The effect of differences in objective and subjective definitions of childhood physical abuse on estimates of its incidence and relationship to psychopathology.

The relationship between objective and subjective definitions of physical abuse and the lifetime prevalence of depression was examined in 280 women attending a family medicine clinic at a large medical center. Based on their responses to a detailed questionnaire regarding discipline and abuse in childhood, 28.2% of these women were objectively defined as abused. Only 11.4% subjectively defined themselves as abused. The proportion of women who experienced depression during their lifetime was highest among those who defined themselves as abused (83%), intermediate among those who met objective criteria for having been physically abused, but did not define themselves as such (56%), and lowest among those who did not meet objective criteria for a history of physical abuse (35%). Similar relationships were found for history of psychotherapy, receipt of psychoactive medication, history of hospitalization for depression, suicide attempts and self-injury.

Self-reported childhood abuse in an adult population in a primary care setting. Prevalence, correlates, and associated suicide attempts.

OBJECTIVE: To describe the prevalence of childhood physical, sexual, and emotional abuse and suicide attempts in a sample of adult patients from a primary care setting and to examine the relationship between suicide attempts and a self-reported history of childhood abuse. DESIGN: Cross-sectional sampling via a self-administered survey that included an abuse questionnaire, the Inventory to Diagnose Depression, and questions regarding suicide. SETTING: University medical center family medicine practice. PATIENTS: A convenience sample of patients aged 18 years and older presenting for care. Of the 778 patients approached, 448 patients (58%) consented and returned their surveys. We report only on the 292 surveys (38%) returned with complete information. Subjects were predominantly middle class and white, with a mean age of 37 years. MEASUREMENT AND MAIN RESULTS: Forty-four percent of the patients reported experience of childhood abuse, and 22% reported multiple forms of abuse. Eighteen percent of abused vs 3% of nonabused patients (P = .00001) reported a history of suicide attempts. Being female, younger, and less educated were associated with any abuse. Females reported more sexual abuse; less educated patients, more physical abuse; and younger patients, more physical and sexual abuse and suicide attempts. Odds ratios for suicide attempts, when adjusted by abuse status, were 6.4 for any abuse (95% confidence intervals [CI], 2.4 to 17.6), 4.1 for sexual abuse (95% CI, 1.7 to 9.9), 3.7 for emotional abuse (95% CI, 1.4 to 10.0), and 1.2 for physical abuse (95% CI, 0.5 to 3.1). CONCLUSION: A history of childhood abuse was a common experience in this sample. Patients with a history of abuse, particularly sexual and emotional abuse, are at increased risk of suicidal behavior. To facilitate more appropriate care and treatment, primary care practitioners should question patients regarding a history of abuse.

Subtypes of psychiatric inpatient women who have been sexually abused.

The sexual abuse histories of 171 women admitted to a psychiatric inpatient service revealed that 40.3% had a positive history of sexual abuse. The DSM-III diagnoses made on discharge were not related to presence of abuse, age of abuse onset, duration and frequency of abuse, or relationship of the victim to the perpetrator. However, the diagnosis of personality disorder was associated with greater invasiveness of sexual abuse. Cluster analysis of the MMPIs provided by these women revealed four clusters. Membership in the more disturbed cluster was associated with a history of sexual abuse, but not with invasiveness, age of onset, relationship to the perpetrator, or duration and frequency of abuse. The implications of these findings for the role of mitigating factors, such as coping style and adaptation to stress, are discussed.

The woman who wanted electroconvulsive therapy and do-not-resuscitate status. Questions of competence on a medical-psychiatry unit.

A case involving an elderly woman suffering concurrently from serious psychiatric and medical illnesses is presented. Ethical considerations concerning her treatment on a medical-psychiatry unit are discussed with special attention to her requests for both electroconvulsive therapy (ECT) and do-not-resuscitate (DNR) status. The compatibility of simultaneous requests for ECT and DNR is examined on three levels. The effect of depression upon competence to request and refuse treatment is analyzed. This case illustrates a conflict between medical and psychiatric treatment goals and ethical traditions which will become more common as psychiatrists treat older and more medically ill patients.

Carbamazepine treatment for benzodiazepine withdrawal.

Nine patients were given carbamazepine before rapid discontinuation of benzodiazepines. Most patients had had long-term benzodiazepine treatment and had abused benzodiazepines; five had taken high doses. All patients tolerated rapid discontinuation well and none developed significant withdrawal symptoms.

Valproate in anxiety and withdrawal syndromes.

Various anticonvulsant medications may have efficacy in the treatment of certain anxiety states as well as withdrawal syndromes occurring after the discontinuation of sedative-hypnotic drugs and alcohol. Preclinical studies and limited anecdotal evidence suggest that valproate may be more effective in controlling panic than carbamazepine. In small studies valproate and carbamazepine have been shown as possible effective agents in the treatment of alcohol withdrawal. Some treatment-resistant patients with panic disorder may respond well to trials of certain anticonvulsants. It is also possible that some patients in the heterogeneous generalized anxiety disorder category may respond to valproate and carbamazepine, particularly in light of the similarity between this type of anxiety and the symptoms of alcohol and sedative-hypnotic drug withdrawal. While benzodiazepines clearly have an important role in the treatment of anxiety and withdrawal states, the role of nonbenzodiazepine anticonvulsants is a promising one which needs to be further delineated with careful, controlled studies.

Tricyclic antidepressants for chronic low-back pain. Mechanisms of action and predictors of response.

Patients with chronic low-back pain and depression were treated double blind with desipramine or doxepin. During this treatment several hypotheses regarding the modes of action of these drugs were examined. A low serotonin hypothesis was supported by the fact that patients who had pain relief following an acute challenge with fenfluramine, a relatively pure releaser of serotonin, were significantly more likely to have pain relief on either antidepressant. The antidepressants did not change cerebrospinal fluid (CSF) beta-endorphin levels, acute pain tolerance, or electromyogram (EMG) levels. The nonsedating antidepressant desipramine was as effective as doxepin; 60% of patients had significant pain relief. Pain relief was associated with depression relief, but several patients had only pain or depression relief. Patients who had a substantial physical basis for their pain responded as well as those who did not.

Skin conductance. A potentially sensitive and specific marker for depression.

Resting skin conductance levels (SCLs) were measured in 50 patients with unipolar depression, in 71 controls (control group 1), and in 334 "stressed" normal controls (control group 2) who were first parents of newborns. The depressed group had significantly (p less than .00001) lower SCLs than did either control group, but the two control groups did not differ from each other. For women a criterion of SCL less than 3.0 micronho/cm2 yielded a sensitivity of 95% (SE 4.4%) and a specificity of 91% (SE 5.0%) for Control Group 1. For males a criterion of SCL less than 4.8 yielded a sensitivity of 93% (SE 4.9%) and a specificity of 89% (SE 5.0%) for control group 1. There was no significant difference in SCL between drug-free and medicated patients. SCL was abnormally low in all depression subtypes.

A comparison of the acute effects of dextroamphetamine and fenfluramine in depression.

Fenfluramine (Fen) 40 mg, a selective releaser of serotonin, and dextroamphetamine (Dex) 15 mg were administered in a double-blind crossover design to 16 subjects with major affective disorder, depression. Three hours after administration both drugs significantly improved depression and improved vigor, fatigue, and confusion-bewilderment on the subscales of the Profile of Mood States. Dex was significantly better than Fen only on the vigor and fatigue subscales. Other data from this study suggest that when used acutely Fen can mimic long-term antidepressant effects, whereas the acute effects of Dex are similar to its stimulating effects in normals.

Skin conductance: a potentially sensitive test for depression.

The mean resting skin conductance level (SCL) in 31 inpatients with major unipolar depression was 2.63 mumho/cm2 +/- SD 1.41 compared to 7.81 mumho/cm2 +/- SD 3.0 in the control group. The best criterion below which an SCL could be considered abnormal was 4.3 mumho/cm2 with a resulting sensitivity of 87% and specificity of 89%. There was a significant difference in SCL between males and females but none between drug-free and medicated patients. SCL was abnormal in all depression subtypes. The SCL may represent a biological final common pathway in depression and may prove to be a very effective diagnostic test for depression.

Factitious mourning: painless patienthood.

Of 20 patients who falsely reported the deaths of loved ones in order to assume the patient role, most presented with depression and suicidal ideation secondary to reported multiple dramatic deaths for which there was no available verification, and many had histories of factitious physical symptoms, manipulative suicide attempts, substance abuse, and sociopathy. Diagnostic categories were of limited usefulness for these patients. Factitious symptoms can better be understood as one form of dysfunctional care-eliciting behavior. The authors recommend early and repeated confrontations in a firm but nonjudgmental manner combined with referral to outpatient psychotherapy focused on the underlying characterological problems.

Urinary 3-methoxy-4-hydroxyphenethylene glycol in the prediction of pain and depression relief with doxepin: preliminary findings.

A group of patients with both depression and chronic pain were treated with doxepin for 4 weeks. Elevated (above median) initial levels of urinary 3-methoxy-4-hydroxyphenethylene glycol (MHPG, a metabolite of central nervous system [CNS] norepinephrine metabolism) were found to be significantly related to final pain relief, but not to improvement in depression. Anxiety, as measured on the Zung Anxiety Scale, was an important covariable, as high anxiety levels were significantly associated with both higher MHPG levels and with pain relief. Possible biochemical and psychophysiological mechanisms associated with the modulation of pain are discussed.

Psychobiological markers in coexisting pain and depression: toward a unified theory.

Psychological and biological variables were examined in two groups of patients with both depression and pain. The relationship of these variables to severity of pain and to pain threshold was examined in a nontreatment evaluation group (N = 25), and their relationship to relief of pain and depression was examined n a doxepin-treated group (N = 16). Eighty-seven percent of the treatment group experienced some pain relief, and 56% experienced complete relief. In the nontreatment group, anxiety as measured on the Zung Anxiety Scale, depression as measured on the Hamilton Depression Scale, and urinary 3-methoxy-4-hydroxyphenylethylene glycol (MHPG) were all found to correlate significantly and positively with severity of pain as rated on the McGill Pain Questionnaire. Each of these variables was related to different dimensions of the pain experience as measured by the McGill-Melzack Pain subscales. Only anxiety correlated significantly with pain threshold. In the treatment group final pain relief was positively correlated with initial MHPG and anxiety and with improvement in depression. A theory unifying biological, psychological, and clinical experimental pain data is presented.

Change in auditory asymmetry with amobarbital: evidence of cerebral pharmacological asymmetry?

Eleven right-handed subjects were administered a dichotic listening test to assess cerebral hemispheric dominance, both under a drug-free condition and following systemic injection of the barbiturate, amobarbital. The finding of increased right ear advantage during the drug period reflects increased left cerebral dominance, and suggests that amobarbital may have an asymmetric, pharmacological effect on the two cerebral hemispheres.

The dexamethasone suppression test as a diagnostic aid in late onset paranoia.

A case of acute paranoia in a 64-year-old woman with a previous history of one depressive episode is described. Accurate diagnosis was hampered by her illogical and tangential answers to questions and the development of an organic brain syndrome while on neuroleptics and anticholinergics. She did not tolerate tricyclic antidepressants and was unresponsive to three electroconvulsive therapy (ECT) treatments. Because of the previous history of depression and the presence of some depressive symptoms, the possibility of a depression underlying her paranoid psychosis was considered. A dexamethasone suppression test (DST) was performed to confirm this and was found to be abnormal. ECT was then continued with the eventual result of complete remission in symptoms. The authors discuss the potential usefulness of the DST in confirming a diagnosis of depression in selected cases of late onset psychosis.