Deliberate clinical inertia: Using meta-cognition to improve decision-making

Deliberate clinical inertia is the art of doing nothing as a positive response. To be able to apply this concept, individual clinicians need to specifically focus on their clinical decision-making. The skill of solving problems and making optimal clinical decisions requires more attention in medical training and should play a more prominent part of the medical curriculum. This paper provides suggestions on how this may be achieved. Strategies to mitigate common biases are outlined, with an emphasis on reversing a 'more is better' culture towards more temperate, critical thinking. To incorporate such an approach in medical curricula and in clinical practice, institutional endorsement and support is required

Uncharted Waters: Treating Trauma Symptoms in the Context of Early Psychosis.

Psychosis is conceptualized in a neurodevelopmental vulnerability-stress framework, and childhood trauma is one environmental factor that can lead to psychotic symptoms and the development of psychotic disorders. Higher rates of trauma are associated with higher psychosis risk and greater symptom frequency and severity, resulting in increased hospitalization rates and demand on outpatient primary care and mental health services. Despite an estimated 70% of individuals in the early stages of psychosis reporting a history of experiencing traumatic events, trauma effects (post-traumatic anxiety or depressive symptoms) are often overlooked in psychosis treatment and current interventions typically do not target commonly comorbid post-traumatic stress symptoms. We presented a protocol for Trauma-Integrated Cognitive Behavioral Therapy for Psychosis (TI-CBTp), an approach to treating post-traumatic stress symptoms in the context of early psychosis care. We provided a brief summary of TI-CBTp as implemented in the context of Coordinated Specialty Care and presented preliminary data supporting the use of TI-CBTp in early psychosis care. The preliminary results suggest that individuals with comorbid psychosis and post-traumatic stress symptoms can be appropriately and safely treated using TI-CBTp within Coordinated Specialty Care

A Multiple Method Evaluation of the Mid Essex Memory Assessment and Support Service

On 3rd February 2009, the Department of Health published “Living well with dementia: A National Dementia Strategy”. This proposed a series of changes to the way services for people with dementia are organised and delivered, from raising awareness and understanding through to “living well” with dementia, whether in the community or in long-term care. This report outlines the work undertaken by Bournemouth University in response to the “Specification for evaluation of newly created memory services in Mid Essex.” (July 2009). It details the consultancy and research advisory/ assistance role in order to comprehensively evaluate the pilot memory service- which commenced in January 2009. The approach was essentially a pragmatic service evaluation utilising existing data, supplemented with additional reviews in order to allow comparison between the new service and previous provision. In addition it makes recommendations which can inform future provision and where necessary improvements. The model identified the component elements of the new service (patient pathway) as well as those previously offered through an initial scoping exercise. From these elements it was possible to obtain comparisons utilising quantitative and qualitative outcome measures. The report identifies a range of positive benefits from the MASS provision and makes recommendations for the future

The Autism Toolbox : An Autism Resource for Scottish Schools

The Autism Toolbox will draw upon a range of practice experience, literature and research to offer guidance for authorities and schools providing for children and young people with Autism Spectrum Disorders (ASD)

Mental health nurses’ attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder:systematic, integrative literature review

Aims and objectives To establish whether mental health nurses responses to people with borderline personality disorder are problematic and, if so, to inform solutions to support change. Background There is some evidence that people diagnosed with borderline personality disorder are unpopular among mental health nurses who respond to them in ways which could be counter-therapeutic. Interventions to improve nurses’ attitudes have had limited success. Design Systematic, integrative literature review. Methods Computerised databases were searched from inception to April 2015 for papers describing primary research focused on mental health nurses’ attitudes, behaviour, experience, and knowledge regarding adults diagnosed with borderline personality disorder. Analysis of qualitative studies employed metasynthesis; analysis of quantitative studies was informed by the theory of planned behaviour. Results Forty studies were included. Only one used direct observation of clinical practice. Nurses’ knowledge and experiences vary widely. They find the group very challenging to work with, report having many training needs, and, objectively, their attitudes are poorer than other professionals’ and poorer than towards other diagnostic groups. Nurses say they need a coherent therapeutic framework to guide their practice, and their experience of caregiving seems improved where this exists. Conclusions Mental health nurses’ responses to people with borderline personality disorder are sometimes counter-therapeutic. As interventions to change them have had limited success there is a need for fresh thinking. Observational research to better understand the link between attitudes and clinical practice is required. Evidence-based education about borderline personality disorder is necessary, but developing nurses to lead in the design, implementation and teaching of coherent therapeutic frameworks may have greater benefits. Relevance to clinical practice There should be greater focus on development and implementation of a team-wide approach, with nurses as equal partners, when working with patients with borderline personality disorder

Examining \u3cem\u3eDSM\u3c/em\u3e Criteria for Trichotillomania in A Dimensional Framework: Implications for \u3cem\u3eDSM-5\u3c/em\u3e And Diagnostic Practice

Background: Diagnosis of Trichotillomania (TTM) requires meeting several criteria that aim to embody the core pathology of the disorder. These criteria are traditionally interpreted monothetically, in that they are all equally necessary for diagnosis. Alternatively, a dimensional conceptualization of psychopathology allows for examination of the relatedness of each criterion to the TTM latent continuum. Objectives: First, to examine the ability of recently removed criteria (B and C) to identify the latent dimensions of TTM psychopathology, such that they discriminate between individuals with low and high degrees of hair pulling severity. Second, to determine the impact of removing criteria B and C on the information content of remaining diagnostic criteria. Third, to determine the psychometric properties of remaining TTM diagnostic criteria that remain largely unchanged in DSM-5; that is, whether they measure distinct or overlapping levels of TTM psychopathology. Fourth, to determine whether information content derived from diagnostic criteria aid in the prediction of disease trajectory (i.e., can relapse propensity be predicted from criteria endorsement patterns). Method: Statistics derived from Item Response Theory were used to examine diagnostic criteria endorsement in 91 adults with TTM who underwent psychotherapy. Results: The removal of two criteria in DSM-5 and psychometric validity of remaining criteria was supported. Additionally, individual trait parameters were used to predict treatment progress, uncovering predictive power where none previously existed. Conclusions: Diagnostic criteria for TTM should be examined in dimensional models, which allow for nuanced and sensitive measurement of core symptomology in treatment contexts

Behavioral Factors Influencing Health Outcomes in Youth with Type 1 Diabetes

The Pediatric Self-Management Model provides an overview of how behavioral factors influence children’s chronic medical illnesses. This general framework is used to organize the present review of how self-management behaviors, contextual factors, and processes impact health outcomes for adolescent youth with type 1 diabetes. Adherence has been widely studied in the diabetes literature, and there are consistent findings demonstrating associations between aspects of self-management, adherence, and metabolic control, yet there are still equivocal approaches to adherence assessment methodology (e.g. global versus specific measures). Metabolic control is a hallmark health outcome for youth with type 1 diabetes, but additional outcomes need to be further explored. Future research should utilize the Pediatric Self-Management Model’s operational definitions to guide empirically-supported interventions for youth with type 1 diabetes

Bayesian latent time joint mixed-effects model of progression in the Alzheimer's Disease Neuroimaging Initiative.

IntroductionWe characterize long-term disease dynamics from cognitively healthy to dementia using data from the Alzheimer's Disease Neuroimaging Initiative.MethodsWe apply a latent time joint mixed-effects model to 16 cognitive, functional, biomarker, and imaging outcomes in Alzheimer's Disease Neuroimaging Initiative. Markov chain Monte Carlo methods are used for estimation and inference.ResultsWe find good concordance between latent time and diagnosis. Change in amyloid positron emission tomography shows a moderate correlation with change in cerebrospinal fluid tau (ρ = 0.310) and phosphorylated tau (ρ = 0.294) and weaker correlation with amyloid-β 42 (ρ = 0.176). In comparison to amyloid positron emission tomography, change in volumetric magnetic resonance imaging summaries is more strongly correlated with cognitive measures (e.g., ρ = 0.731 for ventricles and Alzheimer's Disease Assessment Scale). The average disease trends are consistent with the amyloid cascade hypothesis.DiscussionThe latent time joint mixed-effects model can (1) uncover long-term disease trends; (2) estimate the sequence of pathological abnormalities; and (3) provide subject-specific prognostic estimates of the time until onset of symptoms