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Controversy over using benzodiazepines in a human immunodeficiency virus (HIV)-positive population to relieve sleep and anxiety has not been addressed in the literature. Serious problems with diazepam abuse emerged in a psychiatric outpatient clinic for a predominately HIV-positive and illicit drug-using population, which led to a review of patient characteristics and prescribing policies and to a systematic problem-solving effort. The patients originally prescribed diazepam were significantly more likely to be on methadone and have histories of intravenous drug use compared with the patients not on benzodiazepines. Thus, the patients asking for diazepam are likely to have histories of substance abuse and have a high potential for abusing the medication. The authors found that diazepam can be discontinued without causing a significantly greater drop-out rate in that group.

A 29-year-old single Puerto Rican woman with AIDS was admitted to the Medical Service for pneumonia, seen by the Psychiatric Consultation Service, an eventually transferred to the Inpatient Psychiatric Unit with several possible psychiatric diagnoses including major depression, HIV dementia, delirium, and posttraumatic stress disorder. These possibly coexisting and interacting syndromes are discussed by three psychiatrists, one of whom is also a board-certified neurologist. This case illustrates the combined contribution of organic and psychological factor to complex behavioral disorders, which are increasingly common in HIV infection.

The evolution of central nervous system (CNS) impairments associated with human immunodeficiency virus (HIV) infection was assessed by a prospective, longitudinal study of patients in a methadone maintenance clinic. At a mean of 47 months after baseline testing, which included physical exams, HIV antibody testing and a neuropsychological (NP) screening battery, 121 subjects received a second NP assessment. Forty subjects (33%) who were seropositive at baseline showed statistically significant declines in NP function over the 4 years compared with 81 seronegatives, on the Finger Tapping and Trail Making B tests. This relatively long-term follow-up suggests that subtle cognitive deficits develop over time and can be identified early, but their course is slow and appears generally to parallel that of non-CNS symptoms/signs of HIV infection.

The authors conducted a study to examine the association between neuropsychological markers of central nervous system impairment and systemic human immunodeficiency virus (HIV) disease progression in a sample of 64 HIV-positive asymptomatic patients who were followed for a median of 45.6 months. Patients with poorer baseline scores on the Halstead-Reitan Trail-Making A neuropsychological test developed HIV-related systemic symptoms earlier over the study period than patients with the higher scores on the same test (P < 0.05). Subclinical neuropsychological dysfunction in otherwise asymptomatic HIV-infected individuals may be a harbinger of progressive HIV-related immunologic dysfunction.

Current suicidality and many other characteristics were assessed in 183-patients in the various stages of HIV infection who were referred to a specialized HIV-related psychiatric clinic. Intravenous drug use was the most common HIV risk factor. Patients with AIDS had significantly less current suicidal ideation than patients with AIDS-related complex and asymptomatic HIV positivity. The lower suicidality in AIDS patients was independent of age, gender, HIV risk group, and source of referral. Possible explanations of this association include denial, refocusing of life goals in AIDS patients, and psychological changes related to central nervous system impairment.

Among psychiatric consultation patients, 322 AIDS patients were significantly less suicidal than 82 other HIV-positive patients and were comparable in suicidality to 1,086 patients with negative or unknown HIV status. AIDS patients had significantly more organic mental disorders. Organicity, denial, acceptance, and/or preoccupation with a fatal illness may reduce suicidality in AIDS patients.

The frequency of a psychiatric consultation being requested to assess a patients' capacity to give informed consent varies among institutions, with most recent surveys reporting a frequency of between 3% and 8% of all consultations. At Montefiore Medical Center, a hospital policy was interpreted as mandating such consultations for all patients with possible or even definite lack of decisional capacity. From 1987 to 1988, 55% of all psychiatric consultations in the institution were for consent. Only 9% of the consent patients seen had an Axis I diagnosis other than organic mental syndrome (OMS). Because many of these consultations were believed to be unnecessary, with patient clearly able or unable to give consent, the consultation service worked first with administration to modify the guidelines, and then educated the medical and nursing staff as to when consultation was indicated. With this program, the number of consent consultations fell from 958 in 1988 to 177 in 1990, representing a major saving of staff time and third-party billings. In this era of cost containment and outside review of professional practices, psychiatrists must take responsibility for identifying areas where patient services and billings for them are not justified by clinical indications.

Demographic and clinical data were recorded for 324 patients who visited an AIDS-related psychiatric outpatient clinic over a three-year period. Seventy-five percent of the patients had a diagnosis of AIDS, AIDS-related complex, or asymptomatic HIV seropositivity. Intravenous drug use and heterosexual relations were the most common HIV transmission risk factors. Seventy-three percent of the patients were black or Hispanic; 51 percent were female. In all stages of HIV infection, adjustment disorder was the most common diagnosis; one third to one half of the patients had substance abuse diagnoses. Only 5 percent were diagnosed with dementia, with the incidence highest (12 percent) in patients with AIDS. On the basis of their experience with the clinic, the authors discuss issues that have proved important in the treatment of patients with the triple diagnoses of medical illness, mental illness, and substance abuse.

A unique and novel Clinical Information System has been set up to link all of the Psychiatric Emergency Rooms in The Bronx, New York. The system is designed from a clinician's perspective and it is an inexpensive system using personal computers. This new system of information exchange utilizes two interesting aspects of applying computer technology to assist clinicians: 1) use of a scannable medical record form to speed the input of data; and, 2) information exchange among many emergency rooms via a dial up access to a central database.

A prospective longitudinal study of neuropsychological and psychosocial functioning in a methadone-maintained population was initiated to test the hypothesis that cognitive impairments may be present early in the course of HIV infection, before the onset of other physical symptoms. A total of 220 methadone-clinic patients without evidence of HIV-related illnesses were given baseline psychological screening tests, as well as serological testing for HIV antibodies. At baseline, 83 (38%) had antibodies to HIV and 137 (62%) did not. On initial testing, controlling for race/ethnicity, age, sex and drug use, the seropositives were more cognitively impaired than the seronegatives. The differences were statistically significant for three subtests on univariate analysis: finger tapping (dominant), digit span (forward) and similarities. Ninety-one patients whose current serological status was known were given follow-up neuropsychological and psychosocial assessments after a mean interval of 7.4 months from baseline testing. At follow-up, seropositives continued to be more cognitively impaired than seronegatives, but there was no deterioration in the performance of the initial seropositives over the time interval.

Every clinical service must record certain data about its patient care activities. In low-volume services, such as Psychiatric Inpatient Services, with perhaps 20-30 admissions per month, and an average patient stay of 2-4 weeks, a large amount of data on each patient can be obtained during the contact time with the patient. On the other hand, very large-volume psychiatric services, such as Emergency and Consultation-Liaison (C-L) Services, may not need or be able to gather such a large amount of data on every patient seen. This article describes the development of a brief, optically scannable, and computerized minimal data base form for patients seen by a very large division of C-L Psychiatry. The system is feasible and easily auditable for completeness and reliability. This data base has already served many important functions beyond providing an administrative statistical summary of services rendered. It is presented as a model for the development of similarly efficient data collection methods for other high-volume psychiatric services.

To identify similarities and differences between AIDS patients and non-AIDS patients, all psychiatric consultations done in one year in a large voluntary general hospital were reviewed. A total of 93 consultations were done on 67 AIDS patients and 138 consultations were done on 121 comparably aged patients without AIDS. The most common AIDS risk factor was intravenous drug use. The AIDS patients were more likely to be Hispanic and male than were the non-AIDS patients. The AIDS group was also more likely to have a diagnosis of organic mental disorder, particularly dementia. There were no other differences in Axis I diagnoses, including depression, substance abuse, and adjustment disorder. Suicidal risk was no greater in the AIDS patients than in the non-AIDS patients. Axis II diagnoses were made more often in the non-AIDS patients, who also required more one-to-one nursing supervision. Consultation in AIDS patients took more staff time, and AIDS patients were more likely to have required one or more repeat consultations within the period of the study, thus creating a heavier burden on consultation staff. Although these predominantly heterosexual, Hispanic, and drug-using hospitalized AIDS patients do not show significantly higher rates of psychiatric morbidity than other, non-AIDS patients, except for more organic mental disorders, AIDS seems to create a much higher demand for psychiatric consultation services.

In the last decade, the biopsychosocial concept of medicine had flourished clinically in the form of consultation-liaison (C-L) psychiatry. However, full acceptance by the medical profession will depend, in part, upon scientific demonstration that psychological and social factors influence biological medical illness, and that C-L psychiatric teaching and patient intervention can improve the medical treatment of patients. This review surveys the literature over the last 10 years that describes and evaluates C-L activities as they impact upon clinical medicine and medical education. A conceptual grid for organizing research in the field is presented that distinguishes decision-oriented, or descriptive studies, from conclusion-oriented, or outcome studies. Further, this grid specifies the focus of the C-L activity, either the patient or health care professional. It seems clear that the very recent shift from descriptive studies to more outcome-oriented research, particularly regarding patient outcomes, should be the direction of the future. A greater emphasis on defining the exact components of C-L work that are most useful is also indicated. Several other specific recommendations for evaluative research in C-L psychiatry conclude this review.

Eighteen months' use of DSM-III by a consultation-liaison service in a university hospital is reported. DSM-III's multiaxial system seems to be feasible and revealing, but presents some problems. Adjustment Disorder and Organic Mental Disorders were the most frequent Axis I diagnoses. Approximately one-fourth of the patients received an Axis II diagnosis and 85% received an Axis III diagnosis. In 70% of the patients there was both a psychiatric diagnosis (on Axis I or II) and a physical disorder (on Axis III). On Axis IV and V, this population appeared to be under moderate to severe psychosocial stress and had, as a group, a fair or better level of previous adaptive functioning. The possible significance of these findings and potential areas for further refinements and investigations are discussed.

Gastrointestinal diseases are notoriously protean in their modes of expression. The patient's description of symptoms is particularly important, but psychologic, physiologic, and social factors can cause data-base unreliability. Many of the patients termed crocks have symptoms referable to the gastrointestinal system, and they are at considerable health risk, since they usually alienate health care personnel. Patients with pancreatitis usually have a history of heavy alcohol intake which also needs treatment. Behavioral disturbances are related to toxic psychosis. Pancreatic carcinoma has a higher incidence of associated psychiatric symptoms than other types of cancer. Biologic, psychologic, and environmental factors all interact dynamically to cause peptic ulcer disease. There is a high correlation between the severity of inflammatory bowel disease and degree of emotional disturbances.

Data on religious belief, activity, and connections, and ratings of happiness, life satisfaction, and pain level were obtained periodically from 71 patients with advanced cancer. Religious belief showed substantial positive correlation with life satisfaction, and religious activity and connections were significantly correlated with both happiness and life satisfaction. Religious patients also reported significantly lower levels of pain, even though they were no less likely to report the presence of pain. Data from the 36 patients who have since died show no correlation between the religion variables and duration of survival. In general, the patients showed little change in religious belief over time. Religion seems to be an important source of support for many patients.

To test the hypothesis that cognitive impairment may be present early in the course of HTLV-III/LAV infection, intravenous drug abusers (IDVAs) without overt symptoms of AIDS related illness were tested with standard neuropsychological and psychosocial measures. This study is the baseline for a prospective longitudinal study of the natural history of HTLV-III/LAV infection in this high risk population. Of 211 subjects initially evaluated, 70 (33%) were HTLV-III/LAV seropositive and 141 (67%) were seronegative. At the baseline, by univariate analysis, the seropositive IVDAs were significantly (p less than .05) more impaired than seronegatives on 4 of 8 measures: Finger Tapping--dominant, hand, Digit Span Forward, Trail making A and WAIS-Similarities. However, by multivariate analysis the seropositives were significantly more impaired only on the WAIS-Similarities and Wechsler--Associative Learning tests. Multiple factors such as drug use and psychological stress may have influenced test performance. These preliminary results, however, suggest that seropositive IVDAs may show evidence of impaired neuropsychological function even in the absence of AIDS related symptoms and are consistent with the hypothesis of the early neurotropism of HTLV-III/LAV.

Behavioral medicine is a newly emerging field dating back to the early 1970s. In this short time, a great deal of controversy and confusion has arisen as to even the definition of the term. Similarly, there are now a variety of different operational applications of this concept in patient care, research, and health care system organizations. It is proposed that the title "behavioral medicine" be used in the most general way, consistent with the definition developed by the Institute of Medicine meeting in 1978. In it, behavioral medicine is a term designating a very large field and is not analogous to a profession, medical specialty, or discipline. This term denotes a body of psychologic and social knowledge and a set of techniques applied to research, prevention, and treatment of medical illness, including psychiatric illness. By this definition, behavioral medicine treatment techniques would include psychotherapy, hypnosis, relaxation, behavior therapy, behavior modification, biofeedback, and pharmacotherapy. One of the cardinal principles of behavioral medicine as a field is that well-defined treatment techniques are used for specific target symptoms or signs of illness. It is proposed that individual behavioral medicine treatment programs be called by the name of either the specific treatment utilized or of the target(s) of the intervention. It is important to ensure collaboration between the variety of treatment and research programs that would fall under this general definition of behavioral medicine, which includes consultation-liaison psychiatry. An organizational model is proposed that would combine all such programs within a multidisciplinary division of a department of psychiatry. This division might be entitled with one or both names, e.g., "consultation-liaison psychiatry and behavioral medicine." Perhaps most importantly, this new field should not promise more than it may be able to provide, particularly in trying to achieve the biopsychosocial model of medicine. Many factors have contributed to the rise of biomedicine and to the decline of personal medicine, most of them far beyond the scope and control of behavioral medicine.

Two groups of patients undergoing hemodialysis for chronic renal failure were prospectively studied for twenty-four months. Group A patients (n=12) were dialyzed on Mondays and Thursdays; Group B patients (n=9) on Tuesdays and Fridays. Although patients were supposedly assigned to dialysis groups on a random basis, over a twenty-four month period Group A had significantly more deaths (7 patients) than did Group B (none). This phenomenon is interpreted in the framework of an ongoing intergroup interaction among patients and between patients and staff, as conceptualized in the Tavistock Model propounded by Bion. It is hypothesized that in the dialysis unit, unconscious splitting by the staff led to a bias in patient-group assignment, such that those patients with more severe personality disruption, and "bad" in that sense, were assigned to Group A. Since patients in Groups A and B did not differ significantly in biological or demographic parameters at time of entry into the study, it is suggested that the increasing density of psychopathology in Group A was related to poorer care, more physical morbidity and a decreasing survival rate. Although no intermediary psychobiological mechanisms were defined, these findings suggest a significant interaction between the social, psychological and biological factors determining survival on chronic renal hemodialysis, beginning with the treatment decision and continuing throughout the course of treatment. These phenomena should be studied further and may have important implications for planning patient care and patient-staff interactions.

A multigeneration family with polycystic kidney disease (PCKD) was studied by personal interviews of all affected and most suspected-affected adults. A clear pattern of denial was identified, which strongly influenced individuals' awareness of PCKD and individuals' taking actions appropriate to that awareness, as well as family cohesion and communication. Time lags--in fact, availability, awareness and action-taking had serious consequences in terms of continued genetic transmission, future "burden" to the family and society, and the psychological stability of individual family members. The potentially important roles of the family physician in this type of familial disease are discussed as: a source of information, a facilitator of awareness and appropriate action, and a counselor in assisting adaptation to this major life stress.

The teaching of consultation liaison (CL) psychiatry to psychiatric residents, medical students, and other trainees is reported from 92 medical schools, representing 81% of those surveyed with a one-page questionnaire. Psychiatric residency programs devote approximately 10% of their time to CL training, a slight increase over the percentage ten years ago. Approximately 35% of medical students in programs from which we received responses have some consultation CL education, although this varies from a few seminars to an eight-week full-time rotation. Other trainees receiving CL experience include nonpsychiatric residents and interns (22 programs), psychologists (18), nurses (12), and social workers (5). Program directors report an approximately 90% "favorable" reaction to such training by all trainees. Consultation liaison training for residents still represents a small portion of their entire experience. A surprisingly large percentage of medical students are exposed to CL education, but with tremendous variation in that exposure. Other trainees are not heavily involved in CL programs, indicating a possible future expansion of integrated psychosomatic teaching. The data presented should serve as a comparative baseline for future program design.

The Karnofsky Performance Status Scale (KPS) was designed to measure the level of patient activity and medical care requirements. It is a general measure of patient independence and has been widely used as a general assessment of patient with cancer. Although there is a long history of use of the KPS for judging cancer patients, its reliability and validity have been assumed without formal investigation. The interrater reliability of the KPS was investigated in two ways, both of which gave evidence of moderately high reliability. The patients evaluated in their home were usually assigned a lower KPS score compared with a similar evaluation at the same time done in the outpatient clinic. Costruct validity of the KPS was demonstrated by strong correlation with several variables relating to physical function. On-study KPS score accurately predicted early death, but high initial KPS scores did not necessarily predict long survival. Patient deterioration with subsequent death within a few months could be predicted to a limited extent by a rapidly dropping KPS. These results suggest that the KPS has considerable validity as a global indicator of the functional status of patients with cancer and might be helpful for following other patients with chronic disease.

In a prospective controlled study, patients with incurable cancer and an estimated prognosis of three months to one year were allocated to two patient groups for evaluation of supportive interventions. One group, called "intensive," received home visits by a nurse practitioner acting as an extension of a multidisciplinary team; the other, termed "nonintensive," did not receive such visits. Both patient groups were periodically evaluated in their homes by an observer and by self-ratings, to measure changes in quality of life as their disease progressed. Several methodologic problems were identified, which have implications for future research. Pain problems later in the course of cancer seem to be predictable in those patients with higher scores on the Cornell Medical Index M-R scales (greater emotional disturbance) and on the Rotter Locus of Control (I-E) scale (expectation of more external control of self). The study also found that the home visiting nurse practitioners, specially trained in pain treatment, improved pain control in the "intensive" group of patients over the last 90 days of life, when pain was an increasingly major problem. Such nurses can significantly improve the quality of life for patients dying outside of institutions.

Nine hundred ninety-seven breast biopsies that were performed at one hospital over the five-year period from 1971 through 1975 were reviewed because of a changing pattern in the use of breast biopsies on outpatients who were under local anesthesia. In 1971, 17% of all breast biopsies were performed as outpatient procedures; by 1975, the figure was 60%. In 1971, 5% of all malignant neoplasms were diagnosed by the use of biopsies as outpatient procedures and 30% in 1975. Hospital charges for biopsy on an inpatient basis of benign breast disease were 7.2 times higher than for biopsy on an outpatient basis. Interviews of 102 patients clearly suggested that most patients were satisfied with the outpatient breast biopsy experience. Outpatient breast biopsy under local anesthesia is a safe procedure that is more economical in terms of medical cost, surgeons' time, and patients' time away from home and/or job. Preliminary biopsy of malignant lesions using local anesthesia permits more efficient use of diagnostic procedures to stage the extent of disease prior to treatment. Patient acceptance of breast biopsy as an outpatient procedure under local anesthesia was similar to their acceptance of biopsy on an inpatient basis under general anesthesia.

The dialysis exercise is a small group decision-making clinical simulation which has been completely successful as an educational technique. The success of the exercise stems from its ability to engage students cognitively and affectively while teaching problem solving skills. This complete learning package is presented, together with comments on our experience, for use in other settings.