The delivery of psychotherapy-A Delphi study on the dimensions of psychotherapy delivery and a proposal for reporting guidelines.

Efficacy and effectiveness of psychotherapy are well studied, but we know little about optimal ways of delivering therapy. Evidence of how best to deliver psychotherapy is scarce and difficult to scope because reports of how interventions are delivered lack a common terminology. We therefore conducted a Delphi study on what dimensions of therapy delivery are important to report and examine. The study was conducted between October 2016 and July 2017. Twenty therapy experts rated and commented on various dimensions of therapy delivery (e.g., duration, spacing, or format of session). Experts were asked (a) how relevant these were for reporting of therapy studies, (b) how much they agreed with the guidelines for describing them, (c) how important these were to investigate in future studies, and (d) whether they agreed with the name of the dimension. Experts were asked to suggest other dimensions of therapy delivery they considered relevant and propose revisions of the initial guidelines. The panel agreed on names and guidelines for the description of 13 dimensions of therapy delivery. These were deemed relevant or highly relevant to report and research in future psychotherapy studies. We propose structured guidelines for reporting the delivery of psychotherapy.

Social networks and support in first-episode psychosis: exploring the role of loneliness and anxiety.

PURPOSE: To investigate social support and network features in people with first-episode psychosis, and to examine anxiety as a possible mediator between loneliness and a rating of paranoia. METHOD: Thirty-eight people with first-episode psychosis were recruited for a cross-sectional study. Self-report questionnaires and structured interviews assessed symptoms, functioning, and qualitative social network and support features. A mood-induction task involved watching anxiety-inducing pictures on a computer screen. Visual analogue scales assessed changes in paranoia, anxiety and loneliness and a mediation analysis was conducted. RESULTS: One-third of the sample (34%) had no confidant [95% CI (18.4, 50.0%)]. The average number of weekly contacts was 3.9, with 2.6 lonely days. Poor perceived social support, loneliness and the absence of a confidant were strongly associated with psychosis and depressive symptoms (0.35 < rs < 0.60). The association between loneliness and paranoia was mediated through anxiety (ab = 0.43, z = 3.5; p < 0.001). CONCLUSIONS: Even at first episode, a large proportion of people with psychosis have poor perceived support, no confidant and report several lonely days a week. Patients without a confidant appear to be more susceptible to feeling lonely and anxious. Anxiety may be one pathway through which loneliness affects psychosis. Interventions which focus on this are indicated.

Attenuating experimentally acquired disgust: Comparing counterconditioning, exposure and unconditioned stimulus revaluation.

BACKGROUND AND OBJECTIVES: Disgust is implicated in the aetiology and maintenance of various psychopathologies such as anxiety disorders and obsessive-compulsive disorders. Despite its prominent role in psychopathology, little is known about how to effectively attenuate disgust. The study examined strategies to modify an experimentally acquired disgust response in a sample of undergraduate students. METHODS: A conditioning paradigm was used where participants (N = 175) first underwent acquisition of disgust via repeated presentations of a neutral picture (functioning as conditioned stimulus + [CS+]) paired with a disgusting picture (functioning as unconditioned stimulus [US]). Participants were then randomly assigned to either an exposure (repeated presentation of CS-only trials), counterconditioning (pairing CS+ with pleasant pictures), US revaluation (pairing disgusting US with pleasant pictures) or a control (filler task) condition. We hypothesised that counterconditioning would attenuate evaluative learned disgust to the greatest extent, relative to exposure and US revaluation. Participants' evaluations of the pictures were attained with a disgust-pleasantness visual analogue scale. RESULTS: Exposure, counterconditioning and US revaluation reduced disgusting US expectancies. However, experimental and control conditions did not differ in terms of attenuating disgust towards CS+. LIMITATIONS: Measures of psychopathology and implicit evaluations of disgust were not collected. Modest power might have limited significance of the results. CONCLUSIONS: No statistical support for the effectiveness of disgust attenuation following exposure nor counterconditioning were found. Findings for US revaluation are inconclusive. Implications for future research are discussed.

Mobile Behavioral Health Coaching as a Preventive Intervention for Occupational Public Health: Retrospective Longitudinal Study.

BACKGROUND: Researchers have recently proposed that behavioral health coaching (BHC) is effective in promoting proactive care among employees. However, to qualify as a preventive workplace intervention, more research is needed to evaluate whether BHC can further elevate well-being among moderately mentally healthy employees. OBJECTIVE: Using real-world data, this study evaluates the preliminary effectiveness of app-based BHC against a nonrandomized control group with open access to self-help tools in improving well-being (ie, mood levels and perceived stress). The study also explores the active ingredients of BHC and dose-response associations between the number of BHC sessions and well-being improvements. METHODS: Employees residing across Asia-Pacific countries (N=1025; mean age 30.85, SD 6.97 y) who reported moderately positive mood and medium levels of perceived stress in their first week of using the mental health app Intellect were included in this study. Users who were given access by their organizations to Intellect's BHC services were assigned to the "Coaching" condition (512/1025, 49.95%; mean age 31.09, SD 6.87 y), whereas other employees remained as "Control" participants (513/1025, 50.05%; mean age 30.61, SD 7.06 y). To evaluate effectiveness, monthly scores from the validated mood and stress sliders were aggregated into a composite well-being score and further examined using repeated-measure conditional growth models. Postcoaching items on "Perceived Usefulness of the BHC session" and "Working Alliance with my Coach" were examined as active ingredients of BHC using 1-1-1 multilevel mediation models. Finally, 2-way repeated-measure mixed ANOVA models were conducted to examine dose-response effects on well-being improvements between groups (coaching and control) across time. RESULTS: Growth curve analyses revealed significant time by group interaction effects for composite well-being, where "Coaching" users reported significantly greater improvements in well-being than "Control" participants across time (composite well-being: F1,391=6.12; ηp2=0.02; P=.01). Among "Coaching" participants, dependent-sample 2-tailed t tests revealed significant improvements in composite well-being from baseline to 11 months (t512=1.98; Cohen d=0.17; P=.049). Improvements in "Usefulness of the BHC session" (ß=.078, 95% Cl .043-.118; P<.001) and "Working Alliance" (ß=.070, 95% Cl .037-.107; P<.001) fully mediated within-level well-being enhancements over time. Comparing against baseline or first month scores, significant time by group interactions were observed between the second and sixth months, with the largest effect size observed at the fifth month mark (first month vs fifth month: F1,282=15.0; P<.001; ηp2=0.051). CONCLUSIONS: We found preliminary evidence that BHC is an effective preventive workplace intervention. Mobile-based coaching may be a convenient, cost-effective, and scalable means for organizations and governments to boost public mental health.

Efficacy of Intellect's self-guided anxiety and worry mobile health programme: A randomized controlled trial with an active control and a 2-week follow-up.

Digital self-guided mobile health [mHealth] applications are cost-effective, accessible, and well-suited to improve mental health at scale. This randomized controlled trial [RCT] evaluated the efficacy of a recently developed mHealth programme based on cognitive-behavioral therapy [CBT] principles in improving worry and anxiety. We also examined psychological mindedness [PM] as a mediator by which app engagement is thought to improve outcomes. The Intervention group completed a 2-week "Anxiety and Worry" programme with daily CBT-informed activities, while the active waitlist-control completed a matched 2-week mHealth programme on procrastination. Participants filled out the Generalized Anxiety Disorder [GAD-7], Patient Health Questionnaire [PHQ-9], and Psychological Mindedness Scale [PMS] at baseline, post-intervention, and 2-week follow-up. App engagement was measured at post-intervention only. Contrary to prediction, the Intervention group did not perform better than the Active Control group; both groups showed significant improvements on anxiety and depressive symptoms from baseline to follow-up. From post-intervention to follow-up, only the Intervention group showed further improvements for anxiety symptoms. Higher engagement with the mHealth app predicted lower anxiety and depressive symptoms at follow-up, and this relationship was fully mediated by psychological mindedness. This study provides evidence that [a] engaging in a CBT mHealth programme can reduce anxiety and worry, and [b] Psychological mindedness is a potential pathway by which engaging with a mHealth app improves anxiety and depressive symptoms. While overall effect sizes were small, at the population level, these can make significant contributions to public mental health.

Preliminary effectiveness of an evidence-based mobile application to promote resilience among working adults in Singapore and Hong Kong: Intensive longitudinal study.

Evidence-based mobile health (mHealth) applications on smartphones are a cost-effective way for employees to take proactive steps to improve well-being and performance. However, little is known about what sustains engagement on these applications and whether they could dynamically improve occupational outcomes such as resilience and mood. Using real-world data, this intensive longitudinal study examines (a) which employees would continually engage with a cognitive behavioural therapy-informed mHealth application ('Intellect'); and (b) if daily engagement of 'Intellect' would relate to better occupational outcomes on the following day. A total of 515 working adults in Singapore and Hong Kong (Mage = 32.4, SDage = 8.17) completed daily in-app items on mood and resilience components (i.e. sleep hours, sleep quality, physical activity, and stress levels). Our results revealed that employees with lower baseline resilience (ß = -0.048, odds ratio (OR) = 0.953, p < 0.01), specifically poorer sleep quality (ß = -0.212, OR = 0.809, p = 0.001) and/or higher stress levels (ß = -0.255, OR = 0.775, p = 0.05), were more likely to resume engagement on the application. Among the 150 active users (i.e. ≥3 consecutive days of engagement) (Mage = 32.2, SDage = 8.17), daily engagement predicted higher resilience (ß = 0.122; 95% confidence interval (CI) 0.039-0.206), specifically lower stress levels (ß = 0.018; 95% CI 0.004-0.032), higher physical activity (ß = 0.079; 95% CI 0.032-0.126), and mood levels (ß = 0.020; 95% CI 0.012-0.029) on the following day even after controlling for same-day outcomes. Our preliminary findings suggest that engaging with a mHealth application was associated with higher dynamic resilience and emotional well-being in employees.

Efficacy of the Mental Health App "Intellect" to Improve Body Image and Self-compassion in Young Adults: A Randomized Controlled Trial With a 4-Week Follow-up.

BACKGROUND: Body image concerns are prevalent among young adults, who may be vulnerable to developing body image concerns because of particular risk factors associated with this life period. With technological advancements, digital mobile health (mHealth) apps are cost-effective and scalable interventions. Thus, mHealth apps can be explored as a form of prevention effort to alleviate body image concerns in young adults. OBJECTIVE: In this randomized controlled trial, we examined the effectiveness of a self-guided mHealth app in improving body image and self-compassion in a sample of university students. METHODS: Participants (N=310) were randomized to a 9-day self-guided body image and self-compassion mHealth app (n=149) and to an active waitlist control group (n=161), where they completed a similarly structured 9-day program on cooperation. Both programs consisted of content learning and activities such as quizzes, with the number and length of activities matched for both programs. Measures were obtained at baseline, upon completion of the programs (after the intervention), and at 4-week follow-up. RESULTS: The intervention group for female participants reported significant reduction in body dissatisfaction (P<.001) and improvements in body appreciation (P<.001) and self-compassion (P=.001) compared with the active waitlist control group after the intervention. Similarly, for male participants after the intervention, a significant reduction was found in the intervention group in body dissatisfaction (P<.001) after the intervention as well as improvements in body appreciation (P=.02) and self-compassion (P=.047). The effects were maintained at 4-week follow-up for female participants on body dissatisfaction (P<.001), body appreciation (P<.001), and self-compassion (P=.02) but not for male participants. On body image risk factors, significant reductions were found for female participants after the intervention for thin-ideal internalization (P<.001), peer pressure (P=.002), and media pressure (P<.001) after the intervention, while the effects were only maintained for thin-ideal internalization (P=.008) and media pressure (P=.01) at 4-week follow-up, compared with the active waitlist control group. As for male participants, no intervention effects were found both after the intervention and at follow-up for all body image risk factors of muscularity internalization, peer pressure, and media pressure. Both apps were acceptable and participants engaged equally across the intervention and active waitlist control groups, as indicated on a measure of app engagement (P=.76). CONCLUSIONS: This study provides preliminary evidence for a self-guided mHealth app in improving body image concerns and self-compassion in young adult university students. Future studies should include longer follow-ups, and examine its effects with the wider populations of young adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT04977973; https://clinicaltrials.gov/ct2/show/NCT04977973.

An experimental investigation of intolerance of uncertainty and its impact on sub-clinical psychopathology.

BACKGROUND: Intolerance of Uncertainty (IU) is a transdiagnostic construct that is implicated in psychological difficulties, including Major Depressive Disorder (MDD), Generalised Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), and eating disorders (ED). However, most studies exploring IU have been correlational in nature. This study examined (1) whether a linguistic manipulation of the Intolerance of Uncertainty Scale (IUS) would successfully manipulate IU in an undergraduate sample, (2) whether experimentally increased or decreased levels of IU affect symptoms of MDD, GAD, OCD and ED, and (3) whether increased baseline symptom severity influences the magnitude of change in symptom severity post-manipulation. METHODS: A linguistic manipulation of the IUS was used to manipulate participants' beliefs about their ability to tolerate uncertainty. N = 106 undergraduate participants were randomised to one of two conditions: high IU (HIU; n = 54) or low IU (LIU; n = 52), and completed measures on symptom severity at baseline and one-week follow-up. RESULTS: The manipulation successfully reduced IU in LIU. Participants in this group did not experience significant changes in symptom severity post-manipulation. However, individuals with higher baseline OCD in LIU demonstrated greater decreases in post-manipulation OCD symptoms, compared with individuals in HIU. LIMITATIONS: Only the LIU manipulation was effective, limiting the findings from the HIU. The one-week follow-up and relatively small sample size of predominantly female undergraduate students may dilute and limit the generalisability of results. CONCLUSION: Findings support the utility of this manipulation in reducing IU, and the significance of different levels of IU in OCD.

Efficacy of the Mental Health App Intellect to Reduce Stress: Randomized Controlled Trial With a 1-Month Follow-up.

BACKGROUND: Excessive stress is a major global health concern, particularly in young adults. Short skills-focused self-guided interventions (SGIs) on smartphones are a scalable way to improve stress-coping skills at the population level. OBJECTIVE: In this randomized controlled trial, we aimed to examine the possible efficacy of a recently developed stress-coping SGI (Intellect) in improving psychological distress, relative to an active control group and 2 potential moderators of this predicted relationship (ie, psychological mindedness [PM] and coping self-efficacy [CSE]). METHODS: University students (N=321) were randomly assigned to either an 8-day SGI on stress-coping or an active control group. Self-reported measures were obtained at baseline, after the intervention, and at the 1-month follow-up. The primary outcome was psychological stress (Psychological Stress Measure-9). Secondary outcomes were anxiety (Generalized Anxiety Disorder-7) and depressive symptoms (Patient Health Questionnaire-9). PM and CSE were assessed as potential moderators at baseline. RESULTS: The final sample (n=264) included 188 (71.2%) female, 66 (25%) male, 7 (2.7%) nonbinary, and 3 (1.1%) others participants with a mean age of 22.5 (SD 5.41) years. The intervention group reported significantly lower perceived stress (partial eta-squared [ηp2]=0.018; P=.03) and anxiety (ηp2=0.019; P=.03) levels after intervention relative to the active control group. The effects on perceived stress levels remained statistically significant at the 1-month follow-up (ηp2=0.015; P=.05). Students with the lowest CSE and highest PM experienced the fastest decline in perceived stress levels (ß=6.37, 95% Cl 2.98-9.75). Improvements in anxiety levels were not observed at 1-month follow-up. Similarly, no intervention effects were found for depression levels at postintervention and follow-up periods. CONCLUSIONS: This study provides evidence that the Intellect stress-coping SGI is effective in reducing perceived stress and anxiety levels among university students. Mobile health apps are brief, scalable, and can make important contributions to public mental health. TRIAL REGISTRATION: ClinicalTrials.gov NCT04978896; https://www.clinicaltrials.gov/ct2/show/NCT04978896.

A systematic review on the links between emotion regulation difficulties and obsessive-compulsive disorder.

BACKGROUND: Growing evidence suggests a link between emotion regulation (ER) deficits and obsessive-compulsive symptoms (OCS). AIMS: A systematic review was conducted to integrate empirical research on the nature of ER difficulties associated with obsessive-compulsive disorder (OCD), validated measures of ER for OCD and evidence base for psychological interventions targeting ER difficulties in OCD. METHODS: Database searches were conducted on CINAHL, Cochrane Library, EMBASE, MEDLINE, PUBMED, PsycINFO and Scopus with keywords related to ER and OCD. 2609 articles were found, six were identified from other sources and 21 studies were included in this review. The review was registered on PROSPERO (CDR42020184076). RESULTS: The non-acceptance of emotions was the most consistently related to OCS - albeit not uniformly with all OCS dimensions. There was also some evidence suggesting that difficulties in impulse-control, accessing effective ER strategies and engaging in goal-directed behaviours to be related to OCS. No OCD-specific ER measure was identified. Interventions with ER components appeared to be promising for the treatment of OCD. FUTURE DIRECTIONS: Recommendations on how to build on the existing literature and improve the quality of evidence were provided.

Modulating disgust in mental contamination: Experimental evidence for the role of disgust.

BACKGROUND AND OBJECTIVES: Disgust has been associated with mental contamination (MC), although the evidence has hitherto been nonexperimental. Furthermore, strategies that can target both disgust and MC have not been well explored. We investigated the role of disgust in MC by inducing disgust via olfaction within the "dirty kiss" paradigm and conversely, to see if pairing pleasant olfactory stimulus during re-exposure, based on counterconditioning, can reduce MC. We also examined whether disgust constructs (propensity and sensitivity) and trait MC are associated with state MC arising from the "dirty kiss". METHODS: MC was first evoked using the "dirty kiss" paradigm, in which participants (N = 90) visualized receiving a non-consensual kiss from a physically dirty man (time 1). After a break, participants repeated the "dirty kiss" task in a room that was scented to smell either disgusting, pleasant or neutral (time 2). Participants completed measures of disgust and trait MC after the experiment. RESULTS: Participants in the disgust condition reported increased feelings of dirtiness at time 2. Disgust propensity predicted feelings of dirtiness at time 1. Disgust sensitivity and trait MC were not associated with state MC indices. LIMITATIONS: The use of a non-clinical female sample, extraneous factors during the break and contextual factors arising from room change at time 2 are some potential limitations. CONCLUSIONS: Induced disgust within a MC paradigm resulted in increased feelings of dirtiness, suggestive of disgust-based emotional reasoning. Pairing pleasant olfactory stimulus was not effective at attenuating MC or disgust.

"When I feel the worst pain, I look like shit" - body image concerns in persistent pain.

Background and aims Persistent pain is a pervasive condition that is often associated with a distorted body image. Most research into pain and body image investigated neural or physiological correlates (e.g. phantom limb pain), and much less is known about the psychological experience of body image changes in response to pain such as appearance concerns. The aim was to examine body image concerns in people with persistent pain, in particular appearance concerns and related coping behaviours and appearance-related emotions such as anger and shame. Methods Design was cross-sectional and data was collected through in-depth semi-structured interviews with people suffering from persistent musculoskeletal pain (n=7; six females; age=19-56), and analysed with inductive thematic analysis (TA). Results Two main themes were identified: "Relationship to the painful body" and "Dissatisfaction with the body", each containing three subthemes, along with the side-theme "Appearance concerns affected by pain and mood". All participants reported appearance concerns, predominantly about their weight and related coping behaviours such as avoidance of mirrors, exercising or dieting and pain-induced mood changes that were associated with a negative body image. Conclusions People with persistent pain report appearance concerns, often related to pain-induced negative mood changes, and reduced functioning. It remains unclear to what extent attitudes towards the body change over time in accordance with pain. A wider concept of body image is required, including the perception of reduced functioning, related appraisals (e.g. "I look weak and old") and appearance investment.

Perceptual processing during trauma, priming and the development of intrusive memories.

BACKGROUND: Intrusive reexperiencing in posttraumatic stress disorder (PTSD) is commonly triggered by stimuli with perceptual similarity to those present during the trauma. Information processing theories suggest that perceptual processing during the trauma and enhanced perceptual priming contribute to the easy triggering of intrusive memories by these cues. METHODS: Healthy volunteers (N = 51) watched neutral and trauma picture stories on a computer screen. Neutral objects that were unrelated to the content of the stories briefly appeared in the interval between the pictures. Dissociation and data-driven processing (as indicators of perceptual processing) and state anxiety during the stories were assessed with self-report questionnaires. After filler tasks, participants completed a blurred object identification task to assess priming and a recognition memory task. Intrusive memories were assessed with telephone interviews 2 weeks and 3 months later. RESULTS: Neutral objects were more strongly primed if they occurred in the context of trauma stories than if they occurred during neutral stories, although the effect size was only moderate [Formula: see text] and only significant when trauma stories were presented first. Regardless of story order, enhanced perceptual priming predicted intrusive memories at 2-week follow-up (N = 51), but not at 3 months (n = 40). Data-driven processing, dissociation and anxiety increases during the trauma stories also predicted intrusive memories. Enhanced perceptual priming and data-driven processing were associated with lower verbal intelligence. LIMITATIONS: It is unclear to what extent these findings generalize to real-life traumatic events and whether they are specific to negative emotional events. CONCLUSIONS: The results provide some support for the role of perceptual processing and perceptual priming in reexperiencing symptoms.