London Clinic Research Articles

Training novice clinical psychologist trainees to implement effective CBT for anxiety disorders: training model and clinic outcomes

AbstractThe need for development of effective models of training and superivision for trainee clinical psychologists to build CBT competencies and to implement high-quality CBT is frequently highlighted. Effectiveness of trainee therapist outcomes working within different models of training, supervision and services is also important to establish. This paper reports on the development and outcome effectiveness of a model of training and supervision aimed at increasing CBT clinical skills and competence of trainee clinical psychologists offering CBT for anxiety disorders in an anxiety disorders clinic (ADC) in inner-city London. Details of the training and supervision model are provided, which was conducted over a period of 3 months, with ongoing weekly supervision throughout the intervention period. Pre- and post-intervention data were analysed from service users who attended the ADC over a 2-year period. Over the 2-year period, 10 trainees treated 57 clients. Data from completer and intention-to-treat samples indicated that scores on four outcome measures improved significantly: at post-therapy, 75% of service users who completed the intervention showed reliable and clinically significant recovery or improvement. When supported by appropriate training and supervision, as outlined in this training model, initially inexperienced trainee psychologists can achieve outcomes comparable to those obtained in other secondary-care settings with qualified therapists.

An initial investigation of abnormal bodily phenomena in subjects at ultra high risk for psychosis: Their prevalence and clinical implications

BackgroundContemporary phenomenological research has considered abnormal bodily phenomena (ABP) to be a phenotypic trait of subjects with schizophrenia in their first psychotic episode. Yet the prevalence of ABP and their clinical significance in subjects at Ultra High Risk (UHR) of psychosis remain unidentified. This study is an exploratory investigation of ABP in UHR subjects and matched healthy controls (HCs) examining their relation to clinical features and basic self-disturbances. MethodsA sample of 26 UHR and 14 HC subjects from three prodromal and early intervention clinics in South London, West London and Cambridge was assessed with the Abnormal Bodily Phenomena questionnaire (ABPq), Comprehensive Assessment of At-Risk Mental States (CAARMS), the Positive and Negative Syndrome Scale (PANSS), the Social and Occupational Functioning Assessment Scale (SOFAS) and the Examination of Anomalous Self Experiences (EASE) checklist. ResultsIn our sample ABP occurred in 73.1% of UHR subjects and prominent ABP (proABP) were referred in 53.8% of them. No HC subject reported ABP. The UHR group with proABP had lower CAARMS total score (t=−9.265, p=0.006). There were no differences in PANSS total score (t=−1.235, p=0.277), SOFAS score (H(2) 22.27, p=0.666) and EASE total scores (z=8.565, adjusted p=0.185) in the UHR subjects with prominent ABP versus those that did not. DiscussionThis initial investigation suggests that ABP could be a prevalent phenotypic feature of UHR subjects.

Domestic violence and abuse in gay and bisexual men attending a sexual health clinic: pilot testing of an educational support intervention for sexual health practitioners

BackgroundDomestic violence and abuse is recognised globally as a pervasive public health issue, but there is less research in relation to gay and bisexual men. This study aimed to measure the occurrence of negative and potentially abusive behaviour and associations with health problems in gay and bisexual men; and pilot test an educational intervention for practitioners to increase awareness of domestic violence and abuse and provide skills in inquiry and support. MethodsBetween Sept 21, 2010, and May 25, 2011, an anonymous Health and Relationships survey was administered to English-literate men (aged 18 years) attending a sexual health clinic in London, UK. Negative behaviour included: feeling frightened of the behaviour of a partner; having to ask permission (beyond being considerate to and checking with a partner); being slapped, hit, kicked, or physically hurt; and forced sex or sexual activity. Health problems included mental health, sexual health, and alcohol and illicit drug use. Sexual health practitioners received training on the educational intervention HERMES (HEalthcare Responding to MEn for Safety). 6 weeks after training, 21 semi-structured interviews were conducted with the practitioners to assess acceptability of HERMES, changes in awareness, and confidence in identifying and responding to gay and bisexual men who were experiencing domestic violence and abuse. FindingsOf 2657 men who attended the clinic, 1132 (42·4%) completed the survey. 532 (47·2%) self-identified as gay or bisexual. 33·9% (95% CI 24·9–37·9) of gay and bisexual men reported ever experiencing a negative and potentially abusive behaviour from a partner. Ever being frightened by a partner and having to ask a partner's permission were associated with increased odds of being anxious (odds ratio [OR] 2·5, 95% CI 2·0–3·1 and 2·7, 1·6–4·7, respectively). Being frightened of a partner, being physically hurt, and physically hurting a partner were associated with increased odds of using a class A drug in the previous 12 months (OR 2·2, 1·5–3·2; 2·3, 1·4–3·8; and 3·1, 2·3–4·2, respectively). Practitioners welcomed HERMES and felt that it raised their awareness and confidence in dealing with domestic violence and abuse among gay and bisexual men. InterpretationIn this clinical setting the occurrence of potentially abusive behaviours in gay and bisexual men was high. HERMES increased sexual health practitioners’ awareness of domestic violence and abuse and confidence in asking about abuse. The results can only be interpreted within the context of the sexual health clinic. Because of the cross-sectional design, it is not possible to determine the temporal direction of the associations between negative behaviour and health problems. FundingThis report presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0108-10084).

When Debility Provides a Future: Preventing Vertical Transmission of HIV

In this article we investigate the way in which viral load assays are used to assess the viruses of Human Immunodeficiency Virus (HIV)-positive pregnant women who are cared for in an HIV-specialist antenatal clinic in London. One of the viral load assays has been made more sensitive to subtypes of the virus that are considered to be local, possibly reading the viruses of those who have ‘foreign’ subtypes as undetectable. Consequently, the patient might not be offered the kind of care needed to prevent transmission of HIV, as her body is not recognised as sufficiently debilitated. Thus, being identified as a debilitated body in this setting facilitates the prevention of vertical transmission of HIV and the management of the HIV-positive pregnant patient's virus. Further to this, we argue that in our example, having a debilitated body as constructed by the viral load assay is thus a ‘privilege’ that is accorded to HIV-positive persons depending on the geographic origin of their virus. Using Karen Barad's agential realism, we argue that the manner in which HIV is read through the viral load assay constructs a specific woman/foetus/HIV phenomenon. The specificity of this phenomenon directly impacts on the course of care, opening up or foreclosing the possibility of her child having a future free from HIV.

Empirical evaluation of a theory of stigma in children and adolescents with sickle cell disease

Background. There is limited research in self-perceived stigma among children and adolescents with sickle cell disease (SCD). We applied the concept of “stigma dimensions” to measure the predictors of self-perceived stigma in young people with SCD.Objective. In accordance with “stigma dimensions”, we hypothesized that young people with visible clinical features of SCD (jaundice and leg ulcers), and greater interference with their daily lives and social activities (frequent hospital admissions and school absences) would have increased self-perceived stigma. Patients and methods. 93 children and adolescents with SCD aged 10-19 years in the UK completed questionnaires on self-perceived stigma. Socio-demographic and clinical characteristics of SCD were also obtained. Young people were recruited from paediatric haematology or sickle cell outpatient clinics in London and the Sickle Cell Society (National Charity). Participants with all types of SCD were included; exclusions were those who were not fluent in English or unwell at the time of the survey. Results. Mean age was 14.2 years (SD 2.1 years) with 51% males and 49% females. 66% of the respondents had one or more hospital admissions in the preceding year, 46% were jaundiced, and 5% had leg ulcers. Consistent with our hypothesis and “stigma dimensions”, regression analysis showed that those who experienced more disruption in their daily lives (frequent hospital admission and less school attendance) had increased self-perceived stigma. However, the presence of leg ulcers or jaundice was not associated with increased self-perceived stigma. Conclusion. Interventions in SCD that effectively moderate disruption of daily activities and improve quality of life could help reduce self-perceived stigma among young people with SCD.

Empirical evaluation of a theory of stigma in children and adolescents with sickle cell disease

Background. There is limited research in self-perceived stigma among children and adolescents with sickle cell disease (SCD). We applied the concept of “stigma dimensions” to measure the predictors of self-perceived stigma in young people with SCD. Objective . In accordance with “stigma dimensions”, we hypothesized that young people with visible clinical features of SCD (jaundice and leg ulcers), and greater interference with their daily lives and social activities (frequent hospital admissions and school absences) would have increased self-perceived stigma. Patients and methods. 93 children and adolescents with SCD aged 10-19 years in the UK completed questionnaires on self-perceived stigma. Socio-demographic and clinical characteristics of SCD were also obtained. Young people were recruited from paediatric haematology or sickle cell outpatient clinics in London and the Sickle Cell Society (National Charity). Participants with all types of SCD were included; exclusions were those who were not fluent in English or unwell at the time of the survey. Results. Mean age was 14.2 years (SD 2.1 years) with 51% males and 49% females. 66% of the respondents had one or more hospital admissions in the preceding year, 46% were jaundiced, and 5% had leg ulcers. Consistent with our hypothesis and “stigma dimensions”, regression analysis showed that those who experienced more disruption in their daily lives (frequent hospital admission and less school attendance) had increased self-perceived stigma. However, the presence of leg ulcers or jaundice was not associated with increased self-perceived stigma. Conclusion . Interventions in SCD that effectively moderate disruption of daily activities and improve quality of life could help reduce self-perceived stigma among young people with SCD.

P08.22 How high is high risk? sexual behaviour and chlamydia infections in women attending genitourinary medicine clinics

Introduction Population based surveys provide valuable data for the general population but most testing for sexually transmitted infections (STI) is done in health care settings. The objective of this cross-sectional study was to describe sexual behaviour characteristics of women attending genitourinary medicine (GUM) clinics and compare them with nationally representative data. Methods This study was conducted from January 2014 to March 2015 in two London clinics. Women were eligible if they were aged 16–29 years and able to provide informed consent. Participants completed a web-based questionnaire that included several questions from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). We compared clinic attenders with women aged 16–24 years in the general population, surveyed in Natsal-3 in 2010–2011. Results We enrolled 1808 women, of whom 1806 provided clinical data and 1792 completed the questionnaire. Most (61.9%) were 16–24 years old and from white ethnic groups (48.8%). Four fifths reported having ever been tested for chlamydia with an average of 3.3 (SD 1.8) tests per participant. One third had ever been diagnosed with chlamydia. Compared with women age 16–24 years in Natsal-3, clinic attenders were more likely to report ≥5 lifetime partners (47.0% vs. 37.3%, p Conclusion This study provides detailed data about differences in sexual activity and practices between women attending clinics and those in the general population. These results can be used in studies to understand the impact of interventions such as point-of-care testing to improve chlamydia screening outcomes. Disclosure of interest statement This study was funded by the UK Technology Strategy Board; HHL is an equity holder of the company Diagnostics for the Real World.

Use of Diabetes Registry Data for Comparing Indices of Diabetes Management: A Comparison of 2 Urban Sites in Canada and Colombia.

To demonstrate the use of a multinational diabetes registry for comparing indices of diabetes management among countries with differing levels of income, healthcare systems and ethnic backgrounds. A cross-sectional study was conducted among 1742 people with type 2 diabetes attending diabetes clinics in London, Ontario, Canada, and Bogota, Colombia. The data were extracted from the Global Registry and Surveillance System for Diabetes (GRAND). Canadian patients were diagnosed with diabetes at significantly younger ages than Colombian patients (49 years and 53 years, respectively) and were heavier (body mass indices of 33 and 28, respectively). The Colombian patient population had significantly higher mean glycated hemoglobin (A1C) levels (9.4% vs. 8.6%) and fewer patients (22% vs. 26%) at the glycemic target (A1C <7.0%) than Canadian patients. In Colombia, 1 or more diabetes-related complications were present in 51% of the study population compared with 37% in Canada. Newly diagnosed Colombians had higher mean A1C levels (9.1% vs. 8.7%) and low-density lipoprotein-C levels (3.3 mmol/L vs. 2.5 mmol/L) than did newly diagnosed Canadians. A multination diabetes registry collecting standardized data facilitates transnational comparison of diabetes clinical parameters for the purpose of identifying potential gaps in care.

Patient perception of a randomised, controlled trial of laryngeal reinnervation versus thyroplasty for unilateral vocal fold paralysis.

To explore unilateral vocal fold paralysis patients' perception of a proposed randomised, controlled trial of laryngeal reinnervation versus thyroplasty, and to identify patients' concerns regarding their voice. Seventeen patients from five voice clinics in London were identified as being eligible for the randomised, controlled trial. Eleven of these patients (9 females and 2 males; age range, 18-65 years) were interviewed using a semi-structured topic guide (they were given a minimum of 2 weeks to read through the study information sheet). The interviews were recorded, transcribed and analysed using thematic analysis. The patients were satisfied with the clarity of the information sheet. Most of them perceived that reinnervation was a more 'attractive' option than thyroplasty. This may have been the result of certain phraseology used in the information sheet and by recruiters. Patients' main concern was reduced voice strength and the effects of this on work and social life. Phraseology that needed changing was identified; these changes may optimise the recruitment process for a trial. We propose using the voice handicap index 10 as the primary measure of outcome in the proposed randomised, controlled trial.

Delving into the ‘emotional storms’: A thematic analysis of psychoanalysts’ initial consultation reports

Psychoanalysts’ written reports on initial consultations are a window into the complexities of a crucial aspect of psychoanalytic work. However, systematic research in this area has largely focused on patients’ demographic factors or standardized measures. The present study looked at reports of all the consultations taking place at the London Clinic of Psychoanalysis over one calendar year (N = 100). The aim was to explore psychoanalysts’ different explicit styles of working and reporting as well as further understanding implicit processes used in thinking and writing about each particular consultation experience. A thematic analysis revealed a set of themes that related to a style of working and thinking about the consultation process as a dyadic experience, where the interaction, affective reactions and contact made between the two are the focus when thinking of making a recommendation for psychoanalysis. The majority of the reports had an open, exploratory quality. The writing of reports appears to give the analyst an opportunity to process the consultation experience and arrive at a more triangular position. Writing reports is a more valuable part of the consultation process than has formally been recognized and acknowledged. The limitations of this study as well as the relevance of these findings for future research are discussed.

P29 Audit of re-testing and reinfection in london men who have sex with men with acute stis in a large gum outpatient clinic

Background Men who have sex with men (MSM) in the UK are at relatively high risk of acquiring new STIs. The British Association of Sexual Health and HIV recommend active recall of MSM diagnosed with sexually transmitted infections (STIs) for retesting after 3 months. Objectives An audit was undertaken to assess the incidence of bacterial STIs, and rates of re-screening and re-infection amongst MSM attending a large genitourinary (GU) outpatient clinic in London. Methods A retrospective audit of GU coding data on MSM attendees aged >18 years between January and December 2014 was performed. Data was collected on patient demographics, STI tests performed and diagnoses. Results 397 MSM were diagnosed with 826 new bacterial STIs during the audit period (762 STIs over 534 episodes occurred in the initial 9 month period). 145 (37%) patients were HIV infected. In 98/534 (18%) episodes, a repeat screen was performed within 3 months (excluding screening within the initial 6 weeks after an STI was diagnosed); in 21 (21%) of these episodes, a further 1 ≥ STI was diagnosed. Overall, the mean time to re-screening during the study period was 108 days (excluding initial 6 weeks; range 43–282). In 149/534 (28%) of STI episodes, no repeat STI screen was performed within the period analysed. Conclusion The incidence of STIs and re-infection in this high risk group is high, however prompt re-screening rates are low, highlighting the need for active recall. Routine 3 month text recall of MSM with an STI has since been implemented.

P186 High levels of use of recreational drugs and alcohol within an inner london sexual health clinic: Abstract P186 Table 1

Background Drug and alcohol use by patients attending sexual health clinics is not widely assessed as routine. BASHH history taking guidelines and position statement on recreational drug use recommend obtaining such histories, enabling identification of patients at risk and refer appropriately. Aim To identify drug and alcohol use among GU patients attending a routine clinic appointment. Methods Anonymous questionnaires were offered to all patients over a five day period. Drug and alcohol use over past 6 months, whether it was patient-identified as problematic and where help would be sought were obtained Results Of the 116 respondents, with an average age of 30 years, there were 61 (52%) women, 30 (26%) MSM and 25 (22%) heterosexual men. Of these 60 (52%) disclosed drug use and 105 (81%) disclosed drinking alcohol; 4 respondents were concerned about their drug use and 48 (49%) reported high alcohol intake. Conclusion There is a high level of drug and high alcohol use by a significant number of patients of all genders and ages. However it is self-deemed as problematic by only a small proportion. More routinely collected data is required to fully understand this and the potential impact it may have on sexual health.

Treatment-resistant depression: experience of the first repetitive transcranial magnetic stimulation clinic in the UK

ABSTRACT Aim: To report the clinical outcomes of 62 treatment-resistant depressed patients treated with repetitive transcranial magnetic stimulation (rTMS) in the first rTMS clinic in the UK during 2013. Materials &amp; methods: Sixty-two treatment-resistant depressed patients (12 of them bipolar) referred to an rTMS Clinic in London during 2013 completed self-report Beck Depression (BDI-II) and Anxiety Inventories (BAI) at baseline and at the end of their treatment course. Results: Sixty-six percent reached remission, as defined by a score of 12 or below in the BDI-II at the end of the treatment course. Length of illness did not affect the likelihood of recovery. The treatment was generally well tolerated. Conclusions: rTMS appears to be a safe and effective intervention for ‘real world’ treatment-resistant patients.

P153. Use of acellular dermal matrix (ADM) in nipple reconstruction following breast reconstruction; the ‘central-pillar technique’

P153. Use of acellular dermal matrix (ADM) in nipple reconstruction following breast reconstruction; the ‘central-pillar technique’

P180. Audit of referrals to a family history clinic

P180. Audit of referrals to a family history clinic

P181. Integration of physical activity into breast cancer care pathway “Can-Move” programme

P181. Integration of physical activity into breast cancer care pathway “Can-Move” programme

P152. Is lipomodelling after breast cancer safe?

P152. Is lipomodelling after breast cancer safe?

Oral human papillomavirus (HPV) infection in men who have sex with men: prevalence and lack of anogenital concordance.

ObjectivesTo estimate the prevalence of oral detectable human papillomavirus (HPV) DNA in HIV-negative men who have sex with men (MSM) attending a sexual health clinic in London and concordance with anogenital HPV infection. Such data are important to improve our understanding of the epidemiology of oral HPV and the potential use of vaccines to prevent oropharyngeal cancers.MethodsPaired oral rinse samples and anogenital samples were available from 151 HIV-negative MSM within a larger cross-sectional survey. All samples were tested in parallel for 21 types of HPV DNA using an in-house assay.ResultsThe median age of participants was 30 (IQR 25–35). The prevalence of any oral HPV and of high-risk HPV (HR-HPV) was 13.7% (n=21; 95% CI 8.7 to 20.2) and 5.9% (n=9; 95% CI 2.7 to 10.9) compared with 64.9% (n=98; 95% CI 56.7 to 72.5) and 34.4% (n=52; 95% CI 26.9 to 42.6) in any anogenital sample, respectively. The prevalence of types prevented by the bivalent (HPV16/18), quadrivalent (HPV6/11/16/18) and nonavalent (HPV6/11/16/18/31/33/45/52/58) vaccines was 1.3% (95% CI 0.2 to 4.7), 2.6% (95% CI 0.7 to 6.6) and 4.6% (95% CI 1.9 to 9.3), respectively. There was no concordance between HPV genotypes detected in oral and anogenital sites.ConclusionsHR-HPV DNA, including HPV 16/18, was detected in oral specimens from HIV-negative MSM attending sexual health clinics, suggesting a potential role for vaccination, but is far less common than anogenital infection. How this relates to the risk and natural history of HPV-related head and neck cancers warrants further study. Lack of concordance with anogenital infection also suggests that oral HPV infection should be considered separately when estimating potential vaccine impact.

Olympics and Paralympics 2012 mass gathering in London: time-series analysis shows no increase in attendances at sexual health clinics

ObjectiveTo determine whether the 2012 Olympic and Paralympic Games were associated with a change in the number of patients attending or diagnosed with a new sexually transmitted infection (STI) at...

Smoking and Gambling Disorder: Does Tobacco Use Influence Treatment Outcome?

The purpose of this study was to verify whether tobacco use influenced treatment outcome in a population of treatment seeking individuals with gambling disorder. Gambling disorder is defined as persistent and maladaptive gambling behaviour which meets four or more outlined criteria in the DSM-5. Tobacco use is the most frequent comorbidity with gambling disorder. A total of 676 treatment seeking individuals with gambling disorder were assessed at the National Problem Gambling Clinic in London. We analysed differences in socio-demographic, clinical and gambling variables between smokers and non-smokers and the relation between smoking behaviour and treatment completion and outcome. 46.4% (314) of our sample were daily tobacco users and were significantly younger, less likely to be in a stable relationship, more likely to be unemployed and have a lower education level. They were also significantly more likely to score higher on the AUDIT-C score and were significantly more likely to have used drugs in the last 30 days. There was no significant difference in PGSI score between smokers and non-smokers. We found that tobacco smokers did not have higher PGSI scores than non-smokers. Moreover, there was no significant difference between tobacco users and nonusers in terms of treatment completion and treatment outcome.