Pathological visual field and brain tumor]

The general relationships between an operatively or autoptically localized tumor and the visual field determined by means of ikineticer perimetry are investigated, the patient stock being a total of 1756 neurosurgical brain-tumor inpatients. Examination of the visual field was possible with four fifths of the brain-tumor patients. Hemianopic, quadrantanopsic, or scotomatous defects of a topically localizable nature could be found in almost one third of the total patient stock available for examination. The clinically particularly interesting criteria of localization of homonymous-hemianopsia defects such as macular sparing and incongruence/congruence of visual field changes should be of no importance to the localization within the visual pathway of brain-tumor patients.     

Applied tension, applied relaxation, and the combination in the treatment of blood phobia

Thirty patients with phobia for blood, wounds and injuries were treated individually with applied tension, applied relaxation, or the combination of these two methods for 5, 9 and 10 sessions, respectively. They were assessed on self-report, behavioral and physiological measures before and after treatment, and at a 6-month follow-up. All groups improved significantly on 11/12 measures, and the improvements were maintained at follow-up. Applying stringent criteria, 73% of the patients were clinically improved at the end of treatment and 77% were so at follow-up. Despite a failure to find between-group differences, on many measures there was a trend favoring applied tension. Since this method is as effective as the other treatments in only half the time, applied tension should clinically be the treatment of choice for blood phobia.     

Family Functioning, Self-Concept, and Severity of Adolescent Externalizing Problems

We investigated direct and shared effects of family functioning and self-concept on the severity of adolescent externalizing problems in a sample of 224 clinically referred adolescents. Structural equation modeling (SEM) revealed strong, direct relationships between problem behaviors and both family functioning and self-concept. Using R. M. Baron and D. A. Kenny's (1986) and G. N. Holmbeck's (1997) criteria for testing mediation in SEM, family functioning partially mediated the relationship between self-concept and problem behaviors. A moderation model, testing the relationship between externalizing problems and the interaction between family functioning and self-concept, did not yield a significant effect. Our findings indicate that self-concept and family functioning exert direct and shared effects on externalizing problems and suggest that interventions for clinically referred adolescents should target both the individual adolescent and his/her family.     

Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder

The present study investigated the efficacy of a coping-technique, applied relaxation (AR) and cognitive therapy (CT), in the treatment of generalized anxiety disorder. Thirty-six outpatients fulfilling the DSM-III-R criteria for generalized anxiety were assessed with independent assessor ratings and self-report scales before and after treatment and at a 1 yr follow-up. The patients were randomized and treated individually for 12 weekly sessions. The results showed that both treatments yielded large improvements, which were maintained, or furthered at follow-up. There was no difference between AR and CT on any measure. The drop-out rate was 12% for AR and 5% for CT. The proportions of clinically significantly improved patients were 53 and 62% at post-treatment and 67 and 56% at follow-up for AR and CT, respectively. Besides affecting generalized anxiety the treatments also yielded marked and lasting changes on ratings of worry, cognitive and somatic anxiety and depression. The conclusion that can be drawn is that both AR and CT have potential as treatments for generalized anxiety disorder but they have to be developed further in order to increase the efficacy to the level usually seen in panic disorder, 80-85% clinically improved.     

Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia.

Thirty patients with phobia for blood, wounds and injuries were treated individually with applied tension (AT), exposure in vivo (E), or tension-only (T) for 5 sessions. They were assessed on self-report, behavioral and physiological measures before and after treatment, and at a 1 yr follow-up. All groups improved significantly, and the improvements were maintained at follow-up. Applying stringent criteria, 90% of the AT-, 80% of the T-, and 40% of the E-patients were clinically improved at the end of treatment. The corresponding figures at follow-up were 100, 90 and 50%, respectively. AT differed significantly, and T marginally from E at both assessments. Applied tension, or tension-only should, from a clinical point of view, be considered the treatment of choice for blood phobia.     

Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and sub-threshold bulimia nervosa

Increasing empirical evidence supports the validity of binge eating disorder (BED), a research diagnosis in the appendix of DSM-IV, and its inclusion as a distinct and formal diagnosis in the DSM-V. A pressing question regarding the specific criteria for BED diagnosis is whether, like bulimia nervosa (BN), it should be characterized by overvaluation of shape and weight. This study compared features of eating disorders in 436 treatment-seeking women comprising four groups: 195 BED participants who overvalue their shape/weight, 129 BED participants with subclinical levels of overvaluation, 61 BN participants, and 51 participants with sub-threshold BN. The BED clinical overvaluation group had significantly higher levels of specific eating disorder psychopathology than the three other groups which did not differ significantly from each other. Findings suggest that overvaluation of shape and weight should not be considered as a required criterion for BED because this would exclude a substantial proportion of BED patients with clinically significant problems. Rather, overvaluation of shape and weight warrants consideration either as a diagnostic specifier or as a dimensional severity rating as it provides important information about severity within BED.     

Rotting with their rights on: why the criteria for ending commitment or restraint of liberty need not be the same as the criteria for initiating commitment or restraint of liberty, and how the restraint may sometimes justifiably continue after its prerequisites are no longer satisfied

That coerced treatment must end when the criteria for initiating coerced treatment cease to apply appears to be universally accepted by courts and commentators.2 Moreover, the consensus appears to be justified by a steel-trap argument. If coercion is justified only when the patient is mentally ill and incapable, because then the patient lacks autonomous capacities, or lacks practical reasoning abilities that undercut autonomous capacities, then these justifications have no force when the patient either is not mentally ill or is capable. A parallel claim holds for civil commitment. This received wisdom, or in = out thesis, rests upon a conceptual confusion: a failure to distinguish the criteria for initiation of intervention, those for cessation of intervention, and the purpose of the commitment or coerced treatment. If the criteria for commitment were mental illness and dangerousness, and the criteria for release were the same, then the purpose of commitment would be to restore persons to the point where they are either just barely not mentally ill, or just barely not dangerous. That is a silly and self-defeating purpose for that large class of patients who, because of lack of insight, or otherwise, do not become treatment compliant until they are substantially healthier than being barely not mentally ill or barely not dangerous. It sets them up to become revolving-door patients. The purpose of commitment is rather to maximize the patient's mental health, and minimize her dangerousness without unduly burdening her liberty. If society is going to violate a patient's liberty, it should do so in a way that will resolve the problem that justified the restriction on liberty in the first place, so long as the restriction of liberty is not too great in relation to the expected gains from the intervention. The criteria for releasing a patient from commitment are in this way responsive to the purpose of the commitment. For some revolving-door patients, this entails that the criteria for their release from commitment should be stricter than the criteria for initiating commitment in the first place. The criteria for release from commitment for revolving-door patients should be that the criteria for initiation for commitment is not met plus it being more likely than not that the patient will be treatment compliant after release, assuming the additional restriction on liberty is less than the gains from the additional restraint, and the restriction is not unduly burdensome. Spelling this out, the criteria for release should be either not mentally ill, or else not dangerous, or capable, and more likely than not to be treatment compliant after release. For those patients for whom such a test is overly optimistic, we might substitute that there is a reasonable probability of treatment compliance after release, or that the probability of treatment compliance has been enhanced. These criteria are to be thought of as rough and ready rules of thumb, and not as analytically precise tests.     

How should we revise diagnostic criteria for substance use disorders in the DSM-V?

This article reviews literature on the validity and performance characteristics of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for substance use disorders (SUDs) and recommends changes in these criteria that should be considered for the next edition of the DSM (DSM-V). Substantial data indicate that DSM-IV substance abuse and substance dependence are not distinct categories and that SUD criteria are best modeled as reflecting a unidimensional continuum of substance-problem severity. The conceptually and empirically problematic substance abuse diagnosis should be abandoned in the DSM-V, with substance dependence defined by a single set of criteria. Data also indicate that various individual SUD criteria should be revised, dropped, or considered for inclusion in the DSM-V. The DSM-V should provide a framework that allows the integration of categorical and dimensional approaches to diagnosis. Important areas for further research are noted.     

A methodological assessment and evaluation of dual-task paradigms

This article outlines three major assumptions often implicitly made in dual-task experiments conducted to assess attentional capacity requirements of memorial processes. These assumptions are shown to be incorrect. Three criteria which should be met in dual-task experiments that draw inferences from secondary task decrements are proposed: (1) there should be resource trade-off with the secondary task sensitive to the resource demands of the primary task; (2) there should be equivalence of single and dual primary task performance; and (3) the secondary task must remain resource sensitive throughout the experiment. An experiment was carried out in which the primary and secondary tasks were designed according to these criteria. The results demonstrate that when the criteria are met then secondary task performance can be predictive of primary task difficulty: however, the experiment also highlights the fact that a simple assessment of capacity will not predict total task performance.     

On the validity and generality of transfer effects in cognitive training research

Evaluation of training effectiveness is a long-standing problem of cognitive intervention research. The interpretation of transfer effects needs to meet two criteria, generality and specificity. We introduce each of the two, and suggest ways of implementing them. First, the scope of the construct of interest (e.g., working memory) defines the expected generality of transfer effects. Given that the constructs of interest are typically defined at the latent level, data analysis should also be conducted at the latent level. Second, transfer should be restricted to measures that are theoretically related to the trained construct. Hence, the construct of interest also determines the specificity of expected training effects; to test for specificity, study designs should aim at convergent and discriminant validity. We evaluate the recent cognitive training literature in relation to both criteria. We conclude that most studies do not use latent factors for transfer assessment, and do not test for convergent and discriminant validity.     

Prevalence and Characteristics of Patients with Suspected Inherited Renal Cell Cancer: Application of the ACMG/NSGC Genetic Referral Guidelines to Patient Cohorts

Patients with suspected hereditary renal cell cancer (RCC) are under-referred for genetic evaluation. Characterizing the prevalence and characteristics of suspected inherited RCC is a crucial step toward advancing personalized, genetically-based cancer risk management for patients and their families. To evaluate the prevalence and characteristics of suspected inherited RCC syndromes based on consensus criteria, we performed a cross-sectional analysis of patients with a diagnosis of RCC in SEER (2001–2011, n = 105,754) and in our institutional cancer registry (2004–2013, n = 998). Consensus criteria for referral of patients with RCC for genetic evaluation from the American College of Medical Genetics and Genomics and National Society of Genetic Counselors (ACMG/NSGC) were applied to the two cohorts. The associations between meeting referral criteria with demographic characteristics were assessed with chi-square tests. Overall, 24.0 % of the SEER cohort and 33.7 % of our institutional cohort met ACMG/NSGC referral criteria for genetic counseling. While white patients more commonly met early onset clear cell RCC criteria, black patients met papillary RCC criteria at twice the rate of whites in both cohorts (p < 0.0001). As many as 1 in 5 individuals with RCC meet referral criteria for genetic evaluation based on newly emerging guidelines, with differences in pathology noted by race. Prospective genetic testing studies utilizing emerging referral guidelines should help to refine the genetic spectrum of inherited kidney cancer. This study supports efforts to increase awareness of referral of patients with RCC for genetic counseling particularly among urologic providers.     

Measurement Error-Corrected Estimation of Clinically Significant Change Trajectories for Interventions Targeting Comorbid PTSD and Substance Use Disorders in OEF/OIF Veterans

In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and Relapse Prevention (RP). Eighty-one treatment-seeking veterans with a comorbid PTSD/SUD diagnosis were randomized to COPE or RP; data from an additional n = 48 patients who did not meet criteria for both disorders was used to establish a normative threshold. A newly developed, modernized approach to the Jacobson and Truax (1991) clinically significant change framework, using (a) moderated nonlinear factor analysis (MNLFA) scale scoring and (b) measurement error-corrected multilevel modeling (MEC-MLM) was used; this approach was compared to other approaches using conventional total scores and/or assuming no measurement error. Using a conventional approach to estimating the Reliable Change Index (RCI) yielded no differences between COPE and RP in the percentage of patients achieving statistically significant improvement (SSI; 88.9% for both groups). However, under MNLFA/MEC-MLM, higher percentages of patients receiving COPE (75.0%) achieved SSI compared to RP (40.7%). Findings suggest that, even though COPE and RP appear to reduce the same number of PTSD symptoms, MNLFA scoring of outcome measures gives greater weight to interventions that target and reduce “hallmark” PTSD symptoms.     

Affect availability, tolerance, complexity, and modulation in psychoanalysis: followup of a longitudinal, prospective study

Evaluation of 22 patients in supervised psychoanalysis showed that affect availability and tolerance changed in a positive direction during the course of psychoanalysis. In this study, we have defined criteria of change that can be clinically observed. The changes observed were present one year following the completion of psychoanalysis. Ratings of analysts' and patients' interviews, and ratings of psychological tests all revealed that patients had derived "therapeutic benefit" in relation to affect experience and management. Discriminations were made among changes in affect modulation, which reflected both loosening and tightening of controls, changes in affect availability, changes in experience of painful affects, and changes in experience of affect complexity. Analysts' interviews and psychological test data reflected notable changes in affect modulation in the direction of increased control, while patients' interviews more often reflected changes in the direction of increased expressiveness.     

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.     

Delineating generalized anxiety: A preliminary investigation

The present study examined the nature of generalized anxiety, which was defined as the constellation of symptoms listed as diagnostic criteria for generalized anxiety disorder in DSM-III-R. Generalized anxiety was assessed by means of a questionnaire that was especially constructed for this study. Although multidimensional scaling of symptoms reported by a clinically anxious sample produced orthogonal anxiety and panic dimensions, many symptoms were common to both dimensions. Whereas worry was found to be the cardinal feature of generalized anxiety, respiratory symptoms were found to associate closely with panic. These dimensions were replicated in a student sample. It is argued that while generalized anxiety symptoms constitute a unique dimension in the field of anxiety disorders, both panic and generalized anxiety may be linked with a basic anxiety response system. The findings also indicated that worry associated more closely with generalized anxiety than did apprehensive expectations. The heuristic value of the findings are discussed in light of the issue relating to an anxiety-panic continuum.     

Treatment outcome of a group cognitive therapy program for depression

A 12-session group program of cognitive therapy, designed by the first author, was evaluated with 35 persons suffering from major or minor depressive disorders. Effect-size scores were generated using the method of Nietzel, Russel, Hemmings, and Gretter (1987) and compared with cut-off points calculated using the method of Jacobson and Revenstorf (1988) and the norms established by Nietzel et al. (1987) in their meta-analysis. The effects of the Group Cognitive Therapy Program were found to be clinically significant according to the criteria of Jacobson and colleagues (Jacobson and Revenstorf, 1988; Jacobson, Follette and Revenstorf, 1984) for 73% of patients. It is concluded that the Group Cognitive Therapy Program is a clinically efficacious and cost-effective treatment for persons suffering from nonpsychotic, primary, unipolar depression.     

Health Perceptions and Anxiety Sensitivity in Patients with Panic Disorder

Separate lines of research indicate that patients with panic disorder display negative perceptions of physical health and elevated fear of autonomic arousal. Because health perceptions and anxiety sensitivity may be related, the present study evaluated the degree to which these constructs can be distinguished in patients meeting DSM-IV criteria for panic disorder (N = 44). Perceived health, anxiety sensitivity, and the clinical features of panic disorder were assessed at pretreatment and following 12 sessions of cognitive–behavioral treatment. Findings consistently indicated that perceived health and anxiety sensitivity can be meaningfully differentiated. Perceived physical health was only moderately associated with anxiety sensitivity, and each was uniquely associated with pretreatment symptomatology and posttreatment end-state functioning. Perceived physical health appears to be a clinically useful index in the overall evaluation of panic disorder and is readily distinguishable from anxiety sensitivity.