Christopher G. Fichtner

Dissociation of affect recognition and mood state from blunting in patients with schizophrenia.

The present study was designed to investigate the relationships between expression, perception, and experience of emotion in schizophrenic patients with and without affective blunting. Cognitive processing speed, emotional perception, and emotional experience were assessed in 25 schizophrenic patients grouped according to scores on a measure of overt emotional expression (Rating Scale for Emotional Blunting). Results showed dissociation of emotional expression from emotional perception and emotional experience. Blunted schizophrenic patients were no more impaired in the perception of emotion (Profile of Nonverbal Sensitivity) than non-blunted schizophrenic patients. In addition, groups did not differ in intensity of emotional experience as quantified on the self-report of arousal state (Positive and Negative Affect Scales). Accuracy of perception and reported experience of emotion did not differ between groups as a function of emotional valence. Cognitive processing speed (Symbol Digit Modalities Test; SDMT) was related to blunting score and to perception accuracy, although the SDMT did not differ between groups. Results are discussed in terms of a neuropathological basis for impairment of emotional expression.

Hypodensity of platelet serotonin uptake sites in posttraumatic stress disorder: Associated clinical features

We have previously reported that binding to blood platelets of paroxetine, a selective serotonin (5-HT) reuptake inhibitor which binds to 5-HT uptake sites, is decreased in patients with posttraumatic stress disorder (PTSD). Specifically, we found a lower number of platelet 3H-paroxetine binding sites (Bmax) and a lower dissociation constant (Kd) for 3H-paroxetine binding in combat veterans with PTSD compared to normal control subjects. In the current study we assessed the relationship of platelet 3H-paroxetine binding to clinical features in 41 Vietnam combat veterans with SCID-diagnosed PTSD. The results indicated that Bmax of platelet 3H-paroxetine binding was negatively correlated with both state and trait anxiety, as well as with depressive and overall PTSD symptoms. However, there was no evidence that platelet 3H-paroxetine binding differed as a function of comorbid psychiatric diagnoses including major depression, other anxiety disorders, and substance abuse in these patients.

POST-TRAUMATIC STRESS DISORDER : PATHOPHYSIOLOGICAL ASPECTS AND PHARMACOLOGICAL APPROACHES TO TREATMENT

SummaryPost-traumatic stress disorder (PTSD) is a syndrome of psychophysiological sequelae occurring in the aftermath of severe emotional trauma. Phenomenologically, symptoms occur in 3 clusters: re-experiencing, avoidance and hyperarousal. Other psychiatric disorders such as depression, panic disorder and substance abuse frequently co-occur with PTSD.Treatment strategies for PTSD are often multimodal and attempt to integrate biological, behavioural, cognitive, psychodynamic and social formulations. Pharmacotherapy must target specific symptoms in all 3 clusters, and address the presence of comorbid psychiatric disorders. Psychotropic medication can facilitate psychotherapeutic work, or serve as the primary modality in a biologically based approach to treatment.Specific medications used in the treatment of PTSD span a broad spectrum of pharmacological agents. The most empirically studied agents, tricyclic antidepressants and monoamine oxidase inhibitors, demonstrate a definite but limited impact on specific PTSD symptoms. For the patient who presents in an acute symptomatic state, benzodiazepine anxiolytics may be appropriate. For longer term treatment, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), particularly fluoxetine, appear to have broader spectrum therapeutic effects on specific PTSD symptom clusters. Both antidepressants and anxiolytics have, in some studies, shown beneficial effects on depressive symptoms and anxiety, without measurable impact on the symptoms more specific to PTSD.Maintenance pharmacotherapy frequently requires a multidrug regimen; an SSRI may serve as the primary agent, with adjunctive agents targeting residual hyperarousal and re-experiencing symptoms. Benzodiazepines, sedating tricyclic or antihistamine compounds, and the noradrenergic drugs Clonidine and propranolol are used in this way. Buspirone, a serotonergic anxiolytic, may serve a similar role for some patients, and cyproheptadine in particular appears to be helpful for nightmares. The antikindling agents carbamazepine and valproic acid (sodium valproate) have also been reported to be beneficial, and may provide an alternative for patients with persistent hyper-reactivity and explosiveness that have not responded to other treatments.

Open trial of nefazodone for combat veterans with posttraumatic stress disorder

Fourteen combat veterans completed a 9-week open trial of nefazodone for treatment of posttraumatic stress disorder (PTSD). Overall PTSD symptoms as measured by the Clinician-Administered PTSD Scale (CAPS) showed a modest but statistically significant decrease with nefazodone treatment. Decreases in CAPS reexperiencing and avoidance, but not hyperarousal symptoms, approached statistical significance. Anxiety decreased significantly, and there were trends toward decreased depression and anger on structured assessments. This study adds to the clinical evidence that nefazodone may be helpful for the management of PTSD symptoms.

Similar or Disparate Brain Patterns? The Intra-Personal EEG Variability of Three Women with Multiple Personality Disorder

Quantitative EEG was used to assess the intra-personal variability of brain electrical activity for 3 women diagnosed with Multiple Personality Disorder (MPD). Two separate control groups (within-subject and between-subject) were used to test the hypothesis that the intra-personal EEG variability between 2 alters would be less than the interpersonal EEG variability between 2 controls, and similar to the intra-personal EEG variability of a single personality. This hypothesis was partially supported. In general, the 2 EEG records of a MPD subject (alter 1 vs. alter 2) were more different from one another than the 2 EEG records of a single control, but less different from one another than the EEG records of 2 separate controls. Most of the EEG variability between alters involved beta activity in the frontal and temporal lobes.

Psychiatric leadership and the clinical team: simulated in vivo treatment planning performance as teamwork proxy and learning laboratory.

Leadership is an important consideration at many levels within behavioral healthcare systems. The authors developed a training program in a large public hospital system that focused on psychiatric leadership and clinical team functioning. In a learning laboratory format, they used videotaped patient simulations as a stimulus for multidisciplinary treatment planning sessions. Structured self-assessments were performed using a preliminary Scale for Leadership Assessment and Team Evaluation (SLATE). Videotaping the sessions provided an additional team self-assessment tool. Other educational activities supplemented the sessions, and teams proposed steps for transferring their learning to other units. The authors emphasize that leadership must foster team learning, which involves developing adaptive capacities and applying them to new clinical situations.

Sexual offenders in custody for control, care and treatment

Fourteen US states have sexual predator statutes, and legal questions remain in the forefront. The courts continue to examine and question decisions regarding risk assessment, management, treatment, and treatment outcomes. Clinicians working with sexual offenders, particularly sexual predators, need to be aware and informed regarding current sexual offender management and treatment.

Discontinuity of Outpatient Antipsychotic Pharmacotherapy: Risperidone Maintenance after Hospitalization

Objective: To investigate continuity of outpatient antipsychotic pharmacotherapy with risperidone in patients discharged from state psychiatric hospitals. Methods: Of 1,201 patients discharged from Illinois state psychiatric hospitals while taking risperidone during the first year of the medications commercial availability, 627 public aid–eligible patients were trackable on the basis of public aid billing data. Data on risperidone continuation and other medication use for these patients were collected for the two-year period following each patients discharge. Results: Forty-four percent of the patients discontinued risperidone within two weeks of hospital discharge, with one-half receiving no medications and most of the remainder switching to other antipsychotics. More than 75% of the patients discontinued risperidone within one year of hospital discharge, and fewer than 1% received continuous risperidone pharmacotherapy for the two-year follow-up period. Conclusions: Although the study methods do not permit us to draw conclusions regarding specific reasons for risperidone discontinuation in this patient sample, 66% of whom had a diagnosis of schizophrenia or schizoaffective disorder and 86% of whom had psychotic diagnoses, the rapid drop-off and discontinuity in medication management following hospital discharge is almost certainly inconsistent with optimum clinical care for this group of patients. Discontinuities in maintenance pharmacotherapy may compromise medical effectiveness, even for newer antipsychotic medications such as risperidone.