The impact of behavioral impairment of functional ability in Alzheimer's disease

This study sought to determine the relationship between behavioral disturbance and functional status in a longitudinally studied sample of patients with Alzheimer's disease (AD). One hundred and forty-nine patients meeting NINCDS-ADRDA criteria for probable AD were followed for an average of 37.3 months, with follow-up assessments every 6 months. Subjects were seen at the Alzheimer's Disease Research Center clinics at the Mt Sinai Medical Center, New York, and the Veterans Affairs Medical Center, Bronx, New York. Measures included the Physical and Self-Maintenance Scale (PSMS) and Instrumental Activities of Daily Living Scale (IADLS) of Lawton and Brody and the cognitive and non-cognitive subscales of the Alzheimer's Disease Assessment Scale (ADAS). For each patient the assessment at which they had their most severe non-cognitive symptoms as measured by the non-cognitive part of the ADAS (ADAS-NC) was determined. ADAS-NC scores at that assessment were correlated with IADLS and PSMS scores at the same assessment and at the next assessment 6 months later. While there was some modest association of ADAS-NC scores with functional impairment using pairwise correlation coefficients, none of the correlations remained significant when the severity of cognitive impairment was controlled statistically. Findings were not significantly changed when drug status was controlled. These results suggest that behavioral disturbance, while very troubling to caregivers and patients, does not substantially worsen functional ability beyond the contribution of cognitive impairment in AD. Together with previous results indicating that non-cognitive symptoms in AD are episodic and fluctuating rather than progressive, the present data suggest that interventions for non-cognitive disturbances in AD should be viewed as ways to increase patient comfort, safety and ease of care and not as ways to improve functional autonomy. The latter can be achieved only by improving the progressive cognitive deficits of AD.

B lymphocyte antigen D8/17 and repetitive behaviors in autism

OBJECTIVE

Monoclonal antibody D8/17 identifies a B lymphocyte antigen with expanded expression in rheumatic fever, Sydenham's chorea, and subgroups of obsessive-compulsive disorder and Tourette's syndrome with repetitive behaviors. The authors examined the rate of D8/17 expression in children with autism and its correlation with severity of repetitive behaviors.

METHOD

Blood samples from 18 patients with autism and 14 comparable medically ill children were evaluated for percentage of D8/17-positive B cells by immunofluorescence and for streptococcal antibodies. Severity of repetitive behaviors was also determined.

RESULTS

The frequency of individuals with > or =11% D8/17-positive cells was significantly higher in the autistic patients (78%) than the comparison subjects (21%), severity of repetitive behaviors significantly correlated with D8/17 expression, and D8/17-positive patients had significantly higher compulsion scores than D8/17-negative patients.

CONCLUSIONS

D8/17 expression is high in patients with autism and may serve as a marker for compulsion severity within autism.

Dreams of personality disordered subjects

Dreams provide access to underlying personality structure, defensive and adaptive functions, and they elucidate the psychological forces that lead to overt symptomatic behavior. Two hundred three dreams of 39 personality disordered patients were factor analyzed and compared with Hall and Van de Castle's normative data (Hall C, Van de Castle RI [1966] The content analysis of dreams. New York: Appleton-Century-Crofts). Results included a five-factor solution that sheds light on some core issues of the dreamers. Comparisons between the groups resulted in the personality-disordered group demonstrating more estrangement in their dreams, fewer interactions, and more emotionality. In their interactions, they demonstrated a lower ratio of aggressive interactions yet a higher tendency to view themselves as the aggressor. Results are related to theoretical literature on personality and defensive styles, mostly from a psychodynamic perspective.

The detection and measurement of depersonalization disorder

Depersonalization disorder comprises one of the four major dissociative disorders and yet remains poorly studied. There are no reports describing the application of dissociation scales to this population. Our goal was to investigate the applicability of four such scales to depersonalization disorder and to establish screening criteria for the disorder. Two general dissociation scales and two depersonalization scales were administered to 50 subjects with DSM-III-R depersonalization disorder and 20 healthy control subjects. The depersonalization disorder group scored significantly higher than the normal control group in all scales and subscales. Factor analysis of the Dissociative Experiences Scale (DES) yielded three factors as proposed previously, absorption, amnesia, and depersonalization/derealization. A DES cutoff score of 12, markedly lower than those previously proposed for the screening of other dissociative disorders, is required for the sensitive detection of depersonalization disorder. Alternatively, the DES pathological dissociation taxon (DES-taxon) score recently generated in the literature appears more sensitive to the detection of depersonalization disorder and is better recommended for screening purposes. The other three scales were fairly strongly correlated to the DES, suggesting that they may measure similar but not identical concepts, and cutoff scores are proposed for these scales also. General implications for the screening and quantification of depersonalization pathology are discussed.

Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust survivors

OBJECTIVE

There has been considerable controversy regarding the impact of the Holocaust on the second generation, but few empirical data are available that systematically document trauma exposure and psychiatric disorder in these individuals. To obtain such data, the authors examined the prevalence of stress and exposure to trauma, current and lifetime posttraumatic stress disorder (PTSD), and other psychiatric diagnoses in a group of adult offspring of Holocaust survivors (N=100) and a demographically similar comparison group (N=44).

METHOD

Subjects were recruited from both community and clinical populations and were evaluated with the use of structured clinical instruments. Stress and trauma history were evaluated with the Antonovsky Life Crises Scale and the Trauma History Questionnaire, PTSD was diagnosed with the Clinician Administered PTSD Scale, and other psychiatric disorders were evaluated according to the Structured Clinical Interview for DSM-IV.

RESULTS

The data show that although adult offspring of Holocaust survivors did not experience more traumatic events, they had a greater prevalence of current and lifetime PTSD and other psychiatric diagnoses than the demographically similar comparison subjects. This was true in both community and clinical subjects.

CONCLUSIONS

The findings demonstrate an increased vulnerability to PTSD and other psychiatric disorders among offspring of Holocaust survivors, thus identifying adult offspring as a possible high-risk group within which to explore the individual differences that constitute risk factors for PTSD.

The relationship between apolipoprotein E, dementia, and vascular illness

The purpose of this study was to concurrently assess the relationship of Apolipoprotein E (APOE) with both dementias and vascular illnesses in the very old. Nine hundred and fifty nine subjects (mean age 85 years) in a long-term care facility were genotyped and cognitively tested with the Mini Mental State Exam. All subjects were studied for the relationship of APOE with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. Four hundred fifty individuals met criteria for inclusion into one of the following groups: Alzheimer's disease (n = 318), vascular dementia (n = 49), or not demented controls (n = 83) and were investigated for the relationship between APOE and these diagnostic categories. APOE epsilon4 was not associated with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. The APOE epsilon3 allele was more common in men with atherosclerotic heart disease. In contrast, the APOE epsilon4 allele was more common in patients with Alzheimer's disease (22%) and vascular dementia (26%) than in not demented controls (7%). APOE epsilon4 is associated with dementias in the very old, whereas its relationship with either peripheral or central nervous system vascular disease without dementia is not as robust.

Relationship of disease severity to decline on specific cognitive and functional measures in Alzheimer disease

Previous studies have shown that the sensitivity of global cognitive and functional measures to change in Alzheimer disease is related to overall disease severity. The present study assessed the sensitivity to decline, over a 12-month interval, for individual items of the cognitive portion of the Alzheimer Disease Assessment Scale (ADAS-Cog), the Instrumental Activities of Daily Living Scale (IADLS), and the Physical Self-Maintenance Scale (PSMS). This study was conducted in an effort to identify individual items likely to be sensitive at different stages of the disease. A total of 151 patients with Alzheimer disease were classified into four dementia categories by baseline scores on the Blessed Test of Information, Memory, and Concentration. The patients were retested after 12 months. For the individual items and for total scores on both the ADAS-Cog and the IADLS, rate of change was greater for patients in the moderate and severe categories than for mild or very severe patients. For individual items and for the total score on the PSMS, rate of change was greater for severe and very severe patients than for patients with mild or moderate disease.

Plasma norepinephrine and 3-methoxy-4-hydroxyphenylglycol concentrations and severity of depression in combat posttraumatic stress disorder and major depressive disorder

BACKGROUND

Catecholamines are thought to play a significant role in the pathophysiology of posttraumatic stress disorder (PTSD), but findings in PTSD have been discrepant.

METHODS

To obtain more information about catecholamine activity in PTSD, we sampled plasma norepinephrine (NE) and 3-methoxy-4-hydroxyphenylglycol (MHPG) concentrations over a 24-hour period in men with PTSD (n = 15) and major depressive disorder (MDD) (n = 12), and nonpsychiatric comparison subjects (n = 13), under unstimulated conditions. Chronobiological analyses were performed to determine possible changes in the circadian and ultradian release of these hormones.

RESULTS

Significant group differences were present for mean plasma NE levels (p = .03), but not MHPG. NE levels were significantly associated with severity of depression in the PTSD group (p = .002). Therefore, PTSD subjects were further subdivided into those with and without a comorbid secondary depression. Increased NE levels were only present in PTSD subjects who did not have a secondary depression. This study also found no significant group differences on any of the chronobiological parameters.

CONCLUSIONS

The results clarify that increased NE levels in PTSD may be confined to the subgroup of subjects who do not have comorbid depression, and as such, may help resolve some of the discrepancies in the literature regarding basal catecholamine activity.

Bladder cancer risk in patients with spinal cord injury

Bladder cancer (BC) is the fourth most common cancer in men. It is associated with several risk factors (RF), of which only a few have been evaluated in previous studies. Models incorporating only one or a severely restricted number of RFs did not predict BC well. We employed 19 a priori RFs and 12 interactions in a multivariate logistic regression analysis for the prediction of BC in a sample of subjects with spinal cord injury (SCI), of whom 149 were outpatients (7 with BC) and 4 were inpatients with BC. We also replicated dichotomous predictions for 10 of the 19 RFs that have been most frequently associated with a higher BC risk in the literature. The overall test for 31 predictors was significant (p = 0.0038). A dichotomized predictor correctly identified 9 of 11 BC cases and all 142 but one of the cases without BC. A more parsimonious subset of 21 predictors satisfied a Scheffé-type multiple comparison criterion. Although duration of SCI satisfied a Bonferroni criterion for statistical significance, it did not satisfy a Scheffé criterion. In the replication studies, only dichotomized duration of indwelling catheterization for at least 10 years significantly replicated the previous findings. Results of this study suggest that using multiple risk factors and interactions in a comprehensive statistical model may provide useful screening of patients with SCI for BC risk. Since early identification of BC substantially improves prognosis, such a model may identify patients at highest risk who are most likely to benefit from bladder biopsy.

Predictors of cortisol and 3-methoxy-4-hydroxyphenylglycol responses in the acute aftermath of rape

BACKGROUND

Prospective studies of trauma survivors can provide information about the relationship between rape characteristics and the development of subsequent symptoms.

METHODS

The present study examined the relationship of prior assault, rape severity, posttraumatic stress disorder (PTSD) symptoms following rape, and subsequent PTSD diagnosis, to the acute cortisol and 3-methoxy-4-hydroxyphenylglycol (MHPG) response to this traumatic event in 20 women.

RESULTS

Women with a history of prior physical or sexual assault showed a significantly attenuated cortisol response to the acute stress of rape compared to women without such a history. MHPG appeared to be associated with injury-related rape characteristics, and symptoms of active avoidance, but not prior history. PTSD status at the 3-month follow-up was predicted by both a prior history of assault and high injury rape, but was not directly predicted by either cortisol or MHPG levels. MHPG and cortisol were not correlated in the sample as a whole, but were correlated among individuals who did not subsequently develop PTSD (p = .04)

CONCLUSIONS

The results suggest that different neuroendocrine systems may mediate different components of the response to traumatic stress.

Psychosocial, substance use, and delinquency differences among Anglo, Hispanic White, and African-American male youths entering a juvenile assessment center

Using data collected on nearly 4,000 Anglo, Hispanic White, and African-American male youths processed at the Hillsborough County Juvenile Assessment Center, we examine their psychosocial, substance use, and other delinquent behavior differences. In extending the results of previous research in a manner consistent with the concept of relative deviance, significant differences in these variables are found across the three groups. Implications of the findings for theory, service delivery, and policy are also considered.

Relationship between posttraumatic stress disorder characteristics of Holocaust survivors and their adult offspring

OBJECTIVE

There is controversy regarding the long-lasting effects of the Holocaust on the adult children of Holocaust survivors. In the present study the authors examined the relationship between posttraumatic stress disorder (PTSD) characteristics of Holocaust survivors and their adult children to determine whether differences in symptom severity or diagnostic status of parents would be associated with similar characteristics in their adult children.

METHOD

Holocaust survivors (N = 22) and their offspring (N = 22) were interviewed with several instruments to assess lifetime trauma history, effect of trauma on one's life, level of intrusive and avoidance symptoms in response to reminders of the Holocaust, current and lifetime PTSD, and current and lifetime axis I psychiatric disorder other than PTSD.

RESULTS

There were significant relationships between parents and children regarding the effect of trauma on one's life and level of intrusive, but not avoidance, symptoms in response to reminders of the Holocaust. Offspring with traumatic events were more likely to develop PTSD if their parents had PTSD.

CONCLUSIONS

Symptoms in offspring may be related to presence and severity of symptoms in the parent. Furthermore, PTSD in the parent may be a risk factor for PTSD in offspring.

A prospective study of the impact of psychiatric comorbidity on length of hospital stays of elderly medical-surgical inpatients

To determine the difference in length of hospital stay for geriatric medical-surgical inpatients with or without psychiatric comorbidity, the authors prospectively interviewed 467 admissions by using the Structured Clinical Interview for DSM-III-R and the Mini-Mental State Exam. At admission, 208 (44.5%) inpatients had a current psychiatric comorbidity, 51 (10.9%) had an anxiety disorder, 88 (18.8%) had a depressive disorder, and 126 (27%) had cognitive impairment. The patients with cognitive impairment had a significantly prolonged hospital stay compared with those without cognitive impairment (14.6 vs. 10.6 days). No difference existed in length of stay for the patients with and without anxiety disorders (11.6 vs. 11.6 days) or depressive disorders (11.0 vs 11.8 days). In view of the limited resources available for screening elderly medical-surgical inpatients for psychiatric comorbidity, this study suggests the utility of identifying cognitive impairment and targeting it for interventions to reduce the clinical burden and to decrease hospital stays.

Noncognitive disturbances in Alzheimer's disease: frequency, longitudinal course, and relationship to cognitive symptoms

OBJECTIVE

To investigate the frequency and longitudinal course of symptoms of depression, agitation, and psychosis in a longitudinally studied sample of patients with Alzheimer's disease (AD).

DESIGN

Longitudinal study of AD patients with follow-up assessments at 6-month intervals for an average of more than 3 years.

SETTING

Alzheimer's Disease Research Center of the Mount Sinai Medical Center and the Bronx VA Medical Center, New York.

PARTICIPANTS

A total of 153 AD patients.

MEASUREMENTS

Blessed Test of Information, Memory and Concentration (BIMC) and the Alzheimer's Disease Assessment Scale cognitive (ADAS-Cog) and noncognitive (ADAS-NC) subscales.

RESULTS

At entry into the study, more than 90% of patients had a behavioral disturbance that was rated as mild or worse on one of the 10 ADAS noncognitive items; and 40% had at least one rating that was moderate or severe. Correlational analyses indicated that, with the exception of the two mood-related items, noncognitive symptoms on the ADAS were not highly correlated with one another. Only one of the noncognitive items, concentration, was strongly correlated with the severity of cognitive impairment. On average, patients showed progressively worse cognitive functioning over time as measured both by the ADAS-Cog and the BIMC. The mean severity of noncognitive symptoms did not change during the course of a 5-year follow up. The severity of behavioral disturbance at any one evaluation was negatively correlated with change in behavior during the next 6 months and was not correlated with cognitive decline.

CONCLUSION

Mild behavioral disturbances are common, whereas moderate to severe behavioral symptoms are less frequent in this population of AD patients. Disturbances in mood and manifestations of agitation and psychotic symptoms are not closely related to one another and show little progressive worsening over time. Rather, they tend to be episodic such that increasing severity at one time is usually followed by improvement later. Concentration problems are a manifestation of cognitive dysfunction rather than behavioral disturbance in AD. Implications of these results for treatment of noncognitive disturbances in AD are discussed.

A double-blind trial of fluoxetine in pathologic skin picking

BACKGROUND

Our objective was to determine the efficacy of fluoxetine in the treatment of pathologic skin picking in a double-blind, placebo-controlled, parallel trial.

METHOD

Twenty-one adults with chronic pathologic skin picking agreed to participate and received 10 weeks of placebo or fluoxetine with a flexible dosing schedule up to 80 mg/day. Three skin-picking measures were employed: the Clinical Global Impression-Improvement (CGI-I) scale, the Skin Picking Treatment Scale (SPTS), and a visual analog scale of self-rated change (VAS). In addition, depression, anxiety, and obsessions-compulsions were rated using the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), the Spielberger State-Trait Anxiety Inventory (STAI), and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for the duration of the study.

RESULTS

Seventeen subjects (6 treated with fluoxetine and 11 treated with placebo) completed the trial, at a mean fluoxetine dose of 55 mg/day. Fluoxetine was significantly superior to placebo in the treatment of skin picking according to two of the three measures for the completer analysis and to one of the three measures for the intent-to-treat analysis. Neither baseline level nor change in depression, anxiety, or obsessive-compulsive symptoms was significantly related to change in skin picking.

CONCLUSION

This first controlled trial of the treatment of pathologic skin picking suggests that fluoxetine may be of therapeutic benefit. Larger controlled studies are warranted.

Feeling unreal: 30 cases of DSM-III-R depersonalization disorder

OBJECTIVE

In contrast to the recent surge of interest in other dissociative disorders, DSM-III-R depersonalization disorder has not been thoroughly investigated and characterized. The authors systematically elucidated its phenomenology, comorbidity, traumatic antecedents, and treatment history.

METHOD

Thirty adult subjects (19 women and 11 men) were consecutively recruited and administered various structured and semistructured interviews as well as the self-rated Dissociative Experiences Scale. An age- and sex-matched normal comparison group was also recruited.

RESULTS

The mean age at onset of depersonalization disorder was 16.1 years (SD = 5.2). The illness had a chronic course that was usually continuous but sometimes episodic. Severe distress and high levels of interpersonal impairment were characteristic. Unipolar mood and anxiety disorders were common, but none emerged as specifically related to the depersonalization. A wide variety of personality disorders was manifested; avoidant, borderline, and obsessive-compulsive were most common. Although not highly traumatized, the subjects with depersonalization disorder reported significantly more childhood trauma than the normal comparison subjects. Depersonalization had been typically treatment refractory; only serotonin reuptake inhibitors and, to a lesser extent, benzodiazepines had been of any therapeutic benefit.

CONCLUSIONS

This study supports the conceptualization of depersonalization disorder as a distinct disorder with a characteristic course that is independent of mood, anxiety, and personality symptoms. A subtle relationship may exist between childhood trauma and depersonalization disorder that merits further investigation. The disorder appears to be highly treatment refractory, and prospective treatment trials are warranted.

Limitations of controlled augmentation trials in schizophrenia

To assess the empirical basis for add-on augmentation treatments in schizophrenia, this study examined the experimental design components of pharmacologic augmentation trials in schizophrenia and compared them to conventional requirements. A search covering a 5-year period (1988-1992) identified 13 double-blind, placebo-controlled, parallel, add-on neuroleptic augmentation drug trials. The mean number of subjects per trial was 34.5, and the mean number of outcome measures examined was 25.0. The probability for a significant finding by chance was 63%. Mean effect size required to achieve conventional statistical power was 1.6. Mean statistical power (for effect sizes of .5-1.0) was .1-.4. The mean number of subjects actually required for power of .80 was 58-216. The majority of the 13 trials included too few patients and employed too many outcome measures to conclusively prove or disprove therapeutic efficacy. Conclusions drawn from such trials with less than 40-100 subjects or more than one hypothesis must remain tentative at best.

Individual differences in posttraumatic stress disorder symptom profiles in Holocaust survivors in concentration camps or in hiding

Symptom patterns were compared between Holocaust survivors in concentration camp (n = 70) and those who were in "hiding" (n = 30) during the war. The impact of age at the time of the trauma, gender, and cumulative lifetime stress, and the effect of each of these variables controlling for the others, on posttraumatic stress disorder (PTSD) symptoms were also evaluated. A significant negative relationship between age at the time of the trauma and symptoms of psychogenic amnesia, hypervigilence and emotional detachment, and a positive correlation between age and intrusive thoughts, were observed. Cumulative lifetime stress was positively associated with symptoms of avoidance. The study provides the first empirical data regarding the factors that potentially explain individual differences in PTSD symptom patterns in Holocaust survivors.

Eye tracking, attention, and schizotypal symptoms in nonpsychotic relatives of patients with schizophrenia

BACKGROUND

Biological relatives of patients with schizophrenia demonstrate an increased prevalence of schizotypal personality disorder symptoms, eye tracking deficits, and attentional disturbances. We investigated whether these hypothesized components of a schizophrenia-related phenotype are associated with one another or are independent in nonpsychotic relatives of patients with schizophrenia.

METHODS

Eighty-three nonpsychotic first-degree relatives of 38 patients with schizophrenia and 45 control subjects without a psychiatric diagnosis underwent clinical evaluation, eye tracking evaluation, and the Continuous Performance Test (CPT) of visual attention.

RESULTS

Eye tracking qualitative rating was more powerful than quantitative eye tracking measures or CPT measures in discriminating relatives of patients with schizophrenia from control subjects. Correlations between neurocognitive variables and DSM-III-R schizotypal personality disorder symptom clusters suggested that CPT errors of omission are associated with positive schizotypal symptoms. Eye tracking measures were not significantly correlated with schizotypal symptoms or CPT errors in relatives of patients with schizophrenia.

CONCLUSIONS

Eye tracking deficits in the relatives of patients with schizophrenia are unrelated to CPT deficits and schizotypal symptoms. Eye tracking deficits and disturbances in visual attention may be separate components of a schizophrenia-related phenotype and should be considered as independent factors in genetic studies of schizophrenia.

Prolactin response to low-dose dexamethasone challenge in combat-exposed veterans with and without posttraumatic stress disorder and normal controls

The prolactin and cortisol responses to dexamethasone (0.5 mg) were studied in combat veterans with (n = 18) and without (n = 12) posttraumatic stress disorder (PTSD) and normal controls (n = 18). Both veteran groups demonstrated greater prolactin suppression than the normals. In contrast, only veterans with PTSD showed an enhanced cortisol suppression in response to dexamethasone. These findings suggest that the prolactin response to dexamethasone may reflect a feature of combat exposure rather than PTSD per se.

Dissociation in aging Holocaust survivors

OBJECTIVE

This study explored relationships among dissociation, trauma, and posttraumatic stress disorder (PTSD) in elderly Holocaust survivors with and without PTSD and in a demographically comparable group of nontraumatized subjects.

METHOD

Holocaust survivors with PTSD (N = 35) and without PTSD (N = 25) who had been recruited from the community and a comparison group (N = 16) were studied. Dissociation was evaluated with the Dissociative Experiences Scale. Past cumulative trauma and recent stress were evaluated with the Antonovsky Life Crises Scale and the Elderly Care Research Center Recent Life Events Scale, respectively. PTSD symptoms were assessed with the Clinician-Administered PTSD Scale.

RESULTS

The Holocaust survivors with PTSD showed significantly higher levels of current dissociative experiences than did the other groups. However, the extent of dissociation was substantially less than that which has been observed in other trauma survivors with PTSD. Dissociative Experiences Scale scores were significantly associated with PTSD symptom severity, but the relation between Dissociative Experiences Scale scores and exposure to trauma was not significant.

CONCLUSIONS

Possible explanations for this finding include the age of the survivors, the length of time since the traumatic event, and possible unique features of the Holocaust survivor population. Nevertheless, the findings call into question the current notion that PTSD and dissociative experiences represent the same phenomenon. The findings suggest that the relationships among dissociation, trauma, and PTSD can be further clarified by longitudinal studies of trauma survivors.

Examination of the reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) among arrested youths entering a juvenile assessment center

The Problem Oriented Screening Instrument for Teenagers (POSIT) serves as a key aspect of the preliminary screening activities at the Hillsborough County Juvenile Assessment Center. We report on a reliability study of POSIT, involving an examination of the relationships between the youths' initial and second admission POSIT results for different time intervals between administration of the instrument. The results indicate the POSIT provides consistent indication of potentially troubled youths who are in need of in-depth assessment and intervention or treatment services.

D-amphetamine challenge effects on Wisconsin Card Sort Test. Performance in schizotypal personality disorder

The authors assessed the effects on Wisconsin Card Sort (WCST) performance and psychiatric symptoms of 30 mg d-amphetamine, a dopamine and norepinephrine agonist, vs placebo in nine patients with schizotypal personality disorder (SPD). Patients, particularly those who made more perseverative errors, demonstrated amphetamine-associated improvement on WCST performance. The data in this preliminary study suggest that some of the cognitive dysfunction present in SPD may improve with amphetamine challenge.

Development and evaluation of a classification of high risk youths entering a juvenile assessment center

We report the results of developing and evaluating a classification of high risk youth entering a Juvenile Assessment Center in Hillsborough County, Florida, involving over 2,000 youths processed at the center during its first 8 months of operation. Cluster analysis of the youths' potential problems probed by the Problem Oriented Screening Instrument for Teenagers defined four groups. The usefulness of the typology was supported by a discriminant analysis and by recidivism information. The research implications of these results are discussed.

Increased pituitary activation following metyrapone administration in post-traumatic stress disorder

Our previous findings have demonstrated that individuals with post-traumatic stress disorder (PTSD) show lower basal cortisol levels, a larger number of lymphocyte glucocorticoid receptors, and an enhanced suppression of cortisol following the administration of dexamethasone compared to normals and patients with major depression. We have previously suggested that these alterations reflect an enhanced negative feedback inhibition of the hypothalamic-pituitary-adrenal (HPA) axis in PTSD. However, in the absence of direct knowledge of pituitary capability in this disorder, it has been equally likely that the alterations observed reflected either pituitary or adrenal insufficiency. In the present study, we examined ACTH release from the pituitary gland in PTSD following the administration of metyrapone. Metyrapone resulted in a significantly greater increase of ACTH and 11-deoxycortisol in combat veterans with PTSD (n = 11) compared with normal male volunteers (n = 8). When seen in the context of other abnormalities observed in PTSD, the present demonstration of increased pituitary activity in the absence of negative feedback provides unequivocal support for the hypothesis of enhanced negative feedback.

Impact of cumulative lifetime trauma and recent stress on current posttraumatic stress disorder symptoms in holocaust survivors

OBJECTIVE

The purpose of this study was to examine the relationships among cumulative lifetime trauma, recent stressful events, and presence and severity of current posttraumatic stress disorder (PTSD) symptoms in Holocaust survivors and nonexposed comparison subjects.

METHOD

Lifetime trauma, recent stressful events, and presence and severity of PTSD were assessed in Holocaust survivors (N=72) and comparison subjects ( N=19).

RESULTS

Survivors with PTSD (N =40) reported significantly greater cumulative trauma and recent stress than survivors without PTSD (N=32) and comparison subjects. Severity of PTSD symptoms, cumulative trauma, and recent stress were significantly associated.

CONCLUSIONS

The presence and severity of current PTSD were related to having experienced stressful events in addition to the Holocaust.

L-deprenyl and physostigmine for the treatment of Alzheimer's disease

The present study evaluated the safety of and obtained preliminary data on the cognitive effects of L-deprenyl and physostigmine in patients with Alzheimer's Disease. Seventeen outpatients with Alzheimer's Disease participated in a double-blind crossover study in which they received 4 weeks of L-deprenyl at a dose of 10 mg p.o., q.d., and 4 weeks of placebo in random order. During both the L-deprenyl and placebo periods, patients received cognitive assessments during physostigmine (0.5 mg) and placebo infusions separated by 2 days. The cognitive effects of these agents alone and in combination were measured with digit span, verbal fluency, list learning, praxis, delayed recall, and delayed recognition tasks. Fifteen patients completed the study. The two drugs, used alone or in combination, were safe and well tolerated. Analyses of variance demonstrated that neither physostigmine nor L-deprenyl, whether given alone or in combination, significantly improved cognition, when compared with the double placebo condition.

Amantadine does not reduce cocaine use or craving in cocaine-dependent methadone maintenance patients

We tested the efficacy of amantadine to reduce cocaine use or craving in cocaine-dependent methadone maintained patients. Two doses of amantadine (200 mg p.o. daily, n = 16, and 200 mg p.o. bid, n = 21) were tested against placebo, n = 22, in a random assignment, double-blind clinical trial lasting nine weeks. Amantadine was well tolerated. However, neither dose of amantadine was more effective than placebo in reducing cocaine use and craving.

Predictors of recidivism to a juvenile assessment center

We report the results of a study of the predictors of recidivism to a Juvenile Assessment Center in Hillsborough County, Florida, involving over 2,000 youths processed at the center during its first 8 months of operation. Consistent with previous research, younger aged youths, youths with abuse or neglect histories, with previous arrests for property, violence, or drug offenses, with potential vocational, leisure-recreation, and family problems, or who were arrested on property felony charges were likely to recidivate. The program activity and policy implications of these results are discussed.

Plasma 3-methoxy-4-hydroxyphenylglycol (MHPG) and clinical symptoms in Alzheimer's disease

Postmortem findings point to significant abnormalities in central noradrenergic function in Alzheimer's disease (AD) which may be associated with changes in peripheral markers. In this study, the relationship between the peripheral noradrenergic marker, plasma 3-methoxy-4-hydroxyphenylglycol (MHPG), and clinical symptoms was examined in 23 patients with probable AD. Basal MHPG levels correlated significantly with increased cognitive impairment (r = .58, p = .005), controlling for age, age at onset, gender, and time interval between plasma MHPG determination and cognitive testing. These results suggest that plasma MHPG increases as cognitive function in AD deteriorates, further supporting preliminary evidence for increases in noradrenergic indices in association with disease severity in AD.

Age at onset and familial risk in Alzheimer's disease

OBJECTIVE

The authors investigated the relationship between probands' age at onset of Alzheimer's disease with the risk of primary progressive dementia in the probands' first-degree relatives.

METHOD

Two hundred probands with clinically diagnosed Alzheimer's disease and 179 nondemented elderly probands were recruited from the Mount Sinai Alzheimer's Disease Research Center, located at Mount Sinai Hospital and the Bronx Veterans Affairs Medical Center. Demographic and diagnostic data were collected on 1,398 of the first-degree relatives of the probands with Alzheimer's disease and 955 first-degree relatives of the nondemented probands.

RESULTS

Cox proportional hazards regression analysis showed a significant inverse relationship between age at onset of Alzheimer's disease in probands and greater familial risk in their relatives. Follow-up analyses indicated that the most commonly used age at onset cutoff point--65 years--was one of the points where an association with familial aggregation is least likely to be revealed; other onset cutoff ages (e.g., 55, 70, and 75) better identified Alzheimer's disease groups with differing familial/genetic risks.

CONCLUSIONS

The authors conclude that patients with an earlier age at onset of Alzheimer's disease are more likely to have relatives with Alzheimer's disease than are patients with a later age at onset of the disease. An onset age of 70 best differentiated probands whose relatives were at higher risk from those whose relatives were at lower risk.

Neurochemical correlates of dementia severity in Alzheimer's disease: relative importance of the cholinergic deficits

Cholinergic markers, neuropeptides, and amines and their metabolites were sampled from identical specimens across 10 neocortical regions in a large sample of Alzheimer's disease (AD) cases and controls. Levels of choline acetyltransferase, acetylcholinesterase, somatostatin, corticotropin-releasing factor, serotonin, and 5-hydroxyindoleacetic acid were significantly reduced in AD versus controls. After data reduction, the most descriptive neurochemical indices were used to examine the relationship of neurochemical measures and dementia severity within the AD sample, controlling for age effects. Dementia severity ratings were based on antemortem assessments (46.9% of AD sample) and postmortem chart review (53.1% of the AD sample). Choline acetyltransferase activity was highly correlated with clinical dementia ratings across the neocortex of the AD cases. Somatostatin and corticotropin-releasing factor levels were correlated with dementia severity only when control cases were included in the analyses. None of the amines, their metabolites, or the neuropeptides quantified related significantly to dementia severity in the AD cohort. These data (a) confirm the strong association of cholinergic deficits with functional impairment in AD and show that this association is independent of age and (b) suggest that of all the neurochemical species quantified, the cholinergic indices may be unique in their association with dementia severity.

Elevated alpha 1-antichymotrypsin serum levels in a subset of nondemented first-degree relatives of Alzheimer's disease patients

A portion of Alzheimer's disease (AD) patients have elevated serum levels of the acute phase reactant alpha 1-antichymotrypsin (A1ACT) compared to age-matched controls. We measured serum levels of A1ACT in AD patients, age-matched controls, Down's syndrome patients, and nondemented first-degree relatives of AD patients. Significantly elevated levels of A1ACT were found in both AD patients and first-degree-relatives. In AD patients, serum A1ACT concentrations decreased with increasing severity of cognitive impairment. These results may suggest that inflammatory phenomena may be an early component of AD pathophysiology.

Neocortical neurofibrillary tangles correlate with dementia severity in Alzheimer's disease

OBJECTIVE

To determine the relationships between dementia severity and the extent of histopathologic lesions in a variety of brain regions. Neocortical and hippocampal ratings for neurofibrillary tangles (NFTs) and senile plaques (SPs) were compared in 70 cases of clinically and neuropathologically confirmed Alzheimer's disease.

DESIGN

Neuropathologic case series. Dementia severity was assessed by postmortem chart review with use of the extended Clinical Dementia Rating Scale (CDR). Linear association between CDR scores and NFT and SP scores were assessed by partial correlation, controlling for age at death.

SETTING

Studies were conducted at the Alzheimer's Disease Research Center of the Mount Sinai Medical Center, New York, NY.

MAIN OUTCOME MEASURE

Association between CDR scores and neuropathologic changes assessed with the Consortium to Establish a Registry for Alzheimer's Disease semiquantitative scale.

RESULTS

Among these lesion scores, only NFTs showed a significant association with CDR score, and only for neocortical regions. In particular, NFT densities in the superior temporal cortex were most strongly correlated with dementia severity, followed by those in the inferior parietal and midfrontal cortex. No such correlations were apparent for the amygdala, hippocampus, or entorhinal cortex. Medial temporal lobe structures displayed high NFT scores, even in cases of mild dementia. Senile plaques did not correlate significantly with CDR score in any region.

CONCLUSIONS

These data support the notion that neocortical neuronal degeneration, as indicated by NFT formation, is a critical determinant of the clinical progression of Alzheimer's disease and suggest that medial temporal lobe structures may represent the initial site of NFT formation. While SP density correlates with age at death, there is no correlation between SP counts and dementia severity. These results further suggest that the clinical presentation of dementia may be closely related to neurodegeneration in neocortical regions within the temporal lobe.

Assessment of the central dopaminergic index of plasma HVA in schizophrenia

Under fasting conditions, the dopamine (DA) metabolite homovanillic acid (HVA) in plasma originates mainly from central DA neurons or from central and peripheral noradrenergic (NA) neurons. The latter source contributes, in addition to HVA, the norepinephrine metabolites, for example, 3-methoxy-4-hydroxyphenylglycol (MHPG). It has been shown in primates that the association between HVA and MHPG in plasma or urine under varying rates of NA metabolism can be used to obtain an estimate of the central DA neuronal contribution of HVA to plasma or urine. This estimate is called the central dopaminergic index (CDI). Two studies presented here examine the applicability of this model in schizophrenia patients. The results were consistent with the proposed model and suggested that only about 30 percent of the total plasma HVA concentrations in our patients were derived from central DA neurons. A convenient modification of this model is proposed for future studies. Since the CDI of plasma HVA is not likely to be confounded by NA activity, this tool may prove useful in disentangling the roles played by the DA and NA systems in schizophrenia.

Cocaine selling among urban black and white adolescent males

Data from a longitudinal study of juvenile detainees are used to examine the relationships between cocaine selling, substance use, and other delinquency among the Black and White males in the study. A descriptive comparison of rates of cocaine selling among the youths is followed by a descriptive comparison of prevalence of substance use and other delinquency across four subgroups: White and Black males indicating they sold and did not sell cocaine. These comparisons are followed by analyses of variance examining the relationships between involvement in substance use and other delinquency, and ethnicity, cocaine selling, and the interaction of ethnicity and cocaine selling. Important ethnicity and cocaine-selling effects are found, but not ethnicity by cocaine-selling interactions. The implications of our findings for theory and service provision are drawn.

Clinical symptoms associated with age at onset in Alzheimer's disease

OBJECTIVE

The aim of the study was to examine the relationship between age at onset of Alzheimer's disease and demographic and clinical characteristics in a large cohort of patients with Alzheimer's disease.

METHOD

The subjects were 104 patients meeting the criteria for Alzheimer's disease of the National Institute of Neurological and Communicative Disorders and Stroke. The relationships of age at disease onset to cognitive and noncognitive variables and to rate of progression were explored by using multiple regression analysis.

RESULTS

Earlier disease onset was associated with the presence of greater language and praxis difficulties and with the development of higher depression scores during the follow-up study period but not with faster disease progression.

CONCLUSIONS

These findings suggest that in Alzheimer's disease, which is a clinically heterogeneous illness, younger age at onset may be related to the presence of more prominent language and praxis impairment and to development of greater depression during the disease course.

The relationships among family problems, friends' troubled behavior, and high risk youths' alcohol/other drug use and delinquent behavior: a longitudinal study

Data from an ongoing longitudinal study of juvenile detainees are used to test a structural model of the relationships among their alcohol/other drug use and other delinquent behavior, their family problems, and friends' troubled behavior. The hypothesized model fitted the data well. Implications of the results are drawn in regard to theory and program policy.

A pilot study of clonidine plus physostigmine in Alzheimer's disease

To assess the feasibility of one approach to combined cholinergic/noradrenergic treatment in Alzheimer's disease, ten patients were enrolled in a 2-week placebo-controlled study of oral physostigmine plus clonidine. The Alzheimer's Disease Assessment Scale (ADAS) was used as the primary outcome measure. Neither physostigmine alone, nor the combination of physostigmine plus clonidine, was associated with a statistically significant improvement for the group. Three patients did show an improvement of at least 4 points on the total ADAS score with the drug combination. The implications of these results for treatment strategies are discussed.

Patterns of risk in first-degree relatives of patients with Alzheimer's disease

BACKGROUND

Although an increased cumulative risk for primary progressive dementia (PPD) has been repeatedly demonstrated in relatives of probands with Alzheimer's disease (AD), an examination of their rates of illness at different ages has not been previously undertaken. Such an examination might reveal possible age-related characteristics associated with a more familial variety of AD.

METHODS

Using family history interviews and survival analysis, the cumulative risk for and 5-year age-specific hazard rates of PPD were assessed in the first-degree relatives of 200 probands with AD and two nondemented control groups--179 elderly ascertained through the Alzheimer's Disease Research Center (ADRC-derived controls) and 427 elderly ascertained from community senior centers (community controls).

RESULTS

The PPD risk curve for the relatives of probands with AD rose to about 30% and was significantly higher than the curves for the relatives of the ADRC-derived and community controls, where comparable rates were observed (approximately 12%). The age-specific hazard rates of PPD were calculated in three groups of relatives for each 5-year interval from ages 45 to 49 years through ages 85 to 89 years. The age-specific relative risk (RRi) for PPD in the relatives of probands with AD began to steadily diminish from the 75- to 79-year age interval (RRi = 13.49) through the 85- to 89-year age interval (RRi = 0.96) compared with the relatives of ADRC-derived controls and from the 60- to 64-year age interval (RRi = 16.15) through the 85- to 89-year age interval (RRi = 2.03) compared with the relatives of the community controls.

CONCLUSIONS

These data indicate that, for relatives of probands with AD, while the lifetime risk for PPD is greater than in relatives of controls, the familial contribution to the risk for PPD decreases with increasing age. The higher risk for PPD in relatives of probands with AD may be substantially diminished or even eliminated by the latter half of the ninth decade.

Parent and teacher ratings of attention-deficit hyperactivity disorder symptoms: implications for case identification

This study was designed to evaluate the relationship between the DSM-III criteria for attention-deficit deficit disorder with hyperactivity (ADDH) and the DSM-III-R criteria for attention-deficit hyperactivity disorder (ADHD). Seventy-two children from an inner-city elementary school were evaluated using parent and teacher ratings on a scale consisting of the symptoms of DSM-III-R ADHD and oppositional-defiant disorder and DSM-III ADDH. Each child was also assessed using a psychometric test battery designed to examine cognitive function, attention, and activity level. Teacher ratings identified more children as DSM-III-R ADHD than DSM-III ADDH. Among these ADHD children, those who also met the ADDH criteria missed more targets on a continuous performance test (CPT) and were rated more overactive than controls. They also had a greater likelihood of being rated ADHD by parents. Children rated as meeting criteria for DSM-III-R ADHD, but not DSM-III ADDH, were not substantially different from controls on teacher ratings of overactivity, CPT performance, or parent ratings of ADHD, which raises questions regarding the nature and severity of the pathology in this group.

Psychosocial, alcohol/other drug use, and delinquency differences between urban black and white male high risk youth

Using data collected on 286 Black and White male youths entering a juvenile detention center, we examine differences in their psychosocial functioning, substance use, and delinquency/crime. Comparison is made on a wide range of variables, including sociodemographic characteristics, family problems, records of contact with the juvenile court, physical abuse or sexual victimization history, alcohol/other drug use, friends' involvement in substance use and crime, and emotional/psychological functioning problems. Implications of the results for understanding the youths' involvement in the juvenile justice system, and for the development of, and linkage with, appropriate services, are drawn.

A longitudinal study of Alzheimer's disease: measurement, rate, and predictors of cognitive deterioration

OBJECTIVE

This study measured the annual rate of cognitive change in patients with Alzheimer's disease and determined the effects of clinical variables on that rate. It also compared the ability of two cognitive scales to measure change over the entire range of dementia severity.

METHOD

The cognitive subscale of the Alzheimer's Disease Assessment Scale and the Blessed test for information memory and concentration were given to 111 patients with Alzheimer's disease and 72 nondemented elderly comparison subjects at 6-month intervals for up to 90 months. Longitudinal changes in scores on the cognitive subscale were measured with several different methods of data analysis.

RESULTS

For the patients with Alzheimer's disease, the annual rate of change in cognitive subscale scores showed a quadratic relationship with dementia severity in which deterioration was slower for mildly and severely demented patients than for patients with moderate dementia. Gender, age at onset, and family history of dementia had no effect on the rate of cognitive deterioration. The comparison group showed a slight improvement in cognitive performance over time. All data analytic methods gave similar results. The cognitive subscale of the Alzheimer's Disease Assessment Scale was more sensitive to change in both mild and severe dementia than was the Blessed test.

CONCLUSIONS

These results suggest that cognitive deterioration is slow during the early and very late stages of Alzheimer's disease and more rapid during the middle stages. No clinical variables other than degree of cognitive impairment and previous rate of cognitive decline predicted rate of deterioration. These results have implications for treatment trials and attempts to identify subgroups.

Lack of association between cortisol hypersecretion and nonsuppression on the DST in patients with Alzheimer's disease

Among 23 patients with Alzheimer's disease, 11 (48%) exhibited cortisol hypersecretion (> or = 11.8 micrograms/dl) and nine (39%) displayed cortisol nonsuppression on the dexamethasone suppression test. Only four patients exhibited both neuroendocrine abnormalities, demonstrating a lack of association between these two neuroendocrine disturbances of over 50%. Twenty-two of the 23 patients were studied for 4 1/2 years, and 14 died during that period. Six of the eight surviving patients exhibited cortisol hypersecretion without cortisol nonsuppression.

Development and Assessment of a Classification of High Risk Youths

Cluster analysis is applied to substance use and delinquency data collected in a longitudinal study of juvenile detainees to empirically derive five groups of youths from information gathered at their initial interviews (time 1): alcohol/marijuana-hashish users, low-level delinquents, alcohol/ marijuana-hashish and cocaine-using nondelinquents, high delinquency, cocaine users, and heavy cocaine-using nondelinquents. The validity of the typology was supported by a variety of other initial interview and follow-up interview alcohol/other drug use and delinquency data, and by recidivism information — including data on arrests during the three-and-a-half years following the date of the youths' first interviews. Research and policy implications of the findings are drawn.