Current Psychiatry Reviews - Volume 3, Issue 1, 2007

With this issue Current Psychiatry Reviews marks the beginning of its third year of publication. We are making excellent progress in terms of the quantity and quality of the review articles that have been submitted to Current Psychiatry Reviews. The group of articles included herein nicely illustrates the breadth of topics covered by our journal. What you will find in Volume 3, issue 1 is a sampler of contemporary psychiatry. There are topical reviews on personality traits associated with substance abuse disorders (Bardo et al.) and self-regulatory mechanisms in eating disorder (Marsh et al.) that are implicated in the genesis of eating disorders. There are two reviews on contemporary therapeutics that reflect the diversity of modern psychiatric practice: Chanpattana covers the role of electroconvulsive therapy for treatment of schizophrenia and Leichsenring, and Leibing systematically review the essentials of a time-limited and procedurally specified form of psychodynamic psychotherapy- Supportive and Expressive (SE) Psychotherapy is now being studied as a first-line treatment for mood, anxiety, and personality disorders. This issue also includes two articles on topics of considerable importance to practitioners who work in social psychiatry or public mental health settings. Joyal, Dubreucq, Genderon, and Millaud have prepared a comprehensive review of the associations between violence and major mental disorders and Kisely and Campbell survey methods for evaluating the effectiveness of compulsory or court-ordered treatment in community settings. Finally, there are papers examining the evidence that links traumatic brain injury to vulnerability to schizophrenia and other psychotic disorders (Corcoran and Malaspina) and the role of insight as a moderating factor in the course and outcome of schizophrenia spectrum disorders (Lysaker and Buck). Looking back on 2006, I want to thank Muneeza Zamir, our journal's publication manager, without whose tireless efforts Current Psychiatry Reviews would quickly grind to a stop. I would also like to thank our cadre of peer reviewers, who have without fail provided prompt and constructive feedback to authors submitting papers and have helped to ensure that the articles published in Current Psychiatry Reviews are of the highest caliber. As we all are at the onset of a new year, I am in the process of making the first move of my professional career, traveling all the way across the Keystone State from the University of Pittsburgh Medical Center (where I have been since I began internship back in 1979) to join the faculty of the University of Pennsylvania School of Medicine. Although fruitful collaborations with colleagues at Pitt will be ongoing for years-and hopefully decades-to come, I wish to express my gratitude and admiration to the scores of faculty and staff that have made the past 27+ years such an exciting and productive adventure. I want to thank most particularly to Ms. Lisa Stupar and Ms. Christine Johnson for their friendship and professionalism and their outstanding (and often superhuman) efforts in administering and managing my professional life at Pittsburgh.

Sensation seeking (SS) is a personality trait defined by a need to seek novel sensations and experiences, accompanied by a willingness to take risks for the sake of such experiences. Various measures of SS have been developed and validated, including a scale specifically for children. Among different populations, SS has been associated with the expression of various health-related risk behaviors, most notably substance use and abuse. Evidence from basic research with laboratory animals and from human clinical studies indicates that high sensation seekers may have an overactive mesocorticolimbic dopamine system relative to low sensation seekers. While the precise molecular mechanisms underlying SS remain to be elucidated, evidence suggests that low levels of monoamine oxidase activity, as well as altered dopamine receptor and dopamine transporter expression and function may play a role. Since altered monoamine function has been implicated in various psychiatric disorders, and since SS has been associated with some of these disorders, clinicians may find that SS offers a useful adjunct in promoting effective patient care and improving patient counseling. This may be especially useful in treating children, adolescents and young adults, as the risk for substance use and abuse is an especially relevant concern during this developmental period.

The role of electroconvulsive therapy (ECT) in treating patients with schizophrenia remains unclear. This paper aims to determine whether ECT results in clinically meaningful benefit with regard to psychopathology, behavior and functioning for patients with schizophrenia, and whether variations in the practical administration of ECT influences outcome. Existing research in the field and the new information of research in patients with treatment-resistant schizophrenia (TRS) from Thailand are summarized. Independent of gender, duration of the current episode and severity of baseline negative symptoms predict outcome. Treatment results in marked improvement in positive symptoms, with an intermediate effect on affective symptoms, and no effect or worsening of negative symptoms. The combination of ECT and conventional antipsychotic drug is associated with better outcome than either ECT alone or antipsychotic drug alone during both acute and maintenance phases of treatment. This improvement is not only in psychopathology but also in quality of life and social functioning. Electrical stimulus doses 2-4 times the seizure threshold are likely to increase the speed of recovery with bilateral ECT. Thrice-weekly ECT elicits response faster than does twice-weekly ECT. Although this preliminary evidence supports the use of ECT in patients with TRS, the research base for its use is still inadequate and deserves better investigation.

Traumatic brain injury (TBI) is associated with schizophrenia, but the causal nature of this relationship is not clear. Three models for their association exist: 1) TBI causes a phenocopy of schizophrenia (parallelism); 2) TBI is a marker of schizophrenia vulnerability (spurious association); and 3) TBI interacts with genetic vulnerability to cause schizophrenia (interaction or effect modification). We found that TBI is a causal component of some cases of schizophrenia, specifically those with enhanced genetic vulnerability. This has biological plausibility. Prevention of 50% of these cases could lead to a savings of $313 million annually in the United States. Further research on critical windows for traumatic brain injury in vulnerable individuals could shed light on the developmental pathophysiology of schizophrenia.

The possibility of a causal link between major mental disorders (MMDs) and violence has been the matter of a debate for decades in psychiatry. Just as a consensus seemed to emerge, a standout and unprecedented large-scale community investigation lead to contradictory conclusions. The main goal of this review was to provide clinicians with a critical summarizing of all major relevant studies published during 15 years. It is concluded that major mental disorders per se, especially schizophrenia, even without alcohol or drug abuse, are indeed associated with higher risks for interpersonal violence. However, further stigmatization of persons with MMDs should be considered, as between 85% and 95% of community violence is not related with MMDs and the absolute number of assaults committed by psychiatric outpatients is low. A summary Table 1 includes comments and conclusions related with each reviewed study and circumstances related with this type of assaults are discussed. Interpersonal violence associated with MMDs seems to be due to a heterogeneous minority of patients and current research aims at better characterizing subgroups who assault in similar contexts.

There is controversy as to whether compulsory community treatment (CCT) reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers in North America, Europe and Australasia, it is important to assess the benefits and potential harms of this type of legislation. Unfortunately, evidence for their effectiveness remains weak. In our Cochrane systematic review we were only able to identify two randomised controlled trials, and neither study showed any significant reductions in readmission rates, bed-days or arrests for cases on compulsory community treatment compared to appropriate controls. In terms of the number needed to treat (NNT), it would take up to 100 treatment orders to prevent one readmission, 25 to prevent one episode of homelessness and 500 to prevent one arrest. Including other study designs such as controlled before and after (CBA) studies made little difference to the results (total n=1108). There are other concerns for patients. This legislation stigmatises individuals with a severe mental illness, as many of these initiatives are named after a high profile victim of someone who happened to have a psychiatric illness. New York has a 'Kendra's Law', California a 'Laura's Law', and Ontario a 'Brian's Law'. Compulsory community treatment appears to be immune from evidence-based practice, possibly because of the convenience of legislative as opposed to evidence-based solutions such as assertive community treatment.

An updated review of Supportive-Expressive (SE) psychotherapy is presented. The concepts, techniques and research methods of SE therapy are described, and empirical evidence is reviewed. Articles on SE therapy published between 1970 and 2006 were identified by a computerized search using Pubmed, MEDLINE, PsycINFO and Current Contents. In November 2006, the search was updated using database-specific keywords. By this search, 92 individual studies or review articles on SE therapy were identified. In addition, text books and journal articles were used. Only publications referring to Luborsky's concept of SE therapy were included. The information was extracted by two raters. Sixty-seven publications addressing SE therapy according to Luborsky were included. Articles refering to conceptual (clinical) contributions and empirical research on concepts, processes and efficacy of SE therapy were reviewed. Results were summarized by two raters. Empirical data are in general consistent with the concepts of SE therapy. At present, a limited number of randomized controlled trials providing evidence for the efficacy of SE therapy in specific psychiatric disorders is available. Further efficacy studies are required. With regard to processes of SE therapy, studies addressing the interactions among supportive-expressive interventions, patient's level of functioning and outcome are recommended.

While interest has grown steadily in understanding how persons with schizophrenia appraise their disorder and subsequently move towards recovery, the nature of the impact of awareness or admission of schizophrenia on various domains of quality of life has remained a matter of debate. At the level of both theory and empirical study, it has been alternately argued that acknowledgement of one's mental illness is a key to and a detriment to recovery. Acknowledgement of illness has been recognized as something essential in order for a person to be able to make informed decisions about the future, to free oneself from blame for difficulties linked with illness and to form sustaining bonds with others. From another view, however, “awareness of illness” has been suggested as a barrier to recovery because it represents the acceptance of a system of social power in which one's individuality and dignity is diminished. Indeed empirical studies suggest both awareness and lack of awareness have significant risks associated with them. In this chapter we review this evidence and suggest that the impact of insight on quality of life may be mitigated by the degree to which persons have internalized stigmatizing beliefs about their illness. Clinical and theoretical implications are discussed.

Clinical evidence suggests that initial attempts to regulate weight gain quickly become habit-like in individuals with eating disorders. These behaviors are controlled excessively in patients with Anorexia Nervosa (AN) and are controlled more intermittently, with periods of lost control, in patients with Bulimia Nervosa (BN). We suspect that abnormalities in frontostriatal systems that subserve self-regulatory control and habit learning may contribute to the development and perpetuation of AN and BN. We summarize previous findings and present a pathophysiological model that provides a framework for understanding the shared and non-shared clinical phenotypes of AN and BN. Whereas dysregulated control systems produce heightened self-regulatory control, permitting individuals with AN to sustain excessive dietary restriction, dysregulated control systems likely result in impaired self-regulatory control in patients with BN, releasing feelings of hunger and urges to binge, thereby resulting in overeating. Interactions with cultural ideals of thinness and impaired habit learning systems may then allow the dieting behaviors of individuals with restricting-type AN to spiral into the habitual and restrictive eating behaviors that typify the disorder. Although these cultural factors likely contribute to the compensatory purging behaviors in BN, interactions with normal habit learning systems may explain the higher recovery rate of BN relative to AN, in which habit learning may be impaired. We describe neuroimaging methods that we are using to test these hypotheses and emphasize the potential utility of studying AN and BN early in the course of illness, to disentangle their causes from epiphenomena or compensatory responses. We believe that this innovative approach to studying eating disorders will lend explanation to the perplexing fact that although many young people diet and overeat at some point in time, only some go on to develop eating disorders.