An integrative approach to the treatment of obsessive-compulsive disorder

We reviewed the research literature concerning the etiology and treatment of obsessive-compulsive disorder (OCD). Cognitive behavioral and neurobiological treatments were the two most frequently used treatment approaches. The majority of research on the treatment of OCD has focused on implementing these treatment approaches in isolation, rather than in combination, which has often resulted in a high symptom relapse rate. We focused on integrating the most effective elements of each treatment approach into a new treatment regimen. More specifically, the longlasting benefits of cognitive behavioral therapy and the rapid symptom relief of neurobiological treatments are integrated in such a manner as to take full advantage of each, while at the same time controlling for the shortcomings of each treatment approach. It is proposed that this newly integrated treatment approach represents a superior treatment regimen, as compared with the combined treatment approaches currently used.     

An integrative approach to cultural competence in the psychiatric curriculum

OBJECTIVE: As it is increasingly recognized that cultural competence is an essential quality for any practicing psychiatrist, postgraduate psychiatry training programs need to incorporate cultural competence training into their curricula. This article documents the unique approach to resident cultural competence training being developed in the Department of Psychiatry at the University of Toronto, which has the largest residency training program in North America and is situated in an ethnically diverse city and country. METHODS: The authors conducted a systematic review of cultural competence by searching databases including PubMed, PsycINFO, PsycArticles, CINAHL, Social Science Abstracts, and Sociological Abstracts; by searching government and professional association publications; and through on-site visits to local cross-cultural training programs. Based on the results of the review, a resident survey, and a staff retreat, the authors developed a deliberate "integrative" approach with a mindful, balanced emphasis on both generic and specific cultural competencies. RESULTS: Learning objectives were derived from integrating the seven core competencies of a physician as defined by the Canadian Medical Education Directions for Specialists (CanMEDS) roles framework with the tripartite model of attitudes, knowledge, and skills. The learning objectives and teaching program were further integrated across different psychiatric subspecialties and across the successive years of residency. Another unique strategy used to foster curricular and institutional change was the program's emphasis on evaluation, making use of insights from modern educational theories such as formative feedback and blueprinting. Course evaluations of the core curriculum from the first group of residents were positive. CONCLUSION: The authors propose that these changes to the curriculum may lead to enhanced cultural competence and clinical effectiveness in health care.     

Endocrine and behavioral responses to methylphenidate in normal subjects

Methylphenidate (0.3 mg/kg) was administered intravenously to 20 normal subjects. Behavioral responses varied considerably among individuals. Both cortisol and growth hormone showed significant increases (p less than 0.001). The adrenocorticotrophic hormone (ACTH) response seemed insufficient to explain the increase in cortisol. For men only, the increase in cortisol correlated positively with the increase in epinephrine (r = 0.77, p less than 0.05) and correlated negatively with baseline cortisol (r = -0.70, p less than 0.05), with increase in growth hormone (r = -0.70, p less than 0.05), and with the increase in "energy" (r = -0.83, p less than 0.01). The growth hormone response varied between the sexes, and for men, the growth hormone correlated with both an increase in "energy" (r = 0.70, p less than 0.05) and "friendliness" (r = 0.68, p less than 0.05). For all subjects, baseline heart rate correlated with the increase in "energy" (r = -0.69, p less than 0.002). In a separate study, six male subjects received, on different occasions, saline and a lower dose of methylphenidate. Together, these studies show that the increases in cortisol, growth hormone, and epinephrine, and the decrease in prolactin are dose-dependent.     

An integrative treatment approach to child and adolescent suicidal behavior

The suicide rate for adolescents has tripled during the last 30 years in North America and many Western countries. Although some high risk factors have been defined, the literature is weak on the prevention and treatment issues. This article defines an integrative treatment approach for self-destructive behavior. This model attempts to integrate the well-recognized theoretical and therapeutic approaches such as biologic, psychodynamic, behavioral, cognitive, self-directed, strategic, experiential, and systemic frameworks. In the integrative approach, the therapist integrates the use of drug therapy and child, group, milieu, and family therapy, depending on the needs of each child. After a brief presentation of the author's comprehensive, in-depth study with 139 suicidal children and adolescents, the commonly seen family reactions to suicidal behavior were described. Family stage reactions of shock and fear, panic and action, guilt, resentment, reparation, and partial recovery are defined with case examples. The complementary nature of the supportive and therapeutic work for the families of suicidal children and adolescents with other preventative and therapeutic interventions is highlighted.     

Biological markers for schizophrenia and the biological high-risk approach

This review examines two putative biological markers for schizophrenia: reduced blood platelet monamine oxidase (MAO) activity and impaired smooth pursuit eye movements. Studies of these biological markers among patient samples are presented, including their theoretical background, measurement, genetics, validity, and specificity of the markers for schizophrenia, and the artifacts that might lessen their utility. These results are then compared with those from the biological high-risk research strategy, which selects nonpatient volunteers solely on the basis of a deviant marker, and then examines the clinical, psychological, and biological correlates of the marker. The results of these studies suggest that low platelet MAO activity is not an adequate marker for schizophrenia but is associated with characteristics related to hypomanic behavior and sensation seeking. Smooth pursuit eye tracking impairment, in contrast, seems to be directly associated with schizophrenia-related traits, such as the negative symptoms found among chronic schizophrenics, or with the characteristics observed in the biological relatives of schizophrenics. Finally, the implications of these findings are discussed.     

An integrative psychophysiological approach to brain hemisphere functions in schizophrenia

The present paper proposes a new psychophysiological approach to the genesis of positive and negative schizophrenic symptoms. According to this approach, the initial factor in schizophrenic disorders is a functional insufficiency of the right hemisphere which can be determined by early emotional experience in combination with subtle brain damage. This functional insufficiency causes (a) the inability to grasp and select information before its realization; and (b) the inability to produce a polysemantic context which is crucial for creativity, psychological defense, and the restoration of search activity, all of which determine psychophysiological adaptation to the environment. Right hemisphere insufficiency causes left hemisphere hyperactivity as an ineffective attempt to compensate for this functional deficiency. As a result, normal search activity is replaced by artificial search activity which is represented by “positive” symptoms, and which uses the predisposition of the left hemisphere's catecholamine system for its increased activity. The suggestion is made that cognitive impairment in schizophrenia (the inability to use appropriate previous information in relation to current perceptual input) is related to the competition between information processing which requires left hemisphere activity, and the formation of positive symptoms, also based on left hemisphere activity.     

An integrative psychophysiological approach to brain hemisphere functions in schizophrenia

The present paper proposes a new psychophysiological approach to the genesis of positive and negative schizophrenic symptoms. According to this approach, the initial factor in schizophrenic disorders is a functional insufficiency of the right hemisphere which can be determined by early emotional experience in combination with subtle brain damage. This functional insufficiency causes (a) the inability to grasp and select information before its realization; and (b) the inability to produce a polysemantic context which is crucial for creativity, psychological defense, and the restoration of search activity, all of which determine psychophysiological adaptation to the environment. Right hemisphere insufficiency causes left hemisphere hyperactivity as an ineffective attempt to compensate for this functional deficiency. As a result, normal search activity is replaced by artificial search activity which is represented by “positive” symptoms, and which uses the predisposition of the left hemisphere's catecholamine system for its increased activity. The suggestion is made that cognitive impairment in schizophrenia (the inability to use appropriate previous information in relation to current perceptual input) is related to the competition between information processing which requires left hemisphere activity, and the formation of positive symptoms, also based on left hemisphere activity.     

The integrative approach to psychiatry

From the early days of psychiatry as a distinct field of knowledge and clinical practice two competing approaches to the etiology and treatment of mental disorders have vied for dominance: the somatic and the psychic ("moral"). We are witnessing the same struggle today. To speak metaphorically, we can opt for either brainless or mindless psychiatry, as Szasz proposed. He failed to consider a third option, however, one that may be called an integrative approach. The latter is neither mindless nor brainless but rather encompasses both the mind and the brain in its theoretical and practical consideration. I will formulate the integrative approach in this paper and argue that it has a distinct advantage for both the study and treatment of mental disorders.     

Enduring behavioral effects of early exposure to methylphenidate in rats.

BACKGROUND: Methylphenidate (MPH) is a stimulant prescribed for the treatment of attention-deficit/hyperactivity disorder (ADHD). Stimulant drugs can cause enduring behavioral adaptations, including altered drug sensitivity, in laboratory animals. We examined how early developmental exposure to stimulants affects behavior in several rodent models. METHODS: Rats received MPH or cocaine during preadolescence (P20-35). Behavioral studies began during adulthood (P60). We compared how early exposure to MPH and cocaine affects sensitivity to the rewarding and aversive properties of cocaine using place conditioning. We also examined the effects of early exposure to MPH on depressive-like signs using the forced swim test, and habituation of spontaneous locomotion, within activity chambers. RESULTS: In place-conditioning tests, early exposure to MPH or cocaine each made moderate doses of cocaine aversive and high doses less rewarding. Early MPH exposure also caused depressive-like effects in the forced swim test, and it attenuated habituation to the activity chambers.CONCLUSIONS: Early exposure to MPH causes behavioral changes in rats that endure into adulthood. Some changes (reduced sensitivity to cocaine reward) may be beneficial, whereas others (increases in depressive-like signs, reduced habituation) may be detrimental. The effects of MPH on cocaine-related behaviors may be a general consequence of early stimulant exposure.     

Strain differences in the behavioral responses of male rats to chronically administered methylphenidate

Genetic variability in the behavioral responses of experimental subjects to psychostimulants such as amphetamine and cocaine have been reported. However, genetic differences in the locomotor responses of rat strains to methylphenidate (MPD), a commonly used psychostimulant in the treatment of attention deficit/hyperactivity disorder, have not been extensively investigated. Research using genetically defined rodent strains can enhance our understanding of the role genetic factors play in drug-related behaviors and the development of animal models for drug-sensitive diseases or behaviors. The objective of the present study was to investigate strain differences in the locomotor responses to MPD among three rat strains: Sprague-Dawley (SD), Wistar-Kyoto (WKY), and spontaneously hypertensive rats (SHR). Eight-week-old adult, male SD, WKY, and SHR were given a regimen of daily MPD administration (0.6, 2.5, or 10 mg/kg, i.p.) for 6 consecutive days followed by 3 days of washout and a day of MPD re-challenge with similar dosages as previously used. An automated activity monitoring system recorded their horizontal activity, total distance traveled, rearing, stereotypic movements, and number of discrete movements. Repeated administration of 0.6 mg/kg MPD produced no significant effect on locomotor activity compared with saline in all three strains. However, there were strain differences in the locomotor activity of SD, SHR, and WKY rats to repeated 2.5- and 10-mg/kg MPD treatment. Repeated administration of 2.5 mg/kg MPD elicited locomotor sensitization in SD and WKY rats but not in SHR. Repeated administration of 10 mg/kg MPD induced locomotor tolerance in SD and WKY rats, while SHR had variable locomotor responses to this MPD dose. In conclusion, rat strains play a significant role in the response to acute and chronic administration of MPD.     

Sleep deprivation in depression: An integrative approach

The question as to whether the beneficial effect of sleep deprivation in depression is related to the increased wakefulness or to the sleep suppression by itself, is made moot by the search activity concept. According to this concept, rapid eye movement (REM) sleep is functionally deficient in depression and increases feelings of helplessness and hopelessness instead of restoring mood and search activity. Thus, REM sleep deprivation, either selective or not, is beneficial by breaking a vicious circle: depression in wakefulness…giving up (helplessness) in dream scenario…increased depression in the subsequent wakefulness. In addition, sleep deprivation is an important challenge for the depressed patient. The ability to confront this challenge and maintain wakefulness has a positive outcome on depression, especially when wakefulness is accompanied by active behavior.     

An integrative Bayesian approach to matrix‐based analysis in neuroimaging

Understanding the correlation structure associated with brain regions is a central goal in neuroscience, as it informs about interregional relationships and network organization. Correlation structure can be conveniently captured in a matrix that indicates the relationships among brain regions, which could involve electroencephalogram sensors, electrophysiology recordings, calcium imaging data, or functional magnetic resonance imaging (FMRI) data—We call this type of analysis matrix‐based analysis, or MBA. Although different methods have been developed to summarize such matrices across subjects, including univariate general linear models (GLMs), the available modeling strategies tend to disregard the interrelationships among the regions, leading to “inefficient” statistical inference. Here, we develop a Bayesian multilevel (BML) modeling framework that simultaneously integrates the analyses of all regions, region pairs (RPs), and subjects. In this approach, the intricate relationships across regions as well as across RPs are quantitatively characterized. The adoption of the Bayesian framework allows us to achieve three goals: (a) dissolve the multiple testing issue typically associated with seeking evidence for the effect of each RP under the conventional univariate GLM; (b) make inferences on effects that would be treated as “random” under the conventional linear mixed‐effects framework; and (c) estimate the effect of each brain region in a manner that indexes their relative “importance”. We demonstrate the BML methodology with an FMRI dataset involving a cognitive‐emotional task and compare it to the conventional GLM approach in terms of model efficiency, performance, and inferences. The associated program MBA is available as part of the AFNI suite for general use.     

An algebraic approach to the detection of multiple markers in complex neuronal systems

An important class of neuroanatomical problems requires identification of neurons that contain two or more substances. Based on the additivity of neuronal elements that are independently labeled, a simple numerical approach may be applied to these problems. This approach provides a sensitive and viable alternative to direct multiple labeling of endogenous or transported neuronal markers.     

Childhood autism: An appeal for an integrative and psychobiological approach

The difficulty that a person with autism has in establishing relationships, maintaining them (communicating and responding appropriately) is a common experience of those close to them., That impaired perceptual and cognitive processing can underlie this difficulty and the interactions of people with autism with the material environment has been established in the laboratory. The consequences at a psychological level of analysis may converge in the inadequacy of second-order representations of the world. An attenuation of such endogenous monitoring processes could also indirectly account for features of withdrawal and the stereotypies often observed. At another level of analysis there are delays in neurotransmission, in the CNS and a lack of flexibility of physiological response shown by evoked potential recordings. Tomographic studies of blood flow and metabolism illustrate a lack of correlation between information processing centres in the brain that may sometimes arise from diffuse gray matter atrophy. A “stop-go” form of modulation of central processing is mediated by anomalous ascending serotonergic and dopaminergic function (transmitters with inhibitory and switching functions). On these bases it is no wonder that representations are not formed and inappropriate and repetitive behaviors follow, although the link remains somewhat speculative. Both levels of analysis are useful for an explanation. As behavioral and pharmacotherapy, though helpful, are severely limited in their efficacy, more effort is required to synthesize the different levels of analysis into a psycho-biological approach, to remedial programs and new forms of therapy.     

An interdisciplinary approach to the diagnosis and management of a complex case of postencephalitic behavioral disorder

Postencephalitic behavioral syndrome secondary to measles is an almost extinct condition in Western culture. The present paper describes the clinical state of a 13-year-old pubertal female who presented nine years after the original acute febrile illness. In addition, an innovative behavioral approach to treatment of intractable seizures and aggressive behavior is described.     

Implications of the behavioral approach to hypnosis.

The findings of behaviorally oriented research regarding the importance of cognitive-motivational variables in hypnosis are examined and some clinical and theoretical implications are explored. Hypnosis seems usefully conceptualized as a complex configuration or gestalt of interacting variables on several different levels, for example, cognitive, motivational, social, physiologic.     

A behavioral approach to the treatment of depression

Depression is viewed largely as a disorder in which attempts to control one's interpersonal environment have failed. Twenty depressed outpatients were randomly assigned to one of two treatment groups. Treatment for the experimental group consisted of: (1) training in social learning principles; (2) immediate feedback as to the perception of verbal interactions between patient and spouse; and (3) training in the construction and use of reciprocal behavioral contracts. Treatment for the comparison group varied as a function of the treatment agency (i.e. psychiatrist, general practitioner, social work agency etc.), but usually involved either medication, group therapy, individual psychotherapy, or some combination of these.

Results showed a significant change in problematic behaviors, in Depression Adjective Checklist scores and in the verbal communication style of the experimental group, but not in the comparison group.     

A dimensional approach to determine common and specific neurofunctional markers for depression and social anxiety during emotional face processing

Major depression disorder (MDD) and anxiety disorder are both prevalent and debilitating. High rates of comorbidity between MDD and social anxiety disorder (SAD) suggest common pathological pathways, including aberrant neural processing of interpersonal signals. In patient populations, the determination of common and distinct neurofunctional markers of MDD and SAD is often hampered by confounding factors, such as generally elevated anxiety levels and disorder‐specific brain structural alterations. This study employed a dimensional disorder approach to map neurofunctional markers associated with levels of depression and social anxiety symptoms in a cohort of 91 healthy subjects using an emotional face processing paradigm. Examining linear associations between levels of depression and social anxiety, while controlling for trait anxiety revealed that both were associated with exaggerated dorsal striatal reactivity to fearful and sad expression faces respectively. Exploratory analysis revealed that depression scores were positively correlated with dorsal striatal functional connectivity during processing of fearful faces, whereas those of social anxiety showed a negative association during processing of sad faces. No linear relationships between levels of depression and social anxiety were observed during a facial‐identity matching task or with brain structure. Together, the present findings indicate that dorsal striatal neurofunctional alterations might underlie aberrant interpersonal processing associated with both increased levels of depression and social anxiety.