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1.  [No title available] 
PMCID: PMC3985130  PMID: 24290079
2.  Validation of a modified version of the PRIME screen for psychosis-risk symptoms in a non-clinical Kenyan youth sample 
Comprehensive psychiatry  2013;55(2):380-387.
The PRIME screen is a self-administered questionnaire designed to quickly assess individuals at risk for developing a psychotic disorder. It is shorter in both length and administration time compared to the Structured Interview for Psychosis-Risk Syndromes (SIPS)—a standard instrument for psychosis prodromal risk assessment. Validation of the PRIME against the SIPS has not been reported in large non-clinical populations.
A culturally modified version of the PRIME screen (mPRIME) was administered to Kenyan youth between the ages of 14 and 29. 182 completed both the SIPS and mPRIME. Validation measures (sensitivity, specificity, positive predictive value, negative predictive value) were calculated and the study sample was then broken down into true positives, false positives, and false negatives for comparison on different quantitative measures.
Using previously suggested thresholds for a positive screen, the mPRIME had a sensitivity of 40% and a specificity of 64.8% for our entire sample. Positive predictive value (PPV) and negative predictive value (NPV) were 12.3% and 89.7%, respectively. Breaking the sample down by questionnaire outcome showed that true-positive individuals scored higher on average rate and intensity of endorsement of mPRIME items compared to false-positive and false-negatives, while false-negatives on average registered disagreement on all mPRIME questionnaire items.
The mPRIME does not appear to be an effective screener of at-risk individuals for psychosis in our non-clinical sample. Further validation efforts in other general populations are warranted.
PMCID: PMC4148134  PMID: 24262118
3.  Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review 
Comprehensive psychiatry  2013;55(2):233-247.
People with serious mental illness (SMI) die at least 11 years earlier than the general U.S. population, on average, due largely to cardiovascular disease (CVD). Disparities in CVD morbidity and mortality also occur among some U.S. racial and ethnic minorities. The combined effect of race/ethnicity and SMI on CVD-related risk factors, however, remains unclear. To address this gap, we conducted a critical literature review of studies assessing the prevalence of CVD risk factors (overweight/obesity, diabetes mellitus, metabolic syndrome, hypercholesterolemia, hypertension, cigarette smoking, and physical inactivity) among U.S. racial/ethnic groups with schizophrenia-spectrum and bipolar disorders.
Methods and Results
We searched MEDLINE and PsycINFO for articles published between 1986 and 2013. The search ultimately yielded 40 articles. There was great variation in sampling, methodology, and study populations. Results were mixed, though there was some evidence for increased risk for obesity and diabetes mellitus among African Americans, and to a lesser degree for Hispanics, compared to non-Hispanic Whites. Sex emerged as an important possible effect modifier of risk, as women had higher CVD risk among all racial/ethnic subgroups where stratified analyses were reported.
Compared to general population estimates, there was some evidence for an additive risk for CVD risk factors among racial/ethnic minorities with SMI. Future studies should include longitudinal assessment, stratification by sex, subgroup analyses to clarify the mechanisms leading to potentially elevated risk, and the evaluation of culturally appropriate interventions to eliminate the extra burden of disease in this population.
PMCID: PMC4164219  PMID: 24269193
4.  Tic Related Activity Restriction as a Predictor of Emotional Functioning and Quality of Life 
Comprehensive psychiatry  2013;55(1):10.1016/j.comppsych.2013.06.009.
Tourette Syndrome (TS) is a chronic neuropsychiatric condition that frequently persists into adulthood. Existing research has identified demographic and symptom-level variables associated with psychopathology and poor quality of life in TS. However, behavior patterns associated with enhanced or adaptive psychological and global functioning among adults with TS have yet to be empirically identified. The current study examined whether tic-specific activity restriction is related to emotional functioning and quality of life in adults with TS.
Participants were 509 adults from the Tourette Syndrome Impact Survey who completed self-report measures of demographics, tic severity, emotional functioning, quality of life, and tic related general and social activity restriction.
Partial correlations controlling for tic severity indicated that tic related general and social activity restriction were significantly correlated with lower quality of life and poorer emotional functioning. Hierarchical linear regression models indicated that activity restriction significantly predicted lower quality of life and poorer emotional functioning when controlling for tic severity and demographic variables.
Adults who restrict fewer activities due to tics, regardless of tic severity, experience greater quality of life and better emotional functioning. Clinically, adults with chronic tics may benefit from interventions focused on enhancing engagement in valued life activities.
PMCID: PMC3858466  PMID: 24156871
5.  An Investigation of the Relationship between Borderline Personality Disorder and Cocaine-related Attentional Bias Following Trauma Cue Exposure: The Moderating Role of Gender 
Comprehensive psychiatry  2013;55(1):10.1016/j.comppsych.2013.08.011.
Elevated rates of borderline personality disorder (BPD) have been found among individuals with substance use disorders (SUDs), especially cocaine-dependent patients. Evidence suggests that cocaine-dependent patients with BPD are at greater risk for negative clinical outcomes than cocaine-dependent patients without BPD and BPD-SUD patients dependent on other substances. Despite evidence that cocaine-dependent patients with BPD may be at particularly high risk for negative SUD outcomes, the mechanisms underlying this risk remain unclear. The present study sought to address this gap in the literature by examining cocaine-related attentional biases among cocaine-dependent patients with (n = 22) and without (n = 36) BPD. On separate days, participants listened to both a neutral and a personally-relevant emotionally evocative (i.e., trauma-related) script and then completed a dot-probe task with cocaine-related stimuli. Findings revealed a greater bias for attending to cocaine-related stimuli among male cocaine-dependent patients with (vs. without) BPD following the emotionally evocative script. Study findings suggest the possibility that cocaine use may have gender-specific functions among SUD patients with BPD, with men with BPD being more likely to use cocaine to decrease contextually induced emotional distress. The implications of our findings for informing future research on cocaine use among patients with BPD are discussed.
PMCID: PMC3858469  PMID: 24138957
Attentional bias; borderline personality disorder; substance use disorder; cocaine
6.  Interpersonal Problem Areas and Alexithymia in Adolescent Girls with Loss of Control Eating 
Comprehensive psychiatry  2013;55(1):170-178.
This study investigated the links among interpersonal problem areas, depression, and alexithymia in adolescent girls at high-risk for excessive weight gain and binge eating disorder. Participants were 56 girls (Mage = 14.30, SD = 1.56; 53% non-Hispanic White) with a body mass index (BMI, kg/m2) between the 75th and 97th percentiles (MBMI-z = 1.57, SD = 0.32). By design, all participants reported loss of control eating patterns in the past month. Adolescents were individually interviewed prior to participating in a group interpersonal psychotherapy obesity and eating disorder prevention program, termed IPT for the prevention of excessive weight gain (IPT-WG). Participants’ interpersonal problem areas were coded by trained raters. Participants also completed questionnaires assessing depression and alexithymia. Primary interpersonal problem areas were categorized as interpersonal deficits (as defined in the eating disorders (ED) literature) (n = 29), role disputes (n = 22), or role transitions (n = 5). Girls with interpersonal deficits-ED had greater depressive symptoms and alexithymia than girls with role disputes (ps ≤ 0.01). However, girls with role transitions did not differ from girls with interpersonal deficits-ED or role disputes. Interpersonal problem area had an indirect association with depression via alexithymia; interpersonal deficits-ED were related to greater alexithymia, which in turn, was related to greater depressive symptoms (p = 0.01). Among girls at-risk for excess weight gain and eating disorders, those with interpersonal deficits-ED appear to have greater distress as compared to girls with role disputes or role transitions. Future research is required to elucidate the impact of interpersonal problem areas on psychotherapy outcomes.
PMCID: PMC3954602  PMID: 24139852
adolescence; loss of control eating; interpersonal deficits; interpersonal psychotherapy; alexithymia
7.  The Association between Depression and Suicide When Hopelessness Is Controlled for 1 
Comprehensive psychiatry  2013;54(7):790-796.
We retested the relationship between major depression and suicide with hopelessness as a control variable, with the hypothesis that the strong relationship between depression and suicide will decrease or disappear when hopelessness is controlled for. Also, hopelessness can be accounted for by psychological strains resulted from social structure coupled with individual characteristics.
This was a case-control psychological autopsy study, in which face-to-face interviews were conducted to collect information from proxy informants for suicide victims and living subjects in rural Chinese 15–34 years of age who died of suicide (n=392) and who served as community living controls (n=416). Major depression was assessed by the Chinese version of the Structured Clinical Interview for DSM-IV (SCID). Hopelessness was measured by Beck Hopelessness Scale.
A strong association between major depression and suicide was observed after adjustment for socio-demographic characteristics. When hopelessness was added to the analysis, the depression-suicide relationship was significantly decreased in all the six regression models.
Although depression as well as other mental illness is a strong risk factor for suicide, depression and suicide are both likely to be related to hopelessness, which in turn could be a consequence of psychological strains resulted from social structure and life events. Future studies may examine the causal relations between psychological strains and hopelessness.
PMCID: PMC3745521  PMID: 23602028
Suicide; Depression; Hopelessness; Rural China; Strain Theory of Suicide
8.  Childhood sexual abuse increases risk of auditory hallucinations in psychotic disorders 
Comprehensive psychiatry  2013;54(7):1098-1104.
Previous studies point to an association between childhood sexual abuse (CSA) and auditory hallucinations (AH). However, methodological issues limit the strength of these results. Here we compared childhood abuse between psychotic disorder patients and healthy control subjects using a reliable measure of abuse, and assessed the relationship between CSA and AH.
114 psychotic disorder patients and 81 healthy control subjects were administered the Structured Clinical Interview of the DSM-IV (SCID) and the Childhood Trauma Questionnaire (CTQ). We compared the severity of abuse between groups, and tested the relationship between different types of childhood abuse and specific psychotic symptoms.
Psychotic patients reported more childhood abuse than controls (p<.001). Psychotic patients with a history of AH reported significantly more sexual, emotional, and physical abuse than patients without a history of AH (p<.05). Emotional and physical abuse, in the absence of sexual abuse, did not lead to a higher rate of AH. Finally, reports of childhood abuse did not increase the risk of any form of hallucination other than AH or of any form of delusion.
These results suggest that childhood abuse, especially childhood sexual abuse, shapes the phenotype of psychotic disorders by conferring a specific risk for AH.
PMCID: PMC3779472  PMID: 23815887
Childhood abuse; trauma; risk factors; auditory hallucinations; psychotic disorders; schizophrenia; psychosis
9.  Other- and Self-Directed Forms of Violence and Their Relationships to DSM-IV Substance Use and Other Psychiatric Disorders in a National Survey of Adults 
Comprehensive psychiatry  2013;54(7):731-739.
To examine associations between DSM-IV psychiatric disorders and other- and self- directed violence in the general population.
Data were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 & 2 (n=34,653). Four violence categories were derived from a latent class analysis (LCA) of 5 other-directed and 4 self-directed violent behavior indicators. Multinomial logistic regression examined class associations for gender, race-ethnicity, age and DSM-IV substance use, mood, anxiety, and personality disorders.
Approximately 16% of adults reported some form of violent behavior distributed as follows: other-directed only, 4.6%; self-directed only, 9.3%; combined self- and other-directed, 2.0%; and no violence, 84.1%. The majority of the DSM-IV disorders included in this study were significantly and independently related to each form of violence. Generally, other-directed violence was more strongly associated with any substance use disorders (81%) and any personality disorders (42%), while self-directed violence was more strongly associated with mood (41%) and anxiety disorders (57%). Compared with these two forms of violence, the smaller group with combined self- and other-directed violence was more strongly associated with any substance use disorders (88%), mood disorders (63%), and personality disorders (76%).
Findings from this study are consistent with recent conceptualizations of disorders as reflecting externalizing disorders and internalizing disorders. The identification of the small category with combined forms of violence further extends numerous clinical studies which established associations between self- and other-directed violent behaviors. The extent to which the combined violence category represents a meaningful and reliable category of violence requires further detailed studies.
PMCID: PMC3779474  PMID: 23587529
10.  Age at Onset and Clinical Correlates in Body Dysmorphic Disorder 
Comprehensive psychiatry  2013;54(7):893-903.
Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD.
Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD.
BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2.
BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.
PMCID: PMC3779493  PMID: 23643073
Body dysmorphic disorder; dysmorphophobia; age at onset; age of onset; comorbidity; symptom severity; quality of life; suicidality
11.  Substantial Weight Gains Are Common Prior to Treatment-Seeking in Obese Patients with Binge Eating Disorder 
Comprehensive psychiatry  2013;54(7):880-884.
This study examined weight trajectories in obese patients with binge eating disorder (BED) during the year prior to treatment initiation and explored potential correlates of these weight changes. One hundred thirty (N=130) consecutive, treatment-seeking, obese patients with BED were assessed with structured interviews and self-report questionnaires. Eighty-three percent (83%; n=108) of treatment seeking obese BED patients gained weight, and 65% (n=84) gained a clinically significant amount of weight (greater than or equal to 5% body weight), in the year preceding treatment. Overall, participants reported a mean percent weight gain of 8% (16.6 pounds) during the 12 months prior to treatment with a wide range of weight changes across participants (from a 52% weight gain to a 13% weight loss). A substantial proportion of patients (35%), categorized as High Weight Gainers (defined as gaining more than 10% of body weight during previous year), reported gaining an average of 16.7% of body weight. Low Weight Gainers (defined as gaining greater than 5%, but less than 10%) comprised 29% of the sample and were characterized by a mean gain of 6.9% of body weight. Weight Maintainers/Losers (defined as having maintained or lost weight during the 12 months prior to treatment) comprised 17% of the sample and reported losing on average 2.8% of body weight. These three groups did not differ significantly in their current weight and eating behaviors or eating disorder psychopathology. The majority of treatment-seeking obese patients with BED reported having gained substantial amounts of weight during the previous year. These findings provide an important context for interpreting the modest weight losses typically reported in treatment studies of BED. Failure to produce weight loss in these studies may be reinterpreted as stabilization of weight and prevention of further weight gain.
PMCID: PMC3779527  PMID: 23639407
12.  Examining the Relationship between Food Thought Suppression and Binge Eating Disorder 
Comprehensive psychiatry  2013;54(7):1077-1081.
Food thought suppression, or purposely attempting to avoid thoughts of food, is related to a number of unwanted eating- and weight-related consequences, particularly in dieting and obese individuals. Little is known about the possible significance of food thought suppression in clinical samples, particularly obese patients who binge eat. This study examined food thought suppression in 150 obese patients seeking treatment for binge eating disorder (BED). Food thought suppression was not associated with binge eating frequency or body mass index but was significantly associated with higher current levels of eating disorder psychopathology and variables pertaining to obesity, dieting, and binge eating.
PMCID: PMC3779532  PMID: 23751246
13.  A Clinically Useful Social Anxiety Disorder Outcome Scale 
Comprehensive psychiatry  2013;54(7):758-765.
Increasingly, emphasis is being placed on measurement-based care to improve the quality of treatment. Although much of the focus has been on depression, measurement-based care may be particularly applicable to social anxiety disorder (SAD) given its high prevalence, high comorbidity with other disorders, and association with significant functional impairment. Many self-report scales for SAD currently exist, but these scales possess limitations related to length and/or accessibility that may serve as barriers to their use in monitoring outcome in routine clinical practice. Therefore, the aim of the current study was to develop and validate the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS), a self-report measure of SAD. The CUSADOS was designed to be reliable, valid, sensitive to change, brief, easy to score, and easily accessible, to facilitate its use in routine clinical settings. The psychometric properties of the CUSADOS were examined in 2,415 psychiatric outpatients who were presenting for treatment and had completed a semi-structured diagnostic interview. The CUSADOS demonstrated excellent internal consistency, and high item-total correlations and test-retest reliability. Within a sub-sample of 381 patients, the CUSADOS possessed good discriminant and convergent validity as it was more highly correlated with other measures of SAD than with other psychiatric disorders. Furthermore, scores were higher in outpatients with a current diagnosis of SAD compared to those without a SAD diagnosis. Preliminary support also was obtained for the sensitivity to change of the CUSADOS in a sample of 15 outpatients receiving treatment for comorbid SAD and depression. Results from this validation study in a large psychiatric sample show that the CUSADOS possesses good psychometric properties. Its brevity and ease of scoring also suggest that it is feasible to incorporate into routine clinical practice.
PMCID: PMC3740001  PMID: 23642634
14.  The Role of Childhood Traumatic Experience in Personality Disorders in China 
Comprehensive psychiatry  2011;53(6):829-836.
There has been no large-scale examination of the association between types of childhood abuse and personality disorders (PDs) in China using standardised assessment tools and the DSM-IV diagnostic criteria. Hence, this study aimed to explore the relationship between retrospective reports of various types of childhood maltreatments and current DSM-IV PDs in a clinical population in China, Shanghai.
1402 subjects were randomly sampled from the Shanghai Psychological Counselling Centre. PDs were assessed using the Personality Diagnostic Questionnaire (PDQ4+). Participants were also interviewed using the Structured Clinical Interview (SCID-II). The Child Trauma Questionnaire (CTQ) was used to assess childhood maltreatment in five domains (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect).
According to Pearson's correlations, childhood maltreatment had a strong association with most PDs. Subsequently using partial correlations, significant relationships were also demonstrated between Cluster-B PDs and all the traumatic factors except physical neglect. A strongest positive correlation was found between Cluster-B PD and CTQ total scores (r=.312, p <.01). Using the Kruskal-Wallis rank sum test, significant differences in 4 groups of subjects (Cluster-A PD, Cluster-B PD, Cluster-C PD and Non-PD) in terms of emotional abuse (χ2 = 34.864, p <.01), physical abuse (χ2 = 14.996, p <.05), sex abuse (χ2 = 9.211, p <.05), and emotional neglect (χ2 = 17.987, p <.01) were found. Stepwise regression analysis indicated that emotional abuse and emotional neglect were predictive for Cluster-A PD and Cluster-B PD, and sexual abuse was highly predictive for Cluster-B PD, only emotional neglect was predictive for Cluster-C PD.
Early traumatic experiences are strongly related to the development of PDs. The effects of childhood maltreatment in the three clusters of PDs are different. Childhood trauma has the most significant impact on Cluster-B PD.
PMCID: PMC4159500  PMID: 22172919
Personality disorder; Childhood traumatic experience; China; Outpatient; Abuse; Neglect
15.  Childhood Maltreatment Profile in a Clinical Population in China: A Further Analysis with Existing Data of an Epidemiologic Survey 
Comprehensive psychiatry  2013;54(7):856-864.
To determine the lifetime prevalence and diverse profiles of types of childhood maltreatment (CM) in a high-risk clinical sample using standardized assessment tools (Child Trauma Questionnaire, CTQ) in China, Shanghai, 2090 subjects were sampled from the Shanghai Mental Health Centre. Personality disorder (PD) was assessed using the Personality Diagnostic Questionnaire (PDQ-4+) and subjects were interviewed using the Structured Clinical Interview (SCID-II). CTQ was used to assess CM in five domains (emotional abuse, EA; physical abuse, PA; sexual abuse, SA; emotional neglect, EN; and physical neglect, PN). The prevalence estimate of EA in the sample is 22.2%, followed by 17.8% of PA, and 12.5% of SA. The prevalence estimate was more frequent in PN (65.0%) and in EN (34.0%) than in childhood abuse (EA, PA and SA). It seems that males reported more PA and females reported more SA, the older subjects reported more neglect and the younger subjects reported more abuse. There was a higher prevalence of EA and SA in borderline PD patients (44.4%, 22.5%), PA in antisocial PD patients (38.9%). Multi-PD patients reported more forms of CM in childhood. Additionally, factor analysis of CTQ items confirmed factorial validity by identifying a five-factor structure that explained 50% of the total variance. These findings support the view that prevalence of CM was commonly experienced in clinical population during their childhood, especially for subjects with PDs. Factorial validity in PN needs to be further improved, and can in part be culturally explained.
PMCID: PMC4144995  PMID: 23597603
Childhood maltreatment; Personality disorder; Prevalence; Childhood trauma questionnaire; Neglect; Abuse; Culture; China; Outpatient
16.  Time to Emergence of Severe Suicidal Ideation among Psychiatric Patients as a Function of Suicide Attempt History 
Comprehensive psychiatry  2007;49(1):6-12.
Little is known about the emergence of suicidal ideation among psychiatric inpatients with histories of no, single, or multiple suicide attempts. We investigated differences in time to reemergence of severe suicidal ideation among psychiatric patients as a function of their suicide attempt histories.
One hundred seventeen individuals meeting criteria for a major depressive disorder who were recently discharged from a psychiatric hospital and participating in a larger study of treatments for depression were included in the current study. Suicidal ideation, depressive symptoms, hopelessness, and depressogenic cognitions were assessed at baseline, and suicidal ideation was assessed at 3, 6, 12, and 18 month follow up, as well as inpatient readmission if applicable. Time to the reemergence of severe suicidal ideation was analyzed using survival analysis.
Twenty-two percent of our sample reported the occurrence of severe suicidal ideation over an 18-month period. Severe suicidal ideation emerged earlier among patients who had a history of prior suicide attempts than those who did not, but single and multiple suicide attempters did not differ significantly in time to severe suicidal ideation. Suicide attempt history remained a significant predictor of time to severe suicidal ideation when statistically controlling for hopelessness, depressive symptoms, depressogenic cognitions, and suicidal ideation at admission and initial treatment group assignment, especially between single and non-attempters.
Although nearly a quarter of participants endorsed severe, clinically significant suicidal ideation within 18 months of discharge, those with suicide attempt histories reported the occurrence of severe suicidal ideation significantly earlier than those without suicide attempt histories.
PMCID: PMC4120022  PMID: 18063035
17.  Multimodal assessment of emotional reactivity in borderline personality pathology: The moderating role of posttraumatic stress disorder symptoms 
Comprehensive psychiatry  2013;54(6):639-648.
Emotional reactivity has been theorized to play a central role in borderline personality (BP) pathology. Although growing research provides evidence for subjective emotional reactivity in BP pathology, research on physiological or biological reactivity among people with BP pathology is less conclusive. With regard to biological reactivity in particular, research on cortisol reactivity (a neurobiological marker of emotional reactivity) in response to stressors among individuals with BP pathology has produced contradictory results and highlighted the potential moderating role of PTSD-related pathology. Thus, this study sought to examine the moderating role of PTSD symptoms in the relation between BP pathology and both subjective (self-report) and biological (cortisol) emotional reactivity to a laboratory stressor. Participants were 171 patients in a residential substance use disorder treatment center. Consistent with hypotheses, results revealed a significant main effect of BP pathology on subjective emotional reactivity to the laboratory stressor. Furthermore, results revealed a significant interaction between BP pathology and PTSD symptoms in the prediction of cortisol reactivity, such that BP pathology was associated with heightened cortisol reactivity only among participants with low levels of PTSD symptoms. Similar findings were obtained when examining the interaction between BP pathology and the reexperiencing and avoidance/numbing symptoms of PTSD specifically. Results highlight the moderating role of PTSD symptoms in the BP-reactivity relation.
PMCID: PMC3644527  PMID: 23375184
18.  Temporal associations between physical illnesses and mental disorders—Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 
Comprehensive psychiatry  2013;54(6):627-638.
Clinical and epidemiologic evidence has documented the significant associations between medical illnesses and psychiatric disorders. However, extensive research has focused on the comorbidity of medical conditions and depression, and most were cross sectional, focused on clinical samples, and grounded in DSM-III or DSM-III-R diagnostic criteria.
The current prospective investigation examined associations among medical conditions at baseline and incident psychiatric disorders over a 3-year follow-up, using data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
Overall, the 3-year incidence rates of DSM-IV substance use, mood and anxiety disorders ranged from 0.65% (bipolar II) to 5.2% (alcohol abuse). Multiple regression analysis was conducted to examine the prospective physical–mental associations, while controlling for sociodemographic characteristics, psychological stress and health-related risk factors, and comorbid physical and psychiatric disorders.
The present study represents, to our knowledge the largest population-based prospective study examining the physical–mental associations. Our results showed distinctly different patterns of comorbidity of medical illnesses with substance use, mood, and anxiety disorders. Stomach ulcer/gastritis, hypertension and arthritis emerged to be significant predictors of incident psychiatric disorders.
PMCID: PMC3931424  PMID: 23522830
19.  Cognitive and psychosocial functioning in bipolar disorder with and without psychosis during early remission from an acute mood episode: a comparative longitudinal study 
Comprehensive psychiatry  2013;54(6):618-626.
The current investigation aimed to extend previous findings, which linked psychosis in bipolar disorder (BD) to cognitive impairment during hospital discharge and readmission, by examining the recovery of patients with psychosis who were not re-hospitalized. The study compared mood, cognitive and functional outcomes in patients who had, versus had not, experienced psychosis during a recent psychiatric hospitalization. The hypothesis was that patients admitted to the hospital with psychosis would exhibit more residual symptoms, greater cognitive deficits, and lower psychosocial functioning than patients who presented to care without psychosis. Group differences were expected to emerge both at the time of hospital discharge and at a 3-month follow up.
Fifty-five participants (ages 18-59, 25 women, 20 with psychosis) with BD I disorder completed both assessments, which included a clinical and diagnostic interview, functional evaluation, and the administration of mood measures and a neuropsychological battery.
The groups were comparable with respect to illness history (e.g., number of previous hospitalizations, age of onset, employment). At discharge and follow-up, the group with psychosis exhibited more mood symptoms, obtained lower GAF scores, and performed more poorly on measures of memory and executive functioning. At follow-up, participants with psychosis exhibited poorer psychosocial adaptation.
It is possible that some of the observed group differences in cognitive functioning emerged due to differences in medication efficacy or side effects.
The results of this study support the hypothesis that psychosis in BD predicts limited recovery during early remission from mood disturbance, regardless of illness history.
PMCID: PMC4076957  PMID: 23357126
bipolar disorder; psychosis; cognitive impairment; psychosocial functioning
20.  Prevalence of Night Eating in Obese Individuals with Schizophrenia and Schizoaffective Disorder 
Comprehensive psychiatry  2012;54(3):276-281.
The prevalence of Night Eating Syndrome (NES) in the general population is estimated to be 1.5%, however, the rates among individuals with schizophrenia and schizoaffective disorder are not yet established. This study sought to examine the frequency and correlates of NES-related behaviors in a sample of obese patients with schizophrenia. One-hundred outpatients diagnosed with schizophrenia or schizoaffective disorders completed the self-report Night Eating Questionnaire (NEQ) and were then interviewed as a follow-up for the specific assessment of NES. Based on a diagnostic interview, 12% of this sample met full criteria for NES, with an additional 10% meeting partial criteria for NES. Based on the NEQ alone, 8% met full criteria with an additional 8% meeting partial criteria. Night eating behaviors were associated with increased insomnia and depression. Our findings suggest that screening for NES among patients with serious mental illness may efficiently identify a subgroup with additional clinical needs.
PMCID: PMC4088953  PMID: 22959340
Comprehensive psychiatry  2013;54(5):506-516.
The purpose of this investigation was to compare the latent structures of the interview (EDE) and questionnaire (EDE-Q) versions of the Eating Disorder Examination.
Participants were 280 children, adolescents, and young adults seeking eating disorder treatment. Two separate latent structure analyses (LSAs) were conducted; one used variables from the EDE as indicators and the other used the corresponding variables from the EDE-Q as indicators.
The EDE and EDE-Q models both yielded four-class solutions. Three of the four classes from the EDE-Q model demonstrated moderate to high concordance with their paired class from the EDE model. Using the EDE-Q to detect the EDE, the sensitivity and specificity of measuring certain classes varied from poor (18.6%) to excellent (93.7%). The overall concordance was moderate (κ=.49).
These data suggest that LSAs using the EDE and EDE-Q may be directly compared; however, differences between results may represent inconsistencies in response patterns rather than true differences in psychopathology.
PMCID: PMC3687014  PMID: 23375185
22.  An Examination of Food Addiction in a Racially Diverse Sample of Obese Patients with Binge Eating Disorder in Primary Care Settings 
Comprehensive psychiatry  2013;54(5):500-505.
The concept of food addiction in obesity and binge eating disorder (BED) continues to be a hotly debated topic yet the empirical evidence on the relationship between addictive-like eating and clinically relevant eating disorders is limited. The current study examined the association of food addiction as assessed by the Yale Food Addiction Scale (YFAS) with measures of disordered eating, dieting/weight history, and related psychopathology in a racially diverse sample of obese patients with binge eating disorder (BED).
A consecutive series of 96 obese patients with BED who were seeking treatment for obesity and binge eating in primary care were given structured interviews to assess psychiatric disorders and eating disorder psychopathology and a battery of self-report measures including the YFAS to assess food addiction.
Classification of food addiction was met by 41.5% (n=39) of BED patients. Patients classified as meeting YFAS food addiction criteria had significantly higher levels of negative affect, emotion dysregulation, and eating disorder psychopathology, and lower self-esteem. Higher scores on the YFAS were related to an earlier age of first being overweight and dieting onset. YFAS scores were also significant predictors of binge eating frequency above and beyond other measures.
Compared to patients not classified as having food addiction, the subset of 41.5% of BED patients who met the YFAS food addiction cut-off appear to have a more severe presentation of BED and more associated pathology.
PMCID: PMC3638060  PMID: 23332551
23.  Hierarchical Organization of Axis I Psychiatric Disorder Comorbidity through Age 30 
Comprehensive psychiatry  2013;54(5):523-532.
Hierarchical models of psychopathology based on substantial numbers of lifetime diagnostic categories have not been sufficiently evaluated, even though such models have relevance for theories of disorder etiology, course, or prognosis. In this research, a hierarchical component model of 16 Axis I disorders is derived, and model elements are evaluated in terms of their ability to demonstrate distinct associations with several clinically–relevant variables. Participants were 816 randomly selected adolescents from the community who were repeatedly assessed for psychiatric disorders and associated risk and protective factors over a 14-year period. First-degree relatives were also interviewed to establish their lifetime psychiatric history. Patterns of lifetime comorbidity among 16 psychiatric disorders were described at five levels of organization. In addition to the broadest level that accounted for the most variance in disorder covariation, evidence was obtained at successive levels in the hierarchy for internalizing and externalizing broad–band domains that could be subdivided into more refined clusters. The validity and potential utility of the resultant hierarchical model was further supported by distinct associations that components at each level had with exposure to childhood adversities, psychiatric disorders among first–degree relatives, and psychosocial functioning at ~ age 30. A large number of DSM Axis I disorders can be described within broad–band internalizing and externalizing domains, and further differentiation within these domains is possible and likely useful for some purposes. Implications of this research for conceptualizing relations among psychiatric disorders are discussed.
PMCID: PMC3638082  PMID: 23332721
Internalizing disorders; externalizing disorders; hierarchical organization; familial risk; mental health care utilization; psychosocial functioning
24.  Prospective Investigation of a PTSD Personality Typology among Individuals with Personality Disorders 
Comprehensive psychiatry  2011;53(5):441-450.
This study investigated the replicability of a previously proposed personality typology of posttraumatic stress disorder (PTSD) and explored stability of cluster membership over a six-month period. Participants with current PTSD (n = 156) were drawn from the Collaborative Longitudinal Study of Personality Disorders (CLPS). The CLPS project tracked a large sample of individuals who met criteria for one of four target diagnoses (borderline, schizotypal, avoidant, and obsessive-compulsive) and a contrast group of individuals who met criteria for depression but no personality disorder. A cluster analysis using scales from the Schedule of Nonadaptive and Adaptive Personality yielded three clusters: “internalizing,” “externalizing,” and “low pathology.” Using K-means cluster analysis, the results did not replicate prior work. Using Ward’s method, the hypothesized 3-cluster structure was confirmed at baseline, but did not demonstrate temporal stability at 6 months.
PMCID: PMC4050668  PMID: 21864834
Posttraumatic stress disorder; internalizing/externalizing psychopathology; cluster analysis; prospective study
25.  Using the Children’s Depression Inventory in Youth with Inflammatory Bowel Disease: Support for a Physical Illness-Related Factor 
Comprehensive psychiatry  2012;53(8):1194-1199.
The objective of the present investigation was to evaluate the factor structure of the Children’s Depression Inventory (CDI) in adolescents with inflammatory bowel disease (IBD) in order to better understand the CDI’s psychometric properties in a medically complicated population. An exploratory factor analysis (EFA) was performed on CDI data collected from a clinical sample of 191 youth with IBD, aged 11 to 17 years. EFA with quartimax rotation yielded 3 factors: Mood, Behavioral/Motivational, and Somatic Complaints. Only the Somatic factor (i.e., fatigue, sleep, decreased appetite, worry about aches and pain) showed a significant positive correlation with IBD severity. The CDI holds promise as a brief measure for the assessment of depressive features psychometrically independent of IBD severity and common steroid treatments, as well as of non-gastrointestinal specific somatic complaints in a sample of adolescents with IBD. Continued work in this area of research appears promising in honing the assessment of depressive and somatic symptoms in youths with IBD.
PMCID: PMC4017927  PMID: 22682678
depression; physical illness; adolescence; factor analysis; Crohn’s disease; ulcerative colitis

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