Kirupamani Viswasam

Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page.

Objective: To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice. Method: Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases. Results: GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment. Conclusion: GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.

The clinical characteristics of obsessive compulsive disorder associated with high levels of schizotypy

Objectives: This study aims to examine the characteristics of obsessive compulsive disorder (OCD) associated with high levels of schizotypy. Methods: Using the Schizotypal Personality Questionnaire (SPQ) with 177 individuals with OCD, patients with OCD and high levels of schizotypy (OCD-HS) were compared to patients with OCD and low levels of schizotypy (OCD-LS) on a range of clinical characteristics. Self-report and clinician-administered instruments were used. Results were adjusted for the severity of OCD symptoms, age, marital status and comorbidity using logistic regression. Results: Patients with OCD-HS were younger and less likely to have been married. OCD-HS was associated with higher rates of symmetry/order obsessions, ordering/arranging compulsions, checking compulsions, co-occurring major depression, post-traumatic stress disorder, substance use disorders and greater general psychopathology. Previously reported associations, such as higher total scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) were not significant when adjusted for differences in demographic variables and comorbidity. Conclusions: Patients with OCD-HS were associated with specific OCD symptoms and comorbid conditions and may warrant a specific treatment approach.

International prescribing practices in obsessive–compulsive disorder (OCD)

To assess rates of psychotropic medication use in patients with obsessive–compulsive disorder (OCD) in seven different countries on five continents and to compare these with international treatment guidelines.

Comorbidity, age of onset and suicidality in obsessive–compulsive disorder (OCD): An international collaboration

OBJECTIVES To collate data from multiple obsessive-compulsive disorder (OCD) treatment centers across seven countries and five continents, and to report findings in relation to OCD comorbidity, age of onset of OCD and comorbid disorders, and suicidality, in a large clinical and ethnically diverse sample, with the aim of investigating cultural variation and the utility of the psychiatric diagnostic classification of obsessive-compulsive and related disorders. METHODS Researchers in the field of OCD were invited to contribute summary statistics on current and lifetime psychiatric comorbidity, age of onset of OCD and comorbid disorders and suicidality in their patients with OCD. RESULTS Data from 3711 adult patients with primary OCD came from Brazil (n=955), India (n=802), Italy (n=750), South Africa (n=565), Japan (n=322), Australia (n=219), and Spain (n=98). The most common current comorbid disorders were major depressive disorder (28.4%; n=1055), obsessive-compulsive personality disorder (24.5%, n=478), generalized anxiety disorder (19.3%, n=716), specific phobia (19.2%, n=714) and social phobia (18.5%, n=686). Major depression was also the most commonly co-occurring lifetime diagnosis, with a rate of 50.5% (n=1874). OCD generally had an age of onset in late adolescence (mean=17.9years, SD=1.9). Social phobia, specific phobia and body dysmorphic disorder also had an early age of onset. Co-occurring major depressive disorder, generalized anxiety disorder and psychotic disorders tended to have a later age of onset than OCD. Suicidal ideation within the last month was reported by 6.4% (n=200) of patients with OCD and 9.0% (n=314) reported a lifetime history of suicide attempt. CONCLUSIONS In this large cross-continental study, comorbidity in OCD was common. The high rates of comorbid major depression and anxiety disorders emphasize the need for clinicians to assess and monitor for these disorders. Earlier ages of onset of OCD, specific phobia and social phobia may indicate some relatedness between these disorders, but this requires further study. Although there do not appear to be significant cultural variations in rates or patterns of comorbidity and suicidality, further research using similar recruitment strategies and controlling for demographic and clinical variables may help to determine whether any sociocultural factors protect against suicidal ideation or psychiatric comorbidity in patients with OCD.

Inconsistent Portrayal of Medication Dependence, Withdrawal and Discontinuation Symptoms in Treatment Guidelines for Anxiety Disorders

and BDZ cessation, our aim was to ascertain whether recent treatment guidelines for anxiety disorders acknowledge this and whether discontinuation/withdrawal symptoms with SSRIs/SNRIs are considered to reflect dependence on these agents. We focused on treatment guidelines because they are meant to be based on evidence and inform clinical practice. We searched for treatment guidelines for anxiety disorders by means of MEDLINE, PubMed, PsycINFO, and Google Scholar using the search terms ‘treatment guideline’ or ‘clinical practice guideline’ or ‘guideline’ in combination with ‘anxiety disorder’, ‘panic disorder’, ‘generalized anxiety disorder’, ‘social anxiety disorder’, ‘social phobia’, ‘obsessive-compulsive disorder’, and ‘posttraumatic stress disorder’. An additional search was performed using the Google search engine. We restricted the search to guidelines in English published between 2006 and 2015. There was no country restriction. We excluded review and expert opinion articles and similar material published in books and included only treatment guidelines produced by the professional organizations and governmental agencies and bodies or on behalf of them (e.g. the American Psychiatric Association, National Institute for Health and Care Excellence, Ministry of Health). The search was conducted in July 2015. We reviewed each guideline and examined the use of the terms ‘withdrawal symptoms’, ‘discontinuation symptoms’, ‘tolerance’, ‘dependence’, and ‘addiction’ in relation to the specific classes of medications. The search identified 15 treatment guidelines published between 2006 and 2015. Of these, 8 guidelines addressed all anxiety disorders and 7 focused on specific anxiety disorders; 2 guidelines were published by one international body and 13 were produced by national organizations or governmental agencies in the USA (n = 4), UK (n = 3), Canada (n = 2), Spain (n = 1), Singapore (n = 1), Australia (n = 1), and Germany (n = 1). There are many similarities between the withdrawal symptoms that arise in the course of benzodiazepine (BDZ) cessation and discontinuation symptoms that appear during the cessation of selective serotonin reuptake inhibitors (SSRIs), with 37 of 42 symptoms identified as common to both [1] . Moreover, a recent systematic review has found that symptoms occurring during discontinuation of SSRIs are not necessarily prevented by gradual tapering and that they can be severe, last long or appear late and should be considered to constitute a withdrawal syndrome [2] . Treatment guidelines have favoured antidepressants (SSRIs, but also serotonin and norepinephrine reuptake inhibitors, SNRIs) over BDZs in the pharmacological treatment of anxiety disorders. One of the main reasons for this position is the notion that BDZs are associated with withdrawal symptoms and dependence, whereas SSRIs and SNRIs are not. In view of the aforementioned similarities between the withdrawal symptoms occurring during SSRI Received: August 1, 2015 Accepted: August 3, 2015 Published online: September 25, 2015

Do Patients Prefer Face-to-Face or Internet-Based Therapy?

Approval to conduct the study was obtained from the Nepean Blue Mountains Local Health District Human Research Ethics Committee (study 13/17). Forty-two (76.4%) of the sample reported that they had previously received either individual or group face-to-face therapy, and only 1 individual (1.8%) reported having received a course of online therapy previously. The majority of participants (n = 48; 87.3%) had ‘reliable access to the Internet at home’, indicating that they would be able to avail themselves of online therapy if this was available. The proportions of the sample favouring various forms of therapy delivery over each other are summarised in table 1 . The results of our survey suggest that patients overwhelmingly preferred individual face-to-face therapy to all other delivery options. Importantly, this does not appear to be a consequence of a lack of basic and affirmative information about the alternative therapy modalities, given that such information was provided by the survey. It is noteworthy that online therapy with weekly therapist phone contact was preferred over face-to-face group therapy and bibliotherapy. This finding suggests that appropriately resourced online therapy – where clinicians retain regular involvement with each patient – may be a favourable ‘next best’ option for clients when routine individual face-to-face therapy is not available. Also, it seems that therapeutic contact – whether through individual face-to-face therapy or online therapy with weekly therapist phone contact – was considered important by our survey participants. Our findings are broadly consistent with those from studies of non-treatment-seeking populations, where 79.4 [4] and 77.1% [5] of the participants preferred face-to-face mental health support. Also, a survey of primary health care patients showed that 92% were interested in face-to-face interventions, but only 48% in Internet treatment [6] . However, two surveys reported contrasting results [7, 8] . For instance, Wootton et al. [7] found that only 10% of individuals with high levels of obsessive-compulsive symptoms would prefer face-to-face treatment to online therapy. These surveys involved self-selected samples in that they comprised individuals not necessarily seeking treatment who were accessing an online clinic website (www.virtualclinic.org.au). Additionally, the two surveys did not apparently distinguish between individual and group face-to-face therapy, potentially biasing the results. Another possible reason for the different findings is that our participants completed the survey in the waiting room of our Clinic so that any notion that therapy appointments would be inconvenient to attend (in terms of travelling to the appointments, finding parking, etc.) may have been undermined through a favourable experience of attending their first appointment. Our survey had a number of limitations. First, the validity and reliability of the survey items was indeterminate. Also, our sample Delivery of psychological therapies via the Internet holds great promise: there are benefits of accessibility, reduced stigmatisation, as well as potential reductions in the cost of service provision. A large and expanding evidence base suggests that these approaches are as effective as face-to-face therapy for many disorders [1, 2] . Moreover, the patients who complete online psychological therapy programmes typically perceive these as helpful [3] . The aforementioned benefits of online therapies suggest that restructuring of existing face-to-face services into solely online services or some hybrid of online and face-to-face delivery may be useful. However, an additional variable to consider is patient preferences. Given sufficient resourcing of services, where any individual has access to the therapy format of his or her choice, would most patients prefer face-to-face (individual or group) psychological therapy or psychological therapy delivered in an online format, accessible at home or on their mobile phone? The purpose of this report is to shed light on this issue. We administered an anonymous 1-page survey to 55 consecutive patients attending their first appointment at the Nepean Anxiety Disorders Clinic in Penrith, N.S.W., Australia. The survey asked respondents to rate their preferences for 5 forms of therapy delivery: individual face-to-face therapy, group face-to-face therapy, bibliotherapy (where therapy is exclusively provided by means of books and reading materials that are posted to patients), online therapy without therapist contact and online therapy with weekly therapist phone contact. To ensure that respondents were well informed about what each option involved, we provided descriptions of all forms of therapy delivery. Patients completing the survey had a primary anxiety disorder (i.e. panic disorder, generalised anxiety disorder, social anxiety disorder, health anxiety, specific phobia or obsessive-compulsive disorder). The survey was administered to patients before their first appointment to ensure that they had not yet had an opportunity to form an alliance with a therapist at the Clinic as this may have influenced their therapy delivery preferences. Received: August 21, 2014 Accepted after revision: August 28, 2014 Published online: December 24, 2014

Use of benzodiazepines in obsessive-compulsive disorder.

This study aimed to determine the frequency of benzodiazepine (BDZ) use in a large sample of patients with obsessive–compulsive disorder (OCD) and ascertain the type of BDZ used and the correlates and predictors of BDZ use in OCD. The sample consisted of 955 patients with OCD from a comprehensive, cross-sectional, multicentre study conducted by the Brazilian Research Consortium on Obsessive–Compulsive Spectrum Disorders between 2003 and 2009. The rate of BDZ use over time in this OCD sample was 38.4%. Of individuals taking BDZs, 96.7% used them in combination with other medications, usually serotonin reuptake inhibitors. The most commonly used BDZ was clonazepam. Current age, current level of anxiety and number of additional medications for OCD taken over time significantly predicted BDZ use. This is the first study to comprehensively examine BDZ use in OCD patients, demonstrating that it is relatively common, despite recommendations from treatment guidelines. Use of BDZs in combination with several other medications over time and in patients with marked anxiety suggests that OCD patients taking BDZs may be more complex and more difficult to manage. This calls for further research and clarification of the role of BDZs in the treatment of OCD.

The structure and intensity of self-reported autonomic arousal symptoms across anxiety disorders and obsessive-compulsive disorder

BACKGROUND Heightened autonomic arousal symptoms (AAS) are assumed to be a central feature of anxiety disorders. However, it is unclear whether the magnitude and profile of AAS vary across anxiety disorders and whether heightened AAS characterises obsessive-compulsive disorder (OCD). AIMS We sought to determine whether the intensity and structure of AAS varied across anxiety disorders and OCD. METHOD A sample of 459 individuals with a primary anxiety disorder or OCD were administered the Symptom Checklist-90R. Nine items referring to prototypic AAS were included in a latent class analysis. RESULTS A 2-class solution (high and low AAS classes) best fitted the data. Participants comprising the high AAS class scored uniformly high across all assessed AAS symptoms. Older age and the presence of panic disorder, social anxiety disorder and generalized anxiety disorder predicted membership in the high AAS class. No OCD symptom dimension was significantly associated with membership in the high AAS class. LIMITATION AAS were assessed using a self-report measure and replication is needed using other methodologies. CONCLUSIONS These findings suggest that OCD may be sufficiently distinct from anxiety disorders and do not support subtyping of anxiety disorders on the basis of the predominant type of AAS. Therapeutic approaches that target AAS might best be applied in the treatment of panic disorder, social anxiety disorder and generalized anxiety disorder.

Specificity of the Relationships Between Dysphoria and Related Constructs in an Outpatient Sample

Dysphoria has recently been conceptualized as a complex emotional state that consists of discontent and/or unhappiness and a predominantly externalizing mode of coping with these feelings. The Nepean Dysphoria Scale (NDS) was developed on the basis of this model of dysphoria and used in this clinical study to ascertain the specificity of the relationships between dysphoria and relevant domains of psychopathology. Ninety-six outpatients completed the NDS, Symptom Checklist 90-Revised (SCL-90R) and Depression, Anxiety, Stress Scales, 21-item version (DASS-21). The scores on the NDS subscales (Discontent, Surrender, Irritability and Interpersonal Resentment) and total NDS scores correlated significantly with scores on the DASS-21 scales and relevant SCL-90R subscales. Multiple regression analyses demonstrated the following: DASS-21 Depression and Stress each had unique relationships with NDS Discontent and Surrender; DASS-21 Anxiety had a unique relationship with NDS Discontent; SCL-90R Hostility and Paranoid Ideation and DASS-21 Stress each had unique relationships with NDS Irritability; and SCL-90R Paranoid Ideation and DASS-21 Stress, Depression and Anxiety each had unique relationships with NDS Interpersonal Resentment. These findings support the notion that dysphoria is a complex emotional state, with both non-specific and specific relationships with irritability, tension, depression, paranoid tendencies, anxiety, hostility and interpersonal sensitivity. Conceptual rigor when referring to dysphoria should be promoted in both clinical practice and further research.

Effect of three‐ vs four‐dimensional ultrasonography on maternal attachment

Maternal attachment begins its course during early pregnancy with thoughts and feelings for the unborn baby gradually increasing and attachment intensifying in the first weeks after birth of the baby.1.