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Background: Few studies have examined the predictors of psychiatrists' perceived success and personal satisfaction with their careers. The present study examines self-reported success and personal satisfaction with their careers in a cohort of psychiatrists followed for more than 20 years., Methods: A total of 29 psychiatrists, all of whom had participated in a study during their residency 21 to 24 years earlier, completed a self-report questionnaire. The first set of questions addressed the type and characteristics of their professional practice; the second set assessed aspects of their nonprofessional practice; and the third set assessed aspects of their nonprofessional, personal lifestyles. The personality traits of neuroticism and extraversion were assessed during the residency years and were used as predictors. Composite measures of self-perceived external success and personal satisfaction were computed. Regression models were constructed to determine the best predictors of these composite measures., Results: Neuroticism proved to be a significant predictor of external success but not of personal satisfaction, with higher scores predicting a lower rating of perceived external success. There were 2 practice characteristics--involvement with research and practising from an orientation other than psychoanalytic--that predicted perception of success. One personal lifestyle characteristic--the perception that one's nonprofessional life sustained professional life--also predicted perception of success. The best predictor of personal satisfaction was overall satisfaction with nonprofessional aspects of life., Conclusions: Personality, nonprofessional social support, and engaging in research are associated with greater perceived success and personal satisfaction with a career in psychiatry.

The field of psychiatry is experiencing great excitement at this time, much as it was 100 years ago. Current excitement is rooted in the greatly strengthened therapeutics, new models for understanding, and an exponential increase in knowledge of brain function as well as in the opportunity to revise health care delivery. While public expectations of professionals have generally fallen, the role of the healer, which is at the heart of psychiatric practice, has remained high in public regard. Psychiatry has also had to develop new relationships with an active consumer movement. Consumers now appropriately expect to be part of the planning, governance, and evaluation of care. Patients are questioning the research agenda and demand a role in determining the conduct of investigations. This active consumer movement is playing an important role in destigmatizing mental illnesses. Newer, nonmoralistic theories about mental illness and the profession's emphasis on the public trust have also played an important role. The increasing closeness of psychiatry to the rest of medicine has had a greatly beneficial impact, not only on stigma but also on diagnosis and treatment. Care must be taken, however, to see that diagnosis does not become a means to avoiding understanding of people. A welcome recent change has been the reunion between psychiatry and the addictions. This reunion has been facilitated by the development of multifactorial models of care in the mental health field and harm-reduction strategies in the addictions. This bodes well for more integrated treatment in the coming years. The strong psychiatric treatments that are now available and those on the horizon also auger well for an exciting period in our field. The excitement is enhanced by recognizing the multiple approaches to care that have been demonstrated to be effective and the need for great investment in research in this country and by developing new partnerships between the profession and public.

Objective: Patients with eating disorders (EDs) are often difficult to treat. Despite recent advances in treatment, a significant percentage of patients remain treatment refractory. This paper reviews variables that contribute to these difficulties and recent strategies that focus on increasing patient motivation for treatment., Method: The authors relate their clinical experience and synthesize the literature examining aspects of patients with EDs that may contribute to their treatment resistance and therapist variables that may contribute to negative nontherapeutic reactions., Results: Patient variables include the nature of the symptoms that patients experience, issues of trust, the not uncommon failure of ambulatory treatments, and issues related to comorbidity. Aspects of clinicians include lack of understanding of the biopsychosocial pathophysiology of these conditions and lack of experience and appreciation for the countertransferential reactions that these patients evoke in caregivers., Conclusions: Improving understanding of the reasons for treatment refractoriness in patients with EDs is critical to improving their care. New interventions aimed at enhancing motivation may facilitate this process.

Objective: To demonstrate that sexual abuse of patients by psychiatrists can be due to a variety of contributors, which may include therapists' psychopathic and narcissistic personality styles., Method: Data from a prospective cohort of residents training in psychiatry were examined to evaluate the personality traits of 2 psychiatrists subsequently convicted of boundary violations., Results: The 2 psychiatrists who lost their licenses were identifiable at the beginning of their residency training as individuals with significant character pathology., Conclusions: For some psychiatrists, repetitive sexual abuse of patients represents one aspect of an ongoing pattern of exploitative relationships. The professional and ethical implications of these findings as they relate to early identification for those at risk are considered.

Objective: To explore a number of issues related to boundary violations in psychiatry, including the relationship between the individual physician and his or her patient and broader issues related to various dilemmas arising in academic departments of psychiatry., Method: Several potentially troublesome scenarios are presented and discussed in the contexts of 1) the doctor-patient relationship, 2) sexual boundary violations, and 3) nonsexual forms of exploitation, such as finances, confidentiality, dual relationships, and relationships with industry., Conclusions: A number of examples of boundary problems involving psychiatrists have been explored, and although some of these behaviours are clearly forbidden and harmful, others are less clear and require careful consideration if the profession is to arrive at a thoughtful consensus.

Objective: To identify important trends and themes that will affect psychiatric training and practice., Method: Selective literature review and reflections by the authors., Results: Three principal themes are elucidated relating to empiricism and integration, accountability and collaboration, and training and the public trust., Conclusions: There must be debate and action on these and other themes to maintain the relevance of psychiatry to its changing context.

Objective: To highlight developments in the taxonomy of eating disorders since Russell's original description of bulimia nervosa (BN) in 1979 and through 3 versions of the Diagnostic and Statistical Manual., Method: Criteria for anorexia nervosa (AN), BN and binge eating disorder (BED) are systematically described., Results: While criteria for AN remain largely unchanged between DSM-III-R and DSM-IV, the subclassification of binge/purge and restricter subgroups endorses previous research findings. For BN, the definition of "binge" has occupied considerable attention both in quantitative and qualitative terms. The arbitrary choice of 2 episodes per week as a minimum frequency is also discussed in light of recent data from the Ontario Health Supplement. A third eating disorder, BED, is now included in the appendix of DSM-IV under Eating Disorders--Not Otherwise Specified category. The potential overlap between this disorder and nonpurging BN is discussed. Finally, the relationship between eating disorders and other psychiatric disorders including depression, schizophrenia, obsessional, and conversion disorders is considered as well as the continuum from preoccupation with weight to eating disorder., Conclusion: While significant advances have been made in understanding and classifying eating disorders during the past 15 years, further empirical work is necessary to clarify areas of uncertainty.

This paper reviews four areas of research into anorexia nervosa (AN) and bulimia nervosa (BN). First, in terms of diagnosis, the psychological concerns about weight and shape are now addressed in BN, bringing it more in line with the related disorder, anorexia nervosa. Second, studies of psychiatric comorbidity confirm the overlap between eating disorders and depression, obsessive compulsive disorder, substance abuse, and personality disorder. Nevertheless, there are reasons to accept the distinct qualities of each syndrome, and eating disorders are not merely a variant of these other conditions. Third, treatment advances in BN involve mainly cognitive-behavioural or interpersonal psychotherapies and pharmacotherapies primarily with antidepressants. The effect of combining more than one approach is beginning to be addressed. Finally, outcome studies involving people with both AN and BN have shown that the disorders "cross over" and that both conditions have a high rate of relapse. A renewed interest in the treatment of AN is needed.

A survey among psychiatric residents about their satisfaction with and concerns about their training in psychopharmacology was conducted. One hundred and seventy responders (61%) from ten post-graduate psychiatric programs in Canada completed the questionnaire. The questionnaire assessed the residents' satisfaction with the training they had received over the previous six months as well as over their entire residency period. The questionnaire inquired specifically about the quantity and quality of supervision in the use of different medications for different therapeutic purposes. It also looked at the quality of supervision of drug therapies within hospital services, inpatient, outpatient, consultation and emergency services. Residents also were asked about coverage of specific topics and ranked different methods of learning. The survey uncovered a number of deficiencies mostly related to the teaching of basic psychopharmacology, integration of psychopharmacological and psychosocial issues and the lack of teaching of clinical appraisal of recent advances. Factors that may have contributed to the development of such deficiencies as well as specific recommendations are discussed.

Bulimia nervosa is an eating disorder with multiple causes that has been the object of extensive research since it was first described in 1979. This review evaluates both the theoretical rationale and empirical evidence for a model which suggests that disturbed serotonin activity is involved in the development of this disorder. Limitations of the hypothesis and prospects for the future are considered.

The number of patients who are identified as having chronic fatigue syndrome (CFS) has increased, and as a result, chronic fatigue syndrome has received widespread attention. Research has demonstrated that cognitive, affective and behavioural symptoms are prominent in CFS. Psychiatrists are therefore being asked to participate in the assessment and management of patients with this syndrome. This paper will provide an overview of the clinical characteristics of CFS and the current empirical findings related to its pathology, and will conclude with a discussion of the management of these patients.

Three categories of treatments for premenstrual syndrome (PMS) have been proposed: those designed to correct the cause of the disorder; those designed for symptom relief; and those aimed at eliminating the menstrual cycle. Many of these recommendations are based on poor research with loose definitions of the disorder and uncontrolled open trials. This paper reviews the literature on treatment methods with emphasis on recent random, placebo controlled, double-blind studies. The most effective current management of PMS is a conservative one including accurate diagnosis, stress control, sensible levels of diet and exercise and perhaps the use of alprazolam in the premenstrual period. Other approaches such as the use of mefenamic acid and evening oil of primrose remain unproven. Progesterone has been proven uneffective. Further research is required into the value of antidepressant medication.

This paper describes the prevalence and incidence of psychiatric disorders in IBS patients using a standardized psychiatric interview, and proposes a psychological model for investigating one aspect of IBS. Forty-four IBS patients and 28 nonclinical participants received a psychiatric interview (Diagnostic Interview Schedule) and completed the Lie Scale of the Eysenck Personality Inventory (L-EPI). Results indicated that a significant percentage (59%) of the IBS group met DSM-III criteria for a psychiatric disorder within the last year, far more than occurred in the matched nonclinical comparison group. Relative to the comparison group, the IBS group also had significantly higher lie scores on the EPI indicating a response style of social desirability. On the basis of these findings, together with earlier work by Latimer's group, a conceptual model was formulated on the notion that some IBS patients may have a self-schema (i.e. knowledge of self, stored in memory) characterized by social desirability. We suggest that the construct of self-schema may be helpful in differentiating IBS from psychiatric groups both conceptually and therapeutically.

In a prospective study of 28 subjects with major depression, weight was significantly related to nonsuppression in the dexamethasone suppression test (DST) on admission and seven days later. However, changes in weight between these two times did not alter the DST status.

In the past decade much has been learned about the clinical features, diagnosis and understanding of people with anorexia nervosa and bulimia nervosa. In order to provide the next level of improvement in our care for these patients, our understanding of certain problems must be addressed by empirical research. Areas which require further study include the definition of high risk groups, the refinement of diagnoses, understanding factors which result in chronicity, determining the complications of chronicity and comparative evaluations of different treatments. These five areas are outlined in this article. Populations at risk for anorexia nervosa and bulimia nervosa may be those who must be thin and achieve according to career choice, those with a particular family and personal psychiatric history; obesity and chronic medical illnesses may be further risks. Improved diagnostic understanding has occurred by the differentiation of bulimic from restricting subtypes of anorexia nervosa. Further work must determine the relationship between the bulimic subtype of anorexia nervosa and bulimia in normal weight women and to further clarify the relationship between eating disorders and affective disorders. A number of factors may result in a chronic illness. These have been described on a variety of levels. The consequences of starvation in altering an individual's thinking, feeling and behaviour do play a role. It is not clear what factors at a neurochemical level contribute to this. Elevated endogenous opiates decreased noradrenergic function and decreased serotonin may be important. Information about the chronic complications is required for clinicians to understand the broad range of difficulties that may develop over time so that clinicians may use this information in planning treatment strategies.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of diagnostic subtypes within the anorexia nervosa syndrome has given rise to the differentiation of a bulimic subgroup as distinct from the restrictive type of anorexia nervosa. The bulimic subtype is characterized by the use of vomiting and laxatives to induce weight loss; a display of impulse-related behaviours; extraversion and sexual activity in contrast to the isolation of the restrictive group; and a family history of obesity in the mother, all suggesting a subcategory within the primary anorexia nervosa syndrome. Investigation of behaviours and attitudes related to anorexia nervosa in a group of dancers disclosed a significantly elevated attitude toward food and body image characteristic of anorexia nervosa in this group and ten times the expected prevalence of the disorder itself. This is suggestive of the relative importance of cultural pressures towards thinness and anorexia nervosa in certain populations as one factor amongst others in the multi-determined origin of this condition. This cultural pressure is consistent with a disturbance of body image perception in anorexia nervosa. This disturbance seems to be stable in the same individual over a period of one year, is related to a poor prognosis and is correlated with measures of psychopathology including helplessness, depression and anhedonia. It is also correlated with a satiety defect as reflected in a failure to develop an aversion to sucrose when directly tested.

The two following papers describe some of the benefits and problems involved in integrating clinical and investigative work. It is stressed that there are a number of advantages to such integration. Researchers especially benefit from the proximity to patients and clinicians. Education can be significantly enhanced when researchers and clinicians are in one setting and this can benefit residents, medical students and non-medical health personnel. There are a number of problems to such clinical research in psychiatry. These are discussed especially as they relate to senior faculty and their resistances to research. The shortage of clinician scientists in teaching positions means that most residents are not involved with such people as mentors early in their training and do not consider this as a career option after their residency training. Reductionistic thinking on the part of some researchers and when researchers are not first-rate clinicians both contribute to residents not becoming involved in clinical investigation. Funding policies as well as chairmen's hiring policies also play a role here.

The Clinical Investigation Unit has served as a natural focus for clinical research; as such it has a number of advantages and specific problems. On such units a variety of themes may occur. Some of these have the potential to interfere with the integration of clinical and research work. These include the theme that the research itself is therapy, or that research will find all the answers. Both may result in problems for the functioning of the ward. Most problematic of all is the theme that research is harmful and exploitative. Optimally, the unit develops an attitude that the research is compatible with excellent patient care. Problems of patients, staff, ethical issues, admissions policies and problems of the clinician-scientists are reviewed with recommendations on how to minimize difficulties.

Noncompliance is a major contributing factor to therapeutic failure. Many complex variables hae been reported to interfere with patient compliance. Though there are exceptions, educational techniques have been shown to be of value. Patients with diagnoses of schizophrenia, and bipolar and unipolar affective disorders were separated into control and experimental groups and studied to determine the factors associated with poor compliance and the potential value of educational techniques. Following a course of lectures and data sheets, the "educated" patients tended to be more compliant on outpatient follow-up. They were also less fearful of side effects and addiction. Factors associated with poor compliance were related to severity of illness, social isolation, fear of dependency and side effects (extra-pyramidal).

This study has documented resident dissatisfaction with education in psychopharmacology in one large university and has proposed several solutions. These include: - increased awareness of standards of knowledge necessary for a consultant. - the establishment of a central educative office of clinical psychopharmacology to encourage dissemination of selected literature and to facilitate residents' research under supervision. - recognition that not all staff should be considered capable to provide psychopharmacology supervision and that each hospital should have a designated psychiatrist with special expertise in psychopharmacology. - developing study groups for the purpose of teaching critical evaluation of the literature. - increasing encouragement for residents' participating in clinical research - awareness of residents' difficulties in learning "emotional illness, rejection of biological therapies, and knowing what is expected or not suited to psychiatry" and appropriate actions to alter these. - increased use of audio aids, self-teaching manuals and journals to augment lectures and texts. - increased emphasis on training selected senior residents in how to teach.

Recent reports have suggested that family therapy is useful in the treatment of anorexia nervosa. There are, however, recognized contraindications to family therapy. As we were seeing patients with anorexia nervosa for whom family therapy was not possible, we predicted that the formation of a group for the parents would provide benefit through education, support and insight. The present study was designed to develop and evaluate such a group. We selected parents of ten anorectic patients for whom family therapy was contraindicated. There were two therapists, the unit social worker and a former patient who had successfully overcome the symptoms of anorexia nervosa. After an 18-month period, the ten couples were sent anonymous questionnaires assessing the group's value. Six indicated positive feelings about the group and felt they had benefited. One couple reported dissatisfaction. Most perceived the group as an important part of the overall treatment.

Twenty bulimics, 20 depressives and 20 normal controls were studied using the Dexamethasone Suppression Test (DST) as defined by Carroll et al. Their past psychiatric and family histories were compared. We found that actively bulimic subjects had a rate of DST non-suppression of 20%, and that 20% of them had a past history of a major depressive disorder. Forty per cent had a history of alcoholism and/or antisocial personality in a first degree relative, but only 5% had a positive family history of affective disorder. These rates were significantly lower than those found in the depressed group except for the family history of alcoholism and/or antisocial personality for which there was no significant difference. We identified a subgroup of bulimic DST non-suppressors who, like patients with melancholia, were characterized by past history of major depressive illness and high rates of family history of affective disorder, alcoholism and/or antisocial personality in first degree relatives. This group responded to antidepressant medications in a manner similar to depressed patients.