National Institute on Alcohol National Institute on Alcohol Abuse and AlcoholismAbuse and Alcoholism

Section of Clinical Studies Section of Clinical Studies

David T. George, M.D.David T. George, M.D.

Demystifying Demystifying MedicineMedicine

Alcohol and domestic violenceAlcohol and domestic violence– BackgroundBackground– Behavioral CharacteristicsBehavioral Characteristics– DiagnosesDiagnoses– Research FindingsResearch Findings– ModelModel– TreatmentTreatment

Alcohol treatmentAlcohol treatment

Domestic Violence in the Domestic Violence in the United StatesUnited States

20% to 30% of all men and women will 20% to 30% of all men and women will be assaulted by their spouse/significant be assaulted by their spouse/significant other at some time in their livesother at some time in their lives

Domestic violence accounts for:Domestic violence accounts for:

1) 20% of all emergency room 1) 20% of all emergency room visitsvisits

2) 50% of all police calls2) 50% of all police calls

3) 30% of all female murders3) 30% of all female murders

Literature ReviewLiterature Review

70% of perpetrators have an 70% of perpetrators have an alcohol problemalcohol problem

Most studies focus on Most studies focus on psychosocial issues: psychosocial issues:

1) power/control1) power/control2) learned behaviors2) learned behaviors

Minimal emphasis given to Minimal emphasis given to biological concomitantsbiological concomitants

Who Are Perpetrators?Who Are Perpetrators?

Multiple fights during childhoodMultiple fights during childhood

Violence typically occurs in the homeViolence typically occurs in the home

Blame othersBlame others

Impulsive behaviorsImpulsive behaviors

Alcohol calms them downAlcohol calms them down

Behavioral SymptomsBehavioral Symptoms

Racing thoughtsRacing thoughts Super sensitive to environmental Super sensitive to environmental

stimulistimuli Mood swingsMood swings

– CalmCalm– ShutdownShutdown– FlightFlight– FightFight– StalkingStalking

Triggers and symptoms Triggers and symptoms associated with domestic associated with domestic violenceviolence Triggers manifested by partnerTriggers manifested by partner

– A “look”A “look”– A “tone” of voice A “tone” of voice

Symptoms manifested by Symptoms manifested by perpetratorsperpetrators– Autonomic activation Autonomic activation – Escalating anxietyEscalating anxiety– FearFear

Study participantsStudy participants

Healthy comparison subjects Healthy comparison subjects Non-violent alcoholics Non-violent alcoholics Perpetrators of domestic violencePerpetrators of domestic violence

Multiple episodes of domestic violenceMultiple episodes of domestic violenceViolence not limited to periods of Violence not limited to periods of

intoxicationintoxicationNo diagnosis of bipolar, schizophreniaNo diagnosis of bipolar, schizophreniaNormal MRI Normal MRI

All subjects were:All subjects were:– In good health and on no medicationsIn good health and on no medications– No history of seizures or major head traumaNo history of seizures or major head trauma– Sober for at least three weeks prior to researchSober for at least three weeks prior to research

Comparison of non-violent/violent Comparison of non-violent/violent alcoholics: Axis I diagnoses show alcoholic alcoholics: Axis I diagnoses show alcoholic perpetrators have a higher proportion of perpetrators have a higher proportion of anxiety related disorders than non-violent anxiety related disorders than non-violent alcoholicsalcoholics

Axis I DiagnosisAxis I Diagnosis Non-violent Non-violent Perpetrators withPerpetrators withalcoholicsalcoholics alcohol dependencealcohol dependence

(N = 37)(N = 37) (N = 18)(N = 18) PP

Major Depression Major Depression 6 6 8 8 0.030.03Panic Attack Panic Attack 1 1 4 4 0.020.02Social PhobiaSocial Phobia 5 5 7 7 0.040.04Obsessive-Compulsive 0Obsessive-Compulsive 0 3 3 0.010.01Generalized Anxiety Generalized Anxiety 0 0 6 6 <.01<.01

Chi-squareChi-square

PP=level of significance, p<.05.=level of significance, p<.05.

Comparison of non-violent/violent alcoholics: Comparison of non-violent/violent alcoholics: Axis II diagnoses show alcoholic perpetrators Axis II diagnoses show alcoholic perpetrators have a higher proportion of cluster B and C have a higher proportion of cluster B and C personality disorders than non-violent personality disorders than non-violent alcoholicsalcoholics

Axis II Diagnosis Axis II Diagnosis Non-violent Non-violent Perpetrators withPerpetrators withalcoholicsalcoholics alcohol dependencealcohol dependence

(N = 37)(N = 37) (N = 18)(N = 18) PP

Cluster B personality disordersCluster B personality disordersBorderline Borderline 8 8 15 15 <0.01<0.01Antisocial Antisocial 4 4 9 9 0.02 0.02

Cluster C personality disordersCluster C personality disordersDependentDependent 2 2 6 6 0.01 0.01Obsessive-CompulsiveObsessive-Compulsive 6 6 8 8 0.03 0.03Passive-AggressivePassive-Aggressive 1 1 4 4 0.02 0.02

Chi-squareChi-squarePP=level of significance, p<.05.=level of significance, p<.05.

Comparison of perpetrators with/without Comparison of perpetrators with/without alcohol dependence: Axis I diagnoses alcohol dependence: Axis I diagnoses show that perpetrator groups only differ show that perpetrator groups only differ in substance abuse related diagnosesin substance abuse related diagnoses

Axis I DiagnosisAxis I Diagnosis Perpetrators withoutPerpetrators withoutPerpetrators withPerpetrators with

alcohol dependence alcohol dependence alcohol dependence alcohol dependence (N = 12)(N = 12) (N = 18)(N = 18)

PP

Organic MoodOrganic Mood 0 0 21 21 <.01<.01

Alcohol DependenceAlcohol Dependence 0 0 36 36 <.01<.01

Cannabis Dependence Cannabis Dependence 0 0 11 11 <.01<.01

Chi-squareChi-square

PP=level of significance, p<.05.=level of significance, p<.05.

Comparison of perpetrators Comparison of perpetrators with/without alcohol dependence for with/without alcohol dependence for Axis II diagnosesAxis II diagnoses

Axis II Diagnosis Axis II Diagnosis Perpetrators withPerpetrators with outout Perpetrators Perpetrators withwith

alcohol dependence alcohol dependence alcohol dependence alcohol dependence (N = 12)(N = 12) (N = (N =

18)18)

PP

Borderline Borderline 5 5 15 15 0.020.02

Chi-squareChi-square

PP=level of significance, p<.05.=level of significance, p<.05.

Lactate InfusionLactate Infusion

Double-blind, placebo-controlledDouble-blind, placebo-controlled

10cc/kg of 0.5M sodium lactate 10cc/kg of 0.5M sodium lactate infused over 20 minutesinfused over 20 minutes

VideotapedVideotaped

BEHAVIORAL (Sum of the video ratings for speech, breathing, facial grimacing, and motor activity of the hands/arms and legs.)

FEAR

PANIC

RAGE

VIDEO AVE

(mean ± SD)

HCSN=23

N-V ALC N=19

PERPN=28

2.1±2.0

0.5±0.7

0.5±0.7

0.1±0.3

4.5±4.9

p < .001

p = .002

p = .005

p < .001

p < .001

2.9±1.4

0.3±0.3

0.4±0.4

0.1±0.3

5.1±2.8

4.9±3.3

1.1±0.8

1.2±1.0

0.9±0.8

13.3±9.3

LACTATE INFUSION VIDEOTAPE RESULTS

p - value

Dysfunctional fear conditioningpathways

Anxiety/Phobic disorders Misinterpret

environmental stimuli

SHUTDOWN

Active

INWARD•Self-injurious

OUTWARD

•Physical abuse

Active

Passive

FLIGHT

Perceived “threat”

FIGHT

Model for understanding the psychopathology of perpetrators

Conditioned fear Conditioned fear responseresponse

rapid

defensive behaviorautonomic arousalhypoalgesiastress homones

Armony and LeDoux (1997)Davis, Raommie and Cassell (1994)Siegel, et al. (1999)

slow

Importance of cortex - Importance of cortex - amygdala connectionsamygdala connections Bard (1928) - Animals are more likely to respond Bard (1928) - Animals are more likely to respond

to environmental stimuli with “defensive rage” to environmental stimuli with “defensive rage” following cortical ablation at the level of the high following cortical ablation at the level of the high midbrain. midbrain.

Morgan et al., (1993) - Animals with lesions to Morgan et al., (1993) - Animals with lesions to the dorsal medial prefrontal cortex exhibit the dorsal medial prefrontal cortex exhibit increased fear reactivity.increased fear reactivity.

Morgan et al., (1993 and 1995) - Lesions to the Morgan et al., (1993 and 1995) - Lesions to the medial prefrontal cortex impair the ability of an medial prefrontal cortex impair the ability of an animal to extinguish conditioned fear responses.animal to extinguish conditioned fear responses.

Importance of cortex - Importance of cortex - amygdala connectionsamygdala connections Garcia et al., (1999) - The presence of Garcia et al., (1999) - The presence of

threatening stimuli causes the amygdala to threatening stimuli causes the amygdala to decrease the firing rate of the medial decrease the firing rate of the medial prefrontal cortex neurons.prefrontal cortex neurons.

Hariri et al., (2000) – Angry and fearful faces Hariri et al., (2000) – Angry and fearful faces increase rCBF to the amygdala in healthy increase rCBF to the amygdala in healthy controls. Cognitive labeling of the angry and controls. Cognitive labeling of the angry and fearful faces caused a decrease in to the fearful faces caused a decrease in to the amygdala and a simultaneous increase in amygdala and a simultaneous increase in rCBF to the right prefrontal cortex.rCBF to the right prefrontal cortex.

Conceptualization for the Conceptualization for the etiology of domestic etiology of domestic violenceviolence ““Threats” (i.e., looks, tones of voice) Threats” (i.e., looks, tones of voice)

trigger a conditioned fear response, which trigger a conditioned fear response, which is out of proportion to the stimulus, and is out of proportion to the stimulus, and may result in the expression of fear-may result in the expression of fear-induced aggression. induced aggression.

The misinterpretation of “threat” arises The misinterpretation of “threat” arises from a abnormality in the structures from a abnormality in the structures and/or pathways that mediate fear-and/or pathways that mediate fear-induced aggression.induced aggression.

PET (PET (1818FDG) imaging: to study the FDG) imaging: to study the neural structures and pathways neural structures and pathways involved in fear conditioning/fear involved in fear conditioning/fear induced aggressioninduced aggression

MRI and MRI and 1818FDG PET were obtained for each subject.FDG PET were obtained for each subject.

Regions of interest (ROIs) were manually drawn around each Regions of interest (ROIs) were manually drawn around each desired structure on MR images.desired structure on MR images.

T1-weighted MRI scan was co-registered to its corresponding PET T1-weighted MRI scan was co-registered to its corresponding PET volume using a modified surface matching algorithm (Besel et al., volume using a modified surface matching algorithm (Besel et al., 1992).1992).

The average glucose count within each structure (i.e., ROI) was The average glucose count within each structure (i.e., ROI) was then computed from its corresponding matching PET.then computed from its corresponding matching PET.

The CMRglc value for each ROI is the mean value of all voxels The CMRglc value for each ROI is the mean value of all voxels within the ROI. These values are absolute CMRglc values.within the ROI. These values are absolute CMRglc values.

Continuous auditory performance task (Cohen et al., 1992) was Continuous auditory performance task (Cohen et al., 1992) was performed during the brain uptake of performed during the brain uptake of 1818FDG to ensure all FDG to ensure all participants were in a similar cognitive state.participants were in a similar cognitive state.

– Pressing a button in response to the higher pitched of two Pressing a button in response to the higher pitched of two tones while ignoring the lower pitched tone.tones while ignoring the lower pitched tone.

Mean CMRglc in the right hypothalamus is Mean CMRglc in the right hypothalamus is significantly lower in perpetrators with significantly lower in perpetrators with alcohol dependence alcohol dependence

Healthy Healthy ControlsControlsmeanmean++SDSDN=10N=10

Non-violent Non-violent AlcoholicsAlcoholicsmeanmean++SDSDN=11N=11

Perpetrators w Perpetrators w Alc. Depend.Alc. Depend.meanmean++SDSDN=8N=8

dfdf FF pp

Right Posterior Orbitofrontal Cortex Right Posterior Orbitofrontal Cortex 7.557.55++1.441.44 7.487.48++1.211.21 6.786.78++1.211.21 2,262,26 0.950.95 .40.40

Left Posterior Orbitofrontal Cortex Left Posterior Orbitofrontal Cortex 7.607.60++1.781.78 7.557.55++0.850.85 7.437.43++0.720.72 2,262,26 0.040.04 .96.96

Right Amygdala Right Amygdala 5.655.65++1.061.06 5.285.28++0.760.76 5.025.02++0.430.43 2,262,26 1.391.39 .27.27

Left Amygdala Left Amygdala 5.735.73++0.900.90 5.355.35++0.940.94 5.015.01++0.640.64 2,262,26 1.611.61 .22.22

Left Basal Forebrain Left Basal Forebrain 8.828.82++2.012.01 8.078.07++1.551.55 7.587.58++1.191.19 2,262,26 1.321.32 .29.29

Right Basal Forebrain Right Basal Forebrain 8.638.63++1.891.89 7.967.96++1.651.65 7.227.22++1.071.07 2,262,26 1.711.71 .20.20

Right Hypothalamus Right Hypothalamus 7.737.73++1.381.38 6.966.96++1.281.28 5.695.69++0.860.86 2,262,26 6.26.288

.01.01

Left Hypothalamus Left Hypothalamus 7.557.55++1.611.61 6.686.68++1.301.30 5.985.98++0.770.77 2,262,26 3.243.24 .06.06

Anterior Cingulate Cortex Anterior Cingulate Cortex 7.107.10++1.261.26 6.826.82++0.870.87 6.526.52++0.680.68 2,262,26 0.780.78 .47.47

Posterior Cingulate Cortex Posterior Cingulate Cortex 7.497.49++1.381.38 6.986.98++0.970.97 6.786.78++0.860.86 2,262,26 1.031.03 .37.37

Left Caudate Left Caudate 5.845.84++0.940.94 6.476.47++1.301.30 6.006.00++0.750.75 2,262,26 1.011.01 .38.38

Right Caudate Right Caudate 6.076.07++1.281.28 6.366.36++1.121.12 6.346.34++0.860.86 2,262,26 0.210.21 .81.81

Left ThalamusLeft Thalamus 7.797.79++1.901.90 8.308.30++1.591.59 7.487.48++0.540.54 2,262,26 0.710.71 .50.50

Right ThalamusRight Thalamus 7.747.74++1.901.90 8.388.38++1.431.43 8.028.02++0.730.73 2,262,26 0.510.51 .61.61

Alcoholic perpetrators of domestic Alcoholic perpetrators of domestic violence, compared with non-violent violence, compared with non-violent alcoholics, have reduced correlations with alcoholics, have reduced correlations with the left amygdala ROIthe left amygdala ROI

Left Thalamusr = .89r = -.58

Anterior Cingulate

Right Posterior Orbitofrontal Cortex

Right Basal Forebrain

Right Thalamus

Pearson correlations: O Alcoholics versus O Perpetrators

r = .91r = -.03

r = .85r = -.21

r = .67r = -.48

r = .80r = -.39

Left

Amygdala

Alcoholic perpetrators of domestic Alcoholic perpetrators of domestic violence, compared with healthy controls, violence, compared with healthy controls, have reduced correlations with the left have reduced correlations with the left and right amygdala ROI’sand right amygdala ROI’s

Left Thalamusr = .53r = -.58

Anterior Cingulate

Right Posterior Orbitofrontal Cortex

Pearson correlations: O Healthy Controls versus O Perpetrators

r = .84r = -.03

r = .80r = -.21

LeftAmygdala

RightAmygdala

Left Thalamusr = .63r = -.52

Non-violent alcoholics, compared with Non-violent alcoholics, compared with healthy controls, have increased healthy controls, have increased correlations between the left thalamus correlations between the left thalamus and left posterior orbitofrontal cortex and left posterior orbitofrontal cortex ROI’sROI’s

Left Posterior Orbitofrontal Cortex

Pearson correlations: O Healthy Controls versus O Alcoholics

r = .13r = .88

LeftThalamus

Do the differences in Do the differences in correlations indicate correlations indicate different motivations to different motivations to drink alcohol?drink alcohol? The increased correlation found in non-The increased correlation found in non-

violent alcoholics makes them more violent alcoholics makes them more susceptible to conditioned positive susceptible to conditioned positive reinforcement or cues.reinforcement or cues.

Alcoholic perpetrators drink alcohol to Alcoholic perpetrators drink alcohol to decrease anxiety.decrease anxiety.

Lumbar PunctureLumbar Puncture

Lumbar puncture was performed Lumbar puncture was performed in the left lateral decubitus in the left lateral decubitus position after over-night bed rest position after over-night bed rest and fastand fast

5-HIAA was quantified by gas 5-HIAA was quantified by gas chromatography-mass chromatography-mass spectrometryspectrometry

COMPARISON OF CSF 5-HIAA CONCENTRATIONS

HCS vs DV-ALC p=0.477; DV-ALC vs DV-NALC p=0.015ANOVA: F(2,40)=3.5, p=0.041. Pairwise comparisons: HCS vs DV-NALC p=0.042;

5-H

IAA

Con

cent

ratio

ns (

pmol

/ml)

HCS DV-ALC DV-NALC50

60

70

80

90

100

110

120

130

COMPARISON OF CSF TESTOSTERONE CONCENTRATIONS

HCS vs DV-ALC p=0.001; DV-ALC vs DV-NALC p=0.002ANOVA: F(2,40)=7.9, p=0.001. Pairwise comparisons: HCS vs DV-NALC p=0.824;

Test

ost

ero

ne

Co

nce

ntr

atio

ns

(ng

/ml)

HCS DV-ALC DV-NALC0

0

0

0

0

0

0

0

0

Current research in Current research in domestic violencedomestic violence TreatmentTreatment

fMRIfMRI

GenotypingGenotyping

Treatment of Treatment of perpetrators of perpetrators of domestic violencedomestic violence There are no effective treatments There are no effective treatments

for domestic violence.for domestic violence.

Primary Hypothesis:Primary Hypothesis:– Fluoxetine will be more effective than Fluoxetine will be more effective than

placebo in decreasing measures of placebo in decreasing measures of aggression, anxiety, and depression in aggression, anxiety, and depression in a select group of perpetrators of a select group of perpetrators of domestic violence.domestic violence.

Why fluoxetine? Why fluoxetine?

Perpetrators without alcoholism have lower CSF 5-Perpetrators without alcoholism have lower CSF 5-HIAA than non-violent controls.HIAA than non-violent controls.

5-HT acts in the medial prefrontal cortex to 5-HT acts in the medial prefrontal cortex to modulate freezing behaviors.modulate freezing behaviors.

5-HT input at the amygdala, the medial 5-HT input at the amygdala, the medial hypothalamus, and the PAG is involved with the hypothalamus, and the PAG is involved with the control/expression of fight/flight behaviors. control/expression of fight/flight behaviors.

Fluoxetine has been shown to be effective in Fluoxetine has been shown to be effective in previous aggression studies.previous aggression studies.

Study designStudy design

Perpetrators of domestic violence Perpetrators of domestic violence are being randomized to receive up are being randomized to receive up to 40 mg of fluoxetine or placebo to 40 mg of fluoxetine or placebo per day for a duration of 3 months.per day for a duration of 3 months.

PsychotherapyPsychotherapy– EducationEducation– Cognitive-BehavioralCognitive-Behavioral

Outcome measuresOutcome measures

M-Overt Aggression ScaleM-Overt Aggression Scale Anger, Irritability, Assault QuestionnaireAnger, Irritability, Assault Questionnaire Hamilton Depression Rating ScaleHamilton Depression Rating Scale Spielberger State Anxiety InventorySpielberger State Anxiety Inventory The Drinker Inventory of ConsequencesThe Drinker Inventory of Consequences Straus Conflict TacticsStraus Conflict Tactics Spouse/Significant other interviewSpouse/Significant other interview

– Partner Abuse Scale (non-physical and Partner Abuse Scale (non-physical and physical)physical)

– Dyadic Interaction ParadigmDyadic Interaction Paradigm Point Subtraction Aggression ParadigmPoint Subtraction Aggression Paradigm

Functional MRIFunctional MRI

Angry and fearful facial expressions will Angry and fearful facial expressions will activate the amygdala.activate the amygdala.

Labeling the angry/fearful facial Labeling the angry/fearful facial expressions will not decrease the expressions will not decrease the amygdala activation in the perpetrators amygdala activation in the perpetrators as compared to non-violent comparison as compared to non-violent comparison subjects.subjects.

Fluoxetine will normalize the difference Fluoxetine will normalize the difference between perpetrators and non-violent between perpetrators and non-violent comparison subjects.comparison subjects.

Facial expressionsFacial expressions

control perpetrator

Amygdala activation P < .05

control perpetrator

Perpetrators show significant activation in the Orbitofrontal cortex p < 0.05

GenotypingGenotyping

BackgroundBackground– Fluoxetine is thought to exert its therapeutic Fluoxetine is thought to exert its therapeutic

effect by binding to the serotonin transporter (5-effect by binding to the serotonin transporter (5-HTT).HTT).

– The long (l) and short (s) variants of the promoter The long (l) and short (s) variants of the promoter have different transcription efficiencies.have different transcription efficiencies.

– Smeraldi showed that individuals with the l/l and Smeraldi showed that individuals with the l/l and l/s alleles had better antidepressant response to l/s alleles had better antidepressant response to fluvoxamine than subjects with s/s allele.fluvoxamine than subjects with s/s allele.

– Harari using fMRI demonstrated healthy controls Harari using fMRI demonstrated healthy controls with either s/s or l/s alleles have a greater with either s/s or l/s alleles have a greater increase in amygdala activation in response to increase in amygdala activation in response to fearful stimuli than healthy controls with l/l alleles.fearful stimuli than healthy controls with l/l alleles.

Genotyping Genotyping hypotheseshypotheses

– Perpetrators with either l/s or s/s Perpetrators with either l/s or s/s alleles will have greater amygdala alleles will have greater amygdala activation when presented fearful or activation when presented fearful or angry faces in the fMRI, than angry faces in the fMRI, than perpetrators with the l/l allele.perpetrators with the l/l allele.

– Outcome measures will show an Outcome measures will show an interaction between fluoxetine and interaction between fluoxetine and genotype.genotype.

Effect of alcohol Effect of alcohol administration on fear administration on fear conditioningconditioning Alcohol increases the neural Alcohol increases the neural

transmission from the medial transmission from the medial hypothalamus to the PAG hypothalamus to the PAG facilitating defensive rage facilitating defensive rage (Schubert et al. 1996).(Schubert et al. 1996).

Decreased cortical input Decreased cortical input enhances fight / flight / enhances fight / flight / shutdown behavioral responsesshutdown behavioral responses

SHUTDOWN

FLIGHT

OUTWARDPhysical Abuse

INWARDSelf-injurious

Active

Passive

ActiveFIGHT

slow

rapid

Clinical trial of the Clinical trial of the cannabinoid CB1 receptor cannabinoid CB1 receptor antagonist, SR141716antagonist, SR141716 Endogenous cannabinoids have been Endogenous cannabinoids have been

implicated in the control of appetitive implicated in the control of appetitive behaviors in animals and humans.behaviors in animals and humans.

– SR141716 reduces food intake in rodents SR141716 reduces food intake in rodents and obese peopleand obese people

– SR141716 reduces ethanol drinking in SR141716 reduces ethanol drinking in rodentsrodents

SR141716 decreases SR141716 decreases ethanol consumption in ethanol consumption in young rodentsyoung rodents

HypothesisHypothesis

SR141716 will be more effective SR141716 will be more effective than placebo to reduce voluntary than placebo to reduce voluntary drinking in a select group of drinking in a select group of young, healthy, non-treatment young, healthy, non-treatment seeking individuals who consume seeking individuals who consume between 20 and 40 drinks per between 20 and 40 drinks per week.week.

Study designStudy design

Screening Baseline Alcohol Consumption

Days 1 - 7

SR141716

Placebo

8 - 21 22

Randomization Period

Alcohol Self – Administration Paradigm

Outcome measuresOutcome measures

Primary: Primary: – Drinks consumed during self-Drinks consumed during self-

administrationadministration

Secondary:Secondary:– Alcohol Urge QuestionnaireAlcohol Urge Questionnaire– Biphasic Alcohol Effect ScaleBiphasic Alcohol Effect Scale– Videotape of alcohol self-administrationVideotape of alcohol self-administration– ACTH / cortisolACTH / cortisol– Insulin / glucoseInsulin / glucose

CollaboratorsCollaborators

Paolo DePetrillo Paolo DePetrillo Vijay Vijay Ramchandani Ramchandani

Dasha DotsonDasha Dotson Stanley RapoportStanley RapoportLinda Doty Linda Doty Robert RawlingsRobert RawlingsAryeh Herman Aryeh Herman Norman Salem Norman Salem Joe Hibbeln Joe Hibbeln Jasmin Salloum Jasmin Salloum Debra Hill Debra Hill Erick SingleyErick SingleyDaniel Hommer Daniel Hommer John UmhauJohn UmhauGeorge Kunos George Kunos Wendol WilliamsWendol WilliamsMonte PhillipsMonte Phillips

6 West/Outpatient Clinic Nursing Staff6 West/Outpatient Clinic Nursing Staff