June 2017 - Volume 205 - Issue 6

  • John A. Talbott, MD
  • 0022-3018
  • 1539-736X
  • 12 issues / year
  • 1.860


Johns Hopkins Psychiatry at 100 Years
John A. Talbott, MD

Introduction to 100 Years of Psychiatry at Johns Hopkins
J. Raymond DePaulo, Jr., MD and Timothy H. Moran, PhD

Adolf Meyer: His Achievements and Legacy
Paul R. McHugh, MD

This lecture, given to celebrate the centennial of the founding of the Henry Phipps Psychiatric Service at Johns Hopkins, addresses the career and contributions to psychiatry and neurology of Adolf Meyer, the first Phipps Professor. It reviews his achievements, what he did to address them, the sources of help he found from leading figures in the emerging Progressive Era (1890–1917), and how he confronted and overcame resistances. His legacy is reflected in the signal contributions of four leaders of American psychiatry (Drs. Leo Kanner, Alexander Leighton, Jerome Frank, and Paul Lemkau), who were his residents.

One Hundred Years of Psychiatry at Johns Hopkins: A Story of Meyer to McHugh
J. Raymond DePaulo, Jr., MD

This article describes a history of clinical methods and constructs that guide Psychiatry at Johns Hopkins Phipps Clinic today. The contributions of Adolf Meyer and Paul McHugh are central and closely connected. Both emphasize the clinical examination as the central practice of psychiatry as a specialty within medicine. Meyer's comprehensive examination of the patient became the centerpiece of his approach and was the standard for psychiatrists in the English-speaking world. McHugh, with Phillip Slavney, developed a pluralistic and practical framework for interpreting that history and examination. Both argued against the uncritical use of the modern disease construct. McHugh argues that the disease construct, although fundamental, is but one of four useful "perspectives of psychiatry" and is, thus, an insufficient basis for psychiatric practice. The perspectives could be used as an organizing framework by all physicians who seek a practical and truly personalized approach to the care of patients.

Adolf Meyer's Influence on Curt Richter: Selection, Support, and Mentoring
Gerard P. Smith, MD

Adolph Meyer influenced Curt Richter from the time Richter became a graduate student in Psychology at Johns Hopkins in 1919 until Meyer retired in 1941. Meyer was on Richter's thesis committee. After Richter received his degree, Meyer selected him to replace J.B. Watson. During the next 20 years, Meyer gave Richter strong support in terms of equipment, laboratory space for animal research, and opportunities to teach medical students, attend clinical rounds, and do clinical research. It is less well known that Meyer also mentored Richter's scientific and professional development. Meyer's mentoring was so successful that Richter adopted the major scientific ideas of Meyer, especially psychobiology, distrust of theory, and respect for experiment. Thus, Meyer's ideas became the framework for Richter's famous research program that produced his major discoveries of behavior exerting homeostatic controls, psychoendocrinology, and biological clocks.

The Dark Side of Addiction: The Horsley Gantt to Joseph Brady Connection
George F. Koob, PhD

W. Horsley Gantt and Joseph V. Brady laid a rich foundation for understanding the concept of emotion, derived from 2 prominent traditions of physiology and psychology: classic conditioning and operant conditioning, respectively. This framework guided my fierce interest in motivation in general and the interaction between reward and stress, which began at John Hopkins, with my thesis work under the guidance of Drs. Zoltan Annau, Solomon Synder, and Joseph Brady, among many others. Using the study of the neurobiology of addiction as a framework, I argue that drug addiction not only involves positive reinforcement associated with the rewarding effects of drugs of abuse, but also involves another major source of reinforcement, specifically negative reinforcement driven by negative emotional states (termed the "dark side" of addiction). Excessive activation of the brain reward systems leads to anti-reward or a decrease in the function of normal reward-related neurocircuitry and persistent recruitment of the brain stress systems, both of which may be neurobiologically linked. Understanding the neuroplasticity of the neurocircuitry that comprises the negative reinforcement associated with addiction is a key to understanding negative emotional states in general and their pathophysiology.

Healing Through Words: Jerome Frank and Psychotherapy at Johns Hopkins: The Phipps Centennial Lectures: The Jerome Frank Lecture
Kay Redfield Jamison, PhD

This lecture, given to celebrate the centenary of the founding of the Henry Phipps Psychiatric Service at Johns Hopkins, focuses on the contributions of Jerome Frank to the understanding and practice of psychotherapy. It gives an overview of Professor Frank's ideas and work, puts them into the context of the history of psychotherapy research at Johns Hopkins, and discusses psychotherapy and demoralization in bipolar illness.

Predictors of Acquisition of Competitive Employment for People Enrolled in Supported Employment Programs
Marc Corbière, PhD, Tania Lecomte, PhD, Daniel Reinharz, MD, Bonnie Kirsh, PhD, Paula Goering, PhD, Matthew Menear, PhD, Djamal Berbiche, PhD, Karine Genest, MSc, Elliot M. Goldner, MD

This study aims at assessing the relative contribution of employment specialist competencies working in supported employment (SE) programs and client variables in determining the likelihood of obtaining competitive employment. A total of 489 persons with a severe mental illness and 97 employment specialists working in 24 SE programs across three Canadian provinces were included in the study. Overall, 43% of the sample obtained competitive work. Both client variables and employment specialist competencies, while controlling for the quality of SE programs implementation, predicted job acquisition. Multilevel analyses further indicated that younger client age, shorter duration of unemployment, and client use of job search strategies, as well as the working alliance perceived by the employment specialist, were the strongest predictors of competitive employment for people with severe mental illness, with 51% of variance explained. For people with severe mental illness seeking employment, active job search behaviors, relational abilities, and employment specialist competencies are central contributors to acquisition of competitive employment.



Feasibility of Training Frontline Therapists in Prolonged Exposure: A Randomized Controlled Pilot Study of Treatment of Complex Trauma in Diverse Victims of Crime and Violence
Bita Ghafoori, PhD, Marissa C. Hansen, PhD, MSW, Erika Garibay, BA, Olga Korosteleva, PhD

The study aims were to determine whether prolonged exposure (PE) improved mental health and was feasible to implement by frontline clinicians in a culturally diverse sample with complex trauma. Seventy-one individuals were randomly assigned to PE or person-centered therapy (PCT). Outcome measures were administered at baseline and sessions 3, 6, 9, and 12. Mixed modeling was used to regress outcome measures on time, treatment group, and number of visits. Individuals who received PE showed significant moderate association with decline in reported posttraumatic stress disorder (PTSD) symptoms as noted by the PTSD Checklist for DSM-5 (p = 0.05) compared with PCT. Results indicated improved scores on all measures at each follow-up time point compared with baseline (p ≤ 0.01). PE was feasible, shown by positive recruitment and ability of clinicians to effectively implement and maintain treatment fidelity. Findings suggest that PE can be effective for treating complex trauma when used by clinicians in community settings.

Expressed Emotion and Attributions in Relatives of Patients With Obsessive-Compulsive Disorder and Panic Disorder
Keith D. Renshaw, PhD, Dianne L. Chambless, PhD, Sommer Thorgusen, PhD

Relatives' criticism of, hostility toward, and emotional overinvolvement (EOI) with patients are predictive of treatment response and relapse. Although these constructs have been linked to relatives' attributions for patient problems, little research has yet evaluated attributions for specific types of problems. This study examined event-specific attributions (i.e., attributions specifically for either disorder-related [DR] or non-DR problems) in relatives of patients with anxiety disorders. Relatives made more illness attributions (attributing problems to a patient's disorder) than controllable attributions (attributing problems to factors controllable by patients) for DR events, with the reverse pattern for non-DR events. Criticism and hostility were associated primarily with controllability attributions for non-DR events. In contrast, the presence of EOI was associated with illness attributions for non-DR events. Family-based interventions for anxiety disorders might need to focus on relatives' controllability attributions for a broad range of patient behaviors and on reducing tendencies to attribute non-DR problems to patients' disorders.

Exploring the Mechanism Underlying the Association Between Pain Intensity and Mental Health Among Latinos
Michael J. Zvolensky, PhD, Jafar Bakhshaie, MD, Daniel J. Paulus, MA, Kirsten J. Langdon, PhD, Monica Garza, PhD, Jeanette Valdivieso, MD, Joseph Ditre, PhD, Melissa Ochoa-Perez, MD, Chad Lemaire, MD, Daniel Bogiaizian, PhD, Zuky Robles, BA, Rubén Rodríguez-Cano, MA, Kara Manning, BS

There is limited understanding of pain and its relationship to mental health in Latinos, and limited knowledge about the biobehavioral mechanisms that underlie pain–mental health interrelations. To address these gaps, the present investigation sought to address whether anxiety sensitivity explained relations between pain intensity and anxious arousal, depressive symptoms, social anxiety, and depressive and anxiety disorders among an economically disadvantaged Latino sample. Participants included 349 adult Latinos (88% women; Mage = 38.8) who attended a community-based primary health care. In the multiple mediation model, anxiety sensitivity physical concerns accounted for the association between pain intensity and anxious arousal symptoms, cognitive concerns accounted for the association between pain intensity and depressive symptoms, and social concerns accounted for the association between pain intensity and social anxiety symptoms. This is the first study to demonstrate the explanatory role of anxiety sensitivity in pain-affective associations among disadvantaged Latinos.

Positive Association Between Nightmares and Heart Rate Response to Loud Tones: Relationship to Parasympathetic Dysfunction in PTSD Nightmares
Kaloyan S. Tanev, MD, Scott P. Orr, PhD, Edward F. Pace-Schott, MS, MA, PhD, Michael Griffin, PhD, Roger K. Pitman, MD, Patricia A. Resick, PhD, ABPP

Seventy-three women with posttraumatic stress disorder (PTSD), resulting from rape or physical assault, participated in a loud-tone procedure, while skin conductance (SC), heart rate, and electromyogram responses were recorded. Pearson correlations were examined between each psychophysiological response and Clinician-Administered PTSD Scale (CAPS) symptom scores. Significant correlations were adjusted for each remaining individual PTSD symptom score. Heart rate response (HRR) significantly correlated with CAPS total score and with CAPS nightmares. The relationship between HRR and nightmares remained significant after controlling for each of the other 16 individual PTSD symptoms, for the remaining re-experiencing cluster, and for CAPS total score. The zero-order correlations between SC response and nightmares and between electromyography response and nightmares were both not significant. The association of nightmares with larger HRR, in the absence of an association with larger SC response, likely reflects reduced parasympathetic tone. Thus, our findings indirectly support a role for reduced parasympathetic tone in PTSD nightmares.

Sex Differences in Psychiatric Hospitalizations of Individuals With Psychotic Disorders
Inbal Shlomi Polachek, MD, Adi Manor, MD, Yael Baumfeld, MD, Ashlesha Bagadia, MD, Ari Polachek, MD, Rael D. Strous, MD, Zipora Dolev, MD

We identified all acute hospitalizations, between 2010 and 2013, for psychotic disorders in patients younger than 45 and older than 55 years (n = 5411) in the hospital's database. In addition, we identified patients who were prescribed with intramuscular risperidone (n = 280) or clozapine (n = 192) at discharge. The results showed that women younger than 45 years had lower proportions of hospitalizations (33.52% vs. 66.47%) and involuntary hospitalizations (33.85% vs. 45.55%) than did men in the same age group. Women older than 55 years had higher proportions of hospitalizations (57.22% vs. 42.77%) and similar proportion of involuntary hospitalizations. Women younger than 45 years were prescribed similar doses of intramuscular risperidone and lower doses of clozapine (345.8 vs. 380.2 mg) and women older than 55 years were prescribed higher doses of intramuscular risperidone (44.8 vs. 34.4 mg/2 weeks) and clozapine (164.32 vs. 154.5 mg) than were men in the same age group. Women in the reproductive years have better hospitalization characteristics than do men on these measures.


Acknowledging the Risk for Traumatic Brain Injury in Women Veterans
Timothy Amoroso, BS and Katherine M. Iverson, PhD

Since the Iraq and Afghanistan wars began, an unprecedented number of women have been engaging in combat operations. Likewise, the number of women using Department of Veterans Affairs (VA) services has doubled since 2001. Military service, and deployment to combat in particular, poses certain risks for traumatic brain injury (TBI)—for all service members. However, women may have additional military and non-deployment risk factors such as intimate partner violence (IPV). We briefly review the definition and classification issues related to TBI, as well as common acute and chronic health symptoms after TBI. Specific sex differences in prognosis after TBI, in particular the neurobehavioral symptoms, are also reviewed. We then focus on the emerging literature regarding TBI in women veterans, including the etiologies, outcomes, and unique challenges this population faces. The article concludes with suggestions for enhanced screening by VA and non-VA providers alike, as well as directions for future research and clinical inquiry.


Paliperidone Palmitate Once-Monthly Treatment in Recent Onset and Chronic Illness Patients With Schizoaffective Disorder
Cynthia A. Bossie, PhD, Ibrahim Turkoz, PhD, Larry Alphs, MD, PhD, Lucy Mahalchick, BS, Dong-Jing Fu, MD, PhD

Data from a multiphase schizoaffective disorder study (NCT01193153) were used to examine the effects of paliperidone palmitate once-monthly (PP1M) by subjects' illness duration, defined as recent onset (≤5 years since first psychiatric diagnosis; n = 206) and chronic illness (>5 years; n = 461). Symptom and functioning scores, as measured during open-label PP1M acute and stabilization treatment phases, improved in both subpopulations, with greater improvements in recent onset than chronic illness subjects (p ≤ 0.022). Relapse rates, examined during the double-blind, placebo-controlled phase, were higher with placebo than PP1M: 30.0% vs. 10.2% (p = 0.014; hazard ratio [HR]: 2.8; 95% confidence interval [CI]: 1.11–7.12; p = 0.029) in the recent onset subpopulation and 35.5% vs. 18.1% (p=0.001; HR: 2.38; 95% CI: 1.37–4.12;p=0.002) in the chronic illness subpopulation. Growing evidence in the treatment of schizophrenia and schizoaffective disorder supports early intervention with long-acting antipsychotics.

Helping Alliance and Unmet Needs in Routine Care of People With Severe Mental Illness Across Europe: A Prospective Longitudinal Multicenter Study
Katrin Arnold, Dipl-Soz, Sabine Loos, PhD, Benjamin Mayer, PhD, Eleanor Clarke, BSc, Mike Slade, PhD, Andrea Fiorillo, MD, Valeria Del Vecchio, MD, Anikó Égerházi, MD, Tibor Ivánka, BSN, Pøvl Munk-Jørgensen, MD, Malene Krogsgaard Bording, MSSc, Wolfram Kawohl, MD, Wulf Rössler, MD, Bernd Puschner, PhD, and the CEDAR Study Group

The helping alliance (HA) refers to the collaborative bond between patient and therapist, including shared goals and tasks. People with severe mental illness have a complex mixture of clinical and social needs. Using mixed-effects regression, this study examined in 588 people with severe mental illness whether an increase in the HA is associated with fewer unmet needs over time, and whether change in the HA precedes change in unmet needs. It was found that a reduction in unmet needs was slower in patients with higher HA (B = 0.04, p <0.0001) only for patient-rated measures. Improvement in both patient-rated and staff-rated HA over time was associated with fewer subsequent patient-rated (B = −0.10, p < 0.0001) and staff-rated (B = −0.08, p = 0.0175) unmet needs. With positive changes in the HA preceding fewer unmet needs, findings provide further evidence for a causal relationship between alliance and outcome in the treatment of people with severe mental illness.


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