Joseph D. Hamilton

Personality disorders in veterans with posttraumatic stress disorder and depression

Little is known about the frequency of the full-range of personality disorders in outpatients with concurrent posttraumatic stress disorder (PTSD) and depression, a common and oftentimes treatment-resistant combination in clinical practice. In a group therapy outcome study, Axis I and II diagnoses were assessed with the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale to select 115 male combat veterans with PTSD and depressive disorder. Within this sample, 52 (45.2%) had one or more personality disorders—most commonly paranoid (17.4%), obsessive-compulsive (16.5%), avoidant (12.2%), and borderline (8.7%)—and 19 (16.5%) had two or more. Documenting a substantial frequency of personality disorders is a first step in devising appropriate interventions for this treatment-resistant combination of disorders.

Treating comorbid panic disorder in veterans with posttraumatic stress disorder.

This study compares the effectiveness of panic control treatment (PCT) with that of a psychoeducational supportive treatment (PE-SUP) in treating panic disorder among a veteran sample with a primary diagnosis of chronic posttraumatic stress disorder (PTSD). Thirty-five patients randomized to receive 10 individual sessions of either PCT or PE-SUP underwent assessments at pretreatment, at 1-week posttreatment, and at a 3-month follow-up. Intent-to-treat analyses of covariance showed that PCT participants significantly improved on panic severity at posttreatment and panic fear at the 3-month follow-up. The PCT group also showed significant reductions in anxiety sensitivity at posttreatment and follow-up compared with that of the PE-SUP group. A significantly higher proportion of persons (63%) in the PCT group was panic free by the follow-up period compared with that of the PE-SUP group (19%). Patient self-report and clinician ratings showed no changes in general anxiety, depression, and PTSD symptoms in either group. These findings indicated that PCT was superior to an active control therapy in reducing the frequency, severity, and distress associated with panic disorder and suggested that brief cognitive-behavioral therapy for panic is effective for persons with chronic PTSD.

Persistence of Combat-Related Posttraumatic Stress Symptoms for 75 Years

Investigations of the duration of combat-related posttraumatic stress symptoms have focused mainly on survivors of World War II and the Vietnam War, with little attention to surviving veterans of World War I. The authors describe a case in which posttraumatic stress symptoms persisted for 75 years in a World War I combat veteran and increased in frequency toward the end of his life accompanied by advancing dementia and hospitalization. The case illustrates that posttraumatic stress symptoms may be lifelong and exacerbated by various consequences of aging, even if they are not disabling.

The Aging Physician With Cognitive Impairment: Approaches to Oversight, Prevention, and Remediation

There are many important unanswered issues regarding the occurrence of cognitive impairment in physicians, such as detection of deficits, remediation efforts, policy implications for safe medical practice, and the need to safeguard quality patient care. The authors review existing literature on these complex issues and derive heuristic formulations regarding how to help manage the professional needs of the aging physician with dementia. To ensure safe standards of medical care while also protecting the needs of physicians and their families, state regulatory or licensing agencies in collaboration with state medical associations and academic medical centers should generate evaluation guidelines to assure continued high levels of functioning. The authors also raise the question of whether age should be considered as a risk factor that merits special screening for adequate functioning. Either age-related screening for cognitive impairment should be initiated or rigorous evaluation after lapses in standard of care should be the norm regardless of age. Ultimately, competence rather than mandatory retirement due to age per se should be the deciding factor regarding whether physicians should be able to continue their practice. Finally, the authors issue a call for an expert consensus panel to convene to make recommendations concerning aging physicians with cognitive impairment who are at risk for medical errors.

Resolution of Fear of Flying with Fluoxetine Treatment

Fear of flying is a common specific phobia usually treated with behavior therapy; the possibility of pharmacologic treatment has received very little study. The authors report two cases in which successful fluoxetine treatment of major depressive disorder unexpectedly and unintentionally resolved a concomitant fear of flying that had preceded the depressive disorder.

Determinants of behavioral symptoms in dementia patients

Abstract Behavioral symptoms in dementia are common, and lack of a conceptual model has resulted in the use of treatments that address only the symptoms and not the causes. Our conceptual model proposes that the determinants of behavioral symptoms derive from three sources, the patient, the caregiver, and the environment. These determinants are subdivided into those that are mutable and those that are fixed. By identifying mutable determinants, this conceptual model eventually will lead to a more systematic approach to the treatment of behavioral symptoms in dementia and to quality improvement programs.

When Anxiety Symptoms Masquerade as Medical Symptoms: What Medical Specialists Know about Panic Disorder and Available Psychological Treatments

Under-recognition of somatic symptoms associated with panic in primary care settings results in unnecessary and costly diagnostic procedures and inappropriate referrals to cardiologists, gastroenterologists, and neurologists. In the current study specialists’ knowledge regarding the nature and treatment of panic were examined. One-hundred and fourteen specialists completed a questionnaire assessing their knowledge about panic attacks, including their perceptions of psychologists’ role in treating panic. Respondents answered 51% of knowledge items correctly. Although most knew the definition of a panic attack, they knew less about clinical features of panic and its treatment. Specifically, whereas 97.4% believed medication effectively relieves panic symptoms, only 32.5% knew that cognitive-behavioral therapy (CBT) is a first-line treatment. Only 6% reported knowing how to implement CBT, and only 56.1% recognized that psychologists could effectively treat panic. These findings demonstrate significant gaps in specialists’ knowledge about panic and the need to enhance physician knowledge about panic attacks and their treatment.

Outcome of Psychiatric Hospitalization for Very Low-Functioning Demented Patients

The authors determined the outcome of geropsychiatric hospitalization for 73 very low-functioning demented patients (GAF score < 21). General psychiatric symptoms, depression, and agitation decreased significantly, and mean GAF scores increased significantly, with no significant change in cognitive function. Psychiatric hospitalization can meaningfully improve function and quality of life even in this very impaired population. Despite these improvements many patients are discharged to more restrictive settings.