In a 20-year longitudinal study, it was found that after acute hospitalization, continuous psychosis was diagnosed in only 30% of patients with schizophrenia; 20% of patients showed no signs of reoccurrence of psychosis after the acute phase. The study, presented by Martin Harrow, PhD, Thomas Jobe, MD, and Linda Grossman, PhD, of the University of Illinois in Chicago, observed a group of 187 patients, following up with them 7 times over the 20-year period using standardized research instruments. 

Early analysis of the data indicated that patients who were most likely to exhibit recurring psychosis included those who were vulnerable to anxiety or who had responded poorly when exposed to apprehensive situations. 

The analysis also indicated that good premorbid developmental achievements, low vulnerability to anxiety, favorable early prognostic features, and better performance on key neurocognitive variables were protective factors. 

Overall, the 20-year data support a view that a moderate to large percentage (more than 50%) of patients with schizophrenia go through episodic periods, often with adjustment difficulties and some impairment between episodes. The difference between schizophrenia and some other psychotic disorders is that the episodes of major symptoms for many of the patients with schizophrenia are often more severe, more frequent, more prolonged, and patients have slower recovery.

Articles

In a 20-year longitudinal study, it was found that after acute hospitalization, continuous psychosis was diagnosed in only 30% of patients with schizophrenia; 20% of patients showed no signs of reoccurrence of psychosis after the acute phase.

News Brief: Continuous Psychosis Not Common in Long-Term Schizophrenia Study

A study of primary care trainingdirectors conducted by Hoyle Leigh,MD, Ronna Mallios, MPH, andDeborah C. Stewart, MD, found thatmost directors believed their psychiatrytraining programs were inadequate.The researchers, from theUniversity of California, San Francisco,surveyed 1550 US psychiatryand primary care program directors(in family practice [FP], internalmedicine [IM], obstetrics and gynecology[OB], and pediatrics [Peds])with a questionnaire about specificareas of training as well as perceivedadequacy of training programs.

In each area, with the exceptionof FP, the directors responded thatthey were dissatisfied with the psychiatrytraining in their primary careprograms and that training was minimalto suboptimal; this was the viewof 94% of psychiatry training directors,as well as 81% of IM, OB, andPeds training directors. Interestingly,64% of FP training directors felt thattheir psychiatry training programswere optimal to extensive, and 60%were satisfied with training in theirprograms.

The researchers concluded thatwhile the basics of psychiatry trainingwere covered, all programs couldbe enhanced. Leigh told PsychiatricTimes, For IM, enhancements areneeded in training in a variety ofpsychiatric techniques and disorders;for OB, training in diagnostic interview,psychotherapy, counseling, andpsychopharmacology; and for Peds,training in diagnostic interview,somatoform/pain disorder, psychologicalfactors affecting physicalcondition, and adjustment disorders.Most programs, including FP, believetraining in eating disorders should beaugmented.

A study of primary care training directors conducted by Hoyle Leigh,MD, Ronna Mallios, MPH, and Deborah C. Stewart, MD, found thatmost directors believed their psychiatry training programs were inadequate.

Primary Care Directors Critical of Psychiatry Training Programs

Drinking a carbohydrate-rich beverageappeared to improve symptomsof seasonal affective disorder (SAD)in a small double-blind, placebocontrolledtrial. The study, conductedby David Mischoulon, MD, andassociates from the MassachusettsInstitute of Technology in Cambridge,found that 19 of 27 individualcomponents of the HamiltonRating Scale for Depression (HAMD)showed significant improvementin patients taking the beverage,including all components associatedwith SAD and winter blues (eg,oversleeping, weight gain, andfatigue).

The crossover trial, held duringearly winter, included 18 patientswith a diagnosis of SAD, determinedby the Structured ClinicalInterview (SCID) mood module.The drink used contained 40 mg ofa mixture of starch, maltodextrin,dextrose, and dextrin, and was comparedwith a control beverage thatcontained 15 mg of casein and25 mg of the carbohydrate mixture.The researchers explained that thecarbohydrate mixture was believedto contribute to serotonin synthesis,while casein may prevent tryptophanuptake by the brain anddampen synthesis of serotonin.

In the 16 patients who completedthe trial, there was a significantimprovement in work activity, middleinsomnia, and depersonalization/derealization. Given these positiveresults, the researchers suggestedthat replication of this pilot study andfurther investigation of this treatmentare warranted.

Drinking a carbohydrate-rich beverage appeared to improve symptoms of seasonal affective disorder (SAD) in a small double-blind, placebo-controlled trial.

News Brief: Carbohydrate-Rich Mixture Treats SAD

Physicians should be prepared to screen for posttraumatic responses that may be triggered by routine hospital care in previously traumatized patients, according to a group of researchers from the department of psychiatry at George Washington University in Washington, DC. Sarah Birmingham, MD, Lynne M. Gaby, MD, and James L. Griffith, MD, retrospectively reviewed 401 psychiatric consultations completed in a general hospital over 1 year. Eighteen of the consultations involved patients identified as having posttraumatic symptoms (re-experiencing, hyperarousal, avoidance, dissociation) triggered by routine care in the hospital. In all of these cases, the medical team or the patient did not initially associate the symptoms with the patient's previous history of trauma. Since systematic screening was not used in this study, the actual prevalence of posttraumatic reactions was probably higher, the researchers said. They recommended screening for such reactions so that patients can receive appropriate trauma-specific interventions.

Physicians should be prepared to screen for posttraumatic responses that may be triggered by routine hospital care in previously traumatized patients.

News Brief: Posttraumatic Symptoms Triggered by Hospital Care

It is common for mental health professionalsto label a patient as difficult;however, it remains unclear asto what the classification actuallymeans or what it entails. Koekkoekand colleagues reviewed 94 articlespublished between 1979 and 2004in order to answer 3 questions: (1)What are the defining characteristicsof difficult patients? (2) Howis the difficulty explained? and (3)Which treatment strategies are available?Their findings were publishedin the June 2006 issue of 

The researchers placed difficultpatients into 3 categories: the unwillingcare avoider, the ambivalent careseeker, and the demanding careclaimer. Unwilling care avoidersincluded patients with paranoidpsychosis and personality disorders.These patients were predominantlymale and exhibited behaviors thatincluded being withdrawn, hard toreach, and aggressive. Demandingcare claimers included substanceabusers and those with personalitydisorders. They were also predominantlymale and exhibited behaviorssuch as attention seeking, manipulating,aggression, and destruction.Ambivalent care seekers includedpatients with chronic depression, andpersonality disorders. This groupconsisted predominantly of femaleswho could be demanding, claiming,self-destructive, and dependent.

The studies offered 4 explanationsfor difficult patients: chronicity,dependency, character pathology,and lack of reflective capabilities.Some authors focused on transferenceand countertransference issuesin explaining what they conceived asnot a difficult patient, but a difficulttherapeutic relationship.

A variety of treatment interventionswere suggested. These includedcommon practices such as carefullistening and being nonjudgmental.A so-called holding environment, inwhich limits are set and the patientfeels safe to experience different feelingsand experiment with differentbehaviors, was among the otherapproaches suggested, along withindividual supervision of the therapistand interdisciplinary teamconsultation. Koekkoek and associatesconcluded that ambivalent careseekers are the most challenging totreat and are constantly subject todifferent judgments about their healthstatus by professionals.

It is common for mental health professionals to label a patient as difficult, however, it remains unclear as to what the classification actually means or what it entails.

The Challenge of the &#147;Difficult&#148; Patient

Concern has been raised recently about the efficacy andsafety of antidepressants for treatment of depressionin children. Some clinicians, therefore, have suggestedthat psychotherapy be started before medication treatmentof depression in children. How effective is psychotherapyfor the treatment of depression in children and adolescents?

 recently conducted a meta-analysis to assess the effects of psychotherapy for the treatment of depression in children and adolescents. This is the largest study sample to date on this topic. Given the significance of the findings, it is important to understand what kinds of studies were included in the analysis.

The authors applied strict inclusion criteria. Patients were required to have elevated levels of depressive symptoms, a diagnosis of a major depressive disorder or dysthymic disorder, or research diagnostic criteria diagnoses of minor or intermittent depression. Patients had to be randomly assigned to at least 1 active treatment group and to 1 nonactive treatment group (untreated, waiting list, minimally treated, or placebo-control group). The study sample had to have a mean age of 19 years or younger. Finally, the treatments used had to target depressive symptoms or disorder. In addition to including published studies, the authors also included non–peer-reviewed studies and doctoral dissertations in order to avoid possible publication bias.

Thirty-five studies met criteria for inclusion. The number of participants inthe separate studies ranged from 9 to 439. Many types of psychotherapy wereused, including cognitive-behavioral therapy with and without a family component; systemic behavioral family therapy; interpersonal psychotherapy; attachment-based family treatment; social skills training; relaxation training; social competency training; structuredlearning therapy; self-control; behavioral problem solving; rational emotive therapy; role-playing; and cognitive bibliotherapy. The patients were obtained from a wide variety of settings, such as the community, schools, day-treatment programs, and outpatient settings. Theage of the participants included in the sample ranged from 7 to 19 years.

A number of important clinical questions were addressed in the meta-analysis. First, is psychotherapy effective for depression in children and adolescents? The meta-analysis showed that the overall mean effect size for psychotherapy was 0.34, which is a modest effect size. (In general, a small effect size is about 0.20 and a large effect size is about 0.80.)

The investigators also compared the effect size of psychotherapy for depression to psychotherapy for other childhood conditions such as aggression,attention deficit hyperactivity disorder, and fears. The effect size for these nondepression conditions was 0.69, which was significantly higher than the effect of psychotherapy for depression.

Second, does the effect of psychotherapyfor depression in childrenand adolescents last? At follow-upassessments 1 year after treatment, therewas practically no treatment effect. Inessence, the improvements made duringthe course of acute treatment were notapparent a year later.

Third, are psychotherapy treatmentsthat focus on changing cognitions moreeffective than those that do not addresschanging cognitions? The analysisshowed that the mean effect size forcognitive treatments was 0.35 and fornoncognitive treatments was 0.47 Ñ nota significant difference. Therefore, therewas no advantage in using treatment thatemphasized change in cognitions, suchas cognitive-behavioral therapy.

Fourth, does psychotherapy have abeneficial effect on suicidality? Six ofthe studies in the sample included a measureof suicidality and were used for thisanalysis. The mean effect size for thesuicidality measures was 0.18. Therefore,the psychotherapy did not seem tohave an effect on improvement in suicidalthinking and behavior.

Overall, the results of the meta-analysisby Weisz and colleagues showed thatpsychotherapy for depression in childrenand adolescents had a modest effectand that this effect was not long lasting.These results raise concern as to whythe psychotherapy was not more effectivefor youth.

Study design issues such as patient characteristics,comorbid conditions, treatmentduration, assessment measures,skill of the therapist, and concurrenttreatments are some factors that mayaffect study outcome. These may berelated to the finding of weak efficacy for psychotherapy in depressed childrenand adolescents.

Another consideration, perhaps a morecrucial one, is that the leading psychotherapytreatments for depression were developedfor adults. Cognitive-behavioraltherapy, which focuses on changing apersonÕs thinking in order to improvedepressive symptoms, was developed forthe treatment of depressed adults.Similarly, interpersonal psychotherapy,which focuses on interpersonal behavior,was developed for depressed adults.Although these treatments have beenmodified for use in depressed adolescents,their origins are in the treatment of adultpsychopathology. It may be time todevelop new psychotherapy models thatare based on specific developmental levels(eg, social, emotional, and cognitivefeatures) specific to children and specificto adolescents in order to find more effectivepsychotherapy treatments.

Depression in children and adolescentsis a serious disorder that impairsa child's overall functioning and family life. Better medicationtreatments and better psychotherapytreatments are desperatelyneeded for these children. It maybe time to substantiallyincrease collaborationamong psychopharmacology researchers andpsychotherapy researchers in the areaof childhood depression, in the pharmaceuticalindustry, and in the NationalInstitute of Mental Health in order toidentify more effective treatments forchildhood depression.

Dr Wagner is the Robert L. StubblefieldProfessor in the department of psychiatry andbehavioral sciences and director of child andadolescent psychiatry at the University of TexasMedical Branch at Galveston.

 Weisz JR, McCarty CA, Valeri SM. Effects of psychotherapyfor depression in children and adolescents: a metaanalysis.Psychol Bull. 2006;132:132-149.

How effective is psychotherapy for the treatment of depression in children and adolescents?

More Treatments Needed for Childhood Depression

But what we call our despair is often only the painful eagerness of unfed hope.

, May 2006) reviewed the somewhat demoralizing findings that mood disorders cause damage at multiple correlated levels: molecular, clinical, social, and spiritual. I invited readers to join me for this column in which I would discuss new neurobiologic discoveries that bear the promise not just of controlling but of reversing these protean levels of damage. 

The trigger for the initial column had been a passage describing the ability of a midbrain infusion of brain-derived neurotrophic factor (BDNF) to reduce the behavioral despair of a rat. This same animal was subjected to the infamous forced swim test-a proxy for human depression-repeatedly, resulting in decreased levels of BDNF messenger RNA in its stressed hippocampus.

 I will argue that what seems a modestly interesting basic science experiment may actually herald and exemplify an amazing breakthrough in the treatment of serious mental illness. 

The felicitous sounding brain-derived new growth factor is an intimation of the new hope neurobiology is bringing to clinical psychiatry. BDNF does exactly as it promises: it literally grows, sustains, and nourishes new neurons. As we saw with our rat friend, stress and depression seem to switch off the gene for BDNF, leading to the atrophy and even apoptosis of neurons, particularly in the sensitive hippocampus, which plays such a leading role in learning and emotion.

 The shrinkage, impairment, and death of these crucial neurons shown in neuroimaging studies are convincingly hypothesized to contribute to depressive episodes that are more frequent, deep, persistent, and resistant to treatment.

While it may sound as if I am back to announcing my themes of neurobiologic doom and gloom, I am actually setting the stage for the good psychopharmacologic news that BDNF can increase the strength of synapses and the survival and growth of neurons through activation of a transmembrane receptor with intrinsic tyrosine kinase activity (TrkB). Even more pragmatically exciting, electroconvulsive therapy (ECT) and antidepressant therapy up-regulate the gene for BDNF and TrkB.

 Perhaps most incredibly, the old medication workhorse lithium and the much maligned ECT can actually stimulate growth of new neurons in the adult brain.

Neurogenesis as a philosophical concept seems more akin to science fiction than to our practice of writing antidepressant prescriptions in the office for outpatients who are struggling to keep some semblance of a life together. However, a robust body of research demonstrates that ECT, antidepressants, and even lithium all reverse the learned helplessness of human beings, whom nurture and nature have forced to swim against the tide of depression.

BDNF is only the most well established of a host of newly discovered second-messenger chemicals and cascades that likely have the miraculous properties of neurogenesis. The most hopeful quality of these proteins is neuroplasticity, or cellular resiliency, which holds the molecular keys to liberation from the grip of depression and a renewal of psychological flexibility.

As discussed in my earlier column, research has increasingly moved the source of pathology in the major psychiatric disorders from neurochemistry to neuroanatomy. Reports over the last decade have demonstrated reduction in brain volumes and abnormalities in brain structures in nearly every area implicated in psychiatric disorders.

 Scientists are now exploring whether mood stabilizers sold in the local pharmacy, such as valproate and lithium, can promote neuronal plasticity. Glycogen synthase kinase-3β negatively affects neuronal viability, development, and functioning. Laboratory studies have shown that therapeutic doses of lithium powerfully inhibit glycogen synthase kinase-3β-- as does valproate--and, it is theorized, thus enhance neuroplasticity.

These space-age discoveries are fascinating to the researchers we all admire, but are they relevant and useful for the clinicians most of us are? I would not be writing a column about BDNF and its cousins unless I thought they could relieve the suffering and improve the well-being of our patients with mood disorders. The rest of this column will outline what I see as the humanistic, professional, and even spiritual implications of the newly recognized potential of neurotrophic agents.

Recently, considerable and timely attention has been given to the idea that remission is not good enough for patients and that psychiatry must strive to achieve recovery. The 3 Rs--response, remission, and recovery--are often misused, and hence misunderstood, but clarification of the terms is crucial to appreciating the fourth R--restoration. Definitions of the 3 Rs in the context of depression are more consistent and consensual than in bipolar or other mood disorders and so we will adapt those delineations as shown in the 

It is now accepted that partial response and residual symptoms (ie, failure to achieve remission) lead to recurrence, relapse, continued psychosocial problems, poorer physical and mental health, and greater health care utilization-all stemming from unvanquished and still enervating affective symptoms.

 Viewed against the background of BDNF, we now know that these persistent symptoms are the phenotype of underlying secondmessenger system malfunction and that neurons will suffer, wither, and die until we aggressively and definitively treat each episode of depression. Our goal-and the molecular miracles of neurogenesis make it a real possibility, not just a fantasy-is to travel beyond recovery to restoration. Restoration is a global idea of healing and, while only heuristic, we can envision it as a flowchart showing augmentation of human actualization, as sketched in the 

Rather than try to explicate the concept of restoration, it may be more useful to illustrate it with several examples from my clinical work with mood disorder patients. I have a score of men in whom bipolar illness was diagnosed in their 20s; who were hospitalized repeatedly; and who had multiple suicide attempts, legal troubles, and failed marriages stemming from inadequate treatment and nonadherence. Once these patients were able to work through the obstacles of finding competent care and their own internal barriers to accepting the diagnosis of a chronic disorder and consequent need for lifelong medication, their lives gradually but steadily transformed. 

Most of these men are now not only symptom-free but disorder-free. Many of them work full- or part-time, and those who are retired or on a pension are volunteering, traveling, and raising children and grandchildren. They are phenomenally stable on modest but therapeutic levels of lithium, valproate, and perhaps small doses of adjunctive benzodiazepinesand atypical antipsychotics. I see them 2 or 3 times a year for checkups and I can seldom find even mild swings of the mood pendulum. 

Most of these patients have painful memories of their active illness, yet other than having to take pills with the prosaic daily rituals of breakfast and sleep, their Axis I diagnosis has little effect on their lives, self-images, plans, or dreams. They will all readily admit that they may be in a different place socially and economically than they would have been had they not had bipolar disorder; but most are at peace with their genetic legacy and enjoy their quality of life. 

To a patient, they attribute their stability and fulfillment (restoration, if you will) to their mood stabilizers. The only intense emotional reactions I have seen from these patients is when they are afraid that their trusted medication regimens might be altered. As one patient told me at his initial visit, I always am anxious about seeing a new doctor because I am afraid they will feel they have to change my medicines to prove themselves. I know what has kept me out of the hospital and I don't want to fix what is not broken.

At this point, many readers may be rightly wondering if I am a biological reductionist. Far from it: the benefits of neurogenesis are only possible if patients commit to the messages in the bottle, and only psychosocial therapies can foster and sustain such a commitment. It is psychotherapy that enables patients to integrate their illness into their identity and reconcile the losses and traumas it has wrought. It is psychoeducation and case management that teach patients and families early on about the signs of relapse and the triggers of episodes and how to manage side effects; it is supportive employment and consumer groups that help patients develop lifestyles and relationships that enable them to integrate into the community, overcome stigma, and follow the path to recovery.

This coalition of interventions is what Noordsy and colleagues,

 in a pioneering paper on redefining the goals of antipsychotic treatment, call recovery-oriented psychopharmacology. Rather than widening the mind/brain split, restoration offers a synthesizing consilience of Luhrmans' dialectic characterizing a profession divided and divisive over the use of psychopharmacology and psychotherapy.

 This synthesis is a spiritual one, not in a theological sense, but in a transcendent sense. Restoration is more than the sum of any parts of symptom remission or return to functioning or even recovery of original homeostasis. Restoration is a process of growth and healing from neuron to mind to soul or spirit that is holistic in nature and iterative in process and that encompasses the healing of damage from cell to self.

For years, psychiatrists have had a fortress mentality, and have been on the defensive against substance use, noncompliance, and the recurrent nature of affective illness. Our victories of Hamilton Depression Rating Scale response and remission with residual symptoms often seemed Pyrrhic and transient until the next relapse. We watched in frustration and shame while too many patients spiraled into disability payments, group homes, and revolving- door admissions; too few achieved mere remission.

The reality of recovery and the realistic hope of restoration transform psychiatry into what Kupfer,

 in a different context, deemed the mission of therapeutics. This mission involves a vigorous dedication to early diagnosis and intervention of serious mental illness; aggressive treatment with all the neurogenic therapeutic modalities, including psychotherapy, of every patient with an affective disorder; and the professional commitment to an ethic that we will accept nothing less than recovery and ultimately restoration for each patient.

These are the strengths of the mission. Are there limitations? Of course, as with any vision it is a long translational road from bench to examining room; there are enormous economic and policy problems to resolve if we are to have adequate funding for such an ambitious project; psychiatric education will need to undergo a minor revolution if medical students and residents are to embrace the new activist and activated face of psychiatry; and ethical questions regarding the place of pharmaceutical companies, primary prevention, and outpatient commitment must be resolved. We really have no choice, though, except to go forward--because once we found that BDNF could reverse the effects of forced swimming, and treatments already in our possession could generate new neurons, morally, everything has changed.

Dr Geppert is chief of consultation-liaison psychiatry and chief ethics consultant at New Mexico Veterans Affairs Health Care System in Albuquerque. She is also assistant professor in the department of psychiatry and associate director of religious studies at the University of New Mexico in Albuquerque.

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http://www. neuropsychiatryreviews.com/may01/npr_may01_ mood.html

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A discussion of new neurobiologic discoveries that bear the promise not just of controlling but of reversing protean levels of damage.

Restoration

Cognitive-Behavioral Therapy for Adolescent Depression

Developing an Effective Treatment Protocol

Family Therapy in the Treatment of Depression

NAMI Programs Educate Families of Mentally Ill

From Prevention to Preemption: A Paradigm Shift in Psychiatry

 for children with anxiety disorders may be especially effective when the family is included in treatment.

 Family CBT (FCBT) has consistently yielded a high proportion of treatment responders (more than 70%) and in some studies has outperformed CBT programs with little family involvement.

 This article presents the rationale supporting FCBT, provides a case study illustrating FCBT techniques, and summarizes the findings of a recent clinical trial.

 draws on effective cognitive-behavioral techniques

. A good description of fundamental CBT techniques was published in 2003.

 CBT for children’s anxiety disorders consists of 2 phases: skills training, and application and practice. During the skills training phase, children are taught techniques for reappraisal of feared situations, relaxation, and self-reward. In the application and practice phase, a hierarchy is created in which feared situations are ordered from least to most distressing. Children work their way up the hierarchy and are rewarded as they attempt increasingly fearful activities.

Seven studies have compared versions of FCBT with versions of child-focused CBT (CCBT) with little family involvement for children presenting with 

 Five of the studies have reported some outcome measures favoring FCBT over CCBT at the posttreatment assessment, whereas no outcome measures have favored CCBT over FCBT. In contrast, there were no differences found between the FCBT and CCBT programs studied,

 and some longer-term outcome studies have suggested that differences between FCBT and CCBT lessen over the course of time. Nonetheless, the extant evidence suggests that there may be some advantage of the FCBT paradigm, particularly with regard to immediate effects.

Most FCBT programs have not focused on the specific parenting practices that are hypothesized to contribute to the development and maintenance of anxiety in children. In comparison, the FCBT program Building Confidence (J.J. Wood et al, unpublished manual, 2006) was developed by drawing on basic research in parent-child interaction patterns in families of children with anxiety disorders,

 with the goal of enhancing treatment effectiveness. These studies suggest that high levels of parental intrusiveness and a lack of parent-granted autonomy are linked with anxiety disorders in children.

Parents who act intrusively tend to take over tasks that children are (or could be) doing independently and impose an immature level of functioning on their children. Among schoolaged children, parental intrusiveness can manifest in at least 3 domains: unnecessary assistance with children’s daily routines (eg, dressing), infantilizing behavior (eg, using baby words, excessive physical affection), and invasions of privacy (eg, parents opening doors without knocking).

 Parents who act intrusively are posited to interfere with the process of habituation (fear reduction) by preventing children from actually confronting feared but benign stimuli.

 Conversely, parents who grant appropriate levels of autonomy may enhance children’s feelings of mastery and self-efficacy,

 and thus contribute to the regulation of anxiety.

 FCBT manual goes beyond previous CBT programs by directly intervening with parental intrusiveness and parentgranted autonomy.

 program includes individual sessions with the child and complementary parent-training sessions. These parent-training sessions emphasize:

Giving choices when children are indecisive (rather than making choices for them).

Allowing children to struggle and learn by trial and error rather than taking over tasks for them.

Labeling and accepting children’s emotional responses (rather than criticizing them).

Promoting children’s acquisition of novel self-help skills.

An incentive system is also taught to parents to encourage their children’s courageous behavior. A typical FCBT session begins with a 20-minute individual meeting with the child to conduct skills training or application/practice. Skills are reviewed less thoroughly with the child than in CCBT, permitting time for parent-training (20 minutes) and conjoint parent-child meetings (10 minutes). The following case describes a child with separation anxiety, but the issues it raises are also applicable to other types of anxiety disorders.

Ben is an 11-year-old boy living with his single mother in a semirural area of California. They share a small apartment with another single mother and her school-aged son. Ben’s mother works from home and their income is below the poverty line.

Ben is a slender boy with a friendly smile who is extremely nervous about being away from his mother, a behavior that meets the criteria for separation anxiety disorder. He has missed 20 days of school in the 2 months before intake because of reluctance to be away from home, has left school early 5 times because he felt “sick,” and frequently goes to the nurse’s office in school. His pediatrician has found no medical problem that would explain these difficulties.

Ben sleeps in his mother’s bed every night. He is distressed by worries about his mother being in a car accident while he is away from her, a concern not based on previous experience. Ben has avoided playdates, team sports, and afterschool activities because of separation anxiety, causing his mother to worry about his social development. Ben is exceptionally well-behaved and polite, and he has a precocious sense of humor. He noticeably perked up when interacting with male clinicians, flopping around the therapy room in mock slapstick routines or rushing to initiate conversation about topics he thought would be of interest.

There are numerous signs of intrusive parenting: Ben’s mother encourages his sleeping with her; she showers with him and washes his hair (an atypical scenario for an 11- year-old), she dresses and undresses him, and grooms his hair (which tangles easily and is difficult to manage) on a daily basis. Despite receiving assistance from his mother during these routines, Ben is actually capable of self-care in each of these areas. Ben also often sits on his mother’s lap, both he and his mother assert that all of these interactions help him feel less anxious.

FCBT USING THE BUILDING CONFIDENCE PROGRAM

The case study illustrates a typical pre-sentation of a child with separation anxiety disorder.

 Commonly, as in Ben’s case, sexual abuse is screened for and ruled out; nonetheless, the intrusive interactions in question are developmentally inappropriate. In Ben’s case, the interactions appeared to be unintentionally reinforcing to his mother, since she indicated that she enjoyed being able to “be there for him and comfort him.”

Paradoxically, such comforting seems to support Ben’s separation anxiety rather than eradicate it. He feels dependent on his mother’s comforting for the regulation of his anxiety, and when he is away from her he finds it challenging to cope with the anxiety he experiences. Child psychiatrists and psychologists do not always screen for these kinds of intrusive parenting behaviors and, therefore, may be unaware of the role such behaviors play in the maintenance of anxiety disorders in children.

Skills training and focus on autonomy-granting

The first 4 sessions of FCBT focus on teaching core CBT skills, such as positive self-talk, and core parenting skills that can facilitate a child’s independence and self-confidence. Ben was exceptionally motivated, thrived on praise from his therapist, and made rapid progress in learning CBT skills. Coping skills that were emphasized included challenging Ben’s worries about his mother’s safety (eg, “My mom has never been in a car accident before, how likely would it be?”). However, Ben’s separation anxiety symptoms were slow to remit early in treatment. A major focus of parent training was increasing parentgranted autonomy and reducing intrusiveness. In talking with Ben’s mother, it was noted that children feel more confident when they do things for themselves that others have previously done for them and that this confidence can lead to courageous behavior.

Like many parents, Ben’s mother seemed to be caught between agreement (“He is very clingy,” she would acknowledge) and doubt (“He is only 11; can’t he still be a little boy?”). She emphasized that Ben’s clingy behaviors were not burdensome to her. To address her ambivalence, several techniques were employed:

Empathizing with her desire to keep Ben close to her.

Warning her that without him becoming a bit more independent, Ben’s maladaptive anxiety-related behaviors were likely to get worse.

Offering a plan of action that emphasized gradual changes in parent-child interaction.

Parent communication skills, such as giving choices, as described above, were taught to Ben’s mother to support his development of autonomous behaviors. (Note that all parent-training activities in FCBT are directly related to 1 of 2 goals: altering the targeted parent-child interaction patterns or enhancing the child’s application/practice of CBT skills.)

Initial steps in increasing autonomygranting and reducing intrusiveness were selected by Ben, who noted that showering on his own and dressing himself would not be a problem as long as his mother was somewhere in the house. In a family meeting, Ben presented this to his mother and a plan was made to try it out. At the following session, Ben was praised for his followthrough. The therapist assessed the progress of these independent skills during each session, and Ben would flash an enormous smile, proudly affirming his mastery of the self-help tasks. Hair-brushing was added to the list, and when his mother could not tolerate his “lack of skill,” she simply gave him a shorter haircut that was largely maintenance- free-an excellent solution that supported Ben’s autonomy.

Ben’s mother-while not undermining these changes-did express sadness about his emerging independence. This reaction was normalized by the therapist (“All parents feel this way as their children become more mature”). Frequent reminders of the treatment rationale, and particularly the important role parents play in children’s anxiety reduction (by supporting their autonomy), were helpful in maintaining the mother-therapist alliance, as well as the changes in family routines that had been achieved.

Skills application and practice with parent support

A key tenet of FCBT is that early increases in parent-granted autonomy and independent child behaviors in sessions 1 through 4 pave the way for (a) increased self-confidence in the child, which facilitates the child’s engagement in facing feared situations in sessions 5 through 16 and (b) parental adoption of communication techniques (eg, giving choices) that enhance the effectiveness of the application and practice phase of CBT.

Ben’s first task in the application/practice phase was returning to school, and the timing of this coincided closely with his upsurge in self-confidence following the independent behavior sessions. Typical CBT techniques for addressing school refusal were employed,

 and Ben stayed at school for longer and longer periods each day. Though predictably nervous, he tried his hardest, focused on challenging his fearful thoughts about his mother’s safety, and successfully ignored his anxious feelings (which were labeled “false alarms”). Incentives offered by his mother (eg, earning television time) also helped promote his adherence to the school-return plan.

Ben returned to school full time by session 10, evidencing habituation and a humorous “blas” attitude about his success. It is worth additional emphasis that the rapidity and ease with which full school return was accomplished was facilitated by Ben’s early self-confidence in the independent skills exercises and by his mother’s use of parenting skills to support his autonomy, both of which are FCBT-specific strategies.

Reducing cosleeping-a key goal in separation anxiety treatment-proved to be a formidable challenge. Ben agreed in principle by session 8 to sleep in his own bed on a nightly basis, but his mother was noncommittal. Ben’s anxiety was moderately high about sleeping independently even after the many successes he had achieved by midtreatment. Without his complete investment in this task, and with his mother’s reticence about changing their routine, treatment progress plateaued for several sessions (Ben’s mother said they had simply forgotten to have him sleep by himself).

Two shifts in the therapist’s approach proved critical. First, to increase the mother’s motivation, it was noted to her that full remission of separation anxiety rarely occurs unless children sleep on their own (which is true, in our clinical experience) and that excessive anxiety could ultimately interfere with Ben’s social and intellectual development. Second, to increase Ben’s motivation, a checklist was made of a number of highly feared tasks that when completed would lead to what he considered a large reward (a video his mother agreed to purchase for him). This checklist included Ben sleeping independently for 4 weeks in a row, inviting children from school over at least 4 times, and joining an after-school activity (choices were given).

Of course, Ben was given help in applying CBT skills in preparation for these activities. It was thought that by appealing to both Ben and his mother, chances for success would be doubled compared with relying on the solitary (and wavering) motivation of either of them alone.

This multifaceted approach proved effective. Ben’s mother was sufficiently persuaded by the therapist’s logic to permit a trial of the sleeping plan, while Ben was quite invested in his checklist incentive program and began sleeping independently. Within 2 weeks, Ben’s ratings on a 0-to-10 anxiety scale indicated that he felt no anxiety when sleeping by himself (again, reflecting habituation to a feared-but benign- situation). Simultaneously, he initiated playdates with a neighborhood boy that soon became reciprocal, and joined an after-school music program that he enjoyed. Ben’s mother was pleased with these accomplishments and began to praise the therapy program, including its emphasis on Ben’s independence. She voiced no further reservations about the new sleeping arrangements.

While still exhibiting a shy, eagerto- please disposition, Ben had no core anxiety disorder symptoms by session 16 when he was interviewed by an independent evaluator (using a structured diagnostic interview). Treatment gains were maintained at a 1-year follow-up interview

In a recent clinical trial, the Building Confidence FCBT program was compared with traditional CCBT with minimal family involvement.

Forty children with anxiety disorders (aged 6 through 13 years) were randomly assigned to FCBT or CCBT. Anxiety disorders (separation anxiety disorder, social phobia, and/or generalized anxiety disorder) were confirmed by an independent evaluator using a structured diagnostic interview. The 2 treatment conditions were matched for therapist contact time (12 to16 therapy sessions lasting 60 to 80 minutes each). Outcome measures included independent evaluators’ diagnoses, severity ratings for each diagnosis on the Clinician’s Rating Scale,

 and improvement ratings on the Clinical Global Impressions (CGI) scale; child-reports on the Multidimensional Anxiety Scale for Children (MASC)

Overall, results favored FCBT over CCBT, highlights included:

79% of children in FCBT met CGI criteria for good treatment response, compared with only 26% of children in CCBT.

Children in FCBT had greater improvement on independent evaluators’ ratings on the Clinician’s Rating Scale than children in CCBT.

Parent reports of child anxiety on the MASC-but not children’s selfreports- were lower in FCBT than CCBT at posttreatment.

Although both treatment groups showed statistically significant improvement on all outcome measures, FCBT provided additional benefit over and above CCBT on most indices of improvement.

It should be noted that FCBT appears to be equally effective for children with primary diagnoses of separation anxiety disorder, social phobia, and generalized anxiety disorder. Although the case study presented above illustrates how FCBT can address separation anxiety, parental involvement is also beneficial for the treatment of the other 2 primary child anxiety disorder diagnoses. For example, parental intrusiveness is often seen in cases of children with social anxiety. Parents may offer excessive comfort when children are fearful in social situations and take over social tasks (eg, by speaking for their children) that children could handle independently. Variations of the FCBT techniques described above have proved helpful in addressing such family interaction patterns.

FCBT involves a complex interplay of cognitive-behavioral techniques and family restructuring, drawing on the combined (and sometimes complementary) resources and motivations of children and their parents. While CCBT is quite effective by itself, FCBT can lead to even greater improvements in anxiety, at least in the short term.

 Therefore, it may be beneficial for clinicians to assess for parental intrusive-ness and autonomy-granting in cases of school-aged children with anxiety disorder and consider the use of a structured FCBT protocol that explicitly addresses such family dynamics when they are present.

Dr Wood is an assistant professor of psychological studies in education in the department of education at the University of California, Los Angeles. His research focuses on the psychopathology of childhood anxiety, with an emphasis on randomized, controlled trials of cognitive- behavioral therapy interventions. The writing of this paper was supported, in part, by a grant from NIMH awarded to Dr Wood (MH075806). He reports that he has no conflicts of interest with the subject matter of this article.

1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342.
2. Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consut Clin Psychol. 1998;66:893-905.
3. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006; 45:314-321.
4. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994;62:100-110.
5. Silverman WK. Using CBT in the treatment of social phobia, separation anxiety and GAD. Psychiatr Times. September 2003; Vol 20.
6. Nauta MH, Scholing A, Emmelkamp PM, Minderaa RB. Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of a cognitive parent training. J Am Acad Child Adolesc Psychiatry. 2003;42:1270-1278.
7. Spence SH, Donovan C, Brechman-Toussaint M. The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitivebehavioural intervention, with and without parental involvement. J Child Psychol Psychiatry. 2000;41: 713-726.
8. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39:1411-1427.
9. Rapee RM. The development of generalized anxiety. In:Vasey MW, Dadds MR, eds. The Developmental Psychopathology of Anxiety. New York: Oxford University Press; 2001.
10. Wood JJ. Parental intrusiveness and children’s separation anxiety in a clinical sample. Child Psychiatry Hum Dev. In press.
11. Fox NA, Henderson HA, Marshall PJ, et al. Behavioral inhibition: linking biology and behavior within a developmental framework. Annu Rev Psychol. 2005;56:235-262.
12. Chorpita BF, Barlow DH. The development of anxiety: the role of control in the early environment. Psychol Bull. 1998;124:3-21.
13. Kearney CA, Hugelshofer DS. Systemic and clinical strategies for preventing school refusal behavior in youth. J Cog Psychother. 2000;14:51-65.
14. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: Graywind; 1996.
15. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.

Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342.
Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006;45:314-321

Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment.

Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

Avoidant personality disorder (APD) is characterized by a general tendency to fear and avoid social interactions-even interactions with persons who are well known to the individual. In addition to deserving our clinical and research attention in its own right, APD highlights some of the key controversies with our current classification system. These debates include the "horizontal" boundaries between different Axis I and Axis II conditions as well as the "vertical" boundaries between a clinical disorder and certain personality or temperamental traits. In pediatric psychiatry, use of the diagnosis underscores the conflict between the motivation to avoid Axis II diagnoses in children and adolescents and the motivation toward early identification and early intervention of psychiatric illness.

In this article, I will briefly summarize some of the key components of APD, with a focus on epidemiology, assessment, diagnostic dilemmas, and treatment.

 defines APD as "a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts." In persons with APD, the avoidance of, and restraint during, social contact is the result of fears of rejection and humiliation.

APD is one of the cluster C personality disorders, along with dependent and obsessive-compulsive personality disorders. The level of impairment associated with APD is high; employment, interpersonal relationships, and global functioning are all negatively affected. The morbidity associated with APD rivals and even exceeds that associated with such Axis I disorders as major depressive disorder.

APD is relatively common; the prevalence is about 5% in the community

 and nearly 15% among psychiatric outpatients.

 As such, APD is one of the most-if not the most-prevalent personality disorders. APD occurs about equally between males and females.

The symptoms of APD often appear early and the disorder can be distinguished from other personality disorders by elementary school or even earlier. Adults with APD reported less involvement in extracurricular activities and sports, and were less popular than adults with another personality disorder or major depression.

 have characterized a temperamental trait labeled behavioral inhibition that applies to children who have a strong tendency to be shy and restrained in novel situations. Behavioral inhibition-a potential precursor to later social anxiety and avoidance-has been reliably assessed in children 2 years old and perhaps even younger.

Longitudinal research has demonstrated detectable, although certainly not inevitable, links between behavioral inhibition and many disorders in childhood and adolescence. These include social anxiety disorder and avoidant disorder (as defined in 

 Emotional disorders, such as anxiety, depression, and eating disorders, in adolescence predict cluster C personality disorders in adulthood in women.

While there appears to be at least some continuity between adult APD and childhood symptoms, accumulating research is beginning to demonstrate a more waxing and waning course of APD symptoms through adulthood than had originally been expected. A 2-year prospective study from the Collaborative Longitudinal Personality Disorders Study found that over time, feelings of inadequacy and social ineptness and the need to be certain of being liked before entering into social situations were more stable than worries about shame and risks of exposure in one's employment.

Considerably less is known about APD as affected persons age. The disorder is scarcely studied in geriatric psychiatry.

The finding in APD and other personality disorders that there is an onset of symptoms in childhood and adolescence represents a dilemma for many clinicians. On one hand, our training dictates the general principal of early identification and intervention to help avoid or reduce long-term suffering. At the same time, clinicians tend to avoid diagnosing personality disorders in children and adolescents.

 While the reasons for this practice are not entirely clear, the tendency may be based in part on the notion that a child's personality is still "in progress" and thus he or she should not be labeled as "disordered" for fear of stigmatization.

While this concept has some merit, it is also flawed. Symptoms of Axis I disorders, such as attention-deficit/hyperactivity disorder, also tend to undergo change through the course of the person's development, yet this does not prevent clinicians from making a diagnosis at a particular point to allow for the amelioration of impairing symptoms.

Furthermore, personality development does not stop when a patient reaches age 18. As for stigmatization, it is not intuitively obvious why a diagnosis of APD carries a higher burden than many other conditions that can be diagnosed before adulthood, such as social anxiety disorder.

A final obstacle to diagnosing APD in children is the criterion that a cause for social avoidance be identified (eg, fear or shame or embarrassment). Such a cause may be difficult to detect in younger children, whose self-consciousness is still developing.

There has been little research into the cause and pathophysiology of APD per se, although much literature exists about related Axis I conditions or traits, such as shyness. Behavioral inhibition and other temperament traits like it (eg, harm avoidance) are thought to be related to overactivity of regions of the brain that are involved in the fear response. One recent study found evidence that high levels of harm avoidance were related to decreased coupling between the amygdala and the anterior cingulate gyrus which, in turn, may be related to genes involved in serotonin transmission.

The heritability of behavioral inhibition ranges from 25% to 44%, as measured in toddlers.

 Interestingly, there is some evidence to support stronger genetic associations with the personality dimensions that may underlie APD than with the specific APD symptoms themselves.

The differential diagnosis of APD (or its "horizontal" boundaries) includes mainly other psychiatric disorders. While there may be theoretical distinctions between APD and related diagnoses, these differences can be very difficult to untangle in practice, especially if one takes a developmental perspective of the patient. The 

 lists some features that may distinguish other traits and disorders from APD.

The main theoretical distinction between APD and both schizoid personality disorder and an autistic spectrum disorder is the notion that persons with APD very much want social contact-but are afraid to seek it out, while those with schizoid personality disorder or an autistic spectrum disorder are less intrinsically interested in social contact. However, many individuals with an autistic spectrum disorder do seek out human contact but struggle with how to achieve it. It is thus advisable to obtain a good developmental history if both of these disorders are being considered as alternatives to APD.

Developmentally, it is also possible that over time a person with APD who initially craves social contact will begin to settle into a pattern in which this contact is no longer sought. Another point of divergence between APD and an autistic disorder relates to social cues. Children with an autistic spectrum disorder tend to ignore these cues, while those with APD are hypersensitive to them.

Perhaps the greatest diagnostic dilemma pertains to the boundaries between APD and the general subtype of social anxiety disorder (GSAD). The diagnostic criteria overlap considerably. Attempts to find distinguishing characteristics in the epidemiology, physiology, and response to treatment have yielded little in the way of qualitative differences.

 Indeed, there may be more differentiation between the specific and generalized form of GSAD than between generalized GSAD and APD, despite their existence on different axes.

Researchers have similarly been interested in the "vertical" boundaries between APD and established personality or temperamental traits, such as shyness. There certainly appears to be significant overlap between certain disorders, such as APD, and specific personality dimensions. Nevertheless, the increasingly popular hypothesis that APD simply represents the extreme end of a normally distributed trait such as shyness appears to be overly simplistic.

Studies of the relationship between shyness and generalized social phobia show that many people with very high levels of shyness do not meet criteria for GSAD.

 This lack of continuity has stimulated researchers to begin looking for other features that could moderate the relationship between shyness and psychiatric disorders. These include other personality or temperament traits (such as emotion regulation) or specific cognitive factors that may exacerbate shyness into full-fledged APD.

Assessment for APD is part of a general psychiatric evaluation; the condition should be suspected in patients in whom social avoidance, fear of embarrassment, and intimacy difficulties are uncovered. Instruments to aid in the diagnosis of APD and other personality disorders continue to be refined, although their use in routine practice remains limited.

As with most personality disorders, most patients who meet criteria for APD will meet criteria for other Axis I and Axis II conditions. Notable among these are Axis I anxiety and affective disorders, other cluster C disorders, and substance abuse.

Treatment of APD involves psychotherapy and/or medication. Unfortunately, treatment studies rarely focus primarily on APD and instead analyze patients with APD as a subset of those with GSAD or other personality disorders.

 Given this limitation, multiple types of psychotherapy have been shown to be effective in adult APD, including cognitive- behavioral, psychodynamic, and supportive-expressive therapy.

No medications have been specifically approved for the management of APD. However, research has documented improvement in patients who meet criteria for both APD and social anxiety disorder when treated with selected serotonin reuptake inhibitors and benzodiazepines.

 Current recommendations include consideration of pharmacotherapy in APD, regardless of whether a patient meets criteria for a comorbid Axis I disorder,

 although additional research in this area is sorely needed. Given the risk of substance use in APD, physicians should be cautious in prescribing benzodiazepines.

Regardless of treatment modality, however, one of the keys to treatment success (as with other anxiety conditions) is exposure. Patients who simply take a medication or who speak with a therapist are not likely to report symptom relief before they take the risk of confronting their feared situations.

Greater success can be anticipated if the therapist supports patients and encourages them to confront their fears. This can take the shape of a specific homework assignment within a cognitive-behavioral format or therapist support of the patient's willingness to risk intimacy and no longer be the "perfect patient" within a psychodynamically oriented framework.

APD is a relatively common condition that is associated with significant impairment in multiple domains. The boundaries of the disorder-both horizontally with other psychiatric diagnoses and vertically with personality dimensions such as shyness-continue to be blurry and not well established. In particular, there seems to be little to qualitatively distinguish APD from the generalized type of social anxiety disorder.

Research into the course of APD demonstrates the disorder's origin in early temperamental traits. Increasing data exist to suggest that during adulthood APD may be more changeable over time than originally thought. These data suggest that positive responses can occur with psychotherapy and/or medications.

Dr Rettew is assistant professor of psychiatry and pediatrics at the University of Vermont College of Medicine in Burlington.

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A discussion of the epidemiology, assessment, diagnostic dilemmas, and treatment of avoidant personality disorder.

Psychiatric Times Vol 23 No 8

News Brief: Continuous Psychosis Not Common in Long-Term Schizophrenia Study

Primary Care Directors Critical of Psychiatry Training Programs

News Brief: Carbohydrate-Rich Mixture Treats SAD

News Brief: Posttraumatic Symptoms Triggered by Hospital Care

The Challenge of the Difficult Patient

More Treatments Needed for Childhood Depression

Restoration

Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

Avoidant Personality Disorder: Boundaries of a Diagnosis

Stepping on the Oxygen Tube

Psychiatric Times Vol 23 No 8

News Brief: Continuous Psychosis Not Common in Long-Term Schizophrenia Study

Primary Care Directors Critical of Psychiatry Training Programs

News Brief: Carbohydrate-Rich Mixture Treats SAD

News Brief: Posttraumatic Symptoms Triggered by Hospital Care

The Challenge of the &#147;Difficult&#148; Patient

More Treatments Needed for Childhood Depression

Restoration

Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

Avoidant Personality Disorder: Boundaries of a Diagnosis

Stepping on the Oxygen Tube

The Challenge of the Difficult Patient