Tanya N. Alim

Trauma, Resilience, and Recovery in a High-Risk African-American Population

OBJECTIVE Despite increased risk for psychiatric disorders after trauma exposure, many people are able to adapt with minimal life disruption, and others eventually recover after a symptomatic period. This study examined psychosocial factors associated with resilience and recovery from psychiatric disorders in a high-risk sample of African American adults exposed to a range of severe traumas, who participated in structured diagnostic interviews. METHOD The sample included 259 patients exposed to at least one severe traumatic event, recruited from primary care offices at Howard University and administered the Structured Clinical Interview for DSM-IV Axis I disorders. Multinomial logistic regression was used to identify potential psychosocial factors associated with resilience and recovery, including purpose in life, mastery, and coping strategies. RESULTS Forty-seven patients had no lifetime psychiatric disorders (resilient), 85 met criteria for at least one past DSM-IV disorder but no current disorders (recovered), and 127 met criteria for at least one current DSM-IV disorder (currently ill). The resilient group was characterized by a significantly lower lifetime trauma load. Female gender was predictive of currently ill status. In the final model, purpose in life emerged as a key factor associated with both resilience and recovery, and mastery was also significantly associated with recovery. CONCLUSIONS The identification of psychosocial factors associated with resistance to severe trauma can inform future studies of preventive and treatment interventions for high-risk populations. Further study is needed to determine which psychosocial factors are consistently associated with resilience and to what extent they can be modified through clinical intervention.

Sympathoneural and adrenomedullary functional effects of alpha2C-adrenoreceptor gene polymorphism in healthy humans.

Objectives &agr;2-Adrenoreceptors restrain sympathetic nervous outflows and inhibit release of noradrenaline from sympathetic nerves. In-frame deletion of the &agr;2C-adrenoreceptor subtype (&agr;2CDel322–325) increases the risk of congestive heart failure. Increased delivery of catecholamines to cardiovascular receptors might explain this increased risk. Methods Twenty-nine healthy African-Americans genotyped for &agr;2-adrenoreceptor subtype polymorphisms underwent 3H-noradrenaline and 3H-adrenaline intravenous infusion and arterial blood sampling for measurements of rates of entry of endogenous noradrenaline and adrenaline into arterial plasma (total body spillovers) by the tracer dilution technique. Eleven subjects were homozygotes for the &agr;2CDel322–325 polymorphism, nine heterozygotes, and nine non-carriers. Subjects were studied during supine rest and during and after i.v. infusion of the &agr;2-adrenoreceptor antagonist, yohimbine. Results At rest, homozygotes for the &agr;2CDel322–325 polymorphism had higher total body noradrenaline spillover than did heterozygotes (t=2.90, df=18, P=0.023) or non-carriers (t=3.22, df=18, P=0.010). Adrenaline spillover was higher in homozygotes than non-carriers (t=2.61, df=18, P=0.045). Administration of yohimbine produced larger, more sustained increments in noradrenaline spillover, heart rate, and anxiety in homozygotes than in the other groups. Conclusion In healthy people, &agr;2CDel322–325 polymorphism is associated with increased sympathetic nervous and adrenomedullary hormonal activities, both during supine rest and during pharmacologically evoked catecholamine release. Polymorphisms of the &agr;2C-adrenoreceptor may help explain individual differences in predisposition to a variety of disorders of catecholaminergic function, such as cardiovascular disorders, depression or anxiety disorders.

Phenomenologic Comparison of the Idiopathic Psychosis of Schizophrenia and Drug-induced Cocaine and Phencyclidine Psychoses: A Retrospective Study

Summary:Both stimulant-induced and phencyclidine (PCP)-induced psychoses have been proposed as models of the idiopathic psychosis of schizophrenia. In this two-part study, the phenomenology of the psychosis associated with a period of cocaine intoxication was evaluated retrospectively in 34 male crack cocaine-dependent patients without concomitant psychiatric disorder and then was compared with the psychosis of 16 actively psychotic schizophrenic men (without a history of drug or alcohol abuse in the past year). Certain First Rank Schneiderian Symptoms (FRSS) were more commonly observed in the schizophrenic patients (e.g., thought broadcasting, thought withdrawal) than in the cocaine addicts. In the second part of this study, we retrospectively examined the cocaine and PCP experiences of an additional 22 cocaine addicts who had a past history of separate periods of cocaine and PCP use. Overall, the frequency of FRSS recalled during periods of cocaine and PCP intoxication was similar. However, the psychosis related to cocaine intoxication was more associated with an intense suspiciousness and paranoia related to a fear of being discovered or harmed while using cocaine. PCP-induced psychosis was less associated with suspiciousness and more associated with delusions of physical power, altered sensations, and unusual experiences [e.g., out of body experiences, periencing religious figures or events directly (e.g., being with Noah at the time of the Arc)]. As elements of both cocaine and PCP psychosis can be found in schizophrenia, a model integrating the mechanisms of several psychotogenic drugs may be more informative. Such an integrative model might better capture the heterogeneity of psychotic symptoms that can be seen in schizophrenia. Furthermore, different pharmacologic interventions (e.g., “anti-stimulant” versus “anti-PCP”) might address different aspects of the positive symptom picture in schizophrenia.

Anxiety and pupil reactivity in cocaine dependent subjects endorsing cocaine-induced paranoia: preliminary report.

There has been the clinical impression that people with higher levels of anxiety and central arousal are more prone to develop cocaine-induced paranoia (CIP), but this notion has not been formally studied. In the current study, we examined the differences between 28 CIP-endorsing and 16 CIP-denying chronic cocaine users in their levels of state and trait anxiety as measured by the Spielberger State-Tait Anxiety Inventory. We also studied levels of central arousal and reactivity using pupil size measures both during exposure to neutral, abstract, non-drug cues, and after exposure to a cocaine cue. Levels of trait (but not state) anxiety were significantly higher in the CIP group than in the non-CIP group. Moreover, while there were no significant pupil size differences or changes between the two groups while viewing neutral, abstract video images, the CIP group had significantly greater pupillary dilation in response to a video image of crack cocaine than did the non-CIP group. These significant differences remained even after covarying for anxiety scores. The study findings seem relevant to studies of autonomic reactivity in response to drug cues in cocaine-dependent patients; such studies might remain attentive to potential cue reactivity differences between patients endorsing and those denying CIP. Finally, this is the first study showing higher trait anxiety in patients with CIP.

Nimodipine pharmacotherapeutic adjuvant therapy for inpatient treatment of cocaine dependence

Summary:Recent preclinical studies suggest utility for voltage-sensitive calcium channel blockers (VSCCBs) in the treatment of cocaine addiction. The following double-blind placebo-controlled study examined the role of the VSCCB nimodipine in attenuating cocaine craving in 66 recently abstinent cocaine-dependent patients on an inpatient substance abuse treatment unit utilizing an intensive 12-step milieu-oriented psychosocial therapy. While the medication was well tolerated, the dose of nimodipine used in this study (90 mg q.d.) was not superior to placebo in reducing background or cue-induced cocaine craving over the 3 weeks of the study. There was the suggestion that nimodipine might attenuate the severity of some cocaine-induced brain deficits, as detected by evaluation of smooth pursuit eye movement function. A rationale for evaluating higher doses of nimodipine for the treatment of cocaine addiction is presented. As nimodipine might have anticraving and moodstabilizing properties and cardio- and neuroprotective properties in the face of cocaine intoxication and might possibly even reverse some cocaine-induced brain deficits, further investigation of the role of nimodipine (and other VSCCBs) in cocaine addiction appears an attractive avenue of future medication development.

PTSD treatment of African American adults in primary care: the gap between current practice and evidence-based treatment guidelines.

BACKGROUND Posttraumatic stress disorder (PTSD) is a common, potentially disabling, underdiagnosed, and under-treated illness. Primary care physicians assume a critical role in the diagnosis, treatment, and referral of African Americans with PTSD since mental health access is limited for this population. This study is an examination of PTSD treatment of African Americans in the primary care setting. Actual treatment provision is contrasted with existing evidence-based PTSD treatment guidelines. METHOD Researchers screened 738 consenting, mostly African American, adults in 4 academically affiliated primary care offices for both trauma exposure and mental health symptoms, including PTSD. RESULTS Employing criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) (DSM-IV), investigators diagnosed 91 of the participants with current PTSD using the Structured Clinical Interview for DSM and the clinician-administered of PTSD Scale for DSM-IV. Treatment statistics include: 69.2% (n=63) had never received treatment from a mental health provider: 18.6% (n=17) were currently seeing a mental health practitioner; nearly half (47.9%, n=24) of a subsample had never discussed traumatic event exposure or mental health symptoms with their primary care doctor; 32% (n=29) were prescribed psychotropic medication and only 18.6% (n=17) were participating in any form of psychotherapy. Concurrent psychiatric disorders were found in 46.2% (n = 42) of the participants with PTSD. CONCLUSION Most African American adult primary care patients with PTSD were either undiagnosed or undertreated in this inner-city setting. These results demonstrate a clear need to improve screening and treatment services. Both individual (provider and patient) and system-based changes will be required to meet the demonstrated clinical need.

Lack of neurotoxic effect of diethylpropion in crack-cocaine abusers

Dopamine agonists have been used with some success in treating cocaine addiction. However, both cocaine and psychostimulants have been reported to produce neurotoxic effects. We evaluated the effect of the stimulant diethylpropion on cognitive performance in a double-blind, placebo-controlled trial. Forty-six abstinent crack-cocaine users received either placebo, 25-mg, 50-mg, or 75-mg doses of diethylpropion. Patients were tested at baseline and again after 9-14 days of medication. There were no differences between placebo and medication groups on any test, indicating that, within the time frame studied, diethylpropion does not produce neurotoxic effects that can be detected with standardized neuropsychological tests.

Predicting premorbid functioning in crack-cocaine abusers

The Wide Range Achievement Test (Revised) (WRAT-R) reading test, demographic variables and drug use severity were used to develop prediction equations to estimate premorbid ability in 92 cocaine abusers. WRAT-R reading was correlated significantly with full scale, verbal and performance IQ. Stepwise regression indicated that only WRAT-R reading score and age accounted for 23% of the variance in Full Scale IQ (FSIQ) and 28% in Verbal IQ (VIQ). Abstinence and severity of use variables did not correlate with nor predict IQ. Actual and predicted IQ scores were correlated significantly and did not differ based on within group t-tests. Thus, these formulas accurately estimate premorbid functioning in cocaine-dependent research patients with FSIQs in the average to low average range, replicating the results in normal adults with average IQs.

Craving and Depression in Opiate Dependent Mentally Ill African Americans Receiving Buprenorphine/Naloxone and Group CBT (Cognitive Behavioral Therapy)

Given limited research on patient perspectives, we sought to assess craving and depression in dually diagnosed African Americans receiving Buprenorphine/Naloxone and group therapy. Nineteen subjects were recruited and 13 completed the 12 month longitudinal study. Buprenorphine/Naloxone treatment and group therapy were provided weekly. Quarterly evaluations of craving, depression and patient perspectives of treatment were obtained. Craving, depression and reported opiate use significantly declined from baseline. Depression increased slightly at 12 months. Buprenorphine/Naloxone and group therapy resulted in a significant decrease in craving, depression severity, and reported opioid use with improvement in quality of life.

Effect of Alcoholism on the Incidence of Lactate-Induced Panic Attacks

BACKGROUND Chronic alcohol use is associated with higher than expected rates of panic disorder. METHODS To study the relationship between alcoholism and panic disorder, we administered the panicogenic agent, sodium lactate, to 26 alcoholics with either panic disorder or frequent panic attacks (ALCPAN), 20 nonalcoholics with panic disorder (PAN), 14 alcoholics without a history of panic attacks, and 14 healthy volunteers. RESULTS PAN were significantly more likely to have a lactate-induced panic attack (65%) than ALCPAN (23%). ALCPAN who had the onset of panic attacks prior to alcoholism also had a reduced frequency of lactate-induced panic attacks (26.7%) compared to PAN. CONCLUSIONS There is a reduced incidence of lactate-induced panic attacks in ALCPAN. This reduction does not appear to be explained by the relative onset of panic attacks to alcoholism. The role of excessive alcohol consumption in the decreased frequency of lactate-induced panic attacks seen in ALCPAN needs further study.