Uncontrollable anger prevalent among US youth

Intermittent Explosive Disorder affects up to 6 million US adolescents Nearly two-thirds of U.S. adolescents have experienced an anger attack that involved threatening violence, destroying property or engaging in violence toward others at some point in their lives. These severe attacks of uncontrollable anger are much more common among adolescents than previously recognized, a new study led by researchers from Harvard Medical School finds. The study, based on the National Comorbidity Survey Replication Adolescent Supplement, a national face-to-face household survey of 10,148 U.S. adolescents, found that nearly two-thirds of adolescents in the U.S. have a history of anger attacks. It also found that one in 12 young people—close to six million adolescents—meet criteria for a diagnosis of Intermittent Explosive Disorder (IED), a syndrome characterized by persistent uncontrollable anger attacks not accounted for by other mental disorders. The results will be published July 2 in Archives of General Psychiatry. IED has an average onset in late childhood and tends to be quite persistent through the middle years of life. It is associated with the later onset of numerous other problems, including depression and substance abuse, according to senior author Ronald Kessler, McNeil Family Professor of Health Care Policy at HMS and leader of the team that carried out the study. Yet only 6.5 percent of adolescents with IED received professional treatment for their anger attacks. Study findings indicate that IED is a severe, chronic, commonly occurring disorder among adolescents, one that begins early in life. Yet the study also shows that IED is under-treated: although 37.8 percent of youths with IED obtained treatment for emotional problems in the 12 months prior to the study interview, only 6.5 percent received treatment specifically for anger. The researchers argue for the importance of identifying and treating IED early, perhaps through school-based violence prevention programs. "If we can detect IED early and intervene with effective treatment right away, we can prevent a substantial amount of future violence perpetration and associated psychopathology," Kessler said. To be diagnosed with IED, an individual must have had three episodes of impulsive aggressiveness "grossly out of proportion to any precipitating psychosocial stressor," at any time in their life, according to the Diagnostic and Statistical Manual of Mental Disorders. The investigators used an even more stringent definition of IED, requiring that adolescents not meet criteria for other mental disorders associated with aggression, including bipolar disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder and conduct disorder. As a result, researchers found that 1 in 12 adolescents met criteria for IED Anger Management CE Course ### Collaboraters included Katie McLaughlin, an HMS assistant professor of pediatrics and psychology at Boston Children's Hospital, Jennifer Greif Green at Boston University School of Education, Alan Zaslavsky, an HMS professor of health care policy, as well as statistical programmer and data analyst Irving Hwang and Nancy Sampson, a project director at HMS. This research was funded by the National Institute of Mental Health (U01-MH60220 and R01-MH66627), the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation and the John W. Alden Trust. Harvard Medical School has more than 7,500 full-time faculty working in 11 academic departments located at the School's Boston campus or in one of 47 hospital-based clinical departments at 16 Harvard-affiliated teaching hospitals and research institutes. Those affiliates include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, Children's Hospital Boston, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care, Hebrew SeniorLife, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.

Exposure to violence has long-term stress effects among adolescents

UNIVERSITY PARK, Pa. -- Children who are exposed to community violence continue to exhibit a physical stress response up to a year after the exposure, suggesting that exposure to violence may have long-term negative health consequences, according researchers at Penn State and University College London. "We know that exposure to violence is linked with aggression, depression, post-traumatic stress symptoms and academic and cognitive difficulties in the short term, but little is known about the long-term effects of such exposure," said Elizabeth Susman, Jean Phillips Shibley Professor of Biobehavioral Health, Penn State. "Our data show that the stress reaction to violence exposure is not just immediate. There's an effect that endures." The scientists recruited 124 adolescents, ranging in age from 8 to 13 and living in small city and rural communities, to participate in the study social worker continuing education "Most studies of the effects of exposure to violence look at children who live in inner cities and urban communities," said Melissa Peckins, biobehavioral health graduate student, Penn State. "Our study is unique because we focused on children who live in small towns, so they are not children you would normally expect to be exposed to a lot of violence. Also, these were healthy children without a history of reported maltreatment." The researchers gave each of the adolescents a questionnaire, which identified their lifetime exposure to violence and exposure within the past 12 months. They then gave the adolescents the beginning of a story and asked them to complete it in front of two mock judges, whom they were told were evaluating their responses and performances for later comparison to those of other children the same age. Following the story-completion task, adolescents were also given a serial subtraction task. "The story completion task and mental arithmetic task are commonly used to elicit a stress response in laboratory settings," Peckins said. "Our hypothesis was that children who have been exposed to more violent events in the past year will have an attenuated response to the laboratory stressor -- even 12 months after the incidence -- compared with children who experienced fewer violent events." The team measured the children's stress responses by comparing the cortisol levels present in samples of their saliva collected before and after the stress test was administered. "In males, we found that as exposure to violence increased, cortisol reactivity decreased, so cortisol reactivity was attenuated; it was a habituation effect," Peckins said. The finding was not present in females. The results were published online in a recent issue of the Journal of Adolescent Health. "In enduring stressful conditions, we may have adapted evolutionarily to suppress our cortisol levels because higher and more prolonged levels of cortisol in the bloodstream can lead to negative health consequences, such as autoimmune disorders, lowered immunity, arthritis and atypical depression. This may explain why cortisol reactivity was lower for males," Susman said. "However, there is a theory that females may react to stressful situations by talking about it, which may be their way of reducing the negative effects of cortisol in the bloodstream. If parents and other adults are available to discuss episodes of violence with children, it might help the children, especially females, to reduce their cortisol levels." In the future, the team hopes to examine the role of duration of exposure to violence and time elapsed after exposure to violence on cortisol reactivity. ### Other researchers on this project were Samantha Dockray, research fellow, University College London, and Jacey Eckenrode, graduate student in biobehavioral health and Jodi Heaton, administrative assistant, biobehavioral health, both at Penn State. The National Institute of Mental Health, the General Clinical Research Center of the National Institutes of Health and Penn State supported this work.

Therapists phone it in and keep more patients

Telephone therapy retains more patients than face-to-face sessions and improves depression CHICAGO --- Phoning it in is more effective than the therapist's couch when it comes to keeping patients in psychotherapy. New Northwestern Medicine research shows patients who had therapy sessions provided over the phone were more likely to complete 18 weeks of treatment than those who had face-to-face sessions. The study, published in the June 6 issue of the Journal of the American Medical Association, is the first large trial to compare the benefits of face-to-face and telephone therapy. Phone therapy is a rapidly growing trend among therapists. About 85 percent of psychologists now deliver some of their services over the phone because competing demands, transportation time and other problems make it difficult for many patients to get to their offices social worker continuing education "Now therapists can make house calls," said David Mohr, the lead author and a professor of preventive medicine at Northwestern University Feinberg School of Medicine. "Our study found psychotherapy conveniently provided by telephone to patients wherever they are is effective and reduces dropout. This suggests these services now should be covered by insurance." While telephone therapy was as effective as face-to-face sessions in reducing depression during treatment, the improvement ebbed slightly six months after treatment ended compared to face-to-face therapy. The randomized control trial included 325 primary care patients with major depressive disorder. The results showed 20.9 percent of patients who had cognitive behavioral therapy over the phone dropped out compared to 32.7 percent for face-to-face therapy. Patients in both therapies showed equally good improvement in their depression when treatment ended. Six months after treatment ended, all patients remained much improved. However, patients who had the telephone therapy scored three points higher on a depression scale than those who had face-to-face sessions. "The three point difference is of questionable clinical significance but it raises the question whether some individuals are at risk of worsening after treatment with telephone therapy compared to face-to-face," Mohr said. It may be that the slight worsening seen in the telephone therapy after the end of treatment was because patients who had more mental health difficulties and who would have dropped out of face-to-face sessions were retained in telephone therapy, Mohr noted. Thus, this may not be a real finding. "But we can't rule out the possibility that it may be true and there is something about face-to-face treatment that creates better results for some people," Mohr said. "The physical presence of the therapist may be therapeutic in a way that helps some patients maintain their improvement in mood. There may be a unique quality about the human contact that increases resilience and maintains the skills learned to manage depression after treatment has ended." Mohr said he hopes the study results will encourage insurance providers including Medicare to reimburse telephone therapy sessions, which many companies currently don't cover. "There is good reason to reimburse these sessions," Mohr said. "Many people can't get to a therapist's office, but they want to talk to someone. Telephone therapy is highly effective and offers a solution to people with depression who otherwise would be left out." This is particularly true for disabled people or those who live where care is unavailable, such as in rural areas, he noted. Research shows people prefer talk therapy to antidepressant medication, but many quickly drop out of treatment or don't follow up on a referral from their primary care physicians, likely the result of obstacles that prevent them from getting to the therapist's office. ### Other Northwestern authors include: Joyce Ho, Jenna Duffecy, Michelle Nicole Burns, Ling Jin and Juned Siddique. This study was funded by the National Institute of Mental Health of the National Institutes of Health research grant NIMH R01-MH059708.

When being scared twice is enough to remember

One of the brain's jobs is to help us figure out what's important enough to be remembered. Scientists at Yerkes National Primate Research Center, Emory University have achieved some insight into how fleeting experiences become memories in the brain. Their experimental system could be a way to test or refine treatments aimed at enhancing learning and memory, or interfering with troubling memories. The results were published recently in the Journal of Neuroscience. The researchers set up a system where rats were exposed to a light followed by a mild shock. A single light-shock event isn't enough to make the rat afraid of the light, but a repeat of the pairing of the light and shock is, even a few days later. "I describe this effect as 'priming'," says the first author of the paper, postdoctoral fellow Ryan Parsons. "The animal experiences all sorts of things, and has to sort out what's important. If something happens just once, it doesn't register. But twice, and the animal remembers." Parsons was working with Michael Davis, PhD, Robert W. Woodruff professor of psychiatry and behavioral sciences at Emory University School of Medicine, who has been studying the molecular basis for fear memory for several years. Even though a robust fear memory was not formed after the first priming event, at that point Parsons could already detect chemical changes in the amygdala, part of the brain critical for fear responses. Long term memory formation could be blocked by infusing a drug into the amygdala. The drug inhibits protein kinase A, which is involved in the chemical changes Parsons observed. It is possible to train rats to become afraid of something like a sound or a smell after one event, Parsons says. However, rats are less sensitive to light compared with sounds or smells, and a relatively mild shock was used. Fear memories only formed when shocks were paired with light, instead of noise or nothing at all, for both the priming and the confirmation event. Parsons measured how afraid the rats were by gauging their "acoustic startle response" (how jittery they were in response to a loud noise) in the presence of the light, compared to before training began. Scientists have been able to study the chemical changes connected with the priming process extensively in neurons in culture dishes, but not as much in live animals. The process is referred to as "metaplasticity," or how the history of the brain's experiences affects its readiness to change and learn. "This could be a good model for dissecting the mechanisms involved in learning and memory," Parsons says. "We're going to be able to look at what's going on in that first priming event, as well as when the long-term memory is triggered." "We believe our findings might help explain how events are selected out for long-term storage from what is essentially a torrent of information encountered during conscious experience," Parsons and Davis write in their paper social worker ceus ### The research was supported by the National Institute of Mental Health (R37 MH047840 and F32 MH090700). Reference: R.G. Parsons and M. Davis. A metaplasticity-like mechanism supports the selection of fear memories: role of protein kinase A in the amygdala. J. Neurosci 32: 7843-7851 (2012).

Study identifies factors related to violence in veterans

CHAPEL HILL, N.C. – A national survey identifies which U.S. military veterans may be at most risk of aggression after deployment and what strategies could potentially help reduce likelihood of violence when service members return home counselor ceus The study examined protective factors that are important in preventing violence, including employment, meeting basic needs, living stability, social support, spiritual faith, ability to care for oneself, perceived self-determination, and resilience (ability to adapt to stress). Veterans with these factors in place were 92 percent less likely to report severe violence than veterans who did not endorse these factors. The majority of veterans (over three-quarters of those studied) did endorse most of these protective factors and thus posed a low threat of violence. These findings are reported in an article published June 25, 2012 in the Journal of Clinical Psychiatry of a National Institute of Mental Health-funded study led by Eric B. Elbogen, PhD, Research Director of the Forensic Psychiatry Program in the University of North Carolina School of Medicine and Psychologist in the U.S. Department of Veterans Affairs. "When you hear about veterans committing acts of violence, many people assume that post-traumatic stress disorder (PTSD) or combat exposure are to blame," Elbogen said. "But our study shows that is not necessarily true." The national survey revealed that other factors are just as important to understanding violence in veterans, including alcohol misuse, criminal background, as well as veterans' living, work, social, and financial circumstances. In fact, the survey found that veterans who didn't have enough money to cover basic needs were more likely to report aggressive behavior than veterans with PTSD. "Our study suggests the incidence of violence could be reduced by helping veterans develop and maintain protective factors in their lives back home," Elbogen said. The survey was conducted between July 2009 and April 2010. Responses were collected from 1,388 veterans who served in the Iraq and Afghanistan War era and theater after Sept. 11, 2001. The sample included veterans from all branches of the U.S. military and all 50 states. One-third of survey respondents self-identified committing an act of aggression towards others in the past year, most of which involved relatively minor aggressive behavior. Eleven percent of the sample reported more severe violence. Elbogen noted, "Although the majority of study participants did not report aggression, the potential for violence does remain a significant concern among a subset of returning veterans." Dr. Sally Johnson, co-author and Professor in the UNC Forensic Psychiatry Program, points out "Some veterans do not cope well with the loss of the structure, social, and financial support available in the military environment. Attention to helping veterans establish psychosocial stability in the civilian environment can help reduce post-deployment adjustment problems including aggression." ### The other co-authors H. Ryan Wagner, PhD, Virginia M. Newton, PhD Christine Timko, PhD, Jennifer J. Vasterling, PhD, and Jean C. Beckham, PhD are affiliated with the Department of Veterans Affairs.

Avatars may help children with social anxiety overcome fears

A principal standing in the hallway says, "You are one of my favorite students!" In class, a smart girl says, "You are the nicest person in our class!" Many children would smile and eagerly return those compliments, but some with social anxiety may be too terrified to respond. Researchers at the University of Central Florida's Anxiety Disorders Clinic and the Atlanta-based company Virtually Better want to give more children with social anxiety the practice they need to become comfortable in social situations. They have developed a new, one-of-a-kind computer simulation program that enables children to interact with avatars playing the roles of classmates, teachers and a principal. The simulation, designed for children ages 8 to 12, allows clinicians to play the roles of the avatars while the children sit at a computer in a different room and respond to situations they encounter routinely. The children practice greetings, giving and receiving compliments, being assertive and asking and answering questions. "These kids come in and say, 'I don't know how to make a friend,'" said Deborah Beidel, director of the Anxiety Disorders Clinic and a psychology professor at UCF. "We have to teach them the skills that most people learn from being around other people." The National Institute of Mental Health, part of the National Institutes of Health, provided a $500,000 grant to fund the development of the software and a 12-week study that will begin this summer. The study will involve 30 Central Florida children ages 8 to 12. Many children are nervous and slow to warm up in new social situations, but those with social anxiety disorders have severe distress that doesn't go away, Beidel said. "If a fear is so severe that it prevents a child from doing something he or she should be doing, such as going to school, playing on a sports team, being in a dance recital, going to birthday parties or making friends, then a parent should call a mental health professional," she said. Under Beidel's leadership, the UCF Anxiety Disorders Clinic has treated children with anxiety disorders for five years. The clinic offers what Beidel calls the "gold standard" of treatments. Children with anxiety disorders are paired with socially comfortable peers for outings to places such as bowling alleys, restaurants and miniature golf courses. The new study will give parents multiple treatment options at UCF. But parents in most communities aren't so fortunate. Many clinicians who treat children don't have the time or resources to recruit socially comfortable children and organize regular outings. Guiding clients through a simulation in the office may be the only feasible solution for them continuing education for counselors The simulation features a realistic school setting, designed with the help of elementary school teachers. The pre-programmed responses of the avatar classmates – which include a cool girl, a smart girl and a bully -- were recorded by children to ensure the language reflects how they talk. "The most important thing is that this was designed by clinicians with a very specific intention to help people get better. That's the big difference between this and a game, and there is nothing like this on the market," said Josh Spitalnick, clinical psychologist and director of research and clinical services at Virtually Better, an Atlanta-based company bringing interactive technologies to behavioral healthcare for treatment and training. The six characters and the varying levels of difficulty in the simulation allow clinicians to design scenarios appropriate for their patients. More challenging scenarios include dealing with a bully who is demanding that a child give up some of her lunch money. If the initial trial goes well, researchers hope to conduct a yearlong trial with more children. If that is successful, the simulation could then become available to clinicians. The program eventually could be expanded to include other settings, such as playgrounds, and to serve other children who need help improving social skills. ### For more information about UCF's Anxiety Disorders Clinic, go to http://anxietyclinic.cos.ucf.edu. For more information about Virtually Better Technologies, visit www.virtuallybetter.com.

UCLA study uncovers new tools for targeting genes linked to autism

Findings could lead to future therapeutic targets UCLA researchers have combined two tools – gene expression and the use of peripheral blood -- to expand scientists' arsenal of methods for pinpointing genes that play a role in autism. Published in the June 21 online edition of the American Journal of Human Genetics, the findings could help scientists zero in on genes that offer future therapeutic targets for the disorder. "Technological advances now allow us to rapidly sequence the genome and uncover dozens of rare mutations," explained principal investigator Dr. Daniel Geschwind, the Gordon and Virginia MacDonald Distinguished Professor of Human Genetics and a professor of neurology at the David Geffen School of Medicine at UCLA. "But just because a particular genetic mutation is rare doesn't mean it's actually causing disease. We used a new approach to tease out potential precursors of autism from the occasional genetic glitch." Geschwind and his colleagues studied DNA contained in blood samples from 244 families with one healthy child and one child on the autism spectrum. The team used a hybrid method that blended tests that read the order of DNA bases with those that analyze gene expression, the process by which genes make cellular proteins. "Monitoring gene expression provides us with another line of data to inform our understanding of how autism develops," said Geschwind, who is also director of the Center for Autism Research and Treatment at the Semel Institute for Neuroscience and Behavior at UCLA. "Integrating this method with the sequencing of DNA bases expands our ability to find mutations leading to the disease." Gene expression offers a molecular signpost pointing scientists in the right direction by narrowing the field and highlighting specific areas of the genome. For example, if a gene is expressed at substantially higher or lower levels in a patient, researchers will review the patient's DNA to check if that gene has changed. "We found that we can use gene expression to help understand whether a rare mutation is causing disease or playing a role in disease development," said Geschwind. "A true mutation will alter a gene's sequence, modifying the protein or RNA it produces -- or preventing the gene from producing them entirely. "A gene mutation accompanied by a change in expression clues us to a hot spot on the genome and directs us where to look next," he added. "Not all mutations will influence gene expression, but this approach improves our ability to pinpoint those that do." The researchers used the combined method to prioritize gene targets that merit closer investigation, potentially explaining why one person develops autism and their sibling does not. Their search turned up new regions in the genome where genetic variations showed strong links to autism and altered expression patterns. Genes in these regions were more likely to be mutated in the autistic children than in their unaffected siblings. "When we looked at genes associated with nervous-system function we found significantly more genes were expressed at higher or lower levels in the children diagnosed with autism than we did in their siblings unaffected by the disorder," said Geschwind. Finally, the research team discovered that the DNA contained in peripheral blood can help shed light on diseases of the central nervous system. Brain cells and genes related to synaptic function are expressed in the blood, offering a window into gene expression. "Brain tissue from people with autism is not readily available for study, and some people are reluctant to use non-neural tissue in psychiatric disease," explained Geschwind. "But our study demonstrates that even peripheral blood can expand our knowledge of neurological disease." The team's next step will be to replicate their findings in a larger population. ### Autism is a complex brain disorder that strikes in early childhood. The condition disrupts a child's ability to communicate and develop social relationships and is often accompanied by acute behavioral challenges. Autism spectrum disorders are diagnosed in one in 110 children in the United States, affecting four times as many boys as girls. Diagnoses have expanded tenfold in the last decade. The research was supported by grants from the Simons Foundation, the National Institute of Mental Health (5R01 MH081754-04), the Wellcome Trust and Autism Speaks. Geschwind's coauthors included first author Rui Luo, Irina Voineagu, Lambertus Klei, Chaochao Cai, Jing Ou, Jennifer Lowe and Matthew State of UCLA; Stephan Sanders of Yale University; Ni Huang and Matthew Hurles of the Wellcome Trust Sanger Institute; and Su Chu and Bernie Devlin of Carnegie Mellon University. The UCLA Center for Autism Research and Treatment provides diagnosis, family counseling, clinical trials and treatment for patients with autism. UCLA is one of eight centers in the National Institutes of Health–funded Studies to Advance Autism Research and Treatment network and one of 10 original Collaborative Programs for Excellence in Autism social worker ceus