Papers by Marcele Carvalho
Counselling and Psychotherapy Research
Jornal Brasileiro De Psiquiatria, 2008
Transtorno de pânico, terapia cognitivocomportamental, realidade virtual, exposição. resumo O uso... more Transtorno de pânico, terapia cognitivocomportamental, realidade virtual, exposição. resumo O uso de realidade virtual (RV) é útil no tratamento de exposição em pacientes com transtorno de pânico (TP). Em ambientes virtuais, os pacientes experimentam alterações fisiológicas, psíquicas e somáticas similares aos sintomas em situações da vida real, facilitando o processo de habituação. objetivo: Divulgar o panorama atual do uso de RV no tratamento do TP. método: A literatura sobre o tratamento do TP a partir da RV foi revisada com metodologia sistemática na base de dados PubMed, por meio das palavras-chave: virtual reality e panic disorder. resultados: O tratamento do TP com RV está em geral associado a bons resultados e à boa aceitabilidade por parte dos pacientes. São poucos os estudos que mensuram respostas fisiológicas durante a exposição, apesar da importância destes dados para avaliação da eficácia do tratamento. Conclusões: Apesar da utilidade do tratamento do TP por RV ser verificada nos estudos, constata-se necessidade de estudos controlados e protocolos de tratamento padronizados. aBstraCt Virtual reality (VR) is a valuable tool in exposure treatment of panic disorder (PD). In virtual environments the patients experience similar physiological, psychic and somatic changes as in real life situations facilitating the habituation process. Objective: We intend to divulge the current panorama of VR in treatment of PD. Method: The literature on VR treatment for PD was revised with a systematic methodology in the PubMed database, using the keywords: virtual reality and panic disorder. Results: Virtual exposure treatment of PD usually shows good results and a great patient acceptability. Only a few studies measure physiological responses during the exposure despite the importance of these data for evaluation of the treatment effectiveness. Conclusions: Although the VR treatment for PD usefulness is clear in the trials, a lack of controlled studies and standardized treatment protocols are verified.
Psicologia: Teoria E Pesquisa, 2010
RESUMO -Um crescente número de pesquisas têm surgido sobre a aplicação da terapia de exposição po... more RESUMO -Um crescente número de pesquisas têm surgido sobre a aplicação da terapia de exposição por realidade virtual (VRET) para transtornos ansiosos. O objetivo deste estudo foi revisar algumas evidências que apoiam a eficácia da VRET para tratar fobia de dirigir. Os estudos foram identificados por meio de buscas computadorizadas (PubMed/Medline, Web of Science e Scielo databases) no período de 1984 a 2007. Alguns achados são promissores. Índices de ansiedade/evitação caíram entre o início e o fim do tratamento. VRET poderia ser um primeiro passo no tratamento da fobia de dirigir, uma vez que pode facilitar a exposição ao vivo, evitando-se os riscos e elevados custos dessa exposição. Entretanto, mais estudos clínicos randomizados/controlados são necessários para comprovar sua eficácia.
This article considered already existing studies about Deep Brain Stimulation in Mood and Anxiety... more This article considered already existing studies about Deep Brain Stimulation in Mood and Anxiety Disorders. In particular, articles regarding Obsessive-Compulsive Disorder and Major Depression were mostly analyzed, due to the lack of researches about other types of Mood and Anxiety Disorders. We have concentrated on the target areas where Deep Brain Stimulation was most commonly applied, and on the effects this measure had on treatment-refractory patients. The obtained results showed that the stimulation of the: nucleus accumbens, subgenual cingulate cortex and ventral capsule/ventral striatum, has a positive influence on the development of the disorders investigated, sometimes showing the complete remission of the symptoms. Although Deep Brain Stimulation was overall found to be a promising and safe treatment for Mood and Anxiety Disorders, there are not enough studies proving its efficacy in wide samples and in the presence of more complex variables.
Psychology and Neuroscience, 2011
Panic disorder (PD) is a pluridimensional condition that leads to psychological suffering. Due to... more Panic disorder (PD) is a pluridimensional condition that leads to psychological suffering. Due to advances in neuroimaging techniques, important contributions have been made in the understanding of the neurobiological basis of PD. However, because of diverging research designs and protocols, more conclusive data concerning the neurocircuitry of PD remain difficult to achieve. To address this issue, a bibliographical search was performed using the Institute for Scientific Information Web of Science and Medline/PubMed databases. Fifteen articles were found, and their research methodology including sample, comorbidity, gender, and pharmacological criteria were explored. Although current functional magnetic resonance imaging studies of PD constitute fundamental tools for health sciences, more uniform research protocols must be implemented to provide more consistent and conclusive data concerning the neural substrates of PD.
World Journal of Biological Psychiatry, 2009
Panic disorder (PD) is a multidimensional anxiety disorder that involves the activation of a comp... more Panic disorder (PD) is a multidimensional anxiety disorder that involves the activation of a complex brain fear-network. The goals of this systematic review are to pinpoint some working functions of the most important neuroanatomical structures of fear and panic neurocircuitry and to raise hypotheses about how cognitive-behaviour therapy (CBT) may work on modulating the neurocircuitry of fear. The bibliographical search was carried out using mainly the PubMed database. Fifty-six articles were selected. A number of studies regarding several brain sites that participate in fear and anxiety circuitry were found and each region was described with its functionalities within the circuitry. Among the structures chosen were: the amygdala, the hippocampus and the prefrontal cortex, which play a special role. Study hypotheses showed that CBT may operate upstream from the amygdala and exert inhibitory effects on a variety of learned responses. It may work by strengthening the medial prefrontal cortex ability to inhibit firing of amygdala neurons, under the modulation of the hippocampus. Only two studies examined the modulation of fear neurocircuitry with CBT in PD. The results indicate that CBT has the potential to modify the dysfunctional neural circuitry associated with PD, but there is insufficient evidence to support the preliminary hypothesis.
World Journal of Biological Psychiatry, 2010
Background: There are several useful methods to induce anxiety in patients with panic disorder wi... more Background: There are several useful methods to induce anxiety in patients with panic disorder with agoraphobia (PDA). Our aim was to ascertain if a computer simulation (CS) could induce anxiety and physiologic alterations in PDA patients. Methods: 10 healthy controls (HC) and 10 patients who fulfilled DSM-IV criteria for PDA were recruited for this study. The anxiety level was measured with the Subjective Units of Distress Scale (SUDS) and the Diagnostic Symptom Questionnaire (DSQ) was used to ascertain panic attack (PA) symptoms. The heart rate, skin conductance and respiration were monitored during exposure to the CS. The CS was a 3D computer animation of a short bus trip, from a first person perspective. Results: In PDA patients CS exposure increased anxiety levels, they also had higher scores in the DSQ and two of them had PA. Compared to the HC, the PDA patients had higher skin conductance level, electrodermal response magnitude, respiratory rate, tidal volume, and respiratory rate irregularities. The heart rate means were higher for PDA patients who had PA, followed by HC and PDA patients who did not have PA. There were no significant differences between the two groups regarding the sense of presence. Limitations: The main limitations were the small sample size, and some PDA patients under medications.
Revista de Psiquiatria Clínica, 2008
Journal of Clinical Psychopharmacology, 2010
High-potency benzodiazepines, such as clonazepam, are frequently used in the treatment of panic d... more High-potency benzodiazepines, such as clonazepam, are frequently used in the treatment of panic disorder (PD) because of their rapid onset of action and good tolerability. However, there is concern about their potential to cause withdrawal symptoms. We aimed to develop a protocol for safely tapering off clonazepam in patients with PD who had been receiving treatment for at least 3 years. A specific scale for judging withdrawal was also developed, the Composite Benzodiazepine Discontinuation Symptom Scale. We selected 73 patients with PD who had been asymptomatic for at least 1 year and who wished to discontinue the medication. The trial consisted of a 4-month period of tapering and an 8-month follow-up period. The dosage of clonazepam was decreased by 0.5 mg per 2-week period until 1 mg per day was reached, followed by a decrease of 0.25 mg per week. The mean dosage at the start of tapering was 2.7 +/- 1.2 mg/d. In total, 51 (68.9%) of the patients were free of the medication after the 4 months of tapering according to the protocol, and 19 (26.0%) of the patients needed another 3 months to be free of medication. Clonazepam discontinuation symptoms were mostly mild and included mainly: anxiety, shaking/trembling/tremor, nausea/vomiting, insomnia/nightmares, excessive sweating, tachycardia/palpitations, headache, weakness, and muscle aches. The improvement in PD and general well-being was maintained during both the taper and follow-up phases. Clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. We recommend reducing the dosage of clonazepam after intermediate-term use by 0.25 mg/wk.
Journal of Affective Disorders, 2008
Background: Mood disorders are considered related to anxiety disorders and their association may ... more Background: Mood disorders are considered related to anxiety disorders and their association may determine clinical course and prognosis. We aimed to describe with retrospective methodology the demographic, clinical, and treatment features in a group of panic disorder comorbid with bipolar I disorder (PD-BI) patients who were been treated for at least 3 year-period and compare them with bipolar I (BI) patients who were treated during the same period. Method: We compared the demographic and clinical data of 26 PD-BI, 28 BI, and 25 panic disorder (PD) outpatients without history of comorbidity with mood disorder were diagnosed and treated for at least 3 years in the Federal University of Rio de Janeiro. Results: PD group have a higher educational level, are more married, and are more economically active. In the PD-BI and BI patients the disorders started earlier. They also turn out to have an equivalent pattern in the presence of drug abuse episodes, moderate or severe depressive episodes, psychotic episodes, suicide attempts, maniac episodes, mixed episodes, use of fewer days of antidepressants and benzodiazepines, and use of more days of antipsychotics and mood stabilizers. The PD-BI and the BI groups had a higher frequency of depressive episodes and psychotic episodes. Limitations: It is a retrospective data description based on a naturalistic treatment. The sample has a small size and the some data could be different in a large sample. Conclusion: PD-BI patients have demographic, clinical and therapeutic features similar to BI and the data support its validation as a special severe bipolar I disorder subgroup.
Journal of Affective Disorders, 2010
Background: There are several useful methods to induce anxiety in patients with panic disorder wi... more Background: There are several useful methods to induce anxiety in patients with panic disorder with agoraphobia (PDA). Our aim was to ascertain if a computer simulation (CS) could induce anxiety and physiologic alterations in PDA patients. Methods: 10 healthy controls (HC) and 10 patients who fulfilled DSM-IV criteria for PDA were recruited for this study. The anxiety level was measured with the Subjective Units of Distress Scale (SUDS) and the Diagnostic Symptom Questionnaire (DSQ) was used to ascertain panic attack (PA) symptoms. The heart rate, skin conductance and respiration were monitored during exposure to the CS. The CS was a 3D computer animation of a short bus trip, from a first person perspective. Results: In PDA patients CS exposure increased anxiety levels, they also had higher scores in the DSQ and two of them had PA. Compared to the HC, the PDA patients had higher skin conductance level, electrodermal response magnitude, respiratory rate, tidal volume, and respiratory rate irregularities. The heart rate means were higher for PDA patients who had PA, followed by HC and PDA patients who did not have PA. There were no significant differences between the two groups regarding the sense of presence. Limitations: The main limitations were the small sample size, and some PDA patients under medications.
Expert Review of Neurotherapeutics, 2010
Comprehensive Psychiatry, 2014
Driving phobia is associated with serious consequences such as restriction of freedom, career imp... more Driving phobia is associated with serious consequences such as restriction of freedom, career impairments and social embarrassment. The main objective of this paper is to compare clinical characteristics and quality of life between women with driving phobia and women without this phobia. These factors were assessed using structured interviews, semi-structured questionnaires, scales and inventories. We accessed diagnoses, depressive symptoms, anxiety symptoms, anxiety traits, driving cognitions and quality of life. There was no difference between groups with regard to demographic data and driving history. Both groups were also equivalent in the number of traumatic events and accidents experienced while driving or riding. The fear of driving group showed higher state and trait anxiety scores. A high frequency of cognitive distortions can explain why people with driving phobia often engage in maladaptive safety behaviors in an attempt to protect themselves from unpredicted dangers when driving. Regarding quality of life, the control group had slightly higher scores on all subscales, but significant differences were observed for only three scales: "functional capacity", "social aspects", and "mental health". More studies with larger samples more instruments and other contexts are needed to further investigate the clinical characteristics and personality traits of people who have a fear of driving.
Expert Review of Neurotherapeutics, 2010
Thanks to brain imaging great advances have been made concerning the comprehension of neural subs... more Thanks to brain imaging great advances have been made concerning the comprehension of neural substrates related to panic disorder (PD). This article aims to: review the recent functional MRI (fMRI) studies concerning PD; correlate the PD fMRI neurobiological findings with the fear neurocircuitry hypothesis; discuss the fear neurocircuitry hypothesis and link it to cognitive-behavior therapy findings; and comment on fMRI study limitations and suggest methodological changes for future research. As a whole, there is increasing evidence that brain structures such as the prefrontal cortex, the anterior cingulate cortex and limbic areas (hippocampus and amygdala) might play a major role in the panic response. Keywords: amygdala • anterior cingulate cortex • anxiety neurocircuitry • cognitive-behavior therapy • fMRI • hippocampus • panic disorder • prefrontal cortex Current findings of fMRI in panic disorder: contributions for the fear neurocircuitry and CBT effects Expert Rev. Neurother. 10(2), 291-303 (2010)
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Papers by Marcele Carvalho