Review of Management Considerations for Excoriation Disorder in Older Adults.

Excoriation disorder (ED) is defined as compulsive skin picking that results in skin damage and emotional distress. Optimal management of ED includes individualized treatment plans consisting of psychotherapies, behavioral and pharmacologic interventions. Compared with younger populations, older adults are at increased risk for poor outcomes, such as infection and hospitalization, and require unique management considerations. Risk factors that contribute to disease burden include age-related changes to the skin and underlying medical and psychiatric comorbidities. A literature review was conducted on ED yielding limited evidence exclusive to older adults. The authors suggest a therapeutic approach to ED in older adults based on available evidence and experience from inpatient and outpatient psychiatric settings. Finally, opportunities for future research are highlighted.

Digital Collateral Information Through Electronic and Social Media in Psychotherapy: Comparing Clinician-reported Trends Before and During the COVID-19 Pandemic.

BACKGROUND: Patient clinical collateral information is critical for providing psychiatric and psychotherapeutic care. With the shift to primarily virtual care triggered by the COVID-19 pandemic, psychotherapists may have received less clinical information than they did when they were providing in-person care. This study assesses whether the shift to virtual care had an impact on therapists' use of patients' electronic and social media to augment clinical information that may inform psychotherapy. METHODS: In 2018, we conducted a survey of a cohort of psychotherapists affiliated with McLean Hospital. We then reapproached the same cohort of providers for the current study, gathering survey responses from August 10, 2020, to September 1, 2020, for this analysis. We asked clinicians whether they viewed patients' electronic and social media in the context of their psychotherapeutic relationship, what they viewed, how much they viewed it, and their attitudes about doing so. RESULTS: Of the 99 respondents, 64 (64.6%) had viewed at least 1 patient's social media and 8 (8.1%) had viewed a patient's electronic media. Of those who reported viewing patients' media, 70 (97.2%) indicated they believed this information helped them provide more effective treatment. Compared with the 2018 prepandemic data, there were significantly more clinicians with>10 years of experience reporting media use in therapy. There was also a significant increase during the pandemic in the viewing of media of adult patients and a trend toward an increase in viewing of media of older adult patients. CONCLUSIONS: Review of patients' electronic and social media in therapy became more common among clinicians at a large psychiatric teaching hospital during the COVID-19 pandemic. These findings support continuing research about how reviewing patients' media can inform and improve clinical care.

Socio-economic status, executive functions, and theory of mind ability in adolescents: Relationships with language ability and cortisol.

Socio-economic status (SES) is linked to the development of cognitive abilities, particularly language and executive processes. It is unclear whether these represent a single or independent correlates. We studied 110 Ecuadorian youths aged 12-17 with measures of SES, language, executive function, and theory of mind (ToM), a.k.a. mentalizing. A subsample gave hair samples to estimate recent cortisol levels. Restricting analyses to reliable measures, SES was highly associated with language skill, and to a lesser extent with executive function and ToM performance. However, those latter associations were attenuated and non-significant when language ability was controlled for statistically. Systemic cortisol levels were not associated with SES, but were significantly and negatively correlated with ToM, independent of variation in language skills. We conclude that language development underlies most of the impact of SES on executive function and ToM ability of adolescents, but that stress-related cortisol may have an independent, direct effect on mentalizing.

Modulation of striatum based non-declarative and medial temporal lobe based declarative memory predicts academic achievement at university level.

BACKGROUND: There is a dearth of research on the roles of non-declarative (implicit) learning linked to the striatum and declarative (explicit) learning associated with the medial temporal lobes as predictors of academic attainment. METHODS: Participants were 120 undergraduate students, studying Psychology or Engineering, who completed several long-term memory tests. RESULTS: There was a significant interaction between the groups (Psychology or Engineering) and task type (declarative or non-declarative): Engineers performed better at declarative and psychologists at non-declarative learning. Furthermore, non-declarative but not declarative learning scores were significant correlates of academic achievement (r = 0.326, p < .05). Moreover, competitive modulation (activation of non-declarative learning in conjunction with deactivation of declarative learning) was a significant predictor of future academic achievement in both psychology (r = 0.264, p < .05) and Engineering (r = 0.300, p < .05) groups. CONCLUSIONS: The results confirm that these declarative and non-declarative systems interact competitively and that the extent of this competition may have implications for understanding educational attainment.

Socioeconomic deprivation and the development of neuropsychological functions: A study with "street children" in Ecuador.

Socioeconomic status (SES) is known to have a considerable influence on the development of neuropsychological functions. In particular there is strong evidence for less efficient development of prefrontal-cortex-related functions in children raised in low-SES households. "Street children" are a common feature of low SES in many low- and middle-income countries, and some researchers have suggested that the unique life experiences of street children may drive their neurocognitive development. This study compares a group of 36 former street children in Quito, Ecuador with a control group of 26 never street-connected schoolchildren. All children were assessed with a range of neuropsychological tests. Although the street children group performed significantly below the level of the control group on all measures, they did not demonstrate a generalized lower ability. By controlling the effects of fluid intelligence it was found that there are relatively independent effects on visuospatial ability and executive planning ability. Furthermore, the executive function test scores in general are significantly less affected than the other cognitive functions and may be temporary effects caused by recent substance abuse within the street child sample. The findings generally support results from other countries suggesting that low SES is associated with negative effects on neuropsychological development. However, they also suggest that the local social and economic context, such as in the case of street children, might mitigate the harmful effects of low SES on the development of some executive functions.

Exhaled nitric oxide and vascular endothelial growth factor as predictors of cold symptoms after stress.

OBJECTIVE: Prior research has demonstrated that psychosocial stress is associated with respiratory infections. Immunologic, endocrine, and cardiovascular predictors of such infections have been explored with varying success. We therefore sought to study the unexplored role of airway mucosal immunity factors, nitric oxide (NO) and vascular endothelial growth factor (VEGF). NO is secreted by airway epithelial cells as part of the first line of defense against bacteria, viruses, and fungi. VEGF is expressed by mast cells in respiratory infections and recruits immune cells to infected sites, but in excess lead to vulnerability of the airway epithelium. METHODS: In this proof-of-concept study we measured exhaled NO, exhaled breath condensate (EBC) VEGF, salivary VEGF, and salivary cortisol in 36 students undergoing final academic examinations at three occasions: a low-stress baseline during the term, an early phase of finals, and a late phase of finals. Participants also reported on cold symptoms at these time points and approximately 5 and 10days after their last academic examination. RESULTS: Higher baseline NO was associated with fewer cold symptoms after stress, whereas higher baseline VEGF in EBC and saliva were associated with more cold symptoms after stress. Perceived stress at baseline as well as salivary VEGF and cortisol late in the finals also contributed to the prediction of later cold symptoms. CONCLUSION: Basal levels of NO and VEGF may inform about mucosal immunocompetence and add to preventative treatments against airway infections from periods of stress in daily life.

Estimación de la Función Cognitiva Premórbida con el Test de Acentuación de Palabras / Estimation of Premorbid Cognitive Function with the Word Accentuation Test

Resumen Objetivo: La valoración premórbida de la función cognitiva es esencial para la interpretación de la presencia y severidad del deterioro cognitivo. El método más confiable para evaluar esto en países hispanohablantes es el Word Accentuation Test (WAT) / Test de Acentuación de Palabras (TAP), ya que predice los resultados de pruebas de inteligencia mediante una regresión linear. Resultados: En una muestra ecuatoriana, el TAP tiene buena consistencia interna y confiabilidad test-retest. La correlación del TAP con los puntajes del WAIS-IV es alta (r=.827), permitiendo el desarrollo de una ecuación de regresión para estimar las puntuaciones de CI. Además, se encontró que una muestra de pacientes con demencia funcionaba normalmente en el TAP en comparación con el grupo de control. Esto sugiere que el rendimiento del TAP se mantiene en la presencia de una enfermedad neurológica con un deterioro cognitivo y puede usarse para valorar inteligencia premórbida. Conclusiones: El TAP tiene buenas propiedades psicométricas y puede ser utilizado para estimar puntuaciones de pruebas de inteligencia en participantes sanos. También puede valorar puntajes de inteligencia premórbida en pacientes con enfermedades neurológicas o psiquiátricas, permitiendo una interpretación clara de la gravedad del deterioro. Esta evaluación podría utilizarse en contextos clínicos y de investigación.

Abstract Objectives: Premorbid estimation of cognitive function is essential for the interpretation of the presence and severity of actual cognitive impairment. The most reliable method in Spanish speaking countries is with the Word Accentuation Test (WAT) / Test de Acentuación de Palabras (TAP). This is used to predict intelligence test scores by linear regression. Results: In an Ecuadorian sample the TAP was found to have good internal consistency and test-retest reliability. The correlation of the TAP with WAIS-IV full IQ scores was high (r= .827), allowing the development of a regression equation to estimate IQ scores from TAP performance. Furthermore, a sample of dementia patients was found to perform normally on the WAT compared to a matched control group. This suggests that WAT performance holds in the presence of neurological illness with associated cognitive impairment. Conclusions: The WAT has good psychometric properties and can be used to rapidly estimate actual intelligence test scores in healthy participants. It can also estimate premorbid intelligence scores in patients with neurological or psychiatric illnesses, allowing a clearer interpretation of the severity of impairment. This simple assessment could be used in various research and clinical contexts.

A novel biomarker associated with distress in humans: calcium-binding protein, spermatid-specific 1 (CABS1).

Calcium-binding protein spermatid-specific 1 (CABS1) is expressed in the human submandibular gland and has an anti-inflammatory motif similar to that in submandibular rat 1 in rats. Here, we investigate CABS1 in human saliva and its association with psychological and physiological distress and inflammation in humans. Volunteers participated across three studies: 1) weekly baseline measures; 2) a psychosocial speech and mental arithmetic stressor under evaluative threat; and 3) during academic exam stress. Salivary samples were analyzed for CABS1 and cortisol. Additional measures included questionnaires of perceived stress and negative affect; exhaled nitric oxide; respiration and cardiac activity; lung function; and salivary and nasal inflammatory markers. We identified a CABS1 immunoreactive band at 27 kDa in all participants and additional molecular mass forms in some participants. One week temporal stability of the 27-kDa band was satisfactory (test-retest reliability estimate = 0.62-0.86). Acute stress increased intensity of 18, 27, and 55 kDa bands; 27-kDa increases were associated with more negative affect and lower heart rate, sympathetic activity, respiration rate, and minute ventilation. In both acute and academic stress, changes in 27 kDa were positively associated with salivary cortisol. The 27-kDa band was also positively associated with VEGF and salivary leukotriene B4 levels. Participants with low molecular weight CABS1 bands showed reduced habitual stress and negative affect in response to acute stress. CABS1 is readily detected in human saliva and is associated with psychological and physiological indicators of stress. The role of CABS1 in inflammatory processes, stress, and stress resilience requires careful study.

Cortisol response to acute stress in asthma: Moderation by depressive mood.

Both individuals with asthma and depression show signs of a dysregulated hypothalamus-pituitary-adrenal axis. However, little is known about the cortisol response to stress in the context of co-occurring asthma and depressive mood. Thirty-nine individuals with asthma and 41 healthy controls underwent a combined speech and mental arithmetic stressor. During the course of the laboratory session, salivary cortisol was collected 5 times, with 1 sample at 0min before the stressor and 4 samples at 0, 15, 30 and 45min after the stressor. Depressive mood in the past week was assessed with the Hospital Anxiety and Depression Scale at the beginning of the session. Depressive symptoms moderated cortisol response to the acute stressor, but only among asthmatic patients. Higher depressive mood was associated with a significant increase in cortisol, whereas low depressive mood was associated with no cortisol response. In healthy participants, depressive mood had no substantial effect on cortisol response to the stressor. These findings suggest that depressive mood and chronic inflammatory diseases such as asthma can interact to augment cortisol response to stress.

The Role of the Microbiome in the Relationship of Asthma and Affective Disorders.

The effect of stress, anxiety and other affective states on inflammatory conditions such as asthma is well documented. Although several immune pathway mechanisms have been proposed and studied, they cannot fully explain the relationship. In this chapter we present a new perspective on asthma development and exacerbation that integrates findings on the role of psychological factors in asthma with the microbiome and the hygiene hypothesis in asthma development.

Exhaled Nitric Oxide Decreases during Academic Examination Stress in Asthma.

RATIONALE: Fractional exhaled nitric oxide (FeNO) is known to vary with multiple endogenous and exogenous factors. Laboratory stress and depressive mood have been associated with altered FeNO levels, but little is known about the susceptibility of FeNO to longer-lasting states of psychological stress in asthma. OBJECTIVES: We sought to study changes in FeNO, lung function, and endogenous cortisol levels in students in a low-stress period during the academic term and in high-stress periods of up to 5 days during final exams. METHODS: One hundred nine participants (35 with asthma) enrolled in a final examination stress study were assessed during the academic term (low stress) and during final exams (high stress). FeNO, spirometric lung function (FEV1, peak flow), salivary cortisol, and negative affect were measured at three time points. Control variables were medication use, cold symptoms, sex, and age. MEASUREMENTS AND MAIN RESULTS: FeNO decreased substantially from low-stress baseline to the high-stress examination periods, with more pronounced decreases occurring in subjects with asthma (-11.5 ppb) than control subjects (-1.2 ppb). FEV1 decreased in both groups. Negative affect and cortisol increased during final exams, but these increases were smaller in asthma. Greater initial depression and greater cortisol increases were related to larger FeNO decreases during the final exam period, the latter only in asthma. Inhaled corticosteroid use did not affect these changes. CONCLUSIONS: Psychological stress and depressive mood are accompanied by decreases in both FeNO and lung function in asthma. Fluctuations related to life stress and mood levels should be considered in FeNO monitoring for asthma.

Investigating the role of self-disgust in nonsuicidal self-injury.

Self-directed disgust, a component of self-criticism, may present an important, yet unexplored emotion in the context of nonsuicidal self-injury (NSSI). The aim of this study was to examine the role of self-disgust in NSSI, specifically as a potential mediator in the relations between depression and NSSI as well as sexual abuse and NSSI, and to also better understand characteristics that might differentiate recent and past self-injurers. A total of 549 college students completed measures assessing NSSI, self-disgust, depression, anxiety sensitivity, and physical and sexual abuse. Results indicated self-disgust fully mediated the relation between depressive symptoms and NSSI status and partially mediated the relation between sexual abuse and NSSI status. Additionally, compared to past self-injurers (4.6%; n = 25), recent self-injurers (6.4%; n = 35) endorsed significantly higher self-disgust and depressive symptoms. Self-disgust may be an important component in NSSI and should be addressed in treatment.

High cortisol awakening response and cortisol levels moderate exposure-based psychotherapy success.

BACKGROUND: Research suggests that elevated stress hormones during exposure can facilitate fear extinction in laboratory settings. However, prospective studies on the clinical benefits of endogenous cortisol on clinical improvements in naturalistic exposures are lacking. METHODS: Twenty-six patients with panic disorder and agoraphobia completed three weekly in-vivo exposure sessions and a fourth session 2 months following therapy completion, resulting in a total of 94 in-vivo exposure sessions. Salivary cortisol was collected at multiple times during the first exposure day (cortisol morning response, prior, -during, -after exposure) and at subsequent exposure sessions (prior, -during, -after exposure). Cortisol collection on a non-exposure comparison day followed the same time schedule as session 1. RESULTS: Exposure day anxiety and cortisol levels were significantly higher than control day levels. Higher absolute cortisol levels during exposures moderated clinical improvement (avoidance behavior, threat appraisal, perceived control). Therapeutic gains were not just related to exposure day cortisol levels, but were also linked to non-exposure day levels. Greater morning rises in cortisol on exposure day predicted greater treatment gains, but greater rises on the control day were associated with poorer outcomes. CONCLUSIONS: The study provides first evidence for a moderating effect of cortisol awakening response and absolute cortisol levels on fear extinction processes during naturalistic, prospective exposure-therapy. Additionally, we replicated and extended prior findings on the therapeutic benefits of high exposure cortisol levels. Together, the findings suggest that cortisol may act as a general moderator of facilitated learning during exposure therapy.

Increases in exhaled nitric oxide after acute stress: association with measures of negative affect and depressive mood.

BACKGROUND: Increases in fractional exhaled nitric oxide (FeNO) have been observed after acute laboratory stress, which could indicate a strengthening of immune defenses in acute stress because of the quick onset of the response and the role of nitric oxide in airway-protective functions. In addition, because sustained psychological distress and depression are known to deteriorate immune defenses systems, they may dampen the FeNO response to acute stress. METHODS: FeNO and negative affect were measured before and after a speech and mental arithmetic stressor. We examined the association of stress-induced FeNO changes with momentary negative affect and questionnaires of perceived stress, anxious mood, and depressive mood in 39 asthma patients and 41 healthy controls. RESULTS: FeNO increased from baseline to stress in participants with asthma (from 3.38 [0.102] to 3.46 [0.103] ln(ppb)) and controls (2.86 [0.098] to 2.92 [0.099]; F(4,141) = 3.26, p = .014), but the magnitude of the FeNO response did not differ between groups (F < 1). Only low levels of depressive mood were associated with FeNO increases after stress (most pronounced at 0 minute poststress; t(76) = 3.87, p < .001). In contrast, only higher perceived stress was associated with FeNO increases (most pronounced at 0 minute poststress; t(75) = 4.09, p < .001), and momentary negative affect was associated with higher FeNO throughout assessments (ß = 0.08, t(114) = 8.27, p = .005). Associations of FeNO with psychological variables were largely unrelated to asthma status and inhaled corticosteroid use. CONCLUSIONS: Depressive mood is associated with a reduced mobilization of airway nitric oxide in acute stress, whereas other indicators of negative affect are positively associated with overall FeNO levels and reactivity.

Social support as a predictor exhaled nitric oxide in healthy individuals across time.

Psychosocial factors such as social support and depression have long been associated with health outcomes. Elevated depressive symptoms are usually associated with worse health outcomes, whereas social support has been related to improvements in health. Nitric oxide levels are an important marker of both cardiovascular health and immune function. Research suggests that exhaled nitric oxide is affected by stress, negative affect, and depression; however, the effect of social support has not been previously explored. Thus, we sought to examine the association of social support, negative affect, and depression with exhaled nitric oxide in a group of 35 healthy individuals (10 males and 25 females) with a mean age of 20.5years across five weekly assessments. Results showed that changes in social support within individuals were positively associated with levels of exhaled nitric oxide independent of other psychosocial factors. Further exploration of the health implications of this positive relationship between airway nitric oxide and social support is necessary.

Airway nitric oxide and psychological processes in asthma and health: a review.

OBJECTIVE: The fraction of exhaled nitric oxide (FeNO) has been widely used as a marker of airway inflammation in asthma in recent years. However, NO serves multiple functions throughout the organism, and various influences on FeNO levels beyond inflammation have been documented. Emerging literature indicates that psychological processes are systematically linked to FeNO. DATA SOURCES: Academic Search Complete, PubMed, PsychArticles, and PsychInfo databases. STUDY SELECTIONS: Relevant studies were identified using keywords exhaled nitric oxide paired with psychological stress, stress psychology, emotion, major depression, anxiety, or psychopathology. Studies measuring FeNO during naturalistic observation of emotion and stress, laboratory stress and emotion-induction protocols, and correlational designs using psychological questionnaires were included. RESULTS: Acute stress, anxiety, and negative affect have been repeatedly linked with higher FeNO levels, whereas more prolonged states of stress, in particular depression, have been associated with lower FeNO levels. The literature on FeNO is paralleled by research on NO in the cardiovascular and central nervous systems, which also shows systematic associations with psychosocial variables. Potential mechanisms of association include stimulation of NO release from different cells, including the epithelia and macrophages, through noradrenaline, interferon-γ, or vascular endothelial growth factor, changes in oxidative stress or arginase levels, or facilitation of diffusion by mechanical factors. CONCLUSION: Psychosocial factors may need to be considered in the interpretation of longitudinal FeNO changes in monitoring and management of patients with asthma. The distinction between constitutive and inducible sources of NO will be essential for future research.

Academic exam stress and depressive mood are associated with reductions in exhaled nitric oxide in healthy individuals.

Nitric oxide (NO) has beneficial effects on cardiovascular and immune health. Stress and depression have been linked to a reduction in serum NO. In this study, we examined the effect of academic exam stress on the fraction of NO in exhaled air (FeNO) and spirometric lung function in 41 healthy college students. Participants completed assessments at mid-semester as well as in the early and late phase of an academic exam period. Negative affect, depressive mood, and salivary cortisol were elevated during exams, whereas FeNO and lung function decreased. Higher depressive mood was associated with lower FeNO, whereas higher negative affect was associated higher FeNO across time. These findings provide initial evidence that depression and prolonged stress can alter FeNO and lung function in healthy individuals, which could have adverse consequences for cardiovascular, airway, and immune health.

Psychosocial factors and behavioral medicine interventions in asthma.

OBJECTIVE: This review examines the evidence for psychosocial influences in asthma and behavioral medicine approaches to its treatment. METHOD: We conducted a systematic review of the literature on psychosocial influences and the evidence for behavioral interventions in asthma with a focus on research in the past 10 years and clinical trials. Additional attention was directed at promising new developments in the field. RESULTS: Psychosocial factors can influence the pathogenesis and pathophysiology of asthma, either directly through autonomic, endocrine, immunological, and central nervous system mechanisms or indirectly through lifestyle factors, health behaviors, illness cognitions, and disease management, including medication adherence and trigger avoidance. The recent decade has witnessed surging interest in behavioral interventions that target the various pathways of influence. Among these, self-management training, breathing training, and exercise or physical activation programs have proved particularly useful, whereas other essential or promising interventions, such as smoking cessation, dietary programs, perception and biofeedback training, and suggestive or expressive psychotherapy, require further, more rigorous evaluation. Given the high comorbidity with anxiety and mood disorders, further evaluation of illness-specific cognitive behavior therapy is of particular importance. Progress has also been made in devising community-based and culturally tailored intervention programs. CONCLUSION: In concert with an essential medication treatment, behavioral medicine treatment of asthma is moving closer toward an integrated biopsychosocial approach to disease management.