Dual diagnosis in an Australian forensic psychiatric hospital: prevalence and implications for services

Despite a growing awareness of the unique needs of psychiatric patients with co-occurring substance abuse and dependence disorders (i.e. dual diagnosis), there is a dearth of research investigating the prevalence of dual diagnosis in forensic psychiatric populations. Similarly, little work has been done to determine the implications of dual diagnosis for forensic psychiatric patients. Patients at the Thomas Embling Hospital in Victoria, Australia, were assessed to determine the prevalence of substance abuse disorders and mental illnesses within this population. Results reveal that the majority of patients (approximately 74%) have a lifetime substance abuse or dependence disorder. Information was collected concerning patients' criminal histories and the Level of Service Inventory, Revised, was completed for each patient who participated. Results suggest that patients with both major mental illnesses and substance abuse disorders have more extensive criminal histories and demonstrate a higher level of risks and needs when compared with patients with major mental illness alone. The implications for the development and delivery of effective forensic mental health services that address both co-occurring disorders are also discussed.     

A classification of respondents to the CPI socialization scale: Associations with psychiatric diagnosis and implications for research

127 psychiatric in-patients completed the CPI Socialization scale. Their responses were analyzed by principal components analysis and three sub-scales were constructed. The sample was classified by cluster analysis and three types were identified and compared. There were normal and low socialization clusters, and a third cluster which differed from the latter by having a higher score on a scale which we called Problem Behaviour (PB). This scale seems likely to provoke social desirability responses. Associations were found between our types and clinical diagnosis. In particular, it was observed that women with personality disorders of the type described in DSM-111 as ‘dramatic, emotional and erratic’ were found with increased frequency in the low socialization cluster. It is suggested that such patients give naive answers to the PB scale items. Investigators using the Socialization scale to identify subjects for research should consider the possibility of heterogeneity among low scorers.     

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

The six most essential questions in psychiatric diagnosis: A pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM ?C whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

False recognition of facial expressions of emotion: causes and implications

This article examines the importance of semantic processes in the recognition of emotional expressions, through a series of three studies on false recognition. The first study found a high frequency of false recognition of prototypical expressions of emotion when participants viewed slides and video clips of nonprototypical fearful and happy expressions. The second study tested whether semantic processes caused false recognition. The authors found that participants made significantly higher error rates when asked to detect expressions that corresponded to semantic labels than when asked to detect visual stimuli. Finally, given that previous research reported that false memories are less prevalent in younger children, the third study tested whether false recognition of prototypical expressions increased with age. The authors found that 67% of eight- to nine-year-old children reported nonpresent prototypical expressions of fear in a fearful context, but only 40% of 6- to 7-year-old children did so. Taken together, these three studies demonstrate the importance of semantic processes in the detection and categorization of prototypical emotional expressions.     

Work and psychiatric illness in Aotearoa/New Zealand: implications for career practice

ABSTRACT

This paper aims to examine the influence of Māori culture upon psychiatric service provision in Aotearoa/New Zealand and the implications of this for career counselling of people with experience of mental illness in Aotearoa/New Zealand. The research explored the experiences of a group of women in Aotearoa/New Zealand who have been diagnosed with a psychiatric illness, with the aim of gaining some understanding about how they negotiate issues around diagnosis, recovery and resilience development and employment. The women interviewed for the study ranged in age from 17 to late 60s. They displayed academic ability ranging from literacy issues to postdoctoral experience. Their psychiatric illnesses ranged from single episodes to chronic lifetime conditions and from depression to psychotic bi-polar disorder. Their occupations ranged from unemployed status to an acting CEO. All but one of the women identified as Pākehā/tauiwi. One woman had Māori heritage but had been adopted at birth by Pākehā adoptive parents and had no knowledge of her Māori whakapapa [genealogy; descent lines; ancestry] until later in her adult life. The key idea that emerged was the importance of mentors in vocational settings, and the helpfulness of Māori-focused group and family wellness models for renegotiating vocational identity when suffering from a psychiatric illness. Implications for career practitioners are discussed.     

The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM ?C whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

Fully automated psychiatric diagnosis: Some new possibilities

A fully automated psychiatric diagnostic system is outlined that would rely on picture-preference items rather than verbal ones and that would involve a tailored approach rather than conventional “brute-strength” testing. The conditions under which such a system can diagnose patients in a way that might arouse their interest and cooperation are discussed. These include a set of diagnostic categories (perhaps a subset from DSM-III), availability of a single-frame video disk unit allowing random access to each frame, a microprocessor system with a memory capacity of about 32,000 bytes, known base rates of the population of interest, and known probabilities of a particular response to the items for each diagnostic category. Some futuristic extensions of the proposed system are suggested.     

Pastoral diagnosis: assessing the psychotheological themes of freedom and meaning

This article is an exploration of the psychological and theological themes of freedom and meaning within the world of those who experience emotional pain. The article focuses on how freedom and meaning can contribute to the development of a pastorally rigorous diagnostic protocol. It is in the examination of emotional freedom and the search for meaning that practitioners of the pastoral arts come to an understanding of the nature of suffering. The article offers an overview of the state of pastoral diagnosis highlighting and drawing from those resources that emphasize the need for pastoral psychology to construct a diagnostic protocol that is both theological and resonate with the lived experience of clients.     

Moral evil and human freedom: A reply to Tierno

Many theists believe that the so-called ‘free will defence’ successfully undermines the antitheist argument from moral evil. However, in a recent issue of this journal Joel Thomas Tierno provides the ‘adequacy argument’ in order to show an alleged difficulty with the free will defence. I argue that the adequacy argument fails because it equivocates on the notion of moral evil.     

False external feedback modulates posterror slowing and the f-P300: implications for theories of posterror adjustment

People tend to slow down after mistakes. This posterror slowing (PES) has commonly been explained by a change to a more conservative response threshold to avoid future errors. Alternatively, the attention-orienting account posits that all infrequent, surprising events (including errors) elicit an orienting response followed by a time-consuming process of task reorientation, explaining PES without increased response caution. In the present study, we employed both behavioral and electrophysiological measures to compare the predictions of these accounts using a flanker paradigm in which accurate or false external response feedback was provided. Participants demonstrated typical posterror adjustments, responding more slowly and accurately in posterror than in postcorrect trials. This finding provides initial evidence suggesting that posterror adjustments are motivated by the avoidance of subsequent mistakes. Most importantly, PES and an event-related potential relating to the attentional processing of feedback, the feedback-related P300 (f-P300), were modulated by feedback type. More specifically, the f-P300 was larger after false than after accurate feedback, suggesting that participants oriented their attention toward (i.e., were surprised by) inaccurate feedback signals. Interestingly, false feedback differentially modulated reaction times: Participants were slower after correct responses when feedback falsely informed of an error rather than confirmed the correct response. In contrast, faster responses were made after errors when feedback falsely indicated correct rather than incorrect performance. When these patterns of results are regarded together, they are best explained by theories of cognitive control in which posterror adjustments in choice reaction time tasks are assumed to reflect control processes leading to more conservative performance after error signals.     

Cholinergic rebound after chlorpromazine exacerbates lithium muscarinic-induced limbic seizures in rats: implications for psychiatric treatment.

When lithium serum levels were within the (human) therapeutic range, young and old adult male and female rats (housed singly or in groups) all displayed faster limbic seizure onset times in response to a muscarinic cholinergic agonist (pilocarpine 20 mg/kg) if a single systemic dosage of chlorpromazine was injected 24 hours previously. The effect was comparable to injecting an additional 10 mg/kg of pilocarpine. These results strongly suggest that cholinergic rebound from chlorpromazine administrations during lithium treatment could facilitate subclinical electrical lability and very localized neuronal necrosis within the limbic system of clinical patients, resulting in normalization of psychiatric symptoms.     

Luria-nebraska neuropsychological battery: High rates of false positives for geriatirc subjects

This study examined false positive rates obtained for two normal adult age groups, using three different methods for interpreting performances on the Luria-Nebraska Neuropsychological Battery (LNNB). Among normal subjects ages 18 to 30 and ages 65 to 85, false positive rates were found to range from 3.9% to 7.7% for younger subjects and 13.5% to 32.7% for older subjects. Significant differences were found between the proportion of false positives in each age group on each method of interpretation. A lack of agreement was found between the three different methods of interpretation concerningwhich subjects should be classified as impaired. Further analysis was performed by dividing older subjects into two groups, ages 65 to 70 and over 70. False positive rates for subjects over age 70 were found to range from 20.7% to 41.4%. Significant differences were also found between the proportion of false positives in each of these two groups.     

Luria-nebraska neuropsychological battery: High rates of false positives for geriatirc subjects

This study examined false positive rates obtained for two normal adult age groups, using three different methods for interpreting performances on the Luria-Nebraska Neuropsychological Battery (LNNB). Among normal subjects ages 18 to 30 and ages 65 to 85, false positive rates were found to range from 3.9% to 7.7% for younger subjects and 13.5% to 32.7% for older subjects. Significant differences were found between the proportion of false positives in each age group on each method of interpretation. A lack of agreement was found between the three different methods of interpretation concerningwhich subjects should be classified as impaired. Further analysis was performed by dividing older subjects into two groups, ages 65 to 70 and over 70. False positive rates for subjects over age 70 were found to range from 20.7% to 41.4%. Significant differences were also found between the proportion of false positives in each of these two groups.     

Sex steroids and human behavior: implications for developmental psychopathology

In a variety of mammalian species, prenatal androgens organize brain structures and functions that are later activated by steroid hormones in postnatal life. In humans, studies of individuals with typical and atypical development suggest that sex differences in reproductive and nonreproductive behavior derive in part from similar prenatal and postnatal steroid effects on brain development. This paper provides a summary of research investigating hormonal influences on human behavior and describes how sex differences in the prevalences and natural histories of developmental psychopathologies may be consistent with these steroid effects. An association between patterns of sexual differentiation and specific forms of psychopathology suggests novel avenues for assessing the effects of sex steroids on brain structure and function, which may in turn improve our understanding of typical and atypical development in women and men.