Persistent symptoms following SARS-CoV-2 infection amongst children and young people: A meta-analysis of controlled and uncontrolled studies

BACKGROUND

Data on the long-term impact of SARS-CoV-2 infection in children and young people (CYP) are conflicting. We assessed evidence on long-term post-COVID symptoms in CYP examining prevalence, risk factors, type and duration.

METHODS

Systematic search of published and unpublished literature using 13 online databases between 01/12/2019 and 31/07/2021. Eligible studies reported CYP ≤19 years with confirmed or probable SARS-CoV-2 with any symptoms persisting beyond acute illness. Random effects meta-analyses estimated pooled risk difference in symptom prevalence (controlled studies only) and pooled prevalence (uncontrolled studies also included). Meta-regression examined study characteristics hypothesised to be associated with symptom prevalence. Prospectively registered: CRD42021233153.

FINDINGS

Twenty two of 3357 unique studies were eligible, including 23,141 CYP. Median duration of follow-up was 125 days (IQR 99-231). Pooled risk difference in post-COVID cases compared to controls (5 studies) were significantly higher for cognitive difficulties (3% (95% CI 1, 4)), headache (5% (1, 8)), loss of smell (8%, (2, 15)), sore throat (2% (1, 2)) and sore eyes (2% (1, 3)) but not abdominal pain, cough, fatigue, myalgia, insomnia, diarrhoea, fever, dizziness or dyspnoea. Pooled prevalence of symptoms in post-COVID participants in 17 studies ranged from 15% (diarrhoea) to 47% (fatigue). Age was associated with higher prevalence of all symptoms except cough. Higher study quality was associated with lower prevalence of all symptoms, except loss of smell and cognitive symptoms.

INTERPRETATION

The frequency of the majority of reported persistent symptoms was similar in SARS-CoV-2 positive cases and controls. This systematic review and meta-analysis highlights the critical importance of a control group in studies on CYP post SARS-CoV-2 infection.

Brief psychological interventions for psychiatric disorders in young people with long term physical health conditions: A systematic review and meta-analysis

OBJECTIVES

Rates of psychiatric disorders are considerably elevated in young people with long term physical health conditions. Currently few children obtain effective mental health treatments in the context of long term physical health conditions, and ways to improve access to evidence-based mental health interventions are urgently needed. One approach is to deploy briefer, more economical, yet still evidence-based, treatments. The objective of this review was to evaluate the efficacy of brief interventions targeting psychiatric disorders in children and young people with long term physical health conditions.

METHODS

Predefined terms relating to brief psychological interventions for psychiatric disorders in children with long term physical health conditions were used to search relevant databases. A systematic review and meta-analysis was carried out in accordance with the Cochrane guidelines. Two reviewers independently screened titles and abstracts, extracted the data and conducted risk of bias assessments.

RESULTS

A total of 12 randomised controlled trials were found to meet the inclusion criteria of the review. Of those, three studies were suitable for meta-analysis. A large effect size in favour of brief cognitive behavioural therapy for anxiety was found (g = - 0.95, CI -1.49 to -0.041; p < .001) with non-significant moderate-substantial heterogeneity (I² = 58%; p = .09).

CONCLUSION

This review suggests there is preliminary evidence that brief interventions, based on cognitive behavioural principles, may benefit young people with an anxiety disorder in the context of a long term physical health condition. There was insufficient evidence to assess whether this held true for depression and disruptive behaviour.

The interpretation of symptoms of starvation/severe dietary restraint in eating disorder patients

The aims of the study were to test the hypotheses that some symptoms of starvation/severe dietary restraint are interpreted by patients with eating disorders in terms of control. Sixty-nine women satisfying the Diagnostic and Statistical Manual of Mental Disorders-IV edition (DSM-IV) criteria for a clinical eating disorder and 107 controls participated in the study. All the participants completed an ambiguous scenarios paradigm, the Eating Disorder Examination Questionnaire (EDE-Q) and the Beck Depression Inventory (BDI). Significantly more eating disorder patients than non clinical participants interpreted the starvation/dietary restraint symptoms of hunger, heightened satiety, and dizziness in terms of control. The data give further support to the recent cognitive-behavioural theory of eating disorders suggesting that eating disorder patients interpret some starvation/dietary restraint symptoms in terms of control.

Thought-action fusion: a review

The cognitive bias of "Thought Action Fusion" (TAF) has received significant research attention in the past decade. The review addresses the assessment of TAF, its place in cognitive theories of obsessional difficulties, and the evidence demonstrating that TAF is relevant to disorders beyond Obsessive Compulsive Disorder (OCD). Data on the components of TAF, its extension to positive outcomes and its role in the aetiology, maintenance and treatment of OCD are reviewed. It is concluded that the moral form of TAF is less robust than the likelihood form and that scales may be best used as a starting point in identifying beliefs and conducting experimental investigations. It is also suggested that the scales be amended to include harm avoidance, which would also increase their clinical utility.

The interpretation of symptoms of severe dietary restraint

A recent cognitive-behavioural theory of eating disorders proposes that people with eating disorders interpret symptoms of dietary restraint in terms of control. The primary aim of the present study was to test this hypothesis. A second aim was to test the hypothesis derived from clinical observation that people with eating disorders view these symptoms positively. Forty-four participants meeting DSM-IV criteria for a clinical eating disorder and 80 control participants with no history of an eating disorder completed an ambiguous scenario paradigm and self-report measures of eating disorder features and depression. Patients with eating disorders were significantly more likely to interpret symptoms of dietary control in terms of control, providing support for the cognitive-behavioural theory. There was only partial support for the second hypothesis. The implications for the new cognitive-behavioural theory and therapy are discussed.

Neurological soft signs in obsessive compulsive disorder: standardised assessment and comparison with schizophrenia

While several studies have detected raised levels of neurological soft signs in patients with obsessive compulsive disorder (OCD), the specificity of these abnormalities remains uncertain. This study used a new standardised measure, the Cambridge Neurological Inventory (CNI), to assess soft signs in 51 subjects with OCD. Comparison was made with data on patients with schizophrenia and a non-clinical control group from a previously reported study. Individuals with OCD showed raised levels of soft signs compared with non-clinical controls in many categories of the CNI: Motor Coordination, Sensory Integration, Primitive Reflexes, Extrapyramidal Signs, and Failure of Suppression. Compared with patients with schizophrenia, the OCD group had lower levels of neurological signs in some CNI categories: Hard Signs, Motor Co-ordination, Tardive Dyskinesia, Catatonic Signs, and Extrapyramidal Signs. However, levels of soft signs in the OCD group did not significantly differ from those in the schizophrenia group in other CNI categories: Sensory Integration, Primitive Reflexes and Failure of Suppression. The significance of these patterns of findings is discussed.

Perfectionism and psychopathology: a review of research and treatment

Clinical experience suggests that perfectionism can impede the successful treatment of psychological disorders. This review examines the concept of perfectionism, critically evaluates its assessment, reviews the association between existing measures of perfectionism and psychopathology, and considers the impact of perfectionism on treatment. It is concluded that existing measures do not reflect the original construct of perfectionism and that, consequently, new measures are needed. The evidence reviewed indicates that high personal standards are specifically elevated in patients with eating disorders and beliefs about others' high standards for the self are associated with a broad range of psychopathology. The importance of examining mean scares across studies (as well as associations between variables within studies) is emphasized. There has been no systematic evaluation of the treatment of perfectionism despite existing cognitive-behavioral treatment protocols.

Post-event processing in social anxiety

A psychometric study was conducted in order to collect basic information about post-event processing in social anxiety. It was found that such processing occurs commonly after an anxiety-evoking or embarrassing social event and post-event processing scores were significantly correlated (r = 0.40) with social anxiety. The recollections of the social event tended to be recurrent and intrusive, interfering with concentration. Post-event processing was associated with the avoidance of similar social situations. The results are discussed in terms of the Clark and Wells model of social phobia.

Multiple pathways to inflated responsibility beliefs in obsessional problems: possible origins and implications for therapy and research

The purpose of this paper is to consider the possible origins of an inflated sense of responsibility which occupies an important place in the cognitive theory of obsessive compulsive disorder (Rachman, S. (1993). Obsessions, responsibility, and guilt. Behaviour Research and Therapy, 31, 149-154. Salkovskis, P. M. (1985). Obsessional-compulsive Problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23 (5), 571-583). Clinical experience and consideration of current cognitive conceptualisations of obsessions and obsessive compulsive disorder suggest a number of possibilities, each of which is described after a brief introduction to the concept itself. While there are reasons to believe that some general patterns can be identified, the origins of obsessional problems are best understood in terms of complex interactions specific to each individual.

A cognitive distortion associated with eating disorders: thought-shape fusion

OBJECTIVES

The primary objective of this study was to describe and investigate a cognitive distortion associated with eating psychopathology. This distortion, termed 'thought-shape fusion', is said to occur when merely thinking about eating a forbidden food increases the person's estimate of their shape or weight, elicits a perception of moral wrongdoing and makes the person feel fat.

DESIGN

Two studies were conducted. The first was a psychometric study and the second utilized a within-participants experimental design.

METHODS

In Study 1, thought-shape fusion was assessed in a sample of 119 undergraduate students using a questionnaire. In Study 2, 30 students with high thought-shape fusion scores participated in an experiment designed to elicit the distortion.

RESULTS

Thought-shape fusion was found to be significantly associated with measures of eating disorder psychopathology. The questionnaire used to measure thought-shape fusion had high internal consistency, a good factor structure accounting for 46.2% of the variance and predictive validity. The results from Study 2 indicated that the distortion can be elicited under experimental conditions, produces negative emotional reactions and prompts the urge to engage in corrective behaviour (e.g. neutralizing/checking). This corrective behaviour promptly reduces the negative reactions.

CONCLUSION

The results of the two studies indicate that the concept of thought-shape fusion is coherent, unifactorial and measurable. It is associated with eating disturbance and elicits negative emotional and behavioural responses.

A cognitive behavioural theory of anorexia nervosa

A cognitive behavioural theory of the maintenance of anorexia nervosa is proposed. It is argued that an extreme need to control eating is the central feature of the disorder, and that in Western societies a tendency to judge self-worth in terms of shape and weight is superimposed on this need for self-control. The theory represents a synthesis and extension of existing accounts. It is 'new', not so much because of its content, but because of its exclusive focus on maintenance, its organisational structure and its level of specification. It is suggested that the theory has important implications for treatment.

Claustrophobia and the magnetic resonance imaging procedure

We examined fear induced by the magnetic resonance imaging (MRI) procedure in 80 adult patients who were undergoing the procedure for the first time. Participants completed self-report measures of claustrophobia, anxiety sensitivity, thoughts about the scan, and pain. Participants were assessed pre- and postscan, and at 1-month follow-up. Twenty-five percent of the participants experienced moderate to severe anxiety during the MRI scan. Prescan scores on the Claustrophobia Questionnaire (CLQ: Rachman and Taylor, 1993) significantly predicted participants' distress during the scan: pain and anxeity sensitivity did not. Furthermore, CLQ scores discriminated between participants who reported panic during the scan and participants who did not report panic. A brief screening instrument consisting of six items from the 29-item CLQ is suggested. This brief screening instrument administered prior to the scan may help identify in advance those people who are most likely to experience claustrophobic fear and, in particular, those who panic during the MRI procedure.

Treating adolescent obsessive-compulsive disorder: applications of the cognitive theory

The recent cognitive theory of obsessions suggests that catastrophic misinterpretations of the significance of one's unwanted intrusive thoughts gives rise to, and maintains, obsessions (Rachman, Behaviour Research and Therapy, 1997). It follows from this that provision of benign interpretations of the significance of intrusions is likely to challenge and weaken the catastrophic appraisals. This article describes the application of this theory to two adolescents with obsessive-compulsive disorder (OCD). The adolescents were provided with an alternative, benign interpretation of the significance of intrusive thoughts and images using a thought suppression paradigm. It is concluded that a personal demonstration using the thought suppression paradigm is a helpful clinical tool for the cognitive treatment of obsessions in adolescent OCD.

The manipulation of responsibility in obsessive-compulsive disorder

It has been suggested that appraisal of intrusive thoughts in terms of responsibility for harm lies at the core of obsessional complaints. Clinical observation, psychometric data and the effects of manipulating responsibility for threat in compulsive checkers and normal samples have supported this formulation. The purpose of the present study was to manipulate responsibility in 36 obsessional participants with varied phenomenology. Responsibility was manipulated indirectly by varying the presence/absence of the experimenter during a behavioural task. The manipulation was successful in influencing reports of perceived responsibility for threat. In the high responsibility condition; estimates of the urge to neutralize, discomfort and probability of threat were all significantly higher than in the low responsibility condition; estimates of responsibility for thoughts and the control over the threat did not change significantly between the conditions. There was no significant interaction between the responsibility manipulation and the type of compulsion. The results are interpreted as providing support for a cognitive-behavioural formulation which emphasizes the role of responsibility appraisal in obsessive-compulsive disorder.

Enterotoxigenic Escherichia coli (ETEC) in hospitalised Arab infants from Judea area--west bank, Israel

Enterotoxigenic Escherichia coli and other related enterotoxigenic species were isolated from 176 (44%) of 399 infants hospitalised in 'Caritas Baby Hospital' in Bethlehem, during April-December 1993. Ninety four of the patients infected by ETEC, were clinically evaluated. Most of them suffered from diarrhoea, quite often with fever and vomiting. Dehydration occurred in 58.3% of the patients and failure to thrive (FTT) in 28.5% of them. Severe illness resulted in marasmus in five patients and in the death of two others. Most of the ETEC strains (84%) were of ST toxin type. Correlation was found between the degree of toxigenity and the severity of the gastroenteritis. The most prevalent ETEC "O' serogroups were 0-6, 0-20, 0-8, 0-86, 0-126, 0-128 and 0167. Colonization Factors Antigens (CFAs) were identified in 36% of the isolates, CFAI was characteristic of group 0-126 and 0-128. In the principal O-groups there were high percentages of sensitivity to the antibiotics ceftriaxone, nalidixic-acid, gentamicin and norfloxacin, with resistance to anoxycillin, tetracycline and cotrimoxazole.

How to remain neutral: an experimental analysis of neutralization

Many patients with obsessive-compulsive problems engage in neutralizing activity to reduce or "cancel out" the effects of the obsession. In many cases, neutralization is covert and therefore difficult to assess or manipulate experimentally. We hypothesize that neutralization resembles overt compulsions. In particular, it was predicted that: (i) neutralization reduces the anxiety evoked by unacceptable thoughts, and (ii) if neutralization is delayed, anxiety and the urge to neutralize will decay naturally. To test the hypothesis, 63 Ss prone to a cognitive bias known to be associated with obsessional complaints (thought-action fusion) were asked to write a sentence that would evoke anxiety. Measures of anxiety (and other variables of interest such as guilt, responsibility and the likelihood of harm) were taken. Subjects were then instructed to either immediately neutralize (n = 29) or delay for 20 min (n = 34), after which time anxiety and urge to neutralize were re-assessed. The Ss who had neutralized were then instructed to delay, and the Ss who had delayed were now instructed to neutralize, after which time the final assessments were taken. The results confirmed the predictions and supported the hypothesis that neutralization resembles overt compulsions. Of note, there were no differences between anxiety reduction after a 20-min delay, and after immediate neutralization. The problems involved in designing and conducting experiments on covert phenomena are discussed, and the clinical implications of the study are considered.

Investigation into the relationship between personality traits and OCD: a replication employing a clinical population

The relationship between obsessional personality traits and Obsessive Compulsive Disorder (OCD) has long been the subject of debate. Although clinicians have asserted for nearly a hundred years that such a relationship exists, empirical investigations have failed to provide consistent support; however, none of these empirical investigations have undertaken analyses that control for the effect of mood variables. Employing a non-clinical sample, Rosen and Tallis (1995) [Behaviour, Research and Therapy, 4, 445-450] found that when mood variables are taken into account, a unique relationship between obsessional traits and obsessional symptoms emerges. A replication was undertaken on a large group of individuals with OCD. After the effects of depression and anxiety were removed from a correlational analysis, obsessional symptoms were found to be significantly associated with obsessional and passive aggressive traits. Obsessive Compulsive Disorder was not associated with any other grouping of traits as specified in the DSM-III-R (Axis II) classification system.

Perceived responsibility: structure and significance

Given the postulated significance of inflated responsibility in obsessive compulsive disorder (OCD), there is a need for clarification of the concept itself and a means for measuring such responsibility. Two psychometric studies were conducted in order to develop a reliable self-report scale. In the first study 291 students completed the specially constructed Responsibility Appraisal Questionnaire (RAQ). Four factors emerged: responsibility for harm, responsibility in social contexts, a positive outlook towards responsibility, and thought-action fusion (TAF). In the second study, 234 students completed a revised RAQ. Four comparable factors emerged, and the TAF subscale correlated significantly with measures of obsessionality, guilt, and depression. The correlations between TAF and obsessionality and guilt remained significant even after BDI scores were controlled. It is concluded that the broad concept of inflated responsibility needs to be qualified; the connection between inflated responsibility and OCD appears to be situation-specific and idiosyncratic. There is more inflated responsibility than there is OCD. The measured concept of inflated responsibility is multifactorial (harm, social, positive, and TAF), not unitary. The TAF factor appears to be particularly significant in OCD.

Consistency of Behavior: Expect the Unexpected

Clinicians and lay people mistakenly expect behavior to be consistent across time and situations. However, the presence of a psychological disorder can cause large and seemingly inexplicable fluctuations in patient behavior. These fluctuations intrinsically are aversive, and increase the burden on family members. This article outlines the clinical implications of inconsistency in patient behavior. A practical set of guidelines for the mental health worked is issued.

The reduction of claustrophobia--II: Cognitive analyses

A clinical experiment comparing methods of fear reduction in claustrophobia was used as the basis for analysing the relationships between a number of cognitive variables and the reduction of claustrophobia. Both the number and believability of negative cognitions present were associated with fear reduction and return of fear; this was also found when considering the number of body sensations experienced. High fear and panic were always accompanied by these phenomena whilst zero fear was never reported in the presence of believable cognitions and body sensations. An absence of believable cognitions post-test was accompanied by an absence of claustrophobia in 10/13 subjects. Specifically, removal of belief in any of the cognitions "I will be trapped", "I will suffocate" and/or "I will lose control" was associated with removal of belief in all the other cognitions and a dramatic reduction in claustrophobia. Belief in one of these central cognitions was associated with the maintenance of fear. We conclude that it is possible to conceptualize claustrophobia as comprising a number of cognitions centred on key thoughts of trappedness, suffocation and loss of control.