Clinical outcomes for sexual and gender minority adolescents in a dialectical behaviour therapy programme

BACKGROUND

Sexuality and gender minoritised (SGM) adolescents are at increased risk of self-injury and suicide, and experience barriers to accessing mental health support. Dialectical behaviour therapy (DBT) is an effective treatment for self-injury and emotion dysregulation in adolescent populations, but few studies have published outcomes of DBT for SGM young people.

AIMS

This study aimed to investigate treatment outcomes and completion for SGM adolescents and their cisgender and heterosexual peers, in the National & Specialist CAMHS, DBT service (UK).

METHOD

Treatment completion, and opting out before and during treatment were examined for sexual and gender identity groups, as well as changes by the end of treatment in emotion dysregulation, self-injury, in-patient bed-days, emergency department attendances, and borderline personality disorder, depression and anxiety symptoms.

RESULTS

SGM adolescents were over-represented in this service, even after considering their increased risk for self-injury. No statistically significant differences were found for treatment completion between the sexual orientation and gender identity groups, although there were patterns indicating possible lower treatment uptake and completion that warrant further investigation. Clinical outcomes for treatment-completers showed improvement by the end of DBT for each group, with few exceptions.

DISCUSSION

These results are from relatively small subsamples, and it was not possible to separate by sex assigned at birth. Findings should be treated tentatively and as early indications of effect sizes to inform future studies. This study suggests that DBT could be a useful treatment for SGM adolescents in a highly specialist treatment setting.

Gender- and Sexuality-Minoritised Adolescents in DBT: A Reflexive Thematic Analysis of Minority-Specific Treatment Targets and Experience

Gender- and sexuality-minoritised (GSM) adolescents are at increased risk of self-harm and suicidal behaviours compared to their cisgender and heterosexual peers. This increased risk is thought to be explained in part by exposure to stigma and societal oppression. Dialectical Behaviour Therapy (DBT) is an evidence-based intervention for self-harm and suicidal behaviour that may have advantages for supporting GSM young people in distress. No study has yet sought to understand what GSM-associated difficulties may be important to consider in DBT for adolescents, or the experiences of GSM young people in a standard DBT programme. Therefore, this study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Qualitative interviews were conducted with 14 GSM young people in a comprehensive DBT programme and were analysed using Reflexive Thematic Analysis. The analysis was supported by two further GSM young people who had finished DBT. The findings were split into three overarching themes (Identity, Impact of Others, and Space for Sexual and Gender Identity in DBT), each with themes within. The identity-based theme included "identity confusion and acceptance"; the relationship-based themes included "cis-Heterosexism" and "community connectedness"; and the space within DBT themes included "negotiating focus and targeting in DBT" and "creating safety in DBT". Findings are discussed in relation to implications and recommendations for therapists working with GSM young people within and outside of DBT.

Anticipation of and response to exercise in adolescents with CFS: An experimental study

BACKGROUND

Using a laboratory-based exercise task, this study investigated objective exercise performance as well as expectations, anxiety and perceived task performance ratings in adolescents with CFS compared to healthy controls and illness controls.

METHOD

Trials of a sit-stand exercise task (SST) were undertaken (CFS: n = 61, asthma (AS): n = 31, healthy adolescents (HC): n = 78). Adolescents rated their expectations, pre- and post-task anxiety, and perceived task difficulty. Their parents independently rated their performance expectations of their child.

RESULTS

The CFS group took significantly longer to complete the SST than the AS group (MD 3.71, 95% CI [2.41, 5.01] p < .001) and HC (MD 3.61, 95% CI [2.41, 4.81], p < .001). Adolescents with CFS had lower expectations for their performance on the exercise task than AS participants (MD -11.79, 95% CI [-22.17, -1.42] p = .022) and HC (MD -15.08, 95% CI [-23.01, -7.14] p < .001). They rated their perceived exertion as significantly greater than AS (MD 3.04, 95% CI [1.86, 4.21] p < .001) and HC (MD 2.98, 95% CI [1.99, 3.98], p < .001). The CFS group reported greater anxiety pre-task than AS (MD 14.11, 95% CI [5.57, 22.65] p < .001) and HC (MD 11.19, 95% CI [2.64, 19.75], p. = 007). Parental group differences showed similar patterns to the adolescents''.

CONCLUSIONS

Lower expectations and greater anxiety regarding exercise may reflect learning from previous difficult experiences which could impact future exercise performance. Further examination of pre-exercise expectations and post-exercise appraisals could improve our understanding of the mechanisms by which fatigue is maintained.

Mediators of increased self-harm and suicidal ideation in sexual minority youth: a longitudinal study

BACKGROUND

Sexual minority youth have elevated suicidal ideation and self-harm compared with heterosexual young people; however, evidence for mediating mechanisms is predominantly cross-sectional. Using a longitudinal design, we investigated self-esteem and depressive symptoms as mediators of increased rates of suicidal ideation or self-harm (SISH) among sexual minority youth, and the roles of childhood gender nonconformity (CGN) and sex as moderators of these relationships.

METHOD

In total, 4274 youth from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort reported sexual orientation at age 15 years, and past-year SISH at age 20 years. Self-esteem and depressive symptoms were assessed at ages 17 and 18 years, respectively. CGN was measured at 30-57 months. Covariates included sociodemographic variables and earlier measures of mediator and outcome variables. Mediation pathways were assessed using structural equation modelling.

RESULTS

Sexual minority youth (almost 12% of the sample) were three times more likely than heterosexual youth to report past-year SISH (95% confidence interval 2.43-3.64) at 20 years. Two mediation pathways were identified: a single mediator pathway involving self-esteem and a multiple-mediated pathway involving self-esteem and depressive symptoms. Although CGN was associated with past-year SISH, it did not moderate any mediation pathways and there was no evidence for moderation by sex.

CONCLUSIONS

Lower self-esteem and increased depressive symptoms partly explain the increased risk for later suicidal ideation and self-harm in sexual minority youth. Preventive strategies could include self-esteem-enhancing or protecting interventions, especially in female sexual minority youth, and treatment of depression.

Cognitive-behavioural therapy for adult attention-deficit hyperactivity disorder: a proof of concept randomised controlled trial

OBJECTIVE

To investigate efficacy, patient acceptability and feasibility of formulation-based cognitive-behavioural therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD). NICE guidelines for adult ADHD recommend further research into psychological treatments.

METHOD

Sixty participants with adult ADHD were randomly allocated to treatment as usual (TAU) vs. TAU plus up to 16 sessions of individual formulation-based CBT for ADHD.

RESULTS

Adding formulation-based CBT to TAU for ADHD significantly improved ADHD symptoms on the Barkley Current Symptoms Scale and scores on the Work and Social Adjustment Scale. Adjusted effect sizes (ES) were 1.31 and 0.82 respectively. There were also significant improvements on secondary outcomes including independently evaluated clinical global improvement, self-rated anxiety, depression, global distress and patient satisfaction (adjusted effect sizes 0.52-1.01).

CONCLUSIONS

This is the first randomised controlled trial to provide preliminary evidence of efficacy and acceptability of individual formulation-based CBT for ADHD when added to TAU over TAU alone. This approach now needs to be tested in a larger multicentred randomised controlled trial.

Mechanisms of change underlying the efficacy of cognitive behaviour therapy for chronic fatigue syndrome in a specialist clinic: a mediation analysis

BACKGROUND

Several randomized controlled trials (RCTs) have shown that cognitive behavioural psychotherapy (CBT) is an efficacious treatment for chronic fatigue syndrome (CFS). However, little is known about the mechanisms by which the treatment has its effect. The aim of this study was to investigate potential mechanisms of change underlying the efficacy of CBT for CFS. We applied path analysis and introduce novel model comparison approaches to assess a theoretical CBT model that suggests that fearful cognitions will mediate the relationship between avoidance behaviour and illness outcomes (fatigue and social adjustment).

METHOD

Data from 389 patients with CFS who received CBT in a specialist service in the UK were collected at baseline, at discharge from treatment, and at 3-, 6- and 12-month follow-ups. Path analyses were used to assess possible mediating effects. Model selection using information criteria was used to compare support for competing mediational models.

RESULTS

Path analyses were consistent with the hypothesized model in which fear avoidance beliefs at the 3-month follow-up partially mediate the relationship between avoidance behaviour at discharge and fatigue and social adjustment respectively at 6 months.

CONCLUSIONS

The results strengthen the validity of a theoretical model of CBT by confirming the role of cognitive and behavioural factors in CFS.

An experimental investigation of factors involved in the decision to undertake genetic testing for schizophrenia

BACKGROUND

The psychological issues surrounding genetic testing, particularly decision-making processes, are not well understood. Previous studies suggest that apparently "nondirective" strategies intended to help individuals consider the consequences of undergoing predictive testing for physical illness can influence the decision.

AIMS

To investigate the influence of selectively focussing on different aspects of previously provided information concerning genetic testing for schizophrenia.

METHOD

Community participants (n = 120) rated how likely they would be to arrange to have a genetic test for schizophrenia if it were available, before and after being given detailed information about schizophrenia and the implications of testing. Participants were then randomly allocated to four groups, and were implicitly focused on the negative issues (negative group), the positive issues (positive group), both the negative and positive issues (all-focusing group) or schizophrenia-irrelevant health-related issues (control group). All issues on which the experimental groups focussed were included in the information provided and the form of questioning meets current definitions of nondirectiveness.

RESULTS

Hypothetical decisions whether to arrange a genetic test for schizophrenia were influenced by the issues on which participants had focused; the positive group were more likely to say they would be tested relative to the other groups.

CONCLUSIONS

Decisions about genetic testing for schizophrenia were influenced by the specific issues on which individuals were encouraged to focus at that time.

The neural correlates of fatigue: an exploratory imaginal fatigue provocation study in chronic fatigue syndrome

BACKGROUND

Fatigue is the central symptom in chronic fatigue syndrome (CFS) and yet very little is known about its neural correlates. The aim of this study was to explore the functional brain response, using functional magnetic resonance imaging (fMRI), to the imaginal experience of fatigue in CFS patients and controls.

METHOD

We compared the blood oxygen level dependent (BOLD) responses of 12 CFS patients and 11 healthy controls to a novel fatigue provocation procedure designed to mimic real-life situations. A non-fatiguing anxiety-provoking condition was also included to control for the non-specific effects of negative affect.

RESULTS

During the provocation of fatigue, CFS patients reported feelings of both fatigue and anxiety and, compared to controls, they showed increased activation in the occipito-parietal cortex, posterior cingulate gyrus and parahippocampal gyrus, and decreased activation in dorsolateral and dorsomedial prefrontal cortices. The reverse pattern of findings was observed during the anxiety-provoking scenarios.

CONCLUSIONS

The results may suggest that, in CFS patients, the provocation of fatigue is associated with exaggerated emotional responses that patients may have difficulty suppressing. These findings are discussed in relation to the cognitive-behavioural model of CFS.

Treatments for chronic fatigue syndrome

AIMS

To review studies evaluating the treatment of chronic fatigue and chronic fatigue syndrome, to describe predictors of response to treatment and to discuss the role of the occupational health physician.

METHODS

A literature search was carried out using Medline and PsychInfo.

RESULTS

Studies evaluating cognitive behaviour therapy, graded exercise therapy, pharmacological interventions (e.g. antidepressants and corticosteroids), immunological interventions and nutritional supplements were reviewed. The most promising results have been found with cognitive behaviour therapy and graded exercise therapy, and some predictors of outcome have been identified. Most of the other interventions were evaluated in just one or two studies and therefore evidence is insufficient to draw firm conclusions.

CONCLUSIONS

By applying the models of fatigue that form the bases for cognitive behaviour therapy and graded exercise therapy, occupational health physicians may play an important role in helping the patients with chronic fatigue syndrome to reduce their symptoms, improve their functioning and return to work.

The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis

BACKGROUND

A self-rated measure of health anxiety should be sensitive across the full range of intensity (from mild concern to frank hypochondriasis) and should differentiate people suffering from health anxiety from those who have actual physical illness but who are not excessively concerned about their health. It should also encompass the full range of clinical symptoms characteristic of clinical hypochondriasis. The development and validation of such a scale is described.

METHOD

Three studies were conducted. First, the questionnaire was validated by comparing the responses of patients suffering from hypochondriasis with those suffering from hypochondriasis and panic disorder, panic disorder, social phobia and non-patient controls. Secondly, a state version of the questionnaire was administered to patients undergoing cognitive-behavioural treatment or wait-list in order to examine the measure's sensitivity to change. In the third study, a shortened version was developed and validated in similar types of sample, and in a range of samples of people seeking medical help for physical illness.

RESULTS

The scale was found to be reliable and to have a high internal consistency. Hypochondriacal patients scored significantly higher than anxiety disorder patients, including both social phobic patients and panic disorder patients as well as normal controls. In the second study, a 'state' version of the scale was found to be sensitive to treatment effects, and to correlate very highly with a clinician rating based on an interview of present clinical state. A development and refinement of the scale (intended to reflect more fully the range of symptoms of and reactions to hypochondriasis) was found to be reliable and valid. A very short (14 item) version of the scale was found to have comparable properties to the full length scale.

CONCLUSIONS

The HAI is a reliable and valid measure of health anxiety. It is likely to be useful as a brief screening instrument, as there is a short form which correlates highly with the longer version.

The effect of nondirective questioning on women's decisions whether to undergo bone density screening: an experimental study

This study investigated the effects of nondirective counseling on health screening decisions. Ninety women (mean age = 51 years) received information about bone density screening and osteoporosis. They were then randomly allocated to 1 of 4 groups and were encouraged to focus on positive issues about bone density screening (positive group), on negative issues (negative group), on both positive and negative issues (all-focusing group), or on issues relating to the common cold (control group). Women were asked to rate how likely they would be to opt for bone density screening if they saw it available. After being informed that they could have bone density screening, actual uptake was assessed. It was found that the issues on which individuals focused significantly influenced their rate likelihood of opting for the scan. Rated likelihood of testing was significantly associated with whether individuals actually did opt for testing when it was subsequently offered to them.

The effect of nondirective questioning on women's decisions whether to undergo bone density screening: an experimental study

This study investigated the effects of nondirective counseling on health screening decisions. Ninety women (mean age = 51 years) received information about bone density screening and osteoporosis. They were then randomly allocated to 1 of 4 groups and were encouraged to focus on positive issues about bone density screening (positive group), on negative issues (negative group), on both positive and negative issues (all-focusing group), or on issues relating to the common cold (control group). Women were asked to rate how likely they would be to opt for bone density screening if they saw it available. After being informed that they could have bone density screening, actual uptake was assessed. It was found that the issues on which individuals focused significantly influenced their rate likelihood of opting for the scan. Rated likelihood of testing was significantly associated with whether individuals actually did opt for testing when it was subsequently offered to them.

Obsessive-compulsive disorder, anxiety disorders, and self-esteem: an exploratory study

In a preliminary investigation of the link between self-esteem and obsessional problems, patients with OCD were compared with people suffering from other anxiety disorders and non-anxious controls. A questionnaire was devised which allowed the reliable coding of open ended responses focussed on issues surrounding self-worth; standardized measures of self-esteem and clinical symptomatology were also administered. Results indicated that both clinical groups differed significantly from non-clinical controls on generalized self-esteem assessments. There was some evidence of OCD specific effects; obsessionals were more likely than anxious controls to link their self-worth to other people and their relationships. They also regarded the possibility of causing harm as likely to result in other people making extreme negative and critical judgements of them; the other groups expected the responses of others towards them to be more lenient. The implications for future research and for treatment of OCD are discussed.

The prospect of predictive testing for personal risk: attitudes and decision making

As predictive tests for medical problems such as genetic disorders become more widely available, it becomes increasingly important to understand the processes involved in the decision whether or not to seek testing. This study investigates the decision to pursue the possibility of testing. Individuals (one group who had already contemplated the possibility of predictive testing and one group who had not) were asked to consider predictive testing for several diseases. They rated the likelihood of opting for testing and specified the reasons which they believed had affected their decision. The ratio of the numbers of reasons stated for testing and the numbers of reasons stated against testing was a good predictor of the stated likelihood of testing, particularly when the reasons were weighted by utility (importance). Those who had previously contemplated testing specified more emotional reasons. It is proposed that the decision process is internally logical although it may seem illogical to others due to there being idiosyncratic premises (or reasons) upon which the decision is based. It is concluded that the Utility Theory is a useful basis for describing how people make decisions related to predictive testing; modifications of the theory are proposed.

Predictive genetic testing: psychological factors

Advances in medical technology such as those linked to the human genome project are increasing the potential for predictive testing for a wide range of health threats. There have not been comparable advances in understanding of the psychological factors involved in such testing. These factors and issues relating to them are examined, and it is suggested that a cognitive-behavioral approach to the understanding and management of adverse reactions to testing is likely to be particularly fruitful. The use of such an approach should result in the development of effective pre- and posttest interventions to prevent, minimize, and manage distress associated with screening.

Mammography: role of the occupational health nurse

1. According to ACS and NCl guidelines, women should begin screening mammography with a baseline film between 35 and 39 years of age. She should then maintain routine mammography screening per the guidelines. 2. Twenty-five percent of women diagnosed with breast cancer have known risk factors. 3. Further investigation of the effectiveness of worksite mammography and mobile mammography vans is needed. 4. Occupational health nurses are in an optimal position to increase the level of current mammography usage.