EXAMPLE OF SKILLS CLASS

Assessing and treating a Specific Phobia of Vomiting

David Veale, Instiute of Psychiatry, Kings College London

Background: A Specific Phobia of Vomiting (SPOV) commonly develops in childhood with a mean duration of about 25 years and occurs almost exclusively in women (Veale and Lambrou, 2006; Lipsitz and Fyer, 2001). Clinicians generally regard SPOV as more difficult to treat and different in psychopathology compared to other specific phobias. People with SPOV tend to be more handicapped than people with other specific phobias (for example avoidance of a desired pregnancy or being significantly underweight from restriction of food). There is very little research in SPOV and no controlled trials in SPOV. It is however possible to use many of the advances in other disorders such as OCD and health anxiety for understanding the factors that maintain the preoccupation, distress and handicap in SPOV.  Our team provides a national service for treating SPOV and we are developing a research programme for assessing and treating SPOV. A SPOV is not a common specific phobia that presents for therapy but when it does most therapists seek help as patients may be difficult to engage. By the end of the class participants will be able to apply what they have learnt in the class to their everyday practice in treating SPOV and generalise some of the principles to other anxiety disorders.

Learning Objectives: By the end of the class, participants will be able to:
1. Diagnose a Specific Phobia of Vomiting (and differentiate it from an eating disorder; OCD; health anxiety; panic or social phobia).
2. Make a developmental formulation which can be used in engagement
3. Describe a cognitive behavioural formulation and model for treating SPOV
4. Use new assessment measures for monitoring SPOV
5. Use a variety of strategies from imagery rescripting, exposure in imagination and in vivo, and behavioural experiments for dropping of safety and avoidance behaviours.

Skills Class Leader: David Veale is a Consultant Psychiatrist in CBT at the South London and Maudsley Trust and The Priory Hospital North London. He is an Honorary Senior Lecturer at the Institute of Psychiatry, Kings College London. He is a Consultant at the Bethlem Royal Hospital which provides a national out-patient and residential service for people with SPOV and at the Priory Hospital North London which provides a specialist in-patient service for SPOV.  He has published about 70 peer-reviewed articles (mainly in OCD and BDD) and three self help books.

Background readings:
Boschen, M. J. (2007). “Reconceptualizing emetophobia: a cognitive-behavioral formulation and research agenda.” Journal of Anxiety Disorders 21(3): 407-19.

Lipsitz, J. D., A. J. Fyer, et al. (2001). “Emetophobia: preliminary results of an internet survey.” Depression & Anxiety 14(2): 149-52.

Veale, D. and C. Lambrou (2006). “The psychopathology of vomit phobia.” Behavioural and Cognitive Psychotherapy 34(2): 139-150.

Veale, D. (in submission). Treating a specific phobia of vomiting. The Cognitive Behaviour Therapist.

EXAMPLE OF HALF DAY WORKSHOP

Family Cognitive Behavioural Therapy for anxiety disorders in children and adolescents.

Susan Bögels, University of Maastricht, The Netherlands

Who the workshop is aimed at: Experience in cognitive-behavioural treatment of anxiety (in adults and/or children) is needed in order to follow this workshop.

Background: Anxiety disorders run in families; an overlap of 60-80% has been found between parental and child anxiety disorders. Next to genetic factors, “anxiety enhancing” parenting behaviours, like modelling of anxious behaviour, overprotection, and restriction of open expression of opinions and feelings, seem to contribute to this relationship. Family CBT has been found equally effective or more effective in treating child anxiety disorders, and is potentially more cost-effective because more family members are treated at the same time. The goal of family CBT is to decrease child anxiety, parental anxiety, and anxiety-enhancing parenting.

The goal of the family CBT that is outlined in the present workshop consists of three components:
(i) Teaching CBT skills to the anxious child and both parents, the parents being encouraged to use these skills to guide their anxious child and to cope with their own fears (4 sessions).
(ii) Modifying dysfunctional beliefs between parents and child that block the process of change, that is, parental beliefs about their anxious child, parenting, and the safety of their child’s world –often based on their own upbringing or anxiety-, and child’s dysfunctional beliefs about the parents and about the possibility and usefulness of communication with them (4 sessions).
(iii) Improving communication and problem solving, between spouses about their child’s anxiety, and between all family members, including siblings (4 sessions).

Learning Objectives: Participants will acquire the following skills:
1) Conducting a family conversation in order to orient the family towards the treatment goals
2) Coaching parents in guiding their anxious child (e.g. through courageous modelling)
3) Identifying and challenging dysfunctional parental cognitions about the anxiety of their child and their role as a parent
4) Conducting a family discussion on a “hot issue”

Teaching Methods: In this workshop the three components of the treatment will be taught through instruction, modelling, and practice (role-plays).

Workshop Leader: Susan Bögels (clinical psychologist/psychotherapist) works as a researcher and practitioner in the area of child and parental anxiety disorders. One of her major themes of interest is how parents of anxious children influence the anxiety of their child through their own dysfunctional beliefs, their own upbringing, and the interaction between parental and child anxiety. She is currently conducting a Randomised Clinical Trial in 8 centers of child psychiatry in Holland, to compare the effects of family CBT with child CBT for children and adolescents with clinical anxiety disorders.

Background Readings:
1. Barrett, P. M., Dadds, M. R., and Rapee, R. M. (1996). Family treatment of childhood anxiety: a controlled trial. Journal of Consulting and Clinical Psychology, 64, 333-342.

2. Ginsburg, G. S., Silverman, W. K., and Kurtines, W. K. (1995). Family involvement in treating children with phobic and anxiety disorders: A look ahead. Clinical Psychology Review, 15, 457-473.

3. Siqueland, L., and Diamond, G. S. (1998). Engaging parents in cognitive behavioral treatment for children with anxiety disorders. Cognitive and behavioural practice, 5, 81-102.

EXAMPLE OF A PANEL DISCUSSION

Common Language In Psychotherapy (CLiP) Project

Chair: Mehmet Sungur, Medical School of Marmara University, Dept of Psychiatry, Istanbul, Turkey

One of the main requirements for the evolution of psychotherapy from art into a science is to establish a common psychotherapy language. At present, similar procedures are given different names by different schools or the same label (name) may denote different procedures in different hands. The EABCT and AABT have recognized the need to reduce this confusion by appointing a joint task force to work on a project towards a common psychotherapy language. Panel members will outline the project. It aims to evolve a dictionary of psychotherapy procedures of therapists from different schools, with the hope of encouraging shared use of the same terms for given procedures. A common language might reduce confusion and facilitate scientific advance in the field. The project will use plain language. It will not lead to an encyclopaedia or textbook or theoretical exposition of psychotherapies. The dictionary will concisely describe terms for a comprehensive set of psychotherapy procedures in simple language as free from theoretical assumptions as possible, each with a brief case example (up to 450 words), note of its first known use, and 1-2 references. The terms will try to describe what therapists do, not why they do it (the latter too is important and could be the subject of a separate project). Regular updates of the Dictionary will be aimed at via the CLiP website that should operate shortly.  Submissions will be invited of 1st-draft entries of terms to the clip task force. The Panel will describe the project’s significance and hoped-for outcome, give examples of completed entries and their authors, and how to make 1st-draft submissions and the iterative process toward their completion. Most of the Panel’s 1.5 hours is expected to be taken up by audience feedback to help shape the project even further.

EXAMPLES OF OPEN PAPERS

a) Neuroimaging and CBT in anxiety disorders

Prasko, J., Horacek, J, Paskova, B. Prague Psychiatric Centre; 3rd Medical Faculty of Charles University and Centre of Neuropsychiatric Studies, Prague, Czech Republic Praskova, H., Out-patients Psychiatric Clinic, Horni Palata, Prague, Czech Republic

Neuroimaging studies on anxiety disorders is at relatively preliminary stage. Nevertheless, findings are arguably consistent with involvement of limbic, paralimbic, and prefrontal regions. In studies with positron emission tomography (PET) patients suffering with GAD have increased relative metabolic rates in the right posterior temporal lobe, right precentral frontal gyrus, and left inferior area 17 in the occipital lobe but reduced absolute basal ganglia rates (Wu et al. 1991). Imaging studies that have pooled or compared findings across different anxiety disorders may also shed light on the underlying neuroanatomy of anxiety symptoms that are not disorder specific. An analysis of pooled PET symptom provocation data from patients with OCD, PTSD, and specific fobia, for example, reported activation of paralimbic structures (right posterior medial orbitofrontal cortex, bilateral insular cortex), right inferior frontal cortex, bilaterl lenticulate nuclei , and bilaterl brain-stem foci (Rauch et al. 1997). There is growing realization of the importance of various CSTC loops in a range of behavioral disorders (cortico-striatal-thalamic-cortical circuit), particularly in relation to certain kinds of cognitive affective cues, and appear most relevant in OCD. Functional imaging studies provide some of the most persuasive evidence of the role of CSTC circuits in OCD. Patients have increased activity in the orbitofrontal cortex, anterior cingulate, and basal ganglia (Rauch and Baxter 1998). Additionally, question remain about precise nature of CSTC dysfunction in OCD and its normalization by effective treatment. Decreased orbitofrontal activity in OCD predicts positive response to pharmacotherapy, whereas higher orbitofrontal activity predicts positive response to behavioral therapy (Brody et al. 1998). Preliminary evidence from brain imaging shows the importance of amygdala and paralimbic structures in panic disorder. CT study suggested prefrontal abnormalities (Wurthmann et al. 1998), a SPECT study showing asymmetry of inferior frontal cortical perfussion (De Cristofaro et al. 1993). Although it has been hypothesized that cognitive-behavioral therapy exert effects in panic disorder by behavioral desensitization of hyppocampal-mediated contextual conditioning, or by cognitive techniques tha strengthen medial prefrontal cortex inhibition of amigdala (Gorman et al. 2000), the relevant empirical studies have not yet been undertaken. We will present preliminary PET data of 12 patients with panic disorder. Patient were measured before and after therapy with antidepressant or CBT. The finding will be discussed, compared with results of other studies and showed with accordance of neurobiological theories.

b) Relationships between schemas (Young’s model) and the bis/bas individual differences (Gray’s model).

Cid, J, Servei de Rehabilitació. Parc Hospitalari Marti i Julià. I.A.S. Girona ; Torrubia, R, Unitat de Psicología Mèdica. Universitat Autònoma de Barcelona. Barcelona.

Schemas have a central role in cognitive psychopathology. In fact, a cognitive model assumes that schemas are developed in response to biological predispositions and environmental influences. However, little is known in terms of empirical data with regard to how they are related to biological or temperamental variables. Furthermore, the cognitive-behavioural case conceptualization has not usually taken into account the influence of temperamental variables. Nowadays, there are several approaches both to the study of schemas (e.g. Beck et al., 1990; Arntz, 1999; Young, 1990) and to the study of biological or temperamental bases of personality (e.g. Gray, 1988; Cloninger, 1986, 1987). The theoretical frameworks of our research were the schema-focused model (Young, 1990) and Gray’s personality model. The first defines schemas (Early Maladaptive Schemas, EMS) as “broad, pervasive themes regarding oneself and one’s relationship with others, developed during childhood and elaborated throughout one’s lifetime and dysfunctional to a significant degree” (Young, 1994). Gray’s model of personality, includes two neuropsychological systems, the Behavioural Inhibition System (BIS) and the Behavioural Activation System (BAS) which underlie the personality dimensions of anxiety and impulsivity, respectively. The aim of this study was to investigate the psychometric relationships between schemas and the individual differences in the activity of BIS and BAS. A total of 115 psychiatric patients from a Catalonian Mental Health Centre were included in the study. To evaluate schemas, we used the Spanish Version of the Young Schema Questionnaire (Cid, Tejero and Torrubia, 1999; Cid and Torrubia, 2001); this is a 205-item self-report that assesses 16 early maladaptive schemas. To evaluate individual differences in BIS/BAS, we administered the Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSRQ, Torrubia, Avila, Moltó, and Caseras; 2001). Statistical analyses consisted of a Principal component analysis with Varimax rotation including schema and personality scales, and a multiple regression analysis using the Sensitivity to punishment (SP) and Sensitivity to reward (SR) scales as independent variables, and each schema as a dependent variable. Principal component analysis yielded three factors with eigen values higher than 1 which accounted for 69.19 % of variance. The first was loaded by SP and the schema scales Failure, Social Undesirability, Dependence, Defectiveness, Social Isolation, Insufficient Self-control and Subjugation, the second by the schema scales Self-sacrifice, Unrelenting standards, Emotional deprivation, Mistrust, Emotional inhibition, Abandonment and Vulnerability to harm and illness, and the third by SR and the schema scales Enmeshment and Entitlement. Results from multiple regression analyses showed that SP and SR scales accounted for a significant percentage of variance in all of the schemas. In the discussion, we develop the implications of these results for the assessment, case conceptualization, and cognitive-behavioural treatment of personality disorders.

EXAMPLES OF POSTERS

a) Black women’s’ phenomenological experience of providing home-care for a family member with AIDS in a third world context

Basson, P.J. and Whelan, M. Rand Afrikaans University

World statistics show that HIV infection is on the increase. Much attention is thus currently paid to the prevention of AIDS. A growing problem, however, is the increasing number of people in the terminal phase of HIV – especially in developing countries like South Africa. During this phase of the illness serious infections manifest themselves and there is a general decline in the patient’s functioning, leading to increased dependence on others for activities of daily living. Often these people in the final phase of HIV are accommodated in hospitals and hospices. Due to rising health care costs, inadequate and understaffed facilities and overwhelmed health care workers, more and more people in the final phase of HIV are cared for at home. In most developing and third world countries home-based care becomes the responsibility of illiterate, uneducated family members of infected individuals, with little or no resources to provide terminal care. For this reason a phenomenological study was conducted in order to expose the experience of providing care for a family member in the final phase of HIV. Five black female care givers were included in this study. Common themes that emerged from the transcribed interviews included the establishment of an existential baseline as well as diminished independence and freedom of participants. They also expressed the need for support (emotional, financial and medical). Lastly religion and certain coping mechanisms were found to either facilitate or hinder the provision of care, depending on their rigidity and effectiveness respectively.

b) The relationship between delusional ideations and stress coping in Japanese college students.

Syudo Yamasaki, Hiromi Arakawa, Yoshihiko Tanno, Graduate school of Arts and Sciences, University of Tokyo

Introduction : Delusional ideation is one of the symptoms in schizophrenia. In many recent studies, delusional ideation in general population has been investigated. These studies found that there were more people with delusional ideation in general population than that had been expected. However, there were a few studies about the relationship between delusional ideation and stress coping style in healthy samples. Schuldberg et al. (1996) found that psychosis-prone individuals used more coping by Escape-avoidance and Accepting responsibility. In the present study, we tried to examine the relationship between delusional ideation and stress coping style in Japanese college students. Method: The Japanese version of Peters et al. Delusions Inventory (PDI; Yamasaki et al. 2004) and Lazarus Type Stress Coping Inventory (SCI; Lazarus and Folkman, 1984; Motoaki et al. 1991) were administered to 154 college students (106 men and 48 women with mean age±SD of 19.2 ± 0.9). The Japanese version of PDI was consisted of 40 items, which was including assessing measures of presence of ideation, distress, preoccupation and conviction for each item. PDI has four dimensions of delusional ideation. SCI has eight subscales of stress coping (Planful problem solving, Confrontive Coping, Seeking Social Support, Accepting Responsibility, Self-controlling, Escape-avoidance, Distancing, Positive Reappraisal). Results: Correlation coefficients between four dimensions of PDI and eight subscales of SCI were examined. Distress of delusional ideation has positive correlations with escape-avoidance coping (r = 0.23, p < 0.01), Accepting responsibility (r = 0.19, p < 0.05) and Seeking Social Support (r = 0.20, p < 0.05). Distress of delusional ideations has negative correlations with Self-controlling (r = – 0.18, p < 0.05), Positive Reappraisal (r = – 0.20, p < 0.05) and Planful problem solving (r = – 0.20, p < 0.05). The number of presence of delusional ideations was positively correlated with Accepting responsibility (r = 0.22, p < 0.01). Conclusions: In the present study, the result of Schlberg et al. could be replicated in college students. Escape-avoidance and Accepting responsibility coping has positive correlations to distress of delusional ideations. On the other hand, Self-controlling, Positive Reappraisal and Planful problem solving has negative correlations to distress of delusional ideations. Patients with schizophrenia tend to use passive and avoiding coping strategies in stressful situations rather than problem solving coping (Gispen-de Wied, 2000). The result of present study also suggested that delusion-prone college students had the same pattern of coping strategy as the previous studies.

c) Expressed Emotion and Parasuicide

Santos, J.C.P., Bissaya Barreto Nursing School, Portugal, Saravia, C.B., Coimbra University, Portugal, and Sousa, L., Oporto University, Portugal.

Parasuicidal and suicidal behaviour are increasing a lot in some Western countries and are considered a public health problem. Parasuicide occurs mainly in the age group between 15 to 24 years old and therefore it is a priority to study this population group. Expressed Emotion is not a concept that has been studied in these behaviours, although it has been used in other pathologies over the last 30 years. Expressed Emotion is assessed through a semi-structured interview using five scales: hostility, over-involvement, critical comments, warmth and positive comments. This is a prospective study carried out over nine months. The results presented here refer to the first contact, the first week after the Parasuicide behaviour, and research is still in progress. The sample consisted of relatives of 35 individuals (aged between 15 to 24, who committed parasuicidal behaviour), residents in the city of Coimbra and its surrounding areas (in the central region of Portugal). Our first contact was made in the Accident and Emergency Department (from 15 th September 2003 to 31 st March 2004), with people whose cause of admission was parasuicidal behaviour. After this we carried out interviews with the family, in the first week after the parasuicidal behaviour. We used the Camberwell Family Interview (Leff, J and Vaughn, C, 1985) for the interviews which were taped and analysed after. The general aim is to characterise the Expressed Emotion of the family members of those individuals who have parasuicidal behaviour. The sample of 35 parasuicidal individuals was predominantly female with an average age of 19 and who were mainly students. Almost all were single (91,4%). The vast majority of the sample (88,5%) had parasuicidal behaviour involving drug overdose and for the majority (57,2%) this was their first attempt. Out of a total of 57 interviews carried out with relatives and other important people in the lives of the parasuicidal individuals, 31 showed a high EE and 26 a low EE and we classified 26 families with high EE. The interviews lasted on average 50 minutes with a minimum of 30 minutes and a maximum of 90 minutes. We found evidence of high emotional over-involvement in 23 of the situations studied. There was a high level of criticism in 19 with hostility also present in 7 interviews. Some of them had high levels in more than one of the scales. The presence in the results of high levels of EE, particularly emotional over-involvement did not confirm the data obtained by Pollard (1996) who found a higher presence of criticism and hostility rather than emotional over-involvement. We can characterise the behaviour of over-involvement mainly through excessive self-sacrifice and statements of attitude. Critical comments were present suggestion situations involving traits and states according to the cases. The situation that we found has not permitted us, yet to draw generalised conclusions with regards to the stability or development of the critical comments and EE. With regards to hostility, the majority of the situations can be characterised by the presence of generalised criticism and rejecting remarks together. Leff (1989) says that in general the study of EE in any situation requires us: to study the relationship between EE and pathology; to draw up an adequate intervention plan and finally to analyse the appropriateness of the intervention model in a clinical context. In the case of parasuicidal behaviour the assessment of our EE research carried out shows the presence of a high EE mainly through over-involvement which we would like to highlight. We also found high levels of criticism. The research will continue to characterise better the relationship between parasuicidal behaviour and EE.