Searching for secure bases in attachment-focused group therapy: Reaction to Kilmann et al. (1999).

The appropriateness of P. R. Kilmann et al.'s (see record 1999-13879-006) treatment intervention is reviewed in light of attachment theory. As is widely known, J. Bowlby wrote extensively about childhood antecedents of later psychopathology. Not so widely known are Bowlby's insights regarding an attachment–theoretical understanding of therapy and therapeutic change. Bowlby's therapeutic perspective is described, beginning with the notion of the "secure base" and its special relevance for therapy, followed by a discussion of general and specific goals for successful therapy. Kilmann et al.'s treatment is then analyzed with respect to Bowlby's ideas, with suggestions for future research on attachment-focused intervention with individuals experiencing relationship difficulties. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Reactance as a Predictor of Outcome in the Treatment of Chronic Depression.

This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), or combination therapy. Contrary to our hypotheses, reactance positively predicted treatment outcome in CBASP on 2 of 4 scales. These effects were independent of the therapeutic alliance, which also positively predicted outcome. Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP. The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship. Results support the importance of Aptitude × Treatment interactions in psychotherapy outcome. The direction and significance of such interactions may vary with different forms of psychopathology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The importance of nonshared (E?) environmental influences in behavioral development.

Defines "nonshared" influences as those that make siblings different from one another and suggests that such influences account for any substantial variation in personality, cognition, and psychopathology. With the belief that this is especially true of environmental causes of variation, different types of nonshared environmental influence (NEI) are considered: accidental factors, sibling interaction, family structure, differential parental treatment, and extrafamilial networks. Though the preliminary evidence suggests that NEI's may be difficult to identify and that these influences may be relatively trait specific, a fuller understanding of NEI's will be possible only when research includes more than 1 member of a family. (42 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Decision support of clinical laboratory test by object-oriented data base

There is growing interest in the role of the nitric oxide (NO) pathway in idiopathic psychotic disorders such as schizophrenia. In this preliminary study, we examined the therapeutic efficacy of methylene blue (MB), a "downstream" inhibitor of one of NO's actions, administered orally as an adjuvant to conventional neuroleptic medications. Specifically, MB blocks NO's activation of soluble guanylyl cyclase. MB has previously been reported to have therapeutic effects in the treatment of psychosis and mania. Preclinical data also suggest that MB might possess antipsychotic potential. Participants in the current study were eight patients with schizophrenia who had incomplete responses to conventional antipsychotics (as evidenced by a Brief Psychiatric Rating Scale [BPRS] total score of 35 or more). These patients completed a 4-week open-label study with a 1 week "off", 2 week "on", and one final week "off" design. Measures of treatment efficacy were the BPRS, Schedule for the Assessment of Negative Symptoms, and Clinical Global Improvement Scale administered weekly. Final scores for each outcome measure item were based on the consensus of at least two trained raters present during each rating interview. A statistically significant, albeit modest, decrease in the severity of psychopathology was observed while the subjects were taking MB, and psychopathology significantly worsened when MB was discontinued. The results suggest a need for further study with MB or perhaps other NO-dependent guanylyl cyclase-inhibiting medications.     

Lobular carcinoma of the breast: cytological features supporting the diagnosis of lobular cancer

Lobular carcinomas have a distinct natural history with a better response to endocrine therapy and a higher incidence of local recurrence and are more often bilateral. The cytological diagnosis of lobular carcinoma permits a discriminating therapeutic approach with pre-operative Tamoxifen, more generous resection margins, and assessment of the contralateral breast. The cytological features of lobular cancer however are not well defined and the low cell yield from such neoplasms can result in a high false negative rate. To determine whether we could improve the pre-operative diagnosis, we reviewed the cytological features of 112 lobular carcinomas. They had small uniform sized nuclei with irregular outlines and inconspicuous nucleoli. The degree of dissociation was similar to duct carcinomas and the incidence of inadequate aspirates was no higher. We found no features that confidently diagnosed lobular cancer or its sub-types. However, using a combination of features, typing of lobular cancer on aspirated material is possible and should be attempted.     

Vers une compréhension de la dépression dans la perspective des femmes: Exploration de la contribution des approches de la recherche qualitative.

Provides an introduction to the special issue of Canadian Psychology on depression in women. "Depression" is recognized as one of the more common mental health problems and also one that is particularly prevalent among women. One major limitation of mainstream theorizing is the taken-for-granted view of depression as a form of internal "psychopathology," a phenomenon which can be understood without regard to sociocultural context. An approach that avoids this limitation is one in which contextual aspects of women's lives are included from the outset by following a research process that begins with the lived experiences of women. A focus on women's experiences also leads to consideration of the contributions of qualitative approaches to research on depression which are compatible with both a feminist standpoint perspective and social constructionist epistemologies. The articles in this special issue are intended to contribute to the development of new knowledge about depression in women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward an understanding of depression from the standpoint of women: Exploring contributions of qualitative research approaches.

Provides an introduction to the special issue of Canadian Psychology on depression in women. "Depression" is recognized as one of the more common mental health problems and also one that is particularly prevalent among women. One major limitation of mainstream theorizing is the taken-for-granted view of depression as a form of internal "psychopathology," a phenomenon which can be understood without regard to sociocultural context. An approach that avoids this limitation is one in which contextual aspects of women's lives are included from the outset by following a research process that begins with the lived experiences of women. A focus on women's experiences also leads to consideration of the contributions of qualitative approaches to research on depression which are compatible with both a feminist standpoint perspective and social constructionist epistemologies. The articles in this special issue are intended to contribute to the development of new knowledge about depression in women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contribution of molecular biology to the diagnosis of monogenic hereditary nephropathies

Schematically, gene identification can be achieved by functional cloning, based on preexisting knowledge about the basic biochemical defect, positional cloning, initiated by the mapping of the responsible gene to its correct location on a chromosome, or by a combination of these two approaches called "candidate gene" approach. Genes of numerous monogenic hereditary renal disorders have been identified during the last few years by one of these approaches, particularly, the PKD1 and PKD2 genes involved in autosomal dominant polycystic kidney disease, as well as the genes encoding different type IV collagen alpha chains, responsible for Alport syndrome. This allows novel insights in the understanding of the pathogenesis of hereditary renal diseases and has opened new areas of genetic diagnosis.     

Management of follicular lymphoma

Despite the fact that a small proportion of patients with follicular lymphoma may be alive 20 years after the initial diagnosis, and that it is repeatedly, albeit usually only partially, responsive to relatively mild therapy, the disease remains stubbornly incurable for the majority. Therefore, the testing of several new therapeutic approaches is welcome. Interferon has been investigated in two settings: in combination with conventional therapy and as "maintenance" following chemotherapy. Prolongation of remission duration has been demonstrated and one study shows a survival advantage. The purine analogue fludarabine, having originally been shown to induce remissions in patients with chronic lymphocytic leukemia, is also effective in follicular lymphoma, although its precise role remains to be determined. Myeloablative therapy with autologous bone marrow transplantation (which has been the subject of much debate and controversy in the context of low-grade lymphoma), has been shown to prolong duration of remission, although presently, there is no survival advantage. Finally, radiolabeled antibody therapy is showing promise in patients in whom other treatment modalities have failed. The significance of "minimal residual disease" manifest as circulating t(14;18)-containing cells, as demonstrated by polymerase chain reaction analysis awaits clarification.     

Methadone Patients: dosage, psychopathology, and research participation

High and low dose methadone patients from a private methadone clinic were studied to determine whether severity of psychopathology is correlated with methadone dosage. It was found that methadone dosage was not positively correlated with psychopathology, but that diffuse nonspecific psychopathology was observed in all participants. Despite financial incentives it was very difficult to obtain the participation of many individuals in the clinic, and those who agreed to participate saw the research as a means to obtain personal psychiatric treatment. This differential participation based on viewing the research as "therapeutic" must be considered in future evaluation of methadone treatment.     

A return to the source: Rereading Freud in the midst of contemporary trauma theory.

In the current, often contentious, climate that surrounds childhood sexual trauma and its relation to adult forms of psychopathology, Freud's theorizing has received a great deal of attention. There has been much discussion and speculation about the role sexual trauma played in his thinking about psychopathology. While some theorists suggest that Freud overlooked and even suppressed his patients' reports of sexual trauma when he moved from his "seduction" theory to his "fantasy" theory, others suggest that his revision was an extension, rather than a reversal, of his early theorizing. This article will review in detail the development and revisions of Freud's thinking. It will also suggest areas of agreement between Freud's thinking and some contemporary trauma theory, as well as point to areas of divergence. The therapeutic implications of adopting some versions of contemporary trauma theory will also be developed. The aim is to stimulate further discussion about this issue in terms of its theoretical and therapeutic implications. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alternative approaches to refractory depression in bipolar illness

Thus, there appears to be a large variety of approaches to refractory bipolar depression. In contrast to several decades ago, wherein augmentation of lithium with antidepressants and neuroleptics was essentially the only treatment mode available, a panoply of treatment options now exist. However, their relative efficacy in different illness subtypes and stages remains to be better delineated, as do their optimal sequencing and use in combination in individual patients. It is the opinion of these authors and many of our colleagues in the field that initial use of several mood stabilizer drugs in combination may have a preferable long-term outcome in some rapid cycling patients, compared with the immediate use of a unimodal antidepressant with an inadequate single mood stabilizer, although this remains to be systematically studied. The use of thyroid augmentation strategies would appear to have merit in relationship to not only the potential treatment of lithium-related hypothyroidism, but also in augmenting antimanic and antidepressant effects. As one moves toward some of the complex combination treatment strategies discussed in this chapter, one has to be particularly careful about drug interactions and their potential for toxicity as well as therapeutic effects. Perhaps a prevailing guideline would be to use these agents more carefully in combination therapy than in monotherapy, with slow upward titration of dose to individual patients' side effects thresholds, even in preference to targeting of conventional blood level windows. In this way, side effects can be avoided during the assessment of complex combination regimens. In addition, one should be aware of potential pharmacokinetic interactions. For example, with the addition of valproate to carbamazenine, one should reduce the dose of carbamazepine, as valproate will not only increase the free fraction of carbamazepine based on displacement of protein binding, but will lead to increased accumulation of carbamazepine-10,11-epoxide. This epoxide is not measured in conventional assays but could contribute to the side effects profile (Ketter and Post, 1994). Similarly, valproate will markedly increase blood levels of lamotrigine; the starting dose of this agent should be substantially lower than conventional dosage when these two drugs are used in combination. We suggest the utility of detailed mapping with a formal system-such as the Life Chart Methodology (LCM) (Leverich and Post, 1996)-of mood fluctuation vs. medications in order to optimize and rationalize complex combination therapy. In this way, not only can the nuances of partial response be better defined, but also basic decisions about the therapeutic index and relative likelihood of response can be more readily assessed. We have discussed the other merits of the life chart method as an important clinical treatment tool as well as a research tool in other venues, but reemphasize its potential great importance in the treatment of refractory cyclic bipolar patients, in whom an initial period of remission of depression may, in many instances, be as likely attributable to the natural course of illness as the current intervention being offered. As such, it behooves the clinician to have a systematic database for the more subtle issues of dose titration and sequential addition of medications in complex combination regimens. In the face of inefficiency to one combination strategy, how one moves to the next strategy remains a highly individualized, clinically-based algorithm. We suggest the potential utility of moving towards a new set of mood stabilizers and then repeating some of the unimodal antidepressant additions and augmentation trials in an attempt to overcome refractory depression. Refractory depression in bipolar patients should be viewed as a medical emergency in light of the high potential for suicide in the illness in general (Chen and Dilsaver, 1996) and in patients who have either sustained or episodic refracto     

Making personalized health care more precise: Implications of neuroscientific findings.

The individualization of health care occurs when knowledge of what is best for a specific patient is used in a specific treatment situation. Currently the treatment of a patient is dependent on a set of primarily medical parameters that help to individualize the chosen therapy. In the future, supplementary parameters will be needed to enhance therapy success. One possible parameter would be the use of information about the personality of the patient. This article will first review given findings about the relation between personality and health. Subsequently the implications of these findings will be explored and a research proposal will be presented. A literature review was conducted, including articles that discuss the relationship between personality and health in a theoretical or empirical manner. The analysis focused on studies using the NEO-FFI or the TCI in combination with a psychological or somatic illness. Studies of personality measures show a variety of relationships between personality traits and morbidity, even for somatic illnesses. In addition to the existing parameters used to determine therapy, personality data could help determine a more precise etiology, diagnosis and therapy for the individual patient. Also new possibilities are created for a more compatible form of doctor-patient relationship, as well as a more structural approach to strengthen the patient orientation of the physician. Implementing this approach will require extensive discourse about the implied ethical aspects. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Advances and perspectives in acne therapy

Acne is one of the most common diseases in dermatology. It is of considerable esthetic significance, which explains the mental stress in affected patients. Although acne almost always heals spontaneously in early adulthood, treatment measures can shorten the course, reduce the severity of the disease, and avoid complications such as scarring. Treatment has changed substantially in recent years. In accordance with pathogenic principles, effective treatment is possible. In most patients, a combination of drugs aimed at correcting abnormal keratinization and reducing the proliferation of Propionibacterium acnes is sufficient to control the disease. For more severely affected patients with no response to this approach, therapy to suppress sebum production is indicated. Of all therapeutic modalities available, only oral isotretinoin alters the natural course of the disease. In acne inversa, surgical management should be undertaken as early as possible.     

Neurotic excoriations and dermatitis artefacta

Patients with different psychiatric disorders produce artefacts on the skin, each requiring a different therapeutic approach. These different disorders are outlined briefly. The clinical picture, pathology, psychopathology, differential diagnosis, treatment, course, and prognosis of dermatitis artefacta and neurotic excoriations are reviewed in greater detail.     

Interaction, language and the "narrative turn" in psychotherapy and psychiatry

The traditional emphasis in psychiatry about "listening to patients" has recently been added to by the development of what we call the "narrative turn" in mental health care where clients' narratives are emphasised. We shall argue however that both approaches tend to embody similar assumptions about therapeutic transactions and roles, and that much work emphasising narratives reveals little about how therapists and researchers work to reconstruct the clients' accounts. It is therefore vital that the emphasis on narratives be supplemented by a more thoroughgoing approach to shared structures of knowledge which act to prefigure clients' distress, how professional records are a profoundly transformative medium, and how therapeutic encounters work to co-construct clients' narratives, rather than simply reflect or explore them. The radical implications of thinking about therapy in terms of narrative and language need to be more fully discussed in the therapy literature, so the narrative turn does not simply reproduce the common-sense assumptions of more conventional approaches.     

Combined therapy: A cognitive psychoanalytic approach.

Contends that cognitive-psychoanalytic clinical and theoretical considerations support a rationale for combined therapy. The interpenetrative transactions of the individual and group sessions delineate irrational beliefs and belief systems based on unrealistic expectations of threat and injury. The reconstructive aim is to resolve the members' idiosyncratically evolved psychopathology to whatever extent is possible. Detailed probings and introspection are more characteristic of the individual sessions, while outer-directed behavior and defensive engagements are more typical of the group. The complementarity of each modality provides a unified, integrated, therapeutic experience. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Endogenous fungal endophthalmitis

Endogenous fungal endophthalmitis has increased in the past half-century because of the advent of antibiotics and indwelling catheters. The disease process can produce highly suggestive, though nonpathognomonic, ocular signs that assist the clinician in reaching a diagnosis. Intraocular inflammation, especially if it is granulomatous in nature in a patient with one or more of the risk factors already discussed, should raise the suspicion of fungal endophthalmitis. If a diagnosis remains elusive, vitreous biopsy is indicated for proper identification of a fungal organism. Although a particular therapeutic regimen has not yet been prospectively established, compelling arguments can be made to treat nearly all patients with endogenous fungal endophthalmitis with a systemic antifungal such as amphotericin B or fluconazole. A possible exception includes an IVDA-related endophthalmitis in a patient with negative blood cultures and without other evidence of fungemia. Vitrectomy and intravitreal amphotericin B (with or without intravitreal corticosteroid) should be considered in cases of endogenous fungal endophthalmitis in which there is substantial vitreous involvement, and also in cases in which there is clear progression of disease despite initial therapy with an appropriate systemic antifungal agent. Prompt therapy following early diagnosis will help reduce significant visual loss in all forms of fungal endophthalmitis.     

Late toxicity after chemotherapy of malignant testicular tumors

Improved survival in testicular cancer has been accompanied by concern about long-term side effects of chemotherapy or radiotherapy. Secondary malignant neoplasia represents one of the worst possible long-term complications, leading to death in patients cured of their primary malignancy. Patients with testicular germ cell tumors appear to have a 2-fold increased risk of developing any second cancer 25-30 years after the diagnosis, resulting in a cumulative incidence of 16-23% at that time. The risk for secondary solid tumors can be mainly attributed to radiotherapy. There is strong evidence of an increasing risk for secondary solid tumors with time since treatment. Tumor-specific analysis of the risk for second cancers revealed statistically significant excesses for stomach, pancreas, bladder, rectum, prostate, and kidney cancer, as well as for cancer of the thyroid, melanoma, sarcomas, and non-Hodgkin's lymphoma. No significantly elevated risk for secondary solid tumors was observed after treatment with chemotherapy alone. The risk of secondary leukemia was associated with both radiotherapy and in particular with chemotherapy. In recent clinical surveys of patients with testicular cancer, estimates of the risk of leukemia after chemotherapy have ranged from 10- to 300-fold. An elevated risk was observed within the first two decades after diagnosis, later the risk was as expected in the normal population. Etoposide seems to be leukemogenic, especially at cumulative doses higher than 2 g/m2, although the effects of dose and schedule as well as the effects of other cytotoxic agents and radiotherapy remain to be finally clarified. Based on currently available data in patients with testicular cancer, it can be concluded that a significant elevated risk for the development of secondary leukemia exits after chemotherapy. However this risk does by far not outweigh the therapeutic benefit of etoposid-based therapy in patients with germ cell tumors. Secondary Raynaud's phenomenon is the main late vascular toxicity affecting about one third of patients after curative chemotherapy for testicular cancer. Hypertension will occur in one fifths of the patients. The incidence of vascular toxicity appears to be lower following PEB-therapy compared to PVB-therapy and major vascular events seem to be rare. Other frequent symptomatic toxicities are ototoxicity and peripheral neuropathy. A major risk factor for the development of toxicity is the cumulative dose of cisplatin given. Alterations of gonadotropin levels and Leydig cell insufficiency persist in more than half of young patients cured from testicular cancer by cisplatin-based combination chemotherapy. Approximately one fourth of patients have low serum magnesium or phosphat levels, or elevated creatinine levels. These toxicities seldomly result in clinical symptoms. We conclude that 3-4 courses with bleomycin, cisplatin and etoposide in testicular cancer patients will only rarely lead to symptomatic impairment of organ functions and a decrease of quality of life. Germ cell cancers have served as a valuable model for the development of new treatment strategies contributing largely to defining the role of cisplatinum, etoposide and recently ifosfamide in medical oncology. However, germ cell cancer may also be a useful model for investigating the long term side effects of the oncological therapies. Thus, germ cell cancer is not only a "model for a curable neoplasm" (L.H. Einhorn) but can also be seen as a "model for the study of late sequelae of modern oncological therapies".