A meta-analytic approach to growth curve analysis.

A meta-analytic approach to growth curve analysis is described and illustrated by applying it to the evaluation of the Arizona Pilot Project, an experimental project for financing the treatment of the severely mentally ill. In this approach to longitudinal data analysis, each individual subject for which repeated measures are obtained is initially treated as a separate case study for analysis. This approach has at least two distinct advantages. First, it does not assume a balanced design (equal numbers of repeated observations) across all subjects; to accommodate a variable number of observations for each subject, individual growth curve parameters are differentially weighted by the number of repeated measures on which they are based. Second, it does not assume homogeneity of treatment effects (equal slopes) across all subjects. Individual differences in growth curve parameters representing potentially unequal developmental rates through time are explicitly modeled. A meta-analytic approach to growth curve analysis may be the optimal analytical strategy for longitudinal studies where either (1) a balanced design is not feasible or (2) an assumption of homogeneity of treatment effects across all individuals is theoretically indefensible. In our evaluation of the Arizona Pilot Project, individual growth curve parameters were obtained for each of the 13 rationally derived subscales of the New York Functional Assessment Survey, over time, by linear regression analysis. The slopes, intercepts, and residuals obtained for each individual were then subjected to meta-analytic causal modeling. Using factor analytic models and then general linear models for the latent constructs, the growth curve parameters of all individuals were systematically related to each other via common factors and predicted based on hypothesized exogenous causal factors. The same two highly correlated common factors were found for all three growth curve parameters analyzed, a general psychological factor and a general functional factor. The factor patterns were found to be nearly identical across the separate analyses of individual intercepts, slopes, and residuals. Direct effects on the unique factors of each subscale of the New York Functional Assessment Survey were tested for each growth curve parameter by including the common factors as hierarchically prior predictors in the structural model for each of the indicator variables, thus statistically controlling for any indirect effect produced on the indicator through the common factors. The exogenous predictors modeled were theoretically specified orthogonal contrasts for Method of Payment (comparing Arizona Pilot Project treatment or "capitation" to traditional or "fee-for-service" care as a control), Treatment Administration Site (comparing various locations within treatment or control groups), Pretreatment Assessment (comparing general functional level at intake as assigned by an Outside Assessment Team), and various interactions among these main effects. The intercepts, representing the initial status of individual subjects on both the two common factors and the 13 unique factors of the subscales of the New York Functional Assessment Survey, were found to vary significantly across many of the various different treatment conditions, treatment administration sites, and pretreatment functional levels. This indicated a severe threat to the validity of the originally intended design of the Arizona Pilot Project as a randomized experiment. When the systematic variations were statistically controlled by including intercepts as hierarchically prior predictors in the structural models for slopes, recasting the experiment as a nonequivalent groups design, the effects of the intercepts on the slopes were found to be both statistically significant and substantial in magnitude. (ABSTRACT TRUNCATED)

Pervasive emotion recognition deficit common to alexithymia and the repressive coping style.

OBJECTIVE: Previous research has demonstrated a deficit in the ability to recognize emotions in alexithymic individuals. The repressive coping style is thought to preferentially impair the detection of unpleasant compared with pleasant emotions, and the degree of deficit is typically thought to be less severe than in alexithymia. We compared emotion recognition ability in both individuals with alexithymia and those with the repressive coping style. METHODS: Three hundred seventy-nine subjects completed the 20-item Toronto Alexithymia Scale, the Levels of Emotional Awareness Scale, the Marlowe-Crowne Scale (a measure of repressive defensiveness), the Bendig Short Form of the Taylor Manifest Anxiety Scale, and the Perception of Affect Task. The Perception of Affect Task consists of four 35-item emotion recognition subtasks: matching sentences and words, faces and words, sentences and faces, and faces and photographs of scenes. The stimuli in each subtask consist of seven emotions (happiness, sadness, anger, fear, disgust, surprise, and neutral) depicted five times each. Recognition accuracy results were collapsed across subtasks within each emotion category. RESULTS: Highly alexithymic subjects (for all, p<.01) and those with low emotional awareness (for all, p<.001) were consistently less accurate in emotion recognition in all seven categories. Highly defensive subjects (including repressors) were less accurate in the detection of anger, sadness, fear, and happiness (for all, p<.05). Furthermore, scores on the Levels of Emotional Awareness Scale accounted for significantly more variance in performance on the Perception of Affect Task than scores on the Marlowe-Crowne Scale (p<.01). CONCLUSIONS: The results indicate that alexithymia and the repressive coping style are each associated with impairments in the recognition of both pleasant and unpleasant emotions and that the two styles of emotional self-regulation differ more in the magnitude than in the quality of these impairments.

Integrity and research: introducing the concept of dual blindness. how blind are double-blind clinical trials in alternative medicine?

Double-blind methodology is used in clinical studies to control for potential external or nonspecific influences such as belief and expectation, as well as to maintain as much objectivity as possible on the part of the researchers. Despite not being feasible in all medical disciplines, as in the case of some modalities of complementary and alternative medicine, there are numerous studies that spuriously claim its use. Distinctions and standards therefore need to be set to avoid misleading information. We propose a new term in research methodology, dual-blind, to describe a methodological alternative in which the caregiver is not blind but the patient and an external evaluator/investigator are. The term double-blind should be used strictly to describe a methodology in which both the patient and the caregiver are blind. Making the distinction between these two terms will result in more reliable reports of clinical trials and will support integrity in research.

Sociodemographic correlates of alexithymia.

The association between alexithymia and sociodemographic variables is not well understood. Previous studies using the current 20-item and previous 26-item versions of the Toronto Alexithymia Scale (TAS) have shown inconsistent associations with age, sex, socioeconomic status, and years of education. We tested 380 subjects from the community stratified equally across sex, five age groups, and three socioeconomic classes. In addition to the TAS-20, we also administered the Levels of Emotional Awareness Scale (LEAS), a behavioral measure of the ability to be aware of and represent emotions in words, a core component of alexithymia. The TAS-20 and LEAS were each correlated with age, sex, socioeconomic status (SES), and years of education (P < .01) in the same direction and to approximately the same degree. Alexithymia (or low emotional awareness) is associated with older age, male sex, lower SES, and fewer years of education. The TAS-20 and LEAS are only slightly correlated (r = -.19, n = 380, P < .001), but their correlation is largely accounted for by their shared variance with these demographic variables. The convergence of findings with these two quite different measures and the nature of their overlap support the validity of these associations between alexithymia and sociodemographic variables.

Calibration of measures for psychotherapy outcome studies.

Many findings in psychology, including those in psychotherapy, lack interpretability because measures are not in any meaningful metric. Measures need to be calibrated so as to endow them with inherent meaning. In particular, it is important to calibrate measures against behaviors and real events in people's lives. Approaches to calibrating measures include calibration against direct personal experience, against cross-experiential equivalents, and against cross-modal equivalents, to reflect empirically established behavioral implications as well as just noticeable differences in behavior or between people. Psychological measures may never be as closely calibrated as those for physical properties, but wider reporting of unstandardized regression equations would be of great help. Psychological measures also need to be calibrated against each other so as to permit easy transformations of values or substitutions of measures. Finally, greater standardization of measures is recommended so as to produce better bases for calibration.

Impaired verbal and nonverbal emotion recognition in alexithymia.

Although clinical observations suggest that alexithymic individuals have a deficit in their ability to recognize emotional stimuli and that this deficit is not simply due to a problem in verbal labeling, these two hypotheses have not been empirically confirmed. Three hundred eighty participants in a community survey without current or past histories of psychiatric disorder completed two independent measures of alexithymia [the Levels of Emotional Awareness Scale (LEAS) and the Toronto Alexithymia Scale (TAS-20)] and the Perception of Affect Task (PAT), a 140-item measure of the ability to match emotion stimuli. The PAT includes four subtasks that require the subject to match verbal or nonverbal emotion stimuli with verbal or nonverbal emotion responses. The subtasks include matching sentences and words (verbal-verbal), faces and words (nonverbal-verbal), sentences and faces (verbal-nonverbal), and faces and photographs of scenes (nonverbal-nonverbal). Across the entire sample, higher (alexithymic) TAS-20 and lower LEAS scores were both correlated with lower accuracy rates on each of the subtasks of the PAT (p < .001), accounting for 10.5% and 18.4% of the variance, respectively. Fifty-one subjects met TAS-20 criteria for alexithymia. Alexithymic individuals scored lower than other subjects on purely nonverbal matching, purely verbal matching, and mixed verbal-nonverbal matching (all p < .001). These results suggest that alexithymia is associated with impaired verbal and nonverbal recognition of emotion stimuli and that the hallmark of alexithymia, a difficulty in putting emotion into words, may be a marker of a more general impairment in the capacity for emotion information processing.

Recipes for psychotherapy.

Stiles and Shapiro (1994) try to make a case for abandoning the model of drug research in exploring psychotherapy effectiveness--specifically, the idea that psychotherapy can be viewed in terms of effective "ingredients." Although provocative, their analysis can be challenged on methodological grounds involving failure to use multivariate analytic approaches, incomplete exploitation of advantages of growth curve analysis, and lack of attention to issues of statistical power. Acceptance of the conclusions proffered by Stiles and Shapiro would have negative effects on psychotherapy research and practice, and the case against the search for effective elements in psychotherapy process is not yet strongly made.

Effects of non-right-handedness on risk for sudden death associated with coronary artery disease.

The hypothesis that non-right-handedness is associated with sudden cardiac death was tested based on evidence that sympathetic imbalance may contribute to ventricular arrhythmogenesis and evidence that left-handers may have a shorter lifespan than right-handers. The study included 26 patients with coronary artery disease (CAD), a history of ventricular tachycardia-ventricular fibrillation (VT-VF), and implanted defibrillators, and 26 patients with CAD and no history of serious arrhythmias who were matched for age, sex, and New York Heart Association functional class. Patients with any history of neurologic disorders were excluded. Left-handers either wrote with the left hand or were converted from left- to right-handedness in childhood. Non-right-handers used the left hand for writing, drawing, or throwing. Handedness rates in patients with VT-VF and case-control subjects were compared with published norms in the general population to take expected rates into account. The rates of left-handedness (6 of 26 or 23.1%) and non-right-handedness (9 of 26 or 34.6%) in patients with VT-VF were significantly higher (p < 0.003 and p < 0.0001, 2-tailed, respectively) than those of similarly aged adults in the general population (left-handedness, 5%; non-right-handedness, 10.2%). The rates of left-handedness (2 of 26 or 7.7%) and non-right-handedness (4 of 26 or 15.4%) observed in the case-control group correspond closely to the expected values for that group (left-handedness, 1.3 of 26 or 5%; non-right-handedness, 2.65 of 26 or 10.2%) derived from the general population rates and were not significantly different from them.(ABSTRACT TRUNCATED AT 250 WORDS)

Key challenges posed by the Clinton health care reform proposal.

President Clinton's proposal assumes that the bureaucratic, regulatory, informational, and financial demands it places on the health care system may be feasibly met. The authors refute these assumptions and argue that the proposal restricts individual freedom while it requires less individual responsibility. They also challenge the lack of incentives for cost-conscious purchasing of health care and for taking greater responsibility for individual well-being and societal health. The article recommends that behavior that drives up the cost of health care for individuals and society should be strongly discouraged through disincentives.

Preventing problems in prevention research.

The design, conduct, and analysis of prevention research efforts present formidable challenges, but as the papers in this volume illustrate, the problems of prevention research are probably not altogether intractable; they simply require the best of our thinking and the firmest of our commitments. The papers included in this issue represent some of the best thinking likely to be available, and, in aggregate, they give reason for some optimism about prevention research. Which is fortunate, because it is by now abundantly clear that treatment of all the assorted personal and social maladies that afflict us individually and as a society, is impossibly intrusive and expensive, even if we were certain we knew what to do, and we are not. Treatment research is only a step or two ahead of prevention research in nearly any field.

Treatment of Aptitude X Treatment interactions.

The main effects in psychotherapy research have been smaller than expected. Rather than concluding that psychotherapy has weak effects, clinical researchers have argued that average effect sizes are reduced because of mismatches between clients and treatment. Hence, Aptitude X Treatment interaction (ATI) research has been viewed as a promising new frontier in psychotherapy research. If ATI research is to become a productive and progressive program, then researchers will need to focus their attention on interesting and meaningful ATIs. This will require greater theoretical precision and a stronger emphasis on construct validity. Specific issues addressed in this article include Type II and Type III errors, manipulation checks from both the patient and practitioner perspective, considerations of the strength of treatment, the need to test rival hypotheses, and the desirability of collaborative research.

Do consensus conferences work? A process evaluation of the NIH Consensus Development Program.

The purpose of this evaluation study is to identify problems and suggest modifications in the NIH Consensus Development Program. The current program consists of three-day conferences in which experts assess medical technologies for issues of efficacy, safety, conditions of use, and other related topics (e.g., costs and social impact). Eight consensus conferences held between 1980 and 1982 were studied in depth using a variety of methods; five of the conferences were investigated concurrently. In addition, archival material was examined for all but one of the 33 conferences held up to that time, and four planning meetings for future conferences were observed. The delay in publishing our findings provided an opportunity to examine the changes introduced by NIH; it also allowed us to avoid the criticism of numerous prior evaluations for finding fault with programs that are still developing. NIH adopted many of the recommendations in our evaluation report and has investigated others. Based on our evaluation and more recent evidence, however, we conclude that the major problem that was uncovered--selection bias, particularly with respect to the choice of questions and panelists--remains a significant threat to the credibility of the consensus process. More specifically, the results indicate that controversial issues cannot be properly addressed within the present conference format, although that was one of its major purposes. Recommendations for improving the consensus process are presented, as are their implications for a larger set of consensus activities that are currently being conducted.

Group decision making by experts: field study of panels evaluating medical technologies.

Decision-making processes and their outcomes were investigated in six consensus development conferences at the National Institutes of Health in which panels of experts evaluated new medical technologies. One hundred seventy-seven self-administered questionnaires were obtained from participants in these conferences. Questionnaire data were analyzed along with data derived from content analyses of the six consensus statements (CS) produced by the conferences. Results of these analyses provide considerable support for the hypotheses that the quality of the outcome (i.e., the CS) is determined by the existence of an interaction process, a decision procedure, and a chairperson, which facilitate the exchange of relevant information. Strong disagreements among the panelists appear to inhibit such exchange and harm the quality of the CS. Personal satisfaction appears to be more strongly related to the quality of the process and of the information disseminated than to the quality of the outcome. A clear relation was found between the panelists' status and expertise, their participation in the process, and their contribution to the CS. The pattern of these findings is quite similar to that obtained in laboratory studies. The role of preconference organizational factors, such as the selection of conference questions, panel, and speakers, and the characteristics of the technology are discussed.