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Objective: The use of the terms 'mind' and 'brain' in psychiatry is often associated with a set of polarities. Concepts such as environment, psychosocial, and psychotherapy are linked with 'mind,' while genes, biology, and medication are often associated with 'brain.' The author examines these dichotomies as they apply to personality disorders. Method: Research on antisocial and borderline personality disorders that is relevant to these dichotomies is evaluated. The implications of the findings for the understanding of pathogenesis and treatment are reconsidered. Results: In the clinical setting, it is problematic to lump together terms such as 'genes,' 'brain,' and 'biological' as though they are separate and distinct from terms such as 'environment,' 'mind,' and 'psychosocial.' These dichotomies are problematic, because genes and environment are inextricably intertwined in the pathogenesis of personality disorders, psychosocial experiences may result in permanent changes in the brain, and psychotherapy may have its effect by altering brain structure and function. The 'theory of mind' is a useful construct for bridging 'mind' and 'brain' in the treatment of personality disorders. Conclusions: Severe personality disorders are best understood and treated without 'either-or' dichotomies of brain and mind. Each domain has a different language, however, and the language of the mind is necessary to help the patient develop a theory of mind.

Objective: The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry. Method: After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness. Results: Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient. Conclusions: The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs. (Am J Psychiatry 2001; 158:1956-1963)

Objective: The authors reviewed data involving the impact of providing psychotherapy for psychiatric disorders on costs of care. Method: In a search of the MEDLINE database limited to peer-reviewed papers published from 1984 through 1994, 686 articles were identified. Forty-one articles, covering 35 studies, were found in which the intervention tested was psychotherapeutic and the study included measures of outcome that had some implications for cost. The exclusion criteria for reviewing these studies included absence of a comparison group, a focus on medical disorders instead of psychiatric illnesses, and outcomes that did not include cost data or measures from which costs could be inferred. On this basis, 18 of the 35 studies were selected for analysis. The studies were categorized according to whether or not subjects were randomly assigned to study groups. Two reviewers independently read each study to identify the following characteristics: inclusion criteria, exclusion criteria, types of interventions, main outcome variables, sample size, and statistical tests for significant differences between treatments. Outcomes had to include actual cost accounting or data on medical care utilization or work functioning. Results: The findings of eight (80%) of the 10 clinical trials with random assignment and all eight (100%) of the studies without random assignment suggested that psychotherapy reduces total costs. Conclusions: Psychotherapy appears to have a beneficial impact on a variety of costs when used in the treatment of the most severe psychiatric disorders, including schizophrenia, bipolar affective disorder, and borderline personality disorder. Much of that impact accrues from reductions in inpatient treatment and decreases in work impairment.

The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct. These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context. Heightened awareness of the concepts of boundaries, boundary crossings, and boundary violations will both improve patient care and contribute to effective risk management. (Am J Psychiatry 1993; 150:188-196)

Objective and Method: To illustrate the continued relevance of psychodynamic thinking in the practice of contemporary psychiatry, the author reviews a number of studies that demonstrate the intimate connection between psychosocial and neurophysiological factors in the etiology and pathogenesis of psychiatric disorders. A survey of three specific anxiety disorders illustrates the complex interaction between mind and brain in these disorders. Results: Research on both primates and humans suggests that psychological influences result in permanent alterations of a neurobiological nature. Similarly, psychological interventions in a treatment context may have a profound impact on neurophysiology. Clinical case examples demonstrate that 'biologically based' disorders may be rich in unconscious meaning. Clinical understanding of the meaning of symptoms may be instrumental in ensuring patients' compliance with pharmacotherapy regimens and in the removal of other resistances to treatment. Conclusions: In contemporary psychiatry, a psychodynamic perspective must be preserved. Without it, meaning will be lost, and both diagnostic understanding and informed treatment planning will suffer as a result. (Am J Psychiatry 1992; 149:991-998)

Managed care and close scrutiny of third-party reimbursement have had a significant impact on the practice of inpatient psychiatry. Treatment plans are often undermined by untimely loss of coverage. Impulsive, aggressive patients who require long stays in highly structured environments are often discharged prematurely because reviewers insist on discharge as soon as they demonstrate signs of improvement. Several case examples are presented to illustrate ways in which insurance reviews can adversely affect patients. Suicidal patients often react to an impending review as a threat to their treatment and safety. This type of stress has been shown to lead to hopelessness and suicide attempts. Borderline patients, who use primitive defenses such as projection and splitting (tending to see people, oneself or situations as either all good or all bad), are also affected by insurance review. For example, a hostile reviewer becomes an easy target for the patient's negative projections, and can be viewed by the patient as a container for all that is evil and bad, so that the treatment staff then becomes viewed as representing all that is good. This leads to problems during hospital discharge, because such patients cannot successfully separate from caretakers viewed so idealistically. Clinicians given time constraints can unconsciously push patients towards a speedy recovery. This pressure can make patients more oppositional, or make them feel alone and misunderstood. Sometimes, patients who resist or resent treatment can ally with insurance reviewers and demand premature release. Family members may also collude with the reviewers to ensure a release that is not necessarily in the patient's best interests. The point is made that cost-effective and psychodynamically effective solutions will require negotiations and compromise between payers and treatment providers. (Consumer Summary produced by Reliance Medical Information, Inc.)

Drew Westen thinks that the DSM-IV system, a two-pronged diagnostic system proposed by Hughlings Jackson, was confirmed in a study conducted at the Cambridge Hospital. In the said study, clinicians are found to diagnose personality disorders differently from scientific researchers. In addition, the researchers found that the said classification system is atheoretical in terms of examining the character of other persons. Researchers and practitioners must agree on a single set of standards to avoid diagnostic errors from occurring.

Splitting is a concept that describes several different phenomena commonly seen in hospital treatment of psychiatric patients. The authors use it to define situations in which intrapsychic and interpersonal splitting occur simultaneously, recreating the patient's internal object world in the hospital surrounding. In splitting, the patient tends to divide people about whom he or she has ambivalent feelings into glorified saviors and devalued or hated malefactors. Staff members unconsciously identify with projected aspects of the patient and behave accordingly, thus justifying or reinforcing the psychotic behavior. A clearer understanding of splitting in the hospital helps to distinguish between common variants of splitting and to develop strategies to treat the condition. (Consumer Summary produced by Reliance Medical Information, Inc.)

The guideline forwarded by the American Psychiatric Assn regarding the treatment of patients with panic disorder drew some criticisms from a number of experts in the field. Among the criticisms directed against the guideline are the absence of a discussion on the speculative etiology of the disorder, the effective use of clonazepam, the conflicting results of drug trials, the failure of the guideline to recognize psychodynamic psychotherapy and psychoanalysis as effective treatment modalities and the lack of objective evaluation of the recommended modalities in the guideline.