Simple tool may help inexperienced psychiatrists better predict violence risk in patients, U-M study finds

Without assessment tool, inexperienced psychiatrists less likely to accurately predict violence ANN ARBOR, Mich. Inexperienced psychiatrists are less likely than their veteran peers to accurately predict violence by their patients, but a simple assessment checklist might help bridge that accuracy gap, according to new research from the University of Michigan. Led by psychiatrist Alan Teo, M.D., a Robert Wood Johnson Foundation Clinical Scholar of the University of Michigan, researchers examined how accurate psychiatrists were at predicting assaults by acutely ill patients admitted to psychiatric units. Their results found that inexperienced psychiatric resident doctors did no better than a coin flip, whereas veteran psychiatrists were 70 percent accurate in predicting risk of violence. However, when a brief risk assessment tool was applied to the cases that the junior doctors evaluated, their level of accuracy jumped to 67 percent, or nearly as good as the more experienced psychiatrists. Results of the research were published online Sept. 1 in the journal Psychiatric Services. “The tool we used, called the HCR-20-C, is remarkably brief and straightforward. Like a checklist a pilot might use before takeoff, it has just five items that any trained mental health professional can assess,” Teo says. In light of recent violent events, such as the movie theater shooting in Aurora, Colo,, earlier this summer, Teo says predicting violence risk in psychiatric patients is an increasingly important topic. “Given public concern about this issue, I think teaching our budding psychiatrists and others how to use a practical tool like this, and encouraging its use in high-risk settings is a no-brainer,” he says. In the study, researchers were able to assess doctors’ accuracy by comparing patients who had assaulted hospital staff members with similar patients who had not been violent. Because all patients received a threat assessment when admitted to the psychiatric unit, the researchers were able to compare a patient’s predicted violence risk with whether they actually had a documented assault while in the hospital. Incidents of physical aggression typically included punching, slapping, or throwing objects, as well as yelling, directed at staff members of the hospital. The patients studied had severe illnesses, often schizophrenia, and had been involuntarily admitted to the hospital. Teo says this study is the first to compare the predictive success of violence assessment between experienced and inexperienced psychiatrists. The results, he says, highlight the importance of emphasizing violence risk assessment in clinical training programs ceus for counselors “If trainees are indeed less able than trained and experienced clinicians to accurately perform risk assessments for violence, it’s important to figure out a way to improve their accuracy,” he says. “Our study shows that evidence-based structured tools might have the potential to augment training and improve risk assessment.” ### Citation: Psychiatric Services, Sept. 1, 2012; doi: 10.1176/appi.ps.201200019 Other authors: Sarah R. Holley, Ph.D.; Mary Leary, M.D.; Dale E. McNiel, Ph.D. Conflicts of interest: None. Funding: This work was partly supported by the National Institute of Mental Health (grant R25 MH060482), a Minority Fellowship sponsored by the American Psychiatric Association and the Substance Abuse and Mental Health Services Administration, and a Clinical and Translational Science Award (ULI RR024131) from the National Institutes of Health.

That giant tarantula is terrifying, but I'll touch it

Expressing your emotions can reduce fear, UCLA psychologists report "Give sorrow words." —Malcolm in Shakespeare's "Macbeth" Can simply describing your feelings at stressful times make you less afraid and less anxious? A new UCLA psychology study suggests that labeling your emotions at the precise moment you are confronting what you fear can indeed have that effect. The psychologists asked 88 people with a fear of spiders to approach a large, live tarantula in an open container outdoors. The participants were told to walk closer and closer to the spider and eventually touch it if they could. The subjects were then divided into four groups and sat in front of another tarantula in a container in an indoor setting. In the first group, the subjects were asked to describe the emotions they were experiencing and to label their reactions to the tarantula — saying, for example, "I'm anxious and frightened by the ugly, terrifying spider." "This is unique because it differs from typical procedures in which the goal is to have people think differently about the experience — to change their emotional experience or change the way they think about it so that it doesn't make them anxious," said Michelle Craske, a professor of psychology at UCLA and the senior author of the study. "Here, there was no attempt to change their experience, just to state what they were experiencing." In a second group, the subjects used more neutral terms that did not convey their fear or disgust and were aimed at making the experience seem less threatening. They might say, for example, "That little spider can't hurt me; I'm not afraid of it." "This is the usual approach for helping individuals to confront the things they fear," Craske said. In a third group, the subjects said something irrelevant to the experience, and in a fourth group, the subjects did not say anything — they were simply exposed to the spider. All the participants were re-tested in the outdoor setting one week later and were again asked to get closer and closer to the tarantula and potentially touch it with a finger. The researchers measured how close subjects could get to the spider, how distressed they were and what their physiological responses were, focusing in particular on how much the subjects' hands sweated, which is a good measure of fear, Craske said. The researchers found that the first group did far better than the other three. These people were able to get closer to the tarantula — much closer than those in the third group and somewhat closer than those in the other two groups — and their hands were sweating significantly less than the participants in all of the other groups. The results are published in the online edition of the journal Psychological Science and will appear in an upcoming print edition. "They got closer and they were less emotionally aroused," Craske said. "The differences were significant. The results are even more significant given the limited amount of time involved. With a fuller treatment, the effects may be even larger. "Exposure is potent," she added. "It's surprising that this minimal intervention action had a significant effect over exposure alone." So why were the people in the first group — those who performed what the life scientists call "affect labeling" — able to get closer to the tarantula? "If you're having less of a threat response, which is indicated by less sweat, that would allow you to get closer; you have less of a fear response," said study co-author Matthew Lieberman, a UCLA professor of psychology and of psychiatry and biobehavioral sciences. "When spider-phobics say, 'I'm terrified of that nasty spider,' they're not learning something new; that's exactly what they were feeling — but now instead of just feeling it, they're saying it. For some reason that we don't fully understand, that transition is enough to make a difference." The scientists also analyzed the words the subjects used. Those who used a larger number of negative words did better, in terms of both how close they were willing to get to the tarantula and their skin-sweat response. In other words, describing the tarantula as terrifying actually proved beneficial in ultimately reducing the fear of it. "Doing more affect labeling seemed to be better," Lieberman said. "That is so different from how we normally think about exposure therapy, where you try to get the person to think differently, to think it's not so bad," Craske said. "What we did here was to simply encourage individuals to state the negative." "We've published a series of studies where we asked people, 'Which do you think would make you feel worse: looking at a disturbing image or looking at that disturbing image and choosing a negative emotional word to describe it,'" Lieberman said. "Almost everyone said it would be worse to have to look at that image and focus on the negative by picking a negative word. People think that makes our negative emotions more intense. Well, that is exactly what we asked people to do here. In fact, it's a little better to have people label their emotions — multiple studies now show this. Our intuitions here are wrong." This is the first study to demonstrate benefits for affect labeling of fear and anxiety in a real-world setting, Craske and Lieberman said. "The implication," Craske said, "is to encourage patients, as they do their exposure to whatever they are fearful of, to label the emotional responses they are experiencing and label the characteristics of the stimuli — to verbalize their feelings. That lets people experience the very things they are afraid and say, 'I feel scared and I'm here.' They're not trying to push it away and say it's not so bad. Be in the moment and allow yourself to experience whatever you're experiencing." Craske and Lieberman are studying how this approach can help people who have been traumatized, such as rape victims and victims of domestic violence. The approach potentially could benefit soldiers returning from war as well. "I'm far more optimistic than I was before this study," Lieberman said. "I'm a believer that this approach can have real benefits for people. "There is a region in the brain, the right ventrolateral prefrontal cortex, that seems to be involved in labeling our feelings and our emotional reactions, and it is also associated with regulating our emotional responses," he said. "Why those two go together is still a bit of a mystery. This brain region that is involved in simply stating how we are feeling seems to mute our emotional responses, at least under certain circumstances." "There's a trend in psychology of acceptance-based approaches — honestly label your feelings. This study has that flavor to it," Craske said. Katharina Kircanski, a former UCLA graduate student and current postdoctoral scholar at Stanford University, is lead author of the study; she conducted this research as a graduate student in Craske's laboratory MHC Ceus ### The research was federally funded by the National Institutes of Health's National Institute of Mental Health, and by the American Psychological Association. UCLA is California's largest university, with an enrollment of nearly 38,000 undergraduate and graduate students. The UCLA College of Letters and Science and the university's 11 professional schools feature renowned faculty and offer 337 degree programs and majors. UCLA is a national and international leader in the breadth and quality of its academic, research, health care, cultural, continuing education and athletic programs. Six alumni and five faculty have been awarded the Nobel Prize.

Predicting how patients respond to therapy

Brain scans could help doctors choose treatments for people with social anxiety disorder CAMBRIDGE, MA -- A new study led by MIT neuroscientists has found that brain scans of patients with social anxiety disorder can help predict whether they will benefit from cognitive behavioral therapy. Social anxiety is usually treated with either cognitive behavioral therapy or medications. However, it is currently impossible to predict which treatment will work best for a particular patient. The team of researchers from MIT, Boston University (BU) and Massachusetts General Hospital (MGH) found that the effectiveness of therapy could be predicted by measuring patients' brain activity as they looked at photos of faces, before the therapy sessions began. The findings, published this week in the Archives of General Psychiatry, may help doctors choose more effective treatments for social anxiety disorder, which is estimated to affect around 15 million people in the United States. "Our vision is that some of these measures might direct individuals to treatments that are more likely to work for them," says John Gabrieli, the Grover M. Hermann Professor of Brain and Cognitive Sciences at MIT, a member of the McGovern Institute for Brain Research and senior author of the paper. Lead authors of the paper are MIT postdoc Oliver Doehrmann and Satrajit Ghosh, a research scientist in the McGovern Institute. Choosing treatments Sufferers of social anxiety disorder experience intense fear in social situations that interferes with their ability to function in daily life. Cognitive behavioral therapy aims to change the thought and behavior patterns that lead to anxiety. For social anxiety disorder patients, that might include learning to reverse the belief that others are watching or judging them. The new paper is part of a larger study that MGH and BU ran recently on cognitive behavioral therapy for social anxiety, led by Mark Pollack, director of the Center for Anxiety and Traumatic Stress Disorders at MGH, and Stefan Hofmann, director of the Social Anxiety Program at BU. "This was a chance to ask if these brain measures, taken before treatment, would be informative in ways above and beyond what physicians can measure now, and determine who would be responsive to this treatment," Gabrieli says. Currently doctors might choose a treatment based on factors such as ease of taking pills versus going to therapy, the possibility of drug side effects, or what the patient's insurance will cover. "From a science perspective there's very little evidence about which treatment is optimal for a person," Gabrieli says. The researchers used functional magnetic resonance imaging (fMRI) to image the brains of patients before and after treatment. There have been many imaging studies showing brain differences between healthy people and patients with neuropsychiatric disorders, but so far imaging has not been established as a way to predict patients' responses to particular treatments CADC I & II Continuing Education Measuring brain activity In the new study, the researchers measured differences in brain activity as patients looked at images of angry or neutral faces. After 12 weeks of cognitive behavioral therapy, patients' social anxiety levels were tested. The researchers found that patients who had shown a greater difference in activity in high-level visual processing areas during the face-response task showed the most improvement after therapy. Gabrieli says it's unclear why activity in brain regions involved with visual processing would be a good predictor of treatment outcome. One possibility is that patients who benefited more were those whose brains were already adept at segregating different types of experiences, Gabrieli says. The researchers are now planning a follow-up study to investigate whether brain scans can predict differences in response between cognitive behavioral therapy and drug treatment. "Right now, all by itself, we're just giving somebody encouraging or discouraging news about the likely outcome" of therapy, Gabrieli says. "The really valuable thing would be if it turns out to be differentially sensitive to different treatment choices." ### The research was funded by the Poitras Center for Affective Disorders Research and the National Institute of Mental Health. Written by Anne Trafton, MIT News Office

Daily or Severe Tantrums May Point to Mental Health Issues

Most young children lose their temper sometimes, but daily tantrums or tantrums with severe behaviors, such as aggressive or destructive tantrums, are unusual and could signal a larger problem, according to an NIMH-funded study published online August 3, 2012, in a special issue of the Journal of Child Psychology and Psychiatry. Background Distinguishing “normal” misbehaviors of early childhood from clinically worrisome problems can be challenging for pediatricians, parents, and others who work with young children. To address this issue, Lauren Wakschlag, Ph.D., of Northwestern University, Margaret Briggs-Gowan, Ph.D., of University of Connecticut Health Center, and their colleagues examined temper loss among preschoolers as a spectrum of behaviors ranging from mild or normal to “problem indicators” that may be signs of a greater, underlying mental health issue. For this study, the researchers developed the Multidimensional Assessment of Preschool Disruptive Behavior (MAP-DB) questionnaire. Rather than merely asking whether a child had tantrums or not, the MAP-DB assesses the frequency, quality, and severity of behaviors related to temper tantrums and the extent of a child’s anger management skills over the past month. Parents of almost 1,500 preschoolers, ages 3-5, took part in the study. Results of the Study The researchers found that more than 80 percent of preschoolers had one or more tantrums in the past month. However, less than 10 percent had tantrums every day. Also, normal temper loss behaviors showed similar patterns and could be reliably distinguished from problem indicators. For example, over a one month period, tantrums typically occurred: when preschoolers were frustrated, angry, or upset (61 percent) during daily routines, such as bedtime, mealtime, or getting dressed (58 percent) with their parents (56 percent). In contrast, it was less typical for preschoolers to have a tantrum: with an adult who was not their parent, such as a babysitter or teacher (36 percent) during which they broke or destroyed things (28 percent) “out of the blue,” or for which parents could not discern a reason (26 percent) that lasted an unusually long time (26 percent) during which they hit, bit, or kicked someone else (24 percent). Significance The findings provide early evidence that studying behaviors as a spectrum may provide new insights into how mental disorders develop and better target early diagnosis, prevention, and treatment. “Our goal was to provide a standard method that would take the guesswork out of ‘when to worry’ about young children’s behavior and to provide a more developmentally sensitive way of characterizing the emergence of mental health problems, moving away from traditional approaches emphasizing extreme clinical distinctions to a dimensional approach that charts a progression from normal to abnormal,” said Wakschlag. What’s Next Further research is needed to confirm and evaluate the effectiveness of the MAP-DB questionnaire in identifying the point at which very young children would benefit from more specialized mental health screening and treatment. Changes in behavior as the child ages and whether problematic behaviors in early childhood lead to greater mental health issues later in life are also important areas for future study MHC Continuing Education Reference Wakschlag et al. Defining the developmental parameters of temper loss in early childhood: Implications for developmental psychopathology. Journal of Child Psychology and Psychiatry. In press. Related Funding: R01MH082830, R01MH090301

Male mice exposed to chronic social stress have anxious female offspring

BOSTON (August 22, 2012) —A study in mice conducted by researchers at Tufts University School of Medicine (TUSM) suggests that a woman's risk of anxiety and dysfunctional social behavior may depend on the experiences of her parents, particularly fathers, when they were young. The study, published online in Biological Psychiatry, suggests that stress caused by chronic social instability during youth contributes to epigenetic changes in sperm cells that can lead to psychiatric disorders in female offspring across multiple generations. "The long-term effects of stress can be pernicious. We first found that adolescent mice exposed to chronic social instability, where the cage composition of mice is constantly changing, exhibited anxious behavior and poor social interactions through adulthood. These changes were especially prominent in female mice," said first author Lorena Saavedra-Rodríguez, Ph.D., postdoctoral fellow in the Larry Feig laboratory at Tufts University School of Medicine (TUSM). The researchers then studied the offspring of these previously-stressed mice and observed that again female, but not male, offspring exhibited elevated anxiety and poor social interactions. Notably, even though the stressed males did not express any of these altered behaviors, they passed on these behaviors to their female offspring after being mated to non-stressed females. Moreover, the male offspring passed on these behaviors to yet another generation of female offspring LSW Continuing Education "We are presently searching for biochemical changes in the sperm of stressed fathers that could account for this newly appreciated form of inheritance" said senior author Larry A. Feig, Ph.D., professor of biochemistry at Tufts University School of Medicine and member of the biochemistry and neuroscience program faculties at the Sackler School of Graduate Biomedical Sciences at Tufts University. "Hopefully, this work will stimulate efforts to determine whether similar phenomena occur in humans." ### This research was supported by award numbers AA019317 from the National Institute on Alcohol Abuse and Alcoholism, and MH083324 from the National Institute of Mental Health, both part of the National Institutes of Health (NIH). The research was also supported by award number NS047243 from National Institute of Neurological Disorders and Stroke (NIH) to the Tufts Center for Neuroscience Research. Saavedra-Rodríguez L, Feig LA. Biological Psychiatry. "Chronic Social Instability Induces Anxiety and Defective Social Interactions Across Generations." Available online August 20, 2012. http://dx.doi.org/10.1016/j.biopsych.2012.06.035 About Tufts University School of Medicine and the Sackler School of Graduate Biomedical Sciences Tufts University School of Medicine and the Sackler School of Graduate Biomedical Sciences at Tufts University are international leaders in innovative medical education and advanced research. The School of Medicine and the Sackler School are renowned for excellence in education in general medicine, biomedical sciences, special combined degree programs in business, health management, public health, bioengineering and international relations, as well as basic and clinical research at the cellular and molecular level. Ranked among the top in the nation, the School of Medicine is affiliated with six major teaching hospitals and more than 30 health care facilities. Tufts University School of Medicine and the Sackler School undertake research that is consistently rated among the highest in the nation for its effect on the advancement of medical science.

The effects of discrimination could last a lifetime

Increased levels of depression as a result of discrimination could contribute to low birth weight babies Given the well-documented relationship between low birth weight and the increased risk of health problems throughout one’s lifespan, it is vital to reduce any potential contributors to low birth weight. A new study by Valerie Earnshaw and her colleagues from Yale University sheds light on one possible causal factor. Their findings, published online in Springer's journal, the Annals of Behavioral Medicine, suggest that chronic, everyday instances of discrimination against pregnant, urban women of color may play a significant role in contributing to low birth weight babies. Twice as many black women give birth to low birth weight babies than white or Latina women in the U.S. Reasons for this disparity are, as yet, unclear. But initial evidence suggests a link may exist between discrimination experienced while pregnant and the incidence of low birth weight. In addition, experiences of discrimination have also been linked to depression, which causes physiological changes that can have a negative effect on a pregnancy CADCA Continuing Education Earnshaw and her colleagues interviewed 420, 14- to 21-year-old black and Latina women at 14 community health centers and hospitals in New York, during the second and third trimesters of their pregnancies, and at six and 12 months after their babies had been born. They measured their reported experiences of discrimination. They also measured their depressive symptoms, pregnancy distress and pregnancy symptoms. Levels of everyday discrimination reported were generally low. However, the impact of discrimination was the same in all the participants regardless of age, ethnicity or type of discrimination reported. Women reporting greater levels of discrimination were more prone to depressive symptoms, and ultimately went on to have babies with lower birth weights than those reporting lower levels of discrimination. This has implications for healthcare providers who work with pregnant teens and young women during the pre-natal period, while they have the opportunity to try and reduce the potential impacts discrimination on the pregnancy. The authors conclude that "Given the associations between birth weight and health across the life span, it is critical to reduce discrimination directed at urban youth of color so that all children are able to begin life with greater promise for health. In doing so, we have the possibility to eliminate disparities not only in birth weight, but in health outcomes across the lifespan." Data for this study came from the Centering Pregnancy Plus project, funded by the National Institute of Mental Health, and conducted in collaboration with Clinical Directors’ Network and the Centering Healthcare Institute. References 1. Earnshaw VA, Rosenthal L, Lewis JB, Stasko EC, Tobin JN, Lewis TT, Reid AE and Ickovics JR (2012). Maternal experiences with everyday discrimination and infant birth weight: a test of the mediators and moderators among young, urban women of color. Annals of Behavioral Medicine; DOI 10.1007/s12160-012-9404-3

Researchers pursue red flag for schizophrenia relapse

AUGUSTA, Ga. – Blood levels of a protein that helps regulate inflammation may also serve as a red flag for relapse in some schizophrenia patients, researchers said. "There are no good, objective measures of treatment efficacy or indicators for relapse," said Dr. Brian Miller, a psychiatrist specializing in schizophrenia at the Medical College of Georgia at Georgia Health Sciences University. Researchers hope monitoring levels of interleukin-6 can fill that gap for a population in which more than half of patients don't take their medications as prescribed, often because of side effects. The relapse rate is about 80 percent within two years in patients who don't take their medication properly and about half that in those who do, according to the National Institute of Mental Health LSW Continuing Education "We hope the upshot of our studies will lead to new treatment approaches and strategies for care," Miller said, including the kind of personalized, multi-drug therapies that are becoming the standard for controlling other chronic conditions such as diabetes and hypertension. "We want to attack the disease from as many directions as possible." To get a better handle on how IL-6 levels correspond to disease status, they are looking at levels in blood samples taken multiple times over several years in 305 patients enrolled in a study comparing injectable to oral medication. They also are taking one-time measurements in 80 healthy controls and comparing those to levels in 240 patients who are acutely ill, stable outpatients or stable outpatients who smoke marijuana, a drug commonly abused by patients. While many previous studies have excluded drug abusers, marijuana may increase inflammation, so they want to explore the relationship between IL-6 levels and its use, Miller said. Miller received a five-year, $920,000 National Institute of Mental Health Mentored Patient-Oriented Research Career Development Award to measure IL-6 levels as a potential indicator of how well treatment is working to control disease in these vulnerable patients and whether they are headed to relapse. Amazingly the contributions of "immune disturbances" to schizophrenia have been debated for about 100 years yet anti-inflammatory drugs aren't routinely given to patients in addition to their antipsychotic medication, Miller said. Part of the problem is physicians still have no idea what percentage of patients with this very heterogeneous disease have evidence of increased inflammation. In fact, no two patients have the exact constellation of symptoms considered disease hallmarks, such as hallucinations, delusions, disorganized speech and thinking, he said. But mounting evidence suggests inflammation's impact in schizophrenia. A British study of 50 patients experiencing their first episode of schizophrenic behavior found a handful had indicators of an immune response to their brains, called autoantibodies, and no other conditions, such as a brain infection, to explain them. What amounts to a chronic low-grade flu has been found in some patients and rare immune system disorders such as Sjögren's syndrome, which attacks moisture-producing glands resulting in dry eyes and mouth, also tend to be more common in schizophrenics. Additionally, a handful of clinical trials has shown – not surprisingly – that patients with the highest levels of pro-inflammatory factors had the best response to anti-inflammatory drugs. "It's likely we are talking about a subset of people with this illness who would be most likely to respond to anti-inflammatory therapy – in addition to standard anti-psychotics – so part of our work is to begin to piece out who those people are (and whether) they have a particular clinical picture," Miller said. "Even being able to predict relapse or improve therapy in 25 percent of patients would be a tremendous advance," he said, noting that the vast majority of schizophrenia drugs work essentially by the same mechanism. Once patients can be identified, ideally with a blood test of their IL-6 levels, the next questions are which drugs to use and for how long. Miller's primary mentor for the studies is Dr. Andrew Mellor, a molecular geneticist and immunologist who leads the Cancer Immunology, Inflammation Tolerance Program at the GHSU Cancer Center. Mellor also is Bradley-Turner & Georgia Research Alliance Eminent Scholar in Molecular Immunogenetics. Co-secondary mentors are schizophrenia experts Dr. Peter F. Buckley, Dean of the Medical College of Georgia at GHSU, and Dr. Mark Rapaport, Chair of the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine. Schizophrenia affects about 1 percent of the population, or some 2.4 million American adults. Hallucinations are a disease hallmark: patients hear voices and can even see, touch and taste things that are not real. They can become depressed, reclusive and suicidal and have an increased risk of cardiovascular and other health conditions. Patients die on average15-20 years younger than the general population. Miller, a recipient of the 2011 National Alliance on Mental Illness Exemplary Psychiatrist Award, said he felt a calling to psychiatry and specifically schizophrenia as a medical student at The Ohio State University. "The patients are wonderful and their stories are fascinating," he said, noting that the field is "wide open" to improve their care. ###