Frequently Asked Questions

What To Expect:
Explain the problem that brings you here. Who? When? What? Where? Why? Describe the members of your family in detail. Summarize the major events in your life.

You will be asked to type a 2 to 3 page outline of your personal history and the chronology of your illness. If additional medical records are available, it is ideal to provide them to Dr. Joe to review prior to the first meeting. You should make a list of all medications you are taking and the dose. You should also provide and name, address, phone and fax number of other physicans and professionals who have treated you.

Dr. Joe will discuss your diagnosis and a treatment plan. Treatment will include medication targeted to symptoms, and behavioral interventions (e.g changes in sleep habits, work load, or relationships)

Neuropsychiatry places major emphasis on the brain disorders that underline many behavioral problems. These include the major psychiatric disorders as well as conditions at the interface with neurology.

Clinical Neuropsychopharmacology
Clinical Neuropsychopharmacology involves the use of medications for mental and emotional disorders. To be the best requires more than being able to apply neuroscience. The Neurosphycopharmacology must also excel in the Art of Medicine. It is necessary to draw on clinical intuition while maintaining an empathic engagement with the patient. The pratishioner must be skilled in communication and be able to motivate and instill hope. The skills of a healer must blend seemlessly with the knowledge base of the applied neuroscientist. It is rare to find individuals who can master these two worlds.

Neuropsychiatry and Clinical Neuropsychopharmacology

By JR Sicignano MD Dip: ABPN

I have a unique practice profile, which is reflected, in my fee structure. I see individuals for comprehensive and complex consultations. Almost all have been previously diagnosed. Almost all have been in treatment but the results have been less than optimal. These individuals see me in hope of getting better control of symptoms and/or improving their ability to function day-to-day. Individuals are frequently referred to me from other treating professionals (e.g. psychiatrists, neurologists, psychologists, psychiatric social workers). There may be questions as to diagnosis. There may be a problem with treatment resistance. I may see an individual only once to offer a second opinion. The majority come under my care for treatment and long term follow up.

I do not practice as a General Psychiatrist. My sub-specialties are Neuropsychiatry and Clinical Neuropsychopharmacology. Neuropsychiatry places major emphasis on the brain disorders that underline many behavioral problems. These include the major psychiatric disorders as well as conditions at the interface with neurology. In the latter group would be developmental and academic learning disorders such as Dyslexia and Attentional Deficit Hyperactivity Disorder. In addition, would be the late onset effects of brain injury from trauma (post concussion syndrome following, closed head injury), toxins and infections. Neuropsychiatrists diagnose and treat the behavioral problems that may accompany neurological disease such as seizure disorders, and the degenerative diseases such as Alzheimer and Parkinson's.

Clinical Neuropsychopharmacology involves the use of medications for mental and emotional disorders. State-of-the art Clinical Neuropsychopharmacology requires a mastery of the neurosciences and the complexities of the ever-expanding high tech field of psychopharmacological therapeutics. The Clinical Neuropsychopharmacologist is an information manager who applies the advances in medical sciences into clinical practice. The Clinical Neuropsychopharmacologist must also be a master of the healing art.

It takes healing artistry to establish and maintain trust and confidence while identifying the complex neurobehavioral signs and symptoms of a disorder. It takes healing artistry to be able to choose the best medication, and more often a blend of medications that will be effective treatment for this individual. It takes healing artistry to provide the safe passage to improvement and recovery. It takes great sensitivity and humanist skills to be able to work in close collaboration with an individual and their loved ones at a time of great distress. It takes healing artistry to provide effective psychological education, motivation and hope. It is healing artistry plus scientific knowledge and years of experience to obtain practical advantages such as choosing the medications most likely to succeed from the start, and to minimize ineffective clinical trials.

Sub optimal treatment is costly in time, money and loss of productivity. Many of the individuals I treat are often demoralized, hopeless and helpless after years of frustration and ineffective treatment. Prolonged and inadequately treated neuropsychiatric symptoms frequently lead to secondary problems such as loss of social skills, low self esteem, reduced ability to adapt, and increased sensitivity to stress. These individuals frequently have a negative view of themselves, their world and their future. Secondary problems are frequent seen in job, marriage and family history. These problems are frequently compounded by the effects of repeated or prolonged periods of disability, or with educational or career derailment. The cry for help might trigger self-mutilation, suicide gestures or serious attempts at suicide. There may be repeated psychiatric admissions, exhaustion of insurance coverage and personal savings. There may be inappropriate attempts at inappropriate self-medication with alcohol and other substances. There may be a flight from reason to seek relief in faith healing or New Age therapy cults. As friends are lost, the individual's support may be reduced to a hostile-dependent relationship with one or two people.

Virtually all of the individuals I treat are on complex medication regiments. For most individuals I follow, treatment is not elective, and it is certainly not cosmetic. The goal for all the individuals I treat is to improve functional capacity and improve their stability over time. The goal for many I treat is to enable them to survive and function outside of an institution.

I have found that most efficient and comprehensive initial evaluations are those that can be completed in a single setting. Over the years, the amount of information I require for a complex evaluation has expanded. In a day and age when HMO's allow thirty minutes for an initial evaluation, I require two full hours. Instead of stretching out an evaluation in shorter sessions over a number of weeks, I prefer an initial dobule session. Such an approach avoids the pitfalls of "where did we leave off".

I ask the individual to first prepare a history of their disorder, (preferable typed) its antecedents and its consequences. Next, prepare a treatment history, what worked, what did not. Whenever possible I ask that prior medical records be released to me in advance. Third, I ask them to create a personal chronology of major life events. The goad is to collect a behavioral history the "who, what, when, where and why" I invite other family members to also contribute written information in advance. I also invite loved ones to participate.

The min-marathon permits filling in details of the personal history outline. During the mini-marathan, a genealogy table encapsulating psychohistory of family members through several generations is created. I find that that the initial two hour evaluation allows me to master the essential themes and relevant details revealed in the histories. For most individuals, it is unique and revelatory experience. Frequency, the process leads to a revisionist history, with a new perspective and awareness, and alternative explanations, judgments and conclusions. The ability of an individual to present a coherent narrative of his or her life is essential to self understanding.
Many individuals compartmentalize their lives. Many can recall their past life only as unrelated fragments. These fragments need to be sticthed together to develop a true sense of self. For an individual to take charge of their life, it is essential to possess a reliable sense of self.

The initial evaluation and development of a treatment plan involves an intensive use of cognitive services. For every hour spent-face-to face with a patient, I spent another hour on "paper work". Setting up a clinical and administration record, both a paper and an electronic chart. All information must be posted to the paper chart, faxed and e-mail information is posted to the electronic chart. All information arriving as paper is all scanned and filed as image documents in the electronic chart. Time is spent requesting and reviewing prior medical records, preparing the in initial evaluation, lab orders, initia0l prescriptions and refills, preparing up to date patient education information, checking with on line data banks for possible drug interactions, key punching lab orders, progress notes, including telephone calls, faxes, e-mails, plus disability forms, DMV reports, medical insurance requests, etc. Other than my answering service, I do all of these tasks solo. I am on call to my patients twenty-four hours a day, seven days a week. Patients can contact me via fax, e-mail or through my exchange.

My follow up visits are intermediate in length. Individuals can be seen weekly or biweekly initially. Most of the individuals in my practice are seen monthly. The most stable can be seen once a quarter. My malpractice insurance requires a minimum frequency for follow for p patients on medication is every twelve weeks.

Educational materials are provided. Progress is measured by changes in targeted behavior in a specific length of time. Cognitive, behavioral and interpersonal approached are utilized. Couple or family intervention is often essential. Referral to self-help groups is routine and reinforced.


Procedure Description:
Two hours face-to-face

New Understanding of the Bipolar Spectrum

The current estimate is that Bipolar Spectrum Disease may represent as much as 6% of the population. This condition has been well established as genetic in origin. There is a history of mental or emotional disorder in biological relatives. The condition is chameleon like. Individuals may accumulate multiple diagnoses. Panic Disorder, Social Phobia, Obsessive-Compulsive Disorder, Eating Disorders (especially Bulimia) can be sensed years before experiencing sustained depressions. The most common condition in these families is depression. Mania is rare. Hypomania is often not recognized without a detailed history. The first presentation of a psychiatric disorder can frequently be traced back to childhood. The condition often becomes disabling in the late teens. First psychiatric admissions cluster in this age group. There are many individuals who are never diagnosed. The average patient may take ten years to receive a proper diagnosis. Many of these individuals are found in drug treatment programs. Drug dependence is a frequent complication of the condition. The lifelong risk for drug dependence is about 70%. Until the person is drug free, it is almost impossible to be sure of the diagnosis. Even when clean and sober, the individual with bipolar disorder will continue to show major problems with mood, both anxiety and depression.



Hallmarks of Bipolar Disorder

Bipolar spectrum disorder has three major characteristics. First, the condition presents in the first two decades of life. Second, the condition is recurrent. Third, is that the switch in mood, either up or down, is abrupt. Sometimes the predominant mood may be mostly anxiety, which can be in the form of panic attacks, phobia, or obsessive-compulsive symptoms. At other times, the predominant feature is depression. Having both anxiety and depression simultaneously is worse. Judgment may be affected in severe affective disorder. The presence of alcohol or drug abuse worsens the individual's judgment. Drug abuse, which may be hidden, worsens the course of the illness. Substance abuse counters the effectiveness of treatment. Studies have shown that when individuals require psychiatric admission, the overwhelming majority will test positive for illicit drugs.

Bipolar vs. Unipolar Depression

Bipolar Spectrum Disorder now would include many individuals in the past that would be diagnosed as having Unipolar Depression. In this new schema, the diagnosis of Unipolar Depression is narrower. The prototype of Unipolar Depression would occur in middle-aged individuals with serious external losses. The triggers might be having a serious medical illness themselves or that of a partner. Such individuals often have multiple "exit events": Exit events could include a painful divorce, the loss of a job, financial hardship, a handicapped child, or a poorly functioning child, or having to care for an elderly parent. Typically, there are no solutions for these problem stressors. They are chronic burdens. These burdens limit the effectiveness of antidepressants.

Bipolar Diagnosis, Treatment and Outcome

The good news is that receiving the correct diagnosis early in life and cooperating with long tem treatment can have a dramatic positive effect on the lives of these individuals. I have many patients whom I have seen for 15 years, a few more than 25 years. Most of these patients were severely ill in their teens and early twenties with a frequent history of psychiatric hospitalizations. The majority of my long-term patients were able to go on to lead productive lives. They finished school, had stable jobs, and maintain long term relationships.

The improvement in psychopharmacology played a major role in these positive outcomes. However, ongoing psychotherapy also was critical to help reinforce medication compliance. Working with the family of individuals proved very important. Guidance making major decisions in life played an important role. The enduring connection with one psychiatrist over time proved a great asset.


Lithium and Bipolar Disorder Treatment

Lithium was introduced in 1970 as the first mood stabilizer. Mood stabilizers are defined by their ability to reduce the frequency and intensity of mood swings. Lithium became more effective in the second year of use. It was even more effective in the third year of use. Some individuals also needed an antipsychotic medication (Haldol, Prolixin). The frequency of episodes would be cut from once a year to once in five years. In the 80's, anticonvulsants such as Tegretol and Depakote were introduced as additional mood stabilizers. The combination of Lithium plus an anticonvulsant resulted in even better results. Instead of one episode in five years, many individual were able avoid admission for ten or fifteen years. It was possible to treat most episodes on an outpatient basis.
There has been an evolution in the treatment of Bipolar Disorder over the years. In the 80's, the long-term side effects of lithium were becoming evident. They included weight gain and kidney damage. Even off lithium many of these patients must urinate every hour. The antipsychotics frequently resulted in tardive dyskinsea, abnormal tics involving lips, tongue and cheeks. Tardive Dyskinsea persists even when antipsychotics are stopped. The result was that most individuals were taken off lithium and treated with Depakote or Tegretol. Depakote, unfortunately, produced severe weight gain. In young women it could lead to polycystic ovaries and possible infertility. Many of these agents resulted in sexual dysfunction, decreased interest (libido), decreased capacity (erectile dysfunction or inadequate lubrication) and delayed or blocked orgasms.


Bipolar Disorder and Neurological Degeration

Within the last few years, there is clinical evidence that mild but progressive degenerative changes in the brain may accompany Bipolar Disorder over time. The degree of nerve loss appears to relate to the number of episodes. The symptoms associated with these anatomical changes resemble an acquired Attentional Deficit. The symptoms include problems in executive functioning: problems with organization, difficulty with complex tasks, time management, and prioritization. etc. Medications that have proven helpful for these symptoms include psychostimulants (e.g. Adderal), Strattera, or Provigil.

 Alzheimer's Loss of Function in Stages

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