Worry and rumination as a transdiagnostic target in young people: a co-produced systematic review and meta-analysis.

PROTOCOL REGISTRATION: PROSPERO (CRD42023408899).

Symptom dynamics among nightmare sufferers: An intensive longitudinal study.

Nightmares are considerably prevalent in the general population and are known to be closely associated with a variety of mental disorders. However, not much is known about the immediate antecedents and consequences of nightmares. Therefore, we used intensive longitudinal assessments to investigate the night-to-night within-person associations between nightmares on the one hand and fear of sleep, somatic as well as cognitive pre-sleep arousal, and sleep quality on the other hand. Young women with regular nightmares (n = 16) maintained a sleep diary for around 30 days; upon awaking, the participants reported on nightmares and sleep quality during the past night as well as the pre-sleep levels of arousal and fear of sleep (which resulted in 461 observations). Participants also wore an actigraph, which provided objective sleep parameters. Multilevel modeling showed that higher levels of fear of sleep and lower subjective sleep quality were significantly associated with higher levels of nightmare distress. Furthermore, we found individual differences in the strength of these associations, which implies that factors proximate to nightmares may vary across individuals. Pre-sleep arousal, however, did not show expected within-person associations with nightmares or fear of sleep. These findings highlight the crucial role of fear of sleep in the etiology of nightmares and sleep disturbances, while pointing to the importance of pursuing individual, personalised models that explain heterogeneity in the process of triggering nightmares.

Associations between sleep problems and posttraumatic stress symptoms, social functioning, and quality of life in refugees with posttraumatic stress disorder.

Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems, leading to impairments in social functioning and quality of life. Refugees are at high risk for sleep problems due to stressful life circumstances and a high PTSD prevalence. However, limited data on the frequency of sleep problems in refugees with diagnosed PTSD exist. This study examined the frequency of sleep problems in refugees with PTSD and their associations with symptoms of PTSD. Additionally, we investigated the contribution of sleep problems to social functioning and quality of life. Participants (N = 70) were refugees from different countries of origin currently living in Germany. All participants met the criteria for PTSD and completed measures of PTSD symptom severity, subjective sleep problems, social impairment, and quality of life. There was a very high frequency of sleep problems in the sample (100%), and sleep problems were significantly associated with both clinician-rated, r = .47, and self-rated, r = .30, PTSD symptom severity after controlling for overlapping items. Contrary to expectations, sleep problems did not predict social impairment, d = 0.16, nor quality of life, d = 0.13, beyond the effect of other PTSD symptoms. The findings highlight the widespread frequency of sleep problems among refugees. Future studies should assess the causal nature of the association between sleep problems and measures of psychosocial functioning in more detail and examine its dynamic change over time.

The dilemma of trauma-focused therapy: effects of imagery rescripting on voluntary memory.

Trauma-focused imagery-based interventions are suspected to alter or even distort declarative voluntary memory of a traumatic event, especially if they involve the active modification of imagery, e.g., as used in imagery rescripting (ImRs). However, systematic research is lacking so far. To investigate whether ImRs modifies voluntary memory of a standardized autobiographical aversive event (Trier Social Stress Test) (Session 1), healthy participants (N = 100) were randomly assigned to either an intervention condition receiving one session of ImRs or to a no-intervention control condition (NIC) (Session 2). Voluntary memory was examined using a free recall (Sessions 2 and 3) and a cued recall (Sessions 3 and 4). Although voluntary memory tended to deteriorate over time, contrary to expectations, this effect was not associated with ImRs. Remarkably, the number of correct details in free recall even improved in ImRs but not in NIC. This challenges the view that ImRs alters voluntary memory.

Predicting and preventing dropout in research, assessment and treatment with refugees.

Refugees and asylum seekers are exposed to multiple burdensome experiences and suffer from ongoing post-migration stressors that are known to affect the physical and mental health. In psychological treatment offered to refugees and asylum seekers, dropout is an important challenge. The current practice-oriented review aims to provide for the first time knowledge on the prevalence, prediction and prevention of dropout in psychological treatment for refugees and asylum seekers. Due to the limited empirical evidence for this specific population, we synthesized refugee-specific research but also reviewed the existing evidence on dropout from treatment in general and specifically discuss how the findings can be adapted to refugee populations. The review integrates literature from online databases, grey literature, hand search and expert contacts. Prevalence rates of dropout from psychological treatment in Western samples are reported at about 20%. For refugees and asylum seekers, evidence from single efficacy trials showed considerable variability in dropout rates (0%-64.7%). Further, for refugees and asylum seekers, specific sociodemographic variables, high initial impairment, deviating expectations and perceptions of mental health and psychological treatment, as well as external barriers seem to be important predictors for dropout. To prevent dropout, it is important to develop and promote cultural competencies, adapt the treatment to refugee-specific needs and focus on role induction, preparation for treatment, fostering the therapeutic alliance and strengthening hope. Future specific research on dropout in treatment offered to refugees and asylum seekers is needed.

Long-term outcomes of psychological treatment for posttraumatic stress disorder: a systematic review and meta-analysis.

Several types of psychological treatment for posttraumatic stress disorder (PTSD) are considered well established and effective, but evidence of their long-term efficacy is limited. This systematic review and meta-analysis aimed to investigate the long-term outcomes across psychological treatments for PTSD. MEDLINE, Cochrane Library, PTSDpubs, PsycINFO, PSYNDEX, and related articles were searched for randomized controlled trials with at least 12 months of follow-up. Twenty-two studies (N = 2638) met inclusion criteria, and 43 comparisons of cognitive behavioral therapy (CBT) were available at follow-up. Active treatments for PTSD yielded large effect sizes from pretest to follow-up and a small controlled effect size compared with non-directive control groups at follow-up. Trauma-focused treatment (TFT) and non-TFT showed large improvements from pretest to follow-up, and effect sizes did not significantly differ from each other. Active treatments for comorbid depressive symptoms revealed small to medium effect sizes at follow-up, and improved PTSD and depressive symptoms remained stable from treatment end to follow-up. Military personnel, low proportion of female patients, and self-rated PTSD measures were associated with decreased effect sizes for PTSD at follow-up. The findings suggest that CBT for PTSD is efficacious in the long term. Future studies are needed to determine the lasting efficacy of other psychological treatments and to confirm benefits beyond 12-month follow-up.

Reducing worry and rumination in young adults via a mobile phone app: study protocol of the ECoWeB (Emotional Competence for Well-Being in Young Adults) randomised controlled trial focused on repetitive negative thinking.

BACKGROUND: Promoting well-being and preventing poor mental health in young people is a major global priority. Building emotional competence skills via a mobile app may be an effective, scalable and acceptable way to do this. A particular risk factor for anxiety and depression is elevated worry and rumination (repetitive negative thinking, RNT). An app designed to reduce RNT may prevent future incidence of depression and anxiety. METHOD/DESIGN: The Emotional Competence for Well-Being in Young Adults study developed an emotional competence app to be tested via randomised controlled trials in a longitudinal prospective cohort. This off-shoot study adapts the app to focus on targeting RNT (worry, rumination), known risk factors for poor mental health. In this study, 16-24 year olds in the UK, who report elevated worry and rumination on standardised questionnaires are randomised to (i) receive the RNT-targeting app immediately for 6 weeks (ii) a waiting list control who receive the app after 6 weeks. In total, the study will aim to recruit 204 participants, with no current diagnosis of major depression, bipolar disorder or psychosis, across the UK. Assessments take place at baseline (pre-randomisation), 6 and 12 weeks post-randomisation. Primary endpoint and outcome for the study is level of rumination assessed on the Rumination Response Styles Questionnaire at 6 weeks. Worry, depressive symptoms, anxiety symptoms and well-being are secondary outcomes. Compliance, adverse events and potentially mediating variables will be carefully monitored. DISCUSSION: This trial aims to better understand the benefits of tackling RNT via an mobile phone app intervention in young people. This prevention mechanism trial will establish whether targeting worry and rumination directly via an app provides a feasible approach to prevent depression and anxiety, with scope to become a widescale public health strategy for preventing poor mental health and promoting well-being in young people. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04950257 . Registered 6 July 2021 - Retrospectively registered.

Efficacy and cost-effectiveness of a Transdiagnostic group-based exercise intervention: study protocol for a pragmatic multi-site randomized controlled trial.

BACKGROUND: Mental disorders are prevalent and cause considerable burden of disease. Exercise has been shown to be efficacious to treat major depressive disorders, insomnia, panic disorder with and without agoraphobia and post traumatic stress disorder (PTSD). METHODS: This pragmatic, two arm, multi-site randomised controlled trial will evaluate the efficacy and cost-effectiveness of the manualized, group-based six-months exercise intervention "ImPuls", among physically inactive patients with major depressive disorders, insomnia, panic disorder, agoraphobia and PTSD within a naturalistic outpatient context in Germany. A minimum of 375 eligible outpatients from 10 different study sites will be block-randomized to either ImPuls in addition to treatment as usual (TAU) or TAU only. ImPuls will be conducted by trained exercise therapists and delivered in groups of six patients. The program will combine (a) moderate to vigorous aerobic exercise carried out two-three times a week for at least 30 min with (b) behavior change techniques for sustained exercise behavior change. All outcomes will be assessed pre-treatment, post-treatment (six months after randomization) and at follow-up (12 months after randomization). Primary outcome will be self-reported global symptom severity assessed with the Brief Symptom Inventory (BSI-18). Secondary outcomes will be accelerometry-based moderate to vigorous physical activity, self-reported exercise, disorder-specific symptoms, quality-adjusted life years (QALY) and healthcare costs. Intention-to-treat analyses will be conducted using mixed models. Cost-effectiveness and cost-utility analysis will be conducted using incremental cost-effectiveness and cost-utility ratios. DISCUSSION: Despite its promising therapeutic effects, exercise programs are currently not provided within the outpatient mental health care system in Germany. This trial will inform service providers and policy makers about the efficacy and cost-effectiveness of the group-based exercise intervention ImPuls within a naturalistic outpatient health care setting. Group-based exercise interventions might provide an option to close the treatment gap within outpatient mental health care settings. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register (ID: DRKS00024152 , 05/02/2021).

Clustering Individuals on Limited Features of a Vector Autoregressive Model.

Dynamical interplays in emotions have been investigated using vector autoregressive (VAR) models, whose estimates can be used to cluster participants into unknown groups. The present study evaluated a clustering algorithm, the alternating least square (ALS) algorithm, for accuracy in predicting individual group membership. We systematically manipulated (a) the number of variables in a model, (b) the size of group differences in regression coefficients, and (c) the number of regression coefficients that vary across the groups (i.e., effective features). The ALS algorithm works reliably when there are at least 5 effective features with very large group differences in a 5-variable model; and 9 effective features with very large group differences in a 10-variable model. These findings suggest that the ALS algorithm is sensitive to group differences that are present only in several coefficients of a VAR model, but that the group differences have to be large. We also found that the ALS algorithm outperforms another clustering method, Gaussian mixture modeling. The ALS algorithm was further evaluated with unbalanced sample sizes between groups and with a greater number of groups in data (Study 2). A real data application was provided to illustrate how to interpret the detected group differences (Study 3).

Insomnia-related interpretational bias is associated with pre-sleep worry.

Cognitive models of insomnia highlight the role of biased cognition in sleep-related information, which is proposed to underlie pre-sleep worry, which in turn results in both subjective and objective sleep deficits. To test this hypothesis, the current study investigated interpretational bias, which is a tendency to interpret ambiguous stimuli in a threat-related (here: insomnia-related) manner. We specifically hypothesized that interpretational bias would be associated with (a) pre-sleep worry and (b) poor subjective and objective sleep. Interpretational bias was measured using the ambiguous scenario task, in which participants (n = 76, community sample) were presented with two types of scenarios (insomnia and anxiety related) that could be alternatively interpreted in a neutral manner. Participants additionally completed questionnaires to assess global sleep quality and pre-sleep worry, which were followed by 1-week sleep assessments (via diaries and actigraphy) to estimate specific, daily subjective and objective sleep parameters. The results showed that insomnia-related (but not anxiety-related) interpretational bias was positively associated with pre-sleep worry as well as overall sleep quality. However, these associations could be explained by general trait anxiety. We also found no connection to specific subjective or objective parameters of daily sleep, such as sleep onset latency. These findings support the cognitive-hyperarousal mechanism, where biased cognition (together with trait anxiety) underlies pre-sleep worry. The association with overall sleep quality, but not with specific, daily subjective or objective sleep parameters, may suggest that interpretational bias is specifically relevant for how individuals judge and describe their sleep quality.

Predicting instructed simulation and dissimulation when screening for depressive symptoms.

The intentional distortion of test results presents a fundamental problem to self-report-based psychiatric assessment, such as screening for depressive symptoms. The first objective of the study was to clarify whether depressed patients like healthy controls possess both the cognitive ability and motivation to deliberately influence results of commonly used screening measures. The second objective was the construction of a method derived directly from within the test takers' responses to systematically detect faking behavior. Supervised machine learning algorithms posit the potential to empirically learn the implicit interconnections between responses, which shape detectable faking patterns. In a standardized design, faking bad and faking good were experimentally induced in a matched sample of 150 depressed and 150 healthy subjects. Participants completed commonly used questionnaires to detect depressive and associated symptoms. Group differences throughout experimental conditions were evaluated using linear mixed-models. Machine learning algorithms were trained on the test results and compared regarding their capacity to systematically predict distortions in response behavior in two scenarios: (1) differentiation of authentic patient responses from simulated responses of healthy participants; (2) differentiation of authentic patient responses from dissimulated patient responses. Statistically significant convergence of the test scores in both faking conditions suggests that both depressive patients and healthy controls have the cognitive ability as well as the motivational compliance to alter their test results. Evaluation of the algorithmic capability to detect faking behavior yielded ideal predictive accuracies of up to 89%. Implications of the findings, as well as future research objectives are discussed. Trial Registration The study was pre-registered at the German registry for clinical trials (Deutsches Register klinischer Studien, DRKS; DRKS00007708).

Associations between childhood maltreatment and adult depression: a mediation analysis.

BACKGROUND: There is ample evidence showing that childhood maltreatment (CM) is a risk factor for the development of depression in adulthood. However, little is known about the psychological processes mediating this relationship. This study used a large community sample to investigate the mediating role of emotional, cognitive and/or interpersonal dysfunctions on the one hand and posttraumatic stress disorder symptoms on the other hand. METHODS: One thousand twenty seven participants of a community sample filled out an online survey. Mediation analyses were computed via linear structural equation modelling. RESULTS: Results showed a significant mediation of the association between CM and adult depression via emotional impairments, depressogenic attribution style and symptoms of posttraumatic stress disorder. Our study design was cross-sectional and therefore did not allow testing temporal precedence of mediators and causality. Data was collected retrospectively, a confounding effect of current depressive symptoms on retrospective recall of CM therefore cannot be ruled out. CONCLUSIONS: The a priori mediation model showed a good fit with the data. The model suggests promising objectives for further research on CM-related depression and potential treatment targets in the future.

[Diagnostics of posttraumatic stress disorder according to DSM-5 and ICD-11]. / Diagnostik der PTBS im Spannungsfeld von DSM-5 und ICD-11.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11, Version 2018) differ with respect to the diagnostic criteria of posttraumatic stress disorder (PTSD). The present study investigated the implications of these differences for the classification of PTSD within a sample of German survivors of various traumatic events. PATIENTS AND METHODS: A total of 341 trauma survivors who participated in a multicenter study were classified according to DSM-5 and ICD-11 and the results were compared. The PTSD checklist for DSM-5 (PCL-5) was used to diagnose PTSD. The ICD-11 PTSD cases were identified using a "restrictive" and a "wide" operationalization of re-experiencing symptoms (i. e. with and without intrusive memories). Depression and the level of trauma-related impairment were also assessed. RESULTS: The diagnosis rate using ICD-11 was significantly lower than under DSM-5 (DSM-5 64.5%, ICD-11 54.0%, p < 0.001) using a restrictive operationalization of re-experiencing symptoms but differences disappeared when using a wide operationalization. Rates of comorbidity with depression were reduced under ICD-11. Individuals with high and low levels of trauma-related impairment were equally likely to receive a PTSD diagnosis under ICD-11. DISCUSSION: Differences in the diagnosis rates between ICD-11 and DSM-5 depend on the operationalization of the specific ICD-11 re-experiencing requirements. Precise diagnostic guidelines are necessary to avoid inconsistent diagnoses.

Childhood maltreatment and characteristics of adult depression: meta-analysis.

BACKGROUND: Childhood maltreatment has been discussed as a risk factor for the development and maintenance of depression. AIMS: To examine the relationship between childhood maltreatment and adult depression with regard to depression incidence, severity, age at onset, course of illness and treatment response. METHOD: We conducted meta-analyses of original articles reporting an association between childhood maltreatment and depression outcomes in adult populations. RESULTS: In total, 184 studies met inclusion criteria. Nearly half of patients with depression reported a history of childhood maltreatment. Maltreated individuals were 2.66 (95% CI 2.38-2.98) to 3.73 (95% CI 2.88-4.83) times more likely to develop depression in adulthood, had an earlier depression onset and were twice as likely to develop chronic or treatment-resistant depression. Depression severity was most prominently linked to childhood emotional maltreatment. CONCLUSIONS: Childhood maltreatment, especially emotional abuse and neglect, represents a risk factor for severe, early-onset, treatment-resistant depression with a chronic course.

The German version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility.

BACKGROUND: The Posttraumatic Stress Disorder (PTSD) Checklist (PCL, now PCL-5) has recently been revised to reflect the new diagnostic criteria of the disorder. METHODS: A clinical sample of trauma-exposed individuals (N = 352) was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the PCL-5. Internal consistencies and test-retest reliability were computed. To investigate diagnostic accuracy, we calculated receiver operating curves. Confirmatory factor analyses (CFA) were performed to analyze the structural validity. RESULTS: Results showed high internal consistency (α = .95), high test-retest reliability (r = .91) and a high correlation with the total severity score of the CAPS-5, r = .77. In addition, the recommended cutoff of 33 on the PCL-5 showed high diagnostic accuracy when compared to the diagnosis established by the CAPS-5. CFAs comparing the DSM-5 model with alternative models (the three-factor solution, the dysphoria, anhedonia, externalizing behavior and hybrid model) to account for the structural validity of the PCL-5 remained inconclusive. CONCLUSIONS: Overall, the findings show that the German PCL-5 is a reliable instrument with good diagnostic accuracy. However, more research evaluating the underlying factor structure is needed.

Emotional Processing Theory Put to Test: A Meta-Analysis on the Association Between Process and Outcome Measures in Exposure Therapy.

In order to test the predictions derived from emotional processing theory (EPT), this meta-analysis examined correlations between outcome of exposure therapy and three process variables: initial fear activation (IFA), within-session habituation (WSH) and between-session habituation (BSH). Literature search comprised a keyword-based search in databases, a reverse search and the examination of reference lists. Of the 21 studies included in the analyses, 17 provided data concerning IFA (57 endpoints, total N = 490), five concerning WSH (7 endpoints, total N = 116) and eight concerning BSH (22 endpoints, total N = 304). Owing to this data structure, analyses were performed using robust variance estimation with random-effects models being assumed a priori. Results indicated that WSH and BSH are positively related to treatment outcome. By contrast, the statistical association between IFA and outcome of exposure was not confirmed, whereas our moderator analysis suggested that physiological process measures lead to higher correlations than non-physiological ones. The results for IFA and BSH were affected by selective reporting. In sum, our results do not specifically strengthen EPT while matching other theoretical perspectives such as inhibitory learning and reality testing. Further research is needed to provide recommendations concerning the best way of delivering exposure therapy. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: This meta-analysis examined three variables of emotional processing theory (EPT). Initial fear activation was not linearly related to outcomes of exposure therapy. Habituation within and between sessions were shown to correlate with outcome. Outcome reporting bias was shown to play a crucial role in this meta-analysis. Results do not specifically support EPT.

Clinical characteristics of inflammation-associated depression: Monocyte gene expression is age-related in major depressive disorder.

Increased inflammatory activation might only be present in a subgroup of depressed individuals in which immune processes are especially relevant to disease development. We aimed to analyze demographic, depression, and trauma characteristics of major depressive disorder (MDD) patients with regard to inflammatory monocyte gene expression. Fifty-six naturalistically treated MDD patients (32 ± 12 years) and 57 healthy controls (HC; 31 ± 11 years) were analyzed by the Inventory of Depressive Symptomatology (IDS) and by the Childhood Trauma Questionnaire (CTQ). We determined the expression of 38 inflammatory and immune activation genes including the glucocorticoid receptor (GR)α and GRß genes in purified CD14(+) monocytes using quantitative-polymerase chain reaction (RT-qPCR). Monocyte gene expression was age-dependent, particularly in MDD patients. Increased monocyte gene expression and decreased GRα/ß ratio were only present in MDD patients aged ⩾ 28 years. Post hoc analyses of monocyte immune activation in patients <28 years showed two subgroups: a subgroup with a severe course of depression (recurrent type, onset <15 years) - additionally characterized by panic/arousal symptoms and childhood trauma - that had a monocyte gene expression similar to HC, and a second subgroup with a milder course of the disorder (73% first episode depression, onset ⩾15 years) - additionally characterized by the absence of panic symptoms - that exhibited a strongly reduced inflammatory monocyte activation compared to HC. In conclusion, monocyte immune activation was not uniformly raised in MDD patients but was increased only in patients of 28 years and older.

Predictors of posttraumatic stress symptoms following childbirth.

BACKGROUND: Posttraumatic stress disorder (PTSD) following childbirth has gained growing attention in the recent years. Although a number of predictors for PTSD following childbirth have been identified (e.g., history of sexual trauma, emergency caesarean section, low social support), only very few studies have tested predictors derived from current theoretical models of the disorder. This study first aimed to replicate the association of PTSD symptoms after childbirth with predictors identified in earlier research. Second, cognitive predictors derived from Ehlers and Clark's (2000) model of PTSD were examined. METHODS: N = 224 women who had recently given birth completed an online survey. In addition to computing single correlations between PTSD symptom severities and variables of interest, in a hierarchical multiple regression analyses posttraumatic stress symptoms were predicted by (1) prenatal variables, (2) birth-related variables, (3) postnatal social support, and (4) cognitive variables. RESULTS: Wellbeing during pregnancy and age were the only prenatal variables contributing significantly to the explanation of PTSD symptoms in the first step of the regression analysis. In the second step, the birth-related variables peritraumatic emotions and wellbeing during childbed significantly increased the explanation of variance. Despite showing significant bivariate correlations, social support entered in the third step did not predict PTSD symptom severities over and above the variables included in the first two steps. However, with the exception of peritraumatic dissociation all cognitive variables emerged as powerful predictors and increased the amount of variance explained from 43% to a total amount of 68%. CONCLUSIONS: The findings suggest that the prediction of PTSD following childbirth can be improved by focusing on variables derived from a current theoretical model of the disorder.