Treatment of reactivated post-traumatic stress disorder. Imaginal exposure in an older adult with multiple traumas.

A single-case analysis was used to assess the effects of imaginal exposure in a 57-year-old woman suffering from current and reactivated post-traumatic stress disorder (PTSD) following a transient ischemic attack. The client's responses to self-reported depression, anxiety, and PTSD symptoms were repeatedly recorded during four phases: (a) initial psychotherapy, (b) imaginal exposure, (c) skill generalization, and (d) fading of treatment. In addition to dramatic reduction in levels of depression and anxiety, results showed a significant improvement in PTSD symptoms relating to recent and remote traumatic experiences. Improvements were maintained approximately 16 months after imaginal exposure ended, despite ongoing external stressors.

Risk factors in school shootings.

Nine incidents of multiple-victim homicide in American secondary schools are examined and common risk factors are identified. The literature dealing with individual, family, social, societal, and situational risk factors for youth violence and aggression is reviewed along with existing risk assessment methods. Checklists of risk factors for serious youth violence and school violence are used in reviewing each school shooting case. Commonalties among the cases and implications for psychologists practicing in clinical and school settings are discussed.

Substance refusal skills in a population of adolescents diagnosed with conduct disorder and substance abuse.

The present study examined substance refusal skills of 44 conduct-disordered male adolescents. Fifty percent of these adolescents were dually diagnosed with substance abuse/dependence. Substance refusal skills were assessed utilizing a role-play test that consisted of four interpersonal scenarios in which a confederate prompted youths to engage in illicit drug and alcohol activity. The test demonstrated adequate interrater agreement and validity. Overall skill in refusing alcohol was positively related to adolescents' perceptions of belonging and attention, and overall skill in refusing illicit drugs was positively related to school performance and social competence. Contrary to expectations, substance refusal skills of dually diagnosed adolescents were comparable to their non-substance-abusing counterparts. Clinical implications of this study are discussed.

Interpersonal and psychological correlates of marital dissatisfaction in late life: a review.

Developmental studies suggest that marital quality improves in old age (e.g., Guilford & Bengtson, 1979). However, many of the studies are replete with sampling biases that probably led to an overinflated positive report of marital satisfaction in older adults. Our review evaluated contemporary studies that have investigated interpersonal and psychological factors associated with dissatisfaction in long-term marriages. Recent investigations indicate that older marriages benefit from lower levels of conflict and greater sources of mutual pleasure following child-rearing cessation. Studies of social support in long-term marriages suggest that perceptions of spousal support are more strongly related to marital satisfaction and general well-being for older women than for men. A few investigations have found a significant relationship between depression and marital discord in older adult samples, and the causal flow between these two variables appears to be unidirectional in that depression has a detrimental impact on late-life marital quality. Indeed, depression has been found to mediate the link between many age-related stressors (e.g., ill health, retirement) and declines in marital adjustment. However, our preliminary analysis of marital adjustment within a depressed, older adult, outpatient sample of married individuals did not confirm statistically that marital discord is associated with depressive symptomatology. This, in part, was attributed to the very narrow range of older adults sampled (i.e., clinic patients suffering from depression). However, the majority of depressives characterized their marriages as discordant. The implications for these findings are discussed and future directions are offered.

Validation of the Keane MMPI-PTSD Scale against DSM-III-R criteria in a sample of battered women.

The Keane, Malloy, & Fairbank (1984) MMPI-PTSD Scale has proven to be a reliable and valid measure of posttraumatic stress disorder (PTSD) in combat veterans. However, few studies have examined the MMPI-PTSD Scale's validity in civilian trauma victims, including battered women. In the present study, 46 battered women who completed the MMPI-PTSD Scale were assigned to PTSD-Positive and PTSD-Negative groups based on a structured diagnostic interview and then contrasted on the MMPI-PTSD Scale. Significantly higher scores on the scale were found in the PTSD-Positive group. Also, a cutoff score of 22 on the MMPI-PTSD Scale correctly classified 80.4% of the sample. Correlations between the MMPI-PTSD and DSM-III-R criteria suggest that the scale is moderately sensitive to many of the symptoms particularly those involving intrusion and psychological arousal, comprising the diagnosis of PTSD. This investigation provides further support for the validity of the MMPI-PTSD Scale and its utility in screening battered women for PTSD.

Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory with older adult psychiatric outpatients.

In order to assess the psychometric properties and diagnostic utility of the Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI) with older adults, these measures were administered to 217 older adult outpatients with mixed psychiatric disorders. Both the BAI and STAI scales demonstrated high internal reliabilities. The BAI demonstrated good factorial validity, with a somatic anxiety and a subjective anxiety factor emerging. In contrast, the STAI did not evidence factorial validity, with analyses failing to support presence of state and trait anxiety factors. Both the BAI and Trait Anxiety scale of the STAI demonstrated discriminant validity in separating patients with a current anxiety disorder from patients without such a disorder. However, the State Anxiety scale of the STAI did not discriminate between these groups. When used to predict presence of an anxiety disorder, no single cutting score for either the BAI or STAI proved optimal, due to tradeoffs between sensitivity and specificity. Results suggest that both the subjective subscale and total score on the BAI can be somewhat useful as a quick screening instrument in detecting presence of a current anxiety disorder for older adult psychiatric outpatients, although results were not as strong as previous findings regarding screening tests for depression in the elderly.

A prospective study of childhood anxiety disorders.

OBJECTIVE: To evaluate course and outcome of DSM-III-R anxiety disorders prospectively in clinically referred children. METHOD: Children were blindly and repeatedly assessed with a structured diagnostic interview over a 3- to 4-year period to determine recovery from anxiety disorder and development of new psychiatric disorders. Both psychopathological (attention-deficit hyperactivity disorder, n = 50) and never psychiatrically ill (NPI, n = 83) controls served as comparison groups for children with anxiety disorders (n = 84). RESULTS: The majority of children (82%) were free from their intake anxiety disorders by the end of the follow-up. Relapse of these anxiety disorders after remission was rare (8%). During follow-up, anxious children were more likely to develop new psychiatric disorders (30%), primarily new anxiety disorders (16%), than were NPI children (11% and 2%, respectively), but not psychopathological controls (42% and 10%, respectively). CONCLUSIONS: Overall, results suggest a favorable outcome with respect to diagnostic status for clinically referred children with anxiety disorders. However, these children may be at risk for new psychiatric disorders over time.

Assessing the effects of violence on women in battering relationships with the Keane MMPI-PTSD Scale.

The Minnesota Multiphasic Personality Inventory (MMPI)-Keane Posttraumatic Stress Disorder (PTSD) Scale (PK) has proven to be a reliable and valid measure of PTSD in combat veterans. However, few studies have examined the scale's validity in battered women, who often present with PTSD. Using empirically derived cutoff scores for the PK Scale, 69 battered women were assigned to PTSD-Positive and PTSD-Negative groups and then compared on measures of PTSD, distress, social support, and history of abuse in and out of the battering relationship. The PTSD-Positive group scored significantly higher across all measures of PTSD and distress, supporting the concurrent validity of the PK Scale in this population. However, the two groups differed only for the frequency of death threats, suggesting that the PK Scale is only mildly sensitive to the level of trauma exposure. Finally, lower levels of perceived social support were found in the PTSD-Positive than the PTSD-Negative group. Implications of these findings for the assessment of PTSD in battered women are discussed.

Social skills training for depressed, visually impaired older adults. A treatment manual.

Late-onset visual impairment due to cataracts, glaucoma, macular degeneration, or diabetic retinopathy afflicts approximately 10% of people older than 65, and often results in depression and social dysfunction. Whereas the majority of sighted older adults are active participants in their community, individuals suffering from progressively worsening vision experience heightened levels of isolation and reduced social support, and participate in fewer reinforcing recreational activities. This article describes our social skills training package for the treatment of depressed, visually impaired, older adults. Our treatment focuses on increasing the frequency and level of assertiveness with which visually impaired older adults interact with each other. In addition to specified treatment methods, our empirically derived program employs standardized assessment measures to evaluate therapeutic progress. Sessions are implemented to reinforce efforts to apply social skills in the environment and reestablish skills that have begun to fade.

Social skills training in a depressed, visually impaired older adult.

A multiple baseline design was used to assess the effects of social skills training (SST) in a 65-year-old woman suffering from major depression and severe macular degeneration. Responses to role-played scenarios requiring assertiveness, in vivo request for assistance and social involvement, self-reported assertiveness, depression, and happiness were repeatedly recorded during baseline, treatment, and follow-up phases. Results showed progressive improvement in targeted social skills with SST in both clinic and home settings. Concurrent with enhanced levels of social skill were dramatic decreases of depression to a nonclinical level. Improved skill levels and diminished Geriatric Depression Scale scores were maintained during the 7-month follow-up period, except at the 6 month assessment after which booster treatment was applied to reinstate maximum improvement.

Remedying the Achilles heel of behavior research and therapy: prescriptive matching of intervention and psychopathology.

Recent calls for eclecticism in clinical practice have been fueled by the putative limitations of behavioral techniques in treating a variety of psychological problems. However, calls for such integration do not appear to be justified for two related reasons. First, the precise conditions under which behavioral interventions are and are not effective have not yet been adequately delineated. Consequently, rejection of behavioral interventions in favor of relatively indiscriminate application of cognitive strategies is premature. Second, behavior therapy has as its hallmark a thorough grounding in inductive empiricism, while cognitive/dynamic theories are wholly based in deductive rationalism. As a result, wholesale acceptance of alternative theories and techniques by behaviorists is both inconsistent and retrogressive. Cognitive interventions have their place, but only when cognitive distortions have been specifically identified. Therefore, refinement of behavioral treatments into prescriptive interventions is warranted. The parameters of prescriptive behavior therapy are described in this paper.

Reliability of the Structured Clinical Interview for DSM-III-R: an evaluative review.

Research evaluating the reliability of the Structured Clinical Interview for DSM-III-R (SCID) is reviewed. Reliability procedures and studies are examined. Several versions of the SCID are covered, including the SCID-I (axis I disorders), SCID-II (axis II disorders), SCID-Positive and Negative Syndrome Scale (SCID-PANSS; functional-dimensional assessment for psychotic disorders), and SCID-Upjohn Version (panic disorder). The SCID has been found to yield highly reliable diagnoses for most axis I and axis II disorders. Suggestions for future research on the SCID are offered, particularly with respect to (1) the lack of studies in which SCID diagnoses are compared with diagnoses from unstructured interviews or other structured-interview formats, and (2) the need for a more natural evaluation of this instrument. Also, the importance of establishing norms and obtaining reliability data for underserved clinical populations is discussed.

Behavioral assessment and treatment of social phobia. An evaluative review.

This article provides an empirically derived description of social phobia, including onset, prevalence, comorbidity, and issues of differential diagnosis. Assessment and behavioral treatment strategies for social phobia are reviewed. It was not until the past few years that structured clinical interviews and self-report inventories have been developed with adequate reliability and validity to specifically assess social phobia. Thus much of the treatment outcome research is confounded with heterogeneous samples that make generalization of results difficult to interpret. Heterogeneity of samples, lack of controlled comparisons with adequate statistical power to detect treatment differences, and inconsistent findings do not permit the drawing of any definitive conclusions concerning the efficacy of behavioral treatment procedures at this time. More treatment comparison studies for social phobia need to be performed using structured clinical interviews and standardized assessment devices specific for use with social phobia. Pre hoc power analyses should be performed to determine the number of subjects deemed adequate to detect differences when performing comparison studies. Assessment and treatment of social phobia with children is conspicuously nonexistent. Assessment and treatment procedures for social phobia need to be developed and standardized with children.

Maltreatment in psychiatrically hospitalized children and adolescents with developmental disabilities: prevalence and correlates.

OBJECTIVE: The goals of this study were (1) to determine the prevalence of child maltreatment in hospitalized children and adolescents with developmental disabilities and concomitant psychiatric disorders, and (2) to identify the contribution of specific mother and child characteristics to the use of more severe disciplinary practices by mothers. METHOD: One hundred thirty-eight psychiatrically hospitalized children and adolescents with developmental disabilities and mothers were assessed using a semistructured interview (Child Abuse and Neglect Interview Schedule) examining factors associated with risk of child maltreatment, and questionnaires measuring maternal and child functioning. The Child Abuse and Neglect Interview Schedule and hospital charts were then used to derive ratings on the prevalence and severity of child maltreatment. RESULTS: Findings revealed that 61% of children had experienced some form of severe maltreatment by a care provider in their lifetime. Regression analysis indicated that interactions between high levels of social functioning and disruptive/oppositional behaviors and younger age in children, and low levels of social support and increased anger reactivity in mothers, were most predictive of mothers' use of severe disciplinary practices. CONCLUSIONS: Maltreatment in psychiatrically hospitalized children and adolescents with disabilities is very prevalent, and it warrants careful clinical assessment. In the psychiatric setting, families in which the child is younger, higher functioning, and behaviorally disruptive, and where mothers have little social support and exhibit increased anger reactivity, are at especially elevated risk.

Diagnosis and assessment of substance abuse in older adults: current strategies and issues.

Alcohol and substance abuse in older adults until recently has received little empirical attention in the literature. However, in light of the increasing number of older adults in the population, clinicians and researchers alike are recognizing the importance of evaluating specific assessment and treatment strategies for such older substance abusers. Because distinctive biological, cognitive, and psychosocial variables appear to be correlated with substance abuse in older adults, evaluation and intervention methods employed with younger cohorts may be inappropriate or ineffective with individuals 55 and over. Our article, therefore, examines these characteristics as they pertain to the unique problems and service needs of the elderly. Relevant diagnostic and assessment strategies are reviewed. Finally, suggestions for future work in this area are outlined.

Behavioral interventions to reduce maladaptive responding in youth with dual sensory impairment. An analysis of direct and concurrent effects.

Many persons who have multiple sensory, physical, and developmental disabilities display behaviors that interfere significantly with adaptive functioning and social acceptance. In this investigation, the efficacy of multiple component behavioral interventions for reducing maladaptive responding exhibited by two individuals with dual sensory impairment and profound mental retardation was evaluated. Results indicated that differential reinforcement of other behavior (DRO) approaches were not effective in either case. However, when deceleration procedures (overcorrection or brief physical restraint) were added, target behaviors decreased quickly. Also, interventions were faded in such a way that gains were maintained for 6 months with only minimal effort by staff. Ongoing assessment of concurrent effects of behavior reduction strategies revealed increases in time on task or amount of work completed, even though these responses were not targeted specifically. Yet negative side effects (e.g., increases in self-stimulation) also were documented, highlighting the importance of evaluating multiple behaviors during intervention. Finally, despite the fact that objective assessments led to positive conclusions regarding treatment efficacy, ratings of baseline and treatment behavior samples by independent judges showed overall improvement in only one case. These findings suggest the need for multifaceted evaluation to determine the utility of interventions in applied settings.

Behavioral assessment of anxiety in older adults. Some comments.

The behavioral assessment of anxiety in older adults is reviewed in this article. Despite the high rate of anxiety symptoms uncovered during the course of large-scale epidemiological studies, the comprehensive evaluation of anxiety in this age group (55 and over) is not highly sophisticated at this juncture. In this review, diagnostic issues, psychometric evaluation, motoric assessment, and psychophysiological assessment are considered. Throughout the articles, gaps in the extant research are identified, and a research agenda for the future is developed.

Drug abuse prevention for high-risk African American children and their families: a review and model program.

In this article we are specifically concerned with the familial and socioeconomic factors that contribute to the exceedingly high prevalence rates of drug abuse in African-American children. In addition to detailing the impact of drug abuse in African-American children and their families, we consider how this critical health problem can be prevented using existing knowledge and strategies known to mental health professionals. A model program entitled Project for a Substance Abuse-Free Environment (SAFE) is outlined. Its objectives are to implement: (a) a broad-spectrum family intervention to empower disadvantaged and high-risk families in their communities: (b) a competency-based skills intervention to increase resilience and decrease drug use and other maladaptive behaviors in at-risk children; (c) alternative activities that will promote self-efficacy, achievement, and self-esteem; (d) a culturally-relevant evaluation plan that includes both formative (process) and summative (outcome) evaluation; (e) a comprehensive approach for assessing project impact; (e) systematic procedures for enhancing the maintenance and generalization of gains in participating children and families.

DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics.

This study investigated the characteristics of each of the specific DSM-III-R (American Psychiatric Association, 1987) anxiety disorders in a clinic sample of 188 anxiety disordered children. Characteristics examined included sociodemographic variables (age-at-intake, gender, and race of the child, and family marital and socioeconomic status) and clinical variables (disorder age-at-onset and severity, and history of additional disorders). Findings are discussed in light of the contemporary literature on childhood anxiety disorders.