[Exposure in the treatment of anxiety in oral care practice]

For dental anxiety, cognitive behavioral therapy is the treatment of choice and exposure therapy is a major part of this treatment program. This article describes the underlying working mechanism of exposure therapy. Exposure should be directed toward the patient's harm expectancies. Moreover, the patient needs to be ensured that their harm expectation will not be violated, despite being challenged to the maximum. In addition, it is important that patients perform exposure exercises in as many different contexts as possible and to ensure a lot of repetition. Combining different fear-inducing stimuli during exposure sessions is also recommended. Currently, the inhibition model is the best explanatory working mechanism model and this article contrasts the new inhibition model with the older habituation model, that is still often used in clinical practice. The most important clinical implications of the inhibition model are described and illustrated with practical examples.

Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder

Background: There is room for improvement regarding the treatment of severe post-traumatic stress disorder (PTSD). Intensifying treatment to increase patient retention is a promising development. Objective: The aim of this study was to determine the effectiveness of an intensive trauma-focused treatment programme over 8 days for individuals suffering from severe PTSD. Method: Treatment was provided for 347 PTSD patients (70% women; mean age = 38.32 years, SD = 11.69) and consisted of daily sessions of prolonged exposure and eye movement desensitization and reprocessing (EMDR) therapy (16 sessions in total), physical activity, and psycho-education. All participants had experienced multiple traumas, including sexual abuse (74.4%), and suffered from multiple comorbidities (e.g. 87.5% had a mood disorder). Suicidal ideation was frequent (73.9%). PTSD symptom severity was assessed by both clinician-rated [Clinician Administered PTSD Scale (CAPS)] and self-report [PTSD Symptom Scale Self Report (PSS-SR) and Impact of Event Scale (IES)] inventories. For a subsample (n = 109), follow-up data at 6 months were available. Results: A significant decline in symptom severity was found (e.g. CAPS intention-to-treat sample Cohen's d = 1.64). At post-treatment, 82.9% showed a clinically meaningful response and 54.9% a loss of diagnosis. Dropout was very low (2.3%). Conclusions: Intensive trauma-focused treatment programmes including prolonged exposure, EMDR therapy, and physical activity can be effective for patients suffering from severe PTSD and are associated with low dropout rates.

Effectiveness of trauma-focused treatment for patients with psychosis with and without the dissociative subtype of post-traumatic stress disorder

This study presents secondary analyses of a recently published trial in which post-traumatic stress disorder (PTSD) patients with psychosis (n = 108) underwent 8 sessions of trauma-focused treatment, either prolonged exposure (PE) or eye movement desensitisation and reprocessing (EMDR) therapy. 24.1% fulfilled the criteria for the dissociative subtype, a newly introduced PTSD subtype in DSM-5. Treatment outcome was compared for patients with and without the dissociative subtype of PTSD. Patients with the dissociative subtype of PTSD showed large reductions in clinician-administered PTSD scale (CAPS) score, comparable with patients without the dissociative subtype of PTSD. It is concluded that even in a population with severe mental illness, patients with the dissociative subtype of PTSD do benefit from trauma-focused treatments without a pre-phase of emotion regulation skill training and should not be excluded from these treatments.

[Imaginal exposure treatment for a post-traumatic stress disorder in a patient with a comorbid psychotic disorder]

A patient suffering from both post-traumatic stress disorder (PTSD) and a comorbid schizoaffective disorder was treated with imaginal exposure treatment. After 26 sessions the ptsd symptoms were in full remission. This was still the case at follow-up after 12 and 24 months. Furthermore, the patient was no longer on antipsychotic medication. The case shows that ptsd can be treated successfully even if patients have a psychotic disorder. In view of the severity of both disorders it is at least worth trying imaginal exposure treatment.

[Posttraumatic stress disorder in adolescents after sexual abuse is readily treated]

Two patients, a boy aged 19 years and a girl aged 16 years, were diagnosed to be suffering from a posttraumatic stress disorder (PTSD) 7 and 2 years after sexual abuse, respectively. There was thus a serious delay in the correct diagnosis and the start of cognitive behavioural therapy, which was successful. A thorough diagnostic procedure with a semi-structured clinical interview ('Clinician administered PTSD scale') is helpful in preventing such a diagnostic delay. The omission of a structured diagnostic interview can lead to serious misjudgement. Cognitive behavioural therapy with repeated imaginary exposure to the traumatic event(s) or cognitive interventions to maladaptive beliefs is the standard treatment for PTSD in adults. Adolescents with PTSD after sexual abuse achieve a good outcome on cognitive behavioural therapy as well.

A longitudinal, prospective study on emotional adjustment before, during and after consecutive fertility treatment cycles

BACKGROUND

A longitudinal study into the course of the emotional response to IVF from pre-treatment to 6 months post-treatment and factors that contributed to that course.

METHODS

A total of 148 IVF patients and 71 partners completed self-report questionnaires on anxiety, depression, personality characteristics, meaning of fertility problems, coping, marital relationship and social support at pre-treatment. Assessments of anxiety and depression were repeated immediately following the final treatment cycle and again 6 months later (follow-up).

RESULTS

Women showed an increase of both anxiety and depression after unsuccessful treatment and a decrease after successful treatment. Men showed no change in anxiety and depression either after successful or after unsuccessful treatment. In the 6 months after unsuccessful treatment, women showed no recovery. At follow-up, >20% of the women showed subclinical forms of anxiety and/or depression. Personality characteristics, meaning of the fertility problems, and social support determined the course of the emotional response.

CONCLUSIONS

Most women adjusted well to unsuccessful treatment, but at follow-up, a considerable proportion still showed substantial emotional problems. Personality characteristics, pre-treatment meaning of the fertility problems and social support have demonstrated the adjustment to unsuccessful IVF in women. This allows early identification of women at risk as well as tailored interventions.

Stress and outcome success in IVF: the role of self-reports and endocrine variables

BACKGROUND

The aim of this study was to examine the associations between urinary levels of the stress hormones adrenaline, noradrenaline and cortisol during treatment with self reported stress, in order to investigate the mechanism for the previously observed negative association of anxiety and depression with the outcome of IVF/ICSI.

METHODS

In a multicentre prospective cohort study, women entering their first cycle of IVF/ICSI treatment were asked to participate. From each participant nocturnal urine samples were collected; pre-treatment, before oocyte retrieval and before embryo-transfer (ET), to assess hormonal concentrations. Additionally, two questionnaires were administered before the start of the treatment to measure anxiety and depression.

RESULTS

168 women completed the questionnaires and collected at least two urine specimens. A significant positive correlation between urinary adrenaline concentrations at baseline and ET and the scores on depression at baseline were found. In women with successful treatment, lower concentrations of adrenaline at oocyte retrieval and lower concentrations of adrenaline and noradrenaline at ET, compared with unsuccessful women, were found.

CONCLUSIONS

The significant positive association of adrenaline concentration with pregnancy and with depression suggested that this adrenal hormone could be one of the links in the complex relationship between psychosocial stress and outcome after IVF/ICSI.

Variables influencing anxiety of patients with abnormal cervical smears referred for colposcopy

The state anxiety scores of women with abnormal cervical smears referred for colposcopy were investigated to identify causes of anxiety, factors influencing anxiety and emotions involved with anxiety, in order to define strategies to reduce this anxiety. Forty-seven women were interviewed and completed a questionnaire and the Spielberger State and Trait Anxiety Inventory (STAI): 22 women prior to their intake consultation at the colposcopy clinic of the University Medical Center St Radboud, Nijmegen, and 25 women during their second visit before the actual colposcopy. The mean State anxiety score was 48.2, without significant differences between the intake and colposcopy consultation. The majority experienced anxiety because of a fear of cancer and/or the colposcopy. The mean State anxiety score was significantly higher in women who considered the level of information provided by the gynecologist/family practitioner insufficient, who experienced a long waiting time, who did not have a partner, and who experienced additional emotions like anger and sadness. In conclusion, patients referred for colposcopy after an abnormal cervical smear result have high levels of anxiety. High levels of anxiety may be reduced by uniform and explicit information about cervical smear results and colposcopy, by reduction of clinic waiting times, by stimulating social support, and by attention to emotions like anger and sadness.

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.

Stress and marital satisfaction among women before and after their first cycle of in vitro fertilization and intracytoplasmic sperm injection

OBJECTIVE

To determine differences in emotional status (anxiety and depression) and marital satisfaction in pregnant and nonpregnant women before and after their first cycle of IVF and intracytoplasmic sperm injection (ICSI).

DESIGN

Repeated measurement.

SETTING

Fertility department at a university and a regional hospital.

PATIENT(S)

Women entering their first treatment cycle of IVF or ICSI.

INTERVENTION(S)

Questionnaires on psychological factors were administered 3 to 12 days before the start of their first treatment cycle and repeated 3 weeks after the pregnancy test.

MAIN OUTCOME MEASURE(S)

State anxiety, depression, mood, and marital satisfaction.

RESULT(S)

At pretreatment, the women who became pregnant showed lower levels of depression than those who did not. Higher levels of depression in the pregnant women after the first cycle were due to higher scores on vital aspects of depression, related to signs of early pregnancy. Higher levels of depression in the nonpregnant women were due to a higher score on cognitive aspects of depression.

CONCLUSION(S)

Differences in emotional status between pregnant and nonpregnant women were present before treatment and became more apparent after the first IVF and ICSI cycle. There were no differences in emotional status between the women who underwent IVF and those who underwent ICSI.

The effect of anxiety and depression on the outcome of in-vitro fertilization

BACKGROUND

The study aim was to clarify the role of anxiety and depression on the outcome in assisted reproductive treatment. Previous studies on this topic have shown contradicting results, which may have been caused by population characteristics, the design of the study, or small sample sizes.

METHODS

In a multicentre prospective study, 291 out of 359 (81%) consecutively invited women agreed to participate. Before down-regulation by means of gonadotrophin-releasing hormone (GnRH) analogues in a long IVF protocol, patients were asked to complete the Dutch version of the State and Trait Anxiety Inventory to measure anxiety, and the Dutch version of the Beck Depression Inventory (BDI) to measure depression. Multiple logistic regression analysis was used to analyse known predictors of pregnancy and psychological factors and their relationship with treatment outcome.

RESULTS

A significant relationship was shown between baseline psychological factors and the probability to become pregnant after IVF/intracytoplasmic sperm injection (ICSI) treatment, controlling for other factors. State anxiety had a slightly stronger correlation (P = 0.01) with treatment outcome than depression (P = 0.03).

CONCLUSIONS

Pre-existing psychological factors are independently related to treatment outcome in IVF/ICSI, and should therefore be taken into account in patient counselling. Psychological factors may be improved by intervention, whereas demographic and gynaecological factors cannot. Future studies should be directed towards underlying mechanisms involved and the role of evidence-based distress reduction in order to improve treatment results.

A controlled study into the (cognitive) effects of exposure treatment on trauma therapists

Several researchers have reported on therapists' symptoms as a result of trauma treatment, such as disruptions in cognitive schemata and symptoms resembling PTSD-symptoms. Thus far, however, no studies compared the symptoms of trauma therapists and non-trauma therapists. In the present study, both trauma therapists (n = 20) and non-trauma therapists (n = 19) were included. During semi-structured interviews, both therapist groups reported negative and positive effects of their work with patients on their personal and professional functioning. Trauma therapists reported more often changes of cognitions due to trauma work. Results from questionnaires, however, showed that compared with norm-standards and compared with non-trauma therapists, trauma therapists did not show enhanced psychopathology nor distorted cognitive schemata. It is concluded that although exposure treatments with trauma patients are associated with therapists' distress, therapists seem able to cope with it in a healthy way.

Hospital vs. outreach treatment of patients with mental retardation and psychiatric disorders: a controlled study

The aim of this study was to investigate the effectiveness of specialized hospital treatment vs. outreach treatment of patients with mental retardation and serious mental illness. A total of 50 patients were randomly assigned to either the hospital treatment (n = 25) or the outreach treatment group (n = 25). The outcome measures included psychiatric symptoms, family burden, costs and hospital admissions. At most observation points (up to 28 weeks) and at all endpoints the two groups were equivalent with regard to psychiatric symptoms. The burden on carers did not increase significantly during the outreach treatment. Treatment costs were lower for the outreach treatment. Of the 25 patients who received outreach treatment, four had to be admitted to the specialized hospital. Aggressive behaviour, social competence and number of previous psychiatric hospitalizations were found to be predictors of treatment outcome. It is concluded that outreach treatment represents an effective and efficient alternative to hospital treatment for patients with mental retardation and psychiatric disorders.

A Dutch version of the Reiss Screen of Maladaptive Behavior

The Reiss Screen for Maladaptive Behavior, an instrument used to identify mentally retarded persons with mental health problems, was evaluated with 89 mentally retarded adults. Reliability and validity of the Reiss Screen, as well as the relationship with subject characteristics, is reported for a Dutch population. Internal consistency on the total score was good and modest on most subscales. The subscale autism had inadequate internal consistency. Interrater reliability was low to modest. Further, the Reiss Screen had good criterion validity. Last, few relationships were found between Reiss Screen scores and subject characteristics.

A Dutch version of the Psychopathology Inventory for Mentally Retarded Adults (PIMRA)

Eighty-nine mildly mentally retarded adults were assessed using the Psychopathology Inventory for Mentally Retarded Adults (PIMRA). This study reports on the psychometric properties of the PIMRA in a Dutch population, the correlation between self-report and ratings-by-others forms, and the relationship of the PIMRA to both behavior problems and subject characteristics. It was revealed that internal consistency was good for both forms on total scores but modest for most of the subscales. Furthermore, interrater reliability was low to modest. Both forms of the PIMRA showed good criterion validity. The correlation between the two forms was modest. A strong relationship was found between PIMRA scores and behavior problems, as measured using the Reiss Screen of Maladaptive Behavior. Furthermore, the relationship between PIMRA scores and subject characteristics was weak.