Nathaniel R. Herr

Virtual reality for persistent pain: A new direction for behavioral pain management

Recent research indicates that immersive virtual reality (VR) can be used tool in treating acute pain [10,25,23]. For example, VR-based behavioral interventions have been used to decrease acute pain among individuals undergoing painful medical procedures (e.g. wound cleaning of burn injuries [14,15,22,10], urological endoscopies (36)), physical therapy (e.g. for blunt force trauma [16], for burned skin [12,13]), and dental pain [11,5], and experimental pain in healthy volunteers (e.g. thermal pain) [17,18]. Although these data suggest that VR has promise as a tool to help reduce acute pain, there has been limited investigation on the use of VR in the treatment of patients with persistent pain. The purpose of this topical review is to identify and highlight ways in which VR can be used either alone or in combination with other treatments for persistent pain. The review is divided into three parts. First, we briefly describe VR methods currently used in the management of acute pain. Second, we discuss several potential applications of VR as a behavioral intervention for persistent pain. Third, we highlight important future directions for research in this area.

Depressive symptoms predict inflexibly high levels of experiential avoidance in response to daily negative affect: a daily diary study.

Experiential avoidance (EA) is an emotion-regulation strategy used to control or avoid unpleasant internal experiences. Despite the important role of avoidance in depressive disorders, there is relatively little research directly examining the role of EA in the development and maintenance of depression, and most of this research relies on measurement of EA as a global and stable personality trait. In this study we sought to extend the research on EA and depression by using a daily diary design and multilevel analysis to examine how the daily relationship between EA and negative affect (NA) varies as a function of baseline depressive symptoms. In order to achieve this goal we created a new state measure of EA assessing several avoidant behaviors. The findings revealed that participants with more depressive symptoms used more daily EA overall. Additionally, the difference in daily EA between those with higher versus lower depressive symptoms was greater on days when participants experienced less NA. This moderation effect was found only concurrently whereas one-day lagged analysis failed to reveal this effect. These findings provide preliminary support for the hypothesis that depression is associated with an inflexibly high level of avoidant emotion regulation.

Identity Disturbance and Problems With Emotion Regulation Are Related Constructs Across Diagnoses

OBJECTIVE This study examined the relation between identity disturbance and emotion dysregulation in a cross-diagnostic sample. We assessed whether these constructs are related and relevant beyond borderline personality disorder (BPD). METHOD We recruited 127 participants who completed measures assessing identity disturbance, emotion dysregulation, anxiety, and depression. The sample included primarily depressed adults meeting criteria for multiple diagnoses as well as psychiatrically healthy participants. RESULTS Identity disturbance was significantly higher among psychiatric participants with and without BPD compared to healthy controls. Emotion dysregulation was a significant predictor of identity disturbance, even when controlling for BPD diagnosis, depression, and anxiety. In particular, clarity in emotional situations and problems using emotion regulation strategies were most closely related to identity disturbance. CONCLUSION The results of this study suggest that future research should examine identity disturbance and its relation with emotion regulation transdiagnostically.

Does This Patient Have Generalized Anxiety or Panic Disorder?: The Rational Clinical Examination Systematic Review

IMPORTANCE In primary care settings, generalized anxiety disorder (GAD) and panic disorder are common but underrecognized illnesses. Identifying accurate and feasible screening instruments for GAD and panic disorder has the potential to improve detection and facilitate treatment. OBJECTIVE To systematically review the accuracy of self-report screening instruments in diagnosing GAD and panic disorder in adults. DATA SOURCES We searched MEDLINE, PsycINFO, and the Cochrane Library for relevant articles published from 1980 through April 2014. STUDY SELECTION Prospective studies of diagnostic accuracy that compared a self-report screening instrument for GAD or panic disorder with the diagnosis made by a trained clinician using Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria. RESULTS We screened 3605 titles, excluded 3529, and performed a more detailed review of 76 articles. We identified 9 screening instruments based on 13 articles from 10 unique studies for the detection of GAD and panic disorder in primary care patients Across all studies, diagnostic interviews determined that 257 of 2785 patients assessed had a diagnosis of GAD while 224 of 2637 patients assessed had a diagnosis of panic disorder. The best-performing test for GAD was the Generalized Anxiety Disorder Scale 7 Item (GAD-7), with a positive likelihood ratio of 5.1 (95% CI, 4.3-6.0) and a negative likelihood ratio of 0.13 (95% CI, 0.07-0.25). The best-performing test for panic disorder was the Patient Health Questionnaire, with a positive likelihood ratio of 78 (95% CI, 29-210) and a negative likelihood ratio of 0.20 (95% CI, 0.11-0.37). CONCLUSIONS AND RELEVANCE Two screening instruments, the GAD-7 for GAD and the Patient Health Questionnaire for panic disorder, have good performance characteristics and are feasible for use in primary care. However, further validation of these instruments is needed because neither instrument was replicated in more than 1 primary care population.

Negative interpersonal events mediate the relation between borderline features and aggressive behavior: findings from a nonclinical sample of undergraduate women

Interpersonal dysfunction and aggression are features that are frequently found in individuals with borderline personality disorder (BPD); however, few studies have examined the possible causal relationship between aggressive actions and interpersonal problems. In a nonclinical sample of 98 women with a range of BPD features, the present study examined the prospective relationship between aggressive behaviors and negative interpersonal events using a weekly diary method. Results showed that higher BPD symptoms were related to higher aggression and more negative interpersonal events. Furthermore, the aggressive acts endorsed among women with more BPD features were more likely the effect, rather than the cause, of the negative interpersonal events they experienced. Implications for interventions targeting aggression among women with elevated BPD features and suggestions for future research are discussed.

Speed and accuracy of facial expression classification in avoidant personality disorder: a preliminary study.

The aim of this preliminary study was to examine whether individuals with avoidant personality disorder (APD) could be characterized by deficits in the classification of dynamically presented facial emotional expressions. Using a community sample of adults with APD (n = 17) and non-APD controls (n = 16), speed and accuracy of facial emotional expression recognition was investigated in a task that morphs facial expressions from neutral to prototypical expressions (Multi-Morph Facial Affect Recognition Task; Blair, Colledge, Murray, & Mitchell, 2001). Results indicated that individuals with APD were significantly more likely than controls to make errors when classifying fully expressed fear. However, no differences were found between groups in the speed to correctly classify facial emotional expressions. The findings are some of the first to investigate facial emotional processing in a sample of individuals with APD and point to an underlying deficit in processing social cues that may be involved in the maintenance of APD.

The impact of validation and invalidation on aggression in individuals with emotion regulation difficulties.

For individuals with difficulty regulating their emotions, aggression has been found to be a particularly problematic interpersonal behavior. Invalidation (i.e., rejection of ones emotional experience) is thought to play a role in the etiology of disorders of emotion regulation, and it may be a trigger for aggressive behaviors. The present study experimentally manipulated validation and invalidation after a sad mood induction among individuals with few versus many difficulties regulating their emotions. Subsequent aggression was measured using an in-laboratory behavioral task. Results indicate that, among individuals with many difficulties regulating their emotions, validation led to significantly less aggression than did invalidation. However, among individuals with few difficulties regulating their emotions, aggressive behaviors were generally low and did not differ after validation as compared with invalidation. The findings suggest that validation of emotional experiences may help to prevent aggressive behaviors among individuals with difficulties regulating their emotions.

Psychotherapeutic Treatment of Bipolar Depression

The gold standard for treating bipolar depression is based on the combination of mood stabilizers and psychotherapy. Therefore, the authors present evidence-based models and promising approaches for psychotherapy for bipolar depression. Cognitive-behavioral therapy, family focused therapy, interpersonal and social rhythm therapy, mindfulness-based cognitive therapy, and dialectical behavior therapy are discussed. Behavioral activation, the cognitive behavioral analysis system of psychotherapy, and the unified protocol as promising future directions are presented. This review informs medical providers of the most appropriate referral guidelines for psychotherapy for bipolar depression. The authors conclude with a decision tree delineating optimal referrals to each psychotherapy approach.

Emotion differentiation mediates the association between emotion regulation difficulties and caloric intake

Emotion differentiation is the ability to identify and label emotional experiences into discrete categories. The present study examined the influence of emotion regulation difficulties, emotion differentiation, and emotional state-specifically sad versus positive mood-on caloric intake in a laboratory setting. Undergraduate participants completed a series of questionnaires, including measures of emotion regulation difficulties and emotion differentiation, and then underwent a randomly assigned sad or positive mood induction. Afterwards, they participated in a taste test. Food was counted before and after the taste test to determine total caloric intake. Results showed that negative emotion differentiation was significantly inversely associated with overall caloric intake, such that low negative emotion differentiators ate more regardless of mood induction group. Positive emotion differentiation was not associated with caloric intake. Additional analysis found that negative emotion differentiation mediated the relation between emotion regulation difficulties and caloric intake. An alternative model found that emotion regulation difficulties did not mediate the relation between negative emotion differentiation and caloric intake. Our results suggest that reducing caloric intake among individuals with emotion regulation difficulties may involve incorporating strategies to specifically target the ability to differentiate between emotions.

The Messenger Matters: Invalidating Remarks From Men Provoke a More Negative Emotional Reaction Than Do Remarks From Women

Despite negative consequences of emotional invalidation, research has not examined the effect of gender on responses to validation or invalidation or how an invalidating comment from a male versus a female confederate may influence affective responses. We used a two-study quasi-experimental design to examine variables that influence the emotions of individuals validated or invalidated for their emotions. Male and female undergraduates received either validating or invalidating remarks from a gender-ambiguous confederate (Study 1) or invalidating remarks from either a male or female confederate (Study 2). Results showed that invalidation from a gender-ambiguous confederate produced more negative emotional reactions than validation regardless of participants’ gender. Furthermore, being invalidated by a man rather than by a woman provoked a specifically more negative emotional response. Interpersonal interventions should explore ways to reduce invalidation and particularly strive to mitigate the effects of invalidation from men, whose criticisms may provoke heightened negative responses from others.