Stages of decompensation in combat-related posttraumatic stress disorder: A new conceptual model

This conceptual article presents a model of severe, chronic combat-related PTSD based on several years of longitudinal clinical observations of Vietnam veterans. The model describes a repeating cycle of decompensation that profoundly disrupts the veteran’s life. There appear to be “stages” of decompensation that can be described clinically and may be distinct physiologically. The stages describe a wide range of functioning, from adaptive to totally dysfunctional. PTSD core symptoms, as well as several other dimensions of clinical functioning, such as affect regulation, defenses, ego states, interactions with the environment, capacity for self-destruction/suicide and capacity for attachment and insight are described for each stage. Clinical and research implications are discussed.     

Avfail in color avoidance learning by starlings (Sturnus vulgaris) and red-winged blackbirds (Agelaius phoeniceus)

Certain unconditioned stimuli (UCS) in flavor avoidance learning sometimes become ineffective after pairings with relatively stronger UCS. This failure of avoidance learning (avfail) has been demonstrated only with rodents. The present investigations were conducted to determine whether avfail might also occur with avian species, the food selection of which is guided primarily by visual cues. In Experiment 1, starlings were given pairings of methiocarb (a relatively weak UCS) and LiCl (a relatively strong UCS). In Experiment 2, red-winged blackbirds were given pairings of two concentrations of methiocarb (relatively weak and relatively strong UCS, respectively). Pairings were followed by a conditioning trial (UCS gavage in the presence of a color cue) and two-choice tests. Conditioned avoidance was always observed except when methiocarb preceded LiCl and when the low preceded the high methiocarb dose in preconditioning pairings. Experiment 3 demonstrated that UCS habituation could not account for the results of Experiments 1 and 2. The data reflect avfail in the visual modality, and a biological implication of the results is that birds may not learn strong avoidance of aposematic prey containing varied levels of toxicant.     

Age-associated predictors of medication adherence in HIV-positive adults: health beliefs, self-efficacy, and neurocognitive status.

OBJECTIVE: Although most agree that poor adherence to antiretrovirals is a common problem, relatively few factors have been shown to consistently predict treatment failure. In this study, a theoretical framework encompassing demographic characteristics, health beliefs/attitudes, treatment self-efficacy, and neurocognitive status was examined in relationship to highly active antiretroviral therapy adherence. DESIGN: Prospective, cross-sectional observational design. MAIN OUTCOME MEASURES: Neuropsychological test performance, health beliefs and attitudes, and medication adherence tracked over a 1-month period using electronic monitoring technology (Medication Event Monitoring System caps). RESULTS: The rate of poor adherence was twice as high among younger participants than with older participants (68% and 33%, respectively). Results of binary logistic regression revealed that low self-efficacy and lack of perceived treatment utility predicted poor adherence among younger individuals, whereas decreased levels of neurocognitive functioning remained the sole predictor of poor adherence among older participants. CONCLUSION: These data support components of the health beliefs model in predicting medication adherence among younger HIV-positive individuals. However, risk of adherence failure in those ages 50 years and older appears most related to neurocognitive status.     

An analysis of modifications to the three-step guided compliance procedure necessary to achieve compliance among preschool children

After a 3‐step guided compliance procedure (vocal prompt, vocal plus model prompt, vocal prompt plus physical guidance) did not increase compliance, we evaluated 2 modifications with 4 preschool children who exhibited noncompliance. The first modification consisted of omission of the model prompt, and the second modification consisted of omitting the model prompt and decreasing the interprompt interval from 10 s to 5 s. Each of the modifications effectively increased compliance for 1 participant. For the remaining 2 participants, neither modification was effective; differential reinforcement in the form of contingent access to a preferred edible item was necessary to increase compliance. Problem behavior varied across participants, but was generally higher during guided compliance conditions and lower during differential reinforcement conditions.     

A COMPARISON OF DIFFERENTIAL REINFORCEMENT AND NONCONTINGENT REINFORCEMENT TO TREAT FOOD SELECTIVITY IN A CHILD WITH AUTISM

We compared differential reinforcement plus escape extinction to noncontingent reinforcement plus escape extinction to treat food selectivity exhibited by a young child with autism. The interventions were equally effective for increasing bite acceptance and decreasing problem behaviors. However, a social validity measure suggested that noncontingent reinforcement was preferred by the child's caregiver.     

Perceptions of Family Environment and Wraparound Processes: Associations with Age and Implications for Serving Transitioning Youth in Systems of Care

Addressing the unique needs of youth transitioning to adulthood has long been viewed as a priority in implementation of systems of care (SOCs) and wraparound. Developmental research and "practice-based evidence" suggest that there are differences between transitioning youth and their younger peers in family environment and wraparound team processes. Although these differences are thought to have significant implications for wraparound practice, few studies have examined them empirically. The present research involves two studies examining differences across several age cohorts (i.e., 10–12, 13, 14, 15, 16–17 year-olds) ranging from early adolescent to transitioning youth in: (1) caregiver perceptions of role-related strain and family environment quality, and (2) facilitator, caregiver, and youth perceptions of wraparound processes. In Study #1, older age was associated with higher levels of caregiver strain. In Study #2, age was associated with differences between youth and other team members' perceptions of wraparound processes, such that older youth perceived teams as less cohesive than others on their teams. These findings suggest that transitioning youth and their families merit special consideration in wraparound implementation and underscore the importance of considering the perceptions of transitioning youth in system change and practice improvement efforts (192 words).     

An fMRI investigation of analogical mapping in metaphor comprehension: the influence of context and individual cognitive capacities on processing demands

This study used fMRI to investigate the neural correlates of analogical mapping during metaphor comprehension, with a focus on dynamic configuration of neural networks with changing processing demands and individual abilities. Participants with varying vocabulary sizes and working memory capacities read 3-sentence passages ending in nominal critical utterances of the form "X is a Y." Processing demands were manipulated by varying preceding contexts. Three figurative conditions manipulated difficulty by varying the extent to which preceding contexts mentioned relevant semantic features for relating the vehicle and topic of the critical utterance to one another. In the easy condition, supporting information was mentioned. In the neutral condition, no relevant information was mentioned. In the most difficult condition, opposite features were mentioned, resulting in an ironic interpretation of the critical utterance. A fourth, literal condition included context that supported a literal interpretation of the critical utterance. Activation in lateral and medial frontal regions increased with increasing contextual difficulty. Lower vocabulary readers also had greater activation across conditions in the right inferior frontal gyrus. In addition, volumetric analyses showed increased right temporo-parietal junction and superior medial frontal activation for all figurative conditions over the literal condition. The results from this experiment imply that the cortical regions are dynamically recruited in language comprehension as a function of the processing demands of a task. Individual differences in cognitive capacities were also associated with differences in recruitment and modulation of working memory and executive function regions, highlighting the overlapping computations in metaphor comprehension and general thinking and reasoning.     

Legal briefing: The unbefriended: making healthcare decisions for patients without surrogates (Part 1)

This issue's "Legal Briefing" column covers recent legal developments involving medical decision making for unbefriended patients. These patients have neither decision-making capacity nor a reasonably available surrogate to make healthcare decisions on their behalf. This topic has been the subject of recent articles in JCE. It has been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. Moreover, the scope of the problem continues to expand, especially with rapid growth in the elderly population and with an increased prevalence of dementia. Unfortunately, most U.S. jurisdictions have failed to adopt effective healthcare decision-making systems or procedures for the unbefriended. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform". Most providers are "muddling through on an ad hoc basis". Still, over the past several months, a number of state legislatures have finally addressed the issue. These developments and a survey of the current landscape are grouped into the following 14 categories. The first two define the problem of medical decision making for the unbefriended. The remaining 12 categories describe different solutions to the problem. The first six of these solutions are discussed in this article (Part 1). The last eight solutions will be covered in the Summer 2012 issue of JCE (Part 2). 1. Who are the unbefriended? 2. Risks and problems of the unbefriended. 3. Prevention: advance care planning, diligent searching, and careful capacity assessment. 4. Decision-making mechanisms and standards. 5. Emergency exception to informed consent. 6. Expanded default surrogate lists: close friends. 7. Private guardians. 8. Volunteer guardians. 9. Public guardians. 10. Temporary and emergency guardians. 11. Attending physicians. 12. Other clinicians, individuals, and entities. 13. Institutional committees. 14. External committees.