November 2012

Vol. 24. No. 4


Proposed changes for DSM-5: Are they clinically useful?

In this issue, we include 2 articles on skin picking disorder (SPD), a new entry in DSM-5. After conducting a field trial of SPD, Christine Lochner, PhD, and coauthors conclude the proposed DSM-5 criteria are clinically useful. Ivar Snorrason, MA, and colleagues—including Annals Editorial Board member Dan J. Stein, MD, PhD—report results from an Internet survey showing that SPD often is comorbid with other body-focused repetitive behaviors such as hair-pulling disorder (trichotillomania)…



Efficacy of extended-release divalproex combined with “condensed” dialectical behavior therapy for individuals with borderline personality disorder

Richelle Moen, PhD | Mary Freitag, PsyD | Ivan W. Miller, PhD | Susanne S. Lee, PhD | Ann Romine, BA, RN | Sue Song, MA | Adit Adityanjee, MD | S. Charles Schulz, MD

BACKGROUND: Borderline personality disorder (BPD) is a significant psychiatric illness for which medication treatments are still being explored. The goal of this study was to assess divalproex extended release (ER) vs placebo for patients receiving dialectal behavior therapy (DBT).

METHODS: Patients with BPD received 4 weeks of “condensed DBT.” Those with Symptom Checklist-90 (SCL-90) scores >150 after this treatment were then randomly and blindly assigned to placebo or divalproex ER for 12 weeks. Repeated measures analysis of variance utilizing last observation carried forward was used to assess the results.

RESULTS: Seventeen participants completed the full assessment. Two patients had a significant decrease in SCL-90 in the first 4 weeks, leaving 15 patients for the medication phase of the trial. There were no significant differences between the participants assigned to divalproex ER compared with placebo. However, there was a significant improvement in both groups from baseline to endpoint (P = .001).

CONCLUSIONS: The response of 2 of 17 participants in the first 4 weeks prior to medication may point to a practice strategy in approaching outpatients with BPD. Although the patients had a decrease in symptoms during the study, there was no advantage observed for divalproex ER and DBT over placebo and DBT.


Characteristics of children with juvenile bipolar disorder or disruptive behavior disorders and negative mood: Can they be distinguished in the clinical setting?

Daniel F. Connor, MD | Leonard A. Doerfler, PhD

BACKGROUND: Because of continuing controversy over distinguishing juvenile bipolar disorder (JBD) from disruptive behavior disorders (DBDs) in the clinical setting, we investigated whether referred children with a DBD and a negative mood component could be differentiated from those diagnosed with JBD. The distinction is important because treatments differ.

METHODS: In this single-site sample, 96 children with non-attention-deficit/ hyperactivity DBD and depression were compared with 27 JBD children and 187 psychiatric comparison children on measures assessing behavior, functional impairment, symptom severity, psychopathology and comorbid psychiatric diagnosis

RESULTS: Few differences were found between children with DBD and depression and those with JBD on measures of conduct problems, oppositionality, aggression, hostility, and psychopathology. More functional impairment was found in the JBD group who also had higher rates of comorbid posttraumatic stress disorder (PTSD), substance use disorders, and suicidality than the other groups.

CONCLUSIONS: These results do not support the specificity of aggression as a defining criterion for JBD and clinicians assessing such patients also should consider complex DBDs with an associated depressive component in the differential diagnosis. Children with JBD must be specifically assessed for comorbid developmental trauma, substance abuse, and suicidality. The association between JBD and PTSD needs further investigation in clinical research.


Determining the efficacy and tolerance of quetiapine extended release for the management of psychosis and accompanying acute behavioral disturbance in adult acute psychiatry

Stuart J. Lee, BA, DPsych | Fiona Foley, BSc, BHSc | Erica Hannagan, BSc, RN | Jayashri Kulkarni, MBBS, MPM, FRANZCP, PhD | Peter Bosanac, MBBS, MMed (Psychiatry), MD, FRANZCP | David J. Castle, MBBS, MSc, MD, FRCP, FRANZCP | Yitzchak Hollander, BSc, MD, FRCP(C), FRANZCP

BACKGROUND: This study was conducted to explore the efficacy and tolerability of quetiapine extended release (XR) to treat psychosis and accompanying acute behavioral disturbance in hospitalized psychiatric patients.

METHODS: Patients with psychosis who displayed aggression were administered quetiapine XR (day 1 mean dose: 293.3 mg). Symptoms and side effects were assessed prospectively over an 8-day period. Symptoms were measured by the Overt Aggression Scale and Brief Psychiatric Rating Scale (BPRS), and side effects were measured using the Simpson-Angus Scale and Barnes Akathisia Rating Scale.

RESULTS: Fifteen of 16 consenting patients completed the study. Aggression was significantly reduced by day 3. Psychopathology also was significantly reduced, with the greatest improvement in BPRS Thinking Disturbance subscale scores. No significant increase in movement side effects was seen by day 8. Seven participants were administered a concomitant sedating antipsychotic on an as-needed basis, particularly in the first 4 days of treatment; these participants displayed much greater aggression—but not psychopathology— at day 1, and it took longer for their aggression and psychopathology to improve compared with patients treated with quetiapine XR as the sole antipsychotic.

CONCLUSIONS: Further research is needed before definitive recommendations can be made. However, current findings provide tentative support for quetiapine XR as a safe and effective medication for treating concurrent psychosis and behavioral disturbance, particularly in less severely aggressive patients.


Prevalence of problem gambling in Iowa: Revisiting Shaffer’s adaptation hypothesis

Brett McCormick, MA | Mary E. Losch, PhD | Martha Shaw, BS | Gene Lutz, PhD | Jeff Allen, PhD

BACKGROUND: Pathological gambling (PG) is an important public health problem. We assessed the prevalence of PG and problem (at-risk) gambling in a random sample of Iowa adults and compared the results to survey data collected in 1989 and 1995. The goal of this study was to examine whether continued expansion of gambling venues is associated with increased rates of problematic gambling behavior.

METHODS: A random digit dialing telephone screening was conducted in eastern Iowa of men and women age ≥18. Respondents were administered the South Oaks Gambling Screen (SOGS) to assess lifetime gambling behavior. Demographic and clinical variables were collected.

RESULTS: A total of 356 respondents (147 men, 209 women) completed the SOGS, and all reported lifetime gambling participation. PG (SOGS ≥5) was found in 5 (1.4%) and problem gambling (SOGS = 3, 4) in 8 (2.2%) respondents. Disordered gambling (SOGS ≥3) was found in 13 (3.6%) respondents. Risk factors for disordered gambling included age (odds ratio [OR] = 0.64 per 10-year age increase), income (OR = 0.82 per $10,000 increase), minority group status (OR = 5.75), number of lifetime gambling activities (OR = 1.27), and having ever gambled ≥$100 (OR = 13.3). Overall gambling participation was significantly less in the current sample, compared with data collected in 1995.

CONCLUSIONS: Recent gambling participation was less than in 1995, despite the continued expansion of gaming opportunities. Disordered gambling was associated with younger age, lower income, and minority group status. The results are consistent with Shaffer’s “adaptation” hypothesis, which posits that following an initial increase in gambling participation, problematic gambling stabilizes at a lower level.