[Preventing emotional disorders in the elderly with programs based on cognitive-behavioral therapies]. / Prévenir les troubles émotionnels des personnes âgées avec des programmes fondés sur les thérapies cognitivo-comportementales.

The cognitive-behavioral approach is particularly well-suited to older people who are looking for a short-term therapeutic solution to many emotional problems, without necessarily resorting to psychotropic drugs. One of the major advantages of this type of psychological treatment is that it helps seniors develop coping skills that can be beneficial in both the short and long term. However, some adjustments are sometimes necessary to achieve this goal.

Changes in irrational beliefs are responsible for the efficacy of the REThink therapeutic game in preventing emotional disorders in children and adolescents: mechanisms of change analysis of a randomized clinical trial.

The mechanisms of change are rarely investigated in the field of gamified interventions for preventing emotional disorders in children and adolescents despite the wide recognition for the advantages they offer as prevention tool. Therefore, the aim of the present study was to investigate the mechanisms of change of a therapeutic game (REThink), specifically mediators and moderators of its efficacy. We conducted a randomized controlled trial, involving 165 children (age range 10-16 years), who were randomly distributed across three groups: the REThink group (N = 54), the Rational Emotive Behavior Education group (N = 55) and the Waitlist condition (N = 56). Results indicated that changes in irrational beliefs were significant mediators for the REThink intervention on depressive mood and overall negative emotions. Age did not moderate the effect of REThink, which indicates that the program was equally effective for children and adolescents.Trial Registration ClinicalTrials.gov NCT03308981.

Experiences of parenting and clinical intervention for mothers affected by personality disorder: a pilot qualitative study combining parent and clinician perspectives.

BACKGROUND: Evidence-based parenting programmes are recommended for the treatment of child mental health difficulties. Families with complex psychosocial needs show poorer retention and outcomes when participating in standard parenting programmes. The Helping Families Programme (HFP) is a 16-week community-based parenting intervention designed to meet the needs of these families, including families with parental personality disorder. This study aimed to explore the help seeking and participatory experiences of parents with a diagnosis of personality disorder. It further aimed to examine the acceptability of referral and intervention processes for the HFP from the perspectives of (i) clinicians referring into the programme; and (ii) referred parents. METHOD: Semi-structured interviews were conducted with parents recruited to receive HFP (n = 5) as part of a research case series and the referring NHS child and adolescent mental health service (CAMHS) clinicians (n = 5). Transcripts were analysed using Interpretive Phenomenological Analysis. RESULTS: Four themes were identified for parents: (i) the experience of parenthood, (ii) being a parent affected by personality disorder, (iii) experience of the intervention, and (iv) qualities of helping. Three themes emerged for clinicians: (i) challenges of addressing parental need, (ii) experience of engaging parents with personality disorders and (iii) limited involvement during HFP. Comparison of parent and clinician themes led to the identification of two key interlinked themes: (i) concerns prior to receiving the intervention, and (ii) the challenges of working together without a mutual understanding. CONCLUSIONS: This pilot study identifies potentially significant challenges of working with parents affected by personality disorder and engaging them in HFP and other similar interventions. Results have important wider clinical implications by highlighting potential barriers to engagement and participation and providing insights on how these barriers might be overcome. Findings have been used to inform the referral and intervention processes of a pilot RCT and further intervention development.

Online cognitive-behavioral based group interventions for adolescents with chronic illness and parents: study protocol of two multicenter randomized controlled trials.

BACKGROUND: Adolescents with chronic illness (CI) and parents of a child with CI are at risk for psychosocial problems. Psychosocial group interventions may prevent these problems. With the use of cognitive-behavioral therapy, active coping strategies can be learned. Offering an intervention online eliminates logistic barriers (travel time and distance) and improves accessibility for participants. Aim of this study is to examine the effectiveness of two cognitive-behavioral based online group interventions, one for adolescents and one for parents: Op Koers Online. The approach is generic, which makes it easier for patients with rare illnesses to participate. METHODS/DESIGN: This study conducts two separate multicenter randomized controlled trials. Participants are adolescents (12 to 18 years of age) with CI and parents of children (0 to 18 years of age) with CI. Participants are randomly allocated to the intervention group or the waitlist control group. Outcomes are measured with standardized questionnaires at baseline, after 8 (adolescents) or 6 (parents) weeks of treatment, and at 6- and 12-month follow-up period. Primary outcomes are psychosocial functioning (emotional and behavioral problems) and disease-related coping skills. Secondary outcomes for adolescents are self-esteem and quality of life. Secondary outcomes for parents are impact of the illness on family functioning, parental distress, social involvement and illness cognitions. The analyses will be performed according to the intention-to-treat principle. Primary and secondary outcomes will be assessed with linear mixed model analyses using SPSS. DISCUSSION: These randomized controlled trials evaluate the effectiveness of two online group interventions improving psychosocial functioning in adolescents with CI and parents of children with CI. If proven effective, the intervention will be optimized and implemented in clinical practice. TRIAL REGISTRATION: ISRCTN ISRCTN83623452 . Registered 30 November 2017. Retrospectively registered.

Population-Based System of Parenting Support to Reduce the Prevalence of Child Social, Emotional, and Behavioural Problems: Difference-In-Differences Study.

The quality of parenting is recognised as an important determinant of children's mental health. Parenting interventions typically target high-risk families rather than adopting a universal approach. This study examined the population impact of the Triple P Positive Parenting Programme on the prevalence of children's social, emotional, and behavioural problems. A propensity score matching difference-in-differences method was used to compare intervention and comparison regions matched on socio-demographic characteristics in midlands Ireland. The pre-intervention sample included 1501 and 1495 parents of children aged 4-8 years in the intervention and comparison regions respectively. The post-intervention sample included 1521 and 1544 parents respectively. The primary outcome measure was parental reports on the Strengths and Difficulties Questionnaire. There were some significant reductions in the prevalence rates of social, emotional, and behavioural problems in the intervention regions compared to the comparison regions. Children in the intervention sample experienced lower total difficulties, emotional symptoms, and conduct problems than children in the comparison sample, and they were less at risk of scoring within the borderline/abnormal range for total difficulties, conduct problems, and hyperactivity. The programme reduced the proportion of children scoring within the borderline/abnormal range by 4.7% for total difficulties, 4.4% for conduct problems, and 4.5% for hyperactivity in the total population. This study demonstrated that a universal parenting programme implemented at multiple levels using a partnership approach may be an effective population health approach to targeting child mental health.

[Psychosocial Risk Factors and Negative Emotionality in Early Childhood: Mothers' Perspective]. / Psychosoziale Belastungsfaktoren und negative Emotionalität in der frühen Kindheit: die Perspektive der Mütter.

Psychosocial Risk Factors and Negative Emotionality in Early Childhood: Mothers' Perspective Based on a nationally representative study of parents, this study examines risk factors for mothers' perceptions of young children's negative emotionality, focusing the role of mothers' educational resources and related psychosocial risk factors. Participants were 7,311 mothers with children below age 48 month. Mothers' perception of child emotionality was assessed through two factors, irritability and defiance. Findings from regression analyses showed a stable negative relationship between maternal education and perceived defiance of the child. Although this effect was partly mediated by further psychosocial risk factors, lower education was consistently related with higher perceived defiance. Perceived irritability, in contrast, was not affected by mother's education. Further analyses showed age-specific effects (stronger effects for younger children) as well as a predictive value of mothers' perceptions regarding the occurrence of child abuse or neglect. The results are discussed in the context of early prevention programs in Germany, emphasizing the relevance of identifying risk-groups and offering early and multidimensional prevention.

[Parental Reflective Functioning and its Relation to Parenting Stress in a Sample with Early Regulatory Disorders]. / Elterliche Mentalisierungsfähigkeit und der Zusammenhang mit elterlicher Belastung bei frühkindlichen Regulationsstörungen.

Parental Reflective Functioning and its Relation to Parenting Stress in a Sample with Early Regulatory Disorders Parents' capacity to reflect on their child as a mental agent, is defined as an important competence for the early parent-infant relationship. One way to operationalize this is parental reflective functioning (PRF) that distinguishes between mentalizing and non-mentalizing modes of reflection. Until today PRF has not been investigated in samples of infants/toddlers with early regulatory disorders. Goal of the present study is to investigate PRF by comparing a clinical group with parents of infants/toddlers with early regulatory disorders (N = 98) with a healthy control group (N = 27) and testing if PRF is related to parenting stress, past mental illness of the mother, and stress factors related to pregnancy and birth. A semi-structured clinical interview, the Parenting Stress Index, the Symptom-Check-List-90R-S, the Parental Reflective Functioning Questionnaire, and an anamnestic questionnaire were used. Compared to the control group, mothers of infants/toddlers with early regulatory disorders reported significant more prementalizing. Prementalizing in the total sample was significantly predicted by parenting stress, accounting for 16.3 % of the variance. None of the other independent variables significantly predicted prementalizing. Results are discussed in relation to early regulatory disorders and implications for clinical practice.

Sharing information about cancer with one's family is associated with improved quality of life.

OBJECTIVE: The aim of this study was to investigate the association between cancer patients' ability to share information about their illness with their social network and attachment style dimensions, alexithymia, and quality of life. We hypothesised that ability to share information about one's cancer with family, friends, and medical teams would be positively associated with quality of life and secure attachment and negatively associated with alexithymia. METHODS: Forty-five cancer patients were recruited from the Psycho-oncology Unit of the San Camillo-Forlanini Hospital in Rome. We collected anamnestic data and self-report data on social sharing ability, quality of life, alexithymia, and attachment. RESULTS: Sharing with family (B = 4.66; SE = 1.82; ß = .52; SE = 0.20; t(41) = 2.6; P = .0143) was the only predictor of global health status, and attachment security was the only predictor of mean social sharing (B = 0.25; SE = 0.06; ß = .63; SE = 0.14; t(41) = 4.4; P < .0001). CONCLUSIONS: Encouraging patients to share information about their experience of cancer may help to improve their quality of life. Attachment security seems to promote social sharing. Psychological assessments of cancer patients should cover both ability to share information about one's cancer with family and attachment security.

Epigenetic basis of sensitization to stress, affective episodes, and stimulants: implications for illness progression and prevention.

OBJECTIVES: The process of sensitization (increased responsivity) to the recurrence of stressors, affective episodes, and bouts of substance abuse that can drive illness progression in the recurrent affective disorders requires a memory of and increased reactivity to the prior exposures. A wealth of studies now supports the postulate that epigenetic mechanisms underlie both normal and pathological memory processes. METHODS: We selectively reviewed the literature pertinent to the role of epigenetics in behavioral sensitization phenomena and discuss its clinical implications. RESULTS: Epigenetics means above genetics and refers to environmental effects on the chemistry of DNA, histones (around which DNA is wound), and microRNA that change how easily genes are turned on and off. The evidence supports that sensitization to repeated stressor, affective episodes, and substance is likely based on epigenetic mechanisms and that these environmentally based processes can then become targets for prevention, early intervention, and ongoing treatment. Sensitization processes are remediable or preventable risk factors for a poor illness outcome and deserve increased clinical, public health, and research attention in the hopes of making the recurrent unipolar and bipolar affective disorders less impairing, disabling, and lethal by suicide and increased medical mortality. CONCLUSIONS: The findings that epigenetic chemical marks, which change in the most fundamental way how genes are regulated, mediate the long-term increased responsivity to recurrent stressors, mood episodes, and bouts of substance abuse should help change how the affective disorders are conceptualized and move treatment toward earlier, more comprehensive, and sustained pharmacoprophylaxis.

Correlates of emotional and behavioural problems in children with perinatally acquired HIV in Cape Town, South Africa.

In the antiretroviral era, youth perinatally infected with HIV (PHIV+) are surviving into adulthood and are at risk for emotional and behavioural problems. Few studies of these problems have been conducted in low- and middle-income countries and even fewer in sub-Saharan Africa. The aims of this study were to provide a quantitative description of emotional and behavioural problems in a group of PHIV+ youth (n = 78) in South Africa compared with a group of demographically matched HIV-negative controls (n = 30) and to identify correlates of emotional and behavioural problems. A cross-sectional study was conducted employing participants from community and hospital-based clinics. Emotional and behavioural problems were assessed using the Child Behaviour Checklist (CBCL). Several measures were used to assess demographic, biological, cognitive and contextual correlates of problem behaviours. Youth were compared by HIV status on demographic, cognitive and contextual variables as well as the Total Problems and subscale scores of the CBCL. Multivariate comparisons of the influence of contextual and cognitive variables on CBCL Total Problems scores were performed using a stepwise linear regression analytic procedure. In this study, there were no significant differences in between-group comparisons for the prevalence of Internalizing, Externalizing and Total Problems in the PHIV+ youth and control group at the clinical and borderline cut-off ranges of the CBCL. Caregiver depression was the only significant predictor of greater Total Problems scores in the full model, after controlling for age and gender (F = 8.57, df = 5.102, P < .01). An interaction between HIV status and caregiver depression was observed (t = -2.20, P = .03), with follow-up within-group analyses confirming that caregiver depression predicted greater Total Problems scores both in HIV-negative youth (ß = 0.61, P < .001), and to a lesser extent, in HIV-positive youth (ß = 0.25, P < .001). This study highlights the need for adequate screening of depression in the caregivers of HIV-infected youth.

Enhancing Social Responsibility and Prosocial Leadership to Prevent Aggression, Peer Victimization, and Emotional Problems in Elementary School Children.

Testing the theories that form the basis of prevention programs can enhance our understanding of behavioral change and inform the development, coordination, and adaptation of prevention programs. However, theories of change showing the linkages from intervention program components to risk or protective factors to desired outcomes across time are rarely specified or tested. In this 2-year longitudinal study, we test the theory that increases in two protective factors (i.e., children's prosocial leadership and their teachers' expectations of social responsibility) targeted by the WITS Programs (Walk Away, Ignore, Talk it Out, and Seek Help) would be associated with declines in peer victimization, aggression, and emotional problems. Participants included Canadian students, in grades 1-4 at baseline (n = 1329) and their parents and teachers. Consistent with our theory of change, variability in program implementation (adherence and integration) and in children's use of program skills (child responsiveness) are related to increases in both protective factors. Increases in these protective factors are associated with subsequent declines in children's aggression, victimization, and emotional problems. We discuss how enhancement of these protective factors may operate to improve child outcomes and the need for theory-based research to refine and improve the effectiveness of intervention strategies and to improve program scale-up.

Determinants of emotional problems and mood disorders in women with polycystic ovary syndrome.

OBJECTIVES: The aim of the study was to assess the prevalence and severity of emotional problems among Polish women with polycystic ovary syndrome (PCOS) and seek factors which increase the risk of their occurrence. MATERIAL AND METHODS: The study group consisted of 82 women (aged 18-48), who were diagnosed with PCOS based on the Rotterdam criteria. During hospitalization, the patients completed a number of questionnaires, providing their sociodemographic data and information concerning the inconvenience of disease-associated symptoms. The question-naires included the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Multidimensional Self-Esteem Inventory (MSEI). Data obtained during medical examinations (blood tests, transvaginal ultrasound, height and body mass measurements) were analyzed. RESULTS: Out of 82 women, the results detected risk for depression in 42 (51.22%), mild depressive disorders in 32, moderate disorders in 8, and severe disorder in 2 patients. No statistically significant correlation between BDI or state anxiety and the level of the analyzed hormones, insulin resistance, or infertility treatment, was found. General self-esteem, trait anxi-ety, and marital status were associated with the occurrence of depression symptoms. BMI was associated with the level of state anxiety during hospitalization. CONCLUSIONS: Women with PCOS are at risk for mood and anxiety disorders. Disease-related somatic factors are not directly associated with the risk for disorder occurrence. However, severity of depression symptoms has been shown to be influenced by permanent psychological characteristics of the studied women, i.e. self-esteem, trait anxiety, and life situation (marital status). Therefore, it is recommended to include interviews about patient life situation and screening questionnaires for assessing depression into the diagnostic procedures in PCOS patients. Patients should be referred for a psychological or psychiatric consultation, if needed.

Association of usual self-reported dietary intake with ecological momentary measures of affective and physical feeling states in children.

BACKGROUND: Little is known about the relationship between dietary intake and affective and physical feeling states in children. PURPOSE: The current study used Ecological Momentary Assessment (EMA) to examine how usual dietary intake is cross-sectionally associated with both average affective and physical feeling state ratings and rating variability in children. METHODS: Children (N = 110, mean age = 11.0 ± 1.2 years, 52.5% male, 30.1% Hispanic/Latino) completed EMA measures of affective and physical feeling states 3-7 times per day for a full or partial day (weekday evenings and weekend days and evenings) over a 4-day period. Usual intake of pre-selected dietary components was measured prior to the EMA measurement period using the Block Kids Food Screener. Statistical analyses included mixed models and mixed-effects location scale models. RESULTS: Greater usual fiber intake was cross-sectionally associated with higher average positive affect (PA) ratings, lower variability of NA ratings, and higher variability of physical fatigue ratings. Lower usual glycemic load of diet was cross-sectionally associated with lower variability of NA ratings. Lower usual added sugar intake was cross-sectionally associated with higher average physical energy ratings and lower variability of NA ratings. CONCLUSIONS: Although temporal precedence was not established by these findings, they indicate that characteristics of children's usual dietary intake are cross-sectionally associated with both the average and variability of affective and physical feeling states. EMA offers a promising avenue through which to explore the associations between affective states and diet and has the potential to provide insight into nuances of this relationship.

[Mindfulness-based interventions in psychotherapy and in rehabilitation]. / Tudatos jelenlét (mindfulness) alapú módszerek a pszicchoterápiában és a rehabilitációban.

Mindfulness means paying attention in a particular way: on purpose, in the present moment in a nonjudgmental and nonreactive way. During the last years we can see a growing interest about this topic both in psychology both in medicine. Our article reviews the concept of mindfulness, the wide range of its effects (from genexpression to social connections) and the theoretical models of mindfulness. We shortly review the methods which explicitly focus on the improvement of the skill of mindfulness (Mindfulness Based Stress Reduction, Mindfulness Based Cognitive Therapy, Acceptance and Commitment Therapy) and the role of mindfulness in (oncological and neurological) rehabilitation.

Prevention of Emotional Problems in Spanish Schoolchildren: Effectiveness of the Super Skills Multimedia Program to Promote Social-Emotional Skills.

Compared to traditional psychosocial interventions, the transdiagnostic approach focuses on common processes or factors that contribute to the development and maintenance of emotional problems. In Spain, the Super Skills Program has proven its effectiveness, but issues with displacement or scheduling for families can hinder access to the intervention. This study aims to examine the program's effectiveness in preventing children's psychosocial problems through learning socio-emotional skills when self-administered via the Internet. Participants were 283 Spanish children between the ages of 8 and 12. The children and their parents completed anxiety and depression scales before and after receiving the intervention and 12 months later. The program consisted of 8 self-applied sessions, at a rate of two per week, which included emotional education, cognitive restructuring, self-regulation techniques, training in social skills, problem-solving, and video feedback with cognitive preparation. Significant differences in anxiety and depression symptoms were found after the intervention. A significant reduction in anxiety scores and a marginally significant decrease in depression scores was observed at the long-term follow-up. The "intention to treat" analysis revealed a tendency for children who improved to drop out of the program, completing the intervention children with more symptomathology. Learning socio-emotional skills through a self-applied intervention via the Internet effectively reduced emotional symptoms in school children and is a valuable resource to improve child well-being and prevent future psychological problems.

Brief parenting intervention for parents of NICU graduates: a randomized, clinical trial of Primary Care Triple P.

BACKGROUND: Preterm-born or asphyxiated term-born children who received neonatal intensive care show more emotional and behavioral problems than term-born children without a medical condition. It is uncertain whether regular parenting intervention programs to which the parents of these children are usually referred, are effective in reducing child problem behavior in this specific population. Our objective was to investigate whether a regular, brief parenting intervention, Primary Care Triple P, is effective in decreasing emotional and behavioral problems in preterm-born or asphyxiated term-born preschoolers. METHODS: For this pragmatic, open randomized clinical trial, participants were recruited from a cohort of infants admitted to the neonatal intensive care units (NICU) of two Dutch hospitals. Children born with a gestational age <32 weeks or birth weight <1500 g and children born at a gestational age 37-42 weeks with perinatal asphyxia were included. After screening for a t-score ≥60 on the Child Behavior Checklist (CBCL), children were randomly assigned to Primary Care Triple P (n = 34) or a wait-list control group (n = 33). The primary outcome was child emotional and behavioral problems reported by parents on the CBCL, 6 months after the start of the trial. RESULTS: There was no effect of the intervention on the CBCL at the trial endpoint (t64 = 0.54, P = .30). On secondary measurements of child problem behavior, parenting style, parenting stress, and parent perceived child vulnerability, groups either did not differ significantly or the intervention group showed more problems. In both the intervention and control group there was a significant decrease in emotional and behavioral problems during the trial. CONCLUSIONS: Primary Care Triple P, a brief parenting intervention, is not effective in reducing child emotional and behavioral problems in preterm-born children or term-born children with perinatal asphyxia. TRIAL REGISTRATION: Netherlands National Trial Register (NTR): NTR2179.

Work stress and negative affectivity: a multi-method study.

BACKGROUND: In the literature negative affectivity (NA) is considered both a confounding variable as well as a predictive variable for work-related stress. However, a common limitation in this line of research relates to the use of self-report measures for determining NA, perceived stressors and psychophysical strain. AIMS: To test, using a multi-method study, a theoretical model that correlates NA, perceived interpersonal conflict (with co-workers and supervisors), psychophysical strain and medically certified sickness absences. METHODS: A multi-method prospective study was carried out on a sample of metalworkers. NA and interpersonal conflict were determined using self-report (Time 1), whereas psychophysical strain was determined by an occupational physician (Time 2). Data on medically certified sickness absences were collected from the company's database (Time 3). RESULTS: There were 326 participants. The results showed an association between NA and conflict with co-workers, as well as between NA and conflict with supervisors. Psychophysical strain could be predicted from NA and conflict with co-workers but not from conflict with supervisors. NA had a significant indirect effect on psychophysical strain through conflict with co-workers. Lastly, psychophysical strain predicted sickness absences from work. CONCLUSIONS: NA influenced psychophysical strain in the worker, both directly and indirectly, through perceived conflict with co-workers.

Foreign students' experience during a time of war.

BACKGROUND: Due to the war in Gaza in 2009, Ben-Gurion University's Medical School for International Health with a student body of 165 international multicultural students canceled a week of classes. Third-year students continued clerkships voluntarily and fourth-year students returned to Israel before departing for electives in a developing country. A debriefing session was held for the entire school. OBJECTIVES: To assess the academic and psychological effects of political conflict on students. METHODS: We asked all students to fill out an anonymous Google electronic survey describing their experience during the war and evaluating the debriefing. A team of students and administrators reviewed the responses. RESULTS: Sixty-six students (40% of the school) responded (first year 26%, second year 39%, third year 24%, fourth year 8%, taking time off 3%, age 23-40 years old). Eighty-three percent were in Israel for some portion of the war and 34% attended the debriefing. Factors that influenced individuals' decision to return/stay in the war zone were primarily of an academic and financial nature. Other factors included family pressure, information from peers and information from the administration. Many reported psychological difficulties during the war rather than physical danger, describing it as "draining" and that it was difficult to concentrate while studying. As foreigners, many felt their role was undefined. Although there is wide variation in the war's effect on daily activities and emotional well-being during that time, the majority (73%) reported minimal residual effects. CONCLUSIONS: This study lends insight to the way students cope during conflict and highlights academic issues during a war. Open and frequent communication and emphasis on the school as a community were most important to students.

[Botulinum toxin therapy for spasmodic torticollis: medical and non-medical adjunct treatment]. / Botulinum-Toxin-Therapie bei Torticollis spasmodicus: Medizinische und nichtmedizinische Begleitbehandlungen.

BACKGROUND: Spasmodic torticollis patients were investigated with respect to the number of adjunct treatments used before and after the introduction of botulinum toxin therapy (Btx). The study was designed in a similar way to an earlier investigation by Birner et al. (Nervenarzt 70:903-908, 1999). MATERIAL AND METHODS: A total of 247 patients with idiopathic spasmodic torticollis were assessed at three time points for the diagnosis: before 1988 (n = 63), between 1989 and 1998 (n = 107) and after 1999 (n = 77). RESULTS: Independent of the year of diagnosis patients underwent a mean of 14.3 different treatments. In addition to Btx most of the patients were subjected to massage, physiotherapy, medication and a large number of non-medical treatments including praying. No associations to clinical or personal variables were found. Those patients with emotional disorders prior to onset of dystonia displayed a higher rate of medical and non-medical treatments in addition to Btx. CONCLUSIONS: The results confirmed those found by Birner et al.. In order to enhance compliance patients should undergo psychoeducation with respect to illness behaviour and specific history taking with respect to emotional disorders prior to dystonia.