1. What are at least two diagnoses to consider for this woman and why?

ANSWER: The first diagnosis to consider is generalized anxiety disorder (“GAD”), which is defined at DSM-IV-TR §300.02.  The second diagnosis to consider is cyclothymic disorder (“CD”), which is defined at DSM-IV-TR §301.13.  In support of GAD: Px reports she feels “overwhelmed” and “can’t enjoy anything.”  She experiences “insomnia, fatigue and irritability.”  These anxiety symptoms track those set forth at §300.03(c), in particular: (2) being easily fatigued; (3) difficulty concentrating; (4) irritability and (6) sleep disturbance.  In support of CD: Px reports depressive symptoms such as withdrawal from family and friends.  She sometimes feels “there is no point in going on.”  Px also reports hypomanic symptoms such as insomnia and distractibility.  Px does not appear however to meet the DSM criteria for major depressive disorder (“MDD”).

2. What additional information would be useful before making a diagnosis?

ANSWER: Consider requiring the following additional information:

(a) Not due to a general medical condition.

(b) Not due to substance abuse.

(c) When was the onset?  GAD requires at least six months and CD requires at least two years.

(d) What is the frequency?  GAD requires “more days than not” and CD requires “numerous periods” and symptoms not absent for more than two months at a time.

(e) What is her previous psychological history?  GAD requires a hierarchy of rule-outs such as panic attack, social phobia and obsessive-compulsive disorder (“OCD”).  CD requires rule-outs such as major depressive episode, manic episode or mixed episode; and also that symptoms are not better accounted for by more differentiated Axis I pathologies such as schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or psychotic disorder NOS.

(f) Also discern specifics of impairment in social and occupational functioning and obtain a more detailed description of Px subjectively-experienced distress.

3. What information would be useful in order to determine the level of severity of this woman’s presenting problem?

ANSWER: The first and primary concern with Px is she “sometimes feels there is no point in going on.”  This proto-suicidal ideation must be assessed immediately by clarifying the specificity of her intention, if she has devised an operational plan and if she has the means to implement it.  This information should be obtained at intake interview and if indicated Px should be referred for suicide-prevention measures ASAP.

The second concern is the texture and quality of Px lived experience.  GAD and CD (as well as most other DSM diagnoses) have a “subjective” component that can be evaluated only by exploring the Px phenomenological world.  Examples: GAD requires “excessive” anxiety and worry; CD requires sensitivity and specificity to distinguish symptoms and arrive at a clinically-accurate differential diagnosis.  Many of Px complaints have this personal affective dimension, e.g. she “feels overwhelmed.”  What exactly does this mean?

The third concern is the precise extent of her social and occupational dysfunction.  Px reports her work environment is “chaotic” and she can’t finish her work.  She has “withdrawn” from family and friends.  What does this mean operationally?  A baseline level of functioning should be established and Px experience then should be probed carefully to tease out the empirical meaning of these vaguely-reported symptoms.  Only then could their severity be correctly assessed.

4. Identify three treatment goals for this woman.

ANSWER: a. To deter Px from trying to kill herself or further refining her nascent proto-suicidal ideations.

b. To reduce Px somatic complaints such as insomnia, fatigue and irritability.

c. To restore a sense of balance to Px life by (i) promoting a realistic attitude towards job demands; (ii) developing coping skills to deal with adversity; and (iii) devising strategies to enable more facile personal and social interactions with family and friends.

5. What are appropriate interventions to address the treatment goals?

ANSWER: a. Suicidal ideations: immediately escalate Px case profile, consult with supervisor and refer to specialized suicide prevention center.

b. Somatic complaints: refer to a medical doctor for a physical examination to rule out possible medical causes, especially for insomnia, which could have a non-psychological cause.  Also refer to a psychiatrist to prescribe a mild anti-anxiety medication, which should assist Px to focus without distraction on her cognitive and behavioral issues.

c. Accept the reality of Px symptoms as reported and discern if Px should find other less-stressful employment.

d. If not, introduce a classical conditioning model to systematically desensitize Px to the stressful and worrisome aspects of her workplace environment using progressive relaxation techniques.

e. Also consider CBT to challenge Px beliefs and reasoning process and why she “feels overwhelmed” by what may be ordinary life stressors.  Px may be catastrophizing the dynamics and exigencies of a modern, fast-paced work environment (assuming c. supra is inapplicable).

f. Also embark on a program of psychoeducation to inform Px about her symptoms and sensitize her to prevention and coping skills.

6. Would this woman benefit from a medication evaluation and a trial of psychotropic medications?

ANSWER: Yes.  As previously reported a course of mild anxiolytics or mood stabilizers is appropriate.  Individuals presenting as this Px frequently are unable to deal with psychiatric symptoms until their neurochemistry has been properly regulated.  Among other positive effects this will stabilize Px mood, eliminate ruminative symptoms characteristic of mild depression and better enable Px to focus on the important cognitive and behavioral tasks confronting her.  It also is important for Px to have an overall physical examination to rule out any contributory medical conditions.

After eight weeks of treatment this woman cancels several sessions in a row.  When she resumes treatment she informs you she just left an inpatient detoxification program for abuse of alcohol and prescription sleeping pills.  She indicates that since being discharged she has felt even more depressed, hopeless and helpless.  She adds that prior to detoxification she used alcohol excessively for “a few years” to cope with stress but that she never had attended a substance abuse program (before her recent detoxification).

7. What information would be desirable in order to acquire better understanding of her substance abuse problems?

ANSWER: Px is suffering from alcohol dependence, DSM-IV-TR §303.90 and sedative dependence, DSM-IV-TR §304.10.  In order to evaluate the nature, scope and extent of these issues, assess: (a) Was the inpatient detoxification program successful, or has Px relapsed?  (b) What are the frequency, duration and onset of her substance abuse problem?  (c) Where did she get the sleeping pills?  If they were prescribed, obtain medical release and consult with the physician re: recommended dosage, number of refills and similar issues.  (d) What were Px prior social/environmental stressors that precipitated earlier substance abuse?  (e) Why does Px now feel “even more depressed, hopeless and helpless”?  Is this a reaction to detoxification or does Px have genuine psychological difficulty reacclimating to a world where substance abuse is not a viable option for coping with personal/occupational life stressors?  (f) An important component of (d) and (e) is to arrive at a precise, operationalized definition of Px symptoms, subjective experience and behavior.

8. In what ways does the information presented above change relevant diagnostic considerations?

ANSWER: The primary way in which it changes the initial diagnostic information (see Answer # 1) is that it complicates the issue by introducing new complex neurochemical variables, i.e. substances of abuse.  Px symptoms may not be due to subtler or refined cognitive/behavioral issues but rather due to gross biochemical malfunction caused by substance abuse.  Substance abuse is a major contributor to many DSM diagnoses including GAD and CD.  These cannot be addressed proactively until substance abuse has been resolved.  At the very least substance abuse is a confounding variable making it more difficult to define treatment goals and establish a therapeutic treatment regimen.

9. What new treatment goals emerge?

ANSWER: To detoxify Px from substance of abuse prior to/contemporaneous with working on more complex psychological/behavioral issues.  Px substance abuse issue is an obstacle preventing further meaningful progress towards any of the other therapeutic objectives/treatment goals previously outlined.

10. How should these goals be addressed?

ANSWER: (a) Assess and evaluate Px previous inpatient treatment.  Was it successful or has Px relapsed; or does Px still crave the substance of abuse?  (b) Speak with Px MD to insure no more sleeping pills are prescribed; and consider an anti-alcohol medication such as anabuse.  (c) Although its efficacy is mixed refer Px to group therapy such as AA.  (d) Consider a program of classical aversive conditioning to counteract Px substance dependence, possibly by pairing Px maladaptive habit with something unpleasant to reassociate the experience of substance dependency with some other cognition in Px frame of reference.

11. What are other professionals/treatment settings to whom you may need to refer her on an adjunctive basis in order to have a comprehensive treatment plan?

ANSWER: Px would benefit from (a) an overall medical examination/physical to rule out possible physiological causes for her distress.  (b) A psychiatric evaluation with a view towards assessing suitability of a mild anxiolytics or mood stabilizer.  (c) Group therapy, particularly to address issues of substance abuse.  (d) Px also might benefit from a psychoeducation program e.g. at a community college to identify potential stressors in advance of their occurrence thus enabling her to take suitable prophylactic measures.

ANSWER:            Dubious and depends on whether Dr. Z. will be able to use independent judgment.  The hypothetical does not describe the nature of the friendship between the proposed client and Dr. Z.’s ex-wife.  If they are not close and it simply is a casual referral then it is less problematic.  On the other hand if they are close or intimate friends then it is unlikely Dr. Z. will be able to maintain an appropriate professional boundary.  His personal feelings may cloud his judgment and interfere with the therapeutic process.  The client also may know things about him as a result of communication with his ex-wife, which further would complicate matters and make it less likely the client would achieve a beneficial outcome.  If I were Dr. Z. I would assess the situation carefully on intake.  If there were any hint of a boundary issue then I would refer the proposed client to somebody else who was qualified in the field.

2.            In order to keep his overhead expenses low Dr. Z. does not renew his office lease and instead starts to treat patients in his house.  In light of ethical standards is this an appropriate arrangement?  Why or why not?

ANSWER: Dubious, although this increasingly is practiced for economic reasons.  The reason why is the client may become confused and view the therapist as a social colleague rather than as trained professional.  Items such as photographs, memorabilia or even religious artifacts may populate a personal environment.  These would be disclosed unnecessarily to the client, complicating the therapeutic relationship.  They may provoke transference-like reactions from the client.  If I was Dr. Z. it’s not clear to me I’d want the client to know where I lived.  A better alternative would be for Dr. Z. to sub-lease a colleague’s space, if only on a session-by-session basis.

3.            Dr. Z. decides he wants to extend his practice to treating children.  He never has had any training in child psychotherapy but begins to read books on child psychology.  He also starts seeing children for therapy and advertises himself as a child psychologist.  Is Dr. Z. acting ethically?  Why or why not?

ANSWER: No.  Dr. Z. lacks competency in a specialized area.  Separate training and clinical experience are necessary to qualify one to administer therapy in fields outside of one’s core background.  Dr. Z. may miss important issues or misinterpret or misdiagnose those he is able to identify.  For example the child may have medical problems such as dyslexia impeding an overall positive outcome.  An interdisciplinary approach might provide better results.  While advertising is not unethical per se it is an actionable misrepresentation for Dr. Z. to hold himself out as a specialist in a particular field, when in fact he is not.

4.            After working with children for two months Dr. Z. finds himself bored when he is in session with his child patients.  What would be the most ethical course(s) of action for him to take?

ANSWER:            Dr. Z.’s primary client is the children whom he is seeing although their parents are “adjunctive participants” and Dr. Z. owes them a legal duty.  They are the childrens’ legal guardians and have a right to know about issues affecting the progress of therapy.  In this case Dr. Z. no longer can be objective or act in a proper clinical role.  He might consider discussing the issue with the parents, although this most likely would be unproductive or even counter-productive because it would call into question the extent of his commitment to the therapeutic process to date.  There is no indication the goals of therapy have been met.  On-going therapy still is required, but it has to be done by somebody other than Dr. Z.  Dr. Z. should use appropriate termination procedures and refer to another qualified therapist.  A good guideline for Dr. Z. to follow might be: “If I was a parent, would I want to know this?”  Here I think the answer clearly is “yes.”

5.            Dr. Z.’s new patient tells him she was referred by her employer because of disruptive behavior at work such as arguing with colleagues and raising her voice.  She adds her supervisor told her she would be terminated if she does not attend therapy.  After his initial session with this patient Dr. Z. decides it would be a good idea for him to talk to his patient’s supervisor to better understand why she was referred for treatment.  Discuss whether it would be appropriate for Dr. Z. to contact his patient’s employer.

ANSWER: If he did so Dr. Z. would be breaching his obligations of confidentiality, unless he first obtained a proper medical release form from his client.  It is not unusual for an employer to refer an employee to therapy.  However the employee is the therapist’s client, not the employer.  The results and outcomes of the therapy are confidential.  It is an ethical violation for a therapist to disclose confidential information and also a violation of Federal law (the HIPPA statute).  Even if Dr. Z. determines such a consult is in the client’s best interests he should apprise the client of possible consequences to insure informed consent.  For example even though it also is against Federal law for the employer to retaliate against the employee by demoting or firing her, she may become the victim of tacit or subtle discrimination at work that cannot otherwise be identified or recompensed.

6.            Dr. Z. has been treating a patient diagnosed with Major Depressive Disorder.  After the fifth session Dr. Z. discovers the patient’s insurance company has authorized only six sessions for therapy.  In order to behave ethically what should Dr. Z. do in this situation?

ANSWER: Dr. Z. has mistimed the administration of therapy.  He should have discerned the scope of insurance coverage on initial intake.  This would have enabled him to modulate his therapeutic approach in order to maximize the likelihood of benefit to the client.  MDD is a serious Axis I pathology.  It is likely the client may suffer adverse consequences if therapy simply terminates.  Dr. Z. should contact the insurance company and make a case for further therapy.  He might consider offering his services on a reduced-fee or even a pro bono basis, although there is no ethical requirement he do so.  Doing so might be impermissible under the provisions of the client’s insurance.  It also might jeopardize Dr. Z.’s perception of his duties to his other fee-paying patients, i.e. he might come to favor or prefer them more in a variety of subtle ways to this client’s disadvantage.   Dr. Z.’s best alternative is to refer this client to a low-fee or public service agency, which can accommodate the client’s needs and requirements within the scope of the client’s budget.

7.            Dr. Z. has been treating a middle-aged man with relationship problems.  Dr. Z. finds he identifies with his patient’s situation on a personal level and often thinks about his own relationship issues when in session with this patient.  It recently occurred to Dr. Z. he would enjoy being this patient’s friend.  To ensure he behaves ethically what steps (if any) should Dr. Z. take?

ANSWER: Dr. Z. is confusing his role with the client.  He is the client’s therapist, not the client’s friend.  The conventional duties and benefits of friendship based on social exchange are completely different than the professional requirements of being a therapist.  Dr. Z. is permitting his personal feelings to cloud his professional judgment.  His therapeutic approach and techniques may be affected.  This inevitably will disadvantage the client.  The client is seeking psychotherapy, not a social friend.  I do not know if there is any scenario under which Dr. Z. can properly terminate therapy and become the client’s “friend.”  While he can do the former it is difficult to see how he could accomplish the latter.  He still would be under obligations of client confidentiality and non-disclosure.  He still might view the former client as an actual client, and vice versa, to the client’s detriment.  At the very least a considerable length of time would have to elapse before Dr. Z. and his ex-client properly could establish a social relationship.

Dr. Z. also is experiencing a form of counter-transference.  While it may not be uncommon for a therapist’s mind to wander during the course of a session one of the basic duties of the therapist is to concentrate on what the client is saying.  It per se is impossible for a therapist to administer any form of therapy if he isn’t paying attention.  Dr. Z. might consider discussing this problem with the client, though if he does so he runs the risk of making the therapy “about him” instead of “about the client,” which is not in the client’s best interests.  On the whole termination is the better course of action.

8.            In December one of Dr. Z.’s patients gives him a card wishing him a happy new year, which Dr. Z. accepts.  Yet another patient brings him a holiday gift.  Would it be ethical for Dr. Z. to accept this gift?

ANSWER: It depends.  A New Year’s card is uncontroversial and absent unusual circumstances Dr. Z. simply should accept it as a matter of conventional inter-personal niceties.  The same thing is true of a “holiday gift” provided it has minimal value and the client’s intent simply is to acknowledge the spirit of the holiday.  There is no indication in the hypothetical it was given out-of-context, with some covert motive, with any expectation of reciprocity or with the prospect of secondary gain.  It is timed appropriately.  The gift may have symbolic significance to the client arising out of the therapeutic relationship; in some circumstances it even may be a kind of “transitional object.”  It may be an expression of appreciation or gratitude and in this sense enhance the therapeutic alliance.  Conversely the client may feel rejected (for cultural or personal reasons) if Dr. Z. doesn’t accept the gift.  Dr. Z. might consider exploring with the client the reasons why the client has proffered the gift.  In the event Dr. Z. is in doubt he should consult with a supervisor or colleague and document the transaction in his clinical notes.  The goal of therapy is not for the therapist to “become the client’s friend.”  This being so if not over-interpreted the incident described in the hypothetical should not present an ethical issue and Dr. Z. simply needs to exercise good judgment.

9.            Dr. Z. has been treating a man in his early 20’s.  This patient asks him many questions, for example, he wants to know about Dr. Z.’s professional background and his personal life.  How should Dr. Z. respond to these questions?

ANSWER: Guardedly.  According to classic Freudian theory the psychoanalyst should say nothing and possibly not even be seen by the client during the course of a session so as not to interfere with the client’s free association process and the development and resolution of a transference neurosis.  This stance came to be discarded with the advent of Rogerian therapy in the 1960s.  Rogers held two people are in congruence if they are at the same level of discourse, i.e. one isn’t pretending to be more knowledgeable, or an authority figure, or in a dominant power relationship, over the other.  When the therapist is in congruence with the client, she is capable of empathetic listening and supplying unconditional positive regard.  The client feels understood and the therapist radiates this feeling of being understood back to the client.  This last component is crucial.  Without it the client lacks evidence her communication to the therapist has been successfully received.  In supplying this evidence it is appropriate for the therapist to draw analogies from her own experience.  Thus, the therapist might say something like: “I understand what you are saying.  You are saying (briefly reparse what client said).  The reason why I understand it is because (brief self-disclosure by therapist).”

This being so the nature, scope and extent of self-disclosure depend on the texture, caliber and quality of the therapeutic relationship, including factors such as the client’s age and psychological condition.  Disclosures regarding the therapist’s background and training are permitted as are (self-obvious) ones regarding to age, ethnicity and brief biographical details (such as whether one has children).  In some contexts such as addiction therapy the client may not believe the therapist is credible unless the therapist has had (and discloses) hands-on experience with the subject matter.  The therapist should not offer soliloquies, deal with bizarre topics or explore tangents that would disconcert the patient (e.g. a discourse on her favorite color, or religious subjects).  A good litmus test is for the therapist to say: “What makes you ask?” in response to client inquiries, which should provoke further useful dialog.

10.            Dr. Z. administers an MMPI-2 to a Chilean man who obtains elevations on scales 1 and 3 and a low score on scale 5.  Considering this man’s background what are some possible interpretive hypotheses for his MMPI-2 profile?

ANSWER: Scale 1 is hypochondriasis (Hs); scale 3 is hysteria (Hy); and scale 5 is masculinity-femininity (Mf).  MMPI-2 clinical scales are interpretable only if the t-score is ≥ 65 (so I assume this is what “elevated” means).  Generally Hs measures somatic concerns or delusions.  A high-endorser typically lacks energy, is whiny and dissatisfied, may be demanding or complaining and suffers from sleep disturbances.  Hy was developed to identify persons who have hysterical reactions to stress, e.g. psychogenic symptoms and loss of function.  Generally it measures conversion reactions, somatic symptoms, lack of insight into the causes of symptoms, denial, immaturity and self-centeredness and suggestibility.  Hy has five Harris-Lingoes subscales to help discern what area of scale content was endorsed.  Originally developed to identify homosexuality Mf now is thought to measure interests or stereotypical personality traits, not symptoms or problems (in fact it is not even considered to be a “clinical” scale although found within the clinical group).  For men a low t-score means he has very traditional (“macho”) masculine interests.  Without being too stereotypical, persons from Hispanic cultures frequently are thought to possess this personality trait.

A “code type” is a group of clinical scales that interact with each other.  It is interpretable if the scores comprising the code type are ≥ 65; if they are ≥ 5 points higher than the remaining scales; and if they are within 5 points of each other.  The code type for the person identified in the hypothetical is the two-point code type 13/31.  It often is found in inpatient medical settings.  It is associated with chronic medical or physical problems such as chronic pain and an Axis III diagnosis.  Endorsers are preoccupied with physical health.  Their symptoms appear and disappear quickly in response to emotional stress.  They present themselves as psychologically normal and responsible.  They typically resist psychological explanations for their difficulties, instead preferring medical answers.  I would interpret this person’s scores on this basis.

11.            Dr. Z. administers an MMPI-2 to a woman with ADHD who also has a history of impairment in verbal and written skills.  While scoring the test he notices the woman did not answer 20 items and also had significant elevations on the Variable Response Inconsistency (VRIN) scale.  How should Dr. Z. proceed?

ANSWER: Cautiously. As a matter of content-independent validity MMPI-2 permits a maximum of 30 CNS (“cannot say”) items.  VRIN (“variable response inconsistency”) is designed to detect random responding.  It comprises 47 item pairs, 12 of which can be scored two ways.  T-scores range from 30 to 120.  Generally speaking it is interpretable if the t-score is ≥ 80.  VRIN also should be interpreted in light of its counterpart TRIN (“fixed response inconsistency”), which is designed to detect fixed or pattern responding.  Based on the facts of the hypothetical, the test was not invalid based only on the number of CNS items.  One would need to know what the actual VRIN score was in order to assess its contribution to validity.  One also would need to know the TRIN score.  All aspects of the MMPI-2 must be interpreted in light of the clinical interview preceding administration of the test.  The hypothetical states respondent has ADHD and a history of impairment in verbal and written skills.  She may not have been paying attention during the administration of the test, or her attention may have wandered.  Although gauged at a 6th-grade reading level, she may have not understood some of the questions.  While these facts tend to explain CNS/VRIN/TRIN elevations they also reduce my confidence the test is a valid determiner of the respondent’s personality states/traits.

12.            Dr. Z. is asked to assess the IQ of a 10-year-old girl with academic difficulties.  He administers only the non-verbal subtests of the WISC-IV (subtests from PRI and PSI) because he is concerned about the girl’s limited verbal skills.  The girl obtains results in the low average range.  Dr. Z. uses these results as an index of her overall IQ, and bases his recommendations on only these results.  The child then is placed in remedial classes based on the test results and Dr. Z.’s recommendations.  Dr. Z. defends his test administration and recommendations because of his concerns about the child’s limited proficiency in English.  Was Dr. Z.’s test administration and interpretation ethical?  Could he have taken any alternative steps in assessing this child?

ANSWER: No and yes. The WISC-IV generates a full-scale score (FSIQ) and four sub-scores: verbal comprehension (“VCI”), perceptual reasoning (“PRI”), processing speed (“PSI”) and working memory (“WMI”).  It comprises ten core subtests, each of which is given equal weighting towards full-scale IQ.  By dropping VCI and WMI Dr. Z. has eliminated important components of the respondent’s over-all IQ score and the result of the test therefore is uninterpretable.  Research has shown WISC is not effective as a clinical tool.  In particular it should not be used to diagnose ADHD or learning disabilities.  Rather its best use simply is to evaluate a child’s intelligence and cognitive development in relationship to his or her age.  Dr. Z. erred in using it as a device to place the child on a remedial class track.  Dr. Z. also ignored the child’s limited English capacity.  As an intelligence test WISC depends not only on language proficiency to understand it but also the role of language in formulating the constructs and phenotypes, which “intelligence” comprises.  If Dr. Z. does not speak the child’s native language then she should find somebody who does.  In summary Dr. Z. should have (a) administered the test in the child’s native language; (b) administered an alternative test; (c) interpreted the WISC-IV outcome in light of results on other tests and a clinical interview; and (d) in any event not used it as a criterion for education track placement.

California’s basic mental health law is the Lanterman-Petris-Short Act (the “Act”), Cal. Welfare & Institutions C. §5000 et seq. A person may be designated as “gravely disabled” under the Act if unable to take care of basic personal needs such as food, clothing and shelter.  As a consequence the person may be deprived of various civil liberties and may be forcibly medicated or involuntarily committed.  The Act is enforced on a county-by-county basis.

This article reviews data from various California counties during the period 1999 – 2003 to identify those with a greater relative proportion of indigent psychiatric hospitalizations.  There is a well-established relationship between homelessness and mental illness.  Homelessness increases utilization of public mental health facilities.  Using a (poorly-explained) “geocoding” technique the authors found the rate of indigent acute psychiatric hospitalizations varies significantly by county.  They did not correlate the county-by-county data they developed with each county’s population, which would have yielded a more accurate per capita assessment.  Nor did they offer an explanation for this variance.  Their polemical conclusion was the increase in uninsured psychiatric caseload misapplies scarce economic resources and limits access to psychiatric facilities.  However they also could have concluded the Act is a poor proxy for the actual incidence of mental illness.  A person classified as gravely disabled in one county may elude such classification in another or vice versa.  It is absurd to think the population of one county has greater per capita incidence of mental illness than the population of any other county.  These anomalies suggest political factors rather than epidemiological ones underlie the Act’s implementation and raise fundamental questions about the state-wide consistency of criteria for admission to psychiatric facilities, how these criteria are applied, and whether these disparities present equitable issues.

Law enforcement is given a stark choice when dealing with the mentally ill criminal: place in an in-patient psychiatric facility, or send to jail?  California prisons treat more people with mental illness than hospitals and residential treatment centers combined.  Mentally ill prisoners receive inadequate medical and psychiatric care, serve longer terms than the average inmate and are released without sufficient preparation and support for their return to society.  As a result these offenders are more likely to violate parole and return to prison.  The California prison healthcare system presently is in receivership.  The state is poised to spend more money on prisons than on colleges in the coming fiscal year.

This article focuses on three phases in an inmate’s relationship with the prison system: intake, living in prison, and release.  The author notes that inmates are not adequately screened during intake for mental illness.  Any diagnosis they do receive does not travel with them through the prison system.  As a result they frequently go off medication.  Prisons do not offer adequate counseling.  They treat disruptive behavior as a disciplinary problem rather than as a symptom of mental illness.  Because of these and other factors mentally ill inmates experience greater rates of administrative segregation, which leads to further mental deterioration and expensive stays in mental hospitals.  Mentally ill prisoners often are released without adequate treatment programs or housing support.  As a result they face higher parole revocation rates than inmates in the general population.  The author proposes a thorough overhaul of prison mental health care to redress these imbalances.  Whether this is practical in light of California’s current budget crisis remains to be seen.

As set forth at DSM-IV-TR §295 (p. 312) persons with schizophrenia experience a variety of cognitive impairments, including: hallucinations, bizarre delusions and thought disorders.  Hallucinations are auditory, visual or other perceptual disturbances occurring outside the range of normal experience.  Delusions are distortions in thought content or erroneous beliefs usually involving a misinterpretation of perceptions or experience; a delusion is bizarre if it clearly is implausible or incomprehensible and does not derive from ordinary life experience.  A thought disorder is disorganized thinking.  These symptoms need not be co-occurrent: only one bizarre delusion or one hallucination consisting of a voice keeping up a running commentary on the person’s behavior or thoughts (or two or more voices conversing with each other) is required during a one-month period in order to qualify one as a diagnostic candidate, other genetic, neuroanatomical or neurochemical factors notwithstanding.  Informed consent of course is a necessary prerequisite for any form of treatment or human subjects experimental research.  This leads however to a puzzle: how can a person so cognitively impaired possibly be meaningfully “informed” of the risks and benefits of treatment or participation?

The authors of this study compared competence-related abilities of in-patient schizophrenics against a control group with similar age, gender, race and SES characteristics.  The study participants were administered a test called the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), designed to assess competence to give informed consent.  The authors do not explain how they obtained patient consent to administer this test – a logical puzzle.  The authors found significant differences on three different measures of competence-related abililties: understanding, reasoning and appreciation.  Greater degrees of psychopathology (poorer cognitive functioning) were significantly negatively correlated with understanding and appreciation.  The authors concluded that the poor performance of the inpatient group created significant difficulties in providing informed consent, validating my initial concerns as I read this paper.

For many years the issue of medical professionals accepting remuneration from pharmaceutical firms in consideration for testing and possibly recommending their products was unproblematic.  There came a time however when this became a point of contention.  In many contexts physicians now are prohibited or discouraged from accepting drug company money.  At the very least there is a strong ethical mandate to disclose all such relationships.  The reason why this is important is to alert the user of a study of potential research bias.  Whenever a scientist is funded by industry there is at least a theoretical possibility the scientist will skew results so the trial will be successful, thereby inducing industry to supply additional funding, thereby keeping the scientist in business.  Still there remain several vexing questions.  Who else is there to furnish funding for objective, third-party testing of new drug combinations, which may benefit patients in need?  Is there an actual conflict of interest, or is this more of a theoretical concern?

In this article the authors examined funding sources and financial conflicts of interest in all clinical trials published in several psychiatric journals over a period of several years.  They identified 397 clinical trials in all.  239 of them (60%) reported receiving drug company funding and 187 (47%) included at least one researcher who reported a financial conflict of interest.  The authors also examined 162 randomized, double-blind placebo-controlled studies.  Those where there was a conflict of interest were 4.9 times more likely to report positive results.  The authors concluded that conflict of interest appears to be prevalent among psychiatric clinical trials and is associated with a greater likelihood of reporting a drug to be superior to a placebo.  The authors did not explain just how this happened in a double-blind placebo study.  This is an even more worrisome outcome because it suggests the experimental protocol for double-blind placebo trials – supposedly the “gold standard” of experimental research – somehow was transgressed.

Neuroscientists now are on the verge of developing persuasive etiologies for complex psychopathology such as schizophrenia and personality disorder spectra.  They have identified precise genetic and neurochemical contributors with highly granulated detail.  Genetic markers, for example, occur at the allele level; neurochemical ones are based on specific transmitters within the GABAminergic or dopaminergic systems.  Using these techniques such conditions can be empirically modeled – validating one of psychology’s long-cherished objectives, which only can speculate about them at the level of “mind” or “behavior.”  This leads however to a serious confound, which is that personality assessment tests such as the MMPI, TAT and Rorschach only measure traits at a gross level, frequently in as few as a half-dozen categories.  This is a poor match for the literally millions of genetic and neurochemical data points.  What correlates with what?

This article evaluates frequency of use of personality assessment tests by clinical neuropsychologists.  The authors sent a questionnaire to 1,000 practitioners and received 404 responses.  The authors conclude their use is relatively uncommon.  When they were used, MMPI was used more frequently than TAT or Rorschach (both of which had low reliability and validity).  All three were used primarily to assess younger patients, where learning disabilities, forensic issues and psychiatric issues may be more prominent.  While the authors believe personality assessment measures can be used to assess psychopathology in patients with neurological impairments, they reluctantly conclude there is little relationship between neurophysiological measures and (alleged) personality correlates.  They characterize this as presenting a “clinical challenge” when in fact what they should have said is that it is philosophically dubious, for the reasons I set forth.

The Minnesota Multiphasic Personality Inventory (MMPI) test originally was developed in 1939 and amended from time-to-time until now.  It has 567 true-false questions.  These are parsed into various “scales” including clinical scales; sub-scales; content scales; supplementary scales; and critical item scales.  There also are scales purporting to measure the test’s validity.  The basic claim underlying the MMPI is incredible – that a series of true-false questions can accurately assess personality traits.  The questions originally were normed against a group of middle-class persons in Minnesota, who self-selected as relatives of in-patients at a psychiatric facility (this population since has been somewhat expanded).  Many of the questions are stereotypes (“do you like to read mechanic’s magazines”), compound, assume premises and are phrased as double-negatives or colloquialisms.  In some cases a sub-scale is based on endorsement of as few as a half-dozen items.  Nonetheless the MMPI is widely used and has become the de-facto standard of personality testing.

This review article statistically assesses various aspects of the MMPI, particularly with regards to validity and reliability.  The authors surveyed the last decade’s worth of literature.  Conventional interpretation of the MMPI is that an elevated t-score (in excess of around 65 – 70) on a particular scale indicates potential psychopathology for the construct the scale is supposed to measure, subject to caveats such as elevation on related scales, a clinical interview and the like.  The authors of this study believe a better measure is around 90.  None of the MMPI scales meet this criterion.  Even lowering the value to 70, few of the scales are reliable.  In particular the clinical scales are much less reliable than the content and supplementary scales.  The authors conclude the MMPI is only weakly reliable.  In my opinion no series of true-false questions can measure the complex dimensions of human personality, so I concur with this conclusion.

One of the earliest drugs to treat schizophrenia was chlorpromazine (thorazine), discovered by the French surgeon Henri Laborit in 1952.  Chlorpromazine is what is referred to as a “typical antipsychotic.”  A leading hypothesis is that one of the main causes of schizophrenia is too much dopamine.  Chlorpromazine works by blocking dopaminergic receptors (mesolimbic and nigrostriatal) in the central nervous system.  Chlorpromazine was tremendously successful and brought significant relief to millions of patients.  Unfortunately it has a significant side effect (among others).  Not enough dopamine causes muscle tremors known as tardive dyskinesia, which in turn resemble Parkinson’s Disease (ameliorated by L-dopa, a dopamine precursor).  In a way schizophrenia and Parkinson’s are reciprocals.

These and other issues lead to the development of “second generation” antipsychotics such as olanzapine, aripiprazole, quetiapine, risperidone and ziprasidone.  They have the same molecular action of chlorpromazine but without some of its side-effects.  This meta-analysis reviewed 78 clinical trials enrolling a total of 13,558 patients – an impressive level of participation.  It reviewed the efficacy of second-generation antipsychotics and analyzed their side effects.  The authors concluded olanzapine was better than aripiprazole, quetiapine, risperidone and ziprasidone; risperidone was better than quetiapine and ziprasidone; and clozapine was better than zotepine.  These differences mainly were due to improvement in “positive symptoms” (as defined in the DSM) rather than negative ones.  Subject to the caveats pertaining to all meta-analyses (such as whether the underlying data truly is comparable), this study is the most recent and comprehensive one in the literature and provides a useful guide

In addition to being a great writer, Dostoyevsky had temporal lobe epilepsy (“TLE”).  His ecstatic seizures gave him a capacity for mystical experience, which he used to animate characters like Prince Myshkin in The Idiot and Smerdyakov in The Brothers Karamazov.

TLE affects the integrity and function of the hippocampus.  It disrupts inhibitory signaling mediated by GABA_A receptors (GABA stops action potentials; its counterpart glutamate starts them or keeps them going).  For some time the preferred treatment for refractory TLE was surgical resection of the hippocampus.  In the last decade however a variety of less-intrusive anticonvulsive medications such as lamotrigine have been developed.  Basically they work by increasing the supply of GABA (better inhibition = less excessive electrical activity).

This article reviews the history of their development and some of their most common side effects.  In a longitudinal study the authors tracked 1,394 outpatients at a major New York hospital.  16% of patients reported undesirable side effects, the duration and intensity of which varied with the medication prescribed.  As the molecular mechanism of anti-epileptic drugs has become better understood their use can be targeted and their side effects managed.  The authors of this study concluded the class of newer medications not only was more efficacious but also precipitated fewer side effects.

One of the main consequences of TLE is disruption of autobiographical memory.  When a narrative is segmented into bits of information, patients are unable to retrieve it quickly and in the correct chronological order.  The gist of the memory may be maintained but details are lost.  One can’t help but wonder how Dostoyevsky’s writings might have been affected by these newer medications.