Treating post-traumatic stress disorder in survivors of community and domestic violence using narrative exposure therapy: a case series in two public health centers in Rio de Janeiro/Brazil.

Prevalence of violence in Brazil is high, which contributes to an increasing number of trauma-related disorders, especially post-traumatic stress disorder (PTSD). This study aims to present a case series of PTSD patients treated with narrative exposure therapy (NET) in two public health centers in Rio de Janeiro (Brazil). Health professionals were trained in a two-week workshop to deliver NET. Exposure to violence and other potentially traumatic events, as well as PTSD were assessed by interviewers before treatment and six months later in follow-up interviews conducted by blind assessors. Multiple traumatic events, including different types of childhood and sexual abuse, intimate partner violence and community violence were reported. Five patients were exposed to community violence, and one to domestic violence, during or after NET treatment. Treatment delivery was integrated into the routine of health centers. Eight patients completed NET and presented a substantial reduction in PTSD severity at six-month follow-up. NET is a feasible and effective treatment for PTSD patients exposed to ongoing violence, and can be integrated into established public health services.

Interpersonal psychotherapy versus sertraline for women with posttraumatic stress disorder following recent sexual assault: a randomized clinical trial.

Background: Sexual assault often triggers posttraumatic stress disorder (PTSD), a potentially chronic severe mental disorder. Most guidelines recommend selective serotonin reuptake inhibitors (SSRIs) and trauma-focused psychotherapies as treatment options. Interpersonal Psychotherapy (IPT), adapted for PTSD (IPT-PTSD), focuses on interpersonal consequences of trauma rather than confronting the trauma itself. Studies have found IPT-PTSD efficaciously reduced PTSD symptoms with limited attrition. No efficacy trials have compared IPT-PTSD and SSRI. We hypothesized IPT would reduce PTSD, anxiety, and depressive symptoms more than sertraline among women with PTSD following a recent sexual assault. Objectives: To compare the efficacy of IPT-PTSD to SSRI sertraline in a 14-week randomized clinical trial for women with PTSD following a recent sexual assault. Methods: Seventy-four women with PTSD who had suffered sexual assault in the last six months were randomly assigned to 14 weeks of IPT-PTSD (n = 39) or sertraline (n = 35). Instruments assessed PTSD, anxiety, and depressive symptoms. This randomized clinical trial was conducted in São Paulo, Brazil, using the Clinician-Administered PTSD Scale-5 (CAPS-5) as the primary outcome measure. Results: Both treatments significantly reduced PTSD, anxiety, and depressive symptoms, without between-group outcome differences. CAPS-5 mean decreased from 42.5 (SD = 9.4) to 27.1 (SD = 15.9) with sertraline and from 42.6 (SD = 9.1) to 29.1 (SD = 15.5) with IPT-PTSD. Attrition was high in both arms (p = .40). Conclusions: This trial showed within-group improvements without differences between IPT-PTSD and sertraline treatment of PTSD. Our findings suggest that non-exposure-based psychotherapies may benefit patients with PTSD, although we did not directly compare these treatments to an exposure therapy. Brazilian Clinical Trials Registry RBR-3z474z.

Antecedentes: La agresión sexual con frecuencia gatilla un trastorno de estrés postraumático (TEPT), un trastorno mental severo potencialmente crónico. La mayoría de las guías clínicas recomiendan los inhibidores selectivos de la receptación de serotonina (ISRSs) y psicoterapias focalizadas en trauma como opciones de tratamiento. La Psicoterapia Interpersonal (PIP), adaptada para TEPT (PIP-TEPT), se focaliza en las consecuencias interpersonales del trauma en lugar de confrontar el trauma en sí. Los estudios han encontrado que la PIP-TEPT eficazmente redujo los síntomas de TEPT con una deserción limitada. Ningún ensayo de eficacia ha comparado PIP-TEPT e ISRS. Hipotetizamos que la PIP-TEPT puede reducir los síntomas de TEPT, ansiedad y depresión más que la sertralina entre las mujeres con TEPT después de una agresión sexual reciente.Objetivos: Comparar la eficacia de la PIP-TEPT con sertralina, un ISRS en un ensayo clínico aleatorizado de 14 semanas para mujeres con TEPT después de una agresión sexual reciente.Métodos: Setenta y cuatro mujeres con TEPT que habían sufrido de una agresión sexual en los últimos seis meses fueron asignadas aleatoriamente a 14 semanas de PIP-TEPT (n = 39) o sertralina (n = 35). Los instrumentos evaluaron síntomas de TEPT, ansiedad y depresión. Este ensayo clínico aleatorizado se realizó en San Pablo, Brasil, utilizando la Escala de TEPT administrada por el clínico (CAPS-5, por sus siglas en inglés) como medida de resultado primaria.Resultados: Ambos tratamientos redujeron significativamente los síntomas de TEPT, ansiedad y depresión, sin diferencias de resultados entre los grupos. La media del CAPS-5 se redujo de 42.5 (DE = 9.4) a 27.1 (DE = 15.9) con sertralina y de 42.6 (DE = 9.1) a 29.1 (DE = 15.5) con la PIP-TEPT. La deserción fue alta en ambos tratamientos (p = .40).Conclusiones: Este ensayo mostro mejoría entre grupos sin diferencias entre la PIP-TEPT y sertralina en el tratamiento del TEPT. Nuestros hallazgos sugieren que las psicoterapias no basadas en la exposición pueden beneficiar a los pacientes con TEPT, aunque no comparamos directamente estos tratamientos con una terapia de exposición.Registro Brasileño de Ensayos Clínicos RBR-3z474z.

Narrative Exposure Therapy versus treatment as usual in a sample of trauma survivors who live under ongoing threat of violence in Rio de Janeiro, Brazil: study protocol for a randomised controlled trial.

BACKGROUND: One in three individuals who live in Rio de Janeiro experience a traumatic event within a period of 12 months. In the favelas particularly, trauma exposure is ongoing. Psychological sequalae include posttraumatic stress disorder (PTSD), depression and other mental disorders. Trauma-focused therapy approaches have emerged as the treatment of choice when the dangerous events are over, but symptoms have remained for an extended time period. Ideally, the victim is in a safe context during treatment. However, frequently, survivors cannot escape from situations characterised by ongoing threat and traumatic stress. The aim of this study is to research the effectiveness of Narrative Exposure Therapy in a sample of PTSD patients living under these conditions. METHODS: Individuals fulfilling the criteria for PTSD and who live in conditions of ongoing community violence (i.e. in the favelas) in Rio de Janeiro will be randomly assigned to one of two treatments: Narrative Exposure Therapy (NET) or treatment as usual (TAU). Clinical endpoints will be primarily PTSD and secondarily symptoms of shutdown dissociation, depression, substance involvement  and functionality. DISCUSSION: Effective treatment for PTSD patients who live in unsafe conditions could substantially reduce suffering of individuals and their families in Brazil. Based on this result, the extent to which such interventions may be useful as a first step in tackling the consequences of violence on a global scale will be discussed. TRIAL REGISTRATION: Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00017843 . Registered on September 24, 2019.

A randomized clinical trial to assess the efficacy of trial-based cognitive therapy compared to prolonged exposure for post-traumatic stress disorder: preliminary findings.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent mental health condition that is often associated with psychiatric comorbidities and changes in quality of life. Prolonged exposure therapy (PE) is considered the gold standard psychological treatment for PTSD, but treatment resistance and relapse rates are high. Trial-based cognitive therapy (TBCT) is an effective treatment for depression and social anxiety disorder, and its structure seems particularly promising for PTSD. Therefore, we evaluated the efficacy of TBCT compared to PE in patients with PTSD. METHODS: Ninety-five patients (77.6% females) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria for PTSD were randomly assigned to receive either TBCT (n = 44) or PE (n = 51). Patients were evaluated before and after treatment, and at follow-up 3 months after treatment. The primary outcome was improvement in PTSD symptoms as assessed by the Davidson Trauma Scale (DTS). Secondary outcomes were depression, anxiety, and dysfunctional attitudes assessed by the Beck Depression/Anxiety Inventories and Dysfunctional Attitudes Scale, as well as the dropout rate. RESULTS: A significant reduction in DTS scores was observed in both arms, but no significant difference between treatments. Regarding the secondary outcomes, we found significant differences in depressive symptoms in favor of TBCT, and the dropout rate was lower in the TBCT group than the PE group. CONCLUSION: Our preliminary results suggest that TBCT may be an effective alternative for treating PTSD. Further research is needed to better understand its role and the mechanisms of change in the treatment of this disorder.

Virtual reality as complementary treatment in pain relief in burnt children / Realidad virtual como tratamiento complementario en alivio del dolor en niños quemados / Realidade virtual como tratamento complementar no alívio da dor em crianças queimadas

ABSTRACT Objective: to report the use of virtual reality and its effects on clinical parameters, pain and its consequences in the treatment of two burned children in a Burn Treatment Center in southern Brazil. Method: case report on the use of virtual reality in two burned children treated at a reference burn treatment center in southern Brazil. Data were collected from January to February 2017, using the variables: pain, distraction, clinical parameters (heart rate and oxygen saturation) and analgesic medications. The measurements were carried out in five occasions and the intervention was applied for three days. The reports and reactions of children, guardians and the nursing team were also registered. Results: the use of virtual reality during dressings reduced the pain between two to four points on the scale used; oxygen saturation remained between 96 and 98%; heart rate decreased after the intervention. The children reported having fun, less time thinking about pain and were more collaborative during the procedure. Conclusion: this technology is innovative in the treatment of burned children and proved to be effective for the analyzed variables. New clinical studies with a larger sample are needed in the Brazilian context to contribute to these findings.

RESUMEN Objetivo: informar el uso de la realidad virtual y sus efectos bajo parámetros clínicos, dolor y sus consecuencias en el tratamiento de dos niños quemados en un Centro de Tratamiento de Quemaduras en el sur de Brasil. Método: informe de caso sobre el uso de la realidad virtual en dos niños quemados tratados en un centro de tratamiento de quemaduras de referencia en el sur de Brasil. Los datos se recopilaron de enero a febrero de 2017, a partir de las variables: dolor, distracción, parámetros clínicos (frecuencia cardíaca y saturación de oxígeno) y medicamentos analgésicos. Las mediciones se llevaron a cabo en cinco momentos y la intervención se aplicó durante tres días. También se anotaron los informes y las reacciones de los niños, tutores y el equipo de enfermería. Resultados: el uso de la realidad virtual durante el vendaje redujo el dolor entre dos y cuatro puntos en la escala utilizada; la saturación de oxígeno se mantuvo entre 96 y 98%; la frecuencia cardíaca disminuyó después de la intervención. Los niños informaron que se divirtieron, menos tiempo pensando en el dolor y fueron más colaborativos durante el procedimiento. Conclusión: esta tecnología es innovadora en el tratamiento de niños quemados y demostró ser efectiva para las variables analizadas. Se necesitan nuevos estudios clínicos con una muestra más grande en el contexto brasileño para contribuir a estos hallazgos.

RESUMO Objetivo: relatar a utilização da realidade virtual e os seus efeitos sob parâmetros clínicos, dor e suas consequências no tratamento de duas crianças queimadas em um Centro de Tratamento de Queimados do Sul do Brasil. Método: relato de caso sobre a utilização da realidade virtual em duas crianças queimadas atendidas em um centro de tratamento de queimaduras de referência do sul do Brasil. Os dados foram coletados de janeiro a fevereiro de 2017, a partir das variáveis: dor, distração, parâmetros clínicos (frequência cardíaca e saturação de oxigênio) e medicamentos analgésicos. As medidas foram realizadas em cinco momentos e a intervenção foi aplicada durante três dias. Foram anotados, também, os relatos e as reações das crianças, dos responsáveis e da equipe de enfermagem. Resultados: o uso da realidade virtual durante o curativo diminuiu a dor entre dois a quatro pontos da escala utilizada; a saturação de oxigênio manteve-se entre 96 a 98%; a frequência cardíaca obteve redução após a intervenção. As crianças relataram diversão, menor tempo pensando na dor e foram mais colaborativas durante o procedimento. Conclusão: esta tecnologia é inovadora no tratamento de crianças queimadas e mostrou-se eficaz para as variáveis analisadas. Novos estudos clínicos com uma amostragem maior são necessários no contexto brasileiro para contribuir com esses achados.

Desenvolvimento da manipulação do bebê em diferentes idades motoras / Development of the baby in handling different motor ages

Verificar o desenvolvimento manipulativo de bebês de diferentes idades por meio de uma intervenção motora. Participaram do estudo 15 bebês que frequentavam escolas de Educação Infantil da cidade de Porto Alegre. A intervenção foi constituída de atividades de manipulação de uma rica variedade de objetos cotidianos, escolhidos no intuito de oferecer diferentes estímulos ao bebê. As avaliações dos bebês foram realizadas no início e ao final do período interventivo através da Escala do Desenvolvimento do Comportamento da Criança no Primeiro Ano de Vida. Foi utilizado o Teste de Wilcoxon para comparações do período pré para o pós-intervenção e descritivamente foi analisado o desenvolvimento dos bebês conforme o seu trimestre de vida. Os resultados sugerem que os bebês tiveram desempenho superior do período pré-intervenção para o pós-intervenção. Intervenções motoras e sensoriais nos primeiros anos de vida proporcionam mudanças positivas no desenvolvimento global dos bebês...(AU)

To assess the manipulative's development of babies from different ages beyound a motor intervention. Participants were 15 infants who attended early childhood education in Porto Alegre. The intervention consisted of handling activities with rich variety of everyday objects, chosen in order to provide different stimuli to the baby. The Scale of Child Development and Behavior performed the evaluations of the infants at the beginning and intervention's end in his/her First Life's Year. It was used the Wilcoxon test for comparisons in the pre and post-intervention and it was analyzed descriptively the babies development as their three months of life. The results suggest that infants have outperformed the pre-intervention and post-intervention. Sensory and motor interventions in the first ages of life provide positive changes in the overall development of infants...(AU)

An Avoidance-Based Rodent Model of Exposure With Response Prevention Therapy for Obsessive-Compulsive Disorder.

BACKGROUND: Obsessive-compulsive disorder is treated with exposure with response prevention (ERP) therapy, in which patients are repeatedly exposed to compulsive triggers but prevented from expressing their compulsions. Many compulsions are an attempt to avoid perceived dangers, and the intent of ERP is to extinguish compulsions. Patients failing ERP therapy are candidates for deep brain stimulation (DBS) of the ventral capsule/ventral striatum, which facilitates patients' response to ERP therapy. An animal model of ERP would be useful for understanding the neural mechanisms of extinction in obsessive-compulsive disorder. METHODS: Using a platform-mediated signaled avoidance task, we developed a rodent model of ERP called extinction with response prevention (Ext-RP), in which avoidance-conditioned rats are given extinction trials while blocking access to the avoidance platform. Following 3 days of Ext-RP, rats were tested with the platform unblocked to evaluate persistent avoidance. We then assessed if pharmacologic inactivation of lateral orbitofrontal cortex (lOFC) or DBS of the ventral striatum reduced persistent avoidance. RESULTS: Following Ext-RP training, most rats showed reduced avoidance at test (Ext-RP success), but a subset persisted in their avoidance (Ext-RP failure). Pharmacologic inactivation of lOFC eliminated persistent avoidance, as did DBS applied to the ventral striatum during Ext-RP. CONCLUSIONS: DBS of ventral striatum has been previously shown to inhibit lOFC activity. Thus, activity in lOFC, which is known to be hyperactive in obsessive-compulsive disorder, may be responsible for impairing patients' response to ERP therapy.

[Emotional processing theory and prolonged exposure therapy for posttraumatic stress disorder]. / Teoría del procesamiento emocional y terapia de exposición prolongada para el trastorno por estrés postraumático.

Prolonged exposure therapy is a first-line treatment for posttraumatic stress disorder. In this article we discuss the theoretical underpinnings and underlying mechanisms of PE, its efficacy and safety. We briefly describe the procedures involved in PE with special emphasis in imaginal exposure. Also, we present examples of efforts to integrate evidence-based treatments that concurrently target PTSD and borderline personality disorder. Next, we review efforts made to adapt the intervention to Hispanics. Finally, obstacles for disseminating and implementing PE are discussed.

Tripofobia: um relato de caso do tratamento do medo de buracos / Trypophobia: a case study of the fear of holes treatment / TRIPOFOBIA: reporte de un caso de tratamiento del miedo de agujeros

Os estudos sobre tripofobia (ou medo de buracos) são escassos até a presente data, sendo mais frequentemente discutida em textos informais, sites, redes sociais. O objetivo deste artigo foi apresentar o caso de uma jovem que se queixava experimentar fortes respostas fisiológicas como náusea, batimento cardíaco acelerado, na presença de estímulos compreendendo aglomerados de buracos, geralmente em superfícies orgânicas como a pele humana, além de comportamentos característicos de esquiva fóbica como tampar uma imagem contendo buracos com as mãos para evitar visualizá-la ou solicitar a outrem parar de relatar uma história a partir da qual começava a imaginar esses estímulos aversivos. O tratamento empregado, baseado na abordagem comportamental, foi compreendido por uma fase de avaliação inicial, realizada por meio de entrevista e automonitoramento, fase de tratamento baseada em psicoeducação, treino respiratório, hierarquia de estímulos, dessensibilização sistemática e por uma fase de acompanhamento (follow-up). Os resultados apontaram a eficácia das estratégias de intervenção para diminuição das respostas fisiológicas e aumento de comportamentos alternativos aos de esquiva como os comportamentos de enfrentamento.(AU)

Studies on trypophobia (or fear of holes) are scarce to date, and is more often discussed in informal texts, websites, and social networks. The purpose of this article is to present the case of a young woman who complained about experiencing strong physiological responses such as náusea and rapid heartbeat when in the presence of stimuli comprising clusters of holes. These situations are usually related to organic surfaces such as human skin. Some characteristics of her phobic avoidance’s behaviors are covering with her hands an image containing holes to avoid it or requesting another person to stop reporting a story that triggers these aversive stimuli. The treatment applied, based on behavioral approach, is comprised of an initial assessment phase,carried out through interviews and self-monitoring; a treatment phase based on psychoeducation, respiratory training, stimulus hierarchy, systematic desensitization, and a follow-up phase. The results demonstrate the effectiveness of intervention strategies to decrease the physiological responses and to increase alternative behaviors as coping behaviors.(AU)

Lacan: entre linguagem e pulsão, por uma psicanálise do sujeito / Lacan: between language and drive, a subject's psychoanalisis / Lacan: entre el lenguaje y la pulsión, por un psicoanálisis del sujeto / Lacan: entre la langue et la pulsión, la psychanalyse par un sujet

A história de Lacan no campo de saber da psicanálise confunde-se com a construção do conceito de sujeito nesse campo, já que não foi Freud quem estabeleceu suas bases formais. Ao longo do ensino lacaniano, contudo, percebe-se o deslocamento do autor, que parte do centramento na linguagem e passa a caminhar em direção à preponderância do real, o que tem efeitos sobre a noção de sujeito. Aos poucos, fica evidente a dificuldade de Lacan de abranger toda a questão do inconsciente pela linguagem, o que faz com que o autor reconheça inequivocamente o lugar preponderante da pulsão na construção disso que se chama de sujeito de linguagem ou sujeito barrado.

Lacan's role in psychoanalytic field is very close to the construction of the concept of the subject in this field, since it was not Freud who established their formal foundations. Along the Lacanian school, however, we can see that the author moves from a position centered in language issues toward the preponderance of the real instance, path that has effects on the notion of subject. Gradually, it becomes clear the impossibility of covering the unconscious with the symbolic field, which makes the author clearly recognize the predominant role of drive in the construction of what we call the subject in psychoanalysis.

La historia de Lacan en el campo del psicoanálisis es entrelazada con la construcción del concepto de sujeto en este campo, ya que no fue Freud quien estableció sus bases formales. A lo largo del ensino lacaniano, podemos, sin embargo, percibir el desplazamiento del autor de la centralidad del lenguaje hacia la preponderancia de lo real, camino que tiene efectos sobre la noción de sujeto. Poco a poco, se pone de manifiesto la dificultad de Lacan de recubrir integralmente lo inconsciente con el lenguaje, lo que lo hacer e conocer el papel predominante de la pulsión en la construcción de lo que llamamos el sujeto en psicoanálisis.

L'histoire de Lacan dans le domaine de la psychanalyse est liée à la construction du concept de sujet dans ce domaine, car il n'était pas Freud qui a établi leurs bases formelles. On peut percevoir le déplacement de Lacan de la centralité de la langue et su marche vers la prépondérance du réel, ce qui a des effets sur la notion de sujet. Peu à peu, il devient clair la difficulté de Lacan de couvrir complètement l'inconscient avec la langage, cet qui rend l'auteur reconnaît le rôle de la pulsión dans la construction de le sujet barré.

Psicoterapia cognitivo-comportamental para o transtorno de estresse agudo: uma revisão sistemática / Cognitive-behavioral psychotherapy for acute stress disorder: a systematic review

A Psicoterapia Cognitivo-Comportamental (TCC) tem sido considerada a terapia de escolha para o tratamento do Transtorno de Estresse Agudo (TEA), sendo empregada como forma de prevenção ao Transtorno de Estresse Pós-Traumático (TEPT). No entanto, não há um consenso sobre as estratégias mais eficazes dentro desta abordagem. O presente artigo teve por objetivo identificar, por meio de uma revisão sistemática de estudos clínicos controlados, as estratégias que apresentam maior eficácia dentro da abordagem cognitivo-comportamental. Foram consultadas as bases de dados Scielo, LILACS, MedLine/PubMed, Web of Science e PsychInfo em Junho de 2012. Foram inicialmente identificados 1103 estudos. Após a adoção dos critérios de exclusão, cinco estudos foram incluídos no processo de revisão. A partir dos estudos encontrados e da análise destes, conclui-se que a terapia de exposição apresenta resultados promissores para tratamento do TEA. A revisão indicou ainda a necessidade de estudos com melhor qualidade metodológica e amostras mais abrangentes.(AU)

Cognitive Behavioral Therapy (CBT) has been considered the gold-standard treatment to Acute Stress Disorder (ASD), with its use in ASD course mainly focusing the prevention of the development of Post Traumatic Stress Disorder (PTSD). However, there is no consensus about effective strategies into CBT approaches for ASD treatment. Thus, this article aims to identify the most efficient strategies in the CBT approach. In order to attend this purpose, a systematic review was conducted, looking for randomized clinical trials addressing ASD treatment, on the following databases: Scielo, LILACS, MedLine / PubMed, Web of Science and PsychInfo in June 2012. Initially, 1103 studies were identified. After the adoption of the exclusion criteria, five studies were included in the review process. The results of the review point that exposure therapy have the most promising outcomes in ASD treatment. Furthermore, the review also indicates the need for studies with better methodological quality, as well as the use of broader samples.(AU)

Psicoterapia cognitivo-comportamental para o transtorno de estresse agudo: uma revisão sistemática / Cognitive-behavioral psychotherapy for acute stress disorder: a systematic review

A Psicoterapia Cognitivo-Comportamental (TCC) tem sido considerada a terapia de escolha para o tratamento do Transtorno de Estresse Agudo (TEA), sendo empregada como forma de prevenção ao Transtorno de Estresse Pós-Traumático (TEPT). No entanto, não há um consenso sobre as estratégias mais eficazes dentro desta abordagem. O presente artigo teve por objetivo identificar, por meio de uma revisão sistemática de estudos clínicos controlados, as estratégias que apresentam maior eficácia dentro da abordagem cognitivo-comportamental. Foram consultadas as bases de dados Scielo, LILACS, MedLine/PubMed, Web of Science e PsychInfo em Junho de 2012. Foram inicialmente identificados 1103 estudos. Após a adoção dos critérios de exclusão, cinco estudos foram incluídos no processo de revisão. A partir dos estudos encontrados e da análise destes, conclui-se que a terapia de exposição apresenta resultados promissores para tratamento do TEA. A revisão indicou ainda a necessidade de estudos com melhor qualidade metodológica e amostras mais abrangentes.

Cognitive Behavioral Therapy (CBT) has been considered the gold-standard treatment to Acute Stress Disorder (ASD), with its use in ASD course mainly focusing the prevention of the development of Post Traumatic Stress Disorder (PTSD). However, there is no consensus about effective strategies into CBT approaches for ASD treatment. Thus, this article aims to identify the most efficient strategies in the CBT approach. In order to attend this purpose, a systematic review was conducted, looking for randomized clinical trials addressing ASD treatment, on the following databases: Scielo, LILACS, MedLine / PubMed, Web of Science and PsychInfo in June 2012. Initially, 1103 studies were identified. After the adoption of the exclusion criteria, five studies were included in the review process. The results of the review point that exposure therapy have the most promising outcomes in ASD treatment. Furthermore, the review also indicates the need for studies with better methodological quality, as well as the use of broader samples.

Preventing return of fear in an animal model of anxiety: additive effects of massive extinction and extinction in multiple contexts.

Fear conditioning and experimental extinction have been presented as models of anxiety disorders and exposure therapy, respectively. Moreover, the return of fear serves as a model of relapse after exposure therapy. Here we present two experiments, with rats as subjects in a lick suppression preparation, in which we assessed the additive effects of two different treatments to attenuate the return of fear. First, we evaluated whether two phenomena known to generate return of fear (i.e., spontaneous recovery and renewal) summate to produce a stronger reappearance of extinguished fear. At test, rats evaluated outside the extinction context following a long delay after extinction (i.e., a delayed context shift) exhibited greater return of extinguished fear than rats evaluated outside the extinction context alone, but return of extinguished fear following a delayed context shift did not significantly differ from the return of fear elicited in rats tested following a long delay after extinction alone. Additionally, extinction in multiple contexts and a massive extinction treatment each attenuated the strong return of fear produced by a delayed context shift. Moreover, the conjoint action of these treatments was significantly more successful in preventing the reappearance of extinguished fear, suggesting that extensive cue exposure administered in several different therapeutic settings has the potential to reduce relapse after therapy for anxiety disorders, more than either manipulation alone.

Tratamento de exposição a estímulos e treinamento de habilidades como coadjuvantes no manejo do craving em um dependente de crack / Cue exposure treatment and coping skills training as adjuvant therapies in the management of craving in a crack cocaine addict

OBJETIVO: Tem-se observado um aumento da prevalência de dependentes de crack em amostras clínicas, o que torna necessária a realização de pesquisas quanto a estratégias de tratamento direcionadas a essa clientela. O objetivo deste estudo foi descrever o caso de um dependente de crack internado no qual foram utilizados o tratamento de exposição a estímulos (TEE) e o treinamento de habilidades (TH) como coadjuvantes ao tratamento tradicional. DESCRIÇÃO DO CASO: O paciente é do sexo masculino, 29 anos de idade, solteiro, ensino médio completo. Era dependente de crack e de maconha e fazia uso nocivo de álcool. O paciente já estava internado havia 2 semanas e tinha passado por um protocolo de quatro sessões com entrevista motivacional e prevenção à recaída. Foram feitas seis sessões, ao longo de 2 semanas, de TEE e TH, nas quais o paciente foi exposto in vivo e pela imaginação a estímulos evocadores de fissura, como cachimbo de crack, isqueiro, pedras simuladas, lembranças de locais e amigos associados ao uso da droga. Ele também foi treinado para utilizar estratégias de manejo da fissura. Após 3 meses da alta hospitalar, foi realizado screening toxicológico para avaliar a manutenção de abstinência. O paciente avaliou o uso das técnicas como importante para a manutenção da abstinência após 3 meses da alta e para sua baixa média de fissura pelo crack. COMENTÁRIOS: Talvez o TEE e o TH para manejo da fissura possam ser úteis como coadjuvantes no tratamento de dependentes de crack. Tal uso deve ser avaliado em ensaios clínicos para demonstrar seu real benefício (AU)

OBJECTIVE: An increased prevalence of crack cocaine users has been observed in clinical samples over the past years, underscoring the need for conducting research and developing treatment strategies aimed at this population. The objective of this study was to describe the case of a crack cocaine addict (inpatient) submitted to cue exposure treatment (CET) and coping skills training (CS) as adjuvant approaches to the conventional addiction treatment. CASE DESCRIPTION: A male patient, 29 years old, single, with complete high school, was dependent on crack cocaine and marijuana and also had a diagnosis of harmful alcohol use. The patient had been hospitalized for 2 weeks and had undertaken a protocol comprising four motivational interview and relapse prevention sessions. Six sessions of CET and CS were carried out over 2 weeks, including both in vivo and imaginal exposure to stimuli evoking craving for crack cocaine, such as a crack pipe, a lighter, and simulated crack cocaine rocks (in vivo exposure), or remembering places and friends associated with drug use (imaginal exposure). The patient was also trained to use strategies for the management of craving. Three months after hospital discharge, toxicological screening was performed to assess abstinence. CET and CS were considered by the patient to be important techniques for the maintenance of abstinence and of a low level of craving 3 months after discharge. COMMENTS: These findings suggest that the two techniques may be useful as adjuvant therapies in the treatment of crack cocaine dependents. CET and CS should be assessed in clinical trials in order to demonstrate their real benefits (AU)

Virtual reality as a mechanism for exposure therapy.

Virtual reality (VR) is as effective in inducing emotional responses as reality and its application is extremely valuable in exposure treatment. In virtual environments, the patients experience similar physiological symptoms and fear as they do in real life situations, thereby facilitating the habituation process. Our goal is to offer an overview of the current panorama of VR and psychotherapy, underlining the (virtual) exposure technique and the studies that focus on panic disorder treatment through the use of VR. The literature was revised through consultation to the ISI and PubMed databases. Virtual exposure treatment offers good results and great patient acceptability. However, despite the importance of this data for the evaluation of treatment efficacy, only a few studies measure physiological responses during exposure. Lack of controlled studies and standardized treatment protocols were observed. Despite the great advance of VR use in psychotherapy, a great deal of its potential is still unknown, therefore requiring the creation of new virtual environments so that controlled studies regarding its clinical application can be conducted. Throughout the process of elaboration and investigation, clinical experiences in virtual environments must be related to real experiences in a flexible context that combines relevant cultural, physical and cognitive aspects.

Transtorno de estresse pós-traumático em pacientes com sequelas de queimaduras / Post-traumatic stress disorder in burn-injured patients

Este trabalho revisa a literatura acerca do transtorno do estresse pós-traumático, acometendo pacientes vítimas de sequelas de queimaduras. São enfocadas definições, critérios para diagnóstico, epidemiologia, patofisiologia, psicopatologias pré-mórbidas em pacientes adultos queimados, aspectos psicológicos da queimadura, aspectos clínicos e tratamento.

This paper revises the literature about the posttraumatic stress disorder in the burn patients with functional, esthetics and psychological modifications. Its relates the definition, diagnostic judgements, epidemiology, pathophysiology, premorbid psychopathology in the patients with functional, esthetics and psychological modifications, psychological aspects of the burn, clinical aspects and treatment.

[Outbreak caused by Escherichia coli in Chalco, Mexico]. / Brote causado por Escherichia coli en Chalco, México.

OBJECTIVE: To identify the etiologic agent responsible for a disease outbreak following an overflow of sewage water in Valle de Chalco, Mexico. MATERIAL AND METHODS: A retrospective cross-sectional study was carried out. Rectal samples were collected from the population of Chalco valley, who suffered from diarrhea and vomiting during a natural disaster that took place on May 31, 2000. The Instituto de Diagnóstico y Referencia Epidemiológicos (Epidemic Reference and Diagnosis Institute, InDRE, Ministry of Health), received 1521 rectal swab samples from diarrhea cases, to test for E. coli strains. Statistical analysis was performed to find a difference of proportions between cases and non-cases (chi-squared test). ETEC, EIEC, EPEC and EHEC pathogenic E. coli groups were hybridized by colony blot. RESULTS: Strains isolated were ETEC (62.2%), EIEC (0.84%), EPEC (0.84%), and EHEC non-O157:H7 (0.08%); there was no hybridization in 36.02% of E. coli strains. Other isolated microorganisms were Salmonella spp (0.45%) and Shigella spp (0.06%). CONCLUSIONS: Enterotoxigenic E. coli was the most likely etiologic agent. Sanitary control strategies should be targeted to preventing outbreaks caused by this pathogenic agent. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Brote causado por Escherichia coli en Chalco, México / Outbreak caused by Escherichia coli in Chalco, Mexico

OBJECTIVE: To identify the etiologic agent responsible for a disease outbreak following an overflow of sewage water in Valle de Chalco, Mexico. MATERIAL AND METHODS: A retrospective cross-sectional study was carried out. Rectal samples were collected from the population of Chalco valley, who suffered from diarrhea and vomiting during a natural disaster that took place on May 31, 2000. The Instituto de Diagnóstico y Referencia Epidemiológicos (Epidemic Reference and Diagnosis Institute, InDRE, Ministry of Health), received 1521 rectal swab samples from diarrhea cases, to test for E. coli strains. Statistical analysis was performed to find a difference of proportions between cases and non-cases (chi-squared test). ETEC, EIEC, EPEC and EHEC pathogenic E. coli groups were hybridized by colony blot. RESULTS: Strains isolated were ETEC (62.2), EIEC (0.84), EPEC (0.84), and EHEC non-O157:H7 (0.08); there was no hybridization in 36.02 of E. coli strains. Other isolated microorganisms were Salmonella spp (0.45) and Shigella spp (0.06). CONCLUSIONS: Enterotoxigenic E. coli was the most likely etiologic agent. Sanitary control strategies should be targeted to preventing outbreaks caused by this pathogenic agent.

Self-exposure therapy for panic disorder with agoraphobia: randomised controlled study of external v. interoceptive self-exposure.

BACKGROUND: Exposure to external phobic cues is an effective therapy for panic/agoraphobia but the value of exposure to interoceptive cues is unclear. AIMS: Randomised controlled comparison in panic/agoraphobia of the effects of (a) external, (b) interceptive or (c) combined external and interoceptive self-exposure to (d) control subjects. METHOD: Eighty out-patients were randomised to a control group or to one of three forms of self-exposure treatment (external, interoceptive, or combined). Each treatment included seven sessions over 10 weeks and daily self-exposure homework. Assessments were at pre- and post-treatment and up to 1 year post-entry. Assessors remained blind during treatment. RESULTS: The three self-exposure groups improved significantly and similarly at post-treatment and up to 1-year followup, and significantly more than did the control subjects. Rates of improvement on main outcome measures averaged 60% at post-treatment and 77% at follow-up. CONCLUSIONS: The three methods of self-exposure were equally effective in reducing panic and agoraphobic symptoms in the short- and long-term.