A Practical Application Primer on Cognitive Behavioral Therapy for Insomnia for Medical Residents

Introduction: Cognitive behavioral therapy for insomnia (CBT-I) is a well-established nonpharmacological intervention that is the gold standard treatment for insomnia. CBT-I has been utilized and empirically validated in many modalities, including group treatment, telemedicine, and primary care. Despite the wealth of evidence on its effectiveness, many medical providers, including those in primary care, where most insomnia complaints are raised, have limited exposure, knowledge, and resources to direct or implement this intervention. Methods: Medical educators from an academic medical center developed a module focused on teaching medical residents the techniques of CBT-I. The educational activity was an interactive 90-minute seminar that included a lecture followed by a case presentation illustrating the application of medical knowledge. A postseminar survey was used to evaluate the topic and content of the seminar. Results: In a survey of 32 primary care and psychiatry residents and sleep medicine fellows, 97% of respondents indicated that the topic of CBT-I should be included in the seminar series, and 84% indicated that the topic was of interest to them. Qualitative feedback underscored the relevance of this topic to trainees' clinical practice, as well as its underratedness. Discussion: The seminar on CBT-I was well received and viewed as a valuable tool in practicing medicine. The slides and vignettes provided enable replication of this workshop in other settings with medical learners who have a cursory knowledge of sleep medicine. The workshop is applicable to other health professionals, including medical students, nurses, social workers, and psychology trainees

The Need for Psychological Rehabilitation in Lung Transplant Recipients

Transplant recipients have significant psychosocial stressors due to unique posttransplant sequela that results in an increased incidence of psychopathology. Posttransplant psychological interventions, especially in lung transplant recipients, are understudied, as the focus of prior research has emphasized pretransplant interventions. However, posttransplant psychological stability affects medical outcomes. The importance of posttransplant psychological intervention is highlighted. Recommendations exist which call for attention to specific psychological domains in the posttransplant recovery period and highlight the impact of psychological rehabilitation on overall wellness and success in recovery. A novel psychological rehabilitation intervention is outlined as a response to posttransplant intervention recommendations to demonstrate implementation

Practice Issues for Evaluation and Management of the Suicidal Left Ventricular Assist Device Patient

There is a high prevalence of depression among left ventricular assist device patients, who present with an increased risk of suicidality given access to means via the device either with nonadherence or disconnection. Suicidality via device nonadherence/disconnection is an underresearched clinical issue, as paradoxically this life-saving procedure can also provide a method of lethal means to patients with significant mental health concerns. A case study is used to highlight the course of an attempted suicide by ventricular assistive device nonadherence. Clinical implications and recommendations for practice include a thorough psychological evaluation presurgery, monitoring quality of life and coping styles before and after placement, psychological testing, outlining specific suicide protocols, psychiatric care considerations for patients with highly specialized medical devices, and related ethical concerns

Drive for thinness is not the same as drive to be thin: On the motivation for dieting in normal weight restrained eaters and bulimic individuals

Drive for thinness has been implicated as an etiological factor for the development of disordered eating. However, existing measures of this construct, such as the EDI-2 Drive for Thinness scale (DFT), appear to measure a desire to be thinner, but not the radical dieting mentality thought to contribute to the development of disordered eating. This study developed a Drive to be Thin (DTBT) scale to assess desire to be objectively thin (15% below ideal BMI); it excluded items regarding fear of fatness or avoidance of weight gain. DTBT items were judged for suitability by eating disorder experts and a Cronbach’s alpha was calculated (∞=.947).The association between DTBT, DFT, and fear of fatness (GFFS) as motivations for dieting was investigated in 64 unrestrained and restrained eaters (RE&URE) identified by the Herman and Polivy Restraint Scale and 22 females with Bulimia Nervosa (BN) or EDNOS-BN. A mixed model ANOVA revealed a significant interaction between group and motivation to diet.DFT and GFFS were significantly greater in REs compared to UREs, while DTBT was low in both. The traditional assumption that normal weight REs drive for thinness reflects an unhealthy need to be skinny appears to be incorrect. Instead, they appear to be motivated to diet mostly by a fear of fatness. This is consistent with a predisposition toward weight gain in REs and our previously proposed hypothesis that restraint represents a proxy risk factor for weight gain.On DTBT, BN had significantly higher scores than REs. Both GFFS and DTBT were elevated in BN, suggesting that bulimic individuals are highly motivated by both a fear of fatness and a drive to be thin, unlike REs who are only motivated by a fear of fatness. For BN, both a fear of fatness and a drive to be thin may motivate unhealthy dieting and eating disordered behavior.Ph.D., Psychology -- Drexel University, 200

Medically Induced Exacerbation of PTSD Following Lung Transplantation: A Case Series

Posttraumatic stress disorder (PTSD) occurs at double the rate in individuals undergoing lung transplantation, compared to the normal population. The psychological sequela of PTSD makes recovery more challenging and may result in poor medical and psychological outcomes. A series of three cases illustrate this presentation. In all cases, PTSD history and symptomatology was undisclosed prior to lung transplantation, despite robust psychological evaluation. All patients experienced traumatic delirium during the acute recovery phase from transplantation. Re-emergence and exacerbation of PTSD symptoms related to remote trauma lasting up to 2 years after transplant. Noncompliance with post-transplant recovery occurred in the sample of cases presented. Major surgeries, such as lung transplant may exacerbate premorbid PTSD possibly via psychological sequela such as delirium, regardless of type or remoteness of trauma experiences. Existing psychological evaluation practices may not be adequate to capture PTSD as many patients may fail to disclose relevant history. Novel evaluation and treatment methods need to be developed

Evaluating the Real-World Effectiveness of Cognitive-Behavior Therapy Efficacy Research on Eating Disorders: A Case Study from a Community-based Clinical Setting

Objective There is a growing consensus that there is a need to test the real-world effectiveness of eating disorder therapies that show promise in efficacy research. The current paper provides a narrative account of an NIMH-funded study that attempted to apply efficacy findings from CBT research to an Intensive Outpatient Program (IOP) at the largest community-based eating disorder program in the United States. Method We describe the study as originally envisioned as well as the various challenges that the researchers and the IOP staff encountered in implementing this study. Results The different training, assumptions, and “ways of knowing” of the research team and the treatment staff in regard to the nature of eating disorders and their treatment created multiple challenges for both groups during the study period. We describe valuable lessons learned about how to - and how not to -implement effectiveness designs in clinical settings that are relatively unfamiliar with empirically-based research findings. Discussion It is hoped that our experience in attempting to apply efficacy-based research findings on eating disorders treatment in a community-based clinical setting will prove helpful to other researchers and service providers engaging in such translational research.NIMH grant R34MH07169

Characterization of the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) in Lung Transplant Candidates

The SIPAT is a standardized measure for pre-transplant psychosocial evaluation. Previous SIPAT studies utilized a relatively small lung transplant sample and only included listed patients. This study characterized the SIPAT in 147 lung transplant candidates to better elucidate its utility. The average score corresponded to a minimally acceptable rating and nearly half of the patients had relative or absolute contraindications. Interstitial Lung Disease (ILD) patients scored more favorably than non-ILD patients (U = 7.69, p < .05). The Total (β = − .05, SE = .018, p < .01), Social Support Subscale (β = − .133, SE = .058, p < .05), and Psychosocial Stability and Psychopathology Subscale (β = − .103, SE = .040, p < .05) significantly predicted listing status. The SIPAT has a unique profile in lung transplant candidates and demonstrated utility for guiding transplant decisions. Future research should examine which lung transplant outcomes are significantly associated with SIPAT scores

Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained?

Although sleep is vital to all human functioning and poor sleep is a known problem in cancer, it is unclear whether the overall prevalence of the various types of sleep disorders in cancer is known. The purpose of this systematic literature review was to evaluate if the prevalence of sleep disorders could be ascertained from the current body of literature regarding sleep in cancer. This was a critical and systematic review of peer-reviewed, English-language, original articles published from 1980 through 15 October 2013, identified using electronic search engines, a set of key words, and prespecified inclusion and exclusion criteria. Information from 254 full-text, English-language articles was abstracted onto a paper checklist by one reviewer, with a second reviewer randomly verifying 50% (k = 99%). All abstracted data were entered into an electronic database, verified for accuracy, and analyzed using descriptive statistics and frequencies in SPSS (v.20) (North Castle, NY). Studies of sleep and cancer focus on specific types of symptoms of poor sleep, and there are no published prevalence studies that focus on underlying sleep disorders. Challenging the current paradigm of the way sleep is studied in cancer could produce better clinical screening tools for use in oncology clinics leading to better triaging of patients with sleep complaints to sleep specialists, and overall improvement in sleep quality

Referral process to further evaluate poor sleep in breast cancer survivors

Objective: Breast cancer survivors (BCS) are twice as likely to report symptoms of poor sleep as those without cancer. However, sleep disorders are under-assessed and under-treated among BCS. The purpose of this study was to determine the portion of BCS who completed referral visits to a sleep specialist and identify the acceptability, facilitators, and barriers to the screening and referral process. Methods: BCS, who reported having sleep problems, completed questionnaires to screen for symptoms suggestive of sleep disorders. Those with symptoms suggestive of sleep apnea, movement disorders, narcolepsy, insomnia syndrome, or circadian disorders, they were referred to a sleep medicine physician or behavioral sleep medicine psychologist. Two months after the referral, participants were interviewed about their perceptions of the acceptability, barriers, and facilitators to sleep screenings and referrals. Results: Of 34 BCS assessed for eligibility, 29 were eligible and had sleep problems. Only eight of 29 participants (27.6%) completed the sleep referral process. Most thought the screening and referral process was acceptable. However, BCS identified barriers to completing the referral visit, including time, not seeing the need for treatment, insurance/sick leave concerns, and distance/transportation. Conclusion: Adequate evaluation and treatment of sleep disorders in BCS are rare. Creative solutions to address barriers to timely sleep referrals are needed to reduce long-term negative consequences of inadequate sleep

Development and testing of measures to assess weight-related motivations for dieting in eating disordered individuals

Motivations for dieting are an important dimension to evaluate in the development and maintenance of eating disorders such as Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Existing measures for these disorders have a number of limitations. Drive for thinness has been implicated as an important factor in BN. However, measures of this construct, such as the Drive for Thinness scale (DFT), appear to measure a desire to be thinner, but not the radical dieting mentality thought to contribute to the development of disordered eating. The Drive for Objective Thinness (DFOT) scale was developed by the author to assess desire to be objectively thin. The DFOT was previously found to be uniquely endorsed by a clinical population of individuals with BN compared to other motivations for dieting and helped to differentiate pathological from non-pathological dieting. In the current study, the DFOT displayed sufficient internal consistency and validity in a clinical population and was similarly related to associated forms eating disordered psychopathology compared to established measures such as the GFFS, EDE, and EDI. The DFOT significantly predicted treatment outcomes in BN spectrum individuals including various forms of psychopathology and length of stay.A secondary goal of this study was to develop a measure which assesses how motivated AN individuals are to avoid treatment goal weight, defined as 90% of ideal body weight. The Fear of Treatment Goal Weight Scale (FTGW) removed the subjectivity that terms such as ‘fatness’ possess by providing an objective body weight and had greater variability than ‘fear of fatness’ among ANs. An initial use of the FTGW established sufficient internal consistency and validity in a clinical population. These novel measures were similarly related to associated forms eating and mood disordered psychopathology compared to established measures. Over the course of treatment, FTGW increased in AN individuals and significantly predicted treatment outcomes in this population.Both the DFOT and FTGW appeared to have incremental validity in predicting multiple outcomes above established measures of motivations for dieting. Utilization of these novel measures may be important in combination with existing measures of psychopathology for identifying individuals who are most appropriate for treatment. Moreover, the high endorsement of these measures in eating disordered psychopathology highlights the need for treatment approaches to address these treatment resistant constructs.Ph.D., Clinical Psychology -- Drexel University, 201