Showing papers in "Archives of General Psychiatry in 1975"

Comparative Studies of Psychotherapies: Is It True That Everyone Has Won and All Must Have Prizes?

Abstract: Tallies were made of outcomes of all reasonably controlled comparisons of psychotherapies with each other and with other treatments. For comparisons of psychotherapy with each other, most studies found insignificant differences in proportions of patients who improved (though most patients benefited). This "tie score effect" did not apply to psychotherapies vs psychopharmacotherapies compared singly—psychopharmacotherapies did better. Combined treatments often did better than single treatments. Among the comparisons, only two specially beneficial matches between type of patient and type of treatment were found. Our explanations for the usual tie score effect emphasize the common components among psychotherapies, especially the helping relationship with a therapist. However, we believe the research does not justify the conclusion that we should randomly assign patients to treatments—research results are usually based on amount of improvement; "amount" may not disclose differences in quality of improvement from each treatment.

A Conceptual Model of Psychosomatic Illness in Children: Family Organization and Family Therapy

Abstract: Linear and open systems (multiple feedback) models of psychosomatic illness in children are contrasted in terms of their implications for cause and treatment. An open systems family model is presented that describes three necessary (but not independently sufficient) conditions for the development and maintenance of severe psychosomatic problems in children: (1) a certain type of family organization that encourages somatization; (2) involvement of the child in parental conflict; and (3) physiological vulnerability. Predisposition for psychosomatic illness, symptom choice, and maintenance are discussed within this conceptual framework. We report on family therapy strategies based on this model and the results of family treatment with 48 cases of "brittle" diabetes, psychosomatic asthma, and anorexia nervosa.

Overview of recent research in depression. Integration of ten conceptual models into a comprehensive clinical frame.

Abstract: Disciplinary fragmentation and nosological and semantic controversies have obscured the impressive advances made in the area of depressive disorders during the past decade. This article is an attempt to translate data derived from psychodynamic, sociobehavioral, and neurobiologic research into a clinically meaningful framework. We review ten models of depression with special emphasis on newer models supported by empirical and experimental studies, and present a new model, which incorporates and synthesizes findings from different schools. Depressive illness is conceptualized as the feedback interaction of three sets of variables at chemical, experiential, and behavioral levels with the diencephalon serving as the field of action.

Sequence and stages in patterns of adolescent drug use.

Abstract: Two prospective longitudinal surveys based on New York State high school students indicate well-defined steps underlying adolescent progression and regression in drug use. At least four stages of involvement with drugs can be identified: (1) beer or wine; (2) cigarettes or hard liquor; (3) marijuana; and (4) other illicit drugs. Two stages of legal drugs are necessary intermediates between nonuse and marijuana. Very few youths progress to other illicit drugs without prior experience with marijuana. This sequence is found in- each year of high school and in- the year following graduation. Progression to a higher-ranked drug is directly related to intensity of use at the prior stage. The identification of stages in drug behavior has implications regarding the optimum strategy for studying factors that predict, differentiate, or result from drug use.

The interictal behavior syndrome of temporal lobe epilepsy.

Abstract: • A distinct syndrome of interictal behavior changes occurs in many patients with temporal lobe epilepsy. These changes include alterations in sexual behavior, religiosity, and a tendency toward extensive, and in some cases compulsive, writing and drawing. The concomitants of abnormal limbic activity therefore include behavior alterations as well as manifest seizures. The demonstration of interictal spike activity in temporal structures provides a pathophysiologic basis for this syndrome. The constellation of behavioral changes may be of great diagnostic value. In addition, it provides an example of a human behavioral syndrome associated with dysfunction at specific anatomic loci. The behavior syndrome of temporal lobe epilepsy may prove to be a useful model in studies on the neural substrates for behavior.

Suicide attempts and recent life events. A controlled comparison.

Abstract: Life events experienced in the six months before a suicide attempt were compared with events for two matched control groups. Suicide attempters reported four times as many events as were reported by subjects from the general population and 11/2 times as many as were reported by depressed patients prior to depressive onset. A substantial peaking of events occurred in the month before the attempt. The excess over general population controls spanned most types of event. That over depressive onset was more selective, and it involved events with threatening implications, including undesirable events, those rated as stressful, and those outside the respondent's control. Unlike depression, suicide attempts were preceded equally by entrances and exits in the social field. Overall, the findings indicate a strong and immediate relationship between suicide attempts and life events.

Memory complaint and impairment in the aged. The effect of depression and altered brain function.

Abstract: To clarify the role of memory impairment in the aged as a normal or psychopathological phenomenon, 153 persons 50-years-old and over with varying degrees of depression and altered brain function were compared for their complaints about memory and actual performance on a series of memory tests. It was found that while performance varied with altered brain function, complaint was related to level of depression, regardless of performance. Exaggerated memory complaint was considered one manifestation of a general pattern of discrepant reporting of symptoms by depressed persons, and apparently related to an underlying personality factor. The complaint of superiority of remote over recent memory was not substantiated empirically, but was considered part of the pattern of stereotyped language and attitudes characteristic of depressed persons.

A Review of REM Sleep Deprivation

Abstract: Studies on the behavioral consequences of rapid eye movement (REM) sleep deprivation in animals and humans are critically reviewed. In animals, converging evidence—some reasonably well controlled—indicates that REM sleep deprivation probably heightens central neural excitability and increases motivational behavior, but has unclear or inconclusive effects on learning. In humans, evidence indicates that REM sleep deprivation is not dream deprivation and is not harmful to schizophrenic, depressed, or healthy subjects. Controversy continues about whether or not (some) schizophrenic patients respond abnormally to REM sleep deprivation by having no REM rebound. Controlled but unconfirmed work indicates that endogenous, but not reactive, depressive patients are improved by REM sleep deprivation, a finding consistent with the animal behavioral consequences of the procedure and with the unique REM-depriving properties of efficacious antidepressant drugs.

Biogenic Amines and Depression: Biochemical and Pharmacological Separation of Two Types of Depression

Abstract: Recent research findings indicate that depressive disorders may be divided into two groups, A and B, using specific biochemical and pharmacological criteria. It is suggested that in the A group there is a disorder of norepinephrine metabolism or disposition, whereas serotonin and probably dopamine systems are not altered. Further, there is the possibility that B type patients have a disorder of serotonin, but not norepinephrine or dopamine systems. This biochemical heterogeneity of human depression has implications for both investigators and clinicians, and may account for disparate findings in biological studies of patients with affective disorders.

Narcotic use in southeast Asia and afterward. An interview study of 898 Vietnam returnees.

Abstract: From all US Army enlistees leaving Vietnam in September 1971, a random sample of 943 men was selected. Of these, 470 represented a "general" sample of all enlistees returning at that time, and 495 represented a "drug-positive" sample whose urine samples had been positive for opiates at the time of departure. We attempted to locate and personally interview all of the men in the samples. Results indicate that before arrival, hard drug use was largely casual, and less than 1% had ever been addicted to narcotics. In Vietnam, almost half the general sample tried narcotics and 20% reported opiate addiction. After return, usage and addiction essentially decreased to pre-Vietnam levels. We discuss the use of nonnarcotic drugs, predictors and correlates of drug use in the samples, and the relationship of drugs to post-Vietnam social adjustment.

Intrusive and repetitive thoughts after experimental stress. A summary

Abstract: Clinical research indicates a tendency to compulsive repetitions of traumatic experiences. Such phenomena have not been studied experimentally and so the generality of the tendency has been uncertain. With development of operational definitions and content analysis techniques, it was possible to quantity and examine intrusive and stimulus-repetitive thought in a series of experiments with controlled variations in subject selection, stimuli, demand set, and context. Comparison of data across experiments indicates a tendency toward intrusive and stimulus-repetitive thought that is not restricted to "traumas" or a few predisposed individuals. Intrusive and repetitive thought appears to be a general stress-response tendency seen in a large proportion of persons after even mild to moderately stressful events. It is concluded that the intrusive repetitions observed clinically are extreme forms of this general stress-response tendency.

Diagnostic criteria and five-year outcome in schizophrenia. A report from the International Pilot Study of schizophrenia.

Abstract: Systematic psychiatric assessment was undertaken on 131 patients (the American cohort of the International Pilot Study of Schizophrenia). Nine areas of outcome functioning were assessed five years later at follow-up evaluation on 63% of these patients. An analysis of 66 clinical and demographic variables established that the patients successfully followed-up were representatives of the entire cohort. Diagnostic data from initial evaluations and follow-up outcome assessment were used to examine the relationship between diagnostic criteria and outcome in schizophrenia. Applying the criteria for schizophrenic diagnosis defined by Langfeldt, by Schneider, and Carpenter et al failed to define a poor outcome group. No difference in outcome was found when traditional schizophrenic subtypes were contrasted. Overall outcome in 61 patients with conditions diagnosed as schizophrenic was heterogeneous. However, despite overlap, the mean outcome in the schizophrenic cohort was poorer than in the 19 nonschizophrenic patients.

Antidepressant Response to Tricyclics and Urinary MHPG in Unipolar Patients: Clinical Response to Imipramine or Amitriptyline

Abstract: The urinary excretion of the norepinephrine metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) was measured in unipolar depressed patients before and during the fourth week of treatment with either imipramine hydrocloride or amitriptyline hydroxhloride. On the basis of strict rating criteria, 24 patients were selected as either unequivocal responders or nonresponders. In the imipramine group the mean pretreatment MHPG was significantly lower in the nine responders in the seven nonresponders; the converse was found with the amitriptyline patients. Of particular interest is that there was no overlap in individual values between the responders and nonresponders to either drug. Treatment with eigher imipramine or amitriptyline was associated with a significant decrease in MHPG excretion, which was independent of clinical response.

The Assessment of Social Adjustment: A Review of Techniques

Abstract: Interest in the community adjustment of psychiatric patients has led to the development of rating techniques for its evaluation. Selection of an appropriate scale for the task should include a review of its item content, anchor points, coverage, method of obtaining information, informant, psychometric properties, precision, cost, scoring, and instructional material. While no scale is without limitations, this report describes 15 currently available scales that meet many of the important criteria for assessing social adjustment and are sufficiently developed to be useful in evaluative research. This review also contains a list of pertinent references to the scales and a guide to the literature on behavioral rating scales.

Amphetamine-Induced Dopaminergic Hypersensitivity in Guinea Pigs: Implications in Psychosis and Human Movement Disorders

Abstract: Following chronic amphetamine pretreatment, guinea pigs demonstrate an increased sensitivity to both d-amphetamine sulfate- and apomorphine hydrochloride-induced stereotyped behavior. This observation suggests that chronic exposure to high doses of a dopamine agonist (d-amphetamine) alters the response of the brain to the subsequent administration of both indirect (d-amphetamine) and direct (apomorphine) dopamine agonists. This altered response may be due to the development of dopamine receptor site hypersensitivity. Clinical evidence suggests that a similar agonist-induced hypersensitivity may play a role in the development of dyskinetic movement disorders and psychoses in humans following the chronic use of such dopamine agonists as amphetamine and levodopa.

The customer approach to patienthood. Attending to patient requests in a walk-in clinic.

Abstract: This report conceptualizes the initial psychiatric interview as a process of negotiation between the clinician and patient. Patients are conceived of as appearing with one or more requests, many of which represent legitimate needs. It is the clinician's task to elicit the request, collect the relevant clinical data, and enter into a "negotiation" that should foster a relationship of mutual influence between patient and clinician. We have attempted to show that this approach to patienthood not only improves patient care and patient satisfaction but also leads to improved staff morale. The "customer approach" has special relevance to those clinical settings (walk-in clinics and community mental health centers) in which clinicians see a broad range of patients with a broad definition of psychiatric problems and requests.

Integration and Sealing Over: Clinically Distinct Recovery Styles From Schizophrenia

Abstract: Concepts of integration and sealing over are common clinical psychiatric parlance. Our experience studying and treating acute schizophrenic patients, primarily with psychosocial techniques, has emphasized the meaningfulness of these concepts. By studying the recovered patient's attitude toward his psychotic experiences, we have obtained material from which to formulate definitions of these concepts. Integrators tend to be curious about their symptoms, regard them as part of their life's pattern, and gain information from them, resulting in a more flexible and variable attitude toward illness than patients who seal over. The latter have rather fixed, usually negative, views of their illness, and tend not to strive to understand their psychotic symptoms nor to place their psychotic experiences in perspective with their lives before and after psychosis.

Akinesia: A Poorly Recognized Drug-Induced Extrapyramidal Behavioral Disorder

Abstract: Akinesia is an extrapyramidal behavioral side-effect of antipsychotic medication characterized by a lessening of spontaneity, paucity of gestures, diminished conversation, and apathy. It can be easily confused with depression, demoralization, and residual schizophrenic defect. Studies of the value of maintenance antiparkinson medication usually overlook this common syndrome. We present eight case histories to illustrate this condition.

REM sleep reduction effects on depression syndromes.

Abstract: Thirty-four endogenous and 18 reactive, depressed patients (hospitalized and nonschizophrenic) were treated in a double-blind, crossover study of the hypothesis that rapid eye movement (REM) sleep reduction (by awakenings) relieves depression. In the endogenous group-but not in the reactive group-subjects deprived of REM sleep for three weeks improved significantly more than control subjects awakened from non-REM sleep. Therapeutic efficacy of REM sleep reduction appeared similar to reported efficacy of imipramine hydrochloride treatment of depression. Eight of nine endogenous patients, unimproved by REM sleep deprivation, did not improve with imipramine. Results suggested (1) that substantial REM sleep reduction has antidepressant activity, and (2) since imipramine and other drug antidepressants reduce REM sleep much more so than nonantidepressant drugs, that an antidepressant "mechanism" of drugs resides in their capacity to substantially reduce REM sleep.

Cerebrospinal fluid amine metabolites in acute schizophrenia.

Abstract: The metabolites of serotonin, dopamine, and norepinephrine, 5-hydroxyindoleacetic acid (5HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxy-phenylethylene glycol (MHPG), respectively, were studied in cerebrospinal fluid of patients with acute schizophrenia. Base line levels of these metabolites were not significantly different from those in normal, neurological, and affectively ill controls. Accumulations of 5HIAA and HVA following probenecid administration, which provide a measure of serotonin and dopamine turnover, were also not significantly different in patients with acute schizophrenia and affective illness. After patients had recovered from their acute schizophrenic illness, HVA accumulations were significantly reduced. We discuss results in relation to amine hypotheses of schizophrenia and the suggestion that altered dopamine metabolism may reflect a biological change predisposing to acute schizophrenia.

Reliably separating identical from fraternal twins.

Abstract: • Blood typing is the most reliable method for assigning zygosity to twinships in psychological research. Cost, ethical considerations, and practical difficulties in obtaining blood specimens from a large group of children suggested the need for a questionnaire method used with young children and completed by parents. One was designed to assess zygosity based on the extent to which the children were rated as looking alike and being confused by family and strangers. Validity was determined with a sample of twins whose zygosity was demonstrated by blood typing. To determine test-retest reliability, and to explore parental beliefs about zygosity, mothers of same-sex twinships completed the questionnaire on two separate occasions, showing very high agreement. The major difference in parental perceptions of monozygotic and dizygotic twinships is convenient for epidemiological research. This difference, however, questions the assumption, made in estimates of heritability using twin data, that both twinships have identical environmental experiences.

Interaction of Drug Therapy With Marital Therapy in Depressive Patients

Abstract: Comparative effects of the antidepressant drug, amitriptyline hydrochloride, marital therapy, and the drug-psychotherapy interaction effects were studied in a 12-week course of treatment of outpatient depressives. Patients were assigned randomly to four treatment groups, in a 2 times 2 factorial design: (1) drug-marital therapy; (2) drug-minimal contact; (3) placebo-marital therapy; and (4) placebo-minimal contact. Both drug and marital therapy showed substantial beneficial advantages over their control conditions, but drug therapy was faster and generally superior in symptom relief and clinical improvement. Marital therapy was superior in family role task performance and perception of the marital relationship. For reducing hostility and enhancing the perception of the marital relationship, drug therapy had a better early effect, but marital therapy had superior effects by the end of treatment.

Psychoactive drugs in mania. A controlled comparison of lithium carbonate, chlorpromazine, and haloperidol

Abstract: Lithium carbonate, haloperidol, and chlorpromazine hydrochloride were compared in a double-blind controlled study with severely ill hospitalized manics. Lithium carbonate and haloperidol produced a highly significant improvement of manic symptoms without sedation. Although producing considerable sedation, chlorpromazine did little to alter the underlying mania qualitatively. Qualitative differences between lithium carbonate and haloperidol indicate that, while haloperidol has a more dramatically rapid impact on behavior-motor activity, lithium carbonate acted more evenly on the entire manic picture, with total normalization realized during active treatment. The majority of lithium carbonate-treated patients met discharge criteria at study termination, but not the patients receiving either neuroleptic drug. The rating scales are not sensitive enough to monitor manic psychopathology; this accounts for the lack of statistically significant differences among drug groups at treatment termination, despite the widely disparate discharge rates.

Methylphenidate and haloperidol in children. Effects on attention, memory, and activity.

Abstract: Twenty-four hyperactive or unsocialized-aggressive children participated in an exploratory double-blind crossover study comparing the cognitive effects of methylphenidate hydrochloride (0.3 mg/kg), two doses (0.25 and 0.05 mg/kg) of haloperidol, and inert placebo. Each subject received each of four drug conditions, drug order being randomized by a Latin square design. At the end of each 18-day trial period, attention, immediate recognition memory, reaction times, and seat activity were tested. While drug effects were small, methylphenidate and, to a lesser extent, the low dose of haloperidol, facilitated performance, whereas there was some suggestion that the high dose of haloperidol may have caused a slight deterioration In performance. These results are contrasted with effects on social behavior where the latter improved behavior. No differences attributable to diagnosis were found.

Physostigmine: Its Use in Acute Anticholinergic Syndrome With Antidepressant and Antiparkinson Drugs

Abstract: We reviewed the use of physostigmine in the diagnosis and management of acute toxic psychosis due to drugs with anticholinergic properties. The syndrome of agitation and toxic confusional psychosis associated with peripheral signs of cholinergic blockade is produced by several plant toxins, antispasmodics, ophthalmic preparations, and certain proprietary sedatives, as well as antiparkinson medications, antidepressants, and some antipsychotic drugs. Physostigmine, uniquely among the available reversible anticholinesterase agents, can pass the blood-brain barrier to exert central as well as peripheral cholinomimetic actions to reverse this syndrome. Psychiatrists should make more use of this safe, specific, rapid, and effective treatment for anticholinergic drug toxicity, and should particularly be alert to reversible anticholinergic brain syndromes associated with antidepressants and antiparkinson medications, and even with antipsychotic medications.

The basis for amine hypotheses in affective disorders. A critical evaluation.

Abstract: • A leading hypothesis concerning a biological basis of the affectove disorders is that altered metabolism of brain amines may underlie the cause or pathophysiology of these conditions. Features of affective illnesses supporting biological hypotheses include the somatic symptoms, diurnal rhythm, and apparent "endogenicity" of many severe depressions, and evidence of a genetic basis of manic-depressive illness. Development and preclinical study of medical therapies for the disorders substantially supported a relationship between mood-disturbances and neurotransmitters and stimulated considerable advances in the physiology and pharmacology of central synaptic neurotransmission. Unfortunately, studies of amine metabolism in patients have not provided consistent support for the amine hypotheses. Moreover, these hypotheses have not led to a coherent biological theory of abnormal behavior, to an objective basis for differential diagnosis, or to the rational development of treatments more effective or safer than those known.

Lithium carbonate response in depression. Prediction by unipolar/bipolar illness, average-evoked response, catechol-O-methyl transferase, and family history.

Abstract: • The antidepressant efficacy of lithium carbonate was assessed in a double-blind trial in 23 hospitalized depressed patients. Unequivocal response was significantly more frequent in bipolar than in unipolar depressed patients. Lithium carbonate responders had a greater visual average-evoked response amplitude increase in response to increased stimulus intensity, termed "augmenting." No correlation could be demonstrated between lithium carbonate efficacy and either erythrocyte catechol-O-methyl tramsferase activity, age of symptom onset, number of hospitalizations, or family history of affective disorders.

Measuring depressive symptomatology in a general population.

Abstract: Three hundred twenty respondents in selected geographic areas were interviewed with a structured questionnaire that included the Zung Self-Rating Depression Scale. Dimensional analysis indicates that some items are not pure measures of the constructs they were originally intended to assess. Moreover, some of the dimensions within the scale apparently convey different meanings to different segments in the population. In addition, different dimensions within the scale have varying demographic correlates. The analysis suggests that in order for the scale to be a truly useful device for assessing depressive symptomatology in a general population, additional items need to be added and some questions need to be followed by probes to clarify the exact frame of reference of the respondents.

Creativity and Psychosis: An Examination of Conceptual Style

Abstract: The performance of creative writers on the Goldstein-Sheerer Object-Sorting Test was compared with that of admitted manic and schizophrenic patients. Writers and manics tended to show more behavioral and conceptual overinclusion, but the writers showed substantially more richness and the manics more idiosyncratic thinking. Schizophrenics tended to be underinclusive rather than overinclusive and showed less richness and bizarreness than the writers and manics. These data imply that the conceptual style of writers may resemble mania more than schizophrenia and that, if overinclusiveness is an index of thought disorder, manics may have a more florid thought disorder than schizophrenics.

Memory functions six to nine months after electroconvulsive therapy.

Abstract: • Memory functions after electroconvulsive therapy (ECT) were assessed in 38 former patients who had received bilateral treatment, right unilateral treatment, or hospitalization without ECT six to nine months previously. Results of six different tests of delayed retention and remote memory provided no evidence for persisting memory impairment. Nevertheless, persons who had received bilateral ECT rated their memory as impaired significantly (P