Decision-making deficits, linked to a dysfunctional ventromedial prefrontal cortex, revealed in alcohol and stimulant abusers.

A decision-making instrument known as the "gambling task" was used, which has been shown to be sensitive to the decision-making impairment of patients with bilateral lesions of the ventromedial prefrontal cortex (VM). Three groups of subjects were tested, substance dependent individuals (SD) (n=41), normal controls (n=40), and VM patients (n=5). All SD met the DSM-IV criteria for dependence, with either alcohol or stimulants (metamphetamine or cocaine) as the primary substance of choice. The results revealed a significant impairment in the performance of SD relative to normal controls. A significantly high proportion of SD (61 vs. only 32.5% of normal controls) performed within the range of the VM patients, while the rest performed within the range of normal controls. General demographic factors such as age, sex, and level of education could not explain these differences in performance. As well, differences in performance were not explained by intelligence (IQ), memory, or performance on standard executive function/frontal lobe tests. Performance on the gambling task was best predicted by a combination of factors, including duration of abstinence, years of abuse, relapses and times in treatment, and the ability to hold gainful employment. The results support the hypothesis that impairment in decision-making linked to a dysfunctional VM cortex is associated with at least a sub-group of SD.

Deny nothing, doubt everything: a comment on Westen and Morrison (2001).

It is remarkable that so many important issues in psychotherapy research are touched on and, in some cases, more thoroughly explored in D. Westen and K. Morrison's (2001) meta-analysis and its discussion. Although no previously unanswered questions are resolved on the basis of their findings, original approaches to familiar questions are attempted and intriguing data are presented. Westen and Morrison's capacity to "think outside the box" while they seek to answer very familiar questions is most impressive. In the final analysis, the most significant outcome of Westen and Morrison's laudable effort can be that it might lead other psychotherapy researchers to do important things differently in the future.

Research on psychotherapy efficacy and effectiveness: between Scylla and Charybdis?

Clinical researchers have recently begun to explore differences between psychotherapy outcome studies that focus on efficacy and those that focus on effectiveness. The authors provide concise descriptions of these research models, followed by more extended consideration of the most important conceptual and empirical distinctions between the two. Research on the efficacy/effectiveness distinction is then put into context: The common treatment variables that also influence treatment outcomes are reviewed. Fifty years of research on psychotherapy outcomes are next considered; contemporary research on the efficacy and effectiveness research models is emphasized. A description and evaluation of current efforts to heighten the value of technique-focused research to clinicians follow. The authors conclude by anticipating some promising future directions in this research domain.

Cerebellar hypoactivity in frequent marijuana users.

It is uncertain whether frequent marijuana use adversely affects human brain function. Using PET, regional cerebral blood flow was compared in frequent marijuana users and comparable, non-using controls after at least 26 h of monitored abstention by all subjects. Marijuana users showed substantially lower brain blood flow than controls in a large region of posterior cerebellum, indicating altered brain function in frequent marijuana users. A cerebellar locus of some chronic and acute effects of marijuana is plausible, e.g. the cerebellum has been linked to an internal timing system, and alterations of time sense are common following marijuana smoking.

Hypothesized simple factor structure for the Alcohol Expectancy Questionnaire: confirmatory factor analysis.

This study proposed and tested a theoretical factor structure for the Alcohol Expectancy Questionnaire (AEQ; S. A. Brown, M. S. Goldman, A. Inn, & L. R. Anderson, 1980). Factors were hypothesized to (a) reflect either positive or negative reinforcement, and (b) target either personal feelings or social contexts, resulting in 4 hypothesized factors (Social Enhancement, Social Coping, Personal Enhancement, Personal Coping). Participants were 180 male and 226 female undergraduates who completed the AEQ and additional self-report measures. Confirmatory factor analysis revealed that the hypothesized model fit the data. Post hoc adjustments further improved the model. Finally, a higher order factor model fit the data best. Factors correlated in hypothesized ways with other measures: (a) Only Personal Coping expectancies correlated with negative affect; (b) self-efficacy to resist drinking for emotional relief correlated highest with Personal Coping; and (c) self-efficacy to resist social pressure to drink correlated highest with Social Enhancement. Correlations with B. C. Leigh and A. W. Stacy's (1993) Drinking Expectancy Questionnaire indicated congruent and divergent validity.

Psychopathology: description and classification.

DSM-IV's strong empirical base has yielded an instrument with good to excellent reliability and improved validity. Diagnostic reliability depends on both the clarity and validity of diagnostic criteria and the changeability of disorders over time: The reliability of schizophrenic spectrum disorders, personality disorders, and some childhood and adolescent disorders remains problematic. Findings on diagnostic validity appear paradoxical: Attempts to validate schizophrenic spectrum disorders with neurobiological and genetic-familial validators have been only modestly successful, whereas the tripartite personality trait model has differentiated a range of depressive and anxiety disorders. Research on comorbidity has identified several highly comorbid disorders (substance-related disorders, personality disorders, depression, and anxiety) as well as some adverse consequences of comorbidity. The advantages of dimensional approaches to diagnosis have largely been demonstrated conceptually; ultimate conclusions about the strengths and weaknesses of dimensional and syndromal methods await substantial additional empirical research.

Physiological alcohol dependence as a "specifier" of risk for medical problems and relapse liability in DSM-IV.

OBJECTIVE: This study tested the ability of DSM-IV physiological alcohol dependence to predict multiple indices of medical problems and relapse behavior. It also tested the ability of three additional variables--DSM-IV nonphysiological dependence, an alternative dichotomous criterion for coding physiological dependence and a dimensional measure of physiological dependence--to predict medical problems and relapse behavior in alcoholism. METHOD: A heterogeneous group of 365 patients was recruited from eight addictions treatment programs in the northeastern United States. A multidimensional assessment battery able to diagnose the presence of physiological dependence according to each of three systems--the criteria of DSM-IV, alternative dichotomous criteria and a dimensional scale-- was administered about 2 weeks after admission, and 241 subjects were reinterviewed 6 months later. The three systems were compared for their ability to predict a variety of external measures of medical complications and relapse liability. RESULTS: Physiological alcohol dependence as diagnosed by DSM-IV bore no relationship to either risk for medical problems or relapse behavior. Further analyses showed that this failure was due to operational problems of physiological dependence in DSM-IV, rather than to a lack of conceptual merit for physiological dependence per se as a course specifier. Use of alternative criteria for coding physiological dependence which are difficult and less internally consistent, and use of a dimensional measure, found improved relationships with the external validators. CONCLUSIONS: Contrary to early reports, physiological dependence can serve as a course specifier for alcohol problems, but must be more sensitively scaled than it was in DSM-IV. Tests of alternative options suggest that a multistage criterion to replace DSM-IV's dichotomous criterion is the best remedy.

On criterion weighting in the DSM-IV.

Differential weighting of illness signs and symptoms has surfaced recurrently in psychiatric nosology. Six alternately weighted algorithms for diagnosing alcohol dependence in accordance with the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), based on statistical, unit, rational and random criterion weighting systems, were used to predict an array of concurrent validators and 6-month drinking outcomes in a regional clinical sample of 365 participants. Comparable predictive efficiency across all algorithms, including the randomly weighted versus statistical best-fit model, was observed. Further analyses and geometric modeling suggested that this was due to the extremely high internal consistency of the DSM-IV criteria. An alternative strategy that favors factorially complex, less homogeneous criteria was used to develop an experimental DSM-IV algorithm from an array of 39 candidate criteria. This algorithm had extremely low internal consistency, high difficulty, and complex factor loadings. Differential weighting of its criteria produced a good range of efficiencies, predictive power for rational models exceeding the random weight model, and a best-fit algorithm with substantial surplus predictive power. These results illustrate an emerging conflict in nosology between 2 opposing trends: a press for the promulgation of criterion arrays with high internal consistency and a clear desire to assign some criteria extra weight for prognosis or decision making. Both cannot be had in the same algorithm. An alternative approach emphasizing diagnostic criteria with complex structures can satisfy the multiple demands of brevity, validity, and weighting performance.

Diagnostic concordance of substance use disorders in DSM-III, DSM-IV and ICD-10.

Diagnostic concordance of DSM-III, DSM-IV and ICD-10 was tested in a heterogeneous unrestricted sample of 370 clinical cases drawn from a regional consortium. Agreement for abuse/harmful use, dependence, and the collapsed category of 'any diagnosis' was studied across eight drug classes. A probabilistic approach to the cross-classifications based on configural frequency analysis was applied, permitting the computation of four indices of agreement. In contrast to earlier studies, ICD-10 appeared to be the most inclusive system, and often diagnosed cases that were undiagnosed by both DSMs. Generally satisfactory coherence between the ICD-10 harmful use category and the DSM category of abuse was found, but this agreement was often due to a preponderance of negative or undiagnosed cases; disagreement was common on which cases in particular warrant a mild diagnosis. In general, the greatest diagnostic concordance was observed for sedative/hypnotics, opiates and alcohol, the poorest for amphetamines, cocaine and PCP. The analytic approach produced an array of cross-system relationships that are more complex and conditional than those previously reported, and scientists and clinicians are cautioned to study particular drugs, diagnostic levels and measures of concordance before applying cross-system results to their own data or design needs.

Lifetime DSM-IV diagnosis of alcohol, cannabis, cocaine and opiate dependence: six-month reliability in a multi-site clinical sample.

Psychiatric research increasingly emphasizes the diagnosis of symptoms and syndromes on a longitudinal basis. This study tests the reliability of lifetime DSM-IV diagnoses of alcohol, cannabis, cocaine and opiate dependence. The CIDI-SAM was administered at intervals not less than six months apart to a multi-site sample of 201 clinical respondents. The reliability of lifetime diagnosis of the syndromes, of the criteria which constitute the syndromes, and of the ages of onset reported for the criteria and for the dependence syndromes as a whole, were studied and the effects of patient characteristics suspected to degrade reliability were examined. There was generally good agreement, statistically, at both the syndrome and criterion level between the two interviews. Lifetime diagnoses for three of the drugs--alcohol, cannabis and opiates--were made at or near levels of agreement generally considered excellent under less strict testing conditions, and cocaine dependence was only marginally below this level. Most criteria showed good reliability and all delivered about equal results when averaged across the four substances, although a relationship between reliability and centrality of the symptom to the individual drug abuse pattern was found. Age of onset was almost uniformly highly reliable. Most patient characteristics bore no detectable relationship to reliability, although patients with multiple drug use patterns may warrant more careful probing by interviewers. Overall, these data indicate that lifetime symptoms and diagnoses can be queried reliably, although they must be reported with less confidence than current state diagnoses.

Headache, thrombolytic therapy, and chronic subdural hemorrhage--a case report.

Subdural hematomas are well known but infrequent complications of thrombolytic therapy. Although these are usually associated with head trauma, the authors describe a case of a patient who received a particularly aggressive thrombolytic regimen and presented six months later with complaints of nothing more than a headache resistant to medical therapy, without associated neurologic manifestations, which was finally diagnosed as a chronic subdural hematoma by computerized tomography. In the era of thrombolysis, physicians should maintain a heightened index of suspicion for subdural hematoma in patients complaining of headache.

Accelerated idioventricular rhythm in pregnancy: a case report.

A seventeen-year-old primigravida, without structural heart disease or abnormalities of serum chemistry, presented with complaints of palpitations during the twenty-fourth week of gestation. Holter monitoring revealed long episodes of accelerated idioventricular rhythm. The authors are not aware of similar reports, but this entity may be more common than realized because of the relative infrequency of rhythm monitoring in this particular group.

Spontaneous pulmonary hemorrhage following coronary thrombolysis.

Excessive bleeding is a major concern during the administration of thrombolytic therapy. Although the great majority of these events occur at sites of vascular interruption, major gastrointestinal, retroperitoneal, genitourinary, and central nervous system hemorrhage are known to occur. We present a patient who developed spontaneous pulmonary hemorrhage during thrombolytic therapy. Lack of recognition that the lungs too may be a site of spontaneous hemorrhage during thrombolytic therapy may lead to a considerable diagnostic and therapeutic delay. Pulmonary hemorrhage should be considered in the differential diagnosis of patients who receive thrombolytic therapy in whom new roentgenographic pulmonary infiltrates present accompanied by decreases in hematocrit value.

Substance use disorders in the DSM-IV.

Since late 1988, the Substance Use Disorders Work Group has considered alternative concepts and definitions of substance abuse and dependence and their significance for possible changes (in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders) in existing criteria for abuse and dependence. The three other matters to which the group has devoted itself include the development of guidelines for distinguishing behaviors that typically accompany the abuse of specific substances from psychiatric disorders with similar behavioral consequences, examination of the predictive validity of possible alcoholic subtypes on the basis of family history, and the relationship of the organic brain syndromes to intoxication and withdrawal.