among juvenile offenders, psychiatrists should become more involved in the development and implementation of services for this group, said Pamela K. McPherson, M.D., of Louisiana State University in Lake Charles. She described how the juvenile justice system was established as separate from the adult system so that juvenile offenders would receive rehabilitation, not punishment. However, the system is growing increasingly punitive toward young offenders, Dr. McPherson observed. Even though only one in ten juveniles who has contact with the juvenile justice system goes on to become involved with the adult system, the media and other social forces have created an impression that every juvenile offender is a dangerous criminal, she said. In a national survey, a large proportion of jurors who had recently completed jury duty indicated that they would consider the death penalty for a 12-year-old. The legal age limit is 16.

Dr. McPherson said that one way psychiatrists can become involved is to serve as investigators of juvenile correctional facilities to determine whether staff, programs, and facilities meet national standards. Evidence from such investigations is the legal basis for the class-action lawsuits that are often the only way to ensure treatment for mentally ill youths. Psychiatrist-investigators must be familiar with state and local laws and ordinances governing these facilities and with four sets of proposed national standards, as well as with relevant case law, Dr. McPherson said. She noted that it is particularly important to ensure that youths are screened for mental health problems before admission to correctional facilities, so they can be diverted from placement in these facilities if possible.

A handbook for mental health advocates to use when investigating juvenile correctional facilities, entitled Checking Up on Juvenile Justice Facilities, has been developed by the National Mental Health Association (NMHA). Michael M. Faenza, M.S.S.W., NMHA president, pointed out that psychiatrists have a long history as social activists and defenders of vulnerable populations, and that focusing on human rights violations in juvenile correctional facilities would be a "natural role for psychiatrists." Through its 340 affiliate associations, NMHA has sent advocates and technical advisers to juvenile justice systems in many states. Mr. Faenza said that most justice personnel welcome the attention and assistance, because the local mental health system has generally turned away from them.

Complementary, or alternative, therapies—treatment modalities used as an adjunct to conventional medical treatments—include herbal remedies, megavitamins, homeopathy, spiritual healing, massage therapy, acupuncture, yoga, and meditation. In a well-attended lecture, Nalini V. Juthani, M.D., associate professor of psychiatry at Albert Einstein College of Medicine in Bronx, New York, reviewed alternative treatments commonly used for psychiatric conditions and discussed challenges faced by health care professionals in responding to their growing popularity.

Alternative therapies are most frequently used for chronic conditions, such as chronic pain, depression, anxiety, headaches, irritable bowel syndrome, memory impairment, and menopausal symptoms, Dr. Juthani reported. Women have been the driving force behind the rapid acceptance of complementary medicine; nearly half the female population of the U.S. has tried some form of alternative medicine, compared with a third of U.S. men, she said.

Many factors account for the popularity of alternative treatments, Dr. Juthani said. The therapies offer hope of relief from symptoms if not cure. They are seen as "natural" and therefore safe. Herbal remedies and supplements are readily available in supermarkets, are considered relatively inexpensive, and are endorsed by people from a wide range of backgrounds. Users of alternative therapies feel that they are taking control of their own health care and derive a sense of empowerment from that experience. The need to pay out-of-pocket for most alternative therapies does not appear to reduce their appeal, Dr. Juthani said.

The impact of increasing use of alternative treatments among psychiatric patients is greater than clinicians have realized, Dr. Juthani said. She summarized findings of a North Carolina study showing that 44 percent of 213 psychiatric outpatients had used some form of alternative treatment for their psychiatric disorder, a fourth of those who used alternative treatments found them more effective than conventional treatments, and close to half of those who used them said they were equally effective. However, physicians may not be aware of patients' use of alternative therapies, and patients may not tell their doctor about the herbal remedies or nutritional supplements they take because they do not consider them medications, Dr. Juthani said.

Herbal remedies commonly used by psychiatric patients include St. John's wort, for depressive symptoms; kava for anxiety; and gingko biloba, for memory loss and concentration difficulties, she said. In addition, SAMe (S-adenosyl-L-methionine) has recently been marketed in the U.S. as a remedy for depression, arthritis pain, and chronic liver disease. These remedies do not require approval by the Food and Drug Administration, and very few randomized, controlled research studies have examined their indications, contraindications, and interactions with conventional medications, Dr. Juthani said. Evidence supporting the efficacy of herbal remedies for psychiatric conditions is insufficient except for St. John's wort and gingko biloba, she said.

Responsible practice requires that conventionally trained health care professionals address their patients' use of alternative health care practitioners and herbal remedies and supplements, Dr. Juthani said. Clinicians should routinely and nonjudgmentally ask patients about their use of alternative therapies and openly discuss the merits of alternative therapies with patients who use them or express interest in them. Clinicians should mention that herbal remedies and supplements may not be inherently safe just because they are "natural" and should point out the absence of evidence-based studies. Patients should be told that herbal remedies and supplements are not FDA-approved and that the possibility exists for harmful interactions between these substances and prescription drugs.

Clinicians should be respectful when patients praise their alternative health care providers and try not to compete with them, Dr. Juthani said. They should remain open to learning more about alternative therapies and to the possibility that alternative providers who address health issues on the boundary between physiology and spirituality can sometimes help patients who find no relief in conventional medicine. Dr. Juthani recommended the PDR for Herbal Medicines as a useful source of information on pharmacology, indications, and precautions for commonly used herbal remedies.

Dr. Juthani reviewed an algorithm, developed by David Eisenberg, M.D., that can be used to guide discussion of patients' use of alternative therapies. (The algorithm was published in an adapted form in the October 1999 issue of Geriatrics.) It involves a formal discussion of patients' preferences and expectations, the maintenance of symptom diaries, and follow-up visits to monitor for potentially harmful situations.

The key ingredients of effective therapeutic relationships were the topic of a lecture by Roger Peele, M.D., who noted that a recent textbook on primary medicine devoted only two pages to the physician-patient relationship. Dr. Peele, who is clinical professor of psychiatry at George Washington University School of Medicine in Washington, D.C., said that managed care has "de-powered" psychiatrists, causing some to forget or doubt the healing power inherent in the clinician-patient relationship.

The patient's informed consent to treatment is critical to the treatment relationship, Dr. Peele emphasized. The clinician provides and interprets information and encourages the patient to participate in treatment decisions. However, the clinician does not step back and ask the patient to make the decision entirely on his or her own. Rather, the clinician guides the patient toward a decision that maximizes the patient's values. Dr. Peele called this approach "paternalism with permission." He said that leaving patients to make their own decisions about treatment without a guiding hand transforms the clinician-patient relationship into a tradesman-customer interaction, with no inherent ethical or professional components.

Two other ingredients essential to effective therapeutic relationships are the clinician's commitment to the welfare of the patient and the clinician's competence to provide effective care, Dr. Peele said. When both are in evidence, the patient is more likely to be hopeful about the outcome and to comply with treatment. The competent clinician knows the power of the placebo effect, said Dr. Peele, and can use the relationship to harness such effects. By addressing not only the patient's illness, but the social experience of being ill, the clinician creates what Dr. Peele called a "hermeneutics" of the patient's illness—a story about becoming and being ill that makes sense to the patient, communicates the clinician's understanding and care, and enlists the patient's values and beliefs to help in the healing process.

Dr. Peele addressed what the American Psychiatric Association can do to enhance the clinician-patient relationship. First, it should ensure that psychiatric residents continue to receive training in psychodynamic psychotherapy. Dr. Peele said there is wide consensus that the best training for understanding the power and the problems of the clinician-patient relationship is training in psychodynamic therapy. In addition, he pointed out that with every placebo-controlled trial, an enormous potential for research on the effects of the clinician-patient relationship is not being followed up. Placebos are used more than any other treatment in research settings. Response to placebo treatment can range up to 80 percent in some studies, and Dr. Peele urged researchers to look at variation in treatment response in placebo groups and evaluate the effects of the clinician-patient relationship on this variation. Dr. Peele urged APA to support requiring psychiatric researchers in all areas to describe the clinician-patient relationship in enough detail so that it can be studied.