Nightmare Disorder, Psychopathology Levels, and Coping in a Diverse Psychiatric Sample.

OBJECTIVE: Nightmares are associated with psychopathology and impaired coping in the general population. However, little is known about this association in a psychiatric population. In this study, we investigate whether patients with diverse psychiatric disorders have increased symptomatology and different coping styles if they suffer from comorbid nightmare disorder. METHOD: Participants were 498 patients with diverse moderate to severe psychiatric disorders. As part of a standard assessment procedure, they filled out questionnaires regarding nightmares, psychopathology, personality pathology, and coping. RESULTS: A multivariate analysis of covariance and post hoc tests showed that patients with nightmare disorder scored higher on psychopathology (ηp2 = .03; p = .001) and personality pathology (ηp2 = .01-.03; p < .05). No significant differences were found with regards to coping strategies. CONCLUSION: Nightmare disorder is associated with higher levels of psychopathology and personality pathology in a sample of patients with diverse psychiatric disorders.

Adaptive and maladaptive rumination after loss: A three-wave longitudinal study.

OBJECTIVES: Rumination is a risk factor after bereavement, predicting higher concurrent and prospective symptom levels of complicated grief and depression in mourners. Research has shown that rumination may consist of adaptive and maladaptive subtypes, but there has been a paucity of research in this topic in the bereavement area. Therefore, we aimed to clarify whether functional and dysfunctional forms of rumination can be distinguished after loss. DESIGN: Two-hundred and forty-two adults, who lost a first-degree family member on average 10 months previously, filled out questionnaires at three time points with 6 months between each time point. METHODS: Multiple regression analyses, controlled for loss-related variables, neuroticism, and baseline symptoms, were run to examine associations of subtypes of depressive rumination (brooding, reflection) and grief rumination (rumination about injustice, meaning, reactions, relationships and counterfactual thinking) with concurrent and prospective symptom levels of complicated grief and depression. RESULTS: Overall, grief rumination explained more variance in symptom levels than depressive rumination. Other major findings were that grief rumination about injustice predicted higher concurrent and prospective symptom levels of complicated grief and higher prospective symptom levels of depression. In contrast, grief rumination about emotional reactions was related to prospective reductions in symptoms of complicated grief. Reflection was also associated with prospective reductions of complicated grief and depressive symptom levels. CONCLUSIONS: Results indicate that adaptive and maladaptive forms of ruminative thinking can be distinguished in bereaved individuals. Therapeutic interventions for complicated grief could potentially be improved by including techniques aimed at reducing maladaptive rumination and increasing adaptive rumination. PRACTITIONER POINTS: Clinical implications: Adaptive and maladaptive components of rumination after loss can be distinguished. They are differentially associated with concurrent and prospective symptom levels of complicated grief and depression in mourners. Adaptive rumination after bereavement is characterized by repetitive, self-focused thinking aimed at understanding one's depressive and loss-related emotional reactions. Maladaptive rumination is characterized by repetitive, self-focused thinking about injustice to the self and making passive comparisons between the current situation (in which one has experienced a loss) and unrealized alternatives. Psychological interventions for complicated grief may be improved by adding therapeutic techniques aimed at reducing maladaptive rumination and increasing adaptive rumination. Cautions and limitations: This investigation relied exclusively on self-report measures. Conjugally bereaved women were overrepresented in the current sample. Complicated grief and depression levels in the current sample ranged from non-clinical to clinical. Effects may be more pronounced in a clinical sample.

Partner-oriented self-regulation among bereaved parents: the costs of holding in grief for the partner's sake.

Bereavement research has focused on individual rather than interdependent processes in coping with loss. Yet bereavement takes place in a social context, and relationship partners are likely to influence each other's grieving process. We examined the impact of a dynamic, interpersonal phenomenon, partner-oriented self-regulation (POSR): the avoidance of talking about loss and remaining strong in the partner's presence to protect the partner. Two hundred nineteen couples who had lost a child participated 6, 13, and 20 months after their loss. Consistent with predictions, results showed that one partner's POSR was associated not only with an increase in his or her own grief, but also with an increase in the other partner's grief. These relationships persisted over time: Self-reported and partner-reported POSR predicted later grief. These results are paradoxical: Although parents try to protect their partners through POSR, this effort has the opposite of the desired outcome. These findings underline the importance of further investigating interpersonal dynamics of coping with bereavement.

Baseline depression levels do not affect efficacy of cognitive-behavioral self-help treatment for insomnia.

BACKGROUND: Cognitive-behavioral therapy can effectively treat insomnia (CBT-I). Randomized controlled trials have shown efficacy of self-help CBT-I, but unclear is whether excluding depressive patients boosted treatment effects. METHOD: We administered unsupported self-help CBT-I to insomnia patients with low and high depression levels. Based on the validated Centre of Epidemiological Studies-Depression (CES-D) scale, the internet-recruited sample (N = 479) was divided into three groups: low depression scores (n = 198), mild depression scores (n = 182), and high depression scores (n = 99). Follow-ups were 4 and 18 weeks after completion of the treatment. RESULTS: At 4-week follow-up, all groups had a similar amelioration on the primary sleep measures (d = 0.1-0.7; P < 0.05) and the secondary insomnia ratings (d = 1.2; P < 0.001). The only difference was that the high/mild depression groups had a steeper reduction in depression (d = 1.0-1.1; P < 0.001) and anxiety scores (d = 0.7-0.8; P < 0.001) than the low depression group (depression and anxiety: d = 0.3; P < 0.01), possibly due to floor effects in the latter group. The observed effects were sustained at the 18-week follow-up. CONCLUSIONS: This study showed that CBT-I is effective regardless of baseline depression levels. Treating the combination of insomnia and depression is an extra challenge since it is associated with increased sleep problems. These data may help us understand the relationship between insomnia and depression and indicate that self-help CBT-I may be a promising addition to regular depression treatment.

Long-term effectiveness of cognitive-behavioural self-help intervention for nightmares.

Nightmares are a prevalent disorder leading to daily impairments. Two cognitive-behavioural self-help interventions--imagery rehearsal and exposure--recently showed short-term efficacy compared to a waiting-list and a group that recorded their nightmares. This paper reports the long-term results of the imagery rehearsal (n=103) and exposure (n=95) interventions. Participants were assigned randomly to a condition after completing baseline measurements; they received a 6-week self-help intervention and completed questionnaires 4, 16 and 42 weeks after end of treatment. Initial effects on nightmare measures were almost completely sustained after 42 weeks (d=0.50-0.70); no differences were found between exposure and imagery rehearsal therapy. These results suggest that nightmares should be targeted specifically and that an internet-delivered self-help intervention seems to be a good first option in a stepped-care model.

Factors associated with outcome of cognitive-behavioural therapy for complicated grief: a preliminary study.

Complicated grief (CG), also called prolonged grief disorder, is a debilitating condition that can develop following a loss. There is growing evidence that cognitive-behavioural interventions are efficacious in the treatment of CG. The present preliminary study used data from 43 patients with CG who were randomly assigned to cognitive-behavioural therapy in an earlier treatment trial to explore (a) predictors of outcome of cognitive-behavioural therapy for CG and (b) the relationship between symptom improvement and changes in loss-related negative cognitions and avoidance behaviours. Analyses showed that worse treatment outcome was associated with lower education attainment, loss of a partner/child (instead of some other relative), early treatment discontinuation, less patient motivation and more severe CG symptoms at pre-treatment. As predicted, stronger reduction in CG severity was significantly associated with stronger reductions in negative cognitions and avoidance. Implications of these findings are discussed.

Cognitive-behavioral self-help treatment for nightmares: a randomized controlled trial.

BACKGROUND: Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary)--in a self-help format--with a waiting list. METHODS: Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline. RESULTS: Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25-0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20-0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19-0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording. CONCLUSIONS: IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.

A prospective examination of catastrophic misinterpretations and experiential avoidance in emotional distress following loss.

This prospective study examined the role of experiential avoidance and catastrophic misinterpretations of grief reactions in emotional distress following the death of a loved one. Eighty-two bereaved individuals completed measures of experiential avoidance, catastrophic misinterpretations, and symptom of prolonged grief disorder (PGD) and depression within the first half year of bereavement, and again completed measures assessing PGD and depression severity 1 year later. The findings showed that experiential avoidance was significantly correlated with endorsement of catastrophic misinterpretations of grief reactions. In addition, both constructs were correlated with concurrent and prospective symptom levels of PGD and depression. However, the associations between experiential avoidance and symptom levels were no longer significant, when controlling for catastrophic misinterpretations of grief reactions. Moreover, catastrophic misinterpretations but not experiential avoidance predicted PGD severity at follow-up, beyond baseline levels of PGD. Both constructs did not predict later depression beyond baseline depression. Theoretical and clinical implications of these findings are discussed.

Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months.

OBJECTIVE: We studied psychological outcomes and predictors for adverse outcome in 147 women 4, 8, and 16 months after termination of pregnancy for fetal anomaly. STUDY DESIGN: We conducted a longitudinal study with validated self-completed questionnaires. RESULTS: Four months after termination 46% of women showed pathological levels of posttraumatic stress symptoms, decreasing to 20.5% after 16 months. As to depression, these figures were 28% and 13%, respectively. Late onset of problematic adaptation did not occur frequently. Outcome at 4 months was the most important predictor of persistent impaired psychological outcome. Other predictors were low self-efficacy, high level of doubt during decision making, lack of partner support, being religious, and advanced gestational age. Strong feelings of regret for the decision were mentioned by 2.7% of women. CONCLUSION: Termination of pregnancy for fetal anomaly has significant psychological consequences for 20% of women up to > 1 year. Only few women mention feelings of regret.

Distress in couples approached for genetic counseling and BRCA1/2 testing during adjuvant radiotherapy.

OBJECTIVE: Breast cancer patients mostly rely on their partners for support in dealing with their cancer diagnosis and treatment. Genetic counseling and BRCA1/2 testing during primary treatment may add to demands made on their partners. This study aimed to gain insight into the extent of psychological distress in partners of recently diagnosed patients and to find factors to help identify couples vulnerable to high psychological distress after an active approach for genetic counseling. METHODS: Breast cancer patients and their partners (n=110) completed psychological distress measures (HADS and IES) prior to the approach for counseling (T0), after the approach (T1), and after leaving the genetic counseling protocol (T2). Couples not approached for counseling (n=85) completed similar questionnaires. RESULTS: Partners reported an equal or lower level of distress than patients, with a positive correlation between the two, although partners and patients differed in the course of their distress. Couples approached for genetic counseling did not differ in the level or course of either distress measure from not approached couples. A high baseline distress best predicts long-term high distress in patients and their partners. Younger patients were found to be particularly vulnerable. CONCLUSIONS: The approach for genetic counseling during adjuvant radiotherapy was not associated with extra psychological distress in partners or patients in the first year following the breast cancer diagnosis. A partner's long-term level of distress was significantly associated with that of the patient. Highly distressed patients with highly distressed partners were most likely to experience high distress in the long term.

Complicated grief and uncomplicated grief are distinguishable constructs.

With data from 242 mourners who received help post-loss and were at least 6 months removed from their loss, it was found that symptoms proposed as denoting complicated grief (CG) are distinguishable from reactions representing uncomplicated grief (UG). With data from a subgroup of 130 mourners, CG but not UG was found to relate to concurrent distress and disability.

Parents grieving the loss of their child: interdependence in coping.

OBJECTIVES: A longitudinal study was conducted among bereaved parents, to examine the relationship between parents' own and their partners' ways of coping in terms of the constructs loss-orientation and restoration-orientation (coping strategies based on the bereavement-specific Dual Process Model (Stroebe & Schut, 1999)), and psychological adjustment following the death of their child. METHOD: 219 couples participated at 6, 13 and 20 months post-loss. Use of the Actor Partner Interdependence Model within multi-level regression analyses enabled assessment of both actor as well as partner effects, and permitted differentiating these effects according to the gender of the parent. RESULTS: Loss-orientation was predictive of negative psychological adjustment, while restoration-orientation was related to better adjustment. Furthermore, high levels of restoration-oriented coping buffered the negative effect of high levels of loss-orientation on depression. In the interpersonal context, results indicated that for men, having a female partner high in restoration-oriented coping was related to positive adjustment. CONCLUSION: In coping with the loss of their child, intra-personal as well as interpersonal processes are relevant for the adjustment process of parents after the loss of their child.

The factor structure of Posttraumatic Stress Disorder symptoms among bereaved individuals: a confirmatory factor analysis study.

Posttraumatic Stress Disorder (PTSD) is defined in DSM-IV as an anxiety disorder that encompasses symptom-clusters of reexperiencing, avoidance, and hyperarousal. Several studies have examined the factor structure of PTSD symptoms. To our knowledge, no studies have yet examined the factor structure of loss-related PTSD symptoms in samples exclusively comprised of bereaved individuals. Such an examination is important because it can advance our understanding of the stability of the structure of PTSD symptoms across groups confronted with different aversive life-events and of processes underlying the occurrence of PTSD symptoms after loss. In this study, five alternative models of the factor structure of PTSD symptoms were examined in a sample of 347 mourners. Results showed that, in this group, PTSD symptoms are best conceptualized as forming four factors: reexperiencing, avoidance, dysphoria, and hyperarousal. Patterns of correlations with depression and complicated grief supported the validity of the model.

Cost-utility of a visiting service for older widowed individuals: randomised trial.

BACKGROUND: Despite a growing understanding of the effectiveness of bereavement interventions and the groups that benefit most from them, we know little about the cost-effectiveness of bereavement interventions. METHODS: We conducted a cost-utility analysis alongside a randomized clinical trial on a visiting service for older widowed individuals (n=110) versus care as usual (CAU; n=106). The visiting service is a selective bereavement intervention that offers social support to lonely widows and widowers by a trained volunteer. Participants were contacted 6-9 months post-loss. Eleven percent of all contacted persons responded and eight percent participated in the trial. The primary outcome measure was quality adjusted life years (QALYs) gained (assessed with the EQ-5D), which is a generic measure of health status. Costs were calculated from a societal perspective excluding costs arising from productivity losses. Using the bootstrap method, we obtained the incremental cost utility ratio (ICUR), projected these on a cost-utility plane and presented as an acceptability curve. RESULTS: Overall, the experimental group demonstrated slightly better results against slightly higher costs. Whether the visiting service is acceptable depends on the willingness to pay: at a willingness to pay equal to zero per QALY gained, the visiting service has a probability of 31% of being acceptable; beyond euro20,000, the visiting service has a probability of 70% of being more acceptable than CAU. CONCLUSION: Selective bereavement interventions like the visiting service will not produce large benefits from the health economic point of view, when targeted towards the entire population of all widowed individuals. We recommend that in depth analyses are conducted to identify who benefits most from this kind of interventions, and in what subgroups the incremental cost-utility is best. In the future bereavement interventions are then best directed to these groups. TRIAL REGISTRATION: Controlled trials ISRCTN17508307.

Barriers to participating in genetic counseling and BRCA testing during primary treatment for breast cancer.

PURPOSE: Little is known about reasons why eligible breast cancer patients decline BRCA mutation testing. They may withdraw at different stages during genetic counseling for different reasons. We prospectively studied perceived benefits and barriers to genetic counseling and BRCA testing in 102 newly diagnosed breast cancer patients approached for genetic counseling at the start of radiotherapy. METHODS: Patients completed questionnaires and participated in interviews at different stages of the counseling protocol. RESULTS: Participation was not influenced by distress, knowledge about hereditary breast cancer, previous genetic testing in relatives, or perceived risks and barriers. Immediate decliners (n = 23) do not believe genetic testing is relevant for them. Patients who decline after pedigree compilation (n = 14) are more hesitant and anxious about the influence of the test result on their future often wishing to postpone further testing. Late decliners (n = 7) withdraw afraid of the test result and/or after a relative's objection. These decliners are not easily identified upon approach because they are similar to patients who receive a DNA test result (n = 58). Notwithstanding their decline, 81% agreed to the timing or would have preferred an earlier approach for genetic counseling. CONCLUSION: Decliners may make more informed decisions after tailored health education, including adequate risk information.

Maternal decision to terminate pregnancy in case of Down syndrome.

OBJECTIVE: This study explores decisional processes regarding termination of pregnancy because of Down syndrome and aims to identify possibilities for improving counseling. STUDY DESIGN: Seventy-one women completed questionnaires 4 months after termination of pregnancy for Down syndrome, including motivations for the decision, reasons for doubt, perceived influence and/or pressure at decision-making, and satisfaction with the received health care. RESULTS: Child-related motivations to the termination were the most frequently mentioned, but almost all women indicated also motives of self-interest. Twenty-one percent of women reported much doubt. Perceived influence of the medical staff was substantial, but most women felt that they had not been put under pressure. Satisfaction with the caregivers was high. CONCLUSION: Women acknowledge that self-interested motives play an important role. Medical caregivers are among the most important persons for women who decide to terminate pregnancy because of Down syndrome.

Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling.

Few studies have examined treatments for complicated grief--a debilitating condition that can develop after the loss of a loved one. This study compared the effectiveness of cognitive-behavioral therapy with a nonspecific treatment with supportive counseling (SC). Using a minimization method, 54 mourners with clinically significant levels of complicated grief were allocated to 1 of 3 treatment conditions: (a) a condition of 6 sessions of cognitive restructuring (CR) and 6 sessions of exposure therapy (ET; CR + ET), (b) a condition in which these interventions were applied in reversed order (ET + CR), and (c) 12 sessions of SC. Outcomes showed that the 2 cognitive-behavioral therapy conditions produced more improvement in complicated grief and general psychopathology than SC in the completers and intention-to-treat groups. Comparison of the cognitive-behavioral conditions showed that "pure" exposure was more effective than "pure" cognitive restructuring, that adding ET to CR led to more additional improvement than adding CR to ET, and that ET + CR was more efficacious than CR + ET. Effect sizes of ET + CR were encouraging and compare favorably with those found in earlier bereavement intervention studies.

Patterns of attachment and parents' adjustment to the death of their child.

The impact of adult attachment on psychological adjustment among bereaved parents and the mediating effect of relationship satisfaction were examined among a sample of 219 couples of parents. Data collection took place 6, 13, and 20 months after loss. Use of the actor partner interdependence model in multilevel regression analysis enabled exploration of both individual as well as partner attachment as predictors of grief and depression. Results indicated that the more insecurely attached parents were (on both avoidance and anxiety attachment), the higher the symptoms of grief and depression. Neither the attachment pattern of the partner nor similarity of attachment within the couple had any influence on psychological adjustment of the parent. Marital satisfaction partially mediated the association of anxious attachment with symptomatology. Contrary to previous research findings, avoidant attachment was associated with high grief intensity. These findings challenge the notion that the avoidantly attached are resilient.

Euthanasia and depression: a prospective cohort study among terminally ill cancer patients.

PURPOSE: To study the association between depression and the incidence of explicit requests for euthanasia in terminally ill cancer patients. PATIENTS AND METHODS: A prospective cohort study was conducted on 138 consecutive cancer patients with an estimated life expectancy of 3 months or less, in the period between September 1999 and August 2003. At inclusion, participants completed the Hospital Anxiety and Depression Scale. To identify "depressed mood" we used a cutoff score of 20. Kaplan-Meier curves and Cox regression analyses were used to assess the association between depressed mood and the risk of a request for euthanasia. RESULTS: Of 138 patients, 32 patients had depressed mood at inclusion. Thirty patients (22%) made an explicit request for euthanasia. The risk to request euthanasia for patients with depressed mood was 4.1 times higher than that of patients without depressed mood at inclusion (95% CI, 2.0 to 8.5). CONCLUSION: Depression in cancer patients with an estimated life expectancy of less than 3 months is associated with a higher likelihood to request for euthanasia. The question of whether depressed mood can adequately be treated in this terminally ill population, and if so, whether it would lower the incidence of requests for euthanasia needs further investigation.