Exploring Remission Dynamics and Prognostic Factors in Lichen Planopilaris: a Retrospective Cohort Study.

INTRODUCTION: Lichen planopilaris (LPP) is a common type of primary cicatricial alopecia. Previous studies focused on the epidemiology, clinical characteristics, and treatment of LPP. A lack of knowledge regarding LPP outcomes and prognostic factors remained. METHODS: To delineate the rate and timing of remission in LPP, as well as the prognostic factors for achieving remission, a retrospective cohort study was conducted. The study included 126 patients, from a single tertiary center, diagnosed with LPP between January 2010 and December 2022, who were followed up for a minimum of 6 months. RESULTS: There were 89 (70.6%) women and 37 (29.4 %) men included in this study. The mean age of the patients was 47.92±14.2 years. The mean time from disease onset to diagnosis was 33.85 (±30) months, indicating significant diagnostic delays. The mean duration of follow-up was 34.13±22.7 months. Among the cohort, 43 patients achieved complete remission (CR) during the follow-up period, whereas 83 patients did not. Of the 83 patients who did not achieve CR, 35 partially improved and 48 did not improve or worsened. The median time for achieving CR was 46±18.8 months. Milder disease at presentation and comorbid lichen planus were associated with higher CR rates. CONCLUSION: This study demonstrates significant diagnostic delays that should be addressed as LPP causes irreversible alopecia, suggests disease severity and comorbid lichen planus as potential prognostic factors. Further, it emphasizes the limited efficacy of current treatments and the need for prolonged treatment in patients with LPP to achieve remission.

A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder.

BACKGROUND: Self-administered cognitive behavior therapy (SCBT) has been shown to be an effective alternative to therapist-delivered treatment for panic disorder (PD). However, it is unknown whether combining SCBT and antidepressants can improve treatment. This trial evaluated the efficacy of SCBT and sertraline, alone or in combination, in PD. METHOD: Patients (n=251) were randomized to 12 weeks of either placebo drug, placebo drug plus SCBT, sertraline, or sertraline plus SCBT. Those who improved after 12 weeks of acute treatment received treatment for an additional 12 weeks. Outcome measures included core PD symptoms (panic attacks, anticipatory anxiety, agoraphobic avoidance), dysfunctional cognitions (fear of bodily sensations, agoraphobic cognitions), disability, and clinical global impression of severity and improvement. Efficacy data were analyzed using general and generalized linear mixed models. RESULTS: Primary analyses of trends over time revealed that sertraline/SCBT produced a significantly greater rate of decline in fear of bodily sensations compared to sertraline, placebo/SCBT and placebo. Trends in other outcomes were not significantly different over time. Secondary analyses of mean scores at week 12 revealed that sertraline/SCBT fared better on several outcomes than placebo, with improvement being maintained at the end of continuation treatment. Outcome did not differ between placebo and either sertraline monotherapy or placebo/SCBT. Moreover, few differences emerged between the active interventions. CONCLUSIONS: This trial suggests that sertraline combined with SCBT may be an effective treatment for PD. The study could not confirm the efficacy of sertraline monotherapy or SCBT without concomitant medication or therapist assistance in the treatment of PD.

Investigating associations between cortisol and cognitive reactivity to sad mood provocation and the prediction of relapse in remitted major depression.

OVERVIEW: In remitted depressed patients, an increase in dysfunctional thoughts following a sad mood induction can predict relapse over 18 months. The current analysis examined whether salivary cortisol levels could also predict relapse in these same individuals. METHOD: 99 subjects with major depression were first treated to full remission using either antidepressant medication or cognitive behavioural therapy. While in the remitted state, subjects were exposed to sad music to trigger dysfunctional thoughts. In a subset of 55 subjects, salivary cortisol levels taken before and after the mood challenge were also obtained. RESULTS: Unexpectedly, cortisol levels tended to decrease rather than increase following the mood challenge, suggesting that anticipation of the mood challenge was more stressful than the challenge itself. We thus used pre-challenge cortisol levels as the main grouping variable. Based on Kaplan-Meier survival curves, among subjects with low pre-challenge cortisol levels, those with a history of three or more prior episodes had significantly higher rates of relapse than did subjects with two or less prior episodes. In subjects with high pre-challenge cortisol levels, there was no significant difference in rates of relapse based on the number of prior episodes. CONCLUSION: In depressed patients with few prior episodes, assessing risk of relapse and thus establishing the duration for treatment can be a difficult clinical problem. Pending replication, the current results suggest that high anticipatory cortisol levels may have utility in predicting relapse even in patients with few prior episodes.

Recurrence of suicidal ideation across depressive episodes.

BACKGROUND: In recent years it has become clear that depression is a recurrent disorder, with the risk of recurrence in those with two or more episodes being as high as 90%. This has prompted interest in the consistency of individual depressive symptoms across consecutive episodes, an issue that is important for symptoms such as suicidal ideation, where a past history may give important indicators of future behaviour. METHODS: We prospectively examined 69 individuals with a history of Major Depression, over 12 months, 38 of whom experienced a recurrence of major depression during the follow-up period. RESULTS: Spearman's rank order correlations between severity ratings of each symptom of major depression during a previous episode and severity ratings at recurrence showed significant associations for suicidality, guilt or worthlessness and thinking difficulties only. Weighted kappa coefficients indicated relatively low levels of agreement across episodes for most diagnostic symptoms, with suicidality showing the strongest relationship. Using a broad definition of suicidality-- any reporting of thoughts of death or suicide during episode-- a much higher level of agreement (kappa = .64) was found, with 83% of individuals falling into the same category (suicidal/non-suicidal) at both episodes. LIMITATIONS: This study was based on a relatively small sample and examines re-emergence of suicidal ideation in the absence of suicidal behaviour. CONCLUSIONS: This study provides preliminary evidence of cross-episode consistency in the recurrence of suicidal ideation, in line with the differential activation theory of suicidality in depression.

Limbic-frontal circuitry in major depression: a path modeling metanalysis.

This paper reports the results of an across lab metanalysis of effective connectivity in major depression (MDD). Using FDG PET data and Structural Equation Modeling, a formal depression model was created to explicitly test current theories of limbic-cortical dysfunction in MDD and to characterize at the path level potential sources of baseline variability reported in this patient population. A 7-region model consisting of lateral prefrontal cortex (latF9), anterior thalamus (aTh), anterior cingulate (Cg24), subgenual cingulate (Cg25), orbital frontal cortex (OF11), hippocampus (Hc), and medial frontal cortex (mF10) was tested in scans of 119 depressed patients and 42 healthy control subjects acquired during three separate studies at two different institutions. A single model, based on previous theory and supported by anatomical connectivity literature, was stable for the three groups of depressed patients. Within the context of this model, path differences among groups as a function of treatment response characteristics were also identified. First, limbic-cortical connections (latF9-Cg25-OF11-Hc) differentiated drug treatment responders from nonresponders. Second, nonresponders showed additional abnormalities in limbic-subcortical pathways (aTh-Cg24-Cg25-OF11-Hc). Lastly, more limited limbic-cortical (Hc-latF9) and cortical-cortical (OF11-mF10) path differences differentiated responders to cognitive behavioral therapy (CBT) from responders to pharmacotherapy. We conclude that the creation of such models is a first step toward full characterization of the depression phenotype at the neural systems level, with implications for the future development of brain-based algorithms to determine optimal treatment selection for individual patients.

Clinical guidelines for the treatment of depressive disorders. III. Psychotherapy.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section on "Psychotherapy" is 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Recommendations are given for the use of psychotherapy in the treatment of depressive disorders. Considerable evidence shows that specific, short-term psychotherapies including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are effective acute-phase treatments. There is also evidence that group and marital/couples formats of psychotherapy are effective. There is only limited evidence that psychotherapy is effective for maintenance treatment of depressive disorders. CONCLUSIONS: Psychotherapy is effective in the treatment of depressive disorders. Despite the evidence for effectiveness of specific psychotherapies, there is still limited access to these treatments in the community.

Clinical guidelines for the treatment of depressive disorders. V. Combining psychotherapy and pharmacotherapy.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, "Combining Psychotherapy and Pharmacotherapy," was 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Recommendations are given for the use of combined psychotherapy and pharmacotherapy for the treatment of depressive disorders. Three methods of combined treatment are identified: concurrent treatment (psychotherapy plus pharmacotherapy) for the acute-treatment phase, sequential treatment (adding the other treatment for nonresponders or partial responders to monotherapy in the acute-treatment phase), and crossover treatment (switching to psychotherapy for the maintenance-treatment phase after response to pharmacotherapy in the acute phase). CONCLUSIONS: Combined treatment with psychotherapy and pharmacotherapy is widely used in clinical practice. The recommendations for use of combined treatment are, however, based on only a limited evidence base.

Mood-induced changes on the Implicit Association Test in recovered depressed patients.

A mood induction paradigm was used to examine dysphoria-related changes in two types of cognitive processing in individuals who had previously experienced depression. Formerly depressed patients (n = 23) and never-depressed controls (n = 27) completed the Dysfunctional Attitudes Scale, a self-report measure of effortful processing, and performed the Implicit Association Test, an automatic-reaction time task that measures evaluative bias, before and after a negative-mood induction. The formerly depressed group showed both an increase in endorsement of dysfunctional attitudes and a more negative evaluative bias for self-relevant information after the induction, relative to controls--however, there was no association between the mood-linked changes observed on these two measures. The shift in evaluative bias shown by the formerly depressed group was similar to that seen in a group of 32 currently depressed individuals. These findings suggest that even a mild negative mood in formerly depressed individuals can reinstate some of the cognitive features observed in depression itself.

A cognitive-interpersonal case study of a self.

This article presents an integrated conception of the self based on cognitive and interpersonal theories. Implications for clinical practice are outlined, which include understanding the therapeutic relationship as a laboratory and change as involving self-expansion. Implications for clinical research are also presented and exemplified by two strategies, which are demonstrated in a single case study of a patient who successfully underwent a brief-term treatment. The first involves the use of Interpersonal Scenarios, which are structured idiographic vignettes scaled on several parameters, to measure change between psychotherapy sessions. The second involves the use of the Structural Analysis of Social Behavior, a measure of interpersonal process, and the Experiencing Scale, a measure of emotional involvement, to measure change within a session.

The frequency of Candida parapsilosis in onychomycosis. An epidemiological survey in Israel.

Candida albicans is regarded as the major pathogen in yeast-induced onychomycosis. Based on our impression of an increasing prevalence of Candida parapsilosis in this disease, we examined the data of two mycology laboratories in the same geographic location, from 1994 to 1996 in one (centre A) and for 1995 (6 months) in the other (centre B). A total of 954 and 230 toenails and 621 and 190 fingernails, respectively, underwent KOH microscopy and culture studies in each centre. Positive findings were noted in 45 and 65% of the toenails and 44 and 72% of the fingernails, respectively. In the toenails, Candida spp. were found in 22 and 15%, respectively, and in the fingernails, in 77 and 63%, respectively. The most frequent Candida species was C. parapsilosis (39.5% in toenails, 36.7% in fingernails), followed by C. albicans (19.5% in toenails, and 34.4% in fingernails). These results demonstrate a higher frequency of isolation of C. parapsilosis compared with C. albicans in onychomycosis. This might have important therapeutic implications.

Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy.

This study evaluated mindfulness-based cognitive therapy (MBCT), a group intervention designed to train recovered recurrently depressed patients to disengage from dysphoria-activated depressogenic thinking that may mediate relapse/recurrence. Recovered recurrently depressed patients (n = 145) were randomized to continue with treatment as usual or, in addition, to receive MBCT. Relapse/recurrence to major depression was assessed over a 60-week study period. For patients with 3 or more previous episodes of depression (77% of the sample), MBCT significantly reduced risk of relapse/recurrence. For patients with only 2 previous episodes, MBCT did not reduce relapse/recurrence. MBCT offers a promising cost-efficient psychological approach to preventing relapse/recurrence in recovered recurrently depressed patients.

Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients.

Previous research on depressed and suicidal patients and those with posttraumatic stress disorder has shown that patients' memory for the past is overgeneral (i.e., patients retrieve generic summaries of past events rather than specific events). This study investigated whether autobiographical memory could be affected by psychological treatment. Recovered depressed patients were randomly allocated to receive either treatment as usual or treatment designed to reduce risk of relapse. Whereas control patients showed no change in specificity of memories recalled in response to cue words, the treatment group showed a significantly reduced number of generic memories. Although such a memory deficit may arise from long-standing tendencies to encode and retrieve events generically, such a style is open to modification.

Measurements for horizontal extraocular muscle surgery from the suture site: outcome and influencing factors.

BACKGROUND: Measurement of recession in strabismus surgery is performed either from the limbus or from the muscle insertion. These measurement methods may result in inaccuracies that may influence the outcome of the procedure. We prospectively evaluated the outcome of recessions measured from the extraocular muscle suture site to its insertion in an incidence cohort. METHODS: Thirty-six consecutive surgical procedures for infantile esotropia and 23 for constant exotropia were performed in which measurements were performed from the suture site. A successful surgery for esotropia was defined as an orthophoria of up to +10 prism dioptres of deviation for non-accommodative targets at a distance of 20 feet, measured by cover and prism test. A successful surgery for exotropia was defined as a residual deviation between -10 and +10 prism dioptres. The statistical significance of the outcome influencing factors was assessed by chi-square test. RESULTS: Six weeks following surgery, 28 procedures (78%) for infantile and non-accommodative esotropia and 19 procedures (83%) for exotropia were successful. At the end of the follow-up period (mean 13.7 months +/- 9.4 for esotropia and 11.6 months +/- 12.8 for exotropia), the success rate was 77% for esotropia and 75% for exotropia. Prematurity and mental retardation in esotropia, exotropia with pre-operative deviations larger than -45 prism dioptres and amblyopia in exotropia were related to unfavourable outcome (p < 0.05). CONCLUSIONS: Measurement for muscle recession can be performed from the suture site. The outcome is comparable to the outcome when measurements are performed from the limbus or the insertion, probably due to the incidence cohort. Refinement of the technique and defining other factors influencing the outcome of strabismus surgery may improve the outcome.

Psychotherapy for depression: current and future directions in research, theory, practice and public policy.

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.

Cognitive therapy for bipolar depression: a pilot study.

OBJECTIVE: While the efficacy of cognitive-behaviour therapy (CBT) for the treatment of acute unipolar major depression is well-documented, there is almost no data evaluating its utility in the treatment of bipolar depression. This pilot study compares the efficacy of CBT combined with mood-stabilizer pharmacotherapy for bipolar depression and CBT alone for unipolar depression. METHOD: A matched-case control design was used to evaluate outcomes following 20 sessions of CBT in 11 depressed bipolar patients and 11 matched recurrent unipolar depressed control subjects. RESULTS: Bipolar depressed patients achieved similar levels of reduction in depressive symptoms following CBT, as did the unipolar depressed group. However, on measures of more pervasive dysfunctional attitudes, bipolar patients did not improve to the same degree. CONCLUSIONS: Preliminary findings suggest that CBT warrants further investigation as an effective psychosocial intervention for depression in bipolar patients already receiving ongoing mood-stabilizing pharmacotherapy.

Differential cognitive response to a mood challenge following successful cognitive therapy or pharmacotherapy for unipolar depression.

This study examined the nature of cognitive reactivity to mood changes in formerly depressed patients. Patients who recovered either through cognitive-behavior therapy (CBT; N = 25) or through pharmacotherapy (PT; N = 29) completed self-reported ratings of dysfunctional attitudes before and after a negative mood induction procedure. In response to similar levels of induced sad mood, PT patients showed a significant increase in dysfunctional cognitions compared with patients in the CBT group. To evaluate the effects of such cognitive reactivity on the subsequent course of depression, follow-up analyses reassessed 30 patients several years after initial testing. Results indicated that patients' reactions to the mood induction procedure were predictive of depressive relapse. These findings argue for differential effects of treatment on cognitive reactivity to mood induction and for the link between such reactivity and risk for later depressive relapse.

Rumination and distraction in major depression: assessing response to pharmacological treatment.

BACKGROUND: Response style theory of depression (RST) predicts that individuals who ruminate in response to their depressed mood will suffer an amplification and prolongation of that mood, whereas individuals who engage in distraction responses will alleviate and attenuate their depressed mood. RST has been shown to predict prolonged depression in samples of non-clinical, untreated individuals with mild to moderate depression but has not been tested in samples of depressed patients undergoing treatment. OBJECTIVE: In this preliminary investigation we examined: (1) whether RST predicts non-response to pharmacotherapy with outpatients suffering from major depression, and (2) whether distractive and ruminative responses are associated with clinical variables hypothesized to be associated with them. METHODS: Eighty-nine depressed outpatients being treated with standard antidepressant pharmacotherapy were administered the Response Style Questionnaire, a scale designed to measure rumination and distraction, prior to treatment. RESULTS: Distraction, but not rumination, predicted change in depression severity over the course of treatment and overall treatment outcome. Neither rumination nor distraction was associated with previous number of depressive episodes or duration of current depressive episode. DISCUSSION: These results provide only partial support for RST as a predictor of treatment response. Future investigations are needed to determine if rumination and distraction are predictive of recurrent depressive episodes in recovered depressed patients. LIMITATIONS: As the data in this study was retrieved from a clinical database, the conclusions of this report must be viewed tentatively. Replication with other clinical samples is needed.

Congenital unilateral buphthalmos in Walker-Warburg syndrome: a clinicopathological study.

BACKGROUND AND PURPOSE: Walker-Warburg syndrome is a congenital autosomal recessive oculocerebral disorder characterised by hydrocephalus, brain agyria, microphthalmos and retinal dysplasia with or without meningoencephalocele. We describe an unusual finding of congenital unilateral glaucoma and buphthalmos in one eye and microphthalmos in the fellow eye of two neonates with Walker-Warburg syndrome. PATIENTS: Two neonates with Walker-Warburg syndrome and unusual findings of buphthalmos in one eye and a microphthalmic fellow eye are presented. RESULTS: Histological examination of the buphthalmic eyes revealed the presence of mesenchymal tissue in the anterior angle covered by endothelium. No anterior chamber angle was identified in the microphthalmic fellow eye and the iris was adherent to the corneal periphery. CONCLUSIONS: Congenital buphthalmos may also appear in Walker-Warburg syndrome. The buphthalmos may result from later embryonal ocular developmental arrest than that of the microphthalmic eye.

Memory and long-term potentiation (LTP) dissociated: normal spatial memory despite CA1 LTP elimination with Kv1.4 antisense.

Long-term potentiation (LTP) in the hippocampal slice preparation has been proposed as an in vitro model for long-term memory. However, correlation of LTP with memory in living animals has been difficult to demonstrate. Furthermore, in the last few years evidence has accumulated that dissociate the two. Because potassium channels might determine the weight of synapses in networks, we studied the role of Kv1.4, a presynaptic A-type voltage-dependent K+ channel, in both memory and LTP. Reverse transcription-PCR and Western blot analysis with specific antibodies showed that antisense oligodeoxyribonucleotide to Kv1.4 microinjected intraventricularly into rat brains obstructed hippocampal Kv1.4 mRNA, "knocking down" the protein in the hippocampus. This antisense knockdown had no effect on rat spatial maze learning, memory, or exploratory behavior, but eliminated both early- and late-phase LTP and reduced paired-pulse facilitation (a presynaptic effect) in CA1 pyramidal neurons without affecting dentate gyrus LTP. This presynaptic Kv1.4 knockdown together with previous postsynaptic Kv1.1 knockdown demonstrates that CA1 LTP is neither necessary nor sufficient for rat spatial memory.

Cognitive-behavioral group therapy for patients with irritable bowel syndrome.

This article is divided into two parts, the first of which focuses on a general overview of irritable bowel syndrome (IBS) and provides a rationale for the use of cognitive-behavioral therapy (CBT) for IBS based on both theoretical and research perspectives. This section includes a critical review of CBT therapies for IBS and provides a model of CBT for IBS. The second section provides the clinician with practical information concerning the application of cognitive-behavioral group therapy for IBS. Possible scripts and case examples are incorporated into this section to highlight factors that may arise in working with IBS patients relative to other clinical groups. The second section also contains themes that are suggested content areas for group sessions. Contingent on the formulation of the presenting or emerging issues and goals, the order and inclusion of themes can be changed to fit the particular needs of a given group. Finally, this section provides initial preliminary data from a randomized controlled study that is suggestive of the efficacy of cognitive-behavioral therapy for IBS.