Clinical Management of Gender Dysphoria in Adolescents

SUMMARY

This paper aims to provide professionals working with adolescents with gender-dysphoric feelings practical clinical guidelines for diagnosis and treatment. The different phases of the assessment procedure and treatment process are described. Differential diagnostic considerations and possible psychotherapeutic treatment options are given. Physical interventions, including GnRH analogues to inhibit puberty and cross-sex hormones, are described with consideration of eligibility and readiness issues. We end with discussion of post-treatment evaluation.     

Evaluation of an Inference‐Based Approach to Treating Obsessive‐Compulsive Disorder

This study evaluated an inference‐based approach (IBA) to the treatment of obsessive‐compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. “Maybe the door is open”, “My hands could be dirty”) as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty‐four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale‐Brown Obsessive Compulsive Scale (Y‐BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y‐BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.     

Social skills and sex‐role functioning in borderline personality disorder: relationship to self‐mutilating behavior

This study compared the social skills functioning and sex role affiliation of female inpatients diagnosed with borderline personality disorder who engaged in self‐mutilating behavior (n?=?30) with female patients with borderline personality disorder who did not engage in such behavior (n?=?18). Patients with borderline personality disorder who engaged in self‐mutilating behavior were found to have relatively poorer skills in communicating non‐verbal emotional information to others and in receiving and interpreting such information from others. In terms of sex role orientation, patients who engaged in self‐mutilating behavior were significantly more likely than non‐mutilators to be typed as undifferentiated using the Bem Sex Role Inventory. These participants were less likely to identify with either masculine or feminine sex roles. Patients who did not self‐mutilate were found to be significantly more likely than those who did self‐mutilate to identify with the masculine sex role.     

Psychological sequelae of remote exposure to the September 11th terrorist attacks in Canadians with and without panic

The purpose of the present investigation was to examine the psychological impact of remote exposure to the events and aftermath of the terrorist attacks in the USA on September 11th, 2001, and to assess what differences, if any, exist between individuals classified with probable panic disorder and those without. Telephone interviews were conducted with 122 residents of the capital city of the Canadian prairie province of Saskatchewan in spring 2002 in order to gather information regarding current mood, fears and avoidance behaviours as well as current post‐traumatic stress disorder symptoms specific to September 11th. Consistent with previous findings and despite the remote nature of exposure, results indicated that the psychological well‐being and behaviour of participants with probable panic disorder was more adversely affected by the events and aftermath of September 11th than those without panic disorder. These results suggest that remote viewing of traumatic events can have a significant and lingering impact on psychological well‐being and behaviour and that these effects are more pronounced in those with panic disorder. Implications of the findings and future research directions are discussed.     

The Effects On and Of Depression - An Exploratory Study of Rehabilitation and Secondary Prevention in Coronary Artery Disease

Forty consecutive participants in a comprehensive, behaviourally oriented coronary rehabilitation and secondary prevention program were followed for three years. Changes in depression (as measured with the Beck Depression Inventory) as well as the influence of baseline levels of depression on achieved changes in lifestyle behaviour and on rehabilitation and secondary prevention effects were analyzed. Subjects with moderate levels of baseline depression experienced short-term reductions of depression, which was maintained at the 12-month follow-up. Clinically depressed subjects experienced less positive results, with smaller immediate reductions as well as relapse to baseline levels after 12 months, specifically in non-physical, cognitive-affective depression symptoms. There were, however, no differences in lifestyle changes or in hospital treatment between groups with different pre-treatment depression levels. These results are discussed in relation to earlier research on the detrimental effects of depression on the prognosis of coronary artery disease.     

A Contemporary View of Applied Relaxation for Generalized Anxiety Disorder

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.     

Social Anxiety and Friendship Quality over Time

Abstract

High social anxiety in adults is associated with self-report of impaired friendship quality, but not necessarily with impairment reported by friends. Further, prospective prediction of social anxiety and friendship quality over time has not been tested among adults. We therefore examined friendship quality and social anxiety prospectively in 126 young adults (67 primary participants and 59 friends, aged 17–22 years); the primary participants were screened to be extreme groups to increase power and relevance to clinical samples (i.e., they were recruited based on having very high or very low social interaction anxiety). The prospective relationships between friendship quality and social anxiety were then tested using an Actor–Partner Interdependence Model. Friendship quality prospectively predicted social anxiety over time within each individual in the friendship, such that higher friendship quality at Time 1 predicted lower social anxiety approximately 6 months later at Time 2. Social anxiety did not predict friendship quality. Although the results support the view that social anxiety and friendship quality have an important causal relationship, the results run counter to the assumption that high social anxiety causes poor friendship quality. Interventions to increase friendship quality merit further consideration.     

Intolerance of Uncertainty Mediates the Relation Between Generalized Anxiety Disorder Symptoms and Anger

Previous research has shown that individuals with generalized anxiety disorder (GAD) report elevated anger compared with nonanxious individuals; however, the pathways linking GAD and anger are currently unknown. We hypothesized that negative beliefs about uncertainty, negative beliefs about worry and perfectionism dimensions mediate the relationship between GAD symptoms and anger variables. We employed multiple mediation with bootstrapping on cross-sectional data from a student sample (N = 233) to test four models assessing potential mediators of the association of GAD symptoms to inward anger expression, outward anger expression, trait anger and hostility, respectively. The belief that uncertainty has negative personal and behavioural implications uniquely mediated the association of GAD symptoms to inward anger expression (confidence interval [CI] = .0034, .1845, P_M = .5444), and the belief that uncertainty is unfair and spoils everything uniquely mediated the association of GAD symptoms to outward anger expression (CI = .0052, .1936, P_M = .4861) and hostility (CI = .0269, .2427, P_M = .3487). Neither negative beliefs about worry nor perfectionism dimensions uniquely mediated the relation of GAD symptoms to anger constructs. We conclude that intolerance of uncertainty may help to explain the positive connection between GAD symptoms and anger, and these findings give impetus to future longitudinal investigations of the role of anger in GAD.     

Brief treatment with alprazolam and behavioral guidance in panic disorder

Abstract

Thirty-two patients with panic disorder, with or without agoraphobic limitations, were treated with alprazolam (mean dose 3.5 mg/d) plus brief behavioral guidance in an open study during eight weeks. The sample had a notorious severity in the frequency of panics and phobic avoidance but was only mildly depressed. Before starting treatment the presence of demoralized mood and extensive avoidance were significant indicators of clinical severity, whereas the presence of dizziness as a relevant somatic complaint was not related to higher severity. After eight weeks of treatment a clinical improvement equal to or exceeding 80% of change was obtained in all cases (29) who completed treatment. Ninety-two percent of the patients were panic free at the end of treatment. There were significant reductions in all the scales with comparable declines in the subgroups formed according to the presence or absence of agoraphobic avoidance and demoralization. The data suggested that moderate doses of alprazolam could be a quick and effective treatment for panic-agoraphobic patients in the short term. The behavioral guidance probably helped in reducing agoraphobic avoidance and in obtaining global good effectiveness although this awaits controlled tests. Finally, the similarity in the response to treatment regardless of the presence of extensive avoidance or demoralized mood argues in favor of not considering the different variants of panic-agoraphobic syndrome differently, at least in samples with similar severity to the present one.     

The direct and indirect benefits of dispositional mindfulness on self-esteem and social anxiety

This study investigated the long‐term health effects of combat stress reaction (CSR) among Israeli CSR casualties (112) and control veterans (184) of the 1973 Yom Kippur war. Posttraumatic stress disorder (PTSD), physical symptoms, and adverse health practices were examined 18 years after the war. The relationship between CSR, PTSD, physical symptoms and adverse health practices was examined via hierarchical linear regression. Findings indicate that although CSR was positively associated with more current physical symptoms and adverse health practices in univariate analyses, these associations were not significant once demographic differences between the groups were controlled. In contrast, current PTSD symptoms were positively associated with current physical symptoms (p < 0.001) and showed a trend association with adverse health practices (p = 0.06). PTSD was the most powerful predictor of current physical symptoms and appears to mediate the association between CSR and physical symptoms almost two decades after the war. Both combat stress reaction and the results of the study were discussed in the light of the theory of Conservation of Resources (COR).