Serby, M. (2003). Psychiatric Resident Conceptualizations of Mood and Affect within the Mental Status Examination. American Journal of Psychiatry, 160, 1527-1529.
In the Mental Status Exam (MSE), affect is conceptualized as "external, objective, visible emotional tone. It is also the moment-to-moment measure, while may be labile or constricted, congruent or not with expressed ideas, and may be varied during any interview." Mood, on the other hand, is conceptualized as "an internal, subjective, and sustained emotional state and should be reported as such". However, this study revealed that psychiatric residents do not typically abide strictly to these definitions. They tend to understand that mood is subjective/internal and affect is objective/external, but appear to be less focused on the temporal distinction between the two.
Showing posts with label 4 Stars. Show all posts
Showing posts with label 4 Stars. Show all posts
Sunday, September 27, 2009
Evidence-Based Assessment of Pediatric Bipolar Disorder
Youngstrom, E.A. & Duax, J. (2005). Evidence-Based Assessment of Pediatric Bipolar Disorder, Part I: Base Rate and Family History. Journal of American Academic Child and Adolescent Psychiatry, 44, 712-716.
Bipolar disorder is rare in children before puberty, there is controversy about how to diagnose it, and there are few published clinical trials to guide treatment. Additionally, there is evidence that use of stimulants or antidepressants might worsen the course of illness; the compounds most likely to be effective also have the potential for serious side effects and therefore should not be prescribed unless one is confident in the diagnosis and the potential for benefit. On the flip side, there are strong concerns that untreated bipolar disorder will follow a progressive and deteorating course. Therefore, diagnosis of pediatric bipolar disorder (PBD) is both controversial and high-stakes.
This article discusses how one might implement recommendations of Evidenced-Based Practice (EBP) to gather additional information and integrate it in order to obtain greater confidence regarding further testing or treatment. A recent meta-analysis indicates that children with a first-degree relative with bipolar have a 5-fold increase in risk, and children with a second-degree relative with bipolar have a 2.5-fold risk increase. Another recent meta-analysis reveals that no other risk factors besides family history have been sufficiently documented to justify integration into clinical decision-making. Therefore, combining the child's familial information with current diagnostic base rates (which can be obtained from publications reporting rates from similar demographies, clinical settings, and interviewing techniques), and using Bayesian methods can yield probabilities that the specific individual has the diagnosis (or alternately, the frequency with which people showing that test result at that particular clinic would have the condition). If the probability yielded is below the test/no-test threshold, then no further testing may be required. If the number is above the treatment threshold, then treatment may be warranted. (Note: Often the treatment threshold is determined by the clinician in consultation with the family, weighing information about the costs and benefits of treatment.) If the number falls in between these thresholds, then further assessment may be prudent.
Bipolar disorder is rare in children before puberty, there is controversy about how to diagnose it, and there are few published clinical trials to guide treatment. Additionally, there is evidence that use of stimulants or antidepressants might worsen the course of illness; the compounds most likely to be effective also have the potential for serious side effects and therefore should not be prescribed unless one is confident in the diagnosis and the potential for benefit. On the flip side, there are strong concerns that untreated bipolar disorder will follow a progressive and deteorating course. Therefore, diagnosis of pediatric bipolar disorder (PBD) is both controversial and high-stakes.
This article discusses how one might implement recommendations of Evidenced-Based Practice (EBP) to gather additional information and integrate it in order to obtain greater confidence regarding further testing or treatment. A recent meta-analysis indicates that children with a first-degree relative with bipolar have a 5-fold increase in risk, and children with a second-degree relative with bipolar have a 2.5-fold risk increase. Another recent meta-analysis reveals that no other risk factors besides family history have been sufficiently documented to justify integration into clinical decision-making. Therefore, combining the child's familial information with current diagnostic base rates (which can be obtained from publications reporting rates from similar demographies, clinical settings, and interviewing techniques), and using Bayesian methods can yield probabilities that the specific individual has the diagnosis (or alternately, the frequency with which people showing that test result at that particular clinic would have the condition). If the probability yielded is below the test/no-test threshold, then no further testing may be required. If the number is above the treatment threshold, then treatment may be warranted. (Note: Often the treatment threshold is determined by the clinician in consultation with the family, weighing information about the costs and benefits of treatment.) If the number falls in between these thresholds, then further assessment may be prudent.
Wednesday, April 1, 2009
Getting comfortable with conversations about race and ethnicity in psychotherapy
Cardemil, E. V., & Battle, C. L. (2003). Guess who’s coming to therapy? Getting comfortable with conversations about race and ethnicity in psychotherapy. Professional Psychology: Research and Practice, 34, 278-286.
This article urges therapists to engage in open conversations with their clients about race and ethnicity as it applies to the client, the therapist, and the therapeutic alliance. By taking a more active stance and initiating such discussions, especially early in treatment, the therapist may enjoy improved treatment retention, therapeutic alliance, and treatment outcome. After defining race and ethnicity as similar but distinct constructs, the article acknowledges that such conversations will vary in terms of frequency and intensity over different clients and times. It then goes on to provide six recommendations for becoming more comfortable and knowledgeable with having such discussions.
First, it is acknowledged that a client's racial/ethnic background may not be obvious and that it is best to suspend preconceptions about a client and their family members. It is recommended that clients be asked early on in therapy how they identify themselves. Second, it is acknowledged that wide variability exists within racial and ethnic groups and that a client's racial identity development and acculturation process may change over time, thus affecting therapy. Third, it is important to consider how the therapist's own racial/ethnic background may affect the therapeutic process in terms of differences in communication styles and conceptualization of mental health/illness, self, and family/community. Fourth, it is acknowledged that racism, power, and privilege can affect the therapeutic process and that failing to acknowledge such societal issues may invalidate a client's painful personal experiences. Fifth, it is recommended that a client expressing reticence and/or frustration with the topics of race and ethnicity be met with an open and non-defensive explanation that such topics are relevant to many clients, but needn't be pursued if they are found irrelevant or uncomfortable. Lastly, resources for further education/training in race and ethnicity are provided.
This article urges therapists to engage in open conversations with their clients about race and ethnicity as it applies to the client, the therapist, and the therapeutic alliance. By taking a more active stance and initiating such discussions, especially early in treatment, the therapist may enjoy improved treatment retention, therapeutic alliance, and treatment outcome. After defining race and ethnicity as similar but distinct constructs, the article acknowledges that such conversations will vary in terms of frequency and intensity over different clients and times. It then goes on to provide six recommendations for becoming more comfortable and knowledgeable with having such discussions.
First, it is acknowledged that a client's racial/ethnic background may not be obvious and that it is best to suspend preconceptions about a client and their family members. It is recommended that clients be asked early on in therapy how they identify themselves. Second, it is acknowledged that wide variability exists within racial and ethnic groups and that a client's racial identity development and acculturation process may change over time, thus affecting therapy. Third, it is important to consider how the therapist's own racial/ethnic background may affect the therapeutic process in terms of differences in communication styles and conceptualization of mental health/illness, self, and family/community. Fourth, it is acknowledged that racism, power, and privilege can affect the therapeutic process and that failing to acknowledge such societal issues may invalidate a client's painful personal experiences. Fifth, it is recommended that a client expressing reticence and/or frustration with the topics of race and ethnicity be met with an open and non-defensive explanation that such topics are relevant to many clients, but needn't be pursued if they are found irrelevant or uncomfortable. Lastly, resources for further education/training in race and ethnicity are provided.
Saturday, November 22, 2008
Different lateral amygdala outputs mediate reactions and actions elicited by a fear-arousing stimulus
Amorapanth, P., LeDoux, J.E., & Nader, K. (2000). Different lateral amygdala outputs mediate reactions and actions elicited by a fear-arousing stimulus. Nature Neuroscience, 3, 1, 74-79.
One common reaction to threat is elicitation of unlearned species-typical defense reactions. Another is the ability to take novel actions in threatening situations, which may also prove advantageous. In escape-from-fear (EFF) tasks, animals come to learn that an arbitrary response (e.g. stepping into the adjoining chamber) terminates a CS which predicts shock. Authors placed lesions throughout the fear circuit to see try to elucidate function. Lateral amygdala (LA) is believed to be the sensory interface where CS information enters the amygdala; lesions here block acquisition of both conditioned freezing responses, as expected, but also block acquisition of the CS's reinforcement of a new response in the EFF task. Central nucleus (CE) lesions block expression of hard-wired motoric output (i.e. freezing itself), but not the EFF. Basal nucleus (B) lesions had no effect on conditioned freezing, but did block the EFF. By way of interactions between the B and striatal circuits, reinforcement in the amygdala may come to reinforce novel motor responses. Thus, it may be that activation of LA by a CS triggers a reactive response output system via the CE and an active output system via the B.
One common reaction to threat is elicitation of unlearned species-typical defense reactions. Another is the ability to take novel actions in threatening situations, which may also prove advantageous. In escape-from-fear (EFF) tasks, animals come to learn that an arbitrary response (e.g. stepping into the adjoining chamber) terminates a CS which predicts shock. Authors placed lesions throughout the fear circuit to see try to elucidate function. Lateral amygdala (LA) is believed to be the sensory interface where CS information enters the amygdala; lesions here block acquisition of both conditioned freezing responses, as expected, but also block acquisition of the CS's reinforcement of a new response in the EFF task. Central nucleus (CE) lesions block expression of hard-wired motoric output (i.e. freezing itself), but not the EFF. Basal nucleus (B) lesions had no effect on conditioned freezing, but did block the EFF. By way of interactions between the B and striatal circuits, reinforcement in the amygdala may come to reinforce novel motor responses. Thus, it may be that activation of LA by a CS triggers a reactive response output system via the CE and an active output system via the B.
Friday, September 19, 2008
Modifying shyness-related behavior through symptom misattribution
Brodt, S.E. & Zimbardo, P.G. (1981). Modifying shyness-related behavior through symptom misattribution. Journal of Personality and Social Psychology, 41, 437-449.
In response to anxiety-evoking stimuli, people develop a complex constellation of reactions. Over time, a general categorical label may come to link these components together and serve as a central explanation. For some people, this label may undergo further transformation from its original situational attribution to a broader usage that includes the person's disposition (personal causality). For example, a person may immediately invoke the label "I am afraid of men" which in turn may kick off a response chain and impose constraints upon it, creating self-fulfilling prophecies. The authors of this study wanted to weaken the 3-part link between perceived symptoms of arousal, the corresponding dispositional label, and resultant behaviors by intervening with symptom misattribution.
In this experiment with 46 college women, the dispositional label studied was shyness -- an excessive self-focus in which potential rejection by other people and social anxiety are salient cognitions. Seeking to redirect the arousal from an anxiety-laden source (being alone with a member of the opposite sex) to a nonpsychological source, the researchers exposed all the groups to intense noise and led the "shy misattribution" group to believe that common side effects of noise bombardment was heart-pounding and increased pulse, symptoms normally associated with their social anxiety. Another group, the "shy comparison" group were led to believe the noise only caused dry mouth. Another "non-shy" group, unlike the other groups did not score high on shyness ratings, were given the same story as the "shy misattribution group". Results showed that shy women, when given an alternative explanation for their social anxiety, were able to overcome normal limitations of their shyness, talking significantly more, acting more assertive, and showing a stronger affiliative preference than the comparison group. Thus, misattribution demonstrates the power of social cognitions in controlling behavior.
In response to anxiety-evoking stimuli, people develop a complex constellation of reactions. Over time, a general categorical label may come to link these components together and serve as a central explanation. For some people, this label may undergo further transformation from its original situational attribution to a broader usage that includes the person's disposition (personal causality). For example, a person may immediately invoke the label "I am afraid of men" which in turn may kick off a response chain and impose constraints upon it, creating self-fulfilling prophecies. The authors of this study wanted to weaken the 3-part link between perceived symptoms of arousal, the corresponding dispositional label, and resultant behaviors by intervening with symptom misattribution.
In this experiment with 46 college women, the dispositional label studied was shyness -- an excessive self-focus in which potential rejection by other people and social anxiety are salient cognitions. Seeking to redirect the arousal from an anxiety-laden source (being alone with a member of the opposite sex) to a nonpsychological source, the researchers exposed all the groups to intense noise and led the "shy misattribution" group to believe that common side effects of noise bombardment was heart-pounding and increased pulse, symptoms normally associated with their social anxiety. Another group, the "shy comparison" group were led to believe the noise only caused dry mouth. Another "non-shy" group, unlike the other groups did not score high on shyness ratings, were given the same story as the "shy misattribution group". Results showed that shy women, when given an alternative explanation for their social anxiety, were able to overcome normal limitations of their shyness, talking significantly more, acting more assertive, and showing a stronger affiliative preference than the comparison group. Thus, misattribution demonstrates the power of social cognitions in controlling behavior.
Tuesday, September 9, 2008
Switching on and off fear by distinct neuronal circuits
Herry, C. et al. (2008). Switching on and off fear by distinct neuronal circuits. Nature, 454, 600-605.
Whereas firing of amygdala neurons is necessary for retrieval of conditioned fear memories, extinction of these fear memories is thought to be controlled by constraining this neural activity by local inhibitory circuitry (under the influence of mPFC). However, fear extinction is known to be a fragile behavioral state, readily influenced by context, i.e. changing context can result in spontaneous recovery. This raises the question of whether there are specialized circuits driving behavioral transitions in opposite directions, namely fear-on and fear-off. This paper showed that neurons in the BA could be divided into distinct functional classes: those exhibiting selective increases in CS+ evoked spike firing during and after fear conditioning (fear neurons) and those exhibiting selective increases in CS+ evoked spike firing during extinction (extinction neurons). Further, close analysis revealed that these two groups were not only functionally different but also differentially connected, with (1) fear neurons selectively receiving input from the hippocampus, and (2) extinction neurons being reciprocally connected to the mPFC while fear neurons only projected unidirectionally to the mPFC. This would indicate that co-localized within the same nucleus, two discrete neuronal circuits exist, intermingled in a salt-and-pepper-like manner. Their close anatomical proximity may serve to facilitate local interactions, although these mechanisms remain unexplored. Taken together with evidence showing emotional perseveration (persistent lack of state change) concomitant with inactivation of the BA, results suggest that the BA is unlikely to be associated with the storage, retrieval, or expression of conditioned fear and extinction memories, but is more likely to mediate context-dependent behavioral transitions between low and high fear states.
Whereas firing of amygdala neurons is necessary for retrieval of conditioned fear memories, extinction of these fear memories is thought to be controlled by constraining this neural activity by local inhibitory circuitry (under the influence of mPFC). However, fear extinction is known to be a fragile behavioral state, readily influenced by context, i.e. changing context can result in spontaneous recovery. This raises the question of whether there are specialized circuits driving behavioral transitions in opposite directions, namely fear-on and fear-off. This paper showed that neurons in the BA could be divided into distinct functional classes: those exhibiting selective increases in CS+ evoked spike firing during and after fear conditioning (fear neurons) and those exhibiting selective increases in CS+ evoked spike firing during extinction (extinction neurons). Further, close analysis revealed that these two groups were not only functionally different but also differentially connected, with (1) fear neurons selectively receiving input from the hippocampus, and (2) extinction neurons being reciprocally connected to the mPFC while fear neurons only projected unidirectionally to the mPFC. This would indicate that co-localized within the same nucleus, two discrete neuronal circuits exist, intermingled in a salt-and-pepper-like manner. Their close anatomical proximity may serve to facilitate local interactions, although these mechanisms remain unexplored. Taken together with evidence showing emotional perseveration (persistent lack of state change) concomitant with inactivation of the BA, results suggest that the BA is unlikely to be associated with the storage, retrieval, or expression of conditioned fear and extinction memories, but is more likely to mediate context-dependent behavioral transitions between low and high fear states.
Monday, September 8, 2008
mPFC neurons signal memory for fear extinction
Milad, M.R. & Quirk, G.J. (7 November 2002). Neurons in the medial prefrontal cortex signal memory for fear extinction. Nature, 420, 70-74.
Extinction is a process thought to form a new memory that inhibits the once-learned conditioned response. This paper suggests that consolidation of extinction learning potentiates activity in the infralimbic cortex (IL) of the mPFC which inhibits fear during subsequent encounters with fear stimuli. Electrophysiological recording showed that IL activity remained unresponsive during the conditioning phase and also during extinction training on Day 1. However, by Day 2, activity in the IL in response to tone was present from the start of the extinction phase. Further, stimulation of the IL paired with tone presentation resulted in less freezing behavior and also accelerated extinction learning. Therefore, enhanced extinction learning could be mediated directly by the stimulation or indirectly by the behavioral feedback of decrease freezing. Since the BLA sends excitatory projections to IL, it is possible that these inputs serve to potentiate IL neurons during the consolidation of extinction. The IL is then likely to inhibit expression of fear behavior via its projections to intercalated (ITC) cells in the CE, dampening the output of the amygdala. Pairing reminder stimuli with activation of the ventral mPFC through transcranial magnetic stimulation (TMS) might help strengthen extinction of fear in clinical settings.
Extinction is a process thought to form a new memory that inhibits the once-learned conditioned response. This paper suggests that consolidation of extinction learning potentiates activity in the infralimbic cortex (IL) of the mPFC which inhibits fear during subsequent encounters with fear stimuli. Electrophysiological recording showed that IL activity remained unresponsive during the conditioning phase and also during extinction training on Day 1. However, by Day 2, activity in the IL in response to tone was present from the start of the extinction phase. Further, stimulation of the IL paired with tone presentation resulted in less freezing behavior and also accelerated extinction learning. Therefore, enhanced extinction learning could be mediated directly by the stimulation or indirectly by the behavioral feedback of decrease freezing. Since the BLA sends excitatory projections to IL, it is possible that these inputs serve to potentiate IL neurons during the consolidation of extinction. The IL is then likely to inhibit expression of fear behavior via its projections to intercalated (ITC) cells in the CE, dampening the output of the amygdala. Pairing reminder stimuli with activation of the ventral mPFC through transcranial magnetic stimulation (TMS) might help strengthen extinction of fear in clinical settings.
Neural mechanisms of extinction
Quirk, G.J. & Mueller, D. (2007). Neural mechanisms of extinction learning and retrieval. Neuropsychopharmacology Reviews, 1-17.
The simplest form of emotional regulation is extinction, is which conditioned responding to a stimulus decreases when the reinforcer is omitted. Exinction, like any learning process, occurs in 3 phases: acquisition, consolidation, and retrieval. Cannabinoid and opioid receptors appear to be implicated in the acquisition of extinction since anandamide and opioid antagonists impair within-session extinction of fear. Consolidation appears to depend on protein synthesis within the BLA, frequency bursting of the infralimbic region (IL) of the vmPFC shortly after extinction, and general involvement of the hippocampus, especially in tasks such as inhibitory avoidance and contextual fear. Retrieval of extinction memories involves the expression of inhibitory circuitry and is highly context-specific. Inhibition circuitry within the amygdala includes local inhibitory neurons within the BLA and CE, as well as islands of GABAergic neurons between these two sites known as the intercalated (ITC) cells. ITC cells could serve as a site of extinction memory since they inhibit CE output neurons and BLA neurons, acting as an off-switch for the amygdala. ITC cells receive strong projection from the IL mPFC, and IL activity is correlated with the extent of extinction retrieval. In fact, electrical stimulation of IL reduces conditioned fear and strengthens extinction memory. The prelimbic (PL) mPFC, on the other hand, excites fear expression and can augment fear expression via projections to the basal nucleus of the amygdala. Thus, the PFC can fully control overall fear expression. Individuals with PTSD show reduced vmPFC and hippocampal volume and activity, as well as increased amygdala activity. Stress may also impair extinction, since chronic stress is shown to decrease dendritic branching and spine count in hippocampus and mPFC, but increase it in BLA, which could be expected to increase conditioning and impair extinction. Pharmacological adjuncts to current extinction-based exposure therapies may accelerate and strengthen extinction. Among them D-cycloserine, yohimbine, sulpiride, and methylene blue show promise. Administration of glucocorticoids such as cortisol before exposure therapy may also help.
The simplest form of emotional regulation is extinction, is which conditioned responding to a stimulus decreases when the reinforcer is omitted. Exinction, like any learning process, occurs in 3 phases: acquisition, consolidation, and retrieval. Cannabinoid and opioid receptors appear to be implicated in the acquisition of extinction since anandamide and opioid antagonists impair within-session extinction of fear. Consolidation appears to depend on protein synthesis within the BLA, frequency bursting of the infralimbic region (IL) of the vmPFC shortly after extinction, and general involvement of the hippocampus, especially in tasks such as inhibitory avoidance and contextual fear. Retrieval of extinction memories involves the expression of inhibitory circuitry and is highly context-specific. Inhibition circuitry within the amygdala includes local inhibitory neurons within the BLA and CE, as well as islands of GABAergic neurons between these two sites known as the intercalated (ITC) cells. ITC cells could serve as a site of extinction memory since they inhibit CE output neurons and BLA neurons, acting as an off-switch for the amygdala. ITC cells receive strong projection from the IL mPFC, and IL activity is correlated with the extent of extinction retrieval. In fact, electrical stimulation of IL reduces conditioned fear and strengthens extinction memory. The prelimbic (PL) mPFC, on the other hand, excites fear expression and can augment fear expression via projections to the basal nucleus of the amygdala. Thus, the PFC can fully control overall fear expression. Individuals with PTSD show reduced vmPFC and hippocampal volume and activity, as well as increased amygdala activity. Stress may also impair extinction, since chronic stress is shown to decrease dendritic branching and spine count in hippocampus and mPFC, but increase it in BLA, which could be expected to increase conditioning and impair extinction. Pharmacological adjuncts to current extinction-based exposure therapies may accelerate and strengthen extinction. Among them D-cycloserine, yohimbine, sulpiride, and methylene blue show promise. Administration of glucocorticoids such as cortisol before exposure therapy may also help.
Friday, September 5, 2008
Emotion Circuits in the Brain
LeDoux, J.E. (2000). Emotion Circuits in the Brain. Annual Reviews in Neuroscience, 23, 155-184.
Emotion research was largely lost for some time in the wake of the cognitive revolution. However, people soon realized a purely cognitive view of the brain -- leaving out emotions, motivations, and the like -- is likely to paint an unrealistic view of real minds. Unfortunately, attempts to dig into emotions once again were hamstrung by the limbic system concept, a flawed and inadequate theory of the emotional brain: cognition does not only reside in the neocortex and emotions do not only reside within the limbic system (a moving target itself).
Emotion research began its official resurgence with a bottoms-up examination of fear conditioning, with a bulk of the work focused on the auditory modality. Research soon named amygdala as centrally important, a site where transmission of information about the CS and US converged and output projections controlled fear reactions. On the input side, CS sensory inputs terminate in the lateral amygdala (LA), coming from both the auditory thalamus and the auditory cortex, although plasticity seems to occur initially through the thalamic pathway. US information also seems to converge in the amygdala, receiving inputs from the spino-thalamic tract, cortical areas that process somatosensory stimuli including nociceptive stimuli, the parabrachial area, and the spinal cord. On the outbound side, the central nucleus of the amygdala (CE) projects to autonomic (hypothalamus) and defensive motoric (periaqueductal gray) centers. Methodologies used have largely been single unit recordings, long-term potentiation (LTP) studies, and pharmacological experiments which block LTP. Studies have focused on two types of fear learning: simple fear conditioning (a benign tone comes to evoke a fear response) and contextual fear conditioning (fear responsivity to environmental cues). Research agrees that the amygdala seems to be required for Pavlovian fear conditioning to occur, although the site of long-term fear memory storage is still unknown: it may very well exist in the amygdala, but it may also be distributed across multiple structures or transferred off to cortical areas over time. However, plasticity within the amygdala is probably not required for learning cognitive aspects of fear.
Human studies have echoed many of the results from animal literature. Additionally, they have found perceptual deficits of the emotional meaning of faces in patients with amygdalar damage. The amygdala also appears activated more strongly in the presence of fearful and angry faces than of happy ones. Further, when the activity of the amygdala during fear conditioning is cross-correlated with other regions of the brain, the strongest relations are seen in subcortical areas, emphasizing the importance of the direct thalamo-amygdala pathway in the human brain. Although a fear conditioning approach cannot account for all aspects of human fear and anxiety disorders, it may be especially elucidating for PTSD, panic disorders, and phobias. Difficulty in extinguishing fear memories witnessed in human disorders may also involve the medial prefrontal cortex circuitry.
Future research needs to integrate both cognition and emotion. How fear processing in the amygdala can influence perceptual, attentional, and memory functions of the cortex, and vice versa, is begging for additional research, although it is known that the amygdala does receive input from cortical sensory processing regions and projects back to these both directly and indirectly. How conscious emotional feelings are manifest is also relatively unexplored, although the models posit that feelings may arise from interactions between the amygdala and prefrontal working memory areas, sensory processing areas in cortex, long-term memory systems in the temportal lobe, and arousal systems which maintain global projections.
Tuesday, July 29, 2008
Acceptance and commitment therapy
Harris, R. (August 2006). Embracing your demons: an overview of acceptance and commitment therapy. Psychotherapy in Australia, 12, 4, 2-8.
Acceptance and Commitment Therapy (ACT) is one of the "third-wave" behavioral therapies which emphasizes mindfulness and is intended to be used with a broad range of clinical conditions. The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it. Western psychology has typically operated under the "healthy normality" assumption which states that by their nature, humans are psychologically healthy. That is, they will naturally be happy and content, and suffering is seen as abnormal. However, research shows that psychiatric disorders are exceedingly commonplace, as is nonclinical psyshological suffering, despite our high standards of living. ACT assumes, rather, that psychological processes of a normal human mind are often destructive. They posit that there is a dark side of language and cognition which sits at the root of this suffering. We often struggle with our thoughts and feelings, hoping to change them, avoid them, ameliorate them, and get rid of suffering. In doing so, ACT points at that some of these tactics often create extra suffering for ourselves. These "emotional control strategies" commonly become costly, life-distorting, or harmful. In ACT, there is no attempt to reduce, change, avoid, suppress, or control these private experiences. Instead, mindfulness is encouraged.
ACT commonly employs six techniques: (1) Cognitive Defusion: Learning to perceive thoughts, images, emotions, and memories as what they are, not what they appear to be. (2) Acceptance: Allowing them to come and go without struggling with them. (3) Contact with the present moment: Awareness to the here and now experience with openness, interest, and receptiveness. (4) Observing the self: Accessing a transcendent sense of self, a continuity of consciousness which is changing. (5) Values: Discovering what is most important to one's true self. (6) Committed Action: Setting goals according to values and carrying them out responsibly.
Acceptance and Commitment Therapy (ACT) is one of the "third-wave" behavioral therapies which emphasizes mindfulness and is intended to be used with a broad range of clinical conditions. The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it. Western psychology has typically operated under the "healthy normality" assumption which states that by their nature, humans are psychologically healthy. That is, they will naturally be happy and content, and suffering is seen as abnormal. However, research shows that psychiatric disorders are exceedingly commonplace, as is nonclinical psyshological suffering, despite our high standards of living. ACT assumes, rather, that psychological processes of a normal human mind are often destructive. They posit that there is a dark side of language and cognition which sits at the root of this suffering. We often struggle with our thoughts and feelings, hoping to change them, avoid them, ameliorate them, and get rid of suffering. In doing so, ACT points at that some of these tactics often create extra suffering for ourselves. These "emotional control strategies" commonly become costly, life-distorting, or harmful. In ACT, there is no attempt to reduce, change, avoid, suppress, or control these private experiences. Instead, mindfulness is encouraged.
ACT commonly employs six techniques: (1) Cognitive Defusion: Learning to perceive thoughts, images, emotions, and memories as what they are, not what they appear to be. (2) Acceptance: Allowing them to come and go without struggling with them. (3) Contact with the present moment: Awareness to the here and now experience with openness, interest, and receptiveness. (4) Observing the self: Accessing a transcendent sense of self, a continuity of consciousness which is changing. (5) Values: Discovering what is most important to one's true self. (6) Committed Action: Setting goals according to values and carrying them out responsibly.
Wednesday, May 7, 2008
Seasonal changes of hippocampus volume in parasitic cowbirds
Clayton, N.S., Reboreda, J.C., & Kacelnik, A. (1997). Seasonal changes of hippocampus volume in parasitic cowbirds. Behavioral Processes, 41, 237-243.
This study compared a set of phylogenetically closely related species with striking differences in natural behavior, offering the opportunity for seeking neural differences in association with these behavioral changes. Notable differences exist in these South American cowbirds of the genus Molothrus related to parasitic nesting. In one species, the birds are especially active during the breeding season, searching and locating potential hosts' nests. In another two species, only females are active during the breeding season in locating potential hosts' nests (sexual dimorphism). A fourth species is non-parasitic and no sexual differences are known with respect to spatial memory use in either season. Results show that the first species shows significantly larger relative hippocampal volume in the breeding season. The sexual dimorphic species show significantly larger relative hippocampal volume in the breeding season, but only in females. The evidence suggests seasonal variation in neuroanatomy associated with specific changes in behavior, namely spatial memory demands, as opposed to purely seasonal fluctuations per se.
This study compared a set of phylogenetically closely related species with striking differences in natural behavior, offering the opportunity for seeking neural differences in association with these behavioral changes. Notable differences exist in these South American cowbirds of the genus Molothrus related to parasitic nesting. In one species, the birds are especially active during the breeding season, searching and locating potential hosts' nests. In another two species, only females are active during the breeding season in locating potential hosts' nests (sexual dimorphism). A fourth species is non-parasitic and no sexual differences are known with respect to spatial memory use in either season. Results show that the first species shows significantly larger relative hippocampal volume in the breeding season. The sexual dimorphic species show significantly larger relative hippocampal volume in the breeding season, but only in females. The evidence suggests seasonal variation in neuroanatomy associated with specific changes in behavior, namely spatial memory demands, as opposed to purely seasonal fluctuations per se.
Tuesday, May 6, 2008
Sign Language in the Brain
Hickok, G., Bellugi, U. & Klima, E.S. (June 2001). Sign Language in the Brain. Scientific American.
Because sign language relies heavily upon visual-spatial contrast, one might expect sign language to be supported by systems in the right hemisphere rather than the traditional left hemisphere language systems. However, this does not appear to be the case. A deaf signer with damage to Wernicke's area is likely to have comprehension difficulties and one with damage to Broca's area may have difficulty producing signs, just like normal speakers. And signers with right hemisphere damage continued to be fluent and accurate in their production of signs, used normal grammar, and comprehended signs with ease. One exception of the left hemisphere's monopoly on language production is creation of a coherent discourse, where right hemisphere damage may lead to rambling as it tends to be involved in more global-level processes. Generally speaking, sign language abilities of lifelong signers appear to be independent of their nonlinguistic spatial skills. Thus, it is likely that signers maintain unique early stages of processing compared to regular speakers, but thereafter neural organization is quite similar, being translated into a format optimized for linguistic processing and being routed to central linguistic systems.
Because sign language relies heavily upon visual-spatial contrast, one might expect sign language to be supported by systems in the right hemisphere rather than the traditional left hemisphere language systems. However, this does not appear to be the case. A deaf signer with damage to Wernicke's area is likely to have comprehension difficulties and one with damage to Broca's area may have difficulty producing signs, just like normal speakers. And signers with right hemisphere damage continued to be fluent and accurate in their production of signs, used normal grammar, and comprehended signs with ease. One exception of the left hemisphere's monopoly on language production is creation of a coherent discourse, where right hemisphere damage may lead to rambling as it tends to be involved in more global-level processes. Generally speaking, sign language abilities of lifelong signers appear to be independent of their nonlinguistic spatial skills. Thus, it is likely that signers maintain unique early stages of processing compared to regular speakers, but thereafter neural organization is quite similar, being translated into a format optimized for linguistic processing and being routed to central linguistic systems.
Monday, May 5, 2008
Love in Infant Monkeys
Harlow, H.F. (June 1959). "Love in Infant Monkeys", Scientific American.
Harlow used baby rhesus monkeys to yield insights into the origin of the infant's love for its mother and concluded that bodily contact comfort is a decisive variable in this relationship. For example, newborn monkeys preferred a surrogate "cloth" mother to a "wire" mother, and sought out the cloth mother in times of emotional stress. Other variables were also explored. A mother's rocking motion appeared to enhance affection, but less so than simple contact. Heat of the mother did not appear to be an important variable. Other visual, auditory, and olfactory stimulation may also play a role. Additionally, a critical period to attachment formation seems to be evident.
Harlow used baby rhesus monkeys to yield insights into the origin of the infant's love for its mother and concluded that bodily contact comfort is a decisive variable in this relationship. For example, newborn monkeys preferred a surrogate "cloth" mother to a "wire" mother, and sought out the cloth mother in times of emotional stress. Other variables were also explored. A mother's rocking motion appeared to enhance affection, but less so than simple contact. Heat of the mother did not appear to be an important variable. Other visual, auditory, and olfactory stimulation may also play a role. Additionally, a critical period to attachment formation seems to be evident.
Thursday, April 17, 2008
The Early Origins of Autism
Rodier, P.M. (February 2000). The Early Origins of Autism. Scientific American.
Miller and Stromland made a surprising observation that 5% of thalidomide victims had autism, a rate about 30 times higher than the rate among the general population. This suggested that autism originates in the early weeks of pregnancy when the nervous system is just beginning to develop. Examining these victims' specific malformations indicated that their development had been impacted about 20-24 days into gestation, before many pregnant women even know they are pregnant. This was way earlier than investigators would have guessed, since very few neurons are even formed by the 4th week. However, most are the motor nerves of the cranial nerves in the brain stem. And indeed, many subjects with autism exhibit abnormalities of eye movement and lack of facial expression, consistent with this observation.
However, it is more likely that these early brain injuries affect more than just the function of the cranial nerve, and may interfere with proper development or wiring of other brain regions in turn. People with autism consistently show a reduction in the number of neurons in the cerebellum of the brainstem, a structure typically thought to involved in fine motor control but also seen activated during certain tasks requiring high-level cognitive processing. Some people with autism also display marked decreases in the facial nucleus (controls muscles of facial expression) and superior olive (a relay station for auditory information). Interestingly, "knock-out" mice engineered to lack the expression of the gene known as Hoxa1 (active when brainstem neurons are forming), show all of these symptoms. While variant alleles of Hoxa1 have been identified, these are only one of many genes involved in the spectrum of autism disorder. Other genes must be found which also increase the risk (or decrease the risk) of developing the disorder.
Miller and Stromland made a surprising observation that 5% of thalidomide victims had autism, a rate about 30 times higher than the rate among the general population. This suggested that autism originates in the early weeks of pregnancy when the nervous system is just beginning to develop. Examining these victims' specific malformations indicated that their development had been impacted about 20-24 days into gestation, before many pregnant women even know they are pregnant. This was way earlier than investigators would have guessed, since very few neurons are even formed by the 4th week. However, most are the motor nerves of the cranial nerves in the brain stem. And indeed, many subjects with autism exhibit abnormalities of eye movement and lack of facial expression, consistent with this observation.
However, it is more likely that these early brain injuries affect more than just the function of the cranial nerve, and may interfere with proper development or wiring of other brain regions in turn. People with autism consistently show a reduction in the number of neurons in the cerebellum of the brainstem, a structure typically thought to involved in fine motor control but also seen activated during certain tasks requiring high-level cognitive processing. Some people with autism also display marked decreases in the facial nucleus (controls muscles of facial expression) and superior olive (a relay station for auditory information). Interestingly, "knock-out" mice engineered to lack the expression of the gene known as Hoxa1 (active when brainstem neurons are forming), show all of these symptoms. While variant alleles of Hoxa1 have been identified, these are only one of many genes involved in the spectrum of autism disorder. Other genes must be found which also increase the risk (or decrease the risk) of developing the disorder.
Monday, March 31, 2008
Aversive learning enhances perceptual and cortical discrimination
Li, W, Howard, J.D., Parrish, T.B., & Gottfried, J.A. (March 28, 2008). Aversive learning enhances perceptual and cortical discrimination of indiscriminable odor cues. Science, Vol. 319, 1842-1844.
With this study, the authors explored the impact of aversive conditioning on olfactory discrimination. While most conditioning studies examine the acquisition of new behavioral responses (CR) to formerly benign stimuli presentations, this examined how associative learning can actually alter the perceptual processing of the conditioned stimulus (CS) itself. Following a conditioning regimen, behavioral accuracy for distinguishing by smell between a previously indistinguishable pair of molecules (CS+) rose by more than a factor of 2, exceeding both chance and preconditioning performance. Interestingly, following conditioning, no improvement in distinguishing between the unconditioned control pair (CS-) was witnessed, indicating that these effects are specific to the CS+. After conditioning, reorganization of neural coding was also observed in the posterior piriform cortex, where neural representations of odor identity are maintained. This may shed new light on anxiety disorders which are characterized by exaggerated sensory sensitivity and hypervigilance, potentially self-reinforcing patterns.
With this study, the authors explored the impact of aversive conditioning on olfactory discrimination. While most conditioning studies examine the acquisition of new behavioral responses (CR) to formerly benign stimuli presentations, this examined how associative learning can actually alter the perceptual processing of the conditioned stimulus (CS) itself. Following a conditioning regimen, behavioral accuracy for distinguishing by smell between a previously indistinguishable pair of molecules (CS+) rose by more than a factor of 2, exceeding both chance and preconditioning performance. Interestingly, following conditioning, no improvement in distinguishing between the unconditioned control pair (CS-) was witnessed, indicating that these effects are specific to the CS+. After conditioning, reorganization of neural coding was also observed in the posterior piriform cortex, where neural representations of odor identity are maintained. This may shed new light on anxiety disorders which are characterized by exaggerated sensory sensitivity and hypervigilance, potentially self-reinforcing patterns.
Tuesday, March 11, 2008
Anterior prefrontal function
Koechlin, E. & Hyafil, A. (October 26, 2007). Anterior prefrontal function and the limits of human decision making. Science, Vol. 318, 594-598.
Based on recent empirical findings and predictions from a neurocomputational model, the authors of this review propose a role for the not-yet-well-understood frontopolar cortex (FPC), also known as the anterior prefrontal cortex or Brodmann's area 10. They argue that processing of 'cognitive branching' is the core function of the FPC. Cognitive branching enables a previously running task to be maintained in a pending state for subsequent retrieval and execution upon completion of the ongoing one. Many of our complex behaviors and mental activities require simultaneous engagement of multiple tasks, and the FPC may perform a domain-general function in these scheduling operations.
Based on recent empirical findings and predictions from a neurocomputational model, the authors of this review propose a role for the not-yet-well-understood frontopolar cortex (FPC), also known as the anterior prefrontal cortex or Brodmann's area 10. They argue that processing of 'cognitive branching' is the core function of the FPC. Cognitive branching enables a previously running task to be maintained in a pending state for subsequent retrieval and execution upon completion of the ongoing one. Many of our complex behaviors and mental activities require simultaneous engagement of multiple tasks, and the FPC may perform a domain-general function in these scheduling operations.
Monday, March 10, 2008
Play therapy with sexually abused children
Hill, A. (2006). Play therapy with sexually abused children: Including parents in therapeutic play. CHILD AND FAMILY SOCIAL WORK. 11 (4), 316-324.
According to this article, situations in which sexual abuse has increased a child's separation anxiety can often be improved by including parents in play therapy. This allows the child to feel more secure in his/her primary attachment relationships, while presenting the often confused and uncomfortable parents with a positive model of interaction to emulate. It may also be beneficial for the therapist to witness and interact in the parent-child relationship which, if strained, can often exacerbate the trauma. It is noted that parents benefit from participating in the therapy by eliminating feelings of exclusion and jealousy they may have developed in response to the new therapist-child relationship, by countering feelings of guilt and failure in the role of parent/protector common to situations of child abuse, and by rebuilding confidence in their parenting abilities.
Possible complications of introducing parents into child therapy are discussed. Issues of the child's privacy and confidentiality are naturally raised, as well as the possibility that some parents might be unwilling to participate or counter-productive in the process. Suggestions or interventions by the therapist may be viewed as criticism by the parent.
Two case studies are provided to exemplify these points and to illustrate the situation of a child expressing anger towards his/her parents in response to sexual abuse (by someone else). While this is a common occurrence in play therapy, it becomes complicated when that parent is present. Lastly, it is noted that including parents in play therapy can counteract the "dynamic of secrecy" often imposed on the sexually abused child by the abuser.
According to this article, situations in which sexual abuse has increased a child's separation anxiety can often be improved by including parents in play therapy. This allows the child to feel more secure in his/her primary attachment relationships, while presenting the often confused and uncomfortable parents with a positive model of interaction to emulate. It may also be beneficial for the therapist to witness and interact in the parent-child relationship which, if strained, can often exacerbate the trauma. It is noted that parents benefit from participating in the therapy by eliminating feelings of exclusion and jealousy they may have developed in response to the new therapist-child relationship, by countering feelings of guilt and failure in the role of parent/protector common to situations of child abuse, and by rebuilding confidence in their parenting abilities.
Possible complications of introducing parents into child therapy are discussed. Issues of the child's privacy and confidentiality are naturally raised, as well as the possibility that some parents might be unwilling to participate or counter-productive in the process. Suggestions or interventions by the therapist may be viewed as criticism by the parent.
Two case studies are provided to exemplify these points and to illustrate the situation of a child expressing anger towards his/her parents in response to sexual abuse (by someone else). While this is a common occurrence in play therapy, it becomes complicated when that parent is present. Lastly, it is noted that including parents in play therapy can counteract the "dynamic of secrecy" often imposed on the sexually abused child by the abuser.
Friday, March 7, 2008
A case study using child-centered play therapy approach to treat enuresis and encopresis
Cuddy-Casey, M. (1997). A case study using child-centered play therapy approach to treat enuresis and encopresis. ELEMENTARY SCHOOL GUIDANCE AND COUNSELLING. 31 (3), 220-225.
Enuresis (bedwetting) and encopresis (bed-defecation) may come from one or more of the following causes: medical-genetic disorders, emotional disturbances, and failure to learn. Depending on the main cause, different treatments are used. Physicians are usually called to deal with the organic problems underlying medical-genetic disorders, while behavioral techniques are used to treat problems stemming from a failure to learn. However, problems rooted in emotional disturbances are commonly lumped into the "failure to learn" category and treated thusly. This article argues for an alternative treatment (i.e. non-directive play therapy) to be used in response enuresis and encopresis rooted in emotional disturbances.
A case example is provided in which an 8-year old male with enuresis and encopresis is treated with play therapy after medical-genetic disorders and failure-to-learn are ruled out. In these sessions, the child began to exhibit aggressive behavior and admitted to wanting to destroy the playroom's pictures and wall clock, which he believed to have cameras hidden behind them. After this admission was received with the permissiveness and acceptance that are the hallmarks of non-directive therapy, the child also admitted that he did not use public restrooms because of this fear of hidden cameras. He spent the next few sessions searching the playroom for cameras and, upon not finding any, began to have less and less problems with enuresis/encopresis.
Enuresis (bedwetting) and encopresis (bed-defecation) may come from one or more of the following causes: medical-genetic disorders, emotional disturbances, and failure to learn. Depending on the main cause, different treatments are used. Physicians are usually called to deal with the organic problems underlying medical-genetic disorders, while behavioral techniques are used to treat problems stemming from a failure to learn. However, problems rooted in emotional disturbances are commonly lumped into the "failure to learn" category and treated thusly. This article argues for an alternative treatment (i.e. non-directive play therapy) to be used in response enuresis and encopresis rooted in emotional disturbances.
A case example is provided in which an 8-year old male with enuresis and encopresis is treated with play therapy after medical-genetic disorders and failure-to-learn are ruled out. In these sessions, the child began to exhibit aggressive behavior and admitted to wanting to destroy the playroom's pictures and wall clock, which he believed to have cameras hidden behind them. After this admission was received with the permissiveness and acceptance that are the hallmarks of non-directive therapy, the child also admitted that he did not use public restrooms because of this fear of hidden cameras. He spent the next few sessions searching the playroom for cameras and, upon not finding any, began to have less and less problems with enuresis/encopresis.
Wednesday, March 5, 2008
Jungian Play Therapy in Elementary Schools
Allan, J., & Brown, K. (1993). Jungian Play Therapy in Elementary Schools. Elementary School Guidance and Counseling. 28 (1), 30-41.
This article discusses the Jungian approach to play therapy and provides a case study to exemplify its methods. As a (or perhaps the) proto-humanistic psychologist, Jung believed that growth and transformation are the main drives in the psyche. Thus, counseling involves mainly providing a safe and protective setting in which these internal processes can propel a child into change. This so-called self-healing archetype requires a healthy connection between the child's conscious and unconscious worlds. Therapy is thus also aimed at creating such a connection.
Jungian play therapy identifies three major themes or stages through which a child's play evolves: chaos, struggle, and resolution. It is through the progression of this resolution that the ego develops a sense of control and mastery as it learns to mediate the "struggle of opposites." Towards the end of therapy, common themes become construction, reparation, and healing.
Jungian play therapy is directive in its counseling style and makes use of interpretation interventions to "deepen affective expression." This is received much more positively by the child if it is initiated after a strong therapeutic relationship of rapport is established. This point and others are illustrated in the case study of a third grader with aggressive behavior problems. His sand play had a recurrent theme of "good guys" struggling against "bad guys." When, later in therapy, this theme was interpreted as analogous to his own feelings of isolation and confliction, he accepted it and showed remarkable change in the next session. In the next sand world he made, there was a fenced off area where kids could go and nothing could happen to them. It is argued that this opportunity to release his feelings allowed the child's positive, integrating mechanisms to guide him to growth, and that the direct interpretations expedited this process.
This article discusses the Jungian approach to play therapy and provides a case study to exemplify its methods. As a (or perhaps the) proto-humanistic psychologist, Jung believed that growth and transformation are the main drives in the psyche. Thus, counseling involves mainly providing a safe and protective setting in which these internal processes can propel a child into change. This so-called self-healing archetype requires a healthy connection between the child's conscious and unconscious worlds. Therapy is thus also aimed at creating such a connection.
Jungian play therapy identifies three major themes or stages through which a child's play evolves: chaos, struggle, and resolution. It is through the progression of this resolution that the ego develops a sense of control and mastery as it learns to mediate the "struggle of opposites." Towards the end of therapy, common themes become construction, reparation, and healing.
Jungian play therapy is directive in its counseling style and makes use of interpretation interventions to "deepen affective expression." This is received much more positively by the child if it is initiated after a strong therapeutic relationship of rapport is established. This point and others are illustrated in the case study of a third grader with aggressive behavior problems. His sand play had a recurrent theme of "good guys" struggling against "bad guys." When, later in therapy, this theme was interpreted as analogous to his own feelings of isolation and confliction, he accepted it and showed remarkable change in the next session. In the next sand world he made, there was a fenced off area where kids could go and nothing could happen to them. It is argued that this opportunity to release his feelings allowed the child's positive, integrating mechanisms to guide him to growth, and that the direct interpretations expedited this process.
The Masterson Approach with Play Therapy
Mulherin, M. A. (2001). The Masterson Approach with Play Therapy: A Parallel Process between Mother and Child. AMERICAN JOURNAL OF PSYCHOTHERAPY. 55, 251-272.
This article illustrates the principles of the Masterson Approach with a long-term case study involving a child and his mother in adjunct therapy. The Masterson Approach (with which I am not very familiar) is a psychodynamic developmental self and object relations approach. It involves providing opportunities for diagnostic assessment, developing a working relationship within therapy, assisting in the breakdown of defenses, facilitating verbalization, providing cathartic release, and preparing the child for future life events. As will be seen, the diagnosis has a large effect on which treatment strategies are deemed appropriate.
The initial diagnosis for both the mother and son was distancing borderline disorder. As a result, the technique of confrontation was used as intervention. However, as confrontation led to increased anxiety in both patients, the diagnosis was changed to schizoid disorder of the self and interpretation of the schizoid dilemma became the primary therapeutic technique. This seemed to have drastic effect, as both patients responded positively. The new diagnosis was thus confirmed.
An interesting aspect of this case study was the enmeshment, or parallel progression of the mother and son. Often the son would act out (in his sand trays) the very same conflicts his mother struggled with in her verbal therapy. They both exhibited signs of the splitting defense mechanism, with the son accepting his mother while rejecting his father, and the mother having panic attacks as she fantasized about reuniting with her separated husband.
Two interesting events in the play therapy are also worth noting. First was when the son explicitly acknowledged the symbolic nature of his play by remarking (after destroying one of his sand worlds) that he was glad those "bad feelings [were] gone". And second was when the creation of a loss/death-themed sand world in his fifth year of treatment seemed to usher in a much more integrated child. After this cathartic experience, his regressive defenses completely disappeared.
This article illustrates the principles of the Masterson Approach with a long-term case study involving a child and his mother in adjunct therapy. The Masterson Approach (with which I am not very familiar) is a psychodynamic developmental self and object relations approach. It involves providing opportunities for diagnostic assessment, developing a working relationship within therapy, assisting in the breakdown of defenses, facilitating verbalization, providing cathartic release, and preparing the child for future life events. As will be seen, the diagnosis has a large effect on which treatment strategies are deemed appropriate.
The initial diagnosis for both the mother and son was distancing borderline disorder. As a result, the technique of confrontation was used as intervention. However, as confrontation led to increased anxiety in both patients, the diagnosis was changed to schizoid disorder of the self and interpretation of the schizoid dilemma became the primary therapeutic technique. This seemed to have drastic effect, as both patients responded positively. The new diagnosis was thus confirmed.
An interesting aspect of this case study was the enmeshment, or parallel progression of the mother and son. Often the son would act out (in his sand trays) the very same conflicts his mother struggled with in her verbal therapy. They both exhibited signs of the splitting defense mechanism, with the son accepting his mother while rejecting his father, and the mother having panic attacks as she fantasized about reuniting with her separated husband.
Two interesting events in the play therapy are also worth noting. First was when the son explicitly acknowledged the symbolic nature of his play by remarking (after destroying one of his sand worlds) that he was glad those "bad feelings [were] gone". And second was when the creation of a loss/death-themed sand world in his fifth year of treatment seemed to usher in a much more integrated child. After this cathartic experience, his regressive defenses completely disappeared.
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