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
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
Neuropsychiatry and Clinical Neuropsychopharmacology
JR Sicignano MD Dip: ABPN
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
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
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
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
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.
Two hours face-to-face
New Understanding of the Bipolar Spectrum
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
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
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
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
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
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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