November 2013

Vol. 25. No. 4


We are all affected by the 2013 government shutdown

I am a victim of the partial government shutdown. Like you, I thought the shutdown affected others— such as the 800,000 government workers who were furloughed—not me. I serve on a National Institutes of Health study section (review panel) that was to meet in Washington, DC, on October 3 to 4. The study section will need to meet in person or by telephone at some point, but this will become a nightmare for the administrator who will need to find a time when 30 busy people can meet…



Stressor-related disorders in tuberous sclerosis

Susana Boronat, MD | Agnies M. Van Eeghen, MD | Julianna E. Shinnick | Peter Newberry , MD | Elizabeth A. Thiele, MD, PhD

BACKGROUND: Patients with tuberous sclerosis complex (TSC) have high rates of psychiatric comorbidity, including mood and anxiety disorders. The aim of this study is to identify patients with stressor-related disorders such as posttraumatic stress disorder (PTSD) or adjustment disorder (AD) and to describe their clinical picture in the setting of TSC.

METHODS: Retrospective review of medical charts of TSC patients referred for a stressor-related disorder to a TSC psychiatric clinic.

RESULTS: We identified 7 females and 2 males (3 PTSD, 6 AD), including 4 children. Two patients with severe intellectual disability presented with aggression and the remaining patients presented with avoidance. The mean duration of symptoms at the time of the study was 21 months (range: 7 to 48 months) and 7 of the 9 patients still were having traumarelated symptoms. All the patients who received an initial diagnosis of AD had their diagnosis changed to another category because their symptoms lasted >6 months. In most cases, selective serotonin reuptake inhibitors improved the symptoms.

CONCLUSIONS: Stressor-related disorders in TSC frequently linger beyond 6 months and may appear with triggering events that typically are not viewed as trauma in a normal population.


The effectiveness of a cognitive-behavioral intervention for pathological gambling: A country-wide study

Sonja C. Pasche, MPsych | Heidi Sinclair, MB, ChB | Peter Collins, PhD | Adele Pretorius, PhD | Jon E. Grant, JD, MD, MPH | Dan J. Stein, FRCPC, PhD

BACKGROUND: Clinicians lack adequate data on the effectiveness of treatment for pathological gambling in low- and middle-income countries.

METHODS: We evaluated a manualized treatment program that included components of cognitive-behavioral therapy, motivational interviewing, and imaginal exposure in a sample of 128 participants diagnosed with pathological gambling. Our team recruited participants via the helpline of the National Responsible Gambling Program (NRGP) of South Africa between May 2011 and February 2012. Eligible participants, who met the DSM-IV-TR criteria for pathological gambling as assessed by the Structured Clinical Interview for Pathological Gambling (SCI-PG), were referred to practitioners who had been trained in the intervention technique. We then compared pre- and post-treatment scores obtained on the Yale-Brown Obsessive-Compulsive Scale Adapted for Pathological Gambling (PG-YBOCS), the primary outcome measure, and the Sheehan Disability Scale (SDS), the secondary outcome measure.

RESULTS: Scores obtained on the PG-YBOCS and the SDS both decreased significantly from the first to the final session (t[127] = 23.74, P < .001, r = .9; t[127] = 19.23, P < .001, r = .86, respectively).

CONCLUSIONS: The urges and disability symptoms related to pathological gambling were significantly reduced among participants completing treatment. These preliminary results hold promise for individuals with pathological gambling in South Africa and other low- and middle-income countries.


Is the distinction between adjustment disorder with depressed mood and adjustment disorder with mixed anxious and depressed mood valid?

Mark Zimmerman, MD | Jennifer H. Martinez, BA | Kristy Dalrymple, PhD | Iwona Chelminski, PhD | Diane Young, PhD

BACKGROUND: In the DSM-IV, adjustment disorder is subtyped according to the predominant presenting feature. The different diagnostic code numbers assigned to each subtype suggest their significance in DSM-IV. However, little research has examined the validity of these subtypes. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical profiles of patients diagnosed with adjustment disorder subtypes to determine whether there was enough empirical evidence supporting the retention of multiple adjustment disorder subtypes in future versions of the DSM.

METHODS: A total of 3,400 psychiatric patients presenting to the Rhode Island Hospital outpatient practice were evaluated with semistructured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity.

RESULTS: Approximately 7% (224 of 3,400) of patients were diagnosed with current adjustment disorder. Adjustment disorder with depressed mood and with mixed anxious and depressed mood were the most common subtypes, accounting for 80% of the patients diagnosed with adjustment disorder. There was no significant difference between these 2 groups with regard to demographic variables, current comorbid Axis I or Axis II disorders, lifetime history of major depressive disorder or anxiety disorders, psychosocial morbidity, or family history of psychiatric disorders. The only difference between the groups was lifetime history of drug use, which was significantly higher in the patients diagnosed with adjustment disorder with depressed mood.

CONCLUSIONS: There is no evidence supporting the retention of both of these adjustment disorder subtypes, and DSM-IV previously set a prec-edent for eliminating adjustment disorder subtypes in the absence of any data. Therefore, in the spirit of nosologic parsimony, consideration should be given to collapsing the 2 disorders into 1: adjustment disorder with depressed mood.


Association of aphthous ulcers with self-reported symptoms of depression in a sample of smartphone users

Jadon R. Webb, MD, PhD | Blake F. Webb, BS | Mary C. Schroeder, PhD | Carol S. North, MD, MPE

BACKGROUND: Our goal is to examine the association of recurrent aphthous stomatitis (RAS) with symptoms of depression using a smartphonebased questionnaire survey.

METHODS: An electronic survey was administered through a smartphone app asking respondents about current depressive symptoms using the Quick Inventory of Depressive Symptoms (QIDS), and asking whether they had ever or recently experienced RAS. Multivariate logistic regression analysis was used to determine associations.

RESULTS: A total of 478 individuals completed the survey, with 64% reporting a lifetime prevalence of RAS, and 21% experiencing an aphthous ulcer within the last month. RAS was significantly associated with increased sleep, decreased appetite, low energy, and feeling sluggish. RAS was not associated with overall depression severity as measured by total QIDS score, or with cardinal features of depression such as sadness, insomnia, impaired concentration, self-blame, thoughts of death, or anhedonia. Prevalence of RAS did not differ by age, sex, or smoking status, but was less likely in blacks and Asians compared with whites.

CONCLUSIONS: RAS was a common phenomenon in this sample of mostly depressed individuals, and was associated with some neurovegetative symptoms of depression, but not depression severity.