Biofeedback and Treatment for Borderline Personality Disorder.

Empirically validated treatments for borderline personality disorder rely on fostering self-awareness of one's internal experience for treatment success, yet these treatments do not include objective tools to assess self-awareness. Integrating biofeedback into empirically supported treatments provides a way to objectively measure physiological correlates of emotional states, thereby enhancing accurate self-assessment. By using biofeedback, individuals with borderline personality disorder may gain skills to increase self-awareness, improve emotion regulation, and enhance behavioral control. The authors propose that biofeedback can be used to objectively measure fluctuating emotional intensity, thereby facilitating structured self-assessment of emotions and enabling more effective use of interventions for emotion regulation; can be delivered by trained mental health professionals; and may even be considered as a stand-alone intervention replacing alternative, more costly, treatments.

Group plus "mini" individual pre-test genetic counselling sessions for hereditary cancer shorten provider time and improve patient satisfaction.

BACKGROUND: Genetic counselling (GC) is an integral component in the care of individuals at risk for hereditary cancer predisposition syndromes (CPS). In many jurisdictions, access to timely counselling and testing is limited by financial constraints, by the shortage of genetics professionals and by labor-intensive traditional models of individual pre and post-test counselling. There is a need for further research regarding alternate methods of GC service delivery and implementation. This quality improvement project was initiated to determine if pretest group GC followed immediately by a 'mini' individual session, would be acceptable to patients at risk for hereditary breast and colon cancer. METHODS: Patients on waitlists for GC at the Provincial Medical Genetics Program in St. John's, NL, Canada (n = 112), were contacted by telephone and offered the option of a group counselling session (GGC), followed by a "mini" individual session, versus (TGC) traditional private appointments. GGC sessions consisted of a cancer genetics information session given to groups of 6-20 followed by brief 20 min "mini" individual sessions with the patient and genetic specialist. TGC individual appointments provided the same cancer genetics information and counselling to one patient at a time in the classic model. All but 2 participants selected group+mini session. A de-identified confidential 12-item, Likert scale survey was distributed at the conclusion of mini-sessions to measure perceptions of GGC and satisfaction with this counselling model. RESULTS: Sixty participants completed questionnaires. The majority of participants strongly agreed that they were comfortable with the group session (58/60); the explanation of cancer genetics was clear (54/59); they understood their cancer risks (50/60); and they would recommend such a session to others (56/59). 38/53 respondents disagreed or strongly disagreed that they would prefer to wait for a traditional private appointment. All 5 participating genetic counselors reported a preference for this model. At the end of the pilot project, the waitlist for counselling/testing was reduced by 12 months. CONCLUSIONS: Group pre-test genetic counselling combined with immediate "mini" individual session is strongly supported by patients and reduces wait times. Additional formal investigation of this approach in larger numbers of patients is warranted.

Transcription factor ASCL2 is required for development of the glycogen trophoblast cell lineage.

The basic helix-loop-helix (bHLH) transcription factor ASCL2 plays essential roles in diploid multipotent trophoblast progenitors, intestinal stem cells, follicular T-helper cells, as well as during epidermal development and myogenesis. During early development, Ascl2 expression is regulated by genomic imprinting and only the maternally inherited allele is transcriptionally active in trophoblast. The paternal allele-specific silencing of Ascl2 requires expression of the long non-coding RNA Kcnq1ot1 in cis and the deposition of repressive histone marks. Here we show that Del7AI, a 280-kb deletion allele neighboring Ascl2, interferes with this process in cis and leads to a partial loss of silencing at Ascl2. Genetic rescue experiments show that the low level of Ascl2 expression from the paternal Del7AI allele can rescue the embryonic lethality associated with maternally inherited Ascl2 mutations, in a level-dependent manner. Despite their ability to support development to term, the rescued placentae have a pronounced phenotype characterized by severe hypoplasia of the junctional zone, expansion of the parietal trophoblast giant cell layer, and complete absence of invasive glycogen trophoblast cells. Transcriptome analysis of ectoplacental cones at E7.5 and differentiation assays of Ascl2 mutant trophoblast stem cells show that ASCL2 is required for the emergence or early maintenance of glycogen trophoblast cells during development. Our work identifies a new cis-acting mutation interfering with Kcnq1ot1 silencing function and establishes a novel critical developmental role for the transcription factor ASCL2.

Clinical Observations About the Potential Benefits and Pitfalls of Between-Session Contacts with Borderline Patients.

Borderline Personality Disorder (BPD) has a reputation for being a challenging disorder to treat due to the nature of the illness. With the development of evidence-based treatments, therapists are becoming more skilled at successfully helping this cohort of patients. A common factor associated with all validated treatments for BPD is the active involvement of therapists. For example, DBT is one treatment where therapists are expected to be available to patients for coaching outside of sessions. However, understanding the benefits and pitfalls associated with therapists' accessibility in between sessions is relevant to any treatment with intersession contact. In this article, three benefits of intersession contact are described: to generalize the use of skills, to improve understanding of the patient's needs, and to facilitate an alliance. This article also addresses the pitfalls of therapists being so accessible to patients. Both the benefits and pitfalls of intersession contact are illustrated using case vignettes. Assessing the function served by a patient's contact in between sessions is an important way to determine whether such contact is a productive part of treatment. Recommendations are provided to avoid detrimental outcomes for both the therapist (therapist burnout) and the patient.

A Dichotomy of Information-Seeking and Information-Trusting: Stem Cell Interventions and Children with Neurodevelopmental Disorders.

Parents and primary caregivers of children with Cerebral Palsy (CP) and Autism Spectrum Disorder (ASD) are faced with difficult treatment choices and management options for their children. The potential of stem cell technologies as an interventional strategy for CP and ASD has gained attention in the last decade. Information about these interventions varies in quality, resulting in a complex landscape for parent decision making for a child's care. Further complicating this landscape are clinics that advertise these interventions as a legitimate treatment for a fee. In this study, we surveyed individuals who considered taking their child with ASD or CP abroad for stem cell interventions on their use of different sources of stem cell related health information and their level of trust in these sources. Participants reported that while the Internet was their most frequent source of information, it was not well-trusted. Rather, information sources trusted most were researchers and the science journals in which they publish, other parents of children with CP and ASD, and healthcare providers. These findings highlight a dichotomy between information-seeking preferences and information-trusted sources. We discuss the challenges of health science communication and present innovative opportunities to increase communication with trusted and reliable sources as part of an integrated multi-pronged approach.

"You don't want to lose that trust that you've built with this patient...": (dis)trust, medical tourism, and the Canadian family physician-patient relationship.

BACKGROUND: Recent trends document growth in medical tourism, the private pursuit of medical interventions abroad. Medical tourism introduces challenges to decision-making that impact and are impacted by the physician-patient trust relationship-a relationship on which the foundation of beneficent health care lies. The objective of the study is to examine the views of Canadian family physicians about the roles that trust plays in decision-making about medical tourism, and the impact of medical tourism on the therapeutic relationship. METHODS: We conducted six focus groups with 22 family physicians in the Canadian province of British Columbia. Data were analyzed thematically using deductive and inductive codes that captured key concepts across the narratives of participants. RESULTS: Family physicians indicated that they trust their patients to act as the lead decision-makers about medical tourism, but are conflicted when the information they are managing contradicts the best interests of the patients. They reported that patients distrust local health care systems when they experience insufficiencies in access to care and that this can prompt patients to consider going abroad for care. Trust fractures in the physician-patient relationship can arise from shame, fear and secrecy about medical tourism. CONCLUSIONS: Family physicians face diverse tensions about medical tourism as they must balance their roles in: (1) providing information about medical tourism within a context of information deficits; (2) supporting decision-making while distancing themselves from patients' decisions to engage in medical tourism; and (3) acting both as agents of the patient and of the domestic health care system. These tensions highlight the ongoing need for reliable third-party informational resources about medical tourism and the development of responsive policy.

Development and validation of the cognitive-behavioral therapy skills questionnaire.

Although several theories exist to describe why patients improve in cognitive-behavioral therapy (CBT), in only a limited number of studies has CBT skill acquisition been examined, particularly among patients with complex clinical profiles. Thus, the overarching aim of this research was to develop a tool to measure patients' use of CBT skills, such that it would have clinical utility for patients and therapists during treatment. In Study 1, the authors developed an initial set of items for the Cognitive-Behavioral Therapy Skills Questionnaire (CBTSQ). They submitted these items to an exploratory factor analysis in an initial administration (n = 350) and to a confirmatory factor analysis in a second administration (n = 378). Results indicated that there were two factors (Behavioral Activation and Cognitive Restructuring) with good factor structure and internal consistency, and both the factors evidenced expected relationships with other constructs. In Study 2, the criterion validity of the CBTSQ was investigated on a patient sample in a CBT-oriented treatment setting. Results showed that CBTSQ scores increased following treatment, and Cognitive Restructuring and Behavioral Activation scores predicted reduction of overall psychiatric symptoms and depression. Thus, the CBTSQ appears to be a promising measure of CBT skill acquisition and treatment outcome as well as an instrument that can help patients and therapists monitor progress specifically related to a CBT skills training treatment approach.

Acute insulin signaling in pancreatic beta-cells is mediated by multiple Raf-1 dependent pathways.

Insulin enhances the proliferation and survival of pancreatic beta-cells, but its mechanisms remain unclear. We hypothesized that Raf-1, a kinase upstream of both ERK and Bad, might be a critical target of insulin in beta-cells. To test this hypothesis, we treated human and mouse islets as well as MIN6 beta-cells with multiple insulin concentrations and examined putative downstream targets using immunoblotting, immunoprecipitation, quantitative fluorescent imaging, and cell death assays. Low doses of insulin rapidly activated Raf-1 by dephosphorylating serine 259 and phosphorylating serine 338 in human islets, mouse islets, and MIN6 cells. The phosphorylation of ERK by insulin was eliminated by exposure to a Raf inhibitor (GW5074) or transfection with a dominant-negative Raf-1 mutant. Insulin also enhanced the interaction between mitochondrial Raf-1 and Bcl-2 agonist of cell death (Bad), promoting Bad inactivation via its phosphorylation on serine 112. Insulin-stimulated ERK phosphorylation was abrogated by calcium chelation, calcineurin and calmodulin-dependent protein kinase II inhibitors, and Ned-19, a nicotinic acid adenine dinucleotide phosphate receptor (NAADPR) antagonist. Blocking Raf-1 and Ca(2+) signaling resulted in nonadditive beta-cell death. Autocrine insulin signaling partly accounted for the effects of glucose on ERK phosphorylation. Our results demonstrate that Raf-1 is a critical target of insulin in primary beta-cells. Activation of Raf-1 leads to both an ERK-dependent pathway that involves nicotinic acid adenine dinucleotide phosphate-sensitive Ca(2+) stores and Ca(2+)-dependent phosphorylation events, and an ERK-independent pathway that involves Bad inactivation at the mitochondria. Together our findings identify a novel insulin signaling pathway in beta-cells and shed light on insulin's antiapoptotic and mitogenic mechanisms.

Cognitive and behavioral changes related to symptom improvement among patients with a mood disorder receiving intensive cognitive-behavioral therapy.

OBJECTIVE: To examine the relationship between cognitive and behavioral changes associated with cognitive-behavioral therapy (CBT) and treatment response in an intensive partial hospital (PH) setting. METHODS: Study participants were 105 patients with mood disorders receiving treatment in a private psychiatric PH setting. The flexible treatment model used evidence-based CBT interventions adapted to the PH context, with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and discharge to assess psychological distress, depression, negative automatic thoughts, and behavioral activation. Mean treatment duration was 9 days. RESULTS: Decreased negative automatic thoughts and increased behavioral activation predicted reduction of depressive symptoms; however, only decreased negative automatic thoughts was predictive of patients' overall level of psychological distress. CONCLUSIONS: These results suggest that a CBT intervention adapted for use in a PH setting can be an effective treatment for severe mood disorders. Furthermore, although the design used in this study precludes causal inferences, depressive symptom improvement appears to be associated with decreased negative automatic thoughts and increased behavioral activation. Implications for the delivery of CBT in PH programs and future directions for research are discussed.

Does exercise impact mood? Exercise patterns of patients in a psychiatric partial hospital program.

OBJECTIVE: To examine the exercise patterns of patients in a partial hospital (PH) program and to determine whether these patterns are associated with mood symptoms and body mass index (BMI). Methods. Eighty-six participants completed self-report questionnaires upon entry to the PH program. We conducted regression analyses to determine the association of exercise, mood, and BMI. Results. We found that the participants' exercise history did not predict automatic thoughts or depressive symptoms. Current exercise did predict fewer depressive symptoms and lower BMI, but not automatic thoughts. A majority of participants were overweight and reported not exercising, despite acknowledging that they were not physically fit and that exercise is beneficial. Conclusion. We recommend that exercise programs be piloted in PH settings to improve patients' mental as well as physical health. Future research should further examine obstacles to exercising in clinical populations.

Short-term cognitive behavioral partial hospital treatment: a pilot study.

OBJECTIVE: Brief, cost-contained, and effective psychiatric treatments benefit patients and public health. This naturalistic pilot study examined the effectiveness of a 2-week, cognitive-behavioral therapy (CBT) oriented partial hospital program. METHODS: Study participants were 57 patients with mood, anxiety, and/or personality disorders receiving treatment in a private psychiatric partial hospital (PH) setting. A flexible treatment model was used that adapts evidence-based CBT treatment interventions to the PH context with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and after 1 and 2 weeks, to assess stabilization and functional improvements, with added attention to the acquisition of cognitive and behavioral skills. The data were analyzed using repeated measures analyses of variance and correlation. RESULTS: Participants reported a decrease in symptoms and negative thought patterns, improved satisfaction with life, and acquisition and use of cognitive and behavioral skills. Skill acquisition was correlated with symptom reduction, reduced negative thought patterns, and improved satisfaction with life. CONCLUSIONS: Results of this pilot study suggest that a 2-week PH program can be effective for a heterogeneous patient population with mood, anxiety, and/or personality disorders. These findings are promising given the prevalence of treatments of such brief duration in private sector PH programs subject to the managed care marketplace. Future studies are planned to test this flexible PH treatment model, with particular attention to the effectiveness of the CBT approach for the treatment of different disorders and to whether effectiveness is sustained at follow-up. Further study should also examine whether skill acquisition is a mechanism of change for symptom reduction and functional improvements.

Effectiveness of cognitive-behavioral treatment for panic disorder versus treatment as usual in a managed care setting: 2-year follow-up.

Eighty clients meeting criteria for panic disorder and receiving either panic control therapy (PCT; M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or treatment as usual (TAU) in a managed care setting were assessed 1 and 2 years following acute treatment. PCT was provided by therapists with little or no previous exposure to cognitive-behavioral therapies. Analyses of the full intent-to-treat sample revealed no significant differences between the treatments across the follow-up period. However, when treatment completer status was added as a moderator, those receiving PCT showed lower levels of panic severity and phobic avoidance and a greater likelihood of achieving and maintaining clinically significant change. Benzodiazepine use during follow-up was associated with greater panic severity for those clients who received PCT, but no such relationship was found for TAU clients. Results are discussed in relation to the dissemination and effectiveness of PCT as well as evidence-based psychotherapies more generally.

Effectiveness of cognitive--behavioral treatment for panic disorder versus treatment as usual in a managed care setting.

Eighty clients enrolled in a managed care health plan who identified panic disorder as their primary presenting problem were randomly assigned to treatment by a therapist recently trained in a manual-based empirically supported psychotherapy or a therapist conducting treatment as usual (TAU). Participants in both conditions showed significant change from pre- to posttreatment on a number of measures. Those receiving panic control therapy (PCT) showed greater levels of change than those receiving TAU. Among treatment completers, an average of 42.9% of those in PCT and 18.8% in TAU achieved clinically significant change across measures. The results are discussed with reference to the dissemination of PCT and other evidence-based psychotherapies to clinical practice settings.

Antecedents and consequences of mothers' autonomy support: an experimental investigation.

This study examined the effects of contextual and individual differences on mothers' autonomy support versus control on homeworklike tasks. Sixty mothers and their third-grade children worked on map and poem tasks, with mothers in either an ego-involving (high pressure) or a non-ego-involving (low pressure) condition. Later, children worked on similar tasks themselves. Mothers in the high-pressure condition were more controlling on the poem task. For the map task, mothers who came in with controlling styles and received the high-pressure manipulation were most controlling. Children whose mothers interacted in a more controlling manner wrote less creative poems when alone. Results suggest the importance of context, children's competence levels, and mothers' styles in determining levels of autonomy support.