Attachment--and loss.

In this paper, we consider the domain of executive functions (EFs) and their possible role in developmental psychopathologies. We first consider general theoretical and measurement issues involved in studying EFs and then review studies of EFs in four developmental psychopathologies: attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), autism, and Tourette syndrome (TS). Our review reveals that EF deficits are consistently found in both ADHD and autism but not in CD (without ADHD) or in TS. Moreover, both the severity and profile of EF deficits appears to differ across ADHD and autism. Molar EF deficits are more severe in the latter than the former. In the few studies of more specific EF tasks, there are impairments in motor inhibition in ADHD but not in autism, whereas there are impairments in verbal working memory in autism but not ADHD. We close with a discussion of implications for future research.

Executive Functions and Developmental Psychopathology

Death is the new sex, last great taboo in Western society and Western medicine, as Richard Smith discusses in his editorial (p 129). In the trinity of births, marriages, and deaths, only death does not have glossy magazines devoted to stylish consumption at the attendant ceremonies. On the web, of course, …

Death and dying

Consumer Reports (1995, November) published an article which concluded that patients benefited very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment, and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy. Furthermore, no specific modality of psychotherapy did better than any other for any disorder; psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctoring. Patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse. The methodological virtues and drawbacks of this large-scale survey are examined and contrasted with the more traditional efficacy study, in which patients are randomized into a manualized, fixed duration treatment or into control groups. I conclude that the Consumer Reports survey complements the efficacy method, and that the best features of these two methods can be combined into a more ideal method that will best provide empirical validation of psychotherapy.

http://psycnet.apa.org/journals/amp/50/12/965.pdf

The Effectiveness of Psychotherapy The Consumer Reports Study

This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.

/pdf/the-empirical-status-of-empirically-supported-2nkuyl6oot.pdf

The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials.

How many and which individuals, with which psychiatric disorders, receive (and do not receive) mental health services from which professionals in what settings? This question falls within the purview of mental health services research, which is a multidisciplinary field that brings together the methodologies of epidemiology, econometrics, and clinical research. First, in this article, we present an explication of what is known about those individuals in need of psychotherapy and how they access services. Next, we describe the numbers, professional affiliations, and service sites of professionals who are engaged in the practice of psychotherapy. We summarize our current knowledge about the actual utilization of psychotherapy services relative to the needs of patients and the professional background of therapists. Finally, we identify aspects of psychotherapy service utilization that are, as yet, unaddressed.

Patterns of Mental Health Service Utilization

The dosage model provides a normative estimate of the overall pattern of patient improvement in psychotherapy The phase model further specifies patterns of change in the domains of subjective well-being, symptom remediation, and functioning The expected treatment response (ETR) approach uses patient characteristics to predict an expected path of progress for each patient With repeated measures of mental health status, the treatment progress of an individual patient can be assessed against the patient's ETR to support decisions that would enhance the quality of a clinical service while it is being delivered

Assessing treatment progress of individual patients using expected treatment response models.

The purpose of this study was to identify empirically patterns of grief among 141 older bereaved spouses. A longitudinal hierarchical cluster procedure with the Ward agglomeration method was used to identify distinct clusters based on grief scores. Three clusters were identified: common (49%), resilient (34%), and chronic (17%) grief. Members of the common grief cluster experienced elevated levels of grief and depressive symptoms that decreased over time. Members of the resilient cluster experienced the lowest levels of grief and depression and the highest quality of life. The chronic grief cluster experienced the highest levels of grief and depression, more sudden deaths, the lowest self-esteem, and the highest marital dependency. The majority in this chronic cluster also met proposed criteria for a diagnosis of complicated grief. Five out of every six bereaved spouses adjusted well over time, and about a third of these showed considerable resilience without negative consequences. One out of six experienced a chronic grief syndrome. Early identification of this syndrome can lead to referral to newly emergent treatments specific for grief.

Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.

Behavioral similarities between antisocial behavior disorders and frontal-lobe cerebral impairment have led to suggestions that conduct disorders are attributable to disinhibition deficit associated with frontal-lobe cerebral functions. This study compared the performance of 21 conduct disorder adolescents on measures of cognitive processes associated with frontal-lobe functions with that of a matched comparison sample. Conduct disorder adolescents performed more poorly on measures sensitive to frontal-lobe dysfunction (conceptual perseveration, poorly sustained attention, impaired sequencing on memory and motor tasks), but not on non-frontal-lobe specific cognitive measures. Although the findings support a neurobehavioral explanation of antisocial behavior as a product of cerebral disinhibition, caution is urged in overinterpreting causal relationships through neurobehavioral data.

Frontal-lobe cognitive dysfunction in conduct disorder adolescents.

Patterns of change in mental health were identified for 118 recently widowed participants using the Integra Outpatient Tracking Assessment, Mental Health Index. Change was measured 4 times over the first 2 years of bereavement using a cohort sequential design. It was hypothesized that application of the psychotherapy phase model would have some use in understanding the various ways in which people grieve. The overall pattern of change in mental health was similar to that of the psychotherapy dosage and psychotherapy phase models and indicated a dramatic change in overall mental health, well-being, and symptoms during the beginning phases of bereavement followed by a plateau. At 24 months after the death, participants had not attained the same level of mental health as the general population. Within limitations of the design and sample, 2 conclusions were reached: (a) the overall pattern of change in bereavement was similar to that of distressed patients receiving outpatient mental health services, and (b) the patterns of change for individuals vary, making it important to consider clinical characteristics that might account for individual differences. These findings help establish an empirical model of grief that has use for clinical interventions.

Robert J. Lueger

Papers

Patterns of Mental Health Service Utilization

Assessing treatment progress of individual patients using expected treatment response models.

Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.

Frontal-lobe cognitive dysfunction in conduct disorder adolescents.

Patterns of change in mental health status during the first two years of spousal bereavement.