Primary Care and Clinical Psychology: Assessment Strategies in Medical Settings

There is ample evidence regarding medical-psychological comorbidity to consider clinical psychology as a viable component of health care services in medical settings. Psychologists can become valuable assets to primary care physicians who treat a high number of primary psychiatric cases as well as medical cases with secondary psychological symptoms. Psychologists who function in hospital-based clinics as well as affiliates with primary care (PC) offices can provide empirically supported assessment services that can make treatment more effective and efficient. Multiple studies indicate high prevalence rates of psychiatric patients in PC settings using various instruments. This paper reviews selected assessment tools that have established diagnostic validity and reliability that can be both strategic for patient care and useful to reinforce psychologist collaboration with primary care physicians (PCP).     

Cognitive Behavior Therapy for Relatively Active and for Passive Chronic Fatigue Syndrome Patients

In chronic fatigue syndrome (CFS), facilitating, initiating, and perpetuating factors are distinguished. Although somatic factors might have initiated symptoms in CFS, they do not explain the persistence of fatigue. Cognitive behavior therapy (CBT) for CFS focuses on factors that perpetuate and prolong symptoms. Recently it has been shown that, based on their level of activity, two groups of patients can be distinguished. For so-called “relatively active” CFS patients, the main perpetuating factors are nonaccepting and demanding cognitions leading to bursts of activity. For so-called “passive” CFS patients, their fear that activity might worsen their symptoms (which results in an avoidance of activity) is the most important perpetuating factor. These differences in perpetuating factors result in separate treatment manuals for relatively active and for passive CFS patients. Before describing the treatment manuals, we outline basic assumptions, considerations before starting CBT for CFS, and ways to determine the activity pattern.     

Family and Partner Facing a Chronic Disease: Chronic Fatigue Syndrome

The purpose of this article is to analyze the growing interest in the influence of the family, particularly the patient's partner, on chronic fatigue syndrome (CFS). Social support is a vital element in many medical conditions. There is growing interest in the influence of the family, particularly the patient's partner, on chronic fatigue syndrome (CFS), but more work is needed in this line. Helping family members to optimize the support they provide may be the key to improving the efficacy of therapeutic interventions in CFS, and have a positive impact on the patient's symptoms.     

Does having a pet make a difference? Highlights from the HBSC Portuguese study

Pets are part of many adolescent’s lives. Objectives: To identify in a large national representative sample of Portuguese adolescents (HSBC study), the percentage of adolescents that have pets, what kind of feelings pets provide, differences by gender and age (through school grades) and to verify whether adolescent health, well-being, life satisfaction and psychological symptoms are associated with having a pet. Methods: The 2014 study provided national data of 6026 Portuguese adolescents (52.3% of which were girls), whose mean age was 13.8 years, randomly selected from those attending 6th, 8th and 10th grades. Measures included asking the participant if he/she had pets, which pet was, and the relationship they had with the pet, ISS, perception of well-being, life satisfaction and psychological symptoms. Results: The large majority of Portuguese adolescents had a pet. Adolescents who referred having a pet reported more frequently having dogs and cats. As for positive feelings related to pets, results showed that pets give them feelings of happiness, companionship, nurturing, tranquility, security and responsibility always/almost always, especially in girls and younger boys. The results also showed that having a dog was associated with a higher socio-economic status, better perception of well-being, more life satisfaction and less psychological symptoms. Conclusion: Since research shows that young people who have pets report higher rates of well-being/health perception, that information should be used to conduct more studies and change policies in ways that benefit adults and children.     

Effects of attitude action identification on congruence between attitudes and behavioral intentions toward social groups

Attitude Representation Theory (ART) holds that attitude-relevant responses are informed by mental representations of the attitude object, which include the individual's actions toward that object. Action Identification Theory (AIT) holds that the same action can be identified at multiple levels. Individuals who identify their actions at lower levels have less flexibility in how they perform the action, and thus enact the action less consistently. An integration of ART and AIT suggested that individuals who spontaneously (Experiment 1) or through manipulation (Experiments 2 and 3) identify their attitude-relevant actions toward a social group at lower levels might display less attitude-intention congruence than would individuals who identify their attitude-relevant actions at higher levels. ART and AIT are discussed as having links with each other and with other theories of attitude and judgment processes.     

Web-Based Intervention for Returning Veterans with Symptoms of Posttraumatic Stress Disorder and Risky Alcohol Use

A substantial number of military personnel who have served in Iraq (Operation Iraqi Freedom; OIF) and Afghanistan (Operating Enduring Freedom; OEF) develop symptoms of posttraumatic stress disorder (PTSD) in response to their military experiences and many of these same individuals will drink in a risky or problematic manner following deployment. If left untreated, PTSD symptoms and alcohol problems can become chronic and have a significant, negative impact on the lives of veterans, their families and communities. Further, OIF and OEF service members are often reluctant to seek treatment for mental health symptoms or alcohol problems secondary to stigma. In order to reach this population it is essential that new strategies and venues for delivering evidence-based care are explored. Web-based interventions are uniquely suited to this cohort of veterans in that they have the potential to reach a significant number of veterans who commonly use the Web and who might not otherwise receive care. This article will review the prevalence of PTSD and alcohol problems among OIF and OEF veterans, common barriers they experience with accessing care in traditional mental health settings, and what is known about the effectiveness of Web-based approaches for PTSD and alcohol problems. It also describes the components of a new Web-based intervention, developed by the authors, that uses motivational enhancement and cognitive-behavioral strategies to intervene with returning veterans who report PTSD symptoms and problem drinking. Recommendations for future directions in working with returning veterans with PTSD and alcohol problems will be offered.     

Chronic Fatigue Syndrome: The Need for Subtypes

Chronic fatigue syndrome (CFS) is an important condition confronting patients, clinicians, and researchers. This article provides information concerning the need for appropriate diagnosis of CFS subtypes. We first review findings suggesting that CFS is best conceptualized as a separate diagnostic entity rather than as part of a unitary model of functional somatic distress. Next, research involving the case definitions of CFS is reviewed. Findings suggest that whether a broad or more conservative case definition is employed, and whether clinic or community samples are recruited, these decisions will have a major influence in the types of patients selected. Review of further findings suggests that subtyping individuals with CFS on sociodemographic, functional disability, viral, immune, neuroendocrine, neurology, autonomic, and genetic biomarkers can provide clarification for researchers and clinicians who encounter CFS characteristically confusing heterogeneous symptom profiles. Treatment studies that incorporate subtypes might be particularly helpful in better understanding the pathophysiology of CFS. This review suggests that there is a need for greater diagnostic clarity, and this might be accomplished by subgroups that integrate multiple variables including those in cognitive, emotional, and biological domains.     

Informing Evidence-Based Assessment of ADHD in Veterans and Service Members

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.5% to 5% of the population, and though epidemiological studies of ADHD in veterans and service members are lacking, available evidence suggests that there may be a higher prevalence of ADHD in service members than in the general population. Assessment of ADHD in military populations is complicated by the higher prevalence rates of many other disorders with symptoms that overlap those of ADHD (e.g., posttraumatic stress disorder), making differential diagnosis an important aspect of the evaluation of ADHD. Although the diagnostic interview remains the gold standard for the evaluation and diagnosis of ADHD with adults, several different types of psychological measures have been developed and validated that can aid the evaluation. Future epidemiological research focused on prevalence and comorbidity rates in military samples is warranted to better understand the scope and complexity of the diagnosis. In addition, continued study of diagnostic assessment techniques, including validity testing and neurocognitive performance of veterans and service members with ADHD, particularly postdeployed veterans pursuing higher education, is warranted. This article reviews relevant findings and identifies initial recommendations for clinicians and researchers.     

Opposite effects of anxiety and depressive symptoms on executive function: The case of selecting among competing options

People constantly face the need to choose one option from among many, such as when selecting words to express a thought. Selecting between many options can be difficult for anyone, and can feel overwhelming for individuals with elevated anxiety. The current study demonstrates that anxiety is associated with impaired selection across three different verbal tasks, and tests the specificity of this finding to anxiety. Anxiety and depression frequently co-occur; thus, it might be assumed that they would demonstrate similar associations with selection, although they also have distinct profiles of symptoms, neuroanatomy and neurochemistry. Here, we report for the first time that anxiety and depressive symptoms counter-intuitively have opposite effects on selection among competing options. Specifically, whereas anxiety symptoms are associated with impairments in verbal selection, depressive symptoms are associated with better selection performance. Implications for understanding the mechanisms of anxiety, depression and selection are discussed.     

Prevalence of Sexual Abuse Among Children with Conduct Disorder: A Systematic Review

Many clinicians and researchers have speculated that child sexual abuse and conduct disorder co-occur frequently, yet no systematic reviews of literature have specifically addressed both these conditions. To estimate the prevalence of sexual abuse among children with conduct disorder, the pertinent literature was systematically reviewed. Ten databases were searched, supplemented with hand search of reference lists from retrieved papers. Blind assessments of study eligibility and quality were conducted by two independent researchers. Disagreements were resolved by consensus. Twenty-three studies meeting minimum quality criteria that were enough to insure objectivity and not to invalidate results and including 7,256 participants with either conduct disorder or child sexual abuse were examined. The prevalence of child sexual abuse among participants with conduct disorder was 27 %; however, such figure might be underestimated due to selection, sampling, and recall biases; poor assessment methods; and narrow definitions of abuse in included studies. Participants with conduct disorder, compared with healthy individuals, reported higher rates of child sexual abuse. However, compared with other psychiatric populations, they reported similar or lower rates. There was also some evidence suggesting that children with conduct disorder might be more likely to report child physical abuse. Female participants with conduct disorder, compared with males, were significantly more likely to report child sexual abuse. Youths with conduct disorder are at risk of being (or having been) sexually abused, although such risk seems to be neither more specific to nor stronger for these individuals, compared with people with other psychiatric disorders.     

Pervasiveness of framing effects among physicians and medical students

Researchers have been documenting the influence of framing upon decision making for more than two decades; decisions appear to change in response to superficial changes in the presentation of possible outcomes. Several studies of medical decision making have revealed; for instance, that clinical decisions differ when options are presented as gains (survival rates) rather than losses (mortality rates). However, most studies of framing effects in the medical domain have utilized a very limited number of clinical problems that have not allowed an adequate test of the prevalence of the phenomena. To extend previous studies, we presented three groups of subjects (experienced internists, residents, and third-year medical students) with booklets containing twelve hypothetical medical cases. Half of the subjects received gain versions and half received loss versions of the same cases. Chi-square analyses revealed that framing did not influence any of the decisions of medical students and influenced the decisions of residents and experienced physicians on only two of the clinical problems (the same two problems). It appears that the prevalence of framing effects in the clinical domain may be limited.     

What Do Chaplains Contribute to Large Academic Hospitals? The Perspectives of Pediatric Physicians and Chaplains

This article analyzes interviews with pediatric physicians (N = 30) and chaplains (N = 22) who work at the same large academic medical centers (N = 13). We ask how pediatric physicians understand and work with chaplains and how chaplains describe their own work. We find that physicians see chaplains as part of interdisciplinary medical teams where they perform rituals and support patients and families, especially around death. Chaplains agree but frame their contributions in terms of the perspectives related to wholeness, presence, and healing they bring. Chaplains have a broader sense of what they contribute to patient care than do physicians.     

Mixed anxiety and depression

We review evidence from community, primary care, and psychiatric samples to determine whether there are a group of patients who have mixed symptoms of anxiety and depression that are below diagnostic thresholds for either group of disorders. A review of the data strongly suggests that such a group of patients exists and that, despite lacking sufficient symptoms to meet diagnostic thresholds from the revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987), they often have significant impairment in social and vocational functioning. Because many of these patients also suffer from medically unexplained somatic symptoms, they may be more likely to frequently use nonpsychiatric medical care. Longitudinal studies suggest that persons with mixed anxiety-depression symptoms may represent a population who are at increased risk for more severe mood and anxiety disorders.     

Symptoms,impairment and illness intrusiveness–their relationship with depression in women with CFS/ME

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is an illness in which physiological and psychological factors are believed to interact to cause and maintain CFS/ME in an individual predisposed to it. The various symptoms and impairments associated with CFS/ME have a large impact on quality of life. The purpose of the present study was to identify the extent to which the core symptoms and impairments associated with CFS/ME relate to depression in women with CFS/ME, and to discover whether these relationships were mediated by illness intrusiveness. CFS/ME was found to be a highly intrusive illness, intruding into more life domains and to a greater degree than other illnesses. The effects of both symptoms and impairment on depression were, in part, mediated by illness intrusiveness. Although symptoms severity and impairment had both direct and indirect effects on depression, illness intrusiveness was the strongest predictor of depression.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

Hyperactivity and the Fragile X Syndrome

Workers who have claimed an association between Fragile X [fra(x)] Syndrome and Hyperactivity and aggressive behavior have done so despite the lack of controlled studies using standard diagnostic criteria. Accordingly, we provided a controlled test of the hypothesis that individuals with the fra(x) Syndrome are more hyperactive and have more symptoms of aggression than other mentally retarded individuals. The test formed part of a study to assess autistic behavior in fra(x) individuals. A sample of fra(x) individuals was obtained from the register of a clinical genetics unit and individually matched for age, sex, and IQ with mentally retarded individuals selected from assessment centres. Fortyfive pairs of fra(x) cases and control individuals were compared on criteria which reflected DSM-III concepts of hyperactivity and on criteria reflecting aggressive behavior. The comparison failed to find a higher prevalence of these symptoms in the fra(x) group. An analysis of the study's statistical power suggested that it is unlikely that the investigation failed to detect a large to medium difference between fra(x) individuals and control individuals in the symptoms investigated.     

How do i know what i feel? Evidence for the role of self‐categorisation in symptom perceptions

This paper extends the self‐categorisation model of symptom appraisals to predict that individuals who believe they have a given illness will perceive concurrent symptoms relevant to that illness to be more severe when they categorise themselves as members of a group of people with that illness. These predictions are supported with opportunity samples of individuals reporting, or not reporting a common cold (Study 1, N = 60) and reporting colds or tinnitus (Study 2, N = 64). In both studies, relevant symptoms were rated as more severe when illness group memberships were salient. The methodological, theoretical and clinical implications of these findings and possible therapeutic applications of self‐categorisation theory (SCT) to symptom perceptions are discussed. Copyright © 2007 John Wiley & Sons, Ltd.     

Co-Rumination Exacerbates Stress Generation among Adolescents with Depressive Symptoms

Through stress generation, individuals’ own thoughts and behaviors can actually lead to increases in their experience of stress. Unfortunately, stress generation is especially common among individuals who are already suffering from elevated depressive symptoms. However, despite the acknowledgement that some individuals with depressive symptoms generate greater stress than others, few studies have identified specific factors that could exacerbate stress generation among individuals with depressive symptoms. The present study examines co-rumination as a factor that might exacerbate stress generation among adolescents with depressive symptoms using a short-term longitudinal design. Considering these processes among adolescents was critical given that many youth experience increases in depressive symptoms at this developmental stage and that co-rumination also becomes more common at adolescence. Participants were 628 adolescents (326 girls; 302 boys) who reported on their depressive symptoms, experiences of stress, and co-rumination with a best friend. Interpersonal stressors (peer and family stress) and non-interpersonal stressors (school and sports stress) were assessed. Consistent with past research, adolescents with depressive symptoms experienced greater interpersonal and non-interpersonal stress over time. Importantly, co-rumination interacted with both depressive symptoms and gender in predicting increases in peer stress. Depressive symptoms predicted the generation of peer stress only for girls who reported high levels of co-rumination with friends. Implications for protecting youth with depressive symptoms against stress generation are discussed.     

Effective Procedures for Conducting Genetic Prevalence Studies With Children1

In this study, the effectiveness of genetic screening study procedures was examined. One analysis was designed to explore whether having a genetic screening study simply introduced by a physician who had just completed a child's evaluation (vs. introduced by an unfamiliar individual) influenced whether the child's parent enrolled the child in the study. Also examined were explanations for nonenrollment and final enrollment decisions among individuals initially uncertain about enrollment. The primary finding was that a physician's introduction to the genetic screening study was associated with a 17% increase in enrollment, and with a 9.9% greater rate of enrollment overall. The rate of increase was greatest among physicians who were most consistent with introducing the screening study. Initially undecided individuals comprised 14% of the final sample. Many parents who chose not to participate felt that the research study was not important. A smaller percentage of parents chose not to enroll in the genetic study because of discomfort with genetic testing. The findings have important implications for designing effective procedures for prevalence research.     

MEDICAL PERCEPTIONS OF MENOPAUSAL SYMPTOMS

Thirty-five physicians in family practice or gynecology, 43 practicing nurses, and 35 menopausal or postmenopausal women rated the frequency, severity, and causality of 15 menopausal symptoms commonly reported in the literature. Subjects also rated their degree of preference for four possible menopause treatments (counseling, estrogen therapy, mood-altering medication, and no treatment) and answered an open-ended question asking them what they saw as the major factor in determining whether a woman would experience difficulty at menopause. The results overall suggest that medical persons see menopausal symptoms as more pathological than women who have experienced or are experiencing menopause and that physicians, relative to menopausal women, adhere to a more psychogenic model in which psychological causality and symptoms are given greater emphasis than menopausal women give them.