The relationship of histrionic personality disorder to antisocial personality and somatization disorders.

The authors examined the association of antisocial personality disorder, somatization disorder, and histrionic personality disorder, both within individuals and within families, in 250 patients. All three disorders overlapped considerably within individuals; the strongest relationship was between antisocial personality and histrionic personality. A high prevalence of antisocial personality was reported in the families of patients with somatization disorder but not in the families of patients with histrionic personality. The authors suggest that histrionic individuals develop antisocial personality if they are male and somatization disorder if female; moreover, all three conditions may represent alternative manifestations or different stages of the same underlying diathesis.

A 5-month, randomized, placebo-controlled trial of galantamine in AD. The Galantamine USA-10 Study Group.

OBJECTIVE: To investigate the efficacy and tolerability of galantamine, using a slow dose escalation schedule of up to 8 weeks, in 978 patients with mild to moderate AD. METHODS: A 5-month multicenter, placebo-controlled, double-blind trial. Following a 4-week placebo run-in, patients were randomized to one of four treatment arms: placebo or galantamine escalated to final maintenance doses of 8, 16, or 24 mg/day. Outcome measures included the cognitive subscale of the AD Assessment Scale (ADAS-cog), the Clinician's Interview-Based Impression of Change plus Caregiver Input (CIBIC-plus), the AD Cooperative Study Activities of Daily Living inventory, and the Neuropsychiatric Inventory. Standard safety evaluations and adverse event monitoring were carried out. RESULTS: After 5 months, the galantamine-placebo differences on ADAS-cog were 3.3 points for the 16 mg/day group and 3.6 points for the 24 mg/day group (p < 0.001 versus placebo, both doses). Compared with placebo, the galantamine 16- and 24-mg/day groups also had a significantly better outcome on CIBIC-plus, activities of daily living, and behavioral symptoms. Treatment discontinuations due to adverse events were low in all galantamine groups (6 to 10%) and comparable with the discontinuation rate in the placebo group (7%). The incidence of adverse events in the galantamine groups, notably gastrointestinal symptoms, was low and most adverse events were mild. CONCLUSIONS: Galantamine 16 and 24 mg/day significantly benefits the cognitive, functional, and behavioral symptoms of AD as compared with placebo. Slow dose escalation appears to enhance the tolerability of galantamine, minimizing the incidence and severity of adverse events.

Dissociative identity disorder and the sociocognitive model: recalling the lessons of the past.

In a recent article in this journal, D. H. Gleaves (1996) criticized the sociocognitive model (SCM; N. P. Spanos, 1994) of dissociative identity disorder (DID) and argued in favor of a posttraumatic model (PTM) in which DID is conceptualized as a consequence of childhood abuse and other traumatic events. The present authors demonstrate that (a) many of Gleaves's arguments were predicated on misunderstandings of the SCM, (b) scrutiny of the evidence regarding the psychopathology and assessment of DID raises questions concerning the PTM's conceptual and empirical underpinnings, (c) the treatment literature suggests that iatrogenic factors play an important role in the etiology of DID, and (d) the evidence linking child abuse to DID is more problematic than implied by Gleaves. The present authors conclude that Gleaves's analysis underemphasized the cultural manifestations of multiple role enactments and that the history of DID imparts a valuable lesson to contemporary psychotherapists.

A meta-analytic review of the relation between antisocial behavior and neuropsychological measures of executive function.

Previous narrative reviews of the relation between antisocial behavior (ASB) and neuropsychological tests of executive functioning (EF) have raised numerous methodological concerns and produced equivocal conclusions. By using meta-analytic procedures, this study attempts to remedy many of these concerns and quantifies the relation between ASB and performance on six reasonably well validated measures of EF. Thirty-nine studies yielding a total of 4,589 participants were included in the analysis. Overall, antisocial groups performed .62 standard deviations worse on EF tests than comparison groups; this effect size is in the medium to large range. Significant variation within this effect size estimate was found, some of which was accounted for by differences in the operationalizations of ASB (e.g., psychopathy vs. criminality) and measures of EF. Evidence for the specificity of EF deficits relative to deficits on other neuropsychological tasks was inconsistent. Unresolved conceptual problems regarding the association between ASB and EF tests, including the problem of localizing EF tests to specific brain regions, are discussed.

Science and pseudoscience in the development of eye movement desensitization and reprocessing: implications for clinical psychology.

The enormous popularity recently achieved by Eye Movement Desensitization and Reprocessing (EMDR) as a treatment for anxiety disorders appears to have greatly outstripped the evidence for its efficacy from controlled research studies. The disparity raises disturbing questions concerning EMDR's aggressive commercial promotion and its rapid acceptance among practitioners. In this article, we: (1) summarize the evidence concerning EMDR's efficacy; (2) describe the dissemination and promotion of EMDR; (3) delineate the features of pseudoscience and explicate their relevance to EMDR; (4) describe the pseudoscientific marketing practices used to promote EMDR; (5) analyze factors contributing to the acceptance of EMDR by professional psychologists; and (6) discuss practical considerations for professional psychologists regarding the adoption of EMDR into professional practice. We argue that EMDR provides an excellent vehicle for illustrating the differences between scientific and pseudoscientific therapeutic techniques. Such distinctions are of critical importance for clinical psychologists who intend to base their practice on the best available research.

The relation of anxiety sensitivity to higher and lower order personality dimensions: implications for the etiology of panic attacks.

The relation of anxiety sensitivity (AS) to personality dimensions has received little attention. In this study, 4 AS indexes were administered along with measures of personality, fears, and panic attacks to 220 undergraduates. At the higher order level, AS was positively correlated with negative emotionality (NE) but was largely unrelated to either positive emotionality or constraint. At the lower order level, AS was positively correlated with absorption and NE indexes. Most of these correlations were significant even among participants with no panic attack history. AS exhibited incremental validity above and beyond a number of personality variables, including absorption and trait anxiety, in the prediction of fears and panic attack history. These findings are consistent with the hypothesis that a propensity toward immersion in sensory experiences is a diathesis for panic attacks.

Mental disorder as a Roschian concept: a critique of Wakefield's "harmful dysfunction" analysis.

J. C. Wakefield (1992a, 1992b, 1993) recently proposed that mental disorder is best conceptualized as a "harmful dysfunction," whereby "harm" is a value judgment regarding the undesirability of a condition, and "dysfunction" is the failure of a system to function as designed by natural selection. The authors maintain, however, that (a) many mental functions are not direct evolutionary adaptations, but rather adaptively neutral by-products of adaptations, (b) Wakefield's concept of the evolutionarily designed response neglects the fact that natural selection almost invariably results in substantial variability across individuals, and (c) many consensual disorders represent evolutionarily adaptive reactions to danger or loss. The authors propose that mental disorder is a Roschian concept characterized by instrinsically fuzzy boundaries and that Wakefield's analysis may only prolong scientific debate on a fundamentally nonscientific issue.

Essentialism revisited: evolutionary theory and the concept of mental disorder.

J. C. Wakefield's (1999) elaboration of his harmful dysfunction analysis (HDA) of mental disorder does little to address previous criticisms (S. O. Lilienfeld & L. Marino, 1995) and instead reveals further conceptual weaknesses in his position. The authors demonstrate that (a) a Roschian analysis can account for the results of all of Wakefield's conceptual experiments and predicts a number of judgments of disorder not predicted by the HDA, (b) the HDA is incapable in many cases of providing a scientifically nonarbitrary distinction between disorder and nondisorder, and (c) the HDA cannot account for failures of cultural ex adaptations, mismatches between evolutionary design and novel environments, or defenses against threat. The authors argue that the HDA has been convincingly falsified and discuss the failure of essentialistic concepts to resolve controversies in other domains of biological science.

Comment on Holloway and McNally's (1987) "Effects of Anxiety Sensitivity on the Response to Hyperventilation".

Holloway and McNally (1987) found that normals with high scores on the Anxiety Sensitivity Index (ASI), an instrument developed to assess beliefs regarding the adverse consequences of anxiety, reported more anxiety and more frequent and intense somatic sensations following hyperventilation than did normals with low scores on the ASI. They concluded that this result provides support for the construct validity of the ASI and thus for the construct of anxiety sensitivity. Nevertheless, we argue that (a) the developers of the ASI have conflated beliefs regarding the adverse consequences of anxiety with fear of these consequences, (b) the accumulated evidence for the construct validity of the ASI is weak, and (c) Holloway and McNally's design and analyses do not permit them to exclude the more parsimonious explanation that trait anxiety accounts for their findings. Implications for research on anxiety sensitivity are discussed.

A preliminary investigation of the construct of psychopathic personality (psychopathy) in chimpanzees (Pan troglodytes).

Although the construct of psychopathy has received considerable attention in humans, its relevance to other animals is largely unknown. We developed a measure of psychopathy for use in chimpanzees (Pan troglodytes), the Chimpanzee Psychopathy Measure (CPM), and asked 6 raters to complete this index on 34 chimpanzees. The CPM (a) demonstrated satisfactory interrater reliability and internal consistency; (b) exhibited marginally significant sex differences (males > females); (c) correlated positively with measures of extraversion, agreeableness, and observational ratings of agonism, sexual activity, daring behaviors, teasing, silent bluff displays, and temper tantrums, and negatively with observational ratings of generosity; and (d) demonstrated incremental validity above and beyond a measure of dominance. Although further validation of the CPM is needed, these findings suggest that the psychopathy construct may be relevant to chimpanzees.

Assessment of sexual function in depressed, impotent, and healthy men: factor analysis of a Brief Sexual Function Questionnaire for men.

We report a study of sexual function in outpatient men with major depressive disorder (n = 42), compared with healthy control men (n = 37) and a clinic sample complaining of erectile dysfunction (n = 13). A principal-components factor analysis of the Brief Sexual Function Questionnaire confirmed differences in the clinical dimensions of sexual activity/performance, interest, satisfaction, and physiological competence. The four factors accounted for 72% of the variance in the analysis. Acceptable test-retest reliability, construct validity, and concurrent validity (with the Derogatis Sexual Function Inventory and a self-report behavioral log) were demonstrated. Parallel observations with findings from previous nocturnal penile tumescence studies in these same men are discussed.

Methodological advances and developments in the assessment of psychopathy.

The last decade has witnessed a number of significant methodological advances and developments in the assessment of psychopathy. The Psychopathy Checklist-Revised and the two-factor model of psychopathy have facilitated the assessment of psychopathy and clarified the differential correlates of the personality- and behavior-based operationalizations of this syndrome. Although preliminary evidence suggests that certain features of psychopathy may be underpinned by a latent taxon, the categorical versus dimensional status of psychopathy requires clarification. Researchers have accorded increasing attention to the assessment of psychopathy in non-criminal samples, although the construct of subclinical psychopathy remains controversial. Other recent methodological developments include: (a) the extension of the Five-Factor Model and other higher-order personality taxonomies to psychopathy; (b) development of a Q-sort methodology to permit the assessment of psychopathy by observers; (c) standardized assessment of psychopaths' interpersonal behaviors; (d) assessment of psychopathy in children; and (e) examination of gender, ethnic, and cross-cultural differences in psychopathy.

The association between anxiety and psychopathy dimensions in children.

Although several theoretical models posit that low levels of anxiety are a risk factor for psychopathy and antisocial behavior, a number of studies have reported elevated levels of anxiety among antisocial individuals. Nevertheless, most investigators in this literature have not distinguished between fearfulness and trait anxiety or attempted to separate the antisocial lifestyle dimension from the callous and unemotional dimension of psychopathy. In a study of clinically referred children (N = 143), we found that (a) measures of trait anxiety and fearlessness (low fearfulness) exhibited low correlations; (b) conduct problems tended to be positively correlated with trait anxiety, whereas callous and unemotional traits tended to be negatively correlated with trait anxiety; and (c) controlling statistically for the effects of one dimension increased the divergent correlations of the other dimension with both trait anxiety and fearful inhibition. These findings bear potentially important implications for the diagnosis and etiology of psychopathy and antisocial behavior and suggest that distinctions between trait anxiety and fearful inhibition, as well as between the two dimensions of psychopathy, may help to clarify longstanding confusion in this literature.

Anxiety sensitivity: relations to psychopathy, DSM-IV personality disorder features, and personality traits.

Relatively few data are available concerning the relations between anxiety sensitivity (AS) and both abnormal and normal personality traits. In particular, little is known about the associations between AS and personality disorders, although Shostak and Peterson [Behav. Res. Ther. 28 (1990) 513.] hypothesized that AS would be negatively correlated with antisocial personality disorder (ASPD) and perhaps related conditions (e.g., psychopathy). We examined the relations between AS, as assessed by the AS Index (ASI), and measures of psychopathy/ASPD, personality disorder features. and personality traits in a sample of 104 undergraduates. The ASI was not significantly associated with global measures of psychopathy or ASPD, although it was negatively correlated in some cases with the core affective deficits of psychopathy. In addition, the ASI was positively correlated with features of several Clusters B (e.g., borderline) and C (e.g., dependent) personality disorders and with features of passive-aggressive personality disorder. In addition, the ASI was positively associated with measures of several normal-range personality traits, including trait anxiety, alienation, well being, Negative Emotionality, and Constraint. Some, although not all, of the abnormal and normal personality correlates of the ASI were attributable to the variance shared by the ASI with trait anxiety measures. Implications and limitations of the present findings for the correlates and etiology of AS are outlined.

Space and motion discomfort in Brazilian versus American patients with anxiety disorders.

Space and motion discomfort (SMD) was studied in 38 Brazilian and 50 U.S. patients belonging to one of three diagnostic groups: (a) panic disorder with agoraphobia, (b) panic disorder without agoraphobia, and (3) other nonpanic anxiety disorders. A group of 30 U.S. normal controls was also included. SMD was assessed by the Situational Characteristics Questionnaire (SitQ), which includes two scales for SMD--the Smd1 and the Smd2, and one scale for non-space-related agoraphobic discomfort, the Ag1. The score in the Smd2 is based on the sum of Likert style items, while the scores of the Smd1 and Ag1 are based on differences between contrasting subitems. A significant diagnosis effect was observed in all scales, with the highest scores in the agoraphobia group. A country effect was found only in the Smd2. A country effect was also observed when all subitems of the Smd1 and Ag1 were added rather than subtracted, suggesting that this country bias is related to a tendency of Brazilian patients to endorse symptoms. Implications of these findings to the trans-cultural validation of rating scales are discussed.

Déjà vu all over again: critical misunderstandings concerning anxiety sensitivity and constructive suggestions for future research.

The debate concerning the relation between anxiety sensitivity (AS) and trait anxiety has been constructive for the field and has suggested a number of important directions for future research. Reiss' (1997) commentary on AS and trait anxiety in this journal, however, contains several serious factual mis-statements and logical errors that confuse, rather than clarify, many of the central issues in this debate. These misunderstandings are corrected and the implications of the issues raised by Reiss are addressed here. The authors suggest that future research on AS (a) embed this construct within the context of broader temperamental and personality variables and (b) explicitly recognize the biodirectionality of emotional and cognitive influences.

Eye Movement Desensitization and Reprocessing: an analysis of specific versus nonspecific treatment factors.

Incremental validity and incremental efficacy have become important issues in the evaluation of psychological assessment and intervention procedures. Incremental validity in assessment is that shown by novel measures over and above established ones. Incremental efficacy is that shown by novel treatments over and above nonspecific and established treatment effects. In this paper, we critically examine the question of whether Eye Movement Desensitization and Reprocessing (EMDR) possesses efficacy above and beyond nonspecific treatment effects and components that are shared with well-established interventions. A review of recently published efficacy studies reveals that (a) the effects of EMDR are largely limited to verbal report indices, (b) eye movements and other movements appear to be unnecessary, and (c) reported effects are consistent with nonspecific treatment features. Examination of individual studies shows that control procedures for nonspecific features have been minimal. We analyze EMDR for nonspecific treatment features and suggest experimental controls to examine the incremental efficacy of EMDR.

The Rorschach Inkblot Test: a case of overstatement?

In the 1940s, inflated claims were often made regarding the Rorschach Inkblot Test. Over half a century later, overstatements regarding the test are still common. The present article identifies problems with the Rorschach regarding norms, cultural sensitivity, interrater reliability, test-retest reliability, validity, factor structure, and accessibility of supporting studies. Contrary to overstated claims made on behalf of the Rorschach, the test continues to be a highly problematic instrument from a psychometric standpoint.

Efficacy and safety of galantamine in patients with mild to moderate Alzheimer's disease: multicentre randomised controlled trial. Galantamine International-1 Study Group.

OBJECTIVE: To evaluate the efficacy and safety of galantamine in the treatment of Alzheimer's disease. DESIGN: Randomised, double blind, parallel group, placebo controlled trial. SETTING: 86 outpatient clinics in Europe and Canada. PARTICIPANTS: 653 patients with mild to moderate Alzheimer's disease. INTERVENTION: Patients randomly assigned to galantamine had their daily dose escalated over three to four weeks to maintenance doses of 24 or 32 mg. MAIN OUTCOME MEASURES: Scores on the 11 item cognitive subscale of the Alzheimer's disease assessment scale, the clinician's interview based impression of change plus caregiver input, and the disability assessment for dementia scale. The effect of apolipoprotein E4 genotype on reponse to treatment was also assessed. RESULTS: At six months, patients who received galantamine had a significantly better outcome on the 11 item cognitive subscale of the Alzheimer's disease assessment scale than patients in the placebo group (mean treatment effect 2.9 points for lower dose and 3.1 for higher dose, intention to treat analysis, P<0.001 for both doses). Galantamine was more effective than placebo on the clinician's interview based impression of change plus caregiver input (P<0.05 for both doses v placebo). At six months, patients in the higher dose galantamine group had significantly better scores on the disability assessment for dementia scale than patients in the placebo group (mean treatment effect 3.4 points, P<0.05). Apolipoprotein E genotype had no effect on the efficacy of galantamine. 80% (525) of patients completed the study. CONCLUSION: Galantamine is effective and well tolerated in Alzheimer's disease. As galantamine slowed the decline of functional ability as well as cognition, its effects are likely to be clinically relevant.