Ronald S. Lipman

The Hopkins Symptom Checklist (HSCL) ☆: Factors derived from the HSCL-90

A factor analysis of the 90-item version of the Hopkins Symptom Checklist, performed on the pretreatment self-ratings of nonpsychotic outpatients with symptoms of depression and anxiety, revealed the presence of 8 clinically meaningful factors. These eight orthogonal factors each contained at least 5 items with loadings above 0.40 and explained 4.5% or more of the matrix variance. They were labeled Somatization, Phobic-Anxiety, Retarded Depression, Agitated Depression, Obsessive-Compulsive, Interpersonal Sensitivity, Anger-Hostility and Psychoticism.

Drug, doctor's verbal attitude and clinic setting in the symptomatic response to pharmacotherapy

Summary138 psychoneurotic outpatients manifesting anxiety were treated for 6 weeks with medication and brief, supportive interviews every 2 weeks with a psychiatric resident. The patients were divided among 12 different treatment conditions composed of 1. meprobamate 1,600 mg q.i.d. versus an identical placebo in a double-blind arrangement, 2. a doctor expressing an enthusiastic attitude toward the medication versus a doctor expressing a skeptical attitude toward the medication and 3. three different psychiatric outpatient clinics.The patients symptomatic condition was assessed at each visit by means of five ratings made by the patient before each interview and three ratings made by his doctor afterward. These ratings included an overall judgment of change, a checklist of 64 common symptoms, a score based on the patients presenting complaints and adjective checklists for registering anxiety and depression.The results at one clinic showed the expected interaction between medication and doctors expressed attitude: with the enthusiastic doctors, patients taking meprobamate improved more than patients taking placebo; whereas with the skeptical doctors, patients taking placebo tended to improve more than patients taking meprobamate. At the other two clinics, however, this interaction was absent or possibly reversed, with meprobamate tending to be superior to placebo with skeptical doctors.Some striking clinic differences among the characteristics of patients were found, particularly in social class status and the commonly associated styles of complaint and goals and expectations regarding treatment. The clinic showing the anticipated interaction between medication and doctors verbal attitude had patients with the lowest social class standing. The doctors at this clinic also came from backgrounds of lower social class than the doctors at the other two clinics. These differences suggest that the participants at this clinic may have assigned meanings to the enthusiastic and the skeptical attitudes contrasting with the meanings assigned at the other two clinics. The possible relevenace of these differences to the results is discussed.

A comparison of patient dosage deviation reports with pill counts

SummaryThis is a report of a comparison between patient verbal reports of dosage deviation during a drug study and pill counts. Pill counts are much more reliable, but verbal reports are of some value, since when there are statements of major deviations they tend to be correct.

Remembering Life Events

Most modern quantitative investigations of life stress depend upon cataloging the life experiences of individual subjects retrospectively over periods ranging from months to years (Dohrenwend & Dohrenwend, 19774; Gunderson & Rake, 1974). Although the unreliability of memory for important events in other contexts is well known (Anderson & Anderson, 1967; Haggard, Brekstad & Shard, 1960; Mechanic & Newton, 1965; Pany, Balter & Cisini, 1970–71; US National Health Survey, 1961, 1963; Wenar & Coulter, 1962), little attention has been paid the issue in relation to studies of life stress (Casey, Masuda, & Holmes, 1967). This paper reports decrements in recall over an l8 month period for stressful events in general, 41 individual events, and various subgroups of events.

Symptomatic volunteers in multicenter drug trials.

1. Symptomatic volunteers were recruited at two collaborating institutions for anti-anxiety and antidepressant drug trials. Advertisements were placed for volunteers with significant symptoms of anxiety, depression, or both, and who were not currently in treatment. 2. It was possible to recruit adequate numbers of volunteers who met the numerous criteria for severity of distress; and who were not ruled out by various exclusion criteria, such as medical contraindications, etc. 3. Acceptable homogeneity across the samples at the collaborating institutions was found for demographic characteristics, level of distress, duration of symptoms, etc. 4. Attrition rates for these volunteers were lower than for the typical anxiolytic and antidepressant trials using outpatients. 5. Symptomatic volunteers appear to present a feasible alternative to the increasingly diminishing pool of outpatients.

Replication Of Symptom Distress Factors In Anxious Neurotic Outpatients.

In an attempt to replicate the factor structure of symptom distress re- ported by Mattsson et al. in their study of 404 anxious neurotic outpatients, the same 68-item pretreatment self-report Symptom Check List was administered to an independent but clinically similar sample of 1,116 patients. Using an identical factor-analytic procedure, five useful factors were extracted: Neurotic Feelings, Somatization, Performance Difficulty, Fear-Anxiety, and Depression. Four of these factors were almost identical to those reported by Mattsson e t al. while the fifth factor, Depression, seemed to represent a composite of the two small Depression factors (Anxious and Somatic) found in the earlier study. This minor discrepancy was discussed and the future research potential of these factors was indicated.

Combined pharmacotherapy and psychotherapy.

This paper summarizes controlled studies on combined pharmacotherapy (chronic dosage) and psychotherapy in the literature since 1950. Studies purportedly or actually comparing the effects of combined treatment with the effects of either treatment alone are included. Major tranquilizers, minor tranquilizers, group psychotherapy, individual psychotherapy, schizophrenic patients and psychoneurotic patients are relatively well represented, along with single studies dealing with insulin, antidepressants and depressed patients. From a practical point of view, these studies consistently suggest that combined treatment is superior to psychotherapy alone, but not to pharmacotherapy alone. From a theoretical point of view, these studies suggest that the effect of two treatment interventions combined is the same as the effect of the more effective intervention alone. Unfortunately, this point remains highly tentative because of limitations in the design and execution of the available studies. The effect of the psychotherapy offered constitutes a major question in most of the studies reviewed. They suggest that the role of psychotherapy in combined treatment may be clarified in part by including assessments of the effects of psychotherapy alone and pharmacotherapy alone in the designs of future studies. Studies of psychotherapy suggest that the role of psychotherapy in combined treatment may be further clarified by providing contrasting “dosages” of psychotherapy in terms of certain crucial indicators: the therapists level of experience; the levels of accurate empathy, nonpossessive warmth and genuineness he offers his patients; his score on the Whitehorn-Betz A-B Scale; and the extent to which his interests on the Strong Vocational Interest Blank correspond to those of a reference group of successful psychiatrists.

Anxiety states and depressive neuroses. Issues in nosological discrimination.

This article reviews current conceptions of the nosology of the neurotic affective disorders with particular emphasis on the controversy concerning the status of the anxiety states and depressive neuroses as distinct clinical syndromes. Empirical evidence in support of both the distinct-syndrome and unitary-syndrome positions is reviewed and related to current theoretical postures. Analysis suggests that the pivotal question does not center on whether distinctions can be made between the two conditions, but rather, whether differences observed are of a magnitude to be clinically significant. Five primary issues—all judged to have substantial nosological relevance—are examined specifically in terms of their influence on the classification of the affective neuroses. Conclusions point up the fact that the development of a definitive system of classification for these conditions represents a complex, multidetermined problem that will demand full utilization of the information and methodology available to contemporary clinical science.

Drug, doctor warmth, and clinic setting in the symptomatic response to minor tranquilizers

An NIMH-PRB collaborative double-blind clinical trial, concerned with the importance of the “doctor variable” for drug treatment outcome, was conducted with 485 anxious neurotic outpatients receiving either chlordiazepoxide, meprobamate, or placebo. The participating clinics were located at the Johns Hopkins Hospital, Philadelphia General Hospital, and the Hospital of the University of Pennsylvania. The doctor variable selected for presentation was “doctor warmth”. Data on the 169 patients completing the 4 week study according to protocol were analyzed using a factorial analysis of covariance procedure, and the main findings were as follows: 1. several main “drug” effects, present only at 2 weeks, indicated chlordiazepoxide to produce significantly more improvement than either meprobamate or placebo; 2. several main “warmth” effects, present only at 4 weeks, showed patients rating their physicians at the initial visit as “warm” to improve significantly more than patients rating their physicians as “non-warm”; and 3. several significant drug X clinic interaction effects at 4 weeks reflected the fact that while hardly any drug differences were seen in 2 clinics, at Philadelphia General Hospital, patients strongly favored chlordiazepoxide. “Drug” and “warmth” effects were particularly marked in initially sicker patients, and “warmth” appeared especially important in the improvement of initially sicker placebo patients.

Drug effects and initial severity of symptomatology

SummaryA recurring question appearing in clinical psychopharmacological research concerns the nature of the relationship between initial severity of symptomatology and the magnitude of a drug effect. Data are presented to show that, with meprobamate and placebo in neurotic outpatients, the magnitude of the pharmacological effect remains constant across all levels of initial severity.