"Congelei com medo de me contaminar": tratando um caso de TEPT crônico com imobilidade tônica em uma fisioterapeuta da linha de frente na pandemia de COVID-19 / "I froze for fear of contaminating myself": treating a case of chronic PTSD with tonic immobility in a physiotherapist frontline during COVID-19 pandemic

RESUMO Objetivo: Neste estudo relatamos o caso de uma profissional de saúde com vivência de imobilidade tônica (IT) e posterior desenvolvimento de transtorno de estresse pós-traumático (TEPT) crônico em decorrência de trauma laboral por conta da COVID-19 que recebeu tratamento remoto com terapia cognitivo-comportamental focada no trauma (TCC-FT). Métodos: Relato de caso de uma paciente acompanhada por seis meses após o recebimento de TCC-FT remota. Resultados: Paciente do sexo feminino, de 36 anos, fisioterapeuta, que desenvolveu TEPT crônico e experienciou IT por medo da contaminação por coronavírus. As escalas psicométricas demonstraram que a TCC-FT reduziu consideravelmente os sintomas de TEPT e depressão e aumentou o apoio social e a resiliência. De acordo com o relato, o tratamento melhorou a concentração e a motivação, e reduziu o sentimento de culpa, a irritabilidade, a insegurança e o desconforto em lidar com outras pessoas. Conclusão: Este artigo demonstra que traumas decorrentes da COVID-19 podem ser capazes de desencadear IT e exemplifica um favorável desempenho da TCC-FT na melhoria global da saúde mental dos pacientes com TEPT crônico com vivência de IT.

ABSTRACT Objective: In this study, we report the case of a health professional with experience of tonic immobility (TI) and subsequent development of post-traumatic stress disorder (PTSD) as a result of occupational trauma due to COVID-19 who received remote treatment with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Methods: A case report of a patient followed for six months after receiving remote TF-CBT. Results: A 36-year-old female patient, the physiotherapist who developed chronic PTSD and experienced TI for fear of coronavirus contamination. Psychometric scales demonstrated that TF-CBT considerably reduced PTSD and depression symptoms and increased social support and resilience. According to the report, the treatment improved concentration and motivation, and reduced feelings of guilt, irritability, insecurity, and discomfort in dealing with other people. Conclusion: This article demonstrates that trauma resulting from COVID-19 can trigger TI and exemplifies a favorable performance of TF-CBT in the global improvement of the mental health of patients with chronic PTSD who experience TI.

Stuck in a Moment: Tonic Immobility Predicts Poor Quality of Life in Treated PTSD Patients.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a prevalent and disabling multisystem disorder, with significant physical and psychiatric morbidity and poor quality of life (QOL). Although peritraumatic reactions - tonic immobility and dissociation - are established predictors of PTSD severity and development, there is a dearth of investigation assessing the impact of peritraumatic reactions on QOL of PTSD patients. Quality of life has become increasingly important in health care and research as a reliable outcome measure. It comprises psychological, physical, social and environmental domains, providing important information about the impact of diseases on patient's life. This study aims to investigate the impact of peritraumatic tonic immobility and peritraumatic dissociation on QOL of PTSD civilian outpatients. SUBJECTS AND METHODS: It is a cross-sectional study of 50 victims of urban violence with current PTSD, recruited in a specialized outpatient clinic. Instruments used were: Structured Clinical Interview IV, Peritraumatic Dissociative Experiences Questionnaire, Tonic Immobility Scale and WHOQOL-BREF (psychological, physical, social and environmental domains). Linear regression models were fitted to evaluate the impact of peritraumatic reactions - tonic immobility and dissociation - on WHOQOL-BREF scores. We controlled for sex as potential confounding. RESULTS: The severity of peritraumatic tonic immobility negatively impacted on psychological and environment domains of quality of life. For each additional point on the Tonic Immobility Scale, there was a decreased of 0.8 points on the scores of these domains of WHOQOL-BREF. Neither the peritraumatic reactions showed effects on physical nor social domains. Possible limitations of this study include cross-sectional design, relatively small sample size of tertiary center outpatients and recall bias. CONCLUSIONS: Peritraumatic tonic immobility is related to poor quality of life, adding new insights about the relationship between this immobility reaction and PTSD.

Absence of definitive scientific evidence that benzodiazepines could hinder the efficacy of exposure-based interventions in adults with anxiety or posttraumatic stress disorders: A systematic review of randomized clinical trials.

BACKGROUND AND OBJECTIVES: Exposure-based interventions (EBIs) are the first-line treatment for anxiety disorders and posttraumatic stress disorder. Although common, the association between EBIs and benzodiazepines is controversial. Therefore, we systematically reviewed the literature to evaluate if benzodiazepines could undermine the efficacy of EBIs in treating these disorders. METHODS: We conducted a systematic review aiming for randomized clinical trials (RCTs) in ISI Web of Science, Scopus, PubMed/MEDLINE, and PsycINFO databases. We scrutinized the reference list of selected papers and other systematic reviews. Finally, we evaluated the methodological quality and the scientific evidence of the studies. RESULTS: We screened 1,529 studies and included 12 RCTs in this review (all showing some concerns or high risk of bias). Benzodiazepines did not impact the efficacy of EBIs in nine studies at posttreatment, improved efficacy in two, and reduced it in one. In the follow-up, benzodiazepines (after its discontinuation) did not impact the efficacy in six studies and reduced it in five. The scientific level of evidence achieved was B for both phases. CONCLUSIONS: Until now there is no definitive evidence that benzodiazepines could hinder the EBIs' efficacy for treating posttraumatic stress disorder and anxiety disorders.

Systematic review of the efficacy of cognitive-behavior therapy related treatments for victims of natural disasters: a worldwide problem.

Natural disasters can have devastating consequences. Each year, about 225 million people are victims of natural disasters worldwide, and up to 13,5 million of these people can develop post-traumatic stress disorder (PTSD) in the first or second year following the disaster. Cognitive-behavior therapy (CBT) is the first-choice treatment for this disorder. In order to evaluate the efficacy of psychotherapeutic treatment based on cognitive-behavior therapy for people who developed post traumatic stress disorder after natural disasters we conducted a systematic search of published studies. We used the terms reported below in the electronic databases ISI Web of Science, PsycINFO, PubMed, PILOTS and Scopus with no restrictions of language or publication date. Articles that described randomized controlled, non-randomized controlled and non controlled studies on the efficacy of cognitive-behavior therapy for individuals diagnosed with post-traumatic stress disorder after exposure to a natural disaster were eligible for inclusion. The studies were required to use a standardized measure of effectiveness before and after the intervention and have a group of patients who had used cognitive-behavior therapy as the only intervention. Our search identified 820 studies, and 11 were selected for this review. These 11 studies involved 742 subjects, 10 related to earthquakes and 1 to a hurricane. The cognitive-behavior therapy techniques used were various: 7 studies used exposure therapy, 2 studies used problem solving, and the only 2 studies with adolescents used techniques including reconstructions and reprocessing of the traumatic experience. As limitations, the search involved only five electronic databases, no experts in the field were consulted, and the heterogeneity of the findings made it impossible to perform a meta-analysis. The results suggest the efficacy of cognitive-behavior therapy, particularly exposure techniques, for the treatment of post-traumatic stress disorder after earthquakes. However, further studies with stronger methodologies, i.e. randomized-control trials and non-randomized controlled trials, are needed.

Impacto da terapia cognitivo-comportamental nos fatores neurobiológicos relacionados à resiliência / Impact of cognitive-behavior therapy on resilience-related neurobiological factors

A resiliência, como uma variável de desfecho, tem sido largamente negligenciada no campo terapêutico. Nosso objetivo foi investigar os efeitos da terapia cognitivo-comportamental (TCC) nos marcadores neurobiológicos de resiliência em pacientes com transtorno de estresse pós-traumático (TEPT). Nesta pesquisa experimental de caso único, foram acessadas variáveis fisiológicas (frequência cardíaca, frequência respiratória, tônus vagal cardíaco, balanço simpático e condutância da pele) e neuroendócrinas (cortisol e de-hidroepiandrosterona - DHEA) e medidas psicométricas de autorrelato (afeto negativo, resiliência, sintomas de TEPT, depressão, ansiedade e apoio social). Foram medidas as respostas fisiológicas, neuroendócrinas e psicométricas em repouso antes e após quatro meses de TCC. O paciente era um homem de 45 anos que sofreu dois assaltos com arma de fogo e não respondeu adequadamente ao tratamento farmacológico com paroxetina. A TCC levou a uma redução da frequência cardíaca, frequência respiratória, balanço simpático, condutância da pele e cortisol, bem como a um aumento no tônus vagal e DHEA. Além disso, a TCC promoveu redução na pontuação dos sintomas de TEPT, depressão, ansiedade e afeto negativo e aumento da pontuação de resiliência e apoio social. Nossos dados sugerem que a TCC aumenta os fatores relacionados à resiliência (DHEA, tônus vagal, autorrelato de resiliência e apoio social). Isso não é somente "antipatológico", mas também pode ser considerado "pró-bem-estar". Adicionalmente, nossos resultados mostram a relevância da investigação dos efeitos do tratamento psicológico em múltiplos sistemas neurobiológicos no mesmo paciente com TEPT, visando desvendar as bases neurobiológicas dos fatores de resiliência.

Resilience, as an outcome variable, has been largely neglected in the field of therapeutics. Our aim was to investigate the effects of cognitive behavioral therapy (CBT) on neurobiological markers of resilience in posttraumatic stress disorder (PTSD) patients. In this single-case experimental research, we assessed physiological (heart rate, respiratory rate, cardiac vagal tone, sympathetic balance and skin conductance) and neuroendocrine (cortisol and dehydroepiandrosterone - DHEA) variables; and psychometric self-report measures (negative affect, resilience, PTSD symptoms, depression, anxiety and social support). Physiological, neuroendocrine and psychometric responses at rest were measured before and after four months of CBT. The patient was a 45-year-old man who had suffered two armed robberies and failed to respond adequately to pharmacological treatment with paroxetine. CBT led to a reduction in heart rate, respiratory rate, sympathetic balance, skin conductance and cortisol. It also led to an increase in cardiac vagal tone and DHEA. Furthermore, CBT promoted reduction of PTSD symptoms, depression, anxiety and negative affect scores and enhancement of resilience and social support scores. CBT in this single case enhanced resilience-related factors such as DHEA, vagal tone, self-reported resilience and social support suggesting that this therapeutic strategy not only contributed to 'anti' pathology effects but to 'pro' well-being. Additionally, our results show the relevance of investigating the effects of psychological treatments in multiple neurobiological systems in the same PTSD patients to unveil the neurobiological underpinnings of resilience factors.

Marcadores neurobiológicos e psicométricos da eficácia da terapia cognitivo-comportamental no transtorno de estresse pós-traumático associado a sintomas dissociativos: relato de caso / Neurobiological and psychometric markers of the efficacy of cognitive behavioral therapy in post-traumatic stress disorder with dissociative symptoms: a case report

INTRODUÇÃO: O transtorno de estresse pós-traumático (TEPT) tem sido associado à desregulação de diversos parâmetros psicofisiológicos e pode apresentar comorbidade com diversas psicopatologias, inclusive a dissociação, podendo dificultar o tratamento. O objetivo do presente trabalho foi investigar os efeitos da terapia cognitivo-comportamental em um paciente com TEPT e sintomas dissociativos com base em medidas psicofisiológicas e psicométricas em diferentes momentos do tratamento. DESCRIÇÃO DO CASO: O paciente é um homem de 38 anos, com diagnósticos de TEPT e transtorno depressivo maior recorrente com sintomas dissociativos e resistência ao tratamento farmacológico. O tratamento psicoterápico teve duração de 4 meses, sendo composto por uma sessão semanal de terapia e três sessões semanais de coterapia. Os parâmetros fisiológicos (frequência cardíaca, tônus vagal, balanço simpático e cortisol) e psicométricos (afeto negativo e positivo, resiliência e sintomas de estresse pós-traumático, depressão, ansiedade e dissociação) foram medidos antes, durante (uma vez ao mês) e após o tratamento. COMENTÁRIOS: Os resultados mostraram diminuição do balanço simpático e aumento do tônus vagal, da frequência cardíaca e dos níveis de cortisol ao longo do tratamento. O tratamento também promoveu redução no afeto negativo e nos sintomas de estresse pós-traumático, depressão, ansiedade e dissociação, além de um aumento nos escores de resiliência, apoio social e afeto positivo. Esses resultados sugerem que a terapia cognitivo-comportamental é um tratamento eficaz para o TEPT com sintomas dissociativos. Além disso, parece promover a normalização das alterações fisiológicas do sistema nervoso autônomo e neuroendócrino relacionadas ao TEPT.

INTRODUCTION: Post-traumatic stress disorder (PTSD) has been associated with dysregulation of many psychophysiological parameters and may present comorbidity with different psychopathologies, including dissociation, potentially affecting treatment outcome. The aim of this study was to evaluate the effects of cognitive behavioral therapy in a patient with PTSD and dissociative symptoms based on psychophysiological and psychometric measures at different time points throughout the course of treatment. CASE DESCRIPTION: Our patient is a 38-year old man diagnosed with PTSD, major depression, and dissociative symptoms, resistant to pharmacotherapy. Psychological treatment lasted for 4 months and consisted of one weekly therapy session and three weekly coaching sessions. Physiological (heart rate, vagal tone, sympathovagal balance, and cortisol) and psychometric measures (negative and positive affect, resilience, and post-traumatic stress, depression, anxiety, and dissociative symptoms) were obtained before, during (once a month) and after treatment. COMMENTS: Results showed a decrease in sympathovagal balance and an increase in heart rate, vagal tone and cortisol levels during the course of treatment. Treatment also lead to a decrease in negative affect and in post-traumatic stress, depression, anxiety, and dissociation symptoms, as well as to an increase in resilience, social support and positive affect scores. These results suggest that cognitive behavioral therapy is an effective treatment for PTSD patients with dissociative symptoms. Moreover, the treatment seems to be able to normalize PTSD-related physiological parameters in the neuroendocrine and autonomic nervous systems.

Terapia cognitivo-comportamental e o TDAH subtipo desatento: uma área inexplorada

O Transtorno de Déficit de Atenção/Hiperatividade (TDAH) é definido a partir de um curso crônico o qual conduz a diversos comprometimentos. Em adultos, as maiores dificuldades são de organização, sustentação da atenção e memória. O transtorno apresenta como características nucleares a desatenção, a hiperatividade e a impulsividade, e seu diagnóstico é fundamentalmente clínico. Nosso objetivo é relatar o caso de uma cliente adulta diagnosticada com TDAH subtipo desatento e Depressão Maior, tratada apenas com Terapia Cognitivo-Comportamental (TCC) em 20 sessões. Inicialmente serão apresentadas as características clínicas do TDAH e breve revisão do tratamento com TCC. As medidas pré e pós-tratamento envolveram o Inventário de Depressão de Beck e Adult Self-Report Scale. Entre as intervenções utilizadas estavam a psicoeducação, o questionamento socrático e as estratégias de organização. Após a TCC a cliente não mais preenche critérios para depressão maior, além de apresentar redução dos sintomas de TDAH.

Attention Deficit Hyperactivity Disorder (ADHD) is defined from a chronic course which leads to several impairments. In adults, the greatest difficulties are in organization, sustained attention and memory. The disorder presents as core characteristics: inattention, hyperactivity and impulsivity and its diagnosis is mainly clinical. Our aim is to report the case of an adult client diagnosed with ADHD inattentive subtype and Major Depression, treated only with Cognitive-Behavioral Therapy (CBT) in 20 sessions. Initially we will present the clinical characteristics of ADHD and a brief review of the treatment of ADHD with CBT. We will then describe the search in the literature about the efficacy of CBT without medication in adults with ADHD inattentive subtype. The measures pre and post-treatment were: Beck Depression Inventory and Adult Self-Report Scale. Some interventions were psychoeducation, Socratic questioning and strategies to improve organization. After CBT, the client no longer meets criteria for major depression and there was a decrease in symptoms of ADHD.

Neurobiologia da regulação emocional: implicações para a terapia cognitivo-comportamental / Neurobiology of emotion regulation: implications for cognitive-behavioral therapy / Neurobiología de la regulación emocional: implicaciones para la terapia cognitivo-conductual

A regulação das emoções representa uma habilidade fundamental para a interação social, influenciando o comportamento e a expressão emocional. É objetivo deste artigo revisar os trabalhos científicos sobre as diferentes estratégias de regulação da emoção e os circuitos cerebrais subjacentes. Os trabalhos que utilizaram a estratégia de reavaliação cognitiva observaram um padrão de ativação cerebral caracterizado por uma ativação significativa do córtex pré-frontal e uma diminuição da ativação da amígdala, sugerindo que o primeiro poderia estar modulando a atividade da última. Trabalhos recentes observaram que mudanças cognitivas e comportamentais mediadas pela psicoterapia parecem levar a alterações na ativação de circuitos cerebrais envolvendo o córtex pré-frontal, e apontam para a possibilidade de modificação de associações neurais observadas em pacientes com transtornos psiquiátricos. Conclui-se que os estudos sobre a neurobiologia da regulação da emoção têm implicações potenciais para a compreensão das bases psicopatológicas subjacentes aos transtornos psiquiátricos, orientando desenvolvimentos heurísticos e clínicos.

Emotion regulation represents a crucial ability for social interaction, guiding behavior and modulating emotional expression. Current essay reviews the available literature on emotion regulation, points out the different coping strategies and investigates the underlying neural network. Studies on cognitive reappraisal of emotion have noted a pattern of brain response characterized by the activation of the prefrontal cortex associated with the reduction of amygdala activity. A modulatory mechanism between these structures has been suggested. Recent work showed that psychotherapeutic approaches may modify the dysfunctional neural circuitry associated with psychiatric disorders. Results show that investigating the neurobiology of emotion regulation offers a potential repercussion on the understanding of the basis of psychiatric disorders, orienting the development of applied studies and improving their clinical relevance.

La regulación emocional se constituye en un elemento clave en el comportamiento social, regulando las acciones y la expresión emocional. Este estudio tiene el propósito de revisar las estrategias de regulación emocional y describir los mecanismos cerebrales que las apoyan. Los estudios que han investigado la actividad cerebral durante la reevaluación cognitiva han mostrado la activación de zonas de la corteza prefrontal y la reducción de la activación de la amígdala, indicando que la primera podría estar modulando la última. Además, estudios recientes han observado que las alteraciones cognitivas y en el comportamiento tras psicoterapia conductual llevan a cambios en la activación de circuitos cerebrales, lo que sostendría la regulación emocional deficiente observada en trastornos mentales. Creemos que el estudio de la regulación emocional como un aspecto del procesamiento afectivo tiene importantes implicaciones para la psicopatología, y puede representar un modelo para el desarrollo de procedimientos de intervención.

Doença do pânico: perspectivas cognitivo-comportamental e biológica / Panic disorder: cognitive-behavioral and biological perspectives

A Doença do Pânico vem sendo estudada, enquanto entidade nosólogica distinta, desde 1980, com a publicaçäo do Manual de Diagnóstico e Estatística de Distúrbios Mentais da Associaçäo Psiquiátrica Americana (DSM-III). As hipóteses etiológicas e o tratamento da Doença do Pânico dentro dos Modelos Cognitivo, Comportamental, Biológico e Modelos Integrados refletem opiniöes diversas, mas complementares, sendo que é prematura a afirmaçäo da superioridade de um modelo teórico para o estudo desta doença

Doenca do panico: perspectivas cognitivo-comportamental e biologica

A Doenca do Panico vem sendo estudada, enquanto entidade nosologica distinta, desde 1980, com a publicacao do Manual de Diagnostico e Estatistica de Disturbio Mentais da Associacao Psiquiatrica America (DSM-III). As hipoteses etiologicas e o tratamento da Doenca do Panico dentro dos Modelos Cognitivo, Comportamental, Biologico e Modelos Integrados refletem opinioes diversas, mas complementares, sendo que e prematura a afirmacao da superioridade de um modelo teorico para o estudo desta doenca.