Effects of Tactile Desensitization on Postoperative Pain After Amputation Surgery

PURPOSE

Pain in the acute setting after amputation is complex with multiple types of pain experienced, including somatic and neuropathic. No studies have measured multiple pain control modalities while using self-management techniques for acute amputation pain. Desensitization could provide a means of pain control for somatic and neuropathic pain. The purpose of this study was to test the efficacious use and effects of tactile desensitization in managing acute postoperative pain after lower limb amputation.

DESIGN

This was a pre-experimental repeated measure study.

METHODS

Pain description, intensity, anxiety, depression, and medication usage were measured during repeated time periods. Pain intensity was measured before and after each intervention along with efficacy.

FINDINGS

Of the times the intervention was self-administered (n = 50) there was a statistically significant reduction in the pain level (P < .001) with large effect sizes for all paired comparisons. Participants found the intervention efficacious and feasible to use.

CONCLUSIONS

The findings support a reduction in pain intensity scores using pain medication coupled with tactile desensitization.

Efficacy of combined traditional Chinese medicine spray with premature ejaculation desensitization therapy for the treatment of primary premature ejaculation

Objectives

We recommend a new kind of spray made from eight kinds of traditional Chinese medicine, we aimed to investigate the safety and clinical efficacy of combined traditional Chinese medicine spray (TCMS) with premature ejaculation desensitization therapy (PEDT) for the treatment of primary premature ejaculation (PPE).

Methods

A total of 90 patients with PPE were randomly assigned to receive TCMS, PEDT monotherapy or TCMS plus PEDT combination therapy for 6 weeks. Intravaginal ejaculation latency time (IELT) and Chinese index of sexual function for premature ejaculation (CIPE-5) were measured to evaluate the effect of each treatment.

Results

Eighty six (86) participants completed the study voluntarily. Both IELT and CIPE-5 in these three groups increased after treatment when compared with baseline levels (p< 0.01). IELT and CIPE-5 after treatment in TCMS plus PEDT group were significantly higher than those in the other two groups (both p <0.05). Additionally, clinical efficacy in TCMS plus PEDT group (89.7%) was significantly higher than in TCMS (65.5%) and PEDT group (67.9%) (p< 0.01).

Conclusion

The self-made TCMS was safe and effective for the treatment of PPE, a combination of TCMS and PEDT therapy was more effective than the TCMS or PEDT monotherapy.

Windows of opportunity for tolerance induction for allergy by studying the evolution of allergic sensitization in birth cohorts

Allergic sensitization is a risk factor for developing IgE-mediated allergic diseases, which are a major cause of chronic illness world-wide. The introduction of allergen molecules to the field of allergy diagnostics has allowed dissecting the IgE response on a molecular level to pinpoint the specific disease-causing allergens. Studying birth cohorts is an essential tool for understanding the development and life course of allergy, enabling the possibility to design preventive strategies. Here we review the evolution of sensitization using data from some of the large European birth cohort studies. Differences and similarities between sensitization to food and various sources of inhalant allergens are discussed and allergen molecules of importance in early childhood predicting disease in adolescence are highlighted. Finally, we discuss windows of opportunity where intervention could be considered and address possible preventive strategies.

Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program

BACKGROUND

The authors evaluated the effectiveness of a dental desensitization program for children with autism spectrum disorder (ASD) and determined characteristics associated with a successful dental examination.

METHODS

The authors performed a retrospective review of clinical behavioral data and previsit questionnaires for 168 children with ASD who attended a university-based dental desensitization program. Data elements included demographic, treatment, and behavioral characteristics. The primary outcome was receiving a minimal threshold examination (MTE) while seated in a dental chair.

RESULTS

An MTE was achieved for 77.4% of all children within 1 to 2 visits and 87.5% in 5 visits or less. Several factors predicted a successful dental examination: ability to be involved in group activities (relative risk [RR], 1.18; P = .02), ability to communicate verbally (RR, 1.17; P < .01), understanding of most language (RR, 1.14; P = .02), moderate versus severe caregiver-rated ASD severity (RR, 1.24; P = .04), and ability to dress self (RR, 1.27; P = .04).

CONCLUSIONS

Desensitization was effective in achieving an MTE for most children. Those with characteristics consistent of a milder presentation of ASD were more likely to be successful.

PRACTICAL IMPLICATIONS

Desensitization can be a successful approach to providing dental care for children with ASD.

Practice comparisons between accelerated resolution therapy, eye movement desensitization and reprocessing and cognitive processing therapy with case examples

Recent outcomes for Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy indicate that as many as 60-72% of patients retain their PTSD diagnosis after treatment with CPT or PE. One emerging therapy with the potential to augment existing trauma focused therapies is Accelerated Resolution Therapy (ART). ART is currently being used along with evidence based approaches at Fort Belvoir Community Hospital and by report has been both positive for clients as well as less taxing on professionals trained in ART. The following is an in-practice theoretical comparison of CPT, EMDR and ART with case examples from Fort Belvoir Community Hospital. While all three approaches share common elements and interventions, ART distinguishes itself through emphasis on the rescripting of traumatic events and the brevity of the intervention. While these case reports are not part of a formal study, they suggest that ART has the potential to augment and enhance the current delivery methods of mental health care in military environments.

Psychodynamic Emotional Regulation in View of Wolpe's Desensitization Model

The current research belongs to the stream of theoretical integration and establishes a theoretical platform for integrative psychotherapy in anxiety disorders. Qualitative metasynthesis procedures were applied to 40 peer-reviewed psychoanalytic articles involving emotional regulation. The concept of psychodynamic emotional regulation was found to be connected with the categories of desensitization, gradual exposure, containment, and transference. This article presents a model according to which psychoanalytic psychotherapy allows anxiety to be tolerated while following the core principles of systematic desensitization. It is shown that despite the antiresearch image of psychoanalytic psychotherapy, its foundations obey evidence-based principles. The findings imply that anxiety tolerance might be a key goal in which the cumulative wisdom of the different therapies can be used to optimize psychotherapy outcomes.

Training Plates: A Solution for Patients Unable to Tolerate a Removable Prosthesis

Dealing with patients who are unable to tolerate dentures can present a challenge to the general dental practitioner (GDP). Careful assessment of patients and their dentures will identify any causes of the intolerance to dentures. Training plates are a useful technique that can be used to allow patients to become accustomed to removable prosthesis but will inevitably lengthen the treatment process. CPD/Clinical Relevance: Training plates offer a possible solution to general dental practitioners who treat patients who are struggling to tolerate dentures.

The Effectiveness of Psychological Treatment for Reducing Recidivism in Child Molesters: A Systematic Review of Randomized and Nonrandomized Studies

In this systematic review, the effectiveness of psychological treatment interventions for child molesters was examined. Studies were restricted to randomized control trials (RCTs), controlled trials, and cohort designs where recidivism had been used as the outcome variable. ASSIA, NCJRS, Medline, PsychINFO, EMBASE, Pro-requests Dissertations and Theses A&I, and the Cochrane Library were searched. Ten experts were contacted and the reference lists of 12 systematic reviews and 40 primary studies were observed. The number of hits was 3,019, of which 564 duplicates, 2,388 irrelevant references, and 38 that did not meet the inclusion criteria were removed. Fourteen studies using mixed samples had to be omitted because it was not possible to determine the recidivism rates of child molesters in the samples described. One RCT and 9 cohort studies were included in the data synthesis, providing 2,119 participants. In all, 52.1% received the intervention under investigation and 47.9% did not. The reported recidivism rates were 13.9% for the treated child molesters compared to 18.6% for the untreated child molesters. Three studies reported statistically significant lower recidivism rates for treated child molesters. Eight studies were assessed as weak. Four studies were assessed as having bias which increased the chance of finding a treatment effect and four studies were assessed as having bias which reduced the chance of finding a treatment effect. It was not possible to determine the direction of bias for two studies.

Pharmacological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a serious social problem, a public health issue, and a major challenge for social policy. Victim surveys indicate high incidence and prevalence levels and it is accepted that there is a high proportion of hidden sexual victimisation. Surveys report high levels of psychiatric morbidity in survivors of sexual offences.Biological treatments of sex offenders include antilibidinal medication, comprising hormonal drugs that have a testosterone-suppressing effect, and non-hormonal drugs that affect libido through other mechanisms. The three main classes of testosterone-suppressing drugs in current use are progestogens, antiandrogens, and gonadotropin-releasing hormone (GnRH) analogues. Medications that affect libido through other means include antipsychotics and serotonergic antidepressants (SSRIs).

OBJECTIVES

To evaluate the effects of pharmacological interventions on target sexual behaviour for people who have been convicted or are at risk of sexual offending.

SEARCH METHODS

We searched CENTRAL (2014, Issue 7), Ovid MEDLINE, EMBASE, and 15 other databases in July 2014. We also searched two trials registers and requested details of unidentified, unpublished, or ongoing studies from investigators and other experts.

SELECTION CRITERIA

Prospective controlled trials of antilibidinal medications taken by individuals for the purpose of preventing sexual offences, where the comparator group received a placebo, no treatment, or 'standard care', including psychological treatment.

DATA COLLECTION AND ANALYSIS

Pairs of authors, working independently, selected studies, extracted data, and assessed the risk of bias of included studies. We contacted study authors for additional information, including details of methods and outcome data.

MAIN RESULTS

We included seven studies with a total of 138 participants, with data available for 123. Sample sizes ranged from 9 to 37. Judgements for categories of risk of bias varied: concerns were greatest regarding allocation concealment, blinding of outcome assessors, and incomplete outcome data (dropout rates in the five community-based studies ranged from 3% to 54% and results were usually analysed on a per protocol basis).Participant characteristics in the seven studies were heterogeneous, but the vast majority had convictions for sexual offences, ranging from exhibitionism to rape and child molestation.Six studies examined the effectiveness of three testosterone-suppressing drugs: cyproterone acetate (CPA), ethinyl oestradiol (EO), and medroxyprogesterone acetate (MPA); a seventh evaluated two antipsychotics (benperidol and chlorpromazine). Five studies were placebo-controlled; in two, MPA was administered as an adjunctive treatment to a psychological therapy (assertiveness training or imaginal desensitisation). Meta-analysis was not possible due to heterogeneity of interventions, comparators, study designs, and other issues. The quality of the evidence overall was poor. In addition to methodological issues, much evidence was indirect.

PRIMARY OUTCOME

recividism. Two studies reported recidivism rates formally. One trial of intramuscular MPA plus imaginal desensitisation (ID) found no reports of recividism at two-year follow-up for the intervention group (n = 10 versus one relapse within the group treated by ID alone). A three-armed trial of oral MPA, alone or in combination with psychological treatment, reported a 20% rate of recidivism amongst those in the combined treatment arm (n = 15) and 50% of those in the psychological treatment only group (n = 12). Notably, all those in the 'oral MPA only' arm of this study (n = 5) dropped out immediately, despite treatment being court mandated.Two studies did not report recidivism rates as they both took place in one secure psychiatric facility from which no participant was discharged during the study, whilst another three studies did not appear directly to measure recividism but rather abnormal sexual activity alone.

SECONDARY OUTCOMES

The included studies report a variety of secondary outcomes. Results suggest that the frequency of self reported deviant sexual fantasies may be reduced by testosterone-suppressing drugs, but not the deviancy itself (three studies). Where measured, hormonal levels, particularly levels of testosterone, tended to correlate with measures of sexual activity and with anxiety (two studies). One study measured anxiety formally; one study measured anger or aggression. Adverse events: Six studies provided information on adverse events. No study tested the effects of testosterone-suppressing drugs beyond six to eight months and the cross-over design of some studies may obscure matters (given the 'rebound effect' of some hormonal treatments). Considerable weight gain was reported in two trials of oral MPA and CPA. Side effects of intramuscular MPA led to discontinuation in some participants after three to five injections (the nature of these side effects was not described). Notable increases in depression and excess salivation were reported in one trial of oral MPA. The most severe side effects (extra-pyramidal movement disorders and drowsiness) were reported in a trial of antipsychotic medication for the 12 participants in the study. No deaths or suicide attempts were reported in any study. The latter is important given the association between antilibidinal hormonal medication and mood changes.

AUTHORS' CONCLUSIONS

We found only seven small trials (all published more than 20 years ago) that examined the effects of a limited number of drugs. Investigators reported issues around acceptance and adherence to treatment. We found no studies of the newer drugs currently in use, particularly SSRIs or GnRH analogues. Although there were some encouraging findings in this review, their limitations do not allow firm conclusions to be drawn regarding pharmacological intervention as an effective intervention for reducing sexual offending.The tolerability, even of the testosterone-suppressing drugs, was uncertain given that all studies were small (and therefore underpowered to assess adverse effects) and of limited duration, which is not consistent with current routine clinical practice. Further research is required before it is demonstrated that their administration reduces sexual recidivism and that tolerability is maintained.It is a concern that, despite treatment being mandated in many jurisdictions, evidence for the effectiveness of pharmacological interventions is so sparse and that no RCTs appear to have been published in two decades. New studies are therefore needed and should include trials with larger sample sizes, of longer duration, evaluating newer medications, and with results stratified according to category of sexual offenders. It is important that data are collected on the characteristics of those who refuse and those who drop out, as well as those who complete treatment.

Nonverbal patient with autism spectrum disorder and obstructive sleep apnea: use of desensitization to acclimatize to a dental appliance

Patients with autism spectrum disorders (ASDs) may have difficulty tolerating conventional dental treatment due to aberrant sensory responsiveness. The purpose of this report was to describe the successful treatment of obstructive sleep apnea (OSA) in a nonverbal 20-year-old male patient with ASD using a dental appliance. A series of appointments prepared the patient for the required treatment procedures and desensitized him for use of the final appliance. The final appliance improved outcomes of a post-treatment sleep study, indicating successful treatment of OSA. Understanding the specific challenges of patients with ASD and the patience and foresight of providers in approaching these challenges, in collaboration with caregivers, can contribute to improved health outcomes for these patients.

In vivo exposure therapy for the treatment of an adult needle phobic

Dental anxiety is a widespread problem. Behavioural interventions are effective in reducing dental anxiety and dentists are well placed to carry out these interventions. This article aims to familiarize dentists with simple behavioural techniques that can be used to treat patients presenting with dental anxiety. A case study detailing the assessment and treatment of an uncomplicated needle phobia using in vivo graded exposure is included in order to demonstrate the use of these techniques.

CLINICAL RELEVANCE

Familiarity with simple, behavioural interventions for dental anxiety will enable dentists to respond appropriately to patients who present with mild fear and anxiety. Early intervention may play a role in the reduction of phobic anxiety in the dental setting. Dentists with an interest in behavioural management may also wish to treat patients with uncomplicated dental phobia.

Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults

BACKGROUND

Anxiety disorders are the most common mental health problems. They are chronic and unremitting. Effective treatments are available, but access to services is limited. Media-delivered behavioural and cognitive behavioural interventions (self-help) aim to deliver treatment with less input from professionals compared with traditional therapies.

OBJECTIVES

To assess the effects of media-delivered behavioural and cognitive behavioural therapies for anxiety disorders in adults.

SEARCH METHODS

Published and unpublished studies were considered without restriction by language or date. The Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR) was searched all years to 1 January 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Complementary searches were carried out on Ovid MEDLINE (1950 to 23 February 2013) and PsycINFO (1987 to February, Week 2, 2013), together with International trial registries (the trials portal of the World Health Organization (ICTRP) and ClinicalTrials.gov). Reference lists from previous meta-analyses and reports of randomised controlled trials were checked, and authors were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials of media-delivered behavioural or cognitive behavioural therapy in adults with anxiety disorders (other than post-traumatic stress disorder) compared with no intervention (including attention/relaxation controls) or compared with face-to-face therapy.

DATA COLLECTION AND ANALYSIS

Both review authors independently screened titles and abstracts. Study characteristics and outcomes were extracted in duplicate. Outcomes were combined using random-effects models, and tests for heterogeneity and for small study bias were conducted. We examined subgroup differences by type of disorder, type of intervention provided, type of media, and recruitment methods used.

MAIN RESULTS

One hundred and one studies with 8403 participants were included; 92 studies were included in the quantitative synthesis. These trials compared several types of media-delivered interventions (with varying levels of support) with no treatment and with face-to-face interventions. Inconsistency and risk of bias reduced our confidence in the overall results. For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants). The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice. Evidence suggested benefit for secondary outcome measures (depression, mental-health related disability, quality of life and dropout), but this evidence was of low to moderate quality. Evidence regarding harm was lacking.

AUTHORS' CONCLUSIONS

Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior. Economic analyses were beyond the scope of this review.Important heterogeneity was noted across trials. Recent interventions for specific problems that incorporate clinician support may be more effective than transdiagnostic interventions (i.e. interventions for multiple disorders) provided with no guidance, but these issues are confounded in the available trials.Although many small trials have been conducted, the generalisability of their findings is limited. Most interventions tested are not available to consumers. Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established. Large, pragmatic trials are needed to evaluate and to maximise the benefits of self-help interventions.

Mediated moderation in combined cognitive behavioral therapy versus component treatments for generalized anxiety disorder

OBJECTIVE

This study examined (a) duration of generalized anxiety disorder (GAD) as a moderator of cognitive behavioral therapy (CBT) versus its components (cognitive therapy and self-control desensitization) and (b) increases in dynamic flexibility of anxious symptoms during the course of psychotherapy as a mediator of this moderation. Degree of dynamic flexibility in daily symptoms was quantified as the inverse of spectral power due to daily to intradaily oscillations in four-times-daily diary data (Fisher, Newman, & Molenaar, 2011).

METHOD

This was a secondary analysis of the data of Borkovec, Newman, Pincus, and Lytle (2002). Seventy-six participants with a principle diagnosis of GAD were assigned randomly to combined CBT (n = 24), cognitive therapy (n = 25), or self-control desensitization (n = 27).

RESULTS

Duration of GAD moderated outcome such that those with longer duration showed greater reliable change from component treatments than they showed from CBT, whereas those with shorter duration fared better in response to CBT. Decreasing predictability in daily and intradaily oscillations of anxiety symptoms during therapy reflected less rigidity and more flexible responding. Increases in flexibility over the course of therapy fully mediated the moderating effect of GAD duration on condition, indicating a mediated moderation process.

CONCLUSIONS

Individuals with longer duration of GAD may respond better to more focused treatments, whereas those with shorter duration of GAD may respond better to a treatment that offers more coping strategies. Importantly, the mechanism by which this moderation occurs appears to be the establishment of flexible responding during treatment.

Interventions for vaginismus

BACKGROUND

Vaginismus is an involuntary contraction of the vaginal muscles which makes sexual intercourse difficult or impossible. It is one of the more common female psychosexual problems. Various therapeutic strategies for vaginismus, such as sex therapy and desensitisation, have been proposed, and uncontrolled case series appear promising.

OBJECTIVES

To assess the effects of different interventions for vaginismus.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) to August 2012. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched reference lists and conference abstracts. We contacted experts in the field regarding unpublished material.

SELECTION CRITERIA

Controlled trials comparing treatments for vaginismus with another treatment, a placebo treatment, treatment as usual or waiting list control.

DATA COLLECTION AND ANALYSIS

The review authors extracted data which we verified with the trial investigator where possible.

MAIN RESULTS

Five studies were included, of which four with a total of 282 participants provided data. No meta-analysis was possible due to heterogeneity of comparisons within included studies as well as inadequate reporting of data. All studies were considered to be at either moderate or high risk of bias. The results of this systematic review indicate that there is no clinical or statistical difference between systematic desensitisation and any of the control interventions (either waiting list control, systematic desensitisation combined with group therapy or in vitro (with women under instruction by the therapist) desensitisation) for the treatment of vaginismus. The drop-out rates were higher in the waiting list groups.

AUTHORS' CONCLUSIONS

A clinically relevant effect of systematic desensitisation when compared with any of the control interventions cannot be ruled out. None of the included trials compared other behaviour therapies (e.g. cognitive behaviour therapy, sex therapy) to pharmacological interventions. The findings are limited by the evidence available and as such conclusions about the efficacy of interventions for the treatment of vaginismus should be drawn cautiously.

Neurobiological correlates of EMDR monitoring - an EEG study

Background

Eye Movement Desensitization and Reprocessing (EMDR) is a recognized first-line treatment for psychological trauma. However its neurobiological bases have yet to be fully disclosed.

Methods

Electroencephalography (EEG) was used to fully monitor neuronal activation throughout EMDR sessions including the autobiographical script. Ten patients with major psychological trauma were investigated during their first EMDR session (T0) and during the last one performed after processing the index trauma (T1). Neuropsychological tests were administered at the same time. Comparisons were performed between EEGs of patients at T0 and T1 and between EEGs of patients and 10 controls who underwent the same EMDR procedure at T0. Connectivity analyses were carried out by lagged phase synchronization.

Results

During bilateral ocular stimulation (BS) of EMDR sessions EEG showed a significantly higher activity on the orbito-frontal, prefrontal and anterior cingulate cortex in patients at T0 shifting towards left temporo-occipital regions at T1. A similar trend was found for autobiographical script with a higher firing in fronto-temporal limbic regions at T0 moving to right temporo-occipital cortex at T1. The comparisons between patients and controls confirmed the maximal activation in the limbic cortex of patients occurring before trauma processing. Connectivity analysis showed decreased pair-wise interactions between prefrontal and cingulate cortex during BS in patients as compared to controls and between fusiform gyrus and visual cortex during script listening in patients at T1 as compared to T0. These changes correlated significantly with those occurring in neuropsychological tests.

Conclusions

The ground-breaking methodology enabled our study to image for the first time the specific activations associated with the therapeutic actions typical of EMDR protocol. The findings suggest that traumatic events are processed at cognitive level following successful EMDR therapy, thus supporting the evidence of distinct neurobiological patterns of brain activations during BS associated with a significant relief from negative emotional experiences.

Auditory-visual integration of emotional signals in a virtual environment for cynophobia

Cynophobia (dog phobia) has both visual and auditory relevant components. In order to investigate the efficacy of virtual reality (VR) exposure-based treatment for cynophobia, we studied the efficiency of auditory-visual environments in generating presence and emotion. We conducted an evaluation test with healthy participants sensitive to cynophobia in order to assess the capacity of auditory-visual virtual environments (VE) to generate fear reactions. Our application involves both high fidelity visual stimulation displayed in an immersive space and 3D sound. This specificity enables us to present and spatially manipulate fearful stimuli in the auditory modality, the visual modality and both. Our specific presentation of animated dog stimuli creates an environment that is highly arousing, suggesting that VR is a promising tool for cynophobia treatment and that manipulating auditory-visual integration might provide a way to modulate affect.

Designing virtual audiences for fear of public speaking training - an observation study on realistic nonverbal behavior

Virtual Reality technology offers great possibilities for Cognitive Behavioral Therapy of fear of public speaking: Clients can be exposed to virtual fear-triggering stimuli (exposure) and are able to role-play in virtual environments, training social skills to overcome their fear. Usually, prototypical audience behavior (neutral, social and anti-social) serves as stimulus in virtual training sessions, although there is significant lack of theoretical basis on typical audience behavior. The study presented deals with the design of a realistic virtual presentation scenario. An audience (consisting of n=18 men and women) in an undergraduate seminar was observed during three frontal lecture sessions. Behavior frequency of four nonverbal dimensions (eye contact, facial expression, gesture, and posture) was rated by means of a quantitative content analysis. Results show audience behavior patterns which seem to be typical in frontal lecture contexts, like friendly and neutral face expressions. Additionally, combined and even synchronized behavioral patterns between participants who sit next to each other (like turning to the neighbor and start talking) were registered. The gathered data serve as empirical design basis for a virtual audience to be used in virtual training applications that stimulate the experiences of the participants in a realistic manner, thereby improving the experienced presence in the training application.

Feeding therapy for children with food refusal

Disabled children suffer not only from their primary disease, but also from other complications, including food refusal. The purpose of this study was to elucidate the relationship between these conditions and food refusal in disabled children. The effectiveness of feeding therapy in treating food refusal was also examined. The study subjects were 67 disabled children (35 boys and 32 girls; mean age at initial examination: 6.5 years, SD: 6.0 years) who attended the Nippon Dental University Hospital between April 2004 and August 2008. Of them, the 13 subjects who were diagnosed as those who refused food received feeding therapy combined with desensitization therapy for hypersensitivity. Approximately 20% of the subjects showed food refusal symptoms. Primary disease, respiratory impairment and gastroesophageal reflux were not causes of food refusal in this population. There was a significant relationship between food refusal and hypersensitivity (p = 0.021). After receiving feeding therapy, six of the seven subjects with hypersensitivity but without dysphagia at initial examination recovered from food refusal. Food refusal did not significantly correlate with tube feeding. Hypersensitivity and/or tube feeding may induce food refusal. For subjects with these conditions, feeding therapy combined with desensitization therapy is effective in achieving recovery from food refusal.

Brief trauma intervention with Rwandan genocide-survivors using thought field therapy

This randomized waitlist control study examined the efficacy of Thought Field Therapy (TFT) in reducing Posttraumatic Stress Disorder symptoms in survivors of the 1994 genocide in Rwanda. Participants included 145 adult genocide survivors randomly assigned to an immediate TFT treatment group or a waitlist control group. Group differences adjusted for pretest scores and repeated measures anovas were statistically significant at p < .001 for 9 of 10 TSI trauma subscales and for both severity and frequency on the MPSS, with moderate to large effect sizes. Reduced trauma symptoms for the group receiving TFT were found for all scales. Reductions in trauma symptoms were sustained at a 2-year follow-up assessment. Limitations, clinical implications, and future research are discussed.

Cue exposure treatment in a virtual environment to reduce nicotine craving: a functional MRI study

Smokers show an increase in cue reactivity during exposure to smoking-related cues. CET aims at extinguishing cue reactivity by repeated presentation of substance-related cues and has been claimed a potentially effective method of treating addictive behaviors, including cigarette smoking. We applied CET to eight late-adolescent smokers in virtual environments (VEs). When comparing pre-CET regions to those of post-CET, the inferior frontal gyrus and superior frontal gyrus were detected. These regions are consistent with previous studies of activated brain regions related to nicotine craving, and VE-CET seems to be an effective method of treating nicotine craving.

Pharmacological enhancement of behavioral therapy: focus on posttraumatic stress disorder

Improved efficacy in the treatment of posttraumatic stress disorder (PTSD) and other anxiety disorders is urgently needed. Traditional anxiety treatments of hypnosis and psychodynamic therapy may be of some help, but uncontrolled studies lead to inconclusive results on the efficacy of these treatment techniques. There is a larger literature supporting the efficacy of cognitive-behavioral procedures with PTSD, including prolonged exposure therapy, eye movement desensitization and reprocessing, and anxiety management techniques. The cutting-edge technology of virtual reality-based exposure therapy for PTSD is particularly exciting. To further build on effective psychosocial treatments, current pharmacological augmentation approaches to emotional learning are being combined with psychotherapy. In particular, D-cycloserine, a partial NMDA agonist, has shown to be effective in facilitating the exposure/extinction therapy to improve the efficacy of treating anxiety disorders, and may guide the way for new pharmacological enhancements of behavioral therapy.

[Treatment of vaginismus with EMDR: a report of two cases]

Vaginismus is a type of sexual dysfunction in which spasm of the vaginal musculature prevents penetrative intercourse. The main diagnostic criterion is the presence of recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. In many cases associated pain or the fear of pain may contribute to its persistence. Herein we report 2 patients that presented with vaginismus that developed secondary to childhood sexual trauma, which was treated with the Eye Movement Desensitization and Reprocessing (EMDR) technique. EMDR is a non-pharmacologic treatment for psychological trauma. Randomized controlled trials with posttraumatic stress disorder patients and with victims of sexual abuse have shown that EMDR is effective. The standard 8-phase EMDR protocol was used in both of the presented cases. Following 3 sessions of EMDR, the patients exhibited a substantial reduction in self-reported and clinician-rated anxiety, and a reduction in the credibility of dysfunctional beliefs concerning sexual intercourse. These findings support the notion that EMDR could be an effective treatment alternative for patients with vaginismus of traumatic etiology.

Virtual reality interoceptive exposure for the treatment of panic disorder and agoraphobia

The efficacy of cognitive-behavioral therapy for panic disorder and agoraphobia (PDA) has been widely demonstrated. The exposure technique is the main component of these programs; interoceptive exposure also plays an important role. The virtual reality (VR) program for treating PDA developed by Botella's group can simulate physical sensations in a controlled manner while the user is immersed in the VR environments in the consultation room. These include audible effects, such as rapid heartbeat and panting, as well as visual effects, such as blurry vision, double vision and tunnel vision. This work examines the efficacy of the interoceptive exposure (IE) component in two treatment conditions: 1) VR Interoceptive Exposure Simultaneous Condition (VRIE-sim; N=14), and 2) Interoceptive Exposure Traditional Condition (IET; N=15). Results obtained showed that both treatment conditions significantly reduced the main clinical variables at post-treatment; these results were maintained or even improved at three month follow-up. Simultaneous VR interoceptive and VR external stimuli exposure is a new and effective way to apply PDA treatment.

Analysis of distributed-collaborative activity during augmented reality exposure therapy for cockroach phobia

Recent research presents Augmented Reality Exposure Therapy (ARET) for treatment of phobia of cockroaches as a potentially effective technique. However, to the authors' knowledge no studies have been published concerning the Human-Computer-Interaction issues of such a system. The aim of this paper is to report some preliminary data on how patients, therapists and an Augmented Reality system collaborate and interact during the therapeutic process. The results show that the therapeutic process is distributed between individuals (patient and therapist) and artifacts (e.g. AR cockroaches, a computer screen, a Head Mounted Display (HMD), a keyboard, a swatter and therapists' notes on paper). The results are discussed in terms of possible improvement of the ARET system.

First-line treatment: a critical appraisal of cognitive behavioral therapy developments and alternatives

In this article, the authors assess the successes, remaining challenges, and new developments in cognitive behavioral therapy (CBT) for anxiety disorders. They define CBT, examine treatment components, review treatment efficacy, and discuss the challenges of attrition, long-term follow-up, co-occurring/comorbid disorders, limited treatment comparisons, treatment mediators, and broader implementation. In addition, they present recent developments in cognitive behavioral therapy for anxiety disorders, including linking exposure therapy to basic science, mindfulness and acceptance-based treatments, and unified or transdiagnostic treatment protocols.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual Psychological Debriefing is not an effective intervention at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of multiple session early psychological interventions commenced within three months of a traumatic event aimed at preventing PTSD. Single session individual/group psychological interventions were excluded.

SEARCH STRATEGY

Computerised databases were searched systematically, the most recent search was conducted in August 2008. The Journal of Traumatic Stress and the Journal of Consulting and Clinical Psychology were handsearched for the last two years. Personal communication was undertaken with key experts in the field.

SELECTION CRITERIA

Randomised controlled trials of any multiple session early psychological intervention or treatment (two or more sessions) designed to prevent symptoms of PTSD.

DATA COLLECTION AND ANALYSIS

Data were entered using Review Manager software. The methodological quality of included studies was assessed individually by two review authors. Data were analysed for summary effects using Review Manager 4.2. Mean difference was used for meta-analysis of continuous outcomes and relative risk for dichotomous outcomes.

MAIN RESULTS

Eleven studies with a total of 941 participants were found to have evaluated brief psychological interventions aimed at preventing PTSD in individuals exposed to a specific traumatic event, examining a heterogeneous range of interventions. Eight studies were entered into meta-analysis. There was no observable difference between treatment and control conditions on primary outcome measures for these interventions at initial outcome (k=5, n=479; RR 0.84; 95% CI 0.60 to 1.17). There was a trend for increased self-report of PTSD symptoms at 3 to 6 month follow-up in those who received an intervention (k=4, n=292; SMD 0.23; 95% CI 0.00 to 0.46). Two studies compared a memory structuring intervention against supportive listening. There was no evidence supporting the efficacy of this intervention.

AUTHORS' CONCLUSIONS

The results suggest that no psychological intervention can be recommended for routine use following traumatic events and that multiple session interventions, like single session interventions, may have an adverse effect on some individuals. The clear practice implication of this is that, at present, multiple session interventions aimed at all individuals exposed to traumatic events should not be used. Further, better designed studies that explore new approaches to early intervention are now required.

Cognitive-behavioural emotion writing tasks: a controlled trial of multiple processes

We report on a controlled trial of three structured writing paradigms that engage the writer with cognitive-behavioural emotion-processes: exposure, devaluation, and benefit-finding. University students (N=198) wrote once a week for three weeks about their most upsetting experience. The long-term effects of these structured writing procedures were compared to an unstructured emotion writing condition and control. Outcomes indicated that exposure writing sped the reduction of intrusive and avoidant symptoms, while benefit-finding writing increased reports of positive growth. Results suggest the use of these paradigms to study emotion-processing mechanisms and, potentially, in practice to enhance coping in process-specific ways.

A systematic review of cognitive-behavioral treatment for nightmares: toward a well-established treatment

The aim of this review is to evaluate the effectiveness of cognitive behavioral therapy (CBT) on nightmare frequency and to determine which kind of CBT is the most effective treatment. A systematic literature search was carried out in PsychInfo and PubMed articles published on or before May 1, 2008. The inclusion criteria were: nightmare treatment study, use of nonpharmacological treatment, not a qualitative case study, randomized-controlled trial (RCT). After selection, 12 peer-reviewed studies about 9 RCTs remained (2 follow-up studies and one displaying preliminary results). Several interventions have been reviewed including, recording one's nightmares, relaxation, exposure, and techniques of cognitive restructuring. The 12 evaluated articles varied in quality, and none fulfilled CONSORT guidelines. All articles used nightmare frequency as the primary dependent variable, and all found significant in-group differences (pre vs. post) for intervention or placebo (range d = 0.7-2.9). Five studies were able to find a significant group effect for the intervention compared to a waiting list control group. Only one study found significant differences between 2 intervention groups. Nightmare-focused CBT (exposure and imagery rehearsal therapy [IRT]) revealed better treatment outcomes than indirect CBT (relaxation, recording). IRT and exposure showed no meaningful differences, but only one RCT directly compared both techniques. Three different research groups demonstrated the effects of exposure, but only one group showed the effect of IRT. Thus, RCTs that compare IRT with exposure by independent research groups are much needed.

The pattern of subjective anxiety during in-session exposures over the course of cognitive-behavioral therapy for clients with social anxiety disorder

Exposure-based therapies are efficacious treatments for social anxiety disorder (i.e., Gould et al., 1997). Much of the theory behind these treatments is derived from Foa and colleagues' (Foa, Huppert, & Cahill, 2005; Foa & Kozak, 1986) work on emotional processing. However, there has been little research examining individual differences in emotional processing patterns within and between treatment sessions among clients with social anxiety disorder. This study utilized longitudinal data analytic methods to examine changes in subjective anxiety during the first 3 exposure sessions in group and individual cognitive-behavioral therapy for social anxiety disorder. The results of this study provide preliminary evidence that, although anxiety generally decreases across exposures, some individuals experience considerable fluctuations in anxiety during a single exposure. Although anxiety during the first exposure was not significantly related to outcome, the relationship between anxiety during exposure and outcome became stronger during subsequent exposures. Overall, this study highlights the need to conduct more fine-grained analyses to better understand the mechanisms underlying exposure-based therapies for social anxiety disorder.

Effects of eye movement versus therapist instructions on the processing of distressing memories

The effectiveness of components of eye movement desensitization and reprocessing (EMDR) was tested by randomly assigning 48 participants to either an eye movement or an eye stationary condition and to one of two types of therapist instructions (reliving or distancing). Participants were university students (mean age 23) who were asked to recall a personal distressing memory with measures of distress and vividness taken before and after treatment, and at follow-up. There was no significant effect of therapist's instruction on the outcome measures. There was a significant reduction in distress for eye movement at post-treatment and at follow-up but overall no significant reduction in vividness. Post hoc analysis revealed a significant reduction in vividness only for the eye movement and distancing instruction condition. The results were consistent with other evidence that the mechanism of change in EMDR is not the same as traditional exposure.

Physiological correlates of eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is an established treatment for post-traumatic stress disorder (PTSD). However, its working mechanism remains unclear. This study explored physiological correlates of eye movements during EMDR in relation to current hypotheses; distraction, conditioning, orienting response activation, and REM-like mechanisms. During EMDR therapy, fingertip temperature, heart rate, skin conductance, expiratory carbon dioxide level, and blood pulse oximeter oxygen saturation, were measured in male subjects with PTSD. The ratio between the low and high frequency components of the heart rate power spectrum (LF/HF) were computed as measures of autonomic balance. Respiratory rate was calculated from the carbon dioxide trace. Stimulation shifted the autonomic balance as indicated by decreases in heart rate, skin conductance and LF/HF-ratio, and an increased finger temperature. The breathing frequency and end-tidal carbon dioxide increased; oxygen saturation decreased during eye movements. In conclusion, eye movements during EMDR activate cholinergic and inhibit sympathetic systems. The reactivity has similarities with the pattern during REM-sleep.

An experimental study of the role of vulnerability related perceptions in spider fear: comparing an imaginal and in vivo encounter

The effect of manipulating perceptions of the uncontrollability, unpredictability and dangerousness of a spider was assessed using both an imaginal and in vivo task involving an encounter with a spider. Participants were randomly assigned to one of eight conditions formed by the crossing of factors. Experimental manipulations of uncontrollability, unpredictability and dangerousness all had a significant effect on Task Related Spider Fear in the in vivo exposure task. Results indicated a greater effect on task related fear for in vivo exposure (R(2)=.258) compared to imaginal exposure (R(2)=.053). Perceptions of spiders as uncontrollable, unpredictable and dangerous accounted for much of the variance in spider fear beyond that accounted for by the experimental manipulations. The idea that perceptions of spiders as uncontrollable, unpredictable and dangerous are causally related to spider fear was supported with in vivo exposure being a stronger modality for fear modification than imaginal exposure.

Sequential cognitive-behavioral therapy for children with obsessive-compulsive disorder with an inadequate medication response: a case series of five patients

Few data have been reported on the efficacy of cognitive-behavioral therapy (CBT) for youth with obsessive-compulsive disorder (OCD) who have not responded to prior treatment with medication. Given this, we report an open trial of CBT for children who have remained symptomatic following medication trials. Five children with OCD who had an inadequate response to psychotropic medications (e.g., limited response and/or unable to be titrated to a complete dose due to side effects) received treatment in a 3-week intensive CBT program. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (much improved or very much improved) and the severity of clinician-rated OCD symptoms and impairment significantly decreased after the intervention. Although a number of limitations of this preliminary report exist, this study provides preliminary support for the utility of an intensive intervention for youth with OCD who have had an inadequate response and/or adverse side effects.

A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth

OBJECTIVE

to explore the possibility of using eye movement desensitisation and reprocessing (EMDR) to treat women who have experienced post-traumatic stress after childbirth.

DESIGN

the pilot study consisted of a 'before and after' treatment design combined with follow-up measurements 1-3 years after EMDR treatment. Quantitative data from questionnaires (Traumatic Event Scale [TES]) were collected. In addition, qualitative data from individual interviews with the participants were collected as well as data from the psychotherapist's treatment notes of the EMDR treatment sessions.

SETTING

the north of Sweden.

PARTICIPANTS

four women with post-traumatic stress disorder (PTSD) after childbirth (one pregnant and three non-pregnant).

FINDINGS

all participants reported reduction of post-traumatic stress after treatment. After 1-3 years, the beneficial effects of EMDR treatment remained for three of the four women. Symptoms of intrusive thoughts and avoidance seemed most sensitive for treatment.

IMPLICATIONS FOR PRACTICE

EMDR might be a useful tool in the treatment of non-pregnant women severely traumatised by childbirth; however, further research is required.

Treatment of complicated grief using virtual reality: a case report

This is the first work exploring the application of new technologies, concretely virtual reality, to facilitate emotional processing in the treatment of Complicated Grief. Our research team has designed a virtual reality environment (EMMA's World) to foster the expression and processing of emotions. In this study the authors present a description of EMMA's World, the clinical protocol, and a case report. The treatment program was applied in eight sessions. We present a brief description of the session agendas including the techniques used. We offer short-term (from pre-test to post-test) and long-term (2-, 6- and 12-month follow-ups) efficacy data. Our results offer preliminary support of the use of EMMA's World for the treatment of Complicated Grief.

Evaluation of a compact tinnitus therapy by electrophysiological tinnitus decompensation measures

Large-scale neural correlates of the tinnitus decompensation have been identified by using wavelet phase stability criteria of single sweep sequences of auditory late responses (ALRs). Our previous work showed that the synchronization stability in ALR sequences might be used for objective quantification of the tinnitus decompensation and attention which link to Jastreboff tinnitus model. In this study, we intend to provide an objective evaluation for quantifying the effect of music therapy in tinnitus patients. We examined neural correlates of the attentional mechanism in single sweep sequences of ALRs in chronic tinnitus patients who underwent compact therapy course by using the maximum entropy auditory paradigm. Results by our measure showed that the extent of differentiation between attended and unattended conditions improved significantly after the therapy. It is concluded that the wavelet phase synchronization stability of ALRs single sweeps can be used for the objective evaluation of tinnitus therapies, in this case the compact tinnitus music therapy.

A framework for treating partner aggressive women

Women are increasingly referred to intervention programs to address their use of physical violence against intimate partners. This article reviews the scant treatment outcome and attrition literature for partner aggressive women and describes important characteristics of partner aggressive women that must be taken into consideration in designing treatment. Recommended treatment modules are described in detail and include skill-building to enhance safety planning, conflict management, emotional regulation, communication and negotiation, and stress management. Additional modules should be included for some women based on individualized needs. These may include parenting skills and education and referral for treatment of conditions that undermine emotional stability, such as posttraumatic stress symptoms, substance abuse, and mood disorders. Treatment structure is outlined and pragmatic issues regarding the implementation of treatment are discussed. Interventions for partner aggressive woman must be designed to address women's victimization experiences as well as their perpetration.

Effects of EMDR psychotherapy on 99mTc-HMPAO distribution in occupation-related post-traumatic stress disorder

BACKGROUND

Post-traumatic stress disorder (PTSD) is a derangement of mood control with involuntary, emotionally fraught recollections that may follow deep psychological trauma in susceptible individuals. This condition is treated with pharmacological and/or cognitive therapies as well as psychotherapy with eye movement desensitization and reprocessing (EMDR). However, only a very limited number of studies have been published dealing with work-related PTSD, and investigations on the effect of treatment on cerebral blood flow represent an even smaller number.

AIM

To investigate the short-term outcome of occupation-related PTSD after EMDR therapy by 99mTc-HMPAO SPECT.

METHOD

Fifteen patients, either train drivers suffering from PTSD after having been unintentionally responsible for a person-under-train accident or employees assaulted in the course of duty, were recruited for the study. 99mTc-HMPAO SPECT was performed on these patients both before and after EMDR therapy while they listened to a script portraying the traumatic event. Tracer distribution analysis was then carried out at volume of interest (VOI) level using a three-dimensional standardized brain atlas, and at voxel level by SPM. The CBF data of the 15 patients were compared before and after treatment as well as with those of a group of 27 controls who had been exposed to the same psychological traumas without developing PTSD.

RESULTS

At VOI analysis significant CBF distribution differences were found between controls and patients before and after treatment (P=0.023 and P=0.0039, respectively). Eleven of the 15 patients responded to treatment, i.e., following EMDR they no longer fulfilled the DSM-IV criteria for PTSD. When comparing only the eleven responders with the controls, the significant group difference found before EMDR (P=0.019) disappeared after treatment. Responders and non-responders showed after therapy significant regional differences in frontal, parieto-occipital and visual cortex and in hippocampus. SPM analysis showed significant uptake differences between patients and controls in the orbitofrontal cortex (Brodmann 11) and the temporal pole (Brodmann 38) both before and after treatment. A significant tracer distribution difference present before treatment in the uncus (Brodmann 36) disappeared after treatment, while a significant difference appeared in the lateral temporal lobe (Brodmann 21).

CONCLUSION

Significant 99mTc-HMPAO uptake regional differences were found, mainly in the peri-limbic cortex, between PTSD patients and controls exposed to trauma but not developing PTSD. Tracer uptake differences between responders and patients not responding to EMDR were found after treatment suggesting a trend towards normalization of tracer distribution after successful therapy. These findings in occupational related PTSD are consistent with previously described effects of psychotherapy on anxiety disorders.

Attention focusing versus distraction during exposure in dental phobia

A survey of the discrepant findings regarding the effects of attention focusing and distraction on exposure suggested that subjective measures of anxiety and avoidance respond better to the latter condition, and heart rate (HR) reaction responds to the former. To test this hypothesis, 63 dental phobics were recruited who had not visited a dentist for a mean of 6.6 (1.5-25) years. Participants received a 1-h exposure session with either attention focusing or distraction. Subjective anxiety and HR to phobia-related pictures were assessed before and after the treatment session and again after 1 week. Avoidance was recorded in terms of adherence to the dental treatment schedule in the following 6 months. Contrary to expectation, state anxiety showed a greater decrease in the attention focusing than the distraction condition after 1 week. Both treatment conditions were similarly effective with regard to HR and avoidance. HR habituated in both groups after exposure and 73% of followed-up patients adhered to the dental treatment schedule. Comparison of the present with previous results suggests that the differences between attentional conditions tend to be more pronounced during shorter exposure sessions than were employed in the present study.