Showing papers in "American Journal of Psychiatry in 1980"

The clinical application of the biopsychosocial model

Abstract: How physicians approach patients and the problems they present is much influenced by the conceptual models around which their knowledge is organized. In this paper the implications of the biopsychosocial model for the study and care of a patient with an acute myocardial infarction are presented and contrasted with approaches used by adherents of the more traditional biomedical model. A medical rather than psychiatric patient was selected to emphasize the unity of medicine and to help define the place of psychiatrists in the education of physicians of the future.

Use of a self-report symptom scale to detect depression in a community sample.

Abstract: The authors gave the CES-D, a self-report depression symptom scale, to 515 people drawn from a longitudinal community survey. The subjects were also interviewed using the Schedule for Affective Disorders and Schizophrenia (SADS). From the information collected on the SADS, the subjects were given diagnoses based on Research Diagnostic Criteria. The results indicate a modest relationship between self-reported symptoms of depression and the diagnosis of a major or minor depression. However, the groups defined as "cases" by such reports also include many people with other diagnoses or with no diagnoses at all. Thus, symptom scales are useful for the screening of depressed persons in research studies but are only rough indicators of clinical depression in the community.

Epidemiology of dysphoria and depression in an elderly population.

Abstract: The authors surveyed 997 elderly people living in the community and found that the rate of significant dysphoric symptomatology was 14.7%. Forty-five (4.5%) of these individuals suffered from dysphoric symptoms only, and 37 (3.7%) had symptoms of a major depressive disorder. Eighteen (1.8%) suffered from symptoms of primary depressive disorder and 19 (1.9%) from symptoms of secondary depressive disorder. Sixty-five (6.5%) had depressive symptoms associated with impaired physical health. The frequency of widowhood, impairment in social resources, and impairment in economic resources was greater for individuals with symptoms of a major depressive disorder. The entire sample used psychiatric services at a very low rate.

Relationship of neuroleptic drug effects at brain dopamine, serotonin, alpha-adrenergic, and histamine receptors to clinical potency.

Abstract: The authors examined the potencies of 22 neuroleptic drugs competing for binding sites associated with dopamine, serotonin, alpha-adrenergic, and histamine receptors in brain membranes. They found that although many neuroleptics are quite potent in competing at several of these receptor sites, the average antipsychotic clinical potency correlates closely only with the drug affinity for dopamine receptors labeled by 3H-spiroperidol At clinically effective doses, however, substantial occupancy of serotonin, alpha-adrenergic, and histamine receptors often occurs and may account for some of the auxiliary actions of neuroleptics.

Relapse in schizophrenia.

Abstract: Although schizophrenia is a chronic illness with exacerbations and remissions, there has been surprisingly little systematic study of early signs of relapse. The authors gave 145 chronic schizophrenic patients and 80 family members a structured interview regarding early signs of relapse and other information related to the relapse period. Most patients and family informants were aware of a prodromal period during which patients experienced such symptoms as having trouble sleeping, having trouble concentrating, loss of appetite, and feeling depressed. The authors discuss the implications of these findings for the treatment of chronic schizophrenic patients.

Carbamazepine in manic-depressive illness: a new treatment.

Abstract: The authors evaluated carbamazepine (Tegretol), a drug of choice for treatment of temporal lobe epilepsy, in a double-blind placebo-controlled trial in patients with manic-depressive illness. Seven of 9 manic patients had a partial to marked response; several also showed relapses when placebo was substituted and improvement when carbamazepine was reinstituted. Five of 13 depressed patients showed significant improvement in depression ratings; 3 additional patients experienced partial relapse when placebo was substituted. Carbamazepine might also have prophylactic as well as acute efficacy in patients with both phases of manic-depressive illness, including some patients who do not respond to lithium. Therapeutic effects were achieved with 600-1600 mg/day at blood levels of 8-12 microgram/ml with relatively few side effects. Carbamazepine may prove to be a useful additional treatment for affective illness.

Unmasking masked depression in children and adolescents.

Abstract: The authors examined depressive symptoms and behavior disorders in 102 systematically interviewed children aged 7 to 17 years to elucidate the category of masked depression. They found that it was possible to diagnose these children using adult research criteria and that more children with depression were identified using a systematic interview than were identified using standard evaluation procedures. Although children with a depressive disorder may also exhibit behavior disorders that overshadow the depression, an alert clinician conducting a thorough interview should be able to identify the "masked" depression.

The psychological organization of depression.

Abstract: On the basis of the intensive psychotherapy of about 40 depressed patients over the course of two decades, the authors describe three premorbid types of depressive personality: 1) one based on a "dominant other" relationship, 2) one based on a "dominant goal," and 3) one that is a form of character structure or personality disorder. They also describe typical childhood experiences of depressive adults and discuss their theory of the nature of depression as a human experience. They characterize depression as a limitation of alternate ways of thinking and as self-inhibition from new experiences.

The Council on National Affairs

Abstract: THE COUNCIL on National Affairs, Bertram Brown, M.D., chairperson, had a productive but difficult year. The tensions and dramatic events surrounding the ERA controversy either stemmed from or sharply affected the Council components, particularly minorities’ and the women’s committees. The Council took no formal actions on the ERA controversy vis-#{224}-visnonattendance at the annual meeting. However, the Council members, acting as individuals, do not plan to attend the New Orleans meeting. The Council took a leadership role regarding the plight of the mentally ill Cuban refugees and developed a statement that was distributed to other Councils and components. During the September 27-28, 1980, meeting the Board of Trustees approved this statement. It was subsequently submitted by APA to the AMA, where it was also approved. The two opposing dynamics ofconsolidation versus differentiation were much in evidence. A request for a new component of Arabic-speaking psychiatrists was carefully considered and deferred. Similarly, a request for a new Council on Ethnic Minority Affairs, proposed by Esther P. Roberts, M.D. , chairperson of the Committee of Black Psychiatrists, was received with caution and not supported at this time. DSM-III continues to evoke special concerns particularly from the Committee of Spanish-Speaking Psychiatrists, who have asked to participate in assuring language and cultural accuracy in translation. At its December 1980 meeting the Board of Trustees authorized APA staff to sign a contract with a foreign publisher to translate DSM-III into Spanish, in accordance with a preliminary proposal from Editorial El Manual Moderno. The committee will review the completed manuscript, and staff will investigate and negotiate contracts for translation into other languages, with appropriate review of the completed manuscript. The Board of Trustees, with the Council’s support, approved several changes. The Committee on Comprehensive Health Planning is to be transferred to the Council on Psychiatric Services some time in the future. The Task Force on Gay, Lesbian, and Bisexual Issues was replaced by a committee with the following charge: 1) to investigate problems and issues that affect the mental health of gay, lesbian, and bisexual populations, such as stigmatization and discrimination; 2) to develop teaching programs to help correct the inadequate training of psychiatrists about homosexual issues; 3) to establish liaison with other components regarding homosexual issues; and 4) to promote the education of the APA membership and the general public about homosexuality. The Council noted that it will receive complaints and referrals from its Committee on Abuse and Misuse of Psychiatry and is concerned that adequate staff be available to handle what will be difficult issues. The Committee on Abuse and Misuse ofPsychiatry in the U.S. , chaired by Israel Zwerling, M.D. , Ph.D. , had its first meeting and clarified its complex mission as the first order of business. Input came from the World Psychiatric Association, the Council on National Affairs, and many other sources. Consensus was reached on the following statements: 1) The committee will receive complaints concerning the actual or potential abuse of psychiatry and of psychiatrists in the United States from three sources: APA components and letters sent directly to the committee; self-referrals stemming from committee members’ own experience and awareness ; and solicitation from nonpsychiatric agencies such as Amnesty International and the Mental Health Law Project. 2) All recommendations and decisions of the committee will be addressed to the Council. Arrangements were made for close collaboration with the APA Committee on Ethics through joint meetings each spring and fall and the sharing of minutes. Issues the committee will coven fall into three general categories: conflict of interest, irrational bias, and forensic psychiatry. First steps toward recommendations in these areas were made. The Committee of American Indian and Alaskan Native Psychiatrists, Johanna Clevenger, M.D., chairperson, focused on research issues concerning alcoholism and depression. To assure validity of methods and measures for the variety of tribes, the committee arranged consultation with a wide array of APA components and other organizations, including the American Academy of Child Psychiatry. Cornmittee members will meet on a Navajo reservation during a healing ceremony in the winter of 1981. The Committee on Asian-American Psychiatrists, Normund Wong, M.D. , chairperson, dealt with many difficult internal and external issues. Adequate representation and participation oflndian and Southeast-Asian psychiatrists has proven difficult. The committee has been active in dealing with ADAMHA to assure Asian psychiatric representation in several areas, such as the Minority Advisory Group. The newsletter has continued but is currently being reassessed. Plans to develop a directory and resource manual are under way. Special efforts on behalf of Indochinese refugees were made. The committee established liaison with many groups, including the APA Committee on Foreign Medical Graduates. The Committee ofBlack Psychiatrists, Esther P. Roberts, M.D., chairperson, has continued to direct its efforts toward developing strategies that would improve psychiatric services for black populations and to respond to documents

DSM-III: the major achievements and an overview.

Abstract: DSM-III will be published early this year. In the first part of this article the authors describe some of the major achievements of DSM-III: the process of its development, reaching consensus on many controversial diagnostic categories and a definition of mental disorder, the provision of diagnostic criteria and a multiaxial evaluation system, and the demonstration of improved diagnostic reliability. In the second part of the article the authors present an overview of DSM-III in which they describe its departures from DSM-II and the reasons for these changes. They conclude that in the next few years there should be systematic study of DSM-III in use, so that information about its strengths and limitations can be made available to those responsible for developing DSM-IV.

Neuroleptic-induced supersensitivity psychosis: clinical and pharmacologic characteristics.

Abstract: Tardive dyskinesia is thought to result from neostriatal dopaminergic receptor supersensitivity induced by chronic treatment with neuroleptics. The authors suggest that dopaminergic supersensitivity also occurs in the mesolimbic region after chronic neuroleptic exposure, resulting in the development of a supersensitivity psychosis. Neuroleptic-induced supersensitivity psychosis is illustrated by data from 10 patients that demonstrate the syndrome's clinical and pharmacologic characteristics. An implication of neuroleptic-induced mesolimbic supersensitivity is that the tenaency toward psychotic relapse in such patients is determined by more than just the normal course of the illness.

Poor premorbid adjustment and CT scan abnormalities in chronic schizophrenia.

Abstract: The authors evaluated the premorbid adjustment of 51 chronic schizophrenic patients by retrospective chart analysis using a novel scale. Those patients with CT evidence suggestive of brain atrophy had significantly worse premorbid scores, particularly during childhood, than did the patients with normal scans. This finding provides further support for the clinical relevance of CT findings in chronic schizophrenic patients and implicates a neuropathological process that occurs early in development.

Evaluation and modification of exercise patterns in the natural environment.

Abstract: Using a new experimental paradigm to evaluate physical activity in the natural environment, the authors made of 45,694 observations of persons using stairs or an adjacent escalator at a shopping mall, train station, and bus terminal. In study 1, stair use more than doubled for both obese and nonobese persons during two-week periods when a colorful sign encouraging use of the stairs was positioned at the stairs/escalator choice point. In study 2, stair use remained elevated for 15 consecutive days while the sign was present, decreased during a 1-month follow-up period, and returned to baseline by 3 months. These results not only demonstrate the usefulness of this paradigm, but also suggest the strength of simple, inexpensive public health interventions to increase physical activity.

GABA levels in CSF of patients with psychiatric disorders.

Abstract: The authors measured gamma-aminobutyric acid (GABA) levels in the lumbar CSF of patients with depression, with psychosis, or undergoing evaluation for a neurologic disorder. GABA levels in the CSF from depressed patients were significantly decreased compared with neurologic control patients. CSF GABA levels in psychotic patients were not different from those in neurologic patients, although the data suggested a decrease in CSF GABA levels in patients with schizoaffective disorder.

Male rape: offenders and victims

Abstract: In an analysis of 22 cases of male rape in a community setting, the gender of the victim did not appear to be of primary importance to some of the rapists, but for others, males appeared to be specific intended targets, and the rapists' assaults were an effort to deal with unresolved and conflictual aspects of their lives. For all offenders the sexual assault was an act of retaliation, an expression of power, and an assertion of their strength and manhood. The impact of rape on the male victims was similar to that on female victims, disrupting their biopsychosocial functioning; however, male rape appears to be underreported due to the stigma associated with it.

A controlled study of self-help intervention for widows.

Abstract: The authors conducted a 2-year study of postbereavement adaptation in 162 widows. Sixty-eight were paired with a widow contact who provided emotional support and practical assistance. The differences between the women receiving intervention and the controls at 6, 12, and 24 months after bereavement suggested that those receiving intervention followed the same general course of adaptation as control subjects but that the rate of achieving landmark stages was accelerated for the intervention group. The Goldberg General Health Questionnaire and two indices derived from the study questionnaire confirmed the hypothesized "pathway" of adaptation" through intra- and interpersonal adaptation to resolution of overall distress and the effectiveness of the intervention.

Psychosocial Aspects of Neoplastic Disease: I. Functional Status of Breast Cancer Patients During Different Treatment Regimens

Abstract: The authors studied 146 breast cancer patients representing three different treatment regimens by means of a structured interview, open-ended questions, and a modified Psychiatric Status Schedule. The major findings indicated that physical disability did not necessarily relate to an increase in emotional disturbance. The most emotionally disturbing time was the first recurrence of the breast cancer, and the most common disturbance reported in all three treatment groups was in the area of mate role functioning. In addition, adjuvant radiation therapy was a potent source of distress during primary cancer treatment, and at least one-third of all patients in each category reported needing help with household chores.

The DSM-III personality disorders section: A commentary.

Abstract: The author reviews the DSM-III section on personality disorders, discusses several of its more controversial diagnoses, and suggests some possible alternatives. He attributes the continued low reliability of personality diagnoses, compared with the other major sections of DSM-III, to two inherent obstacles: the lack of clear boundaries demarcating the personality disorders from normality and from one another, and the confounding influence of state and role factors. Nonetheless, the DSM-III multiaxial system highlights the importance of personality diagnosis and, together with the provision of clearly specified diagnostic criteria, achieves a considerably improved reliability compared with previous nomenclatures.

Psychiatric emergencies: an overview.

Abstract: The psychiatric emergency ward has become a primary entry point into the network of mental health services for people who need help to cope with their problems of living. It is also the only source of treatment for many chronically mentally ill patients living in the community. The authors critically review the literature on emergency psychiatric services, focusing on the ways these services are used, the atmosphere in the emergency room, and the determinants of disposition decision making. On the basis of their research, they suggest a model for emergency services that includes an evaluation of the patient's and his on her community's resources and competence and minimizes subtle diagnostic considerations.

Elevation of brain neuroleptic/dopamine receptors in schizophrenia.

Abstract: To test the dopamine hypothesis of schizophrenia the authors measured specific 3H-neuroleptic/dopamine binding sites in three dopamin-rich regions of 59 postmortem normal human brains and 50 postmortem brains from schizophrenic patients using 3H-haloperidol and 3H-spiperone. The binding of 2 nM 3H-haloperidol and of 1 nM 3H-spiperone was significantly elevated in the brains from schizophrenic patients. The brain regions from patients who had no history of being treated with neuroleptic drugs also exhibited significantly higher binding of the 3H-neuroleptics. These results are compatible with the hypothesis that schizophrenia may be associated with an overactivity of postsynaptic dopamine receptors.

Tardive dyskinesia: review and update.

Abstract: Tardive dyskinesia is an extrapyramidal syndrome associated with the chronic administration of major neuroleptic agents. The pathogenesis of the disorder appears to relate to chronic striatal dopaminergic receptor site blockade; the pathophysiology of tardive dyskinesia appears to relate to the resultant denervation hypersensitivity. Agents that deplete the brain of dopamine are the mainstay of therapy for tardive dyskinesia. Cholinergic agents that potentially modulate the balance between dopamine and acetycholine in the striatum offer possible additional therapeutic options. Clearly, resumption of neuroleptic therapy is treatment with the presumed pathogenic agent and is to be avoided whenever possible.

Cerebellar pathology in schizophrenia: a controlled postmortem study.

Abstract: In a morphometric study of the anterior cerebellar vermis of 47 brains in the Yakovlev collection, the area of the vermis of 5 of 12 brains of schizophrenic patients was smaller than that of any of 11 brains of control subjects without psychiatric or neurologic disease and 9 of 10 brains of control subjects with other psychiatric diagnoses (p less than .02). This finding confirms computerized tomography scan observations in live patients and supports the idea that some schizophrenic patients have structural abnormalities of the cerebellar vermis.

DSM-III: Psychiatric Diagnosis in a University Population

Abstract: Using DSM-III the authors reviewed psychiatric diagnoses in a sample of 500 students at a university psychiatric clinic. They present prevalence data and associated age and sex characteristics of this population in relationship to their diagnostic findings and discuss these in the context of earlier epidemiologic studies and their impact on university mental health services.

Overview: model programs for chronic mental patients.

Abstract: Model programs for chronic mental patients may be viewed from four perspectives: evaluation of individual programs, commonalities in successful programs, generalizability and reproducibility of specific programs, and relevance of model programs to problems of service delivery in mental health systems. Although successful model programs share certain common structural elements, such programs cannot be readily reproduced or generalized. Having limited value for the problems of service delivery in mental health systems, model programs are best seen as experimental efforts, not as solutions. Strategies for translating model-derived knowledge into systems-related action are needed.

Cerebral laterality and psychiatry: a review of the literature.

Abstract: The two sides of the human brain are functionally and anatomically different. Research methods based on this cerebral laterality have been used to investigate regional brain function in psychiatric illness. The author describes the functional and anatomic differences between the two sides of the brain, the research methods based on these differences, and the results of studies that have used these methods to investigate brain dysfunction in psychiatric illness.

Primary affective disorder in relatives of patients with anorexia nervosa.

Abstract: The authors examined the incidence of primary affective disorder (PAD) in relatives of 25 patients with anorexia nervosa and of 25 normal control subjects. Among the relatives of patients with anorexia nervosa, 22% (N = 43) had histories of PAD, while only 10% (N = 17) of the relatives of controls had such histories. Among the PAD relatives of anorectic probands, 34 had histories of unipolar depression and 9 of bipolar affective disorder. These findings provide further evidence of a possible relationship between anorexia nervosa and affective illness.

Natural history of male psychological health: IX. Empirical evidence for Erikson's model of the life cycle.

Abstract: The authors examine Erikson's model of the life cycle by reviewing two 40-year prospective studies, one of 392 men from high-crime core-city neighborhoods and the other of 94 successful college students. The empirically defined developmental stage of each man at age 47 and many other facets of each man's life course were rated by judges blind to other data. The studies identified a well-defined, career consolidation stage that falls between Erikson's stages of intimacy and generativity. The results support three hypotheses. First, the stages of men's life cycle must be passed through sequentially; failure to master one stage usually precludes mastery of subsequent stages. Second, the age at which a given stage is mastered varies enormously. Third, the stage attained by middle life appears quite independent of childhood social class or education, although adult maturation is correlated with whether childhood was conducive to basic trust, autonomy, and initiative.

Pathological Grief and the Activation of Latent Self-Images

Abstract: The authors studied the case material for patients treated with either psychoanalysis or brief therapy to examine the basis for the various states of pathological grief after berevavement. They view these states as intensifications or unusual prolongations of states found in normal grief and describe them in terms of the reemergence of self-images and role relationship models that had been held in check by the existence ofthe deceased person. This conclusion concerning preexisting mental schemata leads to an elaboration and partial revision of theories of regression, ambivalence, and introjection as causes of pathological grief.

Overview: The “Wife-Beater’s Wife” Reconsidered

Abstract: Wife-beating, although not a new phenomenon, has been largely ignored by mental health professionals. Until recently the literature and research on family violence were limited to child abuse and murder, since these categories alone were generally accepted as serious problems deserving of public attention and intervention. Although extensive research and service efforts have focused on family dynamics that foster child abuse and alcoholism, there has been inadequate recognition of the aggression that is often directed toward the wives and mothers in such families. This “selective inattention” has been noted by most contemporary researchers and writers1–3 and was documented by O’Brien’s finding4 that the index of the Journal of Marriage and the Family from its inception in 1939 through 1969 contained no references to “violence.”