Determining prognostic variables of treatment outcome in obsessive-compulsive disorder: effectiveness and its predictors in routine clinical care.

The objectives of this study were to investigate the naturalistic effectiveness of routine inpatient treatment for patients with obsessive-compulsive disorder (OCD) and to identify predictors of treatment outcome. A routinely collected data set of 1,596 OCD inpatients (M = 33.9 years, SD = 11.7; 60.4% female) having received evidence-based psychotherapy based on the cognitive-behavioral therapy (CBT) in five German psychotherapeutic clinics was analyzed. Effect sizes (Hedges' g) were calculated for several outcome variables to determine effectiveness. Predictor analyses were performed on a subsample (N = 514; M = 34.3 years, SD = 12.2; 60.3% female). For this purpose, the number of potential predictors was reduced using factor analysis, followed by multiple regression analysis to identify robust predictors. Effect sizes of various outcome variables could be classified as large (g = 1.34 of OCD-symptom change). Predictors of changes in OCD and depressive symptoms were symptom severity at admission and general psychopathological distress. In addition, patients with higher social support and more washing compulsions benefited more from treatment. Subgroup analyses showed a distinct predictor profile of changes in compulsions and obsessions. The results indicate that an evidence-based psychotherapy program for OCD can be effectively implemented in routine inpatient care. In addition to well-established predictors, social support, and washing compulsions in particular were identified as important positive predictors. Specific predictor profiles for changes in obsessions and compulsions are discussed.

What happens in the course of positive mirror exposure? Effects on eating pathology, body satisfaction, affect, and subjective physiological arousal in patients with anorexia and bulimia nervosa.

OBJECTIVE: Mirror exposure (ME) is a therapeutic technique to improve body image disturbance. However, evidence on the effectiveness of different forms of ME in clinical populations is lacking. The present study therefore analysed effects of ME on trait-like and state measures of body image in patients with anorexia nervosa (AN) and bulimia nervosa (BN). METHOD: The present study therefore analysed effects of ME on trait-like and state measures of body image in patients with anorexia nervosa (AN) and bulimia nervosa (BN). In total, 47 inpatients underwent 3 ME sessions guided by a therapist, with instructions to exclusively verbalise positively about their whole body. Participants completed questionnaires on trait-like eating pathology and body image at the start and end of the study, and instruments on state affect and body satisfaction were administered directly before and after each ME session. Subjective physiological arousal and emotional valence relating to each body part were assessed within each session. RESULTS: The results indicate significant improvements in eating pathology and body image regarding trait-like measures in patients with AN and BN. Concerning state measures, negative affect significantly decreased and body satisfaction increased during ME. Physiological arousal decreased and positively valenced emotions relating to the various body parts increased. CONCLUSIONS: These findings suggest that positively verbalising about one's body during ME improves eating pathology, body image, affect, and subjective physiological arousal, and thus seems to be an effective form of ME.

Psychometric properties of the German version of the fears of compassion scales.

The cultivation of compassion is associated with beneficial effects on physical and psychological health, satisfaction with life and social relationships. However, some individuals, especially those high in psychopathological symptoms or those with particular disorders such as borderline personality disorder (BPD) may demonstrate pronounced fears of engagement in compassionate experiences or behaviours. Furthermore, fears of compassion have been found to impede progress in psychotherapy. The 38-item fears of compassion scales (FCS) is a self-report questionnaire for measuring trait levels of fears of compassion (a) one receives from others (FCFO), (b) one feels towards others (FCTO) and (c) one feels for oneself (self-compassion; FSC). The FCS is an internationally used instrument of proven validity and reliability in both clinical and nonclinical samples. In the present study, a German translation of the FCS including its three subscales was provided, and the psychometric properties were examined in 430 participants from four different samples: (a) a sample from the general population; (b) a mixed sample of psychiatric residential and outpatients; (c) a clinical sample of residential and outpatients with a primary diagnosis of BPD and (d) a sample of healthy control participants. Internal consistencies were excellent for the German version of the FSC and acceptable to excellent for its subscales. Correlations with established measures of mental health demonstrate its validity. Additionally, the German FCS discriminates significantly between individuals from the general population and patients, thus supporting its specificity. The German FCS is suitable to detect potential obstacles in cultivating compassion in psychotherapeutic treatments and beyond.

Predictors of outcome during inpatient psychotherapy for posttraumatic stress disorder: a single-treatment, multi-site, practice-based study.

Objective: The aims of this study were to determine the effectiveness of a routine clinical care treatment and to identify predictors of treatment outcome in PTSD inpatients. Methods: A routinely collected data set of 612 PTSD inpatients (M = 42.3 years [SD = 11.6], 75.7% female) having received trauma-focused psychotherapy was analyzed. Primary outcome was the clinical symptom severity change score, secondary outcomes were assessed using functional, anxiety, and depression change scores. Hedges g-corrected pre-post effect sizes (ES) were computed for all outcomes. Elastic net regulation as a data-driven, stability-based machine-learning approach was used to build stable clinical prediction models. Results: Hedges g ES indicated medium to large effects on all outcomes. The results of the predictor analyses suggested that a combined predictor model with sociodemographic, clinical, and psychometric variables contribute to predicting different treatment outcomes. Across the clinical and functional outcome, psychoticism, total number of diagnoses, and bronchial asthma consistently showed a stable negative predictive relationship to treatment outcome. Conclusion: Trauma-focused psychotherapy could effectively be implemented in a routine inpatient setting. Some important prognostic variables could be identified. If the proposed models of predictors are replicated, they may help personalize treatment for patients receiving routine clinical care.

[Remission, Response and its Prediction after Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in an Inpatient Setting]. / Remission, Response und deren Prädiktion nach einer kognitiven Verhaltenstherapie der Zwangsstörung im stationären Setting.

Cognitive-behavioral therapy, including exposure and response management, is considered the first-choice psychotherapy for obsessive-compulsive disorder. In this study, the therapy outcome of 799 patients was examined in the context of inpatient cognitive-behavioral psychotherapy. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used as the central outcome measure. Therapy outcome was defined in effect sizes (ES) as well as in remission and response rates. In the pre-post comparison of Y-BOCS, the ES was 1.32. Response was classified according to two different definitions: the reliable change index (RCI) and the percental symptom improvement (PSI). The rates of response were 75.5% (RCI) and 37% (PSI). The rates of remission were 39.3% based on RCI and 32.2% based on PSI. 10.4 % of the participating patients finished the treatment prematurely. The risk of dropout was increased in male gender as well as in patients who were additionally treated with neuroleptics. The negative impact of neuroleptics on the outcome of therapy indicates that such medication should be used critically as part of exposure treatment.

The change process in adult anorexia nervosa inpatient treatment: a path model.

PURPOSE: Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment. METHODS: We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model. RESULTS: The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/m2 (SD = 1.6 kg/m2). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2. CONCLUSIONS: The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

Change in obsessive beliefs as predictor and mediator of symptom change during treatment of obsessive-compulsive disorder - a process-outcome study.

BACKGROUND: Cognitive models of obsessive-compulsive disorder suggest that changes in obsessive beliefs are a key mechanism of treatments for obsessive-compulsive disorder. Thus, in the present process-outcome study, we tested whether changes in obsessive beliefs during a primarily cognitive behavioral inpatient treatment predicted treatment outcome and whether these changes mediated symptom changes over the course of treatment. METHODS: Seventy-one consecutively admitted inpatients with obsessive-compulsive disorder were assessed with the Yale-Brown Obsessive-Compulsive Scale and the Obsessive Beliefs Questionnaire at treatment intake, after six weeks of treatment and at discharge, and with the Beck-Depression-Inventory-II at intake and discharge. RESULTS: Changes in obsessive beliefs during the first six weeks of treatment predicted obsessive-compulsive symptoms at discharge when controlling for obsessive-compulsive and depressive symptoms at intake in a hierarchical regression analysis. Multilevel mediation analyses showed that reductions in obsessive beliefs partially mediated improvements in obsessive-compulsive symptoms over time. CONCLUSIONS: Our findings indicate that decreasing obsessive beliefs in inpatient cognitive behavioral therapy for obsessive-compulsive disorder might be a promising treatment approach.

Psychological change mechanisms in anorexia nervosa treatments: how much do we know?

OBJECTIVE: Anorexia nervosa (AN) is a debilitating and often chronic and treatment-resistant disorder. Despite decades of theoretical progress and research, many questions remain with regard to the psychological mechanisms explaining why and how some AN patients respond to treatment whereas others do not. Based on the premise that the broader, noneating disorders psychotherapy research literature, and particularly the common factors literature, can inform AN treatment development efforts, we review a set of selected psychological change mechanisms and describe how they might be relevant in the context of AN treatment response. Specifically, we suggest that a systematic consideration of constructs such as basic psychological needs, expectancies, the therapeutic alliance, experiential avoidance, and patient motivation for change might help illuminate how patients do or do not benefit from AN treatment. We briefly describe an ongoing multicenter trial in which the constructs introduced here are being measured on a weekly basis and are examined as potential mediators of treatment response. The article aims to contribute to the AN literature by introducing a set of potentially important change constructs that we think ought to be studied in greater depth by AN researchers.

Depressive symptoms and weight change in inpatients with anorexia nervosa: A cross-lagged panel model.

OBJECTIVE: Anorexia nervosa (AN) is marked by a high rate of comorbid depression, which raises the question whether depressive symptoms may adversely affect treatment outcome. Thus, we examined whether depressive symptoms at admission would predict weight change from admission to discharge in a large sample of inpatients with AN. In addition, we also explored the reverse direction, that is, whether body mass index (BMI) at admission would predict changes in depressive symptoms. METHODS: A sample of 3011 adolescents and adults with AN (4% male) who received inpatient treatment at four Schoen Clinics was analyzed. Depressive symptoms were measured with the Patient Health Questionnaire-9. RESULTS: BMI significantly increased and depressive symptoms significantly decreased from admission to discharge. BMI and depressive symptoms were unrelated at admission and discharge. Higher BMI at admission predicted smaller decreases in depressive symptoms and higher depressive symptoms at admission predicted larger weight gain. The latter effect, however, was mediated by longer length of stay. CONCLUSION: Results indicate that depressive symptoms do not adversely affect weight gain during inpatient treatment in persons with AN. Instead, higher BMI at admission is predictive of smaller improvements in depressive symptoms but this effect seems to be negligible in terms of clinical relevance.

Psychological consequences and differential impact of the COVID-19 pandemic in patients with mental disorders.

OBJECTIVE: People with mental disorders might be differentially affected by the COVID-19 pandemic. The aim of the current study was to evaluate the impact of the pandemic on patients with various psychiatric disorders who were admitted to inpatient treatment. METHODS: Five-hundred thirty-eight inpatients with mental disorders participated in a survey about psychological consequences of the pandemic between March-December 2020. We examined the perceived burden by restrictions and worries, changes in health care utilization, and helpfulness of coping strategies. RESULTS: More than 50% reported any worsening of symptoms, 40% stated increased need of therapeutic support. High rates of symptom deterioration were observed for depressive symptoms (>55%), anxiety (>40%), and sleeping behavior (>40%). Treatment impairment was stated by 27.9%. Patients with anxiety disorders were less affected by contact restrictions compared with eating disorders and depression. Patients with anorexia nervosa and post-traumatic stress disorder experienced higher helpfulness by daily structuring than patients with depression. DISCUSSION: About half of our sample of psychiatric patients experienced symptom deterioration due to the pandemic and about one quarter reported impairment of treatment modalities. Especially patients with eating disorders and depressive disorders were more frequently affected. The results indicate a needed improvement of treatment options during a pandemic.

Psychometric properties of the German version of the Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS).

Self-criticism is significantly associated with a variety of mental health difficulties affecting vulnerability, presentation, progress, and recovery. In contrast, self-reassurance is associated with good mental health, psychological well-being, and beneficial physiological processes. The 22-item Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS) is an internationally used self-report questionnaire for measuring manifestation and changes in different types of self-criticism and self-reassurance. It has been shown to be a valid and reliable measure in clinical and nonclinical samples. In the present study, a German translation of the FSCRS and its 3 subscales (hated self, inadequate self, reassured self) was provided, and the factor structure and psychometric properties were examined in 415 participants from 4 different population samples: (a) a sample from the general population, (b) a sample of psychiatric residential and outpatients, (c) a clinical sample of residential and outpatients with a primary diagnosis of borderline personality disorder (BPD), and (d) a sample of healthy control participants. Results from confirmatory factor analysis favored a 3-factor solution of the German FSCRS. Furthermore, findings indicate that the German version of the FSCRS and its subscales had good to excellent internal consistencies. Convergent validity was good for all 3 subscales as shown by medium to large correlations with established measures of self-criticism, self-compassion, self-esteem, satisfaction with life, symptoms of depression and anxiety, and secure attachment styles. Additionally, the 3 FSCRS subscales discriminated significantly between the clinical and nonclinical samples, with the BPD sample demonstrating significantly higher levels than the other samples on the hated self subscale. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effects of behavioral therapy or pharmacotherapy on brain glucose metabolism in subjects with obsessive-compulsive disorder as assessed by brain FDG PET.

This prospective study investigated the effect of pharmacotherapy (PT) and cognitive behavioral therapy (CBT) on cerebral glucose metabolism in adults with obsessive-compulsive disorder (OCD). Dynamic positron emission tomography (PET) of the brain with F-18-fluorodeoxyglucose (FDG) was performed before and after treatment in 16 subjects diagnosed for OCD for at least 2 years (PT: n=7). Pre-to-post-treatment change of scaled local metabolic rate of glucose (SLMRGlc) was assessed separately in therapy responders and non-responders. Correlation was tested between SLMRGlc change and change of OCD, depression, or anxiety symptoms. SLMRGlc increased in the right caudate after successful therapy. The increase tended to correlate with the improvement of OCD symptom severity. The finding of increased local caudate activity after successful therapy is in contrast to most previous studies. Possible explanations include effects of therapy on concomitant depression symptoms and/or the large proportion of early-onset OCD in the present sample.

Aggregating factors of the change process in the treatment of anorexia nervosa.

PURPOSE: We aimed to reduce the large body of factors which may be associated with the change process in treatments for Anorexia Nervosa (AN) into a clinically and scientifically useful number of higher-rank dimensions. In addition, we examined the associations between the identified factors and eating disorder psychopathology and body mass index (BMI) in exploratory analyses. METHODS: Within a naturalistic multicenter study we administered the Change Process Questionnaire (CPQ-AN) to inpatients with AN upon admission. The factorial structure of the CPQ-AN was explored via factor analysis. Multiple regression analyses were performed to examine the associations with BMI and eating disorder symptomatology (EDI-2). RESULTS: In total 233 female inpatients with AN (mean BMI=14.9 kg/m(2), SD=1.7) participated. The factor analysis yielded four latent factors: basic need satisfaction, AN-specific cognitions and behavior, emotional involvement and commitment to treatment, and alliance and treatment confidence. Furthermore, greater basic need satisfaction and less AN-specific cognitions and behavior predicted lower EDI-2 scores. Higher alliance and treatment confidence were associated with higher BMI as well as a lower EDI-2 score. CONCLUSION: The associations between the newly derived dimensions and BMI and AN-psychopathology provide evidence to support the clinical relevance of the identified change process dimensions. Future investigations could provide further insights to deepen our understanding of the change process in AN.

Does internet-based prevention reduce the risk of relapse for anorexia nervosa?

Technological advancements allow new approaches to psychotherapy via electronic media. The eating disorder literature currently contains no studies on internet intervention in anorexia nervosa (AN). This study presents a RCT on an internet-based relapse prevention program (RP) over nine months after inpatient treatment for AN. The sample comprised 258 women, randomized to the RP or treatment as usual (TAU). Expert- and self-ratings were evaluated by intent-to-treat analyses. Concerning age, age at onset and comorbidity, both groups were comparable at randomization. During the RP, the intervention group gained weight while the TAU group had minimal weight loss. RP completers gained significantly more body weight than patients in the TAU condition. Group-by-time comparisons for eating-related cognitions and behaviors and general psychopathology showed a significantly more favorable course in the RP program for "sexual anxieties" and "bulimic symptoms" (interview), and "maturity fears" and "social insecurity" (EDI-2). General psychopathology showed no significant group-by-time interaction. Important factors for successful relapse prevention were adherence to the intervention protocol and increased spontaneity. Considering the unfavorable course and chronicity of anorexia nervosa (AN), internet-based relapse prevention in AN following inpatient treatment appears a promising approach. Future internet-based programs may be further improved and enhanced.