American J of Psychiatry

Let us try to project ourselves back into the places and minds of physicians and psychiatrists in, say, 1900. When they spoke of disease, what did they mean? They meant, typically, something like syphilis. ‘Know syphilis in all its manifestations and relations,’ declared Sir William Osler (1849–1919), ‘and all things clinical will be added unto you.’ (1). Obviously, this is no longer true. Indeed, how many cases of syphilis do modern medical students see between the time they enroll in school and the time they graduate? In the United States,…

Kulesza and colleagues (2014) evaluated perceived mental health related stigma, gender, and depressive symptom severity in a psychiatric facility in South India (this issue). Their study is timely because most studies on depression are from the Western world, and far more research is needed from non-Western countries (Li, 2012). Moreover, there is very limited research on stigma in India, and even less on male – female differences regarding stigma, which they take up. They evaluate the experience of perceived stigma in relation to the experience of and diagnosis of depression. The most fundamental and conventional use of the term ‘‘stigma’’ refers to the idea that individuals from a stigmatized group (i.e., people with depression) tend to feel that other people believe that ‘‘depressives’’ are less good, weak, and undesirable. Thus, they are devalued on the basis of their belonging to a class of people that share this social category (Goffman, 1963). Stigma is a crucial concept in p...

Despite evidence for the validity of premenstrual dysphoric disorder (PMDD) and the inclusion of the disorder in DSM-5, variable diagnostic practices compromise the construct validity of the diagnosis and threaten the clarity of efforts to understand and treat its underlying pathophysiology. In an effort to hasten and streamline the translation of the DSM-5 criteria for PMDD into terms compatible with existing research practices, the authors present the development and initial validation of the Carolina Premenstrual Assessment Scoring System (C-PASS). The C-PASS (available as a worksheet, Excel macro, and SAS macro) is a standardized scoring system for making DSM-5 PMDD diagnoses using two or more months of daily symptom ratings with the Daily Record of Severity of Problems (DRSP). Two hundred women recruited for retrospectively reported premenstrual emotional symptoms provided two to four months of daily symptom ratings on the DRSP. Diagnoses made by expert clinician and by the C-P...

There is uncertainty about the future role of psychodynamic psychotherapy in psychiatric practice and education. The Association for Academic Psychiatry and the American Association of Directors of Psychiatry Residency Training formed a joint task force to review the issue. It developed a rationale for continued training in expressive psychotherapy and a model curriculum for such training that is both effective and realistic in terms of the diverse demands and structures of modern residencies. A minimum curriculum was also designed for resource-poor programs.

The purpose of this study was to determine prospectively the optimal length of therapy in a long-term, placebo-controlled continuation study of patients who responded to acute fluoxetine treatment for major depression (defined by DSM-III-R). The study was conducted at five outpatient psychiatric clinics in the United States. Patients who met criteria for remission after 12 or 14 weeks of open-label acute fluoxetine therapy, 20 mg/day (N=395 of 839 patients), were randomly assigned to one of four arms of a double-blind treatment study (50 weeks of placebo, 14 weeks of fluoxetine and then 36 weeks of placebo, 38 weeks of fluoxetine and then 12 weeks of placebo, or 50 weeks of fluoxetine). Relapse rate was the primary outcome measure. Both Kaplan-Meier estimates and observed relapse rates were assessed in three fixed 12-week intervals after double-blind transfers from fluoxetine to placebo at the start of the double-blind period and after 14 and 38 weeks of continued fluoxetine treatment. Relapse rates (Kaplan-Meier estimates) were lower among the patients who continued to take fluoxetine compared with those transferred to placebo in both the first interval, after 24 total weeks of treatment (fluoxetine, 26.4%; placebo, 48.6%), and the second interval, after 38 total weeks of treatment (fluoxetine, 9.0%; placebo, 23.2%). In the third interval, after 62 total weeks of treatment, rates were not significantly different between the groups (fluoxetine, 10.7%; placebo, 16.2%). Patients treated with fluoxetine for 12 weeks whose depressive symptoms remit should continue treatment with fluoxetine for at least an additional 26 weeks to minimize the risk of relapse.

To the Editor: The correlation between gyrus rectus volume and sweet taste pleasantness in the comparison group is striking as it supports the previous literature and is consistent with an important concept established by the works of Rolls, Kringelbach, and others (1). All eating disorder groups in our sample showed increased gyrus rectus volume relative to individuals in the comparison group, suggesting comparable pathophysiology. Groups were combined for that reason, and we did find a positive correlation between sweet taste pleasantness and volume in the eating disorder case subjects. In addition, within eating disorder subgroups, each individual group showed a positive correlation (anorexia nervosa, r50.120; bulimia nervosa, r50.287; recovered anorexia nervosa, r50.345) between sweet taste pleasantness and gyrus rectus volume, supporting the idea that analyzing the groups as a whole was valid. The correlation coefficients were modest. Despite a significant amount of research, we still know little about the connection between brain structure and function and these results are a step toward identifying target areas that could contribute to altered food intake. Taste pleasantness in individuals with eating disorder could be less well mapped (yet still positively) onto gyrus rectus neurons due to the altered volume, and this could interfere with correct value computation. It is important to view eating disorders as complex problems with a variety of factors that most likely contribute to development and then perpetuation of the illnesses. Expecting direct correlations between all those measures would be overly simplistic, and we believe that dissecting eating disorders by brain circuits that may contribute to the psychopathology will be more fruitful. Trait alterations seem to exist that cause heightened sensitivity to various (food- and nonfood-related) rewarding or punishing stimuli, contributing to a sense of instability across individuals with anorexia and bulimia nervosa (2, 3). This instability may contribute to heightened anxiety and intolerance of uncertainty (4). Additionally, as suggested in this study, there may be developmental factors such as altered brain volume in the orbitofrontal cortex that could interfere with the processing of value of food stimuli. We recently published a similarly designed study in adolescents with anorexia nervosa and found similarly larger gyrus rectus volumes, further supporting that this structure could be involved in the pathophys- iology of eating disorders (5). All eating disorder groups share an enlarged gyrus rectus, which could impair a healthy sensory satiety processing. In fact individuals with eating disorders share many similar behaviors but on different scales, and there is overlap in symptoms not only across subgroups but even depending on stage of recovery. For instance, individuals with bulimia nervosa are often able to restrict food intake in-between binge episodes. Furthermore, many individuals who meet criteria for one category of eating disorder will often shift into another eating disorder during the course of illness, which is consistent with a common vulnerability.

The authors describe the psychiatric assessments and trauma testimonies of 20 Bosnian refugees of "ethnic cleansing" who have recently resettled in the United States. Refugees referred from agencies managing refugee resettlement underwent systematic, trauma-focused, clinical interviews that included standardized assessment scales. The traumatic experiences of ethnic cleansing in these Bosnian refugees were genocidal in nature. The number of types of traumatic experiences correlated positively with age. Posttraumatic stress disorder (PTSD) was diagnosed in 65% of the refugees, and depressive disorders in 35%. PTSD severity scores were correlated with the number of types of traumatic events experienced. Ethnic cleansing has caused high rates of PTSD and depression, as well as other forms of psychological morbidity, in this group of resettled Bosnian refugees. The longitudinal sequelae of ethnic cleansing as a form of massive psychic trauma remain to be studied.

Interpersonal psychotherapy (IPT) has been developed for the treatment of depression but has been examined for several other mental disorders. A comprehensive meta-analysis of all randomized trials examining the effects of IPT for all mental health problems was conducted. Searches in PubMed, PsycInfo, Embase, and Cochrane were conducted to identify all trials examining IPT for any mental health problem. Ninety studies with 11,434 participants were included. IPT for acute-phase depression had moderate-to-large effects compared with control groups (g=0.60; 95% CI=0.45-0.75). No significant difference was found with other therapies (differential g=0.06) and pharmacotherapy (g=-0.13). Combined treatment was more effective than IPT alone (g=0.24). IPT in subthreshold depression significantly prevented the onset of major depression, and maintenance IPT significantly reduced relapse. IPT had significant effects on eating disorders, but the effects are probably slightly smaller than those o...

Thirteen experienced supervising psychiatrists independently rated the psychotherapy interviews of six residents, using a detailed assessment instrument. Although interrater agreement was significantly greater than would be expected by chance, the extent of agreement was uniformly low. Agreement was significantly poorer for judgments about technique skills than about communication skills and for second-year than for first-year residents. Other factors, such as the faculty rank and training of the rater, did not covary significantly with observed ratings. The findings suggest that rating methods which purport to assess psychotherapy skills should undergo careful methodological evaluation and testing before they are accepted as valid assessment techniques.

The authors studied the religious beliefs, practices, and experiences of 52 psychiatric inpatients. The rate of belief in the major tenets of faith (God, the Devil, and an afterlife) was uniformly high and in accord with national and local public poll results. Patients with depressive and anxiety disorders tended to score lower than those with other diagnoses on a wide variety of indexes of religion. The authors conclude that religion is an important factor in most patients' lives and that individual inquiry and systematic research into this neglected area are both feasible and important.

Tables and Figures. Foreword (Clarice Kestenbaum). Preface. Acknowledgments. PART ONE: CONCEPTUAL FOUNDATIONS OF SYSTEMS OF CARE. 1 A History of Community Child Mental Health (Ira S. Lourie). 2 Systems of Care: A Framework for Children's Mental Health Care (Beth A. Stroul). 3 Family Advocacy Development in Systems of Care (Charles Huffine, Deborah Anderson). 4 Collaboration Across Disciplines and Among Agencies Within Systems of Care (Mark Chenven, Barbara Brady). 5 Cultural Competence in Systems of Care for Children's Mental Health (Andres J. Pumariega). PART TWO: INTEGRATING CLINICAL MODALITIES INTO SYSTEMS OF CARE. 6 Strengthening the Clinical Perspective (Theodore Fallon, Jr). 7 Pharmacotherapy in Systems of Care for Children's Mental Health (Andres J. Pumariega, Theodore Fallon, Jr). 8 Evidence-Based Community-Based Interventions (Kenneth Rogers). 9 Case Management: The Linchpin of Community-Based Systems of Care (Nancy C. Winters, Elizabeth Terrell). PART THREE: WO...

“Alan” is an 11-year-old boy who was first seen in our clinic 3 years ago. His parents’ chief complaint at admission was Alan’s physically aggressive behavior at home, in particular toward his mother, as well as fights with children and teachers at school. Alan reportedly met his early developmental motor and cognitive milestones, but he showed difficulties with temper control and frustration tolerance as a toddler, having “significant fits” and biting other children. In preschool, Alan’s behavior was generally without significant aggression exceptwhen hismother was there to volunteer. In kindergarten, his parents reported, his behavior was managed with the help of a teacher who was very consistent with discipline and structure, but the followingyear,hisfirst-grade teacher providedmuch less structure, and Alan started getting into fights again with other children. His behavior also worsened at home; for instance, he would fight a neighbor boy and “the kids would scratch each other bloody.” The parents started family counseling at that time, which did not reduce the problem behaviors. In second grade, at the end of the first trimester, Alan reportedly “lost it.” After a family session, he “cleared the entire desk of the therapist” and “threatened to hurt the therapist.” At home, he would take knives from kitchen drawers and threaten family members. He would “shut down” and not talk about his feelings or thoughts. He was referred by the outpatient psychotherapist to the emergencydepartment and was subsequently treated in a day hospital program, which did reduce his outbursts. He was not put on medication. Discharge diagnoses were mood disorder not otherwise specified, rule out depressive disorder, and rule out anxiety disorder. After discharge, Alan was referred to our clinic. He continued to struggle with aggressive outbursts. When he was told to do minor chores or homework, he “would never do it.” Sometimes he would be “good” in themorning, but hismoodwasusually irritable, and little things would set off explosive outbursts, with yelling, throwing things, and punching people around him, resulting inbruises;his parentshad someconcern about the safety of Alan’s sibling, as well as their own safety. He had such outbursts approximately four times per week, each lasting 30 to 45 minutes. His parents also reported an apparent “female authority problem”; Alan responded much better to male authority figures than to women. During a review of Alan’s developmental history, his parents reported that their son had poor eye contact since early age and that he would “suppress” emotions and had a flat affect. They also noted that Alan did well approaching adults but did not attach emotionally to other children and struggled with making same-age friends. His own perception, however, was that he had many friends. Alan was always very much interested in science and was an expert in dinosaurs and rocks. “While other kids look at things in museums and move on,” he would read all the information he could get. Alan excelled in memorizing other people’s names and faces and after years would recognize someone he had seen only once. He was also noted to struggle with change in routines and to fidget with his hands. There was no history of abuse, contact with drugs or alcohol, mania, anxiety, ormajormedical illness. The family environmentwas reported as stable. Alan has one sibling, and no psychiatric family history was reported. Alan had never been hospitalized; he had been seen by three outpatient family therapists in the past, and, as noted, he had been in day hospital treatment. Alan himself reported that at times he did “not feel good,” but he denied depression or anxiety. He acknowledged having fights with other children but did not elaborate on circumstances. He reported hearing “animal voices” fromunder his bed or from the closet, but he could not really make them out. He felt there were ghosts and monsters in his room, and he was afraid of somebody pulling him down under his bed. When he looked, he reported seeing a lot of “stuff under his bed,” but denied seeing monsters. On further questioning, Alan said he thought those voices could be from the wind or his parents, but he was not certain about the absence of monsters. He had these experiencesmostly in thedarkness, atnight.Hedenied paranoia or ideas of reference.

Forty-five panic disorder patients and 26 normal control subjects were surveyed regarding their histories of sleep panic attacks, insomnia, and vulnerability to exogenous panic stimuli. Sixty-nine percent (N = 31) of the patients reported having experienced sleep panic at some time in their lives, and 33% (N = 15) of the patients experienced recurrent sleep panic. The implications of these findings for the management of panic disorder are discussed.

... Transac Med Soc Lond 87:40-50, 1971 Erotomanic Delusions in a Mentally Retarded Patient BY BRUCE GREYSON, MD, AND SALMAN AKHTAR, MD The syndrome of erotomania consists of a patient's delusion that a public figure on briefacquaintance, usu-...

The author reviews major controversies in the literature regarding techniques of intensive psychodynamic therapy with borderline patients. These include debates about the importance of content versus process in the therapist's early interventions, the origins of transference, the primacy of positive versus negative transference in therapeutic work, the usefulness of early interpretation of negative transference, and the therapist's role in providing "corrective" experiences. He suggests that different conceptions of borderline psychopathology, different patient populations studied, variations in therapists' personality styles, and emphasis on different phases of treatment may account for the diversity of treatment techniques advocated in the literature.