Callous-Unemotional Traits and Subtypes of Conduct Disorder

There has been growing consensus that children with conduct disorder (CD) constitute a very heterogeneous group containing children who vary substantially on the development, course, and causes of the disorder. While many have recognized the importance of this heterogeneity for developing better causal theories and for developing more effective treatments, there has been little consensus as to the best way to subtype children with CD. In this paper, we review a number of approaches to subtyping, each with some evidence for its validity for certain purposes. We focus on two recent approaches that have great potential for integrating past subtyping approaches and for advancing causal theory. The first approach is the division of children with CD into those with a childhood onset to their severe antisocial behavior and those with an adolescent onset to their behavior. The second approach is to designate children within the childhood-onset group who show callous and unemotional traits, which is analogous to adult conceptualizations of psychopathy. Both approaches help designate children who many show different causal processes underlying their severe aggressive and antisocial behavior, and who may warrant different approaches to treatment.     

Posttraumatic Stress Disorder and Vietnam Veterans

Many unemployed Vietnam veterans may be sufferers of posttraumatic stress disorder (PTSD). Symptoms and behaviors of PTSD are reviewed to assist employment counselors in identifying such individuals, and suggestions for referral are made.     

Altered White-Matter Microstructure in Conduct Disorder Is Specifically Associated with Elevated Callous-Unemotional Traits

Adolescents with conduct disorder (CD) and elevated callous-unemotional (CU) traits have been reported to present with a more severe and persistent pattern of antisocial behaviour than those with low levels of CU traits. However, relatively few studies have investigated whether there are differences in brain structure between these subgroups.We acquired diffusion tensor imaging data and used tract-based spatial statistics (TBSS) to compare adolescents with CD and high levels of CU traits (CD/CU+; n?=?18, CD and low levels of CU traits (CD/CU-; n?=?17) and healthy controls (HC; n?=?32) on measures of fractional anisotropy (FA), axial (AD), radial (RD) and mean (MD) diffusivity. Compared to CD/CU- adolescents, those with CD/CU+ presented increased FA and reduced RD and MD (lower diffusivity) in several tracts including: body and splenium of the corpus callosum, right inferior longitudinal fasciculus, ILF; right inferior fronto-occipital fasciculus, IFOF; left superior longitudinal fasciculus, SLF; left cerebral peduncle, bilateral internal capsule, left superior and posterior corona radiata, bilateral thalamic radiation and left external capsule. In addition, relative to CD/CU- individuals, adolescents with CD/CU+ showed lower diffusivity (indexed by reduced RD and MD) in left uncinate fasciculus and bilateral fornix. Finally, relative to healthy controls, CD/CU+ individuals showed lower diffusivity (reduced RD) in the genu and body of the corpus callosum and left anterior corona radiata. These results suggest that CD/CU+ individuals present with white-matter microstructural abnormalities compared to both CD/CU- individuals and age-matched healthy controls. This finding is consistent with emerging evidence suggesting that CD/CU+ represents a distinct subtype of CD, and illustrates the importance of accounting for heterogeneity within CD populations.     

Recurrence of Posttraumatic Stress Disorder in Late Life: A Cognitive Aging Perspective

Clinical experience with older adults shows that many will experience PTSD symptoms in older adulthood because of trauma exposure early in life. Some of these patients struggled with PTSD in the distant past and remained symptomfree for decades only to have a recurrence of PTSD in late life. This paper outlines a cognitive aging explanation for the recurrence of PTSD. It is proposed that the age-related decreases in attention make the intrusion of trauma-related memories more likely. The increase in intrusive memories, combined with age-related decreases in working memory, explicit memory, and prospective memory, increases the subjective distress associated with the memories and results in a recurrence of PTSD.     

Virtual Reality Exposure for Veterans with Posttraumatic Stress Disorder

Abstract

Two open trials of Virtual Reality based exposure therapy (VRE) to desensitize Vietnam veterans with Posttraumatic Stress Disorder (PTSD) to some of their traumatic memories are described. A total of 21 patients were exposed to one of two virtual Vietnam computer-generated environments in which their individual traumatic experiences were simulated in response to their recounting these events. Although two patients experienced significant increases in symptoms during VRE, all patients' PTSD symptoms were below baseline by the 3-month post-treatment assessment. When the data from the two open trials was combined, clinically meaningful and statistically significant reductions in PTSD symptoms were found. These changes were long lasting as evidenced by the 6-month follow-up assessments. Two case examples are provided and future applications of this treatment are discussed.     

Reward Processing and Decision-Making in Posttraumatic Stress Disorder

Theory suggests that, in those with posttraumatic stress disorder (PTSD), positive emotion is likely dampened due to reexperiencing of trauma-related stimuli. Prior research has extended positive emotion experiencing to reward processing research but has not yet examined how trauma cues affect reward processing (i.e., the anticipation of and satisfaction with reward) and decision-making in individuals with PTSD. We compared 24 individuals diagnosed with PTSD to 29 trauma-exposed controls in passive and decision-making phases of a wheel-of-fortune task, following both neutral and trauma inductions. Three types of spinners were used in the task: spinners that were obviously advantageous spinners, obviously disadvantageous spinners, and ambiguously advantageous spinners with outcomes averaging to a net gain. We hypothesized that the PTSD group would report lower reward expectation and lower outcome satisfaction and make less advantageous decisions, differences that would be exacerbated following a trauma prime. The PTSD group reported lower reward expectation than controls for the ambiguous spinners only, suggesting that the reduced anticipation of reward associated with PTSD may be specific to ambiguous stimuli. Reward expectation was not affected by the type of prime. Outcome satisfaction was not affected by PTSD or type of prime. Although only marginally significant, the PTSD group played the ambiguous spinners less often than controls, and played the obviously disadvantageous spinners significantly less often than controls, suggesting that those with PTSD are more aversive to loss. Our findings suggest that PTSD-related deficits are more robust for reward expectation than outcome satisfaction, and support future research examining the role of reward-related decision-making in PTSD.     

The Forensic Examination of Posttraumatic Stress Disorder

Abstract

The diagnosis of posttraumatic stress disorder (PTSD) has achieved a major level of significance in our judicial system. The forensic examination of PTSD is identified as a specialized assessment that is non-biased and non-prejudicial. This article attempts to provide a standard methodology to offer an objective and neutral forensic assessment and diagnosis of PTSD that will stand up to legal scrutiny by identifying problems in diagnosing PTSD and establishing a six-step methodology for the differential diagnosis of the disorder. Procedures for providing a forensic examination of PTSD and details of the author's methods of providing a forensic examination are presented.     

Callous-Unemotional Traits as Unique Prospective Risk Factors for Substance Use in Early Adolescent Boys and Girls

Youth with elevated conduct disorder (CD) symptoms who also have callous-unemotional (CU) traits exhibit more antisocial behavior than youth without CU traits. However, evidence regarding whether CU traits increase risk of substance use over and above CD symptoms, and whether these associations differ for boys and girls, is scarce. Using the Developmental Pathways Project sample of 521 middle school students, we examined whether adolescent- and parent-reported CU traits measured in 6th grade prospectively predicted the onset and recurrence of substance use and use-related impairment by 9th grade. We also examined the degree to which CU traits uniquely predicted substance use and impairment over and above CD symptoms, as well as whether gender moderated these associations. Results indicated that adolescent-reported CU traits increased the likelihood of substance use and impairment onset and recurrence by 9th grade. Analyses revealed that CD symptoms accounted for prospective associations between adolescent-reported CU and substance use, but gender moderated these associations. Boys with elevated CU traits and CD symptoms were not more likely to report alcohol use onset or recurrence, but they were at highest risk of recurrent marijuana use, use of both alcohol and marijuana, and use-related impairment by 9th grade. Girls with low CU traits and high CD symptoms were most likely to report onset and recurrent use of alcohol, as well as recurrent marijuana use, use of both substances and impairment. Study findings highlight the importance of accounting for CD symptoms and gender when examining links between CU traits and substance use in early adolescence.     

Moral Emotions,Emotion Self-Regulation,Callous-Unemotional Traits,and Problem Behavior in Children of Incarcerated Mothers

Children with incarcerated mothers are at high risk for developing problem behaviors. Fifty children (6–12 years; 62% girls) participated in summer camps, along with adult mentors. Regression analyses of child and adult measures of child’s emotion self-regulation and callous-unemotional traits, and a child measure of moral emotions, showed that poor emotion regulation, along with low levels of guilt and high levels of shame, predicted children’s externalizing behaviors, while only low levels of guilt predicted a unique subset of child characteristics called callous-unemotional traits. Children who experienced healthy guilt for misdeeds were better able to control their behavior. Adults noted the ability of children with callous/unemotional traits to manage and regulate their emotions, while poor emotion regulation was more predictive of the cluster of externalizing problems. Discussion focuses on prevention efforts aimed at teaching emotion self-regulation and the implications of the high levels of callous-unemotional traits in this population of children.     

Treatment outcomes of Vietnam veterans with Posttraumatic Stress Disorder.

This study examined changes on the Millon Clinical Multiaxial Inventory for 45 Vietnam veterans who completed a specialized inpatient treatment program. The average length of stay for these veterans was 140 days. Patients' scores on the Millon decreased on 12 of the 20 scales and increased on 8, and their Posttraumatic Stress Disorder-related symptoms of anxiety and dysthymia decreased significantly. Posttraumatic Stress Disorder-related character styles, schizoid, avoidant, and passive-aggressive, also showed significant decreases.     

Adapted character styles of Vietnam veterans with Posttraumatic Stress Disorder

A total of 189 male Vietnam veterans who were admitted to a specialized inpatient treatment program were evaluated using the Millon Clinical Multiphasic Personality Inventory to assess character styles. The veterans were assessed for Posttraumatic Stress Disorder by using a subscale of the Minnesota Multiphasic Personality Inventory (MMPI) and 72% of the patients were classified as having Posttraumatic Stress Disorder. The character styles of passive-aggressive, schizoid, avoidant, and borderline were significantly associated with these patients. The most common 2-point profile was passive-aggressive and avoidant (8-2 or 2-8) and was significantly related to the diagnosis. While drug and alcohol abuse were common problem areas for the entire sample, the profile of patients with Posttraumatic Stress was different from those of substance abusers. These results indicate that treating Vietnam veterans with this disorder requires adopting strategies which include a character style focus as well as a symptom focus.     

Modifying Exposure-Based CBT for Cambodian Refugees with Posttraumatic Stress Disorder

Cambodian refugees represent a severely traumatized population living in the United States. In this paper, we describe the modification of a cognitive-behavior therapy program to facilitate delivery of an exposure-based treatment for posttraumatic stress disorder while addressing some of the challenges brought by differences in language and culture between providers and patients. Our treatment modifications include the use of metaphors and culturally relevant examples to aid the communication of core concepts by interpreters, an emphasis on teaching the “process” of exposure therapy rather than relying on specific exposure practice in the group setting, a focus on interoceptive exposure to allow more effective group practice and to address culturally specific symptom interpretations, attention to the way in which treatment procedures interacted with culturally specific beliefs, and efforts to integrate treatment services within the community. Although data are limited, results to date suggest that this modified treatment was acceptable to patients and offered benefits on the order of large effect sizes.     

Posttraumatic Stress Disorder and executive dysfunction among children and adolescents: A Latent Profile Analysis

Background/ObjectiveThe current study aimed to examine the relationship between Posttraumatic Stress Disorder (PTSD) symptoms and executive dysfunction in children and adolescents after psychological trauma.MethodParticipants were 13,438 of children and adolescents aged 6 to 18 years exposed to the 2008 Wenchuan earthquake. PTSD and dysexecutive symptoms were assessed using the UCLA PTSD Reaction Index for Children and the Self-Report Dysexecutive Questionnaire. Latent Profile Analysis (LPA) was conducted using Mplus version 7.4. Subgroup differences in trauma exposure and quality of life were calculated using ANCOVA.ResultsA 4-class parallel model was found to best describe latent PTSD symptom profiles and executive dysfunction. Individuals in higher symptom groups showed more trauma exposure and lower quality of life.ConclusionsThis LPA study shed light on the relationship between PTSD and executive dysfunction symptoms in children and adolescents. The correlation between PTSD and executive dysfunction was maintained after individual differences were taken into consideration. Our findings provide a new view on how PTSD relates to executive dysfunction and several suggestions for treating child and adolescent PTSD patients.     

交通事故伤幸存者与创伤后应激障碍

交通事故是目前导致创伤后应激障碍(posttraumatic stress disorder,PTSD)的主要原因之一,PTSD常常伴发其他精神障碍如焦虑、抑郁等,即使事故过去很长一段时间以后,症状仍然可能残留或复发,容易迁延形成慢性病程,给患者家庭及社会带来沉重的经济负担。本文综述了交通事故所致PTSD的流行病学、临床症状及影响因素、认知功能损伤、对患者生活质量的影响及对未来研究方向展望。     

Unique and Interactive Associations of Callous-Unemotional Traits,Impulsivity and Grandiosity with Child and Adolescent Conduct Disorder Symptoms

The construct of psychopathy remains underrepresented in the clinical diagnosis of Conduct Disorder (CD) as the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) only addresses one out of the three dimensions of child psychopathy, Callous Unemotional (CU) traits. This study tests if and to what extent there are unique and interactive associations of CU traits, impulsivity, and grandiosity with child and adolescent CD symptoms. Data were collected from two separate community samples of children (N?=?1599; Mage?=?9.46, SD?=?1.65; 52% female) and adolescents (N?=?2719; Mage?=?16.99, SD?=?0.99; 49% female), who were followed longitudinally after a year. Hierarchical linear regression analyses were conducted, testing cross-sectional and longitudinal associations with CD symptoms, taking into account all three psychopathy dimensions. The cross-sectional findings indicate that only youth presenting a combination of all three psychopathy dimensions scored above the clinical cut-off score for CD. On the other hand, longitudinal findings provided evidence that the combination of high initial levels of CD and CU traits as well as the combination between CD, grandiosity, and impulsivity can lead to clinical levels of future CD symptoms. Findings also indicated that CU traits and impulsivity more strongly predicted adolescent than child CD symptoms, and that CU traits were more strongly associated with boys’ than girls’ CD symptoms. Findings support the inclusion of CU traits as a specifier for the diagnosis of CD, and provide evidence that other psychopathy dimensions can also help clinicians to better understand and treat youth with CD, and should be considered for future revisions of the DSM.     

Assessment of Callous-Unemotional Traits in 6 to 12 Year-Old Children with Oppositional Defiant Disorder/Conduct Disorder by Parent Ratings

The factorial structure of the Inventory of Callous-Unemotional Traits (ICU; Frick 2004) has been inconsistent across previous studies using different rater versions (self-report, parent, teacher) and versions in different languages applied to both clinical and nonreferred samples predominantly of adolescents. The present study examined the factorial structure of the parent-report version of the ICU in a clinical sample of boys aged 6–12 years with Oppositional Defiant Disorder/Conduct Disorder (n?=?131) using confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). Results from the CFA supported previous findings, but even the preferred model with three independent factors (Callousness, Uncaring, and Unemotional) showed inadequate model fit. Subsequent EFA revealed a three-factor model consisting of two new subscales (Callousness/Lack of Guilt or Remorse, Unconcerned about Performance) and the original subscale Unemotional. Internal consistencies of the three subscales and total score were satisfactory, and intercorrelations of the subscales were weak, except for a moderate correlation between the subscales Callousness/Lack of Guilt or Remorse and Unconcerned about Performance. The corresponding subscales of the original and new versions were highly correlated. As expected, the ICU subscale Callousness/Lack of Guilt or Remorse showed associations with other measures of aggressive and oppositional behavior. The other two ICU subscales were not associated with aggression or oppositional/antisocial behavior, but Unconcerned about Performance correlated with a measure of attention problems and Unemotional correlated with the internalizing problem withdrawn. The implications of these findings are discussed, especially as a callous unemotional specifier for the diagnosis of Conduct Disorder is included in DSM-5.     

Suicide and War: The Mediating Effects of Negative Mood, Posttraumatic Stress Disorder Symptoms, and Social Support among Army National Guard Soldiers

The mediating effects of posttraumatic stress disorder (PTSD) symptoms, negative mood, and social support on the relationship of war experiences to suicidality were examined. The research literature suggested a sequence among study scales representing these constructs, which was then tested on survey data obtained from a sample of National Guard soldiers (N = 4,546). Results from structural equation modeling suggested that war experiences may precipitate a sequence of psychological consequences leading to suicidality. However, suicidality may be an enduring behavioral health condition. War experiences showed no direct effects on postdeployment suicidality, rather its effect was indirect through PTSD symptoms and negative mood. War experiences were, however, predictive of PTSD symptoms, as would be expected. PSTD symptoms showed no direct effect on postdeployment suicidality, but showed indirect effects through negative mood. Results also suggested that suicidality is relatively persistent, at least during deployment and postdeployment. The percentage of those at risk for suicide was low both during and after deployment, with little association between suicidality and time since returning from deployment. Additionally, few soldiers were initially nonsuicidal and then reported such symptoms at postdeployment. Implications of relationships of both negative mood and combat trauma to suicidality are discussed, as well as possible mediating effects of both personal dispositions and social support on relationships of war experiences to PTSD, negative mood, and suicidality.