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Biomedical subjects

A Shaner

Publications and source records attributed to A Shaner.

At least 19 recordsLinked to original sources
PubMed2001

Factors affecting reliability and confidence of DSM-III-R psychosis-related diagnosis.

The relationships between interrater diagnostic reliability, confidence in diagnosis, DSM-III-R criteria ambiguity and case report data quality were examined in 20 case vignettes describing psychosis-related symptomatology. Each of seven diagnosticians made DSM-III-R diagnoses and gave confidence ratings for those diagnoses, as well as ratings on quality of data presented and clarity of diagnostic criteria for each vignette. As hypothesized, confidence ratings significantly predicted interrater diagnostic agreement. Clarity of DSM-III-R criteria positively correlated with both interrater reliability and confidence. Case report data quality correlated with diagnostic confidence but, contrary to the authors' hypothesis, did not correlate with interrater agreement. The authors conclude that confidence ratings may be useful indices of diagnostic reliability among experienced clinicians and suggest that the case report method allows for reliable diagnoses to be made.

Adult↗
PubMed2001

Implementing dual diagnosis services for clients with severe mental illness.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

Counseling↗
PubMed1999

The role of gender in engaging the dually diagnosed in treatment.

Individuals with both a serious mental illness and substance abuse are particularly difficult to engage in treatment. Given known gender differences in both substance abuse and schizophrenia, we examined the impact of gender on treatment engagement. Qualitative interviews with ten males and eleven females focused on how the client perceived the engagement process, and what obstacles they faced. While both males and females are difficult to engage, the interviews suggest that they experience the process differently and that they face different obstacles. We discuss the implication for service providers.

Adult↗
PubMed1999

Delusions, superstitious conditioning and chaotic dopamine neurodynamics.

Excessive mesolimbic dopaminergic neurotransmission is closely related to the psychotic symptoms of schizophrenia. A mathematical model of dopamine neuron firing rates, developed by King and others, suggests a mechanism by which excessive dopaminergic transmission could produce psychotic symptoms, especially delusions. In this model, firing rates varied chaotically when the efficacy of dopaminergic transmission was enhanced. Such non-contingent changes in firing rates in mesolimbic reward pathways could produce delusions by distorting thinking in the same way that non-contingent reinforcement produces superstitious conditioning. Though difficult to test in humans, the hypothesis is testable as an explanation for a common animal model of psychosis--amphetamine stereotypy in rats. The hypothesis predicts that: (1) amphetamine will cause chaotic firing rates in mesolimbic dopamine neurons; (2) non-contingent brain stimulation reward will produce stereotypy; (3) non-contingent microdialysis of dopamine into reward areas will produce stereotypy; and (4) dopamine antagonists will block all three effects.

Amphetamine↗
PubMed1998

Training and quality assurance with the Structured Clinical Interview for DSM-IV (SCID-I/P).

Accuracy in psychiatric diagnosis is critical for evaluating the suitability of the subjects for entry into research protocols and for establishing comparability of findings across study sites. However, training programs in the use of diagnostic instruments for research projects are not well systematized. Furthermore, little information has been published on the maintenance of interrater reliability of diagnostic assessments. At the UCLA Research Center for Major Mental Illnesses, a Training and Quality Assurance Program for SCID interviewers was used to evaluate interrater reliability and diagnostic accuracy. Although clinically experienced interviewers achieved better interrater reliability and overall diagnostic accuracy than neophyte interviewers, both groups were able to achieve and maintain high levels of interrater reliability, diagnostic accuracy, and interviewer skill. At the first quality assurance check after training, there were no significant differences between experienced and neophyte interviewers in interrater reliability or diagnostic accuracy. Standardization of training and quality assurance procedures within and across research projects may make research findings from study sites more comparable.

Clinical Competence↗
PubMed1998

Sources of diagnostic uncertainty for chronically psychotic cocaine abusers.

OBJECTIVE: This study determined the sources and frequency of diagnostic uncertainty for patients with chronic psychosis and active cocaine abuse or dependence and assessed the usefulness of prospective follow-up in clarifying diagnosis. METHODS: A total of 165 male patients with chronic psychoses and cocaine abuse or dependence on inpatient units of a Veterans Affairs medical center were evaluated using the Structured Clinical Interview for DSM-III-R (SCID-R), urine tests, hospital records, and interviews with collateral sources. An algorithm allowing key SCID-R items and diagnostic criteria to be designated as provisionally met or uncertain was applied, resulting in a provisional diagnosis and a list of alternate diagnoses. The assessment was repeated 18 months later in an attempt to resolve diagnostic uncertainty. RESULTS: In 30 cases (18 percent), initial assessment produced a definitive diagnosis, including 21 cases of schizophrenia, six of schizoaffective disorder, and three of psychostimulant-induced psychotic disorder. In the other 135 cases, a definitive diagnosis could not be reached because of one or more sources of diagnostic uncertainty, including insufficient periods of abstinence (78 percent), poor memory (24 percent), and inconsistent reporting (20 percent). Reassessment at 18 months led to definitive diagnoses in 12 additional cases. CONCLUSIONS: It was frequently difficult to distinguish schizophrenia from chronic substance-induced psychoses. Rather than concluding prematurely that psychotic symptoms are, or are not, substance induced, clinicians should initiate treatment of both psychosis and the substance use disorder in uncertain cases. The persistence or resolution of psychosis during abstinence and additional history from the stabilized patient or collateral sources may clarify the diagnosis.

Adult↗
PubMed1997

Monetary reinforcement of abstinence from cocaine among mentally ill patients with cocaine dependence.

OBJECTIVE: The study investigated whether contingency management could reduce cocaine use by patients with schizophrenia. METHODS: An A-B-A research design, with two-month baseline, intervention, and follow-up phases, was used to study two homeless, treatment-resistant male outpatients with DSM-III-R diagnoses of schizophrenia and cocaine dependence. During the intervention phase, subjects provided daily urine specimens for testing for the cocaine metabolite benzoylecgonine (BE) and received $25 for each negative test. Concentrations of BE and metabolites of other illicit drugs were assayed twice a week to determine the amount of drug use in addition to frequency. Analysis of variance was used to compare drug use during the three study phases. RESULTS: During the intervention, the proportion of tests positive for cocaine was lower for both subjects. Mean urinary concentrations of BE were significantly lower during the intervention than during the baseline. CONCLUSIONS: These results suggest that modest monetary reinforcement of abstinence may decrease cocaine use among cocaine-dependent patients with schizophrenia.

Adult↗
PubMed1995

Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door?

BACKGROUND: Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income. METHODS: We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks. RESULTS: Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs. CONCLUSIONS: Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.

Adult↗
PubMed1993

Unrecognized cocaine use among schizophrenic patients.

OBJECTIVE: Unrecognized stimulant use could lead to the misdiagnosis of schizophrenia or the misunderstanding of its course and prognosis. This study was conducted to determine the prevalence of unrecognized stimulant use among patients with a clinical diagnosis of schizophrenia. METHOD: The subjects were 108 schizophrenic patients admitted consecutively to a Veterans Affairs psychiatric hospital. Admitting psychiatrists supplemented routine clinical evaluations with a semistructured interview regarding recent and lifetime use of alcohol, cocaine, amphetamine, marijuana, and opiates. A urine specimen was assayed for the four illicit drugs. RESULTS: Of the 103 patients who provided a urine specimen, 37 (36%) used cocaine during the 6 months before admission, including 31 who used the drug in the week before admission. Because of the poor reliability of negative self-reports of recent cocaine use, clinicians failed to recognize cocaine use in one-third of the patients with a urine toxicology positive for cocaine metabolites. Two other groups of patients were identified; schizophrenic patients without substance abuse (including alcohol) and schizophrenic patients with substance abuse other than stimulants. Both substance-abusing groups were younger than the nonabusing group, but the three groups had similarly high rates of recent psychotic symptoms, homelessness, and unemployment. CONCLUSIONS: Among schizophrenic patients who require hospitalization, clinicians should not rely solely on self-reported stimulant use. Recognition of stimulant use could be improved through routine urine toxicologies for all psychotic patients. The authors suggest that recognition of stimulant use among schizophrenic patients may identify a population with a better prognosis for schizophrenia and different treatment needs.

Adult↗
PubMed1992

Effectively treating stimulant-abusing schizophrenics: mission impossible?

The development of effective treatment programs for dual diagnosis patients is in its initial stages, hampered by a variety of clinical, theoretical, administrative, and even sociopolitical obstacles. These patients are difficult to engage and treat effectively using standard systems of care. The Dual Diagnosis Treatment Program at the Brentwood VA Hospital integrates treatment for both stimulant abuse and chronic psychosis within one comprehensive program, emphasizing continuous treatment teams, optimal pharmacological management, behavior-shaping strategies, skills-training techniques, and assertive case management. The combination of these treatment approaches within one program appears to have helped some patients in our preliminary, one-year experience. Future publications will describe results from controlled outcome comparisons of DDTP with customary VA care.

Adult↗
PubMed1991

Prevalence of substance abuse in a psychiatric evaluation unit.

The prevalence of substance abuse and psychiatric illness was studied in a Psychiatric Evaluations Unit. Twenty-six percent of the subjects received a psychiatric diagnosis only with no concomitant substance use disorder. Thirty-four percent were diagnosed with a substance use disorder but with no other psychiatric disorders. Thirty-nine percent of the subjects had a history of both psychiatric and substance use disorder; 62% of these substance abusers with a psychiatric illness reported using drugs (including alcohol) the week before the interview; 56% used illicit drugs while 44% used alcohol only. Differences among substance abusers with a psychiatric illness, those with a substance abuse diagnosis alone, and those with a psychiatric diagnosis alone are presented.

Adult↗
PubMed1989

Can schizophrenia cause posttraumatic stress disorder?

Theories about schizophrenia have viewed stress and anxiety as both predisposing factors and associated features of the disorder. But these theories ignore a possible fundamental interaction: Terrifying psychotic experiences might act as traumatic events and precipitate a posttraumatic stress syndrome. We present a case of schizophrenia complicated by posttraumatic stress disorder and discuss the implications of this comorbidity for theory, research, and practice.

Adult↗