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OBJECTIVE: This study evaluated the relation between baseline clinical phenomena and response to amitriptyline in patients with posttraumatic stress disorder (PTSD). METHOD: Data were obtained from an 8-week placebo-controlled, double-blind study of combat veterans. Bivariate and multivariate statistics were used to evaluate the relations between the following variables and outcome: age, depression, anxiety, severity of PTSD symptoms, personality, psychiatric comorbidity, level of exposure to trauma, and individual symptoms of depression, anxiety, and traumatic stress. Outcome measures were scores on the Clinical Global Impression scale, Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety, and Impact of Event Scale. RESULTS: Drug response was related to lower baseline levels of depression, neuroticism, combat intensity, anxious mood, impaired concentration, somatic symptoms, feelings of guilt, and one intrusion and four avoidance symptoms of PTSD. CONCLUSIONS: The results demonstrate that response to amitriptyline is related to measures of depression, anxiety, PTSD, personality, and intensity of combat trauma. Similar relationships were not observed in the placebo group, suggesting a specific relationship to the drug.

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Amitriptyline hydrochloride was compared with placebo in 46 veterans with chronic posttraumatic stress disorder. Treatment continued up to 8 weeks, and efficacy was measured by five observer and two self-rated scales. Percent recovery rates were higher for amitriptyline than placebo on two measures. In patients who completed 4 weeks (n = 40), better outcome with amitriptyline was noted on the Hamilton depression scale only. In the group completing 8 weeks of treatment (n = 33), the drug was superior to placebo on Hamilton depression, Hamilton anxiety, Clinical Global Impression severity, and Impact of Event scales. There was no evidence for drug effects on the structured interview for posttraumatic stress disorder. Drug-placebo differences were greater in the presence of comorbidity in general, although recovery rates were uniformly low in the presence of major depression, panic disorder, and alcoholism. At the end of treatment, 64% of the amitriptyline and 72% of the placebo samples still met diagnostic criteria for posttraumatic stress disorder.

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Delusions presented by patients with psychiatric disorders are often a combination of psychopathology and current events. The authors present three cases that document the delusion of having acquired immune deficiency syndrome (AIDS) in patients who were not members of high-risk groups but had psychiatric disorders. This clinical phenomenon raises psychodynamic issues as well as adds a new dimension to the controversy over AIDS testing.

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The authors note the recent controversy about whether the sex of the psychotherapist is an important factor in the treatment of patients with certain neurotic and personality disturbances and suggest that much of the confusion is because supportive and insight-oriented psychotherapy are not clearly distinguished. After reviewing the relevant literature they present five clinical vignettes which suggest that the sex of the therapist is immaterial in insight-oriented psychotherapy and that attention to defenses, transference, and resistance remains the cornerstone of successful psychotherapy.

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The authors present a case of intermittent delirious mania in a hypomanic man. Studies revealed no other cause for the delirium, and it remitted with lithium carbonate therapy.

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From August 5, 1964, the onset of the Vietnam War, until the official ending of the war, May 7, 1975, the Vietnam War tore at the fabric of American society. That tear has not yet been mended. Our nation as a whole has opposed thoughtful reflection about the Vietnam War, and our veterans continue to suffer its consequences. This article summarizes some of the national and psychological problems caused by the war. Special characteristics of the Vietnam War that contributed to these problems are discussed, and post-traumatic stress disorder is reviewed.

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Although neurotic conflicts relating to achievement and success are common among patients in psychoanalysis, the psychoanalytic literature is remarkably limited and tends to portray conflict relating to success only in terms of oedipal conflict. Through four clinical vignettes of patients in psychoanalysis, the authors demonstrate that the fear of success is an overdetermined final common pathway for conflicts at any of several developmental levels.

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The authors discuss the incidence, detection, management, and significance of prolonged seizures with ECT and present a case example. They suggest that the incidence of this phenomenon may be underreported and that its occurrence may be linked to hyperoxygenation, the use of multiple-monitored ECT, and preexisting states of cerebral hyperexcitability. Since prolonged seizures may result in adverse metabolic changes, prompt detection and intervention are essential.

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The clinical basis for the long established contraindication of electroconvulsive therapy (ECT) in the presence of brain tumor is reviewed, as is the recent literature that has questioned the absolute nature of that contraindication. A need for a specific estimate of risk is noted. Seven retrospective case reports are added to the 28 cases reported in the literature. The clinical case report data are then pooled and evaluated by outcome. Results indicate a 74 per cent overall morbidity, including a 28 per cent 1-month mortality rate for patients with brain tumors who receive ECT. Twenty-one per cent of the patients had a positive behavioral response to ECT without complication.

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Reduced platelet MAO activity has been previously reported as a biochemical marker for a subgroup of psychiatric patients, including some chronic schizophrenics. As tryptamine metabolism appears to be sensitive to alterations in MAO activity, urinary tryptamine excretion was measured in chronic schizophrenics with low platelet MAO activity, chronic schizophrenics with normal platelet MAO activity, and age-matched and sex-matched controls. The increased urinary tryptamine excretion observed in chronic schizophrenics with low platelet MAO activity may reflect a pathophysiologic mechanism associated with low MAO activity.

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