Effects of implementation intentions and mental imagery on subjective binge eating.

OBJECTIVE: Binge-eating disorder (BED) and bulimia nervosa (BN) are characterised by binge eating. Changing unwanted behaviour is difficult, as intentions do not automatically lead to action. Implementation intentions (IIs) may help bridging the gap between intentions and behaviour. IIs are 'if-then' plans promoting goal attainment. Effects are moderated by degree of plan formation. Using mental imagery (MI) to impress IIs may strengthen plan formation and goal attainment. METHOD: In a students' sample with subjective binge eating, we compared IIs without MI, IIs with MI, and a control condition regarding their ability to reduce binge eating. Participants received three II-sessions and kept food diaries for 4 weeks. RESULTS: Results showed a significant and medium to large reduction of binge eating in both II-conditions compared to the control condition, that was sustained for 6 months. No additional effects of MI were found. CONCLUSIONS: Applying IIs results in long-lasting reductions in subjective binge eating. The absence of additional effects of MI may be due to floor effects. Also, participants in the IIs without MI condition may have applied MI without being instructed to do so. In future research, ideally with a clinical sample, it is recommended to prevent or control for this.

Emotional and non-emotional mental imagery and auditory verbal hallucinations (hearing voices): A systematic review of imagery assessment tools.

It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non-emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non-emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full-text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non-emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non-emotional mental imagery.

Effects of implementation intentions on subthreshold binge eating.

Binge eating disorder (BED) and bulimia nervosa (BN) are characterized by binge eating. Frequently related to negative affect, binge eating is considered unwanted eating behavior. It is often preceded by a shift away from the goal of a healthy eating pattern. Implementation intentions are 'if-then' plans that may prevent such shifts in goals. In a students' sample with subthreshold binge eating, two implementation intention conditions were compared to a control condition in which only goals were formed. In the behavior-focused condition, implementation intentions targeted binge eating; in the emotion-focused condition, implementation intentions targeted negative affect preceding binge eating. All participants received three sessions and kept food diaries for four weeks, followed by a post-test and a one-month, three-months, and six-months follow-up. Compared to the control condition, both implementation intention conditions showed significant and large reductions in binge eating lasting for six months. Effects did not differ between both implementation intention conditions. Three implementation intention sessions reduced subthreshold binge eating. This continued for six months after the final session. Contrary to expectations, behavior-focused and emotion-focused implementation intentions were equally effective, possibly due to other triggers than negative affect. Future research should address their usefulness in BED and BN.

Patients' perceived lack of goal clarity in psychological treatments: Scale development and negative correlates.

Goal setting in psychological treatments may have favourable effects on patients' motivation and treatment outcomes. Therefore, it seems important to detect when patients do not perceive clear treatment goals. The current study presents a questionnaire measuring patients' perceived lack of goal clarity. The cross-sectional study consisted of 742 adult outpatients with diverse mental disorders. Patients completed the perceived lack of goal clarity questionnaire, and additional items measuring goal setting and evaluation, therapeutic alliance, symptom levels, patients' dependency on their treatment, and their expected and needed number of future treatment sessions. Exploratory factor analysis and reliability analyses resulted in a unidimensional and reliable questionnaire (nine items, α = .85). Additional findings showed that 23% of the treatments lacked initial goal setting according to the patients. Also, perceived lack of goal clarity was lower when treatment goals were established explicitly at the start of treatment, were formulated together with the therapist, and were discussed regularly during treatment, and treatment progress was monitored regularly. Moreover, patients reporting their goals as unclear also reported a poorer quality of the therapeutic alliance, higher symptom levels, increased need for future sessions, but also lower levels of care dependency. These findings underscore the importance of perceived goal clarity in psychological treatments, although the relation with actual goal setting remains uncertain.

Patients' care dependency in mental health care: Development of a self-report questionnaire and preliminary correlates.

OBJECTIVES: Patients' dependency on the therapist or treatment has received little empirical attention. To examine care dependency, we aimed to develop a theory-driven questionnaire based on three hypothetical dimensions (passive-submissive dependency; active-emotional dependency; and lack of perceived alternatives) and to provide a preliminary exploration of several correlates of care dependency. METHOD: Care dependency, perceived social support, therapeutic alliance, remoralization, and symptom severity were measured in a large cross-sectional sample of 742 outpatients with various psychiatric disorders. Test-retest reliability was established in a smaller patient sample. RESULTS: Findings indicated a reliable questionnaire measuring three unidimensional subscales of care dependency (i.e., submissive dependency, need for contact, and lack of perceived alternatives; α's .74, .81, and .86 respectively; rt1,t2 's .78, .76, and .80, respectively). These subscales were all positively correlated with each other and with patients' self-proclaimed care dependency, but divergent from patients' trait dependency and symptoms of a dependent personality disorder. Moreover, higher levels of care dependency were correlated with lower levels of remoralization and more symptoms severity, and with a better therapeutic alliance. CONCLUSIONS: A reliable and valid questionnaire was developed to measure patients' care dependency. Future studies are needed to determine whether care dependency covers an unwanted side-effect or a crucial ingredient of an effective treatment.

Symptom Reduction Without Remoralization: A Randomized, Waiting-List Controlled Study Aimed at Separating Two Beneficial Psychotherapy Outcome Effects.

OBJECTIVE: Treatment effects in psychotherapy outcome research are generally based on the reduction of symptoms. Standard inclusion of other beneficial treatment effects such as remoralization (increase of hope, self-efficacy, well-being) might lead to more elaborate findings in the field of psychotherapy. On the other hand, it is also possible that symptom reduction and remoralization always go hand in hand in the experience of patients. The present study sought to experimentally test this assumption. METHOD: A total of 78 patients suffering from panic disorder were randomly assigned to brief remoralization treatment, brief exposure treatment, or waiting list (WL). RESULTS: Both treatments increased remoralization and both reduced symptoms of panic disorder as compared to WL. CONCLUSION: It is unlikely that patients experience remoralization without symptom reduction or symptom reduction without remoralization. These findings do not favor the assumption that conclusions within psychotherapy outcome research are flawed because of its heavy reliance on measurements of symptom reduction.

Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: a comparison with younger patients.

BACKGROUND: Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive-behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults. METHODS: A total of 172 patients with PDA (DSM-IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18-60 years) and older (≥ 60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions. RESULTS: Attrition rates were 2/31 (6%) for the over-60s and 31/141 (22%) for the under-60s group (χ(2) = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate-to-large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age-related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P-values < .001). Apart from a superior reduction of agoraphobic avoidance in the 60+ participants (ß = -0.30, P = .037), chronological age was not related to outcome, while in the older patients higher chronological age, late-onset type and short DOI were linked to superior improvement of agoraphobic avoidance. CONCLUSIONS: CBT appears feasible for 60+ PDA-patients, yielding outcomes that are similar and sometimes even superior to those obtained in younger patients.

Should cognitive restructuring precede imagery rescripting? An experimental pilot study.

BACKGROUND AND OBJECTIVES: Imagery rescripting (ImRs) is a promising therapeutic technique used in treatment for a variety of psychiatric disorders. During an ImRs session, an aversive disorder-related memory, is activated in imagination and rescripted to a more positive outcome. It has been shown to successfully weaken the negative cognitive meaning, so-called encapsulated beliefs of the targeted aversive memory. In many studies, ImRs is preceded by a cognitive restructuring (CR) technique focused on the encapsulated belief of the target memory. It is not clear whether adding such a CR technique is necessary or that ImRs as standalone technique can achieve comparable effects. METHODS: Students with mild psychological distress (N = 53) were randomized over one session of cognitive restructuring plus imagery rescripting (CR + ImRs), a therapist attention placebo plus imagery rescripting (PLA + ImRs) and a double therapist attention placebo (PLA + PLA). Believability of the idiosyncratic encapsulated belief (primary outcome) and quality (vividness, distress and emotional connotation: secondary outcome) of the target memory were assessed at pre, post and at 1-week follow-up. RESULTS: Results indicate that both, CR + ImRs and PLA + ImRs, reduced the believability of the encapsulated beliefs in greater extent than PLA + PLA. No differences appeared between the two ImRs conditions. For the secondary outcomes no differences between the three conditions were found. LIMITATIONS: This study should be seen as a pilot study, moreover a non-clinical sample was used. CONCLUSION: Findings suggest that a CR technique preceding ImRs is redundant. However, this study needs replication in a larger sample.

Reducing binge eating through behavioral-focused versus emotion-focused implementation intentions in patients with binge eating disorder or bulimia nervosa: An experimental approach.

Binge eating disorder (BED) and bulimia nervosa (BN) are characterized by recurrent binge eating, episodes of consuming large amounts of food in a discrete period of time associated with a loss of control. Implementation intentions are explicit if-then plans that engender goal-directed action, and rely less on cognitive control than standard treatment options. In a sample with BED and BN, we compared two implementation intention conditions to a control condition. In the behavior-focused condition, implementation intentions targeted binge eating behaviors. In the emotion-focused condition, implementation intentions targeted negative affect preceding binge eating. In the control condition, only goal intentions were set. Each condition comprised three sessions. Participants kept food diaries for four weeks. Compared to the control condition both implementation intention conditions showed significant and large reductions of binge eating that persisted for six months. Effects did not differ between the behavior-focused and emotion-focused implementation intention conditions. These results demonstrate that three sessions on implementation intention formation can lead to long-term reductions in binge eating in patients with BED or BN. Learning how to form implementation intentions seems a recommendable addition to the current standard treatment. Future research could investigate the added value of fully personalized implementation intentions. CLINICAL TRIAL REGISTRATION NUMBER: NL52600.068.15.

Predictors of outcome of pharmacological and psychological treatment of late-life panic disorder with agoraphobia.

OBJECTIVE: This study aims to evaluate the differential predictive values of age, age of onset and duration of illness on paroxetine and cognitive-behavioural therapy (CBT) outcome in late-life panic disorder with agoraphobia. METHOD: Patients 60 years and older with a confirmed diagnosis of panic disorder with agoraphobia (n = 49) were randomly assigned to paroxetine (40 mg/day) treatment, individual CBT or a waiting-list control condition. Multiple regression analyses were conducted per treatment arm with post-treatment avoidance behaviour and agoraphobic cognitions as the dependent variables. RESULTS: Higher age at onset and shorter duration of illness were predictors of superior outcomes following CBT, although these variables did not influence the treatment effects of paroxetine. CONCLUSIONS: In late-life agoraphobic panic disorder, chronological age has no impact on treatment modality outcome. In older patients with a late disease onset or shorter duration of illness, CBT is to be preferred over paroxetine, whereas paroxetine might be the treatment of choice for older people with an early onset and short duration of illness.

A neutral face is not neutral even if you have not seen it: social anxiety disorder and affective priming with facial expressions.

Cognitive theories suggest that social anxiety disorder (SAD) is characterized by biased processing of negative facial expressions. Recently, however, it has been proposed that the fear of positive evaluation may play an additional, important role. In order to investigate which specific expressions evoke biased processing, 15 patients diagnosed with SAD and 15 non-anxious controls (NACs) completed an affective priming procedure: they rated neutral symbols which were preceded by sub-optimally presented primes of angry, neutral, and smiling faces. Patients with SAD rated the symbols significantly more negatively than NACs when they were primed with a neutral face. In addition, SAD patients tended to rate all symbols significantly more negatively suggesting that all faces (negative, positive, and neutral) are threatening to SAD patients.

Intraclass correlation associated with therapists: estimates and applications in planning psychotherapy research.

It is essential that outcome research permit clear conclusions to be drawn about the efficacy of interventions. The common practice of nesting therapists within conditions can pose important methodological challenges that affect interpretation, particularly if the study is not powered to account for the nested design. An obstacle to the optimal design of these studies is the lack of data about the intraclass correlation coefficient (ICC), which measures the statistical dependencies introduced by nesting. To begin the development of a public database of ICC estimates, the authors investigated ICCs for a variety outcomes reported in 20 psychotherapy outcome studies. The magnitude of the 495 ICC estimates varied widely across measures and studies. The authors provide recommendations regarding how to select and aggregate ICC estimates for power calculations and show how researchers can use ICC estimates to choose the number of patients and therapists that will optimize power. Attention to these recommendations will strengthen the validity of inferences drawn from psychotherapy studies that nest therapists within conditions.

Agoraphobic cognitions in old and young patients with panic disorder.

OBJECTIVES: To compare the agoraphobic cognitions of younger and older patients suffering from panic disorder with agoraphobia by means of existing questionnaires. METHOD: Agoraphobic cognitions were assessed using the Agoraphobic Cognitions Questionnaire (ACQ) in 205 patients confirmed with confirmed panic disorder with agoraphobia (Diagnostic and Statistical Manual, Fourth Edition, Text Revision) and analyzed at the item level applying a Bonferroni correction. RESULTS: The 48 patients who were older than 60 years had a significantly lower mean (SD) ACQ total score than their younger counterparts (1.6 [0.5] versus 2.1 [0.6]; t = 5.7, df = 203, p < 0.001), with their scores on the items fear of going crazy, acting foolishly, losing control, passing out, and brain tumors (p < 0.004) being significantly lower. CONCLUSION: The differential effect at the ACQ item level suggests that some cognitions seem less relevant for agoraphobic panic disorder in later life. Future research should explore whether and which agerelated cognitions are missed in the current questionnaires.

Culturally Competent Practice: A Mixed Methods Study Among Students, Academics and Alumni of Clinical Psychology Master's Programs in the Netherlands.

This is the first research into preparation for multicultural clinical psychology practice in Europe. It applies the theory of multicultural counselling competency (MCC) to a case study in the Netherlands. It was hypothesized that cross-cultural practice experience, identification as a cultural minority, and satisfaction with cultural training was associated with MCC. The Multicultural Awareness Knowledge and Skills Survey was completed by 106 participants (22 students, 10 academics, 74 alumni) from clinical psychology masters' programs. MANOVA detected a main effect of cross-cultural experience on MCC for all groups and universities. The data were enriched with exploratory qualitative data from 14 interviews (5 students, 5 academics, 4 alumni). Interpretative Phenomenological Analysis revealed three themes: limitations of clinical psychology, strategies for culturally competent practice, and strategies for cultural competency development. These outcomes suggest that cultural competency continues to require attention in master's programs. The paper makes recommendations for further research enquiry related to training clinical psychologists to practice in Europe's multicultural societies.

Cortisol deviations in people with burnout before and after psychotherapy: a pilot study.

Burnout is characterized by exhaustion, cynicism, and feelings of reduced competence. These complaints may be reflected in disturbances in the main stress regulatory endocrine system: the hypothalamus pituitary adrenal (HPA) axis. In this study, the HPA-axis hormone cortisol was sampled after awakening and during the day in 22 participants with clinical burnout and in 21 healthy controls. The cortisol level after awakening was shown to be significantly lower in the burnout group as compared with the control group. Cortisol levels during the day did not differ. The same sampling procedure was repeated after 14 sessions of psychotherapeutic intervention. The intervention led to a significant reduction in complaints and to an increase of the initially lowered morning cortisol levels. No consistent correlations, however, between the changes in subjective complaints and the change in cortisol parameters were found.

Behavioural treatment of trichotillomania: two-year follow-up results.

Post-treatment evaluation studies of behaviour therapy (BT) for trichotillomania (TTM) have shown that BT is successful in reducing symptoms in this impulse-control disorder. The present study was aimed at investigating gain maintenance at long-term follow-up. TTM-related symptoms and other symptom characteristics were evaluated in 28 patients suffering from TTM before and after brief BT and at a 3-month and 2-year follow-up. The manual-based BT consisted of self-control procedures offered in six sessions. Pre-post effect sizes for TTM symptoms at post-treatment evaluation and at the two follow-ups were 2.91, 1.47, and .87. Compared to the post-treatment effects, the 3-month and 2-year follow-up effect sizes had decreased by 49% and 70%, respectively. Better 2-year follow-up results were associated with lower pre-treatment levels of depressive symptoms and with complete abstinence from hair pulling immediately after treatment.

Addressing Self-Control Cognitions in the Treatment of Trichotillomania: A Randomized Controlled Trial Comparing Cognitive Therapy to Behaviour Therapy.

People with trichotillomania often have persistent negative beliefs about giving into one's habit. Central in the present study was the hypothesis that the follow-up effects of cognitive therapy (CT), in which these negative beliefs are directly addressed, are better compared to the follow-up effects of behaviour therapy (BT). Fifty-six trichotillomania patients were randomly assigned to either six sessions CT or BT. Forty-eight completed their treatment. Follow-up measurements took place after a 3 months treatment-free period, and at 12 and 24 months. CT and BT both resulted in clear reductions of trichotillomania symptoms (severity, urge, inability to resist, and negative beliefs) immediately after treatment. There were no differences between the groups. Following the treatment-free period, there was a reoccurrence of symptoms. In contrast to our expectation, we failed to show that CT compared to BT resulted in lower relapse rates after the treatment-free period.

Treatment of trichotillomania with behavioral therapy or fluoxetine: a randomized, waiting-list controlled study.

BACKGROUND: Both behavioral therapy (BT) and serotonin reuptake inhibitors have been reported effective in the treatment of trichotillomania. This study examines the efficacy of BT and fluoxetine hydrochloride compared with a waiting-list (WL) control group. METHODS: Forty-three patients with trichotillomania entered a 12-week randomized, WL-controlled study of BT and fluoxetine (60 mg/d). Forty patients (14 in the BT group, 11 in the fluoxetine group, and 15 in the WL group) completed the trial. Treatment effects were evaluated using the Massachusetts General Hospital Hairpulling Scale, and severity of hair loss was rated by independent assessors. In addition, we measured general symptoms of psychopathologic abnormalities and depression. RESULTS: For reducing the symptoms of trichotillomania, BT was superior. Patients in the BT group showed a significantly greater reduction in trichotillomania symptoms, higher effect sizes (Massachusetts General Hospital Hairpulling Scale: BT, 3.80; fluoxetine, 0.42; and WL, 1.09), and more clinically significant changes (BT, 64%; fluoxetine, 9%; and WL, 20%) than patients in the fluoxetine and WL groups. For severity of hair loss, a similar trend was also found in favor of the BT group. No significant differences between groups were established for general psychopathologic and depressive symptoms. CONCLUSIONS: Behavioral therapy is highly effective for reducing symptoms of trichotillomania in the short term, whereas fluoxetine is not.

Childhood abuse in patients with conversion disorder.

OBJECTIVE: Despite the fact that the assumption of a relationship between conversion disorder and childhood traumatization has a long history, there is little empirical evidence to support this premise. The present study examined this relation and investigated whether hypnotic susceptibility mediates the relation between trauma and conversion symptoms, as suggested by Janet's autohypnosis theory of conversion disorder. METHOD: A total of 54 patients with conversion disorder and 50 matched comparison patients with an affective disorder were administered the Structured Trauma Interview as well as measures of cognitive (Dissociative Experiences Scale) and somatoform (20-item Somatoform Dissociation Questionnaire) dissociative experiences. RESULTS: Patients with conversion disorder reported a higher incidence of physical/sexual abuse, a larger number of different types of physical abuse, sexual abuse of longer duration, and incestuous experiences more often than comparison patients. In addition, within the group of patients with conversion disorder, parental dysfunction by the mother-not the father-was associated with higher scores on the Dissociative Experiences Scale and the Somatoform Dissociation Questionnaire. Physical abuse was associated with a larger number of conversion symptoms (Structured Clinical Interview for DSM-IV Axis I Disorders). Hypnotic susceptibility proved to partially mediate the relation between physical abuse and conversion symptoms. CONCLUSIONS: The present results provide evidence of a relationship between childhood traumatization and conversion disorder.

A randomized, double-blind, placebo-controlled study of the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive-behavioral therapy alone.

BACKGROUND: Both cognitive-behavioral therapy and treatment with selective serotonin reuptake inhibitors (SSRIs) have proved to be effective in the treatment of panic disorder. The present study examined the effects of paroxetine added to continued cognitive-behavioral therapy in patients who were unsuccessfully treated with initial cognitive-behavioral therapy alone. METHOD: 161 patients with panic disorder with or without agoraphobia (DSM-IV criteria) underwent a manual-guided cognitive-behavioral therapy of 15 sessions. Forty-three unsuccessfully treated patients from this group were included in a double-blind, placebo-controlled, next-step treatment study consisting of continued cognitive-behavioral therapy plus adjunctive paroxetine at a dose of 40 mg/day or continued cognitive-behavioral therapy plus placebo. RESULTS: Overall, patients in the cognitive-behavioral therapy plus paroxetine condition improved significantly on agoraphobic behavior (p < .05) and anxiety discomfort (p < .01), whereas patients in the cognitive-behavioral therapy plus placebo condition did not. Effect sizes in the cognitive-behavioral therapy plus paroxetine condition ranged from 1.0 to 1.8 and in the cognitive-behavioral therapy plus placebo condition, from 0.4 to 1.0. CONCLUSION: Patients with panic disorder who are unsuccessfully treated with initial cognitive-behavioral therapy may benefit from the addition of an SSRI as a second treatment modality. The importance of timely evaluation of treatment results is emphasized.