The induction of mental and contact contamination

Background: Extreme fear of contamination within Obsessive Compulsive Disorder is traditionally conceptualised as a physical phenomenon. More recent research has supported the notion of ‘mental’ contamination, in which people feel contaminated in the absence of physical contact. The current research sought to determine whether feelings of contact and mental contamination could be induced within a non-clinical sample, whether the impact of mental and contact contamination was comparable in terms of associated feelings and behaviour and whether related psychopathology related to the impact of the tasks. Methods: Undergraduate students (n=60) completed OCD relevant measures and were randomly assigned to either a contact contamination condition (CC: moving a bucket of fake vomit) or a mental contamination condition (MC: thinking about a bucket of vomit). Results: Both manipulations induced feelings of contamination. Participants in the contact condition had significantly greater urges to wash than those in the mental condition. Neutralising behaviour did not differ across conditions. Conclusions: Feelings of contamination can be induced in the absence of physical contact and for those in the MC group, some aspects of OCD-relevant psychopathology were related to the impact of the manipulation. These findings have implications for the understanding and treatment of contamination-related fears in OCD.

Emotional reasoning and anxiety sensitivity: associations with social anxiety disorder in childhood

Background Two specific cognitive constructs that have been implicated in the development and maintenance of anxiety symptoms are anxiety sensitivity and emotional reasoning, both of which relate to the experience and meaning of physical symptoms of arousal or anxiety. The interpretation of physical symptoms has been particularly implicated in theories of social anxiety disorder, where internal physical symptoms are hypothesized to influence the individual's appraisals of the self as a social object. Method The current study compared 75 children on measures of anxiety sensitivity and emotional reasoning: 25 with social anxiety disorder, 25 with other anxiety disorders, and 25 nonanxious children (aged 7–12 years). Results Children with social anxiety disorder reported higher levels of anxiety sensitivity and were more likely than both other groups to view ambiguous situations as anxiety provoking, whether physical information was present or not. There were no group differences in the extent to which physical information altered children's interpretation of hypothetical scenarios. Limitations This study is the first to investigate emotional reasoning in clinically anxious children and therefore replication is needed. In addition, those in both anxious groups commonly had comorbid conditions and, consequently, specific conclusions about social anxiety disorder need to be treated with caution. Conclusion The findings highlight cognitive characteristics that may be particularly pertinent in the context of social anxiety disorder in childhood and which may be potential targets for treatment. Furthermore, the findings suggest that strategies to modify these particular cognitive constructs may not be necessary in treatments of some other childhood anxiety disorders.

Obsessive–compulsive disorder in young people

Obsessive–compulsive disorder (OCD) is one of the most debilitating psychiatric conditions in young people. In DSM-5 it is no longer characterised as an anxiety disorder, but instead is part of a group of ‘obsessive–compulsive and related disorders’. In the past 10 years, cognitive–behavioural therapy (CBT) has become well established as the first-choice treatment. This article explains some of the elements of CBT and describes new directions in research which might improve interventions.

Clinical significance of lifetime panic disorder in the course of bipolar disorder type I

Objectives: The aim of the study was to analyze the impact of lifetime panic disorder (PD) diagnosis in a sample of patients with bipolar disorder type I (BPI), evaluating clinical and demographic variables. Methods: Ninety-five outpatients from the Bipolar Disorder Research Program at the Institute of Psychiatry of the University of Sao Paulo Medical School were enrolled. Twenty-seven BPI patients with PD were compared to 68 BPI patients without any anxiety disorders regarding clinical and demographic variables. Results: Compared to BPI patients without any anxiety disorders, patients with BPI + PD presented significantly higher number of mood episodes (18.9 +/- 13.8 vs 8.5 +/- 7.8; P < .001), depressive episodes (10.8 +/- 8.2 vs 4.6 +/- 4,8; P = .001), and manic episodes (7.4 +/- 7.3 vs 3.6 +/- 3.6; P = .008). Patients with BPI + PD had more frequently a depressive episode as their first one compared to BPI patients without anxiety disorders (94.1% vs 57.5%; P = .011). Patients with BPI + PD had more comorbidity with lifetime diagnosis of drug abuse or dependence (33.3% vs 8.8%; P = .010) and eating disorders (29.6% vs 6.0%; P = .004). Conclusions: The higher number of mood episodes in general presented by patients with BPI + PD when compared with BPI patients without any anxiety disorders, along with the higher frequencies of drug misuse and eating disorders, indicates that PD comorbidity is associated with a poorer Course and outcome of BPI. The higher frequency of depression as the onset mood episode and the higher number of manic episodes in the group with PD may have important treatment implications and should be further investigated. (C) 2009 Elsevier Inc. All rights reserved.

Guideline-based programs in the treatment of complex PTSD

The term “post-traumatic stress disorder” (PTSD) is a relatively new diagnostic label, being formally recognized in 1980 in the Diagnostic Statistical Manual for Psychiatric Illness – Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980). Complex Post-Traumatic Stress Disorder (CP) is a more recently discussed, and newly-classified, phenomenon, initially discussed in the early 1990s (Herman, 1992a). Thus, as research into effective treatments for CP is sparse, the treatment of CP is the topic of this study, in which a guideline-based treatment program developed by the researcher for the treatment of CP is implemented and evaluated. Ten individuals participated in this study, undertaking individualized, guideline-based treatment programs spanning a period of six months. In providing background information relevant to this study, an explanation is provided regarding the nature of CP, and the reasons for its consideration as a separate phenomenon to PTSD. The adequacy of the PTSD formulation in enabling effective assessment and treatment of CP is also explored, with endorsement of previous researchers’ conclusions that the CP construct is more useful than the PTSD construct for assessing and treating survivors of long-term and multiple forms of abuse. The PTSD classification is restrictive, and not necessarily appropriate for certain forms of trauma (such as prolonged trauma, or multiple forms of trauma), as such trauma experiences may lead to specific effects that lay outside those formerly associated with PTSD. Such effects include alterations in affect regulation, consciousness, self-perception, interpersonal relationships, and in systems of meaning. Following discussion regarding the PTSD/CP classification, an examination of treatment methods currently used in the treatment of PTSD, and a review of treatment outcome studies, takes place. The adequacy of primary treatment methods in treating CP symptoms is then examined, with the conclusion that a range of treatment methods could potentially be useful in the treatment of CP symptoms. Individuals with a diagnosis of CP may benefit from the adoption of an eclectic approach, drawing on different treatment options for different symptoms, and constantly evaluating client progress and re-evaluating interventions. This review of treatment approaches is followed by details of an initial study undertaken to obtain feedback from individuals who had suffered long-term/multiple trauma and who had received treatment. Participants in this initial study were asked open-ended questions regarding the treatment approach they had experienced, the most useful aspect of the treatment, the least useful aspect, and other strategies/treatment approaches that may have been useful – but which were not used. The feedback obtained from these individuals was used to inform the development of treatment guidelines for use in the main study, as were recommendations made by Chu (1998). The predominant focus of the treatment guidelines was “ego strengthening”, a term coined by Chu (1998) to describe the “initial (sometimes lengthy) period of developing fundamental skills in maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing a positive self identity” (p.75). Using a case study approach, data are then presented relating to each of the ten individuals involved in the treatment program: details of his/her trauma experience(s)and the impact of the trauma (as perceived by each individual); details of each individual’s treatment program (as planned, and as implemented); post-treatment evaluation of the positive and negative aspects of the treatment program (from the therapist’s perspective); and details of the symptoms reported by the individual post-treatment, via psychometric assessment and also during interview. Analysis and discussion of the data relating to the ten participants in the study are the focal point of this study. The evaluation of the effectiveness of each individual’s treatment has been based predominantly on qualitative data, obtained from an analysis of language (discourse analysis) used by participants to describe their symptoms pre- and post-treatment. Both blatant and subtle changes in the language used by participants to describe themselves, their behaviour, and their relationships pre- and post-treatment have provided an insight into the possible changes that occurred as a result of the treatment program. The language used by participants has been a rich source of data, one that has enabled the researcher to obtain information that could not be obtained using psychometric assessment methods. Most of the participants in this study portrayed notable changes in many of the CP symptoms, including being more stable and having improved capacity to explore their early abuse. Although no direct cause-effect relationship between the participants’ treatment program and the improvements described can be established from this study, the participants’ perception that the program assisted them with their symptoms, and reported many aspects of “ego strengthening”, is of major importance. Such self-perception of strength and empowerment is important if an individual is going to be able to deal with past trauma experiences. In fact, abreactive work may have a greater chance of succeeding if those who have experienced long-term or multiple trauma are feeling more empowered, and more stable, as were the participants in this study (post-intervention). In concluding this study, recommendations have been made in regard to the use of guideline-based treatment programs in the responsible treatment of CP. Strengths and limitations of this study have also been highlighted, and recommendations have been made regarding possibilities for future research related to CP treatment. On the whole, this study has supported strongly other research that highlights the importance of focusing on “ego strengthening” in assisting those who have suffered long-term/multiple trauma experiences. Thus, a guideline-based program focusing on assisting sufferers of long-term trauma with some, or all, of the symptoms of CP, is recommended as an important first stage of any treatment of individuals who have experienced long-term/multiple trauma, allowing them to develop the emotional and psychological strength required to deal with past traumatic events. Clinicians who are treating patients whose history depicts long-term or multiple trauma experiences (either from their childhood, or at some stage in their adult life) need, therefore, to be mindful of assessing individuals for symptoms of CP – so that they can treat these symptoms prior to engaging in any work associated directly with the past traumatic experiences.

Clinical, ethical and legal considerations in the treatment of newborns with non-ketotic hyperglycinaemia

Non-ketotic hyperglycinaemia (NKH) is a devastating neurometabolic disorder leading, in its classical form, to early death or severe disability and poor quality of life in survivors. Affected neonates may need ventilatory support during a short period of respiratory depression. The transient dependence on ventilation dictates urgency in decision-making regarding withdrawal of therapy. The occurrence of patients with apparent transient forms of the disease, albeit rare, adds uncertainty to the prediction of clinical outcome and dictates that the current practice of withholding or withdrawing therapy in these neonates be reviewed. Both bioethics and law take the view that treatment decisions should be based on the best interests of the patient. The medical-ethics approach is based on the principles of non-maleficence, beneficence, autonomy and justice. The law relating to withholding or withdrawing life-sustaining treatment is complex and varies between jurisdictions. Physicians treating newborns with NKH need to provide families with accurate and complete information regarding the disease and the relative probability of possible outcomes of the neonatal presentation and to explore the extent to which family members are willing to take part in the decision making process. Cultural and religious attitudes, which may potentially clash with bioethical and juridical principles, need to be considered.

Parent management training, comorbidity, and treatment of children with oppositional defiant disorder

This study found that Parent Management Training was a successful treatment for promary school aged children who were referred to a mental health clinic and diagnosed with Oppositional Defiant Disorder. The positive outcome was not affected by the child having comorbid disorders. These findings have relevance to the clinical field.

PTSD symptomatology in children and adolescents : treatment development and evaluation

This thesis developed, implemented and evaluated a cognitive-behavioural group treatment programme for children and adolescents experiencing symptoms of PTSD (Post-traumatic stress disorder). Results of the study indicate that symptoms of sleep disturbance and flashbacks, reduced markedly in the participants, providing a useful tool in reducing synptoms experiences by individuals exposed to trauma. The Professional portfolio presents four case studies that demonstrate the clinical application of the affect of chronic illness on the psychological adjustment of the sufferer and their families.

Clinical characteristics and management of bipolar disorder in women across the life span

Though prevalent in both genders, specific consideration needs to be given when treating a woman suffering from bipolar disorder over her lifetime. Bipolar disorder is a serious and incapacitating illness affecting an estimated 5% of women. The first episode of illness in women is usually a depressive episode. Female gender has been associated with greater axis-one comorbidity, more depressive episodes, rapid cycling and mixed affective states. Special consideration is required for the treatment of bipolar disorder during reproductive events. More studies are required to better understand the course, outcome and gender-specific treatment strategies of this disorder.

Disrupting disordered neurocircuitry : treating refractory psychiatric illness with neuromodulation

Despite the premature and somewhat infamous rise and fall of psychosurgery in the mid-20th century, the current era of functional neuromodulation proffers immense opportunity for surgical intervention in treatment-resistant psychiatric disorders. On the basis of recent successes with novel, focused, less invasive, and reversible treatment strategies for movement disorders, several therapeutic trials have been conducted to investigate the effectiveness of deep brain stimulation (DBS) in treatment-resistant depression, obsessive-compulsive disorder (OCD), and Tourette syndrome. The many anatomic targets for these psychiatric disorders are indicative of both the system-wide effects of DBS and the network-level dysfunction mediating the emotional and cognitive disturbances. To gain insight into the application of neuromodulation therapies and their further advancement, we must elucidate neuroanatomic networks involved in refractory psychiatric illness, the neurophysiological anomalies that contribute to disordered information processing therein, and the local and system-wide modulatory effects of DBS. This review discusses the history of psychosurgical procedures, recent DBS clinical data, current anatomic models of psychopathology, and possible therapeutic mechanisms of action of DBS neuromodulation. Our search criteria for PubMed included combinations of the following terms: neuromodulation, DBS, depression, OCD, Tourette syndrome, mechanism of action, and history. Dates were not restricted. As clinical and basic scientific investigations probe the neuromodulatory effects of DBS in the treatment of refractory neuropsychiatric illness, our knowledge of these disorders and our potential to treat them are rapidly expanding. Indeed, this modern era of neuromodulation may provide the key that unlocks many of the mysteries pertaining to the biological basis of disordered emotional neurocircuitry.

Youth (in)justice : oral language competence in early life and risk for engagement in antisocial behaviour in adolescence

Youth offenders are complex and challenging for policymakers and practitioners alike and face high risks for long-term disadvantage and social marginalisation. In many cases, this marginalisation from the mainstream begins in early life, particularly in the classroom, where they have difficulty both with language/literacy tasks and with the interpersonal demands of the classroom. Underlying both sets of skills is oral language competence—the ability to use and understand spoken language in a range of situations and social exchanges, in order to successfully negotiate the business of everyday life. This paper highlights an emerging field of research that focuses specifically on the oral language skills of high-risk young people. It presents evidence from Australia and overseas that demonstrates that high proportions (some 50% in Australian studies) of young offenders have a clinically significant, but previously undetected, oral language disorder. The evidence presented in this paper raises important questions about how young offenders engage in forensic interviews, whether as suspects, victims or witnesses. The delivery of highly verbally mediated interventions such as counselling and restorative justice conferencing is also considered in the light of emerging international evidence on this topic.

The relationship between body dysmorphic disorder symptoms and self-construals

Background:  Cognitive models of body dysmorphic disorder (BDD) suggest that beliefs and evaluations related to self-concept are central to the maintenance of the disorder, but such beliefs have received little empirical attention. This study examined the relative importance of contingent self-worth and self-ambivalence to BDD symptoms in comparison to their importance to obsessive–compulsive disorder and social phobia symptoms.

Method:  The sample comprised 194 non-clinical participants (female, N = 148; males, N = 46) with a mean age of 24.70 years (standard deviation = 9.34). Participants were asked to complete a battery of self-report questionnaires. Results:  While significant relationships were found between the self-beliefs and symptoms of all three disorders, some specificity was found in the relationships.

Conclusions:  Self-worth based upon appearance was most important in BDD, while contingent self-worth based on the approval of others was important in social phobia. Self-ambivalence was associated with each disorder. Implications and limitations are discussed.

The influence of confidence in memory on checking behaviours

Recent theories of Obsessive Compulsive Disorder have suggested that meta-cognitive beliefs, particular confidence in memory, may relate to the maintenance of symptoms. For example, individuals who worry that their memory is deficient may check in order to ensure that the doors are locked, regardless of their actual memory ability. While studies have related meta-memory beliefs to OCD symptoms, and have found that memory is affected by checking behaviours; to date, no experimental literature has attempted to ascertain whether lowered confidence in memory directly leads to greater checking behaviours. In the current study 46 non-clinical participants completed a battery of questionnaires measuring these constructs, before undertaking a “memory task” designed to manipulate their level of confidence in their memory. The effect of the manipulation on the level of checking on a visuomemory task was subsequently assessed. The questionnaires indicated that cognitive confidence predicted variation in obsessive-compulsive symptoms over-and-above the influence of depressive symptoms and other OCD-related beliefs. However, while confidence in memory was successfully manipulated, the group with increased memory confidence was not found to have lower checking behaviours. Limitations of the study are discussed and directions for further research are suggested.