Showing papers in "American Journal of Psychiatry in 1995"

MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder.

Abstract: Patients with combat-related posttraumatic stress disorder (PTSD) clinically demonstrate alterations in memory, including nightmares, flashbacks, intrusive memories, and amnesia for war experiences. In addition, descriptions from all wars of this century document alterations in memory occurring in combat veterans during or after the stress of battle. These include forgetting one's name or identity and forgetting events that had just taken place during the previous battle (1, 2), as well as gaps in memory that continue to recur for many years after the war (3). Servicemen who had been prisoners of war during the Korean conflict were found to have an impairment in short-term verbal memory, as measured by the logical memory component of the Wechsler Memory Scale, in comparison with veterans of the Korean war who did not have a history of imprisonment (4). We also found deficits in short-term verbal memory, as measured by the logical memory component of the Wechsler Memory Scale, in Vietnam combat veterans with combat-related PTSD in comparison with healthy subjects who were matched for age, years of education, and alcohol abuse (5). Several lines of evidence suggest a relation between stress and damage to the hippocampus (6). The hippocampus and the adjacent perirhinal, parahippocampal, and entorhinal cortex play an important role in short-term memory (7). Studies in humans have shown that reductions in hippocampal volume secondary to either neurosurgery (8) or the pathophysiological effects of epilepsy (9) are associated with deficits in short-term memory as measured by the Wechsler Memory Scale. Monkeys exposed to the extreme stress of improper caging have shown increased glucocorticoid release as well as damage to the CA2 and CA3 subfields of the hippocampus (10). Studies in a variety of animal species suggest that direct glucocorticoid exposure results in a loss of neurons and a decrease in dendritic branching in the hippocampus (11, 12) with associated deficits in memory function (13). The mechanism of action of glucocorticoid toxicity is probably through an increase in the vulnerability of neurons to the toxicity of excitatory amino acids (14–16). Studies using computed tomography in human subjects who are exposed to high levels of glucocorticoids secondary to glucocorticoid steroid therapy (17, 18) or who have affective disorders (also felt to be related to stress) (19) have shown changes in brain structure, including ventricular enlargement and widening of the cortical sulci. Magnetic resonance imaging (MRI) studies in patients with affective disorders have shown a smaller right hippocampal volume (20) and temporal lobe volume (21) in bipolar disorder and abnormalities of the hippocampus, including alterations in T1 (22), but no change in hippocampal volume (23) in major depression. One MRI study (24) found a relation between deficits in short-term memory and smaller hippocampal volume, as well as higher plasma cortisol levels and smaller hippocampal volume, in patients with Cushing's disease. Stress in both healthy human subjects (25) and soldiers undergoing random artillery bombardment (26) results in an increase in urinary cortisol, suggesting the possibility that exposure to the extreme stress of combat may be associated with damage to the hippocampus. The purpose of this study was to use MRI to measure the volume of the hippocampus and comparison brain structures in patients with PTSD and in matched comparison subjects. We hypothesized that PTSD would be associated with smaller hippocampal volume in relation to that of the comparison subjects. We also hypothesized that smaller hippocampal volume would be associated with deficits in short-term verbal memory in patients with PTSD.

Social consequences of psychiatric disorders, I: Educational attainment.

Abstract: Objective This is the first in a series of investigations of the social consequences of psychiatric disorders based on the National Comorbidity Survey. Data on the relationship between preexisting psychiatric disorders and subsequent educational attainment are presented. Method The National Comorbidity Survey is a nationally representative survey of 8,098 respondents in the age range 15-54 years. A subsample of 5,877 respondents completed a structured psychiatric interview and a detailed risk factor battery. Diagnoses of DSM-III-R anxiety disorders, mood disorders, substance use disorders, and conduct disorder were generated, and survival analyses were used to project data on school terminations to the total U.S. population. Results Early-onset psychiatric disorders are present in more than 3.5 million people in the age range of the National Comorbidity Survey who did not complete high school and close to 4.3 million who did not complete college. The most important disorders are conduct disorder among men and anxiety disorders among women. The proportion of school dropouts with psychiatric disorders has increased dramatically in recent cohorts, and persons with psychiatric disorders currently account for 14.2% of high school dropouts and 4.7% of college dropouts. Conclusions Early-onset psychiatric disorders probably have a variety of adverse consequences. The results presented here show that truncated educational attainment is one of them. Debate concerning whether society can afford universal insurance coverage for the treatment of mental disorders needs to take these consequences into consideration.

A family study of obsessive-compulsive disorder.

Abstract: Objective The goal of this study was to determine 1) whether obsessive-compulsive disorder is familial, 2) whether there is a familial relationship between obsessive-compulsive disorder and Gilles de la Tourette's syndrome and chronic tics, and 3) whether different familial types of obsessive-compulsive disorder exist. Method In this family study, all available first-degree relatives of 100 probands with obsessive-compulsive disorder were interviewed directly with structured interviews, and best-estimate diagnoses were assigned. In addition to the 466 first-degree relatives of the probands, 113 comparison subjects who were first-degree relatives of 33 psychiatrically unaffected subjects were studied with the same interviews. Results The rates of obsessive-compulsive disorder and subthreshold obsessive-compulsive disorder were significantly greater among the relatives of the probands with obsessive-compulsive disorder (10.3% and 7.9%, respectively) than among the comparison subjects (1.9% and 2.0%, respectively). Furthermore, the rate of tics (Tourette's disorder and chronic tics) was also significantly greater among the relatives of the probands (4.6%) than among the comparison subjects (1.0%). The relatives of female probands with obsessive-compulsive disorder were more likely to have tics, and the relatives of probands with early onset were at higher risk for both obsessive-compulsive disorder and tics. Conclusions Obsessive-compulsive disorder is a heterogeneous condition. Some cases are familial and related to tic disorders, some cases are familial and unrelated to tics, and in other cases there appears to be no family history of either obsessive-compulsive disorder or tics.

Stressful life events, genetic liability, and onset of an episode of major depression in women.

Abstract: Objective This study was undertaken to clarify how genetic liability and stressful life events interact in the etiology of major depression. Method Information about stressful life events and onset of major depressive episodes in the past year was collected in a population-based sample of female-female twin pairs including 2,164 individuals, 53,215 person-months of observation, and 492 onsets of depression. Results Nine "personal" and three aggregate "network" stressful events significantly predicted onset of major depression in the month of occurrence, four of which predicted onset with an odds ratio of > 10 and were termed "severe": death of a close relative, assault, serious marital problems, and divorce/breakup. Genetic liability also had a significant impact on risk of onset of depression. For severe stressful events, as well as for 10 of the 12 individual stressful events, the best-fitting model for the joint effect of stressful events and genetic liability on onset of major depression suggested genetic control of sensitivity to the depression-inducing effects of stressful life events. In individuals at lowest genetic risk (monozygotic twin, co-twin unaffected), the probability of onset of major depression per month was predicted to be 0.5% and 6.2%, respectively, for those unexposed and exposed to a severe event. In those at highest genetic risk (monozygotic twin, co-twin affected), these probabilities were 1.1% and 14.6%, respectively. Linear regression analysis indicated significant Genotype by Environment interaction in the prediction of onset of major depression. Conclusions Genetic factors influence the risk of onset of major depression in part by altering the sensitivity of individuals to the depression-inducing effect of stressful life events.

Mortality in anorexia nervosa.

Abstract: OBJECTIVE: The author's goal was to shed light on the debate regarding the mortality rate over time associated with anorexia nervosa METHOD: He conducted a meta-analytic study using weighted linear regression to combine crude mortality proportions from 42 published studies to estimate the mortality associated with anorexia nervosa over time RESULTS: The crude rate of mortality due to all causes of death for subjects with anorexia nervosa in these studies was 59% (178 deaths in 3,006 subjects) The aggregate mortality rate was estimated to be 056% per year, or approximately 56% per decade CONCLUSIONS: The aggregate estimated mortality rate for subjects with anorexia nervosa is substantially greater than that reported for female psychiatric inpatients and for the general population Language: en

Relapse and impairment in bipolar disorder.

Abstract: Objective: The purpose ofthis study was to evaluate the outcome ofbipolar disorder in the context of maintenance pharmacotherapy. Method: Eighty-two bipolar outpatients were followed prospectively for a mean of 4.3 years (minimum of 2 years); symptom rating and psychosocial outcome scales were used, and pharmacotherapy was rated on a 5-point scale. J� �yj�: Despite continual maintenance treatment, survival analysis indicated a 5-year risk of relapse into mania or depression of 73%. Of those who relapsed, two-thirds had multiple relapses. Relapse could not be attributed to inadequate medication. Even for those who did not relapse, considerable affective morbidity was observed. A measure ofcumulative affective morbidity appeared to be a more sensitive correlate ofpsychosocial functioning than was the number of relapses. Poor psychosocial outcome paralleled poor syndromal course. Poor psychosocial functioning, especially occupational disruption, predicted a shorter time to relapse. Depressions were most strongly related to social and family dysfunction. Conclusions: Even aggressive pharmacological maintenance treatment does not prevent relatively poor outcome in a significant number of bipolar patients. (AmJ Psychiatry1995; 152:1635-1640)

Brain activity during transient sadness and happiness in healthy women.

Abstract: Objective: The specifit brain regions involved in the normal emotional states of transient sadness or happiness are poorly understood. The authors therefore sought to determine if H 2 15 O position emission tomography (PET) might demonstrate changes in regional cerebral blood flow (rCBF) associated with transient sadness or happiness in healthy adult women. Method: Eleven healthy and never mentally ill adult women were scanned, by using PET and H 2 15 O, during happy, sad, and neutral states induced by recalling affect-appropriate life events and looking at happy, sad, or neutral human fates. Results: Compared to the neutral condition, transient sadness significantly activated bilateral limbic and paralimbic structures (cingulate, medial prefrontal, and mesial temporal cortex), as well as brainstem, thalamus, and caudate/putamen. In contrast, transient happiness had no areas of signifitantly increased activity but was associated with significant and widespread reductions in cortical rCBF, especially in the right prefrontal and bilateral temporal-parietal regions. Conclusions: Transient sadness and happiness in healthy volunteer women are accompanied by significant changes in regional brain activity in the limbic system, as well as other brain regions. Transient sadness and happiness affect different brain regions in divergent directions and are not merely opposite activity in identical brain regions. These findings have implications for understanding the neural substrates of both normal and pathological emotion

Desire for death in the terminally ill.

Abstract: Objective: Euthanasia and physician-assisted suicide have become prominent medical and social issues. This study investigated the prevalence of the desire for death in terminally ill patients, the stability of this desire over time, and its association with psychiatric disorders. Method: Two hundred terminally ill inpatients were given semistructured interviews that assessed their desire for death and evaluated theni for major and minor depressive episodes according to the Research Diagnostic Criteria. Each patient also completed a short form of the Beck Depression Inventory and provided ratings ofpain and socialsupport. When possible, patients who expressed a desire for death received a follow-up interview after a 2-week interval. Results: Although occasional wishes that death would come soon were common (reported by 44.5% of the patients), only I 7 (8.5%) of these individuals acknowledged a serious and pervasive desire to die. The desire for death was correlated with ratings of pain and low family support but most significantly with measures ofdepression. The prevalence ofdiagnosed depressive syndromes was 58.8% among patients with a desire to die and 7.7% among patients without such a desire. Follow-up interviews were conducted with six patients; in four cases, the desire to die had decreased during the 2-week interval. Conclusions: The desire for death in terminally ill patients is closely associated with clinical depression-a potentially treatable condition-and can also decrease over time. Informed debate about euthanasia should recognize the importance of psychiatric considerations, as well as the inherent transience of many patients ‘expressed desire to die. (AmJ Psychiatry 1995; 152:1185-1191)

Complicated grief and bereavement-related depression as distinct disorders : preliminary empirical validation in elderly bereaved spouses

Abstract: Objective: This study sought to determine whether a set of symptoms interpreted as cornplicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Method: Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation ofphysiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects’ spouses, and follow-up data were collected from 56 of the subjects I 8 months after the baseline assessments. Candidate items for assessing complicated griefcame from a variety ofscales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the BriefSymptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. Results: A principal-components analysis conducted on intake data (N=82) revealed a complicated grieffactor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated griefscores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. Conclusions: The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment. (Am J Psychiatry 1995; 152:22-30)

Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis

Abstract: Objective: The authors ‘ goal was to explore the historical, political, and social forces that have played a major role in the acceptance of the idea of trauma as a cause of the specific symptoms of posttraumatic stress disorder (PTSD) and to discuss the impact that current research findings have had on some ofthe initial conceptualizations ofthe disorder. Method: The conceptual origins of PTSD are described, and the literature on the prevalence, longitudinal course, phenomenology, and neurobiology of PTSD is reviewed. Results: Paradoxically, there are a series of findings that support the idea that PTSD is a distinct diagnostic entity, but these are different from those originally developed from psychosocial theory and stress research. �j clusions: PTSD has been a controversial diagnosis and is again at a vulnerable point. It is imperative that the field address how current findings challenge the original conceptualizations of this disorder so that the next generation of conceptual issues can be formulated. (Am J Psychiatry 1995; 152:1705-1713)

Health-care costs associated with depressive and anxiety disorders in primary-care

Abstract: Objective: The authors examined the overall health care costs associated with depression and anxiety among primary care patients. Method: I 1 0 consecutive primary care patients in a health maintenance organization, 1,962 were screened with the 12-item General Health Questionnaire. A stratified random sample of6l 5 patients were selected for further diagnostic assessment; 3 73 ofthese patients completed the Composite International Diagnostic Interview at baseline and 328 were reassessed 12 months later. Computerized cost records were used to calculate total health care costs for the 6-month period surrounding the baseline assessment and a similar period surrounding the follow-up assessment. Cost accounting data were available for 327 patients at baseline and for 206 patients at both assessments. Results: Primary care patients with DSM-III-R anxiety or depressive disorders at baseline had markedly higher baseline costs ($2,390) than patients with subthreshold disorders ($1,098) and those with no anxiety or depressive disorder ($ I ,3 97). Large cost differences persisted after adjustment for medical morbidity. Cost differences reflected higher utilization of general medical services rather than higher mental health treatment costs. Although most patients with baseline anxiety or depressive disorders showed significant improvement, longitudinal analyses did not show any clear relationship between change in psychiatric diagnosis and change in health care cost. Conclusions: Among primary care patients, anxiety and depressive disorders are associated with markedly higher health care costs even after adjustment for medical comorbidity. In this small sample, improvement in depression over 1 year was not clearly associated with decreases incost. (AmJ Psychiatry 1995; 152:352-357)

Remembering the past: two facets of episodic memory explored with positron emission tomography.

Abstract: Objective : This study used positron emission tomography to examine two kinds of personal memory that are used in psychiatric evaluation : focused episodic memory (recall of past experience, employed in taking a history) and random episodic memory (uncensored thinking about experience, examined during analytic therapy using free association). For comparison, a third memory task was used to tap impersonal memory that represents general information about the world (semantic memory). Method : Thirteen subjects were studied using the [ 15 O]H 2 O method to obtain quantitative measurements of cerebral blood flow. The three conditions were subtracted and their relative relationships examined. Results : The random episodic condition produced activations in widely distributed association cortex (right and left frontal, parietal, angular/supramarginal, and posterior inferior temporal regions). Focused episodic memory engaged a network that included the medial inferior frontal regions, precuneus/retrosplenial cingulate, anterior cingulate, thalamus, and cerebellum. The use of medial frontal regions and the precuneus/retrosplenial cingulate was common to both focused and random episodic memory. The major difference between semantic and episodic memory was activation ofBroca's area and the left frontal operculum by semantic memory. Conclusions : These results indicate that free-ranging mental activity (random episodic memory) produces large activations in association cortex and may reflect both active retrieval of past experiences and planning of future experiences. Focused episodic memory shares some components of this circuit (inferior frontal and precuneus), which may reflect the time-linked components of both aspects of episodic memory, and which permit human beings to experience personal identity, consciousness, and self-awareness.

Antidepressant-induced mania and cycle acceleration: a controversy revisited.

Abstract: Objective The longitudinal course of 51 patients with treatment-refractory bipolar disorder was examined to assess possible effects of heterocyclic antidepressants on occurrence of manic episodes and cycle acceleration Method Using criteria established from life charts, investigators rated the patients’ episodes of mania or cycle acceleration as likely or unlikely to have been induced by antidepressant therapy Discriminant function analyses were performed to assess predictors of vulnerability to antidepressant-induced mania or cycle acceleration Further, the likelihood of future antidepressant-induced episodes in persons who had had one such episode was assessed Results Thirty-five percent of the patients had a manic episode rated as likely to have been antidepressant-induced No variable was a predictor of vulnerability to antidepressant-induced mania Cycle acceleration was likely to be associated with antidepressant treatment in 26% of the patients assessed Younger age at first treatment was a predictor of vulnerability to antidepressant-induced cycle acceleration Forty-six percent of patients with antidepressant-induced mania, but only 14% of those without, also showed antidepressant-induced cycle acceleration at some point in their illness Conclusions Mania is likely to be antidepressant-induced and not attributable to the expected course of illness in one-third of treatment-refractory bipolar patients, and rapid cycling is induced in one-fourth Antidepressant-induced mania may be a marker for increased vulnerability to antidepressant- induced cycle acceleration Antidepressant-induced cycle acceleration (but not antidepressant- induced mania) is associated with younger age at first treatment and may be more likely to occur in women and in bipolar II patients (Am J Psychiatry 1995; 152:1130-1138)

Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity.

Abstract: Objective: The authors evaluated the association between attention deficit hyperactivity disorder (ADHD) and psychoactive substance use disorders in adults with ADHD, attending to comorbidity with mood, anxiety, and antisocial disorders. It was hypothesized that psychiatric comorbidity would be a risk factor for psychoactive substance use disorders. Method: Findings for 120 referred adults with a clinical diagnosis ofchildhood-onset ADHD were compared with those for non-ADHD adult comparison subjects (N=268). All childhood and adult diagnoses were obtained by structured psychiatric interviews for DSM-III-R. R� �iiIt.�i There was a significantly higher lifetime risk for psychoactive substance use disorders in the ADHD adults than in the comparison subjects (52% versus 27%). Although the two groups did not differ in the rate ofalcohol use disorders, the ADHD adults had significantly higher rates ofdrug and drug plus alcohol use disorders than the comparison subjects. ADHD significantly increased the risk for substance use disorders independently ofpsychiatric comorbidity. Antisocial disorders significantly increased the risk for substance use disorders independently ofADHD status. Mood and anxiety disorders increased the risk for substance use disorders in both the ADHD and comparison subjects, but more demonstrably in the comparison subjects. Conclusions: Although psychiatric comorbidity increased the risk for psychoactive substance use disorders in adults with ADHD, by itself ADHD was a significant risk factor for substance use disorders. More information is needed to further delineate risk and protective factors mediating the development ofsubstance use disorders in persons with ADHD. (AmJ Psychiatry 1995; 152:1652-1658)

DSM-IV field trial: Obsessive-compulsive disorder.

Abstract: Objective Three issues relevant to revising the DSM-III-R criteria for obsessive-compulsive disorder were examined in a field trial: 1) the requirement that symptoms of obsessive-compulsive disorder be viewed by the patient as excessive or unreasonable, 2) the presence of mental compulsions in addition to behavioral compulsions, and 3) ICD-10 subcategories. Method The authors studied symptom patterns of obsessive-compulsive disorder as well as strength of obsessive belief among 431 patients with obsessive-compulsive disorder at seven hospital outpatient clinics. Two methods of subject selection were used: consecutive entry of everyone who contacted the clinics for evaluation of obsessive-compulsive disorder and entry of patients with obsessive-compulsive disorder who had continuing contact with the clinics since before the field trial and who were still symptomatic. Primary measures were the Yale-Brown Obsessive Compulsive Scale and face-valid questions about fixity of obsessive-compulsive beliefs. Results The large majority of patients were uncertain about whether their obsessive-compulsive symptoms were unreasonable or excessive, and most had both mental and behavioral compulsions. Results on the ICD-10 subcategories were equivocal. Conclusions The present results converge with previous findings to indicate a broad range of insight among patients with obsessive-compulsive disorder. The DSM-III-R requirement for insight should be de-emphasized in DSM-IV, and mental rituals should be included in the definition of compulsions.

Effectiveness of Computer-Generated (Virtual Reality) Graded Exposure in the Treatment of Acrophobia

Abstract: Objective The authors' goal was to examine the efficacy of computer-generated (virtual reality) graded exposure in the treatment of acrophobia (fear of heights) Method Twenty college students with acrophobia were randomly assigned to virtual reality graded exposure treatment (N = 12) or to a waiting-list comparison group (N = 8) Seventeen students completed the study Sessions were conducted individually over 8 weeks Outcome was assessed by using measures of anxiety, avoidance, attitudes, and distress associated with exposure to heights before and after treatment Results Significant differences between the students who completed the virtual reality treatment (N = 10) and those on the waiting list (N = 7) were found on all measures The treatment group was significantly improved after 8 weeks, but the comparison group was unchanged Conclusions The authors conclude that treatment with virtual reality graded exposure was successful in reducing fear of heights

Family accommodation in obsessive-compulsive disorder.

Abstract: Objective: Family accommodation ofpatients with obsessive-compulsive disorder, i.e., participation in symptoms and modification of personal and family routines, was assessed in relation to family stress, functioning, and attitudes toward the patient. Method: Primary caretakers for 34 patients with obsessive-compulsive disorder were interviewed to assess the nature and frequency ofaccommodating behaviors. The caretakers also completed several measures offamily functioning. Results: Ofthe 34 spouses or parents, 30 (88.2%) reported accommodating the patient. Family accommodation correlated with poor family functioning, rejecting attitudes toward the patient, and several types of family stress. Conclusions: Family accommodation of patients with obsessive-compulsive disorder was associated with global family dysfunction and stress. This study suggests that families’ efforts to accommodate patients may be intended to reduce patient anxiety or anger directed at relatives. (Am J Psychiatry 1995; 152:441-443)

Predicting the "Revolving Door" Phenomenon Among Patients With Schizophrenic, Schizoaffective, and Affective Disorders

Abstract: Objective A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. Method Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. Results Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. Conclusions Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Arousal, numbing, and intrusion: symptom structure of PTSD following assault.

Abstract: OBJECTIVE: This study investigated hypotheses concerning the importance of symptoms of numbing in posttraumatic stress disorder (PTSD). METHODS: Symptoms of PTSD were assessed in 72 female rape victims and 86 female victims of nonsexual assault approximately 3 months after the crimes occurred. A principal-components factor analysis of subjects' symptoms was then undertaken. RESULTS: The analysis yielded three factors: arousal/avoidance, numbing, and intrusion. These were somewhat different from the symptom clusters in DSM-III-R, since effortful avoidance and numbing symptoms did not load on the same factor. Numbing symptoms appeared to be particularly important in identifying individuals with PTSD. CONCLUSIONS: The results imply that there are two patterns of posttrauma symptoms, one characterizing PTSD and the second characterizing a phobic reaction. Language: en

Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups.

Abstract: Objective: Previous epidemiological studies of bulimia nervosa have generated differing estimates of the incidence and prevalence of the disorder. These differences are attributable, in part, to varying definitions ofthe illness and a range ofmethodologies. The authors sought to define the prevalence of bulimia nervosa in a nonclinical community sample, examine the clinical significance ofDSM-III-R threshold criteria, and examine comorbidity. Method: Subjects across Ontario (N=8, 1 1 6) were assessed with a structured interview, the World Health Organization Composite International Diagnostic Interview, with specific questions added f or bulimia nervosa. Subjects who met DSM-III-R criteria for bulimia nervosa were compared with those who were missing only the frequency criterion (two or more binge-eating episodes per week for 3 months). Results: In this sample, the lifetime prevalence of bulimia nervosa was I . 1% for female subjects and 0. 1 % for male subjects. The subjects with full- and partialsyndrome bulimia nervosa showed significant vulnerability for mood and anxiety disorders. Lifetime rates ofalcohol dependence were high in the full-syndrome group. Rates of parental psychopathologies were high in both bulimic groups but tended to be higher in the subjects with full-syndrome bulimia nervosa. Both bulimic groups were significantly more likely to experience childhood sexual abuse than a normal female comparison group. Conclusions: This study confirms other prevalence estimates ofbulimia nervosa and its comorbid diagnoses from studies that were based on sound methodologies. It also points to the arbitrary aspects of the frequency of binge eating as a diagnostic threshold criterion for the disorder. (AmJ Psychiatry 1995; 152:1052-1058)

Prevalence of Alzheimer's Disease and Dementia in Two Communities: Nigerian Africans and African Americans

Abstract: ObjectiveThis article reports on a prevalence study of dementia and Alzheimer's disease among two groups ofsubjects with the same ethnic background but widely differing environ- ments. Method: The study was conducted among residents aged 65 years and older in two communities: Yorubas (N=2,494) living in Ibadan, Nigeria, and African Americans (N=2,2 12 in the community and N=106 in nursing homes) living in Indianapolis, Indiana. The study design consisted ofa screening stage followed by a clinical assessment stage for selected subjects on the basis of their performance on the screening tests. Results: The age-adjusted prevalence rates of dementia (2.29%) and Alzheimer's disease (1.41 %) in the Ibadan sample were sig- nificantly lower than those in the Indianapolis sample, both in the community-dwelling sub- jects alone (4.82% and 3.69%, respectively) and in the combined nursing home and commu- nit)' samples (8.24% and 6.24%, respectively). The prevalence rates of dementia and Alzheimer's disease increased consistently with advancing age in both study groups. Conclu- sions: To the authors knowledge, this is the first study, using the same research method at the two sites, to report significant differences in rates ofdementia and Alzheimer's disease in two different communities with similar ethnic origins. (AmJPsychiatry 1995; 152:1485-1492)

Low Urinary Cortisol Excretion in Holocaust Survivors With Posttraumatic Stress Disorder

Abstract: Objective: The authors’ objective was to compare the urinary cortisol excretion of Holocaust survivors with posttraumatic stress disorder (PTSD) (N=22) to that ofHolocaust survivors without PTSD (N=25) and comparison subjects not exposed to the Holocaust (N=15). Method: Twenty-four-hour urine samples were collected, and the following day, subjects were evaluated for the presence and severity ofpast and current PTSD and other psychiatric conditions. Results: Holocaust survivors with PTSD showed significantly lower mean 24-hour urinary cortisol excretion than the two groups ofsubjects without PTSD. Multiple correlation analysis revealed a significant relationship between cortisol levels and severity of PTSD that was due to a substantial association with scores on the avoidance subscale. Conclusions: The present findings replicate the authors’ previous observation oflow urinary cortisol excretion in combat veterans with PTSD and extend these findings to a non-treatment-seeking civilian group. The results also demonstrate that low cortisol levels are associated with PTSD symptoms ofa clinically significant nature, rather than occurring as a result ofexposure to trauma per se, and that low cortisollevels may persist for decades following exposure to trauma among individuals with chronic PTSD. (AmJ Psychiatry 1995; 152:982-986)

Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment.

Abstract: OBJECTIVE: Suicide has been reported to occur in 9%-13% of schizophrenic patients. It has been suggested that neuroleptic-resistant or neuroleptic-intolerant schizophrenic patients are at higher risk for suicide than neuroleptic-responsive patients. Clozapine is the treatment of choice for neuroleptic-resistant patients, but its use has been greatly limited because of its ability to cause potentially fatal agranulocytosis. The purpose of this study was to compare the suicidality of neuroleptic-resistant and neuroleptic-responsive patients and to determine if clozapine treatment decreased suicidality in the former group. METHOD: Prior episodes of suicidality were assessed in a total of 237 neuroleptic-responsive and 184 neuroleptic-resistant patients with schizophrenia or schizoaffective disorder. Eighty-eight of the neuroleptic-resistant patients were treated with clozapine and prospectively evaluated for suicidality for periods of 6 months to 7 years. RESULTS: There was no significant difference in prior suicidal episodes between neuroleptic-responsive and neuroleptic-resistant patients. Clozapine treatment of the neuroleptic-resistant patients during the follow-up period resulted in markedly less suicidality. The number of suicide attempts with a high-probability of success decreased from five to zero. This decrease in suicidality was associated with improvement in depression and hopelessness. CONCLUSIONS: These results suggest a basis for reevaluation of the risk-benefit assessment of clozapine, i.e., that the overall morbidity and mortality of patients with neuroleptic-resistant schizophrenia are less with clozapine treatment than with typical neuroleptic drugs because of less suicidality. This conclusion also has implications for increasing the use of clozapine with neuroleptic-responsive patients. Language: en

Effect of previous trauma on acute plasma cortisol level following rape

Abstract: Objective The authors examined the relationships among history of previous assault, severity of rape, acute plasma cortisol level after rape, and development of rape-related post-traumatic stress disorder (PTSD). Method Blood samples were drawn from 37 adult female rape victims within 51 hours after they had been raped. The subjects were assessed for history of previous assault and for the presence of PTSD 17-157 days (mean = 90 days) after the rape. Results Women with a history of previous assault had a lower mean acute cortisol level after the rape but a higher probability of subsequently developing PTSD. A significant interaction between history of previous assault and the severity of the index rape was observed: only women who had never been assaulted before had higher cortisol levels following high-severity rapes (those which included injury or multiple types of penetration) than low-severity rapes. Conclusions The authors conclude that previous traumatization may attenuate the acute cortisol response to trauma.

An MRI Study of Brain Size in Autism

Abstract: Objective: This study was undertaken to obtain detailed measurements ofthe volume of the brain, using magnetic resonance imaging (MRI), in a carefully selected group ofautistic subjects and comparison subjects. Method: Twenty-two male autistic subjects and 20 male t’olunteer comparison subjects were examined with detailed (1 .5-mm slices) MRI throughout the entire brain. Total brain, total brain tissue, and total lateral ventricle volumes were measured by using manual tracing and automated techniques. Results: After height and performance IQ were controlled, autistic subjects had significantly greater total brain, total tissue, and total lateral ventricle volumes than comparison subjects. Conclusions: These findings suggest that male autistic subjects have enlarged brains and that enlargement is a result of both greater brain tissue volume and greater lateral ventricle volume. -(AmJPsychiatry 1995; 152:1145-1149)

Schizophrenia and smoking: an epidemiological survey in a state hospital.

Abstract: OBJECTIVE The authors sought to determine whether smoking is related to schizophrenia or neuroleptic treatment. METHOD Cigarette smoking was measured in all patients hospitalized at a state hospital (N = 360) and compared in relation to gender and diagnosis (schizophrenic versus nonschizophrenic). RESULTS The overall frequency of smoking was 79% (N = 284). Male schizophrenic patients had the highest frequency of smoking, followed by male nonschizophrenic patients, female schizophrenic patients, and female nonschizophrenic patients, respectively. Schizophrenia and polydipsia were associated with both smoking and heavy smoking. CONCLUSIONS After correction for other variables, schizophrenia appears to increase the risk of being both a smoker and a heavy smoker. There was a possible association between high doses of neuroleptics and smoking but only for nonschizophrenic patients.

Initial reliability and validity of the Childhood Trauma Interview: A new multidimensional measure of childhood interpersonal trauma.

Abstract: OBJECTIVE: The Childhood Trauma Interview, a new instrument for brief and comprehensive retrospective assessment of childhood interpersonal trauma, is presented with initial evidence of its reliability and validity. METHOD: Drug- or alcohol-dependent patients (N = 220) were given the Childhood Trauma Interview and a questionnaire measure of child abuse, the Childhood Trauma Questionnaire. Convergent and discriminant validity for the Childhood Trauma Interview were tested by comparing correlations between analogous and nonanalogous trauma scales to those of the Childhood Trauma Questionnaire. RESULTS: Interrater reliability for the majority of trauma dimensions measured by the Childhood Trauma Interview was very high (63% had intraclass correlations above 0.90). Principal-components analysis yielded six rotated factors that accounted for 74% of the variance among scores: separations and losses, physical neglect, emotional abuse or assault, physical abuse or assault, witnessing violence, and sexual abuse or assault. Since these six factors exactly represented the areas that the interview was designed to assess, the construct validity of the Childhood Trauma Interview was supported. Without exception, convergent correlations were significantly higher than discriminant correlations, and convergence was improved when multidimensional variables from the Childhood Trauma Interview and their interactions were regressed onto Childhood Trauma Questionnaire scores. CONCLUSIONS: These initial findings suggest that the Childhood Trauma Interview is a reliable and valid method for brief assessment of multiple dimensions of six types of childhood interpersonal trauma. Language: en

Corticotropin-Releasing Hormone mRNA Levels in the Paraventricular Nucleus of Patients With Alzheimer's Disease and Depression

Abstract: Objective: Greater activity of the hypothalamic-pituitary-adrenal (HPA) axis is associated with specific neurological and psychiatric disorders, including Alzheimer’s disease and depression. Hyperactivation ofparaventricular corticotropin-releasing hormone (CRH) neurons may form the basis of this increased activity of the HPA axis. Method: Activation of the CRH neurons was determined through measurement ofthe amount ofCRH-mRNA in the paraventricular nucleus by using quantitative, in situ hybridization histochemistry with systematically sampled frontal sections through the hypothalamus of routinely formalin-fixed and paraffinembedded autopsy brain material of 1 0 comparison subjects, 10 patients with Alzheimer’s disease, and seven depressed patients. Results: CRH-mRNA levels in the paraventricular nucleus ofAlzheimer’s patients were markedly higher than those ofcomparison subjects, whereas CRH-mRNA levels in the paraventricular nucleus ofdepressed patients were even higher than the levels ofAlzheimer’s patients. Conclusions: Paraventricular CRH neurons in Alzheimer’s disease and depression are hyperactivated, and this hyperactivation may contribute to the etiology of these disorders. (AmJ Psychiatry1995; 152:1372-1376)

The Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer's Disease

Abstract: Objective: The purpose ofthe study was to develop a standardized instrument, the Behavior Rating Scale for Dementia, for rating psychopathology in patients with probable Alzheimer’s disease and to conduct a multicenter pilot study of this instrument. Method: The rating scale was developed collaboratively on the basis of clinical experience and existing instruments. Items were scaled according to frequency of psychopathology and were administered to an informant who was familiar with the subject. The scale was administered in a standardized manner by trained examiners who had met predetermined certification standards. The study group consisted of303 subjects with probable Alzheimer’s disease who had undergone standardized clinical evaluations by the Consortium to Establish a Registry for Alzheimer’s Disease. Results: Subjects had an average of 1 5 problems rated as present in the preceding month. Wide variability in the nature of disturbances was found, with a number of items rated as present since the illness began but not in the past month. Interrater agreement was high. Factor analysis suggested eight preliminary factors that mapped onto clinically relevant domains: depressive f eatures, psychotic features, defective self-regulation, irritability/agitation, vegetative features, apathy, aggression, and affective lability. Conclusions: The Behavior Rating Scale for Dementia provides a standardized, reliable measure that can be administered to caregivers of demented subjects. On the basis of the present study, the scale has been revised slightly. After additional studies in progress, the Behavior Rating Scale for Dementia will be available for general use in assessing a wide range ofpsychopathology in dementia. (Am J Psychiatry 1995; 152:1349-1357)