Western State Hospital

Research on hepatic encephalopathy is hampered by the imprecise definition of this disabling complication of liver disease. Under this light, the Organisation Mondiale de Gastroentérologie commissioned a Working Party to reach a consensus in this area and to present it at the 11th World Congress of Gastroenterology in Vienna (1998). The Working Party continued its work thereafter and now present their final report. In summary, the Working Party has suggested a modification of current nomenclature for clinical diagnosis of hepatic encephalopathy; proposed guidelines for the performance of future clinical trials in hepatic encephalopathy; and felt the need for a large study to redefine neuropsychiatric abnormalities in liver disease, which would allow the diagnosis of minimal (subclinical) encephalopathy to be made on firm statistical grounds. In the interim, it proposes the use of a psychometric hepatic encephalopathy score, based on the result of 5 neuropsychologic tests. Finally, the need for a careful evaluation of the newer neuroimaging modalities for the diagnosis of hepatic encephalopathy was stressed.

The current study attempts to clarify the multi‐faceted nature of impulsivity through the use of the four‐factor UPPS Impulsive Behaviour scale. In order to build the nomological network surrounding this scale, the UPPS was administered to individuals with borderline personality disorder (BPD), pathological gamblers (PG), alcohol abusers (divided into two groups based on the presence of antisocial features), and a control group. Several of the UPPS scales (e.g. Urgency, lack of Premeditation, and Sensation Seeking) differentiated the BPD, PG, and alcohol abusers with antisocial features from a group of non‐antisocial alcohol abusers and a control group. Overall, the UPPS scales accounted for between 7% (pathological gambling) and 64% (borderline personality disorder features) of the overall variance in the psychopathology measures. Individual UPPS scales also made unique contributions to several of these disorders, which may provide insight into which of these personality traits may predispose individuals to behave in maladaptive or problematic ways. The results provide support for the differentiation of impulsivity‐related constructs into the current four‐factor model. Copyright © 2005 John Wiley & Sons, Ltd.

Relapse rates averaging 41% in the first year after discharge among schizophrenic patients receiving maintenance neuroleptic treatment led to the development of two disorder-relevant treatments: a patient-centered behavioral treatment and a psychoeducational family treatment. Following hospital admission, 103 patients residing in high expressed emotion (EE) households who met Research Diagnostic Criteria for schizophrenia or schizoaffective disorder were randomly assigned to a two-year aftercare study of family treatment and medication, social skills training and medication, their combination, or a drug-treated condition. First-year relapse rates among those exposed to treatment demonstrate a main effect for family treatment (19%), a main effect for social skills training (20%), and an additive effect for the combined conditions (0%) relative to controls (41%). Effects are explained, in part, by the absence of relapse in any household that changed from high to low EE. Only the combination of treatment sustains a remission in households that remain high in EE. Continuing study, however, suggests a delay of relapse rather than prevention.

Presentation de l'etat actuel du traitement des comportements anti-sociaux (modeles d'application et d'evaluation) et des approches prometteuses fondees sur la recherche contemporaine, les limitations et les problemes methodologiques etant egalement discutes

The development, reliability, and discriminative ability of a new instrument to assess social phobia are presented. The Social Phobia and Anxiety Inventory (SPAI) is an empirically derived instrument incorporating responses from the cognitive, somatic, and behavioral dimensions of social fear. The SPAI has high lest-retest reliability and good internal consistency. The instrument appears to be sensitive to the entire continuum of socially anxious concerns and is capable of differentiating social phobics from normal controls as well as from other anxiety patients. The utility of this instrument for improved assessment of social phobia and anxiety and its use as an aid for treatment planning are discussed. Social phobia is perhaps the least understood and the least researched of the anxiety disorders. Although there are several scales available to measure social anxiety, most were constructed prior to publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-lII; American Psychiatric Association, 1980), where the diagnostic criteria for social phobia were first introduced. Because social anxiety is experienced by individuals with many psychiatric disorders as well as by normals, these scales may not be specific to social phobia. Preparation of an instrument designed more specifically to assess social phobia requires consideration of several issues, including the critical features of the disorder, its cognitive, physiological, and behavioral dimensions (Lang, 1977), and the capability to sample behavior across a range of potentially distressful social situations. In addition, because social phobics differ in the degree of distress or functional impairment resulting from the disorder, the ability to assess level of severity would be a particularly positive feature of such an instrument. The Social Phobia and Anxiety Inventory (SPAI) is a new, empirically derived self-report inventory. Its construction was based on the behavioral-analytic model outlined by Goldfried and D'Zurilla (1969). It assesses specific somatic symptoms, cognitions, and behavior across a range of potentially fear-producing situations. In order to assess severity, a Likert-scale format is used. This article describes the development and initial psychometric characteristics of the SPAI.

Major depressive disorder is associated with considerable morbidity, disability, and risk for suicide. Treatments for depression most commonly include antidepressants, psychotherapy, or the combination. Little is known about predictors of treatment response for depression. In this study, 681 patients with chronic forms of major depression were treated with an antidepressant (nefazodone), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or the combination. Overall, the effects of the antidepressant alone and psychotherapy alone were equal and significantly less effective than combination treatment. Among those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among the childhood abuse cohort. Our results suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and a history of childhood trauma.

BACKGROUND: Previous studies in nonclinical samples have shown psychosocial treatments to be efficacious in the treatment of adolescent depression, but few psychotherapy treatment studies have been conducted in clinically referred, depressed adolescents. METHODS: One hundred seven adolescent patients with DSM-III-R major depressive disorder (MDD) were randomly assigned to 1 of 3 treatments: individual cognitive behavior therapy, systemic behavior family therapy (SBFT), or individual nondirective supportive therapy (NST). Treatments were 12 to 16 sessions provided in as many weeks. Intent-to-treat analyses were conducted using all follow-up data. RESULTS: Of the 107 patients enrolled in the study, 78 (72.9%) completed the study, 4 (3.7%) never initiated treatment, 10 (9.3%) had exclusionary criteria that were undetected at entry, 8 (7.5%) dropped out, and 7 (6.5%) were removed for clinical reasons. Cognitive behavior therapy showed a lower rate of MDD at the end of treatment compared with NST (17.1% vs 42.4%; P = .02), and resulted in a higher rate of remission (64.7%, defined as absence of MDD and at least 3 consecutive Beck Depression Inventory scores < 9) than SBFT (37.9%; P = .03) or NST (39.4%; p = .04). Cognitive behavior therapy resulted in more rapid relief in interviewer-rated (vs both treatments, P = .03) and self-reported depression (vs SBFT, P = .02). All 3 treatments showed significant and similar reductions in suicidality and functional impairment. Parents' views of the credibility of cognitive behavior therapy improved compared with parents' views of both SBFT (P = .01) and NST (P = .05). CONCLUSIONS: Cognitive behavior therapy is more efficacious than SBFT or NST for adolescent MDD in clinical settings, resulting in more rapid and complete treatment response.

While two factors are currently thought to underlie individual differences in schizotypal personality, three factors may best explain schizotypal traits. This study used confirmatory factor analysis to assess five competing models of schizotypal personality in the general population: null model, one-factor model, simple two-factor model, Kendler two-factor model, and three-factor model. The computer program LISREL was used to analyze Schizotypal Personality Questionnaire subscale scores that reflect the nine traits of schizotypal personality. The scores were obtained from (1) a sample of 822 undergraduates and (2) a replication sample of 102 subjects drawn from the community. Results indicate replicable support for a three-factor model reflecting cognitive-perceptual, interpersonal, and disorganized latent factors. Low intercorrelations between the first two factors and the lack of fit by a one-factor model are partially inconsistent with recent notions that a single vulnerability dimension underlies schizotypal personality. It is argued that future investigations should assess the correlates of all three schizotypal factors in clinical and nonclinical samples in addition to the two more traditional factors. It is hypothesized that three factors of schizophrenic symptomatology observed in recent studies may reflect an exaggeration of three analogous factors found in the general population.

Neurobehavioral theories of autism have hypothesized core deficits in sensory input or perception, basic attentional abilities or generalized attention to extrapersonal space, anterograde memory, auditory information processing, higher order memory abilities, conceptual reasoning abilities, executive function, control mechanisms of attention, and higher order abilities across domains. A neuropsychologic battery designed to investigate these hypotheses was administered to 33 rigorously diagnosed autistic individuals with IQ scores greater than 80, and 33 individually matched normal controls. Stepwise discriminant function was used to define the profile of neuropsychologic functioning across domains. The neuropsychologic profile in these autistic individuals was defined by impairments in skilled motor, complex memory, complex language, and reasoning domains, and by intact or superior performance in the attention, simple memory, simple language, and visual-spatial domains. This profile is not consistent with mental retardation or with a general deficit syndrome, but rather with a selective impairment in complex information processing that does not involve visual-spatial processing. This profile is not consistent with a single primary deficit, but with a multiple primary deficit model in which the deficit pattern within and across domains is reflective of the complexity of the information processing demands. This neuropsychologic profile is furthermore consistent with the neurophysiologic characterization of autism as a late information processing disorder with sparing of early information processing.

A two-stage assessment of newly admitted outpatients at community mental health centers and primary medical care centers found the Center for Epidemiological Studies Depression Scale to be highly sensitive but relatively nonspecific when compared with assessments of depression by the Diagnostic Interview Schedule. Considerably higher than usual screening scores are recommended with both patient populations to improve the efficiency of the Center for Epidemiological Studies Depression Scale. The reasons for our finding that primary care clinicians underdiagnose depressive disorder while psychiatric clinicians overdiagnose it relative to the Diagnostic Interview Schedule include varied presentations by each sector's patients, differing clinical acumen, and factors affecting third-party reimbursement.

According to the cognitive view, the individual's negative and distorted thinking is the basic psychological problem in the depressive syndrome. The distorted cognitions are supported by maladaptive cognitive schemata, which involve immature "either-or" rules of conduct or inflexible and unattainable self-expectations. These schemata are probably acquired early in development and, if uncritically carried into adulthood, serve to predispose the individual to depression. Since these schemata are long-term identifiable psychological patterns that influence attitude and behavioral responses, they may constitute a cognitive dimension of the depression-prone individual's personality. The authors discuss the treatment implications of the cognitive approach to depression.

Patients with Alzheimer's disease have been suggested to have a semantic memory impairment not present in the normal old. This article reviews the performance of Alzheimer patients on tests of various aspects of semantic memory, including word finding, knowledge of the semantic attributes, and associates of concepts, as well as their category membership. The effect that semantic context has on cognitive processes such as lexical and semantic priming and memory encoding is also reviewed. Finally, the ability of theoretical constructs such as implicit memory and automaticity to explain intertask variability in Alzheimer patients' semantic performance is discussed.

• Using a controlled, clinical-trial format, 44 nonpsychotic, nonbipolar, depressed outpatients were treated with cognitive therapy or imipramine hydrochloride over a 12-week period. Although both interventions were associated with significant reductions in levels of depression, the cognitive-therapy patients showed greater symptomatic improvement and a higher treatment-completion rate. A one-year naturalistic follow-up of the 35 subjects who completed the protocol revealed that although many of the patients had a variable clinical course, both original treatment groups remained generally well. Self-rated depressive symptomatology was significantly lower for those who, one year earlier, had completed cognitive therapy than for those who had been in the clinical trial's pharmacotherapy cell. While there were several other interesting trends in favor of the cognitivetherapy patients, none of the between-group differences were significant. The pragmatic and clinical implications of the followup results are discussed.

BACKGROUND: This paper expands upon recent efforts to advance beyond the examination of concurrent comorbidity between affective and behavioral disorders by testing developmental sequences among disorders. Doing so allows for improved tests of theories, such as Capaldi and Patterson's failure model of Conduct Disorder (CD) and depression. Furthermore, Oppositional Defiant Disorder (ODD) is rarely considered distinctly from CD, minimizing the ability to identify distinct effects among behavioral disorders. METHODS: This paper used data from the Developmental Trends Study, a clinic-referred cohort of 177 boys, along with their parents, who were assessed regularly using a structured clinical interview and a comprehensive set of other measures. Boys were recruited when they were between the ages of 7 and 12, and were reassessed annually until age 18. Predictive regression models tested the continuities among disorders, with depression, overanxious disorder, Attention Deficit Hyperactivity Disorder (ADHD), ODD and CD examined separately as outcomes. RESULTS: Each disorder showed homotypic continuity, but a clear developmental sequence of heterotypic continuity also emerged. ADHD was predicted by no other disorders, and exclusively predicted ODD. CD was predicted only by ODD. However, ODD was also directly predictive of future anxiety and depression, and anxiety predicted future depression as well. A specific test of the failure model of CD and depression supported that model. CONCLUSIONS: ODD appears as a pivotal developmental disorder in young males, in that ODD is notably influential in both subsequent behavioral and affective disorders. CD influences later depression only indirectly, through psychosocial impairment. Anxiety precedes depression, and ADHD is not predicted by other disorders.

Sixty‐seven adolescent suicide victims and 67 demographically matched living controls were compared as to family constellation, familial stressors and familial loading for psychopathology. Suicide victims were less likely to have lived with both biological parents, were more likely to be exposed to stressors such as parent‐child discord, physical abuse and residential instability and showed greater familial loading for depression and substance abuse. Multivariate analyses showed that family history of both depression and substance abuse and lifetime history of parent‐child discord were most closely associated with adolescent suicide. Children who are the offspring of parents with depression or substance abuse should be psychiatrically screened. Family interventions to decrease discord may also be helpful in decreasing the risk of adolescent suicide.

There is increasing evidence for an association between the alteration of cytokine concentrations in blood and the pathophysiology of depressive disorders. Studies in humans have not investigated CSF cytokine concentrations and their relationship to depressive disorders. This study reports on the association of the CSF concentration of proinflammatory cytokines, IL-1beta, IL-6 and TNFalpha, and major depressive disorders. CSF samples were obtained from 13 hospitalized patients with acute unmedicated severe depression and were compared with 10 control subjects. Compared to the control group, the depressed patient group had higher CSF concentrations of IL-1beta, lower IL-6 and no change in TNFalpha. A positive correlation was found between serum IL-1beta and the severity of depression. These results indicate a unique profile for CSF proinflammatory cytokines in acute depression. These findings merit further investigation and if replicated may possibly offer immunological treatment options for depression.

Research on the relation between sex role orientation and psychological well-being has been guided by one of three models. The traditional congruence model holds that psychological well-being is fostered only when one's sex role orientation is congruent with one's gender; the androgyny model proposes that well-being is maximized when one's sex role orientation incorporates a high degree of both masculinity and femininity regardless of one's gender; the masculinity model posits that well-being is a function of the extent to which one has a masculine sex role orientation. The adequacy of these three models was tested by means of a meta-analysis of 35 studies of the relation between sex role orientation and self-esteem, the indicator of psychological well-being most widely used in sex role studies. The results of the meta-analysis were most supportive of the masculinity model and showed that the strength of observed relations between sex role orientation and self-esteem varied as a function of both the sex role measure and the type of self-esteem measure used in the studies. In addition, a number of methodological issues was identified that should be taken into consideration in future research.

The DSM-5 Personality and Personality Disorder Work Group have proposed diagnosing personality disorder based in part on 25 pathological traits. Initial research suggests that five factors explain the covariance among these traits and that these factors reflect the domains of the well-validated Five-Factor Model (FFM) of normative personality. This finding is important because it signifies the potential to apply normative trait research to personality disorder classification in the DSM-5. In this study, trait scale scores on the Personality Inventory for DSM-5 (PID-5) and domain scores from the FFM Rating Form (FFMRF) were subjected to a conjoint exploratory factor analysis (EFA) to test the higher-order convergence of the DSM-5 pathological trait model and the FFM in a nonclinical sample (N = 808). Results indicate that the five higher-order factors of the conjoint EFA reflect the domains of the FFM. The authors briefly discuss implications of this correspondence between the normative FFM and the pathological PID-5.

Recherche des caracteristiques des enfants dont les parents souffrent d'anxiete pathologique: par rapport aux groupes-controle, ils sont plus anxieux et craintifs, ont plus de difficultes scolaires, expriment davantage de soucis personnels ou familiaux et de plaintes somatiques et enfin, ils sont plus souvent occupes a des activites solitaires

Although the case study is usually accorded an important heuristic role, its limitations as a basis for drawing valid conclusions about the efficacy of treatment are widely recognized. The major problem with a case study is the ambiguity related to the precise influences that are responsible for change. Threats to in-ternal validity, normally ruled out in experimentation, make ambiguous the basis for therapeutic change. However, case studies may vary along several dimensions that dictate the extent to which specific threats to internal validity are addressed. The present article discusses the possibility of conceptualizing and conducting cases in such a way as to maximize the likelihood that internally valid conclusions can be drawn. Although case studies can never replace experimentation, the scientific yield from case reports might be improved in clinical practice where methodological alternatives are unavailable. The case study has played a central role in clinical psychology. Indeed, understand-ing the individual person is occasionally con-sidered to be a distinguishing characteristic of clinical psychology relative to other branches of the field (Korchin, 1976; Wat-son, 1951). The intensive study of the indi-vidual has contributed to clinical research and practice by providing a rich source of hypotheses about the bases of personality and behavior and by serving as a place to develop and apply intervention techniques