Gender (r)evolution and contemporary psychiatry.

Perlson et al's editorial 'Envisioning a future for transgender and gender-diverse people beyond the DSM' heralds the arrival of the ICD-11's gender incongruence categories among conditions related to sexual health, brightening the spotlight on the re- (or rather de-)classification of gender-related disorders, which is a step in the right direction.

Personality dimensions and disorders and coping with the COVID-19 pandemic.

PURPOSE OF REVIEW: The COVID-19 pandemic has tested people's coping and resilience. This article reviews research and scholarly work aiming to shed more light on personality-based factors that account for adjustment to the pandemic situation. RECENT FINDINGS: Most studies relied on a cross-sectional design and were conducted using personality dimensions based on the Big Five personality model. Findings suggest that high levels of neuroticism constitute a risk for pandemic-induced distress and poor overall coping. People with prominent extraversion, conscientiousness or agreeableness have generally demonstrated a good adjustment to the pandemic, including compliance with containment and mitigation measures imposed by the authorities to limit the spread of COVID-19. A few studies of individuals with borderline personality disorder identified social isolation as the most destabilising factor for them. Poor compliance with containment and mitigation measures has been strongly associated with various antisocial personality traits. SUMMARY: Personality-based factors account for some individual differences in coping with both COVID-19-related threat and distress and requirements to comply with containment and mitigation measures. Better understanding of these factors could contribute to a more effective adjustment to the challenges of future public health crises.

Epidemiology of personality disorders in individuals with gender dysphoria.

PURPOSE OF REVIEW: Prevalence estimates of personality disorders (PD) in individuals with gender dysphoria (GD) are variable and heterogeneous, as psychiatric comorbidity and long-term follow-up data from gender-diverse samples are still limited. This review aims to assess prevalence rates across age groups and discuss potential reasons for variability in PD prevalence estimates among transgender people. RECENT FINDINGS: International epidemiological data from several countries indicate that the best available estimates of the prevalence of any PD diagnosis in transgender youth are around 20% for adolescents and tend to increase to nearly 50% in trans-adults. The paucity of available data on personality dysfunction in children and adolescents with GD precluded us from definitive conclusions on the trends of emerging PDs in this population. Estimates of PD prevalence in transgender and gender-diverse people seem to be highly affected by methodological characteristics of the studies with no universally agreed reference standards for this population. SUMMARY: The review of epidemiological studies on PD among gender-diverse people highlights the need for using more standardized study methodologies to make findings comparable. Nevertheless, international epidemiological data seem to support the link association between the development of PD and GD.

Recovery in borderline personality disorder: time for optimism and focussed treatment strategies.

PURPOSE OF REVIEW: Borderline personality disorder (BPD) is prevalent, debilitating and clinically challenging. The evolving field of intervention and outcomes in BPD research is considered with a focus on recent research. RECENT FINDINGS: A pattern of clinical and functional improvement is to be expected in patients experiencing BPD. Specialized psychotherapies are shown to be beneficial, but generalist, low-intensity interventions in nonspecialized centres are also showing efficacy. Long-term naturalistic studies show that remission of the disorder is common and promising outcomes are not only possible, but likely. Training in vocational functioning, improving personal competence and promoting resilience needs to be further developed. SUMMARY: BPD diagnosis does not need to overwhelm clinicians, nor does it require therapeutic pessimism. Targeted interventions, including meaningful psychoeducation, are helpful in promoting optimism and enhancing recovery-oriented treatments.

Advancing social and emotional well-being in Aboriginal and Torres Strait Islander Australians: Clinicians' reflections.

OBJECTIVE: An expert reference group met on four occasions to consider ways forward in terms of Indigenous mental health. This paper summarises the discussion and recommendations. CONCLUSION: While the negative effects of colonisation and trans-generational trauma continue, we propose renewed emphasis on improving access, cultural orientation and trauma-informed care, and a focus on the needs of young Indigenous Australians.

Sleep profiles and CBT-I response in schizophrenia and related psychoses.

This study investigated sleep subtypes in schizophrenia, and their response to Cognitive Behavioural Therapy for Insomnia (CBT-I) treatment. Sleep profiling was conducted using latent class analysis on baseline Pittsburgh Sleep Quality Index data (N = 74 outpatients with schizophrenia who were poor sleepers, 52% male, mean age = 41.4 years). Of these, 40 took part in CBT-I treatment. Analyses revealed three sleep subtypes based on total sleep time (TST), sleep efficiency (SE), and sleep onset latency (SOL) parameters: Cluster 1 ('classic severe insomnia', 44.6%), Cluster 2 ('insomnia with normal sleep duration', 37.8%), and Cluster 3 ('insomnia with hypersomnia', 17.6%). Gains analysis of pre- and post-treatment data from CBT-I participants revealed improvements in sleep and psychopathology in all three clusters, although there were some group differences in the areas and magnitude of improvement. Cluster 1 showed the greatest benefits with longer TST and improved SE. Cluster 2 showed a comparatively blunted treatment response although TST moved closer to recommended sleep guidelines. Cluster 3 showed significant reductions in TST. Altogether, this is the first demonstration of different sleep profiles in schizophrenia and their influence on treatment response to CBT-I. It also supports the notion that therapies should be tailored to the person and their insomnia presentation.

'A matter for conjecture': leucotomy in Western Australia, 1947-70.

Very little has been published on the rise and fall of psychosurgery in Australia. In the mid-twentieth century, Western Australia was the largest but most sparsely-populated of the six Australian States, and its local psychiatry practice was, as one commentator put it, 'backward'. Nonetheless, electroconvulsive therapy was introduced in 1945, and leucotomy in 1947. This paper will explore the introduction of leucotomy to Western Australia in the context of wider national and international trends in psychiatry, and posit some reasons for its decline and abandonment in the 1970s. It will present a narrative reconstruction of the local introduction and practice of leucotomy, using retrieved, reconstructed and previously unpublished data.

Pharmacotherapy of borderline personality disorder: replacing confusion with prudent pragmatism.

PURPOSE OF REVIEW: The article aims to examine trends in the pharmacological treatment of borderline personality disorder (BPD) and shed more light on the attendant controversies. RECENT FINDINGS: Although specialized, BPD-centred psychotherapy is considered first-line treatment for BPD and no psychotropic drug has been licensed for BPD, medications are frequently prescribed in the management of this condition. Various classes of psychopharmacological agents are used for BPD and there is a prominent polypharmacy. Use of antidepressants for BPD has been decreasing somewhat and use of mood stabilizers and second-generation antipsychotics has been increasing. Although there is a general agreement that little evidence of efficacy of medications exists for BPD, clinicians are either advised to almost completely avoid pharmacotherapy for BPD or use a 'targeted' approach, administering specific medications for the specific symptoms of BPD. This has created some confusion in clinical practice and contributed to a variety of prescribing practices for BPD. SUMMARY: Well designed studies of the efficacy of pharmacological agents in BPD are needed. Clinicians should use medications for BPD with caution, usually short term and mainly for symptom relief. They should frequently review a need for ongoing pharmacotherapy and make every effort to avoid polypharmacy.

Here and Now Aboriginal Assessment (HANAA): a follow-up survey of users.

OBJECTIVES: To explore users' views of, and experience with, the Here and Now Aboriginal Assessment (HANAA), an instrument developed for screening social and emotional wellbeing (SEWB) in Aboriginal adults. Over the last few years the HANAA has been widely disseminated across Australia. METHODS: All those on our database who had requested the HANAA package were contacted by email and invited to participate in the evaluation by completing an online survey. RESULTS: A total of 38 responses were received; the response rate was 36%. All 10 HANAA domains were highly rated by respondents; the overall mean score was 8.3/10. Each domain was assessed using a dichotomous scale of 'problem' or 'no problem' which respondents rated as being very useful; the mean score was 8.4/10. The mean score for the 'recommendation' section at the end of the HANAA was 7.2/10. CONCLUSIONS: Respondents reported a high level of utility and cultural applicability of the HANAA's assessment domains, semi-structured narrative style of administration and simple rating system. The HANAA is making a useful and practical contribution to the assessment of Aboriginal SEWB at a community level. Recommendations for future work on the HANAA include consideration of addition of a personality domain and development of a child and adolescent version.

Culture and personality disorder: a focus on Indigenous Australians.

PURPOSE OF REVIEW: To examine the validity of concept and diagnosis of personality disorder in transcultural settings using Indigenous Australian people as an example. RECENT FINDINGS: There are significant deficits in comparative research on personality disorders across cultures. There is also a dearth of information regarding Indigenous Australians, and cultural applicability and clinical utility of the diagnosis of personality disorder in this group. SUMMARY: The concept of culture is generally ignored when making a diagnosis of personality disorder. A valid diagnosis should incorporate what would be considered understandable and adaptive behavior in a person's culture. In Indigenous Australian culture, making diagnosis of a personality disorder is complicated by historical trauma from colonization, disruption of kinship networks, and ongoing effects of poverty and social marginalization.

Sleep in Schizophrenia: Exploring Subjective Experiences of Sleep Problems, and Implications for Treatment.

Sleep dysfunction is a pervasive issue in schizophrenia and psychosis. Current knowledge is drawn almost exclusively from studies using quantitative research methodologies that include measures and tools developed in healthy population groups. Qualitative studies investigating the first-person perspectives of sleep problems are therefore important for designing better assessment and treatment tools to meet consumer needs. Focus groups were conducted to elicit detailed information regarding the personal experience of sleep problems, their antecedents and impact, in 14 individuals with schizophrenia-spectrum disorder who experienced insomnia during their illness. Thematic analysis was applied to examine the data and draw treatment implications for sleep management. Insomnia was ubiquitous and frequently co-occurred with other sleep difficulties (nightmares, sleep walking, acting out dreams, etc.) in this group. Discussions revealed themes common across insomnia populations (role of negative mood states and cognitive intrusions) and also new themes on factors contributing to sleep problems in schizophrenia: (1) beliefs that sleep problems cannot be changed; (2) trauma and adversity; (3) lifestyle choices and lack of motivation; and (4) medication side effects. Sleep problems also had profound impact on daytime dysfunctions and disability. The findings point to novel issues that may benefit from consideration in the treatment of sleep problems in schizophrenia. Unhelpful cognitions and behaviours about sleep can be addressed with psychological interventions, activity scheduling and motivational interviewing techniques. Seeking a first-person perspective is vital for identifying issues that will impact on treatment success and recovery.

Early memories: Clinical relevance and significance.

OBJECTIVE: The purpose of this research was to examine earliest memories in patients with a mental disorder and their clinical relevance to diagnosis and treatment. METHOD: A semi-structured early memory questionnaire was developed and 50 patients with anxiety, depression or a psychotic disorder were interviewed. A thematic analysis was conducted to extract dominant themes from the qualitative data. RESULTS: Family events, play, and receiving attention were dominant themes of pleasant memories, while unpleasant memories consisted of fear-provoking situations, abuse/violence, and death-related themes. Participants were able to recall the feelings they had experienced at the time of their earliest memories and most participants stated that their first memories had significant impact in their lives. CONCLUSIONS: The findings of this exploratory study suggest that earliest memories may be of clinical significance for diagnostic and therapeutic interventions in psychiatry.

Mindfulness for personality disorders.

PURPOSE OF REVIEW: Third-wave cognitive-behaviour therapies such as dialectical behaviour therapy have demonstrated effectiveness in the treatment of personality disorders, which are considered difficult to treat. These therapies typically incorporate some component of mindfulness practice. The current study examines current applications and effectiveness of mindfulness to the treatment of personality disorders. RECENT FINDINGS: The majority of evidence available focuses on borderline personality disorder, and highlights positive associations between mindfulness practice and reduced psychiatric and clinical symptoms, less emotional reactivity, and less impulsivity. Fewer studies examine the other personality disorders, though emerging case studies have applied mindfulness techniques to treatment with antisocial, avoidant, paranoid, and obsessive-compulsive personality disorders. SUMMARY: Mindfulness is a promising clinical tool for the treatment of personality disorders, and appears to be adaptable to the unique features of different types of personality disorders. However, further empirical research with greater methodological rigour is required to clarify the effectiveness of mindfulness as a specific skill component, and to identify the underlying mechanisms that contribute to therapeutic change.

Towards culturally appropriate assessment of Aboriginal and Torres Strait Islander social and emotional well-being.

OBJECTIVE: Identification of need for specialist assessment and the use of relevant cultural information to inform mental health assessment and care are two key factors in improving Aboriginal and Torres Strait Islander access to and experience of mental health care. This paper describes the Here and Now Aboriginal Assessment tool (HANAA) and the Cultural Information Gathering Tool (CIGT), two instruments developed to be used respectively by non-mental health clinicians and Aboriginal and Torres Strait Islander mental health workers. METHOD: Following widespread consultations and feedback, two independent groups of mental health clinicians based in Western Australia and Queensland were involved in developing the HANAA and CIGT. RESULTS: Both the HANAA and CIGT fill unmet needs in terms of instruments that can be used by non-specialists working with Aboriginal and Torres Strait Islander people. CONCLUSIONS: Preliminary use of the HANAA and CIGT suggests that they are well received, easy to deploy and effective instruments that promote cultural security and communication with Aboriginal and Torres Strait Islander people.

Future-proofing the psychiatry workforce in Australia: evaluation of an innovative enrichment programme for medical students.

OBJECTIVE: The Claassen Institute of Psychiatry for Medical Students (the Institute) is an innovative enrichment programme aimed at attracting medical students to psychiatry. This paper reports on the effectiveness of the Institute as a strategy to increase interest in psychiatry as a career, and the career pathways of students who have attended since 2008. METHOD: Students completed a baseline questionnaire on day 1 and the final day of the Institute. A follow-up survey was administered electronically to ex-Institute students to determine their career pathways and current level of interest in psychiatry. RESULTS: Since 2008, 117 students have attended the Institute. There was a significant increase in those 'definitely' considering a career in psychiatry from 57% at baseline to 77% at the end of the week. Eighty-nine ex-Institute students were invited to participate in the follow-up survey, and of these 21% were currently psychiatry trainees. CONCLUSION: The Institute has been successful in encouraging medical students to pursue a career in psychiatry. Enrichment programmes are emerging as an effective recruitment strategy and will assist in future-proofing the psychiatric workforce in decades to come.