Exploring Temporal Relationships Between Anxiety, Mood and Mental Imagery in Patients With Bipolar Disorder: A Network Analysis.

INTRODUCTION: Bipolar disorder is a severe mental health problem with limited treatment success. There is a call for improving interventions, requiring an increased understanding of factors driving mood instability. One promising avenue is to study temporal associations between factors that appear relevant according to the emotional amplifier model of Holmes are changes in mood, anxiety and mental imagery. METHODS: The current study used data from a recent RCT for a secondary analysis which applied a network analysis approach to explore temporal associations between weekly measurements of mania, depression, anxiety and mental imagery measured during 32 weeks in two randomised groups (N = 55) receiving either imagery-focused cognitive therapy (ImCT) or group psychoeducation (PE). RESULTS: Both negative intrusive mental imagery and anxiety appeared central in the network analyses, driving changes in both mania and depression, but only in the PE group. In the ImCT group, only anxiety was driving changes in mania and depression. CONCLUSION: Although exploratory, findings suggest that prior increases in anxiety and negative intrusive mental imagery might be associated with subsequent increases in depression and mania symptoms in patients with bipolar disorder. Anxiety might in turn increase negative intrusive imagery and associated negative emotions. Although more research is needed, results are in line with the emotional amplifier model and stress that future interventions with a focus on anxiety and imagery might help to improve psychosocial therapies for patients with bipolar disorder. In addition, this study suggests that a network approach is a helpful and feasible way to study mood instability, anxiety and mental imagery to increase our understanding of mechanisms underpinning mood instability.

Exploring aspects of self-reported emotional mental imagery in patients with bipolar disorder.

BACKGROUND AND OBJECTIVES: CBT for patients with bipolar disorder has modest effects. Across disorders, mental imagery has been used to update CBT to increase effectiveness. In order to enhance CBT for bipolar disorder with imagery techniques, research is needed into emotional imagery quality and, related appraisals of imagery and their relationships with mood instability and subsequent behaviour in bipolar disorder. METHODS: Patients with bipolar disorder (n = 106), unipolar depression (n = 51), creative imagery prone participants (n = 53) and participants without a history of a mood disorder (n = 135) completed the Dutch Imagery Survey (DImS), an online imagery survey, adapted from the Imagery Interview, assessing self-reported emotional imagery aspects. Imagery quality, appraisals and their self-perceived effects on emotion and behaviour were compared between groups. As unexpected differences within the bipolar group appeared, these were additionally explored. RESULTS: Imagery appraisals but not imagery quality discriminated between the patient groups and non-patient groups Imagery was perceived as an emotional amplifier in all groups, but this was specifically apparent in bipolar manic and bipolar depressed groups. Only in the bipolar group imagery was experienced to amplify behavioural tendencies. LIMITATIONS: Results need to be replicated using a larger sample of patients with BD who are currently manic or depressed. CONCLUSIONS: Not only quality of imagery, but especially appraisals associated with imagery are differentiating between imagery prone people with and without mood disorder. Imagery amplifies emotion in all groups, but only in those patients with bipolar disorder currently manic or depressed did this influence behaviour.

Comparing the effectiveness of imagery focussed cognitive therapy to group psychoeducation for patients with bipolar disorder: A randomised trial.

BACKGROUND: Bipolar disorder is a severe, chronic mental disorder. Treatment options are limited, with pharmacological approaches continuing to dominate. However, relapse rates remain high. Several adjunctive psychosocial interventions, mostly psychoeducation (PE) and cognitive behavioural therapy (CBT), have been trialled, but treatment innovation is still needed. In the past, brief group PE has proven as beneficial as longer individual CBT in reducing levels of depression and increasing self-management strategies. We compared the relative effectiveness of group PE to an imagery focussed cognitive behavioural therapy (ImCT). STUDY DESIGN: This was a randomised parallel group study with both daily and weekly measures. A total of 62 adult patients were randomly allocated to either ImCT or group PE. Daily, weekly and pre-and post-intervention measures were used to assess impact on (i) mood instability, (ii) overall levels of depression, anxiety and mania, and (iii) general functioning, hopelessness and imagery characteristics. A four-week baseline and 16-week follow-up period were included. RESULTS: Mood instability reduced in both conditions after intervention. Levels of mania, depression and anxiety also reduced in both conditions, but on the daily measures, depression and anxiety significantly more so in the ImCT condition. Compared with the PE condition, the ImCT condition additionally showed increased level of functioning, reduced hopelessness, and a decrease in intrusive, problematic imagery. LIMITATIONS: These findings need to be replicated in a larger trial. CONCLUSIONS: Findings suggest that ImCT is a promising new avenue for management of bipolar disorder, an area in which treatment development is urgently needed.

[Treatment of anxiety disorders in the elderly]. / Behandeling van angststoornissen bij ouderen.

AIM: To collect empirical evidence concerning the effectiveness of the treatment of anxiety disorders in the elderly. METHOD: Meta-analysis and randomised controlled trials. RESULTS: Meta-analysis showed that cognitive behavioural therapy (CBT) was more successful than waiting-list control or active control as a treatment for older persons with anxiety disorders. In a direct comparison of the treatment of older persons with panic disorder (PD) both CBT an paroxetine were found to be more effective than waiting-list control. CBT was more successful in reducing avoidance behaviours in older persons with PD. Older persons with reported fewer and less severe agoraphobic cognitions than younger patients, but there was no difference between the severity of agoraphobic avoidance in older patients with PD and younger patients with PD. CONCLUSION: There is sufficient empirical evidence to support the effectiveness of CBT in the treatment of older persons with anxiety disorders. In assessing the severity of PD in the elderly, one should carefully consider the severity of avoidance behaviours. Because no difference was found between the effectiveness of CBT and paroxetine for the treatment of PD in the elderly and because was more effective in reducing avoidance behaviours in older patients with PD than in younger patients with pd, there seems to be a slight preference for CBT in the case of older patients with PD. Older age is not associated with a poorer outcome of treatment with CBT.

A randomized controlled study of paroxetine and cognitive-behavioural therapy for late-life panic disorder.

OBJECTIVE: To examine the effectiveness of paroxetine and cognitive-behavioural therapy (CBT) in elderly patients suffering from panic disorder with or without agoraphobia (PD(A)). METHOD: Forty-nine patients aged 60+ years with confirmed PD(A) were randomly assigned to 40 mg paroxetine, individual CBT, or to a 14-week waiting list. Outcomes, with avoidance behaviour and agoraphobic cognitions being the primary measures, were assessed at baseline and at weeks 8, 14 (conclusion CBT/waiting list), and at week 26 (treated patients only) and analysed using mixed models. RESULTS: All outcome measures showed that the patients having received CBT and those treated with paroxetine had significantly better improvement compared with those in the waiting-list condition. With one patient (1/20, 5%) in the CBT and three (3/14, 17.6%) in the paroxetine condition dropping out, attrition rates were low. CONCLUSION: Patients with late-life panic disorder respond well to both paroxetine and CBT. Although promising, the outcomes warrant replication in larger study groups.

Image qualities and mood variability: Evaluating the utility of an imagery survey for bipolar disorder.

OBJECTIVE: Imagery appears to play an important role in mood variability, a core symptom of patients suffering from bipolar disorder. The present study aimed to explore the validity and reliability of an online self-report measure of imagery, the Dutch Imagery Survey (DImS). The DImS is an adaptation of the Imagery interview used in research on imagery in mental disorders. The present study additionally explored the ability of the DImS to detect relationships between self-reported imagery and subsequent mood and subsequent behaviour. METHOD: 135 students completed the DImS and additional mental imagery and mood questionnaires. For re-test reliability, 42 students completed the survey again within two days. RESULTS: Internal consistencies and test-retest scores of the five scales of the DImS were reasonable. Imagery Quality correlated with Emotions, and to a lesser degree with Behaviour. Positive Appraisals correlated with Positive Emotions, Negative Appraisals with Negative Emotions, and Positive appraisals with Behaviour. Frequency of Imagery, Imagery Quality and Positive Appraisals correlated with elevated mood. Imagery Quality and Negative Appraisals correlated with low mood. The DImS took approximately 15 min to complete. LIMITATIONS: Re-test reliability was limited due to participants changing their dominant image. Results need to be replicated in a clinical sample. CONCLUSIONS: Psychometric findings with the DImS appeared reasonable and consistent and showed that, in line with other recent studies, imagery is related to current mood and to both self-perceived emotion and subsequent behaviour. These findings suggested that the DImS is suitable to study the role of imagery in bipolar mood variability.

Cognitive-behavioural therapy for late-life anxiety disorders: a systematic review and meta-analysis.

OBJECTIVE: To examine and estimate the efficacy of cognitive-behavioural therapy (CBT) for late-life anxiety disorders. METHOD: A systematic review and meta-analysis of randomized controlled trials comparing CBT with i) a waiting-list control condition and ii) an active control condition controlling for non-specific effects in patients aged over 60 years and suffering from an anxiety disorder. The main outcome parameter of individual studies, i.e. effect on anxiety, was pooled using the standardized mean difference (SMD). RESULTS: Seven papers fulfilled the inclusion criteria, including nine randomized controlled comparisons for 297 patients. Anxiety symptoms were significantly more reduced following CBT than after either a waiting-list control condition [SMD = -0.44 (95 CI: -0.84 -0.04), P = 0.03] or an active control condition [SMD = -0.51 (95 CI: -0.81, -0.21), P<0.001]. Additionally, CBT significantly alleviated accompanying symptoms of worrying and depression. CONCLUSION: Cognitive-behavioural therapy is efficacious for the treatment of late-life anxiety disorders.

[Treatment of obsessive-compulsive disorder in older patients - case studies]. / Behandeling van ouderen met een obsessievecompulsieve stoornis.

BACKGROUND: Five patients aged 64 to 74 years with obsessive-compulsive disorder were treated successfully, one with cognitive behavioural therapy and four with a combination of antidepressants and cognitive behavioural therapy. The current multidisciplinary guidelines on anxiety treatment, which cover the age-range 18 to 65 years, are a good starting point for the treatment of obsessive compulsive disorder in older patients.

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout.

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.

Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine.

OBJECTIVE: Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behaviour therapy (CBT) have both proven to be effective in the treatment of obsessive compulsive disorder (OCD). It is generally recommended that adequate but unsuccessful SSRI treatment is supplemented with CBT, although only one empirical study was conducted to verify this recommendation. The present study examined the effects of supplemental CBT to continued fluoxetine treatment in OCD patients non-responding to fluoxetine alone. METHOD: After 12 weeks of fluoxetine, 14 of 56 out-patients had a reduction rate less than 25% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and were classified as non-responders. They subsequently received 12 sessions CBT additional to the continued fluoxetine treatment. RESULTS: The mean symptom reduction as rated by the Y-BOCS, for the patients who completed both treatment phases, was 8.5% in the first phase and 41% in the second phase. CONCLUSION: Supplemental CBT for OCD patients, after initial, unsuccessful fluoxetine treatment is shown to be effective.