Psychiatry 2006 - ISSN: 1550-5952 - Volume 3 - Issue 5 - May 2006
Feature Article:
The Neurocognitive Mechanisms of Decision-making, Impulse Control, and Loss of Willpower to Resist Drugs
by Xavier No�l, PhD; Martial Van Der Linden, PhD; and Antoine Bechara, PhD

Many individuals with problems of substance addiction become unable to base their drug-use decisions on the long-term outcome of their choices. We present here a neural framework that explains this �myopia� for future consequences. We suggest that addiction may be the product of an imbalance between two separate, but interacting, neural systems that subserve decision-making: A reactive system for signaling pain or pleasure of immediate prospects with the amygdala as a key structure, and a reflective system for signaling pain or pleasure of future prospects involving highly the prefrontal cortex. Through development, socialization, and individuals� learning of social rules, the reflective system gains control over the reactive system via several cognitive (e.g., response inhibition, shifting) and neural mechanisms (fronto-parietal network). However, this control is not absolute; hyperactivity within the reactive system can override the reflective system and the neurotoxicity of drugs co
Ethical Issues in Diagnosing and Treating Alzheimer Disease
by Edmund G. Howe, MD, JD

abstract Many unique ethical issues arise when diagnosing and treating Alzheimer disease (AD). This article discusses several core ethical dilemmas that arise for psychiatrists during different stages of AD, focusing particularly on areas of consensus and controversy. Issues addressed include screening, genetic testing, and discussions of advance directives during early stages; telling soft and even outright lies during middle and late stages; and withholding life-preserving interventions during the last stage of AD when death is imminent. While there is overwhelming ethical consensus that psychiatrists should be fully honest and respect patient autonomy as much as possible during the early stages of disease, there is more controversy regarding the extent to which psychiatrists should do this during the later stages of disease. Possible, optimal approaches to resolving these ethical issues are presented. Key Words: Alzheimers, ethics, dementia
Vagus Nerve Stimulation (VNS) and Treatment of Depression: To the Brainstem and Beyond
by John P. O�Reardon, MD; Pilar Cristancho, MD; and Andrew D. Peshek, MD

abstract Neuromodulation appears to be emerging gradually as a new therapeutic field in psychiatric treatment. It encompasses neuropsychiatric medical devices, such as vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and electroconvulsive therapy (ECT). As a therapeutic approach to affective disorders, neuromodulation shifts the focus from the monoamine synapse to neural circuitry of the brain, which is dysregulated in depression. This neural circuitry has been elaborated on over the course of 15 years of neuroimaging research in mood disorders and is now believed to encompass disturbances in a frontolimbic network. These include reduced metabolism and blood flow in the prefrontal cortex and anterior cingulate and pathologically increased activity in the subgenual cingulate and amygdala. VNS is an implanted device that has established efficacy in pharmaco-resistant epilepsy. It was approved by the FDA for the treatment of severe, r
Effects of Paroxetine CR on Depressive and Anxiety Symptoms in a Community Sample of Adult Hispanic Women with Major Depression or Generalized Anxiety Disorder
by Paul K. Gross, MD; Rosemary Nourse, RN, CCRC; Thomas E. Wasser, PhD, MEd; and Stan Krulewicz, MA

abstract Objective: Previous research reports higher rates of depression in Hispanic women than Caucasian or African American women. The effectiveness and tolerability of paroxetine CR (controlled release) was examined in women of Hispanic heritage with depression or anxiety. Methods: Thirty-six Hispanic female patients 18 years or older meeting DSM-IV criteria for major depression or generalized anxiety disorder diagnosis with an initial Hamilton Depression Rating scale (17 item) ≥20 or Hamilton Anxiety Rating scale ≥18 measuring no less than 4 on the Clinical Global Impression Severity scale received paroxetine CR (12.5�50mg/day) for 29 weeks of open label treatment. Analysis was conducted using repeated measures methodology. Results: Significant symptom reduction was observed on all scales. Mean dose was 31.7mg. The side effect of sexual dysfunction (17%) appeared most frequently but did not cause any patients to cease study participation. Conclusions: Paroxetine CR
BRIEF REPORT New Pharmacotherapies for Treating the Neurobiology of Alcohol and Drug Addiction
by Helen M. Pettinati, PhD; and Amanda R. Rabinowitz

Forensic Files:
The Last Will and Testament and the Psychiatrist
by Seth Feuerstein, MD, JD; Vladimir Coric, MD; Charles A. Morgan, MD; Humberto Temporini, MD; Frank Fortunati, MD, JD; and Steven Southwick, MD

Letters to the Editor:
Factitious Disorders in Children and Adolescents
Marc D. Feldman, MD