Showing papers in "American Journal of Psychiatry in 1993"

The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder.

Abstract: Objective In an attempt to surmount the problem of retrospectively establishing the childhood diagnosis of attention deficit hyperactivity disorder, the authors constructed the 61-item Wender Utah Rating Scale (WURS) for adults to use to describe their own childhood behavior. In this paper they present their initial data collection and evaluation of the instrument's validity. Method The scale was administered to 81 adult outpatients with attention deficit hyperactivity disorder, 100 "normal" adults, and 70 psychiatric adult outpatients with unipolar depression. The authors analyzed data from the 25 items of the scale that showed the greatest difference between the patients with attention deficit hyperactivity disorder and the normal comparison subjects and the relationship between the WURS and the patients' parents' judgment of childhood activity as measured by the Parents' Rating Scale. Results The patients with attention deficit hyperactivity disorder had significantly higher mean scores on all 25 items than did the two comparison groups. The difference between the mean total scores of the patients with attention deficit hyperactivity disorder and the normal subjects was also highly significant. A cutoff score of 46 or higher correctly identified 86% of the patients with attention deficit hyperactivity disorder, 99% of the normal subjects, and 81% of the depressed subjects. Correlations obtained between WURS scores and Parents' Rating Scale scores were moderate but impressive. The ability of WURS scores to predict response to methylphenidate replicated the authors' finding regarding the ability of Parents' Rating Scale scores to predict response to pemoline. Conclusions The WURS is sensitive in identifying childhood attention deficit hyperactivity disorder and may be useful in recognizing attention deficit hyperactivity disorder in patients with ambiguous adult psychopathology.

Assessment of insight in psychosis.

Abstract: Objective It is frequently reported that patients with psychotic disorders have poor insight into their illness. Previous research has suggested that poor insight may have considerable power in predicting the long-term course of chronic mental disorders and an impact on patients' compliance with treatment plans. The authors, proposing that insight is best viewed as a multidimensional phenomenon, developed the Scale to Assess Unawareness of Mental Disorder, which samples discrete and global aspects of insight across a variety of manifestations of illness. This article reports on a reliability and validity study of the scale. Method The study subjects were 43 patients with schizophrenia and schizoaffective disorder. Various aspects of insight into illness were evaluated with the scale. In addition, ratings of psychopathology, course of illness, and compliance with treatment were made. Results Item variability was high and normally distributed, supporting the authors' contention that insight can be rated on a continuous rather than dichotomous scale. Results of the analyses examining the relations between the various dimensions of insight assessed and the psychopathology, course, and compliance variables were generally as hypothesized. Convergent validity with other global measures of insight was found, and aspects of poor insight were correlated with poorer compliance and course of illness. Examination of the interrelations among the four insight subscales revealed that these subscales sample independent phenomena. Conclusions The Scale to Assess Unawareness of Mental Disorder has good reliability and validity and has certain advantages over previous measures of insight, suggesting the usefulness of a multidimensional view of this complex concept.

Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder.

Abstract: Objective Although attention deficit hyperactivity disorder is a common disorder of childhood, its status as a disorder in adults is not clear. The authors reasoned that if the adult diagnosis of the disorder is a valid clinical entity, it should be similar to the childhood disorder with regard to patterns of psychiatric and cognitive findings. Methods Eighty-four adults with a clinical diagnosis of childhood-onset attention deficit hyperactivity disorder confirmed by structured interview who were referred for treatment were studied. Findings were compared with those from a preexisting study group of referred children with attention deficit hyperactivity disorder, nonreferred adult relatives of those children who also had attention deficit hyperactivity disorder, and adults without the disorder who were relatives of normal children. Subjects were evaluated with a comprehensive battery of psychiatric, cognitive, and psychosocial assessments. Results The referred and nonreferred adults with attention deficit hyperactivity disorder were similar to one another but more disturbed and impaired than the comparison subjects without the disorder. The pattern of psychopathology, cognition, and functioning among the adults with attention deficit hyperactivity disorder approximated the findings for children with the disorder. Conclusions These results show that referred and nonreferred adults with attention deficit hyperactivity disorder have a pattern of demographic, psychosocial, psychiatric, and cognitive features that mirrors well-documented findings among children with the disorder. These findings further support the validity of the diagnosis for adults.

Mental disorders and comorbidity in suicide.

Abstract: OBJECTIVE: The purpose of this study was to investigate the prevalence and comorbidity of current mental disorders defined by DSM-III-R among a random sample of suicide victims from a nationwide suicide population. METHOD: Using a psychological autopsy method, the authors collected comprehensive data on all suicide victims in Finland during 1 year. Retrospective axis I-III consensus diagnoses were assigned to 229 (172 male, 57 female) victims. RESULTS: One or more diagnoses on axis I were made for 93% of the victims. The most prevalent disorders were depressive disorders (59%) and alcohol dependence or abuse (43%). The prevalence of major depression was higher among females (46%) than among males (26%). Alcohol dependence was more common among the males (39% versus 18% for females). A diagnosis on axis II was made for 31% and at least one diagnosis on axis III for 46% of the cases. Only 12% of the victims received one axis I diagnosis without any comorbidity. CONCLUSIONS: The majority of suicide victims suffered from comorbid mental disorders. Comorbidity needs to be taken into account when analyzing the relationship between suicide and mental disorders and in planning treatment strategies for suicide prevention in clinical practice. Language: en

Cigarette Smoking: Implications for Psychiatric Illness

Abstract: Psychiatry has been essentially uninterested in cigarette smoking and nicotine. However, it is the view of this author that both cigarette smoking and smoking cessation are highly relevant to the clinical psychiatrist in the care of patients and that they are potentially a source of important insights into psychopathology. To support that view, the author reviews the evidence that both major depression and depressive symptoms are associated with a high rate of cigarette smoking and that lifetime history of major depression has an adverse impact on smoking cessation. He also reviews the data available on the influence of cigarette smoking cessation on the course of major depression, the relationship between cigarette smoking and other psychiatric diagnoses, particularly schizophrenia, and the neuropharmacology that might underlie these associations. Finally, the implications of these relationships for psychiatry are discussed.

Normalization of Auditory Physiology by Cigarette Smoking in Schizophrenic Patients

Abstract: Objective: Because many schizophrenic patients are heavy smokers, it has been suggested that nicotine normalizes some neuronal deficit involved in their illness. Schizophrenic subjects have various difficulties with maintenance of attention and selective processing of sensory information. One defect in sensorygating in schizophrenia has been characterized by recording auditory evoked potentials. Most normal subjects have a decrease in the evoked response to the second oftwo closely paired stimuli, whereas most schizophrenic subjects do not. The aim of this study was to determine whether smoking normalizes this deficit in auditory sensory gating in schizophrenia. Method: Changes in auditory sensory gating in response to smoking cigarettes were studied in 1 0 smokers without psychiatric illness and 10 schizophrenic smokers. Both groups were asked to abstain from smoking from 1 1 :00 p.m. until 8:00 a.m. the next morning, when their auditory evoked responses to pairs of clicks were recorded. The ability to gate sensory information is reflected in a decrease in the P50 wave amplitude in response to the second of the two stimuli. After baseline recordings, the subjects smoked as much as they wished, and then two postsmoking recordings were performed. Results: The schizophrenic patients had a marked but briefimprovement in P50 auditory gating immediately after smoking, whereas P50 gating for the normalsmokers was slightly impaired. Conclusions: This study suggests that cigarette smoking can transiently normalize the impairment of auditory sensory gating in schizophrenic patients. (AmJ Psychiatry 1993; 150:1856-1861)

The enduring psychosocial consequences of mania and depression.

Abstract: Objective The authors sought to determine the scope, severity, and persistence of psychosocial impairment arising from bipolar and unipolar affective disorder. Method Patients with bipolar (N = 148) or unipolar (N = 240) major affective disorder were assessed as they sought treatment and again after a 5-year follow-up. Concurrently, parents, siblings, and adult children underwent similar assessments and were followed for 6 years. To quantify the impact of affective disorder, probands were individually matched to relatives who had no lifetime history of affective disorder. Sixty-nine relatives who were depressed at intake constituted a separate, nonclinical study group and were also matched to relatives who were well. Results Both unipolar and bipolar patients began follow-up with deficits in annual income. Relative to comparison subjects, affective disorder groups were significantly more likely to report declines in job status and income at the end of follow-up and significantly less likely to report improvements. Similarly, both bipolar and unipolar patients showed significant deficits in nearly all other areas of psychosocial functioning measured at follow-up. Except for relationships with spouses, deficits did not differ significantly by polarity. Surprisingly, probands with recovery sustained throughout the final 2 years of follow-up also showed severe and widespread impairment. Relatives with major depression exhibited substantial deficits on follow-up, but job status and income were not significantly affected. Conclusions The psychosocial impairment associated with mania and major depression extends to essentially all areas of functioning and persists for years, even among individuals who experience sustained resolution of clinical symptoms.

Depressive comorbidity in children and adolescents: empirical, theoretical, and methodological issues.

Abstract: OBJECTIVE The purpose of the study was to examine comorbidity in the context of child and adolescent depression. METHOD The authors reviewed recent epidemiological studies using standardized interviews and DSM-III or DSM-III-R criteria. RESULTS There was a high rate of comorbidity in children and adolescents with major depressive disorders or dysthymia. Comorbidity with conduct disorder/oppositional defiant disorder ranged from 21% to 83%; comorbidity with anxiety disorder ranged from 30% to 75%; and comorbidity with attention deficit disorder ranged from 0% to 57.1%. Rates of depressive comorbidity found in community studies were similar to the rates found in clinical studies. In almost all cases, the disorders were more common in depressed children than expected by chance, and the rates of other disorders in depressed children were higher than the rates of depression in those with depression. CONCLUSIONS The mechanisms by which comorbidity occurs are obscure at present. Several possibilities and their implications for nosology, epidemiology, and treatment research are discussed.

The prediction of major depression in women: toward an integrated etiologic model.

Abstract: Objective The authors develop an exploratory, integrated etiologic model for the prediction of episodes of major depression in an epidemiologic sample of women. Method Both members of 680 female-female twin pairs of known zygosity from a population-based register were assessed three times at greater than 1-year intervals. The last two assessments included a structured interview evaluation for presence of episodes of major depression, defined by DSM-III-R, in the preceding year. The final structural equation model contained nine predictor variables: genetic factors, parental warmth, childhood parental loss, lifetime traumas, neuroticism, social support, past depressive episodes, recent difficulties, and recent stressful life events. Results The best-fitting model predicted 50.1% of the variance in the liability to major depression. The strongest predictors of this liability were, in descending order, 1) stressful life events, 2) genetic factors, 3) previous history of major depression, and 4) neuroticism. While 60% of the effect of genetic factors on the liability to major depression was direct, the remaining 40% was indirect and mediated largely by a history of prior depressive episodes, stressful life events, lifetime traumas, and neuroticism. The model suggested that at least four major and interacting risk factor domains are needed to understand the etiology of major depression: traumatic experiences, genetic factors, temperament, and interpersonal relations. Conclusions Major depression is a multifactorial disorder, and understanding its etiology will require the rigorous integration of genetic, temperamental, and environmental risk factors.

Somatization and the recognition of depression and anxiety in primary care

Abstract: Objective: The authors examined the effect of patients’ style of clinical presentation on primary care physicians’ recognition of depression and anxiety. Method: The subjects were 685 patients attending family medicine clinics on self-initiated visits. They completed structured interviews assessing presenting complaints, self-report measures of symptoms and hypochondriacal worry, the Diagnostic Interview Schedule (DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D). Physician recognition was determined by notation ofany psychiatric condition in the medical chart over the ensuing 12 months. Results: The authors identified three progressively more persistent forms of somatic presentations, labeled “initial, “ “facultative, “ and “true “ somatization. 1 5 patients with CES-D scores of 1 6 or higher, 80% made somatized presentations; of7S patients with DIS-diagnosed major depression or anxiety disorder, 76% made somatic presentations. Among patients with DIS major depression or anxiety disorder, somatization reduced physician recognition from 77%, f or psychosocial presenters, to 22%, for true somatizers. The same pattern was found for patients with high CES-D scores. In logistic regression models education, seriousness of concurrent medical illness, hypochondriacal worry, and number oflifetime medically unexplained symptoms each increased the likelihood of recognition, while somatized presentations decreased the rate of recognition. Conclusions: While physician recognition of psychiatric distress in primary care varied widely with different criteria for recognition, the same pattern of reduction of recognition with increasing level of somatization was found for all criteria. In contrast, hypochondriacal worry and medically unexplained somatic symptoms increased the rate of recognition. (Am J Psychiatry 1993; 150:734-741)

Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans

Abstract: OBJECTIVE: Early trauma in the form of childhood physical or sexual abuse has been associated with adult psychopathology. The purpose of this study was to compare rates of childhood abuse in Vietnam veterans with and without combat-related posttraumatic stress disorder (PTSD). METHOD: Premilitary stressful and traumatic events including childhood abuse and other potential predisposing factors were assessed in Vietnam combat veterans who sought treatment for PTSD (N = 38) and Vietnam combat veterans without PTSD who sought treatment for medical disorders (N = 28). Stressful and traumatic events including childhood physical abuse were assessed with the Checklist of Stressful and Traumatic Events and a clinician-administered interview for the assessment of childhood abuse. Level of combat exposure was measured with the Combat Exposure Scale. RESULTS: Vietnam veterans with PTSD had higher rates of childhood physical abuse than Vietnam veterans without PTSD (26% versus 7%). The association between childhood abuse and PTSD persisted after controlling for the difference in level of combat exposure between the two groups. Patients with PTSD also had a significantly higher rate of total traumatic events before joining the military than patients without PTSD (mean = 4.6, SD = 4.5, versus mean = 2.8, SD = 2.9). CONCLUSIONS: These findings suggest that patients seeking treatment for combat-related PTSD have higher rates of childhood physical abuse than combat veterans without PTSD. Childhood physical abuse may be an antecedent to the development of combat-related PTSD in Vietnam combat veterans. Language: en

DSM-III and the transformation of American psychiatry: a history

Abstract: The author traces the history of the development of DSM-III within the larger context--intellectual, economic, scientific, and ideological--of the development of American psychiatry since World War II. Data were obtained through a literature review, investigation of archival material from the DSM-III task force and APA, and interviews with key participants. This research indicates that from the end of World War II until the mid-1970s, a broadly conceived biopsychosocial model, informed by psychoanalysis, sociological thinking, and biological knowledge, was the organizing model for American psychiatry. However, the biopsychosocial model did not clearly demarcate the mentally well from the mentally ill, and this failure led to a crisis in the legitimacy of psychiatry by the 1970s. The publication of DSM-III in 1980 represented an answer to this crisis, as the essential focus of psychiatric knowledge shifted from the clinically-based biopsychosocial model to a research-based medical model. The author concludes that while DSM-III, and the return to descriptive psychiatry which it inaugurated, has had positive consequences for the profession, at the same time it represents a significant narrowing of psychiatry's clinical gaze.

Association of binge eating disorder and psychiatric comorbidity in obese subjects

Abstract: Objective: The authors determined the prevalence ofbinge eating disorder in a self-referred study group of moderately and severely obese subjects and investigated whether binge eating disorder was associated with psychiatric disorders, a history ofpsychotherapy, a family history ofpsychiatric illness, or a history ofsexualabuse. Method: They interviewed 89 obese women and 39 obese men (body mass index >30 kg/rn2) who were not currently in weight loss treatment, using the Binge Eating Disorder Clinical Interview, the Structured Clinical Interview for DSM-III-R, and the Structured Clinical Interview for DSM-III-R Personality Disorders. Results: Forty-three (34%) of the subjects met criteria for binge eating disorder-33 women and 1 0 men. Black and white subjects had similar rates ofbinge eating disorder. Subjects with binge eating disorder were significantly more likely than those without the disorder to have a lifetime prevalence ofa DSM-III-R axis I or axis II diagnosis and to have undergone psychotherapy or counseling. The lifetime rates ofmajor depression, panic disorder, bulirnia nervosa, borderline personality disorder, and avoidant personality disorder were allsignificantly higher in subjects with binge eating disorder. The rate ofreported sexual abuse was not higher among subjects with binge eating disorder; however, they were significantly more likely to have a family history of substance abuse. The relative risks for psychiatric disorders were higher in both moderately and severely obese subjects with binge eating disorder than in those without the disorder. Conclusions: Among both moderately and severely obese subjects, binge eating disorder is associated with higher rates ofaxis I and axis II psychiatric disorders. (Am J Psychiatry 1993; 150:1472-1479)

Premonitory Urges in Tourette's Syndrome

Abstract: Objective: Tourette's syndrome traditionally has been viewed as a hyperkinetic movement disorder characterized by involuntary motor and phonic tics. Many patients, however, describe their tics as a voluntary response to premonitory urges. This cross-sectional study evaluated premonitory urges and related phenomena in subjects with tic disorders. Method: A total of 135 subjects with tic disorders, aged 8 to 71 years, completed a questionnaire concerning their current and past tic symptoms. Subjects were asked to describe and, if possible, localize their premonitory urges

Enhanced suppression of cortisol following dexamethasone administration in posttraumatic stress disorder.

Abstract: Objective: The authors investigated the possibility ofenhanced negative feedback sensitivity ofthe hypothalamic-pituitary-adrenal (HPA) axis in posttraumatic stress disorder (PTSD) by using a low dose of dexamethasone. Method: Baseline blood samples were obtained at 8:00 a.m., and 0.5 mg ofdexamethasone was administered to 21 male patients with PTSD and 12 normal age-comparable men at 1 1:00 p.m. Cortisol and dexamethasone levels were measured 9 and 1 7 hours after dexamethasone administration. Results: After correction for differences in dexamethasone levels, the PTSD patients showed greater suppression ofcortisol in response to dexamethasone than did the normal subjects. This was true even in patients meeting concurrent diagnostic criteria for major depression. Conclusions: The data support earlier studies showing that HPA abnormalities in PTSD are different from those seen in depression and suggest that the low-dose dexamethasone suppression test may be a potentially useful tool for differentiating the two syndromes and further exploring differences in their pathophysiology. (Am J Psychiatry 1993; 150:83-86)

Achieving cocaine abstinence with a behavioral approach.

Abstract: Objective The authors compared the efficacy of a multicomponent behavioral treatment and drug abuse counseling for cocaine-dependent individuals. Method The 38 patients were enrolled in outpatient treatment and were randomly assigned to the two treatments. Counseling in the behavioral treatment was based on the community reinforcement approach, while the drug abuse counseling was based on the disease model of dependence and recovery. Patients in the behavioral, but not the drug counseling, treatment also received incentives contingent on submitting cocaine-free urine specimens. Results Of the 19 patients who received behavioral treatment, 58% completed 24 weeks of treatment, versus 11% of the patients who received counseling. In the behavioral treatment group 68% and 42% of the patients achieved at least 8 and 16 weeks of documented continuous cocaine abstinence, respectively, versus 11% and 5% in the drug abuse counseling group. Conclusions This multicomponent behavioral treatment appears to be an effective intervention for retaining outpatients in treatment and establishing cocaine abstinence.

Body dysmorphic disorder: 30 cases of imagined ugliness.

Abstract: OBJECTIVE: Body dysmorphic disorder, preoccupation with an imagined defect in appearance, is included in DSM-III-R but has received little empirical study. The authors investigated the demographics, phenomenology, course, associated psychopathology, family history, and response to treatment in a series of 30 patients with the disorder. METHOD: The patients (including 12 whose preoccupation was of probable delusional intensity) were assessed with a semistructured interview and the Structural Clinical Interview for DSM-III-R, and their family histories were obtained. RESULTS: The 17 men and 13 women reported a lifetime average of four bodily preoccupations, most commonly "defects" of the hair, nose, and skin. The average age at onset of body dysmorphic disorder was 15 years, and the average duration was 18 years. Seventy-three percent of the patients reported associated ideas or delusions of reference; 73%, excessive mirror checking; and 63%, attempts to camouflage their "deformities." As a result of their symptoms, 97% avoided usual social and occupational activities, 30% had been housebound, and 17% had made suicide attempts. Ninety-three percent of the patients had an associated lifetime diagnosis of a major mood disorder; 33%, a psychotic disorder; and 73%, an anxiety disorder. The patients generally responded poorly to surgical, dermatologic, and dental treatments and to adequate trials of most psychotropic medications, with the exception of fluoxetine and clomipramine (to which more than half had a complete or partial response). CONCLUSIONS: This often secret, chronic disorder can cause considerable distress and impairment, may be related to obsessive-compulsive disorder or mood disorder, and may respond to serotonin reuptake-blocking antidepressants. Language: en

Association of depression with 10-year poststroke mortality.

Abstract: Objective Depression has been linked to higher than expected mortality from natural causes, particularly among elderly patients with physical illness. The authors examined the effect of depression on mortality among a group of stroke patients followed up for 10 years. Method A consecutive series of 103 patients was assessed for major or dysthymic (minor) depression approximately 2 weeks after stroke with the use of a structured mental status examination and DSM-III diagnostic criteria. Vital status was determined for 91 of these patients 10 years later. Results Forty-eight (53%) of the 91 patients had died. Patients with diagnoses of either major or minor depression were 3.4 times more likely to have died during the follow-up period than were nondepressed patients, and this relationship was independent of other measured risk factors such as age, sex, social class, type of stroke, lesion location, and level of social functioning. The mortality rate among depressed patients with few social contacts was especially high: over 90% had died. Conclusions These results indicate that depressed mood following stroke is associated with an increased risk of subsequent mortality. Patients who are depressed and socially isolated seem to be particularly vulnerable.

The concept of boundaries in clinical practice: theoretical and risk-management dimensions

Abstract: The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct. These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context. Heightened awareness of the concepts of boundaries, boundary crossings, and boundary violations will both improve patient care and contribute to effective risk management.

The Course of Geriatric Depression With "Reversible Dementia": A Controlled Study

Abstract: Objective: The goals ofthis longitudinal investigation were 1) to study the rate of development of irreversible dementia in elderly depressed patients with a dementia syndrome that subsided after improvement ofdepression and 2) to compare it with that ofdepressed, neverdemented patients. Method: The subjects were 57 elderly patients consecutively hospitalized f or major depression. At entry into the study, 23 subjects also met criteria for “reversible dementia, “ while 34 were without dementia. After a systematic clinical evaluation, the subjects were followed up at approximately yearly intervals for an average of 33.8 months. Results: Irreversible dementia developed significantly more frequently in the depressed group with reversible dementia (43 %) than in the group with depression alone (1 2%). Survival analysis showed that the group with reversible dementia had a 4.69-times higher chance of having developed dementia at follow-up than the patients with depression alone. No clinical characteristics at entry into the study were found to discriminate the subjects who developed irreversible dementia during the follow-up period from those who remained nondemented. � clusions: These findings suggest that geriatric depression with reversible dementia is a clinical entity that includes a group ofpatients with early-stage dementing disorders. Therefore, identification ofa reversible dementia syndrome is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders. (Am-”J Psychiatry 1993; 150:1693-1699)

Deficits in short-term memory in posttraumatic stress disorder.

Abstract: Objective: The purpose ofthis study was to compare the memory function ofpatients with posttraumatic stress disorder (PTSD) to that ofmatched comparison subjects. Method: Vietnam veterans with combat-related PTSD (N=26) were compared to physically healthy comparison subjects (N=15) matched for age, race, sex, years ofeducation, handedness, socioeconomic status, and alcohol abuse. Memory and intelligence were assessed with a battery of neuropsychological tests, including the Russell revision of the Wechsler Memory Scale, the Selective Reminding Test, and subtests of the Wechsler Adult Intelligence Scale-Revised (WAIS-R). Results: The PTSD patients scoredsignificantly lower than the comparison subjects on the Wechsler Memory Scale logical memory measures for immediate recall (mean=1 1.6, SD=3.3 versus mean=20.9, SD=6.6) and delayed recall (mean=8.0, SD=3.3 versus mean=l 7.8, SD=6.4). The PTSD patients also scored significantly lower on the total recall, long-term storage, long-term retrieval, and delayed recall measures for the verbal component of the Selective Reminding Test and on the recall, long-term storage, long-term retrieval, and continuous long-term retrieval measures for the visual component ofthe Selective Reminding Test. There was no significant difference between the PTSD patients and comparison subjects in prorated full-scale IQ as measured by the WAIS-R. Conclusions: Patients with PTSD may have deficits in short-term memory. Counseling and rehabilitation that address these deficits may be of value for PTSD patients. (Am J Psychiatry 1993; 150:1015-1019)

Validity of the dissociative experiences scale in screening for multiple personality disorder: A multicenter study

Abstract: OBJECTIVE The Dissociative Experiences Scale has proved a reliable and valid instrument to measure dissociation in many groups, but its capacity to distinguish patients with multiple personality disorder from patients with other psychiatric disorders has not yet been conclusively tested. METHOD A discriminant analysis was performed to classify 1,051 subjects as having or not having multiple personality disorder. Another discriminant analysis was performed on a subgroup of 883 subjects more closely representing patients in a typical psychiatric facility in terms of base rates of dissociative disorders. A cutoff score of 30 was also used to classify subjects, and Bayes's theorem, which allows for the calculation of the positive predictive value and the negative predictive value of a screening test, was applied. RESULTS According to discriminant analysis of the total study group, the scale's sensitivity was 76% and its specificity was also 76%; according to discriminant analysis of the more representative subgroup, the scale's sensitivity was 76% and its specificity was 85%. Use of the cutoff score of 30 produced similar results. Results of the application of Bayes's theorem showed that 17% of the subjects scoring 30 or higher would actually have multiple personality disorder and 99% of those scoring less than 30 would not have multiple personality disorder. CONCLUSIONS These results indicate that the Dissociative Experiences Scale performs quite well as a screening instrument to identify subjects with multiple personality disorder. In addition, the consistency of responses to scale items across centers indicates that the symptoms reported by patients with multiple personality disorder are highly similar across diverse geographic centers. This consistency supports the reliability and validity of the diagnosis of multiple personality disorder across centers.

Intelligence and Brain Structure in Normal Individuals

Abstract: Objective: This study was designed to evaluate the relation between intelligence and a variety ofmeasures ofbrain structure. Method: Magnetic resonance imaging scans were used to measure the volume of the intracranial cavity, cerebral hemispheres, lateral ventricles, temporal lobes, hippocampus, caudate, and cerebellum, as well as the overall volume of gray matter, white matter, and CSF, in 67 healthy, normal volunteers. Intelligence was measured with the Wechsler Adult Intelligence Scale-Revised. Results: Full-scale IQ was found to be significantly correlated with intracranial, cerebral, temporal lobe, hippocampal, and cerebellar volume but not with caudate and lateral ventricle volume. There were also significant correlations offull-scale, verbal, and performance IQ with overall gray matter volume but not with white matter or CSF volume. Gender differences were noted in the pattern and number of correlations between the volume of the brain and its subregions and full-scale, verbal, and performance IQ. Conclusions: The results suggest that the size ofsome cerebral structures may account f or a significant, but modest, proportion of the variance in human intelligence. (Am J Psychiatry 1993; 150:130-1 34)

Help-seeking pathways : a unifying concept in mental health care

Abstract: The authors argue that the concept of help-seeking pathways, defined generically, oriented toward institutional structures, and put at the forefront of research, can help integrate much of what we know about the use of mental health care and how to make such care more accessible and effective among underserved populations. They focus the concept of help-seeking pathways on current issues and research findings pertinent to the onset of psychological distress, the contacting of mental health care facilities, and treatment in such facilities. Pathways are not random; they are structured by the convergence of psychosocial and cultural factors and have sufficient integrity to be studied directly as unfolding processes.

Gender differences in substance use disorders.

Abstract: Objective The goals of this study were to explore gender differences in demographic variables, psychiatric comorbidity, and personality disorders in individuals with substance use disorders. Method A total of 100 treatment-seeking substance users (50 men and 50 women) admitted to a university-based and a university-affiliated private chemical dependency hospital were compared with regard to demographic variables and comorbid psychiatric and personality diagnosis according to the Structured Clinical Interview for DSM-III-R after 14-21 days in treatment. Results Men were significantly more likely to have a higher household income and to be alcohol dependent. Women were significantly more likely to have another axis I disorder in addition to substance use disorder, particularly anxiety disorders, but these gender differences were not substantially different from the gender prevalence of these disorders in the general population. Men had more affective disorders relative to women than would be expected from the general population data. Female alcoholics had substantially more psychopathology than male alcoholics, and generally these differences were consistent with the ratios of these disorders in the general population. For cocaine users, female/male ratios of anxiety and affective disorders were inconsistent with general population ratios and indicated more psychopathology than would be expected in male cocaine users. There were no gender differences in axis II diagnoses. Conclusions Some of the gender differences in psychopathology in substance users are at odds with gender differences for psychopathology in the general population. Further exploration of these differences could have important theoretical and treatment implications.

Prevalence and stability of the DSM-III-R personality disorders in a community-based survey of adolescents.

Abstract: Objective: The purpose of this study was to estimate the prevalence, concurrent validity, and stability of DSM-III-R personality disorders in a large community-based sample of adolescents. Method: A randomly selected community sample of 733 youths ranging in age from 9 to 19 years was followed over a 2-year period. The protocol consisted of structured interviews with the adolescents and their mothers and self-report questionnaires. Algorithms for 10 DSM-III-R axis II disorders were developed to produce diagnoses at two levels of severity; these were validated against multiple indicators of distress and functional impairment. Results: The overall prevalence of personality disorders peaked at age 12 in boys and at age 13 in girls and declined thereafter

Establishing the onset of psychotic illness.

Abstract: Objective To date, the literature has provided no standardized, replicable method for establishing illness onset. The authors describe a method for dating the first appearance of prodromal signs of psychotic illness, the emergence of an acute episode, and the initiation of treatment seeking. Method Using reports by family and friends about a sample of 141 subjects with first-episode psychosis, the investigators derived a checklist of behaviors describing the evolution of various phases of illness. Supplied with the checklist, clinician pairs independently rated the critical phases in the evolution of illness: first appearance of noticeable symptoms, first appearance of prominent psychotic symptoms, and initiation of treatment seeking. Results The judges achieved good reliability in assigning age at the first appearance of psychotic symptoms and at initiation of treatment seeking. Judging the beginning of the prodrome proved more difficult. Insidious onset proved as characteristic of affective psychosis as of schizophrenia, while treatment lag--the interval between emergence of acute psychotic symptoms and initiation of treatment seeking--was longer for schizophrenia than for affective psychosis. Onset of schizophrenia occurred earlier in women than in men. Depression with psychotic features appeared earlier in men than women. Conclusions Although dating the onset of illness phases is probably feasible, efforts to improve reliability must continue. The study results challenge beliefs about gender differences in age at onset.

Interleukin-1 beta: a putative mediator of HPA axis hyperactivity in major depression?

Abstract: Objective There is extensive evidence that major depression, and particularly melancholia, is characterized by hypothalamic-pituitary-adrenal (HPA) axis hyperactivity as well as systemic immune activation, which may be accompanied by increased interleukin-1 beta production. Interleukin-1 beta is known to enhance HPA axis activity during an immune response. This study investigated whether interleukin-1 beta production is related to HPA axis activity in depressed subjects. Method The subjects were 28 inpatients with major or minor depression and 10 normal comparison subjects. The authors measured 1) the subjects' cortisol levels after an overnight 1-mg dexamethasone suppression test (DST) and 2) mitogen-stimulated supernatant interleukin-1 beta production by peripheral blood mononuclear cells. Results Statistically significant positive correlations between interleukin-1 beta production and post-DST cortisol values were found in the study group as a whole and in the depressed and normal subgroups separately. Conclusions It is suggested that constituents of the immune response (such as interleukin-1 beta) in major depression may contribute to HPA axis hyperfunction in that illness.