McLean Hospital Research Articles

Is it possible to diagnose autism by brain imaging?

Harvard University Schools of Medicine & Public Health, MA, USA and Neurostatistics Laboratory, McLean Hospital, MA, USA nlange@hms.harvard.edu The root biological causes of autism spectrum disorder – autism – remain a complex mystery despite 70 years of effort to solve the puzzle. A total of 6 years after Leo Kanner first identified ‘early infantile autism’ in 1943 through astute observation of 11 children [1], he retracted his initial biological theory. Since then, no alternative theory has yet been validated by genetics or molecular biology to take its place [2]. Today’s autism research is awash with an abundance of statistically significant brain imaging results that provide little differentiation between individuals with the disorder and typically developing individuals [3], and this body of findings cannot yet be employed as useful diagnostic criteria in clinical practice. As we know, and as the Oxford English Dictionary reminds us, any image is merely “an artificial imitation or representation of the external form”, a “copy,” “likeness,” “similitude,” “semblance,” “appearance” and “shadow.” Some researchers today have exclaimed, “science is imaging”. Regardless of how ‘real’ the everimproving spatiotemporal image resolution, brilliance of color and attraction of animation appear to be, this statement broadcasts a clear misconception. Much of science is measurement, and we continue to have difficulty measuring the same brain structure twice within a short time interval and getting the same number, even after accounting for the ‘regression to the mean’ effect. The reliability of autism imaging is a major present-day limitation of the technology. MR brain images are perhaps the most beautiful of all image types (so beautiful because so mutable?), and these beauties are sometimes subjected to ‘circular analysis’ in attempts to ground their impressions in solid statistics [4]. MR images, these quantized imitations of reality, are indeed measurements amenable to statistical regression and classification analysis, but they cannot yet

Psychiatrist Crosses Finish Line Just Before Boston Blast

Back to table of contents Previous article Next article Community NewsFull AccessPsychiatrist Crosses Finish Line Just Before Boston BlastMark MoranMark MoranSearch for more papers by this authorPublished Online:17 May 2013https://doi.org/10.1176/appi.pn.2013.5b10AbstractBrent Forester, M.D., says the Boston Marathon attack struck at an iconic city event that is not only about the runners, but about bringing the entire community together.Less than a minute after psychiatrist Brent Forester, M.D., crossed the finish line at Boston’s 117th Marathon—achieving his goal of running the race in under four hours—he heard the sound of what he knew had to be bad news. “It sounded just like a loud cannon, but I was close enough to see there was smoke and debris everywhere, and I knew this was not normal,” Forester said of the attack that killed three people and injured more than 250. “I thought possibly it was an accident, a gas main, or a furnace, but it was clearly an explosion. And I knew there would be many people dead or injured.”Forester, a geriatric psychiatrist at McLean Hospital in nearby Belmont and chair of the APA Council on Geriatric Psychiatry, was running his fourth Boston Marathon and raising money for the Alzheimer’s Association of Massachusetts and New Hampshire. Brent Forester, M.D., is pictured before last month’s Boston Marathon.Brent Forester, M.D.This year he also raised money—some $3,500—for the Scholar’s Program sponsored by the American Association for Geriatric Psychiatry (AAGP) and the Geriatric Mental Health Foundation, which pairs medical students and psychiatry residents with mentors in the field and brings them to the AAGP annual meeting. Running for charity causes is a common feature of the race that has become emblematic of Boston, especially so among those who are not elite athletes, but who run for a meaningful cause and the thrill of crossing the finish line to the cheers of thousands. “The marathon, which is run on Patriots Day, is such a huge event for this city,” Forester said in an interview with Psychiatric News. “The Red Sox begin play at 11 a.m., with fans streaming out of Fenway into Kenmore Square to watch the vast majority of runners making their way to the finish line a mile away on Boylston Street. This event is not only about the runners and their individual stories, but also the hundreds of thousands of spectators lining the marathon course that make the Boston Marathon a true community spectacle from Hopkinton to Boston’s Back Bay. I cannot imagine running 26 miles in the middle of nowhere without the support and motivation that comes from the cheering crowds. It’s also amazing to consider that a regular runner can compete on the same course at the same time as the elite athletes from around the world, with support from the entire community. There’s an overwhelming flood of emotions when you finish.” Forester noted an especially chilling aspect of the attack that Monday: the bombs were timed to go off as those countless “regular-folk” runners were crossing the finish line, and when their family and friends were bound to be there to watch.After crossing the finish line, and after it became clear to all that something catastrophic had happened, Forester recalled a brief “stampede” of runners away from the scene. He spent the next two hours waiting to reconnect with his wife and daughter, who were driving a block from Copley Square at the time of the explosion, and two friends who had finished the marathon about 15 minutes before Forester. At the Boston Commons, he by chance spotted three residents from the Massachusetts General Hospital/McLean psychiatry residency program with cell phones who helped him connect with his wife; they later made it safely out of the city and home. “Those residents were an incredibly welcome source of support and kindness amid the chaos and uncertainty of the moment,” Forester recalled.The next day in Boston was a scene of “eerie quiet,” he said, with a large section of the city being treated as a crime scene. “Local residents who live near the crime scene were not yet allowed back to their homes,” he told Psychiatric News. “I’ve never experienced something like this, and I’m not an expert in disaster psychiatry, but people here need to talk about what they have been through,” Forester emphasized. “I spoke with some of my medical students after the race, and they all wanted to do something to help. Boston’s citizens were being turned away from hospitals because they didn’t need blood at that time, though they will likely in the coming weeks. But I told the students that the injured, their families, and first responders all need a lot of emotional support.” ■ ISSUES NewArchived

Religious coping among psychotic patients: Relevance to suicidality and treatment outcomes

Religious coping is very common among individuals with psychosis, however its relevance to symptoms and treatment outcomes remains unclear. We conducted a prospective study in a clinical sample of n=47 psychiatric patients with current/past psychosis receiving partial (day) treatment at McLean Hospital. Subjects completed measures of religious involvement, religious coping and suicidality prior to treatment, and we assessed for psychosis, depression, anxiety and psychological well-being over the course of treatment. Negative religious coping (spiritual struggle) was associated with substantially greater frequency and intensity of suicidal ideation, as well as greater depression, anxiety, and less well-being prior to treatment (accounting for 9.0–46.2% of the variance in these variables). Positive religious coping was associated with significantly greater reductions in depression and anxiety, and increases in well-being over the course of treatment (accounting for 13.7–36.0% of the variance in change scores). Effects remained significant after controlling for significant covariates. Negative religious coping appears to be a risk factor for suicidality and affective symptoms among psychotic patients. Positive religious coping is an important resource to this population, and its utilization appears to be associated with better treatment outcomes.

Modern Community Mental Health: An Interdisciplinary Approach

Modern Community Mental Health: An Interdisciplinary Approach

Inpatient psychiatric nursing: clinical strategies & practical interventions

Psychiatric nursing practice has changed dramatically over the past decades to accommodate vast changes in our health care system. The patients who now meet the level of care standards for an acute care setting have to be very ill and typically exhibit considerable behavioural impairments and multiple safety issues. This handbook for psychiatric nurses and nursing students reflects these changes and focuses on four particularly challenging aspects of acute psychiatric nursing practice: keeping the patient safe, stabilising symptoms, promoting engagement in treatment, and discharge planning. In a systematic, easy-to-access format, the book offers proven, clinically useful interventions designed to modify and manage disruptive patient behaviour. Also included is a chapter on overcoming one's own barriers to effective nursing in the difficult psychiatric environment. This important interdisciplinary clinical resource grew from a forum of Butler Hospital nurses who convened over a two-year period to identify and explore successful interventions used in the inpatient psychiatric acute care setting. The guide represents a collaboration between these health care professionals and their colleagues at the University of Rhode Island McLean Hospital, New York Presbyterian Hospital, and the Institute of Living.

Dronabinol for the Treatment of Agitation and Aggressive Behavior in Acutely Hospitalized Severely Demented Patients with Noncognitive Behavioral Symptoms

Behavioral disturbances occur frequently in demented individuals and greatly increase the burden of their care. The efficacy of pharmacotherapeutic treatment options is modest. This study was conducted to explore the efficacy and safety of dronabinol as an adjunctive treatment for agitation and aggressive behavior in severely demented patients. Using a retrospective systematic chart review, we studied 40 inpatients from the McLean Hospital Geriatric Neuropsychiatry Inpatient Unit diagnosed with dementia and treated with dronabinol for behavioral or appetite disturbances. A group of geriatric psychiatrists consulted medical records to rate the patients' behaviors prior to initiation of dronabinol treatment and following up to seven days of treatment, using the Pittsburgh Agitation Scale, Clinical Global Impression, and Global Assessment of Functioning. Data on percentage of food consumed ateach meal, sleep duration, and adverse events werealso collected from medical records. The addition of dronabinol to patients' treatment regimens was associated with significant decreases in all domains of the Pittsburgh Agitation Scale. There were also significant improvements in Clinical Global Impression scores, sleep duration and percentage of meals consumed during the treatment periods. Twenty-six adverse events were recorded during dronabinol treatment, none of which led to medication discontinuation. This report represents the largest studied cohort of dementia patients treated with dronabinol to date and confirms earlier reports that dronabinol can serve as an adjunctive treatment for neuropsychiatric symptoms in dementia. Further research, including prospective controlled trials, is needed to clarify dronabinol's role in treating noncognitive behavioral symptoms of demented individuals.

Bibliotherapy: tracing the roots of a moral therapy movement in the United States from the early nineteenth century to the present.

Bibliotherapy: tracing the roots of a moral therapy movement in the United States from the early nineteenth century to the present.

Roles of Nucleus Accumbens CREB and Dynorphin in Dysregulation of Motivation

Psychostimulants such as amphetamine and cocaine are believed to produce dependence by causing rapid, supraphysiological elevations in synaptic dopamine (DA) within the nucleus accumbens (NAc) (Volkow et al. 2009, Neuropharmacology 56: 3-8). These changes in forebrain DA transmission are similar to those evoked by natural reinforcers (Louilot et al. 1991, Brain Res 553: 313-317; Roitman et al. 2004, J Neurosci 24: 1265-1271), but are of greater magnitude and longer duration. Repeated drug exposure causes compensatory neuroadaptations in neurons of the NAc, some of which may modulate excess DA in a homeostatic fashion. One such adaptation is the activation of the transcription factor CREB (cAMP response element-binding protein) within neurons of the NAc. Although elevated levels of transcriptionally active CREB appear to attenuate DA transmission by increasing expression of the endogenous κ opioid receptor (KOR) ligand dynorphin, increased dynorphin transmission may ultimately have undesirable effects that contribute to drug withdrawal states as well as comorbid psychiatric illnesses such as depression. This state may prompt a return to drug use to mitigate the adverse effects of withdrawal. This article summarizes our current understanding of how CREB and dynorphin contribute to the dysregulation of motivation and describes novel therapeutic strategies that derive from preclinical research in this area.

Contingency Management for Patients With Serious Mental Illness and Stimulant Dependence

Contingency Management for Patients With Serious Mental Illness and Stimulant Dependence

Prefrontal Cortical Deficits in Type 1 Diabetes Mellitus

CONTEXT Neural substrates that may be responsible for the high prevalence of depression in type 1 diabetes mellitus (T1DM) have not yet been elucidated. OBJECTIVE To investigate neuroanatomic correlates of depression in T1DM. DESIGN Case-control study using high-resolution brain magnetic resonance images. SETTINGS Joslin Diabetes Center and McLean Hospital, Massachusetts, and Seoul National University Hospital, South Korea. PARTICIPANTS A total of 125 patients with T1DM (44 subjects with ≥1 previous depressive episodes [T1DM-depression group] and 81 subjects who had never experienced depressive episodes [T1DM-only group]), 23 subjects without T1DM but with 1 or more previous depressive episodes (depression group), and 38 healthy subjects (control group). MAIN OUTCOME MEASURES Spatial distributions of cortical thickness for each diagnostic group were compared with the control group using a surface-based approach. Among patients with T1DM, associations between metabolic control measures and cortical thickness deficits were examined. RESULTS Thickness reduction in the bilateral superior prefrontal cortical regions was observed in the T1DM-depression, T1DM-only, and depression groups relative to the control group at corrected P<.01. Conjunction analyses demonstrated that thickness reductions related to the influence of T1DM and those related to past depressive episode influence were observed primarily in the superior prefrontal cortical region. Long-term glycemic control levels were associated with superior prefrontal cortical deficits in patients with T1DM (β=-0.19, P=.02). CONCLUSIONS This study provides evidence that thickness reduction of prefrontal cortical regions in patients with T1DM, as modified by long-term glycemic control, could contribute to the increased risk for comorbid depression.

Metabolic syndrome in psychiatrically hospitalized patients treated with antipsychotics and other psychotropics

We evaluated prevalence and risk factors for metabolic syndrome in inpatients treated with antipsychotics, with or without other psychotropic drugs. Although the literature on metabolic syndrome in psychiatry has expanded in recent years, we seek to elucidate some of the remaining gaps by examining a severely and chronically ill population heavily treated with pharmacological agents. With data from medical records of 589 adults hospitalized at McLean Hospital in 2010 and 2011, we used standard statistical analyses to characterize risks and covariates of metabolic syndrome. With prior antipsychotic treatment, prevalence of metabolic syndrome was 29.5%. The syndrome was strongly associated with being overweight (≥25 kg/m(2) in 60.1% of subjects), older age, longer treatment-exposure, schizoaffective diagnosis (39.8%), more illness-episodes or hospitalizations, polytherapy, and higher total daily chlorpromazine-equivalent doses, but not sex. Notably, metabolic syndrome risk was greater among young, antipsychotic treated patients (15.5-fold at age ≤25 years). The findings extend information on the association of metabolic syndrome with antipsychotic treatment. Metabolic syndrome was found in 30% of antipsychotic-exposed inpatients. Risk was surprisingly high in young persons and after brief treatment-exposure, and psychotropic polytherapy increased risk.

A Bioecological Systems Approach for Navigating the College Mental Health Crisis

McLean Hospital's College Mental Health Program was established four years ago as an institutional response to escalating, national college mental health concerns. The critical factors underlying the college mental health crisis in this country have been debated, examined, and addressed almost exclusively within college and university settings. McLean Hospital is the first psychiatric hospital to develop a comprehensive college student program that bridges the gap between a psychiatric hospital and multiple campus settings as an attempt to address the specific needs of college student-patients across levels of psychiatric care and diagnostic areas/programs. Using a bioecological systems framework, this review examines (1) the strategic clinical, education/outreach, and research efforts that collectively represent a paradigm shift to extend responsibility for addressing serious college mental health challenges beyond college and university campuses, (2) the challenges and benefits of creating stronger multi-campus/hospital collaborations in order to improve our understanding of college students with serious mental illness, and (3) the progress in addressing these needs more effectively and in establishing documented best practices and policies through effective and innovative partnerships.

Research on psychedelic substances

Drug Testing and AnalysisVolume 4, Issue 7-8 p. 539-542 Editorial Research on psychedelic substances Simon D. Brandt, Corresponding Author Simon D. Brandt [email protected] School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street L3 3AF, United Kingdom Simon D. Brandt, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University. E-mail: [email protected]Search for more papers by this authorTorsten Passie, Torsten Passie [email protected] Laboratory for Integrative Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478 USA Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, D-30625 Hannover, GermanySearch for more papers by this author Simon D. Brandt, Corresponding Author Simon D. Brandt [email protected] School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street L3 3AF, United Kingdom Simon D. Brandt, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University. E-mail: [email protected]Search for more papers by this authorTorsten Passie, Torsten Passie [email protected] Laboratory for Integrative Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478 USA Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, D-30625 Hannover, GermanySearch for more papers by this author First published: 06 July 2012 https://doi.org/10.1002/dta.1389Citations: 3 Both authors contributed equally to this editorial. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume4, Issue7-8Special Issue: Psychedelic SubstancesJuly-August 2012Pages 539-542 RelatedInformation

Differences in the Circuitry-Based Association of Copy Numbers and Gene Expression Between the Hippocampi of Patients With Schizophrenia and the Hippocampi of Patients With Bipolar Disorder

GAD67 regulation involves a network of genes implicated in schizophrenia and bipolar disorder. We have studied the copy number intensities of these genes in specific hippocampal subregions to clarify whether abnormalities of genomic integrity covary with gene expression in a circuitry-based manner. To compare the copy number intensities of genes associated with GAD67 regulation in the stratum oriens of sectors CA3/2 and CA1 in patients with schizophrenia, patients with bipolar disorder, and healthy controls. Samples of sectors CA3/2 and CA1 were obtained from patients with schizophrenia, patients with bipolar disorder, and healthy controls. Genomic integrity was analyzed using microarrays, and the copy number intensities identified were correlated with the gene expression profile from a subset of these cases previously reported. Harvard Brain Tissue Resource Center at McLean Hospital, Belmont, Massachusetts. A total of 15 patients with schizophrenia, 15 patients with bipolar disorder, and 15 healthy controls. The copy number intensities for 28 target genes were individually examined using single-nucleotide polymorphism microarrays and correlated with homologous messenger RNA (mRNA) fold changes. The copy number intensities examined using both microarrays and quantitative real-time polymerase chain reaction for the GAD67 gene were significantly decreased in sector CA3/2 of patients with schizophrenia and patients with bipolar disorder. Other genes associated with GAD67 regulation also showed changes in copy number intensities, and these changes were similar in magnitude and direction to those previously reported for mRNA fold changes in sector CA3/2 but not sector CA1. Moreover, the copy number intensities and mRNA fold changes were significantly correlated for both patients with schizophrenia (r=0.649; P=.0003) and patients with bipolar disorder (r=0.772; P=.0002) in sector CA3/2 but not in sector CA1. Insertions and deletions of genomic DNA in γ-aminobutyric acid cells at a key locus of the hippocampal circuit are reflected in transcriptional changes in GAD67 regulation that are circuitry-based and diagnosis-specific.

Insertion of Foreign Bodies (polyembolokoilamania): Underpinnings and Management Strategies

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Dr Unruh is an attending psychiatrist at McLean Hospital, Belmont, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Nejad is an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts, an attending physician on the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and the director of the Burns and Trauma Psychiatric Consultation Service at Massachusetts General Hospital, Boston. Mr Stern is a research assistant in the Department of Psychiatry at Massachusetts General Hospital, Boston. Dr Stern is chief of the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts.Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Unruh and Nejad and Mr Stern report no financial or other affiliations relevant to the subject of this article.

Medication Shows Promise Treating Opioid Painkiller Addiction

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessMedication Shows Promise Treating Opioid Painkiller AddictionLeslie SinclairLeslie SinclairSearch for more papers by this authorPublished Online:3 Feb 2012https://doi.org/10.1176/pn.47.3.psychnews_47_3_20-bAbstractIn what is purported to be the first large-scale study to address treatment of prescription opioid addiction, researchers at McLean Hospital and Harvard Medical School have reported that individuals addicted to prescription painkillers reduce their opioid abuse when treated with sublingual buprenorphine-naloxone (Suboxone).In a press release describing the study from McLean Hospital, a Harvard Medical School affiliate, lead author Roger Weiss, M.D., chief of the Division of Alcohol and Drug Abuse at McLean, explained that “most studies examining treatments for opioid dependence have been done with heroin-dependent patients at methadone clinics, resulting in the lack of data on treatment for patients addicted to prescription painkillers, especially in the offices of primary care doctors.“Despite the tremendous increase in the prevalence of addiction to prescription painkillers, little research has focused on this patient population,” said Weiss, who is also a professor of psychiatry at Harvard Medical School. “This is notable because recent data tell us that the use of prescription painkillers for nonmedical reasons is 20 times more common than use of heroin, and 50 percent more people seek treatment for prescription drug abuse than for heroin.”This study, a randomized, two-phase adaptive treatment research design, was intended to approximate clinical practice, identifying a treatment strategy for a disorder, as well as the optimal response to an initial treatment failure.The study population consisted of 653 treatment-seeking outpatients, aged 18 or older, who were dependent on prescription opioids (DSM-IV criteria), presenting at 10 U.S. sites. Participants were excluded for heroin use or dependence or comorbid physical or mental disorders.The study was conducted in two phases. In phase 1, the “brief treatment” phase, subjects were randomized to receive either standard medical plus individual opioid-dependence counseling (ODC) or standard medical management alone. The ODC was based on drug-counseling manuals with demonstrated efficacy, modified for this particular study, and covered a wide range of relapse-prevention issues in great depth.Brief treatment consisted of induction with buprenorphine-naloxone, two weeks of stabilization, a two-week taper, and eight weeks of follow-up. At each medical visit, the study physician could adjust the dose of buprenorphine-naloxone in increments of up to 8 mg a week, based on opioid use, withdrawal symptoms, adverse effects, and craving, but not for pain. The allowable dose (expressed as buprenorphine) during stabilization was 8 mg to 32 mg a day, consistent with practice guidelines.Overall, 43 of the 653 patients (6.6 percent) had successful outcomes in phase 1, with no difference in success rates between those receiving standard medical management alone versus standard medical management and ODC.Unsuccessful patients were invited into the second “extended treatment” phase of the study, consisting of 12 weeks of buprenorphine-naloxone stabilization, a four-week taper, and eight weeks of follow-up, with the same process of randomization to receive either standard medical management plus individual ODC, or standard medical management alone.In contrast to phase 1, 49.2 percent of phase 2 participants (177 of 360) attained successful outcomes while still taking naloxone, but overall success rates eight weeks after completing the medication taper dropped to 8.6 percent (31 of 360 patients), with no difference between counseling conditions.“We were surprised by some of these findings because there was an overall assumption that this population—those who have had little to no exposure to heroin—would do better in terms of not needing long-term medication intervention,” said Weiss. “It is clear that given the prescription drug abuse epidemic, we need to continue to look at the viability of longer-term use of Suboxone and whether it can continue to provide sustained recovery from addiction to pain medications.”Success may be just around the corner, however. “The study suggests that patients addicted to prescription opioid painkillers can be effectively treated in primary care settings using Suboxone,” said Nora Volkow, M.D., director of the National Institute on Drug Abuse, which funded the work. “However, once the medication was discontinued, patients had a high rate of relapse, so more research is needed to determine how to sustain recovery among patients addicted to opioid medications.”The study was supported by the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN), the EMMES Corp, and the Duke Clinical Research Institute in Durham under contract with the NIDA CTN. Study medication was provided by Reckitt Benckiser to the NIDA CTN.An abstract of “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial” is posted at http://archpsyc.ama-assn.org/cgi/content/abstract/archgenpsychiatry.2011.121. ISSUES NewArchived

The union of the expressive arts and Dialectical Behaviour Therapy with adolescents presenting with traits of Borderline Personality Disorder in a residential setting

This article documents the journey of expressive arts-based Dialectical Behaviour Therapy (DBT) groups with adolescent females struggling with Borderline Personality Disorder at McLean Hospital in Belmont, MA from their inception in 2009 through to the present. There has been minimal research done on the efficacy of fusing the expressive arts with DBT; the theoretical model used at the 3East residential treatment programme. This article documents the rationale, structure and evolution of these groups. Furthermore, we discuss indicators of potential benefits from these groups such as decreasing perfectionism, increasing mastery, coping skills, self esteem and self identity, as well as propose changes that could continue to improve the current groups. Specific interventions and client observations are showcased with the purpose of sharing our experiences and expanding the dialogue between clinical psychology and expressive arts. Our work supports a positive outcome for the combination of these two treatments in this setting.

It Takes a Borderline Village

It Takes a Borderline Village

DeliriousDelirious by PalmerDaniel ; New York, Kensington, 2011, 384 pages, $25

Back to table of contents Previous article Next article Book ReviewsFull AccessDeliriousJeffrey L. Geller, M.D., M.P.H.Jeffrey L. GellerSearch for more papers by this author, M.D., M.P.H.Published Online:1 Dec 2011https://doi.org/10.1176/appi.ps.000621517AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Delirious by PalmerDaniel; New York, Kensington, 2011, 384 pages, $25The book Delirious is author Daniel Palmer's debut novel, and perhaps we can attribute some of its problems to a maiden voyage. The book is not an illuminating addition to the growing list of fiction that focuses on psychopathology. In fact, it's a stigma breeder. Before examining this, let's look at some of Delirious' rough spots.The novel is set in the greater Boston area. Palmer goes to great lengths to provide detailed accounts of geography, neighborhoods, and auto travel. An author of fiction can take all manner of liberties, such as creating fictional places or renaming real ones. In this book, the fictional psychiatric hospital clearly is McLean Hospital. If an author portrays places as they actually are, he or she needs to avoid inaccuracies. For example, specific driving routes are mentioned in the narrative, but the roads on these Massachusetts routes don't actually connect; exits on the Massachusetts Turnpike are misnumbered, and names are misspelled—Worchester for Worcester, for example. Such inaccuracies are distracting to those who know the region. Next time, Palmer should skip such details or pay closer attention to them.In trying to write a psychological thriller, Palmer outwits himself. By the time one finishes reading the two-and-one-half-page prologue, one has a good idea “who did it,” and the evolving plot does little to dissuade the reader from his or her original thoughts. And concluding a thriller with a plethora of happy endings reads more like Hans Christian Andersen than Ian Fleming.But the major difficulty with Delirious is its inaccurate portrayal of psychopathology and psychiatry. Again, a fiction writer can take liberties but should take care to avoid mistakes. The book is titled Delirious, but no character has a delirium. The terms “psychiatrist” and “psychologist” are confused. Descriptions of the procedures followed in Massachusetts civil commitment hearings are skewed. The interfaces between the criminal justice and mental health systems are not accurate. Hallucinations, delusions, and dissociation are not correctly distinguished. Most troubling: there are repeated implications that having a mental illness means you become only your mental illness, acutely losing all aspects of your former self. Boundaries are violated to the point that one man's long-term doctor, treating him for schizophrenia, knowingly becomes his brother's girlfriend. By the way, some of her training as a mental health professional is in handwriting analysis. “Mind control” leads to murder, the controlled person being devoid of any autonomy.Delirious is bad for psychiatry. Let's hope it is not made into a movie, at least not as written. And let's hope Daniel Palmer uses this book as a learning experience for his second novel.Dr. Geller, who is the book review editor, is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School, Worcester.The reviewer reports no competing interests. FiguresReferencesCited byDetailsCited ByNone Volume 62Issue 12 December 2011Pages 1517-1517 Metrics PDF download History Published online 1 December 2011 Published in print 1 December 2011

Maressa Hecht Orzack

Maressa Hecht Orzack passed away 11 November 2010 at the age of 83. Dr Orzack was born in Boston, but spent her earliest years in Europe after which she returned to New York City. Dr Orzack graduated from The University of Rochester with a BA in psychology, followed by a MA and a PhD from Columbia University in experimental psychology. Originally trained as an experimental psychologist, she studied with three of the founders of what is now called radical behaviorism, BF Skinner, WN Schoenfeld, and Fred S Keller. In addition to earning her degrees, Maressa met her future husband, Louis Hirsch Orzack, at Columbia University. She followed him initially to Indiana University, then to Seattle University, and to University of Wisconsin, Madison. Despite the nepotism rule common at the time, she found research work or teaching at each of these places. In Wisconsin, she worked with developmentally challenged individuals in Central Wisconsin Colony, where she used operant conditioning techniques to teach them activities of daily living. Dr Orzack returned to Boston to work for 18 years as an Assistant, then an Associate Professor with Dr Conan Kornetsky and Dr Alan Mirsky at Boston University Medical School. She studied attention-deficit disorder in patients with schizophrenia, utilizing the continuous performance test. Maressa and Dr Mirsky co-directed a special contract mandated by Congress to look at the retrospective study of the results of different psychosurgery procedures. Observing a decline in ‘soft money,' Maressa retrained as a clinician in cognitive behavioral therapy. She joined Dr Jonathan Cole at Harvard University's McLean Hospital, where they tested different psychotropic products for abuse liability. She specialized in cognitive behavior therapy and worked in the field of addictive behaviors, such as smoking, eating disorders, and addiction to chocolate. She subsequently was a Clinical Associate in the Psychology and Psychopharmacology Program, Coordinator of the Behavior Therapy Affective Disease Program at McLean Hospital, and Assistant Clinical Professor of Psychology, Department of Psychiatry, Harvard Medical School. A longtime staff psychologist and founder of McLean's Computer Addictions Service, she founded Computer Addictions Therapy, http://www.computeraddiction.com. In the early 1990s, Dr Orzack was a major pioneer in clinical care and research in the field of computer and Internet addiction. Maressa became a major pioneer in the clinical care and research in the field of computer and Internet addiction. As she stated, ‘I relied on my professional training starting with experimental psychology of learning, studies of recreational drug use, and my clinical training as a cognitive behavior therapist to set up a treatment protocol. It became clear that this was a complex problem, which has all the characteristics of impulsive and compulsive behavior, such as pathological gambling, OCD (obsessive compulsive disorder), sex addiction, eating disorders, and substance abuse. In addition, most of my patients were depressed; lonely, isolated, and often socially phobic … The major problem in treatment is the same as for eating disorders. Abstinence is not an option. Computer use is ubiquitous … The treatment needs to help people control their problematic computer activities in order to survive.' Dr Orzack created her own treatment protocol based primarily on the eating disorder model. Dr Orzack carried the message about Internet-enabled behavior to all ages. She met with parents, guidance counselors, teachers, therapists, psychologists, psychiatrists, social workers, and teenagers, just to name a few. She became the source that television, radio, and computer media called whenever there was a national or international news story involving computer addiction. She worked with the courts and lawyers creating a specific help group for men with Internet-enabled sexual behavior. ‘Maressa was a valued member of the McLean community. She took a thoughtful and caring approach to everything, whether it was teaching, research, or clinical care. Her keen insights led her to develop a program that was way ahead of the curve,' said Philip Levendusky, ABPP, Director of Psychology. On a personal note, Maressa was not only a distinguished psychologist but also a loving mother to her children Deborah S Orzack, Steven S Orzack (wife Ariane Cherbuliez), and Elizabeth Orzack Friedman (husband Joshua Friedman) and grandmother to Margot Elizabeth Friedman, Abraham Jacob Friedman, and Nora Cherbuliez-Orzack. She was predeceased by her husband, Louis Hirsch Orzack in 2003. A caring individual, she will be greatly missed.