American Psychiatric Association 2017 Annual Meeting (APA 2017)

The Mathematics of Attachment and Complicated Grief in Psychiatric Care

LAWRENCE AMSEL, MD, MPH, of Columbia University, delivered a talk at the APA meeting on the application of game theory for issues experienced by individuals grieving for a lost loved one.

In describing the motivation for work in this area, Amsel said the overall goal for doctors is to reduce the “subjectivity inherent to psychiatry by quantitating descriptive information to fit it into mathematical models.”

“The approach taken involves an economic analysis of various behaviors, such as grieving, by use of tools derived from computational cognitive science,” Amsel said.

Referencing early work on grief by Sigmund Freud, Amsel told the audience that in his 1917 essay, “Mourning and Melancholia,” Freud proposed that grieving involved de-cathecting—or emotionally neutralizing the individual, discrete memories of the deceased. “Contemporary psychiatry has, perhaps too quickly, abandoned these ideas,” Amsel said.

Drawing on literature for reward learning and game theory that addresses how human agents utilize information on reward or fear in the service of reaching their goals, Amsel provided equations that form the foundation of a model that uses a reward-learning approach for understanding attachment formation. Amsel described the model as a process that sets up a structure of “expected utilities for shared experiences.”

“The mirror image of attachment is the normal grief reaction to loss that can be given by an equation that captures the difference between expected reward and actual reward set up by the loss,” Amsel said. “This model captures elements of both Freudian and contemporary theories of grief and sees the grieving process as looking backward and forward simultaneously.”

In the forward-looking direction, Amsel told the stand- ing-room-only audience that the model serves as a series of expo-

sure and habituation exercises that allow for a reattribution capable of transforming negative expectations of future experiences into something more tolerable. Looking backward, reattribution allows for piecewise detachment from the shared memories that comprise the relationship with the lost partner.

Presenting the normal grieving process as a rational, “utility-maximizing” program involving a continually updating reward-learning process, Amsel said that these features make it possible to eventually reclaim positive utilities from life’s experiences following a major loss.

“Complicated grief may have a similar structure and can result from any of several different failure modes of the process described above, leading to persistence of grief,” Amsel said.

Further describing the tools used and how they relate to game theory—and, in particular, the concept of the prisoner’s dilemma—Amsel said the second model was shaped around seeing the individual as divided between 2 internal agents.

“The first agent, the desired future self, seeks to restructure life by becoming an independent agent and abandoning the expectations of the relationship,” Amsel said. “The other agent, the ghost, plays a denial position and attempts to maintain the relationship. We show this model can lead to a classic prisoner’s dilemma-like game that under certain circumstances can manifest as a behavioral trap.”

Amsel said that unlike the classic prisoner’s dilemma, this pro- cess is best modeled using 2 agents within a single individual.

He concluded by telling the assembled psychiatrists that these abstract mathematical models can predict the empirical phenomenology of attachment, grief, and complicated grief.

“Psychiatry benefits from the use of such concepts to model psychopathology,” Amsel said. ■

Gender Differences in Response to Childhood Activities

BRUNO MENDONÇA COÊLHO, MD a researcher at the Faculty of Medicine Foundation, Federal University of São Paulo, Brazil, delivered a talk at the APA meeting on a study conducted to examine the adult impact of incidents of adversity that were experienced during childhood.

Coêlho explained that childhood adversities (CAs) comprise the group of negative experiences that individuals suffer up until age 18 and have been implicated in various psychiatric outcomes.

Information was collected from just over 5000 subjects in the general population from the São Paulo metropolitan area that com- prised the occurrence of parental mental illness, substance abuse, criminality, divorce, and death or other loss of either parent during the subject’s childhood, as well as any history of family violence, physical abuse, sexual abuse, neglect, physical illness, or economic adversity that was experienced by the subject during childhood.

Regarding the approach taken for the statistical analysis, Coêlho said, “To address the entire spectrum of CAS and because some adversities are more difficult to disclose than others, the CAS should be considered as clusters of risk factors rather than as a single group with common characteristics.”

CAS were seen in just over half of the subjects, and the majority of these presented with 2 or more CAS. In the overall sample and in the male cohort, a 3-factor model fit best, while a 2-factor model fit best for women.

Coêlho added, “There was a group of 4 adversities consisting of physical abuse, neglect, parental mental disorders, and family violence that co-occurred independent of other factors in either gender and in the overall group, implying that these are common components of dysfunctional families and violent environments.”

Coêlho characterized this observation as important, because of the suggestion by other researchers in the field that general characteristics of the home environment are more important than the presence of any specific adversity in the development of psychopathology. Coêlho noted that sexual abuse, although reported only infrequently in males, appeared to be important for this group. “The relationship to sexual abuse was more related to the parental substance abuse disorder risk factor in the male subgroup, making it possible to infer that there is a clinical distinction between those individuals exposed to sexual abuse and those who were not so exposed.”

Concluding his remarks, Coêlho said, “CAS constitute a multidimensional group of events that are frequently experienced by individuals during childhood and adolescence. The key finding from this study is that CAS occurrence profiles differ in males and females such that they cannot be seen as a homogeneous group.” ■

Beyond PHQ-9: Measurement-Based Care in Psychiatry

MEASUREMENT-BASED CARE (MBC) entails the systematic ad- ministration of symptom rating scales and uses the results to drive clinical decision making at the level of the individual patient,” began Steve Daviss, MD, chief medical officer at M3 Information LLC, at the APA meeting.

What exactly does this enhanced precision and consistency in disease assessment, tracking, and treatment to achieve optimal outcomes, mean? Daviss explained that it’s not just doing a Patient Health Questionnaire-9 (PHQ-9) to assess a patient or determine a diagnosis, but also to track those changes over time. While there are challenges in using such tools—primarily, incorporating such practices into workflows—their use can increase efficiency.

Because symptom ratings would be directly delivered from the patient, MBC “helps to guide clinical decision making.” MBC is highly acceptable to patients, so patient engagement is another positive aspect to this process.

Acceptance is important because the MBC tool should be some- thing that the patient can complete on their own, freeing health care providers to perform other duties involving treatment of the patient. MBC also facilitates communication within treatment teams and with other providers who might be treating the patient.

On MBC related specifically to psychiatry, Daviss said, “MBC also helps to demystify mental health, particularly for primary care providers.”

Daviss discussed various multicondition tools (MINI, DSM Cross Cutting, BH-Works, M3 Checklist) for psychiatric MBC beyond PHQ-9 (which measures only depression). Daviss described these tools as being broader and more comprehensive than PHQ-9.

Daviss emphasized the utility of multicondition questionnaires by referencing a 2005 study that revealed 60% of patients with a psychiatric diagnosis display more than 1 psychiatric condition.

“The organizations that set quality standards, such as the National Committee for Quality Assurance, Joint Commission, US Preventive Services Task Force, and Centers for Medicare & Medicaid Services, are increasingly recognizing the importance of broader assessments for measurement-based behavioral health,” he said.

Daviss also touted the utility of MBC in population health as it can help provide an overall look at the practice. Additionally, it can be useful when trying to assess how different providers are performing at detecting a specific condition. MBC data can also assist in driving interventions for education to improve performance.

He concluded, “Using MBC in population health as a quality- improvement tool even allows you to compare how your program is doing compared with other programs.” ■

NMDA Antagonists May Treat Catatonia With Delirium

WHEN PATIENTS experience delirium in addition to catatonia, the combination presents 2 problems for the treating psychiatrist, Kamalika Roy MD, of the University of Michigan, Department of Psychiatry, told an audience at the APA meeting.

Referencing the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Roy noted that catatonia due to another medical condition cannot be diagnosed exclusively in the context of delirium. “As a result, the combination of catatonia and delirium is often coded as unspecified catatonia, which results in underrecognition of catatonia,” he said, resulting in delays in diagnosis and treatment of the combined disorder.

Continuing, he said, “The use of antipsychotics to treat delirium can actually worsen the catatonia. However, the use of benzodiazepines to treat catatonia can worsen the delirium. It’s a bit of a catch-22 for the physician.”

Roy outlined steps for typical current best practice in treating the combination of catatonia and delirium. “Step 1 is treatment with lorazepam at lower than typical doses to avoid worsening the delirium. Step 2 is electroconvulsive therapy (ECT), which is by far the most effective treatment for any catatonic symptoms, irrespective of their etiology.”

However, access to ECT or obtaining consent for the therapy can be problematic, leading to treatment delays. The third step in Roy’s outline involves the use of memantine, an N-methyl-D-aspartate (NMDA) antagonist. Roy urged the audience to move to this step quickly when ECT is not available or possible.

Roy said the use of NMDA antagonists for catatonia delirium is based on the idea that blocking NMDA receptors reduces glutamate excitotoxicity, which resolves the gamma-aminobutyric acid hypofunction observed in catatonia. He presented 4 cases of delirium-catatonia that were successfully treated with NMDA antagonists in patients who were not able to access ECT, including patients with schizophrenia, unspecified depression, major depressive disorder, and schizoaffective disorder.

“Catatonia symptoms presented concurrently while patients were in delirium. Treatment of the presumed cause of delirium was pursued, but catatonia symptoms persisted,” he said.

Roy concluded by telling the assembled physicians, “Lorazepam, which is otherwise the first line of therapy, is often not useful because of the risk of worsening delirium. The clinical evidence presented here of the successful use of NMDA antagonists for the specific subgroup of catatonia that presents with delirium draws further attention to the potential role of NMDA agonists in treatment of this combination.” ■

Internet-Based Cognitive Behavior Therapy Found to Be Effective

A NEW META-ANALYSIS presented at the APA meeting concluded that cognitive behaviorial therapy (CBT) is effective for treating adult patients with depression when delivered online.

However, cost, access, and a perceived stigma of receiving mental health services are barriers that prevent many patients from accessing these services. It is thought that delivering CBT over the internet (iCBT) may address some of these barriers. The researchers studied whether adult patients with depressive symptoms experienced a re- duction in their symptoms as a result of accessing iCBT.

In self-help or self-study formats, iCBT programs often include text and/or audio files and videos. Some iCBT programs do not include any human contact or support at all, while others involve inter- action with a clinical therapist for greater efficacy.

A major advantage of these types of programs is that they can be accessed anytime, anywhere, as long as a patient has internet access. It is this expanded accessibility that gives iCBT its potential to reach a greater number of patients who might otherwise not seek traditional face-to-face therapy in a clinical therapist’s practice, whether due to cost, no access, or concerns about the stigma associated with receiving mental health services.

In the study presented at APA, the researchers, led by CharlesKoransky, MD, a psychiatric resident at the University of Maryland Medical Center, identified and reviewed 14 randomized controlled studies published between 2005 and 2015 in which iCBT was used in adult patients with depression. They found that CBT delivered via the internet was effective in reducing patients’ symptoms. They further found that iCBT was also effective in maintaining the positive effects on patients’ depressive symptoms for 6 months after therapy was concluded. They found no statistically significant difference in symptoms between studies where clinicians participated in an iCBT program and studies where iCBT treatment was rendered without clinician assistance.

The researchers concluded that iCBT is effective in reducing the symptoms of depression and may be a viable alternative as a treatment modality for patients who are unable or reluctant to access traditional face-to-face therapy. ■