A Clinician's Guide to PTSD Treatments for Returning Veterans

What options are available to mental health providers helping clients with posttraumatic stress disorder (PTSD)? In this paper we review many of the current pharmacological and psychological interventions available to help prevent and treat PTSD with an emphasis on combat-related traumas and Veteran populations. There is strong evidence supporting the use of several therapies including prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and cognitive processing therapies (CPT), with PE possessing the most empirical evidence in favor of its efficacy. There have been relatively fewer studies of non-exposure based modalities (e.g., psychodynamic, interpersonal, and dialectical behavior therapy perspectives), but there is no evidence that these treatments are less effective. Pharmacotherapy is promising (especially paroxetine, sertraline, and venlafaxine), but more research comparing the relative merits of medication vs. psychotherapy and the efficacy of combined treatments is needed. Given the recent influx of combat-related traumas due to ongoing conflicts in Iraq and Afghanistan, there is clearly an urgent need to conduct more randomized clinical trials research and effectiveness studies in military and Department of Veterans Affairs PTSD samples. Finally, we provide references to a number of PTSD treatment manuals and propose several recommendations to help guide clinicians' treatment selections.     

Contextual priming in semantic anomia: a case study

The present case continues the series of anomia treatment studies with contextual priming (CP), being the second in-depth treatment study conducted for an individual suffering from semantically based anomia. Our aim was to acquire further evidence of the facilitation and interference effects of the CP treatment on semantic anomia. Based on the results of the study of , our hypothesis before the treatment was that our participant would show short-term interference and at most modest and short-term benefit from treatment. To acquire such evidence would not only be important for the choice of anomia treatment methods in individual patients, but would also prompt further development of the CP method. The CP technique used for our participant included cycles of repeating and naming items in three contextual conditions (semantic, phonological, and unrelated). As predicted, the overall improvement of naming was modest and short-term. Interestingly, the contextual condition that corresponded with the nature of our patient's underlying naming deficit (semantic) elicited immediate interference in the form of contextual naming errors, as well as short-term improvement of naming. Based on this and a recent study by , it appears that despite short-term positive effects, in its current form the CP treatment is not sufficient for those aphasics who have a semantic deficit underlying their anomia. The possible mechanism and directions for future research are discussed.     

从雌激素替代治疗的历史看临床决策的影响因素

20世纪40年代,动物实验提供的致癌效应证据限制了雌激素替代治疗的应用。20世纪60年代,价值观因素极大地推动了雌激素替代治疗,以至于关于致癌效应的证据被忽视。20世纪70年代,人群研究提供的致癌效应证据使得雌激素替代治疗的应用不断减少。20世纪80年代,致癌效应的消除和观察性流行病学研究提供的心脏保护证据,将雌激素替代治疗的应用推向了顶峰。20世纪末,大规模随机对照试验提供的有害效应证据推动了雌激素替代治疗应用的大幅下降。雌激素替代治疗一波三折的历史体现了证据、价值观在不同时期对临床决策的不同影响,说明只有遵循循证医学的实践模式,基于现有最佳的科学证据,并结合医生的临床经验与患者的价值观,才可能做出科学、有效的临床治疗决策。     

高原缺氧防治探索研究中的一些思考

通过对增氧和增压两种治疗方法在高原缺氧中作用和应用现状的回顾分析,以及对传统高压氧技术和新出现的增压舱技术的优缺点比较,认为增压舱治疗技术是一种简单易行的高原缺氧防治新方法,同时认为探索合理的增压方式是高原缺氧防治研究的发展方向。     

Family therapy as a treatment for children: a critical review of outcome research.

The value of family therapy as a treatment for child psychopathology is considered by reviewing pertinent outcome research. Fourteen studies that met three criteria are included in the review: (a) a child or adolescent was the identified patient or referral; (b) therapy included at least one parent and the child; and (c) outcome was evaluated in terms of the child's symptoms. There are major shortcomings in most of the available data, with only two well-controlled studies. Some empirical evidence does exist that family therapy is an effective treatment for children; the data from studies of adolescents are especially encouraging. However, insufficient data are available for comparing the relative merits of conjoint family treatment and individual child therapy. If the value of family therapy as a treatment alternative or, ideally, as the "treatment of choice" for a referred individual child is to be established, more and better controlled comparative outcome studies will be necessary. Suggestions for future research are presented emphasizing the need for a developmental perspective by recommending, for example, the use of factorial designs in which the intervenaction of treatment and age can be analyzed.     

Assessment of repeated relational patterns for individual cases using the SASB-based Intrex questionnaire

Repeated interpersonal patterns are central to case conceptualization and treatment planning in interpersonal and attachment-based approaches to therapy. In this study, raters (133 college students, 165 inpatients) provided data on the Intrex questionnaire (Benjamin, 2000) about self-treatment, relationship with a significant other, and remembered interactions with parents in childhood. Within-subject profiles were inspected for precise behavioral matches conforming to 3 "copy process" (CP) patterns: identification (behaving like an important other), recapitulation (behaving as if the other person is still present and in charge), and introjection (treating the self the way another did). We observed CP evidence in most individual ratings. Consistent with expectation, nonclinical raters tended to copy a securely attached pattern of affiliation, low hostility, and moderate degrees of enmeshment and differentiation. Only patients copied maladaptive behavior at greater than base rate expectation. We discuss implications and provide recommendations for use of Intrex in individual assessment of CP.     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

Bridging the Theory-Practice Gap by Getting Even Bolder With the Boulder Model

Cognitive behavioral therapy is an effective treatment for virtually all psychiatric disorders. However, very few patients have access to it and few therapists are trained in the theory and practice of cognitive behavioral therapy. Based on the existing evidence and the articles of this series, the following recommendations are made: (a) all mental health care providers (including Psy.D. and social workers) need to be trained in the practice and theories of empirically supported treatments, specifically cognitive behavioral therapy; (b) clinical practice also needs to be based on theory, not just treatment manuals; and (c) psychological treatments have to move beyond the DSM boundaries.     

An intrasubject approach to causal attribution

The present investigation draws on the judgment research tradition in order to examine the causal attributions made by individual subjects in an often used attribution task. Formal empirical tests of Kelley's (1967) attribution theory have demonstrated that attributions are influenced by the interaction of consensus, distinctiveness, and consistency information. None of these studies, however, have separately examined attributions made by individual judges. Implicit assumptions about individual differences, for example, have been made by the template-matching model of causal attribution (Orvis, Cunningham, & Kelley, 1975) but have not been scrutinized at the intrasubject level. Log linear modeling of attributions in the present research showed that while subjects were influenced by the causal information in the task, the relation between this information and attributions was more importantly characterized by individual differences than by uniform patterning. The nature of these individual differences and the significance of an idiographic approach to causal analysis are discussed.     

Group psychotherapy training and effectiveness.

This study surveyed accredited programs in psychiatry, psychology, and social work, replicating and extending previous work in group training. Results detail the curriculum, group faculty/student participation, and predicted future therapy trends in four different formats of group treatment. The number of group courses in the curriculum, the number required, and the percent of students participating in these courses significantly varies among the three disciplines, indicating a discrepancy among those disciplines responsible for training in group therapy regarding the value and role of group training. Consensus does exist among the disciplines in forecasting that individual therapy will decrease and group treatment will increase, but what programs deliver in their training does not coincide with their predicted trends for group therapy use in the future. Ratings of the differential effectiveness of the four group modalities vs. individual are not consistent with empirical evidence. Results call for consensual clarity, accord of values and knowledge, and the integration of science, training, and practice across the three disciplines.     

The relationship between psychometric test scores and reconviction in sexual offenders undertaking treatment

The evidence is mixed regarding the utility of psychometric test scores in prediction of the likelihood of sexual reoffending. This paper summarizes the research examining the relationship between psychometric measures and sexual recidivism, before detailing the findings of four large-scale studies in England and Wales, and comparing the findings of these studies to similar studies from other countries. The implications of the evidence to date are discussed, and recommendations are made for the future of psychometric testing as a way of determining risk of recidivism, dynamic risk factors, change over treatment, and the efficacy of rehabilitative programs.     

The epidemiology of cerebral palsy in term infants

Half of cerebral palsy (CP) arises in infants of normal birthweight; yet, many fewer studies seek to identify risk factors for CP in term and near-term infants than in those born very prematurely. There has been no net decrease in the prevalence of CP in term and near-term infants over recent decades. Potentially asphyxiating birth complications account for a small minority of CP cases. Recent studies suggest that disorders of coagulation and intrauterine exposure to infection or inflammation are associated with risk of CP, and that both can be accompanied by signs of neonatal encephalopathy, the best available predictor of CP in term neonates. Therapeutic interventions directed at preventing interruption of oxygen supply have not been shown to reduce the occurrence of CP. There have not yet been studies examining whether medical interventions directed at infection or coagulation disorder can reduce the frequency of CP.     

Issues in the Treatment of Native Americans With Alcohol Problems

The author reviews the literature on the treatment of Native Americans who have alcohol abuse or dependence disorders and provides an interpretation of the research on this topic. The most common alcohol treatment modalities used with Native Americans are described and critiqued, including adapted versions of standard treatments. Several practiced recommendations are made regarding revising standard treatments to make them more culturally appropriate for Native Americans.     

Selection Criteria for Family Therapy

The patient selection criteria for most modalities of psychotherapy have not yet been clearly articulated. This paper presents a decision-tree model outlining the factors that incline a clinician to perform a family evaluation, then to decide upon family treatment instead of another form of therapy, and finally to settle upon the particular duration and intensity of family treatment. We have compiled screening criteria, based on research and clinical opinion, to be applied in the utilization review of the decisions made at each of these steps. This method can be used to evaluate the appropriateness of care and render decision-making explicit and accountable; it may also have considerable value in training and research.     

Examining the role and functions of self-development in healthcare therapy trainings: A review of the literature with a modest proposal for the use of learning agreements

Many healthcare trainings with a psychodynamic orientation encourage or require students to commit to a process of personal development, such as provided through attending individual psychotherapy and/or an experiential ‘as if therapy’ group. This paper reviews recent literature about training in psychodynamically oriented practices within counselling psychotherapy, psychiatry, the creative arts therapies and clinical psychology. The results indicate that the mandatory personal development dimension of therapy training needs urgent reassessment. Results of studies consistently call for further research about the direct benefits of personal development on students’ development of skills for therapy practice. There is minimal evidence to indicate what self-development through individual psychotherapy can specifically deliver in terms of eventual professional competence. To address some aspects of the current lacuna, this paper summarises the recommendations for training programmes available from the current research, and makes a modest proposal for the use of learning agreements, rather than only mandated hurdle requirements, to ensure that the incremental steps by which the student attains expected requirements is negotiated and agreed within regularised, and widely accepted university course procedures.     

The case for causal influences of action videogame play upon vision and attention

Over the past decade, exciting findings have surfaced suggesting that routine action videogame play improves attentional and perceptual skills. Apparently, performance during multiple-object tracking, useful-field-of-view tests, and task switching improves, contrast sensitivity and spatial-resolution thresholds decrease, and the attentional blink and backward masking are lessened by short-term training on action videogames. These are remarkable findings showing promise for the training of attention and the treatment of disorders of attentional function. While the findings are interesting, evidence of causal influences of videogame play is not as strong as is often claimed. In many studies, observers with game play experience and those without are tested. Such studies do not address causality, since preexisting differences are not controlled for. Other studies investigate the training of videogame play, with some evidence of training benefits. Methodological shortcomings and potential confounds limit their impact, however, and they have not always been replicated. No longitudinal studies on videogame training exist, but these may be required to provide conclusive answers about any benefits of videogame training and any interaction with preexisting differences. Suggestions for methodological improvement are made here, including recommendations for longitudinal studies. Such studies may become crucial for the field of attentional training to reach its full potential.     

Engagement in Behavioral Parent Training: Review of the Literature and Implications for Practice

Engagement in behavioral parent training (BPT), including enrollment, attrition, attendance, within-session engagement, and homework completion, has long been a critical issue in the literature. Several estimates of various aspects of engagement have been suggested in the literature, but a systematic review of the available literature has never been accomplished. This review examines engagement data across 262 studies of BPT. Recruitment attrition, program attrition, attendance, and within-session engagement are examined across studies, with particular emphasis on the impact that SES, study purpose (efficacy vs. effectiveness), treatment format (individual vs. group), and age of child may have on those rates. Results of this review suggest that the significant amount of attrition occurs prior to enrollment in BPT, with at least 25 % of those identified as appropriate for BPT not enrolling in such programs. An additional 26 % begin, but drop out before completing treatment. Still the combined dropout rate of at least 51 % leaves at best half of identified parents completing treatment. While SES status had a small effect on attrition, other variables were not found to meaningfully impact engagement. Information on within-session engagement (homework and ratings of participation) was not often reported in studies. Key issues in this literature (e.g., varying definitions of engagement, limited attention to reporting key aspects of engagement) are discussed, and recommendations are made to further improve this important area of research and clinical practice.     

Behandlungsleitlinie Persönlichkeitsstörungen

The S2 guidelines for the treatment of personality disorders (PD) are summarized. In the diagnostic assessment of personality disorders a clinical interview should be supplemented by (semi-) structured clinical interviews and self-report measures for the categorical and dimensional assessment of PDs. The results of the assessment process should be communicated to the patient based on a psycho-educational framework. The diagnosis should always be linked to the patient’s individual history. Psychotherapy is the treatment of choice for personality disorders. A detailed analysis of the patient’s problems as well as the definition of a hierarchy of treatment goals are part of the process of treatment planning. For three PDs empirical evidence for treatment approaches is available: (1) dialectical behavior therapy, mentalization-based therapy, schema focused therapy and transference focused therapy all proved beneficial in the treatment of borderline personality disorder. Cognitive-behavior therapy proved helpful in the treatment of (2) dissociative personality disorder and (3) avoidant personality disorder. There is limited evidence for interpersonal therapy and psychodynamic therapies in the treatment of avoidant personality disorder.     

A Conceptual Model and Clinical Framework for Integrating Mindfulness into Family Therapy with Adolescents

Individual and group‐based psychotherapeutic interventions increasingly incorporate mindfulness‐based principles and practices. These practices include a versatile set of skills such as labeling and attending to present‐moment experiences, acting with awareness, and avoiding automatic reactivity. A primary motivation for integrating mindfulness into these therapies is compelling evidence that it enhances emotion regulation. Research also demonstrates that family relationships have a profound influence on emotion regulation capacities, which are central to family functioning and prosocial behavior more broadly. Despite this evidence, no framework exists to describe how mindfulness might integrate into family therapy. This paper describes the benefits of mindfulness‐based interventions, highlighting how and why informal mindfulness practices might enhance emotion regulation when integrated with family therapy. We provide a clinical framework for integrating mindfulness into family therapy, particularly as it applies to families with adolescents. A brief case example details sample methods showing how incorporating mindfulness practices into family therapy may enhance treatment outcomes. A range of assessment modalities from biological to behavioral demonstrates the breadth with which the benefits of a family‐based mindfulness intervention might be evaluated.     

Temporal stability in the Rorschach method: a meta-analytic review

The temporal stabilities of the Rorschach method scoring systems were investigated. A comprehensive literature search was conducted to find all test-retest studies, both regular and from control samples in therapy evaluation studies. Meta-analyses were conducted for samples, individual entries, and variables in 36 samples. Separate analyses were made for 10 samples using the Comprehensive System (CS; Exner, 1993). The temporal stability was high, especially those obtained from regression model predictions. The CS consistently shows higher stability than other systems, whereas increasing retest intervals leads to decreasing stability. Shortcomings of the available studies are highlighted and discussed, and recommendations are given for design and methodology.