A randomized clinical trial of prolonged exposure and applied relaxation for the treatment of Latinos with posttraumatic stress disorder.

Robust evidence supports the use of prolonged exposure therapy (PE) as a first-line treatment for posttraumatic stress disorder (PTSD). However, Latinos have not benefitted equally from advancements in the treatment of PTSD and continue to face barriers to receiving care. There is consensus that it is necessary to support the expansion of high-quality culturally and linguistically appropriate treatment to address disparities experienced by racial and ethnic minorities in behavioral health care. The current study was a randomized controlled trial comparing a culturally adapted PE intervention with applied relaxation (AR) among Spanish-speaking Latinos with PTSD in Puerto Rico. Eligible participants (N = 98) were randomly assigned to PE (n = 49) or AR (n = 49). Both treatments included 12-15 weekly sessions each lasting 60-90 min. The primary outcome, clinician-rated PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 at baseline, posttreatment, and 3-month follow-up. Secondary outcomes were assessed using the Patient Health Questionnaire and State-Trait Anxiety Inventory. Results showed a large within-group effect of treatment on PTSD symptoms, PE: d = 1.29, 95% CI [1.12, 2.05]; AR: d = 1.38, 95% CI [1.21, 2.19]. The between-group effect on PTSD symptoms was small, d = -0.09, 95% CI [-0.48, 0.31]. Participants in both treatment conditions reported significant decreases in PTSD symptoms from baseline to follow-up; additionally, significant within-group reductions in depression and anxiety symptoms were observed. These findings underscore the potential benefit of PE and AR for the treatment of Spanish-speaking Latinos with PTSD.

Moral Cognition About Harm in Anxiety Disorders: The Importance of Experienced Emotion.

Recent work has shown that emotional arousal influences decision-making in sacrificial moral dilemmas, with heightened levels of arousal associated with increased aversion to committing moral transgressions to maximize utilitarian outcomes. Patients with anxiety disorders experience pathologically heightened states of arousal and thus may be expected to exhibit reduced utilitarian responding on such dilemmas. Extant evidence has been mixed, however, regarding whether anxious patients differ in their moral decisions from controls, and no study has conducted a careful examination of emotions experienced during decision-making. We administered sacrificial moral dilemmas to a cohort of 95 patients from across the spectrum of anxiety disorders to test whether they differed from matched controls on a) utilitarian decision-making, and b) ratings of experienced emotion during the moral deliberative process. Results showed no group differences between patients and controls on endorsement of utilitarian sacrificial action or on reported experience of emotionality during the experiment. Additionally, exploratory analysis revealed that specific emotions were correlated with utilitarian judgments. These results are in line with the Dual Process Theory model's prediction that decreased utilitarian responding will be concomitant with an increased emotional arousal. Our findings support past work indicating that moral cognition is intact in anxiety disorders despite the emotional dysregulation characteristic of anxious psychopathology. Future work would benefit from the use of process-dissociation techniques to further clarify whether emotional or cognitive processes may differ in anxiety disorders during moral cognition.

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

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

The roles of interoceptive sensitivity and metacognitive interoception in panic.

BACKGROUND: Interoception refers to the ability to sense body signals. Two interoceptive dimensions have been recently proposed: (a) interoceptive sensitivity (IS) -objective accuracy in detecting internal bodily sensations (e.g., heartbeat, breathing)-; and (b) metacognitive interoception (MI) -explicit beliefs and worries about one's own interoceptive sensitivity and internal sensations. Current models of panic assume a possible influence of interoception on the development of panic attacks. Hypervigilance to body symptoms is one of the most characteristic manifestations of panic disorders. Some explanations propose that patients have abnormal IS, whereas other accounts suggest that misinterpretations or catastrophic beliefs play a pivotal role in the development of their psychopathology. Our goal was to evaluate these theoretical proposals by examining whether patients differed from controls in IS, MI, or both. Twenty-one anxiety disorders patients with panic attacks and 13 healthy controls completed a behavioral measure of IS motor heartbeat detection (HBD) and two questionnaires measuring MI. FINDINGS: Patients did not differ from controls in IS. However, significant differences were found in MI measures. Patients presented increased worries in their beliefs about somatic sensations compared to controls. These results reflect a discrepancy between direct body sensing (IS) and reflexive thoughts about body states (MI). CONCLUSION: Our findings support the idea that hypervigilance to body symptoms is not necessarily a bottom-up dispositional tendency (where patients are hypersensitive about bodily signals), but rather a metacognitive process related to threatening beliefs about body/somatic sensations.

How do you feel when you can't feel your body? Interoception, functional connectivity and emotional processing in depersonalization-derealization disorder.

Depersonalization-Derealization Disorder (DD) typically manifests as a disruption of body self-awareness. Interoception -defined as the cognitive processing of body signals- has been extensively considered as a key processing for body self-awareness. In consequence, the purpose of this study was to investigate whether there are systematic differences in interoception between a patient with DD and controls that might explain the disembodiment symptoms suffered in this disease. To assess interoception, we utilized a heartbeat detection task and measures of functional connectivity derived from fMRI networks in interoceptive/exteroceptivo/mind-wandering states. Additionally, we evaluated empathic abilities to test the association between interoception and emotional experience. The results showed patient's impaired performance in the heartbeat detection task when compared to controls. Furthermore, regarding functional connectivity, we found a lower global brain connectivity of the patient relative to controls only in the interoceptive state. He also presented a particular pattern of impairments in affective empathy. To our knowledge, this is the first experimental research that assesses the relationship between interoception and DD combining behavioral and neurobiological measures. Our results suggest that altered neural mechanisms and cognitive processes regarding body signaling might be engaged in DD phenomenology. Moreover, our study contributes experimental data to the comprehension of brain-body interactions and the emergence of self-awareness and emotional feelings.

Dysfunctional cognitions and their emotional, behavioral, and functional correlates in adults with attention deficit hyperactivity disorder (ADHD): is the cognitive-behavioral model valid?

OBJECTIVE: To investigate the presence of dysfunctional cognitions in adults with ADHD and to determine whether these cognitions are associated with emotional symptoms, maladaptive coping, and functional impairment, as predicted by the cognitive-behavioral model. METHOD: A total of 35 adult participants with ADHD, 20 nonclinical controls, and 20 non-ADHD clinical controls were assessed with measures of ADHD symptoms, dysfunctional cognitions, depression and anxiety symptoms, coping strategies, and quality of life. RESULTS: ADHD group showed elevated scores of dysfunctional cognitions relative to nonclinical control group and comparable with clinical control group. Dysfunctional cognitions were strongly associated with emotional symptoms. ADHD group also showed elevated scores in maladaptive coping strategies of the escape-avoidance type. Life impairment was satisfactorily predicted in data analysis when ADHD symptoms, dysfunctional cognitions, and emotional symptoms were fitted into a regression model. CONCLUSION: Cognitive-behavioral therapy model appears to be a valid complementary model for understanding emotional and life impairment in adults with ADHD.

Children and adolescents with Tourette's disorder in the USA versus Argentina: behavioral differences may reflect cultural factors.

To explore behavioral differences as possible cultural factors in presentation of psychiatric comorbidity in two clinically referred, consecutively ascertained samples of youth with Tourette's disorder (TD) from New York and Buenos Aires. Subjects were evaluated between 2002 and 2010 at the Tics and Tourette's Clinical and Research Program at the New York University Child Study Center in New York and the Interdisciplinary Center for Tourette's, Obsessive Compulsive Disorder (OCD) and Associated Disorders (CITTTA)/Institute of Cognitive Psychology (INECO) in Buenos Aires. Demographic, diagnostic, tic severity (Yale Global Tic Severity Scale; YGTSS), clinical (Child Behavior Check List-Parent version; CBCL), and global functioning (Global Assessment of Functioning; GAF) data were compared using descriptive statistics. The sample included 111 subjects ages 6-17 years, who met DSM-IV-TR diagnostic criteria for TD. Findings revealed that the BA sample (n = 35) was significantly older at initial evaluation at the tic specialty clinic, and had higher frequency of oppositional defiant disorder (ODD), mood and non-OCD anxiety disorders than the NY sample (n = 76). There were no differences in gender distribution, age at tic onset or TD diagnosis, tic severity, proportion with current diagnoses of OCD/OC behavior or attention deficit hyperactivity disorder (ADHD), CBCL internalizing, externalizing, or total problems scores, YGTSS scores, or GAF scores. The observed similarities in demographic features, clinical presentation, rates of ADHD and OCD/OCB, and global impairment may reflect similar phenomenology and illness-related characteristics of TD in these referred youth. Differences in age at initial specialty clinic evaluation and rates of ODD, mood and non-OCD anxiety disorders may need further exploration before they may be considered to reflect cultural factors. Because of these limitations (e.g. small sample size), these results can be regarded only as preliminary.

The extended fronto-striatal model of obsessive compulsive disorder: convergence from event-related potentials, neuropsychology and neuroimaging.

In this work, we explored convergent evidence supporting the fronto-striatal model of obsessive-compulsive disorder (FSMOCD) and the contribution of event-related potential (ERP) studies to this model. First, we considered minor modifications to the FSMOCD model based on neuroimaging and neuropsychological data. We noted the brain areas most affected in this disorder -anterior cingulate cortex (ACC), basal ganglia (BG), and orbito-frontal cortex (OFC) and their related cognitive functions, such as monitoring and inhibition. Then, we assessed the ERPs that are directly related to the FSMOCD, including the error-related negativity (ERN), N200, and P600. Several OCD studies present enhanced ERN and N2 responses during conflict tasks as well as an enhanced P600 during working memory (WM) tasks. Evidence from ERP studies (especially regarding ERN and N200 amplitude enhancement), neuroimaging and neuropsychological findings suggests abnormal activity in the OFC, ACC, and BG in OCD patients. Moreover, additional findings from these analyses suggest dorsolateral prefrontal and parietal cortex involvement, which might be related to executive function (EF) deficits. Thus, these convergent results suggest the existence of a self-monitoring imbalance involving inhibitory deficits and executive dysfunctions. OCD patients present an impaired ability to monitor, control, and inhibit intrusive thoughts, urges, feelings, and behaviors. In the current model, this imbalance is triggered by an excitatory role of the BG (associated with cognitive or motor actions without volitional control) and inhibitory activity of the OFC as well as excessive monitoring of the ACC to block excitatory impulses. This imbalance would interact with the reduced activation of the parietal-DLPC network, leading to executive dysfunction. ERP research may provide further insight regarding the temporal dynamics of action monitoring and executive functioning in OCD.

Prolonged exposure for the treatment of Spanish-speaking Puerto Ricans with posttraumatic stress disorder: a feasibility study.

BACKGROUND: Most of the empirical studies that support the efficacy of prolonged exposure (PE) for treating posttraumatic stress disorder (PTSD) have been conducted on white mainstream English-speaking populations. Although high PTSD rates have been reported for Puerto Ricans, the appropriateness of PE for this population remains unclear. The purpose of this study was to examine the feasibility of providing PE to Spanish speaking Puerto Ricans with PTSD. Particular attention was also focused on identifying challenges faced by clinicians with limited experience in PE. This information is relevant to help inform practice implications for training Spanish-speaking clinicians in PE. RESULTS: Fourteen patients with PTSD were randomly assigned to receive PE (n = 7) or usual care (UC) (n = 7). PE therapy consisted of 15 weekly sessions focused on gradually confronting and emotionally processing distressing trauma-related memories and reminders. Five patients completed PE treatment; all patients attended the 15 sessions available to them. In UC, patients received mental health services available within the health care setting where they were recruited. They also had the option of self-referring to a mental health provider outside the study setting. The Clinician-Administered PTSD Scale (CAPS) was administered at baseline, mid-treatment, and post-treatment to assess PTSD symptom severity. Treatment completers in the PE group demonstrated significantly greater reductions in PTSD symptoms than the UC group. Forty percent of the PE patients showed clinically meaningful reductions in PTSD symptoms from pre- to post-treatment. CONCLUSIONS: PE appears to be viable for treating Puerto Rican Spanish-speaking patients with PTSD. This therapy had good patient acceptability and led to improvements in PTSD symptoms. Attention to the clinicians' training process contributed strongly to helping them overcome the challenges posed by the intervention and increased their acceptance of PE.

The Obsessive-Compulsive Inventory: development and validation of a short version.

This article reports on the development of a revised version of the Obsessive-Compulsive Inventory (OCI; E. B. Foa, M. J. Kozak, P. Salkovskis, M. E. Coles, & N. Amir, 1998), a psychometrically sound, theoretically driven, self-report measure. The revised OCI (OCI-R) improves on the parent version in 3 ways: It eliminates the redundant frequency scale, simplifies the scoring of the subscales, and reduces overlap across subscales. The reliability and validity of the OCI-R were examined in 215 patients with obsessive-compulsive disorder (OCD), 243 patients with other anxiety disorders, and 677 nonanxious individuals. The OCI-R, which contains 18 items and 6 subscales, has retained excellent psychometric properties. The OCI-R and its subscales differentiated well between individuals with and without OCD. Receiver operating characteristic (ROC) analyses demonstrated the usefulness of the OCI-R as a diagnostic tool for screening patients with OCD, utilizing empirically derived cutscores.