Prevalence of postnatal anxiety disorders in mothers of preterm infants: a systematic review protocol.

OBJECTIVE: The objective of this systematic review is to evaluate and synthesize the available evidence on the prevalence of postnatal anxiety disorders in mothers of preterm infants within 12 months of delivery. INTRODUCTION: Mothers of preterm infants report more postpartum psychological problems than other mothers. Anxiety disorders are among the most frequently reported manifestations, and affect the quality of maternal care and the baby's development. However, data on the prevalence of postnatal anxiety disorders in mothers of preterm infants are inconsistent and imprecise. It is, therefore, necessary to estimate the prevalence of anxiety disorders among mothers of premature infants in order to develop appropriate interventions for screening, support, and treatment. INCLUSION CRITERIA: This review will consider studies conducted in any setting and any geographical location that report on the prevalence of any anxiety disorders in mothers of preterm infants within 12 months of delivery. Any analytical or descriptive observational studies and experimental or quasi-experimental studies will be included. METHODS: MEDLINE (Ovid), PsycINFO (Ovid), Embase (Elsevier), CINAHL (EBSCOhost), Google Scholar, MedNar, and the World Health Organization website will be searched for studies written in English or French. Screening, critical appraisal, and data extraction will be performed by 2 independent reviewers using the relevant JBI systematic review tools. The findings will be presented in narrative format, including tables and figures to aid in data presentation. REVIEW REGISTRATION: PROSPERO CRD42023428202.

Is the combination of behavioral activation and attention training technique effective to reduce depressive symptomatology? A multiple case study.

Background: This study tested whether the combination of BATD and Attention Training Technique (ATT) is effective to reduce depressive symptomatology and investigate the mechanisms of action underlying the effectiveness of treatment with a multiple N-of-1 trials. Methods: Nine adults with depressive symptoms were randomly included in three different combinations of BATD and ATT, concurrent in Condition 1 and sequential in Conditions 2 and 3 (ATT followed by BATD and BATD followed by ATT, respectively). The sequential components allow investigating the specific changes that occur during the two distinct treatment phases. Multiple self-report and pre-post-assessments were conducted on generic mental health measures (depressive symptoms, life functioning, mood, and well-being) and intervention-specific measures (behavioral activation, behavioral avoidance, self-focused attention, cognitive control and rumination), with two-week and three-month follow-up assessments. We also measured treatment adherence with treatment attendance, homework compliance and a clinical interview. Results: Participants' attendance, homework compliance and satisfaction were acceptable in the three conditions, with higher adherence in Condition 1 and Condition 3. Eight participants out of nine reported a reduction in depressive symptomatology and five an improvement in well-being. Most of their progress was maintained 2 weeks after the intervention but not 3 months later. Conditions 1 and 2 seemed to be associated with a higher response to generic mental health measures in comparison with Condition 3. The three conditions were not associated with consistent changes in intervention-specific measures, except for rumination with five participants out of nine reporting an improvement in rumination immediately after the intervention and eight participants 2 weeks after the intervention. The concurrent format was associated with a better improvement in rumination immediately after the intervention. No specific changes of self-focused attention and rumination characterized ATT, and no specific changes of behavioral activation, behavioral avoidance and rumination characterized BATD. Conclusion: Our three interventions were judged acceptable and showed positive short-term benefit for generic mental health measures and rumination maintained 2 weeks later, but not 3 months later. Results suggest that five sessions of concurrent treatment could be a better option than sequential formats. However, our data did not support the specificity of ATT and BATD treatments.

Can Cognitive Control and Attentional Biases Explain More of the Variance in Depressive Symptoms Than Behavioral Processes? A Path Analysis Approach.

Background: This study explored the proportion of variance in depressive symptoms explained by processes targeted by BA (activation, behavioral avoidance, anticipatory pleasure, and brooding), and processes targeted by cognitive control training (cognitive control, attentional biases, and brooding). Methods: Five hundred and twenty adults were recruited. They completed a spatial cueing task as a measure of attentional biases and a cognitive task as a measure of cognitive control and completed self-report measures of activation, behavioral avoidance, anticipatory pleasure, brooding, and depressive symptoms. With path analysis models, we explored the relationships between these predictors and depressive symptoms. Results: BA processes were significant predictors of depressive symptoms, and activation partially predicted anticipatory pleasure, which in turn predicted depressive symptoms. However, cognitive control and attentional biases predicted neither brooding nor depressive symptoms. A comprehensive model including all processes fit the data but did not explain more of the variance in brooding or depressive symptoms than a model including only BA processes. Limitations: The spatial cueing task was associated with low reliability and the use of a non-clinical sample limited the generalizability of the conclusions. Conclusion: Activation, behavioral avoidance, brooding, and anticipatory pleasure are relevant processes to target in order to reduce depressive symptoms, while cognitive control and attentional biases are not.

Psychometric Properties and Factor Structure of the French Version of the Behavioral Activation for Depression Scale (BADS) in Non-Clinical Adults.

Behavioral activation (BA) is a well-established empirical treatment for depression that aims to improve depressive mood by increasing activation and reducing avoidance. Therefore, it is essential to evaluate activation and avoidance when a BA treatment is applied. The Behavioral Activation for Depression Scale (BADS) was developed to measure the changes in activation and avoidance over the course of BA treatment of depression. This study aims to validate the French version of this scale. In a first study, 131 bilingual adults were recruited to explored internal consistency, test-retest reliability and construct validity of the final French version. In a second study, 409 non-clinical adults completed an online survey assessing concurrent measures. Results of the first study suggested good internal consistency, test-retest reliability and construct validity. The second study revealed a confirmatory factor analysis supporting the original four-factor structure, with Activation, Avoidance/Rumination, Work/School Impairment, and Social Impairment subscales. Results also revealed that a 5-factor model distinguishing Behavioral Avoidance and Rumination had a better fit than the original four-factor structure. All subscales showed adequate internal consistency and good construct validity with evidence of convergent validity with depressive symptoms, brooding, psychological flexibility, negative automatic thought, behavioral inhibition and activation system. Furthermore, the French BADS total scale and subscales showed a good ability to predict depressive symptoms. The French version of the BADS appears to be a reliable tool for clinician and researchers to assess mechanisms of change in BA interventions.

Attentional biases in depression: Relation to disorder severity, rumination, and anhedonia.

INTRODUCTION: According to cognitive models of depression, selective attentional biases (ABs) for mood-congruent information are core vulnerability factors of depression maintenance. However, findings concerning the presence of these biases in depression are mixed. This study aims to clarify the presence of these ABs among individuals with clinical and subclinical depression. METHOD: We compared three groups based on a semi-structured diagnostic interview and a depressive symptoms scale (BDI-II): 34 individuals with major depressive disorder (clinically depressed); 35 with a dysphoric mood but without the criteria of major depressive disorder (i.e., subclinically depressed), and 26 never been depressed individuals. We examined AB for sad and happy materials in three modified versions of the exogenous cueing task using scenes, facial expressions, and words. Brooding, anhedonia, and anxiety were also evaluated. RESULTS: In contrast to our hypotheses, there were no ABs for negative or positive information, regardless of the task and the groups. Neither the association between AB toward negative information and brooding nor the one between AB away from positive stimuli and anhedonia was significant. Bayes factors analyses revealed that the present pattern of findings does not result from a lack of statistical power. DISCUSSION: Our results raise questions about how common AB is in depression. From a theoretical point of view, because individuals with depression did not exhibit AB, our results also seemingly challenge the claim that AB figures prominently in the maintenance of depression. We believe the present null results to be particularly useful for future meta-research in the field.

Sexual Cognitions, Trait Anxiety, Sexual Anxiety, and Distress in Men With Different Subtypes of Premature Ejaculation and in Their Partners.

This study examined trait anxiety and sexual cognitions in 610 men with premature ejaculation (PE) (DSM-IV-TR criteria) and in 107 partners of these men, and compared their scores to normative data. Sexual anxiety, intravaginal ejaculatory latency time, feeling of control over ejaculation, and PE-related distress were also assessed. The scores of 343 participants (56.23%) with clearly identifiable subtypes of PE according to Waldinger's classification system (lifelong, acquired, variable, and subjective subtypes) were compared in these domains. Finally, the predictive value of these factors in determining PE-related distress was explored. The following conclusions can be summarized from the results: (1) Men affected by PE are more distressed by the problem than their partners; (2) there is no evidence that levels of trait anxiety in individuals with PE are dissimilar to those found in the general population; (3) "dysfunctional" sexual cognitions likely play a role in PE, especially with regard to PE-related distress; (4) different subtypes of PE have similar profiles on measures of trait anxiety, sexual anxiety, and sexual cognitions; (5) differences between subtypes are only apparent with regard to feeling of control over ejaculation, with men with lifelong or acquired PE scoring significantly lower than those with a subjective form of the problem.

Depressive symptomatology and the influence of the behavioral avoidance and activation: A gender-specific investigation.

BACKGROUND: Depression is a highly prevalent disorder which is usually considered as differentially experienced depending on gender. Behavioral theories of depression pinpoint the importance of the behavioral avoidance in the maintenance of depression. However, little is known about the specific impact of the behavioral avoidance and activation on each depressive symptom as well as on gender differences on the behavioral features of depression. METHODS: This study's aim was two-fold: (1) to assess the presence of gender differences on the BDI-II; (2) to investigate the respective predictive value of behavioral avoidance and of behavioral activation on each depressive symptom assessed by the BDI-II depending on gender. Community adults and adults attending mental healthcare composed the sample. RESULTS: Results showed differences in symptomatology profiles depending on gender (e.g. higher scores of sadness, self-criticalness in women, higher scores of past failure and loss of pleasure in men). Behavioral avoidance positively predicted almost all depressive symptoms in women and in men while behavioral activation negatively predicted almost all symptoms in both gender. Nevertheless, the strengths of these relationships were different for some symptoms (e.g. pessimism). LIMITATIONS: The use of self-report instruments; the lack of assessment of causal or precipitating factors of the depressive symptomatology; the higher number of women in the sample. CONCLUSIONS: Results are discussed with respect to previous findings and present clinical implications: (1) to underline the relevance of the combination of gender-specific assessment tools; (2) to highlight the need of tailored psychological intervention.

Validation and Psychometric Properties of the French Versions of the Environmental Reward Observation Scale and of the Reward Probability Index.

Background: Low levels of environmental rewards have been related to depression on a number of occasions in the scientific literature. Two scales have been created to assess environmental rewards: the Environmental Reward Observation Scale (EROS) and the Reward Probability Index (RPI). This study aims to validate the French versions of these two scales. Method: 466 non-clinical adults completed an online survey assessing environmental rewards, depression, anxiety, activation, avoidance and behavioural systems. Confirmatory factor analyses were performed to assess the factorial structures of the French EROS and RPI. Results: A one-factor solution for the EROS and a two-factor solution for the RPI best fitted the data. High levels of internal consistency were found for both the EROS and the RPI. Convergent validity was also examined, revealing that high environmental rewards appear to be related to activation and behavioural activation system. Conclusion: The French versions of the EROS and the RPI appear to be reliable assessments of environmental rewards.

Psychometric properties of the French translation of the Behavioral Activation for Depression Scale-Short Form (BADS-SF) in non-clinical adults.

A decrease in the level of engagement in activities ("behavioral activation") is usually observed in major depressive disorder. Because behavioral treatments of depression aim to counteract that mechanism, assessing changes in behavioral activation during treatment is of great interest. Therefore, Manos et al. (2011) developed a scale that assesses these changes, which was called the Behavioral Activation for Depression Scale-Short Form (BADS-SF). The aim of this study is to present a French version of this scale and to discuss its psychometric properties. The BADS-SF was translated into French, and 504 non-clinical adults completed an online survey that was composed of that scale and convergent measures. Exploratory and confirmatory factor analyses were performed in two independent samples, and a two-factor solution was recommended, which references two functions of the engagement in activities (i.e., "activation" and "avoidance"). The results showed high levels of internal consistency and satisfying scores in terms of skewness and kurtosis. Moreover, relationships with measures of depression and behavioral systems indicated a good convergent validity. Therefore, the French BADS-SF can be seen as a reliable and valid instrument.

Overgenerality memory style for past and future events and emotions related in bipolar disorder. What are the links with problem solving and interpersonal relationships?

This study investigated patients with Bipolar Disorder's abilities to generate specific past and future events in response to positive and negative cues words as well as emotional intensity related to these ones. The relationships between the number of generated specific events cognitive functioning, interpersonal problems and the ability to problem solving were investigated. Nineteen BD and nineteen healthy controls completed a French version of the AMT to evaluate the past and future events recall, in function of their valence, and emotions related. Furthermore, they completed the Optional Thinking Test, the Inventory of Interpersonal Problems and the neuropsychological measures. Compared to healthy controls, BD recollected (1) fewer specific past negative events and (2) fewer future specific positive and negative events furthermore, (3) they felt more emotional intensity related to future events. These results were explained in the light of theoretical models. Finally, specific past memories deficits in BD were linked with issues in problem solving but not with levels of distress arising from interpersonal problems. In view of AM functions in everyday life, all types of deficits should be taken into consideration, and AM remediation envisaged.

Identity in schizophrenia: a study of trait self-knowledge.

Identity results from interlock of two systems which are a set of abstracted representations about oneself and a phenomenological self. Literature highlights identity disturbance in schizophrenia that affects each of both systems. In the same vein, the present study investigates the stability and the quality of traits self-knowledge, a component of abstracted representations of self, in schizophrenia patients. Sixty-eight patients with schizophrenia and 68 healthy control subjects completed a short version of a personality scale (LABEL). This scale is composed of two versions (A and B), each comprising 50 adjectives that correspond to synonymous adjectives in the alternate list. Participants indicated how these adjectives described themselves and completed both versions of the scale on two separate occasions, one month apart. The findings showed that schizophrenic patients presented an unstable identity and change in identity quality compared with healthy subjects. However, this identity disturbance was weaker than expected. These results are discussed in a part of autobiographical memory disturbances in schizophrenia, illness duration and the decompensation stage.

Emotional regulation impairments following severe traumatic brain injury: an investigation of the body and facial feedback effects.

The object of this study was to evaluate the combined effect of body and facial feedback in adults who had suffered from a severe traumatic brain injury (TBI) to gain some understanding of their difficulties in the regulation of negative emotions. Twenty-four participants with TBI and 28 control participants adopted facial expressions and body postures according to specific instructions and maintained these positions for 10 s. Expressions and postures entailed anger, sadness, and happiness as well as a neutral (baseline) condition. After each expression/posture manipulation, participants evaluated their subjective emotional state (including cheerfulness, sadness, and irritation). TBI participants were globally less responsive to the effects of body and facial feedback than control participants, F(1,50) = 5.89, p = .02, η(2) = .11. More interestingly, the TBI group differed from the Control group across emotions, F(8,400) = 2.51, p = .01, η(2) = .05. Specifically, participants with TBI were responsive to happy but not to negative expression/posture manipulations whereas control participants were responsive to happy, angry, and sad expression/posture manipulations. In conclusion, TBI appears to impair the ability to recognize both the physical configuration of a negative emotion and its associated subjective feeling.

Functional and psychological characteristics of belgian men with premature ejaculation and their partners.

Physiological, behavioral, cognitive, and emotional factors are generally acknowledged to play a role in premature ejaculation (PE). However, the nature and the extent of their etiological impact remain largely imprecise. The present study examined functional and psychometric dynamics at work in a PE population. A total of 461 men with PE and 80 partners completed an online questionnaire. The main outcome measures were self-reported ejaculatory latency time, the feeling of control upon ejaculation, sexual satisfaction, distress related to PE, trait anxiety (STAI-B), sexual cognitions (Sexual Irrationality Questionnaire [SIQ]), social anxiety (Liebowitz's Social Anxiety Scale [LSAS] and Social Interaction Self-Statement Test [SISST]), and personality traits (Temperament and Character Inventory-Revised [TCI-R]). In our sample, the median latency time to ejaculation was between 1 and 2 min. Sexual satisfaction and distress correlated more strongly with the feeling of control than with the self-reported latency time. Men experienced more distress and dissatisfaction related to PE than did their partners, while overestimating their partners' distress and dissatisfaction. PE participants' scores differed significantly, albeit slightly, from STAI-B, SIQ, LSAS, and SISST norms. The differences were negligible on TCI-R. Some differences became stronger when subtypes were considered. Participants combining generalized and lifelong PE with self-reported latency times of <30 s reported lower sexual satisfaction and control, higher distress, higher social anxiety, and harm avoidance (TCI-R/HA) scores. By contrast, the situational subtype of PE was found to be characterized by a higher level of satisfaction, a greater feeling of control, less distress, and higher trait anxiety scores. However, the trends remained statistically discrete.

Spontaneous and posed emotional facial expressions following severe traumatic brain injury.

AIM: The current study aimed to test the intensity of spontaneous emotional expressions and the accuracy of posed emotional expressions in patients with severe traumatic brain injury (TBI). METHOD: Twenty-three participants with TBI and 27 matched control participants were asked to relate personal angry, happy, and sad events (spontaneous expressivity) and to pose angry, happy, and sad expressions in response to a photo or word cue (posed expressivity). Their emotional facial expressions were coded via judges' ratings. RESULTS: Participants with TBI had less intense sad expressions when relating a sad event than did control participants. No group difference emerged in the happy and angry events, the latter possibly due to differentially low interrater reliability for anger ratings. Participants with TBI were impaired in their ability to pose sad emotions. CONCLUSIONS: These preliminary findings suggest that patients with TBI are impaired at expressing sad expressions either spontaneously or deliberately. This may reflect difficulties in the initiation or suppression of facial expression as well as an impaired semantic knowledge of the facial configuration of sad expression.

Capacity for cognitive and emotional empathy in alcohol-dependent patients.

This study assessed two previously unexplored facets of empathy in alcohol-dependent patients (ADs) divided into two groups according to Cloninger's alcoholism typology: the attribution of intentions according to emotional facial expressions (EFEs) and emotional contagion in reaction to EFEs. Twenty-three male Type-I ADs, 21 male Type-II ADs, and 24 male control participants were compared in two computerized tasks. First, participants rated the extent to which an adjective descriptive of personality weighted on interpersonal dimensions (of rejection, aggressiveness, dominance, and affiliation) corresponded with a video of a neutral EFE that changed to an intense EFE. Second, participants evaluated their own emotional states after watching a series of videos that depicted EFEs while their own face was being filmed. The results showed that Type-I ADs attributed more rejection intentions and fewer affiliation intentions to EFEs compared with controls; however, depression might better explain this biased attribution. Furthermore, AD subtypes showed a different pattern of intention attribution according to the emotions that were portrayed and the sex of the stimulus. In addition, angry EFE mimicry was stronger in Type-II ADs than other participants. Finally, ADs expressed fewer positive emotions and more negative emotions than controls when watching EFEs. These findings emphasize the importance of differentiating alcoholism subtypes and contribute to the understanding of AD interpersonal behaviors.

Clinical outcomes of a new self-help booklet for premature ejaculation.

INTRODUCTION: Premature ejaculation (PE) is quite common. Although effective treatments do exist, only a few affected people consult a practitioner in order to overcome their problem. At the same time, studies have shown that reading didactical documents about their PE problem (bibliotherapy) can be useful to men. AIM: The aim of this study was to improve the bibliotherapy approach using up-to-date knowledge and techniques. The expected benefits were the following: (i) an effective manual shorter than previous ones; (ii) easier to assimilate therapeutic principles; and (iii) a method thereby made accessible to a broad population most of whom usually do not consult for this type of sexual problem. METHOD: A short bibliotherapy titled The Practical Guide of PE[in French] was tested among PE subjects who were diagnosed with PE according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria. Assessments were made at baseline (N = 421), at 4-8 months (N = 120), and at 10-14 months (N = 79) after they read The Practical Guide. A control group of 66 subjects was left on a waiting list and was assessed 2 months after baseline. MAIN OUTCOME MEASURES: The main outcome measures are self-reported ejaculatory latency time, feeling of control upon ejaculation, sexual satisfaction, distress related to PE, anxiety experienced during sexual intercourse, and sexual cognitions (Sexual Irrationality Questionnaire). RESULTS: Significant improvements were found for all the self-reported parameters, both at 4-8 and at 10-14 months after the bibliotherapy. The improvements were associated with an adjustment of sexual cognitions. The response to treatment seemed better for those subjects with moderate PE. Although the severity criteria used in this study did not precisely meet the International Society for Sexual Medicine criteria for lifelong PE, they were likely related. The response did not seem to be affected by variables such as age, education, or personality. CONCLUSION: Its cost/benefit ratio makes The Practical Guide a valuable therapeutic tool.

Specificity deficit in the recollection of emotional memories in schizophrenia.

The influence of emotion on episodic and autobiographical memory in schizophrenia was investigated. Using an experiential approach, the states of awareness accompanying recollection of pictures from the IAPS and of associated autobiographical memories was recorded. Results show that schizophrenia impairs episodic and autobiographical memories in their critical feature: autonoetic awareness, i.e., the type of awareness experienced when mentally reliving events from one's past. Schizophrenia was also associated with a reduction of specific autobiographical memories. The impact of stimulus valence on memory performance was moderated by clinical status. Patients with schizophrenia recognized more positive than negative pictures, and recalled more positive than negative autobiographical memories while controls displayed the opposite pattern. A hypothesis in terms of a fundamental executive deficit underlying these impairments is proposed.

Deficits in decoding emotional facial expressions in Parkinson's disease.

INTRODUCTION: The basal ganglia have numerous connections not only with the motor cortex but also with the prefrontal and limbic cortical areas. Therefore, basal ganglia lesions can disturb motor function but also cognitive function and emotion processing. The aim of the present study was to assess the consequences of Parkinson's disease (PD) on ability to decode emotional facial expressions (EFEs)-a method commonly used to investigate non-verbal emotion processing. METHODS: Eighteen PD patients participated in the study, together with 18 healthy subjects strictly matched with respect to age, education and sex. The patients were early in the course of the disease and had not yet received any antiparkinsonian treatment. Decoding of EFEs was assessed using a standardized, quantitative task where the expressions were of moderate intensity, i.e. quite similar to those experienced in everyday life. A set of tests also assessed executive function. Visuospatial perception, depression and anxiety were measured. RESULTS: Early in the course of the disease, untreated PD patients were significantly impaired in decoding EFEs, as well as in executive function. The deficits were significantly interrelated, although neither was significantly related to severity of the motor symptoms. Visuospatial perception was not impaired, and the patients' impairment was related neither to their depression nor to their anxiety score. The PD patients' impairment in decoding EFEs was related to a systematic response bias. CONCLUSION: Early in the course of PD, non-verbal emotional information processing is disturbed. This suggests that in PD, nigrostriatal dopaminergic depletion leads not only to motor and cognitive disturbances but also to emotional information processing deficits. The observed correlation pattern does not enable adoption of a clear-cut position in the debate over totally or partially segregated functional organization of the basal ganglia circuits.

Genetic association between the phospholipase A2 gene and unipolar affective disorder: a multicentre case-control study.

The co-segregation in one pedigree of bipolar affective disorder with Darier's disease whose gene is on chromosome 12q23-q24.1, and findings from linkage and association studies with the neighbouring gene of phospholipase A2 (PLA2) indicate that PLA2 may be considered as a candidate gene for affective disorders. All relevant genetic association studies, however, were conducted on bipolar patients. In the present study, the possible association between the PLA2 gene and unipolar affective disorder was examined on 321 unipolar patients and 604 controls (all personally interviewed), recruited from six countries (Belgium, Bulgaria, Croatia, Germany, Greece, and Italy) participating in the European Collaborative Project on Affective Disorders. After controlling for population group and gender, one of the eight alleles of the investigated marker (allele 7) was found to be more frequent among unipolar patients with more than three major depressive episodes than among controls (P<0.01); genotypic association was also observed, under the dominant model of genetic transmission (P<0.02). In addition, presence of allele 7 was correlated with a higher frequency of depressive episodes (P<0.02). These findings suggest that structural variations at the PLA2 gene or the chromosomal region around it may confer susceptibility for unipolar affective disorder.

Impaired emotional facial expression recognition is associated with interpersonal problems in alcoholism.

AIMS: Emotional facial expression (EFE) recognition has been shown to be impaired in abstinent alcoholics. The present study investigated the relationship between EFE recognition impairments and interpersonal difficulties in recently detoxified alcoholics (RA). METHODS: Thirty recently detoxified alcoholics were compared to 30 normal controls (NC) matched for age, sex and educational level on an EFE decoding test. This test involves 16 photographs depicting EFE of happiness, anger, disgust and sadness. Subjects were asked to fill in the Inventory of Interpersonal Problems evaluating six dimensions of interpersonal problems (assertiveness, submissiveness, intimacy, reliability, control and sociability). RESULTS: RA had EFE recognition deficits and more interpersonal problems, compared to NC. Reported interpersonal difficulties were correlated with EFE decoding problems. CONCLUSIONS: Interpersonal difficulties serve as a mediator between EFE accuracy problems and alcoholism. Impaired EFE recognition could have a role in the interpersonal difficulties encountered by RA and may therefore constitute a relapse factor.