A Resident's Guide to Psychiatric Education

A Resident's Guide to Psychiatric Education

CRITICAL ISSUES IN PSYCHIATRY An Educational Series for Residents and Clinicians Series Editor: Sherwyn M. Woods, M.D., Ph.D. University of Southern California School of Medicine Los Angeles, California A RESIDENT'S GUIDE TO PSYCHIATRIC EDUCATION Edited by Michael G. G. Thompson, M.D. STATES OF MIND: Analysis of Change in Psychotherapy Mardi J. Horowitz, M.D. DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment Mark A. Schuckit, M.D.

A Resident's Guide to Psychiatric Education Edited by Michael G.G.Thompson, M.D. Director of Education Department of Psychiatry University of Western Ontario and Medical Director and Chief of Staff London Psychiatric Hospital London, Ontario, Canada PLENUM MEDICAL BOOK COMPANY New York and London

Main entry under title: Library of Congress Cataloging in Publication Data A Resident's guide to psychiatric education. (Critical issues in psychiatry) Bibliography: p. I ncludes index. 1. Psychiatry - Handbooks, manuals, etc. 2. Psychiatry - Study and teaching (Residency) I. Thompson, Michael G. G. II. Series. [DNLM: 1. Psychiatry Education. WM18 R433] RC454.4.R47 ISBN-13: 978-1-4615-8197-0 001: 10.1007/978-1-4615-8195-6 616.8'9 e-isbn-13: 978-1-4615-8195-6 78-15961 1979 Plenum Publishing Corporation 227 West 17th Street, New York, N.Y. 10011 Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

EDITORIAL BOARD Members' affi liations at the time of submission RICHARD BALL, M.D. Professor and Censor-in-Chief The Australian and New Zealand College of Psychiatrists Board of Censors, Melbourne, Australia MARC H. HOLLENDER, M.D. Professor and Chairman, Department of Psychiatry Vanderbilt University, Nashville, Tennessee DONALD LANGSLEY, M.D. Professor and Chairman, Department of Psychiatry University of Cincinnati, Cincinnati, Ohio FREDERICK LOWY, M.D. Professor and Chairman, Department of Psychiatry University of Toronto, Toronto, Ontario, Canada HARRY PROSEN, M.D. Professor and Chairman, Department of Psychiatry University of Manitoba, Winnipeg, Manitoba, Canada PROFESSOR KENNETH RAWNSLEY, M.D. Dean, Royal College of Psychiatrists London, England JOEL YAGER, M.D. Director of Residency Education, Department of Psychiatry University of California, Los Angles, California

Foreword This is the inaugural volume of the new series: Critical Issues in Psychiatry: An Educational Series for Residents and Clinicians. It is an appropriate beginning, for this book represents a milestone in the evolution of psychiatric education. For the first time, there will now be a single place where one can find a comprehensive collection of educational goals and objectives to define the broad spectrum of knowledge and skills essential for general and child psychiatry. This collection does not represent the bias of a single educator or program. Rather, it consists of a consensually validated ranking of relative importance for each educational goal and objective as determined by a large and international sampling of experienced psychiatric educators, as well as an editorial board with some of the most distinguished names in psychiatric education. It is even possible to tell at a glance whether the ranked level of importance is the same or different within several national groups, for example Canadians vs. Americans. This book is intended for all students of psychiatry. It is particularly valuable to residents in training, but equally so for experienced clinicians preparing for Board examination or simply attending to the process of continuing education and intellectual renewal. While it might well be used by an institution to delineate the dimensions of a training program in psychiatry, it is intended primarily for the self-evaluation and self-monitoring of one's growth as a psychiatrist. The knowledge base in our field is growing exponentially. This has accentuated the need for a comprehensive instrument to first evaluate areas of strength and weakness across the dimensions of modern psychiatry, and then to direct study and experience. This is obviously most useful when it can be done in terms of educational objectives which are relevant to generally agreed upon standards of knowledge and skills. By noting the attainment of each item, the resident or clinician is able to record and follow his or her growth during the period of formal training and on into professional life. The log book can be used similarly to record clinical experiences with patients across many dimensions: diagnosis, age, sex, social class, etc. It also serves to record experience and the development of skills in a wide variety of clinical activities: diagnostic interviews and procedures, somatic and pharmacologic vii

viii Foreword intervention, behavioral therapies, marital and family therapies, group therapies, individual psychotherapies, etc. This is of particular importance to the trainee who must take care that his or her education is not skewed too heavily in one direction (type of patient, diagnosis, modality of treatment), or, of even more serious concern, lacking with regard to some important aspect of clinical skill development or experience. The reference material, the listing of psychiatric publications, the names and addresses of psychiatric organizations, and the other useful information all contribute toward the goal of providing a complete resource book for the education of the psychiatrist. To inaugurate this series we have conspired to produce a volume which might well be regarded as an educational essential for anyone about to become, in the process of becoming, or wishing to remain an excellent, knowledgeable, and modern clinical psychiatrist. We hope its usefulness to you, the reader and student, will prove the attainment of that goal. Sherwyn M. Woods, M.D., Ph.D. Series Editor

Preface The contents of this guide are an attempt to offer to the psychiatric resident some guidelines in the broad field of psychiatry. The guide is not meant to be static or completely comprehensive. It should be subject to continuing revision through feedback by residents, faculty, and other interested persons. It is hoped that the gradual evolution of such a guide will lead to more precision in the setting of educational objectives and more objectivity in the evaluation of the attainment of such objectives. Because it delineates "objectives" and not "content," it will not require revision either as frequently or as extensively as a comparable textbook. This volume is not a guide to the examinations, nor is it a blueprint for what should be taught in anyone department or asked at the examinations. It should in no way be interpreted as a document that delineates the field precisely. The effort of compiling this guide was a collaborative one. While acknowledging the indispensable contributions of many others, with special appreciation to those mentioned in the various acknowledgments, and to the editorial board, the editor takes responsibility for the final format with any omissions or inconsistencies it may contain. Special thanks are given for secretarial assistance in the preparation of this manuscript to Lois Bolger and Peggy Coleman, London Psychiatric Hospital, London, Ontario; Fran Eggleston, University Hospital, London, Ontario; and Mary Lou DeMarco, Toronto, Ontario. Finally, a very special thanks to the scores of psychiatrists whose names are not listed here but who contributed many hours critically reviewing this work and whose suggestions have been incorporated herein. Michael G. G. Thompson, M.D. ix

Editor's Introduction This manual for residents is both a guide to and a means of monitoring one's educational development in psychiatry. Specifically, the prime purpose of this book is to outline that which the resident should be able to do in order to show that he or she has attained a sufficient level of knowledge and skill to practice as a specialist in general psychiatry. The central core of the manual is therefore Chapter 1, Terminal and Enabling Objectives. The following short sections, which directly relate to and complement this core, have also been included: a list of recommended training experiences to assist the resident in the application of knowledge and the acquisition of new clinical skills (Chapter 2); a means of evaluating one's own training center from the point of view of assessing its ability to meet one's didactic and experiential needs (Chapter 3); a chapter on "extra" objectives for training in the subspecialty area of child psychiatry (Chapter 4); and, last, Appendices A-D, which comprise a listing of professional associations, a brief guide to the psychiatric literature, official statements as to the essentials of residency training in psychiatry, and an introductory reading list for Chapter 1. The driving force behind this guide has been the continual insistence on the part of residents for the profession to establish more clearly the parameters of our field. It has been compiled in the belief that although we as psychiatrists must learn to live with ambiguity, the delineation of our area of expertise does not have to be ambiguous. Michael G. G. Thompson, M.D. xi

Contents Chapter 1 Terminal and Enabling Objectives Editor's Introduction.... Section I. Historical Trends in Psychiatry........................... 6 II. Normality and Normal Psychosexual Development... 8 A. Concept of Normality... 8 B. Normal Psychosexual Development... 9 III. Contributions of the Biological Sciences to Psychiatry... 10 Introduction: Changes in the Delivery of Mental Health Care. 10 A. Core Knowledge in Neuropsychiatry.................. 11 B. Core Knowledge in Neuroendocrinology................ 12 C. Core Knowledge in Neurochemistry and Neurophysiology and the Relationship of These Sciences to Psychiatric Disorders... 14 D. Memory... 16 E. Sleep and Dreams... 17 F. Experimental Psychopathology'... 19 G. Specialized Tests in Neurological Investigation... 20 H. Neurological Correlates of Specialized Procedures... 21 IV. Contributions of the Psychological Sciences to Psychiatry... 22 A. Motivation... 22 B. Ethology... 23 C. Cognition... 24 D. Perception... 27 E. General Systems Theory... 28 F. Communications Theory... 29 V. Contributions of the Sociocultural Sciences to Psychiatry... 30 A. Cultural Anthropology... 30 B. Sociology, Ecology, and Social Psychiatry... 32 C. Transcultural Psychiatry... 35 xiii

xiv Contents VI. Child and Adolescent Psychiatry... 36 A. Child Psychiatry... 36 B. Mental Retardation... 41 C. Genetics... 42 VII. Theories of Personality and Psychopathology... 43 A. Personality Development and the Life Cycle... 43 B. Personality Organization and Component Functions... 45 C. Homeostasis, Motivation, Conflict, and Symptomatology. 47 D. Phenomenology, Nosology, and General Psychopathology... 49 VIII. Psychiatric Assessment... 51 A. The Interview......... 51 B. Assessment in Psychiatry... 54 C. Nosology... 58 IX. Psychiatric Emergencies and Reactive Disorders... 59 A. Crisis Theory... 59 B. Psychiatric Emergencies... 60 C. Suicide... 61 D. Transient Situational and Reactive Disorders... 62 X. Psyche and Soma and Liaison Psychiatry... 64 XI. The Neuroses, Personality Disorders, Addictions, and Sexual Disorders... 67 A. The Neuroses... 68 B. Personality Disorders... 69 C. Drug-Use Disorders... 71 D. Psychosexual Disorders... 72 XII. The "Functional" Psychoses... 72 A. The Schizophrenic Disorders... 76 B. Paranoid Disorders... 76 C. Affective Disorders-Psychotic... 76 D. "Borderline" States... 76 E. Brief Reactive Disorders... 77 F. Atypical "Psychoses"... 77 G. Other Psychoses... 78 XIII. The Organic Mental Disorders... 80 XIV. The Organic Therapies... 83 A. Psychopharmacology... 83 B. Convulsive Therapies... 85 C. Psychosurgery... 86 D. Miscellaneous and Little-Used Biological Treatments... 86 XV. Learning Theory and Behavior Modification... 87 A. Learning Theory... 87 B. Behavior Modification... 89 XVI. The Psychotherapies... 91 A. Individual Psychotherapy... 92 B. Group Psychotherapy... 96 C. Family Psychotherapy... 97

Contents xv D. Psychotherapy with Children... 99 E. Milieu Therapy... 100 F. Activity and Rehabilitation "Therapies"... 101 XVII. Community and Administrative Psychiatry... 102 A. Historical Development and Definition... 102 B. Basic Psychiatric Principles... 103 C. Basic Administrative Principles... 105 D. Methods of Intervention... 107 E. Research... 108 XVIII. Geriatric and Forensic Psychiatry... 109 A. Geriatric Psychiatry... 109 B. Forensic Psychiatry... 110 XIX. Gender and Psychiatry... 113 Introduction... 113 A. Emerging Issues in the Psychology of Women and Men.. 113 B. Sociocultural Aspects... 116 C. Special Issues... 118 D. Psychotherapy... 121 XX. Psychiatric Research and Evaluation... 122 A. History and Philosophy of Psychiatric Research Design.. 123 B. Models, Statistics, and Computers in Psychiatry... 123 C. Psychiatric Epidemiology as Human Ecology... 125 D. Evaluation of Psychiatric Treatment, Treatment Programs, and Training... "... '"........ 127 Chapter 2 Recommended Training Experiences and Skills: A Log Book Editor's Introduction... 131 Section I. History, Examination, Formulation, and Diagnosis... 132 A. Normal... 132 B. Psychiatric Emergencies... 132 C. Clinical Syndromes.............................. 134 D. Other... 138 II. Treatments... 139 A. Organic Therapies... 139 B. Psychotherapies...'............................. 141 C. Milieu Therapy... 146 D. Activity and Rehabilitation Therapies... 146 E. Behavior Therapies... 146 F. Other and Optional Therapies... 147 III. Special Investigations... 147 A. Diagnostic Procedures... 147 B. Psychological Tests... 148 C. Psychophysiology Laboratory Measures... 148

IV. "Special" Experiences... 148 A. Home Visits... 148 B. Experience with Other Human Services Disciplines... 149 C. Experience with Other Human Services "Agencies" or Centers... 149 D. Supervision of Junior Colleagues and Other Mental Health Care Workers... 150 E. Research Experience... 151 F. Involvement in a Journal Club for Two or More Years... 151 Suggested Cross-References to Chapter 1... 152 Chapter 3 The Residency Training Program Audit Editor's Introduction... 157 Section I. General... 157 II. Structure... 158 III. Process... 160 IV. Outcome... 163 Chapter 4 Terminal and Enabling Objectives for Residency Training in Child Psychiatry (by Peter B. Henderson) Foreword: Child Psychiatry Specialist Training (by Quentin Rae-Grant)... 165 Introduction... 167 Section I. Historical Trends in Child Psychiatry... 169 II. Normality and Normal Psychosexual Development... 170 III. Contributions of the Biological Sciences to Psychiatry... 171 IV. Contributions of the Psychological Sciences to Psychiatry... 173 V. Contributions of the Sociocultural Sciences to Psychiatry... 176 VI. Child and Adolescent Psychiatry... 178 VII. Theories of Personality and Psychopathology... 182 VIII. Psychiatric Assessment... 183 IX. Psychiatric Emergencies and Reactive Disorders... 184 X. Psyche and Soma and Liaison Psychiatry.................. 186 XI. The Neuroses, Personality Disorders, Addictions, and Sexual Disorders... 187 XII. The "Functional" Psych.oses... 190 XIII. The Organic Mental Disorders... 193 XIV. The Organic Therapies... 194 XV. Learning Theory and Behavior Modification... 195 XVI. The Psychotherapies... 196

Contents xvii XVII. Community and Administrative Psychiatry... 199 XVIII. Geriatric and Forensic Psychiatry... 203 XIX. Gender and Psychiatry... 205 XX. Psychiatric Research and Evaluation... 205 Bibliography... 206 Appendix A Professional Associations................................... 217 Appendix B A Guide to the Psychiatric Literature General Texts.... Reference Lists.... Journals.... Indices.... Computerized Reference Services 221 221 223 224 225 Appendix C Training Requirements American Medical Association: Excerpts from "Essentials of Approved Residencies"... 231 The Royal College of Physicians and Surgeons of Canada: "Specialty Training Requirements in Psychiatry"...... 237 The Royal Australian and New Zealand College of Psychiatrists: Excerpts from "By-Laws and Booklet for the Information of Candidates, 1978"... 241 The Royal College of Psychiatrists (London, England): Excerpts from "Educational Programmes for Trainees in Psychiatry".......... 246 Appendix 0 Introductory Reading List for Chapter 1 253