Visual Assessment of Therapeutic Relationships in Psychiatric Patients: A Pilot Study Using the Pictorial Representation of Illness and Self Measure.

BACKGROUND: Although the therapeutic relationship (or 'alliance') is well known to be a key component of psychiatric treatment, there has been no simple way to objectively measure the patient-therapist relationship. Here, we measured the psychological distance between patients and their therapists by using the Pictorial Representation of Illness and Self Measure (PRISM). PATIENTS AND METHODS: We analyzed the patient-therapist relationship of 112 patients from two hospitals in Japan (54 males, 57 females, 1 unknown; age 46.20 ± 15.03 years [mean ± SD]) who completed the PRISM and self report questionnaires (LSNS-6, K6, and BASIS-32) about their social network, psychological distress, and outcomes of mental health treatment. RESULTS: PRISM measurements were available for all patients who consented to participate. In the comparison by disease category, schizophrenia recorded the closest distance to the psychiatrist in charge, followed by bipolar disorder, depression, and neurotic disorder. Regarding the distance to the psychiatrist in charge, PRISM showed a weak negative correlation (r = -0.23, p < 0.05) with age, indicating that with increasing age, the therapeutic rela tionship was more important to the patients. CONCLUSION: Our findings indicate the possibility of implementing PRISM to assess the impact of the therapeutic relationship in patients with a wide range of psychiatric disorders, and they suggest that PRISM holds great potential for clinical application.

Novel WNT10A variant in a Japanese case of nonsyndromic oligodontia.

Congenital tooth agenesis is one of the most common anomalies in humans. Many genetic factors are involved in tooth development, including MSX1, PAX9, WNT10A, and LRP6. Thus, mutations in these genes can cause congenital tooth agenesis in humans. In this study, we identified a novel nonsense WNT10A variant, NM_025216.3(WNT10A_v001):c.1090A > T, which produces a C-terminal truncated gene product, p.(Lys364*), in a sporadic form of congenital tooth agenesis. The variant was not found in the healthy parents and thus was considered to cause congenital tooth agenesis in the case.

Sleep disturbance has the largest impact on children's behavior and emotions.

Objective: Children's behavior and emotions are affected by sleep disturbances, the parent-child relationship, media viewing time, and the social status of parents and caregivers. We conducted a questionnaire survey to identify the factors that have the greatest impact on children's behavior and emotions and how these factors relate to each other. Methods: A parental questionnaire survey was performed at a public elementary school. The questionnaire comprised questions on the family environment (e.g., family structure, media and game exposure, after-school lessons, and caregiver's work schedule) and physical information, the Strengths and Difficulties Questionnaire (SDQ), the Children's Sleep Habits Questionnaire (CSHQ), and the Pittsburgh Sleep Quality Index (PSQI) for parents' sleep condition. A path diagram was drawn to hypothesize the complex interrelationships among factors, and structural equation modeling was used to estimate the path coefficients. Result: We identified several factors that significantly affected the SDQ score. The CSHQ total score had the largest impact, followed by after-school lessons, single-mother families, and children's sex. In addition, several indirect pathways that led to the CSHQ score (i.e., a pathway from time spent watching television to CSHQ score via children's bedtime and a pathway from single-mother family to CSHQ score via PSQI total score) significantly affected the SDQ score. Conclusion: Children's sleep habits that were influenced by several environmental factors had the greatest impact on children's behavior and emotions, which suggested that children's behavioral problems can be improved by interventions focused on sleep habits, such as sleep hygiene instructions.

The Japanese version of the children's sleep habits questionnaire (CSHQ-J): A validation study and influencing factors.

SUBJECT: This study aimed to validate the Japanese version of the Child's Sleep Habits Questionnaire (CSHQ-J) and identify which factors affect the CHSQ-J total score. METHODS: The participants were 3158 children (aged 4-12 years) and their parent/guardian, as community samples from large, medium-sized, and small cities. Each parent/guardian filled in the questionnaire set (CSHQ-J, Pittsburgh Sleep Quality Index, demographic data: family structure, sleep environment, participants' present illness, and economic information); we also collected 51 clinical samples from our facility to calculate the cutoff score. According to the age of the participants in the original CSHQ (4-10 years), validation was assessed statistically via exploratory and confirmatory factor analyses and internal consistency (verified by Cronbach's α). Multivariate analysis was conducted to identify factors affecting the CSHQ-J total score. RESULTS: We received responses from 2687 participants (response rate: 85%) and analyzed 1688 participants who were the age of the original CSHQ participants. The alpha coefficients of each subscale of the CSHQ-J ranged from 0.43 to 0.68. The cutoff score was 48 (sensitivity: 0.69, specificity: 0.79). The confirmatory and exploratory factor analyses did not converge. Multivariate analysis showed that the factors that significantly influenced the CSHQ-J total score were co-sleeping, supplemental sleep, and child's age. Present illness, especially adenoids, also significantly influenced CSHQ total score. CONCLUSIONS: The CSHQ-J has adequate internal consistency and is useful for screening for pediatric sleep disorders. Supplemental sleep, habit of co-sleeping, and child's age should be considered when using the CSHQ-J as a screening tool for sleep problems in children.

Adolescent Health Promotion Interventions Using Well-Care Visits and a Smartphone Cognitive Behavioral Therapy App: Randomized Controlled Trial.

BACKGROUND: Adolescent health promotion is important in preventing risk behaviors and improving mental health. Health promotion during adolescence has been shown to contribute to the prevention of late onset of the mental health disease. However, scalable interventions have not been established yet. OBJECTIVE: This study was designed to test the efficacy of two adolescent health promotion interventions: a well-care visit (WCV) with a risk assessment interview and counseling and self-monitoring with a smartphone cognitive behavioral therapy (CBT) app. Our hypothesis was that participants who had received both WCV and the CBT app would have better outcomes than those who had received only WCV or those who had not received any intervention. We conducted a prospective multi-institutional randomized controlled trial. METHODS: Participants were 217 adolescents aged 13-18 years. They were randomly divided into two intervention groups (WCV group and WCV with CBT app group) and a nonintervention group. WCV comprised a standardized physical examination along with a structured interview and counseling for youth risk assessment, which was designed with reference to the Guideline for Health Supervision of Adolescents of Bright Futures. A smartphone-based CBT program was developed based on the CBT approach. The CBT app comprised a 1-week psychoeducation component and a 1-week self-monitoring component. During the CBT program, participants created several self-monitoring sheets based on the CBT model with five window panels: event, thoughts, feelings, body response, and actions. The primary outcome was the change in scores for depressive symptoms. Secondary outcomes included changes in scores for self-esteem, quality of life, self-monitoring, and an adolescent health promotion scale. These outcomes were evaluated at baseline and at 1, 2, and 4 months after baseline. The exploratory outcome was the presence of suicidal ideation during the observation period. Intervention effects were estimated using mixed effect models. RESULTS: In total, 94% (204/217) of the participants completed the 4-month evaluation. Both intervention groups showed a significant effect in the form of reduced scores for depressive symptoms at 1 month in high school students; however, these effects were not observed at 2 and 4 months. The intervention effect was significantly more predominant in those scoring above cutoff for depressive symptoms. There was significantly less suicidal ideation in the intervention groups. As for secondary outcomes, there was significant increase in health promotion scale scores at the 4-month follow-up among junior high school students in the WCV group. Moreover, the CBT app was significantly effective in terms of obtaining self-monitoring skills and reducing depressive symptoms. CONCLUSIONS: Although adolescent health promotion interventions may have short-term benefits, the frequency of WCV and further revision of the CBT app should be considered to evaluate long-term effectiveness. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry UMIN 000036343; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041246.

Prevalence of autism spectrum disorder and autistic traits in children with anorexia nervosa and avoidant/restrictive food intake disorder.

BACKGROUND: Autism spectrum disorder (ASD) and feeding and eating disorders (FEDs) such as anorexia nervosa (AN) are strongly linked as evidenced by frequent comorbidity and overlapping traits. However, eating and social behaviors are shaped by culture, so it is critical to examine these associations in different populations. Moreover, FEDs are heterogeneous, and there has been no examination of autistic traits in avoidant/restrictive food intake disorder (ARFID). METHODS: Therefore, we investigated the prevalence of ASD and autistic traits among Japanese children with AN (n = 92) or ARFID (n = 32) from a prospective multicenter cohort study using the Autism Spectrum Quotient Children's version (AQC) and Children's Eating Attitudes Test (ChEAT26). RESULTS: ASD prevalence was high in both AN and ARFID (16.3 and 12.5%, respectively). The AN group exhibited significantly higher scores on all AQC subscales than an age-matched healthy control (HC) group, but there were no significant correlations between AQC scores and ChEAT26 scores. In the AFRID group, AQC scores did not differ from HCs, but significant correlations were found between total AQC and ChEAT26 scores and between several AQC and ChEAT26 subscales. CONCLUSIONS: Both the AN and ARFID groups had high prevalence rates of ASD. The AN group showed a significantly higher degree of autistic traits than the HC group; however, no difference was found between the ARFID and HC groups. Clinicians need to be aware of these rates when working with children with ED.

Prevalence and associated factors of suicidality in Japanese adolescents: results from a population-based questionnaire survey.

BACKGROUND: Suicide is the leading cause of death among Japanese adolescents. However, knowledge gaps regarding contemporary demographics and factors associated with suicidality among Japanese adolescents are a major concern. This study examined the prevalence of suicidality among Japanese adolescents and investigated associated factors. METHODS: A population-based questionnaire survey investigating general health was administered to 22,419 adolescents aged 13-18 years. The 29-item questionnaire covered emotional status, family function, cyberbullying, suicidality, and stressors (e.g., relationships with parents/friends, school performance, and sexual identity). We conducted multiple logistic regression analysis to identify factors associated with suicidality in this population. RESULTS: The prevalence of suicidal ideation was 21.6% in males and 28.5% in females, and that of attempted suicide was 3.5% in males and 6.6% and in females. Bullying and stress related to family relationships had the strongest associations with suicidality. Exposure to cyberbullying had the highest odds ratio for both junior high (3.1, 95% confidence interval [CI] 2.1-4.4) and high school students (3.6, 95% CI 2.5-5.3). Other factors significantly associated with suicidality were sex, emotional status, and stress about relationships with friends, sexual identity, school records, and academic course. Adolescents accessed a variety of resources to cope with stressors, with the Internet being the most common resource consulted. CONCLUSIONS: Suicidality is commonly experienced among Japanese adolescents. Although there are many associated risk factors, cyberbullying is of particular concern. Recognition of factors associated with adolescent suicidality will inform further research and suicide prevention efforts for healthcare providers and families.

Screening for psychotrauma related symptoms: Japanese translation and pilot testing of the Global Psychotrauma Screen.

Background: The impact of traumatic experiences or adverse life experiences has been shown to potentially affect a wide range of mental health outcomes. However, there was no brief instrument to screen for a range of psychological problems in different domains after a potentially traumatic event, and for risk factors and protective factors. Objective: The aim of this study is to examine the internal consistency and concurrent validity of the Japanese version of the Global Psychotrauma Screen (GPS) in a traumatized sample in Japan. Method: A total sample (n = 58) with varying levels of potential posttrauma symptoms due to domestic violence or other events were recruited into this study. Self-rating measures of posttraumatic stress disorder (PTSD), depression, anxiety, and alcohol problems were conducted to investigate the concurrent validity. Results: The results show that a range of posttrauma symptoms assessed by the GPS were highly endorsed by this traumatized sample in all domains except for self-harm, derealization, and depersonalization. The GPS sum score was highly correlated (r > 0.79) with other measures of PTSD, depression, and anxiety symptoms. Also, the subdomain scores showed acceptable correlations with corresponding domain measures. Participants who had been sexually assaulted or had unwanted sexual experiences, and participants who had been physically assaulted during childhood, had higher scores on the total GPS and on subdomains of PTSD, as well as symptoms associated with Complex PTSD. Conclusions: This study provides an initial indication that the GPS may be a useful screening tool for trauma survivors and elucidates that the consequences of trauma are not limited to PTSD.

Antecedentes: Se ha demostrado que el impacto de las experiencias traumáticas o de las experiencias vitales adversas tiene el potencial de comprometer la salud mental dentro de un amplio rango de consecuencias. Sin embargo, no existía ningún instrumento breve para tamizar una variedad de problemas psicológicos, en diferentes dominios, después de un evento potencialmente traumático, ni para los factores de riesgo, ni para los factores protectores.Objetivo: El objetivo de este estudio es el de examinar la consistencia interna y la validez concurrente de la versión japonesa del Mapeo Global de Psicotrauma (GPS, por sus siglas en ingles) en una muestra de personas traumatizadas en Japón.Método: Para este estudio, se reclutó una muestra total (n=58) con distintos niveles de síntomas postraumáticos potenciales secundarios a violencia domestica u otros eventos. Para investigar la validez concurrente, se realizaron mediciones auto reportadas para el trastorno de estrés postraumático (TEPT), la depresión, la ansiedad y para problemas asociados al consumo de alcohol.Resultados: Los resultados muestran que un espectro de síntomas postraumáticos, evaluados mediante el GPS, se encontraba altamente vinculado a esta muestra de personas traumatizadas en todos los dominios, a excepción de las autolesiones, la desrealización, y la despersonalización. El puntaje final del GPS se encontraba altamente correlacionado (r > 0,79) con otras mediciones del TEPT, la depresión y los síntomas ansiosos. Además, los puntajes de los subdominios del GPS mostraron una correlación aceptable con las medidas de dominios correspondientes. Los participantes que habían sido agredidos sexualmente o habían tenido experiencias sexuales no deseadas, y los participantes que habían sido agredidos físicamente durante su infancia mostraban puntajes más altos en el GPS total y en los subdominios del TEPT, así como para los síntomas asociados al TEPT complejo.Conclusiones: Este estudio proporciona un primer indicio de que el GPS podría ser una herramienta de tamizaje útil para sobrevivientes al trauma, y esclarece que las consecuencias del trauma no se limitan al TEPT.

Workplace Violence and Its Effects on Burnout and Secondary Traumatic Stress among Mental Healthcare Nurses in Japan.

Workplace violence (WPV) in healthcare settings has drawn attention for over 20 years, yet few studies have investigated the association between WPV and psychological consequences. Here, we used a cross-sectional design to investigate (1) the 12-month prevalence of workplace violence (WPV), (2) the characteristics of WPV, and (3) the relationship between WPV and burnout/secondary traumatic stress among 599 mental healthcare nurses (including assistant nurses) from eight hospitals. Over 40% of the respondents had experienced WPV within the past 12 months. A multivariate logistic regression analysis indicated that occupation and burnout were each significantly related to WPV. Secondary traumatic stress was not related to WPV. Our results suggest that WPV may be a long-lasting and/or cumulative stressor rather than a brief, extreme horror experience and may reflect specific characteristics of psychological effects in psychiatric wards. A longitudinal study measuring the severity and frequency of WPV, work- and non-work-related stressors, risk factors, and protective factors is needed, as is the development of a program that helps reduce the psychological burden of mental healthcare nurses due to WPV.

Association between problematic behaviors and individual/environmental factors in difficult children.

BACKGROUND: Difficult children are ones whose behavior deviates from the norm, which manifests as restlessness, violence, and difficulty in separating from the mother. Such problematic behaviors usually exhaust their parents during child rearing. This study aimed to identify individual and environmental factors that influence children's problematic behavior, which could be helpful in supporting parents' child rearing. METHODS: Records of children's problematic behaviors and their individual or environmental information were collected from 8691 children at their 5-year-old health checks. Problematic behaviors were divided into three categories; anxious behaviors, developmental behaviors, and personal habits. Individual factors included sex, parental age, birth order, birth weight, and birth abnormalities. The environmental factors were mother's smoking during pregnancy or currently, partner's cooperation in child rearing, having someone to consult about child rearing, and television viewing time. Using logistic regression, we identified the association between such behaviors and aggravating factors. RESULTS: Problematic behavior was identified in 2.2%, 11.5%, and 16.1% of cases, respectively, with regard to anxious behaviors, developmental behaviors, and personal habits. The individual factors (including birth order and birth abnormality), and the environmental factors (including mothers currently smoking, lack of someone to consult about child rearing, and long television-watching time) were associated with the odd ratio of increased risk for some problematic behaviors. CONCLUSION: Behaviors in difficult children are not influenced by individual factors but by several environmental factors. To reduce the parental child rearing burden, health providers should be aware of these aggravating factors.

Validation of a childhood eating disorder outcome scale.

We developed and validated a childhood eating disorder outcome scale based on outcomes associated with body mass index standard deviation score (BMI-SDS). This prospective observational study included 131 children with eating disorders (aged 5-15 years). Participants' outcomes scales were completed at the first visit and at 1, 3, 6, and 12 months. The scale evaluated 12 outcomes: body weight change (BW), eating attitude (EA), fear of being fat (FF), body image distortion (BD), menstruation (ME), perceived physical condition (PC), attending school (AS), disease recognition by school (RS), family function (FA), disease recognition by parent (RP), social adaptation (SA), and relationships with friends (RF). Responses to all items were on a four-point Likert scale. Exploratory factor analysis was used to determine the number of factors based on the 12 outcomes. The relation between outcome scale scores and BMI-SDS over the 12-month follow-up period was analyzed. Two types of factors were extracted: disease-specific factors (EA, FF, BD) and biopsychosocial factors (BW, PC, AS, FA, SA, RF). Three items (ME, RS, RP) were excluded because they showed no significant loading effect. There was a significant negative correlation between the outcome scale and BMI-SDS, and changes in outcome scale scores from baseline to 12 months were significantly associated with improvement in BMI-SDS. We developed a childhood eating disorder outcome scale characterized by disease-specific and biopsychosocial factors. Biopsychosocial management combined with a therapeutic approach for disease-specific symptoms may support body weight recovery for children with eating disorders.

A child with anorexia nervosa presenting with severe infection with cytopenia and hemophagocytosis: a case report.

BACKGROUND: Patients with anorexia nervosa in the acute phase have physical complications, such as infectious disease. Although hemophagocytic syndrome due to infection is a rare complication in anorexia nervosa, early identification for hemophagocytosis is important for avoiding a life-threatening condition. CASE PRESENTATION: We report a case of a 12-year-old girl with anorexia nervosa presenting with infection with cytopenia and hemophagocytosis during initial nutritional therapy. She developed pyrexia, abdominal pain, and diarrhea during inpatient treatment. Although intravenous antibiotics were administered, the symptoms persisted. Acinetobacter baumannii was detected in blood culture. Hemophagocytosis was present in the bone marrow. Gamma globulin therapy was effective, with improvement in symptoms and cytopenia. CONCLUSIONS: Although our case did not fulfill the criteria of hemophagocytic syndrome, clinicians should consider severe infection in anorexia nervosa with cytopenia and hemophagocytosis.

Altered SPECT (123)I-iomazenil Binding in the Cingulate Cortex of Children with Anorexia Nervosa.

Several lines of evidence suggest that anxiety plays a key role in the development and maintenance of anorexia nervosa (AN) in children. The purpose of this study was to examine cortical GABA(A)-benzodiazepine receptor binding before and after treatment in children beginning intensive AN treatment. Brain single-photon emission computed tomography (SPECT) measurements using (123)I-iomazenil, which binds to GABA(A)-benzodiazepine receptors, was performed in 26 participants with AN who were enrolled in a multimodal treatment program. Sixteen of the 26 participants underwent a repeat SPECT scan immediately before discharge at conclusion of the intensive treatment program. Eating behavior and mood disturbances were assessed using Eating Attitudes Test with 26 items (EAT-26) and the short form of the Profile of Mood States (POMS). Clinical outcome scores were evaluated after a 1-year period. We examined association between relative iomazenil-binding activity in cortical regions of interest and psychometric profiles and determined which psychometric profiles show interaction effects with brain regions. Further, we determined if binding activity could predict clinical outcome and treatment changes. Higher EAT-26 scores were significantly associated with lower iomazenil-binding activity in the anterior and posterior cingulate cortex. Higher POMS subscale scores were significantly associated with lower iomazenil-binding activity in the left frontal, parietal cortex, and posterior cingulate cortex (PCC). "Depression-Dejection" and "Confusion" POMS subscale scores, and total POMS score showed interaction effects with brain regions in iomazenil-binding activity. Decreased binding in the anterior cingulate cortex and left parietal cortex was associated with poor clinical outcomes. Relative binding increases throughout the PCC and occipital gyrus were observed after weight gain in children with AN. These findings suggest that cortical GABAergic receptor binding is altered in children with AN. This may be a state-related change, which could be used to monitor and guide the treatment of eating disorders.

High incidence of sleep problems in children with developmental disorders: results of a questionnaire survey in a Japanese elementary school.

OBJECTIVE: The aim of the present school-based questionnaire was to analyze the sleep problems of children with developmental disorders, such as pervasive developmental disorder and attention deficit hyperactivity disorder. METHODS: The sleep problems of 43 children with developmental disorders were compared with those of 372 healthy children (control group). All children attended one public elementary school in Kurume, Japan; thus, the study avoided the potential bias associated with hospital-based surveys (i.e. a high prevalence of sleep disturbance) and provided a more complete picture of the children's academic performance and family situation compared with a control group under identical conditions. Children's sleep problems were measured with the Japanese version of the Children's Sleep Habits Questionnaire (CSHQ). RESULTS: Children with developmental disorders had significantly higher total CSHQ scores, as well as mean scores on the parasomnias and sleep breathing subscales, than children in the control group. The total CSHQ score, bedtime resistance, sleep onset delay, and daytime sleepiness worsened with increasing age in children with developmental disorders; in contrast, these parameters were unchanged or became better with age in the control group. In children with developmental disorders, there was a significant association between a higher total CSHQ score and lower academic performance, but no such association was found in the control group. For both groups, children's sleep problems affected their parents' quality of sleep. There were no significant differences in physical, lifestyle, and sleep environmental factors, or in sleep/wake patterns, between the two groups. CONCLUSIONS: Children with developmental disorders have poor sleep quality, which may affect academic performance. It is important for physicians to be aware of age-related differences in sleep problems in children with developmental disorders. Further studies are needed to identify the association between sleep quality and school behavioral performance.

Pitfalls in diagnosing psychogenic nonepileptic seizures in a sexually abused child.

A six-year-old girl living in a residential care facility because of previous sexual abuse at home showed intractable seizures with epileptic discharges on interictal EEG. The features of the attacks were sudden impaired consciousness, only in daytime while eating, studying, and walking, with no motor acts and continuing for several minutes to one hour. She could not recall the attacks, and anticonvulsants showed no effects. She gradually became irritated and antisocial, exhibiting impulsive and hyperactive behavior. Interictal EEG repeatedly showed diffuse irregular spikes and wave complexes. The attacks continued sporadically for more than two years and ceased after disclosure of repeated sexual abuse by a boy at the residential care facility. In this case, delayed diagnosis of psychogenic nonepileptic seizures was associated with diagnostic difficulty of dissociative symptoms in a child, the presence of epileptiform EEG in an abused child, and undetected sexual abuse in a residential care facility, the potential for which pediatric neurologists should be aware. These pitfalls are discussed in the context of previous related literature.