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Modular Psychotherapy Outcomes for Youth With Different Latent Profiles of Irritability and Emotion Dysregulation.

ABSTRACT: Background: Severe irritability is a common, impairing problem among youth referred for mental health services, but evidence to guide care is limited. Treatment research can be advanced by adopting a transdiagnostic perspective, leveraging existing evidence-based treatment (EBT) techniques, and situating irritability within the context of emotion dysregulation. Accordingly, this study examined treatment outcomes for youth with different levels of irritability and dysregulation who received cognitive-behavioral therapy (CBT) or behavioral parent training (BPT) in a modular EBT framework. Method: We analyzed data from a community-based implementation trial of a transdiagnostic youth psychotherapy. Two-hundred treatment-referred youths (7-15 years; 47% female; 33% White, 28% Black, 24% Latinx, 14% multiracial, 2% other) and their caregivers completed measures of clinical problems and emotion dysregulation at baseline, with repeated outcomes assessments over 18 months. First, latent profile analysis was applied to baseline irritability and emotion dysregulation data; then, latent growth curve models were used to examine outcome trajectories, controlling for covariates. Results: A two-class solution fit well, differentiating youth with high (n = 54) vs. low (n = 146) levels of dysregulation and irritability at baseline. Nearly all high-dysregulation youth received either BPT (n = 26) or CBT-Depression (n = 23). Across measures, both groups showed statistically and clinically significant improvements over time. High-dysregulation youth had greater baseline severity than low-dysregulation youth, but otherwise their longitudinal trajectories were mostly similar, with few between-group slope differences. There was virtually no evidence of differential effects for BPT vs. CBT on clinical outcomes. Conclusions: Youth with severe irritability and dysregulation, treated with a transdiagnostic, modular, EBT approach, showed significant within-person improvements over time. Their outcome trajectories did not differ according to whether they received BPT or CBT. Findings extend the literature on modular, transdiagnostic, and EBT approaches for irritability and dysregulation, suggesting comparable benefits associated with BPT and CBT when treatment selection is guided by comprehensive assessment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03153904.

SUBMITTER: Evans SC

PROVIDER: S-EPMC8086835 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Importance:Comorbidity is ubiquitous in psychiatry, but it is unclear how to differentiate neural mechanisms of co-occurring symptoms. Pediatric irritability and anxiety symptoms are prevalent and frequently co-occur. Threat orienting is pertinent to both phenotypes and is an ideal context in which to examine their unique and common neural mechanisms. Objectives:To decompose the unique and shared variances of pediatric irritability and anxiety symptoms and to determine neural correlates of these differentiated phenotypes during threat orienting. Design, Setting, and Participants:This investigation was a cross-sectional functional magnetic resonance imaging study. The setting was a research clinic at the National Institute of Mental Health. Participants were youth aged 8 to 18 years spanning multiple diagnostic categories (141 youth with disruptive mood dysregulation disorder, anxiety disorder, and/or attention-deficit/hyperactivity disorder and 56 healthy youth). This combination provided wide variation in levels of irritability and anxiety symptoms. Data were acquired between June 30, 2012, and June 28, 2016. Main Outcomes and Measures:Participants and parents rated youth's irritability on the Affective Reactivity Index and anxiety on the Screen for Child Anxiety Related Emotional Disorders. Bifactor analysis decomposed the unique and shared variances. A functional magnetic resonance imaging dot-probe task assessed attention orienting to angry (ie, threat) vs neutral faces. Whole-brain analyses examined associations between the bifactor-derived phenotypes and both neural activity and amygdala functional connectivity. Results:Among 197 participants included in the final analysis, the mean (SD) age was 13.1 (2.7) years, and 91 (46.2%) were female. The best-fit bifactor model (Comparative Fit Index, 0.959; Root Mean Square Error of Approximation, 0.066) included unique factors of parent-reported irritability, youth-reported irritability, and anxiety, as well as a common factor of negative affectivity. When the task required attention away from threat, higher parent-reported irritability was associated with increased activity in the insula, caudate, dorsolateral and ventrolateral prefrontal cortex, and inferior parietal lobule (t189?4.15 for all, P?<?.001 for all). In contrast, higher anxiety was associated with decreased amygdala connectivity to the cingulate, thalamus, and precentral gyrus (t189?-4.19 for all, P?<?.001 for all). These distinctive neural correlates did not emerge using a diagnostic approach. Conclusions and Relevance:A latent variable approach to parsing co-occurring symptom dimensions revealed a novel double dissociation. During orientation away from threat, only irritability was associated with neural activity, whereas only anxiety was associated with amygdala connectivity. Despite the challenges of symptom co-occurrence for clinical neuroscience, data-driven phenotyping may facilitate a path forward.

Project description:CONTEXT Youth with bipolar disorder (BD) and those with severe, nonepisodic irritability (severe mood dysregulation [SMD]) exhibit amygdala dysfunction during facial emotion processing. However, studies have not compared such patients with each other and with comparison individuals in neural responsiveness to subtle changes in facial emotion; the ability to process such changes is important for social cognition. To evaluate this, we used a novel, parametrically designed faces paradigm. OBJECTIVE To compare activation in the amygdala and across the brain in BD patients, SMD patients, and healthy volunteers (HVs). DESIGN Case-control study. SETTING Government research institute. PARTICIPANTS Fifty-seven youths (19 BD, 15 SMD, and 23 HVs). MAIN OUTCOME MEASURE Blood oxygenation level-dependent data. Neutral faces were morphed with angry and happy faces in 25% intervals; static facial stimuli appeared for 3000 milliseconds. Participants performed hostility or nonemotional facial feature (ie, nose width) ratings. The slope of blood oxygenation level-dependent activity was calculated across neutral-to-angry and neutral-to-happy facial stimuli. RESULTS In HVs, but not BD or SMD participants, there was a positive association between left amygdala activity and anger on the face. In the neutral-to-happy whole-brain analysis, BD and SMD participants modulated parietal, temporal, and medial-frontal areas differently from each other and from that in HVs; with increasing facial happiness, SMD patients demonstrated increased, and BD patients decreased, activity in the parietal, temporal, and frontal regions. CONCLUSIONS Youth with BD or SMD differ from HVs in modulation of amygdala activity in response to small changes in facial anger displays. In contrast, individuals with BD or SMD show distinct perturbations in regions mediating attention and face processing in association with changes in the emotional intensity of facial happiness displays. These findings demonstrate similarities and differences in the neural correlates of facial emotion processing in BD and SMD, suggesting that these distinct clinical presentations may reflect differing dysfunctions along a mood disorders spectrum.

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Modular Psychotherapy Outcomes for Youth With Different Latent Profiles of Irritability and Emotion Dysregulation.

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