Issues related to the diagnosis and treatment of autism spectrum disorders

This paper explores issues and implications for diagnosis and treatment, stemming from the growing number of children identified with autism spectrum disorders (ASDs). Recent developments and innovations in special education and Medicaid programs are emphasized. Eligibility determination policies, innovations in diagnostic practices, the cost and financing of assessment, variability among programs in diagnostic criteria, and racial/ethnic disparities in the timing of diagnosis all influence the capacity of service systems to provide diagnoses in a timely, coordinated, accurate, economical, and equitable manner. There are several barriers to the more widespread provision of intensive intervention for children with ASDs, including lack of strong evidence of effectiveness in scaled-up public programs, uncertainty about the extent of obligations to provide services under the Individuals with Disabilities Education Act, high cost of intervention, and variability among states in their willingness to fund intensive intervention via Medicaid. Innovative policy experiments with respect to financing intensive intervention through schools and Medicaid are being conducted in a number of states.     

Emotion, physiology, and expression in old age

Emotion-specific autonomic nervous system (ANS) activity was studied in 20 elderly people (age 71-83 years, M = 77) who followed muscle-by-muscle instructions for constructing facial prototypes of emotional expressions and relived past emotional experiences. Results indicated that (a) patterns of emotion-specific ANS activity produced by these tasks closely resembled those found in other studies with younger Ss, (b) the magnitude of change in ANS measures was smaller in older than in younger Ss, (c) patterns of emotion-specific ANS activity showed generality across the 2 modes of elicitation, (d) emotion self-reports and spontaneous production of emotional facial expressions that occurred during relived emotional memories were comparable with those found in younger Ss, (e) elderly men and women did not differ in emotional physiology or facial expression, and (f) elderly women reported experiencing more intense emotions when reliving emotional memories than did elderly men.     

Psychological distress, loneliness and disability in old age

With the growth in the number of older people, an increase of mental health problems might be expected. Reducing the amount of suffering and dependence due to poor mental health in old age is a priority requiring a good understanding of the determinants of psychological distress. The objectives were: (a) to measure the prevalence of psychological distress and loneliness in old men and women, living in the community, (b) to clarify the association between psychological distress, health and other explanatory variables and (c) to determine relationship between loneliness and psychological distress. We performed a cross-sectional study of 999 people aged 65+. The variables studied were psychological distress (GHQ-12) and self-reported loneliness. The prevalence of psychological distress was 20%. Illness and disability are related to psychological distress in old age; the feeling of loneliness is the single most important predictor of psychological distress, and not knowing neighbours increases the probability of depression. Attempts to improve detection and management of psychological distress in sick older people, in those who appear isolated and express loneliness should be evaluated.     

Personality disorders and dimensions in pathological gambling

Comorbid DSM-IV Axis II personality disorders appear to be common in pathological gambling (PG) and may contribute to the chronic problems often associated with the disorder. This study sought to examine the relationship between PG, personality disorders, and impulsivity in a sample of pathological gamblers. Personality assessments included the SCID-II, Eysenck Impulsiveness Questionnaire, Tridimensional Personality Questionnaire, and Barratt Impulsiveness Scale. A total of 77 individuals with DSM-IV PG were included in this study, of which 35 (45.5%) met criteria for at least one personality disorder. Specific aspects of impulsivity were associated with certain personality disorders in PG when grouped by cluster, yet the presence of a personality disorder was not positively correlated with gambling severity. It remains unclear how the presence of a personality disorder and aspects of impulsivity may affect treatment outcome. Further exploration of these disorders and dimensions of personality may encourage a more inclusively global treatment approach.     

Creativity in old age

Sixty elderly subjects (M = 72 years) were tested and interviewed to find out how they experience and come to terms with the advent of illness, aging, and death. The choice of test instruments was steered by the necessity to learn how our subjects handled their anxiety (the Meta‐Contrast Technique [MCT]); to operationally define the concept of self‐image (the Identification Test [IT]); and to illuminate the findings from the perspective of creativity (the Creative Functioning Test [CFT]). The results revealed creativity to be a key factor in aging. The attitude of creative individuals towards aging was less negative and their attitude to illness less defensive. On the whole, their self‐projections were not only more flexible but also more emotional. However, creativity is not uninfluenced by context, particularly when it is of medium strength. The results also revealed that the subliminal messages used in the IT to manipulate the projected self‐image were effective.     

Alphabetizing in old age

Abstract: A long term, intensive analysis with a woman in old old age is reported. An attempt is made to answer the question, ‘What, in analytic work, is healing?’. The patient's previous classical Jungian work is contrasted with the author's developmental perspective. It is suggested that an enactment, representing what Neville Symington has called an analyst's act of freedom, was crucial in effecting a profound transformation in the patient's psyche.     

老年人的智慧

智慧是个体在其人生经历中习得的一种德才一体的综合心理素质, 是成功老龄化的重要标志和毕生发展的理想终点。研究发现, 三维智慧量表、自我评估智慧量表、成人自我超越问卷等自陈式测量和柏林智慧范式、智慧推理等表现式测量对老年人智慧评估具有良好性能; 老年人智慧发展受到开放性、自我反思、情绪调节、人格成长等内在因素以及受教育程度、关键生活经历、社会环境等外在因素的交互影响; 毕生发展的智慧为老年人带来更高主观幸福感、生活满意度以及更少社会疏离感、孤独感和抑郁。未来应该开发多测度、整合的老年人智慧测评工具; 深入揭示老年人智慧的预测因素、影响后效及其内部作用机制; 进一步探索社区养老服务中老年人智慧的干预与培育策略。     

Dual diagnosis: Clinical issues in the treatment of substance abuse,and affective,personality, and psychotic disorders

Co-morbidity of alcohol and substance with the spectrum of other psychiatric diagnoses is examined with specific emphasis on diagnostic indicators for anxiety and mood disorders. Diagnostic issues for the chemically dependent person are examined with the context of borderline personality disorder, schizophrenia and other psychiatric disorders. Clinical research related to the dually-diagnosed patient is explored     

ODD dimensions, ADHD, and callous-unemotional traits as predictors of treatment response in children with disruptive behavior disorders

To answer several questions pertinent to DSM-V, the authors examined the predictive validity of pretreatment oppositional defiant disorder (ODD) dimensions, attention-deficit/hyperactivity disorder (ADHD), and callous-unemotional (CU) traits in relation to several treatment outcomes in 177 children diagnosed with ODD or conduct disorder (CD). Multiple informants completed diagnostic interviews and rating scales at 6 assessment points (pretreatment to 3-year follow-up) to document emotional and behavioral outcomes. After controlling for pretreatment CD, the ODD dimension of hurtfulness was related to treatment-resistant CD, delinquent behaviors, and externalizing problems. In contrast, the ODD dimension tapping irritability was associated with treatment-resistant ODD, internalizing problems, and global functional impairment following treatment. Whereas pretreatment ADHD was associated with posttreatment ODD and social problems, it was unrelated to posttreatment CD symptoms and diagnosis. Contrary to predictions, CU traits were unrelated to any posttreatment outcomes after controlling for other covariates. These findings remained after controlling for measures of pretreatment global functional impairment.     

Sacrifice: Psychodynamic,Cultural and Clinical Aspects

Noting that the topic of sacrifice has remained largely unaddressed in psychoanalytic literature, the authors offer a discussion of it. Their elucidation of sacrifice opens with the definition and etymology of the word and moves on to the place of sacrifice in various religious traditions. They then summarize Freud's views on the topic and suggest that the subsequent analytic contributions have gone in three directions: the first extends and modifies Freud's proposal of triadic-hostile origins of sacrifice, the second locates such origins in dyadic and loving relations, and the third seeks to synthesize the foregoing trends. The authors then delineate the triad of altruism, masochism, and narcissism that underlie sacrifice. They propose that a spectrum of phenomena, ranging from healthy to pathological, is subsumed under the rubric of sacrifice. They also discuss the significance of such ideas to the conduct of psychotherapy and psychoanalysis.     

The suicidal risk in severe personality disorders: differential diagnosis and treatment.

This article describes the clinical approach to patients with severe personality disorders who present suicidal intention and behavior, developed at the Personality Disorders Institute of the Department of Psychiatry at Cornell University Medical College and the Westchester Division of the New York Presbyterian Hospital. It describes the diagnostic evaluation of patients' suicidal potential, personality disorder, and the presence or absence of a spectrum of regressive illness. The analysis of the combined features in these three symptomatic domains determines alternative strategies of psychotherapeutic and psychopharmacological interventions. Within these strategies, transference-focused psychotherapy is described as a specific psychodynamic psychotherapy geared to treat characterologically based suicidal and parasuicidal tendencies in the context of the treatment of the patient's personality disorder.     

Personality disorders and personality dimensions in anorexia nervosa

Information on the relationship between anorexia nervosa (AN) and personality disorders (PDs) and dimensions of temperament and character (measured by the Temperament and Character Inventory [TCI; Cloninger, Przybeck Svrakic, & Wetzel, 1994]) is limited. This study examines the predictive validity of the TCI for PD diagnoses assessed by the International Personality Disorder Examination-ICD-10 (IPDE-ICD-10; Loranger, Janca, & Sartorius, 1997) interviews of 46 women with DSM-IV-defined AN. Patients with a PD reported higher levels of harm-avoidance and lower levels of self-directedness than those without a PD. Scores on the TCI were predictive of the number of PD features present, particularly for those PDs in the anankastic, anxious, and dependent groups accounting for 40% to 51% of the variance. Cluster analysis based on scores on the TCI identified a subgroup of patients characterized by low levels of novelty seeking, self-directedness, and cooperativeness and high levels of harm avoidance. This cluster included the majority of those with avoidant, anxious, or dependent PDs. Assessment of particular personality dimensions was able to predict PDs in an anorexic sample. Since normal personality dimensions have greater validity than the categorical PDs, a consideration of normal temperament and character may assist in clinical decisionmaking and considerations concerning treatment.     

Language comprehension in old age

Three experiments examined the effects of aging on comprehension of spoken language. Integrative and constructive aspects of comprehension showed much more marked age-related deficits than registration of surface meaning. Experiment 1 showed that old subjects had difficulty in making inferences based on presented facts. Experiment 2 revealed a similar deficit in old people's ability to detect anomalies in newly presented information by reference to prior everyday knowledge. And Experiment 3, which tested story recall, showed that old subjects were less well able to extract and retain gist information than younger subjects. These difficulties are interpreted as reflecting a limitation in processing capacity such that the demands of concurrently registering surface meaning and simultaneously carrying out integrative and constructive processes exceed capacity in old age.     

Inferential reasoning in old age

Two experiments examined the effects of aging on the kind of inferential reasoning required in comprehending discourse. In Experiment 1 old subjects made more errors than young subjects in solving logical problems framed in everyday language. Unlike the young subjects they had more difficulty when the problems were spoken than when they were written. Experiment 2 revealed that old subjects are inefficient at extracting implicit information during reading; they fail to generate bridging inferences to supply missing information, so that comprehension is restricted to explicitly stated information. The results show that verbal reasoning ability is impaired in old age and that this affects language comprehension in both listening and reading although the deficit is more marked in listening.     

"You're only as old as you feel": self-perceptions of age, fears of aging, and life satisfaction from adolescence to old age

We examined differences in subjective age identification from adolescence to old age and the relation between subjective age and fears about one's own aging and life satisfaction. Using a questionnaire format, 188 men and women from 14 to 83 years of age made judgments about how old they felt, looked, acted, and desired to be. Respondents also answered questions about their personal fears of aging and present life satisfaction. Results revealed that individuals in their teens held older subjective age identities, whereas during the early adult years, individuals maintained same age identities. Across the middle and later adult years, individuals reported younger age identities, and women experienced younger age identities than men across these adults years. Results also revealed that discrepancies between subjective and actual age were associated with personal fears of aging and life satisfaction, especially in younger men and women.