Stress-induced enhancement of auditory startle: an animal model of posttraumatic stress disorder.

An innovative animal model of posttraumatic stress disorder (PTSD) is proposed in which nonhabituation of the acoustic startle response is developed in rats subsequent to tailshock exposure. Subjects (n = 31) received 30 minutes of intermittent tail shock on 2 days followed by exposure to the tailshock apparatus on the third day. Compared to baseline startle reactions, 9 of 31 tailshock-exposed rats developed nonhabituation of startle response reactions during the subsequent 3 weeks of testing. No control rats developed nonhabituation of startle reactions over a similar time period. These data suggest that this system models useful aspects of clinical PTSD emphasizing nonhabituation of startle reactions as a dependent variable. The method consistently identifies a subgroup of rats that develop persistent nonhabituation of startle in response to a tailshock-stress paradigm.

The future of criminal violence: juveniles tried as adults.

Juveniles tried as adults (JTA) represent a select and small subsample of juvenile offenders. This study seeks to provide a profile of habitually violent JTAs transferred to the adult penal system and to compare them with their adult counterparts. Twenty-nine incarcerated violent male juveniles tried as adults were compared with a sample of 27 incarcerated violent male offenders across demographic, neuropsychological, criminal history, psychopathy, and substance abuse variables. The JTAs were characterized by a high rate of gang membership (96%), substance abuse (alcohol, marijuana, and phenylcyclidene), and use of guns. In the juvenile sample, 65 percent used guns in violence not leading to arrest, and 93 percent used guns in a violent crime leading to arrest. Juvenile offenders were similar to their adult counterparts in patterns of criminality, although adult offenders had higher psychopathy scores. Both groups revealed generally intact neuropsychological functioning with the exception of a higher rate of perseverative responses in the adult sample. The results are discussed in terms of the implication of the degree of violence in a young offender population.

A test of behavioral family therapy to augment exposure for combat-related posttraumatic stress disorder.

This study tested a family-based skills-building intervention in veterans with chronic combat-related posttraumatic stress disorder (PTSD). Veterans and a family member were randomly assigned to 1 of 3 conditions: (a) waiting list, (b) 18 sessions of twice-weekly exposure therapy, or (c) 18 sessions of twice-weekly exposure therapy followed by 16 sessions of behavioral family therapy (BFT). Participation in exposure therapy reduced PTSD positive symptoms (e.g., reexperiencing and hyperarousal) but not PTSD negative symptoms. Positive symptom gains were maintained at 6-month follow-up. However, participation in BFT had no additional impact on PTSD symptoms.

Psychophysiologic parameters of traumatic stress disorder in rats.

Nonhabituation of the acoustic startle response is used to identify rat subjects with altered alarm responses subsequent to trauma exposure. Subjects (n = 31) were exposed to 30 minutes of intermittent tail shock on 2 days followed by exposure to the apparatus on the third day. Twenty-nine percent of traumatized rats developed nonhabituation of startle over the subsequent 3 weeks of testing. No control rats developed nonhabituation of startle reactions over a similar time period. These data suggest that this system represents a more accurate representation of clinical PTSD than do other animal models.

Treatment of posttraumatic stress disorder: a review.

This article analyzes the literature on the treatment of posttraumatic stress disorder (PTSD). It briefly exposes the theoretical basis for each treatment modality and extensively examines pharmacological, behavioral, cognitive, and psychodynamic therapies, as well as group and family therapies, hypnosis, inpatient treatment, and rehabilitation. Articles were identified by scanning Medline and PsychLit for all papers in English reporting treatment of PTSD. Anecdotal case reports were, then, excluded. Eighty one articles were identified and categorized as either biological or psychological, with the latter category further divided into behavioral, cognitive, psychodynamic, and other treatment modalities. Information regarding the type of trauma, the sample studied, the treatment method, and the results of the treatment has been extracted from each article and is presented briefly. A synthesis of findings in each area is provided. Most studies explored a single treatment modality (e.g., pharmacological, behavioral). The cumulated evidence from these studies suggests that several treatment protocols reduce PTSD symptoms and improve the patient's quality of life. The magnitude of the results, however, is often limited, and remission is rarely achieved. Given the shortcoming of unidimensional treatment of PTSD, it is suggested that combining biological, psychological, and psychosocial treatment may yield better results. It is further argued that rehabilitative goals should replace curative techniques in those patients with chronic PTSD. A framework for identifying targets for each treatment modality is presented.

Tales of the crypt for psychiatrists: mourning, melancholia, and mortuary malpractice.

Death awaits all, leaving in its wake relatives and friends affected by the loss of a loved one. Immediately following death, the funeral process begins, resulting in permanent burial in a cemetery. This report investigates the dysfunctional interactions between grief-stricken relatives and mortuaries that are associated with civil litigation for negligence. Psychiatric evaluations of 25 bereaved plaintiffs from nine separate lawsuits were performed. In addition, medical records and legal pleadings were reviewed as sources of additional information. General themes from the clinical material are identified and illustrated by two cases. Surviving relatives are in an acute state of emotional turmoil, rendering them exquisitely sensitive to lapses in expected routine and perceived disrespect toward the decreased. These issues are intensified when the circumstances of the death were traumatic, when the relationship with the deceased was ambivalent, when specific cultural and religious factors are present, and when the influence of litigation is felt. If the burial process is disrupted, civil suits for negligence may be filed that exacerbate grief and challenge the psychiatrist's efforts to resolve diagnostic ambiguity in the face of emotionally charged cultural and religious practices.

Behavioral family therapy for Vietnam combat veterans with posttraumatic stress disorder.

Severe interpersonal problems are common in veterans with combat-related posttraumatic stress disorder (PTSD) and their families. The authors first detail the rationale and use of behaviorally based family therapy to help reduce avoidance and withdrawal symptoms of PTSD and improve the active coping capacities of both veterans and their loved ones, then present a case example of the model, and finally discuss the clinical application of behavioral family therapy to the unique concerns of veterans with combat-related PTSD.

Behavioural family management in schizophrenia. Outcome of a clinic-based intervention.

To test further the highly successful outcomes of a controlled study of in-home behavioural family management (BFM) for schizophrenic patients, a clinic-based version of this intervention was compared with customary care alone for 41 schizophrenic patients in a Veterans Administration (VA) mental health clinic. Monthly Brief Psychiatric Rating Scale (BPRS) ratings, conducted by clinic psychiatrists who were 'blind' to the patients' assignment, revealed that 3 (14%) patients who received behavioural family management as well as customary care, as compared with 11 (55%) patients who received customary care alone, had symptomatic exacerbations during the first year of treatment.

Dental management of the child with developmental dyslexia.

Dyslexia, a biologically determined reading disorder effects an estimated 3 percent to 10 percent of school-age children in the United States. Standard pediatric dental protocols frequently have to be modified because many of these children concurrently suffer attention-deficit-hyperactivity disorder (ADHD), asthma, thyroiditis and inflammatory bowel disease (ulcerative colitis and Crohn's disease). Youngsters suffering from dyslexia and ADHD should have their dental appointments scheduled in the morning when they are most attentive and best able to remain seated in the dental chair. An aspirating dental syringe must be used in order to avoid an intravascular injection and the possibility of an adverse interaction between the pressor agents used with local anesthesia and the medication used to treat ADHD. Aspirin, other nonsteroidal antiinflammatory agents (e.g., ibuprofen) and local anesthetic agents containing vasoconstrictor and preservative (antioxidants, i.e., sulfite) agents should be avoided in children with concurrent asthma because of their propensity to trigger an asthmatic attack. Children with uncontrolled hyperthyroidism should receive only emergency care and this care should be provided in a hospital. Children with hypothyroidism are hyperresponsive to even small dosages of analgesics and anesthetic agents; proper dosing and venue of dental procedures should be a joint decision between the child's dentist and pediatrician. Children with dyslexia and concurrent inflammatory bowel disease may require shorter appointments and nitrous oxide sedation to reduce stress. Those receiving corticosteroids or with a history of steroid therapy within the past year may need supplementation to avoid an adrenal crisis brought about by the stress of dental care.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental management of the adolescent with panic disorder.

Panic disorder is a psychiatric disease without obvious cause. It is accompanied by signs of terror, such as chest pain, palpitation, and shortness of breath. One of every 75 Americans is afflicted. Onset occurs most commonly during adolescence. Some infants and children exhibit anxiety-like responses, such as retreat and avoidance, and behavioral restraint when faced with unfamiliar people, objects, and events. Panel disorder has a special relevance for dentistry, because it is frequently associated with mitral valve prolapse. Furthermore, medications used to treat the disorder are associated with detrimental changes in the oral cavity and adverse interactions with dental therapeutic agents. The authors discuss the podromal characteristics of children at risk for panic disorder and the characteristics of the malady recognized by the American Psychiatric Association. Associated medical problems are also presented and discussed. A survey of ninth graders found as many as 12 percent had spontaneous panic attacks. Approximately 20 percent of all adults with the disorder report its onset before age ten. Etiology, medical and dental management are discussed.

Dental management of child and adolescent patients with schizophrenia.

Schizophrenia is a psychiatric disorder in which thought disturbances and aberrant behavior lessen an individual's ability to care for him or herself and to effectively work and communicate with others. The disorder affects 1 percent of the United States population. Onset of the florid psychotic symptoms most commonly occurs during adolescence or young adulthood, but most of these youngsters exhibit unusual behavior and peculiar thinking during childhood. Medications used in managing the disorder have numerous systemic and orofacial adverse side effects that must be recognized by dentists. Dental treatment strategies for the identification and management of these side effects are described as is a method to improve compliance with oral hygiene techniques.

Levels of trauma: a multidimensional approach to the treatment of PTSD.

The historical course of professional interest in psychological trauma in the 20th century parallels the cycle of intrusion and denial characteristic of traumatized individuals, in which periods of recognition and concern alternate with times of forgetfulness and neglect (Glass et al. 1966; Ingraham et al. 1986). The inclusion of the diagnostic category of posttraumatic stress disorder (PTSD) in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III-1980) inescapably confronted the mental health community with the problem of psychic trauma and catalyzed the quest for a deeper understanding of the disorder. This has led to a variety of explanatory models from such distant fields as neurobiology (Krystal et al. 1989; Pitman 1989; van der Kolk et al. 1985), psychophysiology (Kolb 1987), learning theory (Keane et al. 1985), psychoanalysis (Krystal 1978; Laufer 1988), cognitive psychology (Janoff Bulman 1985), and existential-humanistic philosophy (Lifton 1988).

Dental management of the child and adolescent with major depression.

Major depression is a psychiatric disorder in which mood, thought content, and behavioral patterns are impaired, often for an extended period of time. This condition appears to have an increasing prevalence among young children and adolescents. It may be associated with a disinterest in performing appropriate preventive oral hygiene techniques, a cariogenic diet, rampant dental decay, and advanced periodontal disease. Appropriate dental management necessitates a vigorous preventive dental education program and special precautions when administering local anesthetics and prescribing sedative and analgesic medications.

The psychotherapist as witness for the prosecution: the criminalization of Tarasoff.

The "duty to protect" doctrine heralded by the Tarasoff decision seeks to prevent physical harm to third parties by psychiatric patients. Recent court cases have mandated the testimony of a criminal defendant's psychotherapist both about the Tarasoff warning itself and about confidential treatment information that was associated with the warning. One court further ruled that some clinical sessions were not psychotherapy and therefore were not afforded the protection of psychotherapist-patient privilege. The continuing erosion of confidentiality has resulted in psychiatrists and other mental health professionals becoming prosecution witnesses at the criminal trials of their own patients.

Dental management considerations in children who stutter.

Stuttering is one of the most common speech disorders of childhood. It is characterized by involuntary pauses, reiteration and prolongation of sounds and syllables. Oral motor incoordination may make provision of dental treatment arduous. Familiarity with the verbal and nonverbal manifestations of the disorder and with the possible adverse psychosocial implications prepares the dentist best to meet the needs of this unique group of children.