(This is the second installment in a series on the 41st Annual NCDEU meeting. Part I was published in the October issue of Psychiatric Times, p40 -- Ed.)

Promising investigational agents and innovative methodologies for clinical investigation were considered at the 41st annual New Clinical Drug Evaluation Unit (NCDEU) meeting sponsored by the National Institute of Mental Health in Phoenix, May 28-31.

Tomoxetine is a novel compound for attention-deficit/hyperactivity disorder (ADHD) that enhances noradrenergic function by selectively blocking the pre-synaptic norepinephrine transporter. This non-stimulant, non-dopaminergic agent was found to be well-tolerated through meta-analysis of safety data from over 1,000 children receiving doses as high as 3.5 mg/kg/day. Anorexia was the most frequently reported adverse event, occurring in 23% of patients and associated with a mean weight loss of approximately 0.5 kg over nine weeks of treatment.

Summarizing three efficacy studies in children and two in adults, Eli Lilly and Company researchers reported that tomoxetine was superior to placebo in reducing ADHD symptoms assessed with both hyperactive and inattentive subscales of the ADHD rating scale. University of Nebraska researchers reported long-term open trial data with pediatric patients indicating that 19 out of 35 patients who participated for one year maintained their initial decrease in symptom severity ratings over the course of treatment.

The abuse liability of tomoxetine was considered by Eli Lilly researchers and colleagues at University of Vermont in a study of subjective medication responses of 16 healthy volunteers who had previously used recreational drugs. The subjects were provided three different doses of tomoxetine, two of methylphenidate (Ritalin) and placebo in randomized, double-blind cross-over design on separate days. Their response to each drug and dose was assessed using a seven-item visual analog scale (VAS), the Addiction Research Center Inventory (ARCI) short-form and Adjective Rating Scale (ARS) questionnaires.

The researchers reported that mean scores on the stimulant subscales of the VAS and ARCI, as well as the amphetamine and euphoria subscales of the ARCI, were all greater for methylphenidate 40 mg daily than for placebo, while scores for tomoxetine did not differ from placebo on these measures. On the other hand, tomoxetine 90 mg daily was associated with significantly greater increases on the sick and bad subscales of the VAS and the sedative subscale of the ARCI, compared with placebo. Tomoxetine 90 mg daily and methylphenidate 40 mg daily both significantly differed from placebo but not from each other on the ARCI dysphoria group.

"The profile associated with tomoxetine differed from that typically observed with stimulants," the researchers concluded, "and significant scores on non-pleasurable subscales suggest tomoxetine is unlikely to have significant abuse liability."

Another noradrenergic agent, reboxetine (Vestra), which is a selective norepinephrine reuptake inhibitor now under review by the U.S. Food and Drug Administration for treating depression, was evaluated for depression, anxiety and panic disorder in three separate studies.

Researchers at University of California, Los Angeles, conducted a nine-week, single-blind study with 25 patients with major depression. Thirteen patients who completed four weeks of treatment with reboxetine 4 mg twice daily without adequate improvement were provided 5 mg twice daily for the remainder of the trial. Using response criterion of final Hamilton Rating Scale for Depression (HAM-D) score 

10, 11 (65%) of 17 patients completing the nine-week trial were deemed responsive. Applying several assessment instruments, the researchers reported that treatment with reboxetine was effective in improving symptoms of depression as well as social functioning and psychomotor activity.

In the evaluation of effectiveness for anxiety associated with major depression, 381 patients were randomized to receive eight weeks of treatment with either reboxetine 8 mg/day, fluoxetine (Prozac) 20 mg/day to 40 mg/day or placebo. The two antidepressants were found comparable and significantly superior to placebo in the number of patients improving on the HAM-D anxiety items 10 and 11. In a separate comparison of reboxetine 6 mg/day to 8 mg/day to placebo for panic disorder, reboxetine was significantly more effective in reducing the number of major panic attacks per week and in reducing phobic symptomatology.

Two investigational antipsychotics appeared well-tolerated in separate reports. Iloperidone exhibits a characteristic atypical antipsychotic pharmacologic profile in blocking serotonin as well as dopamine receptors. Aripiprazole is an agonist at presynaptic dopamine receptors, in addition to postsynaptic blockade of serotonin and dopamine.

The safety of iloperidone was evaluated for psychotic and behavioral symptoms in elderly patients with dementia in flexible daily doses of 0.5 mg to 6 mg in a placebo-controlled study sponsored by Novartis Pharmaceuticals. With recent attention to the cardiac effects of atypical antipsychotics, the researchers pointed out that none of the 10 patients receiving active medication developed clinically significant electrocardiogram abnormalities. They also noted that no patient experienced a QT

 interval prolongation of greater than 480 msec, the approximate threshold for risk of 

The efficacy and safety of aripiprazole was compared to that of haloperidol (Haldol) in 404 patients with schizophrenia or schizoaffective disorder in a study sponsored by Otsuka America Pharmaceuticals. Efficacy measures distinguished both drugs from placebo, but not from each other in this four-week study of two aripiprazole daily doses (15 mg and 30 mg) and haloperidol 10 mg. Safety monitoring revealed "no clinically meaningful increases" in QT

 prolongation, and the extrapyramidal symptoms (EPS) in patients receiving aripiprazole were comparable to those in patients receiving placebo.

Duloxetine, an investigational antidepressant progressing in the Eli Lilly development pipeline as the fluoxetine patent expires, is a dual reuptake inhibitor of serotonin and norepinephrine. In an eight-week, double-blind study, 173 patients with depression were randomized to receive either duloxetine, fluoxetine or placebo. Duloxetine was titrated from 20 mg twice daily to 60 mg twice daily, and fluoxetine was maintained at 20 mg daily. The researchers reported comparable efficacy from the active agents, and both were superior to placebo.

Escitalopram is the single, active s-isomer of citalopram (Celexa), which is a racemic mixture of the active s- and the non-antidepressant r-isomers. In March, Forest Laboratories, which now markets citalopram, filed a New Drug Application for escitalopram. 

A fixed-dose study of escitalopram 10 mg/day, escitalopram 20 mg/day, citalopram 40 mg/day or placebo randomly assigned to 491 outpatients for eight weeks showed the superiority of both 10 mg and 20 mg doses to placebo on depression efficacy measures. Researchers at University of Nebraska found significant improvement in patients receiving escitalopram compared to those on placebo on the Montgomery-Asberg Depression Rating Scale (MADRS) beginning at week 2 and on the Clinical Global Impression (CGI) beginning at week 1.

 receptor partial agonist being investigated for treatment of depression. A dose of 20 mg to 90 mg was administered in open-label design to 134 patients for six weeks. The 70 patients whose symptoms improved then continued into a placebo-controlled phase for an additional six weeks, allowing comparison of relapse rates between those continuing on active agent and those switched to placebo. The reported 26% relapse rate among patients receiving gepirone was significantly lower than the 55% relapse rate with placebo. The active agent was well-tolerated according to the report, although four patients receiving the medication dropped from the double-blind phase due to side effects.

A lack of standardization in administering and scoring the HAM-D has been a long-standing concern and was addressed at the 1999 NCDEU meeting with the formation of the Depression Rating Scale Standardization Team (DRSST), comprising researchers from academia and industry. The DRSST recommendations presented at the 2001 meeting included developing a consensus scoring system in which intensity and frequency of a symptom are rated separately and yield an overall severity score for each item. In addition, the DRSST clarified item anchors and provided clinical examples for each severity level.

Telecommunication technologies were embraced to facilitate clinical studies and diagnostic screening at several U.S. sites. Researchers from Hillside Hospital in Glen Oaks, N.Y., reported successfully administering neurocognitive tests by telephone to 42 patients with schizophrenia. The researchers noted that, despite recent elucidation of neurocognitive correlates with functional disability in schizophrenia, application of standardized neurocognitive tests has been limited by the requirement of in-person administration.

"This can lead to studies with sampling bias caused by patients withdrawing from studies because they are unwilling or unable to travel to the testing site," they observed. "Also, researchers may choose to use samples of convenience or less frequent follow-up assessments, which restricts [generalizing] the study results."

To ascertain whether neurocognitive testing can reliably be administered over the telephone, the researchers selected a small battery of tests and adapted them to telephone administration. These tests involved both oral administration and oral response and required no presentation of materials to the patient. The battery included tests of short-term memory, working memory, ideational fluency and verbal learning. These were administered twice, once by telephone and once in person, approximately one month apart.

The researchers found no significant differences between in-person and telephone administration of the tests in scores for working memory, semantic fluency and short-delay free recall. There were, however, different results in phonemic fluency and immediate attention and recall between these two administration methods.

University of South Florida researchers found the Telephone Interview for Cognitive Status-Modified (TICS-M) of limited use as the sole instrument in screening for Alzheimer's disease or mild cognitive impairment. Although the researchers promoted a no-cost, telephone-based memory screening based on the TICS-M to the community, they improved screening efficiency by adding other instruments. They remain advocates, however, of screening procedures that can overcome the cost, transportation and confidentiality concerns that can be barriers to early medical evaluation of memory.

An interactive voice response (IVR) system from Healthcare Technology Systems was used for screening patients with dementia and, in another study, patients with generalized anxiety disorder. In the first study, 155 subjects were assessed by clinical interview and scores from the Clinical Dementia Rating (CDR) scale to serve as the criterion standard. A battery of neuropsychological tests were also administered by IVR with a standard touch-tone telephone.

The researchers reported that six of eight domains in the IVR testing correlated with CDR status and concluded that computer-automated telephone screening for early dementia is feasible. "Such systems could provide wide-scale, cost-effective screening, education, and referral services to patients and caregivers," they suggested.

The second IVR study, assessing its utility in screening for anxiety, follows others that have shown discrepancies between the IVR patient self-report of anxiety symptoms and clinician ratings. Open-label data were obtained from an ongoing anxiety disorder clinical trial, and patients received the IVR version of the Hamilton Rating Scale for Anxiety (HAM-A) in addition to traditional measurements at screening, baseline and after an eight-week intervention phase. The IVR HAM-A scores were found to be significantly lower than clinician scores at screening and baseline but not after intervention. 

Several reports examined the issue of patients with psychotic disorders providing informed consent to participate in clinical trials. Researchers at University of California, San Diego, compared an enhanced informed-consent presentation with slides to a standard written form. They found that, even in older patients with chronic psychotic disorders, "Understanding of protocols may be enhanced when educational interventions are utilized."

They further advocated that, rather than assume patients have limited capacity to make decisions about their participation, "procedures for improving patients' comprehension of informed consent should be actively sought."

Articles

In this second article of a series, innovative research and technologies presented at the 41st Annual New Clinical Drug Evaluation Unit meeting are highlighted.

Investigational Agents and Methodologies at NCDEU

In the wake of the recent horrors, many of us in the mental health care community turn reflexively to the diagnosis of posttraumatic stress disorder (PTSD) in trying to understand how these historic crimes affect our bodies and minds. A majority of Americans were exposed to the trauma by witnessing the mass murder on their televisions again and again. A large proportion of those people experienced firsthand the symptoms of re-experiencing, hyperarousal and avoidance.

However, most Americans will never develop PTSD because their symptoms will fade with time. Enough strength will be drawn from families and friends, work, service, art, sports, nation, or spirituality. It is the people most directly affected -- the bereaved, the physically injured, the escapees and the eyewitnesses from nearby -- who should be considered at greatest risk. We are right to be concerned that these people will develop PTSD, as well as other trauma-related disorders such as depression and anxiety. 

What we trauma mental health care professionals should also be concerned with is that the diagnosis of PTSD which we are using has been rendered highly problematic by the very events it now attempts to address. That is because the diagnosis of PTSD is itself a cultural product of an era in American history that has passed. Posttraumatic stress disorder best fits a situation in which a person has been exposed to a traumatic event and bears the marks of that experience, but has then been removed from the actual event. 

The term PTSD is most appropriately used for traumas acquired "over there." Young Americans got it after they went to Vietnam. Torture survivors and refugees got it in their troubled countries. Part of why we say post is precisely because we make the assumption that victims are now in a safe place. 

We have applied the same approach to people exposed to traumas at home. Sometimes "there" was a point in time. Adults who suffered abuse or incest as children got it. Victims of sexual assault or a disaster that we comfortably assume will not occur ever again got it.

What changed on Sept. 11 is that for all Americans, suddenly "there" was now "here." Our old assumption that we are safe "here" does not fit, now that we are "there." Posttraumatic stress disorder was a designer diagnosis for the old "here." Will it work in the newly endangered world that we inhabit now? 

Some of us who have worked in dangerous places always knew that PTSD was a preciously American disorder. We thought of it as a product of our culture of individual autonomy or our history of war in Vietnam. What we failed to realize until Sept. 11 was that it was also the product of an era of innocence in American history that let us all indulge in the shared fantasy that "here" was safe. Of course, PTSD never really fit the ghetto experience either, but for many Americans, that was also "over there."

Psychiatrists in Bosnia-Herzegovina and Kosovo have told us again and again that PTSD just does not make sense in their world. "War is a part of life," they told us. "There is no posttrauma." Even so, professional experts persisted in teaching them that the concept of PTSD was real and would help victims. What's more, the clinical perspective of PTSD led international helpers to focus their efforts too much upon individuals, and not enough upon families, communities, services and public health.

The idea that PTSD might not fit the reality "over there" did not seem to matter much in America. Our behaviors in Bosnia-Herzegovina and Kosovo never came under serious scrutiny, and we never had a public mental health care emergency of this magnitude at home. Now that "there" is "here," many American professionals find themselves needing to learn from our colleagues who do mental health care work in conditions of persistent dangers, insecurities and uncertainties. 

As trauma mental health care professionals, we are now naked. We have been stripped of the very social context that bred our diagnosis, as well as the colonial garb that we used to sell PTSD abroad. We must respond appropriately to the horrors that have been witnessed and experienced, but we cannot let our quickness to invoke PTSD prevent us from realizing what has been changed forever. 

It is understandable that in a desperate moment, we as professionals would turn first to what we know best and start educating others about diagnosing and treating individuals with PTSD. But it is time to get real. Americans will expect us to do a lot more than talk about and treat PTSD in this new public mental health care crisis that is not about to end.

Trauma mental health care can be helpful, but it will not work through selling PTSD, as we did abroad. The trauma field should first be oriented to the actual conditions of the new reality, through directly engaging with survivors, families, communities, businesses and government. We must be willing to change our way of thinking to face the public mental health care challenges in a new era of vulnerability for Americans. Whether we are able to help people and help America depends upon how much and how quickly we are willing to learn.

The very immediacy of the recent terrorist attacks makes the diagnosis of posttraumatic stress disorder problematic since there is no distance of time or space from the event itself. How can clinicians deal with this shift to best treat patients?

Naked Before Trauma

Paul R. McHugh, M.D., of Johns Hopkins University has proposed a conceptual structure for psychiatry that seeks to identify the essence of mental disorders as expressions of psychological life in a context of pathology and misdirection. This would replace the current focus on symptoms found in the 

, which McHugh claims has led to an unwieldy and outmoded system with overlapping conditions and confusing diagnoses. McHugh's criticism and proposed solution appeared in the summer issue of 

, a quarterly publication from the American Psychiatric Association's division of research. His discussion can be found on the Internet at <

www.hopkinsmedicine.org/press/2001/august/McHugh.htm

McHugh, Henry Phipps Professor and chair of the department of psychiatry and behavioral sciences at Johns Hopkins, proffers an approach based on four explanatory methods or perspectives used at Johns Hopkins for over 20 years. While these methods may be used implicitly by many practicing psychiatrists, by making them explicit, McHugh and colleagues hope to bring forth a new structure for psychiatry. The four perspectives are disease, dimension or psychological variation, behavior, and life story.

The disease perspective identifies psychiatric disorders that are neuropathic. It explains clinical presentations by tying symptoms to disrupted functional or structural body parts. Examples given by McHugh include delirium (disruption of consciousness), bipolar and panic disorders (disruption of affective control), and schizophrenia (disruption of executive and psychointegrative brain functions). Research on the disease perspective works to tie pathologic disruptions to clear etiologies.

Patients' cognitive and affective constitutions are the focus of the dimension perspective. Rather than originating from a disease, according to McHugh, emotional distress may be the outcome of the combination of cognitive or affective potential and provocative situations that attack this vulnerable potential. Laying at an extreme of a dimension (for example, scoring low on cognitive capability or high on neuroticism) could lead to strong emotional responses requiring psychiatric attention.

The behavior perspective identifies troubles resulting from patients' own goal-directed activities. According to McHugh, some behavior disorders are related to problems with control and choice, particularly when tied to innate motivated drives like eating, drinking, sleeping and sexuality. Other behavior disorders, such as anorexia nervosa, false memory syndrome and adult gender identity disorder, are related to the personal viewpoint that emerges from meaningful experience, which McHugh calls the 

 of an individual. Treatment of behavior disorders must include confronting and ending the patient's reluctance to change.

Disorders that represent a meaningful response to life's encounters call for the life-story perspective. This perspective, McHugh notes, "forges a narrative that illuminates the troubled outcome and suggests some role of the self in it." The life-story perspective reveals a common presentation in patients who have been demoralized and overmastered by circumstances. Treatment calls for the reinterpretation of a distressful setting, sequence and outcome.

While quick to say this format is not a final solution, McHugh told the press, "What I am saying is that solutions of this sort should be the subject of psychiatric attention and academic work."

A Conceptual Structure for Diagnoses

The mainstream of our profession has ceased paying much formal attention to the help our patients get from the doctor-patient relationship itself. But patients are stubborn. They still expect to have helpful relationships with us! Witness the ill-informed boyfriend of a public-clinic patient who asked me, at the close of a medication visit, "But when is she going to see a psychiatrist? She has things to talk about!" Equally disturbing was the well-meaning enthusiasm of a young psychiatrist interviewing for work at the same facility when I told him that I use my psychotherapy training in many a patient encounter there. "Oh, like if there's time, you might do a little cognitive therapy on 'em?"

We psychotherapists have ourselves to blame for this state of affairs, having husbanded our subspecialty's development in two narrow directions while psychopharmacology and neuroscience have dramatically broadened their own worldviews. Some of us have manualized and proceduralized psychotherapy (or rather, certain psychotherapies) in imitation of procedural, technology-driven medicine, so as to be good citizens in the world of indications, interventions and outcomes. Most new psychiatrists have had some exposure to these techniques, but few seem inspired by them.

Another potentially influential group has circled the wagons for psychoanalysis and psychodynamic therapy. The large body of literature this group continues to generate takes many fascinating forms, from the quasi-literary to the quasi-neurological, but few psychiatrists-in-training read it.

Neither of these two currents in psychotherapy convincingly illuminate, or render more effective, our work with the entire spectrum of patients we see in everyday general psychiatric practice.

What sense can we possibly expect our trainees to make of this Tower of Babel? Unless they are unusually persistent, they will either stick to the 

 and the meds and/or develop their own ways of conceptualizing personality and human nature, often with the help of pop psychology or New Age spirituality. In both cases, this dooms them to repeat sundry mistakes of the past, because an intellectually rigorous psychology of relationship, cognizant of boundaries and power arrangements, is missing. Should those of us who still try to teach psychotherapy in this inhospitable clime simply accept that the next generation will have to reinvent the wheel, or can we do any better for them?

We can, and it isn't all that hard. A global overview of the psychotherapeutic enterprise, based not upon theory but upon what therapists actually do, is easy to provide and reveals that there are really only three kinds of psychotherapy. I will begin my description with the rather typical odyssey of a real patient at a residency training program.

This patient's prolonged panic attack began when her mother arrived from out-of-state at the local bus terminal in a hospital johnny, seeking her care. Unable to cope, the patient was brought to the emergency department by her husband. She was so desperately anxious as to admit to suicidal ideation: the "Open sesame!" of our triage culture. At age 31, this secured her first psychiatric hospitalization and evaluation.

The patient settled down quickly with the help of anxiolytics and an alternative placement for her regressed, mentally ill mother. But during her brief stay, an alert inpatient resident noticed that she engaged in several classic compulsive rituals, including much hand-washing and showering. Referral was made for outpatient psychotherapy with another resident who would obtain supervision in the cognitive-behavioral treatment (CBT) of obsessive-compulsive disorder (OCD) in addition to the usual medication trials.

The outpatient resident got more than he had bargained for. It was difficult for him to concentrate on response-prevention and thought-stopping techniques under the silent, watchful eye of the patient's husband -- and she insisted upon his presence in order to "feel comfortable." The resident kept trying, and one day when the husband had to leave the session early, the patient volunteered that in her own mind, the pervasive sense of dirtiness that kept her always washing had something to do with repeated episodes of sexual abuse by her mother in childhood. There was also fear of retribution by her mother for "not being a good girl," which transferred in the present to her husband. His idea of good behavior was that she never leave their apartment alone.

It became clear to this intelligent resident that, beyond the illness dimension of Axis I OCD, a relational dimension would have to be entered to treat this patient successfully. A newcomer to the incoherent shipwreck of non-psychopharmacological psychiatry, he understandably groped for some of the remaining scraps of a psychological outlook that are still afloat. Childhood trauma...pathological dependence...Axis II borderline personality disorder (BPD)? Well, close enough to try dialectical-behavior therapy (DBT), opined the supervisor.

And so, aided by the husband's periodic departures after check-in, the resident soldiered on with chain analyses of anxious thoughts and other such techniques in a DBT-like individual therapy (the skills classes, of course, were unacceptably anxiety-provoking). Eventually the patient stopped coming, and when the resident finally called, she told him that she was afraid she would always be a disappointment to him and was wasting his valuable time. Could she see the hospital resident who had originally admitted her, "just to talk?"

To the second resident's chagrin, the patient proceeded to settle in comfortably with the original resident, attending regularly although she (the hospital resident) was even more of a therapeutic neophyte and knew no specific techniques. In fact, she said, "I have no idea what I'm doing!" But she is clearly doing something specifically effective for the first goal of any therapy: keeping the patient in the room. The patient is comfortable enough to dispense with the husband's presence. A second "safe place" is emerging that can compete with the safety of the husband's total control, and within which she can begin to take possession of herself.

We can imagine where things might go from here if the utilization reviewers are kept at bay. Perhaps patient and resident (or the resident's successor) will feel ready to retry the response-prevention strategies that failed at first, building on the strength of a working relationship. Or perhaps they will work directly on that relationship itself, when the idealized "safe" therapist inevitably falls from grace and disappoints (or enrages) the patient. Ideally, the patient will eventually work on both behavior and relationship, although not necessarily with the same therapist.

This patient exemplifies the everyday complexity of the real-world population psychiatrists treat. Hers is not a pure form of a 

-described illness that dutifully improves like the cases in academic studies ("OCD+CBT=OK," "BPD+DBT=OK" and so on, as I like to joke). Instead, she is the usual biopsychosocial layer cake (Table 1) of Axis I syndrome (bio-), relational disturbance (psycho-) and developmental damage (-social). Because of this, benign power -- here, the doctor who tries to do response-prevention -- is not a viable reality for her. Before she can get help, she needs help with getting help. And that is what the resident who "doesn't know what she's doing" is giving the patient.

In the real world of clinical practice, based not on theory but on the unspoken power narrative embedded in the therapeutic relationship, there are only three kinds of therapy (Table 2): supportive, directive and relational. Our patient began her odyssey in the directive column, where most contemporary psychiatric treatment starts, first with the CBT, then DBT. When she came back, it was to the supportive column, albeit to a therapist who had not yet learned its language. If all goes well, she will finish in the relational column, probably availing herself again of directive techniques along the way.

The underlying premises of each kind of therapy establish a power structure within doctor-patient relationships -- a structure that doctors may not have thought through in advance and that they might not endorse if they had. With deliberate exaggeration, therefore, let me explicitly voice the power narrative of each of these three forms of therapy to show the differences between them. 

When I speak of power, I refer to the therapist's power to define the nature of reality. Thus, in directive therapies, the unspoken narrative is, "I, the therapist, am powerful and know what is or isn't dangerous [in anxiety disorders], is or isn't negativistic [depression], is or isn't real [psychosis]. I know the diagnosis and causes of your illness, and I direct you to change your thoughts/feelings in the following way," and so on.

Such a narrative reiterates the existing social status quo and asks the patient to adjust to it. This is often a good and necessary thing, as with a potentially violent paranoid man in the emergency department, or a widowed woman whose grief has extended into major depression. But because many damaged patients are unable to let themselves be helped by a benign authority -- unable, in D.W. Winnicott's words, to "use the object" -- directive therapies don't work as often as their academic proponents would like to think.

While the supportive therapies are centered on the person rather than the symptoms, their power narrative has a remarkable underlying similarity to that of their directive cousins. "I, the therapist, am powerful-powerful enough to keep the world at bay. I will create the environment and give you the nurturance that you need. Let yourself unfold under my protection, bask in my empathy," and so on.

Instead of actively reinforcing the social status quo, this narrative provides the patient a temporary respite from it. Once again, this is often a good and necessary ("indicated") thing, as in the resident's case presented earlier. I want to stress, though, that it is a technical approach in that it purports to know what is wrong -- environmental stresses, developmental deficits from childhood -- and to be able to ameliorate or correct it through consciously (even if intuitively) modulated enactments on the part of the therapist. In comparison to directive therapy, the harsh diagnostic language is muffled and there is some implicit faith in an intrinsic healing process, which supportive therapy tries, indeed, to support. But the power arrangement in which a knowing therapist administers techniques to a malfunctioning patient remains the same. I maintain that this is even true of Kohutian self-psychology, which has developed a rich and beautiful theoretical language to describe its own version of supportive therapy. Such language does not change the fact that the therapist largely defines the nature of reality -- an arrangement much more obvious and above-board in the less humanistically couched directive therapies. Of course, what the experienced practitioners from any well-established school of psychotherapy actually do is likely to span all three of the types of therapy in this classification scheme at some time or another; it is only either very new, or very partisan, practitioners who refuse to adapt their behavior to the needs of a reasonable range of patients.

Relational therapy remains to be described, and it is as important not to idealize it as it is not to devalue the other two forms. It does not fit all or even most patients' needs, and its irresponsible application can be not only "contraindicated," but cruel. However, it is the only form of therapy whose power narrative allows both doctor and patient to be subjects engaged in an unpredictable process, rather than an Expert and the object of their technique. "I, the therapist, possess an institutionally sanctioned role, as well as education and experience. But my power and knowledge are limited. I offer no more nor less than an honest professional relationship whose primary purpose is to address your problem(s), but through which I fully expect to question myself, learn and grow as well."

The language of Martin Buber's "I-Thou" dialogue, Jurgen Habermas' "communicative action" or Winnicott's ingenuous term "object use" (which is really about subjects), all aptly describe such a relationship. Therapy takes the form of questions and statements about one's experience of self and other, and its power lies chiefly in the immediate interaction regardless of how much importance the therapist attributes to constructs such as transference, the unconscious, developmental issues, the Gestalt cycle of experience and so on. We all have our favorite constructs, our own ways of skinning a cat.

Because honest reciprocal dialogue fosters autonomy, independent thinking and acceptance of one's own emotional reality, it is subversive to the social status quo and its usual power arrangement of Expert and object. While patients retain, even improve upon, their ability to get help (including medical care) through relational therapy, its premise encourages them to become the ultimate Experts and Authorities on their own mental and interpersonal lives. 

Before I conclude, two important corollaries to this triune scheme deserve mention. First is the place of the powerful modality of group psychotherapy. The various approaches to it fall into the same categories: supportive (peer and professional support groups), relational (process-oriented groups) and directive (psychoeducational and skills groups). As in individual therapy, actual practice favors hybrids rather than pure forms. Family therapies, with which I am less familiar, probably follow analogous patterns.

The other corollary involves the role of medication. It may be directive (as with antipsychotics in acute delusional mania, which aim to change mental content) or supportive (as with temporizing anxiolytics or antidepressants when used to prolong a patient's survival in an intolerable home situation: here the effort is to dull mental content). But medications can never be relational, much as patients sometimes attempt to have relationships with us through them, symbolically mediated by "side effects," paradoxical responses and refractoriness to treatment. This is one reason why longer visits and individual attention lead to more successful pharmacotherapy.

Giving psychiatric trainees an overview of these three kinds of psychotherapy demystifies the field and helps them to find their place in it. They can then move beyond the procedural "see one, do one, teach one" mentality of medical school. Instead of learning to "do some therapy on 'em" in only standardized ways, trainees will begin to look at their own natural aptitudes, as well as their intrinsic limitations, and how possibly to stretch them. Otherwise we consign them to the learning of an ever-narrowing, mechanistic approach to human problems.

Dr. Genova offers the antidote to the complexities of manualized and proceduralized psychotherapy that have arisen in imitation of procedural, technology-driven medicine. Supportive, directive and relational types of therapy and their correlation with various power structures within the doctor-patient relationship are described.

There Are Only Three Kinds of Psychotherapy

"Nothing in my life so far has prepared me to face the sights, sounds, smells and emotions that accompanied the horror of Sept. 11," said Spencer Eth, M.D. For the last 20 years, Eth has spent his professional career treating and studying children, Vietnam veterans and others struggling with issues of trauma and grief.

Saint Vincent Catholic Medical Centers, where Eth is vice chair of the department of psychiatry, is an academic medical center of New York Medical College. Its Manhattan campus was the closest trauma hospital to "Ground Zero."

Eth's self-disclosure parallels the reactions of many psychiatrists and other mental health care professionals who remain on the frontlines providing help to anguished rescue workers, police, firefighters, families and co-workers of the missing or dead, teams in the medical examiner's office, workers aiding bereaved families, and countless others.

Eth recently testified before the U.S. Senate Committee on Health, Education, Labor and Pensions on "Psychological Trauma and Terrorism: Assuring That Americans Receive the Support They Need." In his testimony and in a subsequent interview with 

, he provided a glimpse of those first hours and days.

"Within minutes of the first plane crash at 8:45 a.m. in Building 1 of the World Trade Center, Saint Vincent's was ready to respond to the expected demand for emergency care. Over 600 patients were examined, of whom 162 were firefighters, police and rescue workers," Eth told the Senate committee. "Although these patients were treated for physical injuries, many also wanted to share with our mental health staff their terrifying experiences. One dehydrated firefighter being seen in the emergency room began to shake and cry as he confided to me that he had just carried the headless body of his commander out from the rubble."

In the days since the terrorist attack on New York, Saint Vincent's family support center staff has provided information and counseling to more than 7,000 people. Additionally, Saint Vincent's established a telephone counseling service that has received more than 10,000 calls since the disaster, according to Eth, who is also medical director of Saint Vincent's Behavioral Health Services and professor of psychiatry at New York Medical College.

The family support center also has become a respite place for hospital staff.

"We thought it would be for families," Eth told 

, "but we find that our colleagues really need it as well. We have offered massage, acupuncture, and a quiet place to relax and get away from the heavy physical and emotional burdens of responding to this disaster. People are working longer hours, and the work is more intense."

Initially, the disaster was a medical/surgical emergency, Eth said. But within 12 hours it evolved into a mental health crisis. 

"The New York hospitals and community mental health agencies are trying to coordinate efforts to provide mental health services in concert with the City Department of Mental Health, Mental Retardation and Alcoholism; the New York State Office of Mental Health; and various federal agencies. It is a huge task to plan for mental health services, to coordinate the services, to train clinicians, and to provide the services and outreach that [are] necessary. That process is underway, but has a while to go before we are able to meet the need," he said.

At the same Senate hearing, Cynthia Pfeffer, M.D., professor of psychiatry and director of the Childhood Bereavement Program at Weill Medical College of Cornell University and New York Presbyterian Hospital, discussed her involvement in helping families and children.

"I had many responsibilities during the aftermath of this tragic event to assist schools, corporations, community leaders and affected families to process and develop plans to cope with the emotional, behavioral, physical and social consequences of this tragic episode. I met many children and their parents who revealed concerns with profound implications," she told the committee.

"Some parents reported that they were overwhelmed with fear, crying and helplessness. They could not easily communicate with their children and wanted support and guidance. Teachers were not sure about what to tell their students, how to interact with parents and how to cope with their own feelings. Parents debated with each other about how to explain what occurred fearing that their children would be traumatized."

At New York University's (NYU) Bellevue Hospital Center, Carol A. Bernstein, M.D., who supervises the nation's largest psychiatric residency training program (72 residents), has had her own share of daunting challenges since Sept. 11.

"We have been centrally involved right from the beginning," she told 

. "It's been hard to cope with all the personal issues that come in a situation like this at the same time [that] we are charged with providing the mental health services in the disaster and trying to train the next generation of psychiatrists." 

Within two hours after the World Trade Center collapsed, Bellevue Hospital was running in full disaster mode, with several hundred doctors and medical students prepared to deliver care, according to a 

"We discharged a lot of people from psychiatric services in order to provide beds for the expected injured and set up all sorts of extra staffing for psychiatric emergencies, but nobody came," said Bernstein. Only about 100 patients from the disaster were treated at Bellevue that morning, a telling sign of the later massive loss of life.

When Bernstein came in to Bellevue the next day (Wednesday), she was absolutely staggered by the fact that all of the residents had gotten there, despite the city being clamped shut and every access closed.

"I went to every group of residents that I could find -- at Bellevue, at the clinic, on the unit, in the emergency room -- and talked with them. Everybody was really quite shaken up but determined to help in whatever way they could," said Bernstein, associate professor of clinical psychiatry at NYU School of Medicine.

By Wednesday, families of those missing in the disaster were starting to check hospitals for their loved ones and go to a designated assistance site in the children's services building, located between NYU and Bellevue Hospital.

"A lot of psychiatry residents were actually out with lines and lines of people helping them go over what, at the time, were handwritten lists of people who had been admitted to various emergency rooms around the city," she said.

In the beginning, mental health care services were disorganized, Bernstein said, and "every day there was a new plan of what types of psychiatric services might be necessary."

Later in the week, some of the psychiatry residents were enlisted to help major corporations address the emotional devastation. Cantor Fitzgerald Partners, the brokerage house that lost some 600 employees from their World Trade Center location, arranged for a meeting with families and friends of the missing at the Pierre Hotel.

"Some of my residents went out to try to help the families. There were several PGY2s involved and, for them, it was an overwhelming experience. When people realize that family members have died tragically and suddenly, there is a lot of emotion," she said, adding that survivors in the firm also experienced intense emotions.

Throughout that first week following the terrorist attack, Bernstein did what she could to reduce the anxieties of the residents.

"Everybody was so frightened," she said. "All of the disaster literature talks about workers going to a disaster situation, but they don't talk about a situation where the workers are traumatized themselves," she said. For Bernstein, everyone in Manhattan was at "Ground Zero," and the experience was "off the chart."

"I was meeting pretty much every single day with as many residents as I could gather together. On Thursday, I was able to meet with all of my PGY3 residents to debrief them and talk about what was going on. And at noon, we had a resident-wide journal club that was led by several of our attendings, including one who was cofounder of a disaster psychiatry outreach group at the morgue. We used some materials that the American Psychiatric Association put up on its Web site and any material I could get my hands on," she said. "Yet, there isn't much written on a disaster of this magnitude in a major urban area It must have been like the Blitz in London during World War II, but people were not writing about posttraumatic stress disorder then."

By Sept. 17, Bernstein asked her residents seeking to participate in volunteer activities to talk with her. She explained that studies indicate psychiatric patients are at particular risk in a disaster situation. "The residents really needed to be there for their patients and to conserve their energies for the long haul."

She explained that some of the residents are currently helping at the New York City Family Assistance Center on Pier 94, located at 54th Street and 12th Avenue. "It looks kind of like an exhibit hall at an annual meeting. There are places for people to go to get death certificates, to get unemployment benefits, to see about housing, and, of course, there are counseling services," she said. "NYU is now sending a team on Mondays and Tuesdays during the day-one attending and one resident-to the pier to provide counseling services for anyone who needs help. To me, this is good, because it is structured. There is attending supervision, and we will relieve the residents of their regular responsibilities during the day to do this."

Beyond counseling families, the residents are also helping professionals working with families. For example, they are debriefing lawyers who are providing legal assistance to families filing death certificates.

Because the city's medical examiner's office is located at NYU, some residents have volunteered to provide counseling to individuals involved in identifying body parts and working with victims' personal effects.

Looking at her own contribution, Bernstein said she is linking traumatized people around the country with psychiatric resources -- individual practitioners, clinics and the like. And she is also looking after the residents. "The challenge for me on my job is to try to hold them together, teach them and also give them the opportunity to volunteer if they want to. Everybody feels so helpless when something like this happens, so you want to do something to make it better."

Asked about the ongoing effects of the disaster on herself, the staff and the people of New York City, Bernstein said that seeing the Wall of Prayer -- photos and flyers about the people who are still missing in the disaster -- on a construction barrier outside the entrance to Bellevue Hospital impacts "us, the residents and our patients." She added, "There is a hole in lower Manhattan. Subway service is still out. Access to hospitals is restricted. There are police everywhere...For myself, each week is a little better, but I wouldn't say each day is better. Some days are good, and some days are bad. There is a gradual movement in the return to normalcy as it were, but it is not the same."

What was it like to be at "Ground Zero"? Three psychiatrists discuss their experience and the impact the attack on the World Trade Center will have on the future.

Psychiatrists in the Midst of the Horror

With the recent terrorist attacks on New York City and Washington, D.C., it appears as though the nation is on edge for further occurrences, including the use of biological weapons.

While it is necessary to be vigilant for future attacks, according to Carol North, M.D., professor of psychiatry at Washington University School of Medicine in St. Louis, it is also important to do so without encouraging panic in others. North, who has specialized in studying bioterrorism, stressed in an interview with 

She said, "There will be different responses in different people, ranging from logical to excitable, even for psychiatrists, because we are also human. It is very important to use common sense and be a good role model for patients."

Robert J. Ursano, M.D., professor and chair of the department of psychiatry at Uniformed Services University of the Health Sciences in Bethesda, Md., agreed with North on the necessity for balancing awareness and common sense. Ursano, who has also studied the psychiatric effects of trauma and disaster, told PT, "Psychiatrists need to be able to educate their patients, colleagues and community leaders in the accurate assessment of risk, the normal anxiety and hypervigilance that accompanies serious threat that is of a low probability for any one group, and how to assist families and children in managing feelings of altered safety that may have come since the Sept. 11 event."

One key to helping people deal with anxiety is understanding how the recent anthrax cases in Florida and elsewhere differ from a real bioterrorist attack. North, who stressed that the Florida cases were all contained in a single location and not contagious, said, "Unlike smallpox, the only way to get anthrax poisoning is through contact with the contagion itself. Furthermore, anthrax poisoning is easy to diagnose and treat." She added that she is not aware of any mass hysteria outbreaks in Florida as a result of the cases.

Despite this, Ursano still feels that the threat of bioterrorism is valid. He stated, "Bioterrorism remains of significant concern and, as has been again demonstrated with recent events, [there are a] large number of people who may be worried about exposure when none has occurred. The issues of behavioral and psychiatric responses to bioterrorism are among the most important to be dealt with if our public health system is to be able to function."

Part of helping the public health system contend with the threat of bioterrorism is having reliable research available. North stressed this importance, "Right now, we don't have much good data on bioterrorism. We have to extrapolate and anticipate from what we have available." 

(For more information on the threat of bioterrorism, please see the cover story in the July issue of 

Given the recent anthrax scares, it is important for psychiatrists to be on the alert. However, this should be balanced with the realization that life must continue as normal as possible.

Cautious Wake-Up Call for Bioterrorism

Since Sept. 11, health care professionals and their patients have been trying to make sense of the tragedy as well as cope with the possibility of future attacks. While the following list of books, articles, Web sites and so forth is certainly not exhaustive, it serves as a starting point of information sharing.

We envision this resource to be an evolving database. To do so, we need your help. If there are other resources you find especially helpful, 

. If you have comments about resources that you would like to share with your colleagues, please send them to the 

. And, please be sure to visit this site regularly for new information. 


John P. Wilson, Ph.D., Terence M. Keane, Ph.D., eds.
New York: Guilford Press (1996)

Theories, standardized measures and physiological techniques used in the assessment of traumatic stress syndromes are discussed. Another area of focus is context-specific traumatic reactions of victim and survivor populations.


by Edna B. Foa, Ph.D., Terence M. Keane, Ph.D., Matthew J. Friedman, M.D., Ph.D., eds. 
New York: Guilford Press (2000)

Developed under the auspices of the Postraumatic Stress Disorder (PTSD) Treatment Guidelines Task Force of the International Society for Traumatic Stress Studies, this book discusses an array of treatment options for children, adolescents and adults. Acute interventions, cognitive-behavioral therapy, pharmacotherapy, eye movement desensitization and reprocessing, group therapy, psychodynamic therapy, inpatient treatment, psychosocial rehabilitation, hypnosis, and creative therapies are among the approaches covered.

Emotional Aftermath of the Persian Gulf War: Veterans, Families, Communities and Nations


by Robert J. Ursano, M.D., Ann E. Norwood, M.D., eds.
Washington, D.C.: American Psychiatric Press (1996)

The stressors, psychological responses and care needs of Operation Desert Storm veterans are explored. Some relevant chapters include the effects of chemical and biological warfare, management of psychiatric illness in the injured, the effects of mobilization on National Guard and Reserve forces and their families, and the stress of SCUD missile attacks.

Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos


Robert J. Ursano, M.D., Brian G. McCaughey, D.O., Carol S. Fullerton, Ph.D., eds. 
New York: Cambridge University Press (1996)

This volume discusses the nature of traumatic stress and the role of psychosocial context in responses to trauma and disaster, as well as responses to trauma across the lifecycle.


by John P. Wilson, Ph.D., Matthew J. Friedman, M.D., Ph.D., Jacob D. Lindy, M.D., eds. 
New York: Guilford Publications (2001)

The editors identify 65 PTSD symptoms contained within five symptom clusters and describe 80 target objectives for treatment. Expert contributors provide detailed presentations of core therapeutic approaches as well as approaches to working with specific populations, such as children and refugees.

American Academy of Child and Adolescent Psychiatry (AACAP)
<

AACAP has gathered together a "disaster relief kit," which includes publications to assist parents and children dealing with the Sept. 11 tragedy.


American College of Occupational and Environmental Medicine
<

The Mental Health Committee and the Council on Scientific Affairs of the American College of Occupational and Environmental Medicine has prepared a set of response guidelines for employers dealing with psychological trauma of the events of Sept. 11. The guidelines cover such topics as three questions often asked by survivors and emergency response team members and how to approach an employee in distress.


American Psychiatric Association's Committee on Psychiatric Dimensions of Disaster 
< 

www.psych.org/pract_of_psych/disaster_psych.cfm

This site provides resources on immediate responses to disaster, such as debriefing following trauma and managing the stress of those who must recover the bodies, as well as links and references for further information on disasters. Several publications offering victim-specific recommendations, such as "Helping Children Cope with a National Tragedy" and "Teachers Helping Students: Listening and Talking," are also provided.


Center for Mental Health Services (CMHS)
< 

www.mentalhealth.org/cmhs/EmergencyServices

The CMHS works in partnership with the Federal Emergency Management Agency to oversee national efforts to provide emergency mental health services to survivors of disasters. The Web site provides links to such online, full-text booklets as 

Field Manual for Mental Health and Human Service Workers in Major Disasters, Responding to the Needs of People With Serious and Persistent Mental Illness in Times of Major Disaster, and Psychosocial Issues for Older Adults in Disasters.

Geared toward patients, this site provides answers to frequently asked questions on medication and psychotherapy options for anxiety disorders as well as discussion on such topics as "Comorbidity, Impairment, and Suicidality in Subthreshold PTSD" and "Help in Moving Past Trauma." 


International Society for Traumatic Stress Studies
<

Fact sheets on treating survivors in the acute aftermath of traumatic events and acute responses to traumatic stress as well as links to specialized trauma resources and organizations are provided on the site. Resources for the media and the public are also included; therefore, mental health care professionals can also recommend this source to their patients. 


National Alliance for the Mentally Ill (NAMI)
< 

www.nami.org/helpline/traumaresources.html

NAMI has posted a brief list of resources on how to deal with the impact of terrorism and traumatic events, including a Spanish language fact sheet on PTSD and links to counseling services in New York City.


National Organization for Victim Assistance (NOVA) 
<

This nonprofit organization has posted several articles to help survivors of the terrorist attacks, including "Long-Term Stress Reactions to Terrorism" and "Surviving the Holidays After Sept. 11, 2001: Ten Thoughts on Coping."


National Institute of Mental Health (NIMH)
<

www.nimh.nih.gov/outline/responseterrorism.cfm

In a special section called "Response to Terrorist Acts Against America," NIMH has provided links to several online and print resources, including "Helping Children and Adolescents Cope with Violence and Disaster" and "Facts About Anxiety Disorders."


The National Mental Health Association provides links to several online, full-text publications including "When to Seek Help" and "Helping Your Workforce Cope and Return to Work."


PTSD Alliance (a coalition of the Anxiety Disorders Association of America, the International Society for Traumatic Stress Studies, the Sidran Traumatic Stress Foundation, and the American College of Obstetricians and Gynecologists)
<

The PTSD Alliance offers free educational booklets, videos and other trauma-related resources for professionals working with PTSD patients and trauma survivors, as well as the survivors' families.


Disaster Psychiatry Outreach is a non-profit volunteer organization of psychiatrists committed to providing high quality disaster mental health care services. This site provides information about the most recent developments, new initiatives and ways for professionals to provide help to disaster victims. The current focus is the Sept. 11 relief effort.

"Biological Responses to Disasters"
by Arieh Y. Shalev, M.D.


www.psych.org/pract_of_psych/biological_responses_to_disasters3501.cfm

"Coping With Disaster: Suggestions for Helping Children With Cognitive Disabilities"
by Anne Farrell, Ph.D., and Daniel Crimmins, Ph.D
Administration for Children and Families, U.S. Department of Health and Human Services (2001) 
Available at: 

www.acf.dhhs.gov/programs/add/Sept11/addcoping.html

"Debriefing Following Trauma"
by Carol S. Fullerton, Ph.D., Robert J. Ursano, M.D., Kelley Vance, M.P.H., Lemming Wang, M.S.


www.psych.org/pract_of_psych/debriefing_following_trauma3501.cfm

"Disaster Mental Health: Crisis Counseling Programs for the Rural Community"
by Glenn Jackson, M.Div., LSW, LCPC, and Charles G. Cook, LSW
Substance Abuse and Mental Health Services Administration (1999) 
DHHS Publication No. SMA 99-3378. 
Available at: 

www.mentalhealth.org/cmhs/EmergencyServices/CrisisCounseling_toc.asp

"Disaster Psychiatry: Principles and Practice"
by Ann E. Norwood, M.D., Robert J. Ursano, M.D., Carol S. Fullerton, Ph.D.


"Field Manual for Mental Health and Human Service Workers in Major Disasters"
by Deborah J. DeWolfe 
Substance Abuse and Mental Health Administration (2000)
DHHS Publication No. ADM 90-537
Available at: 

www.mentalhealth.org/publications/allpubs/ADM90-537/Default.asp

"Psychiatric Issues in Medical-surgical Disaster Casualties: A Consultation-liaison Approach"
by James R. Rundell, M.D. 


www.psych.org/pract_of_psych/consultation_liaison_approach3501.cfm

"Stress and Vulnerability to Posttraumatic Stress Disorder in Children and Adolescents"
by Raul R. Silva, M.D., Murray Alpert, Ph.D., Dinohra M. Munoz, M.D., Sanjay Singh, M.D., Fred Matzner, M.D., and Steven Dummit, M.D. 


www.forensic-psych.com/articles/artSilva.html

"What is posttraumatic stress disorder?"
by Arieh Y. Shalev, M.D.


Resources for Coping With Disaster

It can come with a doctor's steady stare
or words blunt as a headstone.
The news is published in lab reports,
breaks when old men stand
and femurs crack like branches in ice storms.
Headlines are written by fingers on a lump, 
by eyes reporting shapes in an X-ray shadow,
and with stained sentences of cells on slides.
Sometimes it comes on fruity breath,
jaundiced skin, or sheets soaked
with banners of bright red blood.
We read it when a priest appears
and the nurse leaves, when a wife begs
her wasted husband to eat, when friends stop
calling and children run away.
Most days, news rants loud and public
as a tuned-out politician,
but if we have the courage to look,
it is broadcast from every face,
a black script all reporters know 
by heart.

How the News Comes

Over the past two decades, there has been considerable progress in understanding the functions of the prefrontal cortex of the brain and its regulation of mental activities that allow for self-control and goal-directed behaviors. These mental activities are unified under the term 

Executive functions are thought to enable a person to successfully engage in independent, purposeful and self-serving behaviors. The major executive functions include response inhibition, which permits impulse control, resistance to distraction and delay of gratification; nonverbal working memory, which permits the holding of events in the mind and allows self-awareness across time; verbal working memory, which comprises the internalization of speech and permits self-description, questioning and reading comprehension; and self-regulation of emotion and motivation, which permits motivation, persistence toward a goal and emotional self-control.

Over the past two decades, there has been considerable progress in understanding the functions of the prefrontal cortex of the brain and its regulation of mental activities that allow for self-control and goal-directed behaviors. These mental activities are unified under the term executive functions.

Psychiatric Times Vol 18 No 11

Investigational Agents and Methodologies at NCDEU

Naked Before Trauma

A Conceptual Structure for Diagnoses

There Are Only Three Kinds of Psychotherapy

Psychiatrists in the Midst of the Horror

Cautious Wake-Up Call for Bioterrorism

Resources for Coping With Disaster

How the News Comes

Executive Functions in Parents With ADHD

Obsessive-Compulsive Symptoms in Schizophrenia

Posttraumatic Spectrum Disorder: A Radical Revision

Introduction to Culture-Bound Syndromes