Showing papers in "Archives of General Psychiatry in 1989"

The Yale-Brown Obsessive Compulsive Scale: I. Development, Use, and Reliability

Abstract: • The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessivecompulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's α coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.

The Yale-Brown Obsessive Compulsive Scale: II. Validity

Abstract: • The development design and reliability of the Yale-Brown Obsessive Compulsive Scale have been described elsewhere. We focused on the validity of the Yale-Brown Scale and its sensitivity to change. Convergent and discriminant validity were examined in baseline ratings from three cohorts of patients with obsessive-compulsive disorder (N = 81). The total Yale-Brown Scale score was significantly correlated with two of three independent measures of obsessive-compulsive disorder and weakly correlated with measures of depression and of anxiety in patients with obsessive-compulsive disorder with minimal secondary depressive symptoms. Results from a previously reported placebo-controlled trial of fluvoxamine in 42 patients with obsessive-compulsive disorder showed that the Yale-Brown Scale was sensitive to drug-induced changes and that reductions in Yale-Brown Scale scores specifically reflected improvement in obsessive-compulsive disorder symptoms. Together, these studies indicate that the 10-item Yale-Brown Scale is a reliable and valid instrument for assessing obsessive-compulsive disorder symptom severity and that it is suitable as an outcome measure in drug trials of obsessive-compulsive disorder.

National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments.

Abstract: • We investigated the effectiveness of two brief psychotherapies, interpersonal psychotherapy and cognitive behavior therapy, for the treatment of outpatients with major depressive disorder diagnosed by Research Diagnostic Criteria. Two hundred fifty patients were randomly assigned to one of four 16-week treatment conditions: interpersonal psychotherapy, cognitive behavior therapy, imipramine hydrochloride plus clinical management (as a standard reference treatment), and placebo plus clinical management. Patients in all treatments showed signifi-cant reduction in depressive symptoms and improvement in functioning over the course of treatment. There was a consistent ordering of treatments at termination, with imipramine plus clinical management generally doing best, placebo plus clinical management worst, and the two psychotherapies in between but generally closer to imipramine plus clinical management. In analyses carried out on the total samples without regard to initial severity of illness (the primary analyses), there was no evidence of greater effectiveness of one of the psychotherapies as compared with the other and no evidence that either of the psychotherapies was significantly less effective than the standard reference treatment, imipramine plus clinical management. Comparing each of the psychotherapies with the placebo plus clinical management condition, there was limited evidence of the specific effectiveness of interpersonal psychotherapy and none for cognitive behavior therapy. Superior recovery rates were found for both interpersonal psychotherapy and imipramine plus clinical management, as compared with placebo plus clinical management. On mean scores, however, there were few significant differences in effectiveness among the four treatments in the primary analyses. Secondary analyses, in which patients were dichotomized on intial level of severity of depressive symptoms and impairment of functioning, helped to explain the relative lack of significant findings in the primary analyses. Significant differences among treatments were present only for the subgroup of patients who were more severely depressed and functionally impaired; here, there was some evidence of the effectiveness of interpersonal psychotherapy with these patients and strong evidence of the effectiveness of imipramine plus clinical management. In contrast, there were no significant differences among treatments, including placebo plus clinical management, for the less severely depressed and functionally impaired patients.

Reduction of prefrontal cortex glucose metabolism common to three types of depression.

Abstract: • Using positron emission tomography, we studied cerebral glucose metabolism in drug-free, age- and sex-matched, righthanded patients with unipolar depression (n =10), bipolar depression (n =10), obsessive-compulsive disorder (OCD) with secondary depression (n =10), OCD without major depression (n =14), and normal controls (n =12). Depressed patients were matched for depression on the Hamilton Depression Rating Scale, and subjects with OCD without depression and OCD with depression had similar levels of OCD pathology. We also studied six non—sex-matched patients with mania. Mean ( ± SD) glucose metabolic rates for the left dorsal anterolateral prefrontal cortex, divided by the rate for the ipsilateral hemisphere as a whole (ALPFC/hem), were similar in the primary depressions (unipolar depression = 1.05 ±0.05; bipolar depression =1.04 ± 0.05), and were significantly lower than those in normal controls (1.12 ± 0.06) or OCD without depression (1.15 ± 0.05). Results for the right hemisphere were similar. Values in subjects with OCD with depression (1.10 0.05) were also significantly lower than in subjects with OCD without depression, and values in subjects with bipolar depression were lower than those in manic subjects (1.12 ± on this measure in the left hemisphere, although results were not significant in the right hemisphere. There was a significant correlation between the HAM-D score and the left ALPFC/hem. With medication for depression (n =12), the left ALPFC/hem increased significantly and the percentage change in the Hamilton scale score correlated with the percentage change in the left ALPFC/hem. These data support other findings that major depression is associated with a left ALPFC abnormality.

Serotonergic Studies in Patients with Affective and Personality Disorders: Correlates with Suicidal and Impulsive Aggressive Behavior

Abstract: • Dysfunction of the central serotonergic system has been variously associated with depression and with suicidal and/or impulsive aggressive behavior. To evaluate central serotonergic function in relation to these variables, prolactin responses to a singledose challenge with fenfluramine hydrochloride (60 mg orally), a serotonin releasing/uptake-inhibiting agent, were examined in 45 male patients with clearly defined major affective (n = 25) and/or personality disorder (n 20) and in 18 normal male control patients. Prolactin responses to fenfluramine among all patients were reduced compared with responses of controls. Reduced prolactin responses to fenfluramine were correlated with history of suicide attempt in all patients but with clinician and selfreported ratings of impulsive aggression in patients with personality disorder only; there was no correlation with depression. These results suggest that reduced central serotonergic function is present in a subgroup of patients with major affective and/or personality disorder and is associated with history of suicide attempt in patients with either disorder, but with impulsive aggression in patients with personality disorder only.

Cerebral glucose metabolism in childhood-onset obsessive-compulsive disorder.

Abstract: The cerebral metabolic rate for glucose was studied in 18 adults with childhood-onset obsessive-compulsive disorder (OCD) and in age- and sex-matched controls using positron emission tomography and fludeoxyglucose F 18. Both groups were scanned during rest, with reduced auditory and visual stimulation. The group with OCD showed an increased glucose metabolism in the left orbital frontal, right sensorimotor, and bilateral prefrontal and anterior cingulate regions as compared with controls. Ratios of regional activity to mean cortical gray matter metabolism were increased for the right prefrontal and left anterior cingulate regions in the group with OCD as a whole. Correlations between glucose metabolism and clinical assessment measures showed a significant relationship between metabolic activity and both state and trait measurements of OCD and anxiety as well as the response to clomipramine hydrochloride therapy. These results are consistent with the suggestion that OCD may result from a functional disturbance in the frontal-limbic-basal ganglia system.

Obsessive-Compulsive Disorder in Children and Adolescents Clinical Phenomenology of 70 Consecutive Cases

Abstract: • We reviewed the phenomenology of obsessive-compulsive disorder (OCD) in 70 consecutive children and adolescents studied prospectively at the National Institute of Mental Health, Bethesda, Md, between 1977 and 1987. There is striking similarity between the clinical presentation of OCD in children and in adult patients. Washing, grooming, and checking rituals and/or preoccupation with disease, danger, and doubt account for the great majority of cases. Twenty-five percent of subjects had a first-degree relative with OCD. The fixed content and style of symptoms within and across subjects, and the identical presentation across a wide age range, suggest an ethological model for OCD.

Epidemiological findings of seasonal changes in mood and behavior. A telephone survey of Montgomery County, Maryland.

Abstract: Patterns of seasonal changes in mood and behavior in Montgomery County, Maryland, were evaluated in randomly selected household samples by lay interviewers using a telephone version of the Seasonal Pattern Assessment Questionnaire. The method for selecting the sample unit was random-digit dialing. We found that 92% of the survey subjects noticed seasonal changes of mood and behavior to varying degrees. For 27% of the sample seasonal changes were a problem and 4.3% to 10% of subjects, depending on the case-finding definition, rated a degree of seasonal impairment equivalent to that of patients with seasonal affective disorder. The seasonal pattern of "feeling worst" exhibited a bimodal distribution with a greater winter and a substantially lower summer peak (ratio, 4.5:1). Younger women who have a problem with seasonal changes and who feel worse on short days tended to exhibit the highest seasonality scores. It is apparent from our study that seasonal affective disorder represents the extreme end of the spectrum of seasonality that affects a large percentage of the general population. The influence of environmental factors on mood disorders and mood changes in the general population might provide valuable insight into pathogenesis, treatment, and prevention of affective illness.

Schizophrenia as an Anomaly of Development of Cerebral Asymmetry: A Postmortem Study and a Proposal Concerning the Genetic Basis of the Disease

Abstract: • Schizophrenia is associated with structural changes (eg, a mild degree of ventricular enlargement) in the brain, although whether these precede onset of illness or progress with episodes is not established. In a postmortem study, we find that ventricular enlargement affects the posterior and particularly the temporal horn of the lateral cerebral ventricle. By comparison with controls and with patients suffering from Alzheimer-type dementia (in which there is also temporal horn enlargement), the change is highly significantly selective to the left hemisphere. This deviation was not accompanied by an increase in glial cell number (examined chemically by assay of diazepam-binding inhibitor immunoreactivity and microscopically by density of staining with the Holzer' technique). The findings are consistent with the view that schizophrenia is a disorder of the genetic mechanisms that control the development of cerebral asymmetry.

The influence of an illusion of control on panic attacks induced via inhalation of 5.5% carbon dioxide-enriched air

Abstract: The current study tested the notion that a sense of control can mitigate anxiety and panic attacks caused by the inhalation of 5.5% carbon dioxide (CO2)-enriched air. Twenty patients with panic disorder inhaled a mixture of 5.5% CO2-enriched air for 15 minutes. All patients were instructed that illumination of a light directly in front of them would signal that they could decrease the amount of CO2 that they were receiving, if desired, by turning a dial attached to their chair. For ten patients, the light was illuminated during the entire administration of CO2. For the remaining ten patients, the light was never illuminated. In fact, all patients experienced the full CO2 mixture, and the dial was ineffective. When compared with patients who believed they had control, patients who believed they could not control the CO2 administration (1) reported a greater number of DSM-III-revised panic attack symptoms, (2) rated the symptoms as more intense, (3) reported greater subjective anxiety, (4) reported a greater number of catastrophic cognitions, (5) reported a greater resemblance of the overall inhalation experience to a naturally occurring panic attack, and (6) were significantly more likely to report panic attacks. These data illustrate the contribution of psychologic factors to laboratory induction of panic attacks through inhalation of 5.5% CO2-enriched air.

Quality of Life in Panic Disorder

Abstract: Data from the Epidemiologic Catchment Area study showed that a lifetime Diagnostic Interview Schedule/DSM-III diagnosis of panic disorder was associated with pervasive social and health consequences similar to or greater than those associated with major depression. These consequences included subjective feelings of poor physical and emotional health, alcohol and other drug abuse, increased likelihood of suicide attempts, impaired social and marital functioning, financial dependency, and increased use of psychoactive medications, health services, and the hospital emergency department for emotional problems. Comorbidity of panic disorder with major depression, agoraphobia, and alcohol or other drug abuse did not explain these findings. The social and health consequences of panic disorder (quality of life) should be considered, as risks and benefits of currently available acute and maintenance treatments are evaluated. Clinical trials of panic disorder, whether of drugs or behavioral treatment, should include quality of life assessments as outcome measures. Long-term prospective studies based on clinical samples of patients with panic disorder are indicated to relate the illness more precisely to social morbidity.

Hippocampal pathologic findings in schizophrenia. A morphometric study.

Abstract: • We studied hippocampal sections from 13 schizophrenic patients, 9 nonschizophrenic patients, and 16 normal controls from the Yakovlev brain collection. The three groups were similar in age, gender distribution, and brain weight. Most patients had never received neuroleptics, and the two patient groups had had similar types of leukotomies. We used a semiautomated image analysis system to compute volume and pyramidal-cell density in each of the four sectors of the cornu ammonis, CA 1 through CA 4 , in the right and left hippocampi. Sections from schizophrenic patients had almost consistently the lowest volume and pyramidal-cell density in all sectors. The differences were greatest in left CA 4 , with schizophrenic patients having significantly lower pyramidal-cell density than normal controls and significantly lower volume than leukotomy controls. Our findings confirm the results of several recent studies showing hippocampal pathologic features in schizophrenia. Our study suggests, however, that the hippocampal neuropathologic findings in schizophrenia may be more subtle and more localized than those reported previously.

Confirming unexpressed genotypes for schizophrenia: risks in the offspring of Fischer's Danish identical and fraternal discordant twins

Abstract: • Margit Fischer reported in 1971 that the risk of schizophrenia in the offspring of her Danish schizophrenic monozygotic twins and their normal cotwins was equal and not different from the risks in the children of schizophrenics in the literature. All of her identical and fraternal twins who had children and all of their offspring have been followed up through the Danish National Psychiatric Register as of 1985, some 18 years after study by Fischer. The morbid risk (age-corrected) for schizophrenia and schizophrenia-related disorders in the offspring of schizophrenic identical twins is 16.8%; it is 17.4% in their normal cotwins' offspring. The risks in the offspring of schizophrenic fraternal twins and their normal cotwins are 17.4% and 2.1%, respectively. The results suggest that discordance in identical twins may primarily be explained by the capacity of a schizophrenic genotype or diathesis to be unexpressed unless it is released by some kinds of environmental, including nonfamilial, stressors. Sporadic cases and phenocopies caused by cerebral abnormalities, diseases, or viruses would thus be deemphasized as necessary or sufficient explanatory causes for schizophrenia in our study but could account for some of the remaining discordance. Infrequent phenocopies should encourage linkage researchers, but unexpression of genotypes will frustrate them.

Premorbid Personality Assessments of First Onset of Major Depression

Abstract: • This is a report on personality traits associated with the first onset of major depression in a sample of high-risk subjects. The subjects are the first-degree relatives, spouses, and their controls of patients with affective disorders. None of these subjects had any history of mental disorder as of their initial evaluation. In the subsequent six years, 29 subjects had a first onset of major depression. These first onset subjects were compared with 370 subjects who continued to be free of illness during the six-year follow-up. Personality traits were assessed at the initial evaluation (ie, before the onset of depression in subjects with first onset) by means of scales from five self-report inventories. Lower emotional strength and resiliency significantly differentiated the first onset from the never ill group; overall differences were not found on measures of interpersonal dependency or extraversion. Age was a significant predictor of first onset, both alone (younger age predicted first onsets) and in interaction with personality measures. Among younger subjects (17 to 30 years of age), personality variables did not significantly discriminate between the two comparison groups. Among older subjects (31 to 41 years of age), however, decreased emotional strength, increased interpersonal dependency, and increased thoughtfulness were associated with first onset of depression.

Depressive disorders in childhood. IV. A longitudinal study of comorbidity with and risk for anxiety disorders.

Abstract: As part of a longitudinal nosologic study of major depressive disorder (MDD), dysthymic disorder (DD), and adjustment disorder with depressed mood (ADDM) in a school-age cohort, we examined the prevalence and clinical consequences of comorbid anxiety disorders We also estimated the risk of a first anxiety disorder and examined its predictors Of 104 cases, 41% had anxiety disorders in conjunction with their index depression, which was more likely with MDD and DD than with ADDM The age-corrected risk of a first anxiety disorder was 047 up to age 18 years Separation-anxiety disorder was the most frequent diagnosis of anxiety, followed by overanxious disorder of childhood Among the MDD cases with comorbidity, the anxiety disorder preceded the depression about two thirds of the time and often persisted after the depression remitted The effect of comorbid anxiety disorder on the length of index MDD depended on the presence of other clinical features, but it did not seem to affect the risk of subsequent MDD or the course of DD or ADDM Concurrent maternal psychopathology and poor physical health increased the risk of anxiety disorder in the children, but a history of prior separation from parental figures did not seem to have an effect

P3 in schizophrenia is affected by stimulus modality, response requirements, medication status, and negative symptoms.

Abstract: • Eighteen schizophrenics who were not taking medication, 13 schizophrenics who were taking medication, and 37 agematched controls were tested with event-related potential paradigms designed to elicit P3response automatically or effortfully (ie, with a choice reaction time task). Electroencephalograms were recorded from the 19 standard 10-20 electrode sites. Compared with controls, both groups of schizophrenics had reduced P3amplitudes for both effortful and automatic paradigms. P,latencies were delayed relative to controls for the medicationtaking schizophrenics in the effortful paradigms. Negative symptoms derived from the Brief Psychiatric Rating Scale within 1 week of event-related potential testing correlated negatively with both auditory and visual P3amplitude in the subjects who were not taking medication. There was no evidence that P3is smaller over left temporal electrode sites in schizophrenics, as has been reported by others. P3amplitude reduction in schizophrenia is a robust psychobiological phenomenon that is present regardless of medication status or task demands.

A comparison of male and female cocaine abusers.

Abstract: Little has been written about the differences between male and female cocaine abusers. We therefore compared sociodemographic characteristics, reasons for cocaine use, drug effects, depressive symptoms, and psychiatric diagnoses in 95 men and 34 women hospitalized for cocaine abuse. Men were more likely to be employed, to hold higher status jobs, and to be self-supporting. Women were more likely to cite specific reasons for drug use, while men tended to use cocaine as part of a larger pattern of antisocial behavior. Women were diagnosed more often as having major depression, and their depressive symptoms improved much more slowly than men's when drug free. These findings suggest that women cocaine abusers may initially experience more residual problems, eg, depression and job dissatisfaction, than men after becoming drug free. Drug treatment centers should be alert to possible differences based on gender.

DSM-III Personality Disorder Diagnoses in a Nonpatient Sample: Demographic Correlates and Comorbidity

Abstract: • Seven hundred ninety-seven first-degree relatives of normal controls and patients with a variety of psychiatric disorders were interviewed with the Diagnostic Interview Schedule and the Structured Interview for DSM-III Personality Disorders. Slightly more than one sixth of the sample received a personality disorder (PD) diagnosis, and of those with a PD, almost one fourth had more than one. The most prevalent diagnoses were mixed, passive-aggressive, antisocial, histrionic, and schizotypal PD. The demographic correlates and frequency of Axis I disorders in individuals with each specific PD were examined, and all but histrionic and passive-aggressive PDs had distinctive profiles.

Efficacy of Fluvoxamine in Obsessive-Compulsive Disorder: A Double-blind Comparison With Placebo

Abstract: • A six- to eight-week double-blind placebo-controlled trial of the potent and selective serotonin reuptake inhibitor fluvoxamine was conducted in 42 patients with primary obsessive-compulsive disorder (OCD). Approximately one half of the patients also had symptoms of major depression. Fluvoxamine was significantly better than placebo on all measures of obsessive-compulsive symptoms. Nine of 21 patients were responders ("much improved") with fluvoxamine compared with no responders with placebo, and fluvoxamine was effective in patients with OCD both with and without secondary depression. Response of OCD was not correlated with severity of baseline depression. These data lend partial support to the serotonin hypothesis of OCD. However, since a number of patients failed to respond to fluvoxamine, the role of other neurochemical systems in this disorder needs to be explored.

Cholinergic Hyperactivity and Negative Schizophrenic Symptoms: A Model of Cholinergic/Dopaminergic Interactions in Schizophrenia

Abstract: Despite renewed interest in negative schizophrenic symptoms, the pathophysiological mechanisms involved in their development remain obscure. Although the cholinergic system has been implicated in schizophrenia, it has not been accorded a major role in current theories of pathophysiology. We present evidence from several lines of research that suggests that muscarinic hyperactivity may be implicated in the pathogenesis of negative schizophrenic symptoms. Specifically, cholinergic overdrive leads to a behavioral syndrome strikingly similar to the negative schizophrenic syndrome, anticholinergic agents may alleviate negative symptoms, schizophrenic patients with negative symptoms tend to "abuse" anticholinergics, and polysomnographic, neuroendocrine, and other pharmacological findings appear to be generally consistent with this hypothesis. The hypothesis is testable and is presented as a heuristic model that focuses on the dynamic interplay between cholinergic and dopaminergic systems in schizophrenia.

Desipramine facilitation of initial cocaine abstinence.

Abstract: • We conducted a double-blind, random assignment, six-week comparison of desipramine hydrochloride (n = 24), lithium carbonate (n = 24), and placebo (n = 24) treatments for cocaine dependence. Subjects were 72 outpatient cocaine abusers who met DSM-III-R dependence criteria for cocaine but not for other substance abuse. Subjects in each treatment group were similar in history of cocaine and other substance abuse, cocaine craving, sociodemographics, and other psychiatric comorbidity. Desipramine, compared with both other treatments, substantially decreased cocaine use. Lithium treatment outcome did not differ from that of placebo. Desipramine-treated subjects attained contiguous periods of abstinence substantially more frequently than subjects receiving lithium or placebo. Fifty-nine percent of the desipramine-treated subjects were abstinent for at least three to four consecutive weeks during the six-week study period, compared with 17% for placebo and 25% for lithium. Cocaine craving reductions were also substantially greater in the desipraminetreated subjects. Establishment of initial abstinence is the first stage in recovery from cocaine dependence. Our findings indicate that desipramine is an effective general treatment, for this first treatment stage, in actively cocaine-dependent oupatients.

Controlled Study of Haloperidol, Pimozide, and Placebo for the Treatment of Gilles de la Tourette's Syndrome

Abstract: • The results of this controlled study of the treatment of 57 patients with Gilles de la Tourette's syndrome suggested that both haloperidol and pimozide were more effective than placebo, but that haloperidol was slightly more effective than pimozide. Adverse effects occurred more frequently with haloperidol vs placebo than with pimozide vs placebo, but the frequency was not significantly different for haloperidol compared with pimozide. Clinically significant cardiac effects did not occur at a maximum dosage of 0.3 mg/kg or 20 mg/d for pimozide and 10 mg/d for haloperidol. However, the QTc interval was prolonged during pimozide treatment compared with that during haloperidol treatment, although the values for both medications were not in an abnormal range.

Cholecystokinin tetrapeptide induces panic-like attacks in healthy volunteers. Preliminary findings.

Abstract: • A total of 31 intravenous injections of the tetrapeptide cholecystokinin (30-33) were carried out in ten healthy subjects. In seven subjects, cholecystokinin-4 provoked a short-lasting (one to four minutes) panic-like attack (an intense unexplainable fear) at doses between 20 and 100 μg. In the other three subjects, doses of 80 to 100 μ induced severe anxiety, but no panic-like attack. All subjects experienced severe gastrointestinal symptoms. Pretreatment with lorazepam, but not with meprobamate or naloxone, prevented the psychic effects of cholecystokinin-4 in subjects who had experienced a panic-like attack with the same dose of this peptide. Following the peptide injection, levels of plasma free catecholamines, lactate, and glucose were unchanged, whereas levels of plasma cortisol and prolactin were increased. The intravenous injection of the sulfated cholecystokinin octapeptide (26-33) in two subjects (doses of 35 and 40 μg, respectively) produced severe gastrointestinal symptoms, but failed to induce any anxiety or panic-like attacks. These preliminary findings suggest that cholecystokinin-4 may have a panicinducing effect. It remains to be established if this peptide exerts this effect via a direct activation of central cholecystokinin receptors.

Neuroanatomical correlates of a lactate-induced anxiety attack.

Abstract: • Positron emission tomographic measurements of regional blood flow were used to assess local neuronal activity in patients with panic disorder and in normal control subjects before and during the infusion of sodium lactate. A new technique for the analysis of positron emission tomographic data was employed to identify significant changes in regional blood flow associated with lactate infusion in the panicking patients, nonpanicking patients, and controls. Lactate-induced panic was associated with significant blood flow increases bilaterally in the temporal poles; bilaterally in insular cortex, claustrum, or lateral putamen; bilaterally in or near the superior colliculus; and in or near the left anterior cerebellar vermis. Lactate infusion was not associated with significant changes in regional blood flow in the nonpanicking patients or control subjects. Thus, the identified regions seemed to be involved in an anxiety attack.

The Determination of Defense Style by Questionnaire

Abstract: The Defense Style Questionnaire was relabeled in terms of DSM-III-R defenses and administered to three groups: a normal population, family practice patients, and patients with anxiety disorders. The preferred factor structure identified mature defenses (sublimation, humor, anticipation, and suppression), neurotic defenses (undoing, altruism, idealization, and reaction formation), and immature defenses (projection, passive aggression, acting out, etc). Factor scores varied systematically with group membership and with measures of total symptoms. In this cross-sectional study, the vulnerability factors of neuroticism, locus of control, and defense style were all correlated with neurotic symptoms, but defense style added little to the variance explained by the other two. Within the patient group, however, neuroticism and locus of control did not distinguish among panic disorder, agoraphobia, social phobia, and obsessive-compulsive disorder, while defense style showed patterns characteristic of each disorder.

Hyperactive Boys Almost Grown Up: IV. Criminality and Its Relationship to Psychiatric Status

Abstract: • Attention-deficit disorder with hyperactivity is believed, by some, to be a developmental antecedent (predisposing factor) to antisocial personality disorder and criminality. However, evidence supporting this association has not been consistent. We report on a prospective follow-up study of 103 males (ages 16 to 23 years), who were diagnosed as hyperactive (attention-deficit disorder with hyperactivity) between ages 6 and 12 years, and 100 normal controls. The official arrest records of all subjects who resided in New York State during the follow-up interval were obtained. Blind diagnoses (based on structured interviews with subjects and their parents) were made on 98% of the initial cohort at follow-up. Although other investigators have reported on the delinquent behavior of hyperactive children in a prospective design, to our knowledge, follow-up mental status has not been studied previously in relation to official arrest records. Significantly more probands than controls had been arrested (39% vs 20%), convicted (28% vs 11%), and incarcerated (9% vs 1%). The presence of an antisocial/conduct disorder in young adulthood almost completely accounted for the increased risk for criminal activities in the former hyperactive children whether or not it was accompanied by a substance use disorder. Continuing attentiondeficit disorder with hyperactivity at follow-up, by itself, was not associated with arrest history. The findings support the view that childhood attention-deficit disorder with hyperactivity is a risk factor for later criminality, but that this relationship is almost exclusively mediated by the development of an antisocial disorder in early adulthood.

Treatment of obsessive-compulsive disorder with clomipramine and desipramine in children and adolescents. A double-blind crossover comparison.

Abstract: Forty-eight children and adolescents with severe primary obsessive-compulsive disorder completed a 10-week double-blind crossover trial of clomipramine hydrochloride (mean dose [+/- SD], 150 +/- 53 mg/d) and desipramine hydrochloride (mean dose [+/- SD], 153 +/- 55 mg/d). Clomipramine was clearly superior to desipramine in significantly reducing obsessive-compulsive symptoms. Age at onset, duration and severity of illness, type of symptom, and plasma drug concentrations did not predict clinical response to clomipramine. Sixty-four percent of patients who received clomipramine as their first active treatment showed at least some sign of relapse during desipramine treatment. We further document the specificity of the antiobsessional effect of clomipramine and the need for maintenance treatment.

Major Depressive Disorder and Immunity: Role of Age, Sex, Severity, and Hospitalization

Abstract: • An association between depression and altered immunity has been suggested but has not been consistently demonstrated. We have studied 91 patients with unipolar major depressive disorder, and no mean differences were found between the patients and concurrently studied matched controls in mitogen-induced lymphocyte proliferation, lymphocyte subsets, and natural killer cell activity. There were, however, significant age-related differences between the depressed patients and controls in mitogen responses and in the number of T4 lymphocytes. In contrast to age-related increases in mitogen response and in T4 cells in controls, depressed patients did not show increased lymphocyte responses or numbers of T4 lymphocytes with advancing age. Severity of depression and hospitalization status were also associated with immune system changes. Altered immunity does not appear to be a specific biologic correlate of major depressive disorder but may occur in subgroups of depressed patients.

Diagnosing Diagnoses: Receiver Operating Characteristic Methods and Psychiatry

Abstract: With every issue of theArchives, the reader is inundated with psychiatric research: new treatments, new biological abnormalities, new diagnostic methods, new diagnoses—the list seems endless. It is difficult to conceive of anyone, except, of course, our dedicated Editor, who bothers to read every article in every issue. Indeed, it would be a rare individual who had the time to read every abstract. In the current issue of theArchives, Mossman and Somoza 1 reexamine the dexamethasone suppression test (DST) using a statistical method that is new to psychiatry, namely, receiver operating characteristic (ROC). Using this method, they are able to demonstrate that there is significant variability in the performance of the DST among different psychiatric centers. As with any statistical method, ROC involves more than a little mathematics, and the natural question as one leafs through the See also p 653 .Archivesis "Why should I bother with this?"

Predictors of drug response in depression.

Abstract: • Although the major classes of antidepressant drugs have been available for over 30 years, clinicians are still unable to predict accurately the response of their depressed patients to medication. This article reviews both clinical and biologic predictors of treatment response and makes recommendations for future studies. The tricyclic antidepressants remain the drugs of choice in major depressive disorders. Lithium has a place in bipolar depressions. Monoamine oxidase inhibitors have a role in depressions accompanied by marked anxiety and/or panic symptoms, in patients who have previously responded to them, and as a second-choice treatment in those depressed patients who have not responded to tricyclic antidepressants. Electroconvulsive therapy or additional antipsychotic drugs are frequently necessary in very severe and delusional depressions. Biologic predictors of response, despite some interesting leads that may in the long term be of considerable importance, are not yet sufficiently established to be of routine clinical usefulness, although either dexamethasone nonsuppression or a shortened rapid eye movement latency may identify depressed patients who require biologic treatment.