Antisocial personality disorder and pathological gambling

The prevalence of antisocial personality disorder and its relationship to criminal offenses in pathological gamblers was investigated. A semi-structured interview schedule containing DSM-III criteria for antisocial personality and the California Psychological Inventory Socialisation subscale was administered to a sample of 306 pathological gamblers. Of the total sample, 35% reported no offense. Forty eight percent admitted to the commission of a gambling related offense, 6% to a non-gambling related offense, and 11% to both types of offense. Fifteen percent of subjects met DSM-III diagnostic criteria for antisocial personality disorder. Though these subjects were at greatest risk for committing criminal offenses, offenses were committed independently of DSM-III antisocial personality disorder in the majority of gamblers. It was concluded that features of antisocial personality emerged in response to repeated attempts to conceal excessive gambling and gambling induced financial difficulties.

Should we ignore dimensional risk factors in prevention of schizophrenia? Signposts to prevention

OBJECTIVE

The objective was to outline the development of the concept of allusive thinking as a genetic marker of predisposition to schizophrenia and relate this to other cognitive markers of this predisposition.

METHOD

Publications were reviewed which were considered relevant to the objective.

RESULTS

Allusive thinking as detected clinically could be measured objectively from subjects' performance on an Object Sorting Test. Using this test it was shown that parents, both of patients with schizophrenia and of university students with allusive thinking, themselves showed allusive thinking, indicating it was familially transmitted. Subjects with allusive thinking showed reduced cortical evoked brain P300 potentials, suggesting the transmission was genetic. The hypothesis that allusive thinking was associated with weaker cortical inhibitory processes was supported by the finding that subjects with such thinking chose more remote word associations. It was suggested that reasons allusive thinking has not been used as a marker in intervention studies is that as a dimension of abstract thinking, marked allusive thinking is not associated with a high risk of developing schizophrenia, and that administration of the Object Sorting Test is time-consuming. Other dimensional cognitive factors, such as psychoticism and perceptual anhedonia and aberration, are independent of allusive thinking and are also associated with a low risk of developing schizophrenia. Genetic transmission of schizophrenia would appear to involve a number of predisposing factors distributed dimensionally in the population with the contribution of each factor being small.

CONCLUSIONS

As they are associated with only a low risk of predisposition to schizophrenia, cognitive markers may not be of immediate value in the prevention of schizophrenia when compared with the less specific markers used for this purpose. However, it would seem that their study will be necessary if the nature of the genetic transmission of the illness is to be understood. This understanding could be expected to ultimately lead to more effective prevention.

Schizotypy: phenotypic marker as risk factor

OBJECTIVE

To evaluate measures of schizotypy as familial risk factors for schizophrenia with the aim of making recommendations for assessing schizotypy as part of screening procedures for identifying people at risk of schizophrenia.

METHOD

Published studies using self-report and interview-based measures of schizotypy to assess relatives of patients with schizophrenia are reviewed. A parent study is reported evaluating the diagnostic accuracy of parental schizotypy as assessed by three questionnaire-based measures: the Chapman Perceptual Aberration and Physical Anhedonia Scales, and the Eysenck Psychoticism Scale. Group scores for these self-report ratings of 23 parent-pairs of patients with schizophrenia, 20 parent-pairs of patients with chronic nonpsychotic psychiatric disorder, and 19 parent-pairs of healthy comparison subjects are compared.

RESULTS

Consistent with published evidence that self-report measures of psychosis-proneness and schizotypy do not consistently reflect familial risk factors that are specific for schizophrenia, scores on questionnaire measures of schizotypy did not distinguish the parents of patients with schizophrenia from the parents in the other two groups.

CONCLUSIONS

Interview-based assessments of schizotypy better assess familial risk factors than self-report measures of schizotypy. Questionnaire measures of schizotypy should be supplemented by interview-based assessments when screening for individuals at risk of schizophrenia.

Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission

OBJECTIVE

The objective of this study was to investigate the readmission rate, and the level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales, Australia.

METHOD

The readmission rates of all patients given CTOs within a 4-year period and a matched comparison group were investigated. The following factors were compared before, during and following a CTO: medication non-compliance, number of clinical services and duration of disturbed behaviour preceding hospitalisations.

RESULTS

Of 123 patients on CTOs (mean length, 288 days; SD, 210 days), 38 were readmitted during the CTO, the majority in the first 3 months and a further 21 patients were readmitted following termination of the CTO. Evidence of lower severity of illness in the comparison patients prevented meaningful evaluation of the readmission rates of the two groups. While on CTOs, patients receiving depot medications showed high compliance and a significantly reduced readmission rate compared with that of patients receiving oral medications. In the 2 months prior to hospitalisations during CTOs, compared with those before or after CTOs, patients received more frequent consultations and showed a shorter duration of medication non-compliance and disturbed behaviour. The level of services in the 3 months following discharge were comparable for patients on CTOs and the comparison group.

CONCLUSIONS

CTOs may reduce rehospitalisations by use of depot medication. Earlier and possibly more frequent readmissions in the CTO group shortened the disturbance associated with illness recurrence. It would appear that to establish a control group with equivalent severity of disorder necessary to evaluate the impact of CTOs requires a random allocation design.

Emotional suppression: can it predict cancer outcome in women with suspicious screening mammograms?

BACKGROUND

Previous studies have implicated emotional suppression, in particular suppression of anger, in the onset and progression of breast cancer. Many of these studies used non-standardized measures and failed to control for the effects of age and/or possible knowledge of diagnosis. The present study aimed to avoid these methodological errors in investigating the relationship of emotional suppression to a diagnosis of breast cancer in a large mammography screened population.

METHOD

Data were collected from 1151 women with suspicious mammograms recalled to a breast screening programme. Prior to multidisciplinary assessment women were asked to complete the Courtauld Emotional Control Scale. Imaging assessment outcome data and biopsy results were collected.

RESULTS

Fifteen per cent of this population subsequently were diagnosed with breast cancer. There were no significant associations between a cancer outcome and emotional suppression before or after the highly significant effect of age was taken into account.

CONCLUSIONS

These results suggest that suppression of emotion may not be relevant to the development of breast cancer. Its role in the progression of existing disease requires clarification.

Unresolved issues in scientific sexology

A number of unresolved issues in sexology research and practice are reviewed. Penile volume assessment of sexual arousal has consistently proved more sensitive than penile circumference assessment and requires much shorter exposure to the erotic stimuli eliciting the arousal, reducing the subjects' ability to modify their responses. Failure to acknowledge this has allowed acceptance of evidence based on penile circumference assessment that behavioral treatments such as directed masturbation can increase the ability of sex offenders to be heterosexually aroused and aversive therapy can reduce their deviant urges whereas penile volume assessment indicates these procedures are ineffective. A randomized controlled trial of relapse prevention versus no treatment for sex offenders found more treated than untreated subjects reoffended after a mean follow-up period of 4 years. Researchers and therapists accepted that a post hoc statistical manipulation of the results provided evidence of a treatment effect. Subsequently it has been recommended that randomized controlled evaluations of treatments of sex offenders be abandoned. Meta-analysis of outcome studies has been used uncritically. The majority of men and women who report homosexual feelings and/or behavior report predominant heterosexual feelings and behavior and do not identify as homosexual. These consistent findings remain ignored. Studies of the etiology and development of homosexuality and heterosexuality treat them as distributed categorically rather than dimensionally and investigate only self-identified homosexuals and heterosexuals. With this methodology the predominantly heterosexual majority are excluded or misclassified. The belief that the European concept of the homosexual is a late 19th-century invention is based on an inadequate reading of literature. Limitations of the DSM classification of sexual and gender identity disorders are pointed out. The validity of self-report of sexual behavior has been questioned on the basis that men report a markedly higher average number of sexual partners than women. Possible sex differences in reporting the number of partners who are of the same sex, casual, or perpetrators or victims of sexual coercion and child abuse have not been taken into account. Failure of sexology to progress due to lack of resolution of conflicting issues may contribute to the low impact factor of its journals.

Methodological issues concerning evaluation of treatment for sexual offenders: randomization, treatment dropouts, untreated controls, and within-treatment studies

The value of randomized controlled trials in evaluation of sexual offender treatment has been questioned. Concern was expressed that randomization fails to produce equivalent samples, without apparent appreciation this is inevitable when variables are distributed by chance; lack of equivalence is controlled by use of tests of significance. A further uncriticized and inappropriate procedure in treatment evaluation is separation of the results of subjects who did not complete treatment from those who did, when the outcome of the former group was known. Despite an APA Task Force recommendation, no attention has been given to the consistent finding that no treatment is less effective than placebo psychological therapies. The significance of Type II errors is discussed and the recommendation criticized that within-treatment research be encouraged as an alternative to outcome research. Demonstrating a within-treatment response when that response is associated with a better outcome does not necessarily mean that the treatment was effective. Subjects with a good prognosis could be more able to demonstrate a within-treatment response to the treatment. Nonrandomized matched samples do not adequately control all sample differences. The post hoc statistical reversal of a reported trend for sexual offenders treated with relapse prevention to show a worse outcome than untreated offenders, in order to correct lack of equivalence of the two groups, is considered inappropriate. That relapse prevention was found less effective than no treatment raises the possibility that it has a negative effect. To continue the use of relapse prevention other than in randomly controlled evaluative studies would appear to be unethical.

Megavitamin and dietary treatment in schizophrenia: a randomised, controlled trial

OBJECTIVE

The aim of this study was to assess the efficacy of adjunctive megavitamin and dietary treatment in schizophrenia.

METHOD

A random allocation double-blind, controlled comparison of dietary supplement and megavitamin treatment, and an alternative procedure was given for 5 months to 19 outpatients with a diagnosis of schizophrenia. In addition to usual follow-up, the experimental group received amounts of megavitamins based on their individual serum vitamin levels plus dietary restriction based on Radioallergosorbent (RAST) tests. The control group received 25 mg vitamin C and were prescribed substances considered allergenic from the RAST test.

RESULTS

Five months of treatment showed marked differences in serum levels of vitamins but no consistent self-reported symptomatic or behavioural differences between groups.

CONCLUSIONS

This study does not provide evidence supporting a positive relationship between regulation of levels of serum vitamins and clinical outcome in schizophrenia over 5 months.

Paedophilia: a review of the evidence

OBJECTIVE

The aim of this study was to critically review the literature concerning the nature ane prevalence of paedophilia.

METHOD

The literature of the past 30 years was examined in relation to the author's clinical experience and with emphasis on methodologically appropriate empirical studies.

RESULTS

Concern and reporting of child-adult sexual activity has increased markedly in the last decade, although its prevalence has not increased at least since the 1960s. The prevalence in women can be as high as 60%, depending on the definition and method of enquiry used, and female compared to male victims report more negative effects, although a percentage of both men and women report the experience as positive. Validation of effects requires multivariate statistical analysis. Current pro-active procedures to identify paedophiles detect those who victimise boys but do not detect the much greater number of paedophiles who victimise girls. Perpetrators are known to the majority of their female and male victims, and those reported are almost all male; most boys do not consider their prepubertal experiences with older women abusive. Relapse prevention, the current most popular treatment, has been shown to be ineffective for incarcerated child molesters.

CONCLUSIONS

Child-adult sexual activity should be opposed as an infringement of children's rights rather than requiring a false belief that it is invariably harmful; whether it should be mandatory for therapists to report it requires examination. Scientifically appropriate evaluation should be an essential component of current treatment programs.

Defective Self and/or Other Mentalising in Schizophrenia: A Cognitive Neuropsychological Approach

The mentalising abilities of schizophrenic patients and normal controls were tested using picture sequencing and story-telling tasks that required subjects to infer causal mental states in story characters, and a recall task that required subjects to dissociate subjective mental states from objective realities. Selective mentalising deficits were found in some patients. For other patients, general sequencing errors, "sensory" mentalising, and poor recall of symbolic representations suggested more profound problems. Task results were best accounted for by dissociable cognitive abnormalities, rather than graded dysfunction of a central mentalising mechanism. Symptom profiles of patient subgroups and correlations between task measures and clinical ratings linked these cognitive abnormalities to specific symptoms. General sequencing difficulty was associated with both poverty symptoms and reality distortion, suggesting that two mechanisms may underpin such errors: one, inability to manipulate symbolic representations, being linked to poverty; the other, failure to critically evaluate plausible cause-and-effect, being linked to reality distortion. There was some evidence that defective self-monitoring underpins thought disorder. Impaired metarepresentation was linked to the autisticlike symptoms of flat affect, social dysfunction, and alogia, rather than reality distortion. Implications of these findings are discussed with respect to theoretical and methodological issues confronting current schizophrenia research.

The effect of decreased catecholamine transmission on ERP indices of selective attention

This study examines the effect of decreased catecholamine transmission on event-related potential (ERP) indices of selective attention. Intravenous clonidine (1.5 micrograms/kg Catapres), droperidol (15 micrograms/kg Droleptan), or placebo were administered to healthy adult males prior to performance of a multidimensional auditory selective attention task (SAT) in which dichotically presented sequences of tone pips varied on dimensions of location (left or right ear), pitch (high or low), and duration (short or long). Subjects were required to make a button press response to infrequent "target" stimuli that matched a prespecified stimulus on the three dimensions. ERPs were recorded during the task. Clonidine led to a significant increase of processing negativity (PN) over 200-400 ms at the irrelevant location. Droperidol led to a significant increase in reaction time (RT), a significant decrease in hit rate, and an attenuation of PN over the 200- to 400-ms and 400- to 700-ms epochs. Neither substance led to a significant change in P3 amplitude. The role of catecholamines in the selective attention subprocesses of "tuning" and "switching" is discussed.

Impulsivity in pathological gambling: the antisocial impulsivist

The construct of impulsivity has to date remained relatively unexplored in the pathological gambling literature. This is in spite of recent claims suggesting that impulsivity may be an important feature characterizing a subgroup of pathological gamblers who are claimed to suffer from a Multi-Impulse Personality Disorder. The present study examined the potential role of impulsivity using the Eysenck Impulsivity Scale among 115 pathological gamblers. Results indicate that heightened impulsivity is associated with the degree of severity of psychological and behavioural change in pathological gamblers. However, the findings also indicate that impulsivity closely mirrors components contained in Eysenck Personality Questionnaire Psychoticism Scale, the California Personality Inventory Socialization Scale and DSM-III Antisocial Personality Disorder. This is manifest both in terms of high intercorrelations between the measures of psychopathy and impulsivity and in their predictive relationship to the level of psychological distress suggesting a uniform impulsivity/psychopathy construct. Thus, the research supports a model of pathological gambling in which the severity of associated behavioural and psychological disturbance is mediated by a impulsivity/ psychopathy construct.

Increased production of interleukin-2 (IL-2) but not soluble interleukin-2 receptors (sIL-2R) in unmedicated patients with schizophrenia and schizophreniform disorder

This study investigated immune activation, as measured by production of interleukin-2 (IL-2) and soluble interleukin-2 receptors (sIL-2R) from stimulated lymphocytes, in schizophrenia and schizophreniform disorder. The study included 13 neuroleptic-free patients, 13 medicated patients and 13 age- and sex-matched control subjects. Production of IL-2 and sIL-2R by peripheral blood mononuclear cells (PBMCs) was measured after in vitro stimulation with phytohaemagglutinin (PHA). Patients' symptoms were rated on the Scales for Assessment of Positive (SAPS) and Negative Symptoms (SANS) and the Brief Psychiatric Rating Scale (BPRS). IL-2 production by stimulated lymphocytes was significantly elevated in neuroleptic-free patients compared with both medicated patients and control subjects. IL-2 production was inversely correlated with the SAPS subscales of bizarre behaviour and formal thought disorder. The pattern of increased IL-2 production is in contrast to previous findings in patients with schizophrenia. Significant associations with clinical rating scores suggest that IL-2 production may vary in different biological subgroups of schizophrenia and schizophreniform disorder.

Heterosexual and homosexual coercion, sexual orientation and sexual roles in medical students

Rape has been conceptualized on a dimension of normal male behavior. The Koss and Oros (1982) study used a questionnaire that allowed men to respond only as sexual aggressors of women, and women only as victims of men. Medical students' responses to a modified questionnaire, in which both sexes reported being aggressors and/or victims, revealed that relatively comparable proportions of men and women were victims of coercive experiences: 35% of women and 30% of men experiencing constant physical attempts to have sexual activity. Forms of coercion not involving threat or use of force were more common, more exclusively heterosexual, and carried out by more equivalent percentages of men and women. 15% of women and 12% of men felt initially coerced into sexual activity but then enjoyed it. Threat or use of force to attempt to or to obtain intercourse were employed by 4% of men and 2% of women and experienced by 5% of both sexes. Half the male victims and female aggressors and a quarter of the male aggressors and female victims who reported such coercion stated it was homosexual. The ratio of homosexual/heterosexual feelings reported by male, but not female, students correlated with the degree of the homosexual coercion they both carried out and experienced. The degree of sexual coercion carried out by men and women correlated with their masculine sex role scores, suggesting, if the dimensional concept of rape is valid, that rape is on a continuum with masculine rather than male behaviors.

Sissiness, tomboyism, sex-role, sex identity and orientation

Masculinity and femininity have been studied by self-ratings in independent areas of research: one investigating personality traits considered masculine (M) or feminine (F); the other, behaviours statistically more common in one than in the other sex (sex-linked behaviours). The two approaches were compared for the first time in the present study of 66 male and 51 female medical students. Consistent with previous findings using the second approach, male but not female subjects' opposite sex-linked "sissy" and "tomboyish" behaviours correlated significantly with their reported ratio of homosexual to heterosexual feelings (Ho/Het). Ho/Het did not correlate with either sex's M and F scores, but high M scores in women correlated strongly with several "tomboyish" behaviours. As "tomboyish" behaviours are shown more strongly by women exposed prenatally to increased levels of opposite sex hormones compared to controls, the findings have implications for the biological theory attributing Ho/Het to such prenatal hormonal exposure.

Brain potential evidence for an auditory sensory memory deficit in schizophrenia

OBJECTIVE

The multiple disorders of selective attention found in schizophrenia could be secondary to disturbances in sensory processing. The authors investigated this possibility by using an event-related potential index of auditory sensory memory, called "mismatch negativity."

METHOD

Medicated (N = 11) and neuroleptic-free (N = 11) patients with schizophrenia and patients with bipolar affective disorder (N = 11) were compared with age- and sex-matched healthy comparison subjects. Auditory stimuli were presented while the subjects were distracted with an attention-demanding visual task. Event-related potentials were elicited by infrequently occurring auditory stimuli (deviants) and by regularly presented auditory stimuli (standards), which differed slightly in duration. The difference in amplitude between the event-related potentials elicited by the deviant and standard stimuli was the mismatch negativity.

RESULTS

The amplitude of the mismatch negativity was significantly lower in both groups of schizophrenic patients than in the healthy comparison subjects. Mismatch negativity amplitude was significantly correlated with ratings of negative schizophrenic symptoms but not with positive symptoms. Compared with the matched comparison subjects, the bipolar affective disorder patients did not show lower amplitude of mismatch negativity. There was a significant negative correlation between age and mismatch negativity amplitude.

CONCLUSIONS

The abnormal auditory sensory memory processing indicated by low mismatch negativity amplitude in the schizophrenic patients cannot be accounted for by neuroleptic medication status. Because this abnormality was significantly related to measures of negative symptoms only, it may be a chronicity marker or reflect a predisposition to the development to schizophrenia. These findings implicate the auditory cortex in the pathophysiology of schizophrenia.

Opposite sex-linked behaviors and homosexual feelings in the predominantly heterosexual male majority

Whether homosexual feelings are distributed categorically or dimensionally remains controversial. In an earlier series of studies, medical students anonymously reported a dimensional distribution of homosexual feelings, the ratio of homosexual to heterosexual feelings in men correlating with opposite sex-linked behaviors in childhood and adolescence, and, in both sexes, with current degree of opposite sex identity. Prevalence of homosexual feelings was markedly higher than that found in nonanonymous studies. In the present investigation, a study of male twins allowed investigation of the findings in 411 educationally more representative subjects. Awareness of some homosexual feelings was reported in adolescence by 20% and currently by 12%. As with medical students, the majority of those who reported some homosexual feelings were predominantly heterosexual, which could be considered to indicate such feelings were distributed dimensionally. Correlations between degree of homosexual feelings and avoidance of contact sport in childhood and adolescence, current wish to be of the opposite sex, and opposite sex identity remained present when subjects with equally bisexual and predominantly homosexual feelings were excluded from analysis. The finding that the majority of men with homosexual feelings are predominantly heterosexual renders implausible the theory that homosexual feelings result from fear of heterosexuality.

Non-sexist Sexual Experiences Survey and Scale of Attraction to Sexual Aggression

Sixty-six male and 51 female second year medical students anonymously completed the Sexual Experiences Survey (SES) and the Attraction to Sexual Aggression (ASA) Scale, both modified so that women could report behaviours in which they were aggressors, and men, behaviours in which they were victims. Men's aggression scores on the two scales were significantly correlated. As expected, more men than women reported both the likelihood and the experience of being sexual aggressors, although 6% of women reported being so aroused they couldn't stop when their partner didn't want intercourse and 13% of men reported having intercourse against their will. In men sexually coercive behaviours correlated positively with the masculinity scale of the Bem Sex Role Inventory. Fewer female medical students reported experiencing sexually aggressive behaviours compared to US or New Zealand university students; however, the percentage of male students who reported using or threatening to use physical force was in the same range as that of US students. Significant attention to the issue of sexual coercion would appear necessary in the education of medical students.

Event-related potential indices of semantic processing in schizophrenia

Event-related potentials (ERPs) were recorded while schizophrenic patients and healthy controls read congruous and incongruous sentences in anticipation of a memory test. The schizophrenic group performed more poorly in both recognition memory and cued recall tests. The two groups did not differ in the amplitude of the N400 component of the ERP but the difference between the ERPs to congruous and incongruous sentences persisted longer in the schizophrenic sample. The schizophrenic sample also showed reduced parietal positivity and a reduced effect of congruity on the late positive component that follows N400. Within the schizophrenic sample, measures of attentional impairment and positive thought disorder were correlated with mean amplitude of both the N400 and the subsequent positivity. The results imply that the structure and spread of activation within semantic memory is not impaired in schizophrenia. Rather, impairments appear to lie in processes required to integrate activated information with the current context.

Allusive thinking in parents of schizophrenics. Meta-analysis

Romney (J. Nerv. Ment. Dis. 178:481-486, 1990) performed a meta-analysis of studies examining psychometrically assessed "thought disorder" in the relatives of schizophrenics. He concluded that thought disorder was more prevalent in the relatives of schizophrenics than control subjects. The present review focuses on only those studies that measured "allusive thinking" using the Lovibond-Rapaport Object Sorting Test in parents of schizophrenics. Even when the meta-analysis included this more limited number of studies, it demonstrated that the parents of schizophrenics were 2.42 times more likely to obtain high scores on the Object Sorting Test, confirming replication of the original McConaghy (J. Neurol. Neurosurg. Psychiatry 22:243-246, 1959) finding. This effect remained significant when the original study was excluded from the meta-analysis. The predictive strength of parental Object Sorting Test score as a familial risk factor for the development of schizophrenia is discussed.

Event-related potentials and repetition priming in young, middle-aged and elderly normal subjects

Although the structure of semantic memory appears to be unaffected with increasing age, there is evidence that older adults are less efficient at accessing stored memory representations. Aging also results in a decline in the ability to use contextual information effectively, suggesting a deficit in episodic memory processes. The present experiment examines the effects of age on memory retrieval of stored representations and the use of contextual information. Event-related potentials (ERP) were recorded to immediate and delayed word repetition during a lexical decision task. Three groups of subjects were tested: young (mean = 27.3 years), middle (mean = 46.7 years) and old (mean = 67.4 years). Behavioral facilitation due to repetition did not significantly differ across groups. With increasing age, the ERP waveform showed a positive shift which began around 300-400 ms post-stimulus and was apparent across all stimulus types and response conditions. This positive shift may reflect an age-related decrease in cortical excitation. Although the onset of the ERP repetition effect was not affected by age, its duration for both immediate and delayed repetition was significantly prolonged. In the light of recent models of ERP word repetition effects, these results suggest that processes related to accessing stored representations in memory are unaffected by age. The extended duration of the repetition effect and the increase in the magnitude of the effect of delayed repetition with age suggest that aging affects processes related to the retrieval and use of contextual information in integrating a stimulus with its context.

P300 indexes thought disorder in schizophrenics, but allusive thinking in normal subjects

Loosening of thinking as assessed by the Object Sorting Test (OST) has been found in a percentage of normal subjects but in a higher percentage of schizophrenics, and is familially transmitted in both groups. Loosening of thinking in normal subjects is not associated with evidence of impaired function or increased psychopathology, and in recognition of this, it was termed allusive thinking rather than thought disorder. Both OST-assessed loosening and concreteness of thinking were found to be present independently in a high percentage of schizophrenics, so that both were considered to contribute to schizophrenic thought disorder. The presence of OST-assessed loosening in schizophrenics would, therefore, be predicted to correlate partially rather than totally with measures of schizophrenic thought disorder. It has been suggested that OST-assessed loosening in normal subjects is due to a genetically determined reduction in strength of an inhibitory process that limits the spread of activation of semantic associations and results in a predisposition to schizophrenia. The brain event-related potential P300, which is, in part, under genetic control, may index this inhibitory process. Therefore, it was predicted that in normal subjects, P300 would correlate with OST-assessed loosening of associations. If schizophrenic thought disorder is due to a further weakening of this inhibitory process, it can be predicted that P300 in schizophrenics correlates only weakly with OST-assessed loosening of thinking, but more strongly with schizophrenic thought disorder. In a study in which P300 was elicited using a difficult selective attention task with 15 unmedicated schizophrenics and 22 healthy subjects, all three predictions were supported.

P300 and conceptual loosening in normals: an event-related potential correlate of "thought disorder?"

Reduced amplitude of the P300 component of the event-related potential (ERP) has frequently been reported in schizophrenic patients and their first-degree relatives. The present study examined the relationship between this ERP measure of attentional processing and loosening of associations in normal university students (termed "allusive thinking"). Among male subjects, scores reflecting increased conceptual loosening, measured using the Lovibond scoring method for the Goldstein-Scheerer Object Sorting Test (OST), were significantly correlated with smaller P300 amplitude recorded during an auditory target detection task. There was no association between OST score and either performance of the target detection task or self-reported psychopathology. It is suggested that reduced P300 amplitude could reflect altered attentional processing in individuals with a constitutional trait factor of thought disorder.

The relationship between relative's Expressed Emotion and schizophrenic relapse: an Australian replication

We report a predictive study, carried out in Sydney Australia, investigating the association between the Expressed Emotion (EE) status of the household to which the patient is discharged and schizophrenic relapse. Expressed Emotion was not related to illness severity either at admission or discharge, but was related to variables reflecting chronicity and employment history. There was a significant association between returning to a high EE household and both re-hospitalisation and relapse. The significant association between EE and relapse held only for: patients not on medication, males, and those patients in high contact with their relatives. A discriminant function analysis found that decline in occupational status and the number of critical comments expressed by the relative were the strongest predictors of relapse. The results presented here are consistent with the majority of published reports on EE and relapse and contradict the negative findings of a recently published but smaller study also carried out in Sydney.

The Sydney intervention trial: a controlled trial of relatives' counselling to reduce schizophrenic relapse

The result of a psychosocial intervention which aimed to reduce schizophrenic relapse through relatives' counselling is presented. Thirty-six schizophrenic patients living in high Expressed Emotion (EE) parental households were randomly allocated to an intervention or control group. The parents of patients allocated to the intervention were offered ten weekly sessions of counselling. The patient was not included in these sessions. Patients in both groups received standard after-care of medication and support. Relapses in the intervention group, although fewer, were not significantly different from the control group. Given the impressive evidence in favour of family interventions in reducing relapse rates in schizophrenic patients possible reasons for this result are discussed. Aspects of the intervention described here, exclusion of the patient, no control over the patients' medication or involvement with their management, short duration of intervention and lack of individual assessment, could explain this finding. This negative result is important in indicating what factors should be included in an effective psychosocial intervention.

A comparison of relapsed and non-relapsed abstinent pathological gamblers following behavioural treatment

Eighteen pathological gamblers reporting abstinence at a 2-9-year follow-up period were classified into two samples; those reporting complete abstinence, or those abstinent with intermittent relapse episodes. Results indicated that both samples improved significantly on post-treatment psychological and demographic measures, and did not differ from each other. It was concluded that a subgroup of gamblers may experience intermittent brief relapses that are not invariably associated with a continued return to addictive gambling habits. Complete abstinence as a criterion for successful treatment outcome may be too stringent in that it fails to acknowledge the possibility of continued abstinence following brief episodes of relapse.

Active and passive attention in schizophrenia: an ERP study of information processing in a linguistic task

Attentional dysfunctions in schizophrenia were investigated using a sentence priming task. Schizophrenic patients and healthy control subjects were presented with sentences to which they were required to make a response based on either semantic or physical stimulus features. Schizophrenics' behavioural responses were slower than those of controls, particularly when attending to semantic relationships, but their performance was no less accurate. Both the P300 and the N400 components of the event-related potentials (ERPs) recorded to the sentence completions were attenuated in the schizophrenic sample. The results are interpreted in terms of a deficit in the active maintenance of semantic information in memory and the integration of new information with this representation.

Comparison of imaginal desensitisation with other behavioural treatments of pathological gambling. A two- to nine-year follow-up

Of 120 pathological gamblers randomly allocated to imaginal desensitisation (ID) or to other behavioural procedures (60 to each group, all procedures administered over one week) 63 subjects were contacted two to nine years later. Twenty-six of the 33 who received ID reported control or cessation of gambling compared with 16 of 30 who received other behavioural procedures. This difference was significant, indicating ID had a specific effect additional to that of the other behavioural procedures. It is suggested the other procedures could be regarded as placebos. As the response at a mean of over five years to one week of ID is comparable with that reported to more intensive therapies, after briefer follow-up, it is suggested ID is a cost-effective therapy for pathological gambling, and is worth considering when resources are limited.

The effect of repeated testing on ERP components during auditory selective attention

The present study examined long-term repetition effects on human auditory event-related potentials (ERPs). ERPs were recorded from subjects performing the same multidimensional auditory selective attention task on six separate occasions spaced one week apart. The task required subjects to attend to tones that varied along the dimensions of location (L), pitch (P), and duration (D) and to detect prespecified target (L + P + D +) combinations of these attributes. Processing negativity (PN) between 100-400 ms did not change in amplitude or onset latency as a function of repeated experience with the task. In contrast, two measures of "very late" PN were reduced with practice. Specifically, the location effect measured over the 400-700-ms epoch was significant only for Weeks 1 and 2, and the separation of the L + P + D- ERP from other D- ERPs, measured over the 700-1000-ms epoch, was significantly reduced from Week 1 to Week 2. A late negative component (700-1000 ms) elicited by correctly identified targets increased between Weeks 1 and 2, consistent with subjects adopting the strategy of rehearsal of the target itself rather than the L + P + D- standard. P2 amplitude increased significantly for all standards, possibly due to decreased latency jitter in later weeks. N1 latency became significantly shorter over weeks, reflecting either increasing confidence in stimulus discrimination with repeated testing or the overlapping of an unchanging N1 with an increasing P2.

The assessment and management of obsessive-compulsive disorder

This article describes obsessive-compulsive disorder (OCD) and discusses its diagnosis and its management by behavioural therapy combined with antidepressant medication. Patients with OCD experience recurrent distressing thoughts which may lead them to avoid certain situations and to carry out protective rituals. Behavioural treatment is considered specific. The therapist establishes a relationship with the patient by which he or she can be motivated to cease the thoughts and the avoidance and ritual behaviour. The patient's family can play an important role in the therapy. The treatment is usually easier if the patient can accept taking clomipramine. Patients who, despite severe symptoms, are able to carry out their normal activities usually respond well to treatment. Those who cannot tolerate stress and have had to cease most of their normal activities usually do not respond well and require supportive therapy.

Effects of inter-item lag on word repetition: an event-related potential study

Prior exposure to a word can greatly facilitate performance to subsequent presentations of that word. ERP studies have shown that this facilitation is associated with an attenuation of a negative peak normally occurring around 400 ms poststimulus. Recent studies have interpreted this repetition effect as reflecting either lexical access or episodic memory mechanisms. However, there is now increasing evidence that neither of the above mechanisms alone can fully account for repetition effects. The present experiment recorded ERPs to immediate and delayed word repetition during a lexical decision task in order to investigate the time-course of ERP repetition effects. Immediate repetition was found to produce greater response facilitation than delayed repetition. The ERP waveforms of both immediate and delayed word repetition diverged from that of initial word presentation at approximately 300 ms poststimulus. The waveforms for repeated words separated around 400 ms poststimulus with immediate repetition showing a more rapid resolution of negativity and earlier late positivity than delayed repetition. It is suggested that the negativity may reflect processes involved in the overall activation contributing to word recognition, whereas the late positivity may be related to the repetition of stimulus categorization and decision processes.

Auditory selective attention and event-related potentials in schizophrenia

Brain ERPs were recorded in ten unmedicated schizophrenic patients and age- and sex-matched healthy controls during a multidimensional listening task. Patients showed a marked reduction in a long-duration attention-related negative ERP component, termed 'processing negativity' (PN), which was elicited by attended stimuli. The amplitude of PN was significantly correlated with SANS and SAPS scores of schizophrenic symptoms. The P300 component was also reduced in amplitude in patients, and was significantly correlated with SANS ratings of negative thought disorder. These findings provide neurophysiological evidence of impairment in the maintenance of selective attention and the cognitive processes associated with target detection among schizophrenic patients. The reduced PN in schizophrenics implicates frontostriatal pathways in the aetiology of attentional deficits in schizophrenia.

Control versus abstinence in the treatment of pathological gambling: a two to nine year follow-up

A structured gambling interview schedule, the Eysenck Personality Questionnaire, Spielberger's State-Trait Anxiety Inventory, Zuckerman's Sensation Seeking Scale and Beck Depression Inventory were administered to 63 out of 120 pathological gamblers who had 5 years previously completed a behavioural treatment for uncontrollable gambling behaviour. Results indicated that both abstinence and controlled gambling outcomes were associated with continued improvement in self-report and psychological indices of social functioning and psychopathology. Response to treatment was associated with a reduction in arousal levels, anxiety and depression. Uncontrolled gamblers failed to show post-treatment changes on parameters of improvement. It was concluded that abstinence is not the only possible therapeutic outcome in behavioural treatment and further, that controlled gambling is not a temporary response which is followed by a return to continued uncontrollable gambling.

Opposite sex behaviours correlate with degree of homosexual feelings in the predominantly heterosexual

There is extensive evidence that subjects who identify as homosexual show opposite sex-linked behaviours. However no attempt has been made to investigate whether a similar association exists between such behaviours and the presence of homosexual feelings in the predominantly heterosexual. Eighty medical students completed an anonymous questionnaire reporting the ratio of their heterosexual to homosexual feelings and the presence of sex-linked behaviours in their earlier life and currently. As in previous studies correlations between opposite sex behaviours and subjects' degree of homosexual feelings were found in the male subjects. Correlations remained present, though mainly at a weaker level, in the predominantly heterosexual students. It is suggested this evidence of a dimensional relationship between opposite sex-linked behaviours in childhood and degree of homosexual feeling in adulthood renders irrational the classification of such behaviours as a gender identity disorder of childhood when homosexuality in adults is not regarded as a disorder.

Initial stages of validation by penile volume assessment that sexual orientation is distributed dimensionally

Kinsey concluded that homosexuality and heterosexuality were distributed dimensionally in the normal population, a significant percentage of whom experienced homosexual feelings. This conclusion has been ignored by most sex researchers. Twenty men seeking treatment for compulsive sexual behaviours reported a dimensional distribution of heterosexual and homosexual feelings, rated by questionnaire on 11-point scales. Their penile volume responses to 10-second movies of nude women and men were assessed. Significant correlations were found between individual subjects' penile volume and questionnaire assessment of heterosexual/homosexual feelings, validating their questionnaire-assessed dimensional distribution of their feelings. The finding was considered to provide the initial stage of physiological validation of the questionnaire, which in previous studies demonstrated a dimensional distribution of heterosexual/homosexual feelings in representative samples of medical students, supporting Kinsey's conclusion.

Can reliance be placed on a single meta-analysis?

Meta-analysis replaced statistical significance with effect size in the hope of resolving controversy concerning evaluation of treatment effects. Statistical significance measured reliability of the effect of treatment, not its efficacy. It was strongly influenced by the number of subjects investigated. Effect size as assessed originally, eliminated this influence but by standardizing the size of the treatment effect could distort it. Meta-analyses which combine the results of studies which employ different subject types, outcome measures, treatment aims, no-treatment rather than placebo controls or therapists with varying experience can be misleading. To ensure discussion of these variables meta-analyses should be used as an aid rather than a substitute for literature review. While meta-analyses produce contradictory findings, it seems unwise to rely on the conclusions of an individual analysis. Their consistent finding that placebo treatments obtain markedly higher effect sizes than no treatment hopefully will render the use of untreated control groups obsolete.

Boredom proneness in pathological gambling

To test the hypothesis that pathological gamblers seek stimulation as a means of reducing aversive under-aroused states of boredom and/or depression, the Beck Depression Inventory, Zuckerman's Sensation Seeking Scale and a Boredom Proneness Scale were administered to 48 diagnosed pathological gamblers and a control group of 40 family physician patients. Analyses of variance showed pathological gamblers obtained significantly higher boredom proneness and depression scores than those of controls. That the Boredom Proneness Scale failed to correlate with the Zuckerman Boredom Susceptibility subscale suggested the two measure differing dimensions. Results indicated the possible existence of three subtypes of pathological gamblers, one group characterized by boredom, another by depression, and a third by a mixture of both depression and boredom.

Assessment and treatment of sex offenders: the Prince of Wales Programme

The treatment programme for sex offenders at the Prince of Wales Hospital, Sydney, is described. Penile circumference assessment is not used as there is no evidence it provides a valid measure of individuals' paedophile or rapist tendencies. Sex offenders' self-reports remain the major source of information in their assessment. The development of the two major techniques used--imaginal desensitization and short-term medroxyprogesterone--is outlined. About 80% of subjects can be expected to show a good response to one or other of these therapies. Of those who do not, most respond to the alternative or aversive therapy. Adolescent offenders appear to require more intensive treatment. Results appear comparable with those of more intensive programmes in use overseas.

Event-related potential indices of selective attention and cortical lateralization in schizophrenia

Auditory event-related potentials (ERPs) from a multidimensional selective attention task were recorded from 10 unmedicated schizophrenic patients and 10 age- and sex-matched healthy controls. Tone pip stimuli varying on the dimensions of pitch (high or low) and location (left or right ear) formed four 'channels' of stimuli: left low, left high, right low, and right high. The pitch difference was considerably more difficult to discriminate than the location difference. Subjects were instructed to pay attention to a designated channel and press a button whenever they detected a long-duration, rare target tone that occurred amongst frequent short-duration standard tones. There were a number of differences between unmedicated schizophrenics and controls in processing negativity elicited by standard tones. There was no evidence of hierarchical processing of stimulus dimensions in the early processing negativity component, and the late frontal component was virtually absent in schizophrenics. Furthermore, there was evidence that in schizophrenics the processing of the location dimension was delayed for standard tones having the same pitch as the target. The P300 component to attended target tones was substantially reduced in schizophrenics over parietal sites but there was no difference between the two groups over frontal sites. The results are interpreted in terms of multiple attentional deficits in schizophrenics that are indicative of a failure in the planning and execution of selective listening strategies. Such a failure may result from a dysfunction in the prefrontal regions of the brain.

Thought disorder or allusive thinking in the relatives of schizophrenics? A response to Callahan, Madsen, Saccuzzo, and Romney

Romney and Saccuzzo et al. (J Nerv Ment Dis 176:364-367; 368-371, 1988) disagreed concerning the need for further studies investigating the presence of thought disorder and associative cognitive dysfunction in relatives of schizophrenics. Saccuzzo et al. were concerned at the variations in the results of previous studies. Methodological issues relevant to such variation are discussed. It is pointed out that the study (McConaghy J Neurol Neurosurg Psychiatry 22:243-246, 1959) initiating psychometric investigation of cognitive processes of relatives of schizophrenics was based on the belief that what was familially transmitted was not thought disorder, but a nonpathological looseness of associations, shown also by a percentage of normal subjects. This looseness was later termed allusive thinking. It was considered that allusive thinking acted as an inherited predisposition to schizophrenia. It required the addition of impairment of abstract thinking to constitute the characteristic thought disorder originally described by Bleuler. To account for the significant degree of thought disorder found in 6% to 12% of normal subjects, some researchers now accept that thought disorder exists in normal subjects on a continuum with schizophrenic thought disorder. It is suggested that replication of a later study demonstrating familial transmission of allusive thinking in university students and their parents could aid in clarifying the significance of the findings of increased incidence of looseness of associations in the families of schizophrenics.

Behaviour completion mechanisms, anxiety and agoraphobia

Little attention has been paid to the situations which provoke the initial attack of anxiety in agoraphobia. According to the behaviour completion hypothesis many normal subjects experience increased tension in such situations when there is a delay in the completion of a behaviour. One hundred and eight medical students completed a questionnaire designed to investigate this hypothesis. They reported experiencing increased tension or anxiety significantly more frequently in situations provoking agoraphobia when the situations contained a component of delay, as compared to such situations without this component, or to situations not commonly provoking agoraphobia. It is proposed that tension, anxiety and panic form a continuum of increasing levels of arousal, but are associated with different cognitions. It is further proposed that the arousal level of agoraphobics is sensitized, so that delay which provokes mild increases of arousal in the healthy, provokes high arousal in agoraphobics. This finding supports the hypothesis that delay in behaviour completion is a mechanism in the generation of tension and anxiety.

Anxiety and/or depression in the pathogenesis of addictive gambling

The Spielberger State-Trait Anxiety Inventory and the Beck Depression Inventory were administered to 75 pathological gamblers seeking behavioral treatment, to investigate the hypothesis that anxiety and depression were important determinants in the maintenance of gambling behavior. Further, subgroups of "pure" poker-machine and "pure" horse-race gamblers were isolated and compared to determine whether differences existed between groups of individuals who selected different forms of gambling. Although the desire to win money was given as the main reason for participation, need for money played a less significant role in precipitating further gambling. Rather, the concept that pathological gambling is a behavioral stress reaction received some support. As a group pathological gamblers had moderate levels of depression. State or trait anxiety scores were no different from Spielberger's normative sample of neuropsychiatric patients, but were higher than those of college students. No significant differences were found between the poker-machine and horse-race gambling subgroups on age, years gambling, years of uncontrolled gambling, state and trait anxiety, or depression. It was suggested that environmental factors are of importance in determining the form of gambling selected, but differences between these subgroups on other psychological dimensions could not be excluded on the basis of the present study.

Assessment and management of pathological gambling

This article describes a brief treatment--imaginal desensitization--which enables pathological gamblers to retain control of gambling, discusses its development and advances evidence from 2-9 years' follow-up of its efficacy.

Behavior completion versus stimulus control in compulsive gambling. Implications for behavioral assessment

Twenty subjects were randomly allocated to receive either imaginal relaxation (IR) or imaginal desensitization (ID) to reduce compulsive gambling. As predicted from a behavioral completion model, but not a stimulus control model, subjects' response to IR was comparable with that to ID. Also as predicted, response correlated with subjects' levels of tension following treatment. Detailed assessment of the situations in which subjects' gambling occurred was not necessary for effective IR therapy. The result established the treatment validity of the assessment used, this study being the first to compare the treatment validity of different behavioral assessments. The finding that manipulation of an organismic variable level of arousal is as effective as a manipulation of a stimulus variable in the treatment of compulsive gambling supports the trend among behavior therapists to place more emphasis on the importance of organismic variables as determinants of pathological behaviors.