The hyperventilation syndrome in panic disorder, agoraphobia and generalized anxiety disorder

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.     

Mental disorder as a black box essentialist concept.

This is a reply to commentaries on the target article (J. C. Wakefield, 1999) on the evolutionary foundations of the concept of mental disorder in defense of the harmful dysfunction analysis (HDA) of disorder. The author argues that the HDA is adequate to explain disorder and nondisorder judgments and is not disconfirmed by any of the claimed counterexamples put forward by the commentators; the commentators' proposed alternatives to the HDA are inadequate to explain disorder and nondisorder judgments; and the concept of natural function is a factual, scientific concept, contrary to K. W. M. Fulford's (1999) claim that it is inherently evaluative. The foundations of the HDA are clarified by providing a black box essentialist analysis (H. Putnam, 1975; J. C. Wakefield, 1997, in press) of the concept of natural function that underlies the concept of disorder.     

An empirically-based classification of personality disorder

An empirically-based classification is proposed based on studies of the phenotypic structure and genetic architecture of personality disorder. The proposed system has two parts: (1) a definition of general personality disorder, and (2) a system for diagnosing different forms of disorder. General personality disorder is conceptualized as a pervasive disturbance in the overall structure and organization of the personality system that is manifested as the failure to establish a coherent self-system and the capacity for adaptive interpersonal and social behavior. Different forms of disorder are represented by a dimensional system consisting of 30 primary traits organized into four higher-order domains. The system is intended to offer a systematic and comprehensive diagnosis of personality disorder for clinical and research purposes. It is also intended to be used in a flexible but prescribed way to provide a diagnostic assessment tailored to different assessment needs.     

Interoceptive exposure therapy combined with trauma-related exposure therapy for post-traumatic stress disorder: a case report

Trauma-related exposure therapy is a useful but not universally effective treatment for post-traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post-traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma-related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician-Administered Post-traumatic Stress Disorder Scale, a self-report measure of post-traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post-traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1- and 3-month follow-up. Symptoms of anxiety sensitivity and post-traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post-traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma-related exposure therapy as a means of boosting treatment efficacy.     

Is personality disorder inherited? An overview of the evidence

Genetic factors appear to be of considerable importance in determining normal variation in personality. This is suggested by family, twin, and adoption studies as well as by indirect findings based on animal and psychophysiological studies. In contrast, there is consistent evidence that the contribution of shared family environment is minimal. Despite difficulties in defining personality disorder, it appears that many types of personality disorder, in particular schizotypal personality disorder and antisocial personality disorder/criminality, are also influenced genetically. The genetic transmission of normal personality traits and disorder is most easily explained by the contribution of multiple genes of small effect rather than by single-gene inheritance. Recent advances in molecular genetics have led to the localization of genes of minor effect for some traits. This raises the possibility of detecting a molecular basis of traits and disorders such as personality and personality disorder.Anita Thapar is supported by a Research Training Fellowship from the Medical Research Council.     

Craziness and criminal responsibility.

This article addresses why mental disorder is relevant to criminal responsibility. It begins by considering the meaning of criminal responsibility because it is impossible to understand the relevance of mental disorder unless one understands responsibility clearly. The next section provides a theoretical account of responsibility and excuse in general and addresses common misconceptions about these topics. The third section examines in detail why mental disorder can sometimes produce either a complete or partial excusing condition, such as legal insanity or "partial responsibility," and whether the U.S. Constitution requires the provision of an excuse based on mental disorder. The section proposes that mental disorder should produce an excusing condition in appropriate cases. The next section considers the relation of mental disorder to mens rea, the mental state "element" that is a definitional criterion of most crimes, and whether the U.S. Constitution requires that defendants be permitted to use evidence of mental disorder to negate mental state elements of the crime charged. This section argues that mental disorder rarely negates mens rea, but in those cases in which a plausible claim for negation could be made, defendants should be allowed to make this claim.     

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.     

Discriminating among diagnostic categories using the Dissociative Disorders Interview Schedule

The Dissociative Disorders Interview Schedule was administered to 1,308 subjects in eight diagnostic categories, including 296 with dissociative identity disorder. The study tested three hypotheses: (1) the Mahalanobis distance between dissociative identity disorder and each of seven other diagnostic categories would be large, (2) the closest diagnostic category to dissociative identity disorder would be dissociative disorder not otherwise specified, and (3) nondissociative diagnostic categories would be closer to each other than any one to dissociative identity disorder. All three hypotheses were confirmed by these data. The findings support the conclusion that dissociative identity disorder is a discrete category or taxon.     

The concept of mental disorder. On the boundary between biological facts and social values.

Although the concept of mental disorder is fundamental to theory and practice in the mental health field, no agreed on and adequate analysis of this concept currently exists. I argue that a disorder is a harmful dysfunction, wherein harmful is a value term based on social norms, and dysfunction is a scientific term referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution. Thus, the concept of disorder combines value and scientific components. Six other accounts of disorder are evaluated, including the skeptical antipsychiatric view, the value approach, disorder as whatever professionals treat, two scientific approaches (statistical deviance and biological disadvantage), and the operational definition of disorder as "unexpectable distress or disability" in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987). The harmful dysfunction analysis is shown to avoid the problems while preserving the insights of these other approaches.     

Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report

Trauma‐related exposure therapy is a useful but not universally effective treatment for post‐traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post‐traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma‐related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician‐Administered Post‐traumatic Stress Disorder Scale, a self‐report measure of post‐traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post‐traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1‐ and 3‐month follow‐up. Symptoms of anxiety sensitivity and post‐traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post‐traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma‐related exposure therapy as a means of boosting treatment efficacy.     

双相障碍及其社会-心理治疗的研究现状

双相障碍是以起伏性躁狂或抑郁为特征的慢性周期性精神疾病。近年来,社会-心理疗法作为药物治疗的辅助手段被引入到该类疾病的治疗过程中。本文基于近期关于双相障碍的病因学的研究,评述了各种不同形式的社会-心理疗法在双相障碍治疗中的应用及其疗效,指出今后的研究需要进行严格的临床设计,以保证不同研究间的可比性和可重复性;应尽可能延长追踪观察的时间,并进行大样本多变量研究,以保证研究结果的普遍性。     

Computerized perceptual analysis of patients with body dysmorphic disorder: a pilot study

Many factors influence the development of body image, one of which is the perception we have of our body. Perception can refer to actual visual input or the interpretation of vision; in other words, cognitive appraisal. The goal of this preliminary study is to determine if three groups (body dysmorphic disorder, obsessive-compulsive disorder, and a non-psychiatric control group) differed in the perception of their faces. Thirty individuals, 10 in each group, were asked to make changes to a computerized image of their face. In addition, affective and perceptual tests were administered. The groups did not differ on affective and perceptual organizational measures, although the obsessive-compulsive disorder group reported a higher level of anxiety than the body dysmorphic disorder group. Imaging software showed that facial features were modified by patients with body dysmorphic disorder and obsessive-compulsive disorder in about 50% of cases. No modifications were made in the control group. Future studies need to investigate the possible causes of these differences.     

Publication trends in individual DSM personality disorders: 1971–2015

Growth in personality disorder research has been documented by previous authors up to 1995. The aim of the present study was to extend this by examining publications rates for individual DSM personality disorders over the period 1971–2005, and making projections to 2015 based on these data. It was found that personality disorder research has grown in absolute terms, and as a proportion of overall psychopathology research. Research output is dominated by borderline personality disorder, with strong publication rates in other conditions such as antisocial and schizotypal personality disorders. In contrast, several personality disorders such as schizoid and paranoid personality disorder have failed to attract research interest. Based on current projections, there is expected to be no research output in 2015 for schizoid personality disorder. It was found that the rate of publications for personality disorders was not influenced by the publication of the last three revisions of the DSM diagnostic criteria. Several potential explanations such as the difficulty in conducting certain types of personality disorder research, and the validity of the current DSM diagnostic taxonomy are discussed.     

Dynamic fearful gaze does not enhance attention orienting in individuals with Asperger’s disorder

Although impaired joint attention is one of the core clinical features of pervasive developmental disorder including autistic disorder and Asperger’s disorder, experimental studies failed to report its impairment. This discrepancy might be the result of differences between real-life and experimental situations. The present study examined joint attention in 11 individuals with Asperger’s disorder and 11 age-matched controls under naturalistic conditions using a target detection paradigm with dynamic emotional gaze cues. Although both groups showed gaze-triggered attention orienting as assessed by the differences in reaction time for invalid minus valid cues, enhancement of joint attention by fearful (vs. neutral) gaze was observed in the control, but not in the Asperger group. This suggests that the integration of emotion and gaze direction that elicits strong joint attention is impaired in individuals with Asperger’s disorder.     

A brief review of selective mutism literature

Selective mutism is a disorder characterized by a persistent failure to speak in certain social situations. It is typically diagnosed in childhood, and the disorder can last from just a few months to several years in some individuals. Debate surrounds the origins and causes of this disorder. Recent literature suggests that selective mutism may be a form of social phobia. The present article is a brief review of the literature on the etiology, assessment, comorbid diagnoses, and treatment perspectives from several theoretical orientations, including behavioral, family systems, and psychopharmacological.     

Evolutionary Theory and Neighborhood Quality: A Multilevel Selection-inspired Approach to Studying Urban Property Conditions

Actions that increase individual quality of life (QoL) can often undermine QoL at some higher level of aggregation. In cities, this “fundamental problem of social life” is regularly played out in the form of physical disorder. When an urban actor allows his or her property to fall into disrepair, perhaps to allocate resources to more essential uses, this decision reduces the relative quality of that actor’s neighborhood by contributing to local disorder. Researchers and policymakers therefore devote significant attention to understanding and controlling patterns of such behaviors. The central thesis of this paper is that evolutionary theory has much to offer this discourse. First, through synthesizing existing arguments from the urban disorder/decline literature, I develop a framework for studying intra-city disorder that is inspired by evolutionary multilevel selection (MLS) theory. Next, to empirically demonstrate the utility of this framework, I draw on longitudinal data and space-time analysis to find that population-level patterns of substandard property conditions in a given study area—i.e., measurable manifestations of physical disorder—are generated by a combination of individual and group “selective” pressures on property maintenance behavior. The results suggest that adopting an MLS perspective might aid policymakers in managing the processes that produce patterns of urban disorder, which can ultimately help to improve urban QoL.     

Culture and context in the evolutionary concept of mental disorder.

The evolutionary theory of the concept of mental disorder as harmful dysfunction that J. C. Wakefield (1999) proposed (a) does not correspond to how the term disorder is used in psychiatric nosology or in clinicians' everyday practice; (b) does not cover the territory to which the term reasonably could be applied; and (c) is not especially useful for research, clinical, or social purposes. The broad concept of disorder is a polythetic, not a monothetic, concept. As such, there need be no essential characteristic, criterion, or single prototype of disorder. Instead, multiple prototypes with varying features are used to group together a wide range of disparate phenomena by analogy. Useful refinements of our concepts of disorder have come from analyses of the nature of action and intentionality. What are most needed now are careful analyses of the social embedding of our concepts in cultural knowledge and practice.     

Bipolar disorder in children and adolescents

There is increased recognition that bipolar disorder has an early age of onset. The prevalence of bipolar disorder in prepubertal children has not been determined, however the prevalence in adolescence is approximately 1%. Bipolar disorder in children poses a diagnostic challenge since the symptoms may differ from those in late adolescence and adulthood. Comorbid disorders, such as attention-deficit/hyperactivity disorder, further complicate both the diagnosis and course of the disorder. There is increasing evidence of the chronicity and severity of this disorder in youths. Bipolar disorder significantly disrupts a child's psychosocial development including impairments in academic functioning, family functioning, and relationship with peers. Although this disorder has significant morbidity in children and adolescents, there is a paucity of controlled studies to assess the efficacy and safety of mood stabilizers in the treatment of this disorder in youths. The treatment literature consists largely of case studies, retrospective chart reviews, and open-label studies. There is a compelling need for double-blind, placebo-controlled trials to determine whether commonly used medications to treat this disorder are significantly superior to placebo. Since many children in clinical practice require more than one psychotropic medication to adequately manage this disorder, studies of combination treatments are warranted. This review will provide an overview of the literature of bipolar disorder in children and adolescents, including discussion of the prevalence, diagnosis, epidemiology, course of the illness, and treatment issues.     

Dynamic fearful gaze does not enhance attention orienting in individuals with Asperger’s disorder

Although impaired joint attention is one of the core clinical features of pervasive developmental disorder including autistic disorder and Asperger’s disorder, experimental studies failed to report its impairment. This discrepancy might be the result of differences between real-life and experimental situations. The present study examined joint attention in 11 individuals with Asperger’s disorder and 11 age-matched controls under naturalistic conditions using a target detection paradigm with dynamic emotional gaze cues. Although both groups showed gaze-triggered attention orienting as assessed by the differences in reaction time for invalid minus valid cues, enhancement of joint attention by fearful (vs. neutral) gaze was observed in the control, but not in the Asperger group. This suggests that the integration of emotion and gaze direction that elicits strong joint attention is impaired in individuals with Asperger’s disorder.