Showing papers in "American Journal of Psychiatry in 1992"

Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders.

Abstract: Objective: This study was designed to determine the effectiveness ofa group stress reduction program based on mindfulness meditation for patients with anxiety disorders. Method: The 22 study participants were screened with a structured clinical interview and found to meet the DSM-IH-R criteria for generalized anxiety disorder or panic disorder with or without agoraphobia. Assessments, including self-ratings and therapists’ ratings, were obtained weekly bef ore and during the meditation-based stress reduction and relaxation program and monthly during the 3-month follow-up period. Results: Repeated measures analyses ofvariance documented significant reductions in anxiety and depression scores after treatment for 20 of the subjects-changes that were maintained at follow-up. The number of subjects experiencing panic symptoms was also substantially reduced. A comparison of the study subjects with a group ofnonstudy participants in the program who met the initial screening criteria for entry into the study showed that both groups achieved similiar reductions in anxiety scores on the SCL-90-R and on the Medical Symptom Checklist, suggesting generalizability of the study f indings. Conclusions: A group mindfulness meditation training program can effectively reduce symptoms ofanxiety and panic and can help maintain these reductions in patients with

Transduction of psychosocial stress into the neurobiology of recurrent affective disorder.

Abstract: Early clinical observations and recent systematic studies overwhelmingly document a greater role for psychosocial stressors in association with the first episode of major affective disorder than with subsequent episodes. The author postulates that both sensitization to stressors and episode sensitization occur and become encoded at the level of gene expression. In particular, stressors and the biochemical concomitants of the episodes themselves can induce the protooncogene c-fos and related transcription factors, which then affect the expression of transmitters, receptors, and neuropeptides that alter responsivity in a long-lasting fashion. Thus, both stressors and episodes may leave residual traces and vulnerabilities to further occurrences of affective illness. These data and concepts suggest that the biochemical and anatomical substrates underlying the affective disorders evolve over time as a function of recurrences, as does pharmacological responsivity. This formulation highlights the critical importance of early intervention in the illness in order to prevent malignant transformation to rapid cycling, spontaneous episodes, and refractoriness to drug treatment.

Revising axis V for DSM-IV: a review of measures of social functioning.

Abstract: Objective Axis V, which uses the Global Assessment of Functioning Scale in the multiaxial system of DSM-III-R, is under review for DSM-IV. This article examines what is known about axis V and selectively reviews the literature on measures of social functioning to identify potential alternatives to the Global Assessment of Functioning Scale. Method About 25 studies on the use, reliability, and validity of axis V in DSM-III and DSM-III-R are reviewed. In addition, nearly 30 measures of social functioning are reviewed and analyzed as potential substitutes for the Global Assessment of Functioning Scale. The analysis focuses on the strengths and weaknesses of each measure for assessing functioning on axis V. Results Axis V measures are modestly reliable and valid but not widely used. The authors identify and discuss two particular limitations of the Global Assessment of Functioning Scale: 1) the combination of measures of symptoms and measures of social functioning on a single axis and 2) the exclusion of physical impairments from the rating of functioning. Conclusions None of the measures of social functioning reviewed is clearly superior to the Global Assessment of Functioning Scale for use on axis V. A modified version of the Global Assessment of Functioning Scale, separating the measures of social and occupational functioning from the measures of symptoms and psychological functioning, is proposed for field testing, along with a new set of instructions permitting the rating of limitations due to both physical and mental impairments.

Depression and Parkinson's disease: a review.

Abstract: Objective The purpose of this review is to provide an update of the research regarding depression in Parkinson's disease and to synthesize the information into a neurobiological model relating the structural and biochemical changes in this disorder to the behavioral manifestations. Method The author used a computer-based search of the literature, augmented by extensive bibliography-guided article reviews, to find information on depression and Parkinson's disease. Findings Depression occurs in approximately 40% of patients with Parkinson's disease; depression in Parkinson's disease is distinguished from other depressive disorders by greater anxiety and less self-punitive ideation. Lower CSF levels of 5-hydroxyindoleacetic acid, a past history of depression, and greater functional disability are associated with a greater risk of depression in Parkinson's disease. Female gender, early age at onset of Parkinson's disease, and greater left brain involvement may also be risk factors. Approximately half of depressed patients with Parkinson's disease meet criteria for major depressive episodes; half have dysthymia. Depression is more common in Parkinson's disease with prominent bradykinesia and gait instability than in tremor-dominant syndromes. Depressed patients with Parkinson's disease have greater frontal lobe dysfunction and greater involvement of dopaminergic and noradrenergic systems than nondepressed patients with the disease. Mood changes in Parkinson's disease respond to treatment with conventional tricyclic antidepressants or ECT. Conclusions Neurobiological investigations suggest that depression in Parkinson's disease may be mediated by dysfunction in mesocortical/prefrontal reward, motivational, and stress-response systems. Neuropsychological, metabolic, clinical, pharmacological, and anatomical studies support the involvement of frontal dopaminergic projections in patients with Parkinson's disease and depression.

Duration of psychosis and outcome in first-episode schizophrenia.

Abstract: Objective; This study was undertaken to assess the potential effect ofduration of untreated illness on outcome in a group offirst-episode schizophrenic patients. Method: Seventy patients with schizophrenia diagnosed according to the Research Diagnostic Criteria entered the study and were followed for up to 3 years. All patients received standardized treatment and uniform assessments both during the acute phase of their illness and throughout the follow-up period. Outcome was measured in terms of time to remission ofacute psychotic symptoms as well as degree ofsymptom remission. Results: The mean duration ofpsychotic symptoms before initial treatment was 52 weeks, preceded by a substantial prepsychotic period. According to survival analysis, duration of illness before treatment was found to be significantly associated with time to remission as well as with level ofremission. The effect ofduration ofillness on outcome remained significant when diagnosis and gender variables, themselves associated with outcome, were controlled in a regression analysis. Duration ofiliness was not correlated with age at onset, mode of onset, premorbid adjustment, or severity of illness at entry into the study. Conclusions: Duration ofpsychosis before treatment may be an important predictor of outcome in first-episode schizophrenia. Acute psychotic symptoms could reflect an active morbid process which, if not ameliorated by neuroleptic drug treatment, may result in lasting morbidity. Further implications of these findings are discussed. (AmJ Psychiatry 1992; 149:1183-1188) C onsiderable attention has been focused on clinical factors that may influence the outcome of patients

Evidence of dysfunction of a prefrontal-limbic network in schizophrenia: a magnetic resonance imaging and regional cerebral blood flow study of discordant monozygotic twins.

Abstract: Objective: The authors previously reported that in monozygotic twins discordant for schizophrenia the affected twin almost invariably had a smaller anterior pes hippocampus, measured with magnetic resonance imaging (MRI), and invariably had less regional cerebral blood flow (rCBF) in the dorsolateralprefrontal cortex duringperformance ofthe Wisconsin Card Sorting Test. The present study was an investigation ofthe relationship between hippocampalpathology and prefrontal hypofunction in the same twin pairs. Method: Nine pairs of monozygotic twins discordant for schizophrenia underwent MRI scanning for determination of anterior hippocampalvolume andxenon-inhalation rCBF testingfor determination of prefrontal physiological activation associated with the Wisconsin Card Sorting Test. Results: The differences within twin pairs on the MRI and rCBF measures were strongly and selectively correlated. Specifically, the more an affected twin differed from the unaffected twin in left hippocampal volume, the more they differed in prefrontal physiological activation during the Wisconsin Card Sorting Test. In the affected twins as a group, prefrontal activation was strongly related to both left and right hippocampal volume. These relationships were not found in the group ofunaffected twins. Conclusions: This finding is consistent with the notion that schizophrenia involves pathology ofand dysfunction within a widely distributed neocortical-limbic neural network that has been implicated in, among other activities, the performance ofcognitive tasks requiring working memory. (Am J Psychiatry 1992; 149:890-897)

Religious coping and depression among elderly, hospitalized medically ill men.

Abstract: Objective: The investigators examined the frequency ofreligious coping among older medical inpatients, the characteristics of those who use it, and the relation between this behavior and depression. Method: The subjects were 850 men aged 65 years and over, without psychiatric diagnoses, who were consecutively admitted to the medical or neurological services of a southern Veterans Administration medical center. Religious coping was assessed with a threeitem index. Depressive symptoms were assessed by self-rating (the Geriatric Depression Scale) and observer rating (the Hamilton Rating Scale for Depression). Results: One out of every five patients reported that religious thought and/or activity was the most important strategy used to cope with illness. Variables that were associated with religious coping included black race, older age, being retired, religious affiliation, high level of social support, infrequent alcohol use, a prior history ofpsychiatric problems, and higher cognitive functioning. Depressive symptoms were inversely related to religious coping, an association which persisted after other sociodemographic and health correlates were controlled. When 202 men were reevaluated during their subsequent hospitaladmissions an average of6 months later, religious coping was the only baseline variable that predicted lower depression scores at follow-up. Conclusions: These findings suggest that religious coping is a common behavior that is inversely related to depression in hospitalized elderly men. (Am J Psychiatry 1992; 149:1693-1700)

Cigarette smoking in schizophrenia: relationship to psychopathology and medication side effects.

Abstract: Objective The authors' goal was to study the relationship between smoking status and clinical characteristics in schizophrenic patients. Method Seventy-eight schizophrenic outpatients were assessed by a single rater using the Brief Psychiatric Rating Scale (BPRS), the Abnormal Involuntary Movement Scale, and the Simpson-Angus Scale for extrapyramidal symptoms. Current smokers (N = 58) were compared with nonsmokers (N = 20) on clinical variables by independent t tests and chi-square tests. Differences in outcome variables were tested by multiple analysis of covariance (ANCOVA) with smoking status and gender as factors and age, neuroleptic dose, and caffeine consumption as covariates. Results Seventy-four percent of patients were current smokers and reported a mean of 19 cigarettes smoked per day. Compared to nonsmokers, current smokers were significantly more likely to be men, to be younger, and to have had an earlier age at onset and a greater number of previous hospitalizations. Current smokers and nonsmokers received mean neuroleptic doses of 1160 and 542 mg/day (chlorpromazine equivalents); the difference was significant. Current smokers also displayed significantly less parkinsonism and more akathisia and had higher total scores on the BPRS. Overall multiple ANCOVA demonstrated a significant main effect for smoking status but not gender or the interaction between gender and smoking status. Univariate ANCOVAs demonstrated a significant main effect of smoking status only for the Simpson-Angus Scale score. Conclusions Cigarette smokers receive significantly higher neuroleptic doses, in part because of a smoking-induced increase in neuroleptic metabolism. Smoking is also associated with significant reduction in levels of parkinsonism. Smoking status is a significant factor that should be considered in assessment of neuroleptic dose requirements and neuroleptic side effects.

Posttraumatic stress disorder among substance users from the general population

Abstract: OBJECTIVE The purpose of the study was to evaluate the prevalence of posttraumatic stress disorder (PTSD) among substance users in the general population. METHOD The St. Louis Epidemiologic Catchment Area study, a survey of psychiatric illness in the general population, collected data on PTSD and substance use with the Diagnostic Interview Schedule. Among the 2,663 respondents, 430 reported a traumatic event that could qualify for PTSD; however, the rate of PTSD was low, 1.35% overall. To evaluate the relationship between PTSD and substance use, respondents were hierarchically classified into one of four substance use categories ranging from polydrug use to alcohol use only. Substance users from each category as well as substance users in general were compared with persons who did not meet the substance use threshold (comparison subjects). RESULTS Findings indicate that cocaine/opiate users are over three times as likely as comparison subjects to report a traumatic event, report more symptoms and events, and are more likely to meet diagnostic criteria for PTSD. Physical attack, but not combat-related events, was the most prevalent event reported among cocaine/opiate users. Onset of substance use preceded onset of posttraumatic symptoms, suggesting that substance use predisposes the individual to exposure to traumatic events. When other variables--including antisocial behavior--were controlled, female gender and use of cocaine/opiates predicted PTSD. CONCLUSIONS These analyses of the co-occurrence of substance abuse and PTSD warrant further study and suggest that PTSD is much more common among substance abusers than was previously known.

Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania.

Abstract: Objective The authors reviewed available evidence regarding the status of dysphoric or mixed mania as a distinct clinical state and formulated operational criteria for its diagnosis. Method Studies of dysphoric mania or hypomania in patients with bipolar disorder were analyzed with regard to clinical characteristics, prevalence, demographic features, course of illness, outcome, family history, associated conditions, biological tests, and response to biological treatment. Results Although some studies suggest that dysphoric and nondysphoric mania are similar conditions, others suggest that, compared with nondysphoric mania, dysphoric mania may be more severe; more likely to occur in women; more likely to be associated with suicidality, a younger age at onset, a longer duration of illness, higher rates of personal and familial depression, concomitant alcohol or sedative-hypnotic abuse, neuropsychiatric abnormalities, and poorer outcome; more frequently associated with cortisol nonsuppression; and less likely to respond adequately to lithium but perhaps more likely to respond to ECT or anticonvulsants. Conclusions Substantial evidence suggests that dysphoric mania may be a distinct affective state. Contrary evidence, however, suggests that dysphoric mania may be a form of typical mania, a stage-related or severe form of mania, or a transitional state between mania and depression. Because the evidence may be inconsistent because of varying definitions of dysphoric mania among studies, the authors propose preliminary operational diagnostic criteria for the future study of dysphoric mania.

Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity.

Abstract: Objective Despite progress in epidemiologic research on posttraumatic stress disorder (PTSD), little is known about factors that distinguish chronic from nonchronic PTSD. In a previous report, the authors identified a set of personal predispositions associated with PTSD following traumatic events in a general population sample of young adults. The purpose of this analysis was to identify characteristics of chronic PTSD and examine whether any of the suspected risk factors for PTSD was associated specifically with chronic PTSD. Method A random sample of 1,007 21- to 30-year-old members of a large health maintenance organization in the Detroit area was interviewed, using the National Institute of Mental Health Diagnostic Interview Schedule (DIS), revised for DSM-III-R. The analysis was performed on data from 394 respondents who reported traumatic events, of whom 93 met criteria for PTSD. Chronic PTSD was defined as duration of symptoms for 1 year or more. Results Persons with chronic PTSD (N = 53) had, on the average, a significantly higher total number of PTSD symptoms and higher rates of overreactivity to stimuli that symbolized the stressor and interpersonal numbing than persons with nonchronic PTSD. The rates of one or more additional anxiety or affective disorders and a variety of medical conditions were higher in persons with chronic than nonchronic PTSD. Family history of antisocial behavior and female sex were associated specifically with chronic PTSD. Conclusions The findings suggest that chronic PTSD may be associated with specific risk factors and clinical features. Longitudinal data on the course of PTSD are needed to determine whether the distinct features and the medical and psychiatric histories of persons with chronic PTSD are complications attendant on a chronic course or coexisting disturbances that inhibit recovery.

Dissociation and posttraumatic stress disorder in Vietnam combat veterans

Abstract: Objective: This study compared current dissociative symptoms and dissociation at the time of specific traumatic events in Vietnam combat veterans with posttraumatic stress disorder (PTSD) and Vietnam combat veterans without PTSD. Method: Vietnam combat veterans who sought treatment for PTSD (N=53) were compared to Vietnam combat veterans without PTSD (N=32) who sought treatment for medical problems. Dissociative symptoms were evaluated with the Dissociative Experiences Scale. Dissociation at the time ofa combat-related traumatic event was evaluated retrospectively with the modified Dissociative Experiences Questionnaire. The Combat Exposure Scale was used to measure level of combat exposure. Results: There was a significantly higher level of dissociative symptoms, as measured by the Dissociative Experiences Scale, in patients with PTSD (mean=27.O, SD=1 8.0) than in patients without PTSD (mean=13.7, SD=1 6.0). This difference persisted when the difference in level of combat exposure was controlled with analysis of covariance. PTSD patients also reported more dissociative symptoms at the time of combat trauma, as measured retrospectively by the Dissociative Experiences Questionnaire (mean=1 1 .5, SD=1 .6) than non-PTSD patients (mean=1 .8, SD=2.1). Conclusions: Dissociative symptoms are an important element ofthe long-term psychopathological response to trauma. (Am J Psychiatry 1992; 149:328-332)

The meaning of expressed emotion: theoretical issues raised by cross- cultural research

Abstract: The finding that expressed emotion is associated with the course of psychiatric disorder has generated a great deal of clinical and research interest in expressed emotion as an important risk factor. Theoretical elucidation of the construct of expressed emotion has lagged considerably behind this interest, however. The authors contribute to a dialogue on what is inside the "black box" called expressed emotion. They argue that cross-cultural research can provide an empirical basis for the theoretical grounding of expressed emotion factors. A comparative approach reveals that the construct of expressed emotion is essentially cultural in nature. The constellation of emotions, attitudes, and behaviors that are indexed by the expressed emotion method represent cross-culturally variable features of family response to an ill relative. Questions surrounding the cultural validity of the construct of expressed emotion, the qualitative dimensions of expressed emotion, and statistically significant cross-cultural variations in expressed emotion profiles are discussed. Finally, the authors provide an outline of diverse (cultural, psychobiological, social-ecological) features of expressed emotion. Anthropological analysis of expressed emotion reveals that although expressed emotion indexes a Pandora's box of diverse features, culture provides the context of variation through which these factors are most productively analyzed.

Neuropsychological functioning of first-episode schizophreniform patients.

Abstract: Objective and Method: This study compared 32 consecutively admitted first-episode schizophreniform patients, 26 patients with chronic schizophrenia according to the DSM-III-R criteria, and 25 normal comparison subjects on a comprehensive battery of neuropsychological tests to determine the degree of cognitive impairment existing at the onset of schizophrenic illness. Patients were tested within 2 weeks of admission to the hospital, after their medication had been stabilized

Self-mutilation in personality disorders: psychological and biological correlates.

Abstract: OBJECTIVE: The goal of this study was to determine whether self-mutilators with personality disorders differ from nonmutilators with personality disorders in impulsivity, aggression, and other psychopathology and whether serotonergic dysfunction contributes to self-mutilation. METHOD: Twenty-six self-mutilators with personality disorders were matched to 26 control subjects with personality disorders for gender, age, education, axis I diagnosis of affective disorder, and axis II diagnosis of personality disorder. Numerous indexes of psychopathology as well as CSF 5-hydroxyindoleacetic acid (5-HIAA) levels and platelet imipramine binding sites (Bmax) and affinity (Kd) were determined. RESULTS: Self-mutilators had significantly more severe character pathology, had greater lifetime aggression, and were more antisocial than the control subjects. The self-mutilators scored higher on the Hamilton Rating Scale for Depression but not on the Beck Depression Inventory or the Beck Hopelessness Scale. The two groups did not differ on the Buss-Durkee Hostility and Guilt Inventory or on the Sensation Seeking Scale. The degree of self-mutilation was significantly correlated with impulsivity, chronic anger, and somatic anxiety. Both self-mutilation and impulsivity showed significant negative correlations with Bmax, although the two groups did not differ in CSF 5-HIAA levels or in platelet imipramine binding. CONCLUSIONS: The results demonstrate the contribution of severe character pathology, aggression, impulsivity, anxiety, and anger to self-mutilation and provide preliminary support for the hypothesis of underlying serotonergic dysfunction facilitating self-mutilation. Language: en

Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity.

Abstract: OBJECTIVE The purpose of this study was to examine patterns of co-occurrence of axis II disorders in a group of consecutive patients evaluated with two contrasting structured interviews. METHOD One hundred of 106 consecutive applicants for long-term, inpatient treatment of severe personality psychopathology were assessed, face-to-face, by psychiatrists using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Personality Disorder Examination (PDE). The percent of co-occurrence of pairs of disorders diagnosed by each structured interview separately was calculated, and significance levels were determined by using chi-square tests of independence. Finally, odds ratios were computed for the odds of each pair of disorders occurring together compared with the odds for the occurrence of each disorder alone. RESULTS The two interview methods revealed different comorbidity patterns. Significant covariation was found for 29 pairs of disorders diagnosed with the PDE, compared with 12 pairs diagnosed with the SCID-II. Six pairs of disorders covaried significantly and were associated with odds ratios greater than 4: histrionic with borderline, histrionic with narcissistic, narcissistic with antisocial, narcissistic with passive-aggressive, avoidant with schizotypal, and avoidant with dependent. CONCLUSIONS Substantial overlap occurred among personality disorders. In this group of patients, consistent patterns of comorbidity involving narcissistic, avoidant, and histrionic personality disorders suggest that categorical distinctions between them and certain other DSM-III-R personality disorders may be illusory. The question of which of two overlapping disorders is more valid, however, is left unanswered. For clinical purposes, a two-level diagnostic convention is proposed.

Problems and considerations in the valid assessment of personality disorders.

Abstract: This article reviews evidence for the reliability and diagnostic concordance of structured-interview and self-report questionnaire methods for the diagnosis of personality disorders. The findings of nine studies that compared two or more axis II diagnostic instruments administered to the same groups of subjects are summarized. Across the eight studies with sufficient data, a summary of the overall diagnostic agreement between any two instruments yielded a low reliability (median kappa = 0.25) for making individual personality disorder diagnoses. Diagnostic concordance was lower between self-report questionnaire and interview methods than between interview methods. Comparing dimensional scores of different methods did not appreciably improve the level of agreement. The author concludes that current methods for making personality disorder diagnoses have high reliability but yield diagnoses that are not significantly comparable across methods beyond chance, which is not scientifically acceptable. Sources for the disagreement include variance due to different raters, interview occasions, data sources (self-report versus observer report), information bases obtained, and instrument sensitivity to state effects (e.g., mood). Serious problems in assessment validity may also arise from the yes/no format, which, despite probes for confirmatory examples, may fail to distinguish adequately between sporadic occurrences and longstanding patterns. Efforts should be made to improve and demonstrate the validity of axis II diagnostic methods. One route to increasing validity is to improve the clinical interview, because personality patterns are best revealed by the recurring patterns one finds when taking a systematic history.

Bright light treatment of behavioral and sleep disturbances in patients with Alzheimer's disease.

Abstract: Objective The authors tested the hypothesis that evening bright light pulses would improve sleep-wake patterns and reduce agitation in patients with Alzheimer's disease who have severe sundowning (a syndrome of recurring confusion and increased agitation in the late afternoon or early evening) and sleep disorders. Method Ten inpatients with Alzheimer's disease on a research ward of a veterans' hospital were studied in an open clinical trial. All patients had sundowning behavior and sleep disturbances. After a week of baseline measurements, patients received 2 hours/day of exposure to bright light between 7:00 p.m. and 9:00 p.m. for 1 week. During the baseline week, the treatment week, and a posttreatment week, patients were rated by nurses for agitation, sleep-wake patterns, use of restraints, and use of prescribed-as-needed medication. On the last 2 days of each week, patients wore activity monitors. Activity counts were analyzed for circadian rhythmicity. Results Clinical ratings of sleep-wakefulness on the evening nursing shift improved with light treatment in eight of the 10 patients. The proportion of total daily activity occurring during the nighttime decreased during the light-treatment week. The relative amplitude of the circadian locomotor activity rhythm, a measure of its stability, increased during the light-treatment week. More severe sundowning at baseline predicted greater clinical improvement. Conclusions Evening bright light pulses may ameliorate sleep-wake cycle disturbances in some patients with Alzheimer's disease. This effect may be mediated through a chronobiological mechanism.

Tics and Tourette's disorder: a 2- to 7-year follow-up of 54 obsessive-compulsive children.

Abstract: Objective: This study examined a hypothesized etiologic relationship between Tourette’s disorder and obsessive-compulsive disorder. Method: Fifty-four children who had initially participated in treatment protocols for obsessive-compulsive disorder (Tourette’s disorder was an exclusionary criterion) were reevaluated 2-7 years later with a neurological examination and a structured interview to establish the presence or absence oftics and Tourette’s disorder. The children’s first-degree relatives (N=1 71) were also screened for tic disorders. Results: At baseline, 57% (N=31) ofthe patients had lifetime histories oftics. At follow-up, 59% (N=32) had lifetime histories of tics; eight of these (all males) met the criteria for Tourette’s disorder (six had developed the disorder, and two, it could be argued in retrospect, might have met the criteria at baseline). The patients with lifetime histories of tics had greater anxiety, a higher ratio of CSF 5-hydroxyindoleacetic acid to homovanillic acid, and a younger age at onset of obsessive-compulsive disorder than those without tics. The patients with Tourette’s disorder differed from other male patients only in having an earlier age at onset of obsessive-compulsive disorder. Ofthe first-degree relatives, 1.8% (N=3) had Tourette’s disorder, and 14% (N=24) had a tic disorder. Conclusions: Except for their earlier age at onset of obsessive-compulsive disorder, the patients with Tourette’s disorder were indistinguishable from those without. The apparent high rate oftics and Tourette’s disorder in the subjects and their relatives is consistent with the hypothesis that in some cases, obsessive-compulsive disorder and Tourette’s disorder may be alternative manifestations of the same underlying illness. (Am J Psychiatry 1992; 149:1244-125 1) O bsessive-compulsive disorder has been reported in association with a number of basal ganglia disorders, specifically, Sydenham’s chorea (1), postencephalitic Parkinson’s disease (2), Huntington’s chorea (S. Fobstein, personal communication), and Tourette’s disorder (3). Of these, obsessive-compulsive disorder has been noted most often in Tourette’s disorder; the more recent systematic studies have reported that one-third to one-half of adult (3-5) and child (6) patients with Tourette’s disorder are afflicted. Studies of patients with obsessive-compulsive

An outcome study of psychotherapy for patients with borderline personality disorder

Abstract: Objective: This study evaluated the effectiveness ofwell-defined outpatient psychotherapy for patients with borderline personality disorder. Method: Thirty patients with borderline personality disorder diagnosed according to the DSM-III criteria were given twice weekly outpatient psychotherapy for 12 months by trainee therapists who were closely supervised. The treatment approach was based on a psychology ofself(this term being used in its broad sense), and strong efforts were made to ensure that all therapists adhered to the treatment model. Outcome measures included frequency ofuse ofdrugs (both prescribed and illegal), number ofvisits to medical professionals, number of episodes of violence and self-harm, time away from work, number of hospital admissions, time spent as an inpatient, score on a self-report index of symptoms, and number of DSM-III criteria (weighted for frequency, severity, and duration) fulfilled. Results: The subjects showed statistically significant improvement from the initial assessment to the end ofthe year offollow-up on every measure. Moreover, 30% ofthe subjects no longer fulfilled the DSM-III criteria for borderline personality disorder. This improvement had persisted 1 year after the cessation oftherapy. Conclusions: The results suggest that a specific form of psychotherapy is of benefit for patients with borderline personality disorder. (Am J Psychiatry 1 992; 149:358-362)

Psychotic (delusional) major depression: should it be included as a distinct syndrome in DSM-IV?

Abstract: To review data supporting or not supporting the designation of unipolar psychotic major depression as a distinct syndrome in DSM-IV, the authors used computerized literature searches to identify reports of studies that have directly compared the characteristics, biology, familial transmission, course/outcome, and response to treatment of psychotic and nonpsychotic major depression. The review showed that statistically significant differences between the two types of depression have been found on each of these dimensions. There are greater guilt feelings and psychomotor disturbance, among other features, in psychotic depression. Studies have found significant differences between patients with psychotic and nonpsychotic depression in glucocorticoid activity, dopamine beta-hydroxylase activity, levels of dopamine and serotonin metabolites, sleep measures, and ventricle-to-brain ratios. Family studies show higher rates of bipolar disorder in first-degree relatives of probands with psychotic major depression than of probands with nonpsychotic major depression. Greater morbidity and residual impairment have also been reported in patients with psychotic major depression, and they respond more poorly to placebo and to tricyclic antidepressants. Differences between patients with psychotic and nonpsychotic major depression on many of these measures were not due to differences in severity or endogenicity. Since the data indicate that psychotic and nonpsychotic major depression can be separated, the frequency with which the diagnosis of psychotic major depression is missed and its unique course and response to treatment point to the practical importance of a separate diagnosis for this disorder. However, further studies are needed to resolve important methodological issues and to develop an optimal set of operational criteria.

Anticholinergic effects of drugs commonly prescribed for the elderly: potential means for assessing risk of delirium.

Abstract: Anticholinergic effects of the 25 drugs most commonly prescribed for the elderly were measured by radioreceptor assay. Fourteen had detectable anticholinergic drug levels; 10 of these had levels that have been associated with impairments in memory and attention in normal elderly subjects. These data indicate that patients taking multiple medications may be at increased risk for side effects from psychotropic drugs, most of which have anticholinergic effects.

Effect of sleep deprivation on brain metabolism of depressed patients.

Abstract: Objective: Sleep deprivation is a rapid, nonpharmacologic antidepressant intervention that is effective for a subset of depressed patients The objective of this study was to identify which brαin structure's activitity differentiales responders from nonresponders and to study how metabolism in these brain regions changes with mood Method: Regional cerebral glucose metabolism was assesse by positron emission tomography (PET) with [ 18 F] deoxyglucose (FDG) before

A double-blind comparison of valproate and lithium in the treatment of acute mania.

Abstract: Objective This study was carried out to compare the efficacy of lithium carbonate with that of valproate in acute mania and to determine whether pretreatment clinical characteristics, such as the presence of a mixed affective state, might predict a differential response to the two drugs. Method Twenty-seven patients meeting DSM-III-R criteria for acute manic episodes underwent a 3-week, randomized, double-blind, parallel-groups trial of treatment with lithium carbonate or valproate. Symptom severity was measured by using the Schedule for Affective Disorders and Schizophrenia, change version (SADS-C), the Global Assessment Scale (GAS), and the Brief Psychiatric Rating Scale (BPRS). Drug effects were compared by using repeated measures analysis of variance (ANOVA). Results At the end of the study, nine of 14 patients treated with valproate and 12 of 13 patients treated with lithium had responded favorably, as measured by changes in the SADS-C mania, BPRS, and GAS scores. Elevated pretreatment SADS-C depression scores were associated with good response to valproate. ANOVA revealed a significant interaction between drug and mixed affective state with respect to treatment response. Conclusions Lithium and valproate were both effective in improving manic symptoms, and lithium was slightly more efficacious overall. Unlike the case with lithium, favorable response to valproate was associated with high pretreatment depression scores. Therefore, treatment with valproate alone may be particularly effective in manic patients with mixed affective states.

Associations between dimensions of religious commitment and mental health reported in the American Journal of Psychiatry and Archives of General Psychiatry: 1978-1989.

Abstract: The authors assessed all measures of religious commitment (N = 139) reported in research studies published in the American Journal of Psychiatry and Archives of General Psychiatry in 1978 through 1989 (N less than 35). For nearly two-thirds of the measures, the studies either made no hypotheses or reported no results concerning the relationship of religious commitment to mental health status. For the great majority of the measures assessed, the studies reported a positive relationship between religious commitment and mental health.

Relapse after cognitive behavior therapy of depression: potential implications for longer courses of treatment.

Abstract: OBJECTIVE: The authors studied the risk of relapse among depressed patients after cognitive behavior therapy in order to document the need and potential indications for longer-term models of treatment. METHOD: Forty-eight patients with major depression who responded during a 16-week course of cognitive behavior therapy entered a 1-year prospective follow-up study, as did two patients who received 20 weeks of therapy. Standardized, independent clinical assessments were completed 1, 3, 6, 9, and 12 months after treatment. Relapse was defined as, at minimum, a 2-week period in which the subject met the DSM-III-R criteria for major depression and had a Hamilton depression scale score of 15 or more. RESULTS: Sixteen patients (32%) relapsed during the 1-year follow-up. Correlates of relapse included a history of depressive episodes, higher levels of depressive symptoms and dysfunctional attitudes, slower response to therapy, and being unmarried. Patients who fully recovered during therapy (Hamilton depression score of 6 or less for 8 weeks or more) were at significantly lower risk for relapse than those who partially recovered (9% and 52%, respectively). Slower response to therapy, unmarried status, and high residual scores on the Dysfunctional Attitudes Scale were independently and additively related to increased risk of relapse. CONCLUSIONS: These findings provide further evidence of a relation between residual symptoms and relapse after cessation of active treatment. The authors strongly recommend that models of longer-term psychotherapy be developed for depressed patients who do not recover fully during time-limited cognitive behavior therapy.

Sensory gating deficits in schizophrenia: new results.

Abstract: Objective: It has been widely hypothesized that sensory gating failures and sensory overload occur in schizophrenic patients compared to normal subjects. The authors ofthis study sought to confirm and extend results ofearlier studies that showed specific sensory gating deficits in schizophrenic patients. Method: Age- and sex-matched schizophrenic patients (N=20) and normal subjects (N=20) were tested using electrophysiologically recorded P50 event-related potentials to assess the overall competence ofthe subjects’ central sensory inhibitory capacity by measuring sensory filtering or gating. P50 area responses to two 75-dB (conditioning and test) click stimuli of O.04-msec duration, averaged over 60 trials, were recorded for each subject. Normally, the first (conditioning) click stimulus induces gating mechanisms that result in diminished or gated P50 event-related potentials in response to the second click stimulus. Results: The schizophrenic subjects manifested a significant sensory gating deficit at frontal, central, and parietal electrode placement sites, with a nonsignificant tendency for the deficit to be most prominent in the frontal areas of the brain. Conclusions: These data reflect a regionally diffuse loss of normal sensory gating in schizophrenic patients. (Am J Psychiatry 1992; 149:488-493)

Nicotine withdrawal symptoms and psychiatric disorders: findings from an epidemiologic study of young adults.

Abstract: Objective Earlier, the authors reported on the association of nicotine dependence with major depression and anxiety disorders in a group of young adults This report describes the occurrence of withdrawal symptoms and their sociodemographic and psychiatric correlates in persons in that group who tried unsuccessfully to abstain from smoking Method A random sample of 1,007 members of a health maintenance organization, 21-30 years old, were interviewed with a revised version of the NIMH Diagnostic Interview Schedule Data on nicotine withdrawal came from a subset of 239 smokers who had tried unsuccessfully to quit or cut down on smoking Results With two exceptions, each of the DSM-III-R nicotine withdrawal symptoms was reported by more than one-half of these smokers Withdrawal symptoms were more severe in white than in black smokers but were unrelated to sex, educational level, or marital status Persons with histories of major depression or any anxiety disorder reported more severe withdrawal symptoms than persons with neither of these disorders Severity of withdrawal, or any specific symptom, did not account for the association between major depression and continued smoking Furthermore, severity of withdrawal was unrelated to continued smoking Conclusions While the long-term clinical significance of nicotine withdrawal is unclear, the evidence indicates that in the general population, abstinence from smoking is associated with a variety of disturbances, including a craving for cigarettes, dysphoria, and symptoms of irritability or nervousness In this study disturbances were more severe in persons with histories of major depression or anxiety disorders

Depression in patients with acute traumatic brain injury.

Abstract: Objective: This study was undertaken to examine patients with closed head injuries for the presence ofdepressive disorders. Method: A consecutive series of66 patients with closed head injuries but no significant spinal cord or other organ system injury were examined by means ofa semistructured psychiatric interview. The Hamilton Rating Scale for Depression as well as scales measuring impairment in activities ofdaily living, intellectualfunctioning, and social fi4 nctioning were administered. The patients’ CTscans were also examined. Results: Seventeen patients had major depression and two had minor depression. The presence ofleft dorsolateral f rontal lesions and/or left basal ganglia lesions and, to a lesser extent, parietal-occipital and right hemisphere lesions was associated with an increased probability of developing major depression. Compared to the nondepressed group, the group with major depression had a higher frequency ofprevious psychiatric disorder and showed evidence ofpoorer social functioning. Conclusions: Major depression occurs in about one-quarter ofpatients after traumatic brain injury. This is the same frequency as in other major disorders such as stroke. Major depression appears to be provoked by one or more factors that include poor premorbid social functioning and previous psychiatric disorder or injury to certain critical brain locations. (Am J Psychiatry 1992; 149:918-923)

The efficacy of brief dynamic psychotherapy: a meta-analysis.

Abstract: Objective Insurance companies, legislators, and funding agencies have become increasingly concerned with efficacy and accountability in regard to psychotherapy, and psychodynamic therapy is a primary target of concern because it is widely practiced in outpatient settings. This paper is a meta-analytic review of recent well-controlled studies of the efficacy of brief dynamic therapy. Method The meta-analysis included both published studies, located through an extensive computerized search of psychiatry and psychology journals, and studies reported at conferences. Eleven studies met the inclusion criteria: use of a specific form of short-term dynamic psychotherapy as represented in a treatment manual or manual-like guide; comparison of brief dynamic therapy and a waiting list control condition, nonpsychiatric treatment, alternative psychotherapy, pharmacotherapy, or other form of dynamic therapy; provision of the information necessary for calculation of effect sizes; at least 12 therapy sessions; and therapists who were trained and experienced in brief dynamic therapy. The outcome measures compared were target symptoms, psychiatric symptoms generally, and social functioning. Results Brief dynamic therapy demonstrated large effects relative to waiting list conditions but only slight superiority to nonpsychiatric treatments. Its effects were about equal to those of other psychotherapies and medication. Conclusions These data confirm previous indications that various psychotherapies do not differ in effectiveness, although this finding should not be generalized to all patient populations, outcome measures, and treatment types. Also, the highly controlled conditions of these studies limit conclusions about actual practice. Future studies should address various treatment lengths, follow-up assessments, and specific treatments, patient groups, and outcome measures.