Dimensions of personality: clinicians' perspectives

OBJECTIVE

To obtain the opinions and preferences of practising clinicians about the clinical utility of personality scales included within 8 alternative dimensional models of personality disorder for inclusion within an official diagnostic nomenclature.

METHOD

Psychiatrists (n = 226) and psychologists (n = 164) from 2 continents provided clinical utility ratings on personality scales organized from 8 alternative dimensional models of personality disorder.

RESULTS

The psychiatrists and the psychologists supported the inclusion of most of the scales from all 8 of the models that were compared. Normal personality traits were endorsed, although abnormal personality traits generally received higher levels of endorsement. The list of endorsed traits was reduced further by organizing the scales into groups based on redundancy within each of 5 broad domains and then selecting within each group the scale that received the highest rating.

CONCLUSIONS

This list appears to represent each domain in a manner that is comprehensive both in its coverage of the respective domain, as well as in representing particular strengths of each of the alternative dimensional models, at least for the stated preferences of psychiatrists and psychologists.

Life Stress and Major Depression

People have long believed that adversity and stress contribute to emotional problems in general and to depression in particular. A considerable body of research has supported this intuition, documenting a consistent association between major stressful life events and the onset of clinical depression. However, most individuals under stress do not become depressed, sometimes depression develops without prior stress, and distinguishing psychological distress from major depression can be diagnostically challenging. In varying forms and degrees, life stress may play multiple roles in relation to major depression. In this article, we outline the opportunities and obstacles associated with conceptualizing depression from a life-stress perspective and discuss the implications for future research.

The contribution of callous-unemotional traits and conduct problems to bullying in early adolescence

BACKGROUND

Although a lot is known about the association of conduct problems with bullying, less attention has been paid to co-occurring traits, such as callous-unemotional (CU) traits that might additionally contribute to the risk of engaging in bullying. This study investigated the contribution of CU traits to direct and indirect bullying, alongside the contributions made by conduct problems and gender.

METHODS

Seven hundred and four 11-13-year-olds completed self-report measures of callous-emotional traits and psychopathology, including conduct problems. Peer-report measures of direct and indirect bullying were collected from classmates.

RESULTS

Higher levels of CU traits were associated with higher levels of direct bullying, over and above the association between bullying and conduct problems. Conduct problems and CU traits interacted in the prediction of both direct and indirect bullying. In line with previous research, males were more likely to engage in direct and females in indirect bullying.

CONCLUSIONS

This study highlights the importance of viewing CU traits and conduct problems, not only as related phenomena, but also as distinct entities in mediating the underlying susceptibility of children to bully others directly. Furthermore, a combination of these traits appears to be a particularly potent risk factor for both direct and indirect bullying. Implications for intervention are discussed, in particular the concern that lack of empathy and insensitivity to punishment in those with CU traits may also make them particularly resistant to current forms of bullying intervention.

Heterogeneity in comorbidity between major depressive disorder and generalized anxiety disorder and its clinical consequences

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are highly comorbid and, as diagnoses, problematic because they are heterogeneous, may impair functioning even in subclinical manifestations, and may not predict important external criteria as well as empirically-derived classifications. The present study employed a latent class analysis using data from National Comorbidity Survey (1990-1992) and focused on respondents who endorsed at least 1 screening question for MDD and 1 for GAD (N = 1009). Results revealed 4 symptom domains (somatic anxiety, somatic depression, psychological anxiety, and psychological depression) reflecting the heterogeneity of MDD and GAD, and 7 respondent classes. Analysis revealed that people in classes with a high prevalence of either somatic anxiety or somatic depression symptoms presented with the highest levels of disability, distress, and service utilization. Evidence also was found for clinically meaningful subthreshold comorbid conditions. Anxiety-related and depression-related symptoms can be meaningfully differentiated, but differentiating between somatic and psychological symptoms has the greatest practical significance.

Psychopathology and cognition in divergent functional outcomes in schizophrenia

Cognitive performance rather than symptoms, especially positive symptoms, is regarded as the primary predictor of functional outcome in schizophrenia. However, contradictory evidence exists and many studies fail to sample from the extremes of outcome measures. This study tested whether the differential importance assigned to symptoms and cognitive impairment is supportable in patients with high and low levels of community independence. Schizophrenia patients with highly unfavorable (n=24) and highly favorable (n=28) functional outcomes as defined by community support requirements were studied. Standard cognitive and psychopathology measures were analyzed using independent groups comparisons and outcome prediction with logistic regression methods. Symptom severity and cognitive data separately accounted for significant amounts of variance in community independence. Positive as well as negative symptoms, non-psychotic psychopathology and cognition generated large effect sizes between highly unfavorable and favorable outcome groups. The conditional validity of both overall psychopathology and positive symptoms was significant over and above the contribution of cognition to outcome prediction. Results suggest researchers may have underestimated the role of psychopathology in general and positive symptoms in particular as potential determinants of functional status in schizophrenia.

Colon cancer patient information seeking and the adoption of targeted therapy for on-label and off-label indications

BACKGROUND

Despite the rise in publicly available cancer information, little is known about the association between patient information seeking and the adoption of cancer technologies. The authors of this report investigated the relation between patient information seeking and awareness about and receipt of novel targeted therapy (TT) for colon cancer among patients for whom therapy is approved by the US Food and Drug Administration (FDA) and among patients for whom therapy is not FDA approved.

METHODS

A retrospective, population-based survey of 633 colon cancer patients were identified through the Pennsylvania Cancer Registry. Outcome measures were self-reported awareness about and receipt of TT (bevacizumab and cetuximab).

RESULTS

After adjusting for sociodemographic characteristics, high levels of treatment information seeking were associated strongly with hearing about TT (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.49-5.38) and receiving TT (OR, 3.22; 95% CI, 1.36-7.62). These associations were present for patients with metastatic disease, for whom the use of TT is FDA approved, and for patients with localized disease, for whom the use of TT is not FDA approved (P for interactions = .29). Internet use (OR, 2.88; 95% CI, 1.40-5.94) and newspaper/magazine use (OR, 3.44; 95% CI, 1.34-8.84) were associated with hearing about TT. Seeking information from nontreating physicians was associated with hearing about TT (OR, 1.95; 95% CI, 1.03-3.68) and receiving TT (OR, 2.64; 95% CI, 1.16-5.97).

CONCLUSIONS

Patient information seeking was related to the adoption of TT for colon cancer in both appropriate and inappropriate clinical settings. These findings emphasize the importance of exploring patient influence on physician prescribing patterns and understanding the impact of information seeking on cancer outcomes.

BDNF Val66Met polymorphism is associated with HPA axis reactivity to psychological stress characterized by genotype and gender interactions

BACKGROUND

A key protein in maintaining neuronal integrity throughout the life span is brain-derived neurotrophic factor (BDNF). The BDNF gene is characterized by a functional polymorphism, which has been associated with stress-related disorders such as anxiety-related syndromes and depression, prompting us to examine individual responses by Genotype and Sex to a standardized social stress paradigm. Gender differences in BDNFxstress responses were posited because estrogen induces synthesis of BDNF in several brain regions.

METHODS

97 university students (51 females and 46 males) participated in a social stress procedure (Trier Social Stress Test, TSST). Indices of stress were derived from repeated measurement of cortisol, blood pressure, and heart rate during the TSST. All subjects were genotyped for the Val66Met polymorphism.

RESULTS

Tests of within-subject effects showed a significant three-way interaction (SPSS GLM repeated measures: Time (eight levels)xBDNF (val/val, val/met)xSex: p=0.0002), which reflects gender differences in the pattern of cortisol rise and decline during the social challenge. In male subjects, val/val homozygotes showed a greater rise in salivary cortisol than val/met heterozygotes. In female subjects, there was a trend for the opposite response, which is significant when area under the curve increase (AUCi) was calculated for the val/val homozygotes to show the lowest rise. Overall, the same pattern of results was observed for blood pressure and heart rate.

CONCLUSIONS

These results indicate that a common, functionally significant polymorphism in the BDNF gene modulates HPA axis reactivity and regulation during the TSST differently in men and women. Findings may be related to gender differences in reactivity and vulnerability to social stress.

Preschool Bipolar Disorder

Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder (BPD) remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. While there is a need for well controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3. The need for large scale and focused studies of this issue is underscored by the high and increasing rates of prescriptions of atypical antipsychotics and other mood stabilizing agents for preschool children with presumptive clinical diagnosis of BPD or a related variant. Clarifying the nosology of preschool BPD may also be important to better understand of the developmental psychopathology of the disorder during childhood. Data elucidating this developmental trajectory could then inform the design of earlier potentially preventive interventions that may have implications for the disorder across the lifespan.

Chronic stress and stressful life events in the offspring of parents with bipolar disorder

BACKGROUND

The stress generation theory suggests that depressed individuals and children of depressed mothers are prone to create stressors that are interpersonal and dependent on their own behaviour. Exposure to "self-generated" stress is believed to increase the risk for onset and recurrence of depression. Much less is known about stress in the offspring of parents with bipolar disorder (OBD).

METHODS

As part of a longitudinal study, 37 OBD and 33 offspring of parents with no affective disorder (13 to 26 years old) were interviewed using the UCLA Life Stress Interview, assessing their current life circumstances (chronic stress) and recent negative life events (episodic stress).

RESULTS

The OBD reported more difficulties in interpersonal and non-interpersonal domains of chronic stress than controls. The group differences remained significant after controlling for the presence of affective disorders, indicating that the effect of risk status on chronic stress is independent of the problems associated with having a disorder. With respect to episodic stress, the OBD were 3.9 times more likely to have experienced a moderate to severe interpersonal stressor compared to the control group. There was no group difference for dependent events, but the OBD experienced more severe independent events than controls.

LIMITATIONS

Methodological limitations include a small sample size, large age range, and the absence of parent-reported stress and symptomatology.

CONCLUSIONS

Although the findings do not support the stress generation theory, they suggest that elevated levels of episodic and chronic stress may be important markers of risk for affective disorders in high-risk participants.

Experience Sampling Methods: A Modern Idiographic Approach to Personality Research

Experience sampling methods are essential tools for building a modern idiographic approach to understanding personality. These methods yield multiple snapshots of people's experiences over time in daily life and allow researchers to identify patterns of behavior within a given individual, rather than strictly identify patterns of behavior across individuals, as with standard nomothetic approaches. In this article, we discuss the origin and evolution of idiographic methods in the field of personality and explain how experience sampling methods function as modern day idiographic methods in this field. We then review four primary ways in which experience sampling methods have been used to foster idiographic approaches in personality research. Specifically, we highlight approaches that examine individual differences in temporal and behavioral distributions, situation-behavior contingencies, daily processes, and the structure of daily experience. Following a brief methodology primer, we end by discussing future directions for idiographic experience sampling approaches in personality psychology and beyond.

Adolescents' ability to read different emotional faces relates to their history of maltreatment and type of psychopathology

Emotional processing styles appear to characterize various forms of psychopathology and environmental adversity in children. For example, autistic, anxious, high- and low-emotion conduct problem children, and children who have been maltreated, all appear to show specific deficits and strengths in recognizing the facial expressions of emotions. Until now, the relationships between emotion recognition, antisocial behaviour, emotional problems, callous-unemotional (CU) traits and early maltreatment have never been assessed simultaneously in one study, and the specific associations of emotion recognition to maltreatment and child characteristics are therefore unknown. We examined facial-emotion processing in a sample of 23 adolescents selected for high-risk status on the variables of interest. As expected, maltreatment and child characteristics showed unique associations. CU traits were uniquely related to impairments in fear recognition. Antisocial behaviour was uniquely associated with better fear recognition, but impaired anger recognition. Emotional problems were associated with better recognition of anger and sadness, but lower recognition of neutral faces. Maltreatment was predictive of superior recognition of fear and sadness. The findings are considered in terms of social information-processing theories of psychopathology. Implications for clinical interventions are discussed.

Common and distinct amygdala-function perturbations in depressed vs anxious adolescents

CONTEXT

Few studies directly compare amygdala function in depressive and anxiety disorders. Data from longitudinal research emphasize the need for such studies in adolescents.

OBJECTIVE

To compare amygdala response to varying attention and emotion conditions among adolescents with major depressive disorder (MDD) or anxiety disorders, relative to adolescents with no psychopathology.

DESIGN

Case-control study.

SETTING

Government clinical research institute.

PARTICIPANTS

Eighty-seven adolescents matched on age, sex, intelligence, and social class: 26 with MDD (14 with and 12 without anxiety disorders), 16 with anxiety disorders but no depression, and 45 without psychopathology.

MAIN OUTCOME MEASURES

Blood oxygen level-dependent signal in the amygdala, measured by means of event-related functional magnetic resonance imaging. During imaging, participants viewed facial expressions (neutral, fearful, angry, and happy) while attention was constrained (afraid, hostility, and nose-width ratings) or unconstrained (passive viewing).

RESULTS

Left and right amygdala activation differed as a function of diagnosis, facial expression, and attention condition both when patients with comorbid MDD and anxiety were included and when they were excluded (group x emotion x attention interactions, P < or = .03). Focusing on fearful face-viewing events, patients with anxiety and those with MDD both differed in amygdala responses from healthy participants and from each other during passive viewing. However, both MDD and anxiety groups, relative to healthy participants, exhibited similar signs of amygdala hyperactivation to fearful faces when subjectively experienced fear was rated.

CONCLUSIONS

Adolescent MDD and anxiety disorders exhibit common and distinct functional neural correlates during face processing. Attention modulates the degree to which common or distinct amygdala perturbations manifest in these patient groups, relative to healthy peers.

Affective status in relation to impulsive, motor and motivational symptoms: personality, development and physical exercise

The contributions of impulsive and risk-taking behaviour in depressive and bipolar disorders, motivational and motor behaviours in anhedonic and substance addictive states, and the factors, particularly distress and trauma, underlying the development of neuropathology in affective status are described from clinical, epidemiological and laboratory perspectives. In order to distinguish one case factor for biopsychological substrates of health, an array of self-reported characteristics, e.g., positive or negative affect, stress or energy, optimism, etc., that may be predictive or counterpredictive for the propensity for physical exercise and activity were analysed using a linear regression in twelve different studies. Several individual characteristics were found to be markedly and significantly predictive of the exercise propensity, i.e., positive affect, energy, health-seeking behaviour and character, while optimism was of lesser, though significant, importance. Several individual characteristics were found to be significantly counterpredictive: expression of BDI- and HAD-depression, major sleep problems and lack/negligence of health-seeking behaviour. The consequences of physical activity and exercise for both affective well-being, cognitive mobility and neurogenesis is noted, particularly with regard to developmental assets for younger individuals. Affective disorder states may be studied through analyses of personal characteristics that unfold predispositions for symptoms-profiles and biomarkers derived from properties of dysfunction, such as impulsiveness, temperament dimensions, anhedonia and 'over-sensitivity', whether interpersonal or to reward.

Lifetime psychiatric disorders in school-aged offspring of parents with bipolar disorder: the Pittsburgh Bipolar Offspring study

CONTEXT

Whether offspring of parents with bipolar disorder (BP) are at specifically high risk to develop BP and other psychiatric disorders has not been adequately studied.

OBJECTIVE

To evaluate lifetime prevalence and specificity of psychiatric disorders in offspring of parents with BP-I and BP-II.

DESIGN

Offspring aged 6 to 18 years who have parents with BP and community control subjects were interviewed with standardized instruments. All research staff except the statistician were blind to parental diagnoses.

SETTING

Parents with BP were recruited primarily through advertisement and outpatient clinics. Control parents were ascertained by random-digit dialing and were group matched for age, sex, and neighborhood to parents with BP.

PARTICIPANTS

Three hundred eighty-eight offspring of 233 parents with BP and 251 offspring of 143 demographically matched control parents.

MAIN OUTCOME MEASURES

Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) Axis I disorders.

RESULTS

Adjusting for demographic factors, living with 1 vs both biological parents, both biological parents' non-BP psychopathology, and within-family correlations, offspring of parents with BP showed high risk for BP spectrum disorders (odds ratio [OR] = 13.4; 95% confidence interval [CI], 2.9-61.6) and any mood (OR = 5.2; 95% CI, 2.3-11.4), anxiety (OR = 2.3; 95% CI, 1.3-4.0), and Axis I (OR = 2.2; 95% CI, 1.5-3.3) disorders. Offspring of parents with BP with high socioeconomic status showed more disruptive behavior disorders and any Axis I disorders than offspring of control parents with high socioeconomic status. Families in which both parents had BP had more offspring with BP than families with only 1 parent with BP (OR = 3.6; 95% CI, 1.1-12.2). More than 75.0% of offspring who developed BP had their first mood episode before age 12 years, with most of these episodes meeting criteria for BP not otherwise specified and, to a lesser degree, major depression.

CONCLUSIONS

Offspring of parents with BP are at high risk for psychiatric disorders and specifically for early-onset BP spectrum disorders. These findings further support the familiality and validity of BP in youth and indicate a need for early identification and treatment.

An evaluation of a brief motivational interviewing training course for HIV/AIDS counsellors in Western Cape Province, South Africa

HIV/AIDS counselling in South Africa covers a range of areas of prevention and treatment with a commonly used model of lay counsellors trained by non-governmental organisations and working alongside professionals in public health settings. This study presents a single group evaluation of a six-session (12-hour) course of Motivational Interviewing (MI) delivered to 17 HIV/AIDS lay counsellors working in peri-urban settings in Western Cape Province, South Africa. Counsellors reported that they used MI techniques both at the start and at the end of the training. In addition, they reported confidence in their ability to influence their clients' motivation at both time points. The results from the ratings of role play performance showed that there was a marked change in emphasis over the group of counsellors from MI non-adherent practice before training (with advice giving, directiveness, control and confrontation) to more MI adherent practice (asking permission before giving advice, emphasising client autonomy, affirming the client and stressing the client's responsibility to change) at the end of the training. Only a small proportion of the counsellors reached the level of beginning proficiency (according to the Motivational Interviewing Treatment Integrity code) on the measure of the ratio of MI adherent to non-adherent responses. The ratio of reflections to questions and the percentage of open questions also showed improvements in performance across the group but generally to levels below that suggesting beginning proficiency in MI. There was no evidence of any change on global therapist ratings (of empathy and the spirit of MI, i.e. collaboration, evocation and autonomy support) or the percentage of complex reflections across the group of counsellors. Possible explanations for the results and public health implications are discussed.

The promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews

I provide a review and critique of meta-analyses and systematic reviews of school-based smoking prevention programs that focus on long-term effects. Several of these reviews conclude that the effects of school-based smoking prevention programs are small and find no evidence that they have significant long-term effects. I find that these reviews all have methodological problems limiting their conclusions. These include severe limiting of the studies included because of performance bias, student attrition, non-reporting of ICCs, inappropriate classification of intervention approach, and inclusion of programs that had no short-term effects. The more-inclusive meta-analyses suggest that school-based smoking prevention programs can have significant and practical effects in both the short- and the long-term. Findings suggest that school-based smoking prevention programs can have significant long-term effects if they: 1) are interactive social influences or social skills programs; that 2) involve 15 or more sessions, including some up to at least ninth grade; that 3) produce substantial short-term effects. The effects do decay over time if the interventions are stopped or withdrawn, but this is true of any kind of intervention.

Resonating minds: a school-independent theoretical conception and its empirical application to psychotherapeutic processes

The resonating minds theory will be introduced as a means to describe psychotherapeutic processes and change. It builds on the mind-brain interface with psychotherapeutic interventions causing change in the brain, an altered brain causes changes in the emotional, cognitive, and behavioral regulation, and this again will change the types of subsequent therapeutic interventions. For the empirical assessment of this theory the therapeutic cycles model will be used. It is based on computer assisted analysis of verbatim transcripts using emotional tone, abstraction and narrative style as language measures. Sample applications and studies are shortly presented in order to provide evidence for the applicability and face validity of this approach.

Risk information exposure and direct-to-consumer genetic testing for BRCA mutations among women with a personal or family history of breast or ovarian cancer

BACKGROUND

Direct-to-consumer (DTC) BRCA testing may expand access to genetic testing and enhance cancer prevention efforts. It is not known, however, if current DTC websites provide adequate risk information for informed medical decision making.

METHODS

A total of 284 women with a personal or family history of breast/ovarian cancer were randomly assigned to view a "mock" DTC commercial website [control condition (CC); n = 93] or the same "mock" website that included information on the potential risks of obtaining genetic testing online. Risk information was framed two ways: risk information attributed to expert sources (ES; n = 98) and unattributed risk information (URI; n = 93). Participants completed an online survey. End points were intentions to get BRCA testing, testing site preference, and beliefs about DTC BRCA testing.

RESULTS

The sample was 82% white, had a mean age of 39 years (range, 18-70 years) and had a mean education of 3 years of college. Women exposed to risk information had lower intentions to get BRCA testing than women in the CC [adjusted odds ratio (OR), 0.48; 95% confidence interval (95% CI) 0.26-0.87; P = 0.016], and less positive beliefs about online BRCA testing (adjusted OR, 0.48; 95% CI, 0.27-0.86; P = 0.014). Women in the ES condition were more likely to prefer clinic-based testing than were women in the CC (adjusted OR, 2.05; 95% CI, 1.07-3.90; P = 0.030).

CONCLUSION

Exposing women to information on the potential risks of online BRCA testing altered their intentions, beliefs, and preferences for BRCA testing. Policy makers may want to consider the content and framing of risk information on DTC websites as they formulate regulation for this rapidly growing industry.

Gender bias in medicine

Gender bias has implications in the treatment of both male and female patients and it is important to take into consideration in most fields of medical research, clinical practice and education. Gender blindness and stereotyped preconceptions about men and women are identified as key causes to gender bias. However, exaggeration of observed sex and gender differences can also lead to bias. This article will examine the phenomenon of gender bias in medicine, present useful concepts and models for the understanding of bias, and outline areas of interest for further research.

Correlates of depression at baseline among African Americans enrolled in cardiac rehabilitation

PURPOSE

To compare baseline psychosocial characteristics of African Americans entering phase 2 cardiac rehabilitation who have depression symptoms at or above threshold (Center for Epidemiological Studies Depression Scale [CES-D] score >or=16) with those who do not (CES-D score <16).

METHODS

A nonrandom sample of 112 men and women (n = 78 without depression, n = 34 with depression) was recruited through local phase 2 cardiac rehabilitation programs. Data were obtained by a structured interview and brief physical examination using several reliable and valid instruments. Chi-square tests, Kruskal-Wallis 2-sample tests, Spearman rank correlation coefficients, and logistic regression models were used for analyses.

RESULTS

We found that 30% of the participants were above the depression symptom threshold. Demographic characteristics were not significantly different between individuals at or above threshold and those below threshold. However, depressed individuals above threshold were more likely to be dissatisfied with their neighborhoods (P = .01) and had lower optimism scores (P < .0001), higher stress scores (P < .0001), lower adaptive coping scores (P = .05), and higher problematic coping scores (P < .01) than their counterparts who were below threshold. In the logistic regression model, the odds of being above the depression symptom threshold increased with stress (P < .001) and decreased with optimism (P = .03); none of the other psychosocial characteristics had an independent effect on depression symptoms.

CONCLUSIONS

At baseline, African Americans starting phase 2 cardiac rehabilitation with depression symptoms at or above threshold had more stress and fewer stress resilience factors. Assessing depression and stress resilience factors is important and may lead to more active participation in cardiac rehabilitation once enrolled, as well as optimal cardiovascular health outcomes.

Adolescent siblings of individuals with an autism spectrum disorder: testing a diathesis-stress model of sibling well-being

The purpose of this study was to test a diathesis-stress model of well-being for siblings who have a brother or sister with an autism spectrum disorder (ASD). Data were collected from 57 adolescents and their mothers. Sisters reported higher levels of depressive and anxiety symptoms than brothers. Having a family history of ASDs was associated with depressive, but not anxiety, symptoms. A high level of maternal depression was also associated with more depressive and anxiety symptoms. A diathesis-stress model was partially supported, primarily through the findings that sibling sub-threshold autism characteristics were associated with depressive and anxiety symptoms in siblings, but only in the presence of a high number of stressful life events.

Stimulus- and response-locked neuronal generator patterns of auditory and visual word recognition memory in schizophrenia

Examining visual word recognition memory (WRM) with nose-referenced EEGs, we reported a preserved ERP 'old-new effect' (enhanced parietal positivity 300-800 ms to correctly-recognized repeated items) in schizophrenia ([Kayser, J., Bruder, G.E., Friedman, D., Tenke, C.E., Amador, X.F., Clark, S.C., Malaspina, D., Gorman, J.M., 1999. Brain event-related potentials (ERPs) in schizophrenia during a word recognition memory task. Int. J. Psychophysiol. 34(3), 249-265.]). However, patients showed reduced early negative potentials (N1, N2) and poorer WRM. Because group differences in neuronal generator patterns (i.e., sink-source orientation) may be masked by choice of EEG recording reference, the current study combined surface Laplacians and principal components analysis (PCA) to clarify ERP component topography and polarity and to disentangle stimulus- and response-related contributions. To investigate the impact of stimulus modality, 31-channel ERPs were recorded from 20 schizophrenic patients (15 male) and 20 age-, gender-, and handedness-matched healthy adults during parallel visual and auditory continuous WRM tasks. Stimulus- and response-locked reference-free current source densities (spherical splines) were submitted to unrestricted Varimax-PCA to identify and measure neuronal generator patterns underlying ERPs. Poorer (78.2+/-18.7% vs. 87.8+/-11.3% correct) and slower (958+/-226 vs. 773+/-206 ms) performance in patients was accompanied by reduced stimulus-related left-parietal P3 sources (150 ms pre-response) and vertex N2 sinks (both overall and old/new effects) but modality-specific N1 sinks were not significantly reduced. A distinct mid-frontal sink 50-ms post-response was markedly attenuated in patients. Reductions were more robust for auditory stimuli. However, patients showed increased lateral-frontotemporal sinks (T7 maximum) concurrent with auditory P3 sources. Electrophysiologic correlates of WRM deficits in schizophrenia suggest functional impairments of posterior cortex (stimulus representation) and anterior cingulate (stimulus categorization, response monitoring), primarily affecting memory for spoken words.

Sex differences in learning processes of classical and operant conditioning

Males and females learn and remember differently at different times in their lives. These differences occur in most species, from invertebrates to humans. We review here sex differences as they occur in laboratory rodent species. We focus on classical and operant conditioning paradigms, including classical eyeblink conditioning, fear-conditioning, active avoidance and conditioned taste aversion. Sex differences have been reported during acquisition, retention and extinction in most of these paradigms. In general, females perform better than males in the classical eyeblink conditioning, in fear-potentiated startle and in most operant conditioning tasks, such as the active avoidance test. However, in the classical fear-conditioning paradigm, in certain lever-pressing paradigms and in the conditioned taste aversion, males outperform females or are more resistant to extinction. Most sex differences in conditioning are dependent on organizational effects of gonadal hormones during early development of the brain, in addition to modulation by activational effects during puberty and adulthood. Critically, sex differences in performance account for some of the reported effects on learning and these are discussed throughout the review. Because so many mental disorders are more prevalent in one sex than the other, it is important to consider sex differences in learning when applying animal models of learning for these disorders. Finally, we discuss how sex differences in learning continue to alter the brain throughout the lifespan. Thus, sex differences in learning are not only mediated by sex differences in the brain, but also contribute to them.

Managing unwanted intrusive thoughts in obsessive-compulsive disorder: relative effectiveness of suppression, focused distraction, and acceptance

Suppression is one of various mental control techniques that people may use to manage unwanted thoughts. Evidence suggests that it is at best unsustainable and at worst counterproductive. This leads to the question: If suppression is a futile way to respond to unwanted, intrusive thoughts, what is a more effective alternative? In the current study, we evaluated the relative effectiveness of suppression and two alternative mental control techniques-focused distraction and acceptance-on the frequency of intrusions and distress associated with them. Results support the claim that suppression is a counterproductive technique for dealing with unwanted, intrusive thoughts in OCD. However, the harmfulness of suppression was reflected primarily in the magnitude of distress and not in intrusion frequency. Focused distraction and acceptance were the more effective techniques for managing clinically significant intrusive thoughts. We discuss implications for the cognitive treatment for OCD.

Assessment and treatment of suicide risk in bipolar disorders

Completed suicide and suicide attempts are major issues in the management of bipolar disorders. There is evidence that suicide rates among these patients are more than 20-fold higher than the general population and, furthermore, suicidal behavior is much more lethal in bipolar disorder than in the general population. Patients with mood disorders may sometimes exhibit highly perturbed mixed states, which usually increase the risk of suicide. Such states are particularly frequent in bipolar II patients, especially if patients are treated with antidepressant monotherapy (unprotected by mood stabilizers), when depression switches into mania (or vice versa), or when depression lifts and functioning approaches normality. Researchers worldwide agree that treatment involving lithium is the best way to protect patients from suicide risk. Psychosocial activities, including psychoeducation, can protect bipolar patients either directly or, more probably, indirectly by increasing adherence to treatment and helping in daily difficulties that otherwise may lead to demoralization or hopelessness. An extensive understanding of the psychosocial circumstances and the psychopathology of bipolar patients (including temperament) may help clinicians describe the clinical picture accurately and prevent suicidal behavior in these patients.

PTSD Symptoms and Self-Rated Recovery Among Adult Sexual Assault Survivors: The Effects of Traumatic Life Events and Psychosocial Variables

Prior research has demonstrated that self-blame is predictive of more posttraumatic stress disorder (PTSD) symptoms and poorer recovery ( Frazier, 2003 ; Koss, Figueredo, & Prince, 2002 ), and perceived control over recovery is associated with less distress ( Frazier, 2003 ) in adult sexual assault (ASA) survivors. A structural equation model was tested to examine the role of traumatic events, self-blame, perceived control over recovery, and coping strategies on PTSD symptoms and self-rated recovery in women ASA survivors. Adaptive coping partially mediated the effects of other traumas, self-blame, and perceived control over recovery on PTSD symptoms and showed a small positive association with increased PTSD symptoms. As hypothesized, maladaptive coping partially mediated the effects of other traumas, self-blame, and perceived control over recovery on both PTSD symptoms and self-rated recovery; greater maladaptive coping was associated with increased PTSD symptoms and lower self-rated recovery. Implications and directions for future research are discussed.

Prevalence and risk of atopic disorders among schizophrenia patients: a nationwide population based study

OBJECTIVE

Although a body of evidence indicates a link between psychiatric illnesses and allergies, no one has investigated the association between schizophrenia and atopic disorders. The objective of this nationwide population-based study was to examine the prevalence and risk of atopic disorders (asthma, allergic rhinitis, urticaria, and atopic dermatitis) among schizophrenia patients.

METHOD

This study used data from the Taiwan National Health Insurance Research Database covering the years 2000 to 2002. A total of 44,187 patients diagnosed with schizophrenia in the year 2000 were included, together with 132,561 matched non-psychiatric controls. Follow up until the end of 2002 identified concurrent diagnoses of atopic disorders. Logistic regression analyses were performed after controlling for the covariates of socio-demographic characteristics.

RESULTS

Findings indicated high comorbidity, with 20.2% of schizophrenia patients (approximately one in five) experiencing concurrent atopic disorders. Moreover, schizophrenia in patients was independently associated with a 1.3-fold increased risk (95%CI=1.24-1.39) of concurrent asthma, after adjusting for socio-demographic characteristics. Yet the risk of diagnosed allergic rhinitis and urticaria was 23% (95%CI=0.74-0.81) and 26% (95%CI=0.72-0.77) lower, respectively, among schizophrenia patients compared to people without any psychiatric disease.

CONCLUSION

Data suggests an increased risk of asthma and decreased risk of allergic rhinitis and urticaria among schizophrenia patients. Future studies on the identification of common etiologic pathways for schizophrenia and asthma could be significant for developing innovative treatments that target both illnesses concurrently.

Changes in respiration mediate changes in fear of bodily sensations in panic disorder

The purpose of the study was to examine whether changes in pCO(2) mediate changes in fear of bodily sensation (as indexed by anxiety sensitivity) in a bio-behavioral treatment for panic disorder that targets changes in end-tidal pCO(2). Thirty-five panic patients underwent 4 weeks of capnometry-assisted breathing training targeting respiratory dysregulation. Longitudinal mediation analyses of the changes in fear of bodily symptoms over time demonstrated that pCO(2), but not respiration rate, was a partial mediator of the changes in anxiety sensitivity. Results were supported by cross lag panel analyses, which indicated that earlier pCO(2) levels predicted later levels of anxiety sensitivity, but not vice versa. PCO(2) changes also led to changes in respiration rate, questioning the importance of respiration rate in breathing training. The results provide little support for changes in fear of bodily sensations leading to changes in respiration, but rather suggest that breathing training targeting pCO(2) reduced fear of bodily sensations in panic disorder.

Group cognitive behavior therapy for chronic posttraumatic stress disorder: an initial randomized pilot study

Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment(GCBT) or a minimum contact comparison group (MCC).Compared to the MCC participants (n=16), individuals who completed GCBT (n=17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to31.3% of the MCC participants. Examination of anxiety,depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs.Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.

Increased pituitary volume in schizophrenia spectrum disorders

While hypothalamic-pituitary-adrenal (HPA) axis hyperactivity has been implicated in psychotic disorders, previous magnetic resonance imaging (MRI) studies of the pituitary gland volume in schizophrenia have yielded controversial results. It is also unknown whether patients with schizophrenia spectrum such as schizotypal disorder exhibit pituitary volume changes. In this study, we investigated the pituitary volume using MRI in 47 schizotypal disorder patients (29 males, mean age=25.0 years), 72 schizophrenia patients (38 males, mean age=26.2 years), and 81 age and gender matched healthy controls (46 males, mean age=24.5 years). Both patient groups had a larger pituitary volume compared with controls, but no difference was found between the schizophrenia and schizotypal patients. The pituitary volume was larger in females than in males for all diagnostic groups. There was no association between the pituitary volume and type (typical versus atypical), daily dosage, or duration of antipsychotic medication in either patient group. These findings are consistent with a stress-diathesis model of schizophrenia and further suggest that the schizotypal patients share HPA axis hyperactivity with young established schizophrenia patients reflecting a common vulnerability to stress within the schizophrenia spectrum.

Stressful life events, chronic difficulties, and the symptoms of clinical depression

Major life events and chronic difficulties have been found to be associated with the onset of depression. Little is known, however, about how exposure to such stressors is related to the clinical presentation of this disorder. We addressed this issue by administering an interview-based measure of life stress, the Beck Depression Inventory, and the Global Assessment of Functioning scale to 100 adults diagnosed with major depressive disorder. Participants who experienced a preonset severe life event exhibited greater overall levels of depression severity, endorsed more cognitive and somatic symptoms of depression, and functioned at lower levels than did their counterparts without preonset severe life events. In contrast, exposure to a preonset severe difficulty was unrelated to participants' severity of depression, cognitive and somatic symptoms, or level of global functioning. These findings highlight the potentially greater importance of acute stress compared with chronic stress for influencing these key clinical features of depression.

Motivational change in an inpatient anorexia nervosa population and implications for treatment

OBJECTIVE

The relationship between motivation and recovery in anorexia nervosa has received increased attention in the research literature although few controlled investigations of increasing motivation in this population exist. Three questions were therefore examined in an inpatient anorexia nervosa population: (i) does baseline motivation predict change in eating pathology; (ii) does change in motivation predict change in eating pathology; and (iii) can we increase motivation to recover in this group?

METHOD

Inpatients (n=47) in a specialist weight disorder unit with a mean age of 21.85 years (SD=5.37) were randomly allocated to receive four sessions of motivational interviewing with a novice therapist in addition to treatment as usual (n=22) or treatment as usual alone (n=25). Assessment of eating pathology and motivation to recover was conducted on three occasions: at admission (baseline), and at 2- and 6 week follow up. Eating pathology was assessed using the Eating Disorder Examination and self-reported motivation was assessed using the Anorexia Nervosa Stages of Change Questionnaire and six Likert scales.

RESULTS

Higher baseline motivation across five of the seven measures predicted significant decreases in eating pathology, and increased Anorexia Nervosa Stages of Change Questionnaire scores between baseline and 2 week follow up predicted significant improvement in eating pathology between baseline and 6 week follow up. Significantly more patients were lost to follow up from the treatment as usual compared to the motivational interviewing group. More patients in the motivational interviewing condition moved from low readiness to change at baseline to high readiness to change at 2 and 6 week follow up.

CONCLUSIONS

Motivation is an important predictor of change in anorexia nervosa and preliminary evidence is provided that motivation can be improved in this population. Further investigations, however, of ways of improving motivation in this population need to be conducted, along with the impact of motivational changes on treatment outcome.

Reconsidering the placebo response from a broad anthropological perspective

This paper considers how the full range of human experience may catalyze a placebo response. The placebo effect has been characterized as something to control in clinical research, something to cultivate in clinical practice and something present in all healing encounters. We examine domains in which the term 'placebo' is used in discourse: clinical research, clinical practice, media representations of treatment efficacy and lay interpretations of placebo--an underresearched topic. We briefly review major theoretical frameworks proposed to explain the placebo effect: classical conditioning, expectancy, the therapeutic relationship and sociocultural 'meaning.' As a corrective to what we see as an overemphasis on conscious cognitive approaches to understanding placebo, we reorient the discussion to argue that direct embodied experience may take precedence over meaning-making in the healing encounter. As an example, we examine the neurobiology of rehearsing or visualizing wellness as a mode of directly (performatively) producing an outcome often dismissed as a 'placebo response.' Given body/mind/emotional resonance, we suggest that the placebo response is an evolutionarily adaptive trait and part of healing mechanisms operating across many levels--from genetic and cellular to social and cultural.

Mindfulness-based acceptance and posttraumatic stress symptoms among trauma-exposed adults without axis I psychopathology

The present investigation examined the incremental predictive validity of mindfulness-based processes, indexed by the Kentucky Inventory of Mindfulness Skills, in relation to posttraumatic stress symptom severity among individuals without any axis I psychopathology. Participants included 239 adults who endorsed exposure to traumatic life events. Results indicated that the Accepting without Judgment subscale was significantly incrementally associated with posttraumatic stress symptoms; effects were above and beyond the variance accounted for by negative affectivity and number of trauma types experienced. The Acting with Awareness subscale was incrementally associated with only posttraumatic stress-relevant re-experiencing symptoms; and no other mindfulness factors were related to the dependent measures. Findings are discussed in relation to extant empirical and theoretical work relevant to mindfulness and posttraumatic stress.

Attitude formation in depression: evidence for deficits in forming positive attitudes

While a wealth of research has found that depressive symptoms are related to current attitudes, new evidence suggests depressive symptoms may be related to a fundamental deficit in forming new attitudes. Researchers investigating individual differences in attitude formation have found that depressive symptoms are strongly correlated with poorer learning of positive stimuli. This study extended these findings to a sample including clinically depressed participants. Results show that, as compared to nondepressed individuals, depressed individuals are characterized by a large deficit in their learning of positive stimuli. Implications of this fundamental deficit are discussed.

Recent evidence supports emotion-regulation interventions for improving health in at-risk and clinical populations

PURPOSE OF REVIEW

The regulation of strong emotions has important implications for health, particularly among individuals with chronic illness. We focus this brief review on effective psychosocial interventions that emphasize and teach skills to improve emotion regulation in the context of health-related outcomes.

RECENT FINDINGS

Recent work in the area of emotion-regulation interventions has tested the effects of emotion-regulation family therapy, group-based emotion-regulation psychotherapy, expressive writing, and school-based prevention programs. Emotion-regulation psychotherapy for families shows some benefits for both patients and their family members. Group emotion-regulation interventions and expressive writing result in physical and psychosocial improvement for patients with medical or psychiatric illness. School-based programs show improved emotion knowledge, emotion regulation, and emotional competence, relative to standard academic curricula and existing prevention programs.

SUMMARY

Evidence generally supports the use of a variety of emotion-regulation interventions to improve health and well being in at-risk and clinical populations, although factors related to treatment response warrant additional research.

Disparities in treating culturally diverse children and adolescents

This article considers disparities in the psychiatric care of racial and ethnic children and adolescents, with respect to their under-utilization and under-treatment, especially with psychotropic medications. Culturally adapted psychotherapeutic approaches are discussed, as well as the notion of a culturally competent clinician who strives to apply his or her clinical skills while constantly making adjustments to the beliefs, habits, and circumstances of culturally diverse children and their parents, one patient at a time.

Neurobiology of empathy and callousness: implications for the development of antisocial behavior

Information on the neurobiology of empathy and callousness provides clinicians with an opportunity to develop sophisticated understanding of mechanisms underpinning antisocial behavior and its counterpart, moral decision-making. This article provides an integrated in-depth review of hormones (e.g. peripheral steroid hormones such as cortisol) and brain structures (e.g. insula, anterior cingulate cortex, and amygdala) implicated in empathy, callousness, and psychopathic-like behavior. The overarching goal of this article is to relate these hormones and brain structures to moral decision-making. This review will begin in the brain, but will then integrate information about biological functioning in the body, specifically stress-reactivity. Our aim is to integrate understanding of neural processes with hormones such as cortisol, both of which have demonstrated relationships to empathy, psychopathy, and antisocial behavior. The review proposes that neurobiological impairments in individuals who display little empathy are not necessarily due to a reduced ability to understand the emotions of others. Instead, evidence suggests that individuals who show little arousal to the distress of others likewise show decreased physiological arousal to their own distress; one manifestation of reduced stress reactivity may be a dysfunction in empathy, which supports psychopathic-like constructs (e.g. callousness). This integration will assist in the development of objective methodologies that can inform and monitor treatment interventions focused on decreasing antisocial behavior.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS): school-based treatment on a rural American Indian reservation

This study examines a pilot school-based treatment program for American Indian adolescents residing on a reservation who presented with symptoms of Posttraumatic Stress Disorder (PTSD) and symptoms of depression. This is the first study directed at treating American Indian children with trauma; seven case studies demonstrate our findings that a manualized cognitive behavior therapy intervention delivered in group format for 10 weeks has potential for helping some children who experience PTSD symptoms and depression. The findings generally replicate previous research conducted with groups of non-Indian adolescents in urban settings. PTSD and depressive symptoms decreased for three of the four students who completed treatment. Directions for future research include the need to understand and control attrition and to address cultural influences, including making adaptations in the cognitive behavioral formulations and techniques regarding feelings as operant behaviors. Results contribute to knowledge of feasibility and acceptability of cultural adaptations of CBT for trauma in an under-served population.