Pearls

Often we encounter patients who are angry about having been “forced” to see a psychiatrist:

• In the emergency room or inpatient setting, patients who present with an apparent medical problem may become upset after learning that a psychiatric evaluation has been ordered without their knowledge or against their wishes.
• In outpatient clinics, patients who arrive under “coercion” from parents, spouses, or employers can also be hostile.

Defusing the hostility and engaging the patient are critical first steps toward a therapeutic alliance. When faced with a hostile patient, take a deep breath, control your emotions, and follow the PEACE principle: presence, empathy, acceptance, collaboration, and empowerment.

Presence. From the outset, make it clear that the patient has your undivided attention. Nonverbal cues such as sitting down, maintaining comfortable eye contact, and not writing notes during the interview’s initial stages give this impression.

Empathy. As you sit quietly and attentively, encourage the patient to vent his or her anger over being “forced” to see a psychiatrist. Most of us can empathize with a person who feels powerless, patronized, or coerced.

Acceptance. Acknowledging the patient’s distress can go far toward diminishing or defusing the anger. For example, tell the patient, “I understand that this is unsettling for you,” or “I, too, wish the circumstances were different because this is obviously difficult for you.”

Collaboration. Tell the patient you only want to help him, to be his partner in a therapeutic alliance.

Empower. Never force the evaluation. Rather, let the patient decide whether to proceed. Tell her, “I want to help you with what’s been going on in your life, but it’s totally up to you to continue. I cannot—and don’t want to—force you to do something you choose not to do.”

Then offer alternatives such as:

• a follow-up appointment
• a visit the next day if the patient is hospitalized
• or telling the emergency physician that the patient declined the psychiatric evaluation.

I find that when using this approach the patient usually agrees to a therapeutic assessment.

Often we encounter patients who are angry about having been “forced” to see a psychiatrist:

• In the emergency room or inpatient setting, patients who present with an apparent medical problem may become upset after learning that a psychiatric evaluation has been ordered without their knowledge or against their wishes.
• In outpatient clinics, patients who arrive under “coercion” from parents, spouses, or employers can also be hostile.

Defusing the hostility and engaging the patient are critical first steps toward a therapeutic alliance. When faced with a hostile patient, take a deep breath, control your emotions, and follow the PEACE principle: presence, empathy, acceptance, collaboration, and empowerment.

Presence. From the outset, make it clear that the patient has your undivided attention. Nonverbal cues such as sitting down, maintaining comfortable eye contact, and not writing notes during the interview’s initial stages give this impression.

Empathy. As you sit quietly and attentively, encourage the patient to vent his or her anger over being “forced” to see a psychiatrist. Most of us can empathize with a person who feels powerless, patronized, or coerced.

Acceptance. Acknowledging the patient’s distress can go far toward diminishing or defusing the anger. For example, tell the patient, “I understand that this is unsettling for you,” or “I, too, wish the circumstances were different because this is obviously difficult for you.”

Collaboration. Tell the patient you only want to help him, to be his partner in a therapeutic alliance.

Empower. Never force the evaluation. Rather, let the patient decide whether to proceed. Tell her, “I want to help you with what’s been going on in your life, but it’s totally up to you to continue. I cannot—and don’t want to—force you to do something you choose not to do.”

Then offer alternatives such as:

• a follow-up appointment
• a visit the next day if the patient is hospitalized
• or telling the emergency physician that the patient declined the psychiatric evaluation.

I find that when using this approach the patient usually agrees to a therapeutic assessment.

Often we encounter patients who are angry about having been “forced” to see a psychiatrist:

• In the emergency room or inpatient setting, patients who present with an apparent medical problem may become upset after learning that a psychiatric evaluation has been ordered without their knowledge or against their wishes.
• In outpatient clinics, patients who arrive under “coercion” from parents, spouses, or employers can also be hostile.

Defusing the hostility and engaging the patient are critical first steps toward a therapeutic alliance. When faced with a hostile patient, take a deep breath, control your emotions, and follow the PEACE principle: presence, empathy, acceptance, collaboration, and empowerment.

Presence. From the outset, make it clear that the patient has your undivided attention. Nonverbal cues such as sitting down, maintaining comfortable eye contact, and not writing notes during the interview’s initial stages give this impression.

Empathy. As you sit quietly and attentively, encourage the patient to vent his or her anger over being “forced” to see a psychiatrist. Most of us can empathize with a person who feels powerless, patronized, or coerced.

Acceptance. Acknowledging the patient’s distress can go far toward diminishing or defusing the anger. For example, tell the patient, “I understand that this is unsettling for you,” or “I, too, wish the circumstances were different because this is obviously difficult for you.”

Collaboration. Tell the patient you only want to help him, to be his partner in a therapeutic alliance.

Empower. Never force the evaluation. Rather, let the patient decide whether to proceed. Tell her, “I want to help you with what’s been going on in your life, but it’s totally up to you to continue. I cannot—and don’t want to—force you to do something you choose not to do.”

Then offer alternatives such as:

• a follow-up appointment
• a visit the next day if the patient is hospitalized
• or telling the emergency physician that the patient declined the psychiatric evaluation.

I find that when using this approach the patient usually agrees to a therapeutic assessment.

Personal digital assistants (PDA) are in a state of flux. Thanks to a flurry of hardware and operating system improvements over the last 18 months, PDAs that were cutting-edge last year pale in comparison to newer models.

Should you buy a new PDA now, or stick with your current model and wait for still more innovations? This article can help you decide.

Why upgrade?

Pros. Today’s PDAs are more versatile and intuitive. For example, many combination PDA/mobile phones have newer operating systems, more memory, and greater software compatibility than earlier devices.

A frequent PDA user who craves more speed or added features might want to upgrade now. Likewise, users who are constantly on the road might want a new combination PDA/global positioning system.

Cons. PDA operating systems are updated frequently, reflecting continuing improvements in handheld hardware. Microsoft late last year upgraded its Pocket PC operating system and changed its name to Windows Mobile.

Although frequent users will rejoice in the opportunity to do more, others might not want to spend $300 or more to get the latest features—only to see their new device become outmoded in a few months.

Hardware advances

Processors. The processor, the heart of a PDA, has also seen much change. Newer Palm and Pocket PC devices are based on the strongARM microprocessor produced by Intel under the Xscale brand. Each new processor has more speed, better multimedia, an improved camera interface, and lower power consumption than previous processors.

Smartphones, which reached the market in 2002, are geared to physicians who rely mostly on email and calendar functions and have little need for mobile medical information.

A Windows Mobile smartphone typically looks like a mobile phone but has basic Pocket PC capabilities, such as viewing mail, a calendar, to-do list, and notes.

Windows Mobile smartphones, however, are compatible only with smartphone-specific programs, not with general Pocket PC software. This means that drug reference guides, DSM-IV-TR, and other commonly used medical programs cannot be viewed on a smartphone. If you love the idea of a smartphone but want a specialized program, check out www.smartphone.net.

Pocket PC phone. By contrast, the Pocket PC phone looks and works more like a PDA than a phone. Because it is connected to the cellular network, the device has wider Internet access than does a WiFi-enabled Pocket PC3. At 3.5-by-3.5 inches, the screen size is about twice that of the smartphone’s screen. The device also is compatible with all Pocket PC software.

Pocket PC phones typically have more main memory than smartphones. Smartphones are limited to secure digital-based external memory, but Pocket PC phones have infrared and other connectivity options.

Palm-based smartphones can run most Palm software, depending upon operating system compatibility. Previous Palm smartphones were more limited because of an older operating system and lack of external memory cards.

The palmOne Treo 600, based on the new Palm Version 5 operating system, offers an external memory slot, built-in digital camera, and text messaging. palmOne offers a GSM (global system for mobile communication) protocol version for the T-Mobile, Cingular, and AT&T networks, and a CDMA (code-division multiple access) protocol version for the Sprint network.

Operating system improvements

Palm Source has released version 6 of its operating system—code named “Cobalt”—to hardware developers. This versatile new version—with higher resolution, Word and JPEG file support, simultaneous multiple communications, and other features—could reach the market around the winter holiday.

Microsoft has released Windows Mobile 2003 Second Edition. With certain devices, the operating system will help users read text or browse the Web by using more of the screen. With larger screen resolutions packed into a smaller area, fonts are smaller and hard to read. Windows Mobile 2003 Second Edition provides additional font-size controls to compensate for this change.

The new Windows Mobile version also features a start menu that displays frequently used applications, and WiFi security is improved compared with the previous version.

The future

Tiquit, OQO, and FlipStart plan to release fully operable handheld computers later this year.

These new devices will run on Windows XP and other operating systems and will feature full central processing units, hard disks, liquid crystal display panels, USB connectivity, and built-in QWERTY keyboards. It remains to be seen if these computers will supersede Palm and Windows Mobile PDAs.

Sony’s new Vaio U70 handheld computer, recently released in Japan, is available in the United States via specialty retailers such as dynamism.com.

Personal digital assistants (PDA) are in a state of flux. Thanks to a flurry of hardware and operating system improvements over the last 18 months, PDAs that were cutting-edge last year pale in comparison to newer models.

Should you buy a new PDA now, or stick with your current model and wait for still more innovations? This article can help you decide.

Why upgrade?

Pros. Today’s PDAs are more versatile and intuitive. For example, many combination PDA/mobile phones have newer operating systems, more memory, and greater software compatibility than earlier devices.

A frequent PDA user who craves more speed or added features might want to upgrade now. Likewise, users who are constantly on the road might want a new combination PDA/global positioning system.

Cons. PDA operating systems are updated frequently, reflecting continuing improvements in handheld hardware. Microsoft late last year upgraded its Pocket PC operating system and changed its name to Windows Mobile.

Although frequent users will rejoice in the opportunity to do more, others might not want to spend $300 or more to get the latest features—only to see their new device become outmoded in a few months.

Hardware advances

Processors. The processor, the heart of a PDA, has also seen much change. Newer Palm and Pocket PC devices are based on the strongARM microprocessor produced by Intel under the Xscale brand. Each new processor has more speed, better multimedia, an improved camera interface, and lower power consumption than previous processors.

Smartphones, which reached the market in 2002, are geared to physicians who rely mostly on email and calendar functions and have little need for mobile medical information.

A Windows Mobile smartphone typically looks like a mobile phone but has basic Pocket PC capabilities, such as viewing mail, a calendar, to-do list, and notes.

Windows Mobile smartphones, however, are compatible only with smartphone-specific programs, not with general Pocket PC software. This means that drug reference guides, DSM-IV-TR, and other commonly used medical programs cannot be viewed on a smartphone. If you love the idea of a smartphone but want a specialized program, check out www.smartphone.net.

Pocket PC phone. By contrast, the Pocket PC phone looks and works more like a PDA than a phone. Because it is connected to the cellular network, the device has wider Internet access than does a WiFi-enabled Pocket PC3. At 3.5-by-3.5 inches, the screen size is about twice that of the smartphone’s screen. The device also is compatible with all Pocket PC software.

Pocket PC phones typically have more main memory than smartphones. Smartphones are limited to secure digital-based external memory, but Pocket PC phones have infrared and other connectivity options.

Palm-based smartphones can run most Palm software, depending upon operating system compatibility. Previous Palm smartphones were more limited because of an older operating system and lack of external memory cards.

The palmOne Treo 600, based on the new Palm Version 5 operating system, offers an external memory slot, built-in digital camera, and text messaging. palmOne offers a GSM (global system for mobile communication) protocol version for the T-Mobile, Cingular, and AT&T networks, and a CDMA (code-division multiple access) protocol version for the Sprint network.

Operating system improvements

Palm Source has released version 6 of its operating system—code named “Cobalt”—to hardware developers. This versatile new version—with higher resolution, Word and JPEG file support, simultaneous multiple communications, and other features—could reach the market around the winter holiday.

Microsoft has released Windows Mobile 2003 Second Edition. With certain devices, the operating system will help users read text or browse the Web by using more of the screen. With larger screen resolutions packed into a smaller area, fonts are smaller and hard to read. Windows Mobile 2003 Second Edition provides additional font-size controls to compensate for this change.

The new Windows Mobile version also features a start menu that displays frequently used applications, and WiFi security is improved compared with the previous version.

The future

Tiquit, OQO, and FlipStart plan to release fully operable handheld computers later this year.

These new devices will run on Windows XP and other operating systems and will feature full central processing units, hard disks, liquid crystal display panels, USB connectivity, and built-in QWERTY keyboards. It remains to be seen if these computers will supersede Palm and Windows Mobile PDAs.

Sony’s new Vaio U70 handheld computer, recently released in Japan, is available in the United States via specialty retailers such as dynamism.com.

Personal digital assistants (PDA) are in a state of flux. Thanks to a flurry of hardware and operating system improvements over the last 18 months, PDAs that were cutting-edge last year pale in comparison to newer models.

Should you buy a new PDA now, or stick with your current model and wait for still more innovations? This article can help you decide.

Why upgrade?

Pros. Today’s PDAs are more versatile and intuitive. For example, many combination PDA/mobile phones have newer operating systems, more memory, and greater software compatibility than earlier devices.

A frequent PDA user who craves more speed or added features might want to upgrade now. Likewise, users who are constantly on the road might want a new combination PDA/global positioning system.

Cons. PDA operating systems are updated frequently, reflecting continuing improvements in handheld hardware. Microsoft late last year upgraded its Pocket PC operating system and changed its name to Windows Mobile.

Although frequent users will rejoice in the opportunity to do more, others might not want to spend $300 or more to get the latest features—only to see their new device become outmoded in a few months.

Hardware advances

Processors. The processor, the heart of a PDA, has also seen much change. Newer Palm and Pocket PC devices are based on the strongARM microprocessor produced by Intel under the Xscale brand. Each new processor has more speed, better multimedia, an improved camera interface, and lower power consumption than previous processors.

Smartphones, which reached the market in 2002, are geared to physicians who rely mostly on email and calendar functions and have little need for mobile medical information.

A Windows Mobile smartphone typically looks like a mobile phone but has basic Pocket PC capabilities, such as viewing mail, a calendar, to-do list, and notes.

Windows Mobile smartphones, however, are compatible only with smartphone-specific programs, not with general Pocket PC software. This means that drug reference guides, DSM-IV-TR, and other commonly used medical programs cannot be viewed on a smartphone. If you love the idea of a smartphone but want a specialized program, check out www.smartphone.net.

Pocket PC phone. By contrast, the Pocket PC phone looks and works more like a PDA than a phone. Because it is connected to the cellular network, the device has wider Internet access than does a WiFi-enabled Pocket PC3. At 3.5-by-3.5 inches, the screen size is about twice that of the smartphone’s screen. The device also is compatible with all Pocket PC software.

Pocket PC phones typically have more main memory than smartphones. Smartphones are limited to secure digital-based external memory, but Pocket PC phones have infrared and other connectivity options.

Palm-based smartphones can run most Palm software, depending upon operating system compatibility. Previous Palm smartphones were more limited because of an older operating system and lack of external memory cards.

The palmOne Treo 600, based on the new Palm Version 5 operating system, offers an external memory slot, built-in digital camera, and text messaging. palmOne offers a GSM (global system for mobile communication) protocol version for the T-Mobile, Cingular, and AT&T networks, and a CDMA (code-division multiple access) protocol version for the Sprint network.

Operating system improvements

Palm Source has released version 6 of its operating system—code named “Cobalt”—to hardware developers. This versatile new version—with higher resolution, Word and JPEG file support, simultaneous multiple communications, and other features—could reach the market around the winter holiday.

Microsoft has released Windows Mobile 2003 Second Edition. With certain devices, the operating system will help users read text or browse the Web by using more of the screen. With larger screen resolutions packed into a smaller area, fonts are smaller and hard to read. Windows Mobile 2003 Second Edition provides additional font-size controls to compensate for this change.

The new Windows Mobile version also features a start menu that displays frequently used applications, and WiFi security is improved compared with the previous version.

The future

Tiquit, OQO, and FlipStart plan to release fully operable handheld computers later this year.

These new devices will run on Windows XP and other operating systems and will feature full central processing units, hard disks, liquid crystal display panels, USB connectivity, and built-in QWERTY keyboards. It remains to be seen if these computers will supersede Palm and Windows Mobile PDAs.

Sony’s new Vaio U70 handheld computer, recently released in Japan, is available in the United States via specialty retailers such as dynamism.com.

Early in training, psychiatry residents learn to formulate specific medication plans, but then add the vague, “I would recommend psychotherapy as well.” To help them understand each psychotherapy’s features and clinical applications, tell them to prescribe psychotherapy as if it were medication.

Like pharmacotherapy, psychotherapy has numerous forms, indications, and contraindications. It can be categorized by:

• theoretical orientation (psychodynamic, cognitive-behavioral, interpersonal)
• treatment duration (time-limited, open-ended)
• number of persons in attendance (individual, couples, family, group).

Teach residents to prescribe psychotherapy in a specific dose and frequency to address target symptoms. A sample treatment plan for a patient with major depressive disorder is shown in the Table.

Table

Sample treatment plan for major depressive disorder

Urge residents to prescribe psychotherapy “off-label” if it might help. For example, some clinicians offered cognitive-behavioral therapy (CBT) to patients with schizophrenia before CBT gained wider acceptance for that disorder.

Finally—like any treatment—psychotherapy may be associated with side effects, including anxiety, anger, and grief. Encourage residents to review these risks with their patients before beginning psychotherapy.

Choosing a psychotherapy type

Psychotherapy may be prescribed alone or with pharmacotherapy, as clinically indicated. When choosing a particular psychotherapy, research supports use of:

• behavior therapy, cognitive therapy, and CBT for depression, certain anxiety disorders (such as obsessive-compulsive disorder), and other mental disorders (substance use disorders, eating disorders, chronic pain syndromes)
• dialectical behavior therapy for reducing self-injurious behavior and hospitalizations in borderline personality disorder
• interpersonal psychotherapy for depression.

Some research supports using psychodynamic psychotherapy to treat severe, chronic personality disorders, but the nature of this therapy makes controlled studies difficult. Similarly, though no published data have shown supportive psychotherapy to be effective—in general or for specific disorders—lack of evidence does not necessarily correlate with lack of efficacy.

A model that’s easy to learn

Once residents become familiar with this model, it is remarkable to see the sophistication with which they incorporate specific psychotherapeutic recommendations into their treatment plans.

Use of this model need not be restricted to residents, however. A good model helps all clinicians sharpen their skills and improve the care they provide.

Related resources

1. Hales RE, Yudofsky SC (eds). Textbook of clinical psychiatry (4th ed). Washington, DC: American Psychiatric Publishing, 2003.
2. Sadock BJ, Sadock VA (eds). Kaplan & Sadock’s comprehensive textbook of psychiatry (7th ed). New York: Lippincott Williams & Wilkins, 1999.

Drug brand names

• Sertraline • Zoloft

Early in training, psychiatry residents learn to formulate specific medication plans, but then add the vague, “I would recommend psychotherapy as well.” To help them understand each psychotherapy’s features and clinical applications, tell them to prescribe psychotherapy as if it were medication.

Like pharmacotherapy, psychotherapy has numerous forms, indications, and contraindications. It can be categorized by:

• theoretical orientation (psychodynamic, cognitive-behavioral, interpersonal)
• treatment duration (time-limited, open-ended)
• number of persons in attendance (individual, couples, family, group).

Teach residents to prescribe psychotherapy in a specific dose and frequency to address target symptoms. A sample treatment plan for a patient with major depressive disorder is shown in the Table.

Table

Sample treatment plan for major depressive disorder

Urge residents to prescribe psychotherapy “off-label” if it might help. For example, some clinicians offered cognitive-behavioral therapy (CBT) to patients with schizophrenia before CBT gained wider acceptance for that disorder.

Finally—like any treatment—psychotherapy may be associated with side effects, including anxiety, anger, and grief. Encourage residents to review these risks with their patients before beginning psychotherapy.

Choosing a psychotherapy type

Psychotherapy may be prescribed alone or with pharmacotherapy, as clinically indicated. When choosing a particular psychotherapy, research supports use of:

• behavior therapy, cognitive therapy, and CBT for depression, certain anxiety disorders (such as obsessive-compulsive disorder), and other mental disorders (substance use disorders, eating disorders, chronic pain syndromes)
• dialectical behavior therapy for reducing self-injurious behavior and hospitalizations in borderline personality disorder
• interpersonal psychotherapy for depression.

Some research supports using psychodynamic psychotherapy to treat severe, chronic personality disorders, but the nature of this therapy makes controlled studies difficult. Similarly, though no published data have shown supportive psychotherapy to be effective—in general or for specific disorders—lack of evidence does not necessarily correlate with lack of efficacy.

A model that’s easy to learn

Once residents become familiar with this model, it is remarkable to see the sophistication with which they incorporate specific psychotherapeutic recommendations into their treatment plans.

Use of this model need not be restricted to residents, however. A good model helps all clinicians sharpen their skills and improve the care they provide.

Related resources

1. Hales RE, Yudofsky SC (eds). Textbook of clinical psychiatry (4th ed). Washington, DC: American Psychiatric Publishing, 2003.
2. Sadock BJ, Sadock VA (eds). Kaplan & Sadock’s comprehensive textbook of psychiatry (7th ed). New York: Lippincott Williams & Wilkins, 1999.

Drug brand names

• Sertraline • Zoloft

Early in training, psychiatry residents learn to formulate specific medication plans, but then add the vague, “I would recommend psychotherapy as well.” To help them understand each psychotherapy’s features and clinical applications, tell them to prescribe psychotherapy as if it were medication.

Like pharmacotherapy, psychotherapy has numerous forms, indications, and contraindications. It can be categorized by:

• theoretical orientation (psychodynamic, cognitive-behavioral, interpersonal)
• treatment duration (time-limited, open-ended)
• number of persons in attendance (individual, couples, family, group).

Teach residents to prescribe psychotherapy in a specific dose and frequency to address target symptoms. A sample treatment plan for a patient with major depressive disorder is shown in the Table.

Table

Sample treatment plan for major depressive disorder

Urge residents to prescribe psychotherapy “off-label” if it might help. For example, some clinicians offered cognitive-behavioral therapy (CBT) to patients with schizophrenia before CBT gained wider acceptance for that disorder.

Finally—like any treatment—psychotherapy may be associated with side effects, including anxiety, anger, and grief. Encourage residents to review these risks with their patients before beginning psychotherapy.

Choosing a psychotherapy type

Psychotherapy may be prescribed alone or with pharmacotherapy, as clinically indicated. When choosing a particular psychotherapy, research supports use of:

• behavior therapy, cognitive therapy, and CBT for depression, certain anxiety disorders (such as obsessive-compulsive disorder), and other mental disorders (substance use disorders, eating disorders, chronic pain syndromes)
• dialectical behavior therapy for reducing self-injurious behavior and hospitalizations in borderline personality disorder
• interpersonal psychotherapy for depression.

Some research supports using psychodynamic psychotherapy to treat severe, chronic personality disorders, but the nature of this therapy makes controlled studies difficult. Similarly, though no published data have shown supportive psychotherapy to be effective—in general or for specific disorders—lack of evidence does not necessarily correlate with lack of efficacy.

A model that’s easy to learn

Once residents become familiar with this model, it is remarkable to see the sophistication with which they incorporate specific psychotherapeutic recommendations into their treatment plans.

Use of this model need not be restricted to residents, however. A good model helps all clinicians sharpen their skills and improve the care they provide.

Related resources

1. Hales RE, Yudofsky SC (eds). Textbook of clinical psychiatry (4th ed). Washington, DC: American Psychiatric Publishing, 2003.
2. Sadock BJ, Sadock VA (eds). Kaplan & Sadock’s comprehensive textbook of psychiatry (7th ed). New York: Lippincott Williams & Wilkins, 1999.

Drug brand names

• Sertraline • Zoloft

Patients with psychosis often hold on to delusional beliefs while on medication. Learning more about these beliefs through cognitive therapy can improve drug efficacy, engagement, and coping skills for any chronically or acutely psychotic patient who is willing to discuss his or her delusions.

Start by asking these five questions:

1. How strong is your belief? When starting therapy, ask the patient to rate the certainty of his belief from 0 to 100%. A patient who remains 100% certain over several visits probably will not respond to treatment.

Then engage the patient by suggesting that together you’ll view the belief as a scientist or detective would, carefully evaluating all evidence before reaching a conclusion.

2. How long have you had this belief? Some patients say they have always held a specific belief. Beliefs that have lasted years may be harder to change than more-recently adopted ones.

Looking back, some patients acknowledge initial doubts and recall considering alternate beliefs, which the physician can help strengthen.

3. How has the belief affected your life? Have the patient write down the advantages and disadvantages of his delusional thinking;¹ seeing the consequences in writing may discourage the belief. For example, a patient might stop thinking he is a prophet if he realizes the belief could lead to alienation and hospitalization.

4. Until now, how have you coped with negative aspects of this belief (such as ‘death threats’)? For 10 years, one patient believed gangsters were trying to kill him. We asked how he survived attempts on his life. He identified activities and situations in which he felt safer, such as being with his parents, playing basketball with others, and visiting the doctor. We encouraged him to spend more time in these situations. He acknowledged his role in improving his sense of safety and felt empowered to confront the delusion.

5. What if the delusion is/is not true? Asking this question may uncover other dysfunctional thinking that can be addressed in therapy.

Have the patient rate certainty at each visit, and document changes in score. Patients with delusions usually are relieved that they are not being judged and that their beliefs are not invalidated. They often start questioning their delusions and develop coping skills to deal with them.

Some patients feel depressed after abandoning a delusion that once shielded them from low self-esteem (eg, “the FBI is after me because I’m important”). Steer patients toward various activities and have them rate their enjoyment and mastery of them. This will help them find alternate beliefs.

Patients with psychosis often hold on to delusional beliefs while on medication. Learning more about these beliefs through cognitive therapy can improve drug efficacy, engagement, and coping skills for any chronically or acutely psychotic patient who is willing to discuss his or her delusions.

Start by asking these five questions:

1. How strong is your belief? When starting therapy, ask the patient to rate the certainty of his belief from 0 to 100%. A patient who remains 100% certain over several visits probably will not respond to treatment.

Then engage the patient by suggesting that together you’ll view the belief as a scientist or detective would, carefully evaluating all evidence before reaching a conclusion.

2. How long have you had this belief? Some patients say they have always held a specific belief. Beliefs that have lasted years may be harder to change than more-recently adopted ones.

Looking back, some patients acknowledge initial doubts and recall considering alternate beliefs, which the physician can help strengthen.

3. How has the belief affected your life? Have the patient write down the advantages and disadvantages of his delusional thinking;¹ seeing the consequences in writing may discourage the belief. For example, a patient might stop thinking he is a prophet if he realizes the belief could lead to alienation and hospitalization.

4. Until now, how have you coped with negative aspects of this belief (such as ‘death threats’)? For 10 years, one patient believed gangsters were trying to kill him. We asked how he survived attempts on his life. He identified activities and situations in which he felt safer, such as being with his parents, playing basketball with others, and visiting the doctor. We encouraged him to spend more time in these situations. He acknowledged his role in improving his sense of safety and felt empowered to confront the delusion.

5. What if the delusion is/is not true? Asking this question may uncover other dysfunctional thinking that can be addressed in therapy.

Have the patient rate certainty at each visit, and document changes in score. Patients with delusions usually are relieved that they are not being judged and that their beliefs are not invalidated. They often start questioning their delusions and develop coping skills to deal with them.

Some patients feel depressed after abandoning a delusion that once shielded them from low self-esteem (eg, “the FBI is after me because I’m important”). Steer patients toward various activities and have them rate their enjoyment and mastery of them. This will help them find alternate beliefs.

Patients with psychosis often hold on to delusional beliefs while on medication. Learning more about these beliefs through cognitive therapy can improve drug efficacy, engagement, and coping skills for any chronically or acutely psychotic patient who is willing to discuss his or her delusions.

Start by asking these five questions:

1. How strong is your belief? When starting therapy, ask the patient to rate the certainty of his belief from 0 to 100%. A patient who remains 100% certain over several visits probably will not respond to treatment.

Then engage the patient by suggesting that together you’ll view the belief as a scientist or detective would, carefully evaluating all evidence before reaching a conclusion.

2. How long have you had this belief? Some patients say they have always held a specific belief. Beliefs that have lasted years may be harder to change than more-recently adopted ones.

Looking back, some patients acknowledge initial doubts and recall considering alternate beliefs, which the physician can help strengthen.

3. How has the belief affected your life? Have the patient write down the advantages and disadvantages of his delusional thinking;¹ seeing the consequences in writing may discourage the belief. For example, a patient might stop thinking he is a prophet if he realizes the belief could lead to alienation and hospitalization.

4. Until now, how have you coped with negative aspects of this belief (such as ‘death threats’)? For 10 years, one patient believed gangsters were trying to kill him. We asked how he survived attempts on his life. He identified activities and situations in which he felt safer, such as being with his parents, playing basketball with others, and visiting the doctor. We encouraged him to spend more time in these situations. He acknowledged his role in improving his sense of safety and felt empowered to confront the delusion.

5. What if the delusion is/is not true? Asking this question may uncover other dysfunctional thinking that can be addressed in therapy.

Have the patient rate certainty at each visit, and document changes in score. Patients with delusions usually are relieved that they are not being judged and that their beliefs are not invalidated. They often start questioning their delusions and develop coping skills to deal with them.

Some patients feel depressed after abandoning a delusion that once shielded them from low self-esteem (eg, “the FBI is after me because I’m important”). Steer patients toward various activities and have them rate their enjoyment and mastery of them. This will help them find alternate beliefs.

Want to take an online audio CME course or view educational film clips while traveling? Don’t forget your handheld.

Once limited to text-based information, today’s more powerful personal digital assistants (PDAs) can also play audio and video files. Innovations in capture and conversion technology allow you to store media-rich online files on your PDA, letting you access multimedia Internet content while you are offline.

File portability

PEG-audio layer 3 (MP3) is a compression algorithm used to decrease an audio file’s size, allowing numerous audio files to be stored onto an MP3 player.

Other formats-including WAV, Real Audio, and Ogg-Vorbis-can be used to compress files, but MP3 is the most popular and has become the standard.

Video files usually contain massive amounts of data-including synchronized audio-and are quite large. Files created via advanced systems format (ASF) typically are uncompressed general video files. Windows Media and Real Media are other common online video formats.

Several compression algorithms exist for online video, including MPEG-1, MPEG-2, and MPEG-4. Each compression type is geared towards a specific media delivery mechanism.

Playing online audio on PDAs

Pocket PC devices come with Windows Media Player, which enables users to play MP3s. Alternate programs-such as RealOne Player, Pocket Mind, Pocket Player, and withMP3 (Table 1)-offer features such as an equalizer and can handle streaming audio and play audio books.

To store an MP3 file onto your PDA, simply download the file and store it in the “My Pocket PC” folder on your computer desktop. Storing the file this way, however, consumes much of the PDA’s main memory. To preserve PDA memory:

• Store the file in the PDA’s compact flash or secure digital card by enter your Pocket PC via the “Activesync” window, then store the file in the device’s secure digital card
• Or use a separate USB memory card reader to transfer the file to the memory card, then place the card into the Pocket PC. This is the fastest option.

Palm OS devices can play MP3 files with RealOne Player, Aero Player, and Pocket Tunes. Audio files are easily installed using Palm Quick Install.

Drag a copy of the file into the expansion card, and it will be transferred at the next HotSync (synchronization of information from PDA to desktop). However, this process takes about 10 minutes depending on the file’s size because the file must go through the Palm memory. To save time, place the file on a separate USB memory card reader, then transfer the file directly.

Playing video files

Older PDAs could not display video data quickly enough, making images appear jerky and blotchy. Today’s Palm OS and Pocket PC PDAs have faster processors, more memory, and can display video at decent quality.

Pocket PC devices can play Windows Media Video and ASF video files with the Pocket PC version of Windows Media Player. Other third-party video players include Project Mayo, Pocket MVP, Pocket TV, and RealOne Player.

Because these video players are not compatible with older Palm OS devices, vendors have created converters that can convert video files for use with the vendors’ proprietary video formats (Table 2). All video files must be converted via the desktop and then installed onto the PDA or memory card.

By contrast, newer Palm OS devices (such as OS 5) have enough processing power to display MPEG-4 files using software such as MMPlayer.

Portability issues

Video. Online grand rounds or other lectures are designed for viewing online. “Streaming” allows a Web site to distribute the video to many users at once. 1 Web casts typically are created in Real Media or Windows Media format, but the streaming is not stored on the computer hard drive for later use. More importantly, the link from the Web site does not contain the media when accessed, but actually is a command to the streaming server.

To capture the video stream, try WM Recorder or HiDownload.

Audio files cannot be heard on PDAs without headphones, making them difficult to listen to while driving. FM radio broadcast devices such as the iRock 400 or Belkin Tunecast solve this problem by transmitting a low-strength signal that can be picked up on a car radio.

Other devices

Aside from PDAs, other portable devices are made for viewing audio and video, and others are being invented.

Many MP3 players are smaller and more portable than PDAs. Video “jukeboxes” such as the Archos AV320 and TightSystems TAZ are also available.

Tiquit, OQO, and FlipStart plan later this year to release fully capable computers. They contain hard drives, central processing units and other necessities of full-sized computers, but are only the size of a PDA. These innovations could make the aforementioned devices and programs obsolete by year’s end. (For information on these developing technologies, watch for future installments of Psyber Psychiatry.)

Table 1

Audio player programs for PDA

Table 2

Video conversion programs for Palm OS devices

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

Related Resources

• NPI Webcasting. UCLA grand rounds, Department of Psychiatry and Behavioral Sciences. http://www.mentalhealth.ucla.edu/opce/gr.html
• Prelinger Archives. Movie archives of patients with schizophrenia. http://www.archive.org/movies/movieslisting-browse.php?collection=prelinger (Click on “schizophrenia” in subject index)
• Luo J. Psyber Psychiatry: A world of information in your pocket. Current Psychiatry April online edition. http://www.currentpsychiatry.com/psyber_psy.asp.

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Want to take an online audio CME course or view educational film clips while traveling? Don’t forget your handheld.

Once limited to text-based information, today’s more powerful personal digital assistants (PDAs) can also play audio and video files. Innovations in capture and conversion technology allow you to store media-rich online files on your PDA, letting you access multimedia Internet content while you are offline.

File portability

PEG-audio layer 3 (MP3) is a compression algorithm used to decrease an audio file’s size, allowing numerous audio files to be stored onto an MP3 player.

Other formats-including WAV, Real Audio, and Ogg-Vorbis-can be used to compress files, but MP3 is the most popular and has become the standard.

Video files usually contain massive amounts of data-including synchronized audio-and are quite large. Files created via advanced systems format (ASF) typically are uncompressed general video files. Windows Media and Real Media are other common online video formats.

Several compression algorithms exist for online video, including MPEG-1, MPEG-2, and MPEG-4. Each compression type is geared towards a specific media delivery mechanism.

Playing online audio on PDAs

Pocket PC devices come with Windows Media Player, which enables users to play MP3s. Alternate programs-such as RealOne Player, Pocket Mind, Pocket Player, and withMP3 (Table 1)-offer features such as an equalizer and can handle streaming audio and play audio books.

To store an MP3 file onto your PDA, simply download the file and store it in the “My Pocket PC” folder on your computer desktop. Storing the file this way, however, consumes much of the PDA’s main memory. To preserve PDA memory:

• Store the file in the PDA’s compact flash or secure digital card by enter your Pocket PC via the “Activesync” window, then store the file in the device’s secure digital card
• Or use a separate USB memory card reader to transfer the file to the memory card, then place the card into the Pocket PC. This is the fastest option.

Palm OS devices can play MP3 files with RealOne Player, Aero Player, and Pocket Tunes. Audio files are easily installed using Palm Quick Install.

Drag a copy of the file into the expansion card, and it will be transferred at the next HotSync (synchronization of information from PDA to desktop). However, this process takes about 10 minutes depending on the file’s size because the file must go through the Palm memory. To save time, place the file on a separate USB memory card reader, then transfer the file directly.

Playing video files

Older PDAs could not display video data quickly enough, making images appear jerky and blotchy. Today’s Palm OS and Pocket PC PDAs have faster processors, more memory, and can display video at decent quality.

Pocket PC devices can play Windows Media Video and ASF video files with the Pocket PC version of Windows Media Player. Other third-party video players include Project Mayo, Pocket MVP, Pocket TV, and RealOne Player.

Because these video players are not compatible with older Palm OS devices, vendors have created converters that can convert video files for use with the vendors’ proprietary video formats (Table 2). All video files must be converted via the desktop and then installed onto the PDA or memory card.

By contrast, newer Palm OS devices (such as OS 5) have enough processing power to display MPEG-4 files using software such as MMPlayer.

Portability issues

Video. Online grand rounds or other lectures are designed for viewing online. “Streaming” allows a Web site to distribute the video to many users at once. 1 Web casts typically are created in Real Media or Windows Media format, but the streaming is not stored on the computer hard drive for later use. More importantly, the link from the Web site does not contain the media when accessed, but actually is a command to the streaming server.

To capture the video stream, try WM Recorder or HiDownload.

Audio files cannot be heard on PDAs without headphones, making them difficult to listen to while driving. FM radio broadcast devices such as the iRock 400 or Belkin Tunecast solve this problem by transmitting a low-strength signal that can be picked up on a car radio.

Other devices

Aside from PDAs, other portable devices are made for viewing audio and video, and others are being invented.

Many MP3 players are smaller and more portable than PDAs. Video “jukeboxes” such as the Archos AV320 and TightSystems TAZ are also available.

Tiquit, OQO, and FlipStart plan later this year to release fully capable computers. They contain hard drives, central processing units and other necessities of full-sized computers, but are only the size of a PDA. These innovations could make the aforementioned devices and programs obsolete by year’s end. (For information on these developing technologies, watch for future installments of Psyber Psychiatry.)

Table 1

Audio player programs for PDA

Table 2

Video conversion programs for Palm OS devices

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

Related Resources

• NPI Webcasting. UCLA grand rounds, Department of Psychiatry and Behavioral Sciences. http://www.mentalhealth.ucla.edu/opce/gr.html
• Prelinger Archives. Movie archives of patients with schizophrenia. http://www.archive.org/movies/movieslisting-browse.php?collection=prelinger (Click on “schizophrenia” in subject index)
• Luo J. Psyber Psychiatry: A world of information in your pocket. Current Psychiatry April online edition. http://www.currentpsychiatry.com/psyber_psy.asp.

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Want to take an online audio CME course or view educational film clips while traveling? Don’t forget your handheld.

Once limited to text-based information, today’s more powerful personal digital assistants (PDAs) can also play audio and video files. Innovations in capture and conversion technology allow you to store media-rich online files on your PDA, letting you access multimedia Internet content while you are offline.

File portability

PEG-audio layer 3 (MP3) is a compression algorithm used to decrease an audio file’s size, allowing numerous audio files to be stored onto an MP3 player.

Other formats-including WAV, Real Audio, and Ogg-Vorbis-can be used to compress files, but MP3 is the most popular and has become the standard.

Video files usually contain massive amounts of data-including synchronized audio-and are quite large. Files created via advanced systems format (ASF) typically are uncompressed general video files. Windows Media and Real Media are other common online video formats.

Several compression algorithms exist for online video, including MPEG-1, MPEG-2, and MPEG-4. Each compression type is geared towards a specific media delivery mechanism.

Playing online audio on PDAs

Pocket PC devices come with Windows Media Player, which enables users to play MP3s. Alternate programs-such as RealOne Player, Pocket Mind, Pocket Player, and withMP3 (Table 1)-offer features such as an equalizer and can handle streaming audio and play audio books.

To store an MP3 file onto your PDA, simply download the file and store it in the “My Pocket PC” folder on your computer desktop. Storing the file this way, however, consumes much of the PDA’s main memory. To preserve PDA memory:

• Store the file in the PDA’s compact flash or secure digital card by enter your Pocket PC via the “Activesync” window, then store the file in the device’s secure digital card
• Or use a separate USB memory card reader to transfer the file to the memory card, then place the card into the Pocket PC. This is the fastest option.

Palm OS devices can play MP3 files with RealOne Player, Aero Player, and Pocket Tunes. Audio files are easily installed using Palm Quick Install.

Drag a copy of the file into the expansion card, and it will be transferred at the next HotSync (synchronization of information from PDA to desktop). However, this process takes about 10 minutes depending on the file’s size because the file must go through the Palm memory. To save time, place the file on a separate USB memory card reader, then transfer the file directly.

Playing video files

Older PDAs could not display video data quickly enough, making images appear jerky and blotchy. Today’s Palm OS and Pocket PC PDAs have faster processors, more memory, and can display video at decent quality.

Pocket PC devices can play Windows Media Video and ASF video files with the Pocket PC version of Windows Media Player. Other third-party video players include Project Mayo, Pocket MVP, Pocket TV, and RealOne Player.

Because these video players are not compatible with older Palm OS devices, vendors have created converters that can convert video files for use with the vendors’ proprietary video formats (Table 2). All video files must be converted via the desktop and then installed onto the PDA or memory card.

By contrast, newer Palm OS devices (such as OS 5) have enough processing power to display MPEG-4 files using software such as MMPlayer.

Portability issues

Video. Online grand rounds or other lectures are designed for viewing online. “Streaming” allows a Web site to distribute the video to many users at once. 1 Web casts typically are created in Real Media or Windows Media format, but the streaming is not stored on the computer hard drive for later use. More importantly, the link from the Web site does not contain the media when accessed, but actually is a command to the streaming server.

To capture the video stream, try WM Recorder or HiDownload.

Audio files cannot be heard on PDAs without headphones, making them difficult to listen to while driving. FM radio broadcast devices such as the iRock 400 or Belkin Tunecast solve this problem by transmitting a low-strength signal that can be picked up on a car radio.

Other devices

Aside from PDAs, other portable devices are made for viewing audio and video, and others are being invented.

Many MP3 players are smaller and more portable than PDAs. Video “jukeboxes” such as the Archos AV320 and TightSystems TAZ are also available.

Tiquit, OQO, and FlipStart plan later this year to release fully capable computers. They contain hard drives, central processing units and other necessities of full-sized computers, but are only the size of a PDA. These innovations could make the aforementioned devices and programs obsolete by year’s end. (For information on these developing technologies, watch for future installments of Psyber Psychiatry.)

Table 1

Audio player programs for PDA

Table 2

Video conversion programs for Palm OS devices

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

Related Resources

• NPI Webcasting. UCLA grand rounds, Department of Psychiatry and Behavioral Sciences. http://www.mentalhealth.ucla.edu/opce/gr.html
• Prelinger Archives. Movie archives of patients with schizophrenia. http://www.archive.org/movies/movieslisting-browse.php?collection=prelinger (Click on “schizophrenia” in subject index)
• Luo J. Psyber Psychiatry: A world of information in your pocket. Current Psychiatry April online edition. http://www.currentpsychiatry.com/psyber_psy.asp.

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Differentiating premenstrual dysphoric disorder (PMDD) from depression or premenstrual syndrome (PMS) is crucial to restoring the patient’s well-being. PMS is relatively mild; its symptoms range from bloating to breast tenderness to irritability. PMDD is more severe and is characterized by marked and persistent irritability, depressed mood, anxiety, or affective lability.

Symptoms of clinical depression are present throughout the month, but PMDD symptoms emerge only during the luteal phase of most menstrual cycles. Having the patient keep a menstruation log can provide valuable clues to diagnosis.

Choosing the right tool

PMDD diagnosis requires confirmation of symptoms by prospective daily ratings over at least two menstrual cycles.

Available monitoring tools include:

• Daily Record of Severity of Problems (DRSP), the only scale keyed to DSM-IV criteria for PMDD. The patient rates symptoms daily from 1 (not present) to 6 (extreme).
• Premenstrual Symptom Diary (PSD), which uses a 4-point scale. It includes common psychological and physical symptoms and allows the patient to add others.
• Calendar of Premenstrual Experiences (COPE). One of the best-validated scales, COPE contains many more symptoms (10 physical and 12 psychological) than the others, making it both more thorough and more difficult to use.

How to use the log

Although many symptoms point to PMDD, a woman with this disorder tends to have the same symptoms across cycles. Common symptoms include irritability, anxiety, mood swings, sadness, crying spells, fatigue, lethargy, insomnia or hypersomnia, bloating, headaches, breast tenderness, poor concentration, and food cravings. The patient can rate each symptom or choose three or four that bother her most, then rate them daily from absent to severe.

Have the patient begin charting on the first day of her period. Few or no symptoms during the follicular phase (days 7-14) and an increase in symptoms during the luteal phase (days 14-28) may indicate PMDD.

Compare postmenstrual follicular phase and luteal phase scores. A luteal phase symptom increase of 30% to 50% (depending on which scale is used) confirms the PMDD diagnosis. The log can also help distinguish PMDD from pre-menstrual worsening of major depression or other disorders.

By keeping a menstruation log, a patient can predict and manage days when she will be most symptomatic. For example, the patient can adjust her diet, maximize sleep and exercise, and—where possible—avoid stressful events the week before her period. In severe cases, the log can help determine when antidepressants are warranted.

Differentiating premenstrual dysphoric disorder (PMDD) from depression or premenstrual syndrome (PMS) is crucial to restoring the patient’s well-being. PMS is relatively mild; its symptoms range from bloating to breast tenderness to irritability. PMDD is more severe and is characterized by marked and persistent irritability, depressed mood, anxiety, or affective lability.

Symptoms of clinical depression are present throughout the month, but PMDD symptoms emerge only during the luteal phase of most menstrual cycles. Having the patient keep a menstruation log can provide valuable clues to diagnosis.

Choosing the right tool

PMDD diagnosis requires confirmation of symptoms by prospective daily ratings over at least two menstrual cycles.

Available monitoring tools include:

• Daily Record of Severity of Problems (DRSP), the only scale keyed to DSM-IV criteria for PMDD. The patient rates symptoms daily from 1 (not present) to 6 (extreme).
• Premenstrual Symptom Diary (PSD), which uses a 4-point scale. It includes common psychological and physical symptoms and allows the patient to add others.
• Calendar of Premenstrual Experiences (COPE). One of the best-validated scales, COPE contains many more symptoms (10 physical and 12 psychological) than the others, making it both more thorough and more difficult to use.

How to use the log

Although many symptoms point to PMDD, a woman with this disorder tends to have the same symptoms across cycles. Common symptoms include irritability, anxiety, mood swings, sadness, crying spells, fatigue, lethargy, insomnia or hypersomnia, bloating, headaches, breast tenderness, poor concentration, and food cravings. The patient can rate each symptom or choose three or four that bother her most, then rate them daily from absent to severe.

Have the patient begin charting on the first day of her period. Few or no symptoms during the follicular phase (days 7-14) and an increase in symptoms during the luteal phase (days 14-28) may indicate PMDD.

Compare postmenstrual follicular phase and luteal phase scores. A luteal phase symptom increase of 30% to 50% (depending on which scale is used) confirms the PMDD diagnosis. The log can also help distinguish PMDD from pre-menstrual worsening of major depression or other disorders.

By keeping a menstruation log, a patient can predict and manage days when she will be most symptomatic. For example, the patient can adjust her diet, maximize sleep and exercise, and—where possible—avoid stressful events the week before her period. In severe cases, the log can help determine when antidepressants are warranted.

Differentiating premenstrual dysphoric disorder (PMDD) from depression or premenstrual syndrome (PMS) is crucial to restoring the patient’s well-being. PMS is relatively mild; its symptoms range from bloating to breast tenderness to irritability. PMDD is more severe and is characterized by marked and persistent irritability, depressed mood, anxiety, or affective lability.

Symptoms of clinical depression are present throughout the month, but PMDD symptoms emerge only during the luteal phase of most menstrual cycles. Having the patient keep a menstruation log can provide valuable clues to diagnosis.

Choosing the right tool

PMDD diagnosis requires confirmation of symptoms by prospective daily ratings over at least two menstrual cycles.

Available monitoring tools include:

• Daily Record of Severity of Problems (DRSP), the only scale keyed to DSM-IV criteria for PMDD. The patient rates symptoms daily from 1 (not present) to 6 (extreme).
• Premenstrual Symptom Diary (PSD), which uses a 4-point scale. It includes common psychological and physical symptoms and allows the patient to add others.
• Calendar of Premenstrual Experiences (COPE). One of the best-validated scales, COPE contains many more symptoms (10 physical and 12 psychological) than the others, making it both more thorough and more difficult to use.

How to use the log

Although many symptoms point to PMDD, a woman with this disorder tends to have the same symptoms across cycles. Common symptoms include irritability, anxiety, mood swings, sadness, crying spells, fatigue, lethargy, insomnia or hypersomnia, bloating, headaches, breast tenderness, poor concentration, and food cravings. The patient can rate each symptom or choose three or four that bother her most, then rate them daily from absent to severe.

Have the patient begin charting on the first day of her period. Few or no symptoms during the follicular phase (days 7-14) and an increase in symptoms during the luteal phase (days 14-28) may indicate PMDD.

Compare postmenstrual follicular phase and luteal phase scores. A luteal phase symptom increase of 30% to 50% (depending on which scale is used) confirms the PMDD diagnosis. The log can also help distinguish PMDD from pre-menstrual worsening of major depression or other disorders.

By keeping a menstruation log, a patient can predict and manage days when she will be most symptomatic. For example, the patient can adjust her diet, maximize sleep and exercise, and—where possible—avoid stressful events the week before her period. In severe cases, the log can help determine when antidepressants are warranted.

With wireless Internet available in hospitals, coffee shops, airports, universities, and libraries, real-time Internet access away from the home or office is just a click away on your personal digital assistant (PDA). But what if you’re somewhere without wireless Internet-such as in flight or at the local department of motor vehicles?

Transferring and storing online content onto your PDA lets you access critical online information in places without a connection, making your down time more productive.

Portable online content

Much Web-based information can easily be captured or stored onto your PDA.

Electronic books, or e-books, have long been one of the pleasures of using PDAs and handheld devices such as the Beating the high cost of software,” Psyber Psychiatry, March 2004.)

Plucker also is free, but it creates documents primarily for Palm OS handhelds. A Pocket PC version of Plucker is in development. iSiloX documents can be viewed on Pocket PC or Palm OS devices, but the paid version of the viewer iSilo, available for $20, is required to use the navigational links. The free version of iSilo can read but cannot navigate with hyperlinks. Adobe Acrobat PDFs can be viewed on Pocket PC and Palm OS devices, but these PDFs must be distilled a second time for the handheld.

One disadvantage of all viewing systems is that Web pages with complicated formatting or specialized layers may not be accurately captured or well viewed on a PDA’s small screen.

Table

Sample systems for viewing Web-based content on PDAs

Related Resources

• Microsoft Windows XP. Make web pages available for offline viewing.
• Kansas City Clinical Oncology Program. Mobile users help page.
• PDACorps discussion forum (topic: Plucker for Pocket PC).

If you have any questions about these products or comments about Current Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

With wireless Internet available in hospitals, coffee shops, airports, universities, and libraries, real-time Internet access away from the home or office is just a click away on your personal digital assistant (PDA). But what if you’re somewhere without wireless Internet-such as in flight or at the local department of motor vehicles?

Transferring and storing online content onto your PDA lets you access critical online information in places without a connection, making your down time more productive.

Portable online content

Much Web-based information can easily be captured or stored onto your PDA.

Electronic books, or e-books, have long been one of the pleasures of using PDAs and handheld devices such as the Beating the high cost of software,” Psyber Psychiatry, March 2004.)

Plucker also is free, but it creates documents primarily for Palm OS handhelds. A Pocket PC version of Plucker is in development. iSiloX documents can be viewed on Pocket PC or Palm OS devices, but the paid version of the viewer iSilo, available for $20, is required to use the navigational links. The free version of iSilo can read but cannot navigate with hyperlinks. Adobe Acrobat PDFs can be viewed on Pocket PC and Palm OS devices, but these PDFs must be distilled a second time for the handheld.

One disadvantage of all viewing systems is that Web pages with complicated formatting or specialized layers may not be accurately captured or well viewed on a PDA’s small screen.

Table

Sample systems for viewing Web-based content on PDAs

Related Resources

• Microsoft Windows XP. Make web pages available for offline viewing.
• Kansas City Clinical Oncology Program. Mobile users help page.
• PDACorps discussion forum (topic: Plucker for Pocket PC).

If you have any questions about these products or comments about Current Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

With wireless Internet available in hospitals, coffee shops, airports, universities, and libraries, real-time Internet access away from the home or office is just a click away on your personal digital assistant (PDA). But what if you’re somewhere without wireless Internet-such as in flight or at the local department of motor vehicles?

Transferring and storing online content onto your PDA lets you access critical online information in places without a connection, making your down time more productive.

Portable online content

Much Web-based information can easily be captured or stored onto your PDA.

Electronic books, or e-books, have long been one of the pleasures of using PDAs and handheld devices such as the Beating the high cost of software,” Psyber Psychiatry, March 2004.)

Plucker also is free, but it creates documents primarily for Palm OS handhelds. A Pocket PC version of Plucker is in development. iSiloX documents can be viewed on Pocket PC or Palm OS devices, but the paid version of the viewer iSilo, available for $20, is required to use the navigational links. The free version of iSilo can read but cannot navigate with hyperlinks. Adobe Acrobat PDFs can be viewed on Pocket PC and Palm OS devices, but these PDFs must be distilled a second time for the handheld.

One disadvantage of all viewing systems is that Web pages with complicated formatting or specialized layers may not be accurately captured or well viewed on a PDA’s small screen.

Table

Sample systems for viewing Web-based content on PDAs

Related Resources

• Microsoft Windows XP. Make web pages available for offline viewing.
• Kansas City Clinical Oncology Program. Mobile users help page.
• PDACorps discussion forum (topic: Plucker for Pocket PC).

If you have any questions about these products or comments about Current Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Understanding how a patient’s cultural background intertwines with relationship concerns, communication issues, and family problems is key to diagnosis and to building a therapeutic alliance.

Asking patients from any culture these six questions can uncover subtleties of cultural interaction that may be contributing to an adjustment, anxiety, depressive, or other disorder.

1. Are your parents content living in the United States? This is especially pertinent when treating children or second-generation adults for relationship problems or for an adjustment, anxiety, or depressive disorder. In clinical practice, we have seen that when parents are satisfied with their new home, children adapt more readily.
2. What mainstream practices has your family adopted? Families tend to incorporate customs and values of the surrounding environment while maintaining much of their core culture. The family’s overriding desire to maintain cultural purity may turn some family members against their ethnicity. For example, children may marry outside their culture to escape a rigid or controlling family or ethnic environment. These divergences, however, are often fraught with guilt and consternation among family members.
3. What value clashes persist in your family? Disagreements over dating or participation in athletics or cheerleading are common. Respect, which may be defined as acquiescing to elders’ opinions, can be an issue regarding personal relationships, occupational choices, or nursing home placement.
4. Can everyone speak freely in your family? In many cultures, assertiveness is perceived as rude. Therefore, patients may need alternate methods of conflict resolution. For example, teaching the patient a more-direct communication pattern (such as politely asking the boss for a raise) may help him or her in the majority culture but can create problems within his or her native culture.
5. Do you or a family member dread being alone? Individuals inured to a nuclear family may be uncomfortable with solitude. Also, some cultures define emotional closeness as the presence of multiple family members, rather than companionship between husband and wife.
6. Is your family comfortable with people from the mainstream culture? Cultural integration requires multicultural contacts. Some families, however, try to maintain their culture at the expense of their stated values. For example, a dishonest, superficial friend from the native culture may be more highly valued than an honest person from the mainstream. These cultural distortions produce mixed messages for all involved.

Understanding how a patient’s cultural background intertwines with relationship concerns, communication issues, and family problems is key to diagnosis and to building a therapeutic alliance.

Asking patients from any culture these six questions can uncover subtleties of cultural interaction that may be contributing to an adjustment, anxiety, depressive, or other disorder.

1. Are your parents content living in the United States? This is especially pertinent when treating children or second-generation adults for relationship problems or for an adjustment, anxiety, or depressive disorder. In clinical practice, we have seen that when parents are satisfied with their new home, children adapt more readily.
2. What mainstream practices has your family adopted? Families tend to incorporate customs and values of the surrounding environment while maintaining much of their core culture. The family’s overriding desire to maintain cultural purity may turn some family members against their ethnicity. For example, children may marry outside their culture to escape a rigid or controlling family or ethnic environment. These divergences, however, are often fraught with guilt and consternation among family members.
3. What value clashes persist in your family? Disagreements over dating or participation in athletics or cheerleading are common. Respect, which may be defined as acquiescing to elders’ opinions, can be an issue regarding personal relationships, occupational choices, or nursing home placement.
4. Can everyone speak freely in your family? In many cultures, assertiveness is perceived as rude. Therefore, patients may need alternate methods of conflict resolution. For example, teaching the patient a more-direct communication pattern (such as politely asking the boss for a raise) may help him or her in the majority culture but can create problems within his or her native culture.
5. Do you or a family member dread being alone? Individuals inured to a nuclear family may be uncomfortable with solitude. Also, some cultures define emotional closeness as the presence of multiple family members, rather than companionship between husband and wife.
6. Is your family comfortable with people from the mainstream culture? Cultural integration requires multicultural contacts. Some families, however, try to maintain their culture at the expense of their stated values. For example, a dishonest, superficial friend from the native culture may be more highly valued than an honest person from the mainstream. These cultural distortions produce mixed messages for all involved.

Understanding how a patient’s cultural background intertwines with relationship concerns, communication issues, and family problems is key to diagnosis and to building a therapeutic alliance.

Asking patients from any culture these six questions can uncover subtleties of cultural interaction that may be contributing to an adjustment, anxiety, depressive, or other disorder.

1. Are your parents content living in the United States? This is especially pertinent when treating children or second-generation adults for relationship problems or for an adjustment, anxiety, or depressive disorder. In clinical practice, we have seen that when parents are satisfied with their new home, children adapt more readily.
2. What mainstream practices has your family adopted? Families tend to incorporate customs and values of the surrounding environment while maintaining much of their core culture. The family’s overriding desire to maintain cultural purity may turn some family members against their ethnicity. For example, children may marry outside their culture to escape a rigid or controlling family or ethnic environment. These divergences, however, are often fraught with guilt and consternation among family members.
3. What value clashes persist in your family? Disagreements over dating or participation in athletics or cheerleading are common. Respect, which may be defined as acquiescing to elders’ opinions, can be an issue regarding personal relationships, occupational choices, or nursing home placement.
4. Can everyone speak freely in your family? In many cultures, assertiveness is perceived as rude. Therefore, patients may need alternate methods of conflict resolution. For example, teaching the patient a more-direct communication pattern (such as politely asking the boss for a raise) may help him or her in the majority culture but can create problems within his or her native culture.
5. Do you or a family member dread being alone? Individuals inured to a nuclear family may be uncomfortable with solitude. Also, some cultures define emotional closeness as the presence of multiple family members, rather than companionship between husband and wife.
6. Is your family comfortable with people from the mainstream culture? Cultural integration requires multicultural contacts. Some families, however, try to maintain their culture at the expense of their stated values. For example, a dishonest, superficial friend from the native culture may be more highly valued than an honest person from the mainstream. These cultural distortions produce mixed messages for all involved.