Original Article
The heritability of cluster A personality disorders assessed by both personal interview and questionnaire
- KENNETH S. KENDLER, JOHN MYERS, SVENN TORGERSEN, MICHAEL C. NEALE, TED REICHBORN-KJENNERUD
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- Published online by Cambridge University Press:
- 16 January 2007, pp. 655-665
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Background. Personality disorders (PDs) as assessed by questionnaires and personal interviews are heritable. However, we know neither how much unreliability of measurement impacts on heritability estimates nor whether the genetic and environmental risk factors assessed by these two methods are the same. We wish to know whether the same set of PD vulnerability factors are assessed by these two methods.
Method. A total of 3334 young adult twin pairs from the Norwegian Institute of Public Health Twin Panel (NIPHTP) completed a questionnaire containing 91 PD items. One to 6 years later, 1386 of these pairs were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV). Self-report items predicting interview results were selected by regression. Measurement models were fitted using Mx.
Results. In the best-fit models, the latent liabilities to paranoid personality disorder (PPD), schizoid personality disorder (SPD) and schizotypal personality disorder (STPD) were all highly heritable with no evidence of shared environmental effects. For PPD and STPD, only unique environmental effects were specific to the interview measure whereas both environmental and genetic effects were found to be specific to the questionnaire assessment. For SPD, the best-fit model contained genetic and environmental effects specific to both forms of assessment.
Conclusions. The latent liabilities to the cluster A PDs are highly heritable but are assessed by current methods with only moderate reliability. The personal interviews assessed the genetic risk for the latent trait with excellent specificity for PPD and STPD and good specificity for SPD. However, for all three PDs, the questionnaires were less specific, also indexing an independent set of genetic risk factors.
A naturalistic study of the effects of pharmacotherapy on substance use disorders among ADHD adults
- STEPHEN V. FARAONE, JOSEPH BIEDERMAN, TIMOTHY E. WILENS, JOEL ADAMSON
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- Published online by Cambridge University Press:
- 12 March 2007, pp. 1743-1752
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Background
Studies of adults with attention deficit hyperactivity disorder (ADHD) show an elevated prevalence of substance use disorders (SUDs) and the substance abuse literature shows that ADHD is elevated in substance users. Some researchers postulate that stimulant treatment of ADHD increases the risk for SUD in ADHD patients but follow-up studies suggest treatment protects patients from subsequent SUDs. This report uses retrospective data to assess the impact of prior ADHD pharmacotherapy on SUDs in 206 ADHD adults (n=79 late-onset ADHD, n=127 full ADHD) grouped by lifetime history of ADHD treatment (no treatment, past treatment, current and past treatment).
MethodStructured Clinical Interview for DSM-IV (SCID) data were used to establish abuse and dependence, and Drug Use Screening Inventory (DUSI) responses were used to establish prevalence of use, preference for cigarettes, alcohol and drugs of abuse, complications from use, and motivation for use (get high, change mood, sleep better).
ResultsNo differences were found in the prevalence of cigarette smoking, alcohol or drug abuse or dependence, as well as no significant differences in 1-month prevalence of any use or use more than 20 times. No differences were found in complications of drug or alcohol use across groups. Subjects with current treatment rated getting high as a motivating factor significantly more frequently than subjects in the past treatment group; this result lost significance when we included ADHD diagnostic category.
ConclusionsOur results are consistent across substances and ADHD diagnoses, and support the hypothesis that pharmacotherapy does not cause subsequent SUDs.
Work stress precipitates depression and anxiety in young, working women and men
- MARIA MELCHIOR, AVSHALOM CASPI, BARRY J. MILNE, ANDREA DANESE, RICHIE POULTON, TERRIE E. MOFFITT
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- Published online by Cambridge University Press:
- 04 April 2007, pp. 1119-1129
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Background
Rates of depression have been rising, as have rates of work stress. We tested the influence of work stress on diagnosed depression and anxiety in young working adults.
MethodParticipants were enrolled in the Dunedin study, a 1972–1973 longitudinal birth cohort assessed most recently in 2004–2005, at age 32 (n=972, 96% of 1015 cohort members still alive). Work stress (psychological job demands, work decision latitude, low work social support, physical work demands) was ascertained by interview. Major depressive disorder (MDD) and generalized anxiety disorder (GAD) were ascertained using the Diagnostic Interview Schedule (DIS) and diagnosed according to DSM-IV criteria.
ResultsParticipants exposed to high psychological job demands (excessive workload, extreme time pressures) had a twofold risk of MDD or GAD compared to those with low job demands. Relative risks (RRs) adjusting for all work characteristics were: 1·90 [95% confidence interval (CI) 1·22–2·98] in women, and 2·00 (95% CI 1·13–3·56) in men. Analyses ruled out the possibility that the association between work stress and disorder resulted from study members' socio-economic position, a personality tendency to report negatively, or a history of psychiatric disorder prior to labour-market entry. Prospective longitudinal analyses showed that high-demand jobs were associated with the onset of new depression and anxiety disorder in individuals without any pre-job history of diagnosis or treatment for either disorder.
ConclusionsWork stress appears to precipitate diagnosable depression and anxiety in previously healthy young workers. Helping workers cope with work stress or reducing work stress levels could prevent the occurrence of clinically significant depression and anxiety.
State affective instability in borderline personality disorder assessed by ambulatory monitoring
- ULRICH W. EBNER-PRIEMER, JANICE KUO, NIKOLAUS KLEINDIENST, STACY S. WELCH, THOMAS REISCH, IRIS REINHARD, KLAUS LIEB, MARSHA M. LINEHAN, MARTIN BOHUS
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- Published online by Cambridge University Press:
- 04 January 2007, pp. 961-970
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Background. Although affective instability is an essential criterion for borderline personality disorder (BPD), it has rarely been reported as an outcome criterion. To date, most of the studies assessing state affective instability in BPD using paper-pencil diaries did not find indications of this characteristic, whereas in others studies, the findings were conflicting. Furthermore, the pattern of instability that characterizes BPD has not yet been identified.
Method. We assessed the affective states of 50 female patients with BPD and 50 female healthy controls (HC) during 24 hours of their everyday life using electronic diaries.
Results. In contrast to previous paper-and-pencil diary studies, heightened affective instability for both emotional valence and distress was clearly exhibited in the BPD group but not in the HC group. Inconsistencies in previous papers can be explained by the methods used to calculate instability (see Appendix). In additional, we were able to identify a group-specific pattern of instability in the BPD group characterized by sudden large decreases from positive mood states. Furthermore, 48% of the declines from a very positive mood state in BPD were so large that they reached a negative mood state. This was the case in only 9% of the HC group, suggesting that BPD patients, on average, take less time to fluctuate from a very positive mood state to a negative mood state.
Conclusion. Future ambulatory monitoring studies will be useful in clarifying which events lead to the reported, sudden decrease in positive mood in BPD patients.
Suicide and occupation: the impact of socio-economic, demographic and psychiatric differences
- ESBEN AGERBO, DAVID GUNNELL, JENS PETER BONDE, PREBEN BO MORTENSEN, MERETE NORDENTOFT
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- Published online by Cambridge University Press:
- 20 April 2007, pp. 1131-1140
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Background
To explore the risk of suicide associated with occupation while evaluating the impact of socio-economic, demographic and psychiatric differences.
MethodA nested case–control study with 3195 suicides and 63 900 matched controls. Information on causes of death, occupation, psychiatric admission, marital status and socio-economic factors was obtained from routine registers.
ResultsAcross the 55 occupations investigated, the risk of suicide ranged from 2·73 [95% confidence interval (CI) 1·77–4·22] among doctors to 0·44 (95% CI 0·27–0·72) among architects and engineers compared with primary school teachers. With the exception of doctors and nurses, most of the excess risk of suicide associated with particular occupations is explained by the social and economic characteristics of people in those occupations. Much, but not all, of the excess risk in doctors and nurses is due to their increased use of self-poisoning, a method for which they have the knowledge to use effectively. Occupation has little association with suicide among people who suffer from a psychiatric illness, except for doctors, where the excess risk is 3·62 (p=0·007).
ConclusionsMost of the considerable variation in suicide risk across occupations is explained by socio-economic factors, except for doctors and nurses. Apart from in doctors, the risk of suicide has little association with occupation among people who suffer from a psychiatric illness. Restriction of access to lethal means is an important strategy in suicide prevention.
Patterns of subjective memory impairment in the elderly: association with memory performance
- FRANK JESSEN, BIRGITT WIESE, GABRIELA CVETANOVSKA, ANGELA FUCHS, HANNA KADUSZKIEWICZ, HEIKE KÖLSCH, TOBIAS LUCK, EDELGARD MÖSCH, MICHAEL PENTZEK, STEFFI G. RIEDEL-HELLER, JOCHEN WERLE, SIEGFRIED WEYERER, THOMAS ZIMMERMANN, WOLFGANG MAIER, HORST BICKEL
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- Published online by Cambridge University Press:
- 11 July 2007, pp. 1753-1762
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Background
The association of subjective memory impairment (SMI) with cognitive performance in healthy elderly subjects is poor because of confounds such as depression. However, SMI is also a predictor for future dementia. Thus, there is a need to identify subtypes of SMI that are particularly related to inferior memory performance and may represent at-risk stages for cognitive decline.
MethodA total of 2389 unimpaired subjects were recruited from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe), as part of the German Competence Network on Dementia. Clusters of SMI according to patterns of response to SMI questions were identified. Gender, age, depressive symptoms, apolipoprotein E (apoE) genotype, delayed recall and verbal fluency were included in a Classification and Regression Tree (CART) analysis to identify discriminators between the clusters.
ResultsWe identified three clusters. Cluster 1 contained subjects without memory complaints. Cluster 2 contained subjects with general memory complaints, but mainly without memory complaints on individual tasks of daily living. Cluster 3 contained subjects with general memory complaints and complaints on individual tasks of daily living. Depressive symptoms, as the first-level discriminator, distinguished between clusters 1 and 2 versus cluster 3. In subjects with only a few depressive symptoms, delayed recall discriminated between cluster 1 versus clusters 2 and 3.
ConclusionsIn SMI subjects with only a minor number of depressive symptoms, memory complaints are associated with delayed recall. As delayed recall is a sensitive predictor for future cognitive decline, SMI may be the first manifestation of future dementia in elderly subjects without depression.
Postpartum psychosis: two cohorts compared, 1875–1924 and 1994–2005
- S. TSCHINKEL, M. HARRIS, J. LE NOURY, D. HEALY
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- Published online by Cambridge University Press:
- 01 November 2006, pp. 529-536
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Background. There has been a long-standing debate as to whether postpartum psychoses are distinct from other psychoses. While the outcomes of postpartum psychosis are in general thought to be good, the disorder is linked to a high rate of suicide.
Method. We have utilized a database of 3872 admissions to the North Wales Asylum during the period 1875–1924 to extract data on the prevalence, course and clinical features of postpartum psychoses during this period. We have collected first admissions for postpartum psychosis between 1994 and 2005 in North West Wales to establish a current incidence rate for the disorder.
Results. The incidence of psychoses with a first onset in the postpartum period in North West Wales has fallen in the modern period, while the incidence of postpartum psychoses in women with a pre-existing mental illness remains the same. Some features of the clinical picture and course of postpartum psychoses differ from other psychoses, but may be gender rather than disorder linked.
Conclusions. These findings suggest that psychoses with their first onset in the postpartum period may be vanishing. If replicated, this would support claims that these disorders are distinct from other disorders. Alternately, if regarded as affective disorders, establishing the basis for the apparent decline in frequency of these disorders may have implications for other affective disorders.
Highly neurotic never-depressed students have negative biases in information processing
- STELLA W. Y. CHAN, GUY M. GOODWIN, CATHERINE J. HARMER
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- Published online by Cambridge University Press:
- 10 May 2007, pp. 1281-1291
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Background
Cognitive theories associate depression with negative biases in information processing. Although negatively biased cognitions are well documented in depressed patients and to some extent in recovered patients, it remains unclear whether these abnormalities are present before the first depressive episode.
MethodHigh neuroticism (N) is a well-recognized risk factor for depression. The current study therefore compared different aspects of emotional processing in 33 high-N never-depressed and 32 low-N matched volunteers. Awakening salivary cortisol, which is often elevated in severely depressed patients, was measured to explore the neurobiological substrate of neuroticism.
ResultsHigh-N volunteers showed increased processing of negative and/or decreased processing of positive information in emotional categorization and memory, facial expression recognition and emotion-potentiated startle (EPS), in the absence of global memory or executive deficits. By contrast, there was no evidence for effects of neuroticism on attentional bias (as measured with the dot-probe task), over-general autobiographical memory, or awakening cortisol levels.
ConclusionsThese results suggest that certain negative processing biases precede depression rather than arising as a result of depressive experience per se and as such could in part mediate the vulnerability of high-N subjects to depression. Longitudinal studies are required to confirm that such cognitive vulnerabilities predict subsequent depression in individual subjects.
Suicide and other causes of mortality in bipolar disorder: a longitudinal study
- RINA DUTTA, JANE BOYDELL, NOEL KENNEDY, JIM VAN OS, PAUL FEARON, ROBIN M. MURRAY
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- Published online by Cambridge University Press:
- 12 March 2007, pp. 839-847
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Background. The high risk of suicide in bipolar disorder is well recognized, but may have been overestimated. There is conflicting evidence about deaths from other causes and little known about risk factors for suicide. We aimed to estimate suicide and mortality rates in a cohort of bipolar patients and to identify risk factors for suicide.
Method. All patients who presented for the first time with a DSM-IV diagnosis of bipolar I disorder in a defined area of southeast London over a 35-year period (1965–1999) were identified. Mortality rates were compared with those of the 1991 England and Wales population, indirectly standardized for age and gender. Univariate and multivariate analyses were used to test potential risk factors for suicide.
Results. Of the 239 patients in the cohort, 235 (98·3%) were traced. Forty-two died during the 4422 person-years of follow-up, eight from suicide. The standardized mortality ratio (SMR) for suicide was 9·77 [95% confidence interval (CI) 4·22–19·24], which, although significantly elevated compared to the general population, represented a lower case fatality than expected from previous literature. Deaths from all other causes were not excessive for the age groups studied in this cohort. Alcohol abuse [hazard ratio (HR) 6·81, 95% CI 1·69–27·36, p=0·007] and deterioration from pre-morbid level of functioning up to a year after onset (HR 5·20, 95% CI 1·24–21·89, p=0·024) were associated with increased risk of suicide.
Conclusions. Suicide is significantly increased in unselected bipolar patients but actual case fatality is not as high as previously claimed. A history of alcohol abuse and deterioration in function predict suicide in bipolar disorder.
Neural correlates of enhanced working-memory performance in dissociative disorder: a functional MRI study
- BERNET M. ELZINGA, ANGELIQUE M. ARDON, MAAIKE K. HEIJNIS, MICHIEL B. De RUITER, RICHARD VAN DYCK, DICK J. VELTMAN
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- Published online by Cambridge University Press:
- 03 October 2006, pp. 235-245
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Background. Memory functioning has been highlighted as a central issue in pathological dissociation. In non-pathological dissociation, evidence for enhanced working memory has been found, together with greater task-load related activity. So far, no imaging studies have investigated working memory in dissociative patients.
Method. To assess working memory in dissociative patients functional magnetic resonance imaging was used during performance of a parametric, verbal working-memory task in patients with a dissociative disorder (n=16) and healthy controls (n=16).
Results. Imaging data showed that both groups activated brain regions typically involved in working memory, i.e. anterior, dorsolateral and ventrolateral prefrontal cortex (PFC), and parietal cortex. Dissociative patients showed more activation in these areas, particularly in the left anterior PFC, dorsolateral PFC and parietal cortex. In line with these findings, patients made fewer errors with increasing task load compared to controls, despite the fact that they felt more anxious and less concentrated during task performance.
Conclusions. These results extend findings in non-pathological high dissociative individuals, suggesting that trait dissociation is associated with enhanced working-memory capacities. This may distinguish dissociative patients from patients with post-traumatic stress disorder, who are generally characterized by impaired working memory.
Genetic overlap between bipolar illness and event-related potentials
- MEI-HUA HALL, FRÜHLING RIJSDIJK, SRIDEVI KALIDINDI, KATJA SCHULZE, EUGENIA KRAVARITI, FERGUS KANE, PAK SHAM, ELVIRA BRAMON, ROBIN M. MURRAY
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- Published online by Cambridge University Press:
- 16 January 2007, pp. 667-678
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Background. Electrophysiological endophenotypes are far less explored in bipolar disorder as compared to schizophrenia. No previous twin study of event-related potentials (ERPs) in bipolar illness has been reported. This study uses a twin design and advanced genetic model fitting analyses aiming to (1) assess and quantify the relationship of a range of ERP components with bipolar disorder with psychotic features, and (2) examine the source of the relationship (due to genetic or environmental factors).
Method. P300, P50 suppression and mismatch negativity (MMN) were recorded in 10 discordant monozygotic (MZ) bipolar twin pairs, six concordant MZ bipolar twin pairs and 78 control twin pairs. Statistical analyses were based on structural equation modelling.
Results. Bipolar disorder was significantly associated with smaller P300 amplitude and decreased P50 suppression. Genetic correlations were the main source of the associations, estimated to be −0·33 for P300 amplitude and 0·46 for P50 ratio. Individual-specific environmental influences were not significant. MMN and P300 latency were not associated with the illness.
Conclusions. The results provide supporting evidence that P300 amplitude and P50 suppression ratio are ERP endophenotypes for bipolar disorder.
Enhanced emotion-induced amnesia in borderline personality disorder
- RENÉ HURLEMANN, BARBARA HAWELLEK, WOLFGANG MAIER, RAYMOND J. DOLAN
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- 16 January 2007, pp. 971-981
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Background. Current biological concepts of borderline personality disorder (BPD) emphasize the interference of emotional hyperarousal and cognitive functions. A prototypical example is episodic memory. Pre-clinical investigations of emotion–episodic memory interactions have shown specific retrograde and anterograde episodic memory changes in response to emotional stimuli. These changes are amygdala dependent and vary as a function of emotional arousal and valence.
Method. To determine whether there is amygdala hyper-responsiveness to emotional stimuli as the underlying pathological substrate of cognitive dysfunction in BPD, 16 unmedicated female patients with BPD were tested on the behavioural indices of emotion-induced amnesia and hypermnesia established in 16 healthy controls.
Results. BPD patients displayed enhanced retrograde and anterograde amnesia in response to presentation of negative stimuli, while positive stimuli elicited no episodic memory-modulating effects.
Conclusion. These findings suggest that an amygdala hyper-responsiveness to negative stimuli may serve as a crucial aetiological contributor to emotion-induced cognitive dysfunction in BPD.
Evaluating suicide-related adverse events in clinical trials of fluoxetine treatment in adults for indications other than major depressive disorder
- SITRA TAUSCHER-WISNIEWSKI, DAMON DISCH, JOHN PLEWES, SUSAN BALL, CHARLES M. BEASLEY, Jr
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- Published online by Cambridge University Press:
- 20 July 2007, pp. 1585-1593
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Background
The association between treatment-emergent suicidality as an adverse event and fluoxetine treatment was examined using a fluoxetine double-blind placebo-controlled database of clinical trials for indications other than major depressive disorder.
MethodThe database consisted of 53 trials for 16 different indications (14 psychiatric, two non-psychiatric). Within each study, patient adverse event reports and narratives were searched extensively for treatment-emergent thoughts and behaviors associated with suicide. The incidence of adverse events was classified using Food and Drug Administration (FDA) codes for completed suicide, preparatory acts, suicidal ideation and the summary category of ‘all suicidality.’ The risk difference and risk ratios between fluoxetine and placebo treatment arms were compared using Mantel–Haenszel methods.
ResultsWithin this large database, patients were randomly assigned to receive treatment with either fluoxetine (n=7066) or placebo (n=4382). Treatment groups did not differ in their risk for the emergence of suicidality for any FDA code; the risk ratio for ‘all suicidality’ was 0·82 (p=0·406), and there were no completed suicides in either group. Analyses based on treatment indication (bulimia, obsessive-compulsive disorder, other psychiatric and non-psychiatric illness) also showed no significant difference in risk between treatment groups. When examined by age categories (18–24, 25–30, 31–65, and ⩾65 years), fluoxetine and placebo treatments did not result in significant risk difference for the emergence of suicidality.
ConclusionsThe risk of treatment-emergent suicidality does not appear to be associated with fluoxetine treatment for adults with various non-MDD conditions.
The use of complementary and alternative medicine in the general population: results from a longitudinal community study
- WULF RÖSSLER, CHRISTOPH LAUBER, JULES ANGST, HELENE HAKER, ALEX GAMMA, DOMINIQUE EICH, RONALD C. KESSLER, VLADETA AJDACIC-GROSS
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- Published online by Cambridge University Press:
- 26 September 2006, pp. 73-84
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Background.Many patients with psychological or physical problems are interested in non-medical approaches. The reasons for the growing popularity of complementary and alternative medicine (CAM) are not well understood considering that evidence of the effectiveness of conventional therapies is greater than ever before. We have examined data from the Zurich Study to determine trends and predictors of CAM use in Switzerland.
Method.The Zurich Study is a longitudinal community study that was started in 1979 with a sample of 591 participants born in 1958 and 1959. In 1999, the last of six interview waves with face-to-face interviews was conducted. CAM use was analyzed with data from interviews in 1993 and 1999. Polytomous logistic regression analysis focused on the personal, demographic and sociocultural background of CAM users.
Results.CAM use in the last 12 months was reported by 21·9% of the participants in 1993 and by 29·5% in 1999. CAM use among those exhibiting either physical or psychological problems was in the ratio of two to one. There was a trend from alternative variants of CAM (homeopathy) to complementary ones (massage, osteopathy, acupuncture). The vast majority of CAM use was in addition to conventional therapies. Predictors of CAM use were, among others, attribution of physical complaints to stress and other psychological variables, very low education level in parents, and lacking political interest.
Conclusions.Besides the sociocultural background, characteristics such as the psychological attribution style play an important role in CAM use. CAM use in Switzerland is mainly of a complementary rather than an alternative nature.
Biased emotional attention in post-traumatic stress disorder: a help as well as a hindrance?
- M. VYTHILINGAM, K. S. BLAIR, D. McCAFFREY, M. SCARAMOZZA, M. JONES, M. NAKIC, K. MONDILLO, K. HADD, O. BONNE, D. G. V. MITCHELL, D. S. PINE, D. S. CHARNEY, R. J. R. BLAIR
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- Published online by Cambridge University Press:
- 11 June 2007, pp. 1445-1455
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Background
From a cognitive neuroscience perspective, the emotional attentional bias in post-traumatic stress disorder (PTSD) could be conceptualized either as emotional hyper-responsiveness or as reduced priming of task-relevant representations due to dysfunction in ‘top-down’ regulatory systems. We investigated these possibilities both with respect to threatening and positive stimuli among traumatized individuals with and without PTSD.
MethodTwenty-two patients with PTSD, 21 trauma controls and 20 non-traumatized healthy participants were evaluated on two tasks. For one of these tasks, the affective Stroop task (aST), the emotional stimuli act as distracters and interfere with task performance. For the other, the emotional lexical decision task (eLDT), emotional information facilitates task performance.
ResultsCompared to trauma controls and healthy participants, patients with PTSD showed increased interference for negative but not positive distracters on the aST and increased emotional facilitation for negative words on the eLDT.
ConclusionsThese findings document that hyper-responsiveness to threat but not to positive stimuli is specific for patients with PTSD.
Social inequalities in antidepressant treatment and mortality: a longitudinal register study
- MIKA KIVIMÄKI, DAVID GUNNELL, DEBBIE A. LAWLOR, GEORGE DAVEY SMITH, JAANA PENTTI, MARIANNA VIRTANEN, MARKO ELOVAINIO, TIMO KLAUKKA, JUSSI VAHTERA
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- Published online by Cambridge University Press:
- 23 November 2006, pp. 373-382
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Background. Despite an increased prevalence of depression among people of low socio-economic position, it remains unclear whether their treatment with antidepressants appropriately matches their increased need compared with people from more affluent backgrounds. This study examined socio-economic differences in antidepressant prescriptions and mortality related to depressive disorders.
Method. A longitudinal register study of 17947 male and 47458 female local government employees with linked information on socio-economic indicators (education and occupational status) and data on antidepressant use and mortality associated with depressive disorder (suicide, alcohol-related deaths) during the years 1994 to 2000.
Results. In men, antidepressant treatment was less common among low educational groups than among high educational groups (OR 0·87, 95% CI 0·76–0·99) and a corresponding difference was seen between occupational statuses (OR for manual v. upper non-manual 0·72, 95% CI 0·62–0·84). In women, socio-economic position was not associated with antidepressant use. However, both among the men and women, employees with low socio-economic position had increased risk for mental-health-related mortality, as indicated by suicides, deaths from alcohol-related causes, and all-cause mortality.
Conclusions. These data suggest a mismatch in the treatment of depression relative to apparent clinical need, with the lowest levels of treatment concentrated in the lower socio-economic groups, despite evidence of their increased prevalence of depression and suicide.
Biological markers of intellectual disability in tuberous sclerosis
- ARMIN RAZNAHAN, NICHOLAS P. HIGGINS, PAUL D. GRIFFITHS, AYLA HUMPHREY, JOHN R. W. YATES, PATRICK F. BOLTON
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- Published online by Cambridge University Press:
- 05 March 2007, pp. 1293-1304
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Background
Intellectual disability (ID) is highly prevalent in tuberous sclerosis (TS). Putative neurobiological risk factors include indices of cortical tuber (CT) load and epilepsy. We have used univariate and multivariate analyses, including both CT and epilepsy measures as predictors, in an attempt to clarify the pattern of cross-sectional associations between these variables and ID in TS.
MethodForty-eight children, adolescents and young adults with TS were identified through regional specialist clinics. All subjects underwent thorough history taking and examination, and had brain magnetic resonance imaging (MRI) scans. The number and regional distribution of CTs was recorded. Subjects were assigned to one of nine ordered intellectual quotient (IQ) categories (range <25 to >130) using age-appropriate tests of intelligence.
ResultsOn univariate analyses, ID was significantly associated with both a history of infantile spasm (IS) (Z=−2·49, p=0·01) and total CT count (Spearman's ρ=−0·30, p=0·04). When controlling for total CT count, the presence of CTs in frontal (regression coefficient=−2·43, p=0·02) and temporal (regression coefficient=−1·60, p=0·02) lobes was significantly associated with ID. In multivariate analyses the association between IS and ID was rendered insignificant by the inclusion of the presence of CTs in temporal and frontal lobes, both of which remained associated (p=0·05 and p=0·06 respectively) with ID.
ConclusionsThe presence of CTs in specific brain regions as opposed to a history of IS was associated with ID in TS. The significance of these findings is discussed in relation to previous work in TS, and the neural basis of intelligence.
Orbitofrontal cortex volume in late life depression: influence of hyperintense lesions and genetic polymorphisms
- WARREN D. TAYLOR, JAMES R. MacFALL, MARTHA E. PAYNE, DOUGLAS R. McQUOID, DAVID C. STEFFENS, JAMES M. PROVENZALE, K. RANGA R. KRISHNAN
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- Published online by Cambridge University Press:
- 05 March 2007, pp. 1763-1773
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Background
Orbitofrontal cortex (OFC) volumetric differences have been reported in depression, but in relatively small samples. Factors associated with these differences are not well described. We examined OFC volumes in a large sample of elderly depressed and non-depressed subjects, exploring the relationship between OFC volume, 5HTTLPR genotype, apolipoprotein E (APOE) genotype and hyperintense lesion volume. We hypothesized that smaller OFC volume would be associated with depression, greater hyperintense lesion volume and severity, and APOE ε4 or 5HTTLPR short allele carriers.
MethodA total of 226 depressed and 144 non-depressed older subjects completed 1·5 T magnetic resonance imaging (MRI) and genotyping. OFC volumes and lesion volumes were measured using standardized methods. Lesion severity was additionally rated using the Coffey rating scale. Differences between groups were compared while controlling for age, sex and total cerebral volume; separate models added lesion measures and genetic polymorphisms.
ResultsDepressed subjects exhibited smaller OFC volumes. There was a trend for a negative association between white-matter lesion volume and OFC volume; however, rated white-matter lesion severity was significantly negatively associated with OFC volume. There was no association between gray-matter lesion measures or 5HTTLPR genotype and OFC volume. Contrary to our hypothesis, subjects who were APOE ε4 allele positive exhibited larger OFC volumes; in secondary analyses, this finding was limited to the non-depressed group.
ConclusionsReduced OFC volumes are seen in depression and associated with greater severity of white-matter lesions. Healthy subjects who are APOE ε4 allele positive exhibited larger OFC volumes. This finding should be examined in other populations.
Comparison of alternative models for personality disorders
- LESLIE C. MOREY, CHRISTOPHER J. HOPWOOD, JOHN G. GUNDERSON, ANDREW E. SKODOL, M. TRACIE SHEA, SHIRLEY YEN, ROBERT L. STOUT, MARY C. ZANARINI, CARLOS M. GRILO, CHARLES A. SANISLOW, THOMAS H. McGLASHAN
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- Published online by Cambridge University Press:
- 23 November 2006, pp. 983-994
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Background. The categorical classification system for personality disorder (PD) has been frequently criticized and several alternative dimensional models have been proposed.
Method. Antecedent, concurrent and predictive markers of construct validity were examined for three models of PDs: the Five-Factor Model (FFM), the Schedule for Nonadaptive and Adaptive Personality (SNAP) model and the DSM-IV in the Collaborative Study of Personality Disorders (CLPS) sample.
Results. All models showed substantial validity across a variety of marker variables over time. Dimensional models (including dimensionalized DSM-IV) consistently outperformed the conventional categorical diagnosis in predicting external variables, such as subsequent suicidal gestures and hospitalizations. FFM facets failed to improve upon the validity of higher-order factors upon cross-validation. Data demonstrated the importance of both stable trait and dynamic psychopathological influences in predicting external criteria over time.
Conclusions. The results support a dimensional representation of PDs that assesses both stable traits and dynamic processes.
A new scale to assess the therapeutic relationship in community mental health care: STAR
- REBECCA McGUIRE-SNIECKUS, ROSEMARIE McCABE, JOCELYN CATTY, LARS HANSSON, STEFAN PRIEBE
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- Published online by Cambridge University Press:
- 09 November 2006, pp. 85-95
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Background. No instrument has been developed specifically for assessing the clinician–patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction.
Method. A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction, test–retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden.
Results. New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test–retest reliability was r=0·76 for STAR-P and r=0·68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit.
Conclusions. STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care.