Robert L. Trestman

CORTISOL REGULATION IN POSTTRAUMATIC STRESS DISORDER AND MAJOR DEPRESSION: A CHRONOBIOLOGICAL ANALYSIS

The aim of the present study was to evaluate the pattern of basal cortisol release in PTSD and major depression using a chronobiological analysis. Plasma for cortisol determination was obtained from 15 combat veterans with PTSD, 14 subjects with major depression, and 15 normal men every 30 min during a 24-hour period of bed rest. Raw cortisol data were modeled using standard and multioscillator cosinor models to determine the best fitting functions for circadian, hemicircadian, and ultradian components of cortisol release. PTSD subjects had substantially lower cortisol levels, and displayed a pattern of cortisol release that was better modeled by circadian rhythm. PTSD subjects also showed a greater circadian signal-to-noise ratio than the other groups. In contrast, depressed patients displayed a less-rhythmic, more chaotic pattern of cortisol release. The pattern of cortisol secretion and regulation observed in the PTSD group under baseline conditions may reflect an exaggerated sensitization, whereas the chronobiological alterations in depression may reflect dysregulation, of the hypothalamic-pituitary-adrenal (HPA) axis.

Cognitive function and biological correlates of cognitive performance in schizotypal personality disorder

There is evidence that some schizophrenic patients have deficits on tests of cognitive function, particularly tests of executive function, including the Wisconsin Card Sorting Test (WCST) and the Trail-making Test, Part B. This study was conducted to determine the generalizability of these findings across the schizophrenia spectrum to schizotypal personality disorder (SPD). Forty DSM-III SPD patients, 56 nonschizophrenia-related other personality disorder (OPD) patients, and 32 normal volunteers from two medical centers performed tests of executive function such as the WCST, Trail-making Part B, Stroop Word-Color Test, and Verbal Fluency, as well as tests of more general intellectual functioning such as the Wechsler Intelligence Scale-Revised Vocabulary and Block Design subtests, and Trail-making Part A. SPD patients performed more poorly on the WCST and on Trail-making Part B than did OPD patients or normal subjects; the groups did not differ on tests of general intellectual functioning. SPD patients may share some of the cognitive deficits observed in schizophrenia.

Serotonergic function and self-injurious behavior in personality disorder patients

Self-directed aggression, whether in the form of non-suicidal self-mutilation or suicidal behavior, is a prominent feature of personality disorders. We hypothesized that self-injurious behavior, like suicidal behavior, represents a form of self-directed aggression, and may, like suicidal behavior and impulsive aggression, be associated with a decrease in central serotonin function in personality disorder patients. Ninety-seven patients with DSM-III personality disorder underwent D,L-fenfluramine challenge as an assessment of serotonergic activity. Patients with a history of self-mutilation or suicide had blunted prolactin and cortisol responses to D,L-fenfluramine compared to those with neither, and those with both had the most blunted responses to fenfluramine. These data raise the possibility that the central 5-HT abnormality, previously associated with suicidal behavior, may be associated with self-directed violence and not necessarily specifically with suicidal intent.

Treatment of impulsive aggression in correctional settings.

PURPOSE This article reports the implementation of Dialectical Behavioral Therapy-Corrections Modified (DBT-CM) for difficult to manage, impulsive and/or aggressive correctional populations. METHODS Participants were English-speaking women (n = 18) and men (n = 45) of diverse cultural backgrounds between the ages of 16 and 59 years old retained in state-run prisons in Connecticut. Following consent, and a psychological assessment battery, twice-weekly DBT-CM groups were held over 16 weeks followed by random assignment to DBT coaching or case management condition, with sessions taking place individually for eight weeks. Data analysis. A mixed effects regression model was used to test the hypotheses: participants will show decreased aggression, impulsivity, and psychopathology, as well as improved coping, after completing the DBT-CM groups; and will show greater reduction in targeted behaviors than those receiving case management at the six month and 12 month follow-up assessment periods. RESULTS Significant reduction in targeted behavior was found from baseline to following the 16 week DBT-CM skills treatment groups. Both case management and DBT coaching were significant at 12 month follow-up. A significant difference was found for adult men and women. CONCLUSIONS The study supports the value of DBT-CM for management of aggressive behaviors in prison settings.

Mental health of prisoners: prevalence, adverse outcomes, and interventions

More than 10 million people are imprisoned worldwide, and the prevalence of all investigated mental disorders is higher in prisoners than in the general population. Although the extent to which prison increases the incidence of mental disorders is uncertain, considerable evidence suggests low rates of identification and treatment of psychiatric disorders. Prisoners are also at increased risk of all-cause mortality, suicide, self-harm, violence, and victimisation, and research has outlined some modifiable risk factors. Few high quality treatment trials have been done on psychiatric disorders in prisoners. Despite this lack of evidence, trial data have shown that opiate substitution treatments reduce substance misuse relapse and possibly reoffending. The mental health needs of women and older adults in prison are distinct, and national policies should be developed to meet these. In this Review, we present clinical, research, and policy recommendations to improve mental health care in prisons. National attempts to meet these recommendations should be annually surveyed.

D-amphetamine challenge effects on Wisconsin Card Sort Test. Performance in schizotypal personality disorder ☆

The authors assessed the effects on Wisconsin Card Sort (WCST) performance and psychiatric symptoms of 30 mg d-amphetamine, a dopamine and norepinephrine agonist, vs placebo in nine patients with schizotypal personality disorder (SPD). Patients, particularly those who made more perseverative errors, demonstrated amphetamine-associated improvement on WCST performance. The data in this preliminary study suggest that some of the cognitive dysfunction present in SPD may improve with amphetamine challenge.

Serum cholesterol and impulsivity in personality disorders

Decreased serum cholesterol has been associated with impulsive aggressive behaviors. This study was designed to explore the relationship between serum cholesterol levels and measures of impulsive aggression in personality disordered patients. Forty-two personality disordered patients (14 borderline personality disorder, 28 other personality disorders) were included. Fasting serum cholesterol was measured by standard enzymatic assay. An ANOVA was performed with factors of gender and diagnosis, looking at two-way interactions between the factors and serum cholesterol. Patients with borderline personality disorder were found to have significantly lower serum cholesterol than non-borderline personality disorders. A significant interaction effect was also seen between gender and diagnosis with the male patients having lower cholesterol levels. This study suggests there may be a relationship between borderline personality disorder and low serum cholesterol.

Regional cerebral blood flow during the wisconsin card sort test in schizotypal personality disorder

Regional cerebral blood flow (rCBF) was measured by single photon emission computed tomography in 10 patients with schizotypal personality disorder (SPD) and nine age- and sex-matched normal volunteers. Subjects performed both the Wisconsin Card Sort Test (WCST) and a control task, the Symbol Matching Test (SMT). Four-way analyses of variance were performed to assess relative rCBF of the prefrontal cortex and of the medial temporal region. Normal volunteers showed more marked activation in the precentral gyrus, while SPD patients showed greater activation in the middle frontal gyrus. Relative flow in the left prefrontal cortex was correlated with better WCST performance in normal volunteers. SPD patients, however, showed no such correlations in the left prefrontal cortex, but demonstrated correlations of good and bad performance with CBF in the right middle and inferior frontal gyrus, respectively. Thus, at least some SPD patients demonstrate abnormal patterns of prefrontal activation, perhaps as a compensation for dysfunction in other regions.

Circadian Regulation of Basal Cortisol Levels in Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a psychiatric condition that can occur following exposure to trauma. Because the hypothalamic-pituitary-adrenal (HPA) axis is a major hormonal system mediating the stress response, and has been found to be altered in response to a variety of acute and chronic stressors, it has been hypothesized that fundamental changes in the HPA axis would be relevant to the pathophysiology of PTSD. There is now converging evidence suggesting that PTSD patients show HPA axis alterations that are substantially different from those that have been described in stress and major depression. For example, in s ~ m e , l ~ but not all studies4 basal 24-hr urinary excretion of cortisol was lower in PTSD compared with normal and depressed patients. Furthermore, in contrast to the “nonsuppression” of cortisol observed in major depression, cortisol levels following dexamethasone (DEX) were lower (i.e., more suppressed) in combat veterans with PTSD than in normals.sd It has also been observed that combat veterans with PTSD exhibit a larger number of cytosolic glucocorticoid receptors (GR) on circulating lymphocytes compared to other psychiatric groups such as bipolar mania, panic disorder, schizophrenia, and major depre~sion.~ Combat veterans with PTSD also appear to have a larger number of GR than combat veterans who do not meet criteria PTSD6 and normal control^.^^^ Veterans who do not meet criteria for PTSD were found to have a larger number of GR than normals? Although the larger number of cytosolic GR in PTSD may simply reflect the lower circulating levels of cortisol, it is also possible that some long-lasting alterations in GR binding parameters result from exposure to traumatic events, and/or the subsequent development of PTSD. Based on the above data, we have hypothesized that HPA axis alterations in chronic PTSD appear to reflect an enhanced negative feedback at one or more sites along the axis? In this model, chronic increases in the release of CRF would lead to an altered responsivity of the pituitary, as evidenced by the blunted ACTH response to CRF previously observed.* However, because of a primary alteration in GR responsivity, there would be a stronger negative feedback resulting in attenuated baseline ACTH and cortisol levels as well as an enhanced responsivity to DEX. According to this model it would be expected that some target tissue of the HPA axis might be unusually responsive or sensitized. Recently, in order to further explore the enhanced sensitivity of the HPA axis in PTSD, we conducted a chronobiological analysis to elucidate the intrinsic regulatory

Risk of Incarceration Between Cohorts of Veterans With and Without Mental Illness Discharged From Inpatient Units

OBJECTIVE This study examined the risk of incarceration among cohorts of veterans treated in the Department of Veterans Affairs (VA) Connecticut Healthcare System. Incarceration rates of persons with and without mental illness were compared and adjusted for various clinical and service utilization variables. Data were compared before and after the closure of over 80% of the Connecticut VA psychiatric inpatient beds in 1996. METHODS Data from five annual cohorts of patients (1993-1997) treated in an inpatient unit in the VA Connecticut Healthcare System (N=36,385) were merged with state Department of Correction data. Logistic regression models were used to identify risk factors for incarceration. RESULTS Bivariate analysis showed that incarceration rates were higher for VA patients with psychiatric disorders and with substance use disorders than for those without such diagnoses, but there were no significant increases in likelihood of incarceration over these years of extensive closures. In multiple logistic regression analysis only diagnoses of substance use disorders and major depression were independently associated with an increased likelihood of incarceration, whereas schizophrenia, personality disorders, and co-occurring psychiatric and substance use disorders were not independently associated with increased likelihood in multivariate analysis. CONCLUSIONS Alcohol and drug problems appeared to account for much of the risk of incarceration among hospitalized veterans during the study period. Unlike in previous studies, schizophrenia and related psychotic disorders were not independently associated with an increased risk of incarceration.