The Treatment Of Psychiatric Disorders

William H. Reid, George U. Balis, Beverly J. Sutton

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134863174
• Edition: 3
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This is the third edition, revised for the DSM-IV, of the one volume, standard, comprehensive text on the treatment of psychiatric disorders - spanning the biological, psychological and psychosocial.; Updated and revised, this book is the result of several thousand studies, clinical reports, and reference works. Information is specifically coordinated with the DSM-IV, and the authors' discussion reflects what is currently known about standard treatments as well as many of the more esoteric therapies.

Part I

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NEUROPSYCHIATRIC DISORDERS

George Ulysses Balis, M.D.

The format for Part I differs somewhat from that of the other sections. Although an effort has been made to follow the DSM-IV outline of psychiatric disorders exactly, such a format would be unwieldy when addressing the treatment of the disorders that were called organic mental disorders in the revised third edition (DSM-III-R). We have accordingly grouped these disorders in a clinically useful way, much as it was done in the previous edition.

The remaining specific substance-related disorders of substance dependence, substance abuse, intoxication, and withdrawal are presented in Part II.

CHAPTER 1

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GENERAL PRINCIPLES OF NEUROPSYCHIATRIC DIAGNOSIS

The term “organic” was eliminated from the DSM-IV. The “correct” term is now the circumlocution “due to a general medical condition,” and “substance-related” if the condition involves the use of a substance. This was done in the noble effort to combat the prevailing Cartesian mind-body dualism in the clinician's thinking (Spitzer et al., 1992). In this reform spirit, it might also appear appropriate to correct the biological versus psychological dichotomy, since all psychological phenomena are eminently biological!

All psychiatric disorders are the result of a multifactorial causative process, which expresses the variable contribution of genetic, developmental, neurophysiologic, systemic, psychological, adaptational, social, and environmental influences. From this perspective, the terms “organic” and “due to a general medical condition” simply denote the significant contribution of brain dysfunction or injury to the multifactorial causative process, and alert the clinician to seek specific etiologic treatment when possible. With this in mind, we will use the term “organic” when we feel it offers simplicity and clarity in communication.

Organic mental syndrome and the older organic brain syndrome have also become extinct in the DSM-IV. Nevertheless, the concept of “syndrome” continues to be very useful in clinical thinking and should be used in the diagnostic process. The term “neuropsychiatric” encompasses those mental disorders that are associated with a brain lesion or dysfunction that is due to a general medical condition or a substance.

In addition to lexically bridging the mind-body dichotomy, it is useful to present a unitary paradigm for conceptualizing psychopathology, based on a systems theory framework.

A UNITARY FRAMEWORK FOR CONCEPTUALIZING PSYCHOPATHOLOGY

From a general systems theory perspective, personality may be viewed as a subsystem level within the multilevel organization of an organism or organismic unity (molecular, cellular, organ system) in which personality represents the emergent phenomena that reflect the structure/process organization of the brain (Balis, 1978a). Family and social systems represent suprasystems relative to personality. Personality is, therefore, the “vantage” system for studying psychological and behavioral phenomena, as they relate to internal matter-energy subsystems (brain, body), to the external family and social suprasystems, and to the environment.

Phenomenologically, personality is introspectively experienced as psychological phenomena and inspectively observed as behavior. Psychological phenomena are viewed as constituting emergent phenomena, expressing the integrative processes of the brain, at the highest level, in the form of introspected experiences (e.g., conscious awareness, perceptions, emotions, cognition) . Only a small fraction of the brain's functions are represented at the personality level, that is, only those with an emergent expression at that level (e.g., neocortical and paleocortical processes integrating limbic, hypothalamic, and centrencephalic processes into emergent experiential [conscious] phenomena). Viewed as the level of organization of emergent phenomena associated with certain brain functions, personality is not necessarily a uniquely human apparatus.

Behavior is viewed as the adaptive functions of an organism that serve the maintenance of the steady state. Behavior, therefore, serves adaptation. In its Janus head expression, behavior must be understood as a function of a concrete system, the brain, and as a function of an abstract system, the personality. A fundamental aspect of behavior is that it is organized along dimensional continua. The concept of dimensionality implies that behavior has evolved longitudinally (phylogenetically and ontogenetically) and is organized cross sectionally (molecular, cellular, organ system, personality, social levels). A behavioral dimension is, therefore, a conceptual construct that defines the functional continua along which behavior appears to have evolved in the time frames of phylogeny (evolution) and ontogeny (development), and as it has been organized at each level of the organismic unity (e.g., biochemical, organ system, neurophysiologic, personality, social).

Psychopathology represents a dysfunctional (maladaptive) state of personality functioning that is the result of the dysregulation of the steady-state dynamics within the organism, that is, the result of the failure of the adjustment processes (intraorganismic, intrapsychic) and adaptive processes (behavioral) to maintain constancy in the face of physical, psychological, and interpersonal stresses on the system. The dysfunctional state is the result of a complex interaction between the organizational dynamics of the steady state (system stability) and the stresses that impinge on it. Stress is defined as any dynamic factor (internal or external) that produces a deviation (strain) beyond the optimal range of the organism's steady state.

Deficiencies in the mechanisms for maintaining stability may result in unstable or “vulnerable” systems that are prone to becoming decompensated and dysfunctional. This paradigm provides for a multifactorial causative process of psychopathology, taking into consideration (1) the internal state of the organismic system (vulnerability), as denned by genetic, developmental, and other structure-process parameters; and (2) stress factors (biochemical, physiological, psychological, interpersonal, environmental) acting at various levels of system organization and interacting with each other in a nonlinear causative process. Psychopathology is thus seen as the decompensated ranges of behavioral/psychological dimensions (continua) of the functioning personality. It expresses states of dysregulation in the steady state relative to its internal subsystems (e.g., brain, genes), external suprasystems (family, society), and ecosystems. Symptoms, signs, and maladaptive traits constitute the phenomenology of psychopathology. The clustering of characteristic signs and symptoms constitutes a clinical syndrome, while the clustering of traits constitutes a personality pattern. (The DSM-IV is a taxonomic system that categorizes various syndromes and maladaptive personality patterns as disorders, using descriptive [categorical] criteria rather than dimensional cutoff points.)

The shifting scope of psychiatry has often been determined by factors neither scientific nor clinical, a fact that points to the need for a more careful definition of the disciplinary boundaries and conceptual constructs (Balis, 1978b). The psychiatric model is viewed as the medical model par excellence (Engel, 1977), in which the person is the vantage point for conceptualizing clinical matters within the unity of a biosystem (Balis, 1978a). This unitary approach rejects ideological polarity in favor of multilevel theoretical perspectives of selective relevance to a particular clinical situation. It requires one to understand complex phenomena at different levels of organization, through a cognitive process, which Yager (1977) has termed the eclectic mental operation (a process of approaching the available information from several points of entry and repatterning the information in an attempt to see alternative possibilities). The clinician must be able to conceptualize behavior by using alternating vantage points (e.g., personality, brain, family, and social) while recognizing the supremacy of personality as the vantage point for understanding the person. This is precisely the modus operandi of the medical model.

THE DIAGNOSTIC PROCESS

A comprehensive evaluation is the principal approach to the diagnosis of all mental disorders. The patient must be understood as a person and as an organismic unit, within a historical perspective and current functioning, and within a family, social, cultural, and environmental matrix.

Both historical and observational information form the database for establishing a diagnosis. Such information generally includes a comprehensive psychiatric and general medical history, family and personal history, mental status examination, physical and neurological examination, screening laboratory tests, and, as appropriate, specialized clinical and laboratory procedures.

Clinical Evidence of Organicity

It is important to recognize the fact that organic psychiatric symptoms are the result of different mechanisms, acting alone or in combination, which may include impairment or loss of function (e.g., loss of memory in Korsakoff's syndrome), exaggerated expression of a central nervous system function (e.g., partial complex seizures), disinhibition of primitive functions (e.g., release phenomena, primitive reflexes), and, most important, psychological reaction to the loss of function (e.g., compensatory or restitutive actions), as determined by patterns of defense mechanisms, the premorbid personality, and coping style (Balis, 1978c).

The diagnostic task for defining an organic contribution to the etiology of a psychiatric disturbance involves two basic steps: identifying a specific organic factor on evidence from history, physical examination, and/or laboratory tests; and judging that factor to be etiologically related to the disturbance. The latter usually involves complex clinical judgment.

A thorough history is the best source of information for identifying organic factors, and includes such items as relevant physical disorders, exposure to environmental or occupational noxae, current use of prescription drugs, alcohol and drug abuse, head injuries, learning disabilities, and family history of hereditary disorders. The history of present illness may also provide valuable clues, including episodic or paroxysmal symptoms, altered states of consciousness, forgetful-ness and other evidence of cognitive impairment, emotional lability, and/or behaviors that are out of character for the individual.

Observations from physical examination (including neurological and mental status examinat...