Article Review: Bullying, Depression, and Suicide Risk in a Pediatric Primary Care Sample (Kodish, Herres, Shearer, et al, 2016)

Kodish, Herres, and Shearer, et al’s Bullying, Depression, and Suicide Risk in a Pediatric Primary Care Sample seeks to explore what, if any, causal relationship there may be between bullying and the prevalence of suicide among youth aged 14 to 24 years.  Uniquely, their study seeks to identify not only the relationship between bullying and suicide among youth, but also to distinguish between the different types of bullying and their associated effects on suicidal ideation, as well as to explore what role depression may have as a moderating factor between bullying and suicide risk.  Kodish, et al, derived their cohort for study from ten primary care practices located in rural and semi-urban Northeastern Pennsylvania,and used the Behavioral Health Screen (BHS) to arrive at a sample of 5,429 participants.

 

By using the DSM in conjunction with the BHS, the surveyors were able to assess risk for bullying by type (verbal, physical, and/or cyber) as well as the presence of depressive symptoms (using five factors gauged over a two week period), and also included a four item mean from the lifetime suicide scale that included questions to determine if the participant had felt life to be not worth living; had considered suicide; planned to commit suicide; or had attempted suicide.  Controlling for depression and demographics, the collected data was then analyzed to determine what relationship, if any, existed between the types of bullying and suicidal risk levels, as well as testing the interactions between each bullying type and incidences of depression (Kodish, et al, 2016).  It was determined that there is a statistically significant relationship between risk of suicide and all three types of bullying, with a cumulative bullying experience also associated with a heightened risk of suicide.  It should also be noted that significance was recognized between all four bullying factors (verbal, physical, cyber, cumulative) and incidences of depression, with a stronger link between bullying occurrences and suicide severity among patients with depressive symptoms.  While the effects of physical, cyber, and cumulative bullying experiences were found not to be statistically significant with regard to suicide attempts, patients who experienced verbal bullying were shown to be 1.5 times more likely to report a suicide attempt (Kodish, et al, 2016).

 

Overall, it was discovered that all three forms of bullying were linked to suicide risk severity, with the effect being acutely heightened when symptoms of depression were present.  Of the three forms of bullying assessed, it was discovered that verbal bullying had, by far, the most impact, which may be due to it being the most common type reported (25% of the sample cohort reported verbal abuse in bullying situations).  This may be due to the fact that it is usually delivered publicly and in person.  By contrast, physical bullying, which may be painful and socially humiliating, may have a lesser psychological impact than other forms of bullying.  This could be due to any number of factors (“David v Goliath”-type situation, physical confrontation being motivated by racism, etc).  In regards to cyber bullying, the fact that it is usually done anonymously as well as the fact that the Internet is impersonal in nature may have a curtailing effect on the impact of this particular type of bullying.  Depression has been shown in this particular study to definitely be a moderator between bullying and suicide risk, but further study is warranted to determine the overall extent to which this relationship exists, as well as determining the extent of moderation for each type of bullying.

 

Looking at the relationship between bullying, suicidal ideation and the relevance of associated depression provides insight into developing appropriate and effective treatment protocols for those who are most at-risk.  By establishing a solid connection between bullying, suicidal ideation, and depression, the authors have furthered insight into a serious issue facing our youth, and it should be noted that not only does this research benefit those who are bullied, but also those who do the bullying; youth who bully others have been found to be at significantly increased risk for suicide and depression as well.

 

Delving further into these issues will help to improve not only the understanding necessary for addressing the victims of bullying but also to understand what it is that causes a bully to victimize others, thus allowing earlier interventions for prevention of escalation, and ultimately the reversal of those trends that lead to bullying, depression, and suicidal ideation.  The authors note that assessing for these issues during primary care visits is warranted.  Going forward, improving the assessment for these issues through clinical interviews should be a priority for those not only in healthcare occupations, but also those who are likely to have the most social non-parental contact with children (teachers, clergy, etc).

 

Kodish, T., Herres, J., Shearer, A., Atte, T., Fein, J., & Diamond, G. (2016). Bullying, Depression, and Suicide Risk in a Pediatric Primary Care Sample. Crisis, 37(3), 241-246. doi:10.1027/0227-5910/a000378

 

 

Teresa King
PMHC Doctoral Intern

 

Friday Factoids Catch-Up: Memory, the Real McCoy?

Memories develop starting at birth and continue to develop throughout the life cycle as we age. The brain remembers by association, strengthening neural connections through repetition (“use it or lose it principle”) (Willingham, 2007).  Research has shown that, although memory is often considered to be a singular ability in and of its self, it is actually a process of at least three inter-related functions: encoding, storage, and retrieval.  The first step to creating a memory is encoding, a crucial step involving the conversion of the perceived item of interest into a construct that can be stored, and then later recalled through retrieval processes, from either short- or long-term memory at some point in the future.  The process of storage occurs between encoding and retrieval, when the memory exists only as a possibility for remembrance. (Arbuthnott, et al., 2001)  Memories are, in a sense, us; they chart our life details.  There are several types of memory processes that deal with differing aspects of how memories are formed.  Short- and long-term memory are the two most common forms people tend to recognize, but there are others, such as associative, elaborative, and autobiographical, that come into play.

 

The study of memory in early childhood is centered around development as it relates to the cognitive self, and a particularly important aspect of early memory centers on childhood amnesia, specifically the fading ability to recall events that occur during early childhood.  Although children may remember events prior to ages 3-4, those memories also tend to fade with time as we age. (Goleman, 1993; Willingham, 2007)  Most adults remember very little prior to age 3 or 4, since this is the age at which our cognitive memory first begins to truly function.  Prior to that age, the cognitive and language skills that are necessary for the processing of external events are not yet developed fully enough to allow this processing to occur, which is essential to the storing of events as memories. (Kihlstrom, 1994)   As aging occurs and cognitive and language skills improve, new knowledge is also being acquired, as well as the establishment of a sense of self.  During the aging process in children, major developments occur in the expansion of memory, perhaps with less processing being required to enable long-term storage.  According to a study published by the New York Times, memories that are autobiographical in nature begin when children learn about themselves and their early years through their parents. (Goleman, 1993)  Over time, as we navigate through the aging process, some memories fade, some are lost, and others are distorted as a natural result of the progression of time and aging.

 

Traditionally, faulty memory has often been associated with either the elderly or those who have suffered a traumatic brain injury, but the ongoing research that has occurred over the last couple of decades tells a different story.  There are certainly instances where people’s memories are obviously faulty, and often this is due to such factors as dementia, Alzheimer’s, concussion, or some other such factor exerting an influence on the brain’s ability to manifest an effective and accurate recall of prior events.  However, the distortion of memories, from the changing of details to the outright planting of false memories, has become an area of real interest and research due to the fact that the accuracy of memories can have much greater implications than just those that directly affect the individual in their quest for resolution of a particular psychological issue.  The likelihood of false memories, in conjunction with the fact that there is still much about the mind that we do not yet understand, make it a dangerous prospect for the therapist to suggest too much.  The evidence exists that people can be led to believe that they have experienced events in their lives that are patently untrue, or at the least, highly unlikely to ever have occurred. (Loftus, 2004)  One particular study showed that even a brief exposure to a false memory of a childhood event serves to boost their confidence that the event actually occurred. (Sharman, Powell, 2012; Garry, et al., 1996; Sharman, et al., 2005)  This was attributed to a phenomenon called imagination inflation.  The study participants were asked to rate their confidence levels on a range of childhood events that occurred prior to 10 years of age.  They were then asked two weeks later to imagine events that they indicated did not occur, and rate their confidence of the event occurrences a second time.  The confidence ratings of the events that did not happen were rated higher in confidence of their occurrence the second time around than the events that actually occurred, which were used as control events.

 

There are several techniques that have been used to attempt to determine the validity of false memories through “planting” of events that were false and never actually occurred, including hypnosis, guided imagery/imagination, dream interpretation, and picture cuing, and all proved successful at inducing false memories in research study participants in statistically significant numbers.  One of the earliest studies that specifically attempted to plant false memories for an entire event used a technique that came to be called the “lost in the mall” technique, which utilized stories about events that happened to participants as related by their parents, and included one wholly false story that was verified as having never occurred, usually lost in a mall, or, alternatively, spilling punch on a bride’s parents at a wedding or having a serious accident.  Based on the results of a series of interviews that utilized memory recovery techniques, 20%-25% of the study participants confirmed a memory of these false events even though they never actually occurred. It was also determined that these false memories exhibited high levels of detail and emotional responses in those that developed them. (Laney, Loftus, 2013)

 

Scoboria et al. (2004) posited a model for autobiographical beliefs and memories that, based on their research, indicated the memories, thoughts, and beliefs concerning plausibility of an event are of a “nested” format.  For a person to remember an event, they necessarily have to believe that it occurred, meaning that the memory itself is nested within confidence.  It also needs to be personally plausible, so confidence is nested within personal plausibility.  The event has to be plausible generally, so personal plausibility is nested within general plausibility. While the research shows that false beliefs and memories will increase due to repeated exposures, brief exposure to false events does not increase confidence or implant false memories. (Sharman, Powell, 2012)

 

The research on false memory has firmly established that people can be led to believe that they have experienced events that have never actually occurred.  Not only can these false memories be wrapped in exquisite detail and sensory associations of recollection, conveying all the characteristics of being the genuine article, but they can be extremely far-fetched in their subject matter such that they are extremely unlikely to be true, yet people will still insist on having experienced them.  The consequences of false memories can have far-reaching, and often unintended, consequences.  There are documented cases of people having spent decades of their lives in prison based on testimony that relied on what turned out to be an instance of false memory, and were only exonerated because of DNA evidence.  While this is an extreme example of the consequences of reliance on memory to be infallible, it clearly illustrates that memory is fluid, malleable, and completely vulnerable to improper influence and subsequent dubious recall.  As a Clinical Psychology student, I previously held to the belief that a memory which is uncovered during therapy is more than likely to be true.  After all, why would a profession devoted to helping people end up doing harm by implanting false memories?  In my opinion, it is not intentional harm on the part of the therapist but, rather, a misuse of techniques which can, and sometimes does, lead to disastrous consequences.  Knowing that memories can become twisted and confused should be reason enough to become skeptical of any method of regression treatment or therapy.

 

References
Arbuthnott, K. D., Arbuthnott, D. W., Rossiter, L. (2001). “Guided imagery and memory: implications for Psychotherapists”. Journal of Counseling Psychology Vol. 48, No. 2, 123-132. Retrieved from Ebscohost, November 17, 2016.

 

Durbin, P. G., Ph.D. Beware false memories in regression hypnotherapy. Retrieved November 16, 2016, from http://alchemyinstitute.com/false-memory.html

 

Goleman, D. (1993, April 6). Studying the secrets of childhood memory. The New York Times. Retrieved from http://www.nytimes.com

 

Kihlstrom, J. E. (1994). “Hypnosis, delayed recall and the principles of memory”. The International Journal of Clinical & Experimental Hypnosis. 1994, Vol. XLII, No. 4, 337-344. Retrieved from Ebscohost, November 15, 2016.

 

Laney, C., Loftus, E. F. (2013). “Recent advances in false memory research”. South African Journal of Psychology 43(2) 137-146. Retrieved from Ebscohost, November 17, 2016.

 

Loftus, Elizabeth F. (2004). ”Memories of things unseen”. Current Directions in Psychological Science. 2004. Vol. 13, No. 4, 145-147. Retrieved from Ebscohost, November 15, 2016.

 

Sharman, S. J., Powell, M. B. (2012). “Do cognitive interview instructions contribute to false beliefs and       memories?”. Journal of Investigative Psychology and Offender Profiling. 10: 114-124 (2013).

 

Willingham, D. T. (2007). Cognition: The thinking animal (3rd ed.). Upper Saddle River, New Jersey: Pearson.

 

Teresa King
Pennyroyal Doctoral Intern

 

Friday Factoids Catch-Up: Heroin and Fentanyl–A Match Made in Hell

 

Heroin use has always been a serious issue where drug abuse is concerned, but in the last few years it has become even more deadly due to fentanyl being added to give it more “kick”.  Dealers have begun including fentanyl to improve the potency of their product; however, the equipment they use to measure out amounts for trafficking don’t usually measure at levels fine enough to ensure that the amount of fentanyl that has been added stays below overdose levels.  To add to the danger, fentanyl sold at the street level is usually manufactured in “underground” labs which produce a far less pure product than pharmaceutical-grade labs, which can cause unpredictable effects on the body (Bond, 2016).

 

Heroin is classified by the DEA (Drug Enforcement Agency) as a Schedule I drug, while fentanyl is classified as a Schedule II drug.  Both are opioid derivatives; however, while heroin is synthesized directly from morphine, fentanyl is a synthetic opioid analgesic, with a potency of 50x to 100x that of morphine (NIDA, 1969, 2011, 2014).  While both have a high potential for abuse, there is a wide gulf between the two drugs with regard to the amount required to induce an overdose.  An average sized adult male would take around 30g of heroin to produce an overdose situation, roughly an amount similar to 7 packets of sugar.  By contrast, it would only take around 3g of fentanyl (little more than a ½ packet) to produce an overdose (Bond, 2016).

 

Fentanyl-laced heroin quickly reached crisis levels as it began to gain popularity among users.  In March of 2015, the (DEA) issued a nationwide alert in response to a surge in overdose deaths from heroin laced with fentanyl (19 March 2015).  While heroin has been recognized as having a high potential for abuse since the mid-1900s, fentanyl wasn’t added as a Schedule II substance until 2015, after recognizing that a variant, acetyl fentanyl, was being manufactured by Mexican cartels and smuggled stateside for distribution (10 September 2015).  The problem has surged so much that “the National Forensic Laboratory Information System, which collects data from state and local police labs, reported 3,344 fentanyl submissions in 2014, up from 942 in 2013” (Leger, 2015).

 

Due to the resurgence in popularity of heroin among IV drug users in recent years, it would seem that fentanyl-laced heroin and the associated use risks and health issues with regard to overdosing are going to be an issue for some time to come.

 

References
Bond, A. (2016, September 29). Why fentanyl is deadlier than heroin, in a single photo. Retrieved November 10, 2016, from https://www.statnews.com/2016/09/29/fentanyl-heroin-photo-fatal-doses/

 

DEA Issues Alert on Fentanyl-Laced Heroin as Overdose Deaths Surge Nationwide – Partnership for Drug-Free Kids. (2015, March 19). Retrieved November 10, 2016, from http://www.drugfree.org/news-service/dea-issues-alert-fentanyl-laced-heroin-overdose-deaths-surge-nationwide/

 

Fentanyl-Laced Heroin Worsening Overdose Crisis, Officials Say – Partnership for Drug-Free Kids. (2015, September 10). Retrieved November 10, 2016, from http://www.drugfree.org/news-service/fentanyl-laced-heroin-worsening-overdose-crisis-officials-say/

 

Leger, D. L. (2015, March 18). DEA: Deaths from fentanyl-laced heroin surging. Retrieved November 10, 2016, from http://www.usatoday.com/story/news/2015/03/18/surge-in-overdose-deaths-from-fentanyl/24957967/

 

NIDA (2011). Fentanyl. Retrieved November 10, 2016, from https://www.drugabuse.gov/drugs-abuse/fentanyl

 

NIDA (1969, rev. October 2014). Heroin. Retrieved November 10, 2016, from https://www.drugabuse.gov/publications/drugfacts/heroin

 

Teresa King
Pennyroyal Doctoral Intern

 

Friday Factoids Catch-Up: New Treatments For Tic Disorders Associated With Tourette’s

 

Tics, which are characterized by sudden, repetitive, non-rhythmic body movements and/or vocalizations associated with tic disorders and Tourette’s syndrome, are involuntary movements that may involve the hands, shoulder shrugging, eye blinking, etc.  In many cases, these tics do not get in the way of living a relatively normal life and consequently little if any treatment is required.  At the other end of the spectrum, the tics may be so severe that they require treatment with medication and behavioral therapy, especially if they are causing pain/injury, are interfering with a normal daily routine in one’s education, job performance, or social life, or are responsible for inducing excessive stress. Prior to the treatment of the presenting tics, the presence of other movement-related disorders like chorea, dystonia, as well as the movements displayed by those with autism (stereotypic movement disorder), or those movements manifested as compulsions of OCD or seizure-related activity, must be ruled out to ensure the patient receives the proper care and treatment that is best suited to address his or her needs.

 

There are various methods for treating the tics that are so often associated with Tourette’s syndrome, including medication, behavioral therapies, and habit reversal.  While medication is most often the go-to panacea for controlling tics, the medications themselves may carry side effects that are as bad, or even worse, than the condition that they may be used to treat.  Behavioral therapies can also be effective as well by teaching those with Tourette’s to manage their tics.  While these can be effective in reducing the number, severity, and impact of the tic behaviors, it is important to realize that behavioral therapy is not a cure, and that although effective it does not mean that tics are merely psychological in their nature.  While these treatment methods are effective in aiding the treatment of, and helping to manage, the tic symptoms of Tourette’s syndrome, it is important to note that they are varied in their efficacy, are not one-size-fits-all in their nature, and in the case of medication, may produce unwanted side effects ranging from mild to debilitating in and of themselves.

 

One of the most promising methods recently developed for the treatment of tics associated with Tourette’s is the Comprehensive Behavioral Intervention for Tics, or CBIT.  This new, evidence-based therapy includes the use of education, teaching relaxation techniques, and habit reversal in a combination that is shown to be effective in reducing symptoms of tics and their related impairments, and seems to work equally well for both children and adults. CBIT involves those with Tourette’s working with a therapist to gain a greater understanding of their particular type of tic and learning to recognize situations that worsen tic symptoms.  When possible, a change in environment may be initiated, and using habit reversal, a new behavior is modeled so that when the urge to tic occurs, the new behavior is substituted.  This method helps to lessen tic occurrences through substituting the new behavior for the tic through repetition, under the guidance of an experienced therapist.

 

Over the last few years, the number of health professionals that have come to know and appreciate the benefits and effectiveness of CBIT has increased; however, there are still relatively few therapists that have the specific training in these methods of treatment targeted specifically at tic disorders and Tourette’s, and work is currently being done by The Tourette Association of America and the Centers for Disease Control and Prevention to provide education for more health professionals with the training necessary to incorporate and apply this method in their treatment approach to managing the symptoms of Tourette’s and other tic disorders.

 

References

  1. Cook CR, Blacher J. Evidence-based psychosocial treatments for tic disorders. Clin Psychol: Science and Practice. 2007;14(3):252–67.
  2. Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S. Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA. 2010;303(19):1929–37.
  3. Harris, Elana, MD, PhD. Children with tic disorders: How to match treatment with symptoms. Current Psychiatry. 2010 March; 9(3):29-36
  4. Qasaymeh MM, Mink JW. New treatments for tic disorders. Current Treat Options Neurol. 2006 Nov;8(6):465-473

 

Teresa King
Pennyroyal Intern

 

Friday Factoids: Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a newer diagnosis in childhood that is depicted by extreme irritability, anger, and frequent outbursts (National Institute of Mental Health [NIMH], 2016).  Irritability is a clinical symptom of both bipolar disorder and DMDD (Wiggins et al., 2016).  Comparatively, irritability in DMDD is “severe and relatively invariant over time,” yet irritability experienced with bipolar disorder may occur while a child is euthymic and may increase during manic or depressive episodes (Wiggins et al., 2016, p. 722). Thus the inclusion of DMDD in part allows for appropriate diagnosis for children with “severe, nonepisodic irritability” that is distinct from bipolar disorder (Wiggins et al., 2016, p. 722).

 

With DMDD being a new diagnosis, treatment is often based on other disorders with shared symptomatology (e.g., attention-deficit/hyperactivity disorder, anxiety disorders, oppositional defiant disorder, and major depression; NIMH, 2016). Cognitive-behavior therapy (CBT), parent training, and computer-based training are recommended psychological interventions (NIMH, 2016) for DMDD, where as medications may also be considered.  For instance, stimulants may help address irritability, antidepressants may mitigate irritability and mood problems, and atypical antipsychotics could be used to alleviate severe outbursts with physical aggression (NIMH, 2016).

 

The potential for adverse effects with some treatments limit their use in children, resulting in the necessity to explore noninvasive means for treatment (Wiggins et al., 2016).  For instance, the use of a video game to reduce the misinterpretation of ambiguous faces in children with irritability has shown to help reduce anger-based reactions found in DMDD.  The literature has shown that children with DMDD and bipolar disorder tend to rate neutral faces as angry (Wiggins et al., 2016). Research conducted by Wiggins et al. (2016) has demonstrated that a computer game helped to change the tendency to misinterpret ambiguous faces as angry in irritable children.  After training, children were more likely to rate ambiguous faces as happy (Wiggins et al., 2016).  Such an intervention may appear superficial, however this research has demonstrated that brain activation patterns when labeling emotional faces differs between DMDD and bipolar disorder (Wiggins et al., 2016).  Specifically, amygdala activation related to irritability differed between children with DMDD and bipolar disorder; and temporo-occipital regions of the brain had “associations between irritability and activation in response to ambiguous angry faces” (Wiggins et al., 2016, p. 728).

 

Thus, differing brain activation patterns helped distinguish the clinical presentation of DMDD versus bipolar disorder (Wiggins et al., 2016).  As a result, the authors conclude that though irritability is a common symptom of both DMDD and bipolar disorder, they are in fact distinct disorders and given the different neural correlates, treatments may also be different (Wiggins et al., 2016).

 

References
National Institute on Drug Abuse (NIDA). (2016). Disruptive Mood Dysregulation Disorder. Retrieved from http://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml

 

Wiggins, J. L., Brotman, M. A., Adleman, N. E., Kin, K., Oakes, A. H. Reynolds, R. C.,…Leibenluft, E. (2016).  Neural correlates of irritability in disruptive mood dysregulation and bipolar disorders.  American Journal of Psychiatry, 173, 722-730.

 

 

Dannie S. Harris, MA
WKPIC Doctoral Intern