State of the Science: The Hierarchical Taxonomy of Psychopathology (HiTOP).

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a dimensional framework for psychopathology advanced by a consortium of nosologists. In the HiTOP system, psychopathology is grouped hierarchically from super-spectra, spectra, and subfactors at the upper levels to homogeneous symptom components and maladaptive traits and their constituent symptoms, and maladaptive behaviors at the lower levels. HiTOP has the potential to improve clinical outcomes by planning treatment based on symptom severity rather than heterogeneous diagnoses, targeting treatment across different levels of the hierarchy, and assessing distress and impairment separately from the observed symptom profile. Assessments can be performed according to this framework with the recently developed HiTOP-Self-Report (HiTOP-SR). Examples of how to use HiTOP in clinical practice are provided for the internalizing spectrum, including the use of the Unified Protocol and other modularized treatments, measurement-based care, psychopharmacology, and in traditionally underserved populations. Future directions are discussed in this State of the Science review including HiTOP's use in further developing transdiagnostic treatments, extending the model to include other information such as environmental factors, establishing the treatment utility of clinical assessment for the HiTOP-SR, developing new treatments, and disseminating the model.

Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study.

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed. Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

Evolutionary systems therapy for paranoid personality disorder: A seven cases series.

Little is known about effective psychosocial treatments for paranoid personality disorder. This study explores the feasibility of a novel treatment, namely Evolutionary Systems Therapy, in supporting individuals diagnosed with paranoid personality disorder. Seven patients attended 10 months of individual therapy without receiving any psychopharmacological treatment. The primary outcome was the feasibility of the intervention, while the secondary outcomes were remission from the diagnosis and reliable changes in personality pathology and paranoid ideation. All recruited patients completed the intervention and did not report any adverse events. Six out of seven patients experienced remission from the diagnosis of paranoid personality disorder. All participants showed reliable changes in personality pathology and paranoid ideation, which were maintained at the 1-month follow-up. Further research is needed to confirm these encouraging results.

Automatic Self Recriminations: Development and Validation of a Measure of Self-Condemnatory Internal Dialogue.

This article introduces a measure of self-condemnatory internal dialogue as an element of the relationship with the self: The Automatic Self-Recrimination Scale (ASRS). Using the construct validation approach to test construction, we describe the initial development of items and report on findings from a clinical and nonclinical sample showing the ASRS is best understood as a multidimensional measure of self-critical internal dialogue composed of one higher-order factor and four lower-order facets: Not Mattering, Self as Failure, Undeserving Self, and Loathsomeness. The overall scale and four subscales demonstrated acceptable internal consistency and test-retest reliability. Moreover, there was evidence of good convergent and incremental validity of the ASRS subscales with measures of perfectionism, self-criticism, and dysfunctional attitudes. Overall, the ASRS appears to be a reliable and valid measure of an automatic self-recriminatory internal dialogue.

Threatening Beliefs About Self and Others Moderate the Association Between Psychoticism and Psychological Distress.

ABSTRACT: Psychoticism is a multidimensional personality construct involving odd or eccentric behavior, quasi-psychotic experiences, mistrust, interpersonal detachment, and liability for schizophrenia-spectrum disorders, as well as significant distress. Recent advances suggest it can be understood as a dimension that is continuously distributed in the population, leading to questions about factors that contribute to distress and dysfunction among people with a schizotypal liability. We investigated in a large nonclinical sample of young adults whether associations between psychoticism and psychological distress would increase in the presence of threatening beliefs. In our study ( N = 2127), we found that the association between psychoticism and psychological distress is moderated by threatening beliefs including self-criticism, fear of compassion, and socially prescribed perfectionism. These results suggest that distress increases among people with schizotypal traits in the context of negative beliefs about self and others. We discuss implications for clinical practice and directions for further research.

Improvements in Compassion and Fears of Compassion throughout the COVID-19 Pandemic: A Multinational Study.

During large-scale disasters, social support, caring behaviours, and compassion are shown to protect against poor mental health outcomes. This multi-national study aimed to assess the fluctuations in compassion over time during the COVID-19 pandemic. Respondents (Time 1 n = 4156, Time 2 n = 980, Time 3 n = 825) from 23 countries completed online self-report questionnaires measuring the flows of compassion (i.e., Compassionate Engagement and Action Scales) and fears of compassion toward self and others and from others (i.e., Fears of Compassion Scales) and mental health at three time-points during a 10-month period. The results for the flows of compassion showed that self-compassion increased at Time 3. Compassion for others increased at Time 2 and 3 for the general population, but in contrast, it decreased in health professionals, possibly linked to burnout. Compassion from others did not change in Time 2, but it did increase significantly in Time 3. For fears of compassion, fears of self-compassion reduced over time, fears of compassion for others showed more variation, reducing for the general public but increasing for health professionals, whilst fears of compassion from others did not change over time. Health professionals, those with compassion training, older adults, and women showed greater flows of compassion and lower fears of compassion compared with the general population, those without compassion training, younger adults, and men. These findings highlight that, in a period of shared suffering, people from multiple countries and nationalities show a cumulative improvement in compassion and reduction in fears of compassion, suggesting that, when there is intense suffering, people become more compassionate to self and others and less afraid of, and resistant to, compassion.

A pilot randomized controlled trial comparing a novel compassion and metacognition approach for schizotypal personality disorder with a combination of cognitive therapy and psychopharmacological treatment.

BACKGROUND: Schizotypal personality disorder is characterized by a pervasive pattern of maladaptive behavior that has been associated with the liability for schizophrenia. Little is known about effective psychosocial interventions. This pilot non-inferiority randomized controlled trial aimed to compare a novel form of psychotherapy tailored for this disorder and a combination of cognitive therapy and psychopharmacological treatment. The former treatment - namely, Evolutionary Systems Therapy for Schizotypy-integrated evolutionary, metacognitively oriented, and compassion focused approaches. METHODS: Thirty-three participants were assessed for eligibility, twenty-four randomized on a 1:1 ratio, nineteen included in the final analysis. The treatments lasted 6 months (24 sessions). The primary outcome was change across nine measurements in personality pathology, the secondary outcomes were remission from diagnosis and pre-post changes in general symptomatology and metacognition. RESULTS: Primary outcome suggested a non-inferiority of the experimental treatment in respect to control condition. Secondary outcomes reported mixed results. There was no significant difference in terms of remission, but experimental treatment showed a larger reduction of general symptomatology (η2 = 0.558) and a larger increase in metacognition (η2 = 0.734). CONCLUSIONS: This pilot study reported promising results about the effectiveness of the proposed novel approach. A confirmatory trial on large sample size is needed to provide evidence about relative effectiveness of the two treatment conditions. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04764708; Registration day 21/02/2021.

Effectiveness of a Mindful Compassion Care Program in reducing burnout and psychological distress amongst frontline hospital nurses during the COVID-19 pandemic: a study protocol for a randomized controlled trial.

BACKGROUND: Recent studies have shown that nurses have been more affected by the COVID-19 pandemic than any other group of hospital workers in terms of anxiety, depression, and burnout. Several clinical studies had previously demonstrated the effectiveness of mindfulness and compassion interventions in reducing burnout and emotional distress amongst healthcare professionals. METHODS AND ANALYSIS: A parallel-group randomized controlled trial will assess the feasibility, acceptability, and efficacy of a mindfulness and compassion-focused programme on frontline nurses who had been working during the COVID-19 pandemic. Seventy-two participants will be recruited from Verona University Hospital Trust (Veneto Region, north-east Italy) and will be divided equally into an intervention group and a control group. Primary outcome will be assessed using the Emotional Exhaustion subscale of the Maslach Burnout Inventory General Survey (MBI-GS). Secondary outcomes will be measured by the Cynicism and Professional Efficacy subscales of the MBI-GS, the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder (GAD-7), the Insomnia Severity Index (ISI), the Impact of Stressful Events (IES-R), the Perceived Stress Scale (PSS), the Five Facet Mindfulness Questionnaire (FFMQ), and the Forms of Self-Criticising/attacking and Self-Reassuring Scale (FSCRS). DISCUSSION: The study aims to fill a gap in the literature and present a scientifically validated intervention for those healthcare professionals most exposed to the stressful conditions of working during the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov; Identifier: NCT05308537.

Compassion Focused Group Therapy for People With a Diagnosis of Bipolar Affective Disorder: A Feasibility Study.

Background: Compassion focused therapy (CFT) is an evolutionary informed, biopsychosocial approach to mental health problems and therapy. It suggests that evolved motives (e.g., for caring, cooperating, competing) are major sources for the organisation of psychophysiological processes which underpin mental health problems. Hence, evolved motives can be targets for psychotherapy. People with certain types of depression are psychophysiologically orientated towards social competition and concerned with social status and social rank. These can give rise to down rank-focused forms of social comparison, sense of inferiority, worthlessness, lowered confidence, submissive behaviour, shame proneness and self-criticism. People with bipolar disorders also experience elevated aspects of competitiveness and up rank status evaluation. These shift processing to a sense of superiority, elevated confidence, energised behaviour, positive affect and social dominance. This is the first study to explore the feasibility of a 12 module CFT group, tailored to helping people with a diagnosis of bipolar disorder understand the impact of evolved competitive, status-regulating motivation on their mental states and the value of cultivating caring and compassion motives and their psychophysiological regulators. Methods: Six participants with a history of bipolar disorder took part in a CFT group consisting of 12 modules (over 25 sessions) as co-collaborators to explore their personal experiences of CFT and potential processes of change. Assessment of change was measured via self-report, heart rate variability (HRV) and focus groups over three time points. Results: Although changes in self-report scales between participants and across time were uneven, four of the six participants consistently showed improvements across the majority of self-report measures. Heart rate variability measures revealed significant improvement over the course of the therapy. Qualitative data from three focus groups revealed participants found CFT gave them helpful insight into: how evolution has given rise to a number of difficult problems for emotion regulation (called tricky brain) which is not one's fault; an evolutionary understanding of the nature of bipolar disorders; development of a compassionate mind and practices of compassion focused visualisations, styles of thinking and behaviours; addressing issues of self-criticism; and building a sense of a compassionate identity as a means of coping with life difficulties. These impacted their emotional regulation and social relationships. Conclusion: Although small, the study provides evidence of feasibility, acceptability and engagement with CFT. Focus group analysis revealed that participants were able to switch from competitive focused to compassion focused processing with consequent improvements in mental states and social behaviour. Participants indicated a journey over time from 'intellectually' understanding the process of building a compassionate mind to experiencing a more embodied sense of compassion that had significant impacts on their orientation to (and working with) the psychophysiological processes of bipolar disorder.

The national COVID-19 vaccination campaign targeting the extremely vulnerable: the Florence Medical Oncology Unit experience in patients with cancer.

BACKGROUND: International and national oncology societies had released recommendations in favor of COVID-19 vaccination in cancer patients. In the context of the national vaccination campaign targeting the so called extremely vulnerable, we aimed to assess the safety and efficacy of the mRNA vaccines in a cohort of 623 patients. METHODS: Between March 26 and April 04, 2021, the Pfizer and BioNTech BNT162b2 mRNA and the Moderna mRNA-1273 vaccines were given as a two-dose prime-boost regimen. Starting on September 25th 2021 a third dose was offered to patients in whom a suboptimal immunogenicity with COVID-19 vaccination could be expected. Safety assessments were performed by phone call 7 days after each dose. Electronic health records were accessed to review demographic information, disease history, treatment detail, and outcome events of participants patients'. FINDINGS: No toxicities were reported in 63.7%, 54%, and in 48.7% patients with cancer after each dose. Mild-to-moderate pain at the injection site was the most commonly adverse event. After the second dose, 46% of the 610 patients reported toxicity, with more systemic side-effects observed. Fever was reported in 45% of patients, with a temperature ≥ 38 °C in 21.4% of them. Of the 335 patients receiving a third vaccine dose, 51% reported toxicity, with 13% of patients reporting more than one effect. Logistic regression analysis reported mixed results, with limited variables or categories reporting a significant odd ratio. The type of vaccine reported a significant value at first dose (OR = 0.12; CI 0.52, 0.26; p = 0.00). Thirty-four cases of COVID-19 infection were reported with only one patient requiring a short-term hospitalization for monitoring. INTERPRETATION: The safety profile of the mRNA vaccines does not raise any specific concerns and support prioritization of vaccination for cancer patients.

Perfectionism unbound: An integrated individual and group intervention for those hiding imperfections.

The tendency to hide and mask suffering and one's perceived imperfections is one of the biggest obstacles in treating those with prominent perfectionistic traits. In this single case, we present an integrative form of psychotherapy for patients with recurrent strategies aimed at neither displaying nor disclosing their perfectionism. Emily was a 26-year-old woman diagnosed with Major Depressive Disorder and reported a personality pathology as diagnosed through the Alternative Model of Personality Disorders. The intervention comprised of a 4-month individual therapy and 2-month group therapy. The former is based on Metacognitive Interpersonal Therapy protocol for personality disorders. The latter is a protocol that integrates the Dynamic Relational Treatment for Perfectionism and Compassion Focused Therapy. At the end of this integrative treatment, Emily remitted from Major Depressive Disorder and personality pathology. Further studies should confirm our promising results in larger samples.

Restrictions on healthcare utilization and psychological distress among patients with diseases potentially vulnerable to COVID-19; the JACSIS 2020 study.

BACKGROUND: Patients with comorbidity are at higher risk of deteriorating COVID-19, but they need to access healthcare services regularly for their primary disease. This study aimed to investigate whether patients restricted healthcare utilization due to the COVID-19 pandemic and to understand the relations between restriction of healthcare utilization and psychological distress of patients with a disease potentially vulnerable to COVID-19. METHODS: Participants were a sub-sample of 6,360 individuals suffering from chronic diseases with hypertension, diabetes, respiratory diseases, cerebrovascular disease, and cancer from the nationally representative cross-sectional internet survey data of Japan. Participants reported healthcare utilization during the first state of emergency, as well as psychological distress (K6: The Kessler Psychological Distress Scale 6) in three months after the state of emergency was ended. Multivariate linear regression analyses were performed to examine the correlation between psychological distress and healthcare utilization. RESULTS: In total, 16% restrained from visiting a hospital as scheduled or canceled a doctor visit. Approximately less than 2% experienced cancellation or delay of hospitalization, treatment, or nursing-care services. After controlling for confounders, multivariate linear regression analysis showed that those who lacked medicines, experienced deteriorated health conditions, and could not visit a hospital during the state of emergency reported severe psychological distress three months later among the patients with all disease types except cancer (ß = 0.10∼0.25). CONCLUSIONS: The study indicated the restriction in healthcare utilization might be a risk factor for psychological distress among patients. Careful attention to the mental status of patients, especially those who were restricted in healthcare utilization, is necessary.

Compassion Protects Mental Health and Social Safeness During the COVID-19 Pandemic Across 21 Countries.

Objectives: The COVID-19 pandemic is having an unprecedented detrimental impact on mental health in people around the world. It is important therefore to explore factors that may buffer or accentuate the risk of mental health problems in this context. Given that compassion has numerous benefits for mental health, emotion regulation, and social relationships, this study examines the buffering effects of different flows of compassion (for self, for others, from others) against the impact of perceived threat of COVID-19 on depression, anxiety, and stress, and social safeness. Methods: The study was conducted in a sample of 4057 adult participants from the general community population, collected across 21 countries from Europe, Middle East, North America, South America, Asia, and Oceania. Participants completed self-report measures of perceived threat of COVID-19, compassion (for self, for others, from others), depression, anxiety, stress, and social safeness. Results: Perceived threat of COVID-19 was associated with higher scores in depression, anxiety, and stress, and lower scores in social safeness. Self-compassion and compassion from others were associated with lower psychological distress and higher social safeness. Compassion for others was associated with lower depressive symptoms. Self-compassion moderated the relationship between perceived threat of COVID-19 on depression, anxiety, and stress, whereas compassion from others moderated the effects of fears of contracting COVID-19 on social safeness. These effects were consistent across all countries. Conclusions: Our findings highlight the universal protective role of compassion, in particular self-compassion and compassion from others, in promoting resilience by buffering against the harmful effects of the COVID-19 pandemic on mental health and social safeness. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-021-01822-2.

The Relationship Between Covid-19 Risk Perception and Vaccine Hesitancy in Cancer Patients: The Moderating Role of Externalizing Traits.

Objective: This mixed-methods study aimed to explore the role of externalizing traits in moderating the relationship between COVID-19 risk perception and vaccine hesitancy in patients diagnosed with cancer. A community-based participatory approach - comprising a preliminary qualitative inquiry and a subsequent cross-sectional research - was used to promote effective vaccination campaigns. Method: 12 people diagnosed with cancer and 7 cancer professionals were recruited for the qualitative inquiry, 356 people either under cancer treatment or in follow-up care for the cross-sectional research.A phenomenological analysis explored the transcripts of two focus groups. The cross-sectional research tested the hypothesis emerged during the previous qualitative inquiry through self-reported questionnaires and moderated regression. Results: Phenomenological analysis suggested a pivotal role of externalizing traits in vaccine hesitancy. Moderated regression revealed how the association between risk perception and vaccine hesitancy is moderated by externalizing traits, even when controlled for treatment adherence. Conclusions: In the present study we found a stronger relationship between risk perception and vaccine hesitancy for patients with higher levels of externalizing traits. We suggest that vaccination campaigns should be personality-informed to offer individualized and effective solutions. Patients with externalizing traits may cope dysfunctionally with vaccination campaigns.

Risk perception, treatment adherence, and personality during COVID-19 pandemic: An international study on cancer patients.

OBJECTIVE: To explore the role of personality traits in moderating the relation between COVID-19 risk perception and treatment adherence, and between risk perception and psychosocial distress in patients diagnosed with cancer. METHODS: An online survey (n = 1281) was conducted worldwide in seven countries (Austria, Germany, Hong Kong, Italy, Spain, Sweden, and Turkey). Inclusion criteria were to be 18 years of age or older, have received a cancer diagnosis, and be in treatment or follow-up. A few moderated regression models were performed with both personality traits and Hierarchical Taxonomy of Psychopathology super-spectra as moderators. RESULTS: Detachment, negative affectivity, psychoticism and all the super-spectra significantly moderated the relation between coronavirus risk perception and psychosocial distress, after the adjusting effect of confidence in safeguards. Only negative affectivity moderated the association between coronavirus risk perception and treatment adherence. CONCLUSIONS: Personality traits may foster the understanding of how a patient might adjust to cancer treatment and, more generically, to highly stressful events such as the COVID-19 pandemic. Further research is needed to confirm the results in different cancer stages and types.

The role of social connection on the experience of COVID-19 related post-traumatic growth and stress.

BACKGROUND: Historically social connection has been an important way through which humans have coped with large-scale threatening events. In the context of the COVID-19 pandemic, lockdowns have deprived people of major sources of social support and coping, with others representing threats. Hence, a major stressor during the pandemic has been a sense of social disconnection and loneliness. This study explores how people's experience of compassion and feeling socially safe and connected, in contrast to feeling socially disconnected, lonely and fearful of compassion, effects the impact of perceived threat of COVID-19 on post-traumatic growth and post-traumatic stress. METHODS: Adult participants from the general population (N = 4057) across 21 countries worldwide, completed self-report measures of social connection (compassion for self, from others, for others; social safeness), social disconnection (fears of compassion for self, from others, for others; loneliness), perceived threat of COVID-19, post-traumatic growth and traumatic stress. RESULTS: Perceived threat of COVID-19 predicted increased post-traumatic growth and traumatic stress. Social connection (compassion and social safeness) predicted higher post-traumatic growth and traumatic stress, whereas social disconnection (fears of compassion and loneliness) predicted increased traumatic symptoms only. Social connection heightened the impact of perceived threat of COVID-19 on post-traumatic growth, while social disconnection weakened this impact. Social disconnection magnified the impact of the perceived threat of COVID-19 on traumatic stress. These effects were consistent across all countries. CONCLUSIONS: Social connection is key to how people adapt and cope with the worldwide COVID-19 crisis and may facilitate post-traumatic growth in the context of the threat experienced during the pandemic. In contrast, social disconnection increases vulnerability to develop post-traumatic stress in this threatening context. Public health and Government organizations could implement interventions to foster compassion and feelings of social safeness and reduce experiences of social disconnection, thus promoting growth, resilience and mental wellbeing during and following the pandemic.

Emerging psychotherapeutic approaches to addressing self-experience in schizophrenia spectrum disorders.

Growing awareness that many who are diagnosed with schizophrenia recover has spurred the development of new psychosocial approaches to treatment. These new approaches include forms of individual and group psychotherapy whose focus extends beyond reducing symptoms and improving skills to subjective outcomes related to sense of self. This paper introduces an issue of In Session which presents six case reports which illustrating these approaches in differing international contexts. First, we explore the larger issues of subjective outcomes from schizophrenia. We then discuss each of the papers separately along with implications of these papers as a group for how treatment might promote the recapturing of a sense of self or place in the world.

A case study on a severe paranoid personality disorder client treated with metacognitive interpersonal therapy.

Paranoid personality disorder (PPD) is a severe condition, lacking specialized and empirically supported treatment. To provide the clinician with insights into how to treat this condition, we present a case study of a 61-year-old man with severe PPD who presented with ideas of persecution, emotionally charged hostility, and comorbid antisocial personality disorder. The client was treated with 6 months of Metacognitive Interpersonal Therapy, which included: creating a shared formulation of his paranoid attitudes; trying to change his inner self-image of self-as-inadequate and his interpersonal schemas where he saw the others as threatening. Guided imagery and rescripting techniques, coupled with behavioral experiments, were used to promote a change. At the end of the therapy the client reported a reliable change in general symptomatology and, specifically, in interpersonal sensitivity, hostility, and paranoid ideation; he could no longer be diagnosed as PPD and only some paranoid and antisocial characteristics remained.

Fears of compassion magnify the harmful effects of threat of COVID-19 on mental health and social safeness across 21 countries.

BACKGROUND: The COVID-19 pandemic is a massive global health crisis with damaging consequences to mental health and social relationships. Exploring factors that may heighten or buffer the risk of mental health problems in this context is thus critical. Whilst compassion may be a protective factor, in contrast fears of compassion increase vulnerability to psychosocial distress and may amplify the impact of the pandemic on mental health. This study explores the magnifying effects of fears of compassion on the impact of perceived threat of COVID-19 on depression, anxiety and stress, and social safeness. METHODS: Adult participants from the general population (N = 4057) were recruited across 21 countries worldwide, and completed self-report measures of perceived threat of COVID-19, fears of compassion (for self, from others, for others), depression, anxiety, stress and social safeness. RESULTS: Perceived threat of COVID-19 predicted increased depression, anxiety and stress. The three flows of fears of compassion predicted higher levels of depression, anxiety and stress and lower social safeness. All fears of compassion moderated (heightened) the impact of perceived threat of COVID-19 on psychological distress. Only fears of compassion from others moderated the effects of likelihood of contracting COVID-19 on social safeness. These effects were consistent across all countries. CONCLUSIONS: Fears of compassion have a universal magnifying effect on the damaging impact of the COVID-19 pandemic on mental health and social safeness. Compassion focused interventions and communications could be implemented to reduce resistances to compassion and promote mental wellbeing during and following the pandemic.