The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients’ interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists’ adherence (r = 0.54) and therapeutic alliance (r = 0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients’ interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r = 0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.     

Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation

Despite its effectiveness, exposure therapy is underutilized and frequently implemented in suboptimal fashion. Research has shown negative beliefs about exposure are related to its underutilization, and these beliefs are held by exposure therapists and may play a causal role in its suboptimal delivery. This study examined the effect of negative beliefs about exposure on treatment delivery. Participants (n = 53) received training in basic exposure implementation and were given additional information intended to elicit either positive or negative beliefs about the treatment's safety, tolerability, and ethicality prior to conducting an exposure session with a confederate client. Results indicated that participants with experimentally induced negative beliefs about exposure delivered the treatment more cautiously (e.g. creation of a less ambitious exposure hierarchy, selection of a less anxiety-provoking exposure task, attempts to minimize client anxiety during exposure) compared to participants with positive beliefs who pursued more ambitious delivery of exposure (e.g. encouraging clients’ use of oppositional actions). The present findings suggest that therapist reservations about exposure cause suboptimal delivery and may adversely affect client outcomes.     

Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

BackgroundThis paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis.MethodsAll clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5 months, 9 months and 18 months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy.ResultsAt baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point.ConclusionsFindings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.     

L’attachement du client au thérapeute en psychothérapie : une revue systématique des études empiriques

Attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Consistent with Bowlby's (1988) secure base conception of attachment in psychotherapy, several instruments have been developed to measure client attachment to therapist. Despite a large number of studies, no review takes into account all published work. The purpose of this systematic review was to compare different measures of client's attachment to therapist, with different groups of client and in different therapeutic contexts. Medline, Embase, Pubmed, PsycInfo, and Web Of Science were searched to identify studies published between 1995 and 2019 reporting on help-seeking client's attachment to therapist. Twenty-five empirical papers met the inclusion criteria. Meta-analyses were conducted for studies that examined client attachment to therapist subscales (Secure, Avoidant–Fearful, Preoccupied–Merger) as correlates of client-rated working alliance (K = 11, 892 clients), and general adult attachment (K = 11, 752 clients). The results show that the client's secure attachment to therapist is strongly correlated with the therapeutic alliance (mean weighted R = 0,71 [95% CI = 0.62–0.79]), moderately correlated with the results, and negatively correlated with the avoidance (mean weighted r = − 0,12 [IC 95% = − 0.06–− 0.21]) and anxiety dimensions (mean weighted R = − 0,11 [IC 95% = − 0.03–− 0.17]) of adult attachment. With the Avoidant–Fearful style, results go in the opposite direction, negatively correlated with the therapeutic alliance (mean weighted R = − 0.55 [IC 95% = − 0.59–− 0.50]), negatively correlated with the results, and correlated with the avoidance dimension of adult attachment (mean weighted R = 0,16 [IC 95% = 0.09–0.23]). The Preoccupied–Merger style shows weak (positive or negative) to zero correlations. In addition, nine studies looked at some dimensions of the psychotherapy process (e.g., resistance, transference, emotions, self-disclosure, and attitude toward psychotherapy), showing that insecurity of attachment to the therapist (both Avoidant–Fearful style and Preoccupied–Merger style) seem to interfere in one way or another with the development of a productive psychotherapy process. Overall, these results are in line with what was expected. They are consistent with Bowlby's conception of a secure base of attachment in psychotherapy. They showed that dysfunction and maladaptive developmental experience interfere with adult's ability needed to establish secure attachments and that psychotherapy may play the role of what has been previously defined as corrective emotional–or intersubjective–experience. In addition, these results do not seem to vary according to the instruments used. Together, the high correlation with therapeutic alliance and the weak correlation with pretherapy adult attachment confirm the relevance of the client's attachment to therapist as a specific variable related to the process of change in psychotherapy.     

Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale

Exposure therapy is underutilized in the treatment of pathological anxiety and is often delivered in a suboptimal manner. Negative beliefs about exposure appear common among therapists and may pose a barrier to its dissemination. To permit reliable and valid assessment of such beliefs, we constructed the 21-item Therapist Beliefs about Exposure Scale (TBES) and examined its reliability and validity in three samples of practicing clinicians. The TBES demonstrated a clear single-factor structure, excellent internal consistency (αs = .90–.96), and exceptionally high six-month test–retest reliability (r = .89). Negative beliefs about exposure therapy were associated with therapist demographic characteristics, negative reactions to a series of exposure therapy case vignettes, and the cautious delivery of exposure therapy in the treatment of a hypothetical client with obsessive-compulsive disorder. Lastly, TBES scores decreased markedly following a didactic workshop on exposure therapy. The present findings support the reliability and validity of the TBES.     

Specific dance movement therapy interventions—Which are successful? An intervention and correlation study

This intervention study examined the correlation between specific DMT interventions and the improvement in quality of life, stress management, and stress reduction. Dance therapists (N = 11) completed 970 Intervention Checklist 1 (specific interventions at the individual level) and 120 Intervention Checklist 2 (specific interventions at the group level) reports during the course of 10 treatment sessions. The scores denoted by each therapist on the Intervention Checklists were compared with the scores of each client in the treatment group (N = 97) on standardized questionnaires. The successful therapists applied a self-selected approach and combined in-depth DMT approaches with specific interventions. These findings demonstrated the relationship between clients’ improvement in quality of life, coping, reduction of stress and the use of psychodynamic-oriented DMT, the Chace approach, the combination of directive and non-directive leadership styles, and interpersonal closure. The clients who performed dance improvisation, spatial synchrony, synchrony in effort and who received focused treatment sessions exhibited improved daily life and decreased somatization symptoms. These results indicate that specific DMT interventions were associated with an improvement in well-being, whereas other DMT interventions should be used cautiously until further research demonstrates their effectiveness. Additional successful DMT interventions must be identified in future studies.     

Balance in essential tremor during tandem gait: Is the first mis-step an important finding?

Essential tremor (ET) is the most commonly diagnosed movement disorder. ET may cause substantial loss of motor skills and balance with advanced age. We compared abnormalities in tandem gait with daily activity and Fahn–Tolosa–Marin Tremor Rating Scale (FTMTRS) scores in 90 ET patients. All patients performed a 15-step tandem three times. The mean of first mis-steps was accepted as the tandem index (TI). The mean age was 61.4 ± 17 years; the mean duration of tremor was 6.7 ± 4 years; and there were 36 men and 54 women. There was no significant difference for age or sex between patients and controls. Head (24.6%), jaw (5.5%), voice (11%), and tongue tremors (1.5%) were identified in ET patients. Rest (2.5%), postural (95%), and kinetic tremors (54%) were detected in the upper extremities. Postural tremor was found in the lower extremities of 5%. The mean TI was 8.3 ± 4 (median, 8) in ET patients, and 10.6 ± 3.9 (median, 10) in controls (p = 0.04). Correlation analysis of TI and FTMTRS scores showed tandem gait was significantly correlated with age, total tremor score, postural and kinetic extremity tremor, writing, drawing, pouring, feeding, and working scores. Linear regression showed a significant effect of age and FTMTRS score on TI. The decrease in balance control is apparent with advancing age. Balance disorders were more pronounced in ET patients. Although first mis-step in tandem gait is not as detailed as dynamic balance tests, it can be a simple method for detecting balance disorders.     

The influence of baseline symptoms and insight on the therapeutic alliance early in the treatment of schizophrenia

BackgroundThe consistent association between therapeutic alliance and outcome underlines the importance of identifying factors which predict the development of a positive alliance. However, only few studies have examined the association between pretreatment characteristics and alliance formation in patients with schizophrenia.ObjectiveThe study examined whether symptoms and insight would predict the therapeutic alliance in psychotherapy of schizophrenia. Further, the associations and differences between patient and therapist alliance ratings were studied.MethodsEighty patients with schizophrenia spectrum disorders received manual-based psychotherapy. Assessment of symptoms and insight was conducted at baseline, and questionnaire-based alliance ratings were obtained three weeks into treatment. Patient and therapist alliance ratings were examined separately.ResultsPatient and therapist alliance ratings were not significantly correlated (r = 0.17). Patient ratings of the alliance were significantly higher than the ratings of their therapists (d = 0.73). More insight in psychosis significantly predicted higher patient ratings of the alliance. Less positive and negative symptoms were significant predictors of higher therapist alliance ratings.ConclusionThe findings indicate that symptoms and insight have an influence on the therapeutic alliance in the treatment of schizophrenia spectrum disorders. Patients' and therapists' perceptions of the alliance do not seem to demonstrate much convergence.     

Quality of life and its determinants in essential tremor

IntroductionDespite Essential Tremor (ET) being the commonest movement disorder, there are few studies on the quality of life (QOL) in patients with ET, with most studies employing generic questionnaires.MethodsWe studied QOL in 50 patients with ET attending the outpatient of a hospital using the Quality of life in Essential Tremor (QUEST) questionnaire a disease specific QOL instrument. The severity of tremor was assessed using a modified Fahn Tolosa Marin tremor rating scale (mFTMRS), co morbid anxiety and depression were studied using the Hamilton Anxiety (HARS) and Depression (HDRS) rating scales respectively. We also analyzed the influence of gender, age at presentation, age of onset, duration of tremor, distribution of tremor, family history and use of medications on the QOL.ResultsThe mean age of onset of tremor was 32.2 ± 18.9 years, mean duration of tremor was 8.4 ± 10.0 years, mean QUEST summary index (QSI) was 24.2 ± 19.2; mean scores in each of the domains were as follows – physical 29.3 ± 26.7, psychosocial 36.4 ± 28.7, communication 23.9 ± 36.9, work & finance 23.5 ± 29.9, hobbies 6.8 ± 17.3. The QSI had significant positive correlation with the mFTMRS, HARS and HDRS. Gender, age at presentation, age of onset, duration of tremor, distribution of tremor, family history and use of medication did not influence the QOL.ConclusionPsychosocial aspects are important in determining the QOL in patients with ET. Tremor severity, co morbid anxiety and depression are associated with a lower QOL whereas tremor characteristics like age of onset, duration, distribution do not influence the QOL.     

Metabolic changes in visual cortex of neonatal monocular enucleated rat: a proton magnetic resonance spectroscopy study

Neonatal monocular enucleation (ME) is often employed to study the developmental mechanisms underlying visual perception and the cross-modal changes in the central nervous system caused by early loss of the visual input. However, underlying biochemical or metabolic mechanisms that accompany the morphological, physiological and behavioral changes after ME are not fully understood. Male Sprague-Dawley rats (N = 14) were prepared and divided into 2 groups. The enucleated group (N = 8) underwent right ME (right eye removal) at postnatal day 10, while the normal group (N = 6) was intact and served as a control. Three weeks after ME, single voxel proton magnetic resonance spectroscopy (¹H MRS) was performed over the visual cortex of each hemisphere in all animals with a point-resolved spectroscopy (PRESS) sequence at 7 T. The taurine (Tau) and N-acetylaspartate (NAA) levels were found to be significantly lower in the left visual cortex (contralateral to enucleated eye) for enucleated animals. Such metabolic changes measured in vivo likely reflected the cortical degeneration associated with the reduction of neurons, axon terminals and overall neuronal activity. This study also demonstrated that ¹H MRS approach has the potential to characterize neonatal ME and other developmental neuroplasticity models noninvasively for the biochemical and metabolic processes involved.     

Blood harmane (1-methyl-9H-pyrido[3,4-b]indole) concentration in essential tremor cases in Spain

BackgroundEnvironmental correlates for essential tremor (ET) are largely unexplored. The search for such environmental factors has involved the study of a number of neurotoxins. Harmane (1-methyl-9H-pyrido[3,4-b]indole) is a potent tremor-producing toxin. In two prior case–control studies in New York, we demonstrated that blood harmane concentration was elevated in ET patients vs. controls, and especially in familial ET cases. These findings, however, have been derived from a study of cases ascertained through a single tertiary referral center in New York.ObjectiveOur objective was to determine whether blood harmane concentrations are elevated in familial and sporadic ET cases, ascertained from central Spain, compared to controls without ET.MethodsBlood harmane concentrations were quantified by a well-established high performance liquid chromatography method.ResultsThe median harmane concentrations were: 2.09 g⁻¹⁰/ml (138 controls), 2.41 g⁻¹⁰/ml (68 sporadic ET), and 2.90 g⁻¹⁰/ml (62 familial ET). In an unadjusted logistic regression analysis, log blood harmane concentration was not significantly associated with diagnosis (familial ET vs. control): odds ratio = 1.56, p = 0.26. In a logistic regression analysis that adjusted for evaluation start time, which was an important confounding variable, the odds ratio increased to 2.35, p = 0.049.ConclusionsBlood harmane levels were slightly elevated in a group of familial ET cases compared to a group of controls in Spain. These data seem to further extend our observations from New York to a second cohort of ET cases in Spain. This neurotoxin continues to be a source of interest for future confirmatory research.     

Embarrassment in essential tremor: Prevalence,clinical correlates and therapeutic implications

BackgroundEmbarrassment is a commonly described feature of essential tremor (ET) but has not been the focus of clinical research.ObjectiveTo estimate the prevalence, identify susceptible patient groups, and quantify the therapeutic correlates of reported embarrassment.MethodsA total of 106 ET cases from a population-based sample and 349 ET cases from a clinical sample were asked, “Does your tremor often embarrass you?”ResultsIn the clinical sample, the prevalence of embarrassment was high (58.2%). Even in those ET cases with no head tremor and mild arm tremor, nearly one-half (29/61 [47.5%]) reported embarrassment. While the prevalence of embarrassment was lower in the population-based sample, it was not negligible (18.9%). Embarrassment was associated with younger age of onset (p = 0.003) and women were nearly twice as likely as men to report embarrassment (OR = 1.85, p = 0.01). Independent of tremor severity, embarrassment nearly doubled the odds of using tremor medication (OR = 1.86, p = 0.01).ConclusionsEmbarrassment may be a source of disability in ET. Even among clinic patients with mild tremor, nearly one-half reported embarrassment. We identified a number of patient characteristics linked to embarrassment. Embarrassment alone (i.e., independent of tremor severity) was responsible for a doubling of tremor medication usage. The majority of clinical trials do not assess the therapeutic effects of medication on embarrassment. These trials may benefit from scaled assessments of level of embarrassment.     

Effects of chronic alcohol consumption on long-term outcomes of thalamic deep brain stimulation for essential tremor

The prevalence of essential tremor (ET) is about 4% above 40 years of age. Chronic alcohol consumption is present in around 20% of patients with ET. Our objective was to identify whether chronic alcohol consumption was associated with a negative effect on tremor outcome after thalamic deep brain stimulation (DBS) in ET patients. We conducted a retrospective chart review, from January 2005 to December 2012, from which 23 patients who had ventral intermediate nucleus (Vim)-DBS surgery for ET were identified. Seven patients had a positive history of chronic alcohol consumption. We defined as chronic alcohol users those patients with a habit of drinking alcohol every day in order to suppress tremor. In the overall group of 23 patients, there was a reduction in the median tremor score from 8 pre-operatively, to 1 post-operatively (p < 0.0001). The alcohol consumers group experienced a reduction in the median tremor score from 6 pre-operatively to 0 post-operatively (p = 0.03). The non-alcohol consumers group had a reduction in the median tremor score from 8 pre-operatively to 1.7 post-operatively (p < 0.0001). Both groups of patients experienced significant benefit from thalamic DBS. A larger study may reveal statistically significant differences between subgroups.     

Distinguishing language and race disparities in epilepsy surgery

This study aimed to identify whether race/ethnicity and limited English proficiency impact the likelihood of pursuing surgical treatment for medically refractory epilepsy.We conducted a retrospective cohort study of 213 patients with medically refractory epilepsy and mesial temporal sclerosis who were being considered for temporal lobectomy between January 1, 1993 and December 31, 2010 with follow-up through December 31, 2012. Demographic and clinical factors potentially associated with surgical utilization, including self-reported race/ethnicity and preferred language, were gathered from the medical record.Patients of Asian/Pacific Islander or African American race were significantly less likely to pursue surgical treatment of epilepsy compared with non-Hispanic whites in a multivariate logistic regression model (adjusted for nonconcordant ictal EEG, age, and limited English proficiency) (OR 0.20, p = 0.003; OR 0.15, p = 0.001, respectively). Limited English proficiency was also significantly associated with lower odds of surgery (OR 0.38, p = 0.034).Both race and limited English proficiency contribute to disparities in the surgical management of medically refractory epilepsy, especially among Asian/Pacific Islanders and African Americans. Culturally sensitive patient–physician communication and patient education materials might aid in surgical decision-making among minority groups.     

Resident simulation training in endoscopic endonasal surgery utilizing haptic feedback technology

Simulated practice may improve resident performance in endoscopic endonasal surgery. Using the NeuroTouch haptic simulation platform, we evaluated resident performance and assessed the effect of simulation training on performance in the operating room. First- (N = 3) and second- (N = 3) year residents were assessed using six measures of proficiency. Using a visual analog scale, the senior author scored subjects. After the first session, subjects with lower scores were provided with simulation training. A second simulation served as a task-learning control. Residents were evaluated in the operating room over six months by the senior author—who was blinded to the trained/untrained identities—using the same parameters. A nonparametric bootstrap testing method was used for the analysis (Matlab v. 2014a). Simulation training was associated with an increase in performance scores in the operating room averaged over all measures (p = 0.0045). This is the first study to evaluate the training utility of an endoscopic endonasal surgical task using a virtual reality haptic simulator. The data suggest that haptic simulation training in endoscopic neurosurgery may contribute to improvements in operative performance. Limitations include a small number of subjects and adjudication bias—although the trained/untrained identity of subjects was blinded. Further study using the proposed methods may better describe the relationship between simulated training and operative performance in endoscopic Neurosurgery.     

Peut-on augmenter l’efficacité de la thérapie cognitive et comportementale pour le trouble obsessionnel compulsif par un adjuvant informatique innovant ?

AimCognitive behavioral therapy (CBT) is recognized as an effective treatment for obsessive-compulsive disorder (OCD). To maximize its effectiveness, we designed an “experimental” CBT defined by the addition of a computerized psychoeducative tool.MethodIn a participative process involving patients through meetings of the French OCD association (AFTOC) and therapists through methodological workshops, we built a therapeutic tool from an experimental checking task. This task, which had been published in an earlier work, was adapted for its psychoeducative dimension. We here report on a randomized double-blind trial which included 35 patients with a moderate to severe OCD (Yale-Brown obsessive-compulsive scale, YBOCS between 16 and 25) predominant checking symptoms, no comorbidities, and 2-month stabilized or no treatment. Patients were randomly assigned to either “standard” versus “experimental” CBT. Both therapies were conducted by four CBT-experienced therapists specialized in OCD through weekly individualized sessions over 3 months. Therapy sessions of the experimental CBT were conducted as the standard CBT except for a short exercise with the computerized psychoeducative tool performed by the patient and debriefed with the therapist at the end of the sessions. Patients were assessed before, during, after therapy and again 6 months later using standard clinical tools and a neurobehavioral assessment based on an original symptom-provocation task with anxiety ratings including three types of photographs: neutral, generic inducing obsessions (e.g., doorknobs, electric wires…) and personalized (taken by the patients in their own environment).ResultsClinically, “standard” and “experimental” CBT resulted in a significant but equivalent improvement (48% vs 45% reduction of the Y-BOCS score; P = 0.36; d = 0.12). Therapists were satisfied with the psychoeducative dimension of the computerized psychoeducative tool but reported variable acceptance across patients. Patients appreciated its usability. The clinical improvement was associated with a reduction of the task-induced anxiety (r = 0.42, P < 0.05), especially towards personalized items (−28,2% vs −20.41% for generic and −6.24% for neutral photographs, P < 0.001). Mid-therapy response level was predictive of the final improvement (r = 0.82, P < 0.001).ConclusionThe computerized tool may provide a well-accepted therapeutic adjuvant even though it doesn’t improve the therapeutic effect. Using a personalized symptom-provocation task reveals the parallel evolution of symptoms and neurobehavioral markers through CBT. Despite the difficulty of improving an evidence-based therapy, mid-therapy results call for investigating the possible adjustments of treatment strategies at an early stage.     

Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial

Acceptance and Commitment Therapy (ACT) can be effective in treating anxiety disorders, yet there has been no study on Internet-delivered ACT for social anxiety disorder (SAD) and panic disorder (PD), nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application. In the current trial, n = 152 participants diagnosed with SAD and/or PD were randomized to therapist-guided or unguided treatment, or a waiting-list control group. Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application. Outcome measures were self-rated general and social anxiety and panic symptoms. Treatment groups saw reduced general (d = 0.39) and social anxiety (d = 0.70), but not panic symptoms (d = 0.05) compared to the waiting-list group, yet no differences in outcomes were observed between guided and unguided interventions. We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD. Smartphone applications may partially compensate for lack of therapist support.     

Quiet eye training facilitates visuomotor coordination in children with developmental coordination disorder

IntroductionQuiet eye training (QET) has been shown to be more effective than traditional training (TT) methods for teaching a throw and catch task to typically developing 8–10 yr old children. The current study aimed to apply the technique to children with developmental coordination disorder (DCD).Method30 children with DCD were randomly allocated into TT or QET intervention groups. The TT group were taught how to control their arm movements during the throw and catch phases, while the QET group were also taught to fixate a target location on the wall prior to the throw (quiet eye1; QE1), followed by tracking the ball prior to the catch (quiet eye2; QE2). Performance, gaze and motion analysis data were collected at pre/post-training and 6-week retention.ResultsThe QET group significantly increased QE durations from pre-training to delayed retention (QE1 = +247 ms, QE2 = +19%) whereas the TT group experienced a reduction (QE1 = −74 ms, QE2 = −4%). QET participants showed significant improvement in the quality of their catch attempts and increased elbow flexion at catch compared to the TT group (QET = −28°, TT = −1°).ConclusionQET changed DCD children's ability to focus on a target on the wall prior to the throw, followed by better anticipation and pursuit tracking on the ball, which in turn led to improved catching technique. QET may be an effective adjunct to traditional instructions, for therapists teaching visuomotor skills to children with DCD.     

Overcoming barriers to disseminating exposure therapies for anxiety disorders: a pilot randomized controlled trial of training methods

The present study evaluated methods for training mental health providers (N = 46) in exposure therapies (ETs) for anxiety disorders. A pilot randomized controlled trial compared: (1) an interactive, multimedia online training (ET OLT), (2) the ET OLT plus a brief Motivational Interviewing-based intervention (ET OLT + MI), and (3) a placebo control OLT. Assessments were completed at baseline, post-training, and one-week following training. Both ET OLT and ET OLT + MI received high satisfaction ratings and were comparably effective at increasing knowledge of ETs as well as clinicians’ overt efforts to learn and use the treatment. ET OLT + MI was the most effective method for improving clinicians’ attitudes toward ETs. Results indicate that OLT is effective for disseminating knowledge about ETs to clinicians, and suggest that supplementing OLT with a brief MI-based intervention may be a promising direction to address potential attitudinal barriers to adopting these highly efficacious treatments.     

Stroke in essential thrombocythemia

BackgroundOur aim was to assess the incidence and the special characteristics of stroke, as a severe complication of patients diagnosed with essential thrombocythemia (ET).MethodsA retrospective analysis was carried out on 102 patients with ET enrolled and analyzed from the period between 1999 and 2012. Patients with one or more strokes were selected. The characteristics of stroke events, the medication, and the median platelet counts were revised.ResultsOne or more stroke events were revealed in 11 cases (4 males and 7 females) with a median age of 67 years [range: 45–82 years]. The median platelet count at hematological diagnosis was 658 × 10⁹/L [range: 514–1157 × 10⁹/L], while during the time of stroke it was 450 × 10⁹/L [range: 320–885 × 10⁹/L]. The median follow-up of the patients with stroke was 60 months [range: 19–127 months]. At the time of the stroke, almost all the patients (8/11 cases, 73%) were already on anti-platelet therapy, alone or in combination with cytoreductive therapy (e.g. hydroxyurea). Brain imaging modalities in most cases demonstrated periventricular and/or subcortical and/or basal ganglia lacunes or confluent chronic white matter ischemic lesions in all cerebral arterial regions. Most patients (9/11; 82%) presented at least two serious conventional vascular risk factors, which may have influenced both the clinical course and the morphologic alterations. No correlation was found between the platelet count and the occurrence of stroke.ConclusionOur findings lead us to suppose that ET may be regarded as a risk factor for stroke (mainly of ischemic, small-vessel type), and the early diagnosis and the personalized management of the patient's global vascular risk in the treatment of ET may promote the prevention of further cerebrovascular events.