The Heart of the Matter: An Essay about the Effects of Managed Care on Family Therapy with Children*

This essay is based on a pilot study that examined the effects of managed care on the treatment of children and families, with special attention to community mental health. We embarked on the pilot study to test the accuracy and generalizability of our impression that family therapy and other systemic practices have been marginalized in ordinary clinics and agencies, and to understand the reasons why. We interviewed managed care providers, researchers, family therapy trainers, and clinicians in the Northeast. Our findings led to seven themes that support our impression that, even though there is a consensus about the need for coordinated family-based services, there is a disconnection between state policies, contractual requirements and what is actually occurring at the implementation level. This study suggests that our knowledge of human systems may be in danger of being disqualified and lost, with damaging consequences for the care of children. Yet, as systemic thinkers and practitioners, it is our belief that ethical and effective treatment need not be at odds with care that is cost-efficient. The direction of our future research will be to study whether the involvement of all stakeholders at all levels of planning and training leads to systemic family-based practices that consistently save costs and provide high-quality care.     

In Vivo Hippocampal Acetylcholine Release During Exposure to Acute Stress

Hippocampal extracellular acetylcholine (ACh) and choline levels were evaluated using in vivo microdialysis in male Fischer 344 rats before, during, and following an 80-min exposure to two different stress conditions. Measurements were taken in rats restrained and immersed in a water bath containing either 37 degreesC (normothermic-restraint) or 20 degreesC (cold-restraint) water. Results were compared to normothermic-freely-moving rats. Cold-restrained rats displayed decreased ACh levels during cold exposure relative to both normothermic-restrained and normothermic-freely-moving rats. By the end of the cold exposure period and following removal from cold, ACh levels had returned to near-baseline values. Normothermic-restrained rats had levels similar to those of normothermic-freely-moving rats, except for a marked increase in ACh following removal from restraint. Cold-restrained rats displayed a gradual elevation in choline levels during cold stress, followed by a gradual decline after stress termination, whereas both normothermic-restrained and normothermic-freely-moving rats displayed gradual decreases during the microdialysis session. These findings demonstrate that central cholinergic neurotransmission can be altered by the application of, and removal from, acute stressors. In addition, the results suggest a possible relationship between the magnitudes of both the stressor and its cholinergic consequences.     

‘As in a theatre’: scientific spectacle in Bacon's New Atlantis

Essay review of Reclaiming Reality, by Roy Bhaskar, London: Verso, 1989, 218 pages, pb £10.95.     

Sleep disturbance and emotion dysregulation as transdiagnostic processes in a comorbid sample

Sleep disturbance and emotion dysregulation have been identified as etiologic and maintaining factors for a range of psychopathology and separate literatures support their relationships to anxiety, depression, PTSD, and alcohol dependence (AD) symptom severity. Previous studies have examined these relationships in isolation, failing to account for the high rates of comorbidity among disorders. It is not yet known whether these processes uniquely predict symptom severity in each of these domains. Participants were 220 patients in residential substance abuse treatment, who had experienced a potentially traumatic event and exceeded screening cutoffs for probable PTSD and problematic alcohol use. Controlling for emotion dysregulation and the interrelationships among the outcome variables, insomnia was uniquely associated with anxiety (B = .27, p < .001), depression (B = .25, p < .001), PTSD (B = .22, p < .001), and AD (B = .17, p = .01) symptom severity. Similarly, controlling for insomnia, emotion dysregulation was uniquely associated with anxiety (B = .40, p < .001), depression (B = .47, p < .001), PTSD (B = .38, p < .001), and AD (B = .26, p < .001) symptom severity. Insomnia and emotion dysregulation appear to be transdiagnostic processes uniquely associated with symptom severity across a number of different domains and might be important treatment targets for individuals with PTSD and AD.     

A Multi-Study Examination of Well-Being Theory in College and Community Samples

Well-being theory (WBT) proposes five indicators of well-being [i.e., positive emotion, engagement, relationships, meaning, achievement (PERMA)] that are, independently, empirically supported predictors of flourishing (i.e., an optimal level of well-being; Seligman in Flourish: a visionary new understanding of happiness and well-being. Free Press, NY, 2011). However, there is limited empirical support for the multidimensional model suggested by WBT. Two studies sought to test and validate the higher-order factor structure of the five components of PERMA and PERMA’s ability to predict concurrent and prospective flourishing outcomes (e.g., physical health, college success). In Study 1, a longitudinal examination of college students, participants completed measures of well-being (including four of the five PERMA indicators), physical health, and college success at the end of their sophomore, junior, and senior years. In Study 2, a larger, cross-sectional study was conducted online to further validate the PERMA model with a broader sample and all five PERMA indicators. Participants completed measures similar to those administered at Study 1 and other measures used to validate Study 1 measures. Results from Study 2 further validated the PERMA model by comparing Study 1 measures to established measures and by adding meaning to the model. Study 1 and Study 2 PERMA models predicted markers of well-being (e.g., vitality, life satisfaction) and flourishing (e.g., physical health). The two studies reported here provide cross-sectional and longitudinal support that WBT is useful for predicting flourishing.     

Group Cognitive Behavioral Treatment for PTSD: Treatment of Motor Vehicle Accident Survivors

Individual cognitive behavioral therapies (CBT) are now considered the first-line treatment for posttraumatic stress disorder (PTSD; Foa, Keane, & Friedman, 2000). As mental health reimbursement becomes more restricted, it is imperative that we adapt individual-format therapies for use in a small group format. Group therapies have a number of advantages, including provision of a natural support group, the ability to reach more patients, and greater cost efficiency. In this article, we describe the development of a group CBT for PTSD in the aftermath of a serious motor vehicle accident (MVA). Issues unique to the group treatment format are discussed, along with special considerations such as strategies to reduce the potential for triggering reexperiencing symptoms during group sessions. A case example is presented, along with discussion of group process issues. Although still in the early stages, this group CBT may offer promise as an effective treatment of MVA-related PTSD.     

Clamped Corticosterone (B) Reveals the Effect of Endogenous B on Both Facilitated Responsivity to Acute Restraint and Metabolic Responses to Chronic Stress

To determine the effects of both corticosterone (B) and chronic stressors on acute ACTH responses to restraint, young male rats were exposed to streptozotocin-induced diabetes, cold (5-7 degreesC) or intracerebroventricular (icv) neuropeptide Y (NPY) for 5 d and then exposed to restraint within 2 h after lights on. Two groups of rats were studied: intact and adrenalectomized replaced with B pellets that maintained plasma B in the normal mean 24-h range of intact rats. In addition to ACTH and B responses to restraint on d 5, body weight, food intake, fat depots, glucose and other hormones were measured to determine the role of stress-induced elevations in B on energy balance. ACTH responses to restraint were normal in intact rats subjected to diabetes or cold. By contrast, there was no ACTH or B response to restraint in NPY-infused intact rats. All 3 groups of chronically stimulated adrenalectomized rats with clamped B had facilitated ACTH responses to restraint compared to their treatment controls. Overall food intake increased in all groups of stressed rats; however, augmented intake occurred only during the light in intact rats and equally in the light and dark in B-clamped rats. White adipose depot weights were decreased by both diabetes and cold and increased by NPY in intact rats; the decreases with cold and increases with NPY were both blunted and changes in fat stores were not significant in adrenalectomized, B-clamped rats. We conclude that: 1. diabetes- and cold-induced facilitation of restraint-induced afferent input to hypothalamic control of the hypothalamo-pituitary-adrenal (HPA) axis is opposed in intact rats by the elevated feedback signal of B secretion; 2. NPY does not induce facilitation of afferent stress pathways; 3. chronic stimulation of the HPA axis induces acute hyperresponsiveness of hypothalamic neurons to restraint provided that the afferent input of this acute stimulus is not prevented by B feedback; 4. stimulus-induced elevations in B secretion result in day-time feeding; 5. insensitivity of both caloric efficiency and white fat stores to chronic stress in adrenalectomized, B-clamped rats results from loss of normally variable B levels.     

The Vasarhelyi method of child art psychotherapy: an adjunctive treatment in childhood depression

We describe the use of child art psychotherapy (CAP) following the Vasarhelyi method in an 11-year-old female with a history of anxiety and depression which limited her capacity to attend school and in a 15-year-old male who had a history of depressive symptoms with suicidal thinking. In each case, the use of other therapies such as cognitive behaviour therapy was not possible or unsuccessful. Through the creation of images, each young person revealed concerns which had not been previously verbalised, and recovery was linked in time to the revelation of these worries. We propose the use of the Vasarhelyi method of CAP as an adjunctive treatment of depression in young people.     

Does comorbid attention-deficit/hyperactivity disorder impact the clinical expression of pediatric obsessive-compulsive disorder?

What is the impact of attention-deficit/hyperactivity disorder (ADHD) on the phenotypic expression of pediatric obsessive-compulsive disorder (OCD). We examined phenotypic features, and functional and clinical correlates in youths with OCD, with and without comorbid ADHD, from a large sample of consecutively referred pediatric psychiatry patients. Although comorbid ADHD had no meaningful impact on the phenotypic expression or clinical correlates of OCD, it was associated with higher rates of compromised educational functioning compared with other OCD youths. Our findings suggest that the OCD phenotype runs true and is not impacted by comorbid ADHD in youths diagnosed with both OCD and ADHD. In such affected youths, both disorders contribute to morbid dysfunction and require treatment. More work is needed to determine whether OCD plus ADHD represents a developmentally and etiologically distinct form of the OCD syndrome.     

MRI-Assessed Volume of Cerebellum Correlates with Associative Learning

Richard F. Thompson's cerebellar model of classical eyeblink conditioning highlights Purkinje cells in cerebellar cortex and principal cells in the deep cerebellar nucleus as the integrating cells for acquisition of conditioned responses (CRs). CR acquisition is significantly slower in rabbits with lesions to cerebellar cortex and in Purkinje cell-deficient mice that lose all cerebellar cortical Purkinje cells. Purkinje cells are the largest neurons in the cerebellum and contribute significantly to cerebellar volume. Magnetic resonance imaging (MRI) was used to assess cerebellar volume in humans. Cerebellar volume was related to eyeblink conditioning (400-ms delay procedure) in 8 adults (21-35 years) and compared to 8 older adults (77-95 years) tested previously (Woodruff-Pak, Goldenberg, Downey-Lamb, Boyko, & Lemieux, 2000). In the young adult sample, there was a high correlation between percentage of CRs in a session and cerebellar volume (corrected for total intracranial volume [TIV], r =.58, p =.066). There were statistically significant age differences in cerebellar volume, t(14) = 8.96, p <.001, and percentage of CRs, t(14) = 3.85, p <.002, but no age difference in TIV. Combining the young and older adult sample, the correlation between percentage of CRs and cerebellar volume (corrected for TIV) was.832 (p <.001). Cerebellar volume showed age-related deficits likely due to Purkinje cell loss. Individual differences in classical eyeblink conditioning are associated with differences in cerebellar volume, supporting Thompson's model of a cerebellar cortical role in facilitating this form of associative learning.