Archives of general psychiatry最新文献

CONTEXT Unlike other areas of medicine, psychiatry is almost entirely dependent on patient report to assess the presence and severity of disease; therefore, it is particularly crucial that we find both more accurate and efficient means of obtaining that report. OBJECTIVE To develop a computerized adaptive test (CAT) for depression, called the Computerized Adaptive Test-Depression Inventory (CAT-DI), that decreases patient and clinician burden and increases measurement precision. DESIGN Case-control study. SETTING A psychiatric clinic and community mental health center. PARTICIPANTS A total of 1614 individuals with and without minor and major depression were recruited for study. MAIN OUTCOME MEASURES The focus of this study was the development of the CAT-DI. The 24-item Hamilton Rating Scale for Depression, Patient Health Questionnaire 9, and the Center for Epidemiologic Studies Depression Scale were used to study the convergent validity of the new measure, and the Structured Clinical Interview for DSM-IV was used to obtain diagnostic classifications of minor and major depressive disorder. RESULTS A mean of 12 items per study participant was required to achieve a 0.3 SE in the depression severity estimate and maintain a correlation of r = 0.95 with the total 389-item test score. Using empirically derived thresholds based on a mixture of normal distributions, we found a sensitivity of 0.92 and a specificity of 0.88 for the classification of major depressive disorder in a sample consisting of depressed patients and healthy controls. Correlations on the order of r = 0.8 were found with the other clinician and self-rating scale scores. The CAT-DI provided excellent discrimination throughout the entire depressive severity continuum (minor and major depression), whereas the traditional scales did so primarily at the extremes (eg, major depression). CONCLUSIONS Traditional measurement fixes the number of items administered and allows measurement uncertainty to vary. In contrast, a CAT fixes measurement uncertainty and allows the number of items to vary. The result is a significant reduction in the number of items needed to measure depression and increased precision of measurement.

Context: Insomnia is a common and seriously impairing condition that often goes unrecognized.

Objectives: To examine associations of broadly defined insomnia (ie, meeting inclusion criteria for a diagnosis from International Statistical Classification of Diseases, 10th Revision, DSM-IV, or Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition) with costly workplace accidents and errors after excluding other chronic conditions among workers in the America Insomnia Survey (AIS).

Design/setting: A national cross-sectional telephone survey (65.0% cooperation rate) of commercially insured health plan members selected from the more than 34 million in the HealthCore Integrated Research Database.

Participants: Four thousand nine hundred ninety-one employed AIS respondents.

Main outcome measures: Costly workplace accidents or errors in the 12 months before the AIS interview were assessed with one question about workplace accidents "that either caused damage or work disruption with a value of $500 or more" and another about other mistakes "that cost your company $500 or more."

Results: Current insomnia with duration of at least 12 months was assessed with the Brief Insomnia Questionnaire, a validated (area under the receiver operating characteristic curve, 0.86 compared with diagnoses based on blinded clinical reappraisal interviews), fully structured diagnostic interview. Eighteen other chronic conditions were assessed with medical/pharmacy claims records and validated self-report scales. Insomnia had a significant odds ratio with workplace accidents and/or errors controlled for other chronic conditions (1.4). The odds ratio did not vary significantly with respondent age, sex, educational level, or comorbidity. The average costs of insomnia-related accidents and errors ($32 062) were significantly higher than those of other accidents and errors ($21 914). Simulations estimated that insomnia was associated with 7.2% of all costly workplace accidents and errors and 23.7% of all the costs of these incidents. These proportions are higher than for any other chronic condition, with annualized US population projections of 274 000 costly insomnia-related workplace accidents and errors having a combined value of US $31.1 billion.

Conclusion: Effectiveness trials are needed to determine whether expanded screening, outreach, and treatment of workers with insomnia would yield a positive return on investment for employers.

Context: Young children raised in institutional settings experience severe deprivation in social, emotional, and cognitive stimulation. Although this deprivation is likely to disrupt brain development in ways that increase the risk for psychopathology, neurodevelopmental mechanisms linking adverse early environments to psychopathology remain poorly understood.

Objective: To examine whether abnormalities in the neural processing of facial and emotional stimuli are related to the high rates of psychopathology observed among institutionally reared children.

Design, setting, and participants: Data were drawn from the Bucharest Early Intervention Project, a cohort of children raised in institutions in Romania and an age-matched sample of community control subjects. At entry to the study (mean age, 22 months), event-related potentials were used to measure neural processing in 2 tasks: familiar and unfamiliar faces (n=114) and facial displays of emotion (n=74).

Main outcome measures: Psychiatric symptoms were assessed using the Preschool Age Psychiatric Assessment among children aged 54 months.

Results: As previously reported, institutionally reared children had elevated symptoms of attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and disruptive behavior compared with control children, and peak amplitudes of the P100 and P700 in response to facial stimuli were blunted among institutionalized children compared with community children in both tasks. Current analyses reveal that children with reduced P100 and P700 amplitudes in response to facial stimuli exhibited higher levels of ADHD and anxiety symptoms. Peak amplitude of the P700 in response to facial stimuli significantly mediated the association between institutional rearing and ADHD symptoms at 54 months.

Conclusion: Exposure to institutional rearing disrupts the P700, conferring risk for the onset of psychopathology. The high levels of ADHD symptoms among children exposed to early life deprivation may be attributable, in part, to abnormal patterns of neurodevelopment generated by these adverse rearing environments.

Context: Psychiatric disorders are prevalent among incarcerated juveniles. Most juveniles eventually return to their communities, where they become the responsibility of the community mental health system. However, no large-scale study has examined psychiatric disorders after youth leave detention.

Objective: To examine changes in the prevalence and persistence of psychiatric disorders during the 5 years after detention, focusing on sex and racial/ethnic differences.

Design: Prospective longitudinal study with up to 5 interviews (1829 youth: 1172 males and 657 females). To ensure representation of key demographic subgroups, the randomly selected sample was stratified by sex, race/ethnicity (African American, non-Hispanic white, and Hispanic), age, and legal status (juvenile or adult court).

Setting: The Northwestern Juvenile Project, sampling youth from the Cook County Juvenile Temporary Detention Center, Chicago, Illinois.

Participants: Detained youth, aged 10 to 18 years at baseline interview.

Main outcome measures: At baseline, the Diagnostic Interview Schedule for Children Version 2.3. At follow-up interviews, the Diagnostic Interview Schedule for Children Version IV (Child and Young Adult versions) and the Diagnostic Interview Schedule Version IV (substance use disorders and antisocial personality disorder).

Results: Five years after baseline, more than 45% of males and nearly 30% of females had 1 or more psychiatric disorders with associated impairment. More than 50% of males and more than 40% of females had 1 or more psychiatric disorders without impairment. Substance use disorders were the most common; males, however, had higher rates over time (5 years after baseline, adjusted odds ratio [AOR], 2.61; 95% CI, 1.96-3.47). Non-Hispanic whites and Hispanics also had higher rates of substance use disorders vs African Americans (AOR, 1.96; 95% CI, 1.54-2.49 and AOR, 1.59; 95% CI, 1.24-2.03). Females had higher rates of major depression over time (AOR, 1.59; 95% CI, 1.22-2.08).

Conclusions: Although prevalence rates of most psychiatric disorders declined as youth aged, a substantial proportion of delinquent youth continue to have disorders. There are notable sex and racial/ethnic differences in the prevalence and persistence of psychiatric disorders in this population.

Context: Recent neuroimaging studies have associated activity in the default mode network (DMN) with self-referential and pain processing, both of which are altered in borderline personality disorder (BPD). In patients with BPD, antinociception has been linked to altered activity in brain regions involved in the cognitive and affective evaluation of pain. Findings in healthy subjects indicate that painful stimulation leads to blood oxygenation level-dependent signal decreases and changes in the functional architecture of the DMN.

Objectives: To connect the previously separate research areas of DMN connectivity and altered pain perception in BPD and to explore DMN connectivity during pain processing in patients with BPD.

Design: Case-control study.

Setting: University hospital.

Participants: Twenty-five women with BPD, including 23 (92%) with a history of self-harm, and 22 age-matched control subjects.

Interventions: Psychophysical assessment and functional magnetic resonance imaging during painful heat vs neutral temperature stimulation.

Main outcome measure: Connectivity of DMN as assessed via independent component analysis and psychophysiological interaction analysis.

Results: Compared with control subjects, patients with BPD showed less integration of the left retrosplenial cortex and left superior frontal gyrus into the DMN. Higher BPD symptom severity and trait dissociation were associated with an attenuated signal decrease of the DMN in response to painful stimulation. During pain vs neutral, patients with BPD exhibited less posterior cingulate cortex seed region connectivity with the left dorsolateral prefrontal cortex.

Conclusions: Patients with BPD showed significant alterations in DMN connectivity, with differences in spatial integrity and temporal characteristics. These alterations may reflect a different cognitive and affective appraisal of pain as less self-relevant and aversive as well as a deficiency in the switching between baseline and task-related processing. This deficiency may be related to everyday difficulties of patients with BPD in regulating their emotions, focusing mindfully on 1 task at a time, and efficiently shifting their attention from one task to another.

Context: Focused hypnotic concentration is a model for brain control over sensation and behavior. Pain and anxiety can be effectively alleviated by hypnotic suggestion, which modulates activity in brain regions associated with focused attention, but the specific neural network underlying this phenomenon is not known.

Objective: To investigate the brain basis of hypnotizability.

Design: Cross-sectional, in vivo neuroimaging study performed from November 2005 through July 2006.

Setting: Academic medical center at Stanford University School of Medicine.

Patients: Twelve adults with high and 12 adults with low hypnotizability.

Main outcome measures: Functional magnetic resonance imaging to measure functional connectivity networks at rest, including default-mode, salience, and executive-control networks; structural T1 magnetic resonance imaging to measure regional gray and white matter volumes; and diffusion tensor imaging to measure white matter microstructural integrity.

Results: High compared with low hypnotizable individuals had greater functional connectivity between the left dorsolateral prefrontal cortex, an executive-control region of the brain, and the salience network composed of the dorsal anterior cingulate cortex, anterior insula, amygdala, and ventral striatum, involved in detecting, integrating, and filtering relevant somatic, autonomic, and emotional information using independent component analysis. Seed-based analysis confirmed elevated functional coupling between the dorsal anterior cingulate cortex and the dorsolateral prefrontal cortex in high compared with low hypnotizable individuals. These functional differences were not due to any variation in brain structure in these regions, including regional gray and white matter volumes and white matter microstructure.

Conclusions: Our results provide novel evidence that altered functional connectivity in the dorsolateral prefrontal cortex and dorsal anterior cingulate cortex may underlie hypnotizability. Future studies focusing on how these functional networks change and interact during hypnosis are warranted.

Context: People with autism spectrum disorders (ASDs) have lifelong deficits in social behavior and differences in behavioral as well as neural responses to facial expressions of emotion. The biological basis to this is incompletely understood, but it may include differences in the role of neurotransmitters such as serotonin, which modulate facial emotion processing in health. While some individuals with ASD have significant differences in the serotonin system, to our knowledge, no one has investigated its role during facial emotion processing in adults with ASD and control subjects using acute tryptophan depletion (ATD) and functional magnetic resonance imaging.

Objective: To compare the effects of ATD on brain responses to primary facial expressions of emotion in men with ASD and healthy control subjects.

Design: Double-blind, placebo-controlled, crossover trial of ATD and functional magnetic resonance imaging to measure brain activity during incidental processing of disgust, fearful, happy, and sad facial expressions.

Setting: Institute of Psychiatry, King's College London, and South London and Maudsley National Health Service Foundation Trust, England.

Participants: Fourteen men of normal intelligence with autism and 14 control subjects who did not significantly differ in sex, age, or overall intelligence.

Main outcome measures: Blood oxygenation level-dependent response to facial expressions of emotion.

Results: Brain activation was differentially modulated by ATD depending on diagnostic group and emotion type within regions of the social brain network. For example, processing of disgust faces was associated with interactions in medial frontal and lingual gyri, whereas processing of happy faces was associated with interactions in middle frontal gyrus and putamen.

Conclusions: Modulation of the processing of facial expressions of emotion by serotonin significantly differs in people with ASD compared with control subjects. The differences vary with emotion type and occur in social brain regions that have been shown to be associated with group differences in serotonin synthesis/receptor or transporter density.