Showing papers in "Journal of Nervous and Mental Disease in 1999"

The psychosocial effects of torture, mass human rights violations, and refugee trauma : Toward an integrated conceptual framework

Abstract: Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.

The association of medical comorbidity in schizophrenia with poor physical and mental health.

Abstract: This study determined the prevalence of medical comorbidities in a cohort of persons receiving treatment for schizophrenia and the association of medical comorbidity with physical and mental health status. A total of 719 persons with schizophrenia sampled from a variety of community and treatment settings as part of the schizophrenia Patient Outcomes Research Team (PORT) participated in a survey interview. Multiple regression analyses were used to assess sociodemographic factors associated with the number of current medical comorbidities and the association of medical comorbidity count with patient ratings of physical health, mental health, symptoms, and quality of life. The majority of patients reported at least one medical problem. Problems with eyesight, teeth, and high blood pressure were most common. A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt. This study underscores the need to attend to somatic health care for persons with schizophrenia as well as the linkage of physical and mental health status.

Family accommodation of obsessive-compulsive symptoms: instrument development and assessment of family behavior.

Abstract: Relatives frequently accommodate patients' obsessive-compulsive symptoms and clinicians hypothesize that such accommodations adversely affect patient outcome This study's purpose was to develop a valid and reliable measure, the Family Accommodation Scale for Obsessive-Compulsive Disorder (FAS), and to investigate the family accommodation construct We administered the FAS and additional family and patient measures to 36 adult obsessive-compulsive patients and their primary caregivers The FAS demonstrated excellent interrater reliability and good internal consistency and performed well on assessment of its convergent and discriminant validity Family accommodation was significantly associated with patient symptom severity and functioning, and with relatives' own obsessive-compulsive symptoms Although most relatives accommodated patient symptoms, many did not believe that such accommodations improved the patient's clinical status The FAS will provide researchers and clinicians with a useful tool for assessing family accommodation and for identifying families who may benefit from interventions aimed at developing more adaptive coping strategies

Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients.

Abstract: The effect of motivational interviewing on outpatient treatment adherence among psychiatric and dually diagnosed inpatients was investigated. Subjects were 121 psychiatric inpatients, 93 (77%) of whom had concomitant substance abuse/dependence disorders, who were randomly assigned to: a) standard treatment (ST), including pharmacotherapy, individual and group psychotherapy, activities therapy, milieu treatment, and discharge planning; or b) ST plus motivational interviewing (ST+MI), which involved 15 minutes of feedback on the results of a motivational assessment early in the hospitalization, and a 1-hour motivational interview just before discharge. Interviewers utilized motivational techniques described in Miller and Rollnick (1991), such as reflective listening, discussion of treatment obstacles, and elicitation of motivational statements. Results indicated that the proportion of patients who attended their first outpatient appointment was significantly higher for the ST+MI group (47%) than for the ST group (21%; chi2 = 8.87, df = 1, p<.01) overall, and for dually diagnosed patients (42% for ST+MI vs. 16% for ST only; chi2 = 7.68, df = 1, p<.01). Therefore, brief motivational interventions show promise in improving outpatient treatment adherence among psychiatric and dually diagnosed patients.

Clinical correlates of self-mutilation in a sample of general psychiatric patients.

Abstract: The aims of this study were to examine whether certain axis I disorders characterized by impulsive aggression were associated with self-mutilative behavior and to evaluate the clinical correlates of self-mutilation in a sample of general psychiatric outpatients. Two hundred fifty-six outpatients were administered diagnostic interviews for axis I and axis II disorders. In addition, questionnaires that measured self-mutilative acts within the last 3 months, dissociation, and childhood abuse were completed. This study found that axis I disorders of substance abuse, posttraumatic stress disorder, and intermittent explosive disorder were significantly related to self-mutilative behavior, independent of borderline personality disorder and antisocial personality disorder. Also, a higher level of dissociation was related to self-mutilation, controlling for borderline personality disorder and childhood abuse. Outpatients with certain axis I disorders and those who dissociate may represent a sizable group of patients who are at risk for self-mutilative behavior.

The place of culture in DSM-IV.

Abstract: This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Depressed patients' perceptions of facial emotions in depressed and remitted states are associated with relapse: a longitudinal study.

Abstract: Within the framework of interpersonal and cognitive theories of depression, we investigated whether the perception of facial emotions was associated with subsequent relapse into depression. The 23 inpatients with major depression who remitted (65 admitted patients) were studied at admission (T0), at discharge (T1), and 6 months thereafter to assess relapse. They judged schematic faces with respect to the expression of positive and negative emotions. Six patients (26.1%) relapsed. High levels of perception of negative emotions in faces, either assessed at T0 or at T1, were associated with relapse. Moreover, subjects saw more negative emotions in depressed than in remitted state. Significant results were confined to ambiguous faces, i.e., faces expressing equal amounts of positive and negative emotions. Our data support the hypothesis that a bias toward the perception of others' facial emotions as negative is an enduring vulnerability factor to depression relapse and depressed mood amplifies this negative bias in perception.

Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans.

Abstract: We used path analysis to model the effects of combat exposure, posttraumatic stress disorder (PTSD) symptoms, and health behaviors on physical health. Participants were 921 male military veterans from the Normative Aging Study. Their mean age at time of study was 65. Measures of combat exposure, PTSD symptoms, smoking, and alcohol problems were used to predict subsequent self-reported physical health status. Both combat exposure and PTSD were correlated with poorer health. In path analysis, combat exposure had only an indirect effect on health status, through PTSD, whereas PTSD had a direct effect. Smoking had a small effect on health status but did not mediate the effects of PTSD, and alcohol was unrelated to health status. We conclude that PTSD is an important predictor of physical health and encourage further investigation of health behaviors and other possible mediators of this relationship.

Longitudinal course and predictors of continuing distress following critical incident exposure in emergency services personnel.

Abstract: This study examines the longitudinal course and predictors of stress-specific and general symptomatic distress in emergency services personnel. A three-group quasi-experimental design was used to determine the responses of 322 rescue workers to the Loma Prieta earthquake Interstate 880 Freeway collapse and to unrelated control critical incidents. Self-report questionnaires, including measures of incident exposure, peritraumatic dissociation and emotional distress, and current symptoms, were administered 1.9 years (initial) and 3.5 years (follow-up) after the freeway collapse. Despite modest symptom improvement at follow-up, rescue workers were at risk for chronic symptomatic distress after critical incident exposure. Peritraumatic dissociation accounted for significant increments in current posttraumatic stress disorder symptoms, over and above exposure, adjustment, years of experience, locus of control, social support, and general dissociative tendencies. The results suggest that rescue workers, particularly those with more catastrophic exposure and those prone to dissociate at the time of the critical incident, are at risk for chronic symptomatic distress.

The relative influences of symptoms, insight, and neurocognition on social adjustment in schizophrenia and schizoaffective disorder.

Abstract: Impaired insight and neurocognitive deficits are commonly seen in schizophrenia. No study to date, however, has documented the relative influences of insight deficits, neurocognitive functioning, and psychotic symptoms on overall social adjustment in this population. This was done in a cohort of individuals recovering from acute exacerbations. Forty-six individuals with schizophrenia or schizoaffective disorder were recruited upon discharge from an inpatient unit. Symptom levels, neurocognitive functioning (information processing, memory, and executive functioning), and symptom awareness were documented, and social adjustment was assessed in three domains: treatment compliance, social behavior, and subjective quality of life. Cross-sectional data from initial assessments are reported. Sequential linear regression analyses identified differential associations between illness characteristics and outcome domains. Treatment compliance was most influenced by insight; social behavior deficits were associated with thought disorder and neurocognitive (working memory and visuo-spatial) impairments; and quality of life was associated with mood disturbances. Outcome is multidimensional in schizophrenia, and there are differential patterns of associations between illness characteristics and domains of social adjustment. Studies such as this can guide clinicians in determining the most appropriate treatments for specific individuals and should also guide researchers in efforts to clarify the processes that underlie treatment response and recovery in schizophrenia.

Postconcussive symptoms and posttraumatic stress disorder after mild traumatic brain injury.

Abstract: Postconcussive symptoms after mild traumatic brain injury (MTBI) may be exacerbated by anxiety associated with posttraumatic stress. The aim of this study was to investigate the relationship between postconcussive symptoms and posttraumatic stress disorder (PTSD) in an MTBI population. Survivors of motor vehicle accidents who either sustained an MTBI (N = 46) or no TBI (N = 59) were assessed 6 months posttrauma for PTSD and postconcussive symptoms. Postconcussive symptoms were more evident in MTBI patients with PTSD than those without PTSD, and in MTBI patients than non-TBI patients. Further, postconcussive symptoms were significantly correlated with PTSD symptoms. These findings indicate that postconcussive symptoms may be mediated by an interaction of neurological and psychological factors after MTBI.

Perceived abuse and neglect as risk factors for suicidal behavior in adolescent inpatients

Abstract: The aim of this study was to assess relative risk of histories of different types of abuse (sexual, physical, and emotional) and neglect (physical and emotional) for suicidal behavior (attempts, ideation, and self-mutilation) in psychiatrically hospitalized adolescents. Seventy-one adolescent inpatients (34 boys, 37 girls) completed self-report measures of abuse and neglect, current suicidal ideation, and lifetime suicide and self-mutilation attempts. The prevalence of sexual and physical abuse was 37.5% and 43.7%, respectively, with 31.3% and 61% of youngsters reporting emotional and physical neglect. Fifty-one percent of youngsters had made suicide attempts, and 39% had self-mutilated. Suicide attempters were significantly more likely to be female, Latino, to report sexual, physical, and emotional abuse, and to endorse emotional neglect. In multivariate analyses, female gender, sexual abuse, and emotional neglect remained significant predictors of self-mutilation and suicidal ideation. Female gender and sexual abuse remained significant predictors of suicide attempts. These findings suggest that emotional neglect is an important and deleterious component of maltreatment experiences and may be a more powerful predictor of suicidal behavior in hospitalized adolescents than physical abuse, emotional abuse, and physical neglect.

Mood and the menopausal transition

Abstract: This study determined which variables affect women's mood state during the menopausal transition by using six prospective annual assessments of a community-based sample of 354 Australian mid-aged women. Repeated measures multivariate analysis of covariance found that negative mood scores decreased significantly over time and were not related to natural menopausal transition, follicle-stimulating hormone, estradiol, inhibin, age, or education. The magnitude of negative mood was significantly predicted by baseline reporting of premenstrual complaints, negative attitudes to ageing and menopause, and parity of one. During follow-up, the magnitude of negative mood was significantly adversely affected by: prior experience of negative mood, experience of bothersome symptoms, poor self-rated health, negative feelings for partner, no partner, current smoking, low exercise, daily hassles, and high stress. Negative mood was reduced by decreasing symptoms, improving health, positive feelings for partner, gaining a partner, and reducing stress. The menopausal transition had an indirect effect in amplifying the effect of reducing paid work, poor health, and daily hassles.

Efficacy of a self-esteem module in the empowerment of individuals with schizophrenia.

Abstract: To enhance empowerment and improve self-esteem among individuals with severe and persistent mental illness, a 12-week "module" (a self-contained program of activities) was created and tested in a randomized clinical trial. Fifty-one individuals with schizophrenia were assigned to the experimental group in addition to regular treatment, and 44 individuals participated in a control group that continued with regular treatment only. Psychosocial, diagnostic, neurocognitive, and symptomatology measures were taken for all 95 subjects before treatment (T0), after treatment (T1), and at a 6-month follow-up (T2). Results indicated module effects on coping skills (active coping skills significantly increased) and psychotic symptoms (positive symptoms significantly decreased), demonstrating the efficacy of this particular type of intervention. Interpretation of the results highlighted the significance of the environment and the role it could potentially play in supporting the empowerment of severely mentally ill individuals.

Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients.

Abstract: The aims of this study were: a) to assess the prevalence of posttraumatic stress disorder (PTSD) after an acute psychotic episode in schizophrenic and delusional patients, b) to explore which psychotic symptoms and aspects of treatment were associated with traumatization, and c) to compare the extent of the traumatic impact of psychosis and involuntary hospitalization. Forty-six schizophrenic and delusional patients were assessed with the Positive and Negative Syndrome Scale (PANSS), the Impact of Event Scale-Revised (IES-R), and the Clinician-Administered PTSD Scale (CAPS) at weeks 1 and 8 after acute psychiatric admission. Traumatic symptoms related to psychosis and coercive measures were scored separately. The prevalence of PTSD was found to be 11%. Sixty-nine percent of traumatic symptoms were related to psychosis and 24% to hospitalization. High PANSS score at week 8 was the strongest risk factor for the development of PTSD. Particularly positive and depressive/anxious symptomatology were associated with psychosis-related traumatic symptoms at both weeks 1 and 8. These data suggest that, in general, schizophrenic and delusional symptoms are more traumatic than the coercive measures used to control them.

Assessing clinical predictions of early rehospitalization in schizophrenia.

Abstract: This study determines patient characteristics that predict early hospital readmission in schizophrenia and evaluates the extent to which inpatient staff accurately predict these readmissions. Adult inpatients with schizophrenia or schizoaffective disorder (N = 262) were evaluated at hospital discharge and 3 months later to assess hospital readmission. At hospital discharge, inpatient staff were asked to identify which patients were likely to be readmitted during this period. Comparisons were made between patients who were or were not readmitted and between readmitted patients who were or were not identified by staff as likely to be readmitted; 24.4% of the sample were readmitted within 3 months of hospital discharge. Early readmission was associated with four or more previous hospitalizations (85.7% vs. 57.7%, p = .004), comorbid substance use disorder (60.3% vs. 35.5%, p = .0006), major depression (40.6% vs. 26.8%, p = .04), absence of a family meeting with inpatient staff (58.2% vs. 41.8%, p = .02), and prescription of a conventional rather than an atypical antipsychotic medication (93.7% vs. 83.8%, p = .045). Twelve of the 63 readmitted patients were correctly predicted by staff to re-hospitalize. Staff tended to overestimate the risk of rehospitalization in patients with a poor therapeutic alliance, low global function, or initial involuntary admission and to underestimate the risk in patients with alcohol use disorders or four or more previous psychiatric hospitalizations. Early rehospitalization is common in schizophrenia and difficult to predict. Greater emphasis on comorbid alcohol use disorders and a history of multiple previous admissions may help clinicians identify patients at greatest risk for early rehospitalization.

Core beliefs in anorexic and bulimic women.

Abstract: There is research evidence to suggest the presence of dysfunctional cognitions in anorexia nervosa and bulimia nervosa that are not related to food, weight, or shape. These maladaptive cognitions have not been addressed by the conventional cognitive behavioral models of etiology or therapy. This study aimed to assess the impact of unhealthy core beliefs on eating disorders and their symptoms. Twenty restricting anorexics, 10 bulimic anorexics, 27 bulimics, and 23 normal controls completed Young's Schema Questionnaire. Eating behaviors and attitudes were also measured. The results indicate that both anorexic and bulimic women had significantly higher levels of unhealthy core beliefs than comparison women, but the clinical groups only differed on one individual core belief (entitlement). However, there were different patterns of association between core beliefs and eating psychopathology in anorexic and bulimic women. It is suggested that future clinical practice should incorporate core beliefs as a potential element in the assessment and treatment of eating disorders.

Is posttraumatic stress disorder underdiagnosed in routine clinical settings

Abstract: The goal of the present study was to examine whether posttraumatic stress disorder (PTSD) is underrecognized in routine clinical practice. One thousand patients were evaluated at the Rhode Island Hospital Department of Psychiatry outpatient practice. The first 500 patients completed a psychiatric diagnostic screening questionnaire that included a PTSD subscale. The next 500 individuals were interviewed with the Structured Clinical Interview for DSM-IV (SCID). In the first 500 patients, 36 (7.2%) patients were diagnosed by their clinicians with PTSD and an additional 18.6% of the sample screened positive on the questionnaire but were not diagnosed with PTSD. The patients who were diagnosed with PTSD and the patients who screened positive but were not given the diagnosis were significantly younger, had lower GAF scores, and less frequently graduated from college than the non-PTSD group. The frequency of suicidal thoughts was identical in the two PTSD groups and twice as high as the frequency in the non-PTSD group. Scores on 9 of the other 12 psychopathology dimensions assessed by the screening questionnaire were significantly higher in the two PTSD groups than the non-PTSD group. In the 500 patients interviewed with the SCID the prevalence of PTSD was two times higher than in the 500 patients diagnosed with an unstructured clinical interview (14.4% vs. 7.2%). The difference in prevalence rates of PTSD between the SCID and clinical samples was significant when considering PTSD as an additional diagnosis; there was no difference in prevalence rates when restricting the analysis to principal diagnoses. The results of this study suggest that PTSD is frequently overlooked in routine clinical practice when symptoms of PTSD are not the presenting complaint.

Does Vaginismus Exist?: A Critical Review of the Literature

Abstract: The basic strategies and methods for assessing and treating vaginismus were proposed by the early 20th century and have not essentially changed. Etiological theories have changed over time but are not supported by controlled empirical studies. This critical review of the literature disputes the widely held belief that vaginismus is an easily diagnosed and easily treated sexual dysfunction. We propose a reconceptualization of vaginismus as either an aversion/phobia of vaginal penetration or a genital pain disorder.

Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review.

Abstract: The author reviews the clinical and special social environmental data from the Soteria Project and its direct successors. Two random assignment studies of the Soteria model and its modification for long-term system clients reveal that roughly 85% to 90% of acute and long-term clients deemed in need

Long-term effects of childhood sexual abuse: Objective and subjective characteristics of the abuse and psychopathology in later life.

Abstract: This study investigates the association between objective and subjective characteristics of childhood sexual abuse and psychopathology in later life. The sample consists of 404 Dutch female adults who had been sexually abused in their childhood or adolescence. The participants were recruited by mean

St. John's wort for depression: a meta-analysis of well-defined clinical trials.

Abstract: Studies concluding that St. John's wort (Hypericum perforatum) is an effective antidepressant can be challenged due to questionable methodology. We attempt to correct this by a meta-analysis utilizing only well-defined clinical trials. Controlled, double-blind studies using strictly defined depression criteria were analyzed by the rate of change of depression and by the number of "treatment responders." Rates of side effects and dropouts were also analyzed. Hypericum was 1.5 times more likely to result in an antidepressant response than placebo and was equivalent to tricyclic antidepressants (TCAs). The meta-analysis also showed that there was a higher dropout rate in the TCA group and that the TCAs were nearly twice as likely to cause side effects, including those more severe than hypericum. Hypericum perforatum was more effective than placebo and similar in effectiveness to low-dose TCAs in the short-term treatment of mild to moderately severe depression. However, design problems in existing studies prevent definitively concluding that St. John's wort is an effective antidepressant.

Quality of life in patients with panic disorder.

Abstract: In this study we assessed the quality of life of patients with panic disorder, with particular attention to the influence of anxiety and depression comorbidity on quality of life. Findings were compared with established general population norms as well as norms for patients with chronic medical conditions and major depression. The Medical Outcomes Study Short-Form Health Survey (SF-36) was administered to panic disorder patients entering clinical trials or treatment in an outpatient anxiety disorders program. Subjects were 73 consecutive patients with a primary diagnosis of panic disorder without current substance abuse or contributory medical illness. Their quality of life scores were compared with population mean estimates using single-sample t-tests, and the influence of comorbidity was examined with between-group comparisons. All SF-36 mental and physical health subscale scores were worse in patients with panic disorder than in the general population. This was true regardless of the presence of comorbid anxiety or mood disorders, although the presence of the comorbid conditions worsened select areas of functioning according to subscale analyses. SF-36 scores in panic patients were at approximately the same level as patients with major depression and tended to be worse in specific areas than patients with select medical conditions. This study provides evidence of the pervasive negative effects of panic disorder on both mental and physical health.

Compulsive physical activity in adolescents with anorexia nervosa : A psychobehavioral spiral of pathology

Abstract: The excessive exercising that is frequently observed in anorexia nervosa (AN) has been viewed both as an addictive behavior and as a type of obsessive compulsive disorder. The present study tested a nonrecursive structural equation model that specified associations among personality factors, cognitions, and behavior in the development and progression of excessive exercise in adolescent patients with AN. As proposed, findings indicated that both addictive personality and obsessive-compulsive personality contributed to excessive exercising by means of their influence on obligatory/pathological cognitions about exercising. Childhood physical activity also predicted excessive exercising. The implications of these results are discussed from a psychobiological perspective.

Violence in the lives of adult borderline patients.

Abstract: The purpose of this study was to assess the experiences of adult violence reported by a sample of criteria-defined borderline patients and axis II controls The experiences of having had a physically abusive partner and/or having been raped reported by 362 personality-disordered inpatients were assessed blind to diagnostic status using a semistructured research interview Forty-six percent of borderline patients reported having been a victim of violence since the age of 18 Borderline patients (N = 290) were significantly more likely than axis II controls (N = 72) to report having had a physically abusive partner, having been raped, having been raped multiple times, having been raped by a known perpetrator, and having been both physically assaulted by a partner and raped Female borderline patients were significantly more likely than male borderline patients to have been physically and/or sexually assaulted as adults (50% vs 26%) However, a significantly higher percentage of borderline patients of both genders reported experiences of adult violence than controls of the same gender Four risk factors were found to significantly predict whether borderline patients had an adult history of being a victim of violence: female gender, a substance use disorder that began before the age of 18, childhood sexual abuse, and emotional withdrawal by a caretaker The results of this study suggest that both male and female borderline patients are at substantial risk for being physically and/or sexually victimized as adults

A specific attentional bias in suicide attempters.

Abstract: Selective attention in patients after an attempted suicide was investigated to find out whether a specific attentional bias for suicide-related materials exists and to clarify the possible role of emotions in the bias. Thirty-one patients who had previously attempted to commit suicide and 31 control participants took part in a modified Stroop task. The suicidal patients took significantly longer to name the colors of suicide-related words compared with other words, whereas color naming times of the control participants did not differ for suicide-related, neutral, positive, or negative words. Therefore, the attentional bias exhibited by suicidal patients was highly specific. There was no relation between the bias and measures of anxiety, depression, or hopelessness, whereas suicidal ideation correlated significantly with the attentional bias.