Anthony Bellissimo

Adolescent depression in a school-based community sample: Preliminary findings on contributing social factors

A two wave survey carried out on a large community sample of adolescents with increased risk for problems with social functioning is described. In this paper we report the prevalence of depression in this population and social factors that contribute to it. The prevalence of depression is twice that in other studies. Stress is both a risk and causal factor in depression while relatively low social self-efficacy moderately increases risk. Being female is a risk factor for depression. The perception of parents and siblings as a source of support appears to be a key factor in protection from the onset of depression.

Chronic pain : psychosocial factors in rehabilitation

Rehabilitation and psychosocial dimension are the central theme of this book which deals with the mind-body problem, medico-legal and occupational issues, pain management, behavioural treatments, psychotherapy, and psychiatric treatment. It also includes a chapter on women and pain.

Coping with the coping concept: a brief comment.

‘Coping’ as a concept has achieved wide modem usage both in common parlance and also in the psychological literature. To those of us in clinical practice, there is something very attractive about using the idea of ‘coping’ in formulation and in treatment. It provides a psychological construct that includes behavioral and cognitive events, permits a prescription for learning by the patient, and helps to distinguish successful from unsuccessful patients. For example, much of the ‘coping’ literature notes that subjects and patients have poor tolerance to pain if they are ‘catastrophizers’ (i.e., individuals who seem to exaggerate the significance of a ‘stressor’ for themselves). Yet, the concept of ‘coping’ still needs some fundamental clarification. Close to 3 decades of research has led to little unanimity regarding what constitutes ‘coping,’ how to identify or measure it. The form of the measures and research methodologies have not changed greatly since ‘coping’ research began, and major advances have been few, raising the possibility that the concept may have reached its heuristic limit. We appeal to the concept of ‘coping’ in our clinical experience in which we encounter individuals who transform calamities into opportunities for growth, while we encounter others who transform everyday ‘hassles’ into overwhelming adversities. However, it is impossible to consistently demonstrate differences in ‘coping strategies’ that would characterize both

Teaching Some Principles of Individual Psychodynamics through an Introductory Guide to Formulations

One objective of psychiatric education can be to help trainees describe and understand major concerns patients experience in their key relationships, inner conflict and sense of self. A precis of major concepts and principles in this area (usually known as psychodynamics) is presented without the metapsychological framework which makes some of the literature difficult to grasp. This is intended to make learning more efficient and to facilitate the formulation of hypotheses about the presence or absence of specific conflicts, and problems in key relationships. We do not propose that these hypotheses necessarily explain psychopathology but that they (a) supplement formal diagnosis; (b) enrich the clinical data base by providing hypotheses which are testable in part by clinical observation and which can be tested scientifically; (c) provide understanding crucial to psychotherapy.

The Likelihood of Remaining Normotensive Following Antihypertensive Drug Withdrawal

Objective:To determine the proportion and characteristics of mild hypertensives who remain normotensive after withdrawal from drug treatment.Design:Longitudinal descriptive study.Setting:A university family practice unit (FPU) and a large steel company (DOFASCO) in Hamilton, Ontario.Patients:Participants were 107 of 125 (86%) eligible hypertensives at the two sites; 103 (96%) subjects completed the study.Intervention:Subjects discontinued antihypertensive medication and were followed until blood pressure (BP) became elevated or for 12 months, whichever was shorter.Measurements and main results:BPs were monitored according to a predefined schedule and before, during, and after mental and physical stress tests. Thirty-eight (37%, 95% confidence interval [CI] 27–46%) subjects remained normotensive at 12 months. Predictors of remaining normotensive included lower medicated standing diastolic blood pressure (DBP) (87.6 versus 91.8 mm Hg, 95% CI for the difference 2.2–6.2, p<0.001) and longer duration of normotension on drugs (12.6 months versus 8.7, 95% CI for the difference 0.9–6.9, p=0.012). There was no significant relationship between maintenance of normotension and age, medication potency, duration of hypertension, weight, lying BP, change in heart rate, or BP during mental or physical stress tests; the power to detect a clinically important difference in lying DBP was 99% but for other variables was lower (21 – 75%).Conclusions:The probability of hypertensives’ remaining normotensive for one year after drug withdrawal increases as the medicated standing DBP decreases and as the number of months of BP control while on medication increases. Studies with larger sample sizes are warranted to determine whether other variables may be significant predictors.

Teaching psychotherapy: Learning objectives in individual psychotherapy.

This paper constitutes an initial attempt to establish specific end-point objectives for the teaching (and learning) of individual psychotherapy skills. A working framework for teaching psychotherapy, which includes intrapsychic as well as interactional phenomena, is articulated. The framework also tries to achieve an integration of basic concepts of psychotherapy and specific skills for clinical practice. It draws on concepts derived from communication theory, psychoanalytic theory, adaptational theory (ego theory), learning theory, and transactional theory. In presenting these objectives three classes of skills are articulated: perceptual, conceptual, and executive. The end-point objectives are described for the following categories: 1) therapeutic stance, 2) history and mental status, 3) models and concepts, 4) communication channels, 5) patients affect, 6) therapists affect, 7) acceptance of affect, 8) interpretation, 9) transactions and 10) reinforcement and adaptation. This framework is truly eclectic in nature and effects a healthy compromise between the technique oriented “ABCs of psychotherapy” school and proponents of the view that psychotherapy is an art that cannot be taught. By drawing from more than one model it encourages the student to recognize early the distinction between theoretical formulation and ideological commitment in psychotherapy. It presents these objectives in the form of an instrument that can, with continuous refinement and testing, be used to evaluate students progress in a psychotherapy training program.

Insomnia. I: Classification, assessment and pharmaceutical treatment

Insomnia is a public health problem because of its high prevalence, the risk of hypnotic drug abuse, and self medication combined with alcohol and other nonprescription chemicals. Clinical experience has given rise to a descriptive classification of the insomnias many of which are secondary to medical disease. The information now available allows us to suggest a systematic approach to the assessment of insomnia emphasizing its history, events associated with sleep onset, observable behaviour and experience associated with interruptions in sleep. This paper attempts to organize the present state of knowledge in a format that can be taught to general physicians who deal with the most insomnia patients.

Insomnia. II: Assessment and treatment of chronic insomnia

Evidence for non-pharmacological effects of hypnotics on sleep is presented. This suggests that behavioural variables may be involved in the regulation of sleep onset in insomnia. Chronic ‘true’ insomnia is described in terms of precipitating events: fixed behavioural patterns which perpetuate it and the disordered timing of electrophysiological and hormonal events. Specific behavioural factors relevant to an individual patients insomnia must be identified. The factors are: (i) the patients expectations of the experience of going to sleep and his / her belief that he can or cannot control the onset of sleep, (ii) the patients’ personal theory of the cause of the problem, (iii) what the patient says to himself privately about the problem, (iv) the presence of stimuli in the sleep setting which arouse the patients including objects, persons and behavioural rituals. Treatment requires that patients be taught special skills, individually tailored to the specific behavioural variables found to perpetuate their insomnia. Non specific ‘placebo’ effects are also involved as is the case with drug administration. Patients who fail to respond to treatment may have a masked disturbance of circadian rhythms. This recent observation requires the addition of new approaches to assessment and treatment.

Teaching Individual Psychotherapy: Learning Objectives in Communication

Communication is the essence of the process of psychotherapy. Understanding the parameters of communication conform the foundations for the development of psychotherapeutic skills in the student therapist. Using learning objectives within the context of teaching psychotherapy, the process of communication in individual psychotherapy is explored in this paper. With the aim of offering a practical framework to assist in the analysis of the communication process involved in individual psychotherapy, the following concepts are first examined: 1) channels of communication; 2) modes of functioning; 3) interaction between channels of communication and modes of functioning. Following this exploration, the learning objectives in communication are discussed. Using clinical examples, the relationship between the communication process and other concepts of individual psychotherapy are illustrated. Finally, some pedagogic reasons for teaching students the analysis of the communication process early in their psychotherapy training are presented.