Former intern Margarita Lorence sent word about a seminar at Vanderbilt that could be useful to staff and students:

The route to psychosis: what differentiates individuals with psychotic experiences with and without a ‘need-for-care’?

It is increasingly recognized that there is a thread of continuity between health and psychosis. Large-scale surveys have confirmed the high incidence of seemingly benign positive symptoms in the general population, and high ‘schizotypes’ resemble psychotic patients on a number of experimental and epidemiological correlates. However most of the evidence for the psychosis continuum is based on psychometric identification of psychotic-like experiences, which some authors have argued do not capture the true essence of psychosis. This talk will present a range of studies, using different methodologies, of individuals who experience full-blown psychotic experiences but are not in need of care.  The findings broadly support the predictions made by cognitive models of psychosis. Specifically, it will be demonstrated that maladaptive appraisals and response styles are key in differentiating individuals displaying psychotic experiences with and without a ‘need for care’. The implications for the psychological route to psychosis will be discussed.

Thursday, September 19^th, 2013
4:10pm
112 Wilson Hall

For more information, please see the flier at  Continuing Education: Vanderbilt.

Thank you, Margarita!

The National Institute on Drug Abuse  (NIDA) has a lot of resources for students and clinicians wanting to learn more about alcohol and drug abuse. Following our recent intern seminar on assessment of alcohol and drug use, our students requested a resource to help them recognize the names and street names of commonly abused drugs.

NIDA has just such a resource, in their Commonly Abused Drugs Chart and their Prescription Drug Abuse Chart. They also offer a very helpful Health Effects Chart.

Check these resources out. They have both street drugs of abuse and most common prescription drugs of abuse. The charts list street names, ways to use, and whether or not the drug is scheduled.

Nora S. Frank, BA CADC, CSC

In case you need a little something to tip your mood scale towards the side of happiness today, read on! The Facial Feedback Hypothesis suggests that you may have the ability to give yourself a little boost in mood–and it would only take a moment out of your busy day.  Robert Zajonc, Ph.D., former professor, Director of the Institute for Social Research, and Director for the Research Center of Group Dynamics at University of Michigan and Professor Emeritus of Psychology at Stanford University, believed that people could manipulate mood through a change in facial expression. Simply put: when we smile we become happier and when we frown we become sadder.

Dr. Zajonc explained that smiling causes facial muscles to stretch and tighten leading to a decrease in blood flow to the internal carotid artery, which is the route taken by much of the blood traveling to the brain.  The idea is that as blood flow decreases, so does brain temperature, which is believed to bring about more positive mood.  In contrast, as the muscles involved in frowning are tightened, the blood flow to the brain increases, increasing the temperature and, therefore, spurring a more negative mood.

Zajonc, R. B., Murphy, S. T. & Inglehart, M. (1989). Feeling and facial efference: Implications for the vascular theory of emotion Psychological Review, 96(3), 395-416.

Cassandra A. Sturycz, B.A.
Psychology Practicum Student

David J. Wright, MA., MSW
WKPIC Doctoral Intern

Schizophrenia causes pain, enormous suffering, and significant physical and emotional distress to the individual, but also to the primary caretakers. Recent headline news has focused on emotional stories that involved mental illness and psychosis. These stories are tangible, and the consequences of untreated mental illness continue to hurt members of our society. Increased understanding of this devastating disorder is essential to stopping this pain and damage.

In their article, the authors examine specific risk factors (i.e., familial liability and perinatal problems) that are often overlooked during young childhood and adolescent stages of development.  Family, twin, and adoption studies strongly suggest that genetic transmission accounts for most of the familial aggregation in schizophrenia. The risk of contracting the  disorder is about 10 times higher if a first-degree relative is ill, and decreases from close to more distant relatives. The authors review numerous studies about risk factors, which indicate that many people who develop schizophrenia are exposed to a variety of stressful perinatal events such as extreme maternal stress, maternal antenatal depression, prenatal exposure to influenza, living in an urban area, obstetrical complications, poor maternal nutrition, and famine, just to name a few.

The authors further present two models for the onset of psychosis; The Vulnerability Model and The Hybrid Model. The Vulnerability model addresses the diathesis-stress model, which explains individual behavior as a predisposition or vulnerability together with stress from life experiences. It can take the form of genetic, psychological, biological, or situational, environmental factors.  The Hybrid/interactive model is more or less an equilibrium model in which vulnerable individuals have possibilities to move in any direction between an asymptomatic and symptomatic state.

Salokangas & McGlashan (2008) take a proactive position about combating the acceleration of prodromal symptoms, which is potentially important for early intervention and comprehending the psychotic process. In clinical practice, a prodrome is an early symptom or set of symptoms that might indicate the start of psychotic-like experiences. The symptom profile of prodromes is extremely variable. The most frequent features include disturbances of attention or inability to concentrate, apathy or loss of drive, depression, sleep disturbances, anxiety, social withdrawal, suspiciousness, deterioration in school, work or other functioning, and anger coupled with irritability. Clearly, these are non-specific to schizophrenia and are very often seen, for example, in the early phases of depression. The prodrome to schizophrenia usually begins with additional nonspecific, neurotic-like symptoms, followed by more specific pre-psychotic symptoms, eventually leading to frank psychosis. The awareness of, early detection of, and aggressive treatment of these symptoms may prevent patients and families and entire communities from descending into the pandemonium of a completed psychotic process.

However, the key question remains: What interventions are available to patients at risk of psychosis? The authors address neuroleptic treatment, cognitive psychotherapy, and integrated treatment to define standards of care and contribute to best practices.

This article was useful to me at an internship level, in better understanding the risk factors associated with the evolution of schizophrenia, and the importance of early intervention into an evolving psychotic process.

References

Salokangas, R.K.R., & McGlashan ,T.H. (2008). Early detection and intervention of
psychosis. A review. Nord J Psychiatry 2008;62:92. Oslo. ISSN 0803-9488.

The Prodromal Phase of First-episode Psychosis: Past and Current Conceptualizations.  Retrieved from http://www.mentalhealth.com/mag1/scz/sb-prod.html.

So, like the internship classes of 1980-1982 (DSM-III) and 1994-1996 (DSM-IV), you’re the “tweeners.” You’re one of those unfortunate few students finishing school and hitting the licensing exam just as we’re switching to a new diagnostic manual. This time around, the madness is heightened by the fact that many, many settings have yet to determine if they will embrace DSM-V, or shift operations to ICD-10/11. Most will be taking full advantage of the two-year grace period before changing systems. Because of this, you face the very real possibility that you’ll train under one system, but have to tackle taking an Examination for the Professional Practice in Psychology (EPPP)  that focuses on a radically different diagnostic framework.

Stop screaming.

It’s do-able.

And here’s how, in two or three easy steps. Okay, maybe not easy, but not impossible, either!

First, remember how smart you are. You didn’t go to graduate school and finish all that work because you have difficulty learning new information. Remember those first few classes? You knew *nothing*, and now look how far you’ve come. Studying for the licensing exam, no matter which diagnostic system you use, is no different than all those exams and papers you’ve already conquered. Scarier, sure. But really, no different. You’ve got this.

Second, for those of you on internship right now, or who already have your Master’s Degree, you can take the examination before you finish internship, or just as you do. If you get in before the July 31, 2014 change date, you’ll miss all of the insanity and answer questions based on the DSM-IV-TR only. Problem solved. If you can pull this off before March, 2014, you’ll also save money, as the cost of the EPPP is going up, too. WKPIC has encouraged our current interns to consider this option, and we’re willing to assist with study time and quizzing as needed. Also, Dr. Kuszak just took the test on October 1, so she knows–she really, really knows–the angst involved and the preparation needed. She feels your pain! (She did great, by the way, YAY DR. K!!).

Finally, if taking the exam before the change date is not an option for you, we suggest that you quickly secure a copy of the DSM-V, or if you’re a WKPIC intern, use the student copy available in the state hospital intern office. Every time you render a diagnosis in DSM-IV-TR or ICD-10/11, take the extra 5-10 minutes to look up and write down the terminology used by the DSM-V as well. Discuss points of confusion with your supervisors. Trust us, we’ll be learning, too. These extra minutes could pay huge dividends for you, come examination time. Consider attending a continuing education seminar related to DSM-V, or viewing one by webinar as well. Your sites may have materials like this already available (we do, on our state hospital intranet), so be sure to ask about this possibility.

Alicia Taylor, Psy.D., WKPIC Internship Director
Susan Vaught, Ph.D., WKPIC Training Director

Keep calm and carry on. . .

Relaxation skills are important for all clinicians and clients. A great resource for guided relaxation exercises is Meditation Oasis. Mary and Richard Maddux have created a great online resource at the Meditation Oasis. On the site, you can find can find dozens of audio files, as well as “how to” guides for different types of relaxation and meditation. This resource is free and the audio files are available on the website and as an iTunes podcast.

Danielle M. McNeill, M.S., M.A.
WKPIC Doctoral Intern

Vanderbilt University’s Kennedy Center is in the process of adapting and augmenting an amazing Canadian toolkit to help practitioners better serve people who have intellectual or developmental disabilities. VUKC’s new toolkit website won’t officially be live and launched until February, 2014, but it is already packed full of extremely useful and well organized information. Interns and residents may find this site to be a life-saver as they learn to navigate care provision for this underserved group.

Susan R. Vaught, Ph.D.
WKPIC Training Director

As treating clinicians, we are interested in what makes a great initial interview with a client. We want the client to feel comfortable with us enough for her to share her most difficult memories and reveal aspects about herself that she is most ashamed of. We want the client to be honest and, as much as possible, not feel uncomfortable when she is honest.

If the client is a potential therapy client, we want her to feel confident enough in us to return for the next session. We need the client to feel that treatment is worthwhile and will ultimately help her. Thus, Carlat (2005) explains in his book, The Psychiatric Interview, the larger goal in mind during the diagnostic interview is treatment. If you do not keep this goal in mind during the first interview, your client may never return for the second visit and “your finely wrought DSM-IV-TR diagnosis will end up languishing in a chart in a file room.”

Studies have shown that up to 50% of clients drop out before the fourth session of treatment and many never return after their first appointment. There are many reasons for treatment dropout. Some clients do not return because they have formed poor alliances with their clinicians, some because they weren’t really interested in treatment in the first place, and others because the initial interview alone helped them enough to get them through their stressors. Thus, much more than diagnosis should occur during the first interview.

Alliance building, morale boosting, and treatment negotiating are all extremely important. You should establish a therapeutic alliance as you learn about your client. The very act of questioning is an alliance builder; people tend to like people who are warmly curious about them. As you ask questions, you formulate possible diagnoses, and thinking through the diagnoses leads naturally to the process of negotiating a treatment plan. These aspects are all important in the initial interview and can help to make the client feel more comfortable and return for further treatment.

Reference: Carlat, D.J. (2005). The psychiatric interview: A practical guide. 2^nd ed. Philadelphia, PA: Lippincott Williams & Wilkins.

Cindy A. Geil, M.A.
WKPIC Doctoral Intern

Have a look at the Telepsychology Update by C. Munro Cullum over on the SCN Neuroblog. Interesting stuff!

Susan R. Vaught, Ph.D.
WKPIC Training Director

It only makes sense that complex trauma generates complex reactions. Courtois (2008) explains these complex reactions are often in addition to those currently included in the DSM-IV diagnosis of posttraumatic stress disorder (PTSD). Complex trauma includes the type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts. Examples of complex trauma include intimate/domestic abuse that occurs over extended periods of time in which the victim feels entrapped and child abuse in which the victim is psychologically and physically immature and her development is often seriously compromised by repetitive abuse and inadequate response from the family members or others on whom she relies for safety and protection.

Various researchers conducted factor analyses of the findings of available studies of child abuse trauma and determined that the effects of such trauma, although posttraumatic in nature, were significantly different from PTSD defined in the DSM-III. Individuals who were exposed to trauma suffered from many psychological problems not included in the diagnosis of PTSD including depression, anxiety, self-hatred, dissociation, substance abuse, self-destructive and risk-taking behaviors, revictimization, problems with interpersonal and intimate relationships (including parenting), medical and somatic concerns, and despair. These problems were categorized as comorbid conditions instead of being recognized as essential elements of complicated posttraumatic adaptations. Clinicians found that these complex conditions were extremely difficult to treat and varied according to the age and stage at which the trauma occurred, the relationship to the perpetrator of the trauma, the complexity of the trauma itself and the victim’s role and role grooming (if any), the duration and objective seriousness of the trauma, and the support received at the time, at the point of disclosure and discovery, and later. Researchers that were involved in this work proposed an alternative conceptualization, complex PTSD (CPTSD) or “disorders of extreme stress not otherwise specified (DESNOS).

Although the diagnosis of CPTSD was not incorporated into the DSM-IV or DSM-V, it was included as an associated feature of PTSD. The diagnostic conceptualization of CPTSD/DESNOS consists of seven different problem areas shown by research to be associated with early interpersonal trauma: alterations in the regulation of affective impulses, alterations in attention and consciousness, alterations in self-perception, alterations in perception of the perpetrator, alterations in relationships to others, somatization and/or medical problems, and alterations in systems of meanings. Various clinicians have observed over the years that adult survivors of childhood abuse present with complex symptom pictures, including engaging in many high-risk situations (self-harm, suicidality, risk-taking, addictions, revictimizations) as well as evidencing impairments in their ability to regulate their emotions, to avoid revictimization, and to stay connected in a therapeutic relationship. These characteristics are most similar to the symptom picture: emotional lability, relational instability, impulsivity, and unstable self-structure associated with borderline personality disorder (BPD), a diagnosis that has come to be understood as a posttraumatic reaction to severe childhood abuse and attachment trauma.  Understanding borderline personality disorder as a posttraumatic adaptation can assist the clinician in being more empathic to these individuals.

The assessment of standard forms of PTSD using instruments developed for the DSM-IV criteria may unfortunately not cover the complexity of the CPTSD/DESNOS individual, in terms of issues such as developmental aspects of the trauma history, functional and self-regulatory impairment, personal resources, and resilience, and patterns of revictimization. The recommended approach to the assessment of trauma is to include it within the standard psychological assessment that is conducted at the beginning of treatment. During the initial intake, the clinician should include questions that are related to possible trauma that the individual currently has or has experienced in his or her past and about posttraumatic and/or dissociative symptomatology. It is recommended that the therapist supplement standard measures such as the Minnesota Multiphasic Personality Inventory (MMPI) and Millon Multiaxial Clinical Inventory (MCMI) with newly developed screening instruments, symptom inventories, and clinical interviews that are designed to address posttraumatic and dissociative symptomatology that these standard measures do not adequately address. The following are instruments that are recommended at this time: Clinician-Administered PTSD Scale (CAPS), Detailed Assessment of Posttraumatic States (DAPS), Posttraumatic Stress Diagnostic Scale (PDS), Trauma Symptom Inventory (TSI), and the Structured Interview for Disorders of Extreme Stress (SIDES). There are also various instruments designed to measure dissociative symptoms such as Dissociative Experiences Scale (DES), the Multiscale Dissociation Inventory (MDI), and the Somatoform Dissociation Scale (SDQ-20). Comprehensive assessment that includes some of the instruments mentioned gives the clinician some understanding of the patient’s symptom picture, defensive and self-structure, capacity for emotional self-regulation, functional competence, and relational ability. It is also important for the clinician to assess the patient’s strengths and resources, as well, so as not to fall into the trap of perceiving the patient as a helpless victim. Whenever possible, the clinician wants to call upon and reinforce the patient’s capacities in order to empower the patient and encourage growth and an identity based upon functionality rather than debilitation.

Treatment of complex trauma has been found to be very difficult. Exposing these individuals too directly or too early to their trauma history in the absence of their ability to maintain safety in their lives can lead to retraumatization. It is important for the therapist to provide a source of secure attachment for the traumatized patient as a base upon which the therapeutic work is conducted. The current standard of care for the treatment of PTSD includes psychotherapy, supplemented by psychopharmacology (where appropriate and used to relieve PTSD symptoms as well as associated symptoms of anxiety, depression, obsessive-compulsive disorder, and psychosis). The treatment model for CPTSD has as its foundation the development of skills for self-management and safety applying cognitive and cognitive-behavioral therapy (CBT) techniques, including exposure therapy, over the course of treatment. CPTSD, like PTSD, has biopsychosocial and spiritual components that require various linked biopsychosocial treatment approaches. CPTSD patients also suffer from developmental/attachment deficits and issues, which requires treatment strategies that are focused on improving these deficits in order to advance the rest of the treatment. The treatment approach that is most recommended for CPTSD is that of a meta-model that encourages careful sequencing of  therapeutic activities and tasks, with specific initial attention to the patient’s safety and ability to regulate his or her emotional state.

The first stage of treatment is focused on the development of the treatment alliance, affect regulation, education, safety, stabilization, self-care, support and skill-building. The middle stage, occurring once the patient has enough life stability and has learned adequate affect modulation and coping skills, is directed toward the processing of traumatic material in enough detail and to a degree of completion and resolution to allow the individual to function with less posttraumatic impairment. This includes deconditioning, mourning, resolution, and integration of the trauma. The third stage focuses on life consolidation and restructuring toward a life that is less affected by the original trauma and its consequences. The third stage also involves self and relational development and enhanced daily living. Courtois (2008) discusses posttraumatic growth, which involves enough consolidation of the biopsychosocial deficits and dysregulations to allow new learning, especially that involving affect identification, expression, and modulation and skill development that leads to higher levels of functioning in different life spheres. Different life spheres that are important include development of trustworthy relationships and intimacy, sexual functioning, parenting, career other life decisions, and ongoing decisions/discussions with abusive others, and so forth. When termination occurs with the CPTSD patient, it is best for it to be as collaborative as possible and be clearly defined. The option should always be left for the patient to return when needed.

Courtois, C.A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 86-100.

Cindy A. Geil, M.A.
WKPIC Doctoral Intern