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 Clinical Psychology. Show all posts
Showing posts with label Clinical Psychology. 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.
Friday, May 1, 2009
The effect of exercise on depression, anxiety, and other mood states
Byrne, A. & Byrne, D.G. (1993). The effect of exercise on depression, anxiety, and other mood states. Journal of Psychosomatic Research, 37, 565-574.
This review supports the claim that exercise treatments are associated with positive psychological benefits for both clinical and non-clinical populations. Although most of the studies employed aerobic interventions, some studies even showed positive improvements associated with non-aerobic exercise (e.g. weight lifting). However, all of these results need to be interpreted with caution as the result of methodological limitations and indirect evidence. If future studies were to show unequivocally positive psychological gains are caused by exercise interventions, including exercise for people with affective disorders will undoubtedly have a number of advantages since it is time and cost effective by comparison to psychotherapy and pharmacotherapy, comes with few side effects if done correctly, and may even by used to prophylactically prevent the occurrence of future affective episodes.
This review supports the claim that exercise treatments are associated with positive psychological benefits for both clinical and non-clinical populations. Although most of the studies employed aerobic interventions, some studies even showed positive improvements associated with non-aerobic exercise (e.g. weight lifting). However, all of these results need to be interpreted with caution as the result of methodological limitations and indirect evidence. If future studies were to show unequivocally positive psychological gains are caused by exercise interventions, including exercise for people with affective disorders will undoubtedly have a number of advantages since it is time and cost effective by comparison to psychotherapy and pharmacotherapy, comes with few side effects if done correctly, and may even by used to prophylactically prevent the occurrence of future affective episodes.
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.
Wednesday, August 13, 2008
An Illustration of DBT
Linehan, M.M. (1998). An Illustration of Dialectical Behavior Therapy. In Session: Psychotherapy in Practice, 4, 2, 21-44.
In addition to providing illustrative transcripts from dialectical behavior therapy (DBT) sessions, the bulk of the read, this paper also summarizes DBT's theoretical perspective, its various treatment stages and targets, as well as treatment strategies. DBT was developed to treat clients meeting criteria for borderline personality disorder (BPD) whose behavioral patterns are commonly problematic and stressful for clients and therapists alike, not the least of which is suicidality. DBT theorizes that BPD individuals lack interpersonal, self-regulation, and distress-tolerance skills, and what skills they do possess are often undermined by behaviors which block the use of the capabilities the client does have. As such, outcomes are typically unpredictable, even for patients who resist the tempting urge to quit and remain in treatment.
DBT recommends splitting up therapy into different stages, each with unique goals. In Stage I, treatment tries to achieve self-control, with control over one's suicidal behaviors being most important. In Stage II, clients try to experience emotions without resistance and to form and maintain connections to people, places, and activities, even if they are somehow associated with past trauma. Stage III focuses on reducing residual problematic patterns that interfere with clients achieving other important goals. When successful, Stage IV achieves a lasting sense of completeness and the capacity for sustained joy.
DBT's treatment strategies include: (1) dialectical strategies which combine acceptance with change, synthesize opposites, and move the client from "either-or" thinking to "both-and" thinking; (2) core strategies of client validation and problem-solving; (3) communication strategies which balance warm responsiveness to the client's wishes with irreverence; and (4) case management strategies which help the therapist tackle the difficult problems of suicidality with team support and aim to ultimately teach the client how to effectively interact with their world, rather than teaching the environment how to interact with them.
In addition to providing illustrative transcripts from dialectical behavior therapy (DBT) sessions, the bulk of the read, this paper also summarizes DBT's theoretical perspective, its various treatment stages and targets, as well as treatment strategies. DBT was developed to treat clients meeting criteria for borderline personality disorder (BPD) whose behavioral patterns are commonly problematic and stressful for clients and therapists alike, not the least of which is suicidality. DBT theorizes that BPD individuals lack interpersonal, self-regulation, and distress-tolerance skills, and what skills they do possess are often undermined by behaviors which block the use of the capabilities the client does have. As such, outcomes are typically unpredictable, even for patients who resist the tempting urge to quit and remain in treatment.
DBT recommends splitting up therapy into different stages, each with unique goals. In Stage I, treatment tries to achieve self-control, with control over one's suicidal behaviors being most important. In Stage II, clients try to experience emotions without resistance and to form and maintain connections to people, places, and activities, even if they are somehow associated with past trauma. Stage III focuses on reducing residual problematic patterns that interfere with clients achieving other important goals. When successful, Stage IV achieves a lasting sense of completeness and the capacity for sustained joy.
DBT's treatment strategies include: (1) dialectical strategies which combine acceptance with change, synthesize opposites, and move the client from "either-or" thinking to "both-and" thinking; (2) core strategies of client validation and problem-solving; (3) communication strategies which balance warm responsiveness to the client's wishes with irreverence; and (4) case management strategies which help the therapist tackle the difficult problems of suicidality with team support and aim to ultimately teach the client how to effectively interact with their world, rather than teaching the environment how to interact with them.
Tuesday, August 12, 2008
Functional analytic psychotherapy
Kohlenberg, R.J. & Tsai, Mavis. Functional analytic psychotherapy. Journal of Psychotherapy Integration, 4, 175-201.
Functional analytic psychotherapy (FAP) is a radical behaviorist approach to psychotherapy. As such, it views everything we do as behavior and believes these behaviors are the result of contingencies of reinforcement we have experienced in past relationships. The therapy emphasizes the importance of the client-therapist relationship since it creates a functionally similar environment [to the "real world"] which can evoke problematic behavior (deemed CRB1's) that can then be observed and responded to with reinforcement, shaping, and interpretations. Improvements witnessed in-session (deemed CRB2's) can be praised and reinforced immediately, and the clinician's reinforcement can be assessed for effectiveness. Further, its emphasis on contextualism leads therapists to develop a comprehensive understanding of the meaning of a client's behaviors and forces practitioners to remain open-minded about an intervention's potential effectiveness given the context. As such, FAP commonly embraces and enhances concepts and techniques from different therapies, such as psychoanalysis and cognitive therapy. Practitioners of FAP are encouraged to tailor their use of therapeutic techniques depending on: what will evoke the client's problems in the session, whether the client's problems are rule-governed or contingency-shaped, and what will be naturally reinforcing of the client's target behaviors.
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.
Sunday, July 27, 2008
Relapse Prevention for Alcohol and Drug Problems
Witkiewitz, K. & Marlatt, G.A. (2004). Relapse Prevention for Alcohol and Drug Problems. American Psychologist, 59, 4, 224-235.
Relapse prevention (RP) is a cognitive-behavioral approach with the goal of identifying and preventing high-risk situations such as substance abuse, obsessive-compulsive behavior, sexual offending, obesity, and depression. Relapse is seen as both an outcome and as a transgression in the process of behavior change. An initial setback (lapse) may either translate into a return to the previous problematic behavior (relapse) or into the individual turning again towards positive change (prolapse). That individuals commonly experience lapses, and even relapses, is not contested. However, an understanding of this phenomenon continues to evolve.
Relapse is thought to be multi-determined, especially by self-efficacy, outcome expectancies, craving, motivation, coping, emotional states, and interpersonal factors. High self-efficacy, negative outcome expectancies, potent availability of coping skills following treatment, positive affect, and functional social support are expected to predict positive outcome. Craving has not historically been shown to serve as a strong predictor.
The article proposes a new reconceptualization of relapse as a multidimensional, complex system. Such a nonlinear dynamical system is believed to be able to best predict the data witnessed, which commonly includes cases where small changes introduced into the equation seem to have large effects. The model also introduces concepts of self-organization, feedback loops, timing/context effects, and interplay between tonic and phasic processes. The effectiveness and efficacy of RP for various goals is also discussed in the article.
(I, Doug Girard, am the author of this article, Relapse Prevention, and I release its content under the terms of the GNU Free Documentation License, Version 1.2 and later.)
Relapse prevention (RP) is a cognitive-behavioral approach with the goal of identifying and preventing high-risk situations such as substance abuse, obsessive-compulsive behavior, sexual offending, obesity, and depression. Relapse is seen as both an outcome and as a transgression in the process of behavior change. An initial setback (lapse) may either translate into a return to the previous problematic behavior (relapse) or into the individual turning again towards positive change (prolapse). That individuals commonly experience lapses, and even relapses, is not contested. However, an understanding of this phenomenon continues to evolve.
Relapse is thought to be multi-determined, especially by self-efficacy, outcome expectancies, craving, motivation, coping, emotional states, and interpersonal factors. High self-efficacy, negative outcome expectancies, potent availability of coping skills following treatment, positive affect, and functional social support are expected to predict positive outcome. Craving has not historically been shown to serve as a strong predictor.
The article proposes a new reconceptualization of relapse as a multidimensional, complex system. Such a nonlinear dynamical system is believed to be able to best predict the data witnessed, which commonly includes cases where small changes introduced into the equation seem to have large effects. The model also introduces concepts of self-organization, feedback loops, timing/context effects, and interplay between tonic and phasic processes. The effectiveness and efficacy of RP for various goals is also discussed in the article.
(I, Doug Girard, am the author of this article, Relapse Prevention, and I release its content under the terms of the GNU Free Documentation License, Version 1.2 and later.)
Thursday, July 10, 2008
Theory-based research for understanding dynamic psychotherapy
Luborsky, L., Barber, J.P., & Crits-Christoph, P. (1990). Theory-based research for understanding the process of dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 58, 3, 281-287.
This article reviews empirical support for 6 basic theoretical assumptions central to psychodynamic psychotherapy. (1) A therapeutic alliance must develop. The strength of therapeutic alliance (the collaborative and affective bond between therapist and client) is shown to predictive of positive outcomes. (2) Patients display transference. Trends from existing studies show central relationship patterns exist which are largely consistent over time and may be projected onto the therapist. (3) Accurate interpretations of transference by the clinician lead to increased benefits for the client. Findings are inconsistent on this point, specifically on the relation between increased number of transference interpretations and outcomes. Mediators may exist, such as how the patient responds to the interpretation. (4) The patient will benefit more from more accurate interpretations. Accurate interpretations correlate with "better" sessions. Accuracy of interpersonal aspects of interpretation predicted outcomes best. (5) Increased insight about themselves and their relationships with others leads to better outcomes. Gaining an understanding about the therapist and others is associated with outcomes. An understanding of self and parents does not seem to be as well correlated. (6) Improved patients show greater change in their transference patterns. Results are consistent with the theory that transference still exists but is under better control and mastery. Patients' expectations of how others will respond becomes less negative and their mental health improves.
This article reviews empirical support for 6 basic theoretical assumptions central to psychodynamic psychotherapy. (1) A therapeutic alliance must develop. The strength of therapeutic alliance (the collaborative and affective bond between therapist and client) is shown to predictive of positive outcomes. (2) Patients display transference. Trends from existing studies show central relationship patterns exist which are largely consistent over time and may be projected onto the therapist. (3) Accurate interpretations of transference by the clinician lead to increased benefits for the client. Findings are inconsistent on this point, specifically on the relation between increased number of transference interpretations and outcomes. Mediators may exist, such as how the patient responds to the interpretation. (4) The patient will benefit more from more accurate interpretations. Accurate interpretations correlate with "better" sessions. Accuracy of interpersonal aspects of interpretation predicted outcomes best. (5) Increased insight about themselves and their relationships with others leads to better outcomes. Gaining an understanding about the therapist and others is associated with outcomes. An understanding of self and parents does not seem to be as well correlated. (6) Improved patients show greater change in their transference patterns. Results are consistent with the theory that transference still exists but is under better control and mastery. Patients' expectations of how others will respond becomes less negative and their mental health improves.
Prolonged Exposure Treatment for PTSD following 9/11
Kazi, A., Freund, B., & Ironson, G. (2008). Prolonged Exposure Treatment for Posttraumatic Stress Disorder following the 9/11 attack with a person who escaped from the Twin Towers. Clinical Case Studies, 7, 100-116.
This article chronicles the progress of one 9/11 survivor through the cognitive-behavioral therapy intervention of prolonged exposure (PE) therapy to address her PTSD and depressive symptomatology. This treatment consists of (1) imaginal exposure, and (2) in vivo exposure. It is designed to elicit emotional processing until the detrimental traumatic memories and avoidances have habituated (desensitized). After 15 sessions this client improved 75% as measured by a composite index. However, there was residual symptomatology 6 months after therapy ended but measures remained sub-clinical. Progress through treatment can be seen as waxing and waning, but trending towards improvement. Still, in this type of therapy clients must be stressed before they are to feel better. With the prevalence of PTSD at 8% in the US population, clinicians are calling more and more for effective treatment regimes. PE may be a promising candidate.
This article chronicles the progress of one 9/11 survivor through the cognitive-behavioral therapy intervention of prolonged exposure (PE) therapy to address her PTSD and depressive symptomatology. This treatment consists of (1) imaginal exposure, and (2) in vivo exposure. It is designed to elicit emotional processing until the detrimental traumatic memories and avoidances have habituated (desensitized). After 15 sessions this client improved 75% as measured by a composite index. However, there was residual symptomatology 6 months after therapy ended but measures remained sub-clinical. Progress through treatment can be seen as waxing and waning, but trending towards improvement. Still, in this type of therapy clients must be stressed before they are to feel better. With the prevalence of PTSD at 8% in the US population, clinicians are calling more and more for effective treatment regimes. PE may be a promising candidate.
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