Treatment-resistant posttraumatic stress disorder: strategies for intervention

The mainstay of treatment for chronic posttraumatic stress disorder (PTSD) is a combination of psychotherapy and medication treatments. The first-line medications for PTSD are antidepressants, with two selective serotonin reuptake inhibitors (sertraline and paroxetine) currently Food and Drug Administration-indicated for PTSD. However, many patients do not have an adequate response to antidepressants, therefore, combinations with other antidepressants or with other classes of psychotropic medication are often utilized to enhance the therapeutic response. Other agents that have been used include mood stabilizers, anti-adrenergics, anxiolytics, and atypical antipsychotics. The heterogeneity of symptom clusters in PTSD as well as the complex psychiatric comorbidities (eg, with depression or substance abuse) further support the notion that combinations of medications may be needed. To date, there is a paucity of data to support specific strategies for augmenting antidepressants in PTSD. This review will address representative existing studies and discuss several potential pharmacologic strategies for patients suffering from treatment-refractory PTSD.     

Enhanced occipital and anterior cingulate activation in men but not in women during exposure to angry and fearful male faces

Blood-oxygenation-level-dependent signal was measured with functional magnetic resonance imaging in 24 healthy young subjects (12 men and 12 women) during viewing of angry, fearful, and neutral male and female face pictures. Exposure to angry male as opposed to angry female faces activated the visual cortex and the anterior cingulate gyrus significantly more in men than in women. A similar sex-differential brain activation pattern was present during exposure to fearful but not neutral faces. Previous behavioral studies indicate enhanced physiological arousal in men but not in women during exposure to angry male as opposed to female faces, and brain imaging studies have shown that the occipital cortex and the anterior cingulate gyrus are influenced by activity in the autonomic nervous system as well as by visual attention. Hence, we suggest that the elevated occipital and anterior cingulate activation in men during confrontation with other angry and fearful males may reflect enhanced vigilance in a potentially dangerous situation.     

Cognitive vulnerability to depression: a taxometric analysis

Although there is increasing support for the hypothesis that negative cognitive styles contribute vulnerability to depression, it remains unclear how best to conceptualize the heterogeneity in cognitive vulnerability to depression. Specifically, does this heterogeneity reflect quantitative or qualitative differences among individuals? The goal of this study was to address this question by examining whether the underlying structure of cognitive vulnerability to depression is best conceptualized as dimensional or categorical. Taxometric analyses provided consistent support for the dimensional nature of negative cognitive styles. It appears, therefore, that cognitive vulnerability to depression is best conceptualized as a dimensional construct, present to a greater or lesser extent in all individuals. Despite this, the strength of the relationship between negative cognitive styles and depressive symptoms does appear to vary as a function of where along the cognitive style continuum one falls.     

An application of item response theory analysis to alcohol, cannabis, and cocaine criteria in DSM-IV

Item response theory (IRT) is supplanting classical test theory as the basis for measures development. This study demonstrated the utility of IRT for evaluating DSM-IV diagnostic criteria. Data on alcohol, cannabis, and cocaine symptoms from 372 adult clinical participants interviewed with the Composite International Diagnostic Interview--Expanded Substance Abuse Module (CIDI-SAM) were analyzed with Mplus (B. Muthen & L. Muthen, 1998) and MULTILOG (D. Thissen, 1991) software. Tolerance and legal problems criteria were dropped because of poor fit with a unidimensional model. Item response curves, test information curves, and testing of variously constrained models suggested that DSM-IV criteria in the CIDI-SAM discriminate between only impaired and less impaired cases and may not be useful to scale case severity. IRT can be used to study the construct validity of DSM-IV diagnoses and to identify diagnostic criteria with poor performance.     

Psychopathy and physiological response to emotionally evocative sounds

Despite considerable evidence that psychopathic criminals are deviant in their emotional reactions, few studies have examined responses to both pleasurable and aversive stimuli or assessed the role of different facets of psychopathy in affective deviations. This study investigated physiological reactions to emotional sounds in prisoners selected according to scores on the 2 factors of Hare's Psychopathy Checklist--Revised (PCL-R; R. D. Hare, 1991). Offenders high on the PCL-R emotional-interpersonal factor, regardless of scores on the social deviance factor, showed diminished skin conductance responses to both pleasant and unpleasant sounds, suggesting a deficit in the action mobilization component of emotional response. Offenders who scored high only on the social deviance factor showed a delay in heart rate differentiation between affective and neutral sounds. These findings indicate abnormal reactivity to both positive and negative emotional stimuli in psychopathic individuals, and suggest differing roles for the 2 facets of psychopathy in affective processing deviations.     

A dual-process model of reactions to perceived stigma

The authors propose a theoretical model of individual psychological reactions to perceived stigma. This model suggests that 2 psychological systems may be involved in reactions to stigma across a variety of social contexts. One system is primarily reflexive, or associative, whereas the other is rule based, or reflective. This model assumes a temporal pattern of reactions to the stigmatized, such that initial reactions are governed by the reflexive system, whereas subsequent reactions or "adjustments" are governed by the rule-based system. Support for this model was found in 2 studies. Both studies examined participants' moment-by-moment approach-avoidance reactions to the stigmatized. The 1st involved participants' reactions to persons with HIV/AIDS, and the 2nd, participants' reactions to 15 different stigmatizing conditions.     

Normative data for the selective reminding test: a random digit dialing sample

Healthy control participants (46 women, M age=44.3 yr., SD=7.6; 29 men) were recruited to undergo a comprehensive neuropsychological battery and serve as a comparison group in a study of cognitive functioning in patients with Lyme isease. Participants were selected using Mitofsky-Waksberg random digit dialing. The Buschke 12-word, six-trial Selective Reminding Test was administered as part of the neuropsychological battery and normative data are presented stratified by age and sex. Performance on alternate forms of this measure were examined. Mean education, intelligence quotient, and Wide Range Achievement Test-3 Reading scores are reported.     

Nikāmakarma: how desireless need one be?1

In the Bhagavadgītā K a advises Arjuna to act without desire. He also describes the nikāmakarmin as possessed of perfect equanimity. Some scholars have argued that K a's advice is a contradiction. Because action requires desire, desireless action is impossible. Others have claimed that this fact only suggests that K a's prohibition is against a subset of desires and not desire as a whole. These ‘subset’ positions, however, are not consistent with the equanimity requirement. The conclusion that K a's advice is a contradiction can be avoided however. The word ‘desire’ in English is ambiguous. In one sense it means ‘whatever motivated’, and in another sense it means a ‘desire proper’ in contrast to beliefs and other mental states. If it is possible that not only desires proper motivate, then it is possible to act desirelessly in this sense. This distinction, I will argue, makes the best sense of K a's advice.     

What's in a (neutral) face? Personality disorders, attachment styles, and the appraisal of ambiguous social cues

Attachment theory suggests that borderline, avoidant, and schizoid personality disorders are differentially associated with anxious and avoidant attachment styles. The variations of insecure attachment in these disorders, in turn, might influence how others are perceived or appraised. To test these ideas, 176 college students completed questionnaires measuring attachment styles and personality disorder features, and each rated 10 emotionally neutral faces on 18 bipolar appraisal dimensions. As expected, borderline personality was associated with anxious attachment, avoidant personality was associated with anxious and avoidant attachment, and schizoid personality was weakly associated only with avoidant attachment. Furthermore, path analyses showed that borderline and avoidant personality features were associated with anxious attachment, which in turn related to negative face appraisals (e.g., tendencies to rate faces as less friendly and more rejecting). Discussion highlights the potential of simultaneously studying biases in social information processing and attachment disturbances among individuals with personality disorders.