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1.
Adv Exp Med Biol ; 1191: 219-235, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002932

RESUMO

Although anxiety and depression have been considered as two distinct entities according to the diagnostic criteria, anxious depression (comorbid anxiety and depression) is relatively a common syndrome. According to the DSM-5 criteria, it uses "with anxious distress specifier" to define anxious depression in its MDD section. Anxious depression is known to have different neurobiological profiles compared to non-anxious depression. Several studies have revealed significant differences between anxious depression and non-anxious depression regarding the hypothalamic-pituitary-adrenal (HPA) axis function, structural and functional brain imaging findings, inflammation markers, etc. Patients with anxious depression were significantly more likely to be found in primary care setting and more likely to be associated with female gender, non-single, unemployed, less educated, and more severe depression. Previous reports also showed that patients with anxious depression had more frequent episodes of major depression and a higher risk of suicidal ideation and previous suicide attempts than those with non-anxious depression. Although anxious depression is known to be associated with poor treatment outcomes in several studies, recent researches have sought to find better treatment strategy to improve patients with anxious depression.


Assuntos
Transtornos de Ansiedade/complicações , Transtornos de Ansiedade/terapia , Transtorno Depressivo Maior/complicações , Transtorno Depressivo Maior/terapia , Ansiedade/complicações , Ansiedade/diagnóstico , Ansiedade/terapia , Transtornos de Ansiedade/diagnóstico , Comorbidade , Depressão/complicações , Depressão/diagnóstico , Depressão/terapia , Transtorno Depressivo Maior/diagnóstico , Humanos
2.
Adv Exp Med Biol ; 1191: 265-289, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002934

RESUMO

Biofeedback refers to the operant training of physiological responding. Variants include electromyography (EMG), electrodermal activity (EDA), skin temperature, heart rate (HR) and heart rate variability (HRV), respiratory biofeedback of end-tidal CO2 (ETCO2), electroencephalography (EEG) signal, and blood oxygen-level dependent signal using functional magnetic resonance imaging (fMRI). This chapter presents a qualitative and quantitative systematic review of randomized controlled trials of biofeedback for anxiety disorders as defined by the 3rd through 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Meta-analytic results indicated that biofeedback (broadly defined) is superior to wait list, but has not been shown to be superior to active treatment conditions or to conditions in which patients are trained to change their physiological responding in a countertherapeutic direction. Thus, although biofeedback appears generally efficacious for anxiety disorders, the specific effects of biofeedback cannot be distinguished from nonspecific effects of treatment. Further, significant limitations were identified in the existing literature, with the majority receiving a "weak" rating according to Effective Public Health Practice Project (EPHPP) rating system guidelines. Future directions for research are discussed.


Assuntos
Transtornos de Ansiedade/terapia , Biorretroalimentação Psicológica , Neurorretroalimentação , Eletroencefalografia , Eletromiografia , Frequência Cardíaca , Humanos , Temperatura Cutânea
3.
Adv Exp Med Biol ; 1191: 291-329, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002935

RESUMO

Anxiety disorders are an enormous societal burden given their high lifetime prevalence among adult populations worldwide. A variety of anxiety disorders can be successfully treated with psychological treatments such as cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT), either as stand-alone individual or group treatment or as adjunctive treatment to pharmacotherapy. Furthermore, a growing body of evidence suggests that therapist-guided Internet-delivered CBT (iCBT) and, to some degree, digitalized mindfulness- and acceptance-based interventions may be an efficacious complement to traditional face-to-face therapy. In view of the current advances regarding the integration of traditional and innovative treatment approaches, this chapter provides an overview on the theory and evidence base for different delivery modes of CBT-related interventions for specific phobia, panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder in adults. Finally, implications for clinical practice and research will be derived, and future directions for the psychological treatment of anxiety disorders will be outlined.


Assuntos
Terapia de Aceitação e Compromisso , Transtornos de Ansiedade/psicologia , Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental , Atenção Plena , Humanos , Transtornos Fóbicos/psicologia , Transtornos Fóbicos/terapia , Resultado do Tratamento
4.
Adv Exp Med Biol ; 1191: 415-449, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002940

RESUMO

Complementary and alternative medicine (CAM) encompasses a wide range of different nonmainstream therapies that have been increasingly used for treatment or adjunctive treatment of various ailments with anxiety/anxiety disorders being one of the commonly CAM (self)-medicated conditions. Thousands of published papers refer to use of CAM in various psychiatric disorders or in healthy or medically ill patients with mood or anxiety difficulties. In this chapter we focus specifically on clinically diagnosed (in line with the standard criteria) anxiety disorders and overview evidence of efficacy/safety of a range of CAM modalities: biologically based therapies (typically herbal preparations and less so nutraceuticals); manipulative and body-based therapies (acupuncture, aerobic exercise, massage, therapeutic touch, repetitive transcranial magnetic stimulation, balneotherapy, and others); mind-body therapies (yoga, Morita therapy, Tai Chi, reiki, Chinese cognitive therapy, religious and spiritual interventions, relaxation, mediation, and mindfulness-based interventions); and alternative medical systems (Ayurveda, homeopathy). We focus exclusively on randomized controlled trials and attempt to evaluate the existing body of evidence in the same manner that is applied to mainstream treatments.


Assuntos
Transtornos de Ansiedade/terapia , Terapias Complementares , Prática Clínica Baseada em Evidências , Terapia por Acupuntura , Exercício , Humanos , Massagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Tai Ji , Ioga
5.
Adv Exp Med Biol ; 1191: 451-464, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002941

RESUMO

Psychodynamic theory is founded on the idea that much, if not most, of human behavior is influenced by forces and experiences that lie outside of conscious awareness. It posits that despite what we may or may not recognize about our lived experience, an essential connection exists between unconscious processes and everyday psychological functioning. By extension, psychodynamic theory presumes that unconscious conflicts are pathognomonic of anxiety disorders and anxiety symptoms more generally. At the same time, the term "psychodynamic" refers not only to that which occurs within one's mind but also what happens between people and within families, groups, and systems. A comprehensive psychodynamic treatment of anxiety attempts to take into account these multiple domains of experience and functioning (including biological and genetic considerations) and applies a specific therapeutic approach to working with patients based in part on clinical techniques first developed by Sigmund Freud 100 years ago.


Assuntos
Transtornos de Ansiedade/psicologia , Transtornos de Ansiedade/terapia , Ansiedade/psicologia , Ansiedade/terapia , Psicoterapia Psicodinâmica , Conscientização , Humanos
6.
Adv Exp Med Biol ; 1191: 489-521, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002943

RESUMO

Anxiety disorders (ADs) are common psychiatric disorders, with a lifetime prevalence estimated at 33.7% in epidemiological studies. ADs are associated with serious disability and severe impairment in quality of life. Although several treatments [e.g. selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs), pregabalin, tricyclic antidepressants and benzodiazepines and/or cognitive-behaviour therapy (CBT)] are recommended, a large number of patients (i.e. from 30 to 70%) do not achieve complete remission. According to the novel paradigm of personalized medicine, the search of possible predictors of both disease vulnerability and treatment response might be the best way to prevent more accurately disease risk and to tailor the most effective treatment for each individual. Although a growing body of studies have proposed several endophenotypes/markers (i.e. neurochemical, neuroimaging, physiological, genetic and epigenetic endophenotypes/markers) as possible predictors of ADs susceptibility and/or treatment response, findings are not robust enough to be considered acceptable to incorporate in the clinical practice. In order to obtain more reliable results, larger studies with a multimodal approach, based on a combination of different biomarkers, are needed.


Assuntos
Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental , Humanos , Inibidores de Captação de Serotonina/uso terapêutico , Inibidores da Recaptação de Serotonina e Norepinefrina/uso terapêutico
7.
Adv Exp Med Biol ; 1191: 561-576, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002946

RESUMO

Recent data has linked anxiety and its disorders in late life to increased morbidity and mortality, especially related to a higher cardiovascular burden and an increased cognitive decline. Clinically, anxiety symptoms may be more difficult to elicit in older adults who are less accurate in identifying anxiety symptoms and tend to minimize symptoms and to attribute symptoms to physical illness. Although SSRIs have proven more effective than psychotherapy in late-life anxiety, many elderly anxious subjects prefer psychotherapeutic interventions. These interventions appear to work best when tailored for the needs, expectations, and cultural background of older anxious subjects.


Assuntos
Transtornos de Ansiedade , Idoso , Ansiolíticos/uso terapêutico , Ansiedade/complicações , Ansiedade/diagnóstico , Ansiedade/psicologia , Ansiedade/terapia , Transtornos de Ansiedade/complicações , Transtornos de Ansiedade/diagnóstico , Transtornos de Ansiedade/psicologia , Transtornos de Ansiedade/terapia , Doenças Cardiovasculares/complicações , Comorbidade , Humanos , Psicoterapia , Inibidores de Captação de Serotonina/uso terapêutico
8.
Adv Exp Med Biol ; 1191: 237-261, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002933

RESUMO

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).


Assuntos
Transtornos de Ansiedade/epidemiologia , Transtornos de Ansiedade/terapia , Transtornos de Ansiedade/complicações , Transtornos de Ansiedade/psicologia , Doença Crônica , Comorbidade , Humanos , Transtorno de Pânico/complicações , Transtorno de Pânico/epidemiologia , Transtorno de Pânico/psicologia , Transtorno de Pânico/terapia
9.
Adv Exp Med Biol ; 1191: 331-346, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002936

RESUMO

Many pharmacological treatments were proved effective in the treatment of panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD); still many patients do not achieve remission with these treatments. Neurostimulation techniques have been studied as promising alternatives or augmentation treatments to pharmacological and psychological therapies. The most studied neurostimulation method for anxiety disorders, PTSD, and OCD was repetitive transcranial magnetic stimulation (rTMS). This neurostimulation technique had the highest level of evidence for GAD. There were also randomized sham-controlled trials indicating that rTMS may be effective in the treatment of PTSD and OCD, but there were conflicting findings regarding these two disorders. There is indication that rTMS may be effective in the treatment of panic disorder, but the level of evidence is low. Deep brain stimulation (DBS) was most studied for treatment of OCD, but the randomized sham-controlled trials had mixed findings. Preliminary findings indicate that DBS could be affective for PTSD. There is weak evidence indicating that electroconvulsive therapy, transcranial direct current stimulation, vagus nerve stimulation, and trigeminal nerve stimulation could be effective in the treatment of anxiety disorders, PTSD, and OCD. Regarding these disorders, there is no support in the current literature for the use of neurostimulation in clinical practice. Large high-quality studies are warranted.


Assuntos
Transtornos de Ansiedade/terapia , Terapia por Estimulação Elétrica , Eletroconvulsoterapia , Transtorno Obsessivo-Compulsivo/terapia , Transtornos de Estresse Pós-Traumáticos/terapia , Estimulação Transcraniana por Corrente Contínua , Estimulação Magnética Transcraniana , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
10.
Adv Exp Med Biol ; 1191: 389-414, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002939

RESUMO

The principal aim to this chapter is to present the latest ideas in virtual reality (VR), some of which have already been applied to the field of anxiety disorders, and others are still pending to be materialized. More than 20 years ago, VR emerged as an exposure tool in order to provide patients and therapists with more appealing ways of delivering a technique that was undoubtedly effective but also rejected and thus underused. Throughout these years, many improvements were achieved. The first section of the chapter describes those improvements, both considering the research progresses and the applications in the real world. In a second part, our main interest is to expand the discussion of the new applications of VR beyond its already known role as an exposure tool. In particular, VR is enabling the materialization of numerous ideas that were previously confined to a merely philosophical discussion in the field of cognitive sciences. That is, VR has the enormous potential of providing feasible ways to explore nonclassical ways of cognition, such as embodied and situated information processing. Despite the fact that many of these developments are not fully developed, and not specifically designed for anxiety disorders, we want to introduce these new ideas in a context in which VR is experiencing an enormous transformation.


Assuntos
Transtornos de Ansiedade/terapia , Terapia de Exposição à Realidade Virtual , Transtornos de Ansiedade/psicologia , Cognição , Humanos , Realidade Virtual
11.
Adv Exp Med Biol ; 1191: 465-485, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002942

RESUMO

In almost all treatments for prevalent psychiatric conditions, particular attention has been devoted to stress and its consequences; this has led to an involuntary and unavoidable reinforcement of negative aspects of life. Because of the important influence of individual and cultural influences on positive health, well-being is a challenge from a clinical and scientific perspective and interventions aimed at enhancing it represent an area of growing interest for the future of clinical practice and research. Well-being therapy (WBT) is a short-term psychotherapeutic strategy aimed at enhancing well-being based on the model originally developed in 1958 by Marie Jahoda. It emphasizes self-observation, with the use of a structured diary, interaction between patients and therapists, and homework. WBT may be used as the only therapeutic strategy or in sequential combination with other psychotherapeutic strategies, mainly cognitive behavioral therapy. WBT can be differentiated from positive interventions based on several features which are described in detail in the present chapter. We also report the clinical use of WBT in the treatment of anxiety disorders, mainly generalized anxiety disorder, panic disorder, and agoraphobia. Potential further clinical application of WBT is withdrawal after antidepressants discontinuation and side effects during long-term antidepressant treatment.


Assuntos
Transtornos de Ansiedade/terapia , Psicoterapia , Agorafobia/terapia , Antidepressivos/efeitos adversos , Terapia Cognitivo-Comportamental , Humanos , Transtorno de Pânico/terapia
12.
Adv Exp Med Biol ; 1191: 523-541, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32002944

RESUMO

Exposure therapy, a key treatment for anxiety disorders, can be modelled in the laboratory using Pavlovian fear extinction. Understanding the hormonal and neurobiological mechanisms underlying fear extinction in females, who are twice more likely than males to present with anxiety disorders, may aid in optimising exposure therapy outcomes in this population. This chapter will begin by discussing the role of the sex hormones, estradiol and progesterone, in fear extinction in females. We will also propose potential mechanisms by which these hormones may modulate fear extinction. The second half of this chapter will discuss the long-term hormonal, neurological and behavioural changes that arise from pregnancy and motherhood and how these changes may alter the features of fear extinction in females. Finally, we will discuss implications of this research for the treatment of anxiety disorders in women with and without prior reproductive experience.


Assuntos
Transtornos de Ansiedade/metabolismo , Transtornos de Ansiedade/terapia , Ansiedade/metabolismo , Ansiedade/terapia , Estradiol/metabolismo , Progesterona/metabolismo , Reprodução , Ansiedade/psicologia , Transtornos de Ansiedade/psicologia , Extinção Psicológica , Medo , Feminino , Humanos , Gravidez
13.
Medicine (Baltimore) ; 99(6): e18480, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32028385

RESUMO

This study aimed to synthetically evaluate the impact of intensive patients' education program (IEP) on anxiety, depression and patient global assessment (PGA) in diabetic foot ulcer (DFU) patients.One hundred eighty DFU patients with Wagner grade 1 and Wagner grade 2 were consecutively recruited in this randomized, controlled study and randomly assigned to IEP group (N = 90) or control group (N = 90) as 1:1 ratio. In the IEP group, patients received the IEP and usual care, and patients in the control group received usual care only. IEP included educating patients and their family members, supervising patients' harmful habits and diets, psychological care for the patients and establishing a patient-physician-nurse WeChat group. Hospital Anxiety and Depression Scale-anxiety/depression (HADS-A/D) and Zung Self-Rating Anxiety/depression Scale (SAS/SDS) were applied to assess anxiety/depression at M0-M3. PGA score was also assessed at M0-M3.For anxiety assessment, IEP group presented decreased HADS-A/SAS scores at M2/M3 and increased HADS-A/SAS score changes (M3-M0) compared to control group. For depression assessment, IEP group displayed reduced HADS-D/SDS scores at M2/M3 and raised SDS score change (M3-M0) compared to control group. Moreover, IEP group exhibited reduced PGA score at M1/M2/M3 and elevated PGA score change (M3-M0) compared to control group. Further subgroup analyses disclosed that IEP reduced HADS-A/SAS/HADS-D/PGA scores at M3 and elevated these score changes (M3-M0) in patients with Wagener grade 2 but not Wagener grade 1.IEP ameliorates anxiety, depression and PGA in DFU patients with Wagner grade 2 but not Wagner grade 1.


Assuntos
Transtornos de Ansiedade/terapia , Transtorno Depressivo/terapia , Pé Diabético/psicologia , Educação de Pacientes como Assunto , Pé Diabético/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Psicometria , Índice de Gravidade de Doença , Resultado do Tratamento
14.
Lancet Psychiatry ; 7(2): 173-190, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31981539

RESUMO

BACKGROUND: Evidence on the effectiveness of psychological interventions for women with common mental disorders (CMDs) who also experience intimate partner violence is scarce. We aimed to test our hypothesis that exposure to intimate partner violence would reduce intervention effectiveness for CMDs in low-income and middle-income countries (LMICs). METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, trials registries, 3ie, Google Scholar, and forward and backward citations for studies published between database inception and Aug 16, 2019. All randomised controlled trials (RCTs) of psychological interventions for CMDs in LMICs which measured intimate partner violence were included, without language or date restrictions. We approached study authors to obtain unpublished aggregate subgroup data for women who did and did not report intimate partner violence. We did separate random-effects meta-analyses for anxiety, depression, post-traumatic stress disorder (PTSD), and psychological distress outcomes. Evidence from randomised controlled trials was synthesised as differences between standardised mean differences (SMDs) for change in symptoms, comparing women who did and who did not report intimate partner violence via random-effects meta-analyses. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42017078611. FINDINGS: Of 8122 records identified, 21 were eligible and data were available for 15 RCTs, all of which had a low to moderate risk of overall bias. Anxiety (five interventions, 728 participants) showed a greater response to intervention among women reporting intimate partner violence than among those who did not (difference in standardised mean differences [dSMD] 0·31, 95% CI 0·04 to 0·57, I2=49·4%). No differences in response to intervention were seen in women reporting intimate partner violence for PTSD (eight interventions, n=1436; dSMD 0·14, 95% CI -0·06 to 0·33, I2=42·6%), depression (12 interventions, n=2940; 0·10, -0·04 to 0·25, I2=49·3%), and psychological distress (four interventions, n=1591; 0·07, -0·05 to 0·18, I2=0·0%, p=0·681). INTERPRETATION: Psychological interventions treat anxiety effectively in women with current or recent intimate partner violence exposure in LMICs when delivered by appropriately trained and supervised health-care staff, even when not tailored for this population or targeting intimate partner violence directly. Future research should investigate whether adapting evidence-based psychological interventions for CMDs to address intimate partner violence enhances their acceptability, feasibility, and effectiveness in LMICs. FUNDING: UK National Institute for Health Research ASSET and King's IoPPN Clinician Investigator Scholarship.


Assuntos
Transtornos de Ansiedade/terapia , Transtorno Depressivo/terapia , Países em Desenvolvimento/estatística & dados numéricos , Violência por Parceiro Íntimo/estatística & dados numéricos , Psicoterapia/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Estresse Psicológico/terapia , Feminino , Humanos
15.
Z Kinder Jugendpsychiatr Psychother ; 48(1): 33-46, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30422059

RESUMO

This meta-review integrates the current meta-analysis literature on the efficacy of internet- and mobile-based interventions (IMIs) for mental disorders and somatic diseases in children and adolescents. Further, it summarizes the moderators of treatment effects in this age group. Using a systematic literature search of PsycINFO and MEDLINE/PubMed, we identified eight meta-analyses (N = 8,417) that met all inclusion criteria. Current meta-analytical evidence of IMIs exists for depression (range of standardized mean differences, SMDs = .16 to .76; 95 % CI: -.12 to 1.12; k = 3 meta-analyses), anxiety (SMDs = .30 to 1.4; 95 % CI: -.53 to 2.44; k = 5) and chronic pain (SMD = .41; 95 % CI: .07 to .74; k = 1) with predominantly nonactive control conditions (waiting-list; placebo). The effect size for IMIs across mental disorders reported in one meta-analysis is SMD = 1.27 (95 % CI: .96 to 1.59; k = 1), the effect size of IMIs for different somatic conditions is SMD = .49 (95 % CI: .33 to .64; k = 1). Moderators of treatment effects are age (k = 3), symptom severity (k = 1), and source of outcome assessment (k = 1). Quality ratings with the AMSTAR-2-checklist indicate acceptable methodological rigor of meta-analyses included. Taken together, this meta-review suggests that IMIs are efficacious in some health conditions in youths, with evidence existing primarily for depression and anxiety so far. The findings point to the potential of IMIs to augment evidence based mental healthcare for children and adolescents.


Assuntos
Transtornos de Ansiedade/terapia , Telefone Celular , Transtorno Depressivo/terapia , Internet , Adolescente , Ansiedade/terapia , Criança , Depressão/terapia , Humanos , Resultado do Tratamento
16.
Med J Aust ; 211 Suppl 9: S3-S46, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31679171

RESUMO

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, includingreal-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.


Assuntos
Bem-Estar da Criança/estatística & dados numéricos , Transtornos Mentais/terapia , Saúde Mental , Planejamento de Assistência ao Paciente/organização & administração , Adolescente , Transtornos de Ansiedade/terapia , Austrália , Transtorno Bipolar/terapia , Gerenciamento Clínico , Diretrizes para o Planejamento em Saúde , Humanos , Masculino , Relações Profissional-Paciente , Transtornos Psicóticos/terapia , Adulto Jovem
17.
Behav Ther ; 50(6): 1042-1052, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31735240

RESUMO

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.


Assuntos
Transtornos de Ansiedade/psicologia , Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental , Transtorno Depressivo/terapia , Ansiedade/psicologia , Depressão/psicologia , Emoções , Feminino , Humanos , Masculino , Metacognição , Motivação , Distribuição Aleatória , Inquéritos e Questionários , Adulto Jovem
18.
Behav Ther ; 50(6): 1063-1074, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31735242

RESUMO

In a recent trial for generalized anxiety disorder (GAD), cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) promoted more long-term worry reduction than CBT alone (Westra, Constantino, & Antony, 2016). A follow-up analysis found that CBT vs. MI-CBT clients evidenced greater increases in friendly submissiveness (FS) across treatment, which in turn promoted lower long-term worry (Constantino, Romano, Coyne, Westra, & Antony, 2018). It was unsurprising that traditional directive CBT promoted more FS than when person-centered MI was integrated; however, given that problematic low agency characterizes GAD, that greater FS promoted better outcome was unexpected. To further unpack this unexpected result, we tested the following moderated mediation hypothesis: for clients with more vs. less problematic low agency at baseline, CBT would still promote more in-session FS than MI-CBT, but this increase would in turn predict increased worry over follow-up. Clients receiving CBT (n = 43) or MI-CBT (n = 42) rated their interpersonal problems at baseline and their worry after treatment and across 12-month follow-up. Therapists rated clients' in-session FS multiple times. As predicted, multilevel modeling revealed that for clients with more problematic low agency, CBT vs. MI-CBT facilitated greater FS, which in turn related to increased worry across follow-up. For clients with more problematic high agency, CBT's facilitation of greater FS related to reduced worry across follow-up. A baseline interpersonal problem characteristic of GAD may have implications for treatment matching and for appreciating different pathways to long-term improvement, or deterioration, for different GAD subgroups.


Assuntos
Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental , Entrevista Motivacional , Adulto , Ansiedade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
19.
Behav Ther ; 50(6): 1112-1124, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31735246

RESUMO

Traditional cognitive-behavioral therapy (CBT) for anxiety disorders has been designed to target reductions in negative affect (NA) associated with defense-related processes. However, a subset of anxiety disorders, including social anxiety disorder (SAD), are also characterized by low positive affect (PA) resulting from separate deficits in appetitive-related processes. In contrast to CBT, "third-wave" approaches, such as acceptance and commitment therapy (ACT), align more consistently with motivational processes and, as a result, PA. However, the differential effect of CBT and ACT on PA and NA has yet to be investigated. Using secondary data from a randomized controlled trial, the present study sought to compare CBT's (n = 45) and ACT's (n = 35) effect on PA and NA in SAD. Findings were compared to a wait-list (WL) control condition (n = 31), as well as normative data from a general adult sample. Baseline PA and NA were also examined as moderators and predictors of theory-relevant treatment outcomes. NA decreased significantly in both CBT and ACT from pre to posttreatment. Although ACT outperformed WL in reducing NA, this effect was not observed for CBT. PA increased significantly in both CBT and ACT from pre to posttreatment, with neither ACT nor CBT outperforming WL in increasing PA. Neither PA nor NA were found to moderate theoretically relevant treatment outcomes. Findings suggest that ACT and CBT share common treatment mechanisms, making them more similar than distinct. Further efforts should be focused on optimizing CBT's and ACT's influence on threat and reward learning, and elucidating common processes of change.


Assuntos
Terapia de Aceitação e Compromisso/estatística & dados numéricos , Afeto , Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Adulto , Cognição , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Fobia Social , Resultado do Tratamento , Listas de Espera , Adulto Jovem
20.
Behav Ther ; 50(6): 1173-1184, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31735251

RESUMO

BACKGROUND: Anxiety sensitivity cognitive concerns (ASCC), or fear of cognitive dyscontrol sensations, confers risk for anxiety and mood psychopathology. Recent work demonstrated that novel perceptual challenges generated by a head mounted display can elicit fear among those with elevated ASCC. This suggests that interoceptive exposure to perceptual challenges may offer a means to mitigate ASCC. This study was designed to evaluate whether repeated exposure to novel perceptual challenges can reduce ASCC, and if these effects are stronger among those experiencing greater negative emotionality as a proxy for individuals likely to present for treatment. METHODS: Participants with elevated ASCC (N = 57) were randomized to one of three experimental conditions utilizing a head-mounted display. In the rotations condition (n = 20), participants viewed themselves spinning in a circle. In the opposite directions condition (n = 20), participants turned their head while the camera moved in the opposite direction creating dissonance in their visual field. In the control condition (n = 17), participants completed a series of simple arithmetic problems. RESULTS: Participants in the rotation condition, relative to control, reported significant reductions in ASCC from pre- to post-exposure and these effects were strongest for those with elevated negative affect. The main effect of the opposite directions exposure on post-treatment ASCC was non-significant, but follow-up analyses revealed that reductions in ASCC were observed among those with elevated negative affectivity. DISCUSSION: Perceptual illusion challenges appear to have utility for reducing ASCC through repeated exposure. There was evidence for the perceptual illusion exercises, particularly the rotations condition, specifically reducing ASCC, making this challenge the first we are aware of that specifically targets ASCC-related concerns. LIMITATIONS: As a proof-of-concept study, the present sample was not recruited for clinically-significant psychopathology, and only a brief follow-up was utilized. Future research should utilize a longer follow-up and test if these exposures mitigate ASCC-relevant psychopathology among clinical samples.


Assuntos
Ansiedade/psicologia , Ilusões/psicologia , Adulto , Afeto , Transtornos de Ansiedade/terapia , Medo/psicologia , Feminino , Humanos , Masculino , Adulto Jovem
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