Anger and irritability

Trait anger representation in microstructural white matter tracts: A diffusion MRI study

BACKGROUND

Understanding the microstructure of the brain that underlies emotions is of pivotal importance for psychology and psychiatry. Herein, we investigated white matter (WM) tracts associated with anger using the diffusion magnetic resonance imaging (DMRI) connectometry approach while exploring potential sex differences.

METHODS

225 healthy participants from the LEMON database were evaluated using the State-Trait Anger Expression Inventory (STAXI). WM images were prepared and analyzed with DMRI. Multiple regression models were fitted to address the correlation of local connectomes with STAXI components with age and handedness as covariates.

RESULTS

There were no statistically significant differences in state anger and trait anger between males and females (p = 0.55 and 0.30, respectively). DMRI connectometry revealed that quantitative anisotropy (QA) values in the bilateral corticospinal tract (CST), splenium of corpus callosum (SCC), middle cerebellar peduncle, left inferior cerebellar peduncle, left cingulum, and left fornix were negatively correlated with trait anger and trait anger temperament (TAT) in males. In contrast, the QA values in the bilateral CST and SCC showed a positive correlation with trait anger and TAT in females, which, however, did not reach statistical significance.

LIMITATIONS

The cross-sectional design and self-reported measures of anger limit the generalizability of our results.

CONCLUSIONS

This is the first DMRI connectometry study to investigate WM circuits involved in anger. We found that the pathways associated with the limbic system and movement-related regions were involved in trait anger and anger expression in men, while no brain pathways showed a significant relationship with anger in women.

A psychodynamic contribution to the understanding of anger - The importance of diagnosis before treatment

This paper starts from the claim that a shared understanding of anger, in both its normal and psychopathological dimensions, is missing and that there are various therapeutic paths that seem to be less effective than those related to other pathologies. A major limitation of anger research and of its treatments lies in the lack of precise clinical diagnoses to inform therapy. For this reason, the first aim of our work is to survey critical literature in order to find useful elements to differentiate anger, starting from the evidence of negative and positive outcomes of treatments. Such evidence will then be enhanced in our proposal of interpretation and intervention, within a dynamic framework and with particular reference to Orefice’s thought. The core focus is to explore the different functions that anger has for the patient and to investigate the elementary functioning of the self. Our reading of the phenomena related to anger will provide useful tools both for understanding the dynamics underlying anger and as a guide for clinical intervention.

Measuring depression in adolescence: Evaluation of a hierarchical factor model of the Children's Depression Inventory and measurement invariance across boys and girls

BACKGROUND

One of the most widely used instruments to measure depression in childhood and adolescence is Kovacs's Children's Depression Inventory (CDI). Even though this particular measure sparked massive interest among researchers, there is no clear consensus about its factorial structure. It has been suggested that inconsistencies in findings can be partly ascribed to the cultural context. The aim of this study was a) to examine and verify the factor structure of CDI in the Czech population and b) to assess gender-related psychometric differences using the mean and covariance structure (MACS) approach and differential item functioning (DIF) analysis.

METHODS

The research sample consisted of 1,515 adolescents (ages 12 to 16 years, 53.7% female) from a non-clinical general population. Based on exploratory factor analysis (EFA) on a random subsample (N = 500), we proposed a model that was subsequently tested on the rest of the sample (N = 1,015) using confirmatory factor analysis (CFA). Following the MACS procedure, we assessed measurement invariance in boys and girls. The between-group comparison was further supplemented by a DIF analysis.

RESULTS

The proposed hierarchical four-factor model (General Symptoms, Negative Self-Concept, Inefficiency, and Social Anhedonia) with a second-order factor of depression fitted the data reasonably well (χ2 = 1281.355; df = 320; RMSEA = 0.054, CFI = 0.925). Regarding gender differences, we found no substantial signs of measurement invariance using the MACS approach. Boys and girls differed in first-order latent means (girls scored higher on General Symptoms with a standardized mean difference of 0.52 and on Negative Self-Concept with a standardized mean difference of 0.31). DIF analysis identified three items with differential functioning. However, the levels of differential functioning were only marginal (in two items) or marginal/moderate and the presence of DIF does not substantially influence scoring of CDI.

CONCLUSION

In the general adolescent population in the Czech Republic, the CDI can be considered a reliable instrument for screening purposes in clinical settings and for use in research practice. Instead of the originally proposed five-factor model, we recommend using the newly established four-factor structure. The measure seems to show only marginal psychometric differences with respect to gender, and overall measurement invariance in boys and girls seems to be a tenable assumption.

The role of genetic and environmental factors in covariation between anxiety and anger in childhood

Higher levels of anger expression, as well as lower levels of anger control, have been reported for adults with anxiety disorders compared to individuals without anxiety disorders. Different to the research on adults, very few studies examined the relationship between anxiety and anger in childhood. In our study, we investigated 398 Italian twin pairs (74 MZ male, 70 MZ female, 134 same-sex dizygotic-53 male, 81 female-, and 120 unlike-sex dizygotic twin pairs), aged 8-17 (mean 13.06 ± 2.59): (i) the heritability of a childhood anger phenotype; (ii) the association between five anxiety domains and anger; (iii) the role of possible common etiological factors in explaining the observed comorbidity and overlap in the risk between anxiety phenotypes and anger. The study demonstrated that anger, assessed by CBCL items, is heritable in children at a similar rate to prior studies (40%). Our research found low to moderate rate of correlation between anger and anxiety (from 0.10 to 0.19). Finally, the present study found that the majority of etiological influences on anxiety and anger are independent of each other. Data showed that shared environmental influences have some small effects on the phenotypic covariation between the anxiety phenotypes and anger (12%); whereas unique environmental influences have an almost negligible effect (1%). Our analyses did not reveal the effect of genetic effects in explaining the covariation between these phenotypes.

Hostility in cancer patients as an underexplored facet of distress

OBJECTIVE

In the present study, we aimed to assess hostility and to examine its association with formal psychiatric diagnosis, coping, cancer worries, and quality of life in cancer patients.

METHODS

The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to make an ICD-10 (International Classification of Disease) psychiatric diagnosis was applied to 516 cancer outpatients. The patients also completed the Brief Symptom Inventory-53 to assess hostility (BSI-HOS), and the Mini-Mental Adjustment to cancer scale (Mini-MAC). A subset of patients completed the Cancer Worries Inventory (CWI), the Openness Scale, and the Quality of Life Index.

RESULTS

By analyzing the distribution of the responses 25% of the patients had moderate and 11% high levels of hostility, with about 20% being BSI-HOS "cases." Hostility was higher in patients with a formal ICD-10 psychiatric diagnosis (mainly major depression, other depressive disorders, anxiety disorders) than patients without ICD-10 diagnosis. However, about 25% of ICD-10-non cases also had moderate-to-high hostility levels. Hostility was associated with Mini-MAC hopelessness and anxious preoccupation, poorer quality of life, worries (mainly problems sin interpersonal relationships), and inability to openly discuss these problems within the family.

CONCLUSIONS

Hostility and its components should be considered as dimensions to be more carefully explored in screening for distress in cancer clinical settings for its implications in negatively impacting on quality of life, coping and relationships with the family, and possibly the health care system.

Influence of traffic congestion on driver behavior in post-congestion driving

Traffic congestion is more likely to lead to aggressive driving behavior that is associated with increased crash risks. Previous studies mainly focus on driving behavior during congestion when studying congestion effects. However, the negative effects of congestion on driving behavior may also affect drivers' post-congestion driving. To fill this research gap, this study examined the influence of traffic congestion on driver behavior on the post-congestion roads (i.e., the roads travelled right after congestion). Twenty-five subjects participated in a driving simulation study. They were asked to complete two trials corresponding to post-congestion and non-congestion conditions, respectively. Driver behavior quantified by driving performance measures, eye movement measures, and electroencephalogram (EEG) measures was compared between the two conditions. Ten features were selected from the measures with statistical significance. The selected features were integrated to characterize drivers' response patterns using a hierarchical clustering method. The results showed that driver behavior in post-congestion situations became more aggressive, more focused in the forward area but less focused in the dashboard area, and was associated with lower power of the β-band in the temporal brain region. The clustering results showed more aggressive and lack-of-aware response patterns while driving in post-congestion situations. This study revealed that traffic congestion negatively affected driver behavior on the post-congestion roads. Practical implications for driving safety education was discussed based on the findings from the present study.

Irritability as a Transdiagnostic Vulnerability Trait:Current Issues and Future Directions

In recent years, irritability has received increasing attention among mental health professionals given its transdiagnostic associations with diverse forms of psychopathology. In contrast to other emotional states and traits, however, literature addressing associations between irritability and related temperament and personality constructs is limited. In addition, those who study irritability have diverse perspectives on its neurobiological substrates. In this comment, we situate irritability in the literatures on child temperament and adult personality, and describe a model in which irritability derives from low tonic dopamine (DA) levels and low phasic DA reactivity in subcortical neural structures implicated in appetitive responding. We note that different findings often emerge in neuroimaging studies when irritability is assessed in circumscribed diagnostic groups versus representative samples. We conclude with directions for future research, and propose that more authors use hierarchical Bayesian modeling, which captures functional dependencies between irritability and other dispositional traits (e.g., trait anxiety) that standard regression models are insensitive too. Treatment implications are also considered.

Moral cognition, the missing link between psychotic symptoms and acts of violence: a cross-sectional national forensic cohort study

BACKGROUND

People with schizophrenia are ten times more likely to commit homicide than a member of the general population. The relationship between symptoms of schizophrenia and acts of violence is unclear. There has also been limited research on what determines the seriousness and form of violence, such as reactive or instrumental violence. Moral cognition may play a paradoxical role in acts of violence for people with schizophrenia. Thoughts which have moral content arising from psychotic symptoms may be a cause of serious violence.

METHOD

We investigated if psychotic symptoms and moral cognitions at the time of a violent act were associated with acts of violence using a cross-sectional national forensic cohort (n = 55). We examined whether moral cognitions were associated with violence when controlling for neurocognition and violence proneness. We explored the association between all psychotic symptoms present at the time of the violent act, psychotic symptoms judged relevant to the violent act and moral cognitions present at that time. Using mediation analysis, we examined whether moral cognitions were the missing link between symptoms and the relevance of symptoms for violence. We also investigated if specific moral cognitions mediated the relationship between specific psychotic symptoms, the seriousness of violence (including homicide), and the form of violence.

RESULTS

Psychotic symptoms generally were not associated with the seriousness or form of violence. However, specific moral cognitions were associated with the seriousness and form of violence even when controlling for neurocognition and violence proneness. Specific moral cognitions were associated with specific psychotic symptoms present and relevant to violence. Moral cognitions mediated the relationship between the presence of specific psychotic symptoms and their relevance for violence, homicide, seriousness of violence, and the form of violence.

CONCLUSIONS

Moral cognitions including the need to reduce suffering, responding to an act of injustice or betrayal, the desire to comply with authority, or the wish to punish impure or disgusting behaviour, may be a key mediator explaining the relationship between psychotic symptoms and acts of violence. Our findings may have important implications for risk assessment, treatment and violence prevention.

Angry Drivers Take Risky Decisions: Evidence from Neurophysiological Assessment

The present study investigated the risk-taking behaviors of angry drivers, which were coincidentally measured via behavioral and electroencephalographic (EEG) recordings. We manipulated a driving scenario that concerned a Go/No-Go decision at an intersection when the controlling traffic light was in its yellow phase. This protocol was based upon the underlying format of the Iowa gambling task. Variation in the anger level was induced through task frustration. The data of twenty-four drivers were analyzed via behavioral and neural recordings, and P300 was specifically extracted from EEG traces. In addition, the behavioral performance was indexed by the percentage of high-risk choices minus the number of the low-risk choices taken, which identified the risk-taking propensity. Results confirmed a significant main effect of anger on the decisions taken. The risk-taking propensity decreased across the sequence of trial blocks in baseline assessments. However, with anger, the risk-taking propensity increased across the trial regimen. Drivers in anger state also showed a higher mean amplitude of P300 than that in baseline state. Additionally, high-risk choices evoked larger P300 amplitude than low-risk choices during the anger state. Moreover, the P300 amplitude of high-risk choices was significantly larger in the anger state than the baseline state. The negative feedback induced larger P300 amplitude than that recorded in positive feedback trials. The results corroborated that the drivers exhibited higher risk-taking propensity when angry although they were sensitive to the inherent risk-reward evaluations within the scenario. To reduce this type of risk-taking, we proposed some effective/affective intervention methods.

Do men need special services?

The targeting of services to groups with special needs is today commonplace in enlightened public health policies. To list men among the ‘minorities’ in need of such special help might have the semblance of satire. This air of levity is not really reduced by listing male's shorter life expectancy, higher infant mortality and higher rates of natural and unnatural deaths in all age groups (Drever & Bunting, 1997; Kelly & Bunting, 1998).

Internalized and Externalized Anger in Adolescent Suicide Attempters

Anger can play an important role in adolescent suicidal behavior However, there is disagreement over the relative importance of internalized versus externalized anger The present study evaluated mode of anger expression in 104 adolescent suicide attempters and 323 high school students. The suicide attempters also completed measures of depression and hopelessness. Results indicated that suicidal adolescents displayed an increased likelihood of experiencing anger, reported significantly higher levels of both internalized and externalized anger, and displayed reduced tendencies for impulse control. Hierarchical multiple regression analyses found that the general inclination to experience anger was most closely related to externalized anger and poor impulse control. Among the adolescent suicide attempters, depression and hopelessness were related to internalized but not externalized anger Thus, it may be useful to assess the mode of anger expression when evaluating adolescents for suicide risk.

Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder

BACKGROUND

There is a broad literature suggesting that cognitive difficulties are associated with violence across a variety of groups. Although neurocognitive and social cognitive deficits are core features of schizophrenia, evidence of a relationship between cognitive impairments and violence within this patient population has been mixed.

METHODS

We prospectively examined whether neurocognition and social cognition predicted inpatient violence amongst patients with schizophrenia and schizoaffective disorder (n = 89; 10 violent) over a 12 month period. Neurocognition and social cognition were assessed using the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Using multivariate analysis neurocognition and social cognition variables could account for 34 % of the variance in violent incidents after controlling for age and gender. Scores on a social cognitive reasoning task (MSCEIT) were significantly lower for the violent compared to nonviolent group and produced the largest effect size. Mediation analysis showed that the relationship between neurocognition and violence was completely mediated by each of the following variables independently: social cognition (MSCEIT), symptoms (PANSS Total Score), social functioning (SOFAS) and violence proneness (HCR-20 Total Score). There was no evidence of a serial pathway between neurocognition and multiple mediators and violence, and only social cognition and violence proneness operated in parallel as significant mediators accounting for 46 % of the variance in violent incidents. There was also no evidence that neurocogniton mediated the relationship between any of these variables and violence.

CONCLUSIONS

Of all the predictors examined, neurocognition was the only variable whose effects on violence consistently showed evidence of mediation. Neurocognition operates as a distal risk factor mediated through more proximal factors. Social cognition in contrast has a direct effect on violence independent of neurocognition, violence proneness and symptom severity. The neurocognitive impairment experienced by patients with schizophrenia spectrum disorders may create the foundation for the emergence of a range of risk factors for violence including deficits in social reasoning, symptoms, social functioning, and HCR-20 risk items, which in turn are causally related to violence.

The anger syndrome hwa-byung and its comorbidity

BACKGROUND

The aim of this study was to identify patients with hwa-byung (HB), a Korean culture-related anger syndrome, and to compare the comorbidities of HB with those of other psychiatric disorders.

METHODS

The study participants included 280 patients with depressive disorders, anxiety disorders, somatoform disorders, adjustment disorders, or self-labeled hwa-byung. For all patients, the DSM-IV diagnosis was made using the Korean version of the Structured Clinical Interview for the DSM-IV Diagnosis (SCID-1). The diagnosis of HB was made according to research diagnostic criteria of HB. Assessment of HB symptoms was performed using the Hwa-byung Scale.

RESULTS

Female patients were more and mean age was older in HB group than non-HB group. Of 280 patients, 183 patients were diagnosed with HB. Forty-seven of these patients had only HB, and the rest had various comorbid DSM-IV diagnoses, with major depressive disorder (MD) and generalized anxiety disorder (GAD) being the most frequent. The distributions of single diagnoses and comorbid diagnoses were similar for HB, MD and GAD.

LIMITATIONS

Sample size may be small, axis II diagnoses were not assessed, and patients with psychotic features were not included.

CONCLUSIONS

Our results suggest that HB, which comprises unique anger-related symptoms, is comparable to MD or GAD in comorbidity profile.

Aggressive behavior model in schizophrenic patients

This study aimed to determine the optimal model for explaining the aggressive behavior of schizophrenic patients in relation to certain behavioral variables including anger, schizophrenic symptoms, and cognitive function. Schizophrenic patients were evaluated with the Modified Overt Aggression Scale (MOAS) for aggressive behaviors, with irritability and resentment; with the Buss-Durkee Hostility Inventory (BDHI) for anger; with the Wisconsin Card Sorting Test (WCST) and the Grooved Pegboard Test for cognitive function; and with the Positive and Negative Syndrome Scale (PANSS) for schizophrenic symptoms. The structural equation model (SEM) in AMOS 7 for the score of "aggressive behavior in the last week" in the MOAS, was used for statistical analysis. For the SEM, two factors (irritability and resentment) were selected from the BDHI and constituted the anger construct. Through factor analysis, two factors (executive function and motor function) were selected from the cognitive function measurements to constitute the cognitive function construct. Two factors (positive and negative symptoms) in the PANSS constituted the symptom construct. The best model for aggressive behavior (MOAS) with three constructs revealed a direct, significant path of "anger emotion to aggressive behavior". This result suggests that the aggressive behavior of schizophrenic patients is directly related to anger. Schizophrenic symptoms and cognitive function were indirectly related to aggressive behavior through the relationship between the emotion of anger and aggressive behavior.

Symptoms to use for diagnostic criteria of hwa-byung, an anger syndrome

OBJECTIVE

The aim of this study was to identify the characteristic symptoms which can be used for the diagnosis of hwa-byung, a culture-related anger syndrome in Korea.

METHODS

The symptoms of the Hwa-byung Scale were correlated with the Korean versions of the Hamilton Depression Rating Scale (K-HDRS) and the State and Trait Anger Inventory (K-STAXI) in 89 patients, who were diagnosed as having major depressive disorder, dysthymic disorder, anxiety disorders, somatoform disorders, or adjustment disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria and who had self-labeled hwa-byung. Also, the symptoms of the Hwa-byung Scale were correlated with each other.

RESULTS

The symptoms of the Hwa-byung Scale which were significantly correlated with the state anger of the K-STAXI but not with the depressive mood (item 1 of K-HDRS) included feelings of unfairness, subjective anger, external anger, heat sensation, pushing-up in the chest, dry mouth, and sighing. The symptoms which were significantly correlated with state anger and depressed mood included respiratory stuffiness, "haan" and hate. The symptoms which were not significantly correlated with depressed mood and state anger included going-out, epigastric mass, palpitation, headache/pain, frightening easily, many thoughts, and much pleading. These symptoms also showed higher correlation with each other in the correlation matrix.

CONCLUSION

Our findings suggest that hwa-byung is different from depressive syndrome in terms of its symptom profile, and suggest what symptoms should be included in the diagnostic criteria of hwa-byung, an anger disorder.

Clinical correlates of hwa-byung and a proposal for a new anger disorder

This paper reviewed the studies on hwa-byung (HB), which literally means anger disorder and this is known as the culture-related chronic anger syndrome of Koreans. Based on these studies and a review of the literature on the anger syndromes of other cultures, I have proposed a new anger disorder. The rationale for this proposition is first that the clinical correlates of HB, including the epidemiological data, the etiological factors, the symptoms and the clinical course, are unique and different from those of the depressive disorders, which have been postulated to be similar to HB. Second, the symptoms of HB are characterized by pent-up anger and somatic and behavioral symptoms related to the release and suppression of anger. Third, a group of patients with only HB and who visit psychiatrists for treatment have been identified. Fourth, anger is thought to be the basic target of treatment for HB patients. Last, anger syndromes like HB have been identified, with various names, in other cultures. By reducing the cultural variation of HB and integrating the common clinical correlates of the syndromes related to anger, a new anger disorder for the mood of anger can be conceptualized, like that for other mood disorders for the corresponding pathological moods. The research diagnostic criteria for HB and the new anger disorder are also suggested. I propose that the new anger disorder to be included in the new international classification system as a member of the larger family of mood disorders. International collaborative studies are needed not only to identify such anger disorder in various cultures, but also to explore giving better treatment to these patients based on the bio-psycho-social model of anger disorder.

Typus melancholicus: personality structure and the characteristics of major unipolar depressive episode

BACKGROUND

The melancholic type of personality (TM) has long been considered in continental and Japanese psychopathology as a relevant vulnerability trait constellation for the development of depression.

METHOD

The symptom presentation in an outpatient population of 116 subjects suffering from a DSM-IV major depressive episode was rated according to the standardized documentation system of the Association for Methodology and Documentation in Psychiatry (AMDP). Personality features were explored by means of the Criteria for Typus Melancholicus (CTM).

RESULTS

Statistically significant differences in depression-related psychopathological scores (i.e. higher level of guilt feelings, feeling of the loss of feelings, loss of vital drive and lower degrees of irritability and dysphoria) were found between TM and non-TM subjects, supporting the phenomenic specificity of TM depression at both symptom and subsyndromal level. LIMITATION AND CONCLUSIONS: Although our results were obtained in a selected sample of outpatients at an University Mental Health Center, they are indicative of psychopathological differences between TM and NTM in the core symptoms of depression. These differences highlight the importance of including TM criteria for phenotypic characterization of depressive disorder, suggesting that it may improve diagnostic and therapeutic practice and might be a reasonable psychopathologic endophenotype in investigating affective-spectrum vulnerability in at-risk populations.

Medication-free research in early episode schizophrenia: evidence of long-term harm?

This study investigates the question of whether short periods of medication-free research in early episode schizophrenia result in demonstrable long-term harm to human subjects. A meta-analysis of published quasi-experimental and random assignment studies that had a majority of first- or second-episode schizophrenia spectrum subjects, at least 1 initially unmedicated group, and a minimum of 1-year results was conducted. Only 6 studies, with 623 subjects, met inclusion criteria. The initially unmedicated groups showed a small, statistically nonsignificant long-term advantage (r = -0.09). Incorporating only random assignment studies into a composite effect size produced a similar near-zero result (r = 0.01). Good-quality evidence is inadequate to support a conclusion of long-term harm resulting from short-term postponement of medication in early episode schizophrenia research. A categorical prohibition against such research should be reconsidered.

Relationship of anger and anger attacks with depression: a brief review

Anger is a common and potentially destructive emotion that has considerable social and public health importance. The occurrence of anger, irritability and hostility in depression have been known for many years, but the prevalence, significance for treatment and prognosis and the mechanisms involved remain poorly understood. More recently, anger attacks have been proposed as a specific form of anger in depression. They are characterized by a rapid onset of intense anger and a crescendo of autonomic arousal occurring in response to trivial provocations. Though the presence or absence of hostility, anger and aggression in depression has been a matter of controversy, anger attacks have been found to occur more often in depressed patients in comparison to healthy controls. Some studies have reported that depressed patients with anger attacks differ from those without such attacks in terms of clinical profile, comorbid personality disorders and certain biological variables. Serotonergic dysfunction may characterize this distinct subtype of depression - depression with anger attacks.

Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria project

The Soteria project (1971-1983) compared residential treatment in the community and minimal use of antipsychotic medication with "usual" hospital treatment for patients with early episode schizophrenia spectrum psychosis. Newly diagnosed DSM-II schizophrenia subjects were assigned consecutively (1971 to 1976, N = 79) or randomly (1976 to 1979, N = 100) to the hospital or Soteria and followed for 2 years. Admission diagnoses were subsequently converted to DSM-IV schizophrenia and schizophreniform disorder. Multivariate analyses evaluated hypotheses of equal or better outcomes in Soteria on eight individual outcome measures and a composite outcome scale in three ways: for endpoint subjects (N = 160), for completing subjects (N = 129), and for completing subjects corrected for differential attrition (N = 129). Endpoint subjects exhibited small to medium effect size trends favoring experimental treatment. Completing subjects had significantly better composite outcomes of a medium effect size at Soteria (+.47 SD, p =.03). Completing subjects with schizophrenia exhibited a large effect size benefit with Soteria treatment (+.81 SD, p =.02), particularly in domains of psychopathology, work, and social functioning. Soteria treatment resulted in better 2-year outcomes for patients with newly diagnosed schizophrenia spectrum psychoses, particularly for completing subjects and for those with schizophrenia. In addition, only 58% of Soteria subjects received antipsychotic medications during the follow-up period, and only 19% were continuously maintained on antipsychotic medications.

Irritability during the month of Ramadan

OBJECTIVES

We hypothesized that people in Morocco are more irritable during the month of Ramadan than during the rest of the year. Our objectives were to measure irritability in fasting Muslims during the month of Ramadan, to describe its various modes of expression, and to examine risk factors for this irritability.

METHODS AND SUBJECTS

We studied 100 healthy volunteers during the month of Ramadan for two successive years (1994 and 1995). All subjects were male (mean age, 32+/-5.8 years), and 51% of them were smokers. Irritability was assessed over a 6-week period (before, four times during, and after the end of Ramadan). We assessed both subjective (visual analog scale) and objective irritability. We also recorded the consumption of psychostimulants, duration of sleep, and anxiety level as measured by the Hamilton Anxiety Scale.

RESULTS

Irritability was significantly higher in smokers than in nonsmokers before the beginning of Ramadan. It was higher in both groups during the Ramadan month. Irritability increased continuously during Ramadan and reached its peak at the end of the month. Consumption of psychostimulants (coffee and tea) and anxiety level followed the same pattern. Smokers and nonsmokers had a similar pattern of irritability over time, but irritability increased more in smokers than in nonsmokers.

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

The author reviews the clinical and special social environmental data from the Soteria Project and its direct successors. Two random assignment studies of the Soteria model and its modification for long-term system clients reveal that roughly 85% to 90% of acute and long-term clients deemed in need of acute hospitalization can be returned to the community without use of conventional hospital treatment. Soteria, designed as a drug-free treatment environment, was as successful as anti-psychotic drug treatment in reducing psychotic symptoms in 6 weeks. In its modified form, in facilities called Crossing Place and McAuliffe House where so-called long-term "frequent flyers" were treated, alternative-treated subjects were found to be as clinically improved as hospital-treated patients, at considerably lower cost. Taken as a body of scientific evidence, it is clear that alternatives to acute psychiatric hospitalization are as, or more, effective than traditional hospital care in short-term reduction of psychopathology and longer-term social adjustment. Data from the original drug-free, home-like, nonprofessionally staffed Soteria Project and its Bern, Switzerland, replication indicate that persons without extensive hospitalizations (<30 days) are especially responsive to the positive therapeutic effects of the well-defined, replicable Soteria-type special social environments. Reviews of other studies of diversion of persons deemed in need of hospitalization to "alternative" programs have consistently shown equivalent or better program clinical results, at lower cost, from alternatives. Despite these clinical and cost data, alternatives to psychiatric hospitalization have not been widely implemented, indicative of a remarkable gap between available evidence and clinical practice.

The concept of affect logic: an integrative psycho-socio-biological approach to understanding and treatment of schizophrenia

In this article, the psycho-socio-biologically integrative concept of affect-logic, and its relevance for a comprehensive understanding and therapy of schizophrenia, is briefly presented. This concept has been developed by the author over the past 20 years, on the basis of the literature, of clinical experience and his own research into long-term evolution, rehabilitation, effects of milieu-therapy, and nonlinear evolutionary dynamics of the illness. It postulates, basically, that fundamental affective states (or emotions, feelings, moods) are continuously and inseparably linked to all cognitive functioning (or "thinking" and "logic" in a broad sense), and that affects have essential organizing and integrating effects on cognition. Schizophrenia is understood as an altered mode of affective-cognitive interaction based, possibly, on disturbed (loosened) affective-cognitive connections. This hypothesis leads to: 1) an integrative psycho-socio-biological model of long-term evolution of the illness; 2) a new understanding of psychopathological core phenomena such as ambivalence, incoherence, and emotional flattening; 3) an innovative therapeutic approach based on an emotion-relaxing milieu and style of care; and 4) the hypothesis that schizophrenia could basically be an affective (and not a cognitive) disease, of another kind than mania or melancholia, however.

Psychiatric disorder among adolescents in custody

OBJECTIVE

To determine the diagnostic breakdown and comorbid patterns of 100 consecutive cases referred for psychiatric consultation at juvenile detention centres, and to compare diagnoses according to gender and legal status.

METHOD

Diagnoses were made at the time of an initial semi-structured clinical interview, and reviewed after follow-up.

RESULTS

There was an appreciable minority of young offenders with non-behaviour disordered diagnoses as well as a large number with conduct disorder and substance abuse. Conduct disorder and affective disorder were most influential on adjustment in the community.

CONCLUSION

Psychiatric initiatives are essential in the management of serious young offenders.