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INDEX

VOLUME 43 • NUMBER 5 • 2016

Original articles

Cross-cultural adaptation of the Events Schedule-Alzheimer’s Disease to Brazilian Portuguese .................. 95Karen Rosângela Silva de Souza Saviotti, Mariana Boaro Fernadez Canon, Marcia Maria Pires Camargo Novelli

The Geriatric Anxiety Inventory in primary care: applicability and psychometric characteristics of the original and short form .................................................................................................................................................. 103Laís dos Santos Vinholi e Silva, Glaucia Martins de Oliveira, Juliana Emy Yokomizo , Laura Ferreira Saran, Cássio Machado de Campos Bottino, Mônica Sanches Yassuda

Social dysfunction and skills in schizophrenia: relationship with treatment response and severity of psychopathology............................................................................................................................................................. 107Hélio Elkis, Silvia Scemes, Mariangela Gentil Savoia, Zilda Del Prette, Paulo Mestriner, Aline Roberta da Silva

Relationship between perceived parenting style with anxiety levels and loneliness in visually impaired children and adolescents ............................................................................................................................................. 112Mualla Hamurcu, Koray Kara, Mehmet Ayhan Congologlu, Ufuk Hamurcu, Mahmoud Almbaıdheen, Ayse Turan, Dursun Karaman

Review article

Interventions for music performance anxiety: results from a systematic literature review .......................... 116Ana Beatriz Burin, Flávia de Lima Osório

Letter to the editor

Resolution of Othello-like syndrome following ventricular shunting in a post traumatic normal pressure hydrocephalus subject .................................................................................................................................................. 132Fernando Campos Gomes Pinto, Gabriela Stump, Leandro Valiengo, Matheus Fernandes de Oliveira

Original article

Address for correspondence: Karen Rosângela Silva de Souza Saviotti. Rua Alfenas, 373 – 30310-230 – Belo Horizonte, MG, Brazil. E-mail: [email protected]

Cross-cultural adaptation of the Events Schedule-Alzheimer’s Disease to Brazilian PortugueseKaren rosângela silva de souza saviotti1, Mariana Boaro Fernadez Canon1, MarCia Maria Pires CaMargo novelli2

1 Federal University of São Paulo (Unifesp), Health Sciences, Santos, SP, Brazil. 2 Federal University of São Paulo (Unifesp), Ageing Research and Attendance Interprofessional Nucleus (NIPAE), Health Care and Management Department, Occupational Therapy Course, Santos, SP, Brazil.

Received: 8/5/2016 – Accepted: 9/14/2016DOI: 10.1590/0101-60830000000093

AbstractBackground: Engagement in pleasant activities for elders with cognitive impairment may improve mood and reduce behavior problems. The Pleasant Events Schedule-Alzheimer’s Disease (PES-AD) has been described as a useful tool for this purpose, and its transcultural adaptation allows professionals to aid caretakers and elders in identifying pleasurable activities. Objective: Submit the PES-AD to process of cross-cultural adaptation to Brazilian Portuguese. Methods: The PES-AD was submitted to a five-stage process of cross-cultural adaptation as follows: 1) translation; 2) summary of translation; 3) back-translation; 4) evaluation of equivalences: semantic, idiomatic, cultural, conceptual; and 5) pre-testing. Results: The five-stage process was conducted on 36 items and three were adjusted. In the evaluation of equivalencies, four items had a level of agreement less than 0.8 and so were modified according to judges’ suggestions. Discussion: Submitting the PES-AD to a five-stage, cross-cultural adaptation maintained the original instrument’s content validity.

Saviotti KRSS et al. / Arch Clin Psychiatry. 2016;43(5):95-102

Keywords: Leisure activity, pleasure, aged, dementia, Alzheimer’s disease.

Introduction

Currently, according to the 2012 census by the Brazilian Institute of Geography and Statistics (IBGE), the elderly constitute 12.6% of the total Brazilian population1. Due to the elderly’s population growth, the number of people affected by age-related diseases has also increased. Studies show that the prevalence of dementia for elders (age group 60 and older) is approximately 7.1% and that according to the individuals age, this percentage gradually increases2.

For radical behaviorism3, behavior denotes all human action, and any behavior that generates consequences for a person’s environment can be reinforced if followed by reinforcing stimuli. If reinforcing stimuli are positive, the probability of the previous behavior reappearing is greatly enhanced. A positive stimulus also generates pleasurable feelings. Thus, observing the frequency of feelings that follow a behavior is essential to studying human behavior3.

Happiness is a fundamental human need and an integral component of quality of life. Humans possess the ability to experience happiness passively through events that occur on a daily basis or actively through efforts at finding it. Thus, the search for happiness can also be propitiated by social contacts and pleasurable activities4. For Skinner5, when a behavior generates consequences for the environment, it is “operating”, and happiness is a by-product of operating reinforcements. Thus, the things that make an individual happy are those he reinforces himself, and these can be identified and used to forecast individual behavior.

Several studies of healthy elderly people have investigated the practice of social and pleasurable activities, relating them to participants’ health, such as diminished motor functionality, enhanced life quality, maintenance of cognitive abilities, reduced risk of depression, and even development of dementia6-11. Other studies of elders with dementia indicate that those who participate in pleasurable activities present fewer behavioral problems and have better relations with their caregivers, reduced incidence of depression, and reduced cognitive decline7,12,13.

For Teri and Logsdon14, one of the most debilitating consequences of dementia is the gradual loss of ability to perform rewarding and pleasurable daily activities. When caregivers recognize elders’ need for significant activities and provide activities that are individually

appropriate and pleasurable, elders frequently experience increased feelings of efficacy as well as reduced feelings of overload and despair14.

The lack or reduction of pleasurable activities has been strongly connected to depression15, a disease commonly associated with dementia. Elders presenting with dementia and depression participate less, communicate less, and find less pleasure in their activities14. Consequently, these individuals start to experience an environment deprived of pleasurable activities15. Thus, identifying pleasurable activities in which dementia patients can participate might aid in relieving depression symptoms and provide personal and interpersonal benefits for both patient and caregiver14. Adding pleasurable activities to this population’s environment might improve mood, reduce behavioral changes, and produce feelings of self-efficiency and accomplishment16.

In Brazil, we found no studies to relate the practice of pleasurable activities and health. Although searches were conducted in Bireme, PubMed, Google Scholar, and PsycINFO (2000 to 2015) to identify studies that objectify such correlations, no Brazilian studies of pleasurable activities for elders were located. Therefore, Brazilian culture needs instruments that evaluate engagement in pleasurable activities and support, providing important information for interventional programs that target improvement in quality of life for individuals with dementia. Until now, Brazil has had no standardized measurements of individuals with cognitive impairment for rate of engagement in pleasurable activities. One instrument is available for our culture, adapted by Ferreira and Barham17; however, it targets elders without cognitive impairment.

The Pleasant Events Schedule-Alzheimer’s Disease (PES-AD) has been described as useful for identifying pleasurable activities for patients with Alzheimer’s disease18, and it can also be used for patients with other types of dementia or cognitive impairment. The long version presents 53 items, and the short version 20. Studies show that both versions have good internal consistency, with Cronbach’s alpha values ranging from 0.76 to 0.95, besides correlation of 0.91 to 0.95 between the long and short versions; furthermore, both versions display a correlation with the severity of depression in elders with Alzheimer’s disease18. Because the short version presents fewer items, it evaluates broader characteristics, therefore presenting

96 Saviotti KRSS et al. / Arch Clin Psychiatry. 2016;43(5):95-102

less cultural discrepancy. Thus, we adapted the 20-item version to Brazilian Portuguese.

Given the background above, this paper presents results of the PES-AD’s cross-cultural adaptation for Brazilian Portuguese, making possible future validation studies. This research project has been approved by the Ethical Committee of São Paulo Federal University (Unifesp), following the rules of resolution 196/96.

Methods

The PES-AD’s cross-cultural adaptation process was based on the recommendations of Guillemin19, and Beaton et al.20, and is presented in Figure 1.

professor in languages. Committee members reviewed every version, considering the translations’ semantic, idiomatic, cultural, and conceptual equivalencies in their decisions. Semantic equivalency indicates whether words used mean the same thing or represent the same idea in both languages. Idiomatic equivalency involves colloquial expressions that must be congruent with the culture to which the instrument is being adapted. Cultural or experiential equivalence verifies that each item is consistent with the culture to which the instrument is being adapted. Lastly, conceptual equivalency confirms that the significance (concept) of words and expressions is the same in both the original culture and the culture to which the instrument is adapted. For example, the concept of family can differ between a culture that defines it as “nuclear” and one that defines it as “extended” (Beaton, 1995).

For equivalence evaluation, the percentage accepted as equivalent was 0.8 or 80% among the specialists. Items that obtained lesser percentages were modified and again judged by the specialists, to suit them to Brazilian Portuguese culture.

In the pre-test all pacticipantes signed an Informed Consent Form.

Results

Table 1 presents the synthesis of translations and discrepant items in the translation phase. Discrepancies were identified in items 1, 2, 3, 8, and 9 and were discussed among translators; they reached consensus based on the most accessible language form, considering that the instrument is addressed to people with different levels of education. On item 13, the words “strolling through the mall” were added after clarification by the author that, in her culture, shopping would be used when meaning to stroll without buying. This item’s final translation was the version that would represent the most similar idea according to the author’s explanation: buying things or strolling through the mall. Translated versions of items 27 and 31 were combined to widen their reach in Brazilian Portuguese culture. A discrepancy on item 30 was also resolved among interpreters so that the language would be as accessible as possible. Table 2 presents the back-translations’ synthesis.

Versions by back-translators were identical or very similar to the original instrument: no discrepancies led to any changes in the instrument’s synthesis. Cultural equivalency for item 3, “This schedule contains a list of events or activities that people sometimes enjoy”, was translated as “This schedule contains a list of events or activities that people sometimes appreciate”, obtaining a first-evaluation percentage of 0.6. The item was modified according to specialists’ suggestions: “sometimes enjoy” was changed to “usually enjoy” so it would better cohere with Brazilian culture; on evaluation after modification, the item obtained a percentage of 1.

Item 7, “The second time, rate each event on how much your relative enjoys the activity”, was translated as “The second time, rate how much your relative enjoys the activity”, which also obtained a percentage of 0.6. The specialist committee’s suggestion was to modify “The second time” to “On the second time” and to add a translation of “each event”, making the item “On the second time, rate each event on how much your relative enjoys the activity”, so that the item was equivalent in both languages.

Item 18, “Shopping, buying things”, was initially translated as “buying things or strolling through the mall”, obtaining a percentage of 0.4 for semantic equivalency. According to the committee, English has the same meaning, thus not presenting semantic equivalency in Brazilian Portuguese. It was explained to them that for the instrument’s author, shopping meant strolling without the purpose of buying things. Additionally, specialists observed that not every Brazilian city has shopping malls, suggesting that the item should be modified to “buying things or window shopping”. After this modification, the item was evaluated at 1.

According to some specialists, translation of item 22, “Laughing”, to “Laughing”, was too embracing, causing it to receive an initial score of 0.6 on the first idiomatic and conceptual evaluations. According to

Step 1 Translation to PortugueseThree interpreters T1, T2, & T3

Step 2 Translation Synthesis T1, T2, & T3Discrepancies resolutions and formulation of the first version os PES-AD

Step 3Retro-translationThree retro-translators B1, B2, & B3

Step 4 Specialist CommitteeEvaluation of equivalency: semantic, idiomatic, cultural and conceptual and formulation of the 2nd translated version of the PES-AD

Step 5 Pre-testTesting of the Scale on targeted population and formulation of the final vesion

Figure 1. Cross-cultural Adaptation Steps.

Interpreters fluent in both languages (English, the instrument’s original language, and Portuguese) made three translations to Portuguese. Two were researchers in the issues to be addressed (T1, T2), and the third had no previous knowledge of the concepts and no history of clinical or medical knowledge (T3). Results were discussed among the interpreters in order to synthetize translations and resolve discrepancies between versions.

After synthesis of the translations, the first PES-AD version in Portuguese was formulated. This version was then back-translated into the original language (English) by three English professors (B1, B2, B3), different from the first interpreters, but also fluent in the instrument’s original language, one of them with English as a first language. None of them had knowledge of the subject or concepts to be studied. A synthesis of back-translations was compared to the original version, and discrepancies were resolved with the original instrument’s authors (Teri and Logsdon).

After the instrument’s translation and back-translation, a specialist committee was gathered to evaluate the instrument’s equivalencies. With the goal of consolidating all versions, this committee was constituted of three health professionals, one translator, a professor in languages, and a back-translator, also a

97Saviotti KRSS et al. / Arch Clin Psychiatry. 2016;43(5):95-102

the specialists’ guidance, and after consulting the instrument’s author, the item received a percentage of 1 after being modified to “Laughing

at situations or events”. The remaining items received agreement of 0.8 or higher. Table 3 presents the equivalency evaluation’s final score.

Table 1. Translation synthesis for Pleasant Events Schedule-Alzheimer’s Disease into Brazilian PortugueseItems of the original version T1 T2 T3 Synthesis

1 Instructions: This schedule contains a list of events or activities that people sometimes enjoy

Instruções: Esta tabela contém uma lista de eventos ou atividades que as pessoas costumam apreciar

Esta agenda contém uma lista de eventos ou atividades que as pessoas às vezes gostam

Instruções: Esta escala contém uma lista de eventos ou atividades que as pessoas às vezes gostam

Instruções: Esta escala contém uma lista de eventos ou atividades que as pessoas costumam apreciar

2 It is designed to find out about things your relative has enjoyed during the past month

Ela está elaborada de forma a descobrir sobre coisas que o seu parente desfrutou durante o mês passado

Ela foi desenvolvida para descobrir coisas que seu parente tem gostado de fazer durante o último mês

Ela é projetada para descobrir sobre coisas que seu parente gostou de realizar durante o último mês

Foi desenvolvida para identificar atividades que seu parente gostou de realizar durante o último mês

3 Please rate each item twice. The first time, rate each item on how many times it happened in the past month (frequency); the second time, rate each event on how much your relative enjoys the activity

Por favor, avalie cada atividade duas vezes. No primeiro momento, diga quantas vezes a atividade aconteceu no mês passado (frequência); no segundo momento, diga o quanto seu parente se divertiu na atividade

Por favor, avalie cada item duas vezes. A primeira avaliação é sobre quantas vezes o item ocorreu no mês passado (frequência), e a segunda vez, avalie o quanto seu parente gosta/apreciar da/a atividade

Por favor, avalie cada item duas vezes. A primeira vez, avalie quantas vezes a atividade aconteceu no último mês (frequência); a segunda vez, avalie o quanto seu parente gostou da atividade

Por favor, avalie cada item (atividade) duas vezes. A primeira vez, avalie quantas vezes a atividade aconteceu no último mês (frequência); a segunda vez, avalie o quanto seu parente gostou da atividade (agradabilidade)

4 Frequency Frequência Frequência Frequência Frequência5 Not at all Nunca Nunca ou nenhuma vez Nunca Nunca6 1 to 6 times De uma a seis vezes 1 a 6 vezes 1 a 6 vezes 1 a 6 vezes7 7 or more times Sete ou mais vezes 7 vezes ou mais 7 ou mais vezes 7 ou mais vezes8 Enjoy Se divertiu Apreciar Gostou Gostou9 Not at all De forma nenhuma Nunca ou nenhuma vez Nem um pouco Nem um pouco

10 Somewhat Um pouco Mais ou menos Um pouco Um pouco11 A great deal Muito Muito/Muitíssimo Muito Muito12 Being outside Estando fora de casa Estar ao ar livre Estar do lado de fora de casa Estar ao ar livre (admirando a

paisagem, caminhando etc.)13 Shopping, buying things Fazendo compras, comprando

coisasFazer compras Comprar coisas Fazer compras ou passear no

shopping14 Reading or listening to stories,

magazines, newspapersLendo revistas, jornais ou escutando histórias

Ler ou ouvir histórias, ler revistas e jornais

Ler ou ouvir histórias, revistas ou jornais

Ler ou ouvir histórias, ler revistas ou jornais

15 Listening to music Ouvindo música Ouvir música Ouvir música Ouvir música16 Watching TV Assistindo à TV Assistir à televisão Assistir à TV Assistir à televisão17 Laughing Rindo Rir Rir Rir18 Having meals with friends or

familyFazendo refeições com os amigos ou a família

Fazer refeições com amigos e/ou família

Realizar refeições com amigos ou familiares

Fazer refeições com amigos e/ou família

19 Making or eating snacks Fazendo ou comendo lanches Fazer ou comer lanches Preparar ou comer lanches Preparar ou comer lanches20 Helping around the house Ajudando no trabalho doméstico Ajudar nas tarefas da casa Ajudar nas tarefas de casa Ajudar nas tarefas da casa21 Being with family Estando com a família Estar com a família Estar com a família Estar com a família22 Wearing favorite clothes Usando as roupas preferidas Vestir roupas favoritas Vestir roupas favoritas Vestir roupas favoritas23 Listening to the sounds of

nature (birdsongs, wind, surf)Ouvindo os sons da natureza (o canto de pássaros, o vento, as ondas do mar)

Ouvir sons da natureza (cantos de pássaros, barulho do vento e/ou arrebentação)

Ouvir os sons da natureza (canto dos pássaros, vento, mar)

Ouvir os sons da natureza (canto de pássaros, vento, ondas do mar)

24 Getting/sending letters, cards Recebendo ou enviando cartas, cartões

Receber ou enviar cartas, cartões

Receber ou enviar cartas ou cartões-postais

Receber ou enviar cartas e/ou cartões

25 Going on outings (to the park, a picnic etc.)

Saindo para se divertir (no parque, num piquenique etc.)

Fazer excursões (para parques, piqueniques etc.)

Ir a passeios (no parque, num piquenique etc.)

Ir a passeios (parque, piquenique, restaurantes ou museus etc.)

26 Having coffee, tea etc. with friends

Tomando café, chá etc. com os amigos

Tomar café, chá etc. com amigos



27 Being complimented Sendo elogiado ou homenageado

Ser elogiada Ser elogiado Ser elogiado e/ou homenageado

28 Exercising (walking, dancing etc.)

Se exercitando (caminhando, dançando etc.)

Fazer exercícios (caminhar, dançar etc.)

Exercitar (dançar, caminhar etc.)

Fazer exercícios (caminhar, dançar etc.)

29 Going for a ride in the car Dando uma volta de carro Dar uma volta de carro Sair para um passeio de carro Dar uma volta de carro30 Grooming (wearing makeup,

shaving, having a haircut)Cuidando da aparência (usando maquiagem, se barbeando, tendo o cabelo cortado)

Se autocuidar (maquiar-se, barbear-se, cortar o cabelo)

Embelezar-se (usar maquiagem, barbear, cortar o cabelo)

Cuidar da aparência (usar maquiagem, barbear, cortar o cabelo)

31 Recalling and discussing past events

Relembrando e discutindo fatos do passado

Recordar e discutir eventos passados

Recordar e discutir eventos passados

Recordar e discutir fatos e/ou eventos passados


Table 2. Back-Translation Synthesis for Pleasant Events Schedule-Alzheimer’s Disease into Brazilian Portuguese1st version items B1 B2 B3 Back-translation

synthesisOriginal instrument items

1 Instruções: Esta escala contém uma lista de eventos ou atividades que as pessoas costumam apreciar

Instructions: This scale contains a list of events or activities that people usually appreciate

Instructions: This scale contains a list of events or activities that people usually enjoy

Instructions: This scale contains a list of events and activities that people usually enjoy doing

Instructions: This scale contains a list of events or activities that people usually enjoy

Instructions: This schedule contains a list of events or activities that people sometimes enjoy

2 Foi desenvolvida para identificar atividades que seu parente gostou de realizar durante o último mês

It was developed to identify activities that your relative enjoyed making during the last month

It was developed to identify activities that your relative liked to perform during the last month

It has been developed in order to identify the activities that your relative has enjoyed doing in the last month

It has been developed in order to identify the activities that your relative has enjoyed doing in the last month

It is designed to find out about things your relative has enjoyed during the past month

3 Por favor, avalie cada item (atividade) duas vezes. A primeira vez, avalie quantas vezes a atividade aconteceu no último mês (frequência); a segunda vez, avalie o quanto seu parente gostou da atividade (agradabilidade)

Please, evaluate each item (activity) twice. The first time, evaluate how many times the activity happened in the last month (frequency); the second time, evaluate how much did your relative enjoy the activity (pleasantness)

Please, evaluate each item (activity) twice. The first time, evaluate how many times the activity happened last month (frequency); the second time, evaluate how much your relative liked the activity (pleasantness)

Please, evaluate each item (activity) twice. The first time round, evaluate how many times the activity has been done during the last month (the frequency of the activity); the second time, evaluate to what extent your relative has enjoyed the activity (enjoyability)

Please, evaluate each item (activity) twice. The first time, evaluate how many times the activity happened in the last month (frequency); the second time, evaluate how much did your relative enjoy the activity (pleasantness)

Please, rate each item twice. The first time, rate each item on how many times it happened in the past month (frequency); the second time, rate each event on how much your relative enjoys the activity

4 Frequência Frequency Frequency Frequency Frequency Frequency5 Nunca Never Never Never Never Not at all6 1 a 6 vezes 1 to 6 times 1 to 6 times 1 to 6 times 1 to 6 times 1 to 6 times7 7 ou mais vezes 7 or more times 7 or more 7 or more times 7 or more times 7 or more times8 Agradabilidade (o quanto

gostou da atividade)Pleasantness (how much he/she liked the activity)

Pleasantness (how much he/she liked it)

Enjoyability (how much your relative enjoyed the activity)

Enjoyability (how much your relative enjoyed the activity)

Enjoy

9 Nem um pouco Nothing at all Not a bit Not at all Not at all Not at all10 Um pouco A little bit A little A bit (slightly enjoyed) A little Somewhat11 Muito A lot Very A lot A lot A great deal12 Estar ao ar livre

(admirando a paisagem, caminhando etc.)

Being outdoors (admiring the landscape, walking etc.)

Being outdoors (admiring the scenery, walking etc.)

Being outdoors (admiring scenery, walking etc.)

Being outdoors (admiring scenery, walking etc.)

Being outside

13 Fazer compras ou passear no shopping

Shopping or walking in the mall

Doing sightseeing or shopping at the mall

Shopping or visiting shopping centers

Shopping or visiting shopping centers

Shopping, buying things

14 Ler ou ouvir histórias, ler revistas ou jornais

Reading or listening to stories, reading magazines or newspapers

Reading or hearing stories, reading magazines or newspapers.



Reading or listening to stories, magazines, newspapers

15 Ouvir música Listening to music Listening to music Listening to music Listening to music Listening to music16 Assistir à televisão Watching TV Watching TV Watching TV Watching TV Watching TV17 Rir Laughing Laughing Laughing Laughing Laughing18 Fazer refeições com

amigos e/ou famíliaHaving meals with friends and/or family

Having meals with friends and/or family

Making meals with friend and/or family

Making meals with friend and/or family

Having meals with friends or family

19 Preparar ou comer lanches

Preparing or eating snacks




Making or eating snacks

20 Ajudar nas tarefas da casa

Helping in the household tasks

Helping with the housework

Helping around the house (chores, cleaning, tidying up)

Helping around the house (chores, cleaning, tidying up)

Helping around the house

21 Estar com a família Being with family Being with family Spending time with family

Being with family Being with family

22 Vestir roupas favoritas Wearing their favorite clothes

Dressing in their favorite clothes

Wearing their favorite clothes



23 Ouvir os sons da natureza (canto de pássaros, vento, ondas do mar)

Hearing the sounds of nature (birds singing, wind, sea waves)

Hear sounds of nature (birds singing, wind, ocean waves)

Listening to sounds of nature (birds singing, the wind, waves)

Listening to sounds of nature (birds singing, the wind, waves)

Listening to the sounds of nature (birdsong, wind, surf)

24 Receber ou enviar cartas e/ou cartões

Receiving or sending letters and/or cards


Receiving or sending cards or postcards


Getting/sending letters, cards

continuation


1st version items B1 B2 B3 Back-translation synthesis

Original instrument items

25 Ir a passeios (parque, piquenique, restaurantes ou museus etc.)

Going on rides (parks, picnics, restaurants, or museums etc.)

Going out (to parks, picnic, restaurants, or museums etc.)

Taking walks and visiting places (parks, picnics, restaurants, museums etc.)

Going out (to parks, picnic, restaurants, or museums etc.)

Going on outings (to the park, a picnic etc.)

26 Tomar café, chá etc. com amigos

Having some coffee or tea etc. with friends

Drinking coffee, tea etc. with friends



Having coffee, tea, etc. with friends

27 Ser elogiado e/ou homenageado

Being praised and/or honored


Being praised and/or honored by others


Being complimented

28 Fazer exercícios (caminhar, dançar etc.)

Doing exercises (walking, dancing etc.)

Doing exercises (walking, dancing etc.)

Exercising (walking, dancing etc.)



29 Dar uma volta de carro Going for a car ride Strolling in the car Going for a ride in the car Going for a ride in the car Going for a ride in the car30 Cuidar da aparência (usar

maquiagem, barbear, cortar o cabelo)

Taking care of the look (doing makeup, shaving, cutting the hair)

Caring for appearance (wearing makeup, shaving, cutting hair)

Taking care of their appearance (using makeup, shaving, cutting their hair)

Taking care of their appearance (using makeup, shaving, cutting their hair)

Grooming (wearing makeup, shaving, having a haircut)

31 Recordar e discutir fatos e/ou eventos passados

Remembering and discussing facts and/or past events


Remembering and discussing facts and talking about past events


Recalling and discussing past events

Table 3. Evaluation of Equivalencies for Pleasant Events Schedule-Alzheimer´s DiseaseItem in English Final version in Portuguese Equivalency Final %

01 PES – Pleasant Events Schedule PES – Escala de Eventos Prazerosos Semantic 0.8Idiomatic 1Cultural 0.8

Conceptual 102 Instructions Instruções Semantic 1

Idiomatic 1Cultural 1

Conceptual 103 This schedule contains a list of events or activities that

people sometimes enjoyEsta escala contém uma lista de eventos ou atividades que as pessoas costumam gostar de fazer

Semantic 1Idiomatic 1Cultural 1

Conceptual 104 It is designed to find out about things your relative has

enjoyed during the past monthFoi desenvolvida para identificar atividades que seu parente gostou de realizar durante o último mês

Semantic 1Idiomatic 1Cultural 0.8

Conceptual 0.805 Please rate each item twice Por favor, avalie cada item (atividade) duas vezes Semantic 1

Idiomatic 0.8Cultural 1

Conceptual 106 The first time, rate each item on how many times it

happened in the past month (frequency)Na primeira vez, avalie quantas vezes a atividade aconteceu no último mês (frequência)

Semantic 0.8Idiomatic 0.8

Cultural 0.8Conceptual 1

07 The second time, rate each event on how much your relative enjoys the activity

Na segunda vez, avalie o quanto seu parente gostou da atividade, considerando cada item

Semantic 1Idiomatic 0.8Cultural 1

Conceptual 108 Frequency Frequência Semantic 1


Conceptual 109 Not at all Nunca Semantic 0.8

Idiomatic 0.8Cultural 0.8

Conceptual 0.8continuation


Item in English Final version in Portuguese Equivalency Final %10 1 to 6 times 1 a 6 vezes Semantic 1


Conceptual 111 7 or more times 7 ou mais vezes Semantic 1


Conceptual 112 Enjoy Agradabilidade Semantic 0.8


Conceptual 0.813 Not at all Nem um pouco Semantic 1


Conceptual 114 Somewhat Um pouco Semantic 1


Conceptual 115 A great deal Muito Semantic 0.8


Conceptual 0.816 Activity Atividade Semantic 1


Conceptual 117 Being outside Estar ao ar livre (admirando a paisagem, caminhando etc.) Semantic 0.8


Conceptual 0.818 Shopping, buying things Fazer compras ou olhar vitrines Semantic 1


Conceptual 119 Reading or listening to stories, magazines, newspapers Ler ou ouvir histórias, ler revistas ou jornais Semantic 1


Conceptual 120 Listening to music Ouvir música Semantic 1


Conceptual 121 Watching TV Assistir à televisão Semantic 1


Conceptual 122 Laughing Rir de situações ou acontecimentos Semantic 1


Conceptual 123 Having meals with friends or family Fazer refeições com amigos e/ou família Semantic 1


Conceptual 1continuation


Item in English Final version in Portuguese Equivalency Final %24 Preparing or eating snacks Preparar ou comer lanches Semantic 1


Conceptual 125 Helping around the house Ajudar nas tarefas da casa Semantic 1


Conceptual 126 Being with family Estar com a família Semantic 1


Conceptual 127 Wearing favorite clothes Vestir roupas favoritas Semantic 1


Conceptual 128 Listening to the sounds of nature (birdsong, wind, surf) Ouvir os sons da natureza (canto de pássaros, vento, ondas

do mar)Semantic 1Idiomatic 0.8Cultural 1

Conceptual 129 Getting/sending letters, cards Receber ou enviar cartas e/ou cartões Semantic 1

Idiomatic 1Cultural 0.8

Conceptual 130 Going on outings (to the park, a picnic etc.) Ir a passeios (parque, piquenique, restaurantes ou museus

etc.)Semantic 1Idiomatic 0.8Cultural 0.8

Conceptual 0.831 Having coffee, tea etc. with friends Tomar café, chá, etc. com amigos Semantic 1


Conceptual 132 Being complimented Ser elogiado e/ou homenageado Semantic 0.8


Conceptual 0.833 Exercising (walking, dancing etc.) Fazer exercícios (caminhar, dançar etc.) Semantic 1


Conceptual 134 Going for a ride in the car Dar uma volta de carro Semantic 1


Conceptual 135 Grooming (wearing makeup, shaving, having a haircut) Cuidar da aparência (usar maquiagem, barbear, cortar o

cabelo)Semantic 1Idiomatic 1Cultural 1

Conceptual 136 Recalling and discussing past events Recordar e discutir fatos e/ou eventos passados Semantic 1


Conceptual 0.8

In July 2014, on the fifth step of the cross-cultural adaptation, a pre-test using the instrument’s final Portuguese version was administered to a sample of caregivers of elders with cognitive impairment. Each caregiver was interviewed on his or her understanding of each item. This step’s objective was to detect

possible mistakes and ascertain occasional comprehension problems with any sentences or items. Ten caregivers of elders with cognitive impairment, all from the city of Belo Horizonte, participated. Their average age was 47.2 and average education was 16.2 years.


Discussion

Caregivers rate PES-AD items twice. First, the item is scored according to the frequency at which the event happened during the last 30 days, using a three-point scale with the options not at all, 1 to 6 times, and 7 or more times. Second, each item is rated according to how pleasant the activity was for the elder: not at all, somewhat, or a great deal. The instrument might also be used with caregivers of elders with any type of cognitive impairment.

According to Beaton20, subjecting an instrument to the entire process of cross-cultural adaptation allows it to approach very near the original instrument, but, at the same time, to be adapted to the target culture. This permits measurement to be used in multicenter studies. And in this way, cross-cultural adaptation is the first step in creating studies that investigate participation in pleasurable activities by elders presenting cognitive impairment and correlation with their health promotion. Adapting the PES-AD for the Brazilian population through systematization of this process has granted the instrument content validity in the target language. In other words, the instrument is comprehended well by those completing it.

Both quantitative and qualitative results obtained from this scale are of great importance for the elaboration of programs for intervention and rehabilitation of elders with cognitive impairment. The scale also allows therapists to aid caregivers in finding ways to enhance the amount of pleasurable activities for elders, contributing mainly to reduction of depression symptoms. Hence, the PES-AD allows therapists and caregivers to work together to develop structured treatment plans for elders with cognitive impairment.

During the pre-test, many family members reported difficulties explaining the items’ meaning in different words, eventually repeating the same words. We believe this is due to the scale items’ simplicity and to concern about comprehension during cross-cultural adaptation. We believe this is a positive point for the PES-AD Portuguese-language final version, for it shows that the instrument was translated broadly and is easily accessed by a wide variety of people.

However, future validation studies must also be conducted so that the instrument is safe for clinical use and provides a basis for research with the Brazilian Portuguese population. In brief, cross-cultural adaptation generated a usable, short, Brazilian Portuguese version of the instrument that contains 20 items and takes around 15 minutes to administer.

Disclosure

None of the authors has conflict of interest.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

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4. Seidlitz L, Lyness JM, Conwell Y, Duberstein PR, Cox C. Profile of discrete emotions in affective disorders in older primary care patients. Gerontologist. 2001;41(5):643-51.

5. Skinner BF. Behavior modification. Science. 1974;185(4154):813.6. Buchman AS, Boyle PA, Wilson RS, Fleischman DA, Leurgans S, Bennett

DA. Association between late-life social activity and motor decline in older adults. Arch Intern Med. 2009;169(12):1139-46.

7. Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integra-ted lifestyle in late life might protect against dementia. Lancet Neurol. 2004;3(6):343-53.

8. Glass TA, De Leon CF, Bassuk SS, Berkman LF. Social engagement and depressive symptoms in late life: longitudinal findings. J Aging Health. 2006;18(4):604-28.

9. James BD, Boyle PA, Buchman AS, Bennett DA. Relation of late-life social activity with incident disability among community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2011;66(4):467-73.

10. James BD, Wilson RS, Barnes LL, Bennett DA. Late-life social activity and cognitive decline in old age. J Int Neuropsychol Soc. 2011;17(6):998-1005.

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12. Schreiner AS, Yamamoto E, Shiotani H. Positive affect among nursing home residents with Alzheimer’s dementia: the effect of recreational activity. Aging Ment Health. 2005;9(2):129-34.

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14. Teri L, Logsdon RG. Identifying pleasant activities for Alzheimer’s disease patients: the pleasant events schedule-AD. Gerontologist. 1991;31(1): 124-7.

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Original article

Address for correspondence: Mônica Sanches Yassuda. Av. Arlindo Bettio, 1000, Prédio I-1, sala 322-J, Ermelino Matarazzo – 03828-000 – São Paulo, SP, Brazil. E-mail: [email protected]

The Geriatric Anxiety Inventory in primary care: applicability and psychometric characteristics of the original and short formlaís dos santos vinholi e silva¹, glauCia Martins de oliveira¹, Juliana eMy yoKoMizo 2, laura Ferreira saran2, Cássio MaChado de CaMPos Bottino2, MôniCa sanChes yassuda¹

1 School of Arts, Sciences and Humanities, University of São Paulo (USP), São Paulo, SP, Brazil.2 Old Age Research Group (PROTER), Institute of Psychiatry, University of São Paulo School of Medicine (FMUSP), São Paulo, SP, Brazil.


AbstractBackground: Generalized anxiety disorder (GAD) has negative implications for people’s lives, but is often underdiagnosed in the elderly. There is a shortage of instruments to assess geriatric anxiety. Objectives: To analyze the applicability and psychometric properties of the Portuguese version of the Geriatric Anxiety Inventory (GAI) and its short form (GAI-SF) within primary care. Methods: Fifty-five seniors were classified as non-demented by a multidisciplinary panel. The protocol included the GAI, the Self-Reporting Questionnaire (SRQ-20), the Depression Scale D-10, Mini-Mental State Examination (MMSE), Bayer Scale for Activities of Daily Living (B-ADL) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). A sub-sample also completed the Beck Anxiety Inventory (BAI). Results: The GAI and GAI-SF showed good internal consistency (0.89; 0.62, respectively) and test-retest stability (0.58, 0.97). The GAI and GAI-SF correlated significantly with the SRQ-20 (0.74, 0.55) and BAI (0.75, 0.58). Discussion: The psychometric characteristics of the Brazilian versions of the GAI and GAI-SF suggest these instruments are suitable for application in the Brazilian elderly population within the primary care setting.

Silva LSV et al. / Arch Clin Psychiatry. 2016;43(5):103-6

Keywords: Elderly, anxiety, GAI, primary care.

Introduction

With the growth in the elderly population both in Brazil and worldwide, the demand for healthcare services by this group is set to rise. The first contact of the elderly with the public health service normally occurs in primary care¹. The healthcare treatment of older adults in primary care should entail multidimensional diagnostic testing, including screening for neuropsychiatric syndromes that can negatively impact cognitive performance and quality of life.

The most prevalent neuropsychiatric syndromes in the elderly population include major depression, anxiety disorders, mild cognitive impairment and dementias2,3. Patients with anxiety disorders have poorer quality of life, are less productive and have higher rates of morbidity, mortality and comorbidity. Anxiety disorders also place a high social burden, both directly, in the form of individual suffering, for example, and indirectly, through the high demand for medical assistance to manage the physical symptoms resulting from anxiety. These social costs can be exacerbated by underevaluation, underdiagnosis and consequent inadequate treatment of this group of disorders3.

Generalized anxiety disorder (GAD) is the most common anxiety disorder in the elderly, whose prevalence tends to increase with aging4. GAD affects cognition and is predominantly associated with decline in memory3,5. Additionally, studies have shown that the risk of cardiac events is greater in patients with GAD3. The prevalence of GAD in older adults varies across studies in the literature. Copeland et al.6 reported a GAD prevalence of 0.7% and 1.1% in elderly from New York and London, respectively. Lindesay et al.7 found a 3.7% GAD prevalence rate in a study involving 890 individuals older than 65 years living in the United Kingdom. In a study of 3,035 individuals aged 55-85 years, Gonçalves et al.3 found that 2.8% were diagnosed with GAD.

Some population-based studies suggest that anxious symptoms affect around 26% of individuals aged 65 or over8,9. In a sample of 3,041 older adults aged 70-79, Mehta et al.10 noted that 15% exhibited anxious symptoms. Xavier et al.11 found that 10.6% of a sample of 77 elderly individuals from Veranópolis, Rio Grande do Sul, presented

anxious symptoms. In a study by Maia et al.12 of 327 elderly from Montes Claros, Minas Gerais, 29.3% of the sample had anxious and depressive symptoms.

Although GAD has serious consequences, the disorder is often underassessed in the elderly. There is a lack of specific instruments while depressive symptoms tend to be given more attention than anxious symptoms. In this context, Pachana et al.13 developed the Geriatric Anxiety Inventory (GAI), a brief screening instrument for assessing anxious symptoms in the elderly. In the validation study of the 20-item GAI, the Cronbach’s alpha coefficient was 0.91 for normal elderly and 0.93 for patients of the psychogeriatric service. Convergent validity was determined by comparing the GAI against the Generalized Anxiety Disorder Severity Scale (GADS) (r = 0.57), the State-Trait Anxiety Inventory (STAI) (r = -0.44), Beck’s Anxiety Inventory (BAI) (r = 0.63), the Penn State Worry Questionnaire (PSWQ) (r = 0.70) and the Positive and Negative Affect Schedule (PANAS) (r = 0.58 and r = -0.34, respectively). Test-retest reliability was found to be high (r = 0.91). Cut-offs indicating presence of GAD were defined as 10/11, with 84% specificity and 75% sensitivity. The GAI has recently been translated and validated in other countries including China, Italy and Spain14-16 where the psychometric parameters of the new versions have proven satisfactory.

More recently, the authors of the GAI developed a short version of the scale (GAI-SF)17, comprising only five of the original items. The GAI-SF has good internal consistency (α = 0.81) and adequate convergent and divergent validity. These results have been confirmed in a clinical and non-clinical sample18.

In Brazil, Martiny et al.19 carried out the translation and semantic adaptation of the GAI into Brazilian Portuguese and performed a pilot application. Massena et al.20 evaluated the psychometric properties of the Brazilian GAI in a sample of 72 elderly recruited from an outpatient psychogeriatric clinic and community centers. The internal consistency (α = 0.91) and test-retest reliability (p = 0.85, p < 0.001) were high. Correlations with the BAI and the STAI were also high (p = 0.68, p < 0.001; p = 0.61, p < 0.001, respectively) evidencing concurrent validation. The cut-off point of 13 showed sensitivity of 83.3% and specificity of 84.6% for detecting GAD.

104 Silva LSV et al. / Arch Clin Psychiatry. 2016;43(5):103-6

To date, no studies have been found on the GAI in the primary care setting while the short form (GAI-SF) has yet to be studied in Brazil. Bearing in mind that Primary Care Units are the entry point to healthcare in this country, and given that neuropsychiatric disorders are often underdiagnosed, assessing the applicability and psychometric characteristics of both the GAI and GAI-SF in the primary care setting is of paramount importance. Therefore, the objective of the present study was to assess some of the psychometric parameters of the Brazilian Portuguese version of the GAI and the GAI-SF to determine their concurrent and convergent validity, internal consistency and temporal stability, among elderly users of two Primary Care Units located in the eastern region of the city of São Paulo.

Methods

Participants

A total of 102 individuals aged over 60 years, registered in two Primary Care Units located in the eastern region of São Paulo, took part in a larger study which aimed to validate cognitive screening instruments. For the present study, the sample was composed of 55 participants who were classified as unimpaired in cognitive and functional performance. A sub-sample of 33 normal controls accepted the invitation for a re-assessment, in order to analyze the temporal stability of the GAI and GAI-SF. This new application was performed within an average of 30 weeks after the first visit. Also, a sub-sample of the group who was re-assessed (n = 15) completed the BAI.

There were no significant differences between the baseline and follow-up sub-sample (n = 33) (mean age = 73.81, SD = 6.51; mean schooling = 4.19, SD = 3.04; mean MMSE = 23.94, SD = 3.80) and the overall group of normal controls (n = 55). The group who completed the BAI in the follow-up (n = 15) was also statistically similar to the baseline and total follow-up sample (mean age = 72.92, SD = 6.59; mean schooling = 3.58, SD = 2.10; mean MMSE = 23.77, SD = 4.78).

To assure absence of dementia in the present sample, participants completed cognitive, functional and neuropsychiatric instruments. The protocols were later discussed by neuropsychologists and a psychogeriatrician and the participants were grouped into those with and without dementia, based on the results of the MMSE21, CAMCOG22, IQCODE23,24, B-ADL25, D-1026 and supplementary information (age, educational level, comorbidities). Cut-off scores from previous national studies were used for each instrument27. The gold standard for dementia diagnosis was clinical, based on the DSM-IV criteria for dementia.

Individuals presenting severe visual and/or auditory deficits, signs of advanced dementia, neurological/psychiatric syndromes (except dementia), present or previous alcohol abuse or diagnosed with depression or delirium, were excluded. Patients with a significant number of depression symptoms (D-10 > 6) were also excluded.

Instruments

Economic classification was established using the sociodemographic questionnaire of ABIPEME Criteria Brazil28, which constitutes a socio-economic scale or classification built by attributing weights to a set of domestic items, in conjunction with the educational level of the head of the household.

The GAI was used to assess anxiety symptoms. Performance on the GAI-SF was calculated by tallying scores for questions 1, 6, 8, 10 and 11 of the GAI, in accordance with recommendations by the authors of the short scale17. The questions for the GAI-SF are: Question 1: I worry a lot of the time; Question 6: Little things bother me a lot; Question 8: I think of myself as a worrier; Question 10: I often feel nervous; Question 11: My own thoughts often make me nervous. These questions when analyzed as items in the full GAI scale had an item-total correlation from 0.388 to 0.552.

The GAI-SF score was extracted from the application of the GAI, and it was not applied separately. The sub-sample reassessed to determine temporal stability of both the GAI and GAI-SF also completed the BAI29 in order to provide a measure of convergent validity. The Self-Reporting Questionnarie (SRQ-20), which includes questions on anxiety symptoms, was used as an additional measure of convergent validity.

Procedures

The duration of the testing session was around 90 minutes. All participants filled out the Informed Consent Form prior to undergoing the first assessment. The project was approved by the Research Ethics Committee of the Municipal Secretariat for Health under the Research Protocol nº 476/11 and by the Research Ethics Committee of the University of São Paulo School of Medicine.

Statistical analyses

A descriptive analysis of the sociodemographic characteristics was carried out. Given that the variables exhibited normal distribution, parametric tests were employed. GAI and GAI-SF internal consistency was calculated using Cronbach’s α. Scores on the GAI and GAI-SF were compared for gender, age and education using ANOVAs. Convergent validity was assessed by correlating GAI and GAI-SF scores with total scores on the BAI and SRQ-20 using Pearson correlation test. For discriminant validity, GAI and GAI-SF scores were correlated with performance on the MMSE, IQCODE and B-ADL. Correlation between the first and second application of the GAI and GAI-SF was calculated using Pearson’s correlation. Statistical analysis was carried out using the SPSS v.17 software program. The level of significance adopted for the statistical tests was 5%, corresponding to a p-value < 0.05.

Results

The sample comprised 55 non-demented older adults, with a predominance of women (78.2%), individuals aged 70-79 years, and with 1-4 years of education (Table 1). The majority of participants reported household work as their main occupation and were classified into the C2 socioeconomic class. The clinical characteristics of the sample are described in Table 2.

The women had higher scores than men on both the GAI and GAI-SF, although this difference was not statistically significant (GAI: men M = 7.25, SD = 4.59; women M = 9.74, SD = 4.88; GAI-SF: men M = 2.67, SD = 1.61; women M = 3.14, SD = 1.42). After stratifying the elderly by age and education, no statistical difference between the groups for GAI and GAI-SF persisted (data not shown).

The GAI showed good internal consistency, with a Cronbach’s alpha of 0.89. The reliability analysis revealed a test-retest correlation of 0.58 (p < 0.001). The GAI-SF had internal consistency of 0.62 and test-retest correlation of 0.97 (p < 0.001).

The correlations (Table 3) revealed a significant association between scores on the GAI and GAI-SF with performance on the SRQ-20. During follow-up assessment, correlations of 0.75 (p = 0.002) between the GAI and the BAI, and of 0.58 (p = 0.031) between the GAI-SF and the BAI, were found. No significant correlations were found between the GAI or GAI-SF and age, education, MMSE, IQCODE or B-ADL scores. A significant correlation was found between the full 20-item GAI and the 5-item GAI-SF in the baseline assessment (r = 0.77, p < 0.001).

Discussion

The objective of the present study was to analyse validation parameters of the GAI and GAI-SF in a primary care setting. The analysis included determination of internal consistency, test-retest reliability, convergent validity with the SRQ-20 and BAI, as well as discriminant validity with the MMSE, IQCODE and B-ADL.

105Silva LSV et al. / Arch Clin Psychiatry. 2016;43(5):103-6

The results showed that the GAI and GAI-SF can be easily applied in primary care, including in the low-educated population. The GAI showed high internal consistency (0.89), proving comparable to the original validation study and the Brazilian version of the GAI20. Accordingly, Márquez-González et al.16 found a Cronbach’s alpha of 0.91 for the Spanish version of the GAI and Diefenbach et al.30, in a North-American sample, found an internal consistency of 0.93. In the present study, a satisfactory test-retest correlation of 0.58 was reported for the GAI, corroborating the results of Massena et al.20 who found a correlation of 0.68. In the study of Diefenbach et al.30, test-retest correlation was 0.95. These discrepant findings may be associated with the length of time between baseline and follow up assessments.

In the present study, internal consistency for the GAI-SF proved adequate (0.62) but lower than the one reported in the original study (0.81)17 and a more recent investigation (0.72)18, both involving Australian seniors. On the other hand, the temporal stability of the GAI-SF was high in the present study (0.97).

In general, the internal consistency and temporal stability for the GAI were lower in the present sample compared to previous studies. However, it should be noted that the present study had a smaller sample and was conducted in primary care with low-educated elderly. Additionally, the time elapsed between initial and post-test assessments varied across studies. These aspects might explain the disparities between the present and previous studies.

Previous studies have shown that women tend to have more anxious symptoms than men. In the study by Gonçalves et al.3, of the 84 patients diagnosed with GAD, 55 were women. In the study of Márquez-González et al.16, women had higher scores on the GAI. In the present study, women also had higher anxious symptomatology, with higher scores on the GAI, yet without statistical significance, perhaps due to small sample size.

In the follow up sub sample, the GAI and GAI-SF correlated significantly with the BAI, suggesting good convergent validity and corroborating the findings of previous studies13,17,18,20. A significant correlation was also found with the SRQ-20, which assesses common mental disorders and includes a number of questions on depression and anxiety. These results are similar to those found by Johnco et al.18 in a non-clinical sample. Satisfactory discriminant validity between the GAI and GAI-SF and scales assessing cognitive and functional domains was observed, again in line with previous studies18,20.

The results of the present study suggest that the psychometric characteristics of the Brazilian versions of the GAI and GAI-SF render these instruments suitable for application in the Brazilian elderly population in the primary care setting. Overall, the statements were readily understood by the elderly participants even in the presence of low education. Nevertheless, this study has some limitations to be addressed in future investigations. The sample studied was small and no comparison between elderly with and without anxiety disorders was made. The use of the GAI and GAI-SF in primary care has the potential to help to diagnose anxiety disorders among seniors. This may help to improve the treatment for this condition.

Table 1. Sociodemographic characterization of the sample (n = 55)Variables N %Sex

Men 12 21.8Women 43 78.2

Age Groups60-69 19 34.570-79 25 45.580 + 11 20.0Mean (SD) 72.78 (7.37)Median 74.00Minimum-Maximum 60-91

Education (in years)*Illiterate 9 16.41 – 4 years 23 41.85 + 22 40.0Mean (SD) 4.78 (3.56)Median 4.00Minimum – Maximum 0-17

OcupationHousework 13 23.6Manual Labor 34 61.8Qualified Labor 8 14.5

Socioeconomic Classification**Class B1 3 5.5Class B2 15 27.3Class C1 14 25.5Class C2 18 32.7Class D 2 3.6

* Missing data = 1; ** Missing data = 3.

Table 2. Clinical characterization of the sample (n = 55)Variable Mean SD± Minimum Median MaximumMMSE 23.98 3.76 16.00 25.00 30.00IQCODE 3.23 0.23 2.34 3.20 3.66B-ADL 2.61 1.34 1.00 2.12 6.09SRQ-20 5.65 3.69 0.00 5.00 14.00D-10 3.15 2.10 0.00 3.00 8.00GAI 9.20 4.89 0.00 8.00 20.00GAI-SF 3.04 1.44 0.00 3.00 5.00

MMSE: Mini-Mental State Examination; IQCODE: The Informant Questionnaire on Cognitive Decline in the Elderly; B-ADL: Bayer Activity of Daily Living; SRQ: Self-Reporting Questionnaire; D-10: Depression scale with tem items; GAI: Geriatric Anxiety Inventory; GAI-SF: Geriatric Anxiety Inventory Short Form.

Table 3. Correlation matrix for study variables (n = 55) GAI GAI-SF Age Education SRQ-20 MMSE IQCODE

Age r 0.02 0.073Education r -0.12 -0.12 -0.13SRQ-20 r 0.74** 0.55** 0.17 0.08MMSE r -0.02 -0.02 0.37** -0.32* 0.00IQCODE r 0.08 0.06 -0.096 0.40** 0.75 -0.32*B-ADL r 0.08 -0.09 -0.15 0.27* 0.14 -0.39** 0.49**

MMSE: Mini-Mental State Examination; IQCODE: The Informant Questionnaire on Cognitive Decline in the Elderly; B-ADL: Bayer Activity of Daily Living; SRQ: Self-Reporting Questionnaire; D-10: Depression scale with ten items; GAI: Geriatric Anxiety Inventory; GAI-SF: Geriatric Anxiety Inventory Short Form.** Correlation significance p < 0.01; * Correlation significance p < 0.05.

106 Silva LSV et al. / Arch Clin Psychiatry. 2016;43(5):103-6

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Original article

Address for correspondence: Hélio Elkis. Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Psiquiatria. Rua Ovídio Pires de Campos, 785, Cerqueira César – 05403-010 – São Paulo, SP, Brazil. Telephone: +55 (11) 2661-7531. E-mail: [email protected].

Social dysfunction and skills in schizophrenia: relationship with treatment response and severity of psychopathologyhélio elKis1, silvia sCeMes1, Mariangela gentil savoia1, zilda del Prette2, Paulo Mestriner1, aline roBerta da silva1

1 Institute of Psychiatry, Hospital das Clínicas, University of São Paulo Medical School (IPq-HCFMUSP), São Paulo, SP, Brazil.2 Federal University of São Carlos (UFSCar), Center for Biological and Health Sciences, Department of Psychology, São Carlos, SP, Brazil.


AbstractBackground: Social dysfunction is an important outcome for schizophrenia and can be measured by the evaluation of social skills. Objectives: To compare social skills in patients with schizophrenia classified according the degree of treatment response and severity of psychopathology with normative controls by using the Del Prette Social Skills Inventory (SSI). Methods: Cross-sectional study where the 38 questions SSI was applied to 62 outpatients with schizophrenia and compared with data of 99 normal controls from the general population. The SSI was evaluated by five domains. Psychopathology was measured by the Positive and Negative Syndrome Scale (PANSS). Patients were classified as Treatment Resistant (TRS) and Non Treatment Resistant (NTRS) by the International Psychopharmacology Algorithm Project (IPAP) criteria. ANCOVA was used to control for demographic differences between populations. Results: Patients showed significantly more impaired than controls except for aggressiveness control. When variables such as age, age of onset, schooling or medication dose entered as covariates, differences between controls and patients, or TRS with NTRS, almost disappeared. The SSI and PANSS showed an inverse relationship between their domains. Discussion: The SSI may represent a useful tool for evaluation of social skills in schizophrenia. Antipsychotics may exert a protective effect on social skills.

Elkis H et al. / Arch Clin Psychiatry. 2016;43(5):107-11

Keywords: Schizophrenia, social dysfunction, social skills, scales, social skills inventory.

Introduction

Schizophrenia is a severe mental disorder which affects 1% of the population and it is associated with personal, social and family burden. The diagnostic of schizophrenia involves a constellation of signs and symptoms associated with impaired occupational or social functioning. Patients with schizophrenia show impairments is several areas or domains of psychopathology such as psychotic (delusions and hallucinations), disorganization (thought disorders), negative symptoms (blunted affect, lack of motivation and social withdrawal), affective symptoms (depression or mania) and cognitive impairment (abstraction, attention, memory and executive functions)1,2.

The treatment of schizophrenia involves a combination of medication and psychosocial interventions such as family orientation, cognitive behavior therapy and social skills training. Patients with schizophrenia are treated with antipsychotics, either or first or second generation, and are considered responders or non-treatment resistant (NTRS) when they improve certain symptoms (e.g. psychotic symptoms) after one or two adequate treatments. When patients do not respond to two adequate treatments they are considered refractory or treatment resistant (TRS) and are eligible to receive clozapine, which is the drug of choice for such condition. Generally patients with TRS are considered more severely compromised than those with NTRS3.

It well known that impairment of social functions is a common feature of schizophrenia and is present from the early stages of the illness. In the past poor social functioning have been described in as core feature of Dementia Praecox by Kraepelin and as well as psychotic or negative symptoms, they also considered hallmarks of the disorder and are required for modern diagnosis schizophrenia, as for example in the DSM 5 criteria2,4.

Social skills are defined as micro components of social functions and include everyday conversations, encounters, and relationships that people have with each other. Social skills include the ability to give and obtain information and to express and exchange attitudes, opinions, and feelings4,5.

Social skills are generally compromised in patients with schizophrenia and the degrees of impairment correlate with some domains of psychopathology such as negative or cognitive symptoms. The treatment of social impairment using social skills training showed to improve social function as well as negative symptoms in patient with schizophrenia6,7.

The measurement of social skills represents an important outcome variable for the evaluation of social dysfunction in patients with schizophrenia. Their evaluation comprise methods such as observation, role-playing, interviews, rating scales and self-assessment, which are employed depending on the type of outcome as well as the cultural norms of the studied population5.

Del Prette et al. developed the Social Skills Inventory (SSI – Del-Prette or SSI) in order to assess social abilities in a normal population in Brazil. The SSI is a self-report instrument which assesses the repertoire of social skills of daily interpersonal situations. It was initially validated for college population (18-25 years) but it is also used to assess social performance in adults8,9.

The SSI has been employed extensively to evaluate social skills in non-psychiatric populations8,9, but its use in psychiatric patients is not well appreciated since only one study used the instrument to evaluate patients with bipolar disorders in comparison with normal controls10 and, to our knowledge, it has never been used to evaluate the degree of impairment of social function in patients with schizophrenia.

Therefore the primary aim of the present is study is test whether social skills are compromised in patients with schizophrenia in comparison with normal controls by using the SSI. The secondary aim is the investigation of the relationship between the SSI with dimensions of psychopathology, as measured by the PANSS, which is the standard scale for measurement of severity of symptoms in schizophrenia11, as well treatment response to antipsychotics either in patients with TRS or NTRS. We hypothesize that SSI and the PANSS have an inverse relationship and that patients with TRS will be more compromised than patients with NTRS regarding their social abilities.

108 Elkis H et al. / Arch Clin Psychiatry. 2016;43(5):107-11

Methods

Study design

This is cross-sectional study performed at the Schizophrenia Research Program of the Institute of Psychiatry of University of São Paulo (Projesq-IPq-HC) and is part of larger study originally aimed to investigate the efficacy of social skills training on negative symptoms in patients with TRS funded by Fundação de Amparo à Pesquisa do Estado de São Paulo (São Paulo Research Support Foundation) (Fapesp) (2009/13934-6).

Study population and assessment

Patients were recruited from the outpatient clinic of the Projesq-IPq-HC and signed an informed consent agreement to participate and have been diagnosed with schizophrenia based on the DSM IV TR criteria12. Patients were excluded if they had documented history of alcohol or drug dependence, brain trauma, mental retardation or severe cognitive impairment. Patients were defined as having TRS according to the International Psychopharmacology Algorithm Project (IPAP) i.e. failure to respond to at least two adequate trials with antipsychotics with the 4-6 weeks duration13 and were receiving clozapine, which is the standard medication for such condition14. Additionally data was obtained from the psychiatry in charge of the patient, as well as chart review. NTRS patients were defined as those who have responded to one or two treatment with antipsychotics according to the IPAP, and were in stable conditions, receiving non-clozapine antipsychotics. In order to compare antipsychotic treatment regimens, doses were transformed into chlorpromazine equivalents using parameters proposed by Woods15,16.

Sixty two patients with schizophrenia were included: thirty three met criteria for TRS while twenty nine were NTRS. Data of ninety nine normal controls derived from the general population (population or normative controls) and who were evaluated for the purpose of re-validation by the SSI – Del-Prette was provided by one of the authors of SSI – Del-Prette inventory who is also a co-author of the present study (ZDP).

Instruments

The SSI is a self-report questionnaire composed of 38 items, each of them describing an interactive social situation and a possible reaction to it. The instrument was developed to evaluate social skills for adult general population and was validated for the Brazilian population8,9. Subjects are asked to estimate how often they react to that particular situation, considering the number of times he or she faced that situation. Responses are rated according to a Likert scale ranging from zero (never or rarely) to four (always or very frequently). Some items have a negative meaning, i.e., the higher the score, the lower the skill. In those cases, the score must be inverted. Results can be measured either the total score as well as percentiles8,9. Higher values of the SSI mean higher social skills abilities. The SSI is usually self-administrated or by a rater, but in the present study it was administrated by trained psychologists blinded for the treatment condition of the patients. The raters read the questions for the patients and took notes about the content of their responses. Questions were repeated as much as necessary since it is well known that patients with schizophrenia can have various degrees of cognitive impairment. The SSI comprises five factors or domains of SSI obtained through factor analysis. These factors and their meaning are displayed in Table 1.

Psychopathology was evaluated by the Positive and Negative Syndrome Scale (PANSS) which comprises 3 subscales (Positive, Negative, General Psychopathology), which evaluate psychotic, negative and general psychopathological symptoms, respectively11.

Table 1. Factors or domains of the SSI – Del-Prette8-10 Domain Name DescriptionF1 Coping and self-

assertion with riskEvaluates assertiveness in interpersonal situations, to safeguard the rights of the individual and maintain self-esteem (e.g. ‘When a friend to whom I’ve lent some money forgets to give it back, I find a way to remind him/her’)

F2 Self-assertion in the expression of positive affect

Analyses self-confidence in the expression of positive feeling, the items depict the need for positive interpersonal feedback and affirmation of self-worth (e.g. ‘When someone does something I think is good, even if it is not directly related to me, I mention it, praising him/her at the first opportunity’)

F3 Conversation and social confidence

Evaluates conversational skill and social boldness, and its items portray neutral situations of initial social encounters (e.g. ‘When I am with a person who I have just met, it is difficult for me to keep an interesting conversation going’)

F4 Self-exposure to unknown people and new situations

Evaluate social openness to new people and new situations, describe situations that involve interacting with new people (e.g. ‘I avoid asking questions of people I don’t know’)

F5 Self-control of aggressiveness

Evaluate self-control of aggressiveness and individual reactions to aversive stimuli that require the management of anger and aggressiveness (e.g. ‘When my schoolmates or work colleagues tease me, I don’t let it bother me’)

Statistical evaluation

Groups were compared using t tests, chi square or ANOVA when appropriate. Variables which differed significantly between groups entered as covariates for the comparisons between domains of the SSI using an ANCOVA model followed by Bonferroni pairwise comparison tests. Comparison between patients with TRS and non TRS were performed using medication doses and age of onset as covariates. The relationship between SSI and the PANSS was evaluated by Pearson correlation coefficients. The level of significance was defined as 0.05. The SPSS 22.0 software was used to run all the analyses.

Ethical aspects

The study was approved by the Internal Review Board of the University of São Paulo General Hospital (Protocol number 0761/08) and registered at site of the Clinicaltrials.gov (NCT 0079 1882).

Results

As can be observed in Table 2 normal controls were 49 males and 50 females, had a mean (sd) age of 31.62 (10.44) years and 14.49 (2.48) years of schooling, while patients with schizophrenia were 24 males and 38 females, had a mean age of 40.29 (10.46) years and had 10.31 (2.37) years of schooling. As expected the whole sample of patients with schizophrenia (n = 62) showed significant less social abilities than controls in all domains of the SSI except for factor F5 (self-control of aggressiveness). However patients and controls differed significantly in terms of age and schooling (Table 2).

109Elkis H et al. / Arch Clin Psychiatry. 2016;43(5):107-11

Table 2. Comparison between normative controls and the whole sample of patients with schizophrenia in terms of demographic variables and Factors of the SSI Factors* of the SSI and demographic variables

Controls(n = 99)

Patients with schizophrenia(n = 62)

Statistical test Significance (p value)

Age 31.62 (10.44) 40.29 (10.46) t = -5.13 0.00Gender 49 males; 50 females 24 males; 38 females Chi-square = 2.14 0.14Schooling (in years) 14.49 (2.48) 10.31 (2.37) t = 10.61 0.00F1 9.88 (2.93) 7.46 (3.29) t = 4.86 0.00F2 9.11 (1.72) 6.73 (2.80) t = 6.02 0.00F3 6.55 (2.17) 5.89 (1.83) t = 2.01 0.05F4 3.24 (1.27) 2.22 (1.49) t = 4.62 0.00F5 0.96 (0.70) 1.33 (0.69) t = - 3.31 0.00

* Factors names: see method section.

Subsequently we compared controls with patients with schizophrenia classified according to treatment response (TRS vs NTRS). Thus thirty three patients composed the TRS group (24 males and 9 females), they had a mean age of 36.42 (7.71) years, the age of onset of illness was 18.97 (4.99) years, they had been ill for 17.45 (7.45) years, had 10.52 (2.15) of schooling. The NTRS group patients was composed by 14 males and 15 females, had a mean age of 44.69 (11.97) years, an age of onset of illness of 31.70 (15.09), a duration of illness of 13.52 (10.75) years and had 10.07 (2.72) years of schooling. As can be observed in Table 3 patients differed marginally in terms of gender (p = 0.05) but significantly in terms of age (p = 0.00) and schooling (p = 0.00). TRS patients and NTRS patients differed significantly in terms of antipsychotic doses when converted into chlorpromazine equivalents (p = 0.00).

However the comparisons of SSI domains of patients according to the response to treatment (TRS and NTRS) with controls, with by age, gender and schooling as covariates, showed that NTRS patients were significantly more impaired on three domains: F1 (coping and self-assertion with risk) (0.02), F2 (expression of positive affect)

(0.00) and F4 (self-exposure to unknown people and new situations) (0.01), but were preserved on the F3 domain (conversation and social confidence) and on the F5 domain (self-control of aggressiveness). The comparison between controls and TRS showed that patients with such condition were more impaired on two domains F2 (0.00) and F3 (0.00), but showed no differences with controls on domains F1, F4 and F5 (Table 4).

The comparison between TRS and NTRS groups with age of onset and antipsychotic doses as covariates showed no differences between these groups in terms of their social abilities, as measured by the SSI (Table 5).

As predicted the majority of the correlations between the five social skills domains of the SSI and the three PANSS subscales showed to be negative. However, in the majority of cases, they were small and non-significant. Only three correlations showed to be more robust as is the case of F1 (copying and self-assertion with risk) with the General Psychopathology subscale and F3 (conversation and social confidence) with the Positive and General Psychopathology, respectively (Table 6).

Table 3. Comparisons Normal Controls and patients with Treatment Resistant and Non Treatment Resistant in terms of demographic variables, antipsychotic medication severity of psychopathology by the PANSS

Controls(N = 99)

TRS(N = 33)

Non TRS(N = 29)

StatisticalTest

Significance(p)

Age (in years) 31.62 (10.44) 36.42 (7.71) 44.69 (11.97) F = 19.00 0.00*Gender M = 49; F = 50 M = 24; F = 9 M = 14; F = 15 Chi-square = 5.85 0.05*Schooling (in years) 14.49 (2.48) 10.52 (2.15) 10.07 (2.72) F = 56.42 0.00*Age of onset of illness (in years) – 18.97 (4.99) 31.70 (15.09) t = -4.20 0.00*Duration of illness (in years) – 17.45 (7.45) 13.52 (10.75) t = 1.61 0.15Antipsychotic medication (chlorpromazine equivalents) mg/day

– 1132.81 (309.9) 347.69 (194.7) t = 11.75 0.00*

PANSS positive – 12.47 (3.87) 9.50 (3.54) t = 1.06 0.30PANSS negative – 27.50 (5.62) 16.50 (4.95) t = 2.70 0.11PANSS general – 29.97 (6.88) 33.50 (6.36) t = -0.71 0.49PANSS total – 69.94 (12.60) 59.50 (14.85) t = 1.13 0.27

* Significant pairwise comparisons. TRS: Treatment Resistant Schizophrenia; NTRS: Non Treatment Resistant Schizophrenia; PANSS: Positive and Negative Syndrome Scale.

Table 4. Comparisons of Factors of the SSI in Normal Controls versus patients with Treatment Resistant and Non Treatment Resistant, controlling for Age, Gender and Schooling Factor* Controls

(N = 99)TRS

(N = 33)NTRS

(N = 29)ANCOVA

ModelBonferroni pairwise comparisons

Mean (SD) Mean (SD) Mean (SD) F; p Controls vs. TRS** Controls vs. NTRS** TRS vs NTRS**F1 9.88 (2.93) 7.85 (3.33) 7.02 (3.24) 5.87; 0.00 0.09 0.02 1.00F2 9.11 (1.72) 6.30 (3.10) 7.22 (2.38) 11.33; 0.00 0.00 0.00 1.00F3 6.56 (2.17) 5.65 (2.09) 6.16 (1.47) 3.99; 0.00 0.00 0.11 0.81F4 3.24 (1.27) 2.50 (1.41) 1.91 (1.54) 5.23; 0.00 0.09 0.01 0.59F5 0.96 (0.70) 1.31 (0.59) 1.36 (0.79) 4.95; 0.00 1.00 0.73 1.00

* Factors names (see method section); ** Significant pairwise comparisons in bold.TRS: Treatment Resistant Schizophrenia; NTRS: Non Treatment Resistant Schizophrenia.

110 Elkis H et al. / Arch Clin Psychiatry. 2016;43(5):107-11

Discussion

The present study found that, as expected, patients with schizophrenia, when compared with normal controls, show more pronounced impairments in various domains of social skills abilities as measured by the SSI – Del-Prette inventory. However, patients performed better than controls on the self-control of aggressiveness (F5) which may be explained by the fact that antipsychotics exert control over aggression, particularly clozapine17 which was received by half of the sample of the patients. Another explanation could be the fact that the controls were younger than patients and, probably, more prone to impulsiveness.

The comparison between patients with controls controlling by age, gender and schooling showed that patients, regardless the use of clozapine or non-clozapine antipsychotics, exhibit impairments in certain social skills areas, such as the expression of positive affects (F2 domain) but are preserved in other aspects such as coping with risk situations (F1 domain), conversational skills (F3 domain), exposure to unknown situations or people (F4 domain) as well as ability to control their aggressiveness (F5 domain).

An explanation for this fact could also rely on the role of antipsychotics, which is known to exert a positive influence on social skills, a phenomenon observed many years ago when phenothiazines, where introduced for the treatment of schizophrenia18. More recently randomized controlled trials of social skills training have shown that the greatest improvement in social outcomes occurred when the training was combined with antipsychotic medication19.

Therefore we found no difference than controls in skills which involve assertiveness, conversational skills, self-exposure to new situations and control of aggression, as evaluated by the SSI when age, gender and schooling were controlled which may reflect the positive influence of the use of antipsychotics which may improve these abilities.

However the only domain were controls showed better results than patients was the expression of positive affects (F2) and it well

Table 5. Factors of SSI in Treatment Resistant in comparison with Non- Treatment Resistant patients with Schizophrenia, controlling for age of onset and medication doseFactor* TRS (N = 33) NTRS (N = 29) ANCOVA

ModelTRS vs NTRS

Bonferroni Pairwise

Comparison (p value)

Mean (SD) Mean (SD) F; pF1 7.90 (3.37) 7.09 (3.23) 0.84; 0.48 0.20F2 6.40 (3.10) 7.16 (2.40) 0.71; 0.55 0.75F3 5.70 (2.11) 6.21 (1.43) 0.75; 0.53 0.75F4 2.50 (1.43) 1.81 (1.60) 0.97; 0.42 0.33F5 1.32 (0.60) 1.36 (0.78) 0.22; 0.89 0.83

* Factors names: see method section.TRS: Treatment Resistant Schizophrenia; NTRS: Non Treatment Resistant Schizophrenia.

Table 6. Correlation coefficients and respective significances between SSI domains and the subscales of Positive and Negative Syndrome Scale (PANSS)SSI Factors*

PANSS Positive PANSS Negative PANSS General Psychopathology

F1 -0.034; p = 0.85 -0.22; p = 0.22 -0,37; p = 0.03F2 -0.03; p = 0.85 -1.94; p = 0.27 -0.15; p = 0.41F3 -0.40; p = 0.02 0.02; p = 0.90 -0.36; p = 0.04F4 -0.03; p = 0.90 -0.13; p = 0.47 -0.07; p = 0.72F5 -0.19; p = 0.29 -0.09; p = 0.61 -0.01; p = 0.94

* Factors names: see method section. PANSS: Positive and Negative Syndrome Scale.

known that deficits in the expression of affect was considered one of the fundamental symptoms of schizophrenia by Bleuler and it is now defined as a persistent or primary negative symptom20 for which the efficacy of antipsychotics it not proven21,22.

Another problem is related to the distinction between primary from secondary negative symptoms (e.g. social withdrawal caused by auditory hallucinations) and this distinction is generally difficult to perform. Therefore a deficit in the expression of emotions may represent either a primary or a secondary negative symptom20.

It is also important to mention that primary negative symptoms also do not improve with social skills training as it was observed in patients with deficit syndrome, characterized by a predominance of primary negative symptoms, in comparison with patients with non-deficit syndrome23,24.

The SSI showed to correlate inversely with the PANSS meaning that, in patients with schizophrenia, the higher the severity of their symptoms, the lower will be their skills abilities. However the fact the correlations showed to be small and no-significant which may reflect that social skills are influenced by other factors, as for example, cultural and situational aspects9. It is noteworthy that the domain of conversation and social confidence (F3) was inversely and significantly correlated with positive and general psychopathological symptoms, which may illustrate the influence exerted by certain symptoms such as delusions and hallucinations (positive or psychotic symptoms) or anxiety or depression (general psychopathology) on this domain.

This study has several limitations, one of then the fact that it is a cross sectional study, where conclusions about causation are limited25. Another aspect is related to the use of the SSI in patients with schizophrenia, an instrument primarily conceived for the evaluation of social skills in non-psychiatric populations8,9.

The present study was not designed to validate the SSI in schizophrenia but it showed to be an useful instrument for the purpose of measuring social abilities in patients with such disorder. Additionally is important to emphasize that the evaluation of social skills in this population is very heterogeneous7 and there is no an instrument like the PANSS, which is considered the gold standard scale for the measurement of severity of symptoms in schizophrenia26.

Another important aspect is that the SSI is self-administered but in the case of the present study it was administered with the help of the psychologists since it is well known that patients with schizophrenia suffers varying degrees of cognitive impairments27. The relationship between with social skills with cognitive impairment was not evaluated in the present study, but will be presented as part of the results in a forthcoming publication of our main study, a randomized controlled trial which evaluated the impact of social skills training on the severity of negative symptoms in patients with TRS.

Finally it is possible that the use of normative controls and not regular controls may have influenced results. However Almeida Rocca et al.10 who used the SSI to compare euthymic patients with bipolar disorders with normal controls using the SSI also found no differences between groups on the domains one, two and five. It is important to emphasize that use of medication may explain these findings, particularly on domain five (self-control of aggressiveness), since bipolar patients were receiving lithium in monotherapy or in combination with antipsychotics or anticonvulsants, which are drugs with proven anti-aggression and impulse control proprieties17.

The present study showed that the SSI may represent a useful tool for evaluation of social skills in schizophrenia and the lack of differences between groups may be explained by the use of antipsychotics, which may exert a protective effect on social skills. Future studies are warranted to validate the SSI – Del-Prette for the evaluation of social skills in patients with schizophrenia.

Source of funding

The study was funded by the São Paulo Research Foundation (Fapesp – grant number 2009/13934-6).

111Elkis H et al. / Arch Clin Psychiatry. 2016;43(5):107-11

Conflict of interests

Hélio Elkis MD PhD has received research grants from Fapesp, Roche and Janssen and received honoraria as speaker, travel support or board participation from Ache, Roche, Janssen, Cristalia and Daiichy-Sankyo. Other participants have no conflicts of interests to disclose.

Acknowledgements

Luciana Monteiro, Vanessa Cunha e Ellen Aversari for the application of the SSI – Del-Prette.

References

1. Haro JM, Altamura C, Corral R, Elkis H, Evans J, Malla A, et al. Understanding the impact of persistent symptoms in schizophrenia: Cross-sectional findings from the Pattern study. Schizophr Res. 2015;169(1-3):234-40.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – DSM-5. 5th ed. Washington DC: American Psychiatric Press; 2013.

3. Elkis H, Buckley PF. Treatment-Resistant Schizophrenia. Psychiatr Clin North Am. 2016;39(2):239-65.

4. Mueser K, Glyn S, McGurk S. Social and Vocational Impairments. Textbook of Schizophrenia. Washington DC: American Psychiatric Publishing Inc.; 2006.

5. Liberman RP. Assessment of social skills. Schizophr Bull. 1982;8(1):62-83.6. Pfammatter M, Junghan UM, Brenner HD. Efficacy of psychological

therapy in schizophrenia: conclusions from meta-analyses. Schizophr Bull. 2006;32 Suppl 1:S64-80.

7. Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia. J Consult Clin Psychol. 2008;76(3):491-504.

8. Del Prette ZAP, Del Prette A. Inventário de Habilidades Sociais (IHS-Del-Prette). Manual de aplicação, apuração e interpretação. São Paulo: Casa do Psicólogo; 2001.

9. Del Prette ZAP, Del Prette A. Social Skills Inventory: Characteristics and Studies in Brazil. In: Osorio FL, editor. Social Anxiety Disorder: From Research to Practice. Psychology Research Progress. Ribeirão Preto, São Paulo, Brazil: Nova Science Publishers, Inc.; 2013. p. 47-60.

10. de Almeida Rocca CC, de Macedo-Soares MB, Gorenstein C, Tamada RS, Issler CK, Dias RS, et al. Social dysfunction in bipolar disorder: pilot study. Aust N Z J Psychiatry. 2008;42(8):686-92.

11. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261-76.

12. Association AP. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revised. Washington DC: American Psychiatric Press; 2000.

13. IPAP. Schizophrenia Algorithm. Available at: <http://www.ipap.org/algorithms.php>.

14. Elkis H. Refractory schizophrenia. Rev Bras Psiquiatr. 2007;29 (suppl. 2):S41-7.

15. Woods SW. Chlorpromazine equivalent doses for the newer atypical antipsychotics. J Clin Psychiatry. 2003;64(6):663-7.

16. Woods SW. Calculation of CPZ Equivalents. Available at: www.scottwilliamwoods.com/files/Equivtext.doc. 2005.

17. Citrome L, Volavka J. The psychopharmacology of violence: making sensible decisions. CNS Spectr. 2014;19(5):411-8.

18. Hersen M, Turner SM, Edelstein BA, Pinkston SG. Effects of phenothiazines and social skills training in a withdrawn schizophrenic. J Clin Psychol. 1975;31(4):588-94.

19. Marder SR, Wirshing WC, Mintz J, McKenzie J, Johnston K, Eckman TA, et al. Two-year outcome of social skills training and group psychotherapy for outpatients with schizophrenia. Am J Psychiatry. 1996;153(12):1585-92.

20. Buchanan RW. Persistent negative symptoms in schizophrenia: an overview. Schizophr Bull. 2007;33(4):1013-22.

21. Kelley ME, van Kammen DP, Allen DN. Empirical validation of primary negative symptoms: independence from effects of medication and psychosis. Am J Psychiatry. 1999;156(3):406-11.

22. Murphy BP, Chung YC, Park TW, McGorry PD. Pharmacological treatment of primary negative symptoms in schizophrenia: a systematic review. Schizophr Res. 2006;88(1-3):5-25.

23. Matousek N, Edwards J, Jackson HJ, Rudd RP, McMurray NE. Social skills training and negative symptoms. Behav Modif. 1992;16(1):39-63.

24. Kopelowicz A, Liberman RP, Mintz J, Zarate R. Comparison of efficacy of social skills training for deficit and nondeficit negative symptoms in schizophrenia. Am J Psychiatry. 1997;154(3):424-5.

25. Grimes D, Schultz K. An overview of clinical research: the lay in the land. Lancet. 2002;359:57-61.

26. Leucht S, Kane JM, Kissling W, Hamann J, Etschel E, Engel RR. What does the PANSS mean? Schizophr Res. 2005;79(2-3):231-8.

27. Saykin AJ, Shtasel DL, Gur RE, Kester DB, Mozley LH, Stafiniak P, et al. Neuropsychological deficits in neuroleptic naive patients with first-episode schizophrenia. Arch Gen Psychiatry. 1994;51(2):124-31.

Original article

Address for correspondence: Koray Kara. Gulhane Military Medical Academy, Department of Child and Adolescent Psychiatry. Etlik, Kecioren, Ankara, Turkey. Telephones: 00 90 312 304 37 96 / 00 90 530 934 21 62. E-mail: [email protected]

Relationship between perceived parenting style with anxiety levels and loneliness in visually impaired children and adolescentsMualla haMurCu1, Koray Kara2, MehMet ayhan Congologlu2, uFuK haMurCu3, MahMoud alMBaidheen2, ayse turan1, dursun KaraMan2

1 TC Saglik Bakanligi Ankara Numune Egitim ve Arastirma Hastanesi, Department of Ophthalmology, Ankara, Turkey.2 Gulhane Askeri Tip Akademisi, Gulhane Military Medical Academy, Department of Child and Adolescent Psychiatry, Etlik, Kecioren, Ankara, Turkey.3 Saglik Bakanligi Ankara Egitim ve Arastirma Hastanesi, Department of Psychiatry, Ankara, Turkey.


AbstractBackground: Visual impairment is a risk factor for psychiatric disorders in the affected children and adolescents, but there are only a limited number of studies concerning the mental health characteristics of visually impaired children and adolescents. Objective: The aim of this study was to determine levels of loneliness and anxiety in visually impaired children and adolescents, to analyze parenting style perceived by visually impaired children and adolescents, to compare those with typically controls. Methods: The study included 40 children and adolescents with visually impairment and 34 control group without visual impairment. Sociodemographic data form, the UCLA loneliness scale, and the State-Trait Anxiety Inventory for Children were used in both groups. The parenting Style Scale was used to determine perceived parental attitudes. Results: This study found more loneliness and trait anxiety levels in visually impaired children and adolescents compared to the control group. Authoritative parenting style was the most frequent type of parental attitude in the visually impaired group. In visual impairment group, loneliness level was higher in subgroups of authoritative and permissive-indulgent parenting style. However, level of trait anxiety was higher in authoritative parenting style subgroup compared to the control group. Discussion: The results of this study showed higher loneliness and anxiety levels in visually impaired children and adolescents. Further studies are needed to determine psychopathological risks in this population.

Hamurcu M et al. / Arch Clin Psychiatry. 2016;43(5):112-5

Keywords: Visual impairment, children and adolescent, parenting style, loneliness, anxiety.

Introduction

Visual impairment in childhood is the impairment of the structure and the function of eye, affecting the process of learning via the sense of sight in a negative way1. World Health Organization (WHO) defined “blindness” as a visual acuity < 3/60 in the better eye, “severe visual impairment” as a visual acuity worse than 6/60 and equal to or better than 3/60, and “moderate visual impairment” as a visual acuity in a range from worse than 6/18 to 6/602. According to WHO criteria, there are 19 million visually impaired children worldwide, and 1.4 million of them are blind3. Vision is a very important sense for communication between the child and the outer world. Congenital loss of vision is a risk factor for psychiatric disorders in the affected children and adolescents4.

Loneliness is a subjective, unpleasant, and painful experience resulting from an imbalance between the present social relationship and the desired social relationship of the individual5,6. Loneliness is a universal phenomenon with an evolutionary basis. Loneliness warns the individual for the threat of standing alone. Loneliness is widely seen in children. A review reported that 10%-15% of the children and adolescents felt very lonely7. It was shown that various factors such as the quality of the social relations were significantly correlated with development of loneliness experience in children and adolescents8,9.

It has been suggested that more psychological problems can appear in children with disabilities and chronic diseases10,11. Disabilities threaten the quality and continuity of the relations with friends, family and other people. Supportive relations with peers, family, and other important people play role in social and emotional development of individuals with disabilities. In some children and adolescents with health problems such as visual impairment, disabilities may affect the quality and continuation of social relationships with family and friends negatively, and those relationships are important for coping with the disability12. Many studies showed higher loneliness and anxiety levels in children and adolescents with disabilities when compared to their peers without any disabilities13-17.

It has been reported that various factors play role in development of loneliness. One of those factors is family support. The quality of the relationships between parents and their children may affect loneliness. Low loneliness levels in the children of warm and loving families18 suggest that family relationships are important in occurrence of loneliness feeling. It has been suggested that the relationship with family members is an important factor in occurrence of loneliness feeling in children and adolescents19. Maccoby and Martin classified parenting styles into four groups as authoritarian, authoritative, permissive-indulgent and permissive-neglectful. It was indicated that the adolescents who perceived a authoritative parenting style felt less loneliness, had more friends and social support compared to the perceived neglectful parenting style20,21.

There are only a limited number of studies concerning the mental health characteristics of visually impaired children and adolescents. The first aim of our study was to compare loneliness and anxiety levels between visually impaired children and adolescents and controls without disability. The second aim of our study was to investigate the frequency of different parenting styles in parents of visually impaired children and adolescents. The third aim was to compare the relation of perceived parenting style with loneliness and anxiety levels in visually impaired and control groups.

Materials and methods

Design and participants

A total of 40 patients (24 females and 16 males) that had severe visual impairment and admitted to Ophthalmology Department of Ankara Numune Education and Research Hospital between March 2014 and January 2015, and agreed to participate in the study were included in the study. The control group consisted of 34 children and adolescents (15 females and 19 males) that admitted to Children and Adolescent Psychiatry Department of Gulhane Military Medical Academy, and found not to have any psychiatric

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disorders. The ones with any organic diseases or mental retardation determined by physical, neurological, or psychiatric examination were excluded in both groups. Informed consent was obtained from both parents or legal guardian after the standard information about the study conducted and the nature of the procedures was explained. The study was approved by the Ethics Committee of Gulhane Military Medical Academy and conducted according to the principles of Declaration of Helsinki.

Measurements

A patient socio-demografic information form was prepared, and the questions regarding demographic data were asked to parent of the patients. The form prepared by the investigators was used to note sociodemographic data of the children such as age, gender, and education level of children. This form was administered at the beginning of the study and the rest of the measures were administered to the children afterwards by a face to face interview. All measurements were filled in about 30 minutes and administered at one visit.

In this study, we used the Parenting Style Scale (PSS) developed by Lamborn et al.22, validated in Turkish by Yılmaz23 and consisted of 3 dimensions (acceptance/involvement, firm control, and psychological autonomy). Acceptance/involvement dimension aims to measure children’s perception of how much parents are loving, careful and participative (for example; “When I have any problem, I am sure that my parents would help me”). Firm control dimension aims to measure children’s perception of how much their parents are controller (for example; “Do your parents let you to go out at night during school time with your friends?”). Psychological autonomy dimension aims to measure how much parents implement their democratic attitudes and how much they encourage their children to express independency (for example; “My parents say that I should argue with elder people”). There are 9 items in acceptance/involvement and psychological autonomy dimensions on a 4-point Likert Scale. The first two items of firm control dimension are answered a 7-point, and the remaining 8 items are answered on 3-point Likert Scales. The measurements can be made in two ways. In the first one, the different levels of authoritative parenting style may be differentiated from the answers of 3 dimensions. In the second one, parental attitudes may be divided into four groups as authoritarian, authoritative, neglectful, and indulgent, regarding the scores of acceptance/involvement, and firm control. The reliability study was done on three different groups consisting of primary school, high school, and university students. Test re-test reliability coefficients and Cronbach alpha internal consistency coefficients were 0.74 and 0.60 for acceptance/involvement dimension, 0.93 and 0.75 for firm control dimension, and 0.79 and 0.67 for psychological autonomy dimension, respectively, in primary school students. Test re-test reliability coefficients and Cronbach alpha internal consistency were 0.82 and 0.70 for acceptance/involvement dimension, 0.88 and 0.69 for firm control dimension, and 0.76 and 0.66 for psychological autonomy dimension, respectively, in high school students23.

The UCLA Loneliness Scale was developed by Russell et al. in order to determine the level of loneliness24. It contains 20 items, and asks subjects to indicate how often they feel the way described in each of the statements. Statements are then evaluated on a 4-point scale, ranging from ‘Never’ (= 1) to ‘Often’ (= 4). For example, item 4 reads, “I do not feel alone”. The total scores range from 20 to 80, with higher scores indicating greater loneliness. The reliability and validity studies of the scale in Turkish were performed by Demir, and Cronbach alpha internal consistency coefficient was found as 0.9625.

The State-Trait Anxiety Inventory for Children (STAI-C) is also called as “How I Feel Questionnaire”. It was developed by Spielberger in 197326. It aims to measure individual differences for tendency of anxiety. Its validity and reliability studies in Turkish were performed by Özusta in 199527. It consists of 2 sections (state and trait) with each section include 20 questions. The children are asked, “How they feel usually and at the moment”, and indicate the most suitable choice on response scale. Twenty items are answered by marking one of the choices that are scored as 1, 2, or 3, in relation with the presence and severity of the anxiety. The score of the scale may be between 20 and 60. Test re-test reliability coefficients of STAI-C were found as 0.60 for State-Anxiety Scale, and as 0.65 for Trait-Anxiety Scale27.

Statistical analysis

The analysis of the data was performed with SPSS 15.0 package program. Number, percent, mean, and standard deviation were used in descriptive statistics. Kolmogorov-Smirnov test was used to determine normal distribution of the continuous variables. Comparison of the continuous variables between the groups was performed with T- and Mann-Whitney U tests. Chi-square test was used to compare discrete variables. Pearson correlation analysis was used to analyze correlations among the variables. p < 0.05 was considered as statistically significant.

Results

The mean age of the visually impaired participants was 12.32 ± 3.38 (7-18) years, and the mean age of the control group was 10.82 ± 2.18 (7-15) years. There was no difference between the groups for their ages (p = 0.06). In visually impaired group, 40% (n = 16) of the participants were boys, and 60% (n = 24) of them were girls. The boys constituted 55.9% (n = 19), and the girls constituted 44.1% (n = 15) of the control group. The duration of education was significantly longer in the visually impaired group (p = 0.027).

UCLA loneliness scale scores indicated significantly a higher level of loneliness perception in visually impaired children (p = 0.005) (Table 1). The mean acceptance/involvement dimension scores of visually impaired and normal children showed a significant difference for PSS (p = 0.049). Two groups were similar for other two dimension scores (Table 1). STAI-C showed that mean trait anxiety scores of the visually impaired children were higher when compared to the control (p = 0.004) (Table 1).

Table 1. Comparisons of the parenting style scale (PSS), the UCLA loneliness scale, and the State-Trait Anxiety Inventory for Children (STAI-C) in the visually impaired and the control groups

Visually impaired Group(n = 40)

Control Group (n = 34) Z p

Parenting Style ScaleAcceptance/involvement 29.83 ± 4.17 31.59 ± 3.24 -2.00** 0.049Psychological autonomy 20.55 ± 4.34 21.55 ± 5.10 -0.74* 0.460Firm control 29.83 ± 2.77 29.85 ± 2.96 -0.69* 0.489

UCLA Loneliness Scale 36.28 ± 10.81 29.12 ± 8.96 -2.83* 0.005*State-Trait Anxiety Inventory For Children

State Anxiety Subtest 30.86 ± 6.29 31.61 ± 9.03 -0.38* 0.702Trait Anxiety Subtest 36.46 ± 8.34 31.00 ± 7.12 2.954** 0.004

* Mann-Whitney U test. ** Student T test.

114 Hamurcu M et al. / Arch Clin Psychiatry. 2016;43(5):112-5

When the visually impaired and control groups were analyzed for perceived parental attitude, no significant statistically difference was found between two groups. The frequencies of the perceived parental attitudes in two groups are shown in Table 2.

Table 2. The frequencies of perceived parenting style in the visually impaired and the control groups

Visually Impaired Group

Control Groupn

P

n % n %Authoritative 18 45 12 35.3 0.18Authoritarian 6 15 11 32.4Permissive-indulgent 6 15 7 20.6Permissive-neglectful 10 25 4 11.8

Comparison of the parenting styles (authoritative, neglectful, authoritarian, and indulgent) and UCLA loneliness score between visually impaired and control subjects is seen in Table 3. There was a statistically significant difference between authoritative and permissive-indulgent parenting style and loneliness scores (p < 0.05).

Table 3. Comparison of the visually impaired and the control groups for perceived parenting styles and the UCLA loneliness scale scores

Visually impaired (n = 40)

Control Group(n = 34)

Z pa

Authoritative 33.3 ± 9.49 25.7 ± 7.4 -2.145 0.032*Authoritarian 36.7 ± 10.4 32.2 ± 12.1 -1.061 0.289Permissive-indulgent 40.8 ± 11.3 29.2 ± 7.2 -2.086 0.037*Permissive-neglectful 38.6 ± 12.8 30.2 ± 3.1 -1.064 0.287

a Mann-Whitney U test was used. * p < 0.05.

Perceived parenting styles and state anxiety scores were compared between the visual impairment and the healthy control groups, and the differences between the groups were not significant (Table 4). Comparison of perceived parenting styles and trait anxiety scores between visually impaired and control groups showed that trait anxiety score was found higher in visually impaired group with a authoritative parenting style when compared to control group (p = 0.001) (Table 5).

Table 4. Comparison of the visually impaired and the control groups for perceived parenting styles and state anxiety scores

Visually impaired (n = 40)


Z pa

Authoritative 30.6 ± 6.3 29.1 ± 8.5 -1.320 0.187Authoritarian 31.6 ± 5.5 31.4 ± 7.1 -0.964 0.335Permissive-indulgent 29 ± 4.2 34.5 ± 11.1 -0.586 0.558Permissive-neglectful 31.2 ± 7.6 34.5 ± 12.6 -0.498 0.618

a Mann Whitney U test was used.

Table 5. Comparison of the visually impaired and the control groups for perceived parenting styles and trait anxiety scores

Visually impaired(n = 40)


Z pa

Authoritative 35.8 ± 7.5 26.1 ± 5.1 -3.370 0.001*Authoritarian 38.5 ± 8.1 33.5 ± 8.7 -1.158 0.247Permissive-indulgent 36.7 ± 3.5 33.7 ± 5.1 -0.956 0.558Permissive-neglectful 36.6 ± 11.5 34 ± 2.5 -0.574 0.339

a Mann Whitney U test was used. * p < 0.05.

Discussion

In this study, we aimed to compare children and adolescents with visually impairment and the control group without visually impairment for loneliness and anxiety levels; perceived parenting style characteristics; and effects of parenting styles on loneliness and anxiety levels. We determined that visually impaired children perceived higher loneliness and trait anxiety levels compared to the control group. The most frequently perceived parenting style was authoritative in visually impaired children and adolescents. The loneliness level was higher in visually impaired participants with authoritative and permissive-indulgent parenting styles when compared to the control group. Similarly, visually impaired participants that described their parents as authoritative had higher trait anxiety levels.

In our study, higher loneliness levels found in visually impaired children and adolescents are in agreement with the literature. The loneliness studies in the visually impaired subjects have usually been performed in the adults; however the studies on children and adolescents are scarce. Similar to our findings, Hadidi and Al Khateeb reported higher loneliness levels in visually impaired students when compared to the control group28. Another study reported higher loneliness levels in visually impaired children and adolescents29. Kef et al. found a higher loneliness level in the visually impaired group30. However, the difference between the visually impaired and the control groups was not statistically significant. In another study, a higher loneliness risk was reported in visually impaired girls; however the risk was lower in the boys31.

It was reported that visually impaired children had fewer friends, limited socializing opportunities, and had less chance to improve interpersonal skills32,33. It was also suggested that individuals with disabilities might have more negativities in their social relationships due to their physical appearance, and they might have less social experience34. The individuals think that they are different and have less social activities may not maintain their activities with their peers35. In addition, visual impairment may result in functional limitations, and difficulties to participate in social activities31.

In our study, we found higher trait anxiety levels in visually impaired children and adolescents when compared to the healthy controls. However, there was no significant difference between the groups for state anxiety levels. Bolat et al. performed a study on visually impaired adolescents, and found higher trait anxiety levels. Visually impaired children have limitations due to the problems of vision13. Therefore, anxiety and dependency feelings may appear36. In addition, visually impaired children and adolescents experience more problems in finding the direction. Therefore, they have a higher chance to have accidents. Hence, it was reported that visually impaired subjects might have higher anxiety levels when compared to their peers13.

Another aim of our study was to determine the frequencies of perceived parenting styles in visually impaired children. In our study, the most frequent perceived parenting style was authoritative. Cardinali and D’Allura performed a study on visually impaired young adults, and the most frequent parenting style was authoritative37. On the other hand, some other studies reported that authoritarian parenting style was more frequent38. It was emphasized that the parents of the subjects with disabilities could be overprotective since they are concerned more for the safety of their children39.

When the correlation of perceived parenting styles with loneliness levels were compared between visually impaired children and adolescents and the healthy controls; it was found that loneliness score was higher in case of authoritative and permissive-indulgent parenting styles. Higher trait anxiety levels were found in visually impaired subjects with authoritative parenting style when compared to the control group. Studies showed that children with a authoritative parenting style had less psychological symptoms, perceived less loneliness, and had lower social anxiety scores21,40. In our study, each parenting styles was compared with the healthy control group for loneliness and anxiety levels. Although loneliness and anxiety scores

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were lower in visually impaired children with authoritative parenting style when compared to other subgroups, but those scores were higher when compared to the healthy control group.

Absence of determining the exact degree of visual impairment in the visually impaired group, small number of the patients included in the study, and the cross-sectional design of study are the limitations of our study. In addition, another limitation of our study is not to evaluate other factors such as school and social environment which could be associated with loneliness.

In conclusion, in this study we found that visually impaired children and adolescents had higher loneliness and anxiety levels; however there were no differences for loneliness and anxiety levels and perceived parenting styles when compared to the healthy control group except authoritative and permissive-indulgent parenting styles. Further studies are needed to determine psychopathological risks and underlying reasons for any patterns that may emerge in visually impaired children and adolescents.

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Review article

Address for correspondence: Flávia de Lima Osório. Departamento de Neurologia, Psiquiatria e Psicologia Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Av. dos Bandeirantes, 3900, Campus Universitário – 14048-900 – Ribeirão Preto, SP, Brazil. E-mail: [email protected]

Interventions for music performance anxiety: results from a systematic literature review ana Beatriz Burin1, Flávia de liMa osório1,2

1 Department of Neuroscience and Behaviour, Medical School of Ribeirão Preto, São Paulo University (FMRP-USP), Ribeirão Preto, SP, Brazil.2 National Institute of Science and Technology, Translational Medicine (CNPq), Brazil.


AbstractBackground: Music performance anxiety (MPA) is characterised by fears related to performing music. It may result in damages to personal life and professional career, so treatment and prevention are very important. Objective: To undertake a systematic literature review on the effectiveness/efficacy of MPA interventions and to integrate these findings to those in the literature reviewed previously. Methods: We used PubMed, PsycINFO and SciELO databases and keywords music*, performance anxiety, treatment, therapy and intervention and manual research. We selected articles published between October-2002/July-2016. Results: Out of 97 articles, 23 were reviewed. Sixteen studies presented inter-group experimental design, and seven presented pre-post experimental design. The intervention modalities reviewed were cognitive behavioural therapy (CBT), virtual reality exposure, biofeedback, yoga, meditation, music therapy and the Alexander technique. Although the interventions presented some indicators of efficacy in the MPA outcomes and improvement in performance quality, important methodological limitations were observed: low number of individuals and non-specific criteria for their inclusion/exclusion. This reinforces previous findings regarding methodological fragilities associated with this context. Discussion: CBT is the most frequently studied modality and with the greatest number of effectiveness indicators. The remaining modalities indicate tendencies in positive outcomes that require further and efficient investigation in more rigorous studies with greater methodological control.

Burin AB, Osório FL / Arch Clin Psychiatry. 2016;43(5):116-31

Keywords: Music performance anxiety, interventions, treatment, therapy, systematic review.

Introduction

Music performance anxiety (MPA) is considered a subtype of social anxiety disorder. It is typified by the presence of specific fears related to performing music1, and it can be related to both solo and group presentations, as well as to any instrument, including singing2-4 MPA can impact not only the performance itself but also the musician’s career and quality of life5,6 therefore, representing a condition that requires the attention of clinicians in its recognition and treatment.

Although MPA has been a part of the human experience for a long time, it was not until the 1970s that medical and psychological treatment and intervention-related research started being conducted. Among these treatments and interventions, behavioural and cognitive behavioural therapies, pharmacological interventions (mainly beta blockers), biofeedback, meditation and music therapy all stand out. There has been a focus on adult musicians, as observed by two previous literature reviews, one of which was systematic7 and the other was non-systematic8.

The results of these reviews denote some evidence of effectiveness. When behavioural and cognitive behavioural therapies were considered, a reduction in MPA and improvement in music performance quality was found7. Combined interventions, such as cognitive behavioural therapy associated with biofeedback and progressive muscle relaxation, were also found to have positive effects on decreasing MPA, as did the use of beta blockers7,8.

According to Kenny7, an important factor to consider is the methodological fragility of the studies carried out in this context, particularly in terms of the low number of participants and of experimental inter-group crossover studies, the lack of rigour in the methods used and the non-standardisation of the instruments utilised in outcome assessment.

The aforementioned reviews concluded that this field has yet to be explored through new research, which should focus on the

methodological refinements necessary in order to create stronger evidence on the efficacy of MPA-related treatments.

It is known that a) the results on the effectiveness of different interventions presented thus far have been inconclusive; b) the reviews published till date7,8 did not include studies that assess children and adolescents (which seems important, as MPA may begin in infancy or adolescence, and as early interventions in this group may prevent suffering and negative effects on their musical careers as adults); and c) new studies are still being published. Given these factors, we propose this present study, the aim of which is to undertake a systematic literature review seeking a) to assess the efficacy and effectiveness of MPA treatments/interventions in children, adolescents and adults and b) to integrate the current findings into the body of knowledge from the previously reviewed literature.

Material and methods

This study was carried out in accordance with the guidelines set in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses9 and in the Cochrane Handbook for Systematic Reviews of Interventions10. A systematic search was performed in the PsycINFO, PubMed and SciELO electronic databases, using the following keywords: (Music* Performance Anxiety) and (treatment or therapy or intervention). Articles published from October 2002 (the date of the latest article included in the systematic literature review conducted by Kenny in 20057 onwards were included, wherein the last search was performed in July 2016. The article inclusion and exclusion process followed the criteria shown in Figure 1.

As shown in Figure 1, 97 articles were found. After applying the inclusion and exclusion criteria, 19 articles were selected, which were independently evaluated in terms of their relevance by two

117Burin AB, Osório FL / Arch Clin Psychiatry. 2016;43(5):116-31

professionals with experience in the field of anxiety. Out of the 19 articles, five were found to have been repeated, which result in a total of 14 articles. Thereafter, a search was performed in handbooks and periodicals specific to the music field (Research in Musical Behaviour, the Journal of Research in Music Education, Medical Problems of Performing Artists, Psychology of Music and Music Education and the Journal of Music Therapy), as well as in the bibliographical references of the articles selected, from which nine new articles were found. Therefore, a total of 23 articles were chosen to be analysed11-33. For studies that show crude numeric data, the size effect of significant differences was calculated. We used the Cohen statistics.

Publication from October 2002(last search July/2016)

Books, book chapters, dissertations/theses, literature reviews and theoretical studies on

general aspects of APM (n = 23)

Aspects clinical, diagnostics, occupational, etiological and of prevalence of APM (n = 12)

Proposition and validation of instruments for assessing APM (n = 3)

Other variables associated to the musical performance (pain/injuries, educational, personality, musical technique) (n = 13)

Systematic reviews of literature (n = 2)

Other types of performance than musical (n = 5)

Music as a therapeutic resource (n = 16)

Not related to the musical performance (n = 4)

Duplicated Articles

n = 5

Manual Research

n = 9

Total n = 23

Studies carried out with humans beings, of both genders, without

age limit

Databases: PubMed, PsychINFO and SciELO

Articles Foundn = 97

Articles Includedn = 19

Articles Excludedn = 78

Language: English, Portuguese and Spanish

Clinical/experimental design

Studies regarding treatment and interventions for APM

Original articles, theses and dissertations

Figure 1. Flowchart regarding the inclusion/exclusion of articles of the review presented.

ResultsOf the 23 studies analysed, most were conducted in the United States (n = 11) and in Australia (n = 4). The intervention modalities studied by the articles were, in descending order: cognitive behavioural therapy (n = 6), yoga (n = 4), meditation (n = 4), virtual reality exposure (n = 3), biofeedback (n = 3), music therapy (n = 2) and the Alexander technique (n = 1). It was found that none of the studies assessed combined interventions pertaining to different modalities and that the interventions assessed were not standardised in terms of duration, session frequency or technique utilised.

118 Burin AB, Osório FL / Arch Clin Psychiatry. 2016;43(5):116-31

Concerning design, in accordance with the inclusion criteria adopted, all of the studies were clinical (experimental). Out of these studies, most (n = 16) employed the intergroup modality (case control), and less than half were randomised (n = 7). The remainder (n = 7) had a pre-experimental design (pre- and post-intervention assessment) with a single group.

The samples were composed of varying numbers of subjects, with a minimum of four and a maximum of 162 (experimental group: mean 21.8 and median 14; control group: mean 19.9 and median 9).

Most of the studies used both genders in their clinical samplings (n = 14); five studied only adolescents, and one studied only children. The remainder focused on young adults.

Most of the subjects had been recruited in music schools and courses, and most of them were music students (n = 19). No study assessed interventions using exclusively professional musicians. It was noted that the musical instruments played by the musicians varied,

with a predominance of the piano (approximately 176 subjects), followed by wind instruments (approximately 119 subjects) and string instruments (approximately 103 subjects).

Few studies were clear as to the criteria adopted for the inclusion and exclusion of subjects (n = 2). Similarly, many studies failed to consider the level of MPA demonstrated by the subjects (whether pathological or considered within an acceptable level of normality).

In the 16 studies with an inter-group experimental design, the control groups were, in general, quite consistent with the socio-demographic characteristics of the experimental group in question, though, as mentioned, these studies often did not monitor the extent of MPA as a variable. The subjects in the control group were recruited from the same locations as those in the experimental groups, meaning they were also music students.

This information can be viewed in Table 1.

Table 1. Socio-demographic characterisation of the samples and methodological aspects used in the studies assessed in the present review

Num

ber

Author/Year/Country

Sample Musician’s Characteristics

Stud

y Des

ign

Inte

rven

tion

Inte

rven

tion

Char

acte

ristic

s

Cont

rol

Inte

rven

tion

Experimental Group Control Group

n Age Education n Age Education Level Instrument

11 Osborne et al. (2007) Australia

6♂ 8♀ 13,9 (1,22) Ad

ES 3♂ 6♀ 13,9 (1,22) Ad

ES S 8st, 5pi, 8w, 2 per

E inter-R CBT 7ss (3Gr, 4I) Behaviour Exposure

Only12 Bien Aime (2011)

USA4♀ 25,0 A U – – – S 1 v, 3pi PE (PP) CBT 3 ss –

13 Clark and Williamon (2011)

England

14♂♀ 24,1 (7,47) A

U 9♂♀ 22,9 (2,56) A

U S 6pi, 5v, 7st, 5w

E inter CBT 18ss (Gr+I)Weekly

None

14 Errico (2012) USA 41♂ 43♀

Ch ES 37♂ 41♀ Ch ES S NI E inter CBT 6ssWeekly

Training the performance

material15 Hoffman and

Hanrahan (2012) Australia

15♂♀ 42,1 (15,18) A

NI 18♂♀ 42,1 (15,18) A

NI S 17v, 16 (pi, st, w)

E inter-R CBT 3ss Weekly None

16 Braden et al. (2015) Australia

30♀ 13,7 (0,87) Ad

JHS 32♀ 13,8 (0,84) Ad

JHS S 16 pi, 21 w, 14 st, 7 v, 3 per,

1 v+st

E inter CBT 8ss (Gr) Weekly

None

17 Khalsa and Cope (2006) USA

5♂ 5♀ 25,3 (3,1) A

NI 4♂ 4♀ 13,8 (0,84) Ad

NI S 4v, 9st, 1w, 3pi, 1per

E inter Y 64ss (Gr) Daily

None

18 Khalsa et al. (2009) USA

EG1: 6♂ 9♀

EG2: 8♂ 7♀

EG1: 24,5 (2,4) A

EG2: 25,4 (3,9) A

EG1: NIEG2: NI

6♂ 9♀ 24,0 (1,6) A

NI S 23st, 13w, 4pi, 5v

E inter Y G1: 24ss (Gr) 3/week

+ 2 days intensive +

6ss problem solving

G2: 24ss (Gr) 3/week

None

19 Stern et al. (2012) USA

17♂♀ 21,7 (3,1) A

U – – – S v, inst PE (PP) Y 14ss 2/week +

homework

–

20 Khalsa et al. (2013) USA

30♂ 54♀

16,4 (0,9) Ad

U 29♂ 22♀ 16,5 (1,5) Ad

U S NI E inter Y 6ssWeekly

None

21 Thurber (2006) USA

4♂ 3♀ 23,42 A NI 5♂ 2♀ 23,42 A NI NI 3w, 3pi, 4v, 1per, 2st,

1comb

E inter BF 4/5ss (I) None

22 Silvana et al. (2008)

Macedonia

3♂ 9♀ * ♂20,0 (0,00) A♀20,9

(2,98) A

U * ♂20,0 (0,00) A♀20,9

(2,98) A

U S NI E inter-R BF 20ss (I) Usual practice

continuation


Num

ber

Author/Year/Country

Sample Musician’s Characteristics

Stud

y Des

ign

Inte

rven

tion

Inte

rven

tion

Char

acte

ristic

s

Cont

rol

Inte

rven

tion

Experimental Group Control Group

n Age Education n Age Education Level Instrument

23 Wells et al. (2012) Australia

22♂ 24♀ *

30,4 (11,98) A

NI * 30,4 (11,98) A

NI NI 30w, 11v, 5st

E inter-R BF 1ss Breathing techniques

orReading their

preferred material

24 Chang et al. (2003) USA

2♂ 7♀ 26,6 (6,8) A

U 3♂ 7♀ 26,5 (6,6) A

U S 12pi, 3st, 3v, 1ot

E inter-R Me 8ss (Gr) Weekly + home practice

None

25 Lin et al. (2008) USA

5♂ 14♀ *

25,1 (6,7) A

U * 25,1 (6,7) A

U S 12pi, 2ot, 3v, 2st

E inter-R Me 8ss (Gr) Weekly + home practice

None

26 Su et al. (2010) Taiwan

26♂ 33♀

NI ES – – – S 46pi, 13st PE (PP) Me 16ss 2/week

–

27 Sousa et al. (2012) Portugal

1♂ 7♀ 11,5 (0,7) Ad

NI 2♂ 6♀ 12 (0) Ad NI S 16w E inter Me 14ss 2/week + Home

practice

None

28 Orman (2003) USA

5♂ 3♀ 20,6 A U – – – S 6w, 2 (w+pi)

PE (PP) VE 12ss (VE) Weekly + 3ss (live

exposure)

–

29 Bissonnette et al. (2011) Canada

9♂♀ 21,8 (5,2) A

NI 8♂♀ 21,8 (5,2) A

NI NI pi, st E inter-R VE 6ssWeekly

None

30 Conklin (2011) USA

12♂♀ NI U – – – S 12pi PE (PP) VE 5 ss –

31 Kim (2005)South Korea

6♀ 25,0 (2,2) A

U – – – NI 6pi PE (PP) MT 6ss Weekly

–

32 Kim (2008) South Korea

GE1 15♀GE2 15♀

20,0 A U – – – S 30pi PE (PP) MT GE1: 6ss weekly

GE2: 6ss weekly

–

33 Hoberg (2008) South Africa

6♀ 12,8 Ad NI 6 (NI) 11-18 Ad NI S 12w E inter AT 12 ss None

A: adult; Ad: adolescent; AT: Alexander Technique; BF: Biofeedback; CBT: Cognitive Behavioural Therapy; Ch: Child; comb: combination of two kinds of instruments; E: experimental; ES: elementary school; G: group; Gr: group; HS: High School; I: Individual; inter: inter-groups; inst: instrument; JHS: junior high school; ls: lessons; Me: Meditation; MT: Music Therapy; NI: not informed; ot: others; P: professional; per: percussion; pi: pianist; PE (PP): pre and post intervention; R: randomized; S: student; ss: session; st: strings; U: university students; USA: United States of America; v: voice; VE: Virtual Exposure; w: wind; Y: yoga. * article does not discriminate the number of subjects on the basis of experimental and control groups. ♀: females; ♂: males.

The effectiveness of the interventions analysed was also considered. The results are summarised in Tables 2 and 3. This data can also be seen in more detail in the Supplementary Material.

The effectiveness of cognitive behavioural therapy (Table 2) was evaluated based on 10 different outcomes. In two studies, a decrease in MPA was found, as were improvements in performance (N = 2), self-efficacy (N = 2) and self-confidence (N = 2), with effect size evaluated as medium-very large. It is important to indicate that one of the studies which showed a decrease in MPA was conducted on adolescents16. However, these findings are not unanimous among the studies, as around half did not find changes to these variables following the cognitive behavioural therapy intervention. This evidence was found to be more present in pre-experimental studies (pre- and post-intervention). It was also found that there was a

relative variability in the instruments utilised to assess the different outcomes.

Virtual reality exposure was also considered. Table 2 shows that the main positive results point to decreases in MPA, discomfort, confidence and heart rate; however, these outcomes were evaluated in three different studies28-30 with a pre-experimental design and a restricted number of subjects. These results, despite showing robust effects sizes, do not allow conclusions, only point to possible trends.

When the biofeedback intervention was considered, no alterations were found in the outcomes for subjective anxiety, whether general or performance-related (Table 2). Two experimental-type studies21,22 showed improvements in different neurophysiological variables.


Table 2. Results of Cognitive Behavioural Therapy, Virtual Reality Exposure and Biofeedback interventions on different outcome variablesOutcome Measures Instrument* Results* Effect size (♦)

Cognitive Behavioural Therapy6 studies

Anxiety – Trait STAI-T13- 15 EG = CC13-15

EGb = EGa13,15

Anxiety – State STAI-S11 EG = CG11

Cognitive Anxiety CSAI-2R13 EG = CG13

Somatic Anxiety CSAI-2R13 EG = CG13

Musical Performance Anxiety – self evaluation

NVI 12

MPAI-A11,16

PAI15

EG < CG16

EG = CG11,15

EGb > EGa15,16

EGb = EGa12

0.41 to 0.93 = medium/large

Musical Performance Quality – self evaluation

NVI12

MSS13

EG = CG13

EGb < EGa12,13

EGb = EGa 12

0.54 to 0.79 = large

Musical Performance Quality – hetero evaluation

PQ15,16 EG = CG15,16

EGb < EGa15

EGb = EGa16

0.39 = medium

Self-efficacy/Self-confidence NVI 12

SEMPQ13 (efficacy)CSAI-2R 13 (confidence)SRLIS 13 (self learning)

EG > CG13 (efficacy, self learning)EGb < EGa

12,13

EGb = EGa 13 (confidence)

EG = CG13 (confidence)

0.46 = medium1.05 to 3.90 = very large

Heart Rate – EG = CG11,15

EGb = EGa15

Frontalis Muscle Movement – EG = CG11

Virtual Reality Exposure3 studies

Anxiety – State STAI-T29 EGb = EGa29

Confidence PRCP29 EGb > EGa29 2.66 = very large


CPAI virtual30

CPAI live30

EGb > EGa30

EGb > EGa30

0.74 = large0.91 = large

Discomfort SUDS28,29 EGb = EGa29

3 subj – M 1 > M 2 > M 328#

3 subj – M 1 < M 2 > M 3 28#

1 subj – M 1 < M 2 < M 328#

1 subj – M 1 = M 2 > M 328#

Heart Frequency – EGb = EGa29

* 1 subj – M 1 > M 2 > M 328#

* 2 subj – M 1 > M2 < M 328#

* 5 subj – M 1 < M 2 > M 328#

Biofeedback3 studies

Anxiety – Trait STAI-T21,22 EG = CG21,22

Anxiety – State STAI-S21-23 EG = CG21-23

Music Performance Anxiety – self evaluation

PAI21 EG = CG21

Music Performance Quality – hetero evaluation

FSS21

NVI22

EG = CG 21

EG> CG 22

Heart Frequency – EG = CG21

Heart Rate Variability – EG = CG21

Alpha Power – EG > CG22

Integrated EMG Power – EG > CG22

Alpha Suppression – EG < CG22

Alpha Peak Frequency – EG < CG22

Individual Alpha Band Width – EG < CG22

Vagal Tone – EGb < EGa23

CG: Control Group; CPAI: Conklin Performance Anxiety Index; CSAI-2R: Revised Competitive State Anxiety Inventory 2; EG: Experimental Group; FSS: Flow State Scale; NVI: Not Validated Instrument; M: moment; MPA: Music Performance Anxiety; MPAI-A: Music Performance Anxiety Inventory for Adolescents; MSS: Music Skills Survey; PAI: Personal Anxiety Inventory; PQ: Performance Quality; PRCP: Personal Report of Confidence as a Performance scale; STAI-S: State Anxiety Inventory; STAI-T: State-Trait Anxiety Inventory-Trait; SRLIS: Self-Regulated Learning Interview Schedule; SUDS: Subjective Units of Distress Scale; a : After Intervention; b : Before Intervention; *: article number, according to Table 1; #: statistical analysis not performed; (♦) effect size: range of variation – calculated only for the study had a mean value and standard deviation, as supplementary material.

Yoga was also used as an intervention technique. Table 3 shows that, unlike the others, this group of studies tended to use the same instruments to evaluate outcomes, a factor which is considered positive. Although they all reported improved MPA indicators in one way or another, only two of the experimental studies17,20 truly presented efficacy indicators on this level (one of these studies was conducted on adolescents), with medium effects sizes. There was

no evidence of changes to the indicators of general mood, stress, disposition, sleep or musculoskeletal disorders except in one study20, in which the severity levels of these disorders decreased. However the effect size is little (d = 0.02).

Meditation was also used as an intervention. Table 3 shows that limited evidence on effectiveness was found, with the exception of MPA and heart rate outcomes, in which positive alterations were


found in isolated form in the studies24,25,27. It is important to note that the study27 involved adolescents and, though experimental, had quite a small sample size (n < 19).

Table 3 also shows that with regards to music therapy, the only two studies which were assessed reported positive evidence only in terms of the decrease in state anxiety (effect size: 0.72-1.14). Concerning the remaining variables, Kim’s study32 indicates improved MPA, stress and tension; however, it was a pre-experimental study which only assessed 20 subjects.

Finally, it is important to note that only one study evaluated the Alexander technique. This study reported improvements in anxiety, physiological symptoms and musculoskeletal symptoms. The significance of these improvements was not assessed from a static perspective in this study.

In an attempt to integrate the findings of this current review with those from previous reviews, we have grouped together the different interventions and the main evidence on effectiveness by the outcome assessed. This data can be seen in Table 4.

The principal intervention modality, which was found to produce positive results for the treatment of MPA in both the previous and current reviews, was behavioural and/or cognitive therapies. It is also important to note that the main effect shown was the reduction in MPA (10 out of 19 studies). The current review has also found evidence of a positive effect on this outcome, as well as on performance quality, self-efficacy and trait anxiety levels, an observation which supports the previous findings, with medium effects size. Nonetheless, it must be noted that the positive findings were not unanimous in any of the reviews, as some of the studies did not show favourable results.

The current review found that other intervention modalities have been attracting a greater interest from researchers, with some signs/tendencies of effectiveness in MPA treatment. These interventions include yoga, virtual reality exposure, biofeedback and music therapy. It is in this way that new tendencies in interventions are revealed; these interventions need to be systematically assessed to determine their efficacy in the treatment of MPA.

Table 3. Results of Yoga, Meditation, Music Therapy and Alexander technique interventions on different outcome variablesOutcome Measure Instrument* Result* Effect size (♦)

Yoga4 studies

Anxiety – Trait STAI-T19,20 EG < CG20

EGb > EGa 19,20

0.34 = medium0.85 to 0.90 = large

Anxiety – State STAI-S20 EG = CG20


MPAI-A20

KMPAI19

EG < CG20

EGb > EGa19

0.31 to 0.40 = medium0.65 = large

PAQ group17-20 EG < CG20

EG = CG17

EGb > EGa 17-19

0.45 = medium0.51 = large

PAQ practice17-20 EG = CG17,20

EGb = EGa19

EGb > EGa 17,18

PAQ solo17-20 EG < CG17,20

EGb > EGa 17-19

0.26 = medium0.35 = medium

Humour POMS17-19 EG = CG17,18

EGb = EGa17-19

Disposition DFS-217 EG = CG17

EGb = EGa17

Sleep PSQUI18 EG = CG18

Stress PSS18 EG = CG18

Skeletal Muscle Disorder PRMD-Q17,18 EG = CG17,18

EGb = EGa17

PRMD-Q frequency20 EG = CG20

PRMD-Q severity20 EG < CG20 0.02 = smallMeditation4 studies

Anxiety – State EADS-C27 EG = CG27

EGb = EGa27


PAI24,25

MPAI-A26

EG = CG24

EG < CG25

EGb > EGa 24

EGb = EGa26

0.02 = small

Musical Performance Quality – hetero evaluation

MPQRF25 EG = CG25

Cognitive Interference CIQ cognitive aspects24

CIQ mind wandering24

CIQ intrusive thoughts24

EG = CG24

EG = CG24

EG = CG24

Salivary Cortisol – EG = CG27

EGb = EGa27

Blood Pressure – EG = CG27

EGb = EGa27

Heart Rate – EG < CG27

EGb > EGa27

0.70 = large0.54 = large

continuation


Outcome Measure Instrument* Result* Effect size (♦)Music Therapy2 studies

Anxiety – Trait STAI-T31 EGb = EGa31

Anxiety – State STAI-S31,32 EGb > EGa31

EGb > EGa32

0.72 = large0.76 to 0.1.15 = large


LAS31

PARQ31

VAS mpa32

MPAQ32

EGb > EGa31

EGb = EGa31

EGb > EGa32

0.95 = large0.19 to 0.87 = small/large

Stress/Tension VAS-stress32 EGb > EGa32 0.66 = large

VAS-tension32 EGb > EGa32 0.75 to 1.14 – large/very large

VAS-comfort32 EGb > EGa32 0.62 = large

Finger Temperature – EG-1b < EG-1a32 0.75 = large

Alexander Technique1 study

Nervousness NVI33 EGb < EGa33#

EG < CG33#

Skeletal Muscle Disorder NVI33 EGb < EGa33#

EG < CG33#

Somatic Symptoms (trembling/dizziness)

NVI33 EGb < EGa33#

EG < CG33#

CG: Control Group; CIQ: Cognitive Interference Questionnaire; CSAI-2R: Revised Competitive State Anxiety Inventory 2; DFS-2: Dispositional Flow Scale; EADS-C: Anxiety, Depression, and Stress Scale for Children; EG: Experimental Group; FSS: Flow State Scale; KMPAI: Kenny Music Performance Anxiety Inventory; LAS: Likert Anxiety Scale; NVI: Not Validated Instrument; MPAI-A: Music Performance Anxiety Inventory for Adolescents; MPAQ: Music Performance Anxiety Questionnaire; MPQRF: Music Performance Quality Rating Form; MSS: Music Skills Survey; PAI: Personal Anxiety Inventory; PAQ: Performance Anxiety Questionnaire; PARQ: Performance Anxiety Response Questionnaire; POMS: Profile of Mood States; PSQI: Pittsburgh Sleep Quality Index; PSS: Perceived Stress Scale; PRMD-Q: Performance Related Musculoskeletal Disorder Questionnaire; STAI-S: State Anxiety Inventory; STAI-T: Trait Anxiety Inventory; VAS: Visual Analogue Scale; a : After Intervention; b : Before Intervention. *: article number, according to Table 1; #: statistical analysis not performed; (♦) effect size: range of variation – calculated only for the study had a mean value and standard deviation, as supplementary material.

Table 4. Comparative analyses of the studies included in three reviews of the literature on the effectiveness of MPA interventions, in terms of the different outcome variables analysed (categories are non-exclusive)Intervention Outcome variable Kenny (2005)

(n = 33)Brugues (2011)A

(n = 13)Burin and Osório (2015)

(n = 23)BT / CBT / C(n = 19) (10+3+6)(A)

Music Performance Anxiety ***** *** **Heart Rate ** *

Performance Quality ** **Self-Efficacy *** **

Self-ConfidenceAnxiety – State *** Anxiety – Trait **

General Anxiety *** **Teacher Anxiety Ratings *

Virtual Reality Exposure(n = 3) (0+0+3)

MPA *Confidence *Discomfort *Heart Rate *

Biofeedback(n = 4) (1+0+3)

Music Performance Anxiety *Neurophysiological Measures **

Performance Quality *Meditation(n = 7) (1+2+4)

Music Performance Anxiety * **Heart Rate *

Music Therapy(n = 3) (1+0+2)

Music Performance Anxiety *Confidence *

Musical Skills *Stress/Tension * **Self-involved *State Anxiety **

Hypnotherapy(n = 1) (1+0+0)

Music Performance Anxiety *

Alexander Technique(n = 3) (1+1+1)

Musical Skills *Active and warm hearted scales

of Nowlis*

General Anxiety *Positive attitude in relation to the

performance*

continuation


Intervention Outcome variable Kenny (2005)(n = 33)

Brugues (2011)A

(n = 13)Burin and Osório (2015)

(n = 23)Ericksonian(n = 1) (1+0+0)

Anxiety – State *Confidence *

Pharmacological(n = 10) (0+10+0)

Performance Quality *****Music Performance Anxiety **

Heart Rate **Stress-related tachycardia **

Shaking hands *Coordination and judgment *

Physical and Vocal Practice(n = 1) (0+1+0)

General Anxiety *

Anxiety Workshop(n = 1) (0+1+0)

Stress *

Yoga(n = 4)(0+0+4)

Anxiety – Trait **Music Performance Anxiety ****

Performance-Related Musculoskeletal Disorder –

severity

*

Combined Intervention(n = 7)(6+1+0)

General Health *Anxiety *

Anxiety-Trait **Music Performance Anxiety **

Stress *Humour *

Confidence *Music Performance *

BT: Behavioural Therapy; C: Cognitive; CBT: Cognitive Behavioural Therapy. *: number of studies with evidence of positive effectiveness. A : only studies not included in the review by Kenny (2005). # : case report. (A) the number in the first parentheses refer to the total number of the studies, and the number in the second parentheses refer to number of the studies in each revision.

Discussion

The impact of MPA on musicians is a frequently referred topic in literature worldwide5,6,34 as is the need for studies which assess ways to treat and minimise this type of anxiety35. Thus, a relatively low number of studies performed thus far have aimed to assess the effectiveness of interventions to combat MPA, particularly if one considers the diversity of interventions and outcomes analysed and the limited number of subjects exposed to the interventions. This is strongly reflected in the quality and level of evidence observed and compiled by the reviews.

It is also important to point out that different fields of research outside health/medicine are increasingly considering this topic. These new approaches deserve attention, since MPA isa largely pathological condition associated with anxiety disorders. In the same vein, it is important to note that, to our knowledge, no study has been developed over the last 13 years with the aim of testing psychotropic drugs for MPA treatment.

Most of the studies have been published in periodicals in the music field or in the form of theses and dissertations, and that does not always guarantee a critical peer review. Furthermore, it is worth mentioning that the studies analysed continue to present important methodological weaknesses, as was mentioned by the previous reviews7,8.

Thus, a large portion of the evidence presented herein requires careful interpretation, as it is not associated with experimental studies with inter-group comparisons. It is also important to note that most of the studies offer no information on the MPA levels experienced by the subjects, especially whether these levels were pathological. This information is essential for coming to conclusions on the success of the interventions analysed. Further limitations at this level are the low number of subjects studied, samples restricted mainly to young adults and music students, the lack of or failure to use subject randomisation, the lack of standardisation in the techniques used and in the duration of each intervention, the use of some non-validated

instruments for outcome assessment and the presence of descriptive and non-statistical analyses of the results.

Another point to be considered involves the wide variety of instruments used to gauge the same outcome variables. An attempt to standardise the instruments used may be promising in that it will aid in the comparison of the evidence found, particularly in cases of meta-analyses.

Once these important methodological considerations are applied, one is able to focus on specific results regarding the interventions, which include more traditional and well-established interventions for different anxiety disorders, such as the cognitive behavioural therapy36 and virtual reality exposure37, as well as interventions that have not been fully endorsed in the literature for use in health care, such as meditation, music therapy, biofeedback, yoga and the Alexander technique.

With respect to the cognitive behavioural interventions, the results from the studies analysed partially support the positive findings previously indicated by earlier reviews, particularly in terms of the reductionsin MPA and trait anxiety rates and improvements in performance quality and self-efficacy.

Cognitive behavioural interventions are psychotherapy modalities comprising different cognitive restructuring techniques which aim to alter thought patterns which are considered dysfunctional38. These thought patterns are common to individuals with anxiety39 and are particularly common among musicians with MPA6. Another aim of these interventions is to improve social and assertiveness abilities, which are usually limited in these clinical groups40. Other resources are also used, such as mental rehearsal techniques and strategies for anxiety coping and relaxation, which favour management and better control over anxiety symptoms. Such interventions are recognised as one of the gold standards for anxiety disorder treatment41.

Considering the fact that MPA is a subtype of social anxiety disorder1, the findings on this specific condition are backed by


this wider context. However, when the three reviews on the topic were compared, what stands out is that the new studies are more contradictory in their findings; they lack evidence on this intervention in 50% of the results. A possible explanation for this discrepancy maybe based on the sample makeup of the studies: the studies are not clear on the criteria for subject inclusion and exclusion and the extent of MPA experienced, especially because every individual, without exception, was recruited from music learning/education centres and not in psychiatric and mental health specialised services. It is assumed that the response of symptomatic subjects to the interventions may differ from that of individuals who present ‘normal’ levels of MPA, which is considered common in the music profession. Two other points that may also explain this divergence is the technique utilised for each study, as well as the diversity in the number of sessions3-18.

The use of virtual reality exposure for treating MPA has resulted in positive outcome tendencies, including reduced MPA, an improvement in self-confidence and decreases in discomfort and heart rate, although only one experimental study with inter-group design has been undertaken with this type of intervention. Considering the fact that virtual reality offers a safe and non-evaluative environment for the confrontation, training and management of anxious experiences, its use for this specific group may, in fact, be promising, especially because it involves habituation and desensitisation processes. Previous studies37,42 also indicate positive results with the use of this intervention modality for other phobic-anxious disorders. Therefore, virtual reality is considered an intervention modality which requires studies with a greater methodological refinement and a larger sampling number so that its effectiveness may be proven.

Regarding the use of yoga, its relative efficacy for emotional symptoms has been studied in other contexts involving clinical aspects such as on cancer patients43, with chronic obstructive pulmonary disease44, and on cases of arterial hypertension45. It has also been used in studies involving psychiatric aspects, such as post-partum depression46

and anxiety disorders47. The results of these studies are promising and suggest positive effects on mental and physical awareness and well-being43 as well as increases in lung capacity44 significant decreases in systolic and diastolic blood pressure in hypertensive patients, decreases in depression and anxiety-related symptoms46 and decreases in anxiety levels47. Despite the aforementioned methodological limitations, the results on MPA management are favourable. It is possible that aspects such as breathing training and meditation techniques are related to the effects observed on the anxiety symptoms, which deserve more refined investigation.

Regarding the findings on meditation, the results tend to reflect a decrease in MPA but are still quite weak and limited. Similar to yoga, meditation, which is often part of the yoga intervention, has been gaining ground in the field of mental health. This is especially true for mindfulness meditation48. For example, this intervention has had positive results in ruminations, which are repetitive thoughts on negative emotional experiences and worries in patients with anxiety and depression49. Positive results were also found regarding levels of anxiety and depression among cancer patients50.

Meanwhile, the two studies that assessed the effectiveness of music therapy showed that this intervention modality may lead to decreases in MPA and stress symptoms, but these results still lack new studies with a greater methodological refinement. It is believed that the effectiveness of this intervention modality is associated with the techniques used, which include breathing exercises, improvisation and relaxation, as well as musical stimuli which may induce physical and emotional changes51. The effects of music therapy for the reduction of anxiety and depression symptoms are also being investigated in individuals with other medical conditions, such as Alzheimer’s52 and terminal illnesses53.

Studies on biofeedback have shown that this technique is being tested as a treatment for other psychiatric conditions, such as anxiety disorders, depression, eating disorders and schizophrenia54. This is a method in which instrumentals are used with a focus on the processes of muscle relaxation, breathing techniques, awareness

techniques and cognitive aspects, all of which result in easing the body’s self-regulatory process55. Such aspects of biofeedback may be related to the alterations observed in the different physiological parameters analysed in the studies21,22. However, the findings are still quite speculative and do not allow for greater conclusions.

It has been observed that studies involving the Alexander technique continue to be conducted as of late; however, they have been focused on the outcome variables associated with musculoskeletal conditions because the technique aims to release muscular tension and to re-educate unbeneficial movement patterns56. Despite signalling evidence of effectiveness for treating MPA, the study analysed herein presents important limitations as it has not been analysed statistically.

Finally, it is worth noting that, regardless of the intervention modality utilised, studies involving children and adolescents are necessary since the number of studies for this age group are quite limited. This fact reflects a well-known bias in the studies on social and performance anxiety, which is linked to the absence of early attention, diagnosis and treatment of the symptoms because they are considered common or of little relevance57.

This perception is stronger in the musical contexts experiencing apprehension and anxiety when facing performances is considered a part of a musician’s routine. This prevents the recognition of its seriousness and the damages associated with MPA. Thus, diagnosis and, more importantly, interventions for musicians at early ages can prevent them from starting a career in music with the disadvantage brought by managing the symptoms of a clinical condition.

Few studies are based on professional musicians, perhaps due to the difficulty involved in recruiting them for experimental studies. Nonetheless, it is believed that this more select group (relative to music students) deserves special and specific attention, as many of them end up creating their own coping strategies, which often include the indiscriminate use of drugs with no medical supervision58.

ConclusionsResearch on the treatment and intervention of MPA has been a focus for researchers in the last decade; however, a limited number of studies have been performed outside the medical/health care fields. The number of interventions and outcome variables analysed is extensive, and the positive results are notably centred around a decrease in states of anxiety. Among the interventions analysed, CBT still offers greater evidence of effectiveness. However, due to the many methodological weaknesses and the limited number of studies on a single intervention and outcome, the results require careful interpretation and do not allow for conclusions regarding intervention efficacy.

These aspects have been pointed7 and are still an important limitation for the field and support her statements that this body of knowledge is still inconsistent, inconclusive and methodologically fragile.

Funding

The São Paulo Research Foundation, Foundation for Research Support of the State of São Paulo (Fapesp) (Process No. 2015/ 00097-0).

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b

>

EGa

55

,80

49,1

0

EG

=

CG

49,1

0

49,5

0

PAQ

-sol

o (s

elf)

EG

b

>

EGa

59

,10

50,8

0

EG

<

CG

50

,80

58,3

0

–PO

MS

– H

umou

r (se

lf)

EGb

=

EGa

45

,2 (3

2,1)

64,6

(6,7

)

EG

=

CG

64,6

(6,7

)

67,4

(18,

0)

DFS

-2 –

Dis

posi

tion

(sel

f)

EGb

=

EGa

11

9,8

(13,

9)

12

8,7

(18,

7)

EG

=

CG

12

8,7

(18,

7)

12

9,3

(24,

9)

PRM

D-Q

(sel

f)

EGb =

EG a

EG =

CG

18. K

hals

a et

al.

(200

9)Yo

ga–

PAQ

-pra

ctic

e (s

elf)

GY

L b

=

GYL a

GY

O b

>

GYO a

PAQ

-gro

up (s

elf)

GY

L b

>

GYL a

GY

O b

>

GYO a

PAQ

-sol

o (s

elf)

GY

L b

>

GYL a

GY

O b

> GY

O a

–PS

S –

Stre

ss (s

elf)

GYL

= GY

O =

GC

PSQ

UI –

Sle

ep (s

elf)

GYL

= GY

O =

GC

POM

S –

tota

l – H

umou

r (se

lf)GY

L =

GCGY

O =

GCGY

L +

GYO

= G

POM

S –

anxi

ety

(sel

f)GY

L <

GCGY

O =

GCGY

L +

GYO

< G

POM

S –

depr

essi

on (s

elf)

GYL

= GC

GYO

= GC

GYL

+ GY

O =

G

POM

S –

ange

r (au

to)

GYL

= GC

GYO

< GC

GYL

+ GY

O <

G

PRM

D-Q

(sel

f)

EG =

CG

cont

inua

tion


Stud

y/In

terv

entio

nGe

nera

l Anx

iety

Perfo

rman

ce A

nxie

ty (s

elf/h

eter

o ev

alua

tion)

Perfo

rman

ce E

valu

atio

n (s

elf/h

eter

o ev

alua

tion)

Self-

Effic

acy/

Confi

denc

e/Hu

mou

r/St

ress

/Cog

nitiv

e As

pect

sPh

ysio

logi

cal p

aram

eter

sM

uscu

losk

elet

al d

isord

ers

19. S

tern

et a

l. (2

012)

Yog

aST

AI-

T (s

elf)

E

G b

>

EGa

42

,47

(7,9

5)

36

,24

(6,6

)

KMPA

I (se

lf)

EGb

>

EGa

57,

25 (2

1,28

)

45,0

6 (1

5,69

)

PAQ

-pra

ctic

e (s

elf)

EG

b =

EG

a

39,

63 (1

1,46

)

36,0

0 (9

,28)

PAQ

– g

roup

(sel

f)

EGb

>

EGa

49,

27 (1

5,12

)

42,8

7 (9

,64)

PAQ

– s

olo

(sel

f)

EGb

>

EGa

60,

60 (1

4,87

)

51,4

0 (1

4,54

)

–PO

MS

– to

tal (

self)

EG

b =

EG

a

14,

56 (1

4,25

)

12,2

5 (1

0,52

)

POM

S –

tens

ion

anxi

ety

(sel

f)

EGb

=

EGa

7,

00 (4

,00)

4,54

(3,5

)

–

20. K

hals

a et

al.

(201

3)Yo

gaST

AI-

S (s

elf)

EG

=

CG

3

5,58

(10,

31)

37

,76

(11,

49)

STA

I-T

(sel

f)

EGb

>

EGa

47,

66 (1

1,66

)

38,1

1 (9

,36)

EG

<

CG

38

,11

(9,3

6)

41

,50

(10,

88)

MPA

I-A

-tot

al (s

elf)

EG

<

CG

4

0,66

(15,

99)

45

,70

(16,

27)

MPA

I-A

som

ativ

e/co

gniti

ve (s

elf)

EG

<

CG

24,4

6 (9

,89)

27,9

1 (1

1,25

)

MPA

I-A

per

form

ance

con

text

(sel

f)

EG

=

CG

7,

44 (4

,33)

7,41

(4,2

3)

MPA

I-A

per

form

ance

eva

luat

ion

(sel

f)

EG

<

CG

8,76

(4,0

2)

10

,39

(4,0

5)

PAQ

-pra

ctic

e (s

elf)

EG

=

CG

33,6

5 (9

,49)

35,0

7 (8

,89)

PAQ

-gro

up

EG

<

CG

4

0,98

(10,

55)

46

,09

(12,

41)

PAQ

-sol

o (s

elf)

EG

<

CG

53

,92

(12,

72)

57

,39

(14,

85)

––

PRM

D-Q

freq

uenc

y (s

elf)

EG

=

CG

2

1,67

(22,

61)

22

,84

(25,

20)

PRM

D-Q

sev

erity

(sel

f)

EG

<

CG

18,

16 (1

8,63

)

18,5

8 (2

4,31

)

cont

inua

tion


Stud

y/In

terv

entio

nGe

nera

l Anx

iety

Perfo

rman

ce A

nxie

ty (s

elf/h

eter

o ev

alua

tion)

Perfo

rman

ce E

valu

atio

n (s

elf/h

eter

o ev

alua

tion)

Self-

Effic

acy/

Confi

denc

e/Hu

mou

r/St

ress

/Cog

nitiv

e As

pect

sPh

ysio

logi

cal p

aram

eter

sM

uscu

losk

elet

al d

isord

ers

21. T

hurb

er (2

006)

Bio

feed

back

STA

I-S

(sel

f)

EG

=

CG

35

,57

(9,8

6)

38

,14

(12,

53)

STA

I-T

(sel

f)

EG

=

CG

31,8

5 (7

,75)

39,1

4 (6

,46)

PAI (

self)

EG

=

CG

44,

42 (1

5,61

)

30,8

5 (8

,09)

FSS

– (s

elf)

EG =

CG

–H

RV

EG

=

CG

4,

28 (8

,05)

53,5

2 (2

3,35

)

HR

EG

=

CG

75 (4

,43)

84,2

8 (1

2,47

)22

. Silv

ana

et a

l. (2

008)

B

iofe

edba

ckST

AI-

S (s

elf)

EG

=

CG

STA

I-T

(sel

f)

EG

=

CG

–Ju

dge

Het

ero

EG >

CG

–A

P –

EG >

CG

IAB

W –

EG

< CG

IEM

GP

– EG

> C

GA

S –

EG <

CG

APF

– E

G <

CG23

. Wel

ls e

t al.

(201

2)B

iofe

edba

ckST

AI-

S (s

elf)

GE

bf

=

GC

GEr

=

GC

––

–Va

gal T

one

EGb <

EGa

24. C

hang

et a

l. (2

003)

Med

itatio

n–

PAI (

self)

EG

b

>

EGa

EG

=

CG

–CI

Q (c

ogni

tive

aspe

cts)

(sel

f)

EG

= CG

CIQ

– (m

ind

wan

deri

ng) (

self)

EG

=

CG

3,

07 (2

,07)

4,13

(1,6

3)

CIQ

– (i

ntru

sive

thou

ghts

) (se

lf)

EG

=

CG 3

9,28

(20,

02)

6,

78 (9

,98)

–

25. L

in e

t al.

(200

8)

Med

itatio

n

–PA

I (se

lf)

EG

<

CG

41,6

(14,

5)

41

,4 (6

,42)

MPQ

RF (h

eter

o)EG

= C

G–

–

26. S

u et

al.

(201

0)

Med

itatio

n

–M

PAI-I

(sel

f)

EGb

=

EGa

39

,49

39,5

3

––

–

27. S

ousa

et a

l. (2

012)

M

edita

tion

EAD

S-C

– st

ate

anxi

ety

(sel

f)

EGb

=

EGa

11

,6 (8

,0)

7,

8 (6

,2)

EG

=

CG

7,

8 (6

,2)

14

,0 (1

4,2)

––

–Co

rtis

ol (S

aliv

ary)

EG

b =

EG

a

5,

46 (1

,51)

2,82

(1,5

8)

EG =

CG

2,

82 (1

,58)

3,21

(3,9

1)

Blo

od P

ress

ure

EG

b =

EG

a

92

(8,7

)

86 (6

,4)

EG

=

CG

86

(6,4

)

79 (6

,2)

HR

E

G b

>

EGa

10

7 (2

1,8)

96 (1

8,9)

EG

<

CG

86

(7,2

)

96 (1

8,9) cont

inua

tion


Stud

y/In

terv

entio

nGe

nera

l Anx

iety

Perfo

rman

ce A

nxie

ty (s

elf/h

eter

o ev

alua

tion)

Perfo

rman

ce E

valu

atio

n (s

elf/h

eter

o ev

alua

tion)

Self-

Effic

acy/

Confi

denc

e/Hu

mou

r/St

ress

/Cog

nitiv

e As

pect

sPh

ysio

logi

cal p

aram

eter

sM

uscu

losk

elet

al d

isord

ers

28. O

rman

(200

3)Vi

rtua

l Rea

lity

Expo

sure

––

–SU

DS*

(dis

com

fort

) (se

lf)3

suj:

M 1

> 2

> 3

3

suj:

M 1

< 2

> 3

1 su

j: M

1 <

2 <

3

1 su

j: M

1 =

2 >

t3

HR*

1 su

j: M

1>

2 >

32

suj:

M 1

> 2

< 3

5 su

j: M

1 <

2 >

3

29. B

isso

nnet

te e

t al.

(201

1)Vi

rtua

l Rea

lity

Expo

sure

STA

I-S(

self)

EG

b =

EG

a

50

,56

(4,4

9)

43

,33

(2,9

0)

––

SUD

S (d

isco

mfo

rt) (

self)

EG

b =

EG

a

6,

00 (0

,66)

5,28

(0,6

6)

PRCP

– c

onfid

ence

(sel

f)

EGb

> E

G a

17,3

3 (1

,96)

12,1

1 (1

,96)

Puls

e Ra

te

EGb

=

EGa

89

,61

(5,6

1)

85

,27

(5,6

1)

30. C

onkl

in (2

011)

Virt

ual R

ealit

y Ex

posu

re

–CP

AI (

self)

Virtu

al

EGb

>

EGa

45

,73

(9,8

4)

38

,45

(9,8

2)

Live

E

G b

>

EGa

59,

36 (1

2,30

)

47,0

9 (1

4,59

)

––

–

31. K

im (2

005)

Mus

ic T

hera

pyST

AI-

S (s

elf)

EG

b >

EG a

61,

17 (1

5,08

)

50,6

7 (1

4,11

)

STA

I-T

(sel

f)

EGb

=

EGa

36

,67

(8,9

1)

36

,17

(7,8

3)

PARQ

(sel

f)

EGb

=

EGa

78

,5 (1

5,2)

74,6

7 (1

2,18

)

LAS

(sel

f)

EGb

>

EGa

7,

33 (2

,16)

5,33

(2,0

7)

––

–

32. K

im (2

008)

Mus

ic T

hera

pyST

AI –

S (s

elf)

EG

-1b

>

EG-1

a

56,0

0 (9

,51)

50,7

3 (9

,9)

E

G-2 b

>

EG

-2a

54

,73

(8,6

5)

45

,07

(8,1

5)

VAS

MPA

(sel

f)

EG-1

b =

EG

-1a

8,

23 (2

,74)

7,07

(3,3

5)

EG-2

b

>

EG-2

a

7,

52 (3

,07)

4,87

(3,0

1)

MPA

Q (s

elf)

EG

-1b

=

EG-1

a

-4

,67

(6,4

4)

57

,33

(7,1

3)

EG

-2b

>

EG-2

a

58

,20

(6,4

4)

51

,13

(4,8

4)

–VA

S St

ress

(sel

f)

EG-1

b

>

EG-1

a

8,

88 (2

,55)

7,07

(2,9

3)

EG-2

b

=

EG-2

a

12,

56 (2

5,87

)

5,50

(4,0

9)

VAS

Tens

ion

(sel

f)

EG-1

b

>

EG-1

a

9,

11 (3

,63)

6,73

(2,6

7)

EG-

2 b

> E

G-2 a

9,

05 (3

,33)

5,23

(3,3

9)

VAS

Com

fort

(sel

f)

EG-1

b =

EG

-1a

7,

47 (3

,39)

7,43

(3,3

5)

EG-2

b

>

EG-2

a

7,

59 (3

,06)

5,36

(4,0

4)

Fing

er T

empe

ratu

re

EG-1

b

<

EG-1

a

84

,8 (5

,65)

88,7

3 (4

,80)

cont

inua

tion


Stud

y/In

terv

entio

nGe

nera

l Anx

iety

Perfo

rman

ce A

nxie

ty (s

elf/h

eter

o ev

alua

tion)

Perfo

rman

ce E

valu

atio

n (s

elf/h

eter

o ev

alua

tion)

Self-

Effic

acy/

Confi

denc

e/Hu

mou

r/St

ress

/Cog

nitiv

e As

pect

sPh

ysio

logi

cal p

aram

eter

sM

uscu

losk

elet

al d

isord

ers

28. O

rman

(200

3)Vi

rtua

l Rea

lity

Expo

sure

––

–SU

DS*

(dis

com

fort

) (se

lf)3

suj:

M 1

> 2

> 3

3

suj:

M 1

< 2

> 3

1 su

j: M

1 <

2 <

3

1 su

j: M

1 =

2 >

t3

HR*

1 su

j: M

1>

2 >

32

suj:

M 1

> 2

< 3

5 su

j: M

1 <

2 >

3

29. B

isso

nnet

te e

t al.

(201

1)Vi

rtua

l Rea

lity

Expo

sure

STA

I-S(

self)

EG

b =

EG

a

50

,56

(4,4

9)

43

,33

(2,9

0)

––

SUD

S (d

isco

mfo

rt) (

self)

EG

b =

EG

a

6,

00 (0

,66)

5,28

(0,6

6)

PRCP

– c

onfid

ence

(sel

f)

EGb

> E

G a

17,3

3 (1

,96)

12,1

1 (1

,96)

Puls

e Ra

te

EGb

=

EGa

89

,61

(5,6

1)

85

,27

(5,6

1)

30. C

onkl

in (2

011)

Virt

ual R

ealit

y Ex

posu

re

–CP

AI (

self)

Virtu

al

EGb

>

EGa

45

,73

(9,8

4)

38

,45

(9,8

2)

Live

E

G b

>

EGa

59,

36 (1

2,30

)

47,0

9 (1

4,59

)

––

–

31. K

im (2

005)

Mus

ic T

hera

pyST

AI-

S (s

elf)

EG

b >

EG a

61,

17 (1

5,08

)

50,6

7 (1

4,11

)

STA

I-T

(sel

f)

EGb

=

EGa

36

,67

(8,9

1)

36

,17

(7,8

3)

PARQ

(sel

f)

EGb

=

EGa

78

,5 (1

5,2)

74,6

7 (1

2,18

)

LAS

(sel

f)

EGb

>

EGa

7,

33 (2

,16)

5,33

(2,0

7)

––

–

32. K

im (2

008)

Mus

ic T

hera

pyST

AI –

S (s

elf)

EG

-1b

>

EG-1

a

56,0

0 (9

,51)

50,7

3 (9

,9)

E

G-2 b

>

EG

-2a

54

,73

(8,6

5)

45

,07

(8,1

5)

VAS

MPA

(sel

f)

EG-1

b =

EG

-1a

8,

23 (2

,74)

7,07

(3,3

5)

EG-2

b

>

EG-2

a

7,

52 (3

,07)

4,87

(3,0

1)

MPA

Q (s

elf)

EG

-1b

=

EG-1

a

-4

,67

(6,4

4)

57

,33

(7,1

3)

EG

-2b

>

EG-2

a

58

,20

(6,4

4)

51

,13

(4,8

4)

–VA

S St

ress

(sel

f)

EG-1

b

>

EG-1

a

8,

88 (2

,55)

7,07

(2,9

3)

EG-2

b

=

EG-2

a

12,

56 (2

5,87

)

5,50

(4,0

9)

VAS

Tens

ion

(sel

f)

EG-1

b

>

EG-1

a

9,

11 (3

,63)

6,73

(2,6

7)

EG-

2 b

> E

G-2 a

9,

05 (3

,33)

5,23

(3,3

9)

VAS

Com

fort

(sel

f)

EG-1

b =

EG

-1a

7,

47 (3

,39)

7,43

(3,3

5)

EG-2

b

>

EG-2

a

7,

59 (3

,06)

5,36

(4,0

4)

Fing

er T

empe

ratu

re

EG-1

b

<

EG-1

a

84

,8 (5

,65)

88,7

3 (4

,80)

Stud

y/In

terv

entio

nGe

nera

l Anx

iety

Perfo

rman

ce A

nxie

ty (s

elf/h

eter

o ev

alua

tion)

Perfo

rman

ce E

valu

atio

n (s

elf/h

eter

o ev

alua

tion)

Self-

Effic

acy/

Confi

denc

e/Hu

mou

r/St

ress

/Cog

nitiv

e As

pect

sPh

ysio

logi

cal p

aram

eter

sM

uscu

losk

elet

al d

isord

ers

33. H

ober

g (2

008)

Ale

xand

er T

echn

ique

EG

b

<

EGa

83

%

1

00%

E

G <

EC

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sis.

Letter to the editor

Address for correspondence: Matheus Fernandes de Oliveira. Rua Loefgreen, 700, ap. 103, Vila Clementino – 04040-000 – São Paulo, SP, Brazil. E-mail: [email protected]

Resolution of Othello-like syndrome following ventricular shunting in a post traumatic normal pressure hydrocephalus subjectFernando CaMPos goMes Pinto1, gaBriela stuMP2, leandro valiengo3, Matheus Fernandes de oliveira1

1 Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery of the Institute of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HCFMUSP), São Paulo, SP, Brazil.2 Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (IPq-HCFMUSP), São Paulo, SP, Brazil.3 Neuroscience Laboratory – LIM 27, Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (IPq-HCFMUSP), São Paulo, SP, Brazil.

Pinto FCG et al. / Arch Clin Psychiatry. 2016;43(5):132-3


Dear Editor,Normal pressure hydrocephalus (NPH) is a syndrome characterized by urinary incontinence, gait disturbance and dementia plus dilation of ventricular system due to disturbance of cerebrospinal fluid (CSF) circulation1-4. There is wide scientifical evidence pointing association between NPH and psychiatric symptoms1-4.

Othello syndrome (OS) is a content-specific jealousy delusion characterized by fixed false belief that one’s partner has been or is being unfaithful5-10. We report an unusual case of NPH associated with Othello-like syndrome5-10, and complete improvement of psychiatric symptoms after proper neurosurgical treatment.

Case description

We report a case of a 66-year-old white man attending to emergency room evaluation in September 2015. In a rainy day, he was driving his car and a tree had fallen just over him. He was conducted to hospital, with preserved consciousness but complaining of headache. His previous medical history was eventless. A full trauma investigation was done without any finding, except for a mild brain traumatic injury, characterized by headache and subarachnoid hemorrhages in skull computed tomography (CT) (Figure 1A).

Initially, patient was submitted only to neurological observation and was discharged after 4 days, with preserved neurological examination.

During hospitalization, he started to behave with aggressivity and jealous with his wife. At home, he continued to behave with aggressivity and suspicion, imagining that his wife was cheating him with anybody who came to his house to visit him during recovery.

First psychiatric evaluation raised the hypothesis of jealous delusions and a trial was done with quetiapine (up to 600 mg) without any results. The second trial with risperidone (up to 6 mg) has also failed. In the follow-up medical consultation this behavior became clear and a control CT and single photon emission cintilography (SPECT) were performed after one month of trauma, disclosing enlarged ventricles compared to post traumatic CT (Figures 1B and 1C). SPECT did not identify clearly a hypoperfusional region.

Then, he was submitted to surgery two months after initial trauma (Figure 1D). Postoperative period was unremarkable, and his jealousy symptoms decreased promptly. Nowadays, six months after trauma, he has returned to routine daily activities and is symptom free.

Discussion

Our case illustrates the improvement of OS after shunting a post traumatic NPH patient. Oliveira et al. showed that up to 70% of patients with NPH may present neuropsychiatric symptoms, which may be from metabolic impairments in frontal lobe, basal ganglia and thalamus, all of which can be involved in pathophysiology of OS1-10.

OS is a content-specific jealousy delusion characterized by fixed false belief that one’s partner has been or is being unfaithful8-10. This delusion can range from mild to severe cases, with negative impact in social interaction and even risk of violence due to extreme jealousy8-10. Some anecdotal cases were described after frontal pathologies like tumors, surgeries, frontal strokes, traumatic injuries and use of medications (ropinirole, pramipexole, zonisamide).

In our case, there was probably a link between initial trauma, development of hydrocephalus and onset of psychiatric symptoms. After shunting, a clear improvement in symptoms was observed.

Figure 1. (A) Skull CT after trauma, revealing small ventricles and small subarachnoid hemorrhages, especially in left hemisphere. (B) Skull CT after psychiatric symptoms, revealing hydrocephalus. (C) SPECT image, disclosing almost symmetrical perfusion in whole brain. (D) Skull CT after shunting, with reduction of ventricular sizes followed by improved psychiatric symptoms.

133Pinto FCG et al. / Arch Clin Psychiatry. 2016;43(5):132-3

References

1. Oliveira MF, Oliveira JR, Rotta JM, Pinto FC. Psychiatric symptoms are present in most of the patients with idiopathic normal pressure hydro-cephalus. Arq Neuropsiquiatr. 2014;72(6):435-8.

2. de Oliveira MF, Pinto FC, Rotta JM. Normal pressure hydrocephalus in a professional athlete: a model of brain functional reserve. J Neuropsy-chiatry Clin Neurosci. 2014;26(2):E39-40.

3. Oliveira MF, Saad F, Reis RC, Rotta JM, Pinto FC. Programmable valve represents an efficient and safe tool in the treatment of idiopathic normal-pressure hydrocephalus patients. Arq Neuropsiquiatr. 2013;71(4):229-36.

4. Pinto FC, Saad F, de Oliveira MF, Pereira RM, de Miranda FL, Tornai JB, et al. Role of endoscopic third ventriculostomy and ventriculoperitoneal shunt in idiopathic normal pressure hydrocephalus: preliminary results of a randomized clinical trial. Neurosurgery. 2013;72(5):845-53.

5. Pinner G, Johnson H, Bouman WP, Isaacs J. Psychiatric manifestations of normal-pressure hydrocephalus: a short review and unusual case. Int Psychogeriatr. 1997;9(4):465-70.

6. Kito Y, Kazui H, Kubo Y, Yoshida T, Takaya M, Wada T, et al. Neu-ropsychiatric symptoms in patients with idiopathic normal pressure hydrocephalus. Behav Neurol. 2009;21(3):165-74.

7. Yusim A, Anbarasan D, Bernstein C, Boksay I, Dulchin M, Lindenmayer JP, et al. Normal pressure hydrocephalus presenting as Othello syn-drome: case presentation and review of the literature. Am J Psychiatry. 2008;165(9):1119-25.

8. Pírez-Mora G, Guilabert-Vidal M, Quintanilla-López MA. Dopamine agonist-induced Othello syndrome (delusional jealousy). Actas Esp Psiquiatr. 2015;43(1):32-4.

9. Zabalza-Estevez RJ. Othello syndrome induced by pramipexole. Rev Neurol. 2012;54(8):509-10.

10. Rubio-Nazabal E, Alvarez-Pérez P, Lema-Facal T, López-Facal S. Othel-lo syndrome secondary to zonisamide. Med Clin (Barc). 2014;142(3): 133-4.

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