Brain activations associated with shifts in response criterion on a recognition test.

Sensitivity and bias can be manipulated independently on a recognition test. The goal of this fMRI study was to determine whether neural activations associated with manipulations of a decision criterion would be anatomically distinct from neural activations associated with manipulations of memory strength and episodic retrieval. The results indicated that activations associated with shifting criteria (a manipulation of bias) were located in bilateral regions of the lateral cerebellum, lateral parietal lobe, and the dorsolateral prefrontal cortex extending from the supplementary motor area. These regions were anatomically distinct from activations in the prefrontal cortex produced during memory-based retrieval processes (manipulations of sensitivity), which tended to be more medial and anterior. These later activations are consistent with previous studies of episodic retrieval. Determining patterns of neural activations associated with decision-making processes relative to memory processes has important implications for Cognitive Neuroscience, including the use of these patterns to compare memory models in different paradigms.

Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.

OBJECTIVES: This study assessed seroprevalence rates of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among individuals with severe mental illness. METHODS: Participants (n = 931) were patients undergoing inpatient or outpatient treatment in Connecticut, Maryland, New Hampshire, or North Carolina. RESULTS: The prevalence of HIV infection in this sample (3.1%) was approximately 8 times the estimated US population rate but lower than rates reported in previous studies of people with severe mental illness. Prevalence rates of HBV (23.4%) and HCV (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively. CONCLUSIONS: Elevated rates of HIV, HBV, and HCV were found. Of particular concern are the high rates of HCV infection, which are frequently undetected. Individuals with HCV infection commonly fail to receive appropriate treatment to limit liver damage and unknowingly may be a source of infection to others.

A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients.

PURPOSE: This study tests the hypothesis that trauma histories, including histories of physical and sexual abuse, and posttraumatic stress disorder (PTSD) are more prevalent in psychogenic non-epileptic seizure (NES) patients than in epilepsy patients. METHODS: Thirty-five inpatients with intractable seizures were evaluated for trauma history and PTSD. After these assessments, patients were diagnosed as having either epileptic or nonepileptic seizures through EEG monitoring. RESULTS: NES diagnosis correlated with PTSD and total number of lifetime traumas, adult traumas, and abuse traumas. Contrary to previous hypotheses, reported childhood sexual abuse (CSA) did not correlate significantly with NES diagnosis. However, CSA predicted PTSD in a discriminant analysis. CONCLUSIONS: We found evidence for the hypothesized relations between trauma, abuse, PTSD, and NES diagnosis. However, elevated levels in both seizure-disorder groups suggest that routine assessment for abuse, trauma, and PTSD might facilitate medical care and treatment for all intractable seizure patients.

The left hemisphere's role in hypothesis formation.

In a probability guessing experiment, subjects try to guess which of two events will occur next. Humans tend to match the frequency of previous occurrences in their guesses. Animals other than humans tend to maximize or always choose the option that has occurred the most frequently in the past. Investigators have argued that frequency matching results from the attempt of humans to find patterns in sequences of events even when told the sequences are random. There is independent evidence that the left hemisphere of humans houses a cognitive mechanism that tries to make sense of past occurrences. We performed a probability guessing experiment with two split-brain patients and found that they approximated frequency matching in their left hemispheres and approached maximizing in their right hemispheres. We obtained a conceptual replication of that finding on patients with unilateral damage to either the left or right hemisphere. We conclude that the neural processes responsible for searching for patterns in events are housed in the left hemisphere.

The relationship between trauma, PTSD, and medical utilization in three high risk medical populations.

OBJECTIVE: Increased use of medical and psychiatric services has been reported as a correlate of exposure to trauma. Recent studies suggest that: 1) physical and sexual abuse traumas are particularly associated with increased utilization and 2) posttraumatic stress disorder (PTSD), a common sequela of abuse, mediates the relationship between trauma exposure andelevated utilization. The goal of this study was to explore the relationships between trauma, abuse, PTSD, and medical utilization in three medical help seeking groups reported to be at high risk for trauma exposure. METHOD: One hundred and seven patients receiving care at a university-affiliated medical center were surveyed for trauma history and PTSD using the Trauma History Questionnaire (THQ) and the PTSD Checklist (PCL). The sample included: forty-eight gynecologic outpatients, thirty-five inpatients with seizure disorders, and twenty-four psychiatric inpatients with non-PTSD admitting diagnoses. Medical utilization data were obtained from a computerized medical center data base. RESULTS: Ninety-six patients reported a trauma history. Of these patients, sixty-six reported abuse and forty-five qualified for PTSD diagnoses. Total number of traumas and reported sexual and physical abuse correlated significantly with elevated medical utilization and PTSD prevalence. PTSD diagnosis was not significantly correlated with utilization, but the five highest utilizers received PTSD diagnoses. CONCLUSIONS: Study results supported hypotheses regarding the relation of trauma exposure to medical utilization, but were less clear about the mediating role of PTSD. These findings suggest that routine screening of high-risk patient groups might promote timely identification of trauma history and PTSD, and subsequently impact health care utilization.

HIV risk factors among people with severe mental illness in urban and rural areas.

No studies have reported HIV risk behavior in rural populations with severe mental illness. A total of 84 rural patients with severe mental illness in New Hampshire and 158 urban patients in Baltimore were interviewed about their HIV risk behavior in the past six months using the Risk Assessment Battery, a 38-item structured clinical interview. Rates of sexual and drug risk behavior among rural patients were significantly lower than among urban patients. Regression analyses showed that urban setting, younger age, never having been married, and a bisexual or gay orientation significantly predicted higher HIV risk scores. The differences in risk behaviors may reflect urban-rural differences in drug availability and sexual practices.

Conduct disorder, antisocial personality disorder and substance use disorders in schizophrenia and major affective disorders.

OBJECTIVE: To examine the relationships between childhood conduct disorder (CD), antisocial personality disorder (ASPD) and substance use disorders (substance abuse or substance dependence) in psychiatric patients with severe mental illness. METHOD: Substance use-related problems on screening instruments, lifetime and recent prevalence of substance use disorders, and family history of substance use disorder were evaluated in four groups of 293 patients with mainly schizophrenia-spectrum and major affective disorders: No ASPD/CD, CD Only, Adult ASPD Only, Full ASPD. RESULTS: Full ASPD was strongly related to all measures of substance use problems and disorders, as well as fathers' history of substance use disorder. The odds ratios for Full ASPD and substance use disorders ranged between 3.96 (lifetime cannabis use disorder) to 11.35 (recent cocaine use disorder). To a lesser extent, patients with CD Only or Adult ASPD Only were also at increased risk for having substance use disorders compared to the No ASPD/CD patients. CONCLUSIONS: Childhood CD and adult ASPD represent significant risk factors for substance use disorders in patients with schizophrenia-spectrum and major affective disorders. Considering other research indicating that CD and ASPD have a higher prevalence in patients with severe mental illness, the present findings suggest that CD and ASPD could reflect a common factor that independently increases patients' vulnerability to both psychiatric and substance use disorders.

How physician communication influences recognition of depression in primary care.

BACKGROUND: The relationship between physician communication patterns and the successful recognition of depression is poorly understood. METHODS: We used unannounced visits by actors playing standardized patients to evaluate verbal communication between primary care physicians and a patient presenting with a minor depression scenario. Participants (n = 77) were assigned to receive 2 visits from a man or woman portraying a 26-year-old patient with chronic headaches who meets the criteria for minor depression. The standardized patients carried hidden audiotape recorders and high-fidelity microphones to document the encounters. The audiotapes were coded at 2-second intervals. These data were linked to information gathered from standardized patient checklists, medical records, and debriefing telephone calls with participants. RESULTS: We obtained complete data on 59 (77%) of the physician-patient encounters; of those, 43 (73%) of the physicians recognized depression. Physicians who recognized depression asked twice as many questions about feelings and affect compared with those who did not (for feelings: 1.9% of total physician activity vs. 0.9%, P = .017; for affect: composite score of 2.7% of total physician activity vs 1.3%, P = .003). We found no differences in the proportion or timing of broad to narrow questioning between those who did and did not recognize depression. Physicians who successfully recognized depression later in the interview showed an increase in questions about feelings in the quartile just before recognition occurred. CONCLUSIONS: Physicians who recognized depression differed significantly in the percentage of questions about feeling and affect, and an increase in questions about feelings may precede a diagnosis of depression, though more research is needed to establish this as an important finding.

Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness.

OBJECTIVE: Despite high rates of co-occurring substance use disorder in people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because underdetection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental illness. METHOD: On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients. RESULTS: The new screening instrument, the Dartmouth Assessment of Lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) use disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders. CONCLUSIONS: Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients.

Getting to go in managed care.

The challenge for leadership and the required changes are great. Our personal limitations include a limited view of the world and the threat of an overwhelming risk if one gets too far out on the limb. "Getting to go" will open up new and strange territories that will provide opportunity and failure for leaders. Capable leaders will pursue the opportunity. Threatened leaders will resist the change. For those leaders who feel that the managed care existing today provides the most cost-effective, quality outcome for the individual, his or her sponsor in the community, they will go no further. Unfortunately for many of us, managed care means a third party trying to micromanage patients (deductions, authorizations, and so on), employers (claims, incentives, and so forth), and providers (approvals, forums, payment, tricks, and the like). Providers need to go ahead and master efficient care. We owe that to the community and the third party nightmare of administrative overkill must be laid to rest. For those healthcare leaders who believe that managed care as a system focused on improving the health status of our communities is superior to our existing system, their individual goals and leadership focus must be changed accordingly. We cannot sit by idly and wait for the system to change us. Instead our obligation is to lead our organizations toward a new era in health care.

Transformations for within-subject designs: a Monte Carlo investigation.

We explored the use of transformations to improve power in within-subject designs in which multiple observations are collected for each S in each condition, such as reaction time and psychophysiological experiments. Often, the multiple measures within a treatment are simply averaged to yield a single number, but other transformations have been proposed. Monte Carlo simulations were used to investigate the influence of those transformations on the probabilities of Type I and Type II errors. With normally distributed data, Z and range correction transformations led to substantial increases in power over simple averages. With highly skewed distributions, the optimal transformation depended on several variables, but Z and range correction performed well across conditions. Correction for outliers was useful in increasing power, and trimming was more effective than eliminating all points beyond a criterion.

Getting to go in managed care.

Managed care has clearly pointed the way to bringing health care costs under control. But the providers themselves, right now, must either take on the responsibility of more directly managing care, bringing utilization down, and sharing in the rewards, or they could find themselves asked to sacrifice while intermediaries prosper.

The conjunction fallacy?

Tversky and Kahneman (1983) showed that when subjects are asked to rate the likelihood of several alternatives, including single and joint events, they often make a "conjunction fallacy." That is, they rate the conjunction of two events as being more likely than one of the constituent events. This, they claim, is a fallacy, since the conjunction of two events can never be more probable than either of the component events. In addition, they found that prior training in probability theory does not decrease the likelihood of making this fallacy. We argue that in some contexts, an alternative that contains the conjunction of two events can be more probable than an alternative that contains only one of the conjunction's constituent events. We carried out four experiments in which we manipulated this context. The frequency of making a conjunction fallacy was affected by the manipulation of context. Furthermore, when the context was clearly specified, prior training in statistics influenced the ratings.

Practice effects in backward masking.

In two experiments we demonstrate that much larger practice effects occur in a backward masking paradigm where patterned masks are used than in similar visual processing paradigms, such as lateral masking and whole report. In additional experiments we examine four possible explanations for the large practice effects: increased familiarity with the paradigm in general, learning about the targets, learning about the masks, and enhanced sensory processing. Because of failure to observe similar practice effects in related paradigms not involving backward masking and because of the sustained nature of the improvement, we reject the first explanation as a source of practice effect. Experiment 3 allowed us to reject target learning as a source of improvement as well; target sets were switched at the end of training, but no decrement in performance was observed. In Experiment 4, mask sets were switched at the end of training, revealing a significant decrement in performance. Learning about the specific masks, then, does contribute to the observed improvement. However, it is responsible for only about one third of the overall improvement in performance. The final experiment provides evidence that the residual improvement is due to enhanced sensory processing. In that experiment, training on backward masking led to a lowered threshold in a two-flash paradigm but not to a significant change in whole-report performance.

Surgical approaches to oral lesions.

Basic surgery of the mouth has been described. Surgery of the anterior one third to one half of the mouth is relatively easy to perform. The patient's medical history, an understanding of the anatomy and histopathology of the oral mucosa, and special instrumentation and techniques are essential to performing oral surgery.