Culturally adapted CBT (CA-CBT) for Latino women with treatment-resistant PTSD: a pilot study comparing CA-CBT to applied muscle relaxation

We examined the therapeutic efficacy of a culturally adapted form of CBT (CA-CBT) for PTSD as compared to applied muscle relaxation (AMR) for female Latino patients with treatment-resistant PTSD. Participants were randomized to receive either CA-CBT (n = 12) or AMR (n = 12), and were assessed before treatment, after treatment, and at a 12-week follow-up. The treatments were manualized and delivered in the form of group therapy across 14 weekly sessions. Assessments included a measure of PTSD, anxiety, culturally relevant idioms of distress (nervios and ataque de nervios), and emotion regulation ability. Patients receiving CA-CBT improved significantly more than in the AMR condition. Effect size estimates showed very large reductions in PTSD symptoms from pretreatment to posttreatment in the CA-CBT group (Cohen’s d = 2.6) but only modest improvements in the AMR group (0.8). These results suggest that CA-CBT can be beneficial for previously treatment-resistant PTSD in Latino women.     

Psychoanalysis and the university: a difficult relationship

A critique of present-day isolation of psychoanalytic institutes and of their lack of emphasis on research and scientific development is followed with concrete proposals for reorienting psychoanalytic education toward university settings, with the ultimate purpose of bringing together psychoanalytic theory and scientific contributions with the contemporary contributions of neurobiological science and the humanities. Efforts already under way in this direction and practical recommendations for further steps to integrate psychoanalytic education and research within university settings are outlined.     

Factors affecting jail detention of defendants adjudicated incompetent to proceed

The movement of defendants through the legal process who have been adjudicated incompetent to proceed is little studied, yet it is important. The purpose of this study was to provide empirical data regarding factors that affected the amount of time defendants adjudicated incompetent to proceed and ordered to undergo hospitalization remained in jail while awaiting transfer to a state hospital. Statewide data collected in Florida between July 2005 and June 2008 were used to determine the lengths of time incompetent defendants spent at certain stages in the legal process. The addition of forensic bed capacity following media attention and litigation resulted in a significant decrease in the amount of time defendants adjudicated incompetent to proceed waited in jail for transfer to a state hospital for treatment. The amount of time it took for completed commitment orders to be submitted to the state mental health authority by the Clerks of Court of each county accounted for a meaningful portion of days defendants spent in jail awaiting transfer to a state hospital, with considerable variation across counties with respect to waiting times. These findings reflect how various stakeholders can affect the amount of time defendants spend in jail while awaiting hospitalization. These issues are discussed in the context of controversy related to Florida's forensic mental health system, as well as issues related to the political process and funding of the state's mental health authority.     

Anxiety sensitivity: a unique predictor of dropout among inner-city heroin and crack/cocaine users in residential substance use treatment

The present study examined the extent to which anxiety sensitivity (AS) at treatment entry was related to prospective treatment dropout among 182 crack/cocaine and/or heroin-dependent patients in a substance use residential treatment facility in Northeast Washington, DC. Results indicated that AS incrementally and prospectively predicted treatment dropout after controlling for the variance accounted for by demographics and other drug use variables, legal obligation to treatment (i.e., court-ordered vs. self-referred), alcohol use frequency, and depressive symptoms. Findings are discussed in relation to the role of AS in treatment dropout and substance use problems more generally.     

Dysfunctional attitudes and episodes of major depression: Predictive validity and temporal stability in never-depressed, depressed, and recovered women

In a large, community-based sample of women (N = 750), the authors examined the nature of associations between dysfunctional attitudes and depression. Dysfunctional attitudes were evaluated both as a vulnerability factor for depression and as a consequence of depression. A link was found between past depression and baseline elevations in dysfunctional attitudes that was independent of current subsyndromal symptoms, but intensification of dysfunctional attitudes following prospectively evaluated episodes of depression (depressive "scarring") was not observed. Although baseline dysfunctional attitudes predicted an episode of major depression over 3 years of prospective study, this prediction, considered alone or in interaction with negative life events, was redundant with that offered by history of past depression. Further, no significant prediction was evident for the Dysfunctional Attitude Scale (A. N. Weissman & A. T. Beck, 1978) when the formerly depressed and never-depressed cohorts were considered separately. Implications for cognitive theories are discussed.     

The almost untreatable narcissistic patient

Clinical experience in the Personality Disorders Institute at Weill Cornell Medical College suggests that patients with borderline personality organization and a narcissistic personality disorder have a more serious prognosis than all other personality disorders functioning at the borderline level, and that those who in addition present significant antisocial behavior have an even worse prognosis (Clarkin, Yeomans, and Kernberg 1999; Stone 1990). This negative trend culminates in a group of practically untreatable patients with antisocial personality disorder, who represent the most severe cases of pathological narcissism. There are also patients with severe narcissistic personality disorder, functioning at an overt borderline level with significant antisocial features, but not presenting an antisocial personality disorder proper, who at times respond to treatment, while others do not. These patients are explored here, with a focus on particular psychotherapeutic techniques that have proven helpful, as well as on the limits of these technical approaches.     

Memento ... life imitates art: the request for an ethics consultation

This was a troublesome case, without complete consensus about the right thing to do. It seemed there were arguments on both sides: those who thought that the goal of comfort care without treatment was most consistent with his wishes, versus those who thought the additional testing and treatment might have produced a net benefit in spite of the burdens. Ultimately, the patient was placed in a facility with a do-not-resuscitate (DNR) order in effect and a plan for comfort care. He may live a few months or more. We all hope that whatever time he has is spent free of pain and symptoms, and that he is able to live a life of quality consistent with his wishes. The main story line is consistent with actual events; however, there have been changes in terms of gender, disease, and relationships that have been included to protect the anonymity of the patient.     

Clinical perspectives on the combination of D-cycloserine and cognitive-behavioral therapy for the treatment of anxiety disorders

In a particular success for translational research agendas, characterization of the neuronal circuits underlying fear extinction, and basic research in animal extinction paradigms, has led to intervention studies examining the use of D-cycloserine (DCS) to enhance therapeutic learning from exposure-based cognitive-behavioral therapy (CBT). In this article, we review these intervention studies, and discuss DCS augmentation of CBT relative to more traditional combination-treatment strategies in the treatment of anxiety disorders. We offer an accounting, based on evidence for internal context effects, of current limitations in the combination of antidepressant or benzodiazepine medications with CBT and discuss the advantages of isolated-dosing strategies with DCS relative to these limitations. This strategy is contrasted with the chronic-dosing applications of DCS for schizophrenia and Alzheimer's disease, and future directions for isolated-dosing strategies are discussed.