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October 10 2016

Friday Factoids: Motivational Interviewing as a Clinical Option for Generalized Anxiety Disorder

Author Susan Vaught Categories Uncategorized 0 Comments

Cognitive-behavior therapy (CBT) has shown to be efficacious for treating anxiety, yet some clients “either fail to respond, respond only partially, or relapse at follow-up” (Westra, Constantino, & Antony, 2016, p. 768).  As reported by Hunot, Churchhill, Teixeria, and Silva de Lima (2007; as cited in Westra et al., 2016), only 46% of clients with Generalized Anxiety Disorder (GAD) demonstrated significant improvement after therapy.  One factor that may contribute to poorer outcomes is ambivalence.  Ambivalence in anxiety is holding positive beliefs about worry and being reluctant to change or let go of the worry (Westra & Arkowitz, 2010; as cited in Westra et al., 2016).  Additionally, therapeutic directness or demands related to change might be met with resistance (Westra et al., 2016).  Thus, additional components that work with ambivalence may boost treatment outcomes by working through resistance, all while remaining anchored in CBT.

 

Motivational Interviewing (MI) is a treatment with a focus on ambivalence (Miller & Rollnick, 2002).  Here the therapist is not the advocate for change, rather therapists assist clients to be their own advocate for change (Westra et al., 2016).   With specific strategies, MI helps reduce resistance and “increases intrinsic motivation” for change (Westra et al., 2016, p. 769).  In their study, Westra, Constantino, and Antony  (2016) investigated the effects of integrating MI and CBT for severe GAD.  In the study, one group received 15 weekly session of CBT alone (CBT-alone) and another group had 4 sessions of MI followed by 11 sessions of CBT integrated with MI (MI-CBT).  Initially, there were no posttreatment differences between groups; yet, at the 6- and 12-month follow-up, several group differences emerged. The MI-CBT group reported a continued improvement on self-reported worry and general distress after treatment ended.  MI-CBT clients also had significantly higher rates of recovery and clinically significant change (five times as likely to not meet diagnostic criteria for GAD).   Westra et al. (2016) indicated that similar sleeper-type effects are often reported with MI use in treating other disorders.

 

So, why did clients continue to improve after treatment?  Westra et al. (2016) indicated that the opportunity to explore ambivalence and becoming more committed to change might help clients not respond to worry, thus reducing relapse rates.  Additionally, the authors suggested that MI techniques fostered the development of personal agency, which may have led to the client’s belief that they are capable of change, resulting in internalization of this belief.  By “rolling with resistance” and viewing the “client-as-expert” helped to “promote internal attributions for progress” (Westra et al., 2016, p. 777).  With this model, the efficacy of CBT treatment for GAD is maintained, yet by integrating MI where clients can openly explore resistance may help clients become more receptive to traditional CBT techniques.

 

 

References
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford Press.

 

Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768-782.

 

Dannie S. Harris, MA
WKPIC Doctoral Intern

September 09 2016

Friday Factoids: Diagnosing Early-Onset Schizophrenia

Author Susan Vaught Categories Uncategorized 0 Comments

 

 

Early-onset Schizophrenia is defined by an onset prior to adulthood, with an onset prior to 12 years of age being rare (Vyas et al., 2011). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) identifies early onset as being associated with a worse prognosis. The DSM-5 further emphasizes that childhood schizophrenia is more difficult to diagnosis, where as compared to adults, “childhood delusions and hallucinations may be less elaborate” (p. 102), and visual hallucinations should be “distinguished from normal fantasy play” (p. 102).  Furthermore, hallucinations are not uncommon in both healthy children and children with a psychiatric illness, yet often with childhood schizophrenia, hallucinations are multimodal (Driver, Gogtay, & Rapoport, 2013). Diagnostic criteria for schizophrenia are “age independent” (Stentebjerg-Olesen, Pagsberg, Fink-Jensen, Correll, & Jeppesen, 2016), which is supported by diagnostic stability throughout the lifespan.

 

Yet there is still ambiguity with differential diagnosis for early-onset schizophrenia.  As noted by Stentebjerg-Olesen, Pagsberg, Fink-Jensen, Correll, and Jeppesen (2016) there is “considerable overlap in phenomenology between schizophrenia and affective symptomatology in children and adolescents with psychosis” (p. 411).  As cited in Stentebjerg-Olesen et al. (2016), Weary (1992) and Masi et al. (2006) the most common diagnostic mistake is a “misclassification of a mood disorder as schizophrenia” (p. 411).  Other diagnostic considerations extend to pervasive developmental disorders, severe personality disorders or traits, posttraumatic stress disorder (PTSD), generalized anxiety disorder, and obsessive-compulsive disorder (Driver et al., 2013).  As such understanding the “developmentally sensitive descriptions of symptomatology, clinical characteristics, and outcome” may offer a clearer diagnostic picture for early-onset schizophrenia (Stentebjerg-Olesen et al., 2016, p. 411).

 

In a systematic review of studies from 1990 to 2014 of early-onset psychosis, Stentebjerg-Olesen et al. (2016) found that hallucinations were mainly auditory (81.9%) and delusions were mostly persecutory and of reference (77.5%). Formal thought disorder was found in 65% of the patients and 36% had disorganized speech or pressured speech.  Negative symptoms were found in about half of the patients, and half of the group with negative symptoms experienced positive symptoms as well.  Comorbidity was high at 32% for substance abuse and 33.5% for ADHD and disruptive behavioral disorders.  Trauma is also thought to play a significant role in early-onset schizophrenia, with Stentebjerg-Olesen et al. (2016) finding a high level of comorbid PTSD (34%).

 

Stentebjerg-Olesen et al. (2016) found that “severity of positive symptoms at baseline, the severity and the persistence of negative symptoms, longer [duration of untreated psychosis], and poorer premorbid adjustment each predicted a worse outcome of illness” (p. 423).  Longer duration of untreated psychosis and poorer premorbid adjustment were also associated with poorer outcomes. In short, patients with early-onset schizophrenia were found to have substantial impairment from positive and negative symptoms, disorganized behavior, and pre- and comorbid conditions and diagnoses.  The authors note that the “high prevalence of negative and disorganized” symptoms “may mask the emergence of psychosis” and delay identification and treatment (p. 424).

 

Dannie S. Harris
WKPIC Doctoral Intern

 

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

Driver, D. I., Gogtay, N., & Rapoport, J. L. (2013). Childhood onset schizophrenia and early onset schizophrenia spectrum disorders.  Child and Adolescent Psychiatric Clinics of North America, 22(4), 539-555.  

Stentebjerg-Olesen, M., Pagsberg, A. K., Fink-Jensen, A., Correll, C. U., & Jeppesen, P. (2016). Clinical characteristics and predictors of outcome of schizophrenia-spectrum psychosis in children and adolescents: A systematic review. Journal of Child and Adolescent Psychopharmacology, 26(5), 410-427.

 

Vyas, N. S., Patel, N. H., & Puri, B. K. (2011). Neurobiology and phenotypic expression in early onset schizophrenia. Early Intervention in Psychiatry, 5, 3-14.

 

 

August 08 2016

Friday Factoids Catch-Up: The Cursed Dissertation Defense

Author Susan Vaught Categories Uncategorized 0 Comments

 

 

I recently traveled back to California in order to complete my final dissertation defense. I decided that I would fly to California a day early so that I did not have to feel rushed. I was already nervous enough without having to worry about more travel logistics. I boarded my flight in Nashville on schedule and was on my way, or so I thought. One passenger started getting up and down using the bathroom. This isn’t necessarily unique, but after the fourth time myself and the passenger sitting next to me were curious. The flight attendants were opening and closing the lavatory door checking on the ill passenger. The Captain then announces that we will be making an emergency landing. The ill passenger apparently had some form of gastrointestinal illness and Norovirus was suspected. We landed in Kansas City to switch planes. I have never been in the Kansas City airport before but I can only describe it as a bunker. If there were a nuclear event while I was in Kansas City I knew I would survive.

 

Our new plane arrived, there were no nuclear events and we were underway again. As we were taking off another passenger started grabbing her chest and left arm. She was yelling at the flight attendant that she was “dying.” As a soon to be psychologist, I am usually very sympathetic to a person who is panicking but NOT today. Over the years in my previous work as a respiratory therapist I have seen many people actively having heart attacks. While you cannot necessarily tell if someone is actively having a heart attack without a proper evaluation, I was pretty convinced this lady was having a panic attack. The flight attendants were able to calm her for a bit and her distress decreased. As the flight proceeded she again started complaining of chest pain so we made emergency landing number two. Thankfully an ambulance was waiting on the runway and we were quickly up in the air again.

 

Several hours delayed, I arrived in Los Angeles at around 1 am and boarded my shuttle to the rental cars. Apparently circadian rhythm disorders are frequent in Los Angeles because the airport traffic was gridlocked. I doubled checked the time and wondered where all these people were going. A part of why I left Southern California was already quite evident. I did eventually make it to the rental car counter where I met the most dedicated rental car employee. Ever. She raised her voice when I declined the extra insurance, she told me (of course) about the “special” that would allow me to upgrade the car I was renting. I am normally quite patient but I stopped her and said, “I just want the car, nothing else.” She then proceeded to give me a lecture about how I had an out of state driver’s licence and needed the extra insurance and some other plan in case I got a flat tire. My response, “The car please.”

 

I traveled from Los Angeles to my room in Orange County near Disneyland. I was relieved to finally be at my destination and sorely in need of sleep. I checked in and the key to my room didn’t work. I returned to the desk, and the desk person tried to open the door and no luck. At this point I really would have slept in my hard won rental car. The front desk person informed me that there was only one room left, on the third floor, no elevator. I shrugged because after coming across the county three flights of stairs seemed a small obstacle. I quickly found out that there was a very good reason my first room was booked on the first floor. I managed to drag my suitcase up one flight of stairs and then proceeded to ask the front desk person to help me. I have some physical issues that limit my ability to gracefully carry a suitcase full of books up three flights of stairs. Finally, I was able to enter this room and collapse on the bed. It was around 4:30 am.

 

I spent the next day mostly sleeping. I was able to prepare a bit more that evening and I felt ready to make my final defense in the morning. I slept well and was going to leave an hour and a half early, again so that I didn’t have to feel pressured. I came out to the parking lot and did not see my rental car in the spot I was quite sure I parked it. I knew I had gotten in late and was generally disoriented after my flight so I proceeded to check the whole parking lot and no car. I started laughing like this situation was the most hilarious thing to ever happen. I’m not all together sure that it was a “good” laugh. One could argue that I had become out of touch with reality. I go into the hotel lobby and explain to the desk staff what is going on. I hear “Oh that was your car? The towing company accidentally towed it.” I took a deep breath in because we all need to breathe and count to ten sometimes. I explained that I was going to defend my dissertation and I needed to go now. The desk staff seemed to be able to read the angry, nervous state I was in. They called a cab for me and even had him wait for me. Good thing I started out early.

 

I made it to the classroom I was assigned to and began to attempt to set up my PowerPoint presentation. I had expected technical difficulties and that was why I allowed myself extra time but that time was cut in half by my missing car. I.T. was called because apparently I am putting off some form of energy into the universe that is not compatible with planes, cars, or computers. It is never good when I.T. says “wow, I’ve never seen this before,” when you are attempting to load your defense presentation. Thankfully my chair came into the room and was able to fix what was going wrong with the technology. I then successfully defended my dissertation. Now nothing else mattered, and my attitude about the travel glitches was cured by the statement: “My dissertation is defended.”

 

Little did I know that in my absence there was a plumbing problem that basically destroyed the kitchen and downstairs area of my house. My husband had wisely waited until after my dissertation was defended to tell me that we had no kitchen, laundry, downstairs bathroom. Nothing. He sent pictures and all I could say was, “My dissertation is defended.” I almost didn’t care that my house was in a state of demolition. I felt great! My car was returned and I was ready to go home (or whatever was left of home) victorious. I boarded my flight and we had a scheduled lay over in Kansas City, a.k.a the bunker port. All seemed to be going well, which at this point in the trip was a bit strange. It very well could have been that pandemonium was breaking out and I was just repeating, “My dissertation is done.”

 

I arrived at Nashville airport to be greeted by my family with flowers and balloons. I went to get my luggage while struggling to keep my very active 10 year old son from creating a public disturbance by riding on the luggage carousel. I was informed that the suitcases are “just like a horse,” meaning there is no good reason why one cannot ride on a suitcase spinning on the baggage carousel. I almost joined in until a security officer walked our way. I didn’t think he would buy my answer of “my dissertations done” as explanation for riding the baggage carousel. Well, as fun as the baggage claims area of the airport had become there was something crucial missing: my suitcases. Yep. Nothing like ending a trip with lost baggage, but you guessed it, I answered with, “My dissertation’s done!”

 

I was receiving supportive texts from my colleagues at WKPIC. Many times supporting one another involves continuing to point out the humor in almost any situation. I am now infamous among my colleagues for plane crashes (yep- see my interview story), emergency landings and other travel mishaps.

 

Rain Smith, MS
WKPIC Doctoral Intern

 

(Director’s Note: We offer these stories so interns will know they are not alone. Cursed times appear to include internship interviews, Match Day, Dissertation Defense, and Licensing Exams/Orals. YOU ARE NOT ALONE.)

 

June 06 2016

Article Review: Comparative Efficacy And Tolerability Of Antidepressants For Major Depressive Disorder in Children and Adolescents: A Network Meta-Analysis

Author Susan Vaught Categories Uncategorized 0 Comments

 

Major Depressive Disorder (MDD) is one of the most common mental disorders in children and adolescents. The researchers noted estimates suggesting it affects about 3 percent of children aged 6 to 12, and 6 percent of teens aged 13 to 18. Whether to use pharmacological interventions in this population and which drug should be preferred are still matters of controversy. The use of antidepressants among U.S. and U.K. children and teenagers up to age 19 has continued to increase. Antidepressant use among children and teens rose from 1.3 to 1.6 percent between 2005 and 2012, according to a separate study published in The Lancet. The U.S National Institutes of Health estimates that some 2.8 million children (or about 11 percent) between the ages of 12 and 17 have suffered from at least one episode of depression.

 

Depressive symptoms in children and adolescents are rather undifferentiated. You notice more irritability, aggressive behavior and problems at school. Consequences of depressive episodes in children and adolescents are dramatic because they include impairments in their social functioning, but also an increased risk of suicidal ideation and attempts. According to a study conducted by researchers from McGill University in Montreal, and published in the Journal of the American Medical Association (JAMA), nearly half of people taking depressants are not suffering from depression at all. After researchers analyzed a decade of antidepressant prescription records, they concluded that only 55 percent were given for depression, while the remaining 45 percent was written for conditions such as anxiety, sleeping problems, pain, panic disorders and Attention Deficit Hyperactivity Disorder (ADHD).

 

For this study, researchers of the University of Oxford conducted a systematic meta-analysis of both published and unpublished randomized control trials on the use of antidepressants for the treatment of major depression in children and young adults up to May 31, 2015. They examined trials on fourteen different antidepressants: amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. They aimed to compare and rank antidepressants and placebo for MDD in young people. The study also used the Cochrane risk of bias measures to account for the quality of the included studies. The bias analysis was essential to their conclusions as 88 percent of all of the trials were found to have a risk for bias and 65 percent of all of the trials were funded by drug companies.

 

They found 34 trials eligible, including 5,260 participants ages 9 to 18. Researchers discovered, for efficacy, only fluoxetine was statistically significantly more effective than placebo. In terms of tolerability, fluoxetine was also better than duloxetine and imipramine. Children taking venlafaxine actually showed an increased risk of suicidal thoughts and attempts. Nortriptyline was less effective than seven other antidepressants and the placebo. Imipramine, venlafaxine and duloxetine were the least tolerable, with many patients discontinuing them.

 

When considering the risk–benefit profile of antidepressants in the acute treatment of MDD, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated. The lack of individual-level data from trials makes it difficult to get accurate estimates of just how these drugs affect patients, and how many become suicidal. The authors warn that this doesn’t paint a full picture, since a lack of reliable data did not allow them to fully assess the risk of suicidality for all drugs. That’s partly because 65 percent of the trials they reviewed were funded by pharmaceutical companies. So those reports could have overestimated how well their drugs worked and minimized the side effects.

 

The authors suggest that parents and medical professionals monitor children and adolescents taking antidepressants closely, regardless of the drug chosen. The brains in children and teens are not yet developed, so it’s important to lead with caution when prescribing medication.

 

Reference:
Cipriani, A., Zhou, X., Giovane, C.D.; Hetrick, S.E.; Qin, B., Whittington, C.,…Coghill, D. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. The Lancet. DOI: http://dx.doi.org/10.1016/S0140-6736(16)30385-3

 

Jonathan Torres, M.S.
WKPIC Doctoral Intern

 

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