Narcissistic personality disorder: Relations with distress and functional impairment

Abstract This study examined the construct validity of Narcissistic Personality Disorder (NPD) by examining the relations between NPD and measures of psychological distress and functional impairment both concurrently and prospectively across two samples. In particular, the goal was to address whether NPD typically "meets" Criterion C of the DSM-IV definition of Personality Disorder, which requires that the symptoms lead to clinically significant distress or impairment in functioning. Sample 1 (N =152) was composed of individuals receiving psychiatric treatment, while Sample 2 (N=151) was composed of both psychiatric patients (46%) and individuals from the community. NPD was linked to ratings of depression, anxiety, and several measures of impairment both concurrently and at 6-month follow-up. However, the relations between NPD and psychological distress were (a) small, especially in concurrent measurements, and (b) largely mediated by impaired functioning. NPD was most strongly related to causing pain and suffering to others, and this relationship was significant even when other Cluster B personality disorders were controlled. These findings suggest that NPD is a maladaptive personality style which primarily causes dysfunction and distress in interpersonal domains. The behavior of narcissistic individuals ultimately leads to problems and distress for the narcissistic individuals and for those with whom they interact. Narcissistic Personality Disorder: Relations with distress and functional impairment Narcissistic personality disorder (NPD), despite substantial interest from a theoretical perspective, has received very little empirical attention (1). In fact, some have concluded that "most of the literature regarding patients suffering with narcissistic personality disorder is based on clinical experience and theoretical formulations, rather than empirical evidence" (2; p. 303). A large majority of empirical studies on narcissism come from a social-personality psychology perspective which, while methodologically sophisticated and important, may not pertain to Narcissistic PD given the reliance on undergraduate samples and the use of the Narcissistic Personality Inventory (NPI, 3). Trull and McCrae (4) have noted that narcissism measured by the NPI appears to be made up of high Extraversion, low Agreeableness, and low Neuroticism from the Five-Factor Model of personality (5), while DSM definitions suggest low Agreeableness, high Neuroticism and no relation with Extraversion. These authors suggest that "most narcissistic scales do not square well with DSM-III-R criteria for NAR" (4; p.53). 1 Correspondence concerning this article can be addressed to Joshua D. Miller, Ph.D., Psychology Building, Department of Psychology, University of Georgia, Athens, GA 30602. Fax: (706) 542-8048 E-mail: [email protected]. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. The field must be cautious about relying on these studies to inform our knowledge of NPD. The few empirical studies of NPD that have used clinical samples and DSM based measures have focused on the underlying factor structure and item content (6-8). In particular, there is a striking lack of data regarding the impairment and distress associated with NPD. Central to the issue of validity for any DSM disorder is whether it is actually associated with distress or impairment -in fact criterion C for PD from the DSM-IV (9, p. 689) mandates that one of the two be present in order to make a PD diagnosis. While there is good evidence for the functional impairment of PDs in general (10-11), and certain specific PDs such as borderline NIH Public Access As noted, the association between NPD and psychological distress is particularly unclear. The DSM-IV suggests that these individuals have a "very fragile" self-esteem (p. 714), are "very sensitive to injury from criticism or defeat" (p. 715), and that "sustained feelings of shame or humiliation…may be associated with social withdrawal" and "depressed mood" (p. 716). However, given the derivation of the DSM over time, these statements appear to be the result of expert opinion rather than empirical findings. Results from clinical samples are both sparse and contradictory. In fact, a meta-analysis of the relations between the FFM and DSM PDs found an effect size (i.e., r) of only .03 between Narcissism and Neuroticism, which measures emotional stability and the tendency to experience negative affective states such as depression, anxiety, and shame (14). However, this hides the substantial variability of the findings; of the 18 included effects, 5 were significantly positive, 7 were significantly negative, and 6 were nonsignificant. Within clinical samples, the effect size was .14 suggesting a small but significant relation to Neuroticism. There has also been some speculation that narcissism may be linked to higher rates of suicide Alternatively, Watson, Sawrie, Greene, and Arredondo (15) found significant negative relations between measures of narcissism (derived from the Minnesota Multiphasic Personality Inventory-2; 16) and depression in two clinical samples. Studies on comorbidity between PDs and Axis I disorders have not found a relation between NPD and depression or anxiety-related disorders Where the clinical lore and social-personality data do converge is on the interpersonal impairment linked with narcissism. The DSM-IV postulates that "interpersonal relations are typically impaired due to problems derived from entitlement, the need for admiration, and the relative disregard for the sensitivities of others" (p.716). Empirical studies of narcissism in the social-personality literature find that it predicts a self-centered, selfish and exploitative approach to interpersonal relationships, including game-playing, infidelity, a lack of empathy, and even violence (24-25). The negative consequences of narcissism are felt especially strongly by those who are involved with the narcissist (26). How quickly this personality style manifests this interpersonal impairment is up for debate. There is some evidence that the interpersonal difficulties associated with narcissism are only apparent over time, with narcissism being associated with apparently positive interpersonal functioning during initial relationship stages (27-28). However, other studies have found that individuals with unrealistically high positive self-evaluations are rated negatively by independent raters following a very brief competitive interaction with a peer (29). Unfortunately, there are very few data on NPD and interpersonal impairment using clinical samples. There are data from therapeutic relationships where items from a measure of countertransference were rated by a sample of psychiatrists and psychologists for patients with NPD. The authors of this study found that "clinicians reported feeling anger, resentment, and dread in working with narcissistic personality disorder patients; feeling devalued and criticized by the patient; and finding themselves distracted, avoidant, and wishing to terminate the treatment" (30, p. 894). These findings provide strong support for the interpersonal impairment these individuals experience as even trained clinicians experience strong negative feelings about these types of clients. Given the relatively stronger evidence of a link between NPD and interpersonal impairment than between NPD and psychological distress, it is plausible that NPD, at times, leads to clinically significant depression and/or anxiety but these negative affective states are probably secondary to the interpersonal impairment. That is, NPD may lead individuals to experience failure in a number of important domains (e.g., romance) that might lead to psychological distress; however, this distress may not be endemic to NPD. This may differ from other PDs such as borderline in which negative affectivity appears to be an intrinsic part of the disorder. The goals of the current study are to: 1. Assess the association between NPD and psychological distress including depression and anxiety. 2. Assess the association between NPD and impairment, including indices of romantic, social, occupational, and general impairment, as well as the spillover effects of NPD on significant others. 3. Assess the predictive power of NPD in relation to psychological distress and impairment over a 6-month period. 4. Test a model in which any positive link between narcissism and psychological distress is accounted for by impairment. 5. Assess the unique predictive power of NPD in predicting psychopathology and impairment, when controlling for the other Cluster B personality disorders. Method Participants and Procedures Sample 1-Participants (n = 152) were solicited from inpatient and outpatient programs at Western Psychiatric Institute and Clinic (WPIC) in Pittsburgh, PA. Patients with psychotic disorders, organic mental disorders, and mental retardation were excluded, as were patients with major medical illnesses that influence the central nervous system and might be associated with organic personality disturbance. Participants (in both samples) provided written informed consent after all study procedures had been explained. See Of the 152 individuals, 85 were women (56%), 135 were Caucasians (89%), 16 were African Americans (11%), and 1 was Asian American (1%), 121 were outpatients (80%), and the mean age was 34.5 years (SD = 9.4). Of the original sample, 105 (69%) were also assessed at a 6-month follow up. Attrition analyses were conducted on the following 16 variables: age, sex, race, treatment condition, marital status, education, and symptom counts for the 10 DSM III-R PDs that remain in the DSM-IV. No significant differences were found. Sample 2-This sample (n = 151) was comprised of 70 psychiatric patients and 81 nonpsychiatric participants. The non-psychiatric patients were recruited from two sources: diabetic patients (n = 23) or university faculty or staff (n = 58). This sample was part of a larger sample (n = 624) that was first screened for PDs. The larger sample was stratified on the basis of initial scores and individuals were randomly selected to participate in the interview portion of the study. The goal was to create a sample that had a 50% prevalence rate for PD. The psychiatric patients were solicited from an adult outpatient clinic at WPIC. The rule-outs used in Sample 1 were also utilized in this study. See Measures Consensus ratings of DSM-III-R (Sample 1) and DSM-IV (Sample 2) personality disorder criteria-Complete details of the assessment methodology are provided elsewhere (11,31). At intake, participants were interviewed for 6-10 hours in a minimum of 3 assessment sessions. The assessments sessions included structured symptom ratings, structured interviews for Axis I and Axis II disorders (e.g., the SCID, the PDE, SIDP-III-R, or SIDP-IV) and a detailed social and developmental history. Patients also completed self-report questionnaires between interviews. Following the evaluation, the primary interviewer presented the case at a two-hour diagnostic conference with colleagues from the research team. All available data (historical and concurrent) were reviewed and discussed at the conference: current and lifetime Axis I information, symptomatic status, social and developmental history, and personality features acknowledged on the Axis II interviews. In addition, significant others (e.g., romantic partners, family members, friends) were interviewed (when available) about patients' characteristic personality features. Each PD symptom was rated on a scale of 0 to 2. The symptom counts used are the addition of these scores across symptoms for each PD. In Sample 1, we altered the NPD count by deleting one DSM-III-R symptom (i.e., reacts to criticism with feelings of rage, shame, or humiliation) in order to approximate the current DSM-IV conceptualization of NPD. PDQ-4+ (Sample 2)-The PDQ-4+ (32) is 99-item self-report measure of DSM-IV PDs and was used in Sample 2. The mean NPD symptom count was 1.98 (SD =1.61). Consensus ratings of impairment (Sample 1 and 2)-Consensus ratings of functional impairment were made separately for romantic relationships, other social relationships (e.g., friends, family members), occupational impairment, distressed caused to significant others (e.g., romantic partners, parents, children, close friends), and an overall impairment. The ratings ranged from 1 to 5 with higher scores indicating greater impairment (e.g., unable to work, no friends, no history of romantic relationships or history of chaotic relationships). As with PD ratings, all ratings were made using the LEAD model. As such, all information gleaned from the extensive interviews with participants and significant others (when available) pertaining to Axis I and II symptomatology, as well as past and present social, romantic, and educational/occupational histories was used to determine consensus ratings of impairment. Clinical ratings of depression, anxiety, and functioning (Sample 1 and 2)-Ratings of psychological distress were conducted with the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A). Functioning was assessed via the Global Assessment of Functioning (GAF). For both samples, intraclass correlation coefficients (ICCs) , computed with all available reliability data, documented good to excellent levels of reliability within our own group of judges. The ICCs for the HAM-D were .96 (Sample 1) and .98 (Sample 2. The ICCs for the HAM-A were .97 (Sample 1) and . 94 (Sample 2). The ICCs for the GAF were .75 (Sample 1) and .80 (Sample 2). Six-month follow-up-The assessment procedures completed at intake were used again at the 6-month follow-up, with the exception of the social/developmental history, which is not repeated. As with intake, all sources of available data were used to inform consensus ratings Statistical Analyses-First, Pearson's rs were used to examine the relations between narcissism and measures of anxiety, depression and various forms of functional impairment both concurrently and longitudinally. Next, we examined a model in which the prospective relations between narcissism and measures of psychopathology are mediated by impairment. Finally, we used hierarchical linear regression analyses to examine the unique predictive relations between Narcissism at Time 1 and distress and impairment measured at 6-month follow-up, after controlling for the effects of the other Cluster B PDs. Two-tailed p values were computed in all analyses. The distributions of all variables were examined and none showed signs of a significant departure from normality using existing guidelines (33; skewness !2.0 and/or kurtosis ! 7.0). As such, Pearson rs are used. Results Capturing narcissism: Concurrent and longitudinal relations Sex differences-There were significant sex differences for narcissism in Sample 1, t(150) =4.14, p".001, and Sample 2, t(149) =1.98, p".05, such that men had higher NPD symptom counts. All correlations presented in Relations with psychological distress and impairment: Concurrent and longitudinal findings-Concurrently, narcissism was related to ratings of depression and anxiety only in Sample 2 (see The pattern of findings between narcissism and impairment was quite consistent across assessments and samples. NPD symptoms were related to lower GAF scores in three of four instances. In addition, NPD symptoms were related to overall impairment, as well as all specific indices of impairment including impairment in romance, work, social life, and causing distress to significant others. Of the specific impairment scores, "distress to significant others" demonstrated the largest weighted effect sizes (rs =.46 and .48). Impairment as a mediator of the relationship between narcissism and psychological distress-We next examined the hypothesis that narcissism may be related to psychological distress primarily due to the impairment it causes in various life domains (see NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript narcissism on psychopathology decreased significantly after impairment was included in the model; in all six cases, narcissism was no longer significantly related to the distress outcome once impairment was included. In fact, the direct effect of narcissism was reduced by between 40% (anxiety, Sample 1) to 100% (depression, Sample 1; GAF, Sample 1; depression, Sample 2) Replicating mediation analyses with self-reported PDQ narcissism scores-In order to reduce concern that the previous results might be due, in part, to common method variance (i.e., consensus rating of both predictor and outcome variables), we replicated the same aforementioned model in Sample 2 but used self-reported symptoms of narcissism (i.e., PDQ) in place of consensus ratings of NPD. The results were nearly identical. Again, Sobel tests were used to test for statistical mediation. There was significant mediation by impairment for the relations between PDQ NPD and Time 2 depression (z = 2.78, p".01), Time 2 anxiety (z = 2.70, p".01), and Time 2 GAF scores (z = 2.93, p".01). The direct effect of narcissism was reduced by between 45% (anxiety) to 70% (GAF). Narcissism: Unique predictive relations of 6-month outcomes controlling for Cluster B PDs-Finally, we examined whether narcissism was a unique predictor of psychopathology and impairment once we controlled for the symptoms of antisocial, borderline and histrionic PDs (see Discussion Despite its placement in the last three editions of the DSM as one of only 10 officially recognized personality disorders, narcissistic PD has received scant empirical attention. Specifically, there has been little data presented that makes a clear and persuasive argument for its inclusion on the basis of the distress and impairment NPD causes. One strategy for dealing with this dearth of data on NPD would be to turn to the substantial empirical literature on narcissism that exists in the fields of social-personality psychology. However, this is problematic due to the use measures (e.g., NPI) that appear to capture only partially the construct as it is currently conceptualized by the DSM-IV and the reliance on undergraduate samples. Even if one were to rely on this body of literature, the central question would remain unresolved as to whether narcissistic individuals experience psychological distress (this literature suggests they do not; 21) or substantial impairment (24,26). The current study addresses these issues by presenting data on the concurrent and longitudinal relations between narcissistic PD and psychological distress and functional impairment in two clinical samples. These constructs are of vital importance in determining whether narcissism warrants continued presence in our diagnostic nomenclature. The current results suggest that NPD symptoms are significantly, but modestly, related to depression and anxiety both concurrently (Sample 2 only) and prospectively. NPD was also significantly and more strongly related to two general measures of impairment and more specific indices of impaired functioning in work, social, and romantic domains. These findings were consistent across samples and assessments (i.e., Times 1 and 2) and are consistent with findings regarding the broad array of impairment attached to other specific PDs (12-13). The GAF scores demonstrated the weakest relations, albeit still significant in 3 of 4 analyses. Across assessments, the weighted effect sizes were largest for impairment related to causing distress for important significant others. Indeed, NPD was only uniquely related to causing significant others pain and duress. This finding is consistent with knowledge gathered about the impact of narcissism in non-clinical samples, where narcissism is associated largely with costs suffered by others (24,26). We found evidence in both samples for a model in which the relation between narcissism and psychological distress was mediated by impaired functioning. That is, overall impairment accounted for the relationship between Time 1 narcissism and lower GAF scores, higher depression and anxiety at Time 2. These findings support the notion that depression and anxiety may not be endemic to narcissism but develop as a result of problems or failures in a variety of contexts. Narcissistic individuals may eventually feel sad or worried as they gain insight into the fact that they are not as successful in their work, love, and friendship relations as they hoped or in comparison to their peers. This finding might also partially explain the differences in the relationship between narcissism and psychological distress as reported in the clinical and social-personality literatures. Most narcissists would enter a clinical setting as a result of some form of failure in their personal or professional life, and this failure would eventually be expected to lead to psychological distress. Individuals with narcissistic personality traits who are able to avoid personal or professional failure, however, may both avoid clinical settings and report low levels of psychological distress. Limitations One potential

Intimate terrorism by women towards men: Does it exist

Abstract Research showing that women commit high rates of intimate partner violence (IPV) against men has been controversial because IPV is typically framed as caused by the patriarchal construction of society and men's domination over women. Keywords intimate partner violence; male victims; intimate terrorism; common couple violence; female perpetrators; female-to-male violence; female violence The findings of high rates of women's use of intimate partner violence (IPV) towards their male partners have been the source of much controversy since such results were first published in the 1970s NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript seeking help for IPV victimization. We will test Johnson's theory of IT victimization with regard to men who sustain IPV. Prevalence and Ensuing Controversy Incidence reports of women physically aggressing toward their male partners have appeared since the study of IPV began in the early to mid-1970s. For example, in Gelles' (1974 groundbreaking study of IPV, he found that "the eruption of conjugal violence occurs with equal frequency among both husbands and wives" (p. 77). Since then, our best populationbased studies show that between 25% and 50% of victims of IPV in a given year are men A final source of data on violence by women toward men comes from family conflict studies, many of which use the Conflict Tactics Scales (CTS) (Straus, Hamby, BoneyMcCoy, & Sugarman, 1996). Studies using the CTS typically show that about 50% of all victims of IPV in a given year are men. National studies, including the National Family Violence Surveys (NFVS) of 1975 and These results have been confirmed by dozens of studies since the 1970s First, critics argue that although women have the capability of being violent, their violence against men needs to be considered within the broader sociocultural context A second argument is that men's violence towards women has much stronger effects than women's violence towards men. For example, men's violence strikes fear in their partners, whereas women's violence does not A final argument suggests that focusing on physical assault is misguided. IPV consists of a range of acts, such as verbal abuse, psychological humiliation, sexual aggression, using or threatening violence against others, and coercive control within the relationship, which are largely ignored, but are found to be the most damaging acts of IPV against women Common Couple Violence versus Intimate Terrorism Johnson (1995) attempted to reconcile these two divergent viewpoints on IPV by women by asserting that each side was drawing their conclusions based on non-overlapping data gathered from two fundamentally different sources. The studies that showed high rates of violence by women are typically studies of community or population-based samples that are unlikely to recruit women who were battered by their partners; on the other hand, researchers studying female victims typically recruit their participants from shelter or other clinical samples (e.g., hospital, police) that focused on severe violence by men towards women. Thus, the two groups, according to Johnson, were analyzing two distinctly different phenomena. He labeled the IPV found in community and population-based samples CCV, which is characterized by low-level (e.g., slapping, pushing), low-frequency violence in a couple where both members are about equally violent; this IPV is not part of an overall pattern of control of one partner over the other, but is the result of a conflict "getting out of hand." He labeled the violence found in shelter and other clinical samples "patriarchal terrorism" or IT. The central feature of IT is that the violence is one tactic in a general pattern of control of one member of the couple over the other. The IPV is more frequent than what is found in cases of CCV, is less likely to be mutual, is more likely to involve Johnson (1995) provides research that gives an indication of the relative frequency of violence in CCV versus IT couples. He cites Straus ' (1990) analysis of the NFVS, which showed that women who experienced CCV sustained an average of 6 assaults per year, whereas women who experienced IT sustained an average of 15 assaults. Others have found that women from shelter samples may sustain an average of 65-68 assaults per year (GilesSims, 1983; Johnson later updated his theory to include the behavior of the partner in IT relationships Male Victims of Severe IPV and Controlling Behaviors In 2007, the first larger-scale study of male victims of IPV was published . This was an exploratory analysis of data collected through 190 phone call logs to the national Domestic Abuse Helpline for Men and Women (DAHMW), a helpline that The results showed a pattern of victimization that might be consistent with IT victimization. Callers to the helpline sustained physical and psychological aggression from their female partners. The most common physical acts were hitting, pushing, kicking, grabbing, and punching. Their female partners' physical aggression was sometimes severe enough to warrant calling the police or getting medical intervention. Over 20% of the sample reported violence that could be considered life threatening (e.g., choking, using a knife). The callers reported that their female partners would target their genitals during physical attacks, and a majority of the callers reported living in fear of their partners' violence. The DAHMW callers reported that their female partners engaged in a variety of psychologically aggressive behaviors: close to 95% of the callers reported that their female partners used controlling behaviors, including threats and coercion (e.g., threatening to kill herself or him, threatening to leave; 77.6%); emotional abuse (e.g., calling him names, humiliation; 74.1%); intimidation (e.g., instilling fear by smashing things, destroying property, abusing pets, displaying weapons; 63.3%); blaming the male caller for the violence, denying the violence (59.9%); misusing the judicial system (e.g., using the court system to gain sole custody of children; falsely obtaining a restraining order against the male caller; 49.0%); isolating the caller from family and friends (41.5%); controlling the household finances and not allowing the caller to see or use the checkbook or credit cards (38.1%); and, using the children to keep the caller in the violent relationship (64.5%). Although valuable in elucidating the experiences of men who sustain IPV from their female partners, this study is limited in a number of ways. For example, because the DAHMW is an advocacy helpline whose primary focus is not research, the data were not systemically collected (e.g., the percentages of each type of IPV are based on men's spontaneous recall of their IPV experiences). Reliable and valid instruments were not used to gather data, and questions were not asked of the men in a systematic manner. Moreover, data from a comparison community sample were not collected, so no firm conclusions about CCV versus IT could be made. The current study improves on this study through the recruitment of a large number of men who were seeking help for IPV victimization and the use of reliable, valid, and consistent data collection instruments to gather information about their experiences of IPV. Moreover, we collected similar data on a community sample of men so that we could compare the IPV experiences of men seeking help for IPV victimization with those of men in the community. These comparisons will allow us to draw conclusions about whether the male helpseekers in our sample can be considered victims of IT. Given 1. CCV will mostly be found in the community sample of men. In other words, we expect that the community men's use of IPV and controlling behaviors will be similar to their female partner's use of IPV and controlling behaviors, that each partner will be equally likely to have initiated the last physical argument, and that their overall frequency of IPV will be less than that found in the helpseeking sample. 2. IT will be found in the helpseeking sample. Given that the female partners' use of IPV and controlling behaviors would theoretically resemble terroristic violence, the female partners of men in the helpseeking sample are expected to use more physical IPV, severe psychological IPV, and controlling behaviors than both their male partners and the female partners of the men in the community sample. In addition, the helpseeking men will be injured more frequently than their partners and men in the community sample. We also expect that the female partners in the helpseeking sample will be the initiators of the assaults in almost all of the cases. Finally, we will explore the male helpseekers' reaction to their female partners' IT. As theorized by Method Participants and Procedure Two separate samples of male participants were recruited for this study: a helpseeking sample and a community sample. For both samples, the men had to speak English, live in the U.S., and be between the ages of 18 and 59 to be eligible; they also had to have been involved in an intimate relationship with a woman lasting at least one month in the previous year. In addition, to be eligible for the helpseeking sample, the men had to have sustained a physical assault from their female partner within the previous year, and they had to have sought help/assistance for their partner's violence. Help/assistance was broadly defined and included seeking help from formal sources such as hotlines, domestic violence agencies, the police, mental health and medical health professionals, lawyers, and ministers, to more informal helpseeking efforts, such as talking with friends and family members and searching the Internet for information or support groups for male victims. The helpseeking sample of men (n = 302) was recruited from a variety of sources, including the DAHMW, and online websites, newsletters, blogs, and listservs that specialized in treatment of IPV, male victims of IPV, fathers' rights issues, divorced men's issues, men's health issues, and men's rights issues. Men who called the DAHMW seeking assistance and who met the eligibility criteria were invited to participate in this study either by calling a survey research center to complete the interview over the phone or by visiting the study website to complete an anonymous, secure version of the study questionnaire online. Men who saw an advertisement for the study online were directed to the study website to complete the online version of the study. Screener questions regarding the study criteria were on the first page of the survey, and men who were eligible were allowed to continue the survey. Men who did not meet the eligibility requirements were thanked for their time and were redirected to an "exit page" of the survey. Sixteen men completed the interview over the phone; the remaining 286 completed it online. Demographics of the helpseeking sample can be found in Participants also included 520 men from the community. Approximately half of the community sample (n = 255) was recruited to participate in a phone version of the survey by a survey research center, using a random digit dialing technique and CATI administration. The interviewers attempted to reach each phone number on 15 different days, at different times of the day, and made call-back appointments whenever possible. They also made refusal conversion efforts when appropriate. Because of low response rates (8%) during the first two months, advanced letters were sent to potential participants informing them that they were randomly selected to participate in a study sponsored by the National Institutes of Health that was focusing on how men and women get along and that they would be contacted within a week by a survey research center interviewer. The response rate for the participants who received an advanced letter was 15.5%. The overall response rate was 9.8%. The other half of the community sample (n = 265) was recruited through a panel of survey participants maintained by Survey Sampling, Inc. (SSI), to complete an online version of the same survey. Email invitations were sent to 16,000 male SSI panel members inviting them to participate in a study on how men and women get along. They were directed to an anonymous, secure, online version of the survey. The first page of the survey included screener questions testing for eligibility. Eligible men were able to continue to the rest of the survey, whereas non-eligible men were thanked for their time. The survey was closed after we met our target sample size of 265 men. Because data collection was ceased when the target goal for the number of completed surveys was reached and we did not wait for all men who received invitations to complete the survey, response rates for the Internet sample cannot be reliably calculated. Demographic information on the full community sample (n = 520) can be found in The methods for this study were approved by the boards of ethics at the participating institutions. All of the men participated anonymously and were apprised of their rights as study participants. Steps were taken to ensure their safety: At the completion of the survey the participants were given information about obtaining help for IPV victimization and how to delete the history on their Internet web browser. Measures Both the helpseeking and community samples were given the same core questionnaires regarding demographics, aggressive behaviors that they and their female partners may have used in the previous year, more detailed information regarding their last physical argument (if applicable), their mental health, and various risk factors. The helpseeking sample was given additional questions pertaining to their specific helpseeking experiences in an aggressive relationship and what prevents them from leaving the relationship. Only the questionnaires used in the current analyses will be described below. Demographic information-Men were asked basic demographic information about both themselves and their partners, including age, race/ethnicity, personal income, education, and occupation. Men were also asked about the current status of their relationship, the length of their relationship with their partners, how long ago the relationship ended (if applicable), and how many minor children were involved in that relationship, if any. Revised Conflict Tactics Scales (CTS2)-The CTS2 Participants responded to items depicting each of the conflict tactics by indicating the number of times these tactics were used by the participant and his partner in the previous year. Participants indicated on a scale from 0 to 6 how many times they experienced each of the acts in the previous year, 0 = 0 times; 1 = 1 time; 2 = 2 times; 3 = 3-5 times; 4 = 6-10 times; 5 = 11-20 times; 6 = more than 20 times. These data were then transformed in order to obtain an approximate count of the number of times each act occurred in the previous year, using the following scale: 0 = 0 acts in previous year; 1 = 1 act in the previous year; 2 NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript = 2 acts in the previous year; 3 = 4 acts in the previous year; 4 = 8 acts in the previous year; 5 = 16 acts in the previous year; 6 = 25 acts in the previous year. Because we supplemented the eight CTS2 psychological aggression items with seven items assessing controlling and monitoring behavior, we conducted a principal axis factor analysis with varimax rotation to investigate subtypes of psychological aggression. We combined both the helpseeking and community samples to achieve greater stability of the factor solution and used the victimization items because they had more variability than the perpetration items. The results of the factor analysis For the present article, we calculated both a dichotomous variable and a chronicity variable for each scale of the CTS2. The dichotomous variable indicates the presence or absence of each type of IPV and thus can be used to indicate the prevalence of perpetration and victimization of each type of IPV. Chronicity is the frequency with which the participant and his partner used each type of IPV, among only those who indicated that a given type of IPV had been used. Thus, the lower bound of the chronicity variables would be 1 (indicating that that person used 1 act of that type of aggression in the past year) because participants and their partners who did not use that particular type of IPV would be removed. The CTS2 has been shown to have good construct and discriminant validity and good reliability, with internal consistency coefficients ranging from .79 to .95 Follow-Up Questions-Following the CTS2, we gathered specific information about the most recent violent episode. These questions were asked of all men in the helpseeking sample and any men in the community sample who reported experiencing at least one violent episode within the previous year. Among the questions asked, the two that will be included in the present study are: who was the first to ever use physical aggression in the relationship and who hit whom first in the last physical argument. Results Comparisons of IPV Perpetration between Men and Women Within Each Sample Our first series of analyses compared men and their partners on the men's reports of IPV perpetration by both partners. Because these are paired variables (i.e., we are using the men's reports on both variables), McNemar's test statistic was used when comparing the prevalence of all types of IPV. However, caution should be taken when interpreting these results because overall, studies show that although men and women tend to provide congruent reports on women's perpetration of IPV, individuals do tend to under-report their own perpetration of IPV Among the helpseeking sample, female partners were reported by the male participants to have used all types of IPV at significantly higher rates than the male participants (see For the community sample, a different pattern emerged. Male participants and female partners engaged in minor psychological, severe psychological, sexual (i.e., insisting on sex), minor physical, and total physical aggression at relatively equal rates (bottom of Differences Between Helpseeking and Community Samples in Rates and Frequency of IPV To investigate whether there were differences between samples in the prevalence of each type of IPV, logistic regressions were conducted using the presence and absence of each type of IPV as the dependent variable and sample type (helpseeking versus community) as the independent variable. Because there were demographic differences between the two samples, correlations were conducted to investigate possible covariates to include in the regression models. The only demographic variables that consistently correlated with the various types of IPV were participant's age, partner's age, whether the participant was currently involved in a relationship with his partner, the length of the relationship, and whether minor children were involved. Participant's age, partner's age, and relationship length were highly intercorrelated (r's = .55-.85, p < .001); therefore, to maintain adequate power and avoid multicollinearity, only participant's age was used as a possible covariate because it is likely to be the most reliable variable. Thus, possible covariates in all logistic regressions included age, whether the participant was currently in a relationship, and whether minors were involved in the relationship. For each regression, nonsignificant covariates were removed to increase power to detect effects. To correct for multiple tests of the same hypothesis, Bonferonni corrections were employed. To investigate whether there were differences between samples in the chronicity of IPV used by male participants and their female partners among those who used IPV, negative binomial regression analyses were conducted. Because the chronicity data represented counts of the number of aggressive acts used or sustained in the previous year, the data were positively skewed. Furthermore, as shown in Male Participants' Use of IPV-For all types of psychologically and physically aggressive behaviors, logistic regression analyses showed that men in the helpseeking sample were significantly more likely to use aggression than men in the community sample. Specifically, for each type of aggression, the overall logistic regression models were significant (Minor Psychological: χ 2 (2, N = 822) = 77. However, when we look at differences in frequency of aggressive behaviors among just those men who reported using each type of aggression NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript psychological aggression, there were no differences between samples in frequency, and among men who used controlling behaviors, male participants in the helpseeking sample used significantly fewer controlling behaviors than male participants in the community sample. For physical IPV, there were no differences between samples in the frequency with which they used total or minor physical aggression in the past year; moreover, among men who used severe physical aggression, men in the community sample used significantly more severe physical aggression in the previous year. For insisting on sex, after controlling for age and whether the relationship was current, logistic regressions revealed that the type of sample did not predict men's insistence on sex when his partner

The Neuroscience Information Framework: A Data and Knowledge Environment for Neuroscience

With support from the Institutes and Centers forming the NIH Blueprint for Neuroscience Research, we have designed and implemented a new initiative for integrating access to and use of Web-based neuroscience resources: the Neuroscience Information Framework. The Framework arises from the expressed need of the neuroscience community for neuroinformatic tools and resources to aid scientific inquiry, builds upon prior development of neuroinformatics by the Human Brain Project and others, and directly derives from the Society for Neuroscience’s Neuroscience Database Gateway. Partnered with the Society, its Neuroinformatics Committee, and volunteer consultant-collaborators, our multi-site consortium has developed: (1) a comprehensive, dynamic, inventory of Web-accessible neuroscience resources, (2) an extended and integrated terminology describing resources and contents, and (3) a framework accepting and aiding concept-based queries. Evolving instantiations of the Framework may be viewed at http://nif.nih.gov, http://neurogateway.org, and other sites as they come on line

Physicians’ Perspectives on Prescribing Benzodiazepines for Older Adults: A Qualitative Study

BACKGROUND: There is a continued high prevalence of benzodiazepine use by older community-residing adults and of their continued prescription by practitioners, despite well known adverse effects and the availability of safer, effective alternatives. OBJECTIVES: To understand factors influencing chronic use of benzodiazepines in older adults. DESIGN: Qualitative study, semistructured interviews with physicians. PARTICIPANTS: Thirty-three practicing primary care physicians around Philadelphia. APPROACH: Qualitative interviews were audiotaped, transcribed, and entered into a qualitative software program. A multidisciplinary team coded transcripts and developed themes. RESULTS: Physicians generally endorsed benzodiazepines as effective treatment for anxiety, citing quick action and strong patient satisfaction. The use of benzodiazepines in older adults was not seen to be problematic because they did not show drug-seeking or escalating dose behavior suggesting addiction. Physicians minimized other risks of benzodiazepines and did not view monitoring or restricting renewal of prescriptions as an important clinical focus relative to higher-priority medical issues. Many physicians expressed skepticism about risks of continued use and considerable pessimism in the successful taper/discontinuation in older patients with long-term use and prior failed attempts. Physicians also anticipated patient resistance to any such efforts, including switching physicians. CONCLUSIONS: Primary care physicians are averse to addressing the public health problem of benzodiazepine overuse in the elderly. Their attitudes generally conflict with practice guidelines and they complain of a lack of training in constructive strategies to address this problem. A 2-pronged effort should focus on increasing skill level and preventing new cases of benzodiazepine dependency through improved patient education and vigilant monitoring of prescription renewal

Why do Asian-American women have lower rates of breast conserving surgery: results of a survey regarding physician perceptions

<p>Abstract</p> <p>Background</p> <p>US Asian women with early-stage breast cancer are more likely to receive a modified radical mastectomy (MRM) than White women, contrary to clinical recommendations regarding breast conserving treatment (BCT).</p> <p>Methods</p> <p>We surveyed physicians regarding treatment decision-making for early-stage breast cancer, particularly as it applies to Asian patients. Physicians were identified through the population-based Greater Bay Area Cancer Registry. Eighty (of 147) physicians completed a questionnaire on sociodemographics, professional training, clinical practices, and perspectives on the treatment decision-making processes.</p> <p>Results</p> <p>The most important factors identified by physicians in the BCT/MRM decision were clinical in nature, including presence of multifocal disease (86% identified this as being an important factor for selecting MRM), tumor size (71% for MRM, 78% for BCT), cosmetic result (74% for BCT), and breast size (50% for MRM, 55% for BCT). The most important reasons cited for the Asian treatment patterns were patient attitudes toward not needing to preserve the breast (53%), smaller breast sizes (25%), and fear and cultural beliefs (12%).</p> <p>Conclusion</p> <p>These survey results suggest that physicians perceive major roles of both clinical and cultural factors in the BCT/MRM decision, but cultural factors may be more relevant in explaining surgical treatment patterns among Asians.</p

Short-term triple therapy with azithromycin for Helicobacter pylori eradication: Low cost, high compliance, but low efficacy

<p>Abstract</p> <p>Background</p> <p>The Brazilian consensus recommends a short-term treatment course with clarithromycin, amoxicillin and proton-pump inhibitor for the eradication of <it>Helicobacter pylori </it>(<it>H. pylori)</it>. This treatment course has good efficacy, but cannot be afforded by a large part of the population. Azithromycin, amoxicillin and omeprazole are subsidized, for several aims, by the Brazilian federal government. Therefore, a short-term treatment course that uses these drugs is a low-cost one, but its efficacy regarding the bacterium eradication is yet to be demonstrated. The study's purpose was to verify the efficacy of <it>H. pylori </it>eradication in infected patients who presented peptic ulcer disease, using the association of azithromycin, amoxicillin and omeprazole.</p> <p>Methods</p> <p>Sixty patients with peptic ulcer diagnosed by upper digestive endoscopy and <it>H. pylori </it>infection documented by rapid urease test, histological analysis and urea breath test were treated for six days with a combination of azithromycin 500 mg and omeprazole 20 mg, in a single daily dose, associated with amoxicillin 500 mg 3 times a day. The eradication control was carried out 12 weeks after the treatment by means of the same diagnostic tests. The eradication rates were calculated with 95% confidence interval.</p> <p>Results</p> <p>The eradication rate was 38% per intention to treat and 41% per protocol. Few adverse effects were observed and treatment compliance was high.</p> <p>Conclusion</p> <p>Despite its low cost and high compliance, the low eradication rate does not allow the recommendation of the triple therapy with azithromycin as an adequate treatment for <it>H. pylori </it>infection.</p

The bed nucleus of stria terminalis and the amygdala as targets of antenatal glucocorticoids: implications for fear and anxiety responses

Rationale: Several human and experimental studies have shown that early life adverse events can shape physical and mental health in adulthood. Stress or elevated levels of glucocorticoids (GCs) during critical periods of development seem to contribute for the appearance of neurospyschiatric conditions such as anxiety and depression, albeit the underlying mechanisms remain to be fully elucidated. Objectives: The aim of the present study was to determine the long-term effect of prenatal erxposure to dexamethasone- DEX (synthetic GC widely used in clinics) in fear and anxious behavior and identify the neurochemical, morphological and molecular correlates. Results: Prenatal exposure to DEX triggers a hyperanxious phenotype and altered fear behavior in adulthood. These behavioral traits were correlated with increased volume of the bed nucleus of the stria terminalis (BNST), particularly the anteromedial subivision which presented increased dendritic length; in parallel, we found an increased expression of synapsin and NCAM in the BNST of these animals. Remarkably, DEX effects were opposite in the amygdala, as this region presented reduced volume due to significant dendritic atrophy. Albeit no differences were found in dopamine and its metabolite levels in the BNST, this neurotransmitter was substantially reduced in the amygdala, which also presented an up-regulation of dopamine receptor 2. Conclusions: Altogether our results show that in utero DEX exposure can modulate anxiety and fear behavior in parallel with significant morphological, neurochemical and molecular changes; importantly, GCs seem to differentially affect distinct brain regions involved in this type of behaviors.This study was supported by a grant from the Institute for the Study of Affective Neuroscience (ISAN). AJR is supported by a Fundação para a Ciência e Tecnologia (FCT) grant