Spiritual issues in family therapy: a graduate-level course

With the advent of the biopsychosocial approach in family therapy, the domain of spiritual issues is increasingly being recognized as important to families. This article will describe a graduate-level seminar on Spiritual Issues in Family Therapy at the University of San Diego that offers family therapy students the opportunity to examine issues of spirituality, religion, and meaning and their place in therapy. One premise of the course is that research has demonstrated that most clients consider their spiritual life to be relevant to personal problems and would prefer a therapist who is comfortable with such topics. The goals of the course include (1) training in opening a dialogue with individuals and families about spiritual issues and discerning when referral may be appropriate; (2) expanding an awareness of wisdom traditions through use of comparative religions material; and (3) identifying from current practice many of the spiritual issues that may arise in the clinical setting.

The comorbidity of borderline personality disorder and other DSM-III-R axis II personality disorders

OBJECTIVE

This study examines the comorbidity of DSM-III-R borderline personality disorder and the other axis II personality disorders. The extent and direction of overlap provides a measure of the clarity of its diagnostic boundaries and descriptive validity.

METHOD

In 110 outpatients without concurrent major axis I conditions, axis II diagnoses were assessed in semistructured format and all DSM-III-R personality disorder criteria were rated. Multiple diagnoses were recorded.

RESULTS

Twenty-two patients (20%) met criteria for borderline personality disorder; 18 (82%) had at least one additional personality disorder diagnosis. Using measures of frequencies and intercorrelation coefficients, the authors found that overlap was extensive and not confined to any one of the three designated axis II clusters. Factor analysis revealed 1) a group containing borderline personality disorder with paranoid, histrionic, narcissistic, antisocial, and passive-aggressive personality disorders and 2) another grouping of schizoid, schizotypal, avoidant, obsessive-compulsive, and self-defeating personality disorders.

CONCLUSIONS

Borderline personality disorder appears to constitute a broad, heterogeneous category with unclear boundaries that embraces a general personality disorder concept. Both further refinement of the borderline personality disorder construct and investigation into alternative models to the DSM-III-R axis II classification system are suggested.

Abuse of the child and anxiety in the adult

We report on the early development and family background of 20 patients admitted to an anxiety disorders clinic serving a disadvantaged population. Sixteen of these 20 patients had been abused or neglected. Nineteen had a diagnosis of at least one personality disorder. We discuss the relationship between the patients' backgrounds and their current disorders. It is our thesis that the traumatic background of our patients is the major factor that allows anxiety to be passed across the generations.

Erb/Duchenne's palsy: a consequence of fetal macrosomia and method of delivery

Methods of delivery, maternal and neonatal characteristics were examined to determine their role in the occurrence of Erb/Duchenne's palsy. Data from 210,947 Washington state birth certificates from 1980 through 1982 were examined. The incidence was 50.2 cases of Erb's palsy per 100,000 live births. A case control study design was used to analyze 106 cases and 386 controls by both univariable and multivariable analysis. Birth weight was shown to be a significant risk factor regardless of which method of delivery was used. A high birth weight infant (4001-4500 g) had 2.5 times the risk of incurring an upper brachial plexus injury compared with normal size infants (2501-4000 g). The risk for infants greater than 4500 g increased another tenfold (OR = 21.0). When birth weight was controlled for in the analysis, midforceps (OR = 18.3), vacuum extraction (OR = 17.2), and low forceps (OR = 3.7) remained significantly associated with the Erb's palsy. Delivery by cesarean section was associated with a significant protective effect (OR = 0.5) compared with instrumental vaginal delivery. These data demonstrate a high risk for serious birth injury associated with instrumental midpelvic delivery.

Panic and generalized anxiety disorders. Developmental antecedents and precipitants

Seventeen subjects with panic disorder (PD) and 16 subjects with generalized anxiety disorder (GAD) were interviewed to obtain their developmental and psychiatric histories. The groups reported a similar incidence of early separation, separation disorder in childhood, and separation causing exacerbation of symptoms. The groups differed significantly in that those with PD had a higher incidence of a grossly disturbed childhood environmental and major depressive episodes. The results of this preliminary study support the validity of the DSM-III distinction between PD and GAD.

The treatment of involuntary patients in the general hospital psychiatric unit

In response to pressure to assume more responsibility for chronic patients, many general hospitals have asserted that they should limit care to those suitable for voluntary treatment on an open ward. This assertion appears to be based primarily on political and symbolic arguments. The limitation of admission to voluntary patients would serve to exclude many acutely psychotic patients with excellent prognosis best treated in a general hospital. The locked ward appears to offer the maximum flexibility in dealing with illnesses which in varying degrees affect the individual's judgment and impulsivity. The limitation of psychiatric units to voluntary patients in open wards would preclude psychiatry from joining in the mission of the general hospital - the best possible care for the community it serves.

Muscle biofeedback and transcendental meditation. A controlled evaluation of efficacy in the treatment of chronic anxiety

Recent articles have suggested that muscle biofeedback and transcendental meditation may be useful in treating chronic anxiety. To assess this, we conducted a controlled study comparing muscle biofeedback, transcendental mediation, and relaxation therapy. The study consisted of a six-week baseline period, six weeks of treatment, a six-week posttreatment observation period, and later follow-up. Thirty-one subjects completed the first part of the study and have been followed up for three to 18 months. Forty percent of the subjects had a clinically significant decrease in their anxiety. There were no differences between treatments with respect to treatment efficacy, onset of symptom amelioration, or maintenance of therapeutic gains. We found no evidence suggesting that the degree of muscle relaxation induced by any of the treatments is related to the therapeutic outcome. Relaxation therapies as a sole treatment appear to have a limited place in the treatment of chronic anxiety.

Controlling the cost of dental care

Methods for controlling dental care expenditures are taking on greater importance with the rapid increase in prepaid dental plans. The use of regulatory systems to monitor provider performance are necessary to prevent gross over-utilization but are unlikely to result in net savings of more than five per cent of total gross premiums. Theoretically, prepaid group dental practice (PGDP) may reduce expenditures by changing the mix of services patients receive. The modest estimated savings and the small number of PGDPs presently in operation limit the importance of this alternative for the next five to ten years. If substantial reductions in dental expenditures are to be obtained, it will be necessary to limit dental insurance plans to cover only those services which have demonstrated cost-effectiveness in improving health for the majority of people. The concept that richer benefit plans may have small marginal effects on improving oral health may not be easy for the public to accept but, until they do, expenditures for dental care will be difficult to control.

Management of interpersonal issues in systematic desensitization

The authors use the management of typical clinical problems that arise during systematic desensitization as a model for the analysis and solution of problems associated with behavior therapy techniques. Three main problem areas are considered: initiation of the technique, therapist and patient difficulties, and therapeutic decision making. The discussion is designed primarily to help therapists with varied backgrounds to deal with clinical issues that arise in the application of behavior therapy techniques such as systematic desensitization.

Decreased skin conductance response habituation in chronically anxious patients

Skin conductance response (SCR) habituation to loud tones was tested in chronically anxious patients and controls matched for age, sex and occupation. The results replicate Lader and Wing's finding of slowed response habituation in the patient group. These results are discussed in light of the Lader and Wing model attributing anxiety-proneness to an innate slowness in habituating to stimulation. Two factors which in themselves could cause slowed response habituation were present in the patient group during testing: increased physiological activity and increased threat appraisal. The latter resulted in the patients' frequently attributing signal value to the irrelevant tones. Because of the presence of these contaminating factors, and decreased response habituation in the patient groups can be considered only weak evidence in support of the slowed habituation model. Since the excessive test anxiety in the patient group contributes to both increased physiological activity and increased threat appraisal, it is suggested that SCR habituation testing be undertaken when both patient and control groups can be brought to equivalent states of relaxation.

Short versus long hospitalization: a prospective controlled study. II. Results for schizophrenic inpatients

The authors compared treatment results for 141 schizophrenic patients randomly assigned to short-term or long-term hospitalization. The patients received intensive treatment and were on partially fixed drug dosage schedules. Test results indicated that the short-term group was functioning better at four weeks. However, at discharge (21 to 28 days for short-term patients; 90 to 120 days for long-term) the long-term group showed significantly better functioning. There were no significant differences between the groups on symptomatology at discharge. The authors discuss the implications of these findings for decisions regarding length and type of hospitalization for schizophrenic patients.

[Study of immunglobulins in 5 cases of myotonic dystrophy]

São estudados 5 casos de distrofia miotônica sob o ponto de vista imunoeletroforético. Os resultados obtidos mostram queda acentuada da imunoglobulina G (IgG) em dois casos.