George Hadjipavlou

Conceptualizing Genetic Counseling as Psychotherapy in the Era of Genomic Medicine

Discussions about genetic contributions to medical illness have become increasingly commonplace. Physicians and other health-care providers in all quarters of medicine, from oncology to psychiatry, routinely field questions about the genetic basis of the medical conditions they treat. Communication about genetic testing and risk also enter into these conversations, as knowledge about genetics is increasingly expected of all medical specialists. Attendant to this evolving medical landscape is some uncertainty regarding the future of the genetic counseling profession, with the potential for both increases and decreases in demand for genetic counselors being possible outcomes. This emerging uncertainty provides the opportunity to explicitly conceptualize the potentially distinct value and contributions of the genetic counselor over and above education about genetics and risk that may be provided by other health professionals. In this paper we suggest conceptualizing genetic counseling as a highly circumscribed form of psychotherapy in which effective communication of genetic information is a central therapeutic goal. While such an approach is by no means new—in 1979 Seymour Kessler explicitly described genetic counseling as a “kind of psychotherapeutic encounter,” an “interaction with a psychotherapeutic potential”—we expand on his view, and provide research evidence in support of our position. We review available evidence from process and outcome studies showing that genetic counseling is a therapeutic encounter that cannot be reduced to one where the counselor performs a simple “conduit for information” function, without losing effectiveness. We then discuss potential barriers that may have impeded greater uptake of a psychotherapeutic model of practice, and close by discussing implications for practice.

Changes in alexithymia following psychological intervention: a review.

AbstractAlexithymia, a deficit characterized by difficulties identifying, differentiating, and articulating emotions, is associated with significant physical and mental health impairment. It is generally accepted that alexithymia has a negative impact on a variety of physical and mental health treatments. Less clear is the extent to which alexithymia itself can be modified. In this article we review studies that have examined the effects of psychological interventions on alexithymia. Taken together, findings from investigations included in this review suggest that alexithymia is partly modifiable with therapeutic interventions. Studies that directly targeted alexithymic symptoms tended to report significant reductions in alexithymia scores following treatment, whereas studies that measured changes in alexithymia but did not employ any psychological interventions specifically intended to treat alexithymia had more inconsistent results. We close by considering the practical implications of the findings, and by offering suggestions for future research.

Bipolar II Disorder: An Overview of Recent Developments

Objective: Recent research on the epidemiology, clinical course, diagnosis, and treatment of bipolar II disorder (BD II) stands to have a considerable impact on clinical practice. This paper reviews these developments. Method: We conducted a Pubmed search, focusing on the period from January 1, 1994, to August 31, 2004. Articles deemed directly relevant to the epidemiology, course, diagnosis, and management of BD II were considered. Results: The prevalence of BD II is likely higher than previously suggested. Systematic probing for particular clinical features and use of screening tools allow for a more timely and accurate detection of the disorder. There is a paucity of good quality data to guide clinicians treating BD II. Conclusion: Significant progress has been made in clarifying diagnostic and treatment issues in BD II. Neither strong nor broad treatment recommendations can be made; a cautious interpretation of available data suggests that lithium or lamotrigine are fairly reasonable first-line choices. More well-designed studies with larger samples are needed to improve the evidence base for managing this disorder.

Promising psychotherapies for personality disorders.

Objective: To provide a narrative review of recent research on the psychotherapeutic treatment of patients with personality disorders (PDs). Method: We conducted PubMed and PsycINFO searches of recently published articles that reported on the treatment outcomes of psychotherapies for PDs. Our focus was on studies that used randomized controlled trial (RCT) methodology. The search period was from January 2006 to June 2009. Results: The effectiveness of various psychotherapy treatment packages for PDs is well supported by favourable results from RCTs. Beneficial effects of psychotherapy included reduced symptomatology, improved social and interpersonal functioning, reduced frequency of maladaptive behaviours, and decreased hospitalization. Equivalent effects among the interventions we compared were common. Many of the treatments studied required only limited training by therapists. Most studies were focused on treating patients with borderline personality disorder (BPD). Some findings were suggestive of psychotherapy being cost-effective; however, few studies actually included formal cost analyses. Only one study included follow-up of treated patients beyond 1-yearposttreatment. Conclusions: There is strong support for the use of psychotherapy to treat patients with PDs. However, most of the evidence is limited to BPD. The findings of recent studies hold promise for training and practice. Future research should attend to identification of appropriate patient-treatment matches, elucidation of active treatment ingredients, and illumination of factors that are common among treatments that account for their equivalent effects.

Burnout among Canadian Psychiatry Residents: A National Survey

Objective: Burnout is a serious problem for health care providers that has implications for clinical practice and personal health. While burnout is known to affect residents, no studies have examined the prevalence or impact of burnout among Canadian psychiatry residents. Method: Residents in all Canadian psychiatry training programs were surveyed between May 1, 2014, and July 1, 2014. The survey included a well-validated, single-item measure to assess symptoms of burnout, several demographic questions, and Likert-scale items to assess residents’ appraisals of empathic functioning and strategies for coping with stress from patient encounters. Results: Responses were obtained from 400 residents, for a response rate of 48%. Twenty-one percent (N = 84) of residents reported symptoms of burnout. Burnout was reported more frequently by residents in postgraduate year 2 than by those in other years and was associated with engagement in personal psychotherapy during residency. No association was found between burnout and age, gender, or location of residency program. Residents who endorsed symptoms of burnout reported higher levels of compromised empathic functioning, were less likely to consult with supervisors about stressful clinical experiences, and were more likely to engage in unhealthy coping strategies. Conclusions: Symptoms of burnout affect one-fifth of Canadian psychiatry residents. The associations between burnout symptoms and problematic clinical and personal functioning suggest areas of concern for those involved in the training of Canadian psychiatry residents.

Psychotherapy in Contemporary Psychiatric Practice

Objective: American data suggest a declining trend in the provision of psychotherapy by psychiatrists. Nevertheless, the extent to which such findings generalize to psychiatric practice in other countries is unclear. We surveyed psychiatrists in British Columbia to examine whether the reported decline in psychotherapy provision extends to the landscape of Canadian psychiatric practice. Method: A survey was mailed to the entire population of fully licensed psychiatrists registered in British Columbia (n = 623). The survey consisted of 30 items. Descriptive statistics were used to characterize the sample and psychotherapy practice patterns. Associations between variables were evaluated using nonparametric tests. Results: A total of 423 psychiatrists returned the survey, yielding a response rate of 68%. Overall, 80.9% of psychiatrists (n = 342) reported practicing psychotherapy. A decline in the provision of psychotherapy was not observed; in fact, there was an increase in psychotherapy provision among psychiatrists entering practice in the last 10 years. Individual therapy was the predominant format used by psychiatrists. The most common primary theoretical orientation was psychodynamic (29.9%). Regarding actual practice, supportive psychotherapy was practiced most frequently. Professional time constraints were perceived as the most significant barrier to providing psychotherapy. The majority (85%) of clinicians did not view remuneration as a significant barrier to treating patients with psychotherapy. Conclusions: Our findings challenge the prevailing view that psychotherapy is in decline among psychiatrists. Psychiatrists in British Columbia continue to integrate psychotherapy and pharmacotherapy in clinical practice, thus preserving their unique place in the spectrum of mental health services.

Genetic counseling for common psychiatric disorders: an opportunity for interdisciplinary collaboration.

In their timely review of recent important genetic findings in psychiatric disorders—specifically, common and rare copy number variants (CNVs) in bipolar disorder, schizophrenia and autism spectrum disorders—Gershon and Alliey-Rodriguez (1) propose that these findings “must lead to profound changes” in genetic counseling and “propose that genetic counseling is more than risk prediction.” The genetic counseling profession has devoted considerable attention to the process of risk communication (2) and the conceptualization of risk as a complex construct that comprises more than probability alone—for instance, by addressing how a client’s context and subjective perception of the severity of a potential outcome influences perceptions of risk (3). Within this framework, the identification of CNVs that play important roles in the etiology of psychiatric disorders represents a refinement in our ability to predict probabilities of illness, rather than a major paradigm shift in the risk communication process. Similarly, psychological and psychotherapeutic dimensions to genetic counseling, such as attending to experiences of stigma, shame and guilt, have been explored in the genetic counseling literature for several decades (4). We fully agree with the authors that a “psychotherapeutic approach” would best serve patients and families seeking psychiatric genetic counseling for high-impact detectable genetic events such as CNVs, and we would add that such an approach ought to inform all genetic counseling encounters. This is consistent with a growing body of evidence from studies of genetic counseling practice indicating that attending to psychological dimensions of practice, such as the facilitation of understanding, empathic responses and lower levels of verbal dominance, are associated with more positive outcomes (5). We agree with the authors that there is a need for expert counseling for families affected by psychiatric disorders, and propose that there is much to be gained by greater collaboration between the psychiatric genetics community and the genetic counseling profession, in particular with regard to exploring how best to implement testing for CNVs in psychiatric populations in clinical practice, and how to manage the attendant ethical challenges.

On overvaluing parental overvaluation as the origins of narcissism

Understanding the developmental roots of narcissism has inspired much theorizing but little systematic inquiry. In this light, the longitudinal study by Brummelman et al. (1), which found that early socialization experiences in the form of parental overvaluation predicts the development of childhood narcissism, is a notable contribution to the empirical literature. Establishing a link between childhood narcissism and parental overvaluation has important implications for helping parents foster appropriate and realistic self-views in their children.

Predictive Neuroimaging Markers of Psychotherapy Response: A Systematic Review

IntroductionPredictive neuroimaging markers of treatment response are increasingly sought in order to inform the treatment of major depressive and anxiety disorders. We review the existing literature regarding candidate predictive neuroimaging markers of psychotherapy response and assess their potential clinical utility. MethodsWe searched Embase, PsycINFO, and PubMed up to October 2014 for studies correlating pretreatment neuroimaging parameters with psychotherapy response in major depressive and anxiety disorders. Our search yielded 40 eligible studies. ResultsThe anterior cingulate cortex, amygdala, and anterior insula emerged as potential markers in major depressive disorder and some anxiety disorders. Results across studies displayed a large degree of variability, however, and to date the findings have not been systematically validated in independent clinical cohorts and have not been shown capable of distinguishing between medication and psychotherapy responders. Also limited is the examination of how neuroimaging compares or might add to other prognostic clinical variables. ConclusionWhile the extant data suggest avenues of further investigation, we are still far from being able to use these markers clinically. Future studies need to focus on longitudinal testing of potential markers, determining their prescriptive value and examining how they might be integrated with clinical factors.

Unravelling the Relationship between Physician Burnout and Depression.

Dear Editor: We thank Dr. Schonfeld and colleagues for their letter responding to our survey regarding burnout symptoms among Canadian psychiatry residents. Their correspondence raises the issue of the connection between burnout and depression, noting that our survey did not consider whether residents who indicated burnout symptoms may have indeed been depressed. We agree that clarifying the relationship between burnout and depression is important. Although a large body of research has established a link between these constructs, it is premature to conclude that burnout and depression are one and the same. Clinical depression is marked by considerable heterogeneity and is optimally assessed using interviews by trained clinicians. Unfortunately, these issues have been inadequately accounted for in burnout research. As Schonfeld and colleagues note in a recent review, this prevents definitive conclusions regarding the overlap between burnout and depression. Alarming rates of depressive symptoms have been reported among residents of various medical specialties. Further research is needed to tease apart the relationship between training-related burnout and other potential depressogenic factors. Our survey was not designed to accomplish this. Rather, we sought to investigate the incidence of emotional exhaustion—a prominent burnout symptom—among psychiatry trainees in Canadian residency programs. While we do not know whether the residents who endorsed burnout symptoms were struggling with clinical depression, our findings may nevertheless provide some stimulus for further work—including research using more comprehensive assessment methods. If unaddressed, burnout may progress to depression. Hopefully, residents’ use of personal psychotherapy—along with other resources—can mitigate this unfortunate trajectory. Whether linked with depression or not, burnout among residents is a significant concern. We thus reiterate our call for attention to this matter on the part of psychiatric educators, administrators, and residents—and we join Schonfeld and colleagues in arguing for further research in this area.