The magnitude of neurocognitive impairment is overestimated in depression: the role of motivation, debilitating momentary influences, and the overreliance on mean differences.

BACKGROUND: Meta-analyses agree that depression is characterized by neurocognitive dysfunctions relative to nonclinical controls. These deficits allegedly stem from impairments in functionally corresponding brain areas. Increasingly, studies suggest that some performance deficits are in part caused by negative task-taking attitudes such as poor motivation or the presence of distracting symptoms. A pilot study confirmed that these factors mediate neurocognitive deficits in depression. The validity of these results is however questionable given they were based solely on self-report measures. The present study addresses this caveat by having examiners assess influences during a neurocognitive examination, which were concurrently tested for their predictive value on performance. METHODS: Thirty-three patients with depression and 36 healthy controls were assessed on a battery of neurocognitive tests. The examiner completed the Impact on Performance Scale, a questionnaire evaluating mediating influences that may impact performance. RESULTS: On average, patients performed worse than controls at a large effect size. When the total score of the Impact on Performance Scale was accounted for by mediation analysis and analyses of covariance, group differences were reduced to a medium effect size. A total of 30% of patients showed impairments of at least one standard deviation below the mean. CONCLUSIONS: This study confirms that neurocognitive impairment in depression is likely overestimated; future studies should consider fair test-taking conditions. We advise researchers to report percentages of patients showing performance deficits rather than relying solely on overall group differences. This prevents fostering the impression that the majority of patients exert deficits, when in fact deficits are only true for a subgroup.

Metacognitive Training for Obsessive-Compulsive Disorder: a study protocol for a randomized controlled trial.

BACKGROUND: A high number of patients with obsessive-compulsive disorder (OCD) do not receive cognitive-behavioral therapy with exposure and response prevention, which is the most effective treatment for OCD. Therefore, Metacognitive Training for OCD (MCT-OCD) was developed, which is a structured group therapy aiming at the modification of dysfunctional (meta-)cognitive biases, beliefs and coping styles. It can be administered by less trained personnel, thus may reach a higher number of patients. An uncontrolled pilot study (MCT-OCD pilot version) provided first evidence that the training is highly accepted by patients; OC symptoms decreased with a high effect size (η2partial = 0.50). The aim of the present study is to address the shortcomings of the pilot study (e.g., no control group) and to assess the efficacy of the revised version of the MCT-OCD in the framework of a randomized controlled trial. METHODS: Eighty patients with OCD will be recruited. After a blinded assessment at baseline (-t1), patients will be randomly assigned either to the intervention group (MCT-OCD; n = 40) or to a care as usual control group (n = 40). The MCT-OCD aims to enhance patients' metacognitive competence in eight modules by addressing dysfunctional (meta-)cognitive biases and beliefs associated with OCD (e.g., intolerance of uncertainty). After 8 weeks, patients will be invited to a post assessment (t1), and then they will receive a follow-up online questionnaire 3 months following t1 (t2). The primary outcome is the Y-BOCS total score, and the secondary outcomes include the HDRS, OCI-R, OBQ-44, MCQ-30, WHOQOL-BREF, BDI-II, and subjective appraisal ratings of the MCT-OCD. We expect that OC symptoms will decrease more in the intervention group compared with the care as usual control group from -t1 to t1 and that treatment gains will be maintained until t2. DISCUSSION: The planned study is the first to investigate the MCT-OCD, a promising new treatment, in a randomized controlled trial. The MCT-OCD may help to overcome existing treatment barriers for patients with OCD. TRIAL REGISTRATION: German Registry for Clinical Studies ( DRKS00013539 ), 22.02.2018.

Imaginal Retraining Reduces Cigarette Smoking: A Randomized Controlled Study.

OBJECTIVES: Smoking is a highly prevalent addictive behavior with severe and life-shortening health consequences. This is the first study to evaluate the efficacy of a newly developed imaginal variant of approach bias modification (ABM) (i.e., imaginal retraining) for the reduction of craving for tobacco and actual smoking behavior. METHODS: We randomized 345 smokers to imaginal retraining (self-help manual) or a control group (either active control or wait-list control). Assessments were carried out online. The treatment interval was 6 weeks. Craving for tobacco represented the primary outcome. The study was registered as DRKS00016860. RESULTS: Retention was 79.7% with no difference between groups. The intention-to-treat (ITT) analyses were significant for the primary outcome (Visual Analogue Scale on craving for tobacco) as well as subjective reduction of smoking (45.5 vs. 26.4%) in favor of imaginal retraining. In the treatment group, 47.6% performed the exercises at least once. This subgroup (per-protocol [PP] sample) showed a significant reduction in tobacco dependency as measured with the Cigarette Dependence Scale (short and long forms) and the Fagerström Test for Nicotine Dependence relative to controls. Number of daily cigarettes declined to a greater extent in imaginal retraining in the PP but not ITT analysis. A small dose-effect relationship emerged between craving and frequency of performance of the technique. CONCLUSION: When used regularly, imaginal retraining may reduce craving for tobacco and actual smoking behavior in a subgroup of smokers. In view of the large subgroup that did not read the manual or did not perform the exercises, alternative ways of conveying the imaginal retraining technique should be sought (e.g., demonstration via video clips). To conclude, imaginal retraining may represent a simple low-threshold technique to reduce smoking and assist current evidence-based treatment programs targeted at abstinence. It needs to be tested whether its mechanism of action deviates from standard ABM.

Session-specific effects of the Metacognitive Training for Obsessive-Compulsive Disorder (MCT-OCD).

Objective: Most studies focus on overall treatment effects by assessing symptom severity before and after treatment, but few investigate session-specific effects of an intervention. The aim of the present study was to elucidate session-specific effects of a group therapy for obsessive-compulsive disorder (OCD) that targets cognitive biases known as the Metacognitive Training for OCD (MCT-OCD).Method: In an uncontrolled pilot trial, 44 inpatients with OCD participated in the MCT-OCD once a week over four weeks. Before and after each session, patients answered questionnaires on thought monitoring, control of thoughts, obsessions, compulsions, and mood.Results: Primary analyses using linear mixed-effect models showed that the module on control of thoughts (within-session effect) significantly reduced patients' control of thoughts. Exploratory analyses displayed an improvement in thought monitoring, control of thoughts, obsessions, and compulsions over the treatment period. Control of thoughts decreaed after the module on biased attention/biased cognitive networks and compulsions reduced one week after the module on overestimation of threat/responsibility (between-session effect). More compulsions were reported one week after the module on thought-action fusion/control of thoughts.Conclusions: Certain MCT-OCD modules seemed to improve specific cognitive biases that might in turn act as mechanisms of change. The results are being used to revise the MCT-OCD.

Mindfulness-based cognitive therapy in obsessive-compulsive disorder: protocol of a randomized controlled trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a very disabling condition with a chronic course, if left untreated. Though cognitive behavioral treatment (CBT) with or without selective serotonin reuptake inhibitors (SSRI) is the method of choice, up to one third of individuals with obsessive-compulsive disorder (OCD) do not respond to treatment in terms of at least 35% improvement of symptoms. Mindfulness based cognitive therapy (MBCT) is an 8-week group program that could help OCD patients with no or only partial response to CBT to reduce OC symptoms and develop a helpful attitude towards obsessions and compulsive urges. METHODS/DESIGN: This study is a prospective, bicentric, assessor-blinded, randomized, actively-controlled clinical trial. 128 patients with primary diagnosis of OCD according to DSM-IV and no or only partial response to CBT will be recruited from in- and outpatient services as well as online forums and the media. Patients will be randomized to either an MBCT intervention group or to a psycho-educative coaching group (OCD-EP) as an active control condition. All participants will undergo eight weekly sessions with a length of 120 minutes each of a structured group program. We hypothesize that MBCT will be superior to OCD-EP in reducing obsessive-compulsive symptoms as measured by the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) following the intervention and at 6- and 12-months-follow-up. Secondary outcome measures include depressive symptoms, quality of life, metacognitive beliefs, self-compassion, mindful awareness and approach-avoidance tendencies as measured by an approach avoidance task. DISCUSSION: The results of this study will elucidate the benefits of MBCT for OCD patients who did not sufficiently benefit from CBT. To our knowledge, this is the first randomized controlled study assessing the effects of MBCT on symptom severity and associated parameters in OCD. TRIAL REGISTRATION: German Clinical Trials Register DRKS00004525 . Registered 19 March 2013.

Interpersonal ambivalence in obsessive-compulsive disorder.

BACKGROUND: The social attitudes and interpersonal relationships of patients with obsessive-compulsive disorder (OCD) are subject to a longstanding controversy. Whereas cognitive-behavioural researchers emphasize exaggerated pro-social attitudes in OCD like inflated responsibility and worry for other people (especially significant others), dynamic theories traditionally focus on anti-social attitudes such as latent aggression and hostility. In two recent studies, we gathered support not only for a co-existence of these seemingly opposing attitudes in OCD, but also for a functional connection: inflated responsibility in part appears to serve as a coping strategy (or "defense") against negative interpersonal feelings. AIMS: In the present study, we tested a shortened version of the Responsibility and Interpersonal Behaviours and Attitudes Questionnaire (RIBAQ-R). METHOD: The scale was administered to 34 participants with OCD and 34 healthy controls. The questionnaire concurrently measures pro-social and anti-social interpersonal attitudes across three subscales. RESULTS: In line with our prior studies, patients displayed higher scores on both exaggerated pro-social attitudes (e.g. "I suffer from a strict conscience concerning my relatives") as well as latent aggression (e.g. "Sometimes I would like to harm strangers on the street") and suspiciousness/distrust (e.g. "I cannot even trust my own family"). A total of 59% of the patients but only 12% of the healthy controls showed marked interpersonal ambivalence (defined as scores higher than one standard deviation from the mean of the nonclinical controls on both the prosocial and at least one of the two anti-social subscales). CONCLUSIONS: The study asserts high interpersonal ambivalence in OCD. Further research is required to pinpoint both the dynamic and causal links between opposing interpersonal styles. Normalization and social competence training may prove beneficial to resolve the apparent problems of patients with OCD regarding anger expression and social conflict management.

A self-guided Internet-based intervention for individuals with chronic pain and depressive symptoms: study protocol of a randomized controlled trial.

BACKGROUND: Despite the existence of evidence-based therapy options for the treatment of chronic pain and comorbid depressive symptoms (e.g., CBT), many individuals remain untreated. Treatment gaps result from a lack of specialists, patient fear of stigmatization, or patient immobility. Internet-based self-help interventions could serve as an anonymous and flexible alternative treatment option. In a pilot study, chronic pain patients with comorbid depressive symptoms who used a generic Internet-based depression program showed a significant reduction in depressive symptoms (but not pain symptoms) compared to a waitlist control group. Based on these findings, we developed the low-threshold, anonymous, and cost-free Internet-based self-help intervention Lenio that is tailored to the specific needs of chronic pain patients with comorbid depressive symptoms. Lenio is accompanied by the smartphone application (app) COGITO designed to increase therapeutic success. With Lenio and COGITO addressing both chronic pain and depressive symptoms, the trial aims to increase treatment effects of online interventions for chronic pain patients by reducing both depressive symptoms and pain. METHODS: The effectiveness of the Internet-based self-help intervention and accompanying smartphone app will be evaluated in a randomized controlled trial (RCT). A total of 300 participants will be randomized into an intervention group (Lenio/COGITO), an active control group (depression-focused smartphone app), or a waitlist control group. Assessments will be done at baseline, after an 8-week intervention period (post), and after 16 weeks (follow-up). The primary outcome is the post-assessment reduction in "pain impairment" (mean value of impairment in daily life, free time, and work) as assessed by the DSF (German pain questionnaire). Secondary outcomes will include the reduction in depressive symptoms as well as in the severity of pain. DISCUSSION: Lenio is one of the first Internet-based interventions to reduce chronic pain and depression that will be empirically evaluated. Internet-based interventions could offer a promising alternative to conventional face-to-face psychotherapy in the treatment of chronic pain patients. The primary objective of the current study is to add essential insight into the feasibility, effectiveness, and acceptance of Internet-based interventions for people with chronic pain and depressive symptoms. TRIAL REGISTRATION: DRKS-ID DRKS00026722, Registered on October 6th, 2021.

Assessment of Adult ADHD in Clinical Practice: Four Letters-40 Opinions.

Objective: Despite guidelines providing detailed recommendations for the assessment of ADHD in adults and increasing clinician awareness of the persistence of ADHD into adulthood, ADHD remains under diagnosed in many countries. Method: A survey of 178 clinicians who regularly perform assessments for adult ADHD was conducted between February 2015 and 2016 to identify possible causes of underdiagnosis related to assessment practices. Results: There was a lack of consensus among clinicians regarding which symptoms are relevant to adult ADHD. Only "difficulties concentrating" was endorsed as a core feature of adult ADHD by a majority of respondents. Few clinicians used (semi-)structured interviews. Psychologists were less likely than physicians to recommend medication. Conclusion: Further clinician training on core symptoms of adult ADHD and diagnostic practices congruent with guideline recommendations may improve symptom recognition among clinicians and diagnostic accuracy. Identification of barriers to the implementation of diagnostic practices recommended by guidelines is needed.

Incorrigibility, jumping to conclusions, and decision threshold in schizophrenia.

INTRODUCTION: Previous studies confirmed a bias against disconfirmatory evidence (BADE) for both delusional and delusion-neutral events in paranoid schizophrenia. In the present study, we examined a potential relationship between the BADE and delusional ideation. METHODS: Fifty-five patients with schizophrenia (32 with current delusions), 20 patients with obsessive-compulsive disorder and 30 healthy participants were presented written scenarios composed of three successive sentences which increasingly disambiguated the situation. Participants were asked to rate interpretations presented along with the sentences. After each new sentence, participants could adjust their judgements in view of the new information. One interpretation ("true") did not seem to fit the first statement but became increasingly plausible, whereas "lure" interpretations appeared very likely initially but were eventually incorrect. Patients were given the option to decide for one of the statements. RESULTS: Patients with schizophrenia, irrespective of delusion severity, attenuated their ratings significantly less for lure interpretations in face of disconfirmatory evidence (BADE) compared to both control groups. We found no impairment regarding the integration of confirmatory evidence. Patients with schizophrenia made more incorrect decisions after the first sentence indicating jumping to conclusions relative to healthy controls. Participants with schizophrenia showed a lowered decision threshold compared to the controls. CONCLUSIONS: The findings lend further evidence to the claim that patients with schizophrenia are hastier and rather inflexible in their decision making. This response pattern may represent a trait-like vulnerability factor for the emergence of delusional incorrigibility, a hallmark symptom of schizophrenia.

Different sides of the same coin? Intercorrelations of cognitive biases in schizophrenia.

INTRODUCTION: A number of cognitive biases have been associated with delusions in schizophrenia. It is yet unresolved whether these biases are independent or represent different sides of the same coin. METHODS: A total of 56 patients with schizophrenia underwent a comprehensive cognitive battery encompassing paradigms tapping cognitive biases with special relevance to schizophrenia (e.g., jumping to conclusions, bias against disconfirmatory evidence), motivational factors (self-esteem and need for closure), and neuropsychological parameters. Psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). RESULTS: Core parameters of the cognitive bias instruments were submitted to a principal component analysis which yielded four independent components: jumping to conclusions, personalising attributional style, inflexibility, and low self-esteem. CONCLUSIONS: The study lends tentative support for the claim that candidate cognitive mechanisms for delusions only partially overlap, and thus encourage current approaches to target these biases independently via (meta)cognitive training.

Generic and illness-specific quality of life in obsessive-compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is a chronic and disabling disorder. It profoundly compromises various aspects of patients' everyday life, thus affecting their quality of life (QoL). Using generic instruments, several studies have confirmed severely impaired health-related QoL in patients diagnosed with OCD. However, there has been a dearth of research on illness-specific QoL. AIMS: The present study aimed to further investigate subjective QoL in individuals with OCD with a focus on illness-specific aspects. METHOD: To assess subjective QoL in a broad OCD sample, an internet survey was conducted with 123 participants with obsessive-compulsive symptoms. The survey comprised both a generic (WHOQOL-BREF) and a novel self-developed OCD-specific QoL measure (QoLOC). Psychopathology was determined with diagnostic standard instruments (self-report forms of: Y-BOCS, OCI-R, BDI-SF). RESULTS: Regression analyses confirmed depression as the best predictor for decreased QoL. In addition, participants reported high despair resulting from OCD-related problems that differed across symptom subtypes. An exploratory factor analysis suggested four domains of OCD-specific problems tapped by the QoLOC: (1) depressiveness in association with OCD; (2) constraints in activities due to OCD symptoms or avoidance; (3) problems with partner and/or family due to OCD symptoms or avoidance; (4) self-concept/coping of own illness. CONCLUSIONS: Results produced a comprehensive picture of QoL impairments and their relation to psychopathology in a representative OCD sample. Illness-specific concerns should be further addressed in QoL research in OCD because such problems are not sufficiently mirrored in generic QoL measures.

Session-specific effects of the Metacognitive Group Training for Obsessive-Compulsive Disorder: significant results for thought control.

The investigation of the session-specific effects is central for the understanding of psychological interventions. For the present study, we investigated the session-specific effects of the Metacognitive Group Training for Obsessive-Compulsive Disorder (MCT-OCD), which was revised based on data of a pilot study. Thirty-four outpatients with OCD participated in the MCT-OCD once a week over 8 weeks. Different metacognitive beliefs (e.g., thought control) and cognitive beliefs (e.g., intolerance of uncertainty), OC symptoms, as well as associated comorbid symptoms were assessed before and after each session. Linear mixed effects models showed that patients' obsessions and compulsions, thought control, the belief of being well informed about the disorder, and action fusion improved over the course of the training. The only session-specific effect emerged for thought control, which improved immediately after the respective module. We were able to replicate the findings of the pilot study and thus corroborate the session-specific effect of the module targeting thought control. Moreover, we generated information on the mode of action of the individual modules of the MCT-OCD that allows a more in-depth evaluation of the intervention. Notably, we were able to eliminate the adverse effects of the pilot version of the MCT-OCD.Trial Registration: German Clinical Trials Register (Deutsches Register Klinischer Studien [DRKS]; DRKS-ID: DRKS00013539; registration date: 22/02/2018).

Long-term effects of mindfulness-based cognitive therapy in patients with obsessive-compulsive disorder and residual symptoms after cognitive behavioral therapy: Twelve-month follow-up of a randomized controlled trial.

We examined the long-term efficacy of mindfulness-based cognitive therapy (MBCT) compared to a psychoeducation group as an active control condition in patients with obsessive-compulsive disorder (OCD) with residual symptoms of OCD after cognitive behavioral therapy. A total of 125 patients were included in a bicentric, interviewer-blind, randomized, and actively controlled trial and were assigned to either an MBCT group (n = 61) or a psychoeducation group (n = 64). Patients' demographic characteristics and the results from our previous assessments have already been reported (Külz et al., 2019). At the 12-month follow-up the completion rate was 80%. OCD symptoms were reduced from baseline to follow-up assessment with a large effect, but no difference was found between groups. Exploratory analyses showed that a composite score of time occupied by obsessive thoughts, distress associated with obsessive thoughts, and interference due to obsessive thoughts differed between groups in the per-protocol analysis, with a stronger reduction in the MBCT group. At the 12-month follow-up, the two groups showed a similar reduction of symptoms. However, preliminary evidence indicates that MBCT has a superior effect on some aspects of OCD. This should be replicated in future studies.

No evidence for object alternation impairment in obsessive-compulsive disorder (OCD).

Recent neuroimaging studies have consistently ascribed the orbito-frontal cortex (OFC) a pivotal role in the pathogenesis of obsessive-compulsive disorder (OCD). Cognitive tests presumed sensitive to this region, such as the Object Alternation Task (OAT), are considered important tools to verify this assumption and to investigate the impact of cortical dysfunction on behavior. The aim of the present study was to assess if patients with OCD show enhanced perseveration errors on the OAT relative to healthy controls taking into account several potential moderators, especially comorbid depression and OCD subtype. Thirty-five OCD patients and 18 healthy controls underwent the OAT as well as the Trail-Making Tests (TMT) A and B. In line with prior studies, OCD patients were slowed on both TMT tasks. In contrast, samples performed similarly on the OAT. While the latter finding does not invalidate the assumption that the OFC is affected in OCD, dysfunctions involving this region may be more subtle than often claimed and likely encompass only a small subset of functional domains hosted in the OFC.

Perseveration and not strategic deficits underlie delayed alternation impairment in obsessive-compulsive disorder (OCD).

The claim that the prefrontal cortex, particularly its orbito-frontal part, is involved in obsessive-compulsive disorder (OCD) is based upon evidence from neuroimaging as well as behavioral studies. Studies have repeatedly suggested problems with delayed alternation learning in OCD, an executive dysfunction that presumably involves the orbito-frontal cortex. However, it is unclear whether such impairment stems from perseveration or strategic deficits as these aspects are intertwined in the original task. In the present study, 36 OCD and 16 healthy controls underwent a variant of the delayed alternation task involving three response options instead of two as in the original task. This modification enabled us to separate perseveration errors (i.e., the participant incorrectly chooses the same response option as before) from shift errors (i.e., the decision is switched to an incorrect response alternative). We found that patients with OCD committed significantly more perseveration errors following previously valid response options, whereas perseveration for previously invalid responses and shift errors did not distinguish groups. Group differences were not accounted for by comorbid depression and may be linked to the pathogenesis of OCD.

Imaginal retraining reduces alcohol craving in problem drinkers: A randomized controlled trial.

BACKGROUND AND OBJECTIVES: Retraining, a psychological intervention derived from the approach-avoidance paradigm, has yielded mixed results for the treatment of alcohol use disorder as well as other forms of addiction. The present study investigated the efficacy of an imaginal variant of retraining that allowed greater personalization of the content. METHODS: Within the framework of a randomized controlled trial (RCT), 84 individuals with self-reported alcohol-related problems were recruited over the Internet and allocated to either imaginal retraining (treatment manual dispatched as a pdf-file via email) or a wait-list control group (with care-as-usual). The intervention period was four weeks. Alcohol craving, as measured with a visual analogue scale (VAS), served as the primary outcome. Other emotional (e.g. self-esteem) and drinking-related variables served as secondary outcomes. RESULTS: Both per-protocol (PP) and intention-to-treat (ITT) analyses showed that imaginal retraining led to a significant reduction in alcohol craving compared to the control group at a large effect size. Self-esteem improved in the retraining condition relative to controls in the PP and one of the ITT analyses; 75% of the individuals in the treatment group reported less alcohol consumption in the treatment period, whereas drinking behavior remained essentially unchanged in the control group (p < .001) (the trial was registered at the German Clinical Trials Register, DRKS00015319). LIMITATIONS: Whether the effects of imaginal retraining are sustained over time needs to be established. Attrition was significantly higher in the retraining group (40.5%) than in the control group (16.7%). Designs with an active control condition are needed as well as dismantling studies to explore which of the treatment's multiple components best predicts improvement. Future studies should verify participants' alcohol consumption levels using objective measures. CONCLUSION: Imaginal retraining led to significant effects on the reduction of alcohol craving.

"Association splitting" versus cognitive remediation in obsessive-compulsive disorder: A randomized controlled trial.

Studies have confirmed the efficacy of the cognitive intervention Association Splitting (AS) in obsessive-compulsive disorder (OCD) when applied as a self-help technique. AS aims to alter symptom-provoking automated cognitive networks of OC-related stimuli by building new or strengthening established but weak neutral associations. The aim of this study was to investigate the acceptance and benefits of therapist-assisted AS as an add-on to cognitive behavioral therapy (CBT). One hundred and nine patients with OCD who were undergoing CBT were randomly assigned to either AS or cognitive remediation (CR). Both groups were assessed at baseline, 4 weeks and 6 months later. The primary measure was the Yale-Brown Obsessive Compulsive Scale. Although patients' acceptance of AS was good, AS was not better than CR regarding overall symptom severity. However, a larger decrease was found from baseline to 6 months follow-up in AS regarding avoidance. Moreover, subsidiary analyses excluding control patients who had obtained information about AS indicated its superiority. Because superiority of AS was found in post hoc analyses excluding control patients who had obtained information on AS, we suggest that contagion effects deserve consideration.

We cannot change the past, but we can change its meaning. A randomized controlled trial on the effects of self-help imagery rescripting on depression.

BACKGROUND: Imagery rescripting is a psychotherapeutic technique that aims to ameliorate negative emotions by altering (i.e., rescripting) inner representations of negative memories and images. Although the treatment was initially developed for traumatized individuals, face-to-face interventions have yielded promising results for patients with other diagnoses as well. The present study explored the feasibility and efficacy of the approach when used as a self-help intervention for depression. METHOD: A total of 127 individuals with diagnosed depression were randomly allocated to either a wait-list control condition or received a brief or long version of a manual teaching imagery rescripting. Six weeks after inclusion, patients were invited to participate in the post assessment. The Beck Depression Inventory (BDI-II) served as the primary outcome (registered at ClinicalTrials.gov (NCT03299127). RESULTS: The long version was superior to the wait-list control condition on the BDI-II, self-esteem, and quality of life at a medium effect size. No effects emerged for anxiety. No significant between-group differences were found for the brief version. Moderation analyses indicated that the self-help approach seems particularly beneficial for those scoring high on symptoms, willingness to change, and expectancy (baseline). Most patients indicated they would use the technique in the future. DISCUSSION: The efficacy of imagery rescripting was confirmed when applied via self-help. Use of the long form of the manual is recommended. Future studies are needed to ascertain whether treatment effects are sustained over time.

Association Splitting: A randomized controlled trial of a new method to reduce craving among inpatients with alcohol dependence.

Association Splitting, a novel cognitive intervention, was tested in patients with alcohol dependence as an add-on intervention in an initial randomized controlled trial. Preliminary support for Association Splitting has been found in patients with obsessive-compulsive disorder, as well as in an online pilot study of patients with alcohol use disorders. The present variant sought to reduce craving by strengthening neutral associations with alcohol-related stimuli, thus, altering cognitive networks. Eighty-four inpatients with verified diagnoses of alcohol dependence, who were currently undergoing inpatient treatment, were randomly assigned to Association Splitting or Exercise Therapy. Craving was measured at baseline, 4-week follow-up, and six months later with the Obsessive-Compulsive Drinking Scale (primary outcome) and the Alcohol Craving Questionnaire. There was no advantage for Association Splitting after three treatment sessions relative to Exercise Therapy. Among Association Splitting participants, 51.9% endorsed a subjective decline in craving and 88.9% indicated that they would use Association Splitting in the future. Despite high acceptance, an additional benefit of Association Splitting beyond standard inpatient treatment was not found. Given that participants were concurrently undergoing inpatient treatment and Association Splitting has previously shown moderate effects, modification of the study design may improve the potential to detect significant effects in future trials.

Further evidence for biased semantic networks in obsessive-compulsive disorder (OCD): when knives are no longer associated with buttering bread but only with stabbing people.

BACKGROUND AND OBJECTIVES: Semantic network models suggest that individuals with obsessive-compulsive disorder (OCD) process words with multiple meanings (e.g., "knife") more likely in an OC-related (i.e., "weapon") than in a neutral way (i.e., "cutlery"). Initial evidence was found in an online study. The aim of the current study was to investigate semantic networks in a clinical OCD sample and particularly to identify whether changes in semantic networks following the add-on intervention association splitting (AS) exceeded changes expected through cognitive behavioral therapy (CBT) alone. METHODS: An association task was presented to 36 healthy controls and 70 OCD patients over a period of eight weeks with OCD patients receiving CBT and an add-on intervention (randomized allocation to either AS or a computerized cognitive training). Participants were asked to generate up to five associations to standardized (OC-relevant, negative, neutral) and individual cue words. Associations were rated with regard to OC-relevance and valence. RESULTS: Analyses revealed that OCD participants produced a) significantly more OC-relevant associations and b) more negative associations than controls for cue words. In the OCD sample, the OC-relevance and valence of associations changed after therapy for personal cue words. This effect was associated with AS at statistical trend level. LIMITATIONS: No clinical control group was recruited; no inter-rater reliability was assessed for the association task. CONCLUSIONS: Further evidence for biased associative networks in OCD was found. Associations of individually chosen cue words proved to be modifiable by therapy.