Early and late cognitive event-related potentials mark stages of HIV-1 infection in the drug-user risk group.

HIV-1 (Human immunodeficiency virus) infection of the brain causes delays in auditory event-related potential (ERP) components. We recorded auditory ERPs from 38 former parenteral drug users (PDUs) at three stages of HIV-1 infection: seronegative; seropositive; stage II; and seropositive, stage IV. There were five response conditions: Go Nogo, Count, Simple Response, Simple Count, and Ignore. P3 peak latencies were significantly delayed and P3 amplitudes were significantly reduced for all seropositives, including asymptomatics, when compared to PDU seronegative controls. In contrast, the P1 and N1 peak latency measures were delayed only for seropositives with acquired immunodeficiency syndrome (AIDS) qualifying illnesses. There was a significant negative correlation between the CD4 count and the latency of P1, N1, and the MMN. Also, increased P1 and N1 amplitudes correlated with indices of disease progression (Choice RT and CD4 counts, respectively). The results extend previous findings by clarifying the pattern of auditory ERP markers of disease progression. Early, as well as late, brain involvement caused by HIV-1 is marked by delays and decreased amplitudes in cognitive components. In addition, late brain involvement is marked by delays and increased amplitudes in specific, automatic, and/or obligatory components.

A brain imaging (single photon emission computerized tomography) study of semantic and affective processing in psychopaths.

Psychopaths have been described as human predators who use charm, intimidation, and violence to control others and to satisfy their own needs. Underlying their propensity to violate social norms and expectations is a profound lack of empathy, guilt, or remorse, affective processes that have long resisted scientific investigation. Using brain imaging technology we found that psychopaths differed from nonpsychopaths in the pattern of relative cerebral blood flow during processing of emotional words. The results were consistent with the hypothesis that there are anomalies in the way psychopaths process semantic and affective information.

Initial reliability and validity of the childhood trauma interview: a new multidimensional measure of childhood interpersonal trauma.

OBJECTIVE: The Childhood Trauma Interview, a new instrument for brief and comprehensive retrospective assessment of childhood interpersonal trauma, is presented with initial evidence of its reliability and validity. METHOD: Drug- or alcohol-dependent patients (N = 220) were given the Childhood Trauma Interview and a questionnaire measure of child abuse, the Childhood Trauma Questionnaire. Convergent and discriminant validity for the Childhood Trauma Interview were tested by comparing correlations between analogous and nonanalogous trauma scales to those of the Childhood Trauma Questionnaire. RESULTS: Interrater reliability for the majority of trauma dimensions measured by the Childhood Trauma Interview was very high (63% had intraclass correlations above 0.90). Principal-components analysis yielded six rotated factors that accounted for 74% of the variance among scores: separations and losses, physical neglect, emotional abuse or assault, physical abuse or assault, witnessing violence, and sexual abuse or assault. Since these six factors exactly represented the areas that the interview was designed to assess, the construct validity of the Childhood Trauma Interview was supported. Without exception, convergent correlations were significantly higher than discriminant correlations, and convergence was improved when multidimensional variables from the Childhood Trauma Interview and their interactions were regressed onto Childhood Trauma Questionnaire scores. CONCLUSIONS: These initial findings suggest that the Childhood Trauma Interview is a reliable and valid method for brief assessment of multiple dimensions of six types of childhood interpersonal trauma.

Initial reliability and validity of a new retrospective measure of child abuse and neglect.

OBJECTIVE: This report presents initial findings on the reliability and validity of a new retrospective measure of child abuse and neglect, the Childhood Trauma Questionnaire. METHOD: Two hundred eighty-six drug- or alcohol-dependent patients were given the Childhood Trauma Questionnaire as part of a larger test battery, and 40 of these patients were given the questionnaire again after an interval of 2 to 6 months. Sixty-eight of the patients were also given a structured interview for child abuse and neglect, the Childhood Trauma Interview, that was developed by the authors. RESULTS: Principal-components analysis of responses on the Childhood Trauma Questionnaire yielded four rotated orthogonal factors: physical and emotional abuse, emotional neglect, sexual abuse, and physical neglect. Cronbach's alpha for the factors ranged from 0.79 to 0.94, indicating high internal consistency. The Childhood Trauma Questionnaire also demonstrated good test-retest reliability over a 2- to 6-month interval (intraclass correlation = 0.88), as well as convergence with the Childhood Trauma Interview, indicating that patients' reports of child abuse and neglect based on the Childhood Trauma Questionnaire were highly stable, both over time and across type of instruments. CONCLUSIONS: These findings provide strong initial support for the reliability and validity of the Childhood Trauma Questionnaire.

Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population.

OBJECTIVE: To present initial findings on the validity of a recently developed maltreatment inventory, the Childhood Trauma Questionnaire (CTQ), in a sample of adolescent psychiatric patients. METHOD: Three hundred ninety-eight male and female adolescents (aged 12 to 17 years) admitted to the inpatient service of a private psychiatric hospital were given the CTQ as part of a larger test battery. Structured interviews were also conducted with the primary therapists of 190 of the patients to obtain ratings of abuse and neglect based on all available data, including clinical interviews with patients and their relatives and information from referring clinicians and agencies. RESULTS: Principal-components analysis of the CTQ items yielded five rotated factors-emotional abuse, emotional neglect, sexual abuse, physical abuse, and physical neglect-closely replicating the factor structure in an earlier study of adult patients. The internal consistency of the CTQ factors was extremely high both in the entire sample and in every subgroup examined. When CTQ factor scores were compared with therapists' ratings in a series of logistic regression analyses, relationships between the two sets of variables were highly specific, supporting the convergent and discriminant validity of the CTQ. Finally, when therapists' ratings were used as the validity criterion, the CTQ exhibited good sensitivity for all forms of maltreatment, and satisfactory or better levels of specificity. CONCLUSIONS: These initial findings suggest that the CTQ is a sensitive and valid screening questionnaire for childhood trauma in an adolescent psychiatric inpatient setting.

Benzodiazepine and sedative use/abuse by methadone maintenance clients.

Clients at three geographically separate methadone maintenance clinics were surveyed regarding their lifetime use of ten commonly used benzodiazepines and barbiturates. In Baltimore (n = 50), 94% reported use of one or more of these drugs in their lifetime, with 66% reporting use in the last 6 months. In Philadelphia (n = 218), 78% reported use in their lifetime, with 53% reporting use in the last 6 months. In New York City (The Bronx) (n = 279), 86% reported use in their lifetime, with 44% reporting use in the last 6 months. Subjects reporting a history of use of at least 7 of 10 of the named sedatives were recruited for a more detailed interview. They reported that, among the benzodiazepines, diazepam, lorazepam, and alprazolam were frequently used for their 'high' producing effects, and for selling to produce income. In contrast, chlordiazepoxide, oxazepam, and phenobarbital, had much lower ratings of 'high' and were much less likely to be obtained for getting 'high' or for resale.

Levels of opioid physical dependence in heroin addicts.

The levels of opioid physical dependence in a group of long-term heroin addicts were ascertained by measuring the severity of the opioid withdrawal syndrome before and after pharmacological challenge with either 0.4 mg naloxone or placebo. Prior to challenge, patients manifested some subjective symptoms but few objective signs of opioid withdrawal. Patients who received placebo (n = 18) showed a significant increase in the mean score on one of three rating scales used to assess opioid withdrawal. Patients who received naloxone (n = 58) showed significant increases in mean scores on all three rating scales, but this was due primarily to increases observed in a minority of patients. Sixty-one percent of patients failed to manifest clinically significant changes in subjective symptoms, and 74% of patients failed to manifest clinically significant changes in objective signs of opioid withdrawal following naloxone administration. The results suggest that a substantial subgroup of heroin addicts are able to use opioids regularly while maintaining relatively low levels of physical dependence.

Amantadine does not reduce cocaine use or craving in cocaine-dependent methadone maintenance patients.

We tested the efficacy of amantadine to reduce cocaine use or craving in cocaine-dependent methadone maintained patients. Two doses of amantadine (200 mg p.o. daily, n = 16, and 200 mg p.o. bid, n = 21) were tested against placebo, n = 22, in a random assignment, double-blind clinical trial lasting nine weeks. Amantadine was well tolerated. However, neither dose of amantadine was more effective than placebo in reducing cocaine use and craving.

Enhanced treatment outcomes for cocaine-using methadone patients.

Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment x cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.

Magnetic resonance abnormalities in HIV infection: a study in the drug-user risk group.

Cognitive impairment is a frequent complication of advanced human immunodeficiency virus-1 (HIV-1) infection. However, structural imaging of the brain has not revealed abnormalities that precede the onset of clinical abnormalities. Cranial magnetic resonance (MR) studies were performed in 28 male subjects with intravenous drug use histories; nine were HIV-1 seronegative, 11 were HIV-1 seropositive but asymptomatic, and eight were seropositive and met symptomatic criteria for acquired immune deficiency syndrome (AIDS). Cortical atrophy, but not the degree of ventricular enlargement or signal abnormalities, was increased in the seropositive group compared with the seronegative group and also differed between asymptomatic seropositive and seronegative patients. An increased level of cortical atrophy may reflect the early impact of HIV-1 infection on the brain.

Hostility is associated with a heightened prolactin response to meta-chlorophenylpiperazine in abstinent cocaine addicts.

The prolactin (PRL) response to the administration of serotonin (5HT) agonists is an index of central nervous system 5HT activity. This index is blunted in association with hostile aggression in personality and depressive disorder patients without substance abuse. We tested whether the PRL response to the oral administration of the partial 5HT agonist meta-chlorophenylpiperazine (MCPP), 0.35 mg/kg, was associated with a measure of trait hostility, the Buss Durkee Hostility Inventory (BDHI), in cocaine addicts who were completing a 3-week detoxification and rehabilitation program. We also tested whether the cocaine addicts differed from healthy volunteers on their PRL, cortisol (CORT) or temperature responses to MCPP. The PRL response to MCPP was positively associated with the total score on the BDHI. There were, however, no differences in the neuroendocrine or temperature responses to MCPP between the cocaine-dependent group and the healthy volunteers once age effects were controlled for.

Patients' perspective on the process of change in substance abuse treatment.

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patient's view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

An enhanced positive reinforcement model for the severely impaired cocaine abuser.

This article describes a cognitive-behavioral treatment approach that has been extensively modified to work with inner-city methadone-maintained cocaine users. Modifications were deemed essential to address the problems of engagement and retention in treatment that are typically encountered with this population. While this approach relies on such basic tenets of treatment as relapse prevention, cognitive restructuring, and psychoeducation, an understanding of the particular psychological vulnerabilities of this population has been incorporated into the model. The modified approach utilizes positive reinforcement extensively. This includes use of concrete reinforcers to facilitate initial engagement, and use of interpersonal reinforcers (therapist positive regard, attention, and respect) to increase program retention and sustain posttreatment change. Preliminary results indicate that 63% of patients can complete this intensive 6-month program, with considerable reductions in cocaine use and significant change in drug injection behavior.

Predicting personality pathology among adult patients with substance use disorders: effects of childhood maltreatment.

The purpose of this study was to examine predictive relationships between types of childhood maltreatment and personality disorders in a substance-abusing population. Three hundred thirty-nine drug- or alcohol-dependent patients completed a reliable and valid retrospective measure of childhood trauma, the CTQ, and a self-report inventory that assesses the entire range of DSM-III-R personality disorders, the PDQ-R. As a preliminary step, factor analyses were used to group personality disorders into the three DSM-III-R Axis II clusters (Clusters A, B, and C), although some diagnostic subclusters were also found. Structural equation modeling analyses revealed several significant paths between types of maltreatment and personality disorder clusters (and subclusters). Physical abuse and physical neglect were related to a subcluster of "psychopathic" personality disorders consisting of childhood and adult antisocial personality traits and sadistic traits. Emotional abuse emerged as a broad risk factor for personality disorders in Clusters A, B, and C. Emotional neglect was related to the traits of schizoid personality disorder, which formed its own subcluster. Finally, sexual abuse, which had been expected to predict borderline personality disorder traits, was unrelated to any personality disorder cluster. These findings support the view that child maltreatment contributes to the high prevalence of co-morbid personality disorders in addicted populations.

A latent variable analysis of coexisting emotional deficits in substance abusers: alexithymia, hostility, and PTSD.

The emotional disturbance of substance abusers is often described as an inability to identify and express feelings coupled with an excess vulnerability to experience negative affect. However, there is only limited empirical support for this perspective. To validate this description, we first defined components of alexithymia, hostility, and posttraumatic stress disorder (PTSD) derived from established measures of each by conducting confirmatory factor analyses based on a self-report data set from a clinical sample of 253 alcoholics and drug addicts. We then fashioned and tested overarching latent variables representing the three aspects of emotional dysfunction (i.e., alexithymia, hostility, and PTSD) and finally tested the correlations among these overarching variables. We found a strong association between a factor labeled Bottled-Up Emotions and another labeled Neurotic Hostility (r = .62) as well as an association between PTSD and Bottled-Up Emotions (r = .66). The structure, magnitude, and intercorrelation of the latent variables did not depend on the type of psychoactive substance abused. These results support the view that features of alexithymia and hostility coexist in substance abusers and that this joint deficit is part of a broad disturbance across multiple psychological domains including pathological response to traumatic stress.

Daily cocaine use patterns: effects of contextual and psychological variables.

This study identifies factors that predict daily cocaine use among clients in a methadone maintenance program who participated in a cocaine treatment trial. Cocaine use decreased the longer clients remained in treatment, and the amount of cocaine used depended upon the day of the week, with Saturday typically having the greatest use and Sunday having the least. Logistic regression analyses showed that several other factors were related to daily cocaine use: peak cocaine craving, resistance to use cocaine, and several triggers or stimuli to use cocaine. These stimuli included receiving money, being offered cocaine, and seeing cocaine and/or related paraphernalia. However, even with these variables controlled, day of the week and time in treatment continued to be significant predictors. This suggests that (a) other time-varying variables need to be included in order to fully account for cocaine use variation from day to day and (b) time in treatment is a robust predictor of reduced cocaine use despite the strong influences of craving, external stimuli, and day of the week.

Gender differences in psychiatric comorbidity among cocaine-using opiate addicts.

Psychiatric comorbidity was examined for a sample of 212 methadone patients dually addicted to opiates and cocaine, focusing on gender differences. Diagnoses were determined by the SCID for DSM-III-R. Men displayed more lifetime (but not current) substance use disorders, while women displayed more lifetime and current non-substance use disorders. There were several significant interactions among psychiatric disorders and gender. Women were more likely than men to present with concurrent mood and anxiety disorders. Women with ASPD were unlikely to have alcohol use disorder, but likely to have opioid use disorder. Men with anxiety were likely to be diagnosed with ASPD. Treatment implications of the findings are discussed.

Neurobehavioral treatment for cocaine-using methadone patients: a preliminary report.

Preliminary outcome evaluation results are reported for an innovative cocaine abuse treatment model adapted for cocaine-using methadone patients. Sixty-two patients were randomly assigned to six months of high intensity ("neurobehavioral") or lower intensity ("control") therapy for cocaine dependence. Therapy was completed by 49% of neurobehavioral and 53% of control patients. In paired comparisons between intake and six-month follow-up, neurobehavioral patients but not controls showed significant declines in cocaine and other drug use (measured by urinalysis and self-reports), as well as significant improvement in psychological status. The findings suggest that specialized cocaine abuse treatment can benefit methadone patients; intake to the study is continuing.

Treatment intensity and reduction in drug use for cocaine-dependent methadone patients: a dose-response relationship.

This study examined the impact of treatment intensity on cocaine use. Seventy-seven cocaine-using methadone patients were enrolled in a six-month, structured, manual-driven, cognitive-behavioral treatment program. Sessions consisted of five individual and/or group sessions per week. At intake subjects showed extensive polydrug abuse, psychiatric comorbidity, criminal histories, and HIV risk behaviors. Treatment intensity was measured by dividing number of sessions attended into quartiles. Paired comparisons, within treatment quartiles, were made between subjects' intake and six-month self-reports of cocaine use. Subjects in quartiles two through four showed significant reductions in frequency of cocaine use at follow-up, with subjects who received the most treatment showing the greatest reductions in cocaine use. Bivariate and multivariate analyses showed that treatment sessions attended remained a strong predictor of reduction in cocaine use at follow-up, even after controlling for drug use at intake and background variables. The results indicate that there is a substantial treatment dose-response relationship.

Health care insolvency and bankruptcy.

Bankruptcy is an event that is often considered a business' worst nightmare. Debt, lawyers, and the U.S. government can lead to the eventual destruction of a business. This article shows how declaring bankruptcy can be a helpful instrument in continuing a successful venture in the health care marketplace.