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Clinician's Digest - Page 2

The power of the IAT is that it doesn't merely score how the words or words and images match—after all, many people try to conceal unflattering answers, from both researchers and themselves—it measures reaction times as well. (You can take a sample IAT at www.implicit.harvard.edu.)

Researchers, led by Matthew Nock of Harvard University, developed a version of the IAT that searched for associations of a person's sense of self in relationship to death, forcing people to rapidly associate "death" words, like lifeless and suicide; "life" words, like survive and thrive; "me" words, like I and self; and "not me" words, like them and others. They administered the IAT to 157 people who'd shown up at a hospital ER with psychiatric emergencies, 43 of whom were there for suicide attempts. The IAT found that the suicidal patients showed a much stronger association between thoughts of "self" and of "death" than the other psychiatric ER admissions did.

That's merely a descriptive finding, but Nock also followed everyone for six months, and the outcome of the follow-up suggests the IAT may have predictive value. Of the initial group that had attempted suicide, 14 made another attempt, and their IAT scores were significantly more accurate at predicting the suicide attempt than were the at-risk ratings by clinicians who'd interviewed them upon admission to the ER. The IAT also was more predictive than patients' own assessments of whether they'd attempt suicide, although the patients assessed their chances of trying again more accurately than the clinicians did.

It's Not Always PTSD

We've been hearing so much about PTSD for so long that we may forget it's only one possible emotional disorder that can develop after a physically traumatic incident. In fact, as a study in the March issue of American Journal of Psychiatry shows, it's not even the most common outcome.

The study, led by Australian psychologist Richard Bryant of Sydney's University of New South Wales, looked at 1,084 people who'd been admitted to hospitals for traumatic injuries, psychologically assessing them at admission and then 3 and 12 months later. About 33 percent of the people developed disorders subsequently. The most common was depression at 16 percent, followed by generalized anxiety disorder (11 percent), substance abuse (9.9 percent), and then PTSD and agoraphobia (9.7 percent each). Less frequent diagnoses were social phobia, panic disorder, and obsessive-compulsive disorder. This outcome is a reminder to clinicians not to assume that depression, anxiety, or other symptoms are secondary to PTSD; rather they need to be a separate, often primary focus of effective trauma treatment.

Bryant's findings are consistent with earlier, smaller studies of trauma victims, and may even provide an answer to the perpetual question of why some people develop PTSD following physical trauma, while others develop depression, anxiety, and other disorders. "Some research suggests that the appraisal of the event and the immediate, or shortly following, emotion may increase the likelihood of one type of disorder over another," says Yale PTSD researcher Joan Cook. For example, fear or horror may be likelier to lead to an anxiety disorder and sadness or guilt to a depressive disorder. Other researchers have noted that people who dissociate, especially shortly before or after the trauma, are likelier to develop PTSD.

However, Bryant's study found a strong connection between mild traumatic brain injury (TBI) and PTSD. Those who suffered mild TBI were more than twice as likely to develop PTSD as those who didn't. This raises the possibility that PTSD could result from a combination of actual brain injury and hyperactivated neural fear circuitries, rather than from strictly neurological and emotional reactions.

Meeting Clients' Needs

A frequently replicated finding in psychotherapy research is that therapists and clients often have different notions about how therapy is progressing. They frequently disagree when asked separately to rate the quality of the therapeutic alliance, whether therapy is working, or what the turning points in treatment were.

"When you're a therapist, you think you know the most important things about your client and therapy," says alliance researcher Robinder Bedi of Bellingham's Western Washington University, "but it's the client's perceptions about how things are going that have the greatest predictive value of the outcome of therapy." Therapists who pay more attention to their own intuitions and conceptions may be more "right" than their clients by some objective measure, but if their clients have other ideas, such therapists are likely to end up with a handful of notes and no clients.

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