Developmental social vulnerability as the intrinsic origin of psychopathology: A paradigm shift from disease entities to psychiatric derivatives within human diversity.

How a social episode is perceived by a person and how the experience affects her/his subsequent behaviors will inevitably and sometimes accidentally vary in each case on the developmental trajectory from the birth of consciousness to death. Both the preceding developmental conditions and the social impact of the episode become a starting point for the following states of human complex conditions, creating the extraordinary diversity that characterizes our complex society. In this evolutionarily carved landscape, genetic factors including stochastic epistasis, environmental modification, and gene-environment interactions are all active. In these processes, interactions between developmental social vulnerability and environmental influences can lead to the emergence and persistence of some derivative states with social maladaptation. In our model, every psychiatric condition including aberrant paranoid-hallucinatory states is classified as a derivative state. The probability distribution curve for these derivative states has a non-linear relationship with the liability in the population, and there is none with probability 1.0 or zero. Individuals with trivial social vulnerability or high resilience may develop the derivative states in tremendously stressful circumstances, and individuals with huge social vulnerability may not necessarily develop the derivative states in the presence of adequate social supports. Social skillfulness/unskillfulness and behavioral flexibility/inflexibility form the core of the vulnerability-related dimensions. The clinical picture of a derivative manifestation is profiled depending on the individual trait levels in the derivative-related dimensions. Each derivative state has a requisite lineup of dimensions and each dimension can contribute to multiple psychiatric conditions. For example, aberrant paranoid-hallucinatory states and bipolar condition may share some developmental conditions as the derivative-related dimensions. Therefore, multiple derivative states can co-occur or be sequentially comorbid. Although the 'learned strategies' can ostensibly mask the clinical manifestation of developmental deviations, the change of the true dimensional position to the socially skillful direction is efficiently obtained through social experiences in a supportive environment. The liability-probability model makes it impossible to discriminate individuals with psychiatric diagnosis from individuals without the diagnosis and allows all of us to reside in the same human complex diversity.

The predictive value of neural reward processing on exposure therapy outcome: Results from a randomized controlled trial.

BACKGROUND: Exposure is the gold standard treatment for phobic anxiety and is thought to represent the clinical application of extinction learning. Reward sensitivity might however also represent a predictive factor for exposure therapy outcome, as this therapy promotes positive experiences and involves positive comments by the therapist. We hypothesized that high reward sensitivity, as expressed by elevated reward expectancy and reward value, can be associated with better outcome to exposure therapy specifically. METHODS: Forty-four participants with a specific phobia for spiders were included in the current study. Participants were randomly assigned to exposure therapy (n = 25) or progressive muscle relaxation (PMR) (n = 19). Treatment outcome was defined as pre- versus post-therapy phobia symptoms. Before treatment, functional brain responses and behavioral responses (i.e. reaction time and accuracy) during reward anticipation and consumption were assessed with the Monetary Incentive Delay task (MID). Behavioral and neural responses in regions of interest (i.e. nucleus accumbens, ventromedial prefrontal cortex and the ventral tegmental area) as well as across the whole-brain were subsequently regressed on treatment outcomes. RESULTS: Exposure therapy was more effective in reducing phobia symptoms than PMR. Longer reaction times to reward cues and lower activation in the left posterior cingulate cortex during reward consumption were selectively associated with symptoms reductions following exposure therapy but not following PMR. Only within the exposure therapy group, greater symptom reduction was related to increased activation in the ventrolateral prefrontal cortex during reward anticipation, and decreased activation in the medial prefrontal cortex during reward consumption. CONCLUSION: Results indicate that individual differences in reward sensitivity can specifically predict exposure therapy outcome. Although activation in regions of interest were not related to therapy outcome, regions involved in attentional processing of reward cues were predictive of phobic symptom change following exposure therapy but not PMR.

Association between happiness and psychopathology in an elderly regional rural population in Crete.

Research has shown that socio-demographic profile and psychopathology symptoms are related to levels of happiness in old age. The aims of this cross-sectional study were: 1) to investigate the effect of recent stressful life events and socio-demographic factors on psychopathological symptoms in elderly residents in mountain regions of Crete, Greece and 2) to explore the mechanism which underlies the relationship between socio-demographic factors and psychopathological symptoms, with levels of happiness in old age. To this end, we used the nine psychopathology dimensions of symptoms as defined in the Symptom Checklist-90-R (SCL-90), while the Holmes and Rahe stress inventory was administered to quantify the stressful life events. A sample of 205 elderly men and women (age=77.1±6.7 years) living in 10 remote rural and isolated villages participated in this study. Data was collected through questionnaires completed upon individual meetings with each participant, with the interviewer's assistance. Each questionnaire included the two aforesaid scales alongside questions on individual socio-demographic characteristics. Analysis of variance was applied to detect socio-demographic factors that have a significant effect on specific psychopathological symptoms. Then, path analysis was applied to quantify the direct and indirect effect of the selected socio-demographic factors on happiness levels. Stressful life events were found to have no statistically significant effect on the presence of specific symptoms (somatization, psychoticism, anxiety) in elderly adults. Furthermore, certain socio-demographic factors (marital status, smoking, family income and social activity) were found to influence happiness, which varied according to the level of psycho-emotional tension. The results suggest that somatization, psychoticism, and phobic anxiety symptoms are psychic reactions independent of recent stressful life events. Our study,despite its regional character, may contribute in the development of appropriate clinical assessment tools and interventions, helping primary care practitioners to approach elderly people living in remote villages in a more appropriate and holistic manner, improving thereby the effectiveness of their interventions.

Anorexia: Anormal Phobia of Normal Weight.

Anorexia nervosa is a disorder of feeding behavior associated with distortion of body image, mood disturbance and a wide variety of hormonal and metabolic abnormalities. It is supposed that the disease could be the consequence of a combination of cultural-social, psychological and biological factors. Our study confirmed that anorexia mentalis is a serious, life threatening disorder which in our country appears earlier than it was expected and that is strongly related to environmental factors (family, school, fashion, society). We showed that specific personality traits are characteristic for both, young patients and mothers. Sublimation of emotional stress by exceptional performances, accompanied by food restrictive consumption together with hypersensitivity, oppositional behavior and aggression are specific for this disorder. High levels of self-imposed standards increase the risk for psychological distress, especially for eating disorder symptomatology. Both genders could be involved as patients. Boys must be especially followed for possible psychiatric manifestation. We confirmed that the biofeedback as additional therapeutic modality is very useful.

Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain.

BACKGROUND: The contribution of kinesiophobia (fear of movement) to the pain experience among older adults has been poorly evaluated. The aim of this study was to study prevalence at baseline, development over a 12-month period and cognitive-affective variables of kinesiophobia in a population-based sample of older adults with chronic pain. METHODS: The study included 433 older adults (+65 years) with chronic pain (mean age 74.8 years) randomly selected using a Swedish register of inhabitants. Kinesiophobia was measured at baseline and 12-month follow-up with the 11-item version of the Tampa Scale of Kinesiophobia (TSK-11). Associations of demographic-, cognitive affective - and pain-related variables to kinesiophobia were analysed with linear regression analyses. RESULTS: The mean level of kinesiophobia was low. Worsening and recovering from kinesiophobia occurred over time, but the mean level of kinesiophobia remained unchanged (p = 0.972). High levels of kinesiophobia (TSK ≥35) were found among frailer and older adults predominately living in care homes, but not dependent on sex. Poor self-perceived health (OR = 8.84) and high pain intensity (OR = 1.22) were significantly associated with kinesiophobia. CONCLUSION: Results indicate that potential interventions regarding kinesiophobia among older adults should aim to decrease pain intensity and strengthen health beliefs.

Assessment and treatment of anxiety disorders in children and adolescents.

Recent advances in the developmental epidemiology, neurobiology, and treatment of pediatric anxiety disorders have increased our understanding of these conditions and herald improved outcomes for affected children and adolescents. This article reviews the current epidemiology, longitudinal trajectory, and neurobiology of anxiety disorders in youth. Additionally, we summarize the current evidence for both psychotherapeutic and psychopharmacologic treatments of fear-based anxiety disorders (e.g., generalized, social, and separation anxiety disorders) in children and adolescents. Current data suggest that these disorders begin in childhood and adolescence, exhibit homotypic continuity, and increase the risk of secondary anxiety and mood disorders. Psychopharmacologic trials involving selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SSNRIs) are effective in pediatric patients with anxiety disorders and have generally demonstrated moderate effect sizes. Additionally, current data support cognitive behavioral therapy (CBT) for the treatment of these conditions in youth and suggest that the combination of psychotherapy + an SSRI may be associated with greater improvement than would be expected with either treatment as monotherapy.

Efficacy of treatments for anxiety disorders: a meta-analysis.

To our knowledge, no previous meta-analysis has attempted to compare the efficacy of pharmacological, psychological and combined treatments for the three main anxiety disorders (panic disorder, generalized anxiety disorder and social phobia). Pre-post and treated versus control effect sizes (ES) were calculated for all evaluable randomized-controlled studies (n = 234), involving 37,333 patients. Medications were associated with a significantly higher average pre-post ES [Cohen's d = 2.02 (1.90-2.15); 28,051 patients] than psychotherapies [1.22 (1.14-1.30); 6992 patients; P < 0.0001]. ES were 2.25 for serotonin-noradrenaline reuptake inhibitors (n = 23 study arms), 2.15 for benzodiazepines (n = 42), 2.09 for selective serotonin reuptake inhibitors (n = 62) and 1.83 for tricyclic antidepressants (n = 15). ES for psychotherapies were mindfulness therapies, 1.56 (n = 4); relaxation, 1.36 (n = 17); individual cognitive behavioural/exposure therapy (CBT), 1.30 (n = 93); group CBT, 1.22 (n = 18); psychodynamic therapy 1.17 (n = 5); therapies without face-to-face contact (e.g. Internet therapies), 1.11 (n = 34); eye movement desensitization reprocessing, 1.03 (n = 3); and interpersonal therapy 0.78 (n = 4). The ES was 2.12 (n = 16) for CBT/drug combinations. Exercise had an ES of 1.23 (n = 3). For control groups, ES were 1.29 for placebo pills (n = 111), 0.83 for psychological placebos (n = 16) and 0.20 for waitlists (n = 50). In direct comparisons with control groups, all investigated drugs, except for citalopram, opipramol and moclobemide, were significantly more effective than placebo. Individual CBT was more effective than waiting list, psychological placebo and pill placebo. When looking at the average pre-post ES, medications were more effective than psychotherapies. Pre-post ES for psychotherapies did not differ from pill placebos; this finding cannot be explained by heterogeneity, publication bias or allegiance effects. However, the decision on whether to choose psychotherapy, medications or a combination of the two should be left to the patient as drugs may have side effects, interactions and contraindications.

[Tocophobia--its origin, prevalence and implications].

Tocophobia is defined as fear from pregnancy in general and fear of vaginal delivery in particular. This is a relatively prevalent phenomenon, which originates due to traumatic events in the past: whether as a result of previous bad obstetric experience or from other non-obstetric related events. Unstable mental disorder may also be expressed as tocophobia. As there is no common agreement regarding the definition of tocophobia, conservative methods of treatment have not proven effective. Male tocophobia is also recognized and can be negatively influential on female males and spouses. The ultimate solution to tocophobia is an elective cesarean section following maternal request, with no obvious medical indication. This creates ethical problems to the attending physicians.

Current issues in the treatment of specific phobia: recommendations for innovative applications of hypnosis.

Specific phobia is the most common and treatable of the anxiety disorders. Exposure-based therapies are the treatment of choice and empirically validated protocols are available that promise rapid and effective results. In many cases, however, patients are reluctant to comply with demanding schedules of exposure, increasing the risk of treatment failure. Furthermore, in clinical practice, patients often present with multiple phobias and other Axis I and Axis II disorders that can further complicate therapy. This article covers four important issues that have been addressed in the literature: (a) managing resistance to treatment, (b) reducing length of treatment, (c) clarifying the optimal application of relaxation training, and (d) applying advances in cognitive neuroscience. These issues are reviewed and recommendations proposed for ways in which to modify current treatments. Specific suggestions are provided for implementing these recommendations including examples of innovative applications of standard hypnotic techniques.

Hypnosis aided fixed role therapy for social phobia: a case report.

This case study details how hypnosis aided fixed role therapy (HAFRT) was employed in the successful treatment of a case of social phobia with a history of refractory outcomes to previous therapy trials. The treatment consisted of 10 office sessions, scheduled every two weeks, of HAFRT along with twice a day self-hypnotic sessions where the patient performed multiple visualization rehearsals of the vignettes that were successfully mastered in hypnosis during office visits. The results indicated that this patient was able to engage in social and professional affairs that were impossible prior to treatment. The patient retained the therapy gains at follow up 6 months later.

Short-term psychoanalytic child therapy for anxious children: a pilot study.

Few studies report treatment outcome for early childhood internalizing disorders following psychotherapy, especially psychodynamic techniques. We aimed to investigate effectiveness of a novel, developmentally appropriate, short-term psychodynamic treatment program for 4- to 10-year-olds with anxiety disorders in an outpatient setting. We conducted a quasi-experimental wait-list controlled study. Thirty children (12 females) with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) anxiety disorders and their families received 20-25 sessions of manualized short-term Psychoanalytic Child Therapy (PaCT). We assessed outcome with standardized diagnostic interviews and parent reports of internalizing and total problems at all time points. Child puppet interviews and teacher reports were also available for pre-post treatment and follow-up analyses. While 18 families entered treatment immediately, 12 families were first wait-listed before receiving treatment. Analyses of symptom improvement were based on comparisons between groups (treatment vs. wait-list) as well as pre-post and 6-month follow-up data across all families (including wait-listed families). Among the 27 completers, 66.67% (n = 18) no longer met criteria for any anxiety disorder (59.88% in intent-to-treat analysis) while no children remitted across the wait-list interval. Parent-reported child internalizing and total problems significantly declined during treatment relative to wait-list. Child and teacher reports also revealed significant pre-post symptom reductions on internalizing and total problems. Diagnostic and symptom remission rates were maintained at 6-month follow-up except on child reports. This preliminary study adds to a growing database showing that psychodynamic treatments may offer an effective line of treatment for childhood internalizing symptoms and disorders in the eyes of clinicians, children, parents, and teachers.

Comparison of attention training and cognitive therapy in the treatment of social phobia: a preliminary investigation.

BACKGROUND: Prominent models of social phobia highlight the role played by attentional factors, such as self-focused attention, in the development and maintenance of social phobia. Elevated self-focused attention is associated with increases in self-rated anxiety. Treatments that aim to modify and change attentional processes, specifically self-focused attention, will have a direct effect on social phobia symptoms. Thus, Attention Training targets attentional focus. AIM: The present study aimed to investigate the efficacy of Attention Training in comparison to an established treatment for social phobia, Cognitive Therapy. METHOD: Participants (Intention-to-treat = 45; completers = 30) were allocated to either 6 weeks of Attention Training or Cognitive Therapy. It was hypothesized that both treatments would be effective in reducing social phobia symptoms, but that Attention Training would work primarily by reducing levels of self-focused attention. RESULTS: The results found an overall effectiveness of both treatment conditions in reducing social phobia symptoms. However, Attention Training significantly improved scores on the Self-Focused Attention questionnaire and the Brief Fear of Negative Evaluation questionnaire compared to Cognitive Therapy. CONCLUSION: Attention Training seems to be a promising treatment for social phobia.

The Analysis of a Phobic Child: Some Problems of Theory and Technique in Child Analysis.

This paper attempts to clarify some theoretical and technical aspects of child analysis by correlating the course of treatment, the structure of the neurosis, and the technique employed in the case of a phobic boy who was in analysis over a period of three years. The case was chosen for presentation: (1) because of the discrepancy between the clinical simplicity of the symptom and the complicated ego structure behind it; (2) because of the unusual clearness with which the patient brought to the fore the variegated patterns of his libidinal demands; (3) because of the patient's attempts at transitory solutions, oscillations between perversions and symptoms, and processes of new symptom formation; (4) because the vicissitudes and stabilization of character traits could be clearly traced; (5) and finally, because of the rare opportunity to witness during treatment the change from grappling with reality by means of pathological mechanisms, to dealing with reality in a relatively conflict-free fashion.

Decentering as a common link among mindfulness, cognitive reappraisal, and social anxiety.

BACKGROUND: The tendency to employ both cognitive reappraisal and mindfulness are associated with reduced trait social anxiety; however, it is unclear whether reappraisal and mindfulness are associated with social anxiety through the same mechanisms. It has been proposed that decentering, or the process of seeing thoughts or feelings as objective events in the mind rather than personally identifying with them, may be a key mechanism underlying both cognitive reappraisal and mindfulness. AIMS: To examine the relationships between reappraisal, mindfulness, decentering, and social anxiety. METHOD: This study utilized structural equation modeling to examine the relationships among cognitive reappraisal, mindfulness, decentering, and social anxiety in a large cross-sectional study. RESULTS: Results indicate that the relationship between mindfulness and social anxiety is partially accounted for by decentering, whereas the relationship between cognitive reappraisal and social anxiety is more fully accounted for by decentering. CONCLUSIONS: These results imply that decentering may be a common mechanism underlying both cognitive reappraisal and mindfulness, although mindfulness may also affect social anxiety through additional mechanisms. However, given the cross-sectional nature of these findings, results should be considered preliminary, with future research being needed to further elucidate these relationships.

Assessing mental imagery in clinical psychology: a review of imagery measures and a guiding framework.

Mental imagery is an under-explored field in clinical psychology research but presents a topic of potential interest and relevance across many clinical disorders, including social phobia, schizophrenia, depression, and post-traumatic stress disorder. There is currently a lack of a guiding framework from which clinicians may select the domains or associated measures most likely to be of appropriate use in mental imagery research. We adopt an interdisciplinary approach and present a review of studies across experimental psychology and clinical psychology in order to highlight the key domains and measures most likely to be of relevance. This includes a consideration of methods for experimentally assessing the generation, maintenance, inspection and transformation of mental images; as well as subjective measures of characteristics such as image vividness and clarity. We present a guiding framework in which we propose that cognitive, subjective and clinical aspects of imagery should be explored in future research. The guiding framework aims to assist researchers in the selection of measures for assessing those aspects of mental imagery that are of most relevance to clinical psychology. We propose that a greater understanding of the role of mental imagery in clinical disorders will help drive forward advances in both theory and treatment.

Transtornos de ansiedade: terapia com estimulação magnética transcraniana / Anxiety disorders: treatment with transcranial magnetic stimulation

Dentre os transtornos psiquiátricos, os transtornos de ansiedade (TAs) são os mais comuns, com prevalência em torno de 20% na população e, portanto, provocam grande prejuízo a pacientes e familiares. São vários os subtipos de transtornos de ansiedade e um diagnóstico correto se baseia em uma avaliação clínica cuidadosa. No presente artigo apresentamos os diagnósticos e os achados mais recentes sobre o tratamento com estimulação magnética transcraniana repetitiva (EMTr) para o transtorno de pânico, transtorno obsessivo-compulsivo, transtorno de estresse pós-traumático e fobia social.

Among psychiatric disorders, anxiety disorders (ATs) are the most common, with a prevalence of around 20% in the population and with great harm to patients and families. There are several subtypes of anxiety disorders and a correct diagnosis is based on a careful clinical assessment. In this paper we present the findings and the latest findings about treatment with repetitive transcranial magnetic stimulation (rTMS) for panic disorder, obsessive-compulsive disorder, post-traumatic stress and social phobia.

Defensive mobilization in specific phobia: fear specificity, negative affectivity, and diagnostic prominence.

BACKGROUND: Understanding of exaggerated responsivity in specific phobia-its physiology and neural mediators-has advanced considerably. However, despite strong phenotypic evidence that prominence of specific phobia relative to co-occurring conditions (i.e., principal versus nonprincipal disorder) is associated with dramatic differences in subjective distress, there is yet no consideration of such comorbidity issues on objective defensive reactivity. METHODS: A community sample of specific phobia (n = 74 principal; n = 86 nonprincipal) and control (n = 76) participants imagined threatening and neutral events while acoustic startle probes were presented and eyeblinks (orbicularis occuli) recorded. Changes in heart rate, skin conductance level, and facial expressivity were also measured. RESULTS: Principal specific phobia patients far exceeded control participants in startle reflex and autonomic reactivity during idiographic fear imagery. Distinguishing between single and multiple phobias within principal phobia and comparing these with nonprincipal phobia revealed a continuum of decreasing defensive mobilization: single patients were strongly reactive, multiple patients were intermediate, and nonprincipal patients were attenuated-the inverse of measures of pervasive anxiety and dysphoria (i.e., negative affectivity). Further, as more disorders supplanted specific phobia from principal disorder, overall defensive mobilization was systematically more impaired. CONCLUSIONS: The exaggerated responsivity characteristic of specific phobia is limited to those patients for whom circumscribed fear is the most impairing condition and coincident with little additional affective psychopathology. As specific phobia is superseded in severity by broad and chronic negative affectivity, defensive reactivity progressively diminishes. Focal fears may still be clinically significant but not reflected in objective defensive mobilization.

Using a semi-structured interview to explore imagery experienced during social anxiety for clients with a diagnosis of psychosis: an exploratory study conducted within an early intervention for psychosis service.

BACKGROUND: Social phobia frequently occurs as a comorbid condition, with high rates reported among people with psychosis. Little is known about the nature of social anxiety in this population or whether current psychological theories apply. AIMS: This paper aims to develop and pilot a suitable measure to explore imagery experienced by participants with comorbid psychosis and social anxiety and to provide preliminary indications as to its nature. METHOD: A semi-structured interview exploring imagery was used with seven participants (adapted from Hackmann, Surawy and Clark, 1998) and the results were analysed using qualitative template analysis. RESULTS: Initial indications from this sample suggest that some participants experience typical social anxiety images, as identified by Hackmann et al. (1998). However, some experience images that appear more threatening, and may be related to residual psychotic paranoia. Image perspective was also explored: typical social anxiety images tended to be seen from an observer perspective, while those that may have been more related to psychosis tended to be seen from a field perspective. CONCLUSIONS: This exploratory study has facilitated the careful adaptation and development of an imagery interview for use in this population and has suggested areas for further research and raised questions around clinical implications.

Blushing propensity and psychological distress in people with rosacea.

UNLABELLED: Rosacea is a chronic skin disorder, characterized by persistent painful facial flushing and often accompanied by papules and pustules. To evaluate the psychological and social impacts of rosacea, 31 individuals with rosacea filled in the Blushing Propensity Scale, the Fear of Negative Evaluation Questionnaire, the Depression Anxiety and Stress Scale, the Social Interaction Anxiety Scale and the Social Phobia Scale. The questionnaires were also completed by 86 controls. Participants with extensive facial papules and pustules had higher blushing propensity, stress and social phobia scores than controls or others without papules or pustules. Childhood blushing was also reported more frequently by participants with rosacea than controls. Cognitive-behavioural therapy appeared to be helpful for managing social anxiety in three individuals with rosacea with a fear of blushing. These findings suggest that people with severe rosacea are anxious about the social consequences of blushing and generally prefer to avoid situations that might involve scrutiny by others. Persistent facial flushing could prime interoceptive cues of blushing or increase anxiety about facial coloration in provocative situations. Treatments that target fear of blushing may help to reduce social anxiety in people with severe rosacea. KEY PRACTITIONER MESSAGE: Blushing propensity scores are elevated in people with severe rosacea. Fear of blushing may contribute to social anxiety and avoidance in such cases. Cognitive-behavioural therapy for fear of blushing may help to reduce social anxiety in people with severe rosacea.