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The current adult and child forensic psychiatrist is well trained, familiar, and comfortable with the use of the semi-structured Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA 2013 (DSM-5) [In APA, 2003] interview style. The author's assertion is not that this method is invalid or unreliable; rather, that it can be complemented by integrating elements of the defendant's four pillar assessment. Assessing the four pillars expands on the information provided by a semi-structured DSM-5-style interview in psychiatry. The four pillars are the foundation of a person's personality; temperament, cognition (learning abilities or weaknesses), cognitive flexibility (theory of mind) and internal working models of attachment, within the backdrop of the family and of the social and cultural environment in which they have lived. The importance of the study of four pillars is based on the understanding that human behavior and psychopathology as a complex and multifaceted process that includes the level of social-emotional maturity and cognitive abilities (In Delgado et al. Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015). The four pillars are not new concepts, rather they had been studied by separate non-clinical disciplines, and had not been integrated to the clinical practice. As far as we know, it wasn't until Delgado et al. (Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015) incorporated the four pillars in a user-friendly manner to clinical practice.

Suicide in children and adolescents is a serious cause of concern for emergency department physicians. Suicide remains a leading cause of death and potential years lost in children and adolescents. Children who are acutely suicidal often present to the emergency department for medical and psychiatric care and evaluation. This article will discuss the epidemiology of suicide in children and provide the emergency physician a framework from which to evaluate and manage children who are acutely suicidal.

Selective serotonin reuptake inhibitors (SSRIs) are usually well tolerated in the pediatric population, and widely used in the treatment of obsessive-compulsive disorder (OCD). Of the 51 pediatric patients with obsessive-compulsive disorder seen in our outpatient clinic between January 2009 and July 2009, 3 of them developed behavioral disinhibition after treatment with fluvoxamine. These cases are described and discussed in relation to the use of CYP2D6 and CYP2C19 pharmacogenetic testing in patients treated with serotonin-selective reuptake inhibitors.

The objective of this study was to determine the efficacy and safety of valproic acid versus risperidone in children, 3-7 years of age, with bipolar I disorder (BPD), during a mixed or manic episode.Forty-six children with Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision (DSM-IV-TR) diagnosis of bipolar disorder, manic, hypomanic, or mixed episode, were recruited over a 6 year period from two academic outpatient programs for a double-blinded, placebo-controlled trial in which subjects were randomized in a 2:2:1 ratio to risperidone solution, valproic acid, or placebo.After 6 weeks of treatment, the least-mean Young Mania Rating Scale (YMRS) total scores change, adjusted for baseline YMRS scores, from baseline by treatment group was: Valproic acid 10.0±2.46 (p=0.50); risperidone 18.82±1.55 (p=0.008); and placebo 4.29±3.56 (F=3.93, p=0.02). The mixed models for repeated measure (MMRM) analysis found a significant difference for risperidone-treated subjects versus placebo treated subjects (p=0.008) but not for valproic acid-treated subjects versus placebo-treated subjects (p=0.50). Treatment with risperidone over 6 weeks led to increased prolactin levels, liver functions, metabolic measures, and weight/body mass index (BMI). Treatment with valproic acid led to increases in weight/BMI and decreases in total red blood cells (RBC), hemoglobin, and hematocrit.In this small sample of preschool children with BPD, risperidone demonstrated clear efficacy versus placebo, whereas valproic acid did not. The laboratory and weight findings suggest that younger children with BPD are more sensitive to the effects of both of these psychotropics, and that, therefore, frequent laboratory and weight monitoring are warranted.

The aim of this retrospective chart review was to evaluate the effectiveness and tolerability of aripiprazole for the treatment of children and adolescents with bipolar disorders.The medical charts of all children and adolescents with a DSM-IV diagnosis of bipolar disorder, type I, type II, not otherwise specified (NOS), or schizoaffective disorder, bipolar type, and who were treated with aripiprazole were reviewed by two child and adolescent psychiatrists who independently confirmed their DSM-IV diagnoses, severity, and the improvement of illness using the Clinical Global Impression (CGI) Severity and Improvement scores for bipolar disorder (CGI-BP) and the Clinical Global Assessment Scale (CGAS).Thirty patients who were treated with aripiprazole were identified (mean starting dose=9 +/- 4 mg/day, mean final dose=10 +/- 3 mg/day). The overall response rate, defined by a CGI-Improvement score ofor = 2 at endpoint, was 67%. There was a statistically significant improvement in CGAS scores (48 +/- 11 to 65 +/- 11, signed rank = 191, p0.0001) and CGI-S scores (4.2 +/- 0.8 to 2.8 +/- 1.0, signed rank=-172, p0.0001, effect size=1.90) from baseline to endpoint. No serious adverse events were identified. Common side effects were sedation (n=10, 33%), akathisia (n=7, 23%), and gastrointestinal disturbances (n=2, 7%). Baseline and endpoint weights were available for 14 (47%) of the patients. Change in weight ranged from +5 to -21 kg and 12 (86%) of 14 patients lost weight (mean weight loss was 3 +/- 6 kg).This retrospective chart review suggests that aripiprazole may be effective and well tolerated for children and adolescents with bipolar disorders. Controlled studies of aripiprazole for the treatment of pediatric bipolar disorder are necessary.

The modern child and adolescent psychiatrist is well trained, familiar, and comfortable with the use of the structured DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA 2013) interview style. In some contexts, an even more structured interview may be desired, and several well-validated tools are available to achieve this, including the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) and the Schedule for Affective Disorders and Schizophrenia for School Aged Children: Present and Lifetime Version (K-SADS-PL ), which have both been demonstrated to have high levels of interrater and test–retest reliability. Thus, our assertion is not that these methods are invalid or unreliable; rather, they are somewhat limited when seen within the context of a contemporary two-person relational psychology model in understanding human behavior and psychopathology.

This chapter reviews some of the leading experts who have contributed to the field of child and adolescent two-person relational psychotherapy through their research. The list is by no means complete as it would be beyond the scope of this book to include all of those who contributed to further expand the understanding of the complexities of infant development . We limit this review to the authors who pursued infant–caregiver research—the “baby watchers,”—and spawned the concepts most applicable to the two-person relational psychodynamic psychotherapy of children and adolescents.

Middle school age youth are those from ages 10–14 years old. This period is also referred as prepuberty , preadolescence , and early adolescence . During this period, youth experience biological, psychological, and social changes. There are dramatic changes in the physical development, encompassing height, weight, and sexual development. Although maturity during this period occurs at varied rates, generally in girls it occurs 1.5–2 years earlier than in boys.

Modern neuroscience has advanced significantly since Freud ’s initial Project for a Scientific Psychology, in which he hoped to apply scientific principles to the emerging discipline of psychoanalysis. As such, a sophisticated quest to understand the human mind—over the last 125 years—has led to the discovery of a radically different landscape than that which Freud had envisioned. In this regard, multimodal scientific investigations have openly questioned the validity of Freud’s concepts: “[Modern] science not only fails to support the central tenets of Freudian dream theory but raises serious questions about other strongly held psychodynamic assumptions including the nature of the unconscious mind, infantile sexuality, the tripartite model of the mind, the concept of ego defense, free association and the analysis of the transference as a way of effecting adaptive change”. Moreover, recent advances in neuroimaging and neurodevelopmental research have profoundly advanced our understanding of the key areas of “the relational brain,” the substrate for two-person relational psychotherapy. Herein, we will briefly review the historical developments of two-person relational psychotherapy, and in doing so, we will detail the specific advances in developmental psychology. Additionally, we will review the key theorists and researchers whose work and behavioral experiments made possible the neurophysiological investigations, which have, in turn, given rise to our nascent understanding of the neurophysiology of attachment and intersubjectivity.

Children typically begin elementary school—primary education—at 5 years old, after kindergarten. Elementary school generally goes through the sixth grade, typically to 11 years old. In elementary school, children learn the basics of reading, math, science, and other subjects on which later learning will build. Socialization skills are an important aspect of this period. Granic and Patterson (Psychol Rev 113(1):101–131, 2006) eloquently stated, “Parents and children are confronted with a variety of daily tasks (e.g., clean-up time, playing games, problem solving when conflict arises, eating dinner together). From our perspective, the extent to which parents and children can flexibly and appropriately respond, emotionally, cognitively, and behaviorally, to shifts in contexts may tap a repertoire of alternative strategies that correspond to how children will adapt to future challenges at school and with peers.” Thus, during this age, the child’s most skilled way in communicating his or her affective states is initially through playing and making drawings, and later, in preadolescent years, verbal communication takes hold.

Adolescence is a developmental period of life that commences with the onset of puberty and artificially ends with adulthood. The twenty-first century saw substantial advances in understanding the biological, psychological, and sociological aspects of adolescent development. Moreover, accumulating data support the notion that adolescent behavior cannot be reduced to purely psychological or biological phenomena. Rather, an understanding of any aspect of adolescence is best derived from an appreciation of biology and psychology and their respective interfaces. For example, imaging studies of adolescent brains confirm aspects of fluidity in decision making and a number of other cognitive capacities. Giedd explains that during adolescence, the area of the brain responsible for organization, planning, and strategizing is not fully developed, as the gray matter continues to thicken. In turn, these neuroanatomic changes likely occur in tandem with changes in the implicit relational memory processes. Further, the scientific literature confirms the belief that adolescence is a period of inordinate risk taking and complexities in decision-making processes.

The empirical study of infants and toddlers confirmed what Bowlby (1969) and Winnicott (1971) had believed: that the infant was indeed a “social being.” This hypothesis inspired a generation of developmental researchers to search for the neurobiological underpinnings of childhood psychological growth and behavioral issues. Today, there is little debate that the human brain is a social organ. The changes undertaken by the brain from infancy to adulthood are mediated by the processes of emotional availability, attachment, affect regulation, and cognition, which all play a central role in two-person relational psychotherapy. Cozolino, a developmental neuroscientist, writes, “A therapist attempts to restructure neural architecture in the service of the more adaptive behavior, cognition, and emotion” (2010). Additional research has demonstrated that infants have an innate bias toward self-regulation and mastery and work to create a coherence of their perceptual experience and maintain organization of their happenings. As such, we currently are in an era in which the importance of what happens during infancy, stored as relational schemas in nondeclarative memory systems, can be nonconsciously retrieved by the patient and changed through here-and-now new emotional experiences with the psychotherapist. This is in contrast to Gilmore and Meersand (2014), who in their very much traditional one-person psychology book on child and adolescent development regrettably state, “Although we concur that certain basic interpersonal, emotional, and biological needs must be met in infancy for development to proceed, we do not see infancy as the preeminent developmental moment” (italics ours). Therefore, we provide the reader the necessary information from infant developmental research to help elucidate that infancy is in fact a preeminent developmental moment.

Attachment theory and infant developmental research have confirmed the ubiquitous nature of the innate bidirectional mode of communication that exists in everyday human interactions. From birth, the infant learns to make meaning of the experiences with its caregivers in order to develop internal working models of attachment that reflect implicit patterns of stable or unstable mental representations of self and others. When the internal working models of attachment are created in a secure and stable manner, it allows the child to understand and predict the intent of others in their environment, and it implicitly becomes a survival-promoting tool allowing for proximity with others, establishing a psychological sense of “felt” security. Further research has provided a better understanding of how cognitive and memory systems shape a person’s experiences when interacting with others in what are called moments of intersubjectivity —the dynamic interplay between two people’s subjective experiences (Chap. 5). Intersubjective experiences allow for “being with” and “getting” another person’s state of mind and their intentions. It is this dynamic interplay of subjectivity that, when things go well, lead to adaptive models of relating with others. These models are stored in nonconscious and nondeclarative memory systems in what is known as “implicit relational knowing ,” which begins to be represented before the availability of language. Intersubjectivity promotes a cohesive and more flexible way of reflective abilities to know what works for healthy social reciprocity with implicit aspects of morality. Rustin and Sekaer (2004) aptly state: “Experience, in an average expectable environment, enables genetic programs to unfold and puts the fine tuning on the genetic framework. From this new perspective the brain itself is relationally constructed.”

In the last two chapters, we laid the groundwork to distinguish between traditional one-person and two-person relational psychologies. The astute reader will recognize that the terms that are used within each theoretical model may, in fact, ultimately complicate one’s ability to distinguish between the two psychologies. As Bornstein (2001) states, “Many psychoanalytic terms and concepts became so widely know that they evolved into colloquialisms, recognized even by persons with little or no formal exposure to psychology.” In fact, some of the two-person relational literature often retains the language of the traditional one-person model. Nonetheless, it is critical to clarify the differences in the meaning of the terms used in one-person psychology, which continue to prevail in the psychotherapeutic lexicon, as ultimately these terms evolved to represent two-person relational model constructs. In this regard, there are numerous everyday examples involving clinicians using traditional one-person psychology concepts to understand another person’s behaviors, as if the clinician clairvoyantly knew the nature of the patient’s unconscious. For example, a clinician may describe an adolescent girl who dates older men as having “father/daddy issues,” or a male adolescent who struggles with intense closeness and “neediness” in his relationships as having “mother/mommy issues.” These comments forestall a true understanding of the patient for several reasons. First, the clinician—in using these terms—assumes that the patient has unconscious intrapsychic conflicts (e.g., maladaptive behaviors represent ego defense mechanisms against the pressures from intrapsychic conflict). Second, the clinician fails to take into account the many aspects of the adolescent’s innate temperament , cognition, and internal working models of attachment that influenced his or her relational patterns. Third, in the case of the adolescent girl who dates older men, it is important to consider that in early childhood, she may have had the emotional availability and affective attunement needed provided by warm and caring men in her family (e.g., father, brothers, uncles, cousins, neighbors) and limited affective attunement from the women in her family. As such, her development occurred in an environment where older men may have represented, in a nonconscious way, implicit relational knowings, as safe and caring and likely adaptive. Herein, her wish for closeness to older men to provide the needed affective attunement may have been adaptive in spite of the age difference, as true compatibility is not a simple issue of biology or social construct. Fourth, this also forestalls the fact that for another adolescent, an older man may represent maladaptive childhood experiences of demanding and abusive men that provided some support to her, seen in disorganized forms of attachment. Thus, in the case of the adolescent with a disorganized attachment style, her choice of older men reflects a return to maladaptive implicit relational knowings during adolescence. For the adolescent boy, his clinginess to women may also represent cocreated experiences of safety when close to women and fearful being close to men as a child, stored in implicit nondeclarative memory . Further, both adolescents may have temperament or cognitive weakness that predisposed them to engage in maladaptive behaviors, and, as such, these behaviors may not be attributable to their parents or to their environment per se. Thus, a two-person relational model allows for teasing apart the complexities of nature and nurture through here-and-now experiences between patient and clinician.

In this chapter, we discuss some of the everyday challenges facing the psychotherapist who embarks upon the regular practice of two-person relational psychodynamic psychotherapy. By actively “setting the frame” for the patient and parents, a psychotherapist starts the psychotherapeutic process on a strong foundation. There is consensus that in most forms of psychotherapy, the psychotherapist benefits by providing an outline of what the patient and his or her family can expect once they agree to participate. It is best to launch the psychotherapeutic process after the psychotherapist sets the frame with the patient and their parents or caregivers so they can have some predictability about what will occur during the process and avoid having surprises when conflict arises.

Difficult psychiatric consultations : , Difficult psychiatric consultations : , کتابخانه دیجیتال جندی شاپور اهواز

In this chapter, we have provided a foundation to better comprehend the importance that innate biological and genetic processes have in forming a patient’s unique core sense of self, as well as their intrapsychic and interpersonal psychological functioning. With a greater grasp of these concepts, the consulting psychiatrist can begin to use the psychodynamic tenets to understand the patient’s personality style and may develop a psychodynamic formulation, regardless of his or her theoretical orientation, to facilitate the implementation of practical treatment interventions in difficult consultations.

Ethical and medicolegal issues are an inherent part of difficult psychiatric consultations and, as we have illustrated, create special challenges for the consulting psychiatrist working with both pediatric [Ascherman and Rubin (Child Adolesc Psychiatr Clin N Am 17:21–35, 2008)] and adult populations [Arras and Steinbock (Ethical issues in modern medicine, Mayfield, 1998); Gutheil et al. (J Am Acad Psychiatry Law 33(4):432–436, 2005)]. Among the key issues which must frequently be addressed include: autonomy , nonmaleficence , beneficence , and justice . Additionally, the consulting psychiatrist should be savvy regarding the state laws related to involuntary hospitalization as well as the process by which this occurs. Finally, it is critical for the consulting psychiatrist working with the difficult psychiatric consultation to have a strong working understanding of confidentiality , privilege , and the limits limitations of these concepts.

In addition to providing standard consultation (e.g., clarifying diagnosis, providing psychopharmacologic recommendations, ordering diagnostic studies), an added goal of the consultant may be to influence, over time, the treatment team's ability to use psychodynamic and attachment theory concepts in difficult cases. It is helpful for the psychiatric consultant to teach treatment-team members that the way patients and families perceive the team is a replay of a dynamic that’s familiar to them and that they therefore unconsciously seek to recreate. When the consultant works with the same treatment team over time, he or she may be in a position to familiarize members with psychodynamic and attachment theory concepts in the medical setting, thus improving the manner in which the team approaches patients. Treatment-team members frequently have countertransference reactions to patients, families, and to psychiatric consultants. The members who are especially at risk are those with a limited ability to mentalize. However, it is important to remember that in contemporary theory, the psychiatric consultant’s countertransference also contributes to consultative process interactions in here-and-now moments.

Presenting case material to colleagues requires preparation, whether the presentation is to be made casually during bedside rounds or in the formal environment of a national meeting. It is rewarding when a presentation is well received, particularly because it may prove helpful to other clinicians, allied health professionals, and researchers. Regardless of the setting, the presenter’s goal is to share their knowledge based on observations they have made and lessons they have learned from the case or cases. The most time-consuming aspect of the patient-oriented presentation is collecting and organizing as much information as possible about the patients, their families, and others who were involved in the patients’ care. Once these tasks are complete, the presenter must summarize the information and place it within the context of treatment data and consensus approaches. Tailoring the talk to the audience is also of paramount importance. Different groups will invariably come from different disciplines, and the presentation will need to be tailored to accommodate each audience’s background, interests and goals.

In psychodynamic psychotherapy with adolescents, termination-the phase of treatment during which the patient and his or her parents end a therapeutic relationship with a therapist-has received limited attention in the extant literature. Despite this oversight, termination is of critical clinical importance. This phase of psychotherapy with adolescents is heralded by the integration and consolidation of progress, relational changes, and the relinquishing of the symptoms that brought the adolescent to treatment. Herein, the relevant literature surrounding termination in psychodynamic psychotherapeutic work with adolescents will be reviewed. Important aspects of termination will be highlighted and discussed, including (1) criteria for termination, (2) techniques for working with parents, (3) "forced terminations," (4) countertransference, and (5) common complications that arise during this phase of treatment. Finally, the complexities of the termination process as well as recent contributions to our understanding of this critically important process from attachment theory and intersubjectivity will be illustrated with clinical material.

The treatment of children and adolescents with psychotherapy is gradually losing ground to psychopharmacology. The author reviews the value the various forms of psychotherapy have in the treatment of children and the importance of having a clear curriculum for teaching this skill in residency programs. Although the importance of psychodynamic psychotherapy has a long history in the treatment of children, the reluctance some faculty have in recommending this form of therapy may be due to limited experience and limited knowledge of its benefits. The author highlights that a psychodynamic diagnostic evaluation is essential to assess a child’s suitability for psychotherapy. The characteristics of children who will benefit from psychodynamic psychotherapy, their defense mechanisms, and optimal characteristics of their parents are reviewed. The qualifications a psychiatrist needs to succeed in this endeavor are discussed. Two cases illustrate not only the importance in the suitability of the patient, but also the application of psychodynamic theory to practice.

Objective: To conduct a pilot study comparing the effects of quetiapine and placebo for the treatment of depressive episodes in adolescents with bipolar I disorder. Method: Thirty-two adolescents (ages 12–18 years) with a depressive episode associated with bipolar I disorder were randomized to eight weeks of double-blind treatment with quetiapine, 300–600 mg/day, or placebo. This two-site study was conducted from March 2006 through August 2007. The primary efficacy measure was change in Children’s Depression Rating Scale–Revised Version (CDRS-R) scores from baseline to endpoint. Secondary efficacy measures included change in CDRS-R scores over the eight-week study period (PROC MIXED), changes from baseline to endpoint in Hamilton Anxiety Rating Scale (HAM-A), Young Mania Rating Scale (YMRS), and Clinical Global Impression–Bipolar Version Severity (CGI-BP-S) scores, as well as response and remission rates. Safety and tolerability were assessed weekly. Results: There was no statistically significant treatment group difference in change in CDRS-R scores from baseline to endpoint (p = 0.89, effect size =−0.05, 95% confidence interval: −0.77–0.68), nor in the average rate of change over the eight weeks of the study (p = 0.95). Additionally, there were no statistically significant differences in response (placebo =67% versus quetiapine = 71%) or remission (placebo = 40% versus quetiapine = 35%) rates, or change in HAM-A, YMRS, or CGI-BP-S scores (all p > 0.7) between treatment groups. Dizziness was more commonly reported in the quetiapine (41%) than in the placebo (7%) group (Fisher’s exact test, p = 0.04). Conclusions: The results suggest that quetiapine monotherapy is no more effective than placebo for the treatment of depression in adolescents with bipolar disorder. However, limitations of the study, including the high placebo response rate, may have contributed to our findings and should be considered in the design of future investigations of pharmacological interventions for this population.