Showing papers in "American Journal of Psychiatry in 1997"

Full and partial posttraumatic stress disorder: findings from a community survey

Abstract: OBJECTIVE: Full and partial posttraumatic stress disorder (PTSD) following trauma exposure were examined in a community sample in order to determine their prevalence and their relative importance and functional significance. METHOD: A standardized telephone interview with a series of trauma probes and a DSM-IV PTSD checklist was administered to a random sample of 1,002 persons in a midsized Midwestern Canadian city. The authors determined current (i.e., 1-months) prevalence rates of full PTSD, i.e., all DSM-IV criteria, and partial PTSD, i.e., fewer than the required number of DSM-IV criterion C symptoms (avoidance/numbing) or criterion D symptoms (increased arousal). Additional questions about interference with functioning were also posed. RESULTS: The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men. Interference with work or school was significantly more pronounced in persons with full PTSD than in those with only partial symptoms, although the latter were significantly more occupationally impaired than traumatized persons without PTSD. CONCLUSIONS: These findings in an epidemiologic sample underscore observations from patient and military groups that many traumatized persons suffer from a subsyndromal form of PTSD. These persons with partial PTSD, although somewhat less impaired than persons with the full syndrome, nonetheless exhibit clinically meaningful levels of functional impairment in association with their symptoms. This subthreshold form of PTSD may be especially prevalent in women. Additional study of partial PTSD is warranted. Language: en

Olanzapine versus haloperidol in the treatment of schizophrenia and schizoaffective and schizophreniform disorders: results of an international collaborative trial.

Abstract: Objective: This international, multicenter double-blind trial was designed to compare the therapeutic profile of an atypical antipsychotic, olanzapine, with that of a conventional dopamine D2 antagonist, haloperidol. Method: A total of 1,996 patients at 174 sites in Europe and North America were randomly assigned to treatment with olanzapine (N=1,336) or haloperidol (N=660) over 6 weeks. The primary efficacy analysis involved the mean change from baseline to endpoint in total scores on the Brief Psychiatric Rating Scale (BPRS). Secondary analyses included comparisons of the mean change in positive and negative symptoms, comorbid depression, extrapyramidal symptoms, and overall drug safety. Results: Olanzapine demonstrated clinical results superior to those of haloperidol on overall improvement according to the BPRS and on every secondary measure, including depression. Olanzapine was also associated with significantly fewer discontinuations of treatment due to lack of drug efficacy or adverse events. Substantially more olanzapine-treated patients (66.5%) than haloperidoltreated patients (46.8%) completed 6 weeks of therapy. Statistically significant advantages of olanzapine treatment were related to 1) change in negative symptoms, 2) extrapyramidal symptom profile, 3) effect on prolactin levels, and 4) response rate. Conclusions: Olanzapine shows a superior and broader spectrum of efficacy in the treatment of schizophrenic psychopathology, with a substantially more favorable safety profile, than haloperidol. It meets several of the criteria for a novel atypical antipsychotic agent. (Am J Psychiatry 1997; 154:457‐465)

Multicenter collaborative panic disorder severity scale.

Abstract: OBJECTIVE: To address the lack of a simple and standardized instrument to assess overall panic disorder severity, the authors developed a scale for the measurement of panic disorder severity. METHOD: Ten independent evaluators used the seven-item Panic Disorder Severity Scale to assess 186 patients with principal DSM-III-R diagnoses of panic disorder (with no or mild agoraphobia) who were participating in the Multicenter Collaborative Treatment Study of Panic Disorder. In addition, 89 of these patients were reevaluated with the same scale after short-term treatment. A subset of 24 patients underwent two independent assessments to establish interrater reliability. Internal consistency, convergent and discriminant validity, and sensitivity to change were also determined. RESULTS: The Panic Disorder Severity Scale was associated with excellent interrater reliability, moderate internal consistency, and favorable levels of validity and sensitivity to change. Individual items showed good convergent and discrimi...

Broader autism phenotype: Evidence from a family history study of multiple-incidence autism families

Abstract: Objective: Studies of families ascertained through a single autistic proband suggest that the genetic liability for autism may be expressed in nonautistic relatives in a phenotype that is milder but qualitatively similar to the defining features of autism. The objective of this study was to examine behaviors that may define this broader phenotype in relatives ascertained through two autistic siblings. Method: The authors used a semistructured family history interview to compare the rates of social and communication deficits and stereotyped behaviors in relatives ascertained through two autistic siblings (families with multiple-incidence autism; 25 families) with the rates in relatives of Down syndrome probands (30 families). Results: Higher rates of social and communication deficits and stereotyped behaviors were found in the relatives in the families with multiple-incidence autism. Conclusions: These data suggest that further studies should be undertaken to delineate the boundaries of the broader autism phenotype and that this broader phenotype should be included in some future genetic analyses of this disorder. (Am J Psychiatry 1997; 154:185‐190)

MRI-defined vascular depression.

Abstract: Objective The authors' goal was to characterize the clinical and demographic features of vascular depression. Method They classified 89 depressed patients into two groups-those with vascular (N = 32) and nonvascular (N = 57) depression-on the basis of examination of brain magnetic resonance images. All of the patients were enrolled in the National Institute of Mental Health Clinical Research Center for the Study of Depression in Later Life, located at Duke University. The patients with vascular and nonvascular depression were compared on several clinical and demographic risk factors. Results Bivariate analyses and a fully adjusted logistic regression model revealed that older age, late age at onset, and nonpsychotic subtype occurred more often in patients with vascular depression than in those with nonvascular depression. A family history of mental illness was found somewhat less often, and anhedonia and functional disability were seen somewhat more often in patients with vascular depression. Conclusions The profile of patients with vascular depression needs to be developed further. This is likely to have important therapeutic and theoretical implications for the management of these patients.

Neuroanatomical correlates of externally and internally generated human emotion

Abstract: Objective: Positron emission tomography was used to investigate the neural substrates of normal human emotion and their dependence on the type of emotional stimulus. Method: Twelve healthy female subjects underwent 12 measurements of regional brain activity following the intravenous bolus administration of [O-15]H2O as they alternated between emotion-generating and control film and recall tasks. Automated image analysis techniques were used to characterize and compare the increases in regional brain activity associated with the emotional response to complex visual (film) and cognitive (recall) stimuli. Results: Film- and recall-generated emotion were each associated with significantly increased activity in the vicinity of the medial prefrontal cortex and thalamus, suggesting that these regions participate in aspects of emotion that no not depend on the nature of the emotional stimulus. Film-generated emotion was associated with significantly greater increases in activity bilaterally in the occipitotemporoparietal cortex, lateral cerebellum, hypothalamus, and a region that includes the anterior temporal cortex, amygdala, and hippocampal formation, suggesting that these regions participate in the emotional response to certain exteroceptive sensory stimuli. Recall-generated sadness was associated with significantly greater increases in activity in the vicinity of the anterior insular cortex, suggesting that this region participates iir the emotional response to potentially distressing cognitive or interoceptive sensory stimuli. Conclusions: While this study should be considered preliminary it identified brain regions that participate in externally and internally generated human emotion.

Symptoms of obsessive-compulsive disorder

Abstract: Objective Obsessive-compulsive disorder encompasses a broad range of symptoms that represent multiple psychological domains, including perception, cognition, emotion, social relatedness, and diverse motor behaviors. The purpose of these analyses was to evaluate the correlational relationships of the symptoms of obsessive-compulsive disorder. Method This study examined the 13 a priori categories used to group types of obsessions and compulsions in the Yale-Brown Obsessive Compulsive Scale symptom checklist in two independent groups of patients with obsessive-compulsive disorder (N = 208 and N = 98). A principal-components factor analysis with varimax rotation was performed, followed by a series of other exploratory analyses. Results The two data sets yielded nearly identical results. Four factors--obsessions and checking, symmetry and ordering, cleanliness and washing, and boarding--emerged in each data set, in total accounting for more than 60% of the variance. Conclusions Obsessive-compulsive disorder is a multidimensional and etiologically heterogeneous condition. The four symptom dimensions identified in this study are largely congruent with those identified in earlier reports. These factors may be of value in future genetic, neurobiological, and treatment response studies.

Neuroanatomical correlates of happiness, sadness, and disgust.

Abstract: Objective: Happiness, sadness, and disgust are three emotions that differ in their valence (positive or negative) and associated action tendencies (approach or withdrawal). This study was designed to investigate the neuroanatomical correlates of these discrete emotions. Method: Twelve healthy female subjects were studied. Positron emission tomography and [15O]H2O were used to measure regional brain activity. There were 12 conditions per subject: happiness, sadness, and disgust and three control conditions, each induced by film and recall. Emotion and control tasks were alternated throughout. Condition order was pseudorandomized and counterbalanced across subjects. Analyses focused on brain activity patterns for each emotion when combining film and recall data. Results: Happiness, sadness, and disgust were each associated with increases in activity in the thalamus and medial prefrontal cortex (Brodmann’s area 9). These three emotions were also associated with activation of anterior and posterior temporal structures, primarily when induced by film. Recalled sadness was associated with increased activation in the anterior insula. Happiness was distinguished from sadness by greater activity in the vicinity of ventral mesial frontal cortex. Conclusions: While this study should be considered preliminary, it identifies regions of the brain that participate in happiness, sadness, and disgust, regions that distinguish between positive and negative emotions, and regions that depend on both the elicitor and valence of emotion or their interaction. (Am J Psychiatry 1997; 154:926‐933)

Elevated CSF Corticotropin-Releasing Factor Concentrations in Posttraumatic Stress Disorder

Abstract: Corticotropin-releasing factor (CRF) plays an important role in mediating the mammalian stress response (1). CRF released during stress (2) from nerve terminals originating in the paraventricular nucleus of the hypothalamus increases the secretion of adrenocorticotropin hormone (ACTH) from the anterior pituitary, which in turn stimulates release of cortisol from the adrenal (3). Cortisol has a number of effects that are beneficial to short-term survival, including suppression of reproductive and immune function, promotion of analgesia, activation of the peripheral autonomic system, suppression of gastric motility and gastric acid secretion, and increases in total oxygen consumption and glucose and glucagon concentrations in plasma (3). Chronic stress results in sustained increases in plasma glucocorticoid levels (4), with a potentiation of glucocorticoid responsiveness to subsequent stressors (5, 6) and neuronal “hypersecretion” of CRF. CRF neurons are distributed in a variety of locations outside of the hypothalamus, including the amygdala, bed nucleus of the stria terminalis, central gray area, locus ceruleus, parabrachial area, and dorsal vagus complex (7). Intraventricular administration of CRF to laboratory animals results in behavioral activation, as evidenced by 1) an increase in EEG activity (8); 2) increases in plasma norepinephrine and epinephrine concentrations (9, 10); 3) an increase in firing of the locus ceruleus, site of the majority of noradrenergic cell bodies in the brain, which results in a state of increased attention and arousal (11); 4) increased locomotor activity, grooming, and rearing (12); and 5) behaviors consistent with anxiety and fear, including a decrease in exploratory activity in an open field (13), decreased punished responding in the conflict test (14), and potentiation of acoustic startle (15, 16). These studies support an important role for CRF in the promotion of anxiety and fear-related behaviors. Findings from clinical studies are consistent with a relationship among CRF, stress, and depression (which has been conceptualized as a chronic stress disorder). Studies in patients with depression consistently reveal an increase in CSF concentrations of CRF and a blunted ACTH response to intravenously administered CRF (17–19). Patients with posttraumatic stress disorder (PTSD) have been found to exhibit alterations in hypothalamic-pituitary-adrenal (HPA) axis function (20, 21), although no studies have directly measured CRF in the CSF in patients with PTSD. Somatostatin is a tetradecapeptide with widespread localization in the CNS that also appears to play a role in the stress response (22–24). Somatostatin and CRF levels tend to covary with one another, so it would be predicted that increased levels of CRF would be associated with increased levels of somatostatin. CSF somatostatin concentrations in patients with affective disorders, however, have been found to be either lower than (25–27) or the same as (28) those of comparison subjects (although elevated levels of somatostatin are seen in mania [29]). The purpose of the present study was to measure CSF CRF and somatostatin concentrations in Vietnam combat veterans with PTSD and matched comparison subjects. We hypothesized that PTSD would be associated with elevated CSF levels of CRF and somatostatin.

Reported pathological childhood experiences associated with the development of borderline personality disorder

Abstract: Objective: The purpose of this study was to assess a full range of pathological childhood experiences reported by patients with criteria-defined borderline personality disorder and comparison patients with other personality disorders. Method: The pathological childhood experiences reported by 467 inpatients with personality disorders were assessed by interviewers who used a semistructured research interview and were blind to clinical diagnosis. Results: Of the 358 patients with borderline personality disorder, 91% reported having been abused, and 92% reported having been neglected, before the age of 18. The borderline patients were significantly more likely than the 109 patients with other personality disorders to report having been emotionally and physically abused by a caretaker and sexually abused by a noncaretaker. They were also significantly more likely to report having a caretaker withdraw from them emotionally, treat them inconsistently, deny their thoughts and feelings, place them in the role of a parent, and fail to provide them with needed protection. The borderline patients with a childhood history of sexual abuse were significantly more likely than those without such a history to report having experienced all but one of the types of abuse and neglect studied. When all significant risk factors were considered together, four were found to be significant predictors of a borderline diagnosis: female gender, sexual abuse by a male noncaretaker, emotional denial by a male caretaker, and inconsistent treatment by a female caretaker. Conclusions: The results suggest that sexual abuse is neither necessary nor sufficient for the development of borderline personality disorder and that other childhood experiences, particularly neglect by caretakers of both genders, represent significant risk factors. (Am J Psychiatry 1997; 154:1101‐1106)

Diagnostic criteria for complicated grief disorder

Abstract: Objective: Some prolonged and turbulent grief reactions include symptoms that differ from the DSM-IV criteria for major depressive disorder. The authors investigated a new diagnosis that would include these symptoms. Method: They developed observer-based definitions of 30 symptoms noted clinically in previous longitudinal interviews of bereaved persons and then designed a plan to investigate whether any combination of these would serve as criteria for a possible new diagnosis of complicated grief disorder. Using a structured diagnostic interview, they assessed 70 subjects whose spouses had died. Latent class model analyses and signal detection procedures were used to calibrate the data against global clinical ratings and self-report measures of grief-specific distress. Results: Complicated grief disorder was found to be characterized by a smaller set of the assessed symptoms. Subjects selected by an algorithm for these symptom patterns did not significantly overlap with subjects who received a diagnosis of major depressive disorder. Conclusions: A new diagnosis of complicated grief disorder may be indicated. Its criteria would include the current experience (more than a year after a loss) of intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks reminiscent of the deceased, unusual sleep disturbances, and maladaptive levels of loss of interest in personal activities. (Am J Psychiatry 1997; 154:904‐910)

Traumatic grief as a risk factor for mental and physical morbidity.

Abstract: Objective: The aim of this study was to confirm and extend the authors’ previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. Method: The study group consisted of 150 future widows and widowers interviewed at the time of their spouse’s hospital admission and at 6-week and 6-, 13-, and 25month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Results: Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. Conclusions: The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction. (Am J Psychiatry 1997; 154:616‐623)

Prevalence, burden, and treatment of insomnia in primary care.

Abstract: OBJECTIVE: The prevalence, burden, and management of insomnia among primary care patients were evaluated METHOD: Consecutive patients aged 18 to 65 years in primary care clinics of a staff-model health maintenance organization (N = 1,962) were screened with the 12-item General Health Questionnaire A stratified random sample (N = 373) completed face-to-face diagnostic assessments including the Composite International Diagnostic Interview, a brief self-rated disability questionnaire (Brief Disability Questionnaire), and the interviewer-rated Social Disability Schedule A telephone follow-up survey was completed 3 months later Use of psychotropic drugs, use of mental health services, and direct health care costs were assessed by using the health plan's automated data systems RESULTS: Approximately 10% of the primary care patients reported major current insomnia (eg, taking at least 2 hours to fall asleep nearly every night) Current insomnia was associated with significantly greater functional impairment (according to both Brief Disability Questionnaire and Social Disability Schedule), more days of disability due to health problems, and greater general medical service utilization While insomnia was associated with depressive disorder and chronic medical illness, adjustment for these factors only partially accounted for the association of insomnia with disability and with health care utilization Of the patients with current insomnia, 28% received any psychotropic drug; 14% received benzodiazepines and 19% received antidepressants CONCLUSIONS: Insomnia among primary care patients is associated with greater functional impairment, lost productivity, and excess health care utilization Language: en

Psychomotor Symptoms of Depression

Abstract: Objective: The authors summarize current knowledge regarding the psychomotor symptoms of depression. Method: Findings from the objective quantification of psychomotor symptoms are reviewed, and methodological issues are considered. The contemporary empirical literature regarding the diagnostic, prognostic, and potential pathophysiologic significance of psychomotor symptoms is summarized. Results: It has been repeatedly shown that depressed patients differ from normal and psychiatric comparison groups with regard to objectively quantified gross motor activity, body movements, speech, and motor reaction time. Course of illness, diurnal variation, medication status, sex, and age are associated with agitation and retardation and should be controlled when one is studying psychomotor symptoms. Psychomotor symptoms in depression may have unique significance. They have high discriminative validity, may be the only symptoms of depression that distinguish depression subtypes, and are predictive of good response to tricyclic antidepressants. Results of brain imaging and biochemical studies link depression and motor symptoms to abnormalities in the basal ganglia and basal ganglia/thalamo-cortical circuits. Conclusions: The investigation of psychomotor disturbance in depression is specifically consistent with neo-Kraepelinian standards for the study of psychiatric disorders. Our current knowledge of psychomotor symptoms is conceptually obscure, yet a large body of evidence specifies their manifestation and supports their significance. Identifying the incidence of abnormal motor behaviors in depressed patients and assessing the component processes that accompany and determine their manifestation may be important advances in the study of psychomotor symptoms in depression. (Am J Psychiatry 1997; 154:4‐17)

Comparability of telephone and face-to-face interviews in assessing axis I and II disorders.

Abstract: OBJECTIVE: The present study examined the comparability of data obtained by telephone and face-to-face interviews for diagnosing axis I and II disorders. METHOD: Sixty young adults from the community were interviewed face-to-face and over the telephone regarding axis I disorders; another 60 subjects were interviewed twice regarding axis II disorders. The order of interviews was counterbalanced, and subjects with a history of disorder were oversampled. Agreement between telephone and face-to-face interviews was contrasted with interrater values, which were obtained by having a second interviewer rate a recording of the original interview. RESULTS: Interrater reliability was excellent. Agreement between telephone and face-to-face assessment was excellent for anxiety disorders and very good for major depressive disorder and alcohol and substance use disorders; agreement was problematic, however, for adjustment disorder with depressed mood. Strong support was shown for the validity of the axis II telephone as...

Mood Improvement Following Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation in Patients With Depression: A Placebo-Controlled Crossover Trial

Abstract: Objective: Preliminary studies have indicated that daily left prefrontal repetitive transcranial magnetic stimulation might have antidepressant activity. The authors sought to confirm this finding by using a double-blind crossover design. Method: Twelve depressed adults received in random order 2 weeks of active treatment (repetitive transcranial magnetic stimulation, 20 Hz at 80% motor threshold) and 2 weeks of sham treatment. Results: Changes from the relevant phase baseline in scores on the 21-item Hamilton depression scale showed that repetitive transcranial magnetic stimulation significantly improved mood over sham treatment. During the active-treatment phase, Hamilton depression scale scores decreased 5 points, while during sham treatment the scores increased or worsened by 3 points. No adverse effects were noted. Conclusions: These placebo-controlled results suggest that daily left prefrontal repetitive transcranial magnetic stimulation has antidepressant activity when administered at these parameters. Further controlled studies are indicated to explore optimal stimulation characteristics and location, potential clinical applications, and possible mechanisms of action. (Am J Psychiatry 1997; 154:1752‐1756)

Psychopathology in Women and Men: Focus on Female Hormones

Abstract: OBJECTIVE: The goal of this overview is to examine male/female differences in psychopathology in light of the known effects of gonadal steroids, especially estradiol, on neural function. METHOD: The epidemiology of specific psychopathological syndromes is highlighted with respect to male/female differences and discussed against the backdrop of recent neuroendocrine findings. RESULTS: A number of differences between the sexes in rates of illness and course of illness are documented, with Alzheimer's disease, schizophrenia, alcoholism, and mood and anxiety disorders each illustrating slightly different hormone-mediated risks and buffers. CONCLUSIONS: Estrogens are neuroprotective with respect to neuronal degeneration, growth, and susceptibility to toxins. The cyclic fluctuations of estrogens and progesterone enhance the response to stress, which confers susceptibility to depression and anxiety. (Am J Psychiatry 1997; 154:1641–1647)

Clinically Defined Vascular Depression

Abstract: Objective: The authors’ goal was to examine the clinical presentation of a group of depressed elderly patients with clinically defined risk factors for vascular depression compared with a group of elderly depressed patients without such risk factors. Method: Cognitive deficits, disability, and depressive symptoms were examined in 33 consecutively recruited elderly patients defined as having vascular depression and 32 patients defined as having nonvascular depression according to their scores on the Cumulative Illness Rating Scale—Geriatrics. Results: The patients with vascular depression had greater overall cognitive impairment and disability than those with nonvascular depression. Fluency and naming were more impaired in patients with vascular depression, and they had more retardation and less agitation as well as less guilt feelings and greater lack of insight. Conclusions: The symptoms of vascular depression are consistent with lesions that may damage striato-pallido-thalamo-cortical pathways and other areas. The concept of vascular depression can provide the impetus for investigations of prevention and treatment of cerebrovascular disease and for studies of the course of vascular depression and selection of antidepressants. (Am J Psychiatry 1997; 154:562‐565)

Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans.

Abstract: Objective: Although posttraumatic stress disorder (PTSD) is a highly prevalent and often chronic condition, the relationship between PTSD and functioning and quality of life remains incompletely understood. Method: The authors undertook an archival analysis of data from the National Vietnam Veterans Readjustment Study. The study subjects consisted of the nationally representative sample of male Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. The authors estimated PTSD at the time of the interview with the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. They examined the following outcomes: diminished well-being, physical limitations, bed day in the past 2 weeks, compromised physical health status, currently not working, and perpetration of violence. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions. Results: The risks of poorer outcome were significantly higher in subjects with PTSD than in subjects without PTSD in five of the six domains. For the outcome domains of physical limitations, not working, compromised physical health, and diminished wellbeing, these significantly higher risks persisted even in the most conservative logistic models that removed the shared effects of comorbid psychiatric and other medical disorders. Conclusions: The suffering associated with combat related-PTSD extends beyond the signs and symptoms of the disorder to broader areas of functional and social morbidity. The significantly higher risk of impaired functioning and diminished quality of life uniquely attributable to PTSD suggests that PTSD may well be the core problem in this group of difficult to treat and multiply afflicted patients. (Am J Psychiatry 1997; 154:1690‐1695)

Cognitive Behavior Therapy for Chronic Fatigue Syndrome: A Randomized Controlled Trial

Abstract: Objective: Cognitive behavior therapy for chronic fatigue syndrome was compared with relaxation in a randomized controlled trial. Method: Sixty patients with chronic fatigue syndrome were randomly assigned to 13 sessions of either cognitive behavior therapy (graded activity and cognitive restructuring) or relaxation. Outcome was evaluated by using measures of functional impairment, fatigue, mood, and global improvement. Results: Treatment was completed by 53 patients. Functional impairment and fatigue improved more in the group that received cognitive behavior therapy. At final follow-up, 70% of the completers in the cognitive behavior therapy group achieved good outcomes (substantial improvement in physical functioning) compared with 19% of those in the relaxation group who completed treatment. Conclusions: Cognitive behavior therapy was more effective than a relaxation control in the management of patients with chronic fatigue syndrome. Improvements were sustained over 6 months of follow-up. (Am J Psychiatry 1997; 154:408‐414)

Characterizing quality of life among patients with chronic mental illness: a critical examination of the self-report methodology.

Abstract: Objective: The purposes of the study were 1) to characterize the quality of life of three patient groups with chronic mental illness, 2) to evaluate differences in reported life quality among the three groups, and 3) to evaluate the validity of a self-report methodology by comparing these results with several objective indicators of life quality. Method: The study group consisted of chronically mentally ill patients with schizophrenia (N=69), bipolar disorder (N=37), or major depression (N=35). Subjects were administered the Quality of Life Index, and comparisons of both objective and self-report life quality indices were made among the three groups. Quality of life ratings of these subjects were also compared with those of patients with a chronic physical illness. Results: The two groups with mood disorders reported significantly lower scores on the Quality of Life Index than the patients with schizophrenia. Moreover, the scores on the Quality of Life Index for patients with schizophrenia were very similar to those of the comparison group of physically ill patients. The opposite trend emerged when groups were compared with respect to objective indicators of life quality. Schizophrenic patients experienced more objectively aversive life circumstances than either of the affectively disturbed groups. Conclusions: The validity of self-report measures of life satisfaction is questioned, particularly for use with affectively disturbed populations, since scores may be influenced by affective bias, poor insight, and recent life events. (Am J Psychiatry 1997; 154:99‐105)

A neurobiological basis of social attachment.

Abstract: Objective: Although an inability to form normal social attachments characterizes many forms of psychopathology, there has been little study of the neural basis of social bond formation. The primary purpose of this article is to describe a novel approach to the neurobiology of attachment. Method: The author reviews animal research on two closely related neuropeptides, oxytocin and vasopressin, implicated in the central mediation of attachment behaviors. These neuropeptides appear to be important for the initiation of pair bonds and parental behaviors as well as the infant’s response to social separation. Results: Both cellular and molecular studies have begun to reveal the mechanisms by which oxytocin and vasopressin neural pathways are regulated, leading to a preliminary understanding of how these hormones act within the brain to influence complex social behaviors. Conclusions: Although their function in the human brain has yet to be demonstrated, the available evidence suggests that oxytocin and vasopressin may prove to be important in the pathophysiology of clinical disorders, such as autism, characterized by an inability to form normal social attachments. (Am J Psychiatry 1997; 154:726‐735)

"Are You Depressed?" Screening for Depression in the Terminally Ill

Abstract: Objective: This study compared the performance of four brief screening measures for depression in a group of terminally ill patients. The methods included 1) a single-item interview assessing depressed mood, 2) a two-item interview assessing depressed mood and loss of interest in activities, 3) a visual analog scale for depressed mood, and 4) the Beck Depression Inventory—Short Form. Method: Semistructured diagnostic interviews for depression were administered to 197 patients receiving palliative care for advanced cancer. The interview diagnoses served as the standards against which the screening performance of the four brief screening methods was assessed. Results: Single-item interview screening correctly identified the eventual diagnostic outcome of every patient, substantially outperforming the questionnaire and visual analog measures. Conclusions: Brief screening measures for depression are important clinical tools for terminally ill patients. For diagnostic purposes, however, they do not approach the validity of a single-item interview that asks, in effect, “Are you depressed?” (Am J Psychiatry 1997; 154:674‐676)

Religion, Psychopathology, and Substance Use and Abuse: A Multimeasure, Genetic-Epidemiologic Study

Abstract: Objective: The authors sought to 1) understand the sources of familial resemblance for religiosity, 2) clarify the relationship between religiosity and current psychiatric symptoms, current substance use, lifetime psychiatric disorders, and lifetime substance dependence, and 3) explore the stress-buffering properties of religiosity. Method: Data were obtained by personal interview of 1,902 twins from female-female pairs in the population-based Virginia Twin Registry. Measures included 1) 10 items reflecting a range of religious behavior and beliefs, 2) a scale of institutional conservatism of current religious affiliation, 3) previous history of stressful life events, 4) current psychiatric symptoms and substance use, and 5) lifetime psychiatric disorders and substance dependence. Statistical methods used included factor analyses, Cox and linear regression, and twin modeling. Results: Personal devotion and personal and institutional conservatism were all strongly familial, and model fitting suggested that this familial resemblance was due largely to the effect of environmental factors. None of the dimensions of religiosity was strongly associated with lifetime psychopathology or current symptoms, but low levels of depressive symptoms were related to high levels of personal devotion. By contrast, personal devotion and personal and institutional conservatism were significantly and inversely associated with current levels of drinking and smoking as well as lifetime risk for alcoholism and nicotine dependence. Personal devotion, but not personal or institutional conservatism, buffered the depressogenic effects of stressful life events. Conclusions: The dimensions of religiosity, are not strongly related to risk for psychiatric symptoms and disorders. However, religiosity may be one of the more important familial-environmental factors that affect the risk for substance use and dependence. Religious devotion but not conservatism assists in coping with stress.

Specific major mental disorders and criminality: a 26-year prospective study of the 1966 northern Finland birth cohort.

Abstract: Objective: The purpose of the study was to examine the quantitative risk of criminal behavior associated with specific mental disorders. Method: An unselected 1966 birth cohort (N=12,058) in Northern Finland was prospectively studied until the end of 1992. The investigation started during the mothers’ pregnancy, and the data on the subjects’ family characteristics, mental and physical development, living habits, psychiatric morbidity, and criminal records were gathered at various times. Results: The prevalence of offenses was the highest among males with alcohol-induced psychoses and male schizophrenic subjects with coexisting alcohol abuse, and more than half of the schizophrenic offenders also had problems with alcohol. Eleven (7%) of the 165 subjects who committed violent crimes were diagnosed as psychotic. Male schizophrenic subjects had a moderately high risk for violent offenses, but the risk for other types of crimes was not elevated significantly. Odds ratios for criminal behavior were adjusted according to the socioeconomic status of the childhood family and were the same as or slightly lower than the crude odds ratios for all disorders except schizophrenia and mood disorders with psychotic features. Conclusions: The results indicate that the risk of criminal behavior was significantly higher among subjects with psychotic disorders, even though the socioeconomic status of the childhood family was controlled. The higher risk for violent behavior was associated especially with alcohol-induced psychoses and with schizophrenia with coexisting substance abuse. The results suggest that schizophrenia without substance abuse may also be associated with a higher risk of offenses, but this finding is tentative and requires further investigation. (Am J Psychiatry 1997; 154:840‐845)

Eating Disorders in Males: A Report on 135 Patients

Abstract: Objective: The goal of this study was to better understand the etiology, clinical characteristics, and prognosis of eating disorders in males. Method: All males with eating disorders who had been treated at Massachusetts General Hospital from Jan. 1, 1980, to Dec. 31, 1994, were identified. Hospital charts and psychiatric departmental records were reviewed to verify that the eating disorders met DSM-IV criteria and to abstract demographic and clinical data. Results: One hundred thirty-five males with eating disorders were identified, of whom 62 (46%) were bulimic, 30 (22%) were anorexic, and 43 (32%) met criteria for an eating disorder not otherwise specified. There were marked differences in sexual orientation by diagnostic group; 42% of the male bulimic patients were identified as either homosexual or bisexual, and 58% of the anorexic patients were identified as asexual. Comorbid psychiatric disorders were common, particularly major depressive disorder (54% of all patients), substance abuse (37%), and personality disorder (26%). Many patients had a family history of affective disorder (29%) or alcoholism (37%). Conclusions: While most characteristics of males and females with eating disorders are similar, homosexuality/bisexuality appears to be a specific risk factor for males, especially for those who develop bulimia nervosa. Future research on the link between sexual orientation and eating disorders would help guide prevention and treatment strategies. (Am J Psychiatry 1997; 154:1127‐1132)

Somatization in cross-cultural perspective: a World Health Organization study in primary care.

Abstract: Objective: The purpose of this study was to examine the phenomenon of somatization in different cultures by determining its frequency and correlates in primary care settings in 14 countries. Method: Consecutive primary care patients (N=25,916) were screened with the 12-item General Health Questionnaire, and a stratified sample (N=5,438) was interviewed with the Composite International Diagnostic Interview. Interviewed patients were also assessed for physical disease burden, self-rated overall health, physician-rated physical health status, number of disability days, and interviewer-rated occupational role functioning. The authors determined center-specific associations with the rise of logistic regression analyses in which confounding variables were controlled. Results: ICD-10-defined somatization disorder was relatively uncommon in most primary care settings. A less restrictively defined form was more common. Symptom rates were much higher in the South American sites. There was a modest association with low education. Otherwise, frequency of unexplained somatic symptoms did not clearly vary according to geography or level of economic development. Somatiz-ing patients were at elevated risk for self-reported disease burden, negative perception of their health, and comorbid depression and generalized anxiety disorder. Somatization was also commonly associated with disability. Cultures did not differ markedly in the pattern of these associated features. Conclusions: Somatization is a common problem in primary care across cultures and is associated with significant health problems and disability.

Consistency of Memory for Combat-Related Traumatic Events in Veterans of Operation Desert Storm

Abstract: Objective: The nature of traumatic memories is currently the subject of intense scientific investigation. While some researchers have described traumatic memory as fixed and indelible, others have found it to be malleable and subject to substantial alteration. The current study is a prospective investigation of memory for serious combat-related traumatic events in veterans of Operation Desert Storm. Method: Fifty-nine National Guard reservists from two separate units completed a 19-item trauma questionnaire about their combat experiences 1 month and 2 years after their return from the Gulf War. Responses were compared for consistency between the two time points and correlated with level of symptoms of posttraumatic stress disorder (PTSD). Results: There were many instances of inconsistent recall for events that were objective and highly traumatic in nature. Eighty-eight percent of subjects changed their responses on at least one of the 19 items, while 61% changed two or more items. There was a significant positive correlation between score on the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder at 2 years and the number of responses on the trauma questionnaire changed from no at 1 month to yes at 2 years. Conclusions: These findings do not support the position that traumatic memories are fixed or indelible. Further, the data suggest that as PTSD symptoms increase, so does amplification of memory for traumatic events. This study raises questions about the accuracy of recall for traumatic events, as well as about the wellestablished but retrospectively determined relationship between level of exposure to trauma and degree of PTSD symptoms. (Am J Psychiatry 1997; 154:173‐177)