Evaluation of Gabapentin in an Outpatient and Office-based Sample of Epilepsy Patients

A retrospective analysis of charts of patients who received gabapentin (GBP) as adjunctive anticonvulsant therapy in its first year of marketing, between March 1994 and April 1995 was conducted to evaluate patterns of use, side effects, and efficacy in the general epilepsy population. Ninety patients (45 men, 45 women) with an average age of 33.5 years (range: 7 months–78 years) were included. Average GBP dosage was 1700 mg/day; 46 patients took <1800 mg, and 44 patients took ⩾1800 mg/day. Duration of GBP treatment ranged from 1 month–14 months. Patients took an average of 1.7 concurrent antiepileptic drugs while on GBP. A total of 13 patients were on GBP monotherapy, four at the outset joined by nine others during the study. Gabapentin was associated with improvement as assessed by reduction of seizure frequency in 69 patients (77%). Sixty patients (67%) who reported no side effects had a mean GBP dosage of 1900 mg/day (median: 2000 mg/day). The 30 patients who experienced side effects had a mean GBP dosage of 1600 mg/day (median: 1500 mg/day). Gabapentin was discontinued in 21 patients, six because of side effects, nine because of lack of efficacy, and six because of a combination of both. Gabapentin was used in more difficult patients with intractable epilepsy and was generally well tolerated. Higher doses were not associated with more side effects, suggesting that GBP-related side effects may not be dose-related.     

Confirmatory Factor Analysis of the Nepean Dysphoria Scale in a Clinical Sample

The construct of dysphoria has been described inconsistently across a broad range of psychopathology. The term has been used to refer to an irritable state of discontent, but is also thought to incorporate anger, resentment and nonspecific symptoms associated with anxiety and depression, such as tension and unhappiness. The Nepean Dysphoria Scale has been developed to allow assessment of dysphoria, but its factor structure has not yet been investigated in clinical samples. We aimed to determine the latent structure of dysphoria as reflected by the Nepean Dysphoria Scale, using a clinical sample. Adults (N?=?206) seeking treatment at a range of mental health services were administered the Nepean Dysphoria Scale. Four putative factor structures were investigated using confirmatory factor analysis: a single-factor model, a hierarchical model, a bifactor model and a four-factor model as identified in previous studies. No model fit the data except for a four-factor model when a revised 22-item version of the original 24-item scale was investigated. A four-factor structure similar to that identified in non-clinical samples was supported, albeit following the removal of two items. The Nepean Dysphoria Scale appears to have utility for the assessment of dysphoria in routine clinical settings.     

Posttraumatic Stress Disorder Symptomatology and Substance Use in an Outpatient Concurrent Disorders Sample

Objective:Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) present a complex and often severe clinical presentation within a concurrent disorders context. The objective of this study was to examine associations between PTSD symptoms and SUD outcomes to better understand the clinical phenomenon of comorbid PTSD and SUD. Multivariate statistical methods were used to test the hypothesis that elevated PTSD symptoms, both at the level of global severity and specific PTSD symptom clusters, are associated with greater substance use and related problems.Methods:Data were collected from an intake assessment battery within a specialized concurrent disorders outpatient service in Hamilton, ON. The sample comprised 326 participants (mean age = 37.19, 45.4% female). Structural equation models examined associations between PTSD and alcohol, cannabis, and substance use frequency and problems, controlling for age and sex. Alcohol was ultimately dropped from the model due to non-significant bivariate associations.Results:Higher global PTSD symptomatology was significantly associated with higher cannabis and other substance use frequency and related problems. Analyses using PTSD cluster scores showed higher scores for alterations in arousal were positively associated with cannabis-related problems, drug-related problems, and cannabis and other substance use frequency. Avoidance was significantly associated with cannabis frequency and cannabis-related problems. In general, effect sizes were small in magnitude, accounting for between 9% and 25% of variance.Conclusion:Significant cluster-level associations indicate the importance of specific PTSD symptoms (hyperarousal, avoidance) in relation to substance use when identifying therapeutic targets among individuals presenting with comorbid PTSD-SUD. This multivariate approach provides a higher resolution and potentially more clinically informative representation of the complex clinical presentation of PTSD and SUD in a concurrent disorder population and could guide the development of more effective treatment paths.     

Clinical Correlates of Non-Suicidal Self-Injury (NSSI) in an Outpatient Sample of Adolescents

Non-suicidal self-injury (NSSI) in adolescents is a major public health concern. The first goal of our study was to describe the characteristics and functions of NSSI and NSSI thoughts in an adolescent outpatient sample. The second goal was to examine which clinical factors discriminate between these two groups of patients. A group of 267 subjects was recruited from the Adolescent Outpatient Psychiatric Services, Jiménez Díaz Foundation (Madrid, Spain) from November 2011 to October 2012. All participants were administered the Spanish version of the Self-Injurious Thoughts and Behaviors Interview (SITBI). A total of 21.7% of patients reported having engaged in NSSI at least once in their lifetime. The most strongly endorsed function for NSSI was automatic negative reinforcement. In comparison with patients in the NSSI Thoughts group and the control group, patients in the NSSI group scored higher in Internalization of Anger and in all the scales comprising the Children's Depression Inventory. Our findings on the prevalence and functions of NSSI are consistent with the literature. NSSI was mainly performed for emotion regulation purposes; specifically, NSSI seems to be used to cope with anger and depression. In addition, internalization of anger might play a significant role in the maintenance of this behavior.     

Specificity in the Relationships Between Stressors and Depressed Mood Among Adolescents: The Roles of Gender and Self - Efficacy

The study's aim was to test for hypothesised specificity in the relationships of stressors (interpersonal stress and worries about daily living) with depressed mood among Romanian adolescents. Six hundred and thirty adolescents in grades 7, 9 and 11 in Bucharest schools participated. Structural equation models assessed the degree to which effects of stressors on depressed mood were mediated through social support and self-efficacy, and moderated by gender and self-efficacy. Neither social support nor self-efficacy had direct or mediating roles in predicting depressed mood among girls. Among boys, social support and self-efficacy played significant roles in the connection between interpersonal stress and depressed mood. Among girls, daily worries were associated with depressed mood only among those with low self-efficacy, and interpersonal stress was associated with depressed mood only among those with high self-efficacy. The data presented here show that different stressors have different relationships to a single outcome — depressed mood — conditioned by gender and self-efficacy.     

A Neurobiological Profile Underlying Comorbidity Load and Prospective Increases in Dysphoria in a Focal Fear Sample

BackgroundKnowledge of the neural mechanisms underlying increased disease burden in anxiety disorders that is unaccounted for by individual categorical diagnoses could lead to improved clinical care. Here, we tested the utility of a joint functional magnetic resonance imaging–electroencephalography neurobiological profile characterized by overvaluation of negative stimuli (amygdala) in combination with blunted elaborated processing of these same stimuli (the late positive potential [LPP], an event-related potential) in predicting increased psychopathology across a 2-year period in people with anxiety disorders.MethodsOne hundred ten participants (64 female, 45 male, 1 other) including 78 participants with phobias who varied in the extent of their internalizing comorbidity and 32 participants who were free from psychopathology viewed negative and neutral pictures during separate functional magnetic resonance imaging blood oxygen level–dependent and electroencephalogram recordings. Dysphoria was assessed at baseline and 2 years later.ResultsParticipants with both heightened amygdala activation and blunted LPPs to negative pictures showed the greatest increases in dysphoria 2 years later. Cross-sectionally, participants with higher comorbidity load (≥2 additional diagnoses, n = 34) showed increased amygdala activation to negative pictures compared with participants with lower comorbidity load (≤1 additional diagnosis, n = 44) and compared with participants free from psychopathology. In addition, high comorbid participants showed reduced LPPs to negative pictures compared with low comorbid participants.ConclusionsHeightened amygdala in response to negative stimuli in combination with blunted LPPs could indicate overvaluation of threatening stimuli in the absence of elaborated processing that might otherwise help regulate threat responding. This brain profile could underlie the worsening and maintenance of internalizing psychopathology over time.     

Assessing and Treating Different Suicidal States in a Danish Outpatient Sample

The studies presented compare two methodologies for categorizing suicidal patients based on clinical data. Discussion follows regarding implications for risk assessment and treatment. In these studies, 52 outpatient subjects were placed into different groups based on coding their “suicidal motivation” (Study 1) and their “internal struggle” ratings (Study 2) using data collected at intake. Self-report ratings of 6 Suicide Status Form (SSF) Core Constructs (Psychological Pain, Stress, Agitation, Hopelessness, Self-Hate, and Overall Risk of Suicide) recorded both at intake and at completion of treatment were then compared to determine differences in Core Construct ratings among groups at different time points. In Study 1, overall differences among motivation groups (Life-motivated, Ambivalent, and Death-motivated) were significant for ratings at treatment completion of Overall Risk of Suicide, Self-Hate, and Psychological Pain. In Study 2, overall differences among groups (Wish to live, Ambivalent, and Wish to die) were significant for ratings at intake of Overall Risk of Suicide. At completion of treatment, overall differences among groups were significant for ratings of Overall Risk of Suicide, Hopelessness, and Self-Hate. In addition, significant interactions were found between test time and group for Overall Risk of Suicide and Self-Hate. Results suggest that categorizing suicidal patients by motivation and by the nature of their internal struggle could be beneficial to differential risk assessment with implications for clinical treatment.     

Predictors of Treatment Attrition Among an Outpatient Clinic Sample of Youths With Clinically Significant Anxiety

Predictors of treatment attrition were examined in a sample of 197 youths (ages 5–18) with clinically-significant symptoms of anxiety seeking psychotherapy services at a community-based outpatient mental health clinic (OMHC). Two related definitions of attrition were considered: (a) clinician-rated dropout (CR), and (b) CR dropout qualified by phase of treatment (pre, early, or late phases) (PT). Across both definitions, rates of attrition in the OMHC sample were higher than those for anxious youths treated in randomized controlled trials, and comorbid depression symptoms predicted dropout, with a higher rate of depressed youths dropping out later in treatment (after 6 sessions). Using the PT definition, minority status also predicted attrition, with more African-American youths lost pre-treatment. Other demographic (age, gender, single parent status) and clinical (externalizing symptoms, anxiety severity) characteristics were not significantly associated with attrition using either definition. Implications for services for anxious youths in public service settings are discussed. Results highlight the important role of comorbid depression in the treatment of anxious youth and the potential value of targeted retention efforts for ethnic minority families early in the treatment process.     

Gender Dysphoria in the Military

Purpose of Review

With the announcement that members of the military who identify as transgender are allowed to serve openly, the need for Department of Defense behavioral health providers to be comfortable in the assessment, diagnosis, and treatment of this population becomes quickly evident. This population has been seeking care in the community and standards have been developed to help guide decision-making, but a comparable document does not exist for the military population.

Recent Findings

Previously published papers were written in anticipation of the policy allowing for open service. The civilian sector has treatment guidelines and evidence supporting the same for reference. There is no similar document for the military population, likely due to the recent change and ongoing development. This paper attempts to provide an overview of the recent Department of Defense policy and walks the reader through key considerations when providing care to a transgender member of the military as it relates to those who are currently serving in the military through the use of a case example.

Summary

The military transgender population faces some unique challenges due to the need to balance readiness and deployability with medically necessary health care. Also complicating patient care is that policy development is ongoing—as of this publication, the decision has not yet been made regarding how people who identify as transgender will access into the military nor is there final approval regarding coverage for surgical procedures. Unique circumstances of this population are brought up to generate more discussion and encourage further evaluation and refinement of the process.

     

Assessing Obesity and Other Related Health Problems of Mentally Ill Hispanic Patients in an Urban Outpatient Setting

Objective This paper describes the role of an agency Clinical Director in developing a project to assess and begin to address obesity-related health problems of patients treated in a community-based mental health clinic in New York City. After a five year review of outpatient deaths revealed a high rate of deaths from cardiovascular and diabetes-related issues, the Clinical Director assembled a group of clinicians, researchers, and administrative staff to design a pilot project to assess health and nutrition status of primarily Hispanic day treatment patients with severe and persistent mental illness. Method About 69 of the 105 patients at the clinic were assessed by chart review, interview about nutritional habits and medical care, and somatic measurements for blood pressure, weight, girth, body mass index (BMI), glucose and lipid levels. Results Patients were predominantly between the ages of 25 and 64 years, 51% were female, and 78% were Hispanic. Around 57% were diagnosed with schizophrenia-spectrum disorders, 86% were receiving antipsychotic medications, and 25% were on two or more antipsychotics. Only 11% of the women and 41% of the men had normal weight. A total of 29% of the women and 18% of the men were overweight (BMI = 25–29.9); and an additional 60% of the women and 41% of the men were obese (BMI ≥ 30). Atypical antipsychotic treatment was significantly associated with obesity (BMI ≥ 30) (chi sq = 5.5, df = 1, P < 0.025). Using American Heart Association criteria, waist measurements showed significant abdominal obesity among female patients. Blood pressure was elevated in 77% of the patients: 45% were pre-hypertensive with BP 120–139/80–89 and 32% were hypertensive with BP ≥ 140/90. About 53% had elevated random blood glucoses (>110 mg/dl). On the positive side, patients generally had had recent medical follow-up, and most had adequate cooking facilities. Conclusions This project revealed that these predominantly Hispanic, severely mentally ill individuals were at high risk for cardiac illness, highlighting the need for developing culturally-sensitive interventions in urban outpatient psychiatric settings. Findings were disseminated in educational presentations and clinical discussions, and have mobilized an institutional effort to significantly improve medical monitoring for these patients.     

Constructs Assessed by the GARS-2: Factor Analysis of Data from the Standardization Sample

The GARS-2 (Gilliam 2006) is widely used for autism screening; however, the validity of its three conceptually-derived subscales has not been evaluated. In this study, exploratory (EFA) and confirmatory (CFA) factor analyses of data from matched subgroups of the standardization sample did not support the GARS-2 subscale structure. EFAs identified four factors in the model development subgroup (n = 496): stereotyped/repetitive behavior, stereotyped/idiosyncratic language, word use problems, and social impairment. CFAs supported this model in the replication subgroup (n = 494). Findings suggest that the GARS-2 subscales have limited clinical utility and that the Autism Index should be interpreted with caution. Although more research is needed, the clinical utility of the four empirically-derived scales may be limited by factors related to item content and test development procedures.     

Genetic Risk for Conduct Disorder Symptom Subtypes in an ADHD Sample: Specificity to Aggressive Symptoms

ObjectiveRecent studies have suggested an association between candidate genes (i.e., COMT, SLC6A4) and conduct disorder (CD). However, it is not clear if these relations extend to CD within the context of attention-deficit/hyperactivity disorder (ADHD). Also, it is uncertain whether the risk is specific to aggressive symptoms or is a risk for CD generally. The aim of this study was to examine the role of the COMT and SLC6A4 genes in the risk for CD and its symptomatic subtypes in the context of ADHD.MethodWe examined subjects with ADHD (n = 444, age range 6–55 years) aggregated across four completed studies. Psychiatric diagnoses were determined by structured interviews. We tested the association between genotype and the diagnosis of CD and aggressive and covert symptom counts.ResultsThere was no significant association between variations in functional polymorphisms of either the COMT gene or the SLC6A4 gene and the risk for CD. The COMT gene was associated with increased aggressive CD symptoms but not covert CD symptoms. The SLC6A4 gene was not associated with either symptom subtype.ConclusionsThese findings contribute to our understanding of the genetic basis of antisocial behavior in the ADHD population and provide additional support for the notion that aggressive and covert CD symptom subtypes are etiologically distinct.     

Psychometric Properties of the Norwegian Aberrant Behavior Checklist and Diagnostic Relationships in a Neuro-Pediatric Sample

ABSTRACT

Introduction: Although the Aberrant Behavior Checklist (ABC) is one of the most widely used behavioral rating scales among people with developmental disabilities, very few studies have examined the factor structure of the non-English versions.Methods: The construct validity of the Norwegian ABC was examined in a clinical sample of children and adolescents with neurological and neurodevelopmental disorders (N = 339). Diagnoses were obtained from direct interdisciplinary assessments in our neuro-pediatric clinics. Results: In an exploratory factor analysis, 46 of the 58 items (79%) loaded most heavily on four of the five original factors in the English version. Confirmatory factor analysis revealed less-than-optimal fit indices for the five-factor solution. Internal consistency was adequate to excellent for all subscales (α range = .76–.95). The ABC showed meaningful overlap and differentiation with the Strengths and Difficulties Questionnaire, the Behavior Rating Inventory of Executive Function, the Vineland Adaptive Behavior Scales, and full scale IQ. There were positive correlations between several of the ABC subscales and diagnoses of attention deficit/hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, and emotional disorder Conclusion: Satisfactory psychometric properties were found for the ABC, with the exception of the Inappropriate Speech factor, in a mixed sample of higher functioning children and adolescents with neurodevelopmental and neurological disorders.     

Dysphoria and aloneness in borderline personality disorder

A close examination of dysphoria, anger and aloneness (three main characteristics of the borderline syndrome) provides a theoretical model of reference for the therapist. Dysphoria results from the cyclical emotional oscillation between hope for stability and disappointment in its inattainability; a dependent-anaclitic depression arises from the mixture of anger, aloneness and inner emptiness which is so characteristic of the borderline syndrome. The tendency to be immersed in the here-and-now, an intra-festum mentality, exacerbates the sense of isolation, causing more irritation, mute frustration and, consequently, anger. The effects and ramifications of anger, and the resultant precarious cohesion of the self, are explored in the borderline syndrome; they are especially illuminated by the application of Kernberg's pain-anger-hate-vengefulness cycle concept. Meanings of solitude, in its forms of aloneness and loneliness, are explored in their pertinence. Aloneness - the constant needy search for, but condemnation to never finding, objects to fill an inner sense of emptiness - is especially germane. Suggestions for assisting subjects with borderline personality disorder to overcome aloneness and the lack of historical progression are made.     

The Association Between Autism Spectrum Traits and the Successful Transition to Mainstream Secondary School in an Australian School-Based Sample

Journal of Autism and Developmental Disorders - The transition to secondary school is an important educational milestone impacting wellbeing and academic achievement. Students with Autism Spectrum...     

Normative Clinical Relationships Between Orientation and Memory: Age as an Important Moderator Variable

The present study examined the relationship between memory and orientation to time, place, and personal and general information, as moderated by age, education, and simple attentional ability. A heterogeneous sample of 312 clinical referrals was divided into four groups, according to delayed memory functioning. Patients with globally good, globally poor, poor visual, and poor auditory memory were at differential risk of being disoriented, with the globally poor memory patients having the greatest risk. Overall, poorly oriented patients were older and less educated, with worse recall of digits backward. Discriminant Function Analysis selected visual and auditory memory and age as predictors of orientation. Normative tables stratified by age and memory performance are presented.     

Investigating the Association Between Autistic-Like and Internalizing Traits in a Community-Based Twin Sample

ObjectivesRecent research has suggested that children with autistic spectrum disorders often experience comorbid symptoms of anxiety and depression. However, despite this overlap, no quantitative genetic studies have addressed the phenotypic overlap and the etiologic association between internalizing and autistic-like traits within the general population. This study aimed to investigate the phenotypic and etiologic relation between internalizing and autistic-like traits using a community-based twin sample.MethodWe investigated the co-occurrence of these traits in a population-based sample of 3,233 twin pairs aged 8 to 9 years, using both parent- and teacher-report questionnaires. Bivariate structural equation modeling techniques were used to determine the extent to which internalizing and autistic-like traits shared common genetic and environmental influences.ResultsOur results showed that there was a modest phenotypic correlation (r = 0.26-0.29) between autistic-like and internalizing traits. The traits were both substantially heritable but were largely independent with regard to their genetic influences (r_G = 0.12-0.19). Shared environmental influences were modest but were largely common to both traits. Similar results were found using both parent- and teacher-reported data.ConclusionsInternalizing and autistic-like traits showed moderate phenotypic overlap within the general population. This association was explained in small part by shared genetic factors, but the results suggested that most genetic influences were specific to either internalizing traits or autistic traits. Given these findings, we discuss the potential mechanisms that may underlie the relation between these traits. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(6):618-627.     

Mediators of the Link Between Autistic Traits and Relationship Satisfaction in a Non-Clinical Sample

People with ASD have deficits in their social skills and may therefore experience lower relationship satisfaction. This study investigated possible mechanisms to explain whether and how autistic traits, measured with the AQ, influence relationship satisfaction in a non-clinical sample of 195 married couples. More autistic traits were associated with lower relationship satisfaction for husbands but not for wives. Multiple mediation analyses revealed that husbands’ responsiveness towards their wives, trust, and intimacy mediated this link between autistic traits and relationship satisfaction. These findings suggest that autistic traits may hamper men’s relationship satisfaction because they impede relationship-specific feelings and behavior. There was no partner-effect of autistic traits, indicating that more autistic traits do not necessarily influence the partner’s perceptions of relationship satisfaction.