Denna studie tar sin grund i fyra förskollärares erfarenheter av selektiv mutism i förskolan. Studiens syfte är att bidra med kunskap kring förskollärares metoder i arbetet med selektiv mutism i förskolan. Föreliggande studies metod tar sin grund i ett kvalitativt tillvägagångssätt med en fenomenologisk inriktning. Empiriinsamlingen grundas i semistrukturerade intervjuer med de fyra utvalda förskollärarna. Resultatet av studien påvisar att förskollärarnas upplevelser i arbetet med selektiv mutism är ytterst likvärdigt, både när det kommer till fördelaktiga arbetsmetoder samt den bristfälliga samverkan som bedrivs i detta arbete. Resultatet påvisar även att intervjuade förskollärare upplever att det finns en utbredd okunskap om selektiv mutism inom både förskolan och hälso- och sjukvården, förskollärarna förtydligar att det krävs utveckling inom detta område.

Elevated social anxiety (SA) is linked to issues with emotional distress, substance use, and social anxiety disorder (SAD). Notwithstanding concerns of how sexuality has been defined in the extant literature, emerging evidence suggests that the prevalence of SA and related challenges may be disproportionately present among sexual minorities, including lesbians, gay men, and bisexuals (LGBs). This trend may be especially relevant within the developmental context of emerging adulthood, an important period for development of sexual identity, and a time when individuals are already predisposed to heightened feelings of SA. The present study examined the relationship between sexual orientation (measured using sexual identity, sexual attraction, and past romantic and sexual behavior) and social anxiety (related to social interaction and social performance) among emerging adults. minority sexual identities [Welch's F(5,48.08) = 5.56, p = .002, ηp2 = .02.], same-sex attraction [Welch's F(4,108.06) = 11.27, p < .001, ηp2 = .04], and same-sex romantic [Welch's F(5,85.91) = 6.88, p < .001, ηp2 = .03] and sexual experiences[F(5,61.95) = 8.88, p < .001, ηp2 = .04], particularly among those who indicated attraction to multiple sexes. Findings support research that indicates that sexual minority adults experience higher levels of SA than majority (i.e., heterosexual, opposite-sex oriented) adults, and that assessment of sexuality may reflect number of sexual minorities identified. Future directions including intersections of race/ethnicity and gender are discussed.

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In this study the technique of role reversal for the treatment of performance anxiety, experienced by learners in the school environment, was investigated. Performance anxiety sometimes presents as part of a larger pattern of social phobia and negatively impacts on an individual’s tasks performance due to the fear of negative evaluation. My qualitative study involved a collective, instrumental case study. Role reversal was implemented as part of a group-therapeutic intervention which continued for approximately three months, and involved participants acting as peer tutors. Data analysis focused on the participant’s personal experiences of the technique as well as therapeutic gains and the usefulness of the technique from a school-based counsellor’s perspective. The research findings revealed that although the helping role held certain challenges for the participants, it seemed to generally impact positively on their social and academic confidence and functioning. Additionally their levels of performance anxiety appeared to decrease. / Psychology of Education / M. Ed. (Guidance and Counselling)

In this study the technique of role reversal for the treatment of performance anxiety, experienced by learners in the school environment, was investigated. Performance anxiety sometimes presents as part of a larger pattern of social phobia and negatively impacts on an individual’s tasks performance due to the fear of negative evaluation. My qualitative study involved a collective, instrumental case study. Role reversal was implemented as part of a group-therapeutic intervention which continued for approximately three months, and involved participants acting as peer tutors. Data analysis focused on the participant’s personal experiences of the technique as well as therapeutic gains and the usefulness of the technique from a school-based counsellor’s perspective. The research findings revealed that although the helping role held certain challenges for the participants, it seemed to generally impact positively on their social and academic confidence and functioning. Additionally their levels of performance anxiety appeared to decrease. / Psychology of Education / M. Ed. (Guidance and Counselling)

Im Rahmen der vorliegenden Arbeit wurde eine Metaanalyse der Daten aller verfügbaren Studien (n = 109) zur medikamentösen Behandlung der drei für den Kliniker wesentlichen Angststörungen (PDA, GAD, SAD) durchgeführt. In die Metaanalyse wurden 187 Studienarme sowie die Daten von insgesamt 28785 Patienten eingeschlossen. Eine vergleichbare Metaanalyse, die alle drei Angststörungen zusammengefasst untersucht hat, wurde in dieser Form bisher nicht durchgeführt, wobei neben der zusammengefassten Analyse im Weiteren auch eine separate Betrachtung jeder einzelnen Angststörung erfolgte. Während im Rahmen aller bisher durchgeführten Metaanalysen zumeist lediglich Treated-vs.-Control-Effektstärken berechnet wurden, wurden in der vorliegenden Arbeit darüberhinaus auch Prae-Post-Effektstärken bestimmt. Dies ermöglicht einen besseren Vergleich der Wirksamkeit verschiedener Medikamente. Es ergab sich folgendes: Die in die Metaanalyse eingeschlossenen Studien zeigten trotz ähnlicher Ein- und Ausschlusskriterien sowie oftmaliger Verwendung gleicher Skalen eine hohe bis sehr hohe Heterogenität. Alle Medikamente bis auf Citalopram, Moclobemid und Opipramol zeigten einen signifikanten Unterschied zu Placebo. Die höchsten unadjustierten Treated-vs.-Control-Effektstärken konnten für Phenelzin (d = 0,98), Lorazepam und Clomipramin (d = 0,87) sowie Hydroxyzin (d = 0,79) berechnet werden. Die höchsten Prae-Post-Effektstärken wurden für Benzodiazepine (z. B. Delorazepam: d = 3,54; Bromazepam: d = 2,86; Lorazepam: d = 2,53), Quetiapin (d = 3,39), Escitalopram (d = 2,67) und Hyd-roxyzin (d = 2,56) berechnet, wobei in die Berechnung dieser Effektstärken zum Teil nur sehr wenige Primärstudien eingingen, so dass diese Ergebnisse als weniger reliabel zu werten sind. Bei Betrachtung der einzelnen Stoffgruppen erreichten die SNRIs mit d = 2,25 die höchste Prae-Post-Effektstärke, gefolgt von den Benzodiazepinen (d = 2,14) und den SSRIs (d = 2,09). Bei der Wahl eines Arzneimittels sollte auf ein angemessenes Verhältnis seines Nutzens zu seinen Risiken (Nebenwirkungen) geachtet werden. Viele der Medikamente, für die in der vorliegenden Arbeit relativ hohe Effektstärken berechnet werden konnten, weisen ein ungünstigeres Nebenwirkungsprofil als beispielsweise SNRIs und SSRIs auf. Vor allem wird aufgrund des bestehenden Abhängigkeitspotentials nicht empfohlen, Benzodiazepine routinemäßig zu verordnen. Ebenso führen trizyklische Antidepressiva häufiger zu Nebenwirkungen als SSRIs (Bandelow et al. 2008a). Weiterhin konnte in der vorliegenden Arbeit gezeigt werden, dass die Effektstärken der Pillenplacebos zwischen 1983 und 2013 stark anstiegen. Die Studien wurden mit Hilfe verschiedener Methoden zur Detektion eines Publication Bias analysiert. Hierbei ergaben sich zwar für mehrere Medikamente Hinweise auf das Vorliegen eines Publication Bias, dies hatte jedoch nicht zur Folge, dass die Annahme einer vormals berechneten signifikanten Überlegenheit des Medikamentes gegenüber Placebo wieder verworfen werden musste. Für 50,8% von insgesamt 187 Studienarmen wurden Allegiance-Effekte angenommen. Die durchschnittliche Effektstärke der Studien mit angenommenem Allegiance-Effekt unterschied sich jedoch nicht signifikant von der ohne solche Effekte. Klinisch tätige Ärzte können sich an den Ergebnissen der Metaanalyse orientieren, um – unter Berücksichtigung von potentiellen Nebenwirkungen und Kontraindikationen – für ihre Patienten das Präparat mit dem günstigsten Nutzen-Risiko-Verhältnis auszuwählen.

Deux articles ont été publiés suite à ce mémoire de maîtrise. Un prix pour la meilleure affiche faite par un étudiant du département de psychiatrie de l'Universtité de Montréal a été obtenu suite à la présentation de résultats préliminaires à la Journée annuelle du Centre de recherche de l’Institut Universitaire en santé mentale de Montréal. Un support financier et des bourses ont été également accordés. Par exemple: Bourse d’excellence pour la recherche en psychiatrie, bourse du Cinquantenaire, Faculté de médecine, Département de psychiatrie, Université de Montréal; Bourse d’excellence du directeur de recherche, Centre d’études sur les troubles obsessionnels compulsifs et les tics- CETOCT; Centre recherche de l’Institut universitaire en santé mentale de Montréal; Bourse de Dépannage de la Faculté de médecine ainsi qu'une bourse de rédaction, Faculté de médecine de l’Université de Montréal, Montréal (QC). / Les troubles anxieux représentent les problèmes de santé mentale les plus répandus. Ils affectent 12% de la population, causent un handicap léger à grave et peuvent représenter un lourd fardeau pour les patients et leurs proches. Ils entrainent un impact économique majeur pour la société en termes d’utilisation accrue des services de santé tant psychiatriques que non psychiatriques, de diminution de productivité au travail, d’absentéisme et du chômage. Cette étude de type série de cas, décrit une stratégie d’augmentation ou de facilitation du changement en psychothérapie basée sur l’amorçage (priming) préconscient et son utilisation dans le traitement de huit patients souffrant de troubles anxieux. Les patients avaient manifesté une réponse symptomatique partielle à la thérapie cognitive-comportementale (TCC) malgré une bonne adhésion au traitement. La démarche d’augmentation de la psychothérapie par amorçage préconscient (APAP) comporte six étapes permettant d’établir des formulations cognitives adaptées à la problématique résiduelle personnelle du patient. Ces formulations sont enregistrées et masquées par une musique relaxante. Les patients ont écouté cet enregistrement dans un état d’inattention pendant 20 minutes deux fois par jour durant huit semaines. L’effet de cette stratégie a été évalué par des mesures de type quantitatif et qualitatif, des mesures auto rapportées par les patients par rapport aux changements cognitifs idiosyncratiques ainsi que par un questionnaire sur la qualité de vie. Les résultats élaborés par une analyse descriptive incluant une exploration de la signification statistique et clinique des effets observés montrent, que la stratégie d’amorçage préconscient est associée à des changements cognitifs favorables, à une diminution du discours intérieur négatif et problématique chez sept patients sur huit. Ces bienfaits ont été également maintenus à la 24ème semaine. Une nette amélioration clinique des symptômes anxieux et du fonctionnement global a été observée chez deux patients qui souffraient uniquement d’un trouble anxieux versus les six autres qui présentent une comorbidité additionnelle à leur diagnostic primaire. Ces derniers ont quand même vu une amélioration de leur qualité de vie comparativement à leur état avant de recevoir la stratégie APAP. L’émergence de pensées et d’attitudes positives et la diminution des pensées dysfonctionnelles observées chez la majorité des patients à la suite du traitement par APAP, suggère un impact favorable de l’intervention. La démarche APAP qui est accessible par Internet pourrait constituer un ajout au traitement par TCC en facilitant ou en augmentant le changement cognitif et symptomatique. / Anxiety disorders represent some of the most common mental health problems. These disorders affect up to 12% of the population causing mild to severe impairment and a potentially heavy burden for patients and their families. In addition, these disorders have a major economic impact on society in terms of increased use of health services both psychiatric and non- psychiatric, lower work productivity, absenteeism and unemployment. The current paper is a case series describing a new method for facilitating change based on Psychotherapy Augmentation through Preconscious Priming (APAP) and its use in the treatment of eight patients suffering from an anxiety disorder. Previously, the patients had shown only a partial response to CBT despite good adherence to treatment. Following this treatment, the patients completed the APAP process, which consisted of six steps during which alternative, more functional thoughts and beliefs were formulated, relevant to the idiosyncratic difficulties experienced by the patients. Subsequently, these formulations were recorded and mixed with masking relaxing music, following which the patient listened to the recordings in a passive state twice daily for 20 minutes for a period of 8 weeks. The effect of this strategy was evaluated by quantitative and qualitative measures administered before treatment with the APAP program, at 8 weeks, 16 weeks and 24 weeks. In addition, idiosyncratic ratings of dysfunctional thoughts, symptoms of anxiety, global functioning and quality of life were assessed at baseline and at 24 weeks. Results showed a significant reduction in dysfunctional thoughts reported by most patients treated with this method. There was substantial clinical improvement in anxiety symptoms both for patients who presented with and without co-morbid psychological disorders. Those with co-morbid psychological disorders who did not have a good quality of life at the start of treatment reported an increase in quality of life following treatment with APAP. In addition, a descriptive analysis of the results supported the notion that a preconscious priming strategy is associated with positive cognitive change with a reduction in negative thoughts in 7 out of 8 patients, which were maintained in the longer term. Further, this descriptive analysis suggested that patients who suffered from an anxiety disorder without co-morbidity showed more clinically significant improvement in anxiety symptoms and improved global functioning in comparison to those who presented with a co-morbid disorder. Overall, results suggested that the APAP intervention had a positive impact on the patients. Results showed that APAP led to positive cognitive changes in all patients and clinically significant improvement in anxiety symptoms and global functioning in patients without additional comorbidities. APAP could be a valuable addition to CBT by facilitating or enhancing cognitive and symptom change.

Anxiety disorders are very common and the primary feature is abnormal or inappropriate anxiety. Fear and anxiety is often mediated by the amygdala, a brain structure rich in substance P (SP) and neurokinin 1 (NK1) receptors. To learn more about how the human amygdala is modulated by fear and anxiety in event-triggered anxiety disorders and to investigate if the SP/NK1 receptor system is affected, regional cerebral blood flow (rCBF) ([15O]-water; Study I and II) and the SP/NK1 receptor system ([11C]GR205171; Study III and IV) were studied with positron emission tomography (PET). In Study I we investigated the neural correlates of affective startle modulation in persons with specific phobia by measuring rCBF during exposure to fearful and non-fearful pictures, paired and unpaired with acoustic startle stimuli. Fear-potentiated startle was associated with activation of the affective part of the anterior cingulate cortex and the left amygdaloid–hippocampal area. In Study II short-term drug treatment effects on rCBF in patients diagnosed with social phobia was evaluated, comparing the NK1 receptor antagonist GR205171 to the selective serotonin reuptake inhibitor citalopram and placebo. Social anxiety and neural activity in the medial temporal lobe including the amygdala was significantly reduced by both drugs but not placebo. In Study III we investigated if activity in the SP/NK1 receptor system in the amygdala would be affected by fear provocation in individuals with specific snake or spider phobia. Fear provocation was associated with a decreased uptake of the NK1 antagonist [11C]GR205171 in the amygdala, possibly explained by an increase in endogenous SP release occupying the NK1 receptors. Study IV was conducted to explore the resting state NK1 receptor availability in PTSD patients as compared to healthy controls. Increased resting state binding of the tracer [11C]GR205171 in the amygdala of patients with PTSD suggested an increased amount of available receptors. In summary, fear and fear-potentiated startle modulates the human amygdala, possibly through the SP/NK1 receptor system.

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.