"When Will All of This End?": A 65-Year-Old Man With Amyotrophic Lateral Sclerosis and Psychiatric Distress.

Patients with amyotrophic lateral sclerosis (ALS) are impacted both physically and psychiatrically during their illness. Emotional distress (ie, anxiety, depression, stress) is common in patients diagnosed with ALS, as prognosis is poor and there are very few effective treatments. The progression of symptoms is unpredictable, and all cases are terminal. Neuropsychiatric symptoms are also increasingly recognized as part of ALS symptomatology. There are currently no empirically supported interventions or best practices for adjustment to ALS. This case presents both the psychological and pharmacologic aspects of caring for a patient with ALS. Psychotherapy utilized a cognitive behavioral therapy-informed approach, and pharmacotherapy was tailored to the specific needs of the patient. We explore how these approaches impacted our patient, as well as how ALS-specific challenges presented throughout the course of treatment.

Psychological Dimensions of Palliative Care Consultation: Approaches to Seriously Ill Patients at the End of Life.

Mental health clinicians often hear seriously ill patients ask the unanswerable: Why did this happen? What is the meaning of my suffering? In the inpatient setting, general medical ward, or oncology unit, patients are confronted with their mortality in new, urgent ways. Palliative medicine, or the specialized, comprehensive care of patients facing a life-limiting illness, occupies a unique and liminal space. Although often practiced by clinicians with non-mental health training backgrounds, there exists ample psychological content to be explored in the palliative care encounter. In this article, we present the case of a husband and international businessperson who experienced terminal complications from an advanced stage lung cancer. His illness was not responsive to multiple cancer-directed treatments, and he developed respiratory failure requiring high levels of supplemental oxygen support, from which he was unable to wean. Palliative care consultation was sought with the multiple objectives of ameliorating his severe death anxiety and persistent dyspnea as well as assisting in the clarification of his end-of-life wishes. Our goal with this case presentation and related discussion is to introduce the psychological aspects of palliative medicine to psychiatrists and psychotherapists.

Psychotherapy for Functional Neurological (Conversion) Disorder: A Case Bridging Mind, Brain, and Body.

Functional neurologic (conversion) disorder (FND) is a core neuropsychiatric condition directly at the intersection of psychiatry and neurology. Over the past several decades, renewed interest in FND has been catalyzed by use of a "rule-in" diagnostic approach leveraging positive clinical signs specific for the diagnosis. In parallel, advances have occurred in identifying mechanisms, etiologic factors, and evidence-based treatments for this population. While "one size fits all" formulations of the "conversion" of psychological distress into physical symptoms are no longer widely accepted, emotion processing and related psychological constructs (eg, alexithymia, dissociation, threat avoidance) remain central to the conceptual understanding of FND. Furthermore, the biopsychosocial model (foundational to psychiatry) is the prevailing model through which to guide longitudinal treatment, with psychotherapy as an emerging first line intervention for FND. Nonetheless, there is a striking dearth of psychotherapists and mental health providers more broadly that feel well versed in the clinical assessment and management of patients with FND. In this article, we seek to address this gap by presenting the psychotherapy treatment narrative of a woman experiencing paroxysmal functional speech and gait disorder symptoms who had a positive clinical outcome. Our goal with this case presentation and related discussion is to increase the proficiency of psychotherapists in providing treatment to patients with FND.

Dialectical Behavior Therapy Group Skills Training for Bipolar Disorder.

There is growing evidence that the capacity for emotion regulation is compromised in individuals with bipolar disorder. Dialectical behavior therapy (DBT), an empirically supported treatment that specifically targets emotion dysregulation, may be an effective adjunct treatment for improving emotion regulation and residual mood symptoms in patients with bipolar disorder. In this open, proof-of-concept pilot study, 37 participants engaged in a 12-week DBT group skills training program, learning mindfulness, emotion regulation, and distress tolerance skills. Repeated measures mixed models revealed skill acquisition in the areas of mindfulness, emotion regulation and distress tolerance, as well as improved psychological well-being and decreased emotion reactivity. The results of this study support a burgeoning literature that DBT is a feasible adjunct intervention for patients with bipolar disorder.

Early improvements in anxiety, depression, and anger/hostility symptoms and response to antidepressant treatment.

BACKGROUND: The purpose of this study was to examine whether treatment response to fluoxetine by depressed outpatients was predicted by early improvement on any of 3 subscales (Anxiety, Depression, and Anger/Hostility) of the Symptom Questionnaire (SQ). METHODS: We evaluated 169 depressed outpatients (52.6% female) between ages 18 and 65 (mean age, 40.3 +/- 10.6 years) meeting DSM-IIIR criteria for major depressive disorder (MDD). All patients completed the SQ at baseline (week 0) and at weeks 2, 4, and 8 of treatment with fluoxetine 20 mg/d. We defined treatment response as a > or= 50% reduction in score on the 17-item Hamilton Rating Scale for Depression, and early improvement on 3 SQ subscales (Anxiety, Depression, and Anger/Hostility) as a >30% reduction in score by week 2. RESULTS: The percentage of patients with significant early improvement in anger was significantly greater than the percentage of those with early improvements in anxiety or depression. When early improvement on the Anxiety, Depression, and Anger/Hostility subscales of the SQ were assessed independently by logistic regression, all 3 subscales were predictors of response to treatment. CONCLUSIONS: Early improvement in anger, anxiety, and depressive symptoms may predict response to antidepressant treatment among outpatients with MDD.

Change in emotional processing during a dialectical behavior therapy-based skills group for major depressive disorder.

Across studies, paying attention to and analyzing one's emotions has been found to be both positively and negatively correlated with depression symptoms. One way of reconciling these seemingly contradictory findings is the possibility that attending to emotions in a skillful manner may help to reduce depression whereas attending to emotions with limited skill may be counterproductive. Dialectical behavior therapy (DBT) is a clinical intervention designed to foster adaptive awareness, expression, regulation, tolerance, and acceptance of emotions. Results of the present report come from a pilot study of a 16-week DBT-based skills training group for treatment-resistant major depressive disorder (MDD) as an adjunctive treatment to pharmacotherapy. Patients were randomized to treatment or a waitlist control group. A significant interaction revealed that increases in emotional processing were associated with decreases in depression symptoms in the DBT-based skills group; however, increases in emotional processing in the waitlist condition were associated with increases in depression. Results offer preliminary support for the idea that participating in DBT-based skills training may help individuals with treatment-resistant MDD to develop skills that facilitate processing emotions in a way that helps to reduce rather than exacerbate depression symptoms.

Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression.

Treatment resistant depression is common, persistent, and results in substantial functional and social impairment. This study describes the development and preliminary outcome evaluation of a dialectical behavior therapy-based skills training group to treat depressive symptoms in adult outpatients for whom antidepressant medication had not produced remission. The 16-session, once-weekly group covered the 4 dialectical behavior therapy skill sets: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Twenty-four patients with ongoing depressive symptoms despite stable, adequate medication treatment for major depressive disorder were randomly assigned to either the skills group or a wait-list condition. The depressive symptoms of participants who completed the study (9 wait-list participants, 10 skills group participants) were compared using a clinician-rated Hamilton rating scale for depression and then replicated using a self-report measure Beck depression inventory. Clinician raters were blind to each participant's assigned study condition. Skills group participants showed significantly greater improvements in depressive symptoms compared with the control condition. Effect sizes were large for both measures of depression (Cohen's d = 1.45 for Hamilton rating scale for depression and 1.31 for Beck depression inventory), suggesting that larger scale trials are warranted.

Extreme response style in recurrent and chronically depressed patients: change with antidepressant administration and stability during continuation treatment.

The authors examined extreme response style in recurrently and chronically depressed patients, assessing its role in therapeutic outcome. During the acute phase, outpatients with major depressive disorder (N = 384) were treated with fluoxetine for 8 weeks. Remitted patients (n = 132) entered a continuation phase during which their fluoxetine dose increased and they were randomly assigned to treatment with or without cognitive-behavioral therapy (CBT). Results showed a predictive relationship between extreme response style and clinical outcome. Patients in the medication-only group showed a significant increase in the frequency of extreme responses, whereas patients receiving CBT showed no significant change. These results are consistent with recent findings suggesting that metacognitive factors may be as important as changes in thought content when treating depression.

Concurrent validity of the Personality Assessment Inventory Borderline scales in patients seeking dialectical behavior therapy.

The purpose of this study was to explore the usefulness of the Personality Assessment Inventory (PAI; Morey, 1991) Borderline full scale (BOR) and subscales in the assessment of patients being evaluated for dialectical behavior therapy (DBT; Linehan, 1993). We administered 67 patients both the PAI and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Structured Clinical Interview for Axis II disorders (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1997). Point biserial correlations showed a significant relationship between the presence of borderline personality disorder (BPD) and scores on the BOR and Schizophrenia (SCZ) scales. A regression analysis showed that among the BOR subscales, those measuring identity disturbance, self-harming behavior, and negative relationships were significantly related to the total number of SCID-II BPD criteria. Diagnostic efficiency statistics between the BOR scale and the number of SCID-II BPD criteria indicated that a T score cutoff of 65 optimally differentiates patients who do and do not meet criteria for BPD. The relationship between BOR and SCID-II BPD demonstrates the concurrent validity of the PAI and shows its usefulness in this setting.

Problem-solving ability and comorbid personality disorders in depressed outpatients.

Major depressive disorder (MDD) is associated with poor problem-solving abilities. In addition, certain personality disorders (PDs) that are common among patients with MDD are also associated with limited problem-solving skills. Attempts to understand the relationship between PDs and problem solving can be complicated by the presence of acute MDD. Our objective in this study was to investigate the relationships between PDs, problem-solving skills, and response to treatment among outpatients with MDD. We enrolled 312 outpatients with MDD in an open, fixed-dose, 8-week fluoxetine trial. PD diagnoses were ascertained via structured clinical interview before and after fluoxetine treatment. Subjects completed the Problem-Solving Inventory (PSI) at both time points. We used analyses of covariance (ANCOVAs) to assess relationships between PD diagnoses and PSI scores prior to treatment. Subjects were divided into three groups: those with PD diagnoses that remained stable after fluoxetine treatment (N=91), those who no longer met PD criteria after fluoxetine treatment (N=119), and those who did not meet criteria for a PD at any time point in the study (N=95). We used multiple chi(2) analyses to compare rates of MDD response and remission between the three PD groups. ANCOVA was also used to compare posttreatment PSI scores between PD groups. Prior to fluoxetine treatment, patients with avoidant, dependent, narcissistic, and borderline PDs reported significantly worse problem-solving ability than did patients without any PDs. Only subjects with dependent PD remained associated with poorer baseline problem-solving reports after the effects of baseline depression severity were controlled. Patients with stable PD diagnoses had significantly lower rates of MDD remission. Across PD groups, problem solving improved as MDD improved. No significant differences in posttreatment problem-solving were found between PD groups after controlling for baseline depression severity, baseline PSI score, and response to treatment. Treatment with fluoxetine is less likely to lead to remission of MDD in patients with stable PDs. More study is needed to investigate causal links between PDs, problem solving, and MDD treatment response.

A twin registry study of familial and individual risk factors for trauma exposure and posttraumatic stress disorder.

This study examines the association of individual and familial risk factors with exposure to trauma and posttraumatic stress disorder (PTSD) in male twins (N = 6744) from the Vietnam Era Twin Registry. Independent reports of familial psychopathology from co-twins were used to avoid the potential biases of the family history method. Risk for exposure to traumatic events was increased by service in Southeast Asia, preexisting conduct disorder, preexisting substance dependence, and a family history of mood disorders whose effects appear to be partly genetic. Preexisting mood disorders in the individual were associated with decreased odds of traumatic exposure. Risk of developing PTSD following exposure was increased by an earlier age at first trauma, exposure to multiple traumas, paternal depression, less than high school education at entry into the military, service in Southeast Asia, and preexisting conduct disorder, panic disorder or generalized anxiety disorder, and major depression. Results suggest the association of familial psychopathology and PTSD may be mediated by increased risk of traumatic exposure and by preexisting psychopathology.