Effectiveness of Moral Developmental Interventions for Youth Engaged in Delinquent Behavior: A Meta-Analysis.

There is vast empirical evidence showing that juvenile delinquency is associated with delays in moral development, including moral judgment, empathy, and self-conscious emotions (guilt and shame). Consequently, interventions have been developed that target moral development of juvenile delinquents to reduce criminal offense recidivism. However, a comprehensive synthesis of studies examining the effectiveness of these interventions was not yet available. The present meta-analysis of (quasi-)experimental research therefore examined the effects of interventions that target moral development of youth engaged in delinquent behavior. Interventions that targeted moral judgment (11 studies and 17 effect sizes) showed a significant and small-to-medium effect on moral judgment (d = 0.39), with intervention type as a significant moderator, but no significant effect on recidivism (d = 0.03; 11 studies and 40 effect sizes). No (quasi-)experimental studies were found that targeted guilt and shame in juvenile offenders, and an insufficient number of studies (i.e., only two) were found to conduct a meta-analysis of interventions that target empathy. The discussion focuses on potential ways to improve moral development interventions for youth engaged in delinquent behavior, and provides suggestions for future research.

From childhood trauma to hyperarousal in adults: The mediating effect of maladaptive shame coping and insomnia.

Introduction: A new line of insomnia research focuses on the developmental trajectories from early live stress to insomnia in adulthood. Adverse childhood experiences (ACE's) might create a vulnerability for later maladaptive coping with distress, as seen in chronic hyperarousal or insomnia. In an functional magnetic resonance imaging (fMRI) study, failure to dissociate the neurobiological components of shame from autobiographical shameful memories in insomnia was reflected by continued activation of the dorsal anterior cingulate cortex (dACC), which may be a result of maladaptive coping in the wake of ACE's. Following up on that study, the current pilot study explores the relation between ACE's, shame coping-styles, adult insomnia, hyperarousal, and neurobiology of autobiographical memory. Methods: We used existing data (N = 57) from individuals with insomnia (N = 27) and controls (N = 30), and asked these participants to complete the childhood trauma questionnaire (CTQ). Two structural equation models were used to test the hypotheses that shame-coping styles and insomnia symptom severity mediate the association between ACE's and (1) self-rated hyperarousal symptoms and (2) dACC activation to recall of autobiographical memories. Results: For the association between ACE's and hyperarousal, there was a significant mediation of shame-coping style (p < 0.05). This model also indicated worse shame coping with more ACE's (p < 0.05) and worse insomnia symptoms with more ACES's (p < 0.05), but no association between shame coping and insomnia symptoms (p = 0.154). In contrast, dACC activation to recall of autobiographical memories could only be explained by its direct association with ACE's (p < 0.05), albeit that in this model more ACE's were also associated with worse insomnia symptoms. Discussion: These findings could have an implication for the approach of treatment for insomnia. It could be focused more on trauma and emotional processing instead of conventional sleep interventions. Future studies are recommended to investigate the relationship mechanism between childhood trauma and insomnia, with additional factors of attachment styles, personality, and temperament.

Mapping Conscience: Network Analysis Into the Differences in Maturation of Offending and Non-Offending Adolescents.

Conscience is a diagnostically relevant concept in forensic psychiatry, but often misinterpreted as an all-or-none phenomenon. We conceptualize the conscience as a psychic function in which elements like empathy, self-conscience emotions such as shame, guilt and pride, and moral orientation work together. The differences in conscience functioning can be described in terms of developmental levels of integration. We conducted network analyses on data collected via a questionnaire survey held among 52 offending and 243 non-offending juveniles. We displayed two networks: One representing the non-offenders' normative and one representing the offenders' defiantly maturing conscience. As was hypothesized, in the non-offenders network, almost all elements clustered into one clinically meaningful network, indicating integration of the different elements of the normative maturing conscience. In the offenders network, the correlations between the elements were sporadic, indicating a lack of integration of the defiantly maturing conscience. The difference between the two networks was more prominent for empathy and moral orientation than for self-conscious emotions. This research supports the theory of differences in maturation of conscience instead of being an all-or-none phenomenon and calls for further research, taking a deeper look at the significance of integration of the conscience and its implications for offending behaviour.

Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet?

Narcissistic Personality Disorder is the new borderline personality disorder of our current era. There have been recent developments on narcissism that are certainly worthwhile examining. Firstly, relational and intersubjective psychoanalysts have been rethinking the underlying concepts of narcissism, focusing on the development of self and relations to others. Secondly, in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) was presented for a dimensional evaluation of the severity of personality disorder pathology. The combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning. Finally, Pincus and Lukowitsky encourage clinicians to use a hierarchical model of pathological narcissism, as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. As for most non-psychodynamic clinicians and researchers the DSM-5 clearly bears dominant weight in their work, we will take the AMPD model for NPD as our point of reference. We will discuss the narcissist's unique pattern of self-impairments in identity and self-direction, and of interpersonal disfunctioning (evaluated by assessing empathy and intimacy). Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD. For us, one of the big advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning and the dimensional evaluation of severity. As psychodynamically oriented therapists, we are enthusiastic about the opportunities for inclusion of psychodynamic concepts, but we also discuss a number of sticking points.

[Shame and guilt due to a complaint]. / Schaamte en schuld door een klacht.

A complaint is not only an attack on our professional expertise, but also on our personal identity. It is difficult for the healthcare professional to retain the duty of care, whereas the patient is free to file a complaint. This can lead to an overly defensive position. Usually a complaint leads to feelings of guilt and shame. Shame about who you are when you are complaint-worthy and guilt because you are accused of having done wrong. A healthy way of dealing with a complaint is to take it seriously, but to experience the additional shame and guilt and view angry feelings towards the patient as bypassing emotions. This is hardly possible for healthcare professionals with an overvalued, inflated self-esteem or with a chronically low self-esteem. The way in which we deal with a complaint is of course strongly linked with our personality: do we punish ourselves for (alleged) mistakes, do we deny the circumstances, or do we appropriate them?

Conscience as a Regulatory Function: An Integrative Theory Put to the Test.

The subject of this study is an integrative theory of the conscience. According to this theory, conscience is operationalised as a regulatory function of one's own behaviour and identity, resulting from an interplay of empathy, self-conscious emotions such as guilt and shame, and moral reasoning. This study aimed to evaluate conscience in an adult forensic psychiatric sample by assessing the underlying factors proposed by Schalkwijk. Offenders (n = 48) appeared to show less affective but not less cognitive empathy, less identification with others, less personal distress in seeing others' suffering, less shame and shame-proneness, and lower levels of moral reasoning than non-offenders (n = 50). In coping with self-conscious emotions, offenders used the same amount of externalising coping strategies, but fewer internalising coping strategies.

Restless REM Sleep Impedes Overnight Amygdala Adaptation.

Animal studies show that insufficient silencing of the locus coeruleus (LC) during REM sleep impairs sleep-related brain plasticity. Restless REM sleep, a characteristic of several psychiatric disorders, likely reflects insufficient LC silencing. We investigated whether endogenous REM sleep interruptions interfere with overnight reorganization of limbic circuits in human volunteers with a wide range of insomnia severity, from no insomnia complaints to fulfilling community-sample criteria for insomnia disorder. We induced a self-conscious emotion during two functional MRI sessions and recorded sleep EEG in between. Amygdala reactivity decreased overnight in proportion to the total duration of consolidated REM sleep. Restless REM sleep, in contrast, impeded overnight amygdala adaptation. Using targeted memory reactivation with odors tagged to the self-conscious emotional stimulus, we could experimentally enhance both the favorable effect of consolidated REM sleep and the unfavorable effect of restless REM sleep. The findings reveal a maladaptive type of sleep, providing a target for interventions in mental disorders characterized by restless REM sleep.

Haunted by the past: old emotions remain salient in insomnia disorder.

Studies suggest that sleep supports persistent changes in the neuronal representation of emotional experiences such that they are remembered better and less distressful when recalled than when they were first experienced. It is conceivable that sleep fragmentation by arousals, a key characteristic of insomnia disorder, could hamper the downregulation of distress. In this study, we sought further support for the idea that insomnia disorder may involve a lasting deficiency to downregulate emotional distress. We used functional MRI in insomnia disorder (n = 27) and normal sleepers (n = 30) to identify how brain activation differs between novel and relived self-conscious emotions. We evaluated whether brain activity elicited by reliving emotional memories from the distant past resembles the activity elicited by novel emotional experiences more in insomnia disorder than in normal sleepers. Limbic areas were activated during novel shameful experiences as compared to neutral experiences in both normal sleepers and insomnia disorder. In normal sleepers, reliving of shameful experiences from the past did not elicit a limbic response. In contrast, participants with insomnia disorder recruited overlapping parts of the limbic circuit, in particular the dorsal anterior cingulate cortex, during both new and relived shameful experiences. The differential activity patterns with new and old emotions in normal sleepers suggest that reactivation of the long-term memory trace does not recruit the limbic circuit. The overlap of activations in insomnia disorder is in line with the hypothesis that the disorder involves a deficiency to dissociate the limbic circuit from the emotional memory trace. Moreover, the findings provide further support for a role of the anterior cingulate cortex in insomnia.

Overnight worsening of emotional distress indicates maladaptive sleep in insomnia.

STUDY OBJECTIVES: Mechanisms underlying the distress of hyperarousal in people with insomnia remain enigmatic. We investigated whether insomnia impedes the overnight adaptation to emotional distress. METHODS: We induced the distressful self-conscious emotion of shame four times across three consecutive days by exposing 64 participants to their often embarrassingly out-of-tune singing, recorded earlier during a Karaoke session. Perceived physical, emotional, and social distress was assessed with the Experiential Shame Scale. RESULTS: Compared to exposures followed by wakefulness, exposures followed by sleep resulted in overnight relief of physical component of shame in normal sleepers, but in a striking opposite overnight worsening in people with insomnia. CONCLUSIONS: Our findings are the first to experimentally show that the benefits of sleep are not only lost when sleep is poor; people with insomnia experience a maladaptive type of sleep that actually aggravates physically perceived distress. Maladaptive sleep could shed new light on posttraumatic stress disorder (PTSD) and on diurnal mood fluctuation and the counterintuitive favorable effects of sleep deprivation in depression.

A New Conceptualization of the Conscience.

With the transition from a one-person psychology of instinctual needs to a two-person psychology of relational needs, the metapsychological focus tends to shift from instinct theory to emotion motivation and systems theory, and, accordingly, familiar concepts have to be rethought. In this article, the superego is reconceptualized as a psychic regulation system for self-evaluation, comprising the capacity for empathy, the proneness to experience self-conscious emotions, such as shame, pride, and guilt, and the capacity for moral reasoning. This new conceptualization provides useful tools for addressing the actual functioning of the conscience in clinical psychoanalysis. Affective neuropsychoanalysis can make important contributions to this rethinking of the superego. It also brings clinical practice and psychoanalytic metapsychology closer to empirical research beyond the scope of clinical psychoanalysis. The new model offers ample opportunities for integrating affective neuroscience into the functioning of the conscience.

The role of avoidant and obsessive-compulsive personality disorder traits in matching patients with major depression to cognitive behavioral and psychodynamic therapy: A replication study.

BACKGROUND: Barber and Muenz (1996) reported that cognitive behavior therapy (CBT) was more effective than interpersonal therapy (IPT) for depressed patients with elevated levels of avoidant personality disorder, while IPT was more effective than CBT in patients with elevated levels of obsessive-compulsive personality disorder. These findings may have important clinical implications, but have not yet been replicated. METHODS: We conducted a study using data from a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy in the outpatient treatment of depression. RESULTS: We found no evidence indicating that avoidant patients may benefit more from CBT compared to short-term psychodynamic supportive therapy (SPSP). CONCLUSIONS: Our results indicate that treatment effect does not depend on the level of avoidance, or obsessive-compulsiveness personality disorders further examine the influence of personality disorders on the effectiveness of CBT or psychodynamic therapy in the treatment of depression.

Slow dissolving of emotional distress contributes to hyperarousal.

The mechanisms underlying hyperarousal, the key symptom of insomnia, have remained elusive, hampering cause-targeted treatment. Recently, restless rapid-eye-movement (REM) sleep emerged as a robust signature of sleep in insomnia. Given the role of REM sleep in emotion regulation, we hypothesized that restless REM sleep could interfere with the overnight resolution of emotional distress, thus contributing to accumulation of arousal. Participants (n = 1,199) completed questionnaires on insomnia severity, hyperarousal, self-conscious emotional distress, and thought-like nocturnal mentation that was validated to be a specific proxy for restless REM sleep (selective fragmentation: R = 0.57, P < 0.001; eye movement density: R = 0.46, P < 0.01) in 32 polysomnographically assessed participants. The experience of distress lasting overnight increased with insomnia severity (ß = 0.29, P < 10(-23)), whereas short-lasting distress did not (ß = -0.02, P = 0.41). Insomnia severity was associated with hyperarousal (ß = 0.47, P < 10(-63)) and with the thought-like nocturnal mentation that is specifically associated with restless REM sleep (ß = 0.31, P < 10(-26)). Structural equation modeling showed that 62.4% of the association between these key characteristics of insomnia was mediated specifically by reduced overnight resolution of emotional distress. The model outperformed all alternative mediation pathways. The findings suggest that restless REM sleep reflects a process that interferes with the overnight resolution of distress. Its accumulation may promote the development of chronic hyperarousal, giving clinical relevance to the role of REM sleep in emotion regulation in insomnia, depression, and posttraumatic stress disorder.

The Conscience as a Regulatory Function: Empathy, Shame, Pride, Guilt, and Moral Orientation in Delinquent Adolescents.

This study examines an emotion-based theory of the conscience, which provides forensic practitioners tools for assessing the state of the conscience. It is operationalized as an emotion-regulating function, making use of empathy, self-conscious emotions, such as shame, pride or guilt, and moral judgment. This was put to test in a questionnaire survey with 59 delinquent and 275 non-delinquent juveniles. As was hypothesized, the functioning of the conscience of these groups differed, with offenders having lower levels of some aspects of empathic capacity, being less prone to experiencing shame and guilt, being more prone to experiencing pride, and being more punishment oriented than victim oriented. The research confirmed that operationalization of the conscience in terms of empathy, self-conscious emotions, and moral orientation is feasible.