Mentalism, mechanisms, and medical analogues: reply to Wakefield (1998).

J. C. Wakefield's (1998) critique of W. C. Follette and A. C. Houts's (1996) article is addressed by raising questions about (a) mentalism as a framework for studying psychopathology, (b) the nature of inferred mechanisms and the process of making such inferences, and (c) the accuracy of claiming that the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association) expansion is analogous to the success of physical medicine. The authors argue that Wakefield's analysis of mental disorders leads to the conclusion that the modern DSMs are not reflective of the progress of physical medicine.

A behavior analytic conceptualization of personality disorders: a response to Clark, Livesley, and Morey.

Clark, Livesley, and Morey critically analyze some of the deficiencies in the DSM approach to classifying personality disorders that derive from the fact that the construct of personality disorders is inadequately specified. This response agrees with their criticism, but argues that any significant improvement will have to entail a theory based taxonomy. A taxonomic system must eventually be explained rather than be an explanation for behavior. The theory chosen must relate to the goals of those creating the classification system. This paper suggests that a taxonomic system that is tied to an experimentally based set of behavioral principles, and can provide treatment utility, would have advantages over DSM-IV. The paper than presents the outline of a classification system founded on behavior analytic principles.

MMPI-2 profiles of adult women with child sexual abuse histories: cluster-analytic findings.

This study used a cluster analysis to examine the clinical profiles of female survivors of child sexual abuse. Eighty-five participants who presented for group therapy to deal specifically with issues related to sexual abuse completed the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2; J. N. Butcher, W. G. Dahlstrom, J. R. Graham, A. Tellegen, & B. Kaemmer, 1989) as part of an extensive assessment procedure. The cluster-analytic procedure used in this study allowed 5 subgroups within the population to emerge, supporting the idea that women who report having been sexually abused as children are not a homogeneous group. Additional analyses indicated differences on the basis of cluster membership on the MMPI-2 content scales, as well other measures of psychological distress. The treatment implications of these findings are discussed.

Introduction to the special section on the development of theoretically coherent alternatives to the DSM system.

This introduction outlines a series of articles in the Journal of Consulting and Clinical Psychology that represent a theoretically organized challenge to the Diagnostic and Statistical Manual of Mental Disorders (DSM; e.g., 4th ed.; American Psychiatric Association, 1994). A criticism of the DSM is offered on the basis that a taxonomy based on inadequately explicated theory has not been and cannot be a successful basis for a scientific research program. The special section offers examples of behaviorally based alternative ways of understanding behavior of clinical interest. Others are invited to develop taxonomies based on different theoretically coherent foundations.

Models of scientific progress and the role of theory in taxonomy development: a case study of the DSM.

The proliferation of categories in recent editions of the Diagnostic and Statistical Manual of Mental Disorders (e.g., 4th ed.; DSM; American Psychiatric Association, 1994) is discussed as an indication that the underlying classification scheme is inadequate and unlikely to produce the scientific progress originally envisioned. In any nosological system, it eventually becomes necessary to reduce the number of categories by an organizing theory that describes the fundamental principles underlying the taxonomy. The DSM has put itself in an awkward position by claiming to be atheoretical. Although taking such a tack had historical advantages to promote the acceptability of the 3rd edition of the DSM, it now limits the progression of science. It is argued that the DSM should not be used as the basis for guiding scientific research programs because it emphasizes primarily behavioral topography rather than providing an explicit theory that would allow for an evaluation of scientific progress. Theoretically driven taxonomies should be allowed to compete on the basis of how successful they are at achieving their specified goals that might include illuminating etiology, course, and response to treatment. Such systems are not likely to attend primarily to behavioral topography alone and would probably organize behavior differently than the current categorical syndromes seen in the 4th edition of the DSM.

Spouse support and long-term adherence to lipid-lowering diets.

Social support is inversely associated with heart disease risk. Support may influence heart disease by encouraging health behavior change in high-risk individuals. This study examined the association between spouse support and maintenance of low-fat diets in men with hypercholesterolemia. Participants were 254 men enrolled in a 24-month randomized trial of lipid-lowering diets initiated in 1985 in Seattle, Washington. The Evaluation of Spouse Support, which assesses the extent to which spouses supported maintenance of lipid-lowering diets, was administered after the last of eight dietary classes and at 3, 12, and 24 months postinstruction. Attainment of dietary goals was determined from food records completed at the end of the class and at 3, 12, and 24 months. Compared with those in the lowest quartile, those in the highest quartile of support were more likely to attain dietary goals at 3 months (odds ratio (OR) = 4.5, 95% confidence interval (CI) 1.9-10.4), 12 months (OR = 5.5, 95% CI 2.4-12.5), and 24 months (OR = 3.9, 95% CI 1.7-9.3). Support was not associated with end-of-class dietary goal achievement. Social support may be an important factor in the maintenance of low-fat diets.

A self-capitalization model for building behavior analysis graduate programs.

The development of the Behavior Analysis Program at the University of Nevada through self-capitalization is described. With this model, both doctoral and master's degree programs were established at almost no cost to the university. Some of the problems encountered along the way, including gaining support for the original proposal, attracting and retaining high-quality faculty, engendering support from the Department of Psychology and the university, developing resources, and balancing academic with entrepreneurial demands are discussed, as are the solutions we have found for those problems.

Relationship of self-effecacy to cholesterol lowering and dietary change in hyperlipidemia.

This study examined whether self-efficacy was associated with lipid lowering and dietary change among men undergoing dietary counseling to lower cholesterol levels. Twenty-five hyperlipidemic men (total cholesterol ≧220 mg/dL) participated in four weeks of dietary instruction. Plasma lipids were measured prior to treatment, at posttreatment, and at three- and twelvemonth follow-up. Dietary intake and self-efficacy as measured by the revised Eating Self-Efficacy Scale (ESES-R) were assessed at pretreatment, posttreatment, and three-month follow-up. Pre-treatment to posttreatment increases in self-efficacy in situations characterized by negative affect were related to extent of lipid lowering and dietary change. Although subjects showed significant reductions in cholesterol levels following treatment, by one year, lipid levels had returned to pretreatment values. Factors related to long-term maintenance of dietary change and lipid lowering among hyperlipidemics merit further research.

A behavior-analytic view of psychological health.

This paper argues that a behavioral analysis of psychological health is useful and appropriate. Such an analysis will allow us to better evaluate intervention outcomes without resorting only to the assessment of pathological behavior, thus providing an alternative to the Diagnostic and Statistical Manual system of conceptualizing behavior. The goals of such an analysis are to distinguish between people and outcomes using each term of the three-term contingency as a dimension to consider. A brief review of other efforts to define psychological health is provided. Laboratory approaches to a behavioral analysis of healthy behavior are presented along with shortcomings in our science that impede our analysis. Finally, we present some of the functional characteristics of psychological health that we value.

Individual predictors of outcome in group treatment for incest survivors.

Sixty-five abused women who participated in time-limited group therapy were evaluated before treatment on demographic variables, sexual abuse history, characteristics of the family of origin, and initial levels of depression and distress. Hierarchical regression analyses were conducted to determine the impact of these variables on response to treatment. Results suggest that education, marital status, type of sexual contact, and initial levels of depression and distress predicted response to treatment. In addition, a history of previous therapy showed a tendency to interact with type of group format to predict outcome. Implications for therapy and further research are considered.

Effect of hypertonic glucose on the muscular cramps of hemodialysis.

The effect of hypertonic (50%) glucose injected for relief of hemodialysis-induced muscular cramps was studied in 15 chronically uremic, nondiabetic patients who experienced a total of 44 cramp episodes. In a double-blind trial either 50 mL (or less) of hypertonic glucose or physiologic (0.9%) saline solution was injected, and the therapeutic response was evaluated. Of a total of 44 episodes of cramps, 26 were treated with hypertonic glucose and 18 with normal saline. Treatment with hypertonic glucose relieved 17 of 26 episodes, in contrast to only five of 18 episodes relieved with 50 mL of normal saline (P less than 0.016). No complications related to hypertonic glucose administration were observed. Hypertonic glucose seems to be safe and effective for the relief of dialysis-induced cramps. It also avoids undesirable loading with sodium and mannitol, which have been suggested for treatment of dialysis-induced cramps.

Less dialysis-induced morbidity and vascular instability with bicarbonate in dialysate.

We devised three protocols to test the postulate that increased morbidity during high-efficiency dialysis with large-surface-area units (LS) might be due in part to the increased flux of bicarbonate out and acetate into the patient inherent is LS dialysis. The first protocol showed that with LS-acetate dialysis there was a marked fall in plasma bicarbonate and Pco2 during the first 3 to 4 h, followed by a rapid rise in bicarbonate above normal and return to control in Pco2. With LS-bicarbonate dialysis, these oscillations were largely eliminated. A second double-blind protocol showed that central nervous system-type symptoms noted during and after LS-acetate dialysis were reduced significantly by switching to LS-bicarbonate dialysis. The third protocol showed that with LS-carbonate the tolerable rate of ultrafiltration could be increased 67% compared with LS-acetate dialysis.

Uremic neuropathy: evidence of middle molecule toxicity.

Ten dialysis patients were followed in a prospective study to determine the neurotoxicity of metabolites in the middle molecule (MM) molecular weight (mol wt) range of 500-200 daltons/molecule. In the absence of readily available direct serum measurements of MM concentrations, a theoretically calculated dialysis index, D1(MM), which included the combined effects of dialysis and residual glomerular filtration rate (GFR) on MM removal was used to estimate changes in their predialysis concentrations. The ten patients were dialyzed on protocols which yielded a D1(MM) less than 1.0. Evidence of uremic neuropathy developed in six of these ten patients, and five of these six also developed a progression in their anemia. Two additional patients with no signs of neuropathy developed a progression in their anemia. One patient developed pericarditis with tamponade. A total of eight patients developed complications. One additional patient developed increased weakness, tiredness and general malaise without change in objective findings. When the dialysis therapy to reduce MM concentrations by increasing the D1(MM) above 1.0 was instituted, the complications were reversed. Our data support the findings of others, namely, that there are toxic substances in the MM mol wt range of 500-2000 daltons/molecule. However, a synergism between elevated concentrations of small molecules and MM cannot be ruled out.

Spontaneous retroperitoneal bleeding in patients on chronic hemodialysis.

Six patients developed spontaneous retroperitoneal bleeding while on maintenance dialysis (3% of all patients so treated). At the time of the bleeding episode, four patients were receiving Coumadin for prevention of recurrent clotting problems in external shunts. In three patients, including two who had not received Coumadin, bleeding developed while on dialysis. The presenting common symptoms and signs of retroperitoneal bleeding included sudden and progressive abdominal pain with blood pressure drop and subsequent development of an abdominal mass. These symptoms were associated with a falling hematocrit without any documented external blood loss and with suggestive X-ray changes, including absence of psoas shadow with soft tissue density. All six patients recovered. Treatment included blood transfusions, temporary regional heparinization, withdrawal of Coumadin, and bed rest. Surgical exploration was undertaken in two patients, but no obvious bleeding source was found. Anticoagulation therapy and functional platelet abnormalities may be contributory causes.