A survival guide for psychiatric residency training directors

This paper catalogues the inevitable problems that beset training directors and describes coping strategies designed to improve the likelihood of the training director's survival and the quality of his or her life. The difficulties of the job include picking residents, struggling to assure that the faculty provides decent teaching programs, contending with repetitive bureaucratic details, being overloaded by numerous tasks, and warily watching as residents who somehow squeaked through the program are sent off on their own. Offsetting the hassles are the exciting jobs of picking residents, guiding the faculty in setting up teaching programs, keeping a complicated program running, mastering numerous challenges, and watching with satisfaction as new, competent psychiatrists graduate.

Older psychiatric residents: a pilot study of stresses and strengths

Residency-related stresses were examined as a function of age or age-related factors in a group of 10 psychiatrists who started psychiatric training at age 32 or older (average age, 36.2). Commonly expressed stresses included feelings of isolation from the group, inflated expectations, and conflicting role obligations. Addressing the stresses on older residents may diminish their anxiety and enhance their morale and overall gratification in the residency program.

Fluoxetine treatment of anorexia nervosa: an open clinical trial

Six patients with chronic, refractory anorexia nervosa were treated with fluoxetine. Depressive symptoms diminished in all patients, and this was associated with weight gain. Subjects, despite frequent medical comorbidity, tolerated fluoxetine well, even in dosages greater than those used for depression.

Professional interests among residency applicants in psychiatry : a pilot study of autobiographical statements

Spontaneous declarations of field of interest by 150 applicants to the UCLA Neuropsychiatric Institute-West Los Angeles V.A. Medical Center psychiatric residency program in 1986 were examined. In essays written as part of the National Resident Matching Program, many applicants expressed several areas of interest. About one-third of applicants expressed an interest in research, and about one-quarter expressed interests in teaching, psychotherapy, biological psychiatry, or child psychiatry. Between 5% and 9% expressed interest in community psychiatry, adolescent psychiatry, psychoanalysis, geriatric psychiatry, and chemical dependency, and <5% expressed interest in cross-cultural, emergency, legal, or administrative psychiatry.

Internal vs. external determinants of coping responses to stressful life-events in the elderly

Coping appears to function in the relationship between stressful life-events and health. Factors that may influence an individual's use of a particular coping strategy, however, are not well understood. Coping consistency within individuals and across situations was examined in a longitudinal study of 74 independently living elderly persons, as were the effects of the type of event experienced, appraisal of its degree of threat, and demographic variables on coping behaviour. Correlational analyses indicated that coping responses were more a function of event type than of an individual's consistent style. A number of distinct life-events were associated with particular types of coping responses. The degree of threat, one's expectation of the changeability of an event, and one's appraisal of possible courses of action were also correlated with specific coping behaviours. Age was negatively correlated with problem-focused coping and total number of coping responses. This study suggests that the type of stressful event an individual experiences may be a more important general determinant of one's coping response than is one's overriding propensity to cope in a particular way.

Physicians' attitudes toward substance abuse and drug testing

Responding to a survey, 303 physicians provided opinions about permissibility of substance use among eight occupational groups, appropriateness of drug-screening programs by employers, and the role of physicians in managing substance abuse problems. The majority felt that neither drugs nor alcohol should be used at lunch by any individuals, but that alcohol and to some degree marijuana use was permissible after work or on weekends. Physicians could not agree about reliability or use of drug-testing programs. However, most believed that employee drug screening was more appropriate after evidence of poor job performance rather than screening all employees or applicants.

Help seeking and satisfaction with care in 641 women with eating disorders. I. Patterns of utilization, attributed change, and perceived efficacy of treatment

Help-seeking patterns and satisfaction with care were described by 641 women with eating disorders participating in a national magazine survey. Between 60.6% and 92.9% of respondents in three diagnostic groups sought professional treatment. Professional treatments most often entered were individual psychotherapy (52.9%), behavioral therapy (28.0%), group therapy (24.6%), and nutritional therapy (18.6%). Treatments were generally seen as helping "a little." Only bulimic anorexia nervosa respondents perceived any interventions to be more harmful than helpful, specifically Overeaters Anonymous and self-help groups, both nonprofessional interventions. Caregivers selected as "experts" regarding eating disorders were rated as more efficacious than others, helping "a little" to "somewhat."

Attitudes toward mental illness prevention in routine pediatric practice

Attitudes toward preventive mental health activities with high-risk children in clinical practice were surveyed in 316 pediatricians. Although generally positive attitudes were expressed regarding appropriateness and efficacy of such activities, uncertainty was expressed regarding the ethical issues and knowledge on which such activities rest. Pediatricians perceived serious barriers to preventive activities related to financial, educational, and time factors. Pediatricians whose personal health beliefs favored an internal locus of control were more positively inclined toward preventive activities. Studies relating reported attitudes and beliefs to actual practice patterns are necessary. Pediatricians also require additional training in mental health-related preventive activities.

Teaching transcultural psychiatry

The ethnic diversity of patients in most training centers requires that attention be given to cultural issues affecting the psychiatric presentation and treatment of patients from different backgrounds. This paper describes programs in transcultural psychiatry for medical students, residents, and fellows that have been implemented and refined at UCLA over the past six years. Suggestions are offered for the development of such programs elsewhere.

Screening for Axis II personality disorders in women with bulimic eating disorders

The Personality Diagnostic Questionnaire (PDQ) was completed by 628 eating-disordered women: 300 with normal-weight bulimia, 15 with anorexia nervosa with bulimic features, and 313 with subdiagnostic eating disorders. Three-quarters (75%) of subjects with normal-weight bulimia had personality disorder diagnoses, compared with 50% of those with subdiagnostic eating disorders. The average number of separate PDQ diagnoses was 2.7 for the normal-weight bulimia group, 2.5 for the group with anorexia nervosa with bulimic traits, and 1.5 for the subdiagnostic group. The most common PDQ diagnoses were schizotypal, histrionic, and borderline disorders, but avoidant and dependent personality features also occurred. Personality disturbances may be common in patients with eating disorders.

Physicians' attitudes toward the legalization of marijuana use

We asked 303 practicing physicians in general internal medicine, family medicine, gastroenterology, or psychiatry to indicate whether possessing or using marijuana should be considered a felony, a misdemeanor, warrant the issuance of a citation, or be legalized. The position physicians advocated was unrelated to their specialty, experience diagnosing or treating substance abuse problems, their attitudes toward the efficacy of the treatment of drug abuse, or any other work role or habit we measured. Legalization or citation as compared with harsher penalties, however, was more likely favored by physicians who were younger, less religious, politically more liberal, and those less likely to perceive a serious drug problem in society. Legalization was also more likely favored by physicians who themselves had used marijuana, cocaine, and amphetamines but was unrelated to the use of alcohol, cigarettes, or tranquilizers. Although physician opinion should be sought as society deals with the drug problem, this study suggests how physicians' characteristics may influence the opinions that are rendered.

Factors associated with physician recognition and treatment of alcoholism

We surveyed internists, family physicians, and psychiatrists regarding their clinical experiences in assessing and treating alcohol abuse, practice characteristics, political and religious beliefs, attitudes toward substance abuse, beliefs about the efficacy of treatment, personal experiences with substance use, and sociodemographic variables. Despite the high prevalence of alcohol abuse, a third of the physicians neither regularly counseled nor referred any patients for outpatient rehabilitation, and more than half had not referred anyone for inpatient treatment. A greater breadth of experience treating alcohol problems was positively correlated with the volume of outpatients and inpatients seen, younger age, more work in primary rather than specialty patient care, less academic work, a stronger belief in the efficacy of treating alcoholism, membership in the Republican party, and a greater religiosity.

Teaching guided imagery

Guided imagery is a technique useful for teaching and practicing psychodynamic assessment and psychotherapy. It combines a state of meditative relaxation with the presentation of evocative scenarios that stimulate the imagination to spontaneously generate almost dream-like fanciful productions. These "daydreams" ordinarily contain highly revealing suppressed and repressed conflicts, wishes, affects, perspectives and other aspects of the self. The instructional program offered to trainees at the UCLA Neuropsychiatrie Institute for almost two decades is described. Suggestions are offered as to how programs that lack faculty acquainted with these techniques can further familiarize themselves in order to evaluate the techniques' value for their curriculum.

Eating disorders among selected female student populations at UCLA

Seven hundred sixteen female UCLA students--drawn from Primary Care Clinic, Women's Health Clinic, sorority, athletic team, dance major, and undergraduate psychology class populations--completed questionnaires regarding eating disorders symptoms and attitudes compatible with the diagnostic criteria published by the American Psychiatric Association in the Diagnostic and Statistical Manual, (3rd ed., DSM-III), the Eating Disorders Inventory, and related information. The purpose of the study was to determine the prevalence of eating disorders and eating disorder-related symptoms in particular subgroups for targeting intervention and prevention programs. Although between 7.5% and 46% of subgroup populations reported the presence of individual eating disorder-related symptoms, the prevalence of active eating disorders for the group as a whole at the time of the survey was 2.1%, with the prevalence of disorders at any time during life 4.8%, using DSM-III diagnosis. The Eating Disorders Inventory scores for the group as a whole were comparable with norms reported by other researchers in the literature. Primary Care Clinic attenders and dance majors reported the highest rates of symptoms and disorders, while athletes reported the lowest rates.

Developing minimal national standards for clinical experience in psychiatric training

There are no minimum standards for the clinical training of psychiatrists with regard to the type and number of patients evaluated or treated. Interest in establishing such standards derives from a need for greater accountability, a high fail rate on the clinical portion of the American Board of Psychiatry and Neurology examinations, and an increasing demand for precise documentation of competence in specific areas by hospital privileging committees. Although considerable disagreement exists as to what the overall requirements should be, some minimum requirements can be agreed on. The authors discuss concerns about minimal standards and make suggestions for further development of standards.

Social supports in relation to physical health and symptoms of depression in the elderly

The authors examined the relationship of social supports to physical and psychological well-being in 118 men and women 65 years old or older who were living independently in the community. Subjects with more symptoms of depression reported having fewer emotionally satisfying consistent supports from relatives, but those who had physical illnesses reported more supports from relatives. The authors conclude that although having fewer key supports may contribute to dysphoria, having a physical illness may mobilize meaningful support. They suggest that social supports and health outcomes be carefully defined so that possible differential relationships between them can be understood more specifically.

The treatment of eating disorders

Anorexia nervosa and bulimia nervosa are common disorders among adolescent and young adult females, estimated to occur in up to 1% to 3% of these populations. A variety of medical and psychological approaches have been used in their treatment, including hospitalization; nutritional rehabilitation; medications; and psychodynamic, behavioral, cognitive-behavioral, family, and group psychotherapies. The author discusses controlled and uncontrolled studies of the different therapeutic approaches that have been used in these disorders and reviews what is known about their prognosis. Important treatment issues include the nature of the disorder, age, degree of malnutrition, motivation, capacity to engage in treatment, personality disturbance, affective state, family situation, and available treatment resources. Based on research data and clinical lore, prudent suggestions for treatment planning are presented.

Age and the antihypertensive effect of aspirin in rats

1. We previously showed that chronic exposure to aspirin (100 mg kg-1 daily, by mouth) is effective in preventing the onset of hypertension in young (28-84 day old) spontaneously hypertensive rats (SHRs). This is contrary to what others have reported using older SHRs. 2. Renal prostaglandin F2 alpha was also reduced in young SHRs and Wistar-Okamoto strain rats (WKYs) exposed to aspirin. 3. In the present study we extended the period of aspirin treatment in young rats to beyond 84 days of age. We found that aspirin lost its antihypertensive effect in SHR and WKY rats at 110 +/- 7 days of age regardless of whether the exposure to aspirin had begun at age 28, 49 or 87 days. 4. We conclude that the loss of antihypertensive effect of aspirin in the SHR and in older WKY rats, is determined by some factor(s) probably not related to prostaglandin F2 alpha, which reaches full expression in the 110 +/- 7 day old rat, or is fully dissipated at this age. 5. The anti-PGF2 alpha activity of aspirin in the SHR and WKY rat was short-lived and apparently unrelated in time to the antihypertensive effect of aspirin.

Psychiatrists' attitudes toward preventive intervention in routine clinical practice

A sample of 189 psychiatrists were surveyed to determine their attitudes toward preventive activities with high-risk children in clinical practice. Respondents indicated generally positive attitudes toward the appropriateness and efficacy of such activities but expressed uncertainty about the ethicality of prevention and about the knowledge base on which such activities rest. Psychiatrists perceived serious barriers to preventive activities due to financial, educational, and time factors. Important attitudinal differences were related to the respondents' age, career aspirations, membership on an academic faculty, number of scholarly articles published, marital status, number of vacation days taken in the previous year, and training in child psychiatry. Psychiatrists whose personal health beliefs favored an internal locus of control were more positively inclined toward preventive activities.

Behaviors and attitudes related to eating disorders in homosexual male college students

To investigate whether homosexuality predisposes males to eating disorders, the authors studied 48 nonpatient homosexual male students at UCLA. The homosexual men had higher prevalences of binge-eating problems, of feeling fat in spite of others' perceptions, of feeling terrified of being fat, and of having used diuretics than other male students. They also scored higher on the Eating Disorders Inventory scales for drive for thinness, interoceptive awareness, bulimia, body dissatisfaction, maturity fears, and ineffectiveness. One of the 48 homosexual men and one of the 300 comparison group men met criteria for probable past histories of eating disorders.

The definition of a psychiatrist: eight years later

In 1980, psychiatric practitioners and educators were surveyed to determine their concepts of the knowledge and skills that define a specialist in psychiatry. The authors repeated this survey, expanding the list of skill and knowledge items and asking respondents to comment on whether particular skills or knowledge were important to a psychiatric subspecialty. Less importance was ascribed in the current survey than in the earlier survey to certain long-term and social psychotherapies, and more importance was ascribed to descriptive or biological psychiatry; brief or supportive therapies; psychopharmacological agents; consultation-liaison psychiatry; evaluation of children, the aged, and alcoholics; and certain desirable personal characteristics of the psychiatrist.

Induced pasteurellosis and pulmonary vascular adrenoceptor function in bull calves

Effects of Pasteurella haemolytica inoculation on pulmonary vascular function were studied in 5 conscious standing Jersey bull calves. Instruments were implanted in each calf to measure pulmonary arterial, pulmonary arterial wedge, left atrial, and systemic arterial pressures and cardiac output. Each calf was challenge exposed with 5 sequential 3-minute infusions of isoproterenol (a beta agonist) or phenylephrine (an alpha agonist) for maximal doses of 1.8 micrograms of isoproterenol or 2.3 micrograms of phenylephrine/kg of body weight/min. The calf was allowed 1 hour to recover, was anesthesized, and administered a 20-ml intratracheal infusion of live P haemolytica (10(6) colony-forming units/ml) followed by a 20-ml saline flush. The pulmonary hemodynamic response to isoproterenol and phenylephrine was examined again in each calf 4 days later. Calves developed a pneumonic pasteurellosis involving 26 to 43% of the lungs. There was a significantly (P less than 0.05) reduced resistance in the pulmonary arterial compartment after inoculation. Isoproterenol infusion decreased resistance in the pulmonary arterial, pulmonary venous, and systemic vascular compartments. The decrease in the pulmonary venous compartment in response to isoproterenol was significantly (P = 0.01) smaller after P haemolytica inoculation. After administration of 1.8 micrograms of isoproterenol/kg/min, resistance in the pulmonary venous compartment was 0.90 +/- 0.22 (mean +/- SD) before and 1.25 +/- 0.39 after Pasteurella inoculation. Phenylephrine resulted in an increase in pulmonary arterial, pulmonary venous, and systemic vascular compartments. There was a mild (P = 0.08) decrease in the pulmonary arterial compartment response to phenylephrine. Seemingly, Pasteurella inoculation blunted beta-receptor function in the pulmonary vascular bed, mainly in the veins, contributing to edema.

The evolving subspecialization of psychiatry: implications for the profession

Psychiatry is likely to evolve into a number of subspecialty areas, paralleling developments in other medical specialties. These changes are impelled both from within psychiatry, where the rapid increase in knowledge and skills makes mastery of the entire field by any one practitioner less possible, and from without, related to new expectations for psychiatric services from referral sources and patients, increasing competition by other physicians and nonphysician mental health care providers, and shifting reimbursement patterns. The authors discuss the advantages and disadvantages of subspecialization as well as implications for psychiatric practitioners and training programs.