Again it is important that staff inform the family before they hear it from other sources. All too often a family member coming on a regular visit could be shocked to hear for the first time that the loved one had been attacked. This also gives staff an opportunity to tell the family steps taken to insure their loved one's safety.

#### **8.5 Meeting with other residents**

Residents having witnessed the attack may feel threatened and not safe. Again this type of meeting is particularly relevant when most of the resident are cognitively aware. The meeting allows to residents to voice their concerns and gives staff an opportunity to assure them of their safety.

#### **8.6 Staff meeting**

Finally, there should be a staff meeting to review the entire episode which will serve many purposes. The tone of the meeting should be assuring, educational, healing rather than punitive and fault finding. It gives staff a chance to express their feelings about attack. Furthermore, staff often can be discouraged by working a stressful combative environment. They had sought employment to help people not to be 'policemen'. It offers an opportunity to learn from the RRA episode. What did they do right? And in what areas could they improve their response? It also provides the nursing home leadership an opportunity to be supportive of their staff.

Violence in the Nursing Homes: Understandings, Management,

Webster College for helping in formatting this chapter.

Goffman, E. Asylums, Garden City, NJ, Anchor, 1961. Health Information Privacy, accessed 9/19/11,

*Geriatr Soc*. Jun;55(6):840-5. 2007

staff turn-over.

be thoroughly documented.

**11. Acknowledgements**

**12. References**

lawyer.com>

Jun 2011

Documentation and Impact of Resident to Resident Aggression 241

the administration. RRA plays a significant role in the quality of life in the nursing home. Incidents of RRA can lead to residents feeling unsafe and anxious. It can result increased

There are a number of identifiable causes of RRA. An appreciation of the roots of residents' aggression can lead to ways of preventing RRA. RRA must be dealt with swiftly and decisively. And after the RRA episode, it must be reviewed . Finally, each RRA event must

David Siddle, Ph.D. has contributed much to my appreciation and understanding RRA. For several years he and I worked together in the Commonwealth of Massachusetts in a training program sponsored its Department of Industrial Accidents, Office of Safety in a day long workshop entitled *A Nurse Safety Program dealing with Resident Aggression in Long-term Care Facilities to Reduce Injuries and Lost Work Days: A Comprehensive Approach.* We trained over a thousand nursing home staff member in over one hundred facilities. He also co-authored *A Caregiver's Guide to Working with Combative Resident.* Thanks also to Elaine Bunker of Daniel

A nursing home abuse lawyer, accessed 8/22/11, <www.a-nursing-home-abuse-

American Psychiatric Association. 2000. *Diagnostic and Statistical Manual of Mental Disorders,*

Bagchi AD, Verdier JM, Simon SE., How many nursing home residents live with a mental

illness? *Psychiatr Serv*.;60(7):958-64. Jul 2009 Birth order, accessed 9/5/11 http://www.childdevelopmentinfo.com/development/birth\_order.shtml>. Cohen-Mansfield, J., Billig, N., Lipson, S., Rosenthal, A.S., Pawlson, L.G., Medical correlates of agitation in nursing home residents, *Gerontology* 36:3, 150-158, 1990. Cornell University (2008, June 4). Aggression Between Nursing-home Residents More

Common Than Widely Believed, Studies Find. *ScienceDaily*. accessed 8/22/ 2011, from <http://www.sciencedaily.com/releases/2008/06/080602170924.htm> Enmarker I, Olsen R, Hellzen O., Management of person with dementia with aggressive and

violent behavior: a systematic literature review. *Int J Older People Nurs.* ;6(2):153- 62.

police contact in nursing homes: findings from a population-based cohort. *J Am*

Fullerton CA, McGuire TG, Feng Z, Mor V, Grabowski DC, Trends in mental health admissions to nursing homes, 1999-2005*. Psychiatr Serv.*;60(7):965-71. Jul 2009

 http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html Lachs M, Bachman R, Williams CS, O'Leary JR. Resident-to-resident elder mistreatment and

Lemke SP, Schaefer JA., Recent changes in the prevalence of psychiatric disorders among

VA nursing home residents. *Psychiatr Serv*. 61(4):356-63. Apr;2010

*Fourth Edition, Text Revision, DSM-IV-TR*. Washington, DC

## **9. Documentation**

Documentation plays an important role in RRA as both a record of the intervention and as for prevention. In both cases those documents become critical in risk management and for accreditation.

## **9.1 Recording the intervention**

Each RRA event must be documented. It should recorded in the assaulter's and the victim's charts. Those charts are one of the key places to best document care issues. However, in those charts, only identify the resident whose chart you are writing in. Therefore, in the victim's chart, do not identify by name or medical record number the assaulter. And in the attacker's chart, do not identify the victim. Document the event without specifically identifying of the other party. This fulfills the HIPAA, the United States' Health Information Privacy requirement. "*Minimum Necessary. A central aspect of the Privacy Rule is the principle of "minimum necessary" use and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request"*. (Health Information Privacy, 2011) However, in the incident report, record both parties and the events completely. The incident report if done thoroughly and competently can be very effective as a risk management document.

## **9.2 Prevention**

Documentation can be used in RRA prevention in several ways.

Documentation prevention involves the use of a Preadmission Behavioral Review. This form consists of a list of the behavioral concerns for a new admission. It offers staff insights into residents who are about to be joining their unit. This is particularly useful since the entrance for the new resident to any unit can be both stressful to the unit and the resident. One specific interesting aspect of this form has been the place for staff to initial that they have read it. Staff by initialing the form , helps to assure effective transmission resident care information. This form provides an excellent place to put in information about the resident's life such as birth order and profession.

A companion piece to the Preadmission Behavioral Review is the Individual Treatment Plan. This form not only outlines specific behavior concerns but also should contain information about emergency management techniques if the resident becomes aggressive. Here again the Treatment Plan offers an excellent place for information about the resident's life such as birth order and profession.

There is one other useful way to record RRA events. This is one master list of all RRA incidents in the facility by time and place. By documenting each RRA event, clinical staff and administration have an important method to track and see patterns of resident aggression. If they identify certain times and units of high RRA events, they use that information to deploy staff to forestall violence episodes.

## **10. Conclusion the impact of RRA**

The impact of resident-to-resident violence is both profound and pervasive. It affects both the actual residents involved, their families, the witnessing residents, the clinical staff and the administration. RRA plays a significant role in the quality of life in the nursing home. Incidents of RRA can lead to residents feeling unsafe and anxious. It can result increased staff turn-over.

There are a number of identifiable causes of RRA. An appreciation of the roots of residents' aggression can lead to ways of preventing RRA. RRA must be dealt with swiftly and decisively. And after the RRA episode, it must be reviewed . Finally, each RRA event must be thoroughly documented.

## **11. Acknowledgements**

240 Essential Notes in Psychiatry

Documentation plays an important role in RRA as both a record of the intervention and as for prevention. In both cases those documents become critical in risk management and for

Each RRA event must be documented. It should recorded in the assaulter's and the victim's charts. Those charts are one of the key places to best document care issues. However, in those charts, only identify the resident whose chart you are writing in. Therefore, in the victim's chart, do not identify by name or medical record number the assaulter. And in the attacker's chart, do not identify the victim. Document the event without specifically identifying of the other party. This fulfills the HIPAA, the United States' Health Information Privacy requirement. "*Minimum Necessary. A central aspect of the Privacy Rule is the principle of "minimum necessary" use and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request"*. (Health Information Privacy, 2011) However, in the incident report, record both parties and the events completely. The incident report if done

thoroughly and competently can be very effective as a risk management document.

Documentation prevention involves the use of a Preadmission Behavioral Review. This form consists of a list of the behavioral concerns for a new admission. It offers staff insights into residents who are about to be joining their unit. This is particularly useful since the entrance for the new resident to any unit can be both stressful to the unit and the resident. One specific interesting aspect of this form has been the place for staff to initial that they have read it. Staff by initialing the form , helps to assure effective transmission resident care information. This form provides an excellent place to put in information about the resident's

A companion piece to the Preadmission Behavioral Review is the Individual Treatment Plan. This form not only outlines specific behavior concerns but also should contain information about emergency management techniques if the resident becomes aggressive. Here again the Treatment Plan offers an excellent place for information about the resident's

There is one other useful way to record RRA events. This is one master list of all RRA incidents in the facility by time and place. By documenting each RRA event, clinical staff and administration have an important method to track and see patterns of resident aggression. If they identify certain times and units of high RRA events, they use that

The impact of resident-to-resident violence is both profound and pervasive. It affects both the actual residents involved, their families, the witnessing residents, the clinical staff and

Documentation can be used in RRA prevention in several ways.

**9. Documentation**

**9.1 Recording the intervention**

life such as birth order and profession.

life such as birth order and profession.

**10. Conclusion the impact of RRA**

information to deploy staff to forestall violence episodes.

accreditation.

**9.2 Prevention**

David Siddle, Ph.D. has contributed much to my appreciation and understanding RRA. For several years he and I worked together in the Commonwealth of Massachusetts in a training program sponsored its Department of Industrial Accidents, Office of Safety in a day long workshop entitled *A Nurse Safety Program dealing with Resident Aggression in Long-term Care Facilities to Reduce Injuries and Lost Work Days: A Comprehensive Approach.* We trained over a thousand nursing home staff member in over one hundred facilities. He also co-authored *A Caregiver's Guide to Working with Combative Resident.* Thanks also to Elaine Bunker of Daniel Webster College for helping in formatting this chapter.

## **12. References**

http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

**Section 3**

**Effectiveness of Selected**

**Mental Health Therapies and Interventions**

<http://www.globalaging.org/elderrights/us/violentpatients.htm,>

Zhang Z, Schiamberg LB, Oehmke J, Barboza GE, Griffore RJ, Post LA, Weatherill RP, Mastin T, Neglect of older adults in Michigan nursing homes .*J Elder Abuse Negl.*;23(1):58-74. Jan 2011

## **Section 3**

**Effectiveness of Selected Mental Health Therapies and Interventions**

242 Essential Notes in Psychiatry

Leone AF, Standoli F, Hirth V., Implementing a pain management program in a long-term c

Leurs P, Huvent-Grelle D, Lelievre-Leroy S, Roche J, Puisieux F; Comité Scientifique de la

older people living in nursing homes, *Presse Med.* 39(12):e280-8. Dec; 2010 Narevic E, Giles GM, Rajadhyax R, Managuelod E, Monis F, Diamond F., The effects of

Natan MB, Lowenstein A, Eisikovits Z., Psycho-social factors affecting elders' maltreatment

Packham, B, Fear in nursing homes Assault claims soar, Herald Sun (Australia) December

Rosen T, Lachs MS, Pillemer K. Sexual aggression between residents in nursing homes:

Rosen T, Lachs MS, Bharucha AJ, Stevens SM, Teresi JA, Nebres F, Pillemer K. Resident-to-

nursing home residents and staff.*J Am Geriatr Soc.* 56(8):1398-408. Aug;2008 Sifford-Snellgrove KS, Beck C, Green A, McSweeney JC., Victim or Initiator?: Certified

Sifford, Krista Susan, *Caregiver perceptions of unmet needs that lead to resident-to-resident*

Shinoda-Tagawa, T., Leonard, R., Pontikas, J., McDonough, JE., Allen, A., Dreyer, PI,

Soreff, S and Siddle, D, *A Caregiver's Guide to Working with Combative Residents* Needham,

Soreff, S. Editor, *Handbook for the Treatment of the Seriously Mentally Ill,* Seattle, Washington,

Williams CL, Hyer K, Kelly A, Leger-Krall S, Tappen RM.Development of nurse competencies to improve dementia care. *Geriatr Nurs.*;26(2):98-105. Mar-Apr 2005 Zambito, T., Violent Patients Loose in Home, The New York Daily News, December 18,

Zhang Z, Schiamberg LB, Oehmke J, Barboza GE, Griffore RJ, Post LA, Weatherill RP,

Mastin T, Neglect of older adults in Michigan nursing homes .*J Elder Abuse*

MA, Lighthouse CCUNIV Pub. Ltd. 2003 ISBN 0-9719578-4-3- 5200

<http://www.globalaging.org/elderrights/us/violentpatients.htm,>

accessed 8/25/11< http://gradworks.umi.com/34/10/3410295.html > Sifford KS, Bharucha A., Benefits and challenges of electronic surveillance in nursing home

literature synthesis of an underrecognized problem.*J Am Geriatr Soc.* ;58(10):1970-9.

resident aggression in long-term care facilities: insights from focus groups of

Nursing Assistants' Perceptions of Resident Characteristics that Contribute to Resident-To-Resident Violence in Nursing Homes. *Res Gerontol Nurs.* 15:1-9. Jun.

*violence involving residents with dementia in nursing homes, dictatorial dissertation* 2010,

Resident-to-Resident Violent Incidents in Nursing Homes *JAMA.* 291:591-598. Feb.

in long-term care facilities. *Int Nurs Rev.* 57(1):113-20. Mar; 2010

Preventing Resident to Resident Altercations in Nursing Homes. accessed 9/3/2011

Jan;10(1):67-73. 2009

Oct . 2010

2011

2004

*Health*. Jan;15(1):103-12. 2011

14, 2009 Monday 1 - FIRST Edition, page 22

<http://www.intergens.com/featurearticle-38.html >

research. *Res Gerontol Nurs.* 3(1):5-10, Jan;2010

Hogrefe & Huber, 1996.ISBN 0-88937-123-7

2000, accessed 8/22/11

*Negl.*;23(1):58-74. Jan 2011

are facility using a quality improvement approach. *J Am Med Dir Assoc.*

Société Septentrionale de Gérontologie Clinique. Alcohol consumption patterns in

enhanced program review and staff training on the management of aggression among clients in a long-term neurobehavioral rehabilitation program. *Aging Ment*

**12**

*China*

**Effectiveness of Participative Community**

**Singing Intervention Program on Promoting**

**and Torres Strait Islander People in Australia**

*1Griffith Health Institute and School of Public Health, Griffith University, Australia*

Aboriginal and Torres Strait Islander people are more likely to have a higher prevalence of mental illness than non-Indigenous people, which may be caused by multiple factors (Australian Bureau of Statistics, 2008; Australian Institute of Health and Welfare, 2008; Pink & Allbon, 2008). These factors have been shown to be closely related to resilience. The concept was introduced by Masten and Coatsworth (1998) and includes key factors that affect recovery from illness and maintenance of health. The key factors of resilience entail (1) an ability of bouncing back, through which a person can recover from stressful event quickly; (2) a sense of family support, through which a person can manage a stressful event process; and (3) a sense of social connectedness, through which a person feels supported and connected to the community and social environment in a stressful event (Masten & Coatsworth, 1998; Weinberger, Schwartz & Davidson, 1979; Werner & Smith, 2001). Previous studies have shown an association with the sense of resilience score and depression. A high resilience score is related to a lower degree of depression (Weinberger et al., 1979), a lower level of anxiety (Weinberger et al., 1979), and a lower mental or physical stress response (Werner & Smith, 2001). These studies suggest the importance of resilience for coping with stress and adverse events and to prevent mental illness. A community participative singing approach (CPSA) is an effective intervention in promoting resilience and mental health in a range of population groups (Cohen et al., 2006, 2007). The CPSA programme is modelled on the work of Clift and colleagues at the Canterbury Christ

Church University in England (Clift & Hancox, July 2008; Clift et al., 2007).

The programme is based on the principle of multi-psychosocial functions development, 'divided into environmental and social processes (interpersonal mechanisms) and cognitive and emotional processes (intrapersonal mechanisms). These processes are bi-directional, as the interpersonal mechanisms can trigger intrapersonal responses, and vice versa' (Lob et

**1. Introduction**

*2Griffith Health Institute and Health Group, Griffith University, Australia*

**Resilience and Mental Health of Aboriginal**

Jing Sun1,3 and Nicholas Buys2,3

*3Peking University, Beijing,*

## **Effectiveness of Participative Community Singing Intervention Program on Promoting Resilience and Mental Health of Aboriginal and Torres Strait Islander People in Australia**

Jing Sun1,3 and Nicholas Buys2,3

*1Griffith Health Institute and School of Public Health, Griffith University, Australia 2Griffith Health Institute and Health Group, Griffith University, Australia 3Peking University, Beijing, China*

## **1. Introduction**

Aboriginal and Torres Strait Islander people are more likely to have a higher prevalence of mental illness than non-Indigenous people, which may be caused by multiple factors (Australian Bureau of Statistics, 2008; Australian Institute of Health and Welfare, 2008; Pink & Allbon, 2008). These factors have been shown to be closely related to resilience. The concept was introduced by Masten and Coatsworth (1998) and includes key factors that affect recovery from illness and maintenance of health. The key factors of resilience entail (1) an ability of bouncing back, through which a person can recover from stressful event quickly; (2) a sense of family support, through which a person can manage a stressful event process; and (3) a sense of social connectedness, through which a person feels supported and connected to the community and social environment in a stressful event (Masten & Coatsworth, 1998; Weinberger, Schwartz & Davidson, 1979; Werner & Smith, 2001). Previous studies have shown an association with the sense of resilience score and depression. A high resilience score is related to a lower degree of depression (Weinberger et al., 1979), a lower level of anxiety (Weinberger et al., 1979), and a lower mental or physical stress response (Werner & Smith, 2001). These studies suggest the importance of resilience for coping with stress and adverse events and to prevent mental illness. A community participative singing approach (CPSA) is an effective intervention in promoting resilience and mental health in a range of population groups (Cohen et al., 2006, 2007). The CPSA programme is modelled on the work of Clift and colleagues at the Canterbury Christ Church University in England (Clift & Hancox, July 2008; Clift et al., 2007).

The programme is based on the principle of multi-psychosocial functions development, 'divided into environmental and social processes (interpersonal mechanisms) and cognitive and emotional processes (intrapersonal mechanisms). These processes are bi-directional, as the interpersonal mechanisms can trigger intrapersonal responses, and vice versa' (Lob et

Effectiveness of Participative Community Singing

collate details of those volunteering to participate.

and reducing depression symptoms of the participants.

depression total score against clinical diagnosed depression results.

each local council.

held after six months.

**2.3 Measures**

al., 2008).

**2.2 Participatory community singing intervention approach**

Intervention Program on Promoting Resilience and Mental Health of Aboriginal... 247

the vicinity of the venues. Two 'taster sessions' were held in each venue, which included the provision of information, an invitation for questions and an opportunity for individuals to sample the nature of the proposed intervention programme. A dedicated phone line and email address was set up to deal with responses and queries and a checklist was devised to

The chief investigator met with Queensland Aboriginal and Islander Health Council (QAIHC) representatives to discuss the initial concept. QAIHC representatives met with and discussed the concept with each Chief Executive Officer (CEO) from each Aboriginal and Islander CCHS. A reference committee was established made up of CEOs, health workers, counsellors and music therapists, the majority of which identified as Aboriginal and/or Torres Strait Islander. QAIHC took on an active role in meeting with community elders via

Each singing group was led by a skilled and experienced singing group leader. Leaders were provided with five days of training and met regularly throughout the project to ensure a broadly consistent approach. The singing programme took place in the five groups over two three-month blocks. Groups came together at the end of each block for a choral performance event. Each session lasted 120 minutes, with a break for socialising. Sessions commenced with 30 minutes of relaxation, posture, breathing and vocal exercises followed by singing. Two performances for five communities were organised after three months and again after six months of intervention. Monthly performances for each community were

A number of reliable and valid questionnaires was used to assess the effectiveness of the participative community singing programme on improving resilience and quality of life,

**Resilience:** The Brief Resilience Scale is a five-item scale used to assess resilience and individual strength, defined as the ability to bounce back and recover from stress (Smith et

**Depression:** The Indigenous Risk Impact Screen (IRIS) scale is a six-item scale used to assess depressive symptoms and it is designed for use with the Aboriginal and Torres Strait population (Schlesinger et al., 2007). Scores range from six to 18, with higher scores reflecting greater levels of depressive symptoms, and a score of 11 is the cut-off point (Schlesinger et al., 2007). Sensitivity and specificity of the measure was checked by using a

**Singing questionnaire:** The singing questionnaire, consisting of eight questions, was modified based on Clift and colleagues (2010) to measure the improvement of quality of life through community participative singing activities. These questions were designed to measure participants' feelings about their emotional, physical health, spiritual, and social aspects of health. An example question is 'Singing has spiritual significance for me personally'. For each question, participants were asked to choose one of the answers from

al., 2011, p. 46). The goal of the CPSA programme is to guide participants through breathing exercises, group singing, and social interaction and collaboration. It aims to maximise their collective experience in a non-judgemental and accepting way, one where individuals feel a sense of belonging and safety, and to build relationships in which individuals socialise with others and are able to work on their social skills in a safe setting. A second aim is to develop individuals' inner psychological state such as competence*,* purposefulness*,* managing emotions and wellbeing, and creating a meaningful life. It is effective for mood disturbance and stress symptoms (Lob et al., 2011), for quality of life (Cohen et al., 2006, 2007) and the immune profile (Clift et al., 2008). However, few studies have examined interventions for mental health promotion in the Aboriginal and Torres Strait Islander population. Thus, the present study was performed to investigate the efficacy of community participative singing on the sense of resilience and psychological wellbeing of Aboriginal and Torres Strait Islander people. The study was performed for Aboriginal and Torres Strait Islanders who reside in five Aboriginal and Torres Strait Islander communities in South East Queensland, Australia. These Aboriginal and Torres Strait Islander people may be under particular stress and have a mental illness status since many of them have gone through the colonisation process and had traumatic experiences related to it. The aim of the study was to assess the effectiveness for Aboriginal and Torres Strait Islander people of active engagement in community music activities on measures of resilience, mental health, and quality of life.

It is hypothesised that Aboriginal and Torres Strait Islander people will have increased resilience, mental health and quality of life after they participate in a community singing intervention programme for six months.

## **2. Methods**

The study used the participatory community singing approach and the prospective intervention method for the intervention trial. A multi-method design was used to monitor and evaluate the programme. Participants were invited to participate in the project in June 2010 and completed questionnaires towards the end July 2010, and they were asked to fill in the questionnaire again in January and February 2011. They were also asked over the course of the project to provide qualitative comments on their experiences. The present paper only focuses on changes over a six-month period from July 2010 to the January 2012 based on the quantitative results. The study was granted ethical approval by Research Ethics Committee at Griffith University with GU Ref No: PBH/13/10/HREC

#### **2.1 Participants and data collection procedure**

Participants were adults aged 18 and above. They were all able to speak English, provide informed consent and complete questionnaires. Individuals who were unable to provide informed consent or complete questionnaires were excluded from the study.

Researchers, in conjunction with five Community Controlled Health Services (CCHSs) providing the intervention, sought suitable venues across five South East Queensland communities to conduct intervention activities. Advertisements seeking participants were placed in each CCHS and in local newspapers, and leaflets were delivered to homes within the vicinity of the venues. Two 'taster sessions' were held in each venue, which included the provision of information, an invitation for questions and an opportunity for individuals to sample the nature of the proposed intervention programme. A dedicated phone line and email address was set up to deal with responses and queries and a checklist was devised to collate details of those volunteering to participate.

## **2.2 Participatory community singing intervention approach**

The chief investigator met with Queensland Aboriginal and Islander Health Council (QAIHC) representatives to discuss the initial concept. QAIHC representatives met with and discussed the concept with each Chief Executive Officer (CEO) from each Aboriginal and Islander CCHS. A reference committee was established made up of CEOs, health workers, counsellors and music therapists, the majority of which identified as Aboriginal and/or Torres Strait Islander. QAIHC took on an active role in meeting with community elders via each local council.

Each singing group was led by a skilled and experienced singing group leader. Leaders were provided with five days of training and met regularly throughout the project to ensure a broadly consistent approach. The singing programme took place in the five groups over two three-month blocks. Groups came together at the end of each block for a choral performance event. Each session lasted 120 minutes, with a break for socialising. Sessions commenced with 30 minutes of relaxation, posture, breathing and vocal exercises followed by singing. Two performances for five communities were organised after three months and again after six months of intervention. Monthly performances for each community were held after six months.

#### **2.3 Measures**

246 Essential Notes in Psychiatry

al., 2011, p. 46). The goal of the CPSA programme is to guide participants through breathing exercises, group singing, and social interaction and collaboration. It aims to maximise their collective experience in a non-judgemental and accepting way, one where individuals feel a sense of belonging and safety, and to build relationships in which individuals socialise with others and are able to work on their social skills in a safe setting. A second aim is to develop individuals' inner psychological state such as competence*,* purposefulness*,* managing emotions and wellbeing, and creating a meaningful life. It is effective for mood disturbance and stress symptoms (Lob et al., 2011), for quality of life (Cohen et al., 2006, 2007) and the immune profile (Clift et al., 2008). However, few studies have examined interventions for mental health promotion in the Aboriginal and Torres Strait Islander population. Thus, the present study was performed to investigate the efficacy of community participative singing on the sense of resilience and psychological wellbeing of Aboriginal and Torres Strait Islander people. The study was performed for Aboriginal and Torres Strait Islanders who reside in five Aboriginal and Torres Strait Islander communities in South East Queensland, Australia. These Aboriginal and Torres Strait Islander people may be under particular stress and have a mental illness status since many of them have gone through the colonisation process and had traumatic experiences related to it. The aim of the study was to assess the effectiveness for Aboriginal and Torres Strait Islander people of active engagement in community music activities on measures of resilience, mental health, and quality of life.

It is hypothesised that Aboriginal and Torres Strait Islander people will have increased resilience, mental health and quality of life after they participate in a community singing

The study used the participatory community singing approach and the prospective intervention method for the intervention trial. A multi-method design was used to monitor and evaluate the programme. Participants were invited to participate in the project in June 2010 and completed questionnaires towards the end July 2010, and they were asked to fill in the questionnaire again in January and February 2011. They were also asked over the course of the project to provide qualitative comments on their experiences. The present paper only focuses on changes over a six-month period from July 2010 to the January 2012 based on the quantitative results. The study was granted ethical approval by Research Ethics Committee

Participants were adults aged 18 and above. They were all able to speak English, provide informed consent and complete questionnaires. Individuals who were unable to provide

Researchers, in conjunction with five Community Controlled Health Services (CCHSs) providing the intervention, sought suitable venues across five South East Queensland communities to conduct intervention activities. Advertisements seeking participants were placed in each CCHS and in local newspapers, and leaflets were delivered to homes within

informed consent or complete questionnaires were excluded from the study.

intervention programme for six months.

at Griffith University with GU Ref No: PBH/13/10/HREC

**2.1 Participants and data collection procedure**

**2. Methods**

A number of reliable and valid questionnaires was used to assess the effectiveness of the participative community singing programme on improving resilience and quality of life, and reducing depression symptoms of the participants.

**Resilience:** The Brief Resilience Scale is a five-item scale used to assess resilience and individual strength, defined as the ability to bounce back and recover from stress (Smith et al., 2008).

**Depression:** The Indigenous Risk Impact Screen (IRIS) scale is a six-item scale used to assess depressive symptoms and it is designed for use with the Aboriginal and Torres Strait population (Schlesinger et al., 2007). Scores range from six to 18, with higher scores reflecting greater levels of depressive symptoms, and a score of 11 is the cut-off point (Schlesinger et al., 2007). Sensitivity and specificity of the measure was checked by using a depression total score against clinical diagnosed depression results.

**Singing questionnaire:** The singing questionnaire, consisting of eight questions, was modified based on Clift and colleagues (2010) to measure the improvement of quality of life through community participative singing activities. These questions were designed to measure participants' feelings about their emotional, physical health, spiritual, and social aspects of health. An example question is 'Singing has spiritual significance for me personally'. For each question, participants were asked to choose one of the answers from

Effectiveness of Participative Community Singing

**4.2 Change in singing-related quality of life**

depression rate among participants with depression.

**4. Discussion**

**4.1 Changes in resilience**

difficult events in life.

bereavement.

**4.3 Change in depression**

Intervention Program on Promoting Resilience and Mental Health of Aboriginal... 249

Our findings show a statistically significant improvement in the percentage of participants who are able to recover from stress and difficult events in post-intervention phase. It should be remembered that the sample in the study is people with Aboriginal and Torres Strait Islander background. It includes not only people with current mental health and chronic diseases issues, but also individuals with a history of colonisation, 49% of whom gave depression scores below the clinical cut-off point. The significant change in the resilience scores indicate that the community singing programme helps to build participants' resilience. This result confirmed the findings of a previous study that choir singing enhanced confidence and self-esteem, gave a sense of purpose and of achievement (Tonneijck et al., 2008). In the present study, the community singing programme has resulted in improved sense of ability to recover and bounce back from the stressful and

Statistically significant changes are also found for aspects within the singing-related quality of life questionnaire regarding physical health, social and emotional health, stress reduction, spiritual significance, suggesting that group singing helps to create improvements in all these areas equally. The findings of our study are consistent with those of other studies that singing carries benefits to physical, mental and social health. Clift et al. (2010) and Clift et al. (2008) examined the effects of choral singing on wellbeing in participants with relatively low psychological wellbeing, as assessed by the World Health Organization Quality of Life (WHOQOL)-BREF, and high scores on the singing scale, indicating a strong perceived impact of singing on a sense of personal wellbeing. In Clift et al.'s (2010) study, it was found that singing provided support in coping with challenges in four aspects: enduring mental health problems, family and relationship problems, physical health challenges and recent

Our results show a statistically significant reduction in the percentage of participants who had depression in the post-intervention phase. It should be noted that the sample includes not only people with current mental health issues, 37.8% of whom gave depression scores below the clinical cut-off point. There was 9% reduction in the percentage of people who had depression, suggesting that the singing programme helps some people with mental illness to recover from the depression status. This is consistent with a recent study by Clift and Morrison (2011), who also found that singing programmes significantly reduce the

The findings of our study indicate that a participative community singing programme is effective in preventing the deterioration of depression, and in improving resilience and quality of life. A CPSA can foster a sense of happiness, positive attitude towards life, and feelings of the significance of life. Singing is considered by participants a means to release

the three options 'never', 'sometimes' or 'all the time'. The more participants that choose the answer 'all the time', the more likely it is that the participative singing programme has impacted on the quality of life of participants.

## **3. Results**

Table 1 shows that there are statistically significant differences between the pre- and postintervention phases through a decreased depression rate, improved quality of life, and a reduction of depression symptoms, reduced medication use in participants after six months of intervention activities. This indicates that the participative community singing is effective in improving Aboriginal and Torres Strait Islander participants' resilience, quality of life and mental health.

Table 1. Improved mental health, resilience and quality of life post-intervention time.

Table 2. Difference in medication use between the pre- and post-intervention phases

## **4. Discussion**

248 Essential Notes in Psychiatry

the three options 'never', 'sometimes' or 'all the time'. The more participants that choose the answer 'all the time', the more likely it is that the participative singing programme has

Table 1 shows that there are statistically significant differences between the pre- and postintervention phases through a decreased depression rate, improved quality of life, and a reduction of depression symptoms, reduced medication use in participants after six months of intervention activities. This indicates that the participative community singing is effective in improving Aboriginal and Torres Strait Islander participants' resilience, quality of life and

> **Pre (%) N=217**

Depression (yes) 80(37.2%) 14 (28.2%) 9% decrease 6.61 0.03

Singing is something I like to do 58(26.5%) 42(80.8%) Significant

Singing helps to make me a happier person 61(27.9%) 44(84.6%) Significant

Table 1. Improved mental health, resilience and quality of life post-intervention time.

Medication use for Chronic disease **Pre Post Differences 2 p**  Medication use (yes) 44.2% 31.9% 12.3% decrease 6.35 <0.01 Medication reduced the last 6 month 18.3% 27.3% 9% medication reduction 7.91 <0.01

Table 2. Difference in medication use between the pre- and post-intervention phases

**Post (%)**

50(22.9%) 42(80.8%) Significant

61(27.9%) 41(78.8%) Significant

55(25.1%) 41(78.8%) Significant

61(27.9%) 44(84.6%) Significant

51(23.3%) 43(82.7%) Significant

45(20.5%) 35(67.3%) Significant

**N=50 difference 2 p**

52(24.2%) 5(9.6%) 14.6% 6.47 0.04

55 (25.7%) 5(9.6%) 14.1% 7.60 0.02

increase

increase

increase

increase

increase

increase

increase

increase

75.92 0.001

63.38 0.001

69.11 0.001

69.30 0.001

73.13 0.001

67.93 0.001

73.19 0.001

impacted on the quality of life of participants.

**Variables**

Resilience1: It takes me a long time to get through stressful events (all the time)

Resilience2: I tend to take a long time to get over difficult things in my life (all the time)

Singing has spiritual significance to me

Singing really helps to improve my general

Singing helps to give me a positive attitude

Being in a singing group and singing is a

Singing is an activity that has made me

I find singing helps me to relax and deal

with the stresses of the week

very important part of my life

physically healthier

**3. Results**

mental health.

personally

wellbeing

to life

## **4.1 Changes in resilience**

Our findings show a statistically significant improvement in the percentage of participants who are able to recover from stress and difficult events in post-intervention phase. It should be remembered that the sample in the study is people with Aboriginal and Torres Strait Islander background. It includes not only people with current mental health and chronic diseases issues, but also individuals with a history of colonisation, 49% of whom gave depression scores below the clinical cut-off point. The significant change in the resilience scores indicate that the community singing programme helps to build participants' resilience. This result confirmed the findings of a previous study that choir singing enhanced confidence and self-esteem, gave a sense of purpose and of achievement (Tonneijck et al., 2008). In the present study, the community singing programme has resulted in improved sense of ability to recover and bounce back from the stressful and difficult events in life.

## **4.2 Change in singing-related quality of life**

Statistically significant changes are also found for aspects within the singing-related quality of life questionnaire regarding physical health, social and emotional health, stress reduction, spiritual significance, suggesting that group singing helps to create improvements in all these areas equally. The findings of our study are consistent with those of other studies that singing carries benefits to physical, mental and social health. Clift et al. (2010) and Clift et al. (2008) examined the effects of choral singing on wellbeing in participants with relatively low psychological wellbeing, as assessed by the World Health Organization Quality of Life (WHOQOL)-BREF, and high scores on the singing scale, indicating a strong perceived impact of singing on a sense of personal wellbeing. In Clift et al.'s (2010) study, it was found that singing provided support in coping with challenges in four aspects: enduring mental health problems, family and relationship problems, physical health challenges and recent bereavement.

## **4.3 Change in depression**

Our results show a statistically significant reduction in the percentage of participants who had depression in the post-intervention phase. It should be noted that the sample includes not only people with current mental health issues, 37.8% of whom gave depression scores below the clinical cut-off point. There was 9% reduction in the percentage of people who had depression, suggesting that the singing programme helps some people with mental illness to recover from the depression status. This is consistent with a recent study by Clift and Morrison (2011), who also found that singing programmes significantly reduce the depression rate among participants with depression.

The findings of our study indicate that a participative community singing programme is effective in preventing the deterioration of depression, and in improving resilience and quality of life. A CPSA can foster a sense of happiness, positive attitude towards life, and feelings of the significance of life. Singing is considered by participants a means to release

Effectiveness of Participative Community Singing

Christ Church University College.

Inclusion. 2011 Vol. 15(No.2):88-97.

Aging, Humanities and the Arts Vol. 1: 5–22.

Institute of Health and Welfare, Canberra.

10.1386/jaah.1.1.19/1: 19-34.

Psychologist Vol. 53: 205–220.

Alcohol Review Vol. 26: 109–117.

15(No. 3): 173–180.

Behavioral Medicine Vol. 15: 194–200.

Music, Rome.

6): 726–734.

Intervention Program on Promoting Resilience and Mental Health of Aboriginal... 251

Clift, S. & Hancox, G. (July 2008, in press). The significance of choral singing for sustaining

Clift, S., Hancox, G., Morrison, I., Hess, B., Kreutz, G. & Stewart, D. (2007, November).

Proceedings of the International Symposium on Performance Science, Porto. Clift, S., Hancox, G., Staricoff, R. & Whitmore, C. (2008). A systematic mapping and review

Clift, S., Hancox, G., Morrison, I., Hess, B., Kreutz, G., & Stewart, D. (2010). Choral singing

Clift S, Morrison I. (2011). Group singing fosters mental health and wellbeing: findings from

Cohen, G. D., Perlstein, S., Chapline, J., Kelly, J., Firth, K. M. & Simmens, S. (2006). The

Cohen, G. D., Perlstein, S., Chapline, J., Kelly, J., Firth, K. M. & Simmens, S. (2007). The

Lob, G. V., Camic, P. & Clift, S. (2011). The use of singing in a group as a response to adverse

Masten, A. S. & Coatsworth, J. D. (1998). The development of competence in favorable and

Pink, B. & Allbon, P. (2008). The Health and Welfare of Australia's Aboriginal and Torres

Schlesinger, C. M., Ober, C., McCarthy, M. M., Watson, J. D. & Seinen, A. (2007). The

Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P. & Bernard, J. (2008). The Brief

Tonneijck, H. I. M., Kinebanian, A. & Josephsson, S. (2008). An exploration of choir singing:

psychological welbeing: Findings from a survey of choristers in England, Germany and Australia. Paper presented at the ISME Commision Seminar on Community

Choral singing and psychological wellbeing: Findings from English choirs in a cross-national survey using the WHOQoL-BREF. Paper presented at the

of research on singing and health-non-clinical studies. Canterbury: Canterbury

and psychological wellbeing: Quantitative and qualitative findings from English choirs in a cross-national survey. Journal of Applied Arts and Health doi:

the East Kent ''singing for health'' network project. Mental Health and Social

impact of professionally conducted cultural programs on the physical health, mental health, and social functioning of older adults, The Gerontologist Vol. 46(No.

impact of professionally conducted culturally programs on the physical health, mental health and social functioning of older people-2 year results, Journal of

life events, International Journal of Mental Health Promotion Vol. 12(No. 3): 45–53.

unfavorable environments: lessons from research on successful children, American

Strait Islander Peoples 2008, Australian Bureau of Statistics, and Australian

development and validation of the Indigenous Risk Impact Screen (IRIS): A 13-item screening instrument for alcohol and drug and mental health risk, Drug and

Resilience Scale: Assessing the ability to bounce back, International Journal of

Achieving wholeness through challenge, Journal of Occupational Science Vol.

stress, and deal with worries and negative emotions. Singing is also regarded as a way to make them physically healthy as indicated in the reduced level of medication use.

A community-based participatory research approach can foster a sense of selfdetermination, create greater commitment and can ultimately improve self-esteem and increase a sense of belonging.

## **5. Limitations**

There are a number of limitations for the study. The first limitation is lack of control group as a comparison to intervention group in the post intervention phase. The difference between pre intervention and post intervention in resilience, quality of life and depression would not be attributable to the singing activities. The second limitation is that the standard measure of depression, for example, Beck's Depression Scale, and WHO Quality of Life Questionnaire were not used, and this may have limited the generalisation of the study results to other populations. Further study is needed to ensure the control group data are collected to strengthen the methodology and evidence of the present study. In addition, standard measures are needed in the next step of the study so that the results can be compared with previous published literature, and be generalised to wide population groups.

## **6. Conclusion**

The results of the study found that the community singing programme is effective in promoting social and emotional wellbeing, and preventing the deterioration of depression and chronic conditions. The results of the study may inform future studies of preventative and treatment interventions for high-risk populations that integrate community singing into prevention and intervention strategies in the Aboriginal and Torres Strait Islander population in Australia.

## **7. Acknowledgement**

The authors received financial support from Griffith Health Institute and Provost Chancellor Office at Logan Campus at Griffith University, and Queensland Aboriginal and Islander Health Council. The authors also wish to acknowledge the support of the following Aboriginal Community Controlled Health Services: *Brisbane Kambu Medical Service Centre Pty Ltd, Kalwun Health Service*, *Aboriginal and Torres Strait Islander Community Health Service Brisbane Ltd, Goolburri Health Advancement Corporation, and Warwick Peace Festival Community. The authors also wish to thank all participants' participation from five Aboriginal and Torres Strait Islander communities.* In addition, authors wish to express great thanks to Lindsay Johnson, Dion Tatow, Lennart Dahlen in Queensland Aboriginal and Islander Health Council for their contribution in data collection and intervention coordination work.

## **8. References**

Australian Bureau of Statistics. (2008). The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, ABS, Canberra.

Australian Institute of Health and Welfare. (2008). Australia's Health, Canberra.

stress, and deal with worries and negative emotions. Singing is also regarded as a way to

A community-based participatory research approach can foster a sense of selfdetermination, create greater commitment and can ultimately improve self-esteem and

There are a number of limitations for the study. The first limitation is lack of control group as a comparison to intervention group in the post intervention phase. The difference between pre intervention and post intervention in resilience, quality of life and depression would not be attributable to the singing activities. The second limitation is that the standard measure of depression, for example, Beck's Depression Scale, and WHO Quality of Life Questionnaire were not used, and this may have limited the generalisation of the study results to other populations. Further study is needed to ensure the control group data are collected to strengthen the methodology and evidence of the present study. In addition, standard measures are needed in the next step of the study so that the results can be compared with previous published literature, and be generalised to wide population

The results of the study found that the community singing programme is effective in promoting social and emotional wellbeing, and preventing the deterioration of depression and chronic conditions. The results of the study may inform future studies of preventative and treatment interventions for high-risk populations that integrate community singing into prevention and intervention strategies in the Aboriginal and Torres Strait Islander

The authors received financial support from Griffith Health Institute and Provost Chancellor Office at Logan Campus at Griffith University, and Queensland Aboriginal and Islander Health Council. The authors also wish to acknowledge the support of the following Aboriginal Community Controlled Health Services: *Brisbane Kambu Medical Service Centre Pty Ltd, Kalwun Health Service*, *Aboriginal and Torres Strait Islander Community Health Service Brisbane Ltd, Goolburri Health Advancement Corporation, and Warwick Peace Festival Community. The authors also wish to thank all participants' participation from five Aboriginal and Torres Strait Islander communities.* In addition, authors wish to express great thanks to Lindsay Johnson, Dion Tatow, Lennart Dahlen in Queensland Aboriginal and Islander Health Council for

Australian Bureau of Statistics. (2008). The Health and Welfare of Australia's Aboriginal and

their contribution in data collection and intervention coordination work.

Australian Institute of Health and Welfare. (2008). Australia's Health, Canberra.

Torres Strait Islander Peoples, ABS, Canberra.

make them physically healthy as indicated in the reduced level of medication use.

increase a sense of belonging.

**5. Limitations**

groups.

**6. Conclusion**

population in Australia.

**7. Acknowledgement**

**8. References**

**13**

*Canada*

**Antipsychotics Versus Cholinesterase**

**in Alzheimer's: A Critical Review**

*1Douglas Institute of Mental Health, Department of Psychiatry,*

*and Department of Psychiatry, McGill University, Montreal,*

*2Clinical Psychopharmacology Unit, McGill University Health Centre*

*McGill University, Montreal,*

**Inhibitors for the Treatment of Psychosis**

Emmanuelle Lévy1, Howard C Margolese2 and Serge Gauthier3

*3Professor of Neurology, Neurosurgery and Medicine, McGill University, and Director of the Alzheimer's disease Research Unit, McGill Centre for Studies in Aging, Montreal,*

In the later stages of dementia, more than 50% of patients will experience behavioral and psychological symptoms of dementia (BPSD) including psychosis (Hemels, 2001). These symptoms reputably cause distress in both patients and care-giving family members. Caregivers typically have reduced quality of life and see increases in the cost of care (Finkel, 1997; Herrmann, 2001), whereas patients tend to increase resource utilization and form a high-risk group for institutionalization (Daniel, 2000). Behavioral disorders being paramount, it is surprising that there is little agreement on the actual description of these symptoms (Stoppe, 1999). This reason among others, contributes to the perception that

"*treating secondary symptoms of AD is more of an art than a science*" (Corey-Bloom, 1995).

**2. Definition and clinical presentation of behavioral and psychological**

*thought content, mood or behavior frequently observed in demented patients*".

In seeking pharmacological treatment options for psychotic symptoms in Alzheimer's disease, this review will attempt to address the following four questions: 1) What is the definition and clinical presentation of BPSD? 2) What is the prevalence and impact of psychotic symptoms on the progression of dementia in AD? 3) What are the indications for the use of antipsychotics in the treatment of BPSD? 4) What are the evidence-based

In 1996, the International Psychogeriatric Association consensus group defined behavioral and psychological symptoms of dementia (BPSD) as: "*symptoms of disturbances of perception,*

Many classifications of BPSD have been proposed. When pharmacological treatment is concerned, classifying BPSD by syndromes is most useful. Although it is often difficult to

**1. Introduction**

treatments for BPSD?

**symptoms of dementia (BPSD)**

## **Antipsychotics Versus Cholinesterase Inhibitors for the Treatment of Psychosis in Alzheimer's: A Critical Review**

Emmanuelle Lévy1, Howard C Margolese2 and Serge Gauthier3 *1Douglas Institute of Mental Health, Department of Psychiatry, McGill University, Montreal, 2Clinical Psychopharmacology Unit, McGill University Health Centre and Department of Psychiatry, McGill University, Montreal, 3Professor of Neurology, Neurosurgery and Medicine, McGill University, and Director of the Alzheimer's disease Research Unit, McGill Centre for Studies in Aging, Montreal, Canada*

## **1. Introduction**

252 Essential Notes in Psychiatry

Weinberger, D. A., Schwartz, G. E. & Davidson, R. J. (1979). Low-anxious, high-anxious, and

responses to stress, Journal of Abnormal Psychology Vol. 88: 369–380. Werner, E. E. & Smith, R. S. (2001). Journeys from childhood to midlife: Risk, resilience, and

Vol. 39(No. 5): 657–670.

repressive coping styles: Psychometric patterns and behavioral and physiological

recovery. Introduction to the special issue on resilience, Substance Use & Misuse

In the later stages of dementia, more than 50% of patients will experience behavioral and psychological symptoms of dementia (BPSD) including psychosis (Hemels, 2001). These symptoms reputably cause distress in both patients and care-giving family members. Caregivers typically have reduced quality of life and see increases in the cost of care (Finkel, 1997; Herrmann, 2001), whereas patients tend to increase resource utilization and form a high-risk group for institutionalization (Daniel, 2000). Behavioral disorders being paramount, it is surprising that there is little agreement on the actual description of these symptoms (Stoppe, 1999). This reason among others, contributes to the perception that "*treating secondary symptoms of AD is more of an art than a science*" (Corey-Bloom, 1995).

In seeking pharmacological treatment options for psychotic symptoms in Alzheimer's disease, this review will attempt to address the following four questions: 1) What is the definition and clinical presentation of BPSD? 2) What is the prevalence and impact of psychotic symptoms on the progression of dementia in AD? 3) What are the indications for the use of antipsychotics in the treatment of BPSD? 4) What are the evidence-based treatments for BPSD?

### **2. Definition and clinical presentation of behavioral and psychological symptoms of dementia (BPSD)**

In 1996, the International Psychogeriatric Association consensus group defined behavioral and psychological symptoms of dementia (BPSD) as: "*symptoms of disturbances of perception, thought content, mood or behavior frequently observed in demented patients*".

Many classifications of BPSD have been proposed. When pharmacological treatment is concerned, classifying BPSD by syndromes is most useful. Although it is often difficult to

Antipsychotics Versus Cholinesterase Inhibitors

**4. Use of antipsychotics in the elderly**

replace atypical agents in the treatment of BPSD.

treatment of BPSD, what are the evidence-based alternatives?

**5. Evidence-based treatment-options for BPSD**

Rubin, 1989).

between antipsychotics.

**Non-pharmacological options**

for the Treatment of Psychosis in Alzheimer's: A Critical Review 255

al., 1992; Lopez et al., 1991; Stern et al., 1987). Interestingly, patients manifesting earlier psychotic symptoms were found to live longer than those without psychosis (Drevets &

Though outside of the official FDA indication, in the elderly, atypical antipsychotics are most frequently prescribed for the treatment of behavioral symptoms of dementia. In May 2004, the FDA issued a warning of an increased death risk in elderly patients using atypical antipsychotics (Jeste et al., 2008). This warning was based on a meta-analysis of seventeen randomized double-blind controlled trials revealing a drug-related death risk increasing by 1.6-1.7 times when compared to placebo (Jeste et al., 2008). Most frequent causes of death were cardiovascular (heart failure or sudden death) and infectious (pneumonia). In April 2005, the FDA followed suit with a black box warning cautioning against the use of atypical antipsychotics in the elderly. Later the same year, a meta-analysis of 15 randomized controlled trials (Schneider *et al.,* 2005) examined the mortality risk between placebo and atypical antipsychotics as well as a comparison between various atypical antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone). This study found a small increased mortality risk compared to placebo (OR = 1.54; 95%CI: 1.06-2.23). No difference was found

Given that this meta-analysis and the FDA warning did not apply to typical antipsychotics, the remaining assumption was that typical agents could be warranted in the treatment of BPSD. However, a study published in the New England Journal of Medicine compared the use of typical and atypical antipsychotics in the elderly and found that typical antipsychotics were associated with a significantly higher risk of death than atypical antipsychotics (Wang *et al*., 2005). Hence, typical antipsychotics should not be used to

Currently, the FDA has not approved of any treatment for BPSD. Facing agitation in the elderly and consequent caregiver distress, clinicians are left with unclear choices. In the

In the treatment of BPSD, an initial assessment of the underlying causes of behavioral changes is necessary. Co-morbid medical illnesses and sensory impairment should be corrected prior to medication use. It has even been suggested that non-pharmacological approaches, including music therapy, light therapy, changes in stimulation, and specific behavioral techniques such as positive reinforcement could be attempted before medication (Beck & Shue, 1994; Opie et al., 1999). Although pharmacological treatment of BPSD should not be first line, high rates of psychotropic drug use have been reported, particularly in very old patients living in institutions (Giron, 2001). Between 39% and 51% of elderly institutionalized patients were found to be treated with antipsychotics (Avorn et al., 1989; Lantz et al., 1990). In the pharmacological treatment of BPSD, antipsychotic are the agents

subgroup behavioral symptoms, psychological symptoms can be grouped into three syndromes: psychotic, depressive and delirious. A more descriptive classification summarizes the characteristic symptoms of BPSD in table 1.

Different BPSD appear at different stages of the illness. Affective symptoms tend to appear in the early stages of dementia (Reisberg et al., 1989; Rubin et al., 1988), whereas psychotic symptoms and agitation are more frequent in patients with moderate cognitive dysfunction. In fact, most BPSD are present prior to the later stages of the illness, when they abate possibly because of the physical and neurological deterioration of the patient (Tariot & Blazina, 1994).

## **3. Prevalence and impact of psychotic symptoms in dementia**

In a review of 30 studies of patients with AD, affective and psychotic symptoms were found to occur in 30%-40% of patients (Wragg & Jeste, 1989). However, up to 90% of patients living in institutions may suffer BPSD (Finkel, 1998). In patients with AD, the prevalence of psychotic symptoms alone is quite variable and was found to cluster around 20%-40% (Raskind & Barnes, 2002). In a study following patients longitudinally from the beginning to the later stages of AD, presence of psychotic symptoms was documented in over 50% of patients, and was more common at moderate and severe stages of dementia (42 to 84%) (Drevets & Rubin, 1989). Furthermore, in a one year longitudinal study, recurrence rates of psychotic symptoms in untreated patients have been estimated at 95% (Levy et al., 1996).

The two most common psychotic symptoms that develop in AD are delusions and hallucinations. The median prevalence of delusions is 36%, ranging between 9% and 63% (Ropacki and Jeste, 2005). Among the most frequent types of delusions identified are persecutory (involving theft) in 18-43% of patients followed by delusions of abandonment in 3-18% and delusions of jealousy (involving infidelity) in 1-9% (Tariot & Blazina, 1994). Hallucinations were estimated to vary between 4-41% hallucinations with a median of 18% (Ropacki and Jeste, 2005). Visual hallucinations were reported in up to 30% of moderately demented patients, whereas auditory hallucinations may occur in up to 10% of patients (Swearer, 1994). Other types of hallucinations such as olfactory, tactile, gustatory and haptic are rarely observed (Tariot & Blazina, 1994).

Aggression, one of the major behavioral symptoms in dementia, causes great distress in caregivers and can lead to earlier institutionalization (Chenoweth & Spencer, 1986; Rabins PV et al., 1982; Rabins et al., 1982). Delusions, mainly persecutory, have been identified as a risk factor for physical and verbal aggression in patients with AD (Deutsch et al., 1991). For instance, Deutsch et al. (1991) reported that out 181 AD patients, 43.5% suffered delusions, of which 29.6% were noted to be physically aggressive. Furthermore, delusions preceded and were significantly associated with aggressive behavior (Deutsch et al., 1991). The converse has also been shown in another study where 80% of patients with high levels of aggression (more than one episode/month) also presented with delusions (Gilley et al., 1997). This suggests that the presence of delusions predicts the frequency of physically aggressive behavior.

Increased rates of cognitive deterioration are also associated with psychotic symptoms in AD particularly in patients manifesting psychosis earlier in the course of dementia (Jeste et al., 1992; Lopez et al., 1991; Stern et al., 1987). Interestingly, patients manifesting earlier psychotic symptoms were found to live longer than those without psychosis (Drevets & Rubin, 1989).

## **4. Use of antipsychotics in the elderly**

254 Essential Notes in Psychiatry

subgroup behavioral symptoms, psychological symptoms can be grouped into three syndromes: psychotic, depressive and delirious. A more descriptive classification

Different BPSD appear at different stages of the illness. Affective symptoms tend to appear in the early stages of dementia (Reisberg et al., 1989; Rubin et al., 1988), whereas psychotic symptoms and agitation are more frequent in patients with moderate cognitive dysfunction. In fact, most BPSD are present prior to the later stages of the illness, when they abate possibly because of the physical and neurological deterioration of the patient (Tariot &

In a review of 30 studies of patients with AD, affective and psychotic symptoms were found to occur in 30%-40% of patients (Wragg & Jeste, 1989). However, up to 90% of patients living in institutions may suffer BPSD (Finkel, 1998). In patients with AD, the prevalence of psychotic symptoms alone is quite variable and was found to cluster around 20%-40% (Raskind & Barnes, 2002). In a study following patients longitudinally from the beginning to the later stages of AD, presence of psychotic symptoms was documented in over 50% of patients, and was more common at moderate and severe stages of dementia (42 to 84%) (Drevets & Rubin, 1989). Furthermore, in a one year longitudinal study, recurrence rates of psychotic symptoms in untreated patients have been estimated at 95%

The two most common psychotic symptoms that develop in AD are delusions and hallucinations. The median prevalence of delusions is 36%, ranging between 9% and 63% (Ropacki and Jeste, 2005). Among the most frequent types of delusions identified are persecutory (involving theft) in 18-43% of patients followed by delusions of abandonment in 3-18% and delusions of jealousy (involving infidelity) in 1-9% (Tariot & Blazina, 1994). Hallucinations were estimated to vary between 4-41% hallucinations with a median of 18% (Ropacki and Jeste, 2005). Visual hallucinations were reported in up to 30% of moderately demented patients, whereas auditory hallucinations may occur in up to 10% of patients (Swearer, 1994). Other types of hallucinations such as olfactory, tactile, gustatory and haptic

Aggression, one of the major behavioral symptoms in dementia, causes great distress in caregivers and can lead to earlier institutionalization (Chenoweth & Spencer, 1986; Rabins PV et al., 1982; Rabins et al., 1982). Delusions, mainly persecutory, have been identified as a risk factor for physical and verbal aggression in patients with AD (Deutsch et al., 1991). For instance, Deutsch et al. (1991) reported that out 181 AD patients, 43.5% suffered delusions, of which 29.6% were noted to be physically aggressive. Furthermore, delusions preceded and were significantly associated with aggressive behavior (Deutsch et al., 1991). The converse has also been shown in another study where 80% of patients with high levels of aggression (more than one episode/month) also presented with delusions (Gilley et al., 1997). This suggests that the presence of delusions predicts the frequency of physically

Increased rates of cognitive deterioration are also associated with psychotic symptoms in AD particularly in patients manifesting psychosis earlier in the course of dementia (Jeste et

summarizes the characteristic symptoms of BPSD in table 1.

**3. Prevalence and impact of psychotic symptoms in dementia**

Blazina, 1994).

(Levy et al., 1996).

aggressive behavior.

are rarely observed (Tariot & Blazina, 1994).

Though outside of the official FDA indication, in the elderly, atypical antipsychotics are most frequently prescribed for the treatment of behavioral symptoms of dementia. In May 2004, the FDA issued a warning of an increased death risk in elderly patients using atypical antipsychotics (Jeste et al., 2008). This warning was based on a meta-analysis of seventeen randomized double-blind controlled trials revealing a drug-related death risk increasing by 1.6-1.7 times when compared to placebo (Jeste et al., 2008). Most frequent causes of death were cardiovascular (heart failure or sudden death) and infectious (pneumonia). In April 2005, the FDA followed suit with a black box warning cautioning against the use of atypical antipsychotics in the elderly. Later the same year, a meta-analysis of 15 randomized controlled trials (Schneider *et al.,* 2005) examined the mortality risk between placebo and atypical antipsychotics as well as a comparison between various atypical antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone). This study found a small increased mortality risk compared to placebo (OR = 1.54; 95%CI: 1.06-2.23). No difference was found between antipsychotics.

Given that this meta-analysis and the FDA warning did not apply to typical antipsychotics, the remaining assumption was that typical agents could be warranted in the treatment of BPSD. However, a study published in the New England Journal of Medicine compared the use of typical and atypical antipsychotics in the elderly and found that typical antipsychotics were associated with a significantly higher risk of death than atypical antipsychotics (Wang *et al*., 2005). Hence, typical antipsychotics should not be used to replace atypical agents in the treatment of BPSD.

Currently, the FDA has not approved of any treatment for BPSD. Facing agitation in the elderly and consequent caregiver distress, clinicians are left with unclear choices. In the treatment of BPSD, what are the evidence-based alternatives?

## **5. Evidence-based treatment-options for BPSD**

#### **Non-pharmacological options**

In the treatment of BPSD, an initial assessment of the underlying causes of behavioral changes is necessary. Co-morbid medical illnesses and sensory impairment should be corrected prior to medication use. It has even been suggested that non-pharmacological approaches, including music therapy, light therapy, changes in stimulation, and specific behavioral techniques such as positive reinforcement could be attempted before medication (Beck & Shue, 1994; Opie et al., 1999). Although pharmacological treatment of BPSD should not be first line, high rates of psychotropic drug use have been reported, particularly in very old patients living in institutions (Giron, 2001). Between 39% and 51% of elderly institutionalized patients were found to be treated with antipsychotics (Avorn et al., 1989; Lantz et al., 1990). In the pharmacological treatment of BPSD, antipsychotic are the agents

Antipsychotics Versus Cholinesterase Inhibitors

(Gauthier et al., 2008).

alone (Weiser et al., 2002).

**6. Conclusion**

al., 1999).

al., (2006).

with other agents are warranted.

for the Treatment of Psychosis in Alzheimer's: A Critical Review 257

A systematic review and meta-analysis quantified the efficacy of cholinesterase inhibitors as a group for neuropsychiatric symptoms in patients with mild to moderate AD (Trinh et al., 2003). This study found a modest beneficial impact on neuropsychiatric and functional outcomes. Other studies looking at the effects of galantamine (Hermann et al, 2005), donepezil (Holmes et al., 2004) and metrifonate (Kaufer, 1998) showed a modestly better outcome in behavioral symptoms than placebo-treated subjects. Another study compared memantine and placebo in AD patients treated with donepezil (Cummings et al., 2006 Neurology). Patients treated with donepezil and memantine had better behavioral outcomes that those treated with donepezil and placebo. Finally, a recent pooled analysis from six RCTs found a small but significant benefit from memantine in behavioral outcome scores

Finally, one pilot open-label study assessed the safety of co-administration of rivastigmine with risperidone in dementia patients with behavioral disturbances (Weiser et al., 2002). The authors' main findings were two-fold: first, both these agents could be coadministered with no significant adverse effects and second, significant improvement in NPI scores were found in the rivastigmine-risperidone group of patients. These findings suggest that combination of these two agents might be more efficacious than either one

Addressing behavioral and psychological symptoms of dementia is paramount. Psychotic symptoms in AD occur in a majority of patients, and have a very high recurrence rate. Untreated BPSD can result in increased rates of hospitalization, institutionalization, cost of care and diminished quality of life for both patients and caregivers. Pharmacological treatment of BPSD should not be first line. Initial assessments of the underlying causes of BPSD are warranted and co-morbid medical illnesses should be corrected before initiating pharmacological treatment. In mild to moderate cases, non-pharmacological approaches (including music therapy, light therapy, changes in stimulation, and behavioral techniques) could be attempted before medications are used (Beck & Shue, 1994; Opie et

Given the FDA warnings, atypical antipsychotics should only be considered in moderate to severe cases on a case-by-case basis after careful evaluation of the risk-benefit ratio. The preferred antipsychotic seems to be risperidone as it was the only agent found in a metaanalysis of six RCTs to non-significantly increase mortality (Haupt et al., 2006) while another meta-analysis of fifteen trails found it to significantly improve psychosis scores (Schneider et

Facing the paucity of safe and effective medications available, cholinesterase inhibitors may be used as first line pharmacotherapy. Cholinesterase inhibitors have positive psychotropic effects in AD and are modestly effective in the treatment of BPSD. However, many AD patients are taking cholinesterase inhibitors and nevertheless develop BPSD. In such cases, the augmentation with memantine (Cummings et al, 2006) or risperidone (Weiser et al, 2002) may be warranted. More studies examining the combination of cholinesterase inhibitors

that have been most frequently studied (Stoppe, 1999). In mild or moderate BPSD cases, particularly when symptoms are not interfering strongly with functioning, clinicians may opt not to treat BPSD. In such mild to moderate cases, psychosocial interventions (eg music therapy, cognitive therapy, behavioral management techniques, caregiver education) may have modest effectiveness (Cohen-Mansfield, 2001; Livingston et al, 2005).

In severe cases where psychotic symptoms and agitation interfere with functioning and cause significant caregiver distress, lack of treatment may be dangerous. Below we review the pharmacological treatment options for BPSD.

## **Antipsychotics**

A number of well-controlled trials predating the 2005 FDA warnings had examined the effectiveness of atypical antipsychotics in the treatment of BPSD. These studies are summarized and presented in Table 2. In the treatment of BPSD, atypical antipsychotics seem to be of significant though modest effectiveness. However, given the FDA black box warnings, much caution is necessary in using antipsychotics in the elderly.

The large NIMH funded Clinical Antipsychotic Trial of Intervention Effectiveness study for Alzheimer's Disease (CATIE-AD) trial found that olanzapine, quetiapine, and risperidone were no better than placebo in the treatment of psychotic symptoms of dementia. However, in a review of 15 randomized controlled trials (RCTs) of atypical antipsychotics for the treatment of BPSD, only risperidone was found to significantly improve psychosis scores (Schneider et al (2006).

## **Cholinesterase inhibitors**

There is some evidence supporting the relationship between cholinergic neurotransmission and behavioral symptoms of AD (Cummings & Kaufer, 1996). Given that neuropsychiatric changes in AD are associated with cholinergic deficits, one expects neuropsychiatric changes to respond to cholinergic therapy. Supporting this cholinergic hypothesis, Cummings (2000b) linked cholinergic deficits to behavior by identifying the following four dimensions of behavioral symptoms: "1) *induction of AD-like behaviours in normal individuals by administration of anticholinergic drugs;* 2) *the exaggeration of behavioural disturbances in AD patients by anticholinergic agents;* 3) *the correlation of the distribution of cholinergic deficits of AD with regions that are relevant to the observed behaviours, i.e. frontal and temporal regions; and* 4) *improvement of behavioural disturbances in AD patients treated with cholinergic receptor agonists and cholinesterase inhibitors*" (Cummings, 2000b).

Cummings also provides some compelling evidence that cholinesterase inhibitors have positive psychotropic effects in AD (Cummings, 2000a). For instance, patients with anticholinergic delirium (agitation and psychosis) were found to be similar to AD patients with non-cognitive symptoms (hallucinations and agitation). Given that these symptoms responded well to treatment enhancing cholinergic activity (Cummings, 1993), adjusting acetylcholine levels can reduce psychosis.

Displayed in table 3 are open label and double-blind studies on cholinesterase inhhibitors (tacrine, donepezil, metrifonate, galantamine and rivastigmine) that have found reductions of non-cognitive behaviors over placebo.

A systematic review and meta-analysis quantified the efficacy of cholinesterase inhibitors as a group for neuropsychiatric symptoms in patients with mild to moderate AD (Trinh et al., 2003). This study found a modest beneficial impact on neuropsychiatric and functional outcomes. Other studies looking at the effects of galantamine (Hermann et al, 2005), donepezil (Holmes et al., 2004) and metrifonate (Kaufer, 1998) showed a modestly better outcome in behavioral symptoms than placebo-treated subjects. Another study compared memantine and placebo in AD patients treated with donepezil (Cummings et al., 2006 Neurology). Patients treated with donepezil and memantine had better behavioral outcomes that those treated with donepezil and placebo. Finally, a recent pooled analysis from six RCTs found a small but significant benefit from memantine in behavioral outcome scores (Gauthier et al., 2008).

Finally, one pilot open-label study assessed the safety of co-administration of rivastigmine with risperidone in dementia patients with behavioral disturbances (Weiser et al., 2002). The authors' main findings were two-fold: first, both these agents could be coadministered with no significant adverse effects and second, significant improvement in NPI scores were found in the rivastigmine-risperidone group of patients. These findings suggest that combination of these two agents might be more efficacious than either one alone (Weiser et al., 2002).

## **6. Conclusion**

256 Essential Notes in Psychiatry

that have been most frequently studied (Stoppe, 1999). In mild or moderate BPSD cases, particularly when symptoms are not interfering strongly with functioning, clinicians may opt not to treat BPSD. In such mild to moderate cases, psychosocial interventions (eg music therapy, cognitive therapy, behavioral management techniques, caregiver education) may

In severe cases where psychotic symptoms and agitation interfere with functioning and cause significant caregiver distress, lack of treatment may be dangerous. Below we review

A number of well-controlled trials predating the 2005 FDA warnings had examined the effectiveness of atypical antipsychotics in the treatment of BPSD. These studies are summarized and presented in Table 2. In the treatment of BPSD, atypical antipsychotics seem to be of significant though modest effectiveness. However, given the FDA black box

The large NIMH funded Clinical Antipsychotic Trial of Intervention Effectiveness study for Alzheimer's Disease (CATIE-AD) trial found that olanzapine, quetiapine, and risperidone were no better than placebo in the treatment of psychotic symptoms of dementia. However, in a review of 15 randomized controlled trials (RCTs) of atypical antipsychotics for the treatment of BPSD, only risperidone was found to significantly improve psychosis scores

There is some evidence supporting the relationship between cholinergic neurotransmission and behavioral symptoms of AD (Cummings & Kaufer, 1996). Given that neuropsychiatric changes in AD are associated with cholinergic deficits, one expects neuropsychiatric changes to respond to cholinergic therapy. Supporting this cholinergic hypothesis, Cummings (2000b) linked cholinergic deficits to behavior by identifying the following four dimensions of behavioral symptoms: "1) *induction of AD-like behaviours in normal individuals by administration of anticholinergic drugs;* 2) *the exaggeration of behavioural disturbances in AD patients by anticholinergic agents;* 3) *the correlation of the distribution of cholinergic deficits of AD with regions that are relevant to the observed behaviours, i.e. frontal and temporal regions; and* 4) *improvement of behavioural disturbances in AD patients treated with cholinergic receptor agonists*

Cummings also provides some compelling evidence that cholinesterase inhibitors have positive psychotropic effects in AD (Cummings, 2000a). For instance, patients with anticholinergic delirium (agitation and psychosis) were found to be similar to AD patients with non-cognitive symptoms (hallucinations and agitation). Given that these symptoms responded well to treatment enhancing cholinergic activity (Cummings, 1993), adjusting

Displayed in table 3 are open label and double-blind studies on cholinesterase inhhibitors (tacrine, donepezil, metrifonate, galantamine and rivastigmine) that have found reductions

have modest effectiveness (Cohen-Mansfield, 2001; Livingston et al, 2005).

warnings, much caution is necessary in using antipsychotics in the elderly.

the pharmacological treatment options for BPSD.

*and cholinesterase inhibitors*" (Cummings, 2000b).

acetylcholine levels can reduce psychosis.

of non-cognitive behaviors over placebo.

**Antipsychotics**

(Schneider et al (2006).

**Cholinesterase inhibitors**

Addressing behavioral and psychological symptoms of dementia is paramount. Psychotic symptoms in AD occur in a majority of patients, and have a very high recurrence rate. Untreated BPSD can result in increased rates of hospitalization, institutionalization, cost of care and diminished quality of life for both patients and caregivers. Pharmacological treatment of BPSD should not be first line. Initial assessments of the underlying causes of BPSD are warranted and co-morbid medical illnesses should be corrected before initiating pharmacological treatment. In mild to moderate cases, non-pharmacological approaches (including music therapy, light therapy, changes in stimulation, and behavioral techniques) could be attempted before medications are used (Beck & Shue, 1994; Opie et al., 1999).

Given the FDA warnings, atypical antipsychotics should only be considered in moderate to severe cases on a case-by-case basis after careful evaluation of the risk-benefit ratio. The preferred antipsychotic seems to be risperidone as it was the only agent found in a metaanalysis of six RCTs to non-significantly increase mortality (Haupt et al., 2006) while another meta-analysis of fifteen trails found it to significantly improve psychosis scores (Schneider et al., (2006).

Facing the paucity of safe and effective medications available, cholinesterase inhibitors may be used as first line pharmacotherapy. Cholinesterase inhibitors have positive psychotropic effects in AD and are modestly effective in the treatment of BPSD. However, many AD patients are taking cholinesterase inhibitors and nevertheless develop BPSD. In such cases, the augmentation with memantine (Cummings et al, 2006) or risperidone (Weiser et al, 2002) may be warranted. More studies examining the combination of cholinesterase inhibitors with other agents are warranted.

Antipsychotics Versus Cholinesterase Inhibitors

for the Treatment of Psychosis in Alzheimer's: A Critical Review 259

Part II

NPI = Neuropsychiatric Inventory, NPI-NH: Neuropsychiatric Inventory Nursing Home Version

1 - NOSIE = Nurses' Observation Scale for Inpatient Evaluation 2 - SCAG = Sandoz Clinical Assessment Geriatric Scale

CGI-S = Clinical Global Impression-Severity of Illness Scale

BPRS = Brief Psychiatric Rating Scale

NA = Not Available

BEHAVE-AD = Behavioural Pathology in Alzheimer's Disease Rating Scale

Table 2. Treatment of psychosis in AD: Atypical antipsychotics.

Table 1. Slassification of behavioral and psychological symptoms of dementia (BPSD).

#### Table 2. Part I.

Table 1. Slassification of behavioral and psychological symptoms of dementia (BPSD).

Table 2. Part I.

1 - NOSIE = Nurses' Observation Scale for Inpatient Evaluation

2 - SCAG = Sandoz Clinical Assessment Geriatric Scale

NPI = Neuropsychiatric Inventory, NPI-NH: Neuropsychiatric Inventory Nursing Home Version BEHAVE-AD = Behavioural Pathology in Alzheimer's Disease Rating Scale

BPRS = Brief Psychiatric Rating Scale

CGI-S = Clinical Global Impression-Severity of Illness Scale

NA = Not Available

Table 2. Treatment of psychosis in AD: Atypical antipsychotics.

Antipsychotics Versus Cholinesterase Inhibitors

for the Treatment of Psychosis in Alzheimer's: A Critical Review 261

Part II

CIBIC-Plus: Clinician's Interview-Based Impression of Change Plus scale

Table 3. Cholinesterase inhibitors for psychosis in AD.

ADAS-non-cog: Non-Cognitive portion of the Alzheimer's Disease Assessment Scale

Table 3. Part I

CIBIC-Plus: Clinician's Interview-Based Impression of Change Plus scale ADAS-non-cog: Non-Cognitive portion of the Alzheimer's Disease Assessment Scale

Part II

Table 3. Cholinesterase inhibitors for psychosis in AD.

260 Essential Notes in Psychiatry

Table 3. Part I

Antipsychotics Versus Cholinesterase Inhibitors

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**14**

**The Relative Efficacy of Live Graded Exposure,**

**Live Modeling, and Computer-Based Symbolic**

This chapter describes a research work that investigated whether a computer-based symbolic modeling procedure could be successfully used in the treatment of a maladaptive emotional condition, namely spider phobia. It also examined whether the procedure would prove to be as effective as other conventional treatments for the same clinical condition.

The efficacy of any therapeutic strategy presumably depends considerably on the accuracy with which the systems of the human body, as well as the ways in which they function, are conceived. Accordingly, an accurate model of human emotional functioning is crucial for the construction of a therapeutic framework that expresses an integral set of scientifically established facts about emotion and sets forth relevant objectives and specific principles for clinical application. A major line of investigation in this research was concerned with the diversity of existing concepts of emotion (such as fear and anxiety) and its components, which has led the various therapeutic approaches to emphasize different emotional components as the major target of their therapeutic techniques. The objective in this respect was to investigate whether specific conceptualizations of emotion, fear and anxiety in particular, could be consolidated to form a coherent theoretical basis for the proposed, computer-based, delivery system. In this respect, a specific psychological problem (i.e., specific phobia) was targeted to provide a reference point in exploring the theoretical and clinical dimensions of this investigation. This principal line of research is reviewed in detail in the next section below.

Another line of investigation in this research concerned the usability of computers in delivering treatment for behavioral problems such as anxiety-related disorders including phobias. The objective was to verify the efficacy of a self-administered, computer-based, treatment technique in producing effective therapeutic change, hence providing theoretical and empirical bases for expanding behavioral treatment to meet a substantial proportion of the current demand. This line of research is outlined in section 3 on human-computer interaction.

Current Address: *Department of Mental Health, King Faisal Specialist Hospital & Research Center, Riyadh,*

**1. Introduction**

 \*

*Saudi Arabia*

**Modeling in the Treatment of Spider Phobia:**

*Department of Anatomy, School of Medicine, and Department of Psychology,*

**A Perspective of Emotion**

Ahmed M. Hassan\*

*Leeds University,*

*UK*

## **The Relative Efficacy of Live Graded Exposure, Live Modeling, and Computer-Based Symbolic Modeling in the Treatment of Spider Phobia: A Perspective of Emotion**

Ahmed M. Hassan\*

*Department of Anatomy, School of Medicine, and Department of Psychology, Leeds University, UK*

## **1. Introduction**

268 Essential Notes in Psychiatry

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treatment of neuropsychiatric symptoms and functional impairment in Alzheimer

atypical antipsychotic medications." New England Journal of Medicine 353(22):

pilot, randomized, open-label trial assessing safety and pharmakokinetic parameters of co-administration of rivastigmine with risperidone in dementia

randomized, placebo-controlled study of donepezil in patients with mild to

This chapter describes a research work that investigated whether a computer-based symbolic modeling procedure could be successfully used in the treatment of a maladaptive emotional condition, namely spider phobia. It also examined whether the procedure would prove to be as effective as other conventional treatments for the same clinical condition.

The efficacy of any therapeutic strategy presumably depends considerably on the accuracy with which the systems of the human body, as well as the ways in which they function, are conceived. Accordingly, an accurate model of human emotional functioning is crucial for the construction of a therapeutic framework that expresses an integral set of scientifically established facts about emotion and sets forth relevant objectives and specific principles for clinical application. A major line of investigation in this research was concerned with the diversity of existing concepts of emotion (such as fear and anxiety) and its components, which has led the various therapeutic approaches to emphasize different emotional components as the major target of their therapeutic techniques. The objective in this respect was to investigate whether specific conceptualizations of emotion, fear and anxiety in particular, could be consolidated to form a coherent theoretical basis for the proposed, computer-based, delivery system. In this respect, a specific psychological problem (i.e., specific phobia) was targeted to provide a reference point in exploring the theoretical and clinical dimensions of this investigation. This principal line of research is reviewed in detail in the next section below.

Another line of investigation in this research concerned the usability of computers in delivering treatment for behavioral problems such as anxiety-related disorders including phobias. The objective was to verify the efficacy of a self-administered, computer-based, treatment technique in producing effective therapeutic change, hence providing theoretical and empirical bases for expanding behavioral treatment to meet a substantial proportion of the current demand. This line of research is outlined in section 3 on human-computer interaction.

<sup>\*</sup> Current Address: *Department of Mental Health, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia*

The Relative Efficacy of Live Graded Exposure, Live Modeling, and Computer-

concepts of emotion.

they focus on maladaptive thought patterns and related cognitive processes.

Based Symbolic Modeling in the Treatment of Spider Phobia: A Perspective of Emotion 271

speaking, these approaches argue that an individual's emotional reactions are determined by the way he/she interprets events (Greenberg and Safran, 1987). Therefore, these personal meanings of events are the primary targets of change in cognitive therapy; hence

These, rather 'skewed', concepts of the emotion of fear, which underlie the therapeutic approaches so far outlined, are probably a contributory factor in the frequently observed discordance between autonomic, somatic motor, and cognitive components of fear in their rate of response to treatment (Rachman, 1978, 1990). However, despite the diverse notions about emotion, there seems to be a consensus on the multi-component nature of emotion (Lang, 1971, 1985; Scherer, 1984; Frijda, 1986; Gray, 1990). Lang's (1968, 1971) three-system model of emotion conceptualizes fear and anxiety in terms of overt behavioral, cognitive, and autonomic components. Further, Rachman (1977) has found that the response systems underlying these three components of fear do not always co-vary and, therefore, a treatment procedure that affects only one or two response systems may result in incomplete treatment in terms of residual fear in other response systems. On the basis of this proposition, an effective treatment of, for example, phobia would be expected to induce a therapeutic change in all response systems. Nevertheless, different theoretical and therapeutic perspectives of emotion tend to emphasize the primacy of one component over the others. Rachman (1981), for example, suggests that behaviorally-based treatments will probably prove more effective than cognitive treatments of emotional disorders. Further, Zajonc (1984) proposes the independence of emotion from cognition (For a critical review of Zajonc's (1984) proposition on the primacy of emotion, see Hassan and Ward, 1991). Accordingly, one may logically argue that if a behaviorally based treatment of an irrational emotional state, such as phobia, would prove effective, then there must be a central mechanism whereby the behaviorally induced therapeutic change also mediates cognitive and autonomic change. This proposition is pursued below after reviewing some major

The cognitive-appraisal theories of emotion (e.g., Schachter, 1964; Lazarus, 1982, 1984; Scherer, 1984) argue for the primacy of cognitive processes in determining an emotional state. They hold that an emotional state is the product of an interaction between two components: physiological arousal, and cognition about the cause of that arousal. Therefore, the perception or attribution of a causal connection between the two components is necessary for the generation of an emotional state. According to these theories, cognitions determine the quality of emotions, while arousal determines the intensity of these emotions. Hence, like Cannon's (1927) assertion, it is proposed that arousal in itself is emotionally non-specific. However, the various studies conducted to test the predictions derived from the cognitive-appraisal theory, concerning the mis-attribution of drug-induced arousal to emotional or neutral cues, revealed that the evidence for the theory was generally weak (Leventhal and Tomarken, 1986). Further, some studies (e.g., Rogers and Deckner, 1975; Marshal and Zimbardo, 1979; Maslach, 1979) showed that the unexplained arousal was in fact found to induce heightened negative affect. Similarly, the manipulation of attributions concerning anxiety and other negative emotional states, in clinical settings, have generally failed (e.g., Bootzin, Herman and Nicassio, 1976;

On the other hand, Leventhal (1984) identifies a hierarchical emotional processing mechanism, consisting of a series of temporal stages, in the cognitive system. He argues that

Chamblis and Murray, 1979; Cotton, Baron and Borkovec, 1980).

Subsequently, a prototype computer-based symbolic modeling technique for the treatment of spider phobia, which was constructed on the basis of a proposed theoretical concept of emotion, was described in section 4. The effectiveness of the technique was compared with that of two conventional methods for treating spider phobia in order to validate its clinical efficacy. Spider phobia was selected as the clinical problem of investigation mainly because of its clinical specificity. The clinical results, described and discussed in sections 5 and 6, further suggest that the effect induced in either of the cognitive or overt verbal response systems underlying respective fear components is likely to similarly and equally affect the fear component manifested by the other systems. The findings of this work may warrant the development of similar techniques for the treatment of other similar behavioral problems concerned with anxiety and fear.

## **2. Emotion: review and implications**

The literature on emotion shows that the nature of emotion and the mechanisms involved in its experience and expression constitute a field of long-standing controversy (e.g., James, 1890/1950; Cannon, 1927; Papez, 1937; MacLean, 1950; Schachter, 1964; Lazarus, 1984; Zajonc, 1984; Panksepp, 1988, 1990; Gray, 1982, 1990; Hassan and Ward, 1991). The result of this controversy has been a set of concepts of emotion that are neither exclusive nor complementary, and which have projected a range of divergent clinical implications (e.g., Rachman, 1981). In fact, different theories of emotion are found to be emphasizing different response systems as being underlying the mechanisms involved in emotional experience or expression (Leventhal and Tomarken, 1986, 1988). A brief outline of controversies about emotion will follow.

Early theories of emotion (e.g., James, 1950/1890; Lange, 1967/1885; Zajonc, 1980, 1984) point out that the autonomic processes are the prime determinant of emotion, or that emotion is potentially independent of cognition. Further, the primary role of subcortical structures within the brain in mediating emotional functioning is emphasized by yet another set of theories on emotion (e.g., Cannon, 1927; Papez, 1937; McLean, 1950). Each of these theories offers its own concepts of emotion and proposes specific mechanisms for its experiencing and expression. One major implication of such controversy on psychotherapy is that the various therapeutic approaches tend to place a primary emphasis on one response system to the relative neglect of the others (Wilson, 1978). This can be clearly observed by looking to the therapeutic strategies of these approaches in the treatment of an emotion such as fear. For example, behavioral approaches to therapy focus on overt behavior as the subject matter of therapy. They explain emotional responses in terms of learning principles (e.g., Eysenck, 1987). They argue that fear reactions, for instance, are learned as a way of reducing the anxiety elicited by a particular object or situation. Therefore, exposure to the feared stimulus without harmful consequences leads to extinction of the fear; hence, exposure to the un-reinforced conditioned stimulus (i.e., the harmless object of fear) is the conceptual basis of behavior therapy. Wolpe's (1958) counter-conditioning approach emphasizes autonomic responsiveness. Based on his theory of reciprocal inhibition, Wolpe argues that the induction of an autonomic responsiveness of relaxation can reduce or eliminate preexisting anxiety symptoms since the autonomic states of relaxation and anxiety are incompatible and cannot co-exist. Cognitive approaches, on the other hand, conceptualize emotion as a post-cognition phenomenon (e.g., Beck, 1976; Lazarus, 1982, 1984). Generally

Subsequently, a prototype computer-based symbolic modeling technique for the treatment of spider phobia, which was constructed on the basis of a proposed theoretical concept of emotion, was described in section 4. The effectiveness of the technique was compared with that of two conventional methods for treating spider phobia in order to validate its clinical efficacy. Spider phobia was selected as the clinical problem of investigation mainly because of its clinical specificity. The clinical results, described and discussed in sections 5 and 6, further suggest that the effect induced in either of the cognitive or overt verbal response systems underlying respective fear components is likely to similarly and equally affect the fear component manifested by the other systems. The findings of this work may warrant the development of similar techniques for the treatment of other similar behavioral

The literature on emotion shows that the nature of emotion and the mechanisms involved in its experience and expression constitute a field of long-standing controversy (e.g., James, 1890/1950; Cannon, 1927; Papez, 1937; MacLean, 1950; Schachter, 1964; Lazarus, 1984; Zajonc, 1984; Panksepp, 1988, 1990; Gray, 1982, 1990; Hassan and Ward, 1991). The result of this controversy has been a set of concepts of emotion that are neither exclusive nor complementary, and which have projected a range of divergent clinical implications (e.g., Rachman, 1981). In fact, different theories of emotion are found to be emphasizing different response systems as being underlying the mechanisms involved in emotional experience or expression (Leventhal and Tomarken, 1986, 1988). A brief outline of controversies about

Early theories of emotion (e.g., James, 1950/1890; Lange, 1967/1885; Zajonc, 1980, 1984) point out that the autonomic processes are the prime determinant of emotion, or that emotion is potentially independent of cognition. Further, the primary role of subcortical structures within the brain in mediating emotional functioning is emphasized by yet another set of theories on emotion (e.g., Cannon, 1927; Papez, 1937; McLean, 1950). Each of these theories offers its own concepts of emotion and proposes specific mechanisms for its experiencing and expression. One major implication of such controversy on psychotherapy is that the various therapeutic approaches tend to place a primary emphasis on one response system to the relative neglect of the others (Wilson, 1978). This can be clearly observed by looking to the therapeutic strategies of these approaches in the treatment of an emotion such as fear. For example, behavioral approaches to therapy focus on overt behavior as the subject matter of therapy. They explain emotional responses in terms of learning principles (e.g., Eysenck, 1987). They argue that fear reactions, for instance, are learned as a way of reducing the anxiety elicited by a particular object or situation. Therefore, exposure to the feared stimulus without harmful consequences leads to extinction of the fear; hence, exposure to the un-reinforced conditioned stimulus (i.e., the harmless object of fear) is the conceptual basis of behavior therapy. Wolpe's (1958) counter-conditioning approach emphasizes autonomic responsiveness. Based on his theory of reciprocal inhibition, Wolpe argues that the induction of an autonomic responsiveness of relaxation can reduce or eliminate preexisting anxiety symptoms since the autonomic states of relaxation and anxiety are incompatible and cannot co-exist. Cognitive approaches, on the other hand, conceptualize emotion as a post-cognition phenomenon (e.g., Beck, 1976; Lazarus, 1982, 1984). Generally

problems concerned with anxiety and fear.

**2. Emotion: review and implications**

emotion will follow.

speaking, these approaches argue that an individual's emotional reactions are determined by the way he/she interprets events (Greenberg and Safran, 1987). Therefore, these personal meanings of events are the primary targets of change in cognitive therapy; hence they focus on maladaptive thought patterns and related cognitive processes.

These, rather 'skewed', concepts of the emotion of fear, which underlie the therapeutic approaches so far outlined, are probably a contributory factor in the frequently observed discordance between autonomic, somatic motor, and cognitive components of fear in their rate of response to treatment (Rachman, 1978, 1990). However, despite the diverse notions about emotion, there seems to be a consensus on the multi-component nature of emotion (Lang, 1971, 1985; Scherer, 1984; Frijda, 1986; Gray, 1990). Lang's (1968, 1971) three-system model of emotion conceptualizes fear and anxiety in terms of overt behavioral, cognitive, and autonomic components. Further, Rachman (1977) has found that the response systems underlying these three components of fear do not always co-vary and, therefore, a treatment procedure that affects only one or two response systems may result in incomplete treatment in terms of residual fear in other response systems. On the basis of this proposition, an effective treatment of, for example, phobia would be expected to induce a therapeutic change in all response systems. Nevertheless, different theoretical and therapeutic perspectives of emotion tend to emphasize the primacy of one component over the others. Rachman (1981), for example, suggests that behaviorally-based treatments will probably prove more effective than cognitive treatments of emotional disorders. Further, Zajonc (1984) proposes the independence of emotion from cognition (For a critical review of Zajonc's (1984) proposition on the primacy of emotion, see Hassan and Ward, 1991). Accordingly, one may logically argue that if a behaviorally based treatment of an irrational emotional state, such as phobia, would prove effective, then there must be a central mechanism whereby the behaviorally induced therapeutic change also mediates cognitive and autonomic change. This proposition is pursued below after reviewing some major concepts of emotion.