Decreased mononuclear cell NR3C1 SKA2 and FKPB5 expression levels among adult survivors of suicide bombing terror attacks in childhood are associated with the development of PTSD.

Life threatening trauma and the development of PTSD during childhood, may each associate with transcriptional perturbation of immune cell glucocorticoid reactivity, yet their separable longer term contributions are less clear. The current study compared resting mononuclear cell gene expression levels of the nuclear receptor, subfamily 3, member 1 (NR3C1) coding the glucocorticoid receptor, its trans-activator spindle and kinetochore-associated protein 2 (SKA2), and its co-chaperon FKBP prolyl isomerase 5 (FKBP5), between a cohort of young adults first seen at the Hadassah Emergency Department (ED) after surviving a suicide bombing terror attack during childhood, and followed longitudinally over the years, and matched healthy controls not exposed to life threatening trauma. While significant reductions in mononuclear cell gene expression levels were observed among young adults for all three transcripts following early trauma exposure, the development of subsequent PTSD beyond trauma exposure, accounted for a small but significant portion of the variance in each of the three transcripts. Long-term perturbation in the expression of immune cell glucocorticoid response transcripts persists among young adults who develop PTSD following life threatening trauma exposure in childhood, denoting chronic dysregulation of immune stress reactivity.

Psychiatric referrals to the general hospital emergency department: are we being effective?

Introduction: General hospital emergency departments (GHEDs) are notoriously overcrowded. This is caused, in part, by ineffective referrals, that is to say referrals that do not require medical examination or other interventions in the context of a general hospital. This study aims to investigate the contribution of psychiatric referrals to this issue, to identify potential determinants of these referrals and offer means to reduce them. Materials and methods: Retrospective data were collected from psychiatric admission files within a GHED of a tertiary-care city hospital over a 1 year period. Two experienced clinicians separately reviewed each file to determine rationale of referrals according to predetermined criteria. Results: A total of 2,136 visits included a psychiatric examination, 900 (42.1%) were determined "effective," and 1,227 (57.4%) were deemed "potentially ineffective." The leading causes for potentially ineffective referrals to a GHED were psychiatric illness exacerbation (43.4%), and suicidal ideations (22%). Most referrals (66.9%) were initiated by the patient or their family, and not by a primary care physician or psychiatrist. Conclusion: More than half of the psychiatric referrals did not necessarily require the services of a general hospital, and may be more suitable for referral to a dedicated psychiatric facility. Ineffective referrals to the GHED pose a burden on general hospital resources, and may be less effective for the psychiatric patients. This calls for clear guidelines for the provision of optimal emergency treatment for mental-health patients.

Aberrant Intrinsic Brain Network Functional Connectivity During a Face-Matching Task in Women Diagnosed With Premenstrual Dysphoric Disorder.

BACKGROUND: Premenstrual dysphoric disorder (PMDD) is characterized by affective, cognitive, and physical symptoms, suggesting alterations at the brain network level. Women with PMDD demonstrate aberrant discrimination of facial emotions during the luteal phase of the menstrual cycle and altered reactivity to emotional stimuli. However, previous studies assessing emotional task-related brain reactivity using region-of-interest or whole-brain analysis have reported conflicting findings. Therefore, we utilized both region-of-interest task-reactivity and seed-voxel functional connectivity (FC) approaches to test for differences in the default mode network, salience network, and central executive network between women with PMDD and control participants during an emotional-processing task that yields an optimal setup for investigating brain network changes in PMDD. METHODS: Twenty-four women with PMDD and 27 control participants were classified according to the Daily Record of Severity of Problems. Participants underwent functional magnetic resonance imaging scans while completing the emotional face-matching task during the midfollicular and late-luteal phases of their menstrual cycle. RESULTS: No significant between-group differences in brain reactivity were found using region-of-interest analysis. In the FC analysis, a main effect of diagnosis was found showing decreased default mode network connectivity, increased salience network connectivity, and decreased central executive network connectivity in women with PMDD compared with control participants. A significant interaction between menstrual cycle phase and diagnosis was found in the central executive network for right posterior parietal cortex and left inferior lateral occipital cortex connectivity. A post hoc analysis revealed stronger FC during the midfollicular than the late-luteal phase of PMDD. CONCLUSIONS: Aberrant FC in the 3 brain networks involved in PMDD may indicate vulnerability to experience affective and cognitive symptoms of the disorder.

Seizure phobia: A distinct psychiatric disorder among people with epilepsy.

OBJECTIVE: Epilepsy is characterized by unpredictable attacks. Hence, people with epilepsy (PWE) may develop anxious anticipation of upcoming seizures. Seizure phobia is an anxiety disorder wherein seizure anticipatory situations trigger fear, accompanied by avoidance behaviors. Research on seizure phobia among PWE is scarce. Therefore, we aimed to describe the diagnosis of seizure phobia and its association with demographic, psychiatric and neurological variables. METHODS: This is a cross-sectional study of adult PWE in a tertiary epilepsy outpatient clinic. Data were collected from semi-structured interviews, demographic questionnaires and medical records. Patients with and without seizure phobia were compared in terms of sociodemographic, psychiatric, and neurological variables. A logistic regression analysis was performed to identify variables that predicted seizure phobia. RESULTS: Among 69 PWE included in the study, 19 (27.5%) were diagnosed with seizure phobia. In comparison with PWE without seizure phobia, PWE with seizure phobia were predominantly female (84.2% vs 44.2%, p = 0.005), and had more comorbid anxiety disorders (84.2% vs 34.9%, p = 0.01), past major depressive episode (MDE) (63.2% vs 20.9%, p = 0.003), and post-traumatic stress disorder (26.3% vs 7%, p = 0.05). There was a significant association between seizure phobia and comorbid psychogenic non-epileptic seizures (36.8% vs 11.6%, p = 0.034). However, no significant association was found with epilepsy-related variables. A multivariate logistic regression model indicated anxiety and a past MDE as predictive factors for seizure phobia (R2 = 0.43). CONCLUSION: Seizure phobia is a distinct psychiatric entity among PWE. Further research is required to understand its etiology, risk factors, and potential interventions for these patients.

Resting mononuclear cell NR3C1 and SKA2 expression levels predict blunted cortisol reactivity to combat training stress among elite army cadets exposed to childhood adversity.

Childhood adversity (CA) may alter reactivity to stress throughout life, increasing risk for psychiatric and medical morbidity, yet long-term correlates of milder CA levels among high functioning healthy adolescents are less studied. The current study examined the prevalence and impact of CA exposure among a cohort of healthy motivated elite parachute unit volunteers, prospectively assessed at rest and at the height of an intensive combat-simulation exposure. We found significantly reduced gene expression levels in resting mononuclear cell nuclear receptor, subfamily 3, member 1 (NR3C1), and its transactivator spindle and kinetochore-associated protein 2 (SKA2), that predict blunted cortisol reactivity to combat-simulation stress among CA exposed adolescents. Long-term alterations in endocrine immune indices, subjective distress, and executive functions persist among healthy high functioning adolescents following milder CA exposure, and may promote resilience or vulnerability to later real-life combat exposure.

The imprint of childhood adversity on emotional processing in high functioning young adults.

Adverse childhood experiences (ACEs) have been acknowledged as risk factors for increased mental health complications in adulthood, specifically increasing susceptibility to developing psychopathology upon exposure to trauma. Yet, little is known regarding the impact of mild ACEs on highly functioning population. In this study forty participants were selected from a group of 366 highly selected military parachute trainees using the self-report "childhood trauma questionnaire," and classified into two groups of 20 each, with and without ACEs. Behavioral measurements were obtained before and at the peak of an intensive combat training period, including anxiety, depression and executive function assessment. Functional MRI including a negative emotional face perception task was conducted at the first time point. Psychometric and cognitive measurements revealed higher levels of anxiety and depressive symptoms, and more difficulties in executive functioning in the ACE group at baseline. Slower reaction time to emotional faces presentation was found in the ACE group. Lower activation in response to negative emotional faces stimuli was found in this group in bilateral secondary visual areas, left anterior insula, left parietal cortex and left primary motor and sensory regions. In contrast, higher activation in the ACE group was found in the right ventral lateral prefrontal cortex (Vlpfc). No significant differences between groups were detected in the amygdala. To conclude, mild adverse childhood experiences produce long-term sequela on psychological wellbeing and neurocircuitry even in high functioning population. Brain regions modulated by childhood trauma may instigate avoidance mechanisms dampening the emotional and cognitive effects of intensive stress.

Gender differences in the effect of medical humanities program on medical students' empathy: a prospective longitudinal study.

BACKGROUND: Previous studies have suggested that Medical students' empathy declines during medical school, especially during the clinical studies. The aim of this study was to examine. Changes in medical students' empathy during their first clinical experience, and to determine the impact of gender and humanities curriculum on empathy changes. METHODS: In this prospective longitudinal study, 262 4th year students from three consecutive classes were assessed. Empathy was assessed before and at 4th-year-end, using the Jefferson Scale of Physician Empathy-Student Version (JSPE-S). The three classes differed in humanities curriculum [limited Medical Humanities (MH(lim)) vs. extended Medical Humanities (MH(ext))], and in admission system [Personal Interview (PI) vs. multiple mini interviews (MMI)]. RESULTS: Overall, there was a small but significant decrease in JSPE-S during the fourth year (114.40 ± 11.32 vs. 112.75 ± 14.19, p = 0.034). Among men there was a statistically significant decline in JSPE-S during the fourth year, and the MH(ext) (but not the MH(lim)) was associated with the decline (t(35) = 2.38, p = 0.023). Women students showed no decline in empathy during the fourth-year of studies, regardless of type of humanities program. In addition, women who participated in MH(ext) had a higher JSPE-S scores during the 4th -year as compared to women who participated in MH(lim). CONCLUSION: Pre-clinical humanities program was associated with a decline in empathy among men medical students during the fourth-year of medical studies. Gender differences in response to medical humanities programs require further study.

Trait-related changes in brain network topology in premenstrual dysphoric disorder.

The female predominance in the prevalence of depression is partially accounted by reactivity to hormonal fluctuations. Premenstrual dysphoric disorder (PMDD) is a reproductive subtype of depression characterized by cyclic emotional and somatic symptoms that recur before menstruation. Despite the growing understanding that most psychiatric disorders arise from dysfunctions in distributed brain circuits, the brain's functional connectome and its network properties of segregation and integration were not investigated in PMDD. To this end, we examined the brain's functional network organization in PMDD using graph theoretical analysis. 24 drug naïve women with PMDD and 27 controls without premenstrual symptoms underwent 2 resting-state fMRI scans, during the mid-follicular and late-luteal menstrual cycle phases. Functional connectivity MRI, graph theory metrics, and levels of sex hormones were computed during each menstrual phase. Altered network topology was found in PMDD across symptomatic and remitted stages in major graph metrics (characteristic path length, clustering coefficient, transitivity, local and global efficiency, centrality), indicating decreased functional network segregation and increased functional network integration. In addition, PMDD patients exhibited hypoconnectivity of the anterior temporal lobe and hyperconnectivity of the basal ganglia and thalamus, across menstrual phases. Furthermore, the relationship between difficulties in emotion regulation and PMDD was mediated by specific patterns of functional connectivity, including connections of the striatum, thalamus, and prefrontal cortex. The shifts in the functional connectome and its topology in PMDD may suggest trait vulnerability markers of the disorder.

Elevated salivary uric acid levels among adolescents with eating disorders.

OBJECTIVE: Uric acid (UA) is increasingly recognized as having important physiological roles and associated with several peripheral and central pathophysiological outcomes, and might play a role in eating disorders (ED) pathogenesis. We investigated whether UA levels are altered among adolescents with ED. METHODS: Morning salivary UA concentrations were compared between adolescents referred to treatment at the Herman Dana Center receiving a DSM-V diagnosis of an ED and matched healthy controls. RESULTS: Salivary UA was significantly elevated among ED compared with control values (ED mean 3.9 ± 1.2 mg/dl, control mean 2.9 ± 1.9 mg/dl, t = - 3.13 df = 81, p = 0.003). DISCUSSION: Salivary UA is elevated among adolescents with ED. Further studies are required to replicate and extend this finding and evaluate its generalizability as a state or trait marker as regards ED subtypes, other body fluids (plasma and cerebrospinal fluid), and recovery or premorbid stages, as well as its putative mechanistic relevance to ED. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Selflessness as a predictor of remission from an eating disorder: 1-4 year outcomes from an adolescent day-care unit.

OBJECTIVE: To assess the potential role of selflessness in predicting remission from an eating disorder (ED) following discharge from an adolescent day-care unit. METHOD: Participants were 95 female patients (aged 13-19 years) with an ED diagnosis across the spectrum admitted to an adolescent day-care unit for EDs between 2008 and 2012. Forty-one of these participants completed the follow-up assessment, between 12 and 46 months following discharge. No significant differences were found in Time 1 variables between patients who participated in Time 2 and those who did not. At both time points, ED and psychiatric comorbidity diagnoses were made using standard structured interviews. Patients were also administered the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), The Eating Attitude Test (EAT-26), The Eating Disorder Inventory (EDI-2) and the Selflessness Scale (SS)*. RESULTS: Only baseline Selflessness Scale was significant in predicting the continuous variable of ED symptomatology level in follow-up. When dividing EDI total score into its subscales at baseline, one of those, maturity fears, was found, together with the SS, significant in the prediction. In predicting remission (this time as a dichotomized variable) in follow-up, only the SS, maturity fears, EDI total, and EAT-26, at baseline, predicted remission at follow-up, but the strength of selflessness was the greatest. CONCLUSIONS: Psychological features are not the main target of the important search for predictors of remission from ED. The findings of the present study add the psychological feature of selflessness to this search. Psychotherapy can be enriched by identifying psychological features such as selflessness as one of its foci. The present findings might also renew interest in maturity fears as an additional focus in psychotherapy. LEVEL OF EVIDENCE: Level III, cohort study.

Sex differences during emotion processing are dependent on the menstrual cycle phase.

Sex differences in the neural processing of emotion are of special interest considering that mood and anxiety disorders predominant in females. However, these sex-related differences were typically studied without considering the hormonal status of female subjects, although emotion processing in the brain was shown to differ between phases of the menstrual cycle. In this functional MRI study, we demonstrated the influence of the menstrual cycle phase on sex differences in brain activity and functional connectivity during negative and positive emotions, using two different paradigms: emotion perception and emotion experience. Twenty naturally cycling healthy women without premenstrual symptoms were scanned twice: during the mid-follicular and late-luteal menstrual phases, and compared to a matched group of twenty healthy men. During negative emotion perception, men showed increased neural activity in the right hippocampal formation relative to women in the mid-follicular phase, and increased activity in the right cerebellum relative to women in the late-luteal phase. During experience of amusement, reduced putamen-ventrolateral prefrontal cortex and putamen-dorsomedial prefrontal cortex functional connectivity were observed for women in the late-luteal phase relative to men and associated with levels of sex hormones. These neural and hormonal findings were complemented by behavioral reports of reduced amusement and increased sadness in late-luteal women. Our results demonstrate menstrual phase-dependent sex differences in emotion perception and experience and may suggest a biological tendency for a deficient experience of pleasure and reward during the late-luteal phase. These findings may further shed light on the underlying pathophysiology of premenstrual dysphoric disorder.

The effect of food-related stimuli on inhibition in high vs. low restrained eaters.

Restrained eaters constantly limit their eating behavior to avoid gaining weight. Previous research suggests that fundamental deficits in response inhibition might play a role in the development of disinhibited eating among restrained eaters. The current study focuses on the impact of food vs. non-food stimuli on response inhibition in high vs. low restrained eaters. Seventy-five females (38 high and 37 low restrained eaters) completed a novel food stop-signal task in which they were required to discriminate between food and non-food images while inhibiting their response when a stop-signal appeared. The ability to inhibit a response was assessed separately for food and non-food trials, which were used to assess specific inhibition to food and general inhibitory abilities, respectively. Overall, high restrained eaters exhibited poorer response inhibition to non-food stimuli compared to low restrained eaters. Most importantly, high restrained eaters were better able to inhibit a response following presentation of food compared to non-food stimuli. In contrast, low restrained eaters were better at inhibiting a response following non-food compared to food stimuli. We suggest that this pattern is due to fast and strong activation of the response inhibition system in high restrained eaters when facing food stimuli - an activation which might later lead to a paradoxical breakdown of control over eating behavior.

Anorexia Nervosa, Selflessness, and Gender-role Identity: A Study of Daughters and Parents.

BACKGROUND: This study examines the relationship between anorexia nervosa (AN), selflessness, and genderrole identity in young Israeli women and explores their parents' gender-role identity. METHOD: Forty-seven AN women and 50 non-clinical controls completed the Eating Attitudes Test (EAT26), Eating Disorder Inventory (EDI-2), Bem Sex-Role Inventory (BSRI), and Selflessness Scale. Twenty-four parents from the AN group, and 41 mothers and 38 fathers from the control group also completed the BSRI. RESULTS: As predicted, masculine traits protected against the detrimental effects of selflessness on eating disorder symptoms. The AN participants obtained lower masculinity scores, their mothers also scoring lower on both the masculinity and femininity measures than the control-group. Conclusions drawn from the BSRI must be adopted with caution since gender-role characteristics may vary over time. CONCLUSIONS: The findings suggest the need to integrate the self-psychological approach, which emphasizes the anorexic's tendency to ignore her own interests in favor of others' needs, with feminist views that stress the role society plays in putting pressure on women to become alienated from themselves.

Long-Term Immune Alterations Accompanying Chronic Posttraumatic Stress Disorder following Exposure to Suicide Bomb Terror Incidents during Childhood.

BACKGROUND AND AIM: Long-term immune alterations have been proposed to play a mechanistic role in posttraumatic stress disorder (PTSD) as well as in its associated increase in medical morbidity and mortality. Better characterization of altered immune function may help identify diagnostic and prognostic biomarkers and potentially targets for preventive intervention. METHODS: As part of an ongoing study, we conducted a preliminary case-control comparison of resting immune inflammatory profiles between terror victims treated in childhood at the emergency department over the previous decade, who developed chronic PTSD upon long-term follow-up, and healthy controls. RESULTS: Our preliminary results in a subsample of this ongoing study support and extend elevated resting levels of granulocyte colony-stimulating factor, interleukin-4, and regulated on activation, normal T cell expressed and secreted in childhood onset chronic PTSD. CONCLUSION: Chronic immune alterations may participate in inflammatory activation and signal to the CNS through the neurovascular unit, as well as modulate the neuroendocrine axis. Better characterization and understanding of these preliminary findings may point to diagnostic and prognostic biomarkers and potentially elucidate mechanistic involvement of immune activation in PTSD.

Emotional regulation difficulties and premenstrual symptoms among Israeli students.

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) reported to affect 3-8 % of women of reproductive age and resulting in marked emotional and occupational impairment. Despite its prevalence, the etiology of PMDD is largely unknown, and patients remain mostly undiagnosed and poorly treated. It has been suggested that PMDD is a manifestation of underlying depressive disorder which is associated with the inability to regulate emotions in an adaptive manner. Therefore, we hypothesized that women with PMDD would exhibit increased difficulty with emotional regulation. A total of 648 female Israeli college students were assessed by the Premenstrual Symptoms Screening Tool (PSST) and the Difficulties in Emotion Regulation Scale (DERS). Of these women, 166 (25.6 %) met the criteria for PMS. Sixty-four (9.9 %) suffered from PMDD. More emotion regulation deficits were observed in the PMDD and PMS groups compared to the control group. Furthermore, there were more emotional regulation deficits among the predominantly psychological and mixed symptom subtype compared to the predominantly physical symptom subtype group. This is the first study to report an association between emotional dysregulation and PMDD. These findings may lead to development of more individually tailored treatment protocols focused on improving emotional regulation techniques.

Transitioning home: A four-stage reintegration hospital discharge program for adolescents hospitalized for eating disorders.

PURPOSE: Treatment for adolescents with eating disorders (ED) is multidimensional and extends after hospitalization. After participating in a four-step reintegration plan, treatment success including post-discharge community and social reintegration were examined from perspectives of patients, family members, and healthcare providers. DESIGN AND METHODS: Six pairs of patients and parents, and seven parents without their children were interviewed 2 to 30 months following discharge. RESULTS: All but two adolescents were enrolled in, or had completed school. Five worked in addition to school, and three completed army or national service. Twelve were receiving therapeutic care in the community. PRACTICE IMPLICATIONS: Adolescents with ED can benefit from a systematic reintegration program, and nurses should incorporate this into care plans.

The Role of Narcissistic Vulnerability in Predicting Adult Posttraumatic Symptoms from Childhood Sexual Abuse.

The aim of the present study is to determine whether narcissistic vulnerability can aid in clarifying the debate regarding the relationship between childhood sexual abuse (CSA) and adulthood adjustment to traumatic events. 157 survivors (mean age = 31.1, SD = 10.9) of a traumatic event (war activities and road and work accidents) were assessed 1 week, 1, and 4 months following the event. Of the 157 participants, 15 reported experiencing CSA, and 26 reported experiencing childhood physical abuse (CPA). In the first-week assessment, patients were administered the Narcissistic Vulnerability Scale (NVS) and the Beck Depression Inventory (BDI). In the follow-up assessments, subjects were interviewed on the Clinician-Administered PTSD Scale. Narcissistic vulnerability was found, both in 1- and 4-month follow-ups, to increase the likelihood of participants who experienced CSA to develop PTSD symptoms later in their adult life, when exposed to other additional trauma. Narcissistic vulnerability, in both follow-ups, did not increase the likelihood of participants who experienced CPA to develop PTSD symptoms later in their life when exposed to other additional trauma. The NVS predicted the development of PTSD symptoms in the whole sample, both in the 1- and 4-month follow-ups, above and beyond the prediction of the BDI. In other words, narcissistic vulnerability can add additional information above and beyond general negative emotionality. In conclusion, it is recommended to take into consideration the interplay between CSA and the individual's narcissistic vulnerability when assessing the long term effects of CSA such as acute or chronic PTSD.

The effect of medical students' gender, ethnicity and attitude towards poetry-reading on the evaluation of a required, clinically-integrated poetry-based educational intervention.

BACKGROUND: Art-based interventions are widely used in medical education. However, data on the potential effects of art-based interventions on medical students have been limited to small qualitative studies on students' evaluation of elective programs, and thus their findings may be difficult to generalize. The goal of this study is to examine, in an unselected students' population, the effect of students' gender, ethnicity and attitude towards poetry on their evaluation of a clinically-integrated poetry-based educational intervention. METHODS: A required Clinically- Oriented Poetry-reading Experience (COPE) is integrated into the 4th year internal medicine clerkship. We constructed a questionnaire regarding the program's effects on students. Students completed the questionnaire at the end of the clerkship. We performed a Confirmatory Factor Analysis, and examined the relationship between students' evaluation of the program and students' ethnicity, gender, attitude towards poetry-reading, and the timing of the program (early/late) during the fourth year. RESULTS: 144 students participated in the program, of which 112 completed the questionnaires. We identified two effect factors: "student-patient" and "self and colleagues". The average score for "student-patient" factor was significantly higher as compared to the "self and colleagues" factor.Evaluation the "student- patient" effect factor was higher among Arab and Druze as compared to Jewish students. Students' attitude towards poetry-reading did not correlate with the "student-patient" effect, but correlated with the "self and colleagues" effect. The evaluation of the "self and colleagues" effect was higher among students who participated in the program during their second as compared with the first clerkship. Students' gender was not associated with any of the effects identified. Students favored obligatory participation in COPE as compared with elective course format. CONCLUSIONS: According to students' evaluation, a format of integrated, obligatory poetry-based intervention may be suitable for enhancing "student-patient" aims in heterogeneous student populations. The higher evaluation of the "patient-student" effect among Arab and Druze as compared to Jewish students may be related to cultural differences in the perception of this component of medical professionalism. Further research can provide insight into the effect of cultural and ethnic differences on actual empathy of medical students in patient encounters.

The impact of personality on adult patients' adjustability to orthodontic appliances.

OBJECTIVE: To evaluate the impact of psychological traits on patients' choice of orthodontic appliances and their adjustability to orthodontic treatment. MATERIALS AND METHODS: The sample consisted of 68 adult patients divided into three groups (28 buccal, 19 lingual, and 21 clear aligners). Prior to treatment participants filled out the Brief Symptom Inventory to assess symptoms of mental distress and the Narcissistic Vulnerability Scale to assess narcissistic personality traits. During the first week after appliance delivery and on day 14, patients completed a Health-Related Quality of Life questionnaire to assess their perception of pain and four areas of dysfunction. The correlation between personality traits and patients' reaction to treatment was evaluated. RESULTS: Somatization was the only trait that affected the choice of lingual and clear aligner appliance. Reduced self-esteem regulation was associated with increased pain in all patients, while exploitation was associated with pain in lingual patients. Narcissistic vulnerability slightly influenced patients' adaptability to orthodontic appliances. Although adjustability to lingual appliances was the most difficult, only two parameters were affected by personality features. In the buccal group, adjustability was affected by numerous parameters. Adaptation to the clear aligner appliance was relatively uneventful and least affected by psychological features. CONCLUSION: Anxious individuals tend to prefer lingual and clear aligner appliances. The selection of lingual and clear aligner appliances governs the patient's response and recovery process, leaving little room for the effect of psychological features. On the other hand, the buccal appliance allows for greater impact of personality traits on adjustability.