Biomarkers as predictors of CBT responsiveness in major depressive disorder: The role of heart rate variability and inflammation.

OBJECTIVE: Biological risk factors for cardiovascular disease may relate to poor treatment responsiveness in major depressive disorder (MDD). These factors encompass low-grade inflammation and autonomic dysregulation, as indexed by decreased heart rate variability (HRV) and increased heart rate (HR). This secondary analysis examined whether higher levels of inflammatory markers or autonomic alterations relate to lower responsiveness to cognitive behavioral therapy (CBT) among individuals with MDD. METHODS: Eighty antidepressant-free patients with MDD were randomly assigned to 14 weeks of CBT or waitlist (WL). Potential biological moderators at study entry included HR and HRV (24-h, daytime, nighttime) and inflammatory markers such as C-reactive protein (CRP), interleukin (IL)-6, and tumor necrosis factor (TNF)-α. Forty non-clinical controls were involved to verify biological alterations in MDD at study entry. Depressive symptoms were assessed at baseline and at the end of treatment. RESULTS: Individuals with MDD exhibited reduced total 24-h HRV (i.e., triangular index) and daytime HRV (i.e., triangular index, HF-HRV, LF-HRV, RMSSD), as well as increased levels of inflammatory markers. Patients who received CBT exhibited stronger reductions in self- and clinician-rated depressive symptoms, compared to WL. False discovery rate-adjusted moderation analyses did not show overall moderating effects of biological measures on treatment responsiveness. However, higher CRP levels were specifically associated with poorer improvement in somatic depressive symptoms. CONCLUSIONS: There was no overall evidence for a moderating role of inflammation or autonomic features in CBT responsiveness in MDD. Higher levels of CRP might, however, specifically be associated with less improvement in somatic depressive symptoms during CBT.

Side-effect expectations are associated with disability, physical fitness, and somatic symptoms 3 months after post-COVID neurological inpatient rehabilitation.

INTRODUCTION: The COVID-19 pandemic, caused by SARS-CoV-2, has led to long-term health issues known as post-COVID-19 condition, including fatigue and cognitive disruptions. Despite its recognition as a public health concern, the efficacy of therapeutic interventions, especially in neurological rehabilitation, remains unclear. This study examines how treatment expectations are associated with psychological and physical outcomes in post-COVID-19 condition neurological rehabilitation. METHODS: In an observational cohort study 61 patients with confirmed post-COVID-19 condition were included. Baseline (T0) data on treatment and side effect expectations were collected, before participants underwent a 4-6 week multidisciplinary rehabilitation program. Primary outcome was illness-related disability (Pain Disability Index). Secondary outcomes included depressive symptoms (PHQ-9), anxiety levels (GAD-7), functional status (PCFS), fatigue (CFS), and physical fitness (6MWT). Regression models analyzed the associations of baseline expectations with outcomes at the end of rehabilitation (T1) and three months post-rehabilitation (T2). RESULTS: After adjusting for multiple testing, higher baseline side-effect expectations were associated with greater illness-related disability (ß = 0.42, p = 0.007), reduced physical fitness (ß = - 0.24, p = 0.04), and more somatic symptoms (ß = 0.33, p = 0.006) at follow-up (T2). Positive treatment expectations were associated with poorer functional status (ß = 0.35, p = 0.011) at T2. CONCLUSION: This study highlights the associations of side-effect expectations with post-COVID-19 condition rehabilitation outcomes. Higher side-effect expectations were associated to poorer outcomes, indicating a nocebo effect. Surprisingly, positive expectations were linked to worse outcomes, possibly due to unrealistic optimism. Managing patient expectations realistically and addressing side-effect concerns seems crucial for optimizing rehabilitation outcomes.

Competence-Based Trainings for Psychological Treatments - A Transtheoretical Perspective.

Background: Although in most countries psychotherapy trainings focus on one treatment orientation, such an approach is associated with systematic shortcomings. The priorities from teaching one theoretical framework should be moved to a more rigorous orientation in science and evidence-based practice, and to the needs of patients, even if strategies of different theoretical approaches need to be combined. Method: We discuss whether competence-based trainings in psychological treatments offer a better framework to facilitate the progress of psychological treatments to a professional academic discipline with transtheoretical exchange, and we provide an example of a transtheoretical education in the basic competences of psychological treatments. A transtheoretical education program requires an umbrella model for case formulation and a transtheoretical definition of intervention goals. Results: We provide an adaptation of the traditional model distinguishing vulnerability/resilience, exacerbation, and maintenance of clinical problems for case conceptualization. Dynamic network models offer a further perspective for developing modern, transtheoretical case formulations. Treatment methods should be better classified according to their transtheoretical goals, which offers opportunities to better compare or combine them. We report a case example of how to transform a general competence-based approach in the training of psychological treatments in the academic education system, which found exceptional acceptance from participating students. Conclusion: Thus, a rigorous competence-based approach to training early clinicians in applying psychological treatments helps to bridge the artificial divide between psychotherapeutic traditions. It also supports the evolution of psychological treatments into an academically robust and highly professional, integrative discipline.

Depressive symptoms and the processing of unexpected social feedback: Differences in surprise levels, feedback acceptance, and "immunizing" cognition.

Negative social expectations are a key symptom of depression. It has been suggested that individuals with depressive symptoms tend to maintain these expectations by devaluing new experiences that do not fit prior expectations. However, our understanding of the role of such "immunizing" cognition in response to unexpected social feedback in depression, as well as the cognitive mechanisms involved, remains limited. This study investigated the association between depressive symptoms and the cognitive processing of unexpected positive or negative social feedback using a novel, video-based approach featuring naturalistic social stimuli in a subclinical online sample (N = 155). We also examined how surprise levels, feedback acceptance and immunizing cognition relate to other cognitive processes, such as attributional style and rumination, using cross-sectional network analyses. Robust multiple linear regression analyses revealed that depressive symptoms were associated with higher surprise levels (R2adj. = .27), lower feedback acceptance (R2adj. = .19), and higher levels of immunizing cognition (R2adj. = .09) in response to unexpected positive social feedback, but only partially to unexpected negative social feedback. The network analysis suggested that self-efficacy expectations for coping with negative feelings and acceptance of positive social feedback had the strongest expected influence on the different cognitive processes. Our study highlights the challenges that individuals with depressive symptoms face in utilizing positive social feedback to modify negative expectations. For clinicians, our findings suggest the importance of promoting acceptance of positive social feedback, while simultaneously inhibiting immunizing cognition and avoiding the use of overly positive feedback.

Collaborative advance care planning in palliative care: a randomised controlled trial.

OBJECTIVE: An effective tool for establishing concordant end-of-life (EOL) care in patients with cancer is advance care planning (ACP). However, various barriers, including psychological obstacles, hamper the access to ACP. Therefore, a new conceptual model combining a psycho-oncological approach with structured ACP was developed. The effectiveness and efficiency of this new concept of collaborative ACP (col-ACP) is evaluated in the present randomised controlled trial in patients with palliative cancer. METHODS: 277 patients with palliative cancer and their relatives were randomised into three groups (1) collaborative ACP (col-ACP) consisting of a psycho-oncological approach addressing barriers to EOL conversations followed by a standardised ACP procedure, (2) supportive intervention (active control) and (3) standard medical care. RESULTS: Patients in the col-ACP group completed advance directives (p<0.01) and healthcare proxies (p<0.01) significantly more often. Additionally, they felt better planned ahead for their future treatment (p<0.01) and were significantly more confident that their relatives were aware of their treatment wishes (p=0.03). In fact, their goals of care were known and highly fulfilled. However, patients' and caregivers' quality of life, patients' stress, depression and peace did not differ between the groups. CONCLUSIONS: The new, well-received, concept of col-ACP improves readiness and access to ACP and results in more consistent EOL care. Further, even if no direct influence on quality of life could be proven, it supports patients in planning their treatment, making autonomous decisions and regaining self-efficacy in the face of life-limiting cancer. Therefore, a closer interlocking and information exchange between psycho-oncological and ACP services seems to be reasonable. TRIAL REGISTRATION NUMBER: NCT03387436.

Elevated accuracy in recognition of subliminal happy facial expressions in patients with panic disorder after psychotherapy.

Background: Individuals with anxiety disorders (ADs) often display hypervigilance to threat information, although this response may be less pronounced following psychotherapy. This study aims to investigate the unconscious recognition performance of facial expressions in patients with panic disorder (PD) post-treatment, shedding light on alterations in their emotional processing biases. Methods: Patients with PD (n=34) after (exposure-based) cognitive behavior therapy and healthy controls (n=43) performed a subliminal affective recognition task. Emotional facial expressions (fearful, happy, or mirrored) were displayed for 33 ms and backwardly masked by a neutral face. Participants completed a forced choice task to discriminate the briefly presented facial stimulus and an uncovered condition where only the neutral mask was shown. We conducted a secondary analysis to compare groups based on their four possible response types under the four stimulus conditions and examined the correlation of the false alarm rate for fear responses to non-fearful (happy, mirrored, and uncovered) stimuli with clinical anxiety symptoms. Results: The patient group showed a unique selection pattern in response to happy expressions, with significantly more correct "happy" responses compared to controls. Additionally, lower severity of anxiety symptoms after psychotherapy was associated with a decreased false fear response rate with non-threat presentations. Conclusion: These data suggest that patients with PD exhibited a "happy-face recognition advantage" after psychotherapy. Less symptoms after treatment were related to a reduced fear bias. Thus, a differential facial emotion detection task could be a suitable tool to monitor response patterns and biases in individuals with ADs in the context of psychotherapy.

Working with patients' treatment expectations - what we can learn from homeopathy.

The usual homeopathic remedy, "globules," does not contain any pharmacologically active ingredient. However, many patients and practitioners report beneficial effects of homeopathic treatment on various health outcomes. Experimental and clinical research of the last two decades analyzing the underlying mechanisms of the placebo effect could explain this phenomenon, with patients' treatment expectations as the predominant mechanism. Treatment expectations can be optimized through various factors, such as prior information, communication, and treatment context. This narrative review analyses how homeopathy successfully utilizes these factors. Subsequently, it is discussed what evidence-based medicine could learn from homeopathic practice to optimize treatment expectations (e.g., using an empathic, patient-centered communication style, deliberately selecting objects in practice rooms, or using clear treatment rituals and salient contextual stimuli) and thereby treatment effectiveness. Homeopathic remedy does not work beyond the placebo effect but is recommended or prescribed as an active treatment by those who believe in it. Thus, practitioners need to understand the manner in which homeopathy (as an example of inert treatment) works and are advised to reintegrate its underlying effective placebo mechanisms into evidence-based medicine. This promises to increase treatment efficacy, tolerability, satisfaction, and compliance with evidence-based treatments, and addresses the desires patients are trying to satisfy in homeopathy in an ethical, fully informed way that is grounded in evidence-based medicine.

Patients' perspective on the chronic pain classification in the 11th revision of the International Classification of Diseases (ICD-11): results from an international web-based survey.

ABSTRACT: The 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11) aims at improving the lives of persons with the lived experience of chronic pain by providing clearly defined and clinically useful diagnoses that can reduce stigma, facilitate communication, and improve access to pain management, among others. The aim of this study was to assess the perspective of people with chronic pain on these diagnoses. An international web-based survey was distributed among persons with the lived experience of chronic pain. After having seen an information video, participants rated the diagnoses on 8 endorsement scales (eg, diagnostic fit, stigma) that ranged from -5 to +5 with 0 representing the neutral point of no expected change. Overall ratings and differences between participants with chronic primary pain (CPP) and chronic secondary pain (CSP) were analyzed. N = 690 participants were included in the data analysis. The ratings on all endorsement scales were significantly higher than the neutral point of 0. The highest ratings were obtained for "openness" (2.95 ± 1.93) and "overall opinion" (1.87 ± 1.98). Participants with CPP and CSP did not differ in their ratings; however, those with CSP indicated an improved diagnostic fit of the new diagnoses, whereas participants with CPP rated the diagnostic fit of the new diagnoses similar to the fit of their current diagnoses. These results show that persons with the lived experience of chronic pain accept and endorse the new diagnoses. This endorsement is an important indicator of the diagnoses' clinical utility and can contribute to implementation and advocacy.

Lack of evidence for predictive utility from resting state fMRI data for individual exposure-based cognitive behavioral therapy outcomes: A machine learning study in two large multi-site samples in anxiety disorders.

Data-based predictions of individual Cognitive Behavioral Therapy (CBT) treatment response are a fundamental step towards precision medicine. Past studies demonstrated only moderate prediction accuracy (i.e. ability to discriminate between responders and non-responders of a given treatment) when using clinical routine data such as demographic and questionnaire data, while neuroimaging data achieved superior prediction accuracy. However, these studies may be considerably biased due to very limited sample sizes and bias-prone methodology. Adequately powered and cross-validated samples are a prerequisite to evaluate predictive performance and to identify the most promising predictors. We therefore analyzed resting state functional magnet resonance imaging (rs-fMRI) data from two large clinical trials to test whether functional neuroimaging data continues to provide good prediction accuracy in much larger samples. Data came from two distinct German multicenter studies on exposure-based CBT for anxiety disorders, the Protect-AD and SpiderVR studies. We separately and independently preprocessed baseline rs-fMRI data from n = 220 patients (Protect-AD) and n = 190 patients (SpiderVR) and extracted a variety of features, including ROI-to-ROI and edge-functional connectivity, sliding-windows, and graph measures. Including these features in sophisticated machine learning pipelines, we found that predictions of individual outcomes never significantly differed from chance level, even when conducting a range of exploratory post-hoc analyses. Moreover, resting state data never provided prediction accuracy beyond the sociodemographic and clinical data. The analyses were independent of each other in terms of selecting methods to process resting state data for prediction input as well as in the used parameters of the machine learning pipelines, corroborating the external validity of the results. These similar findings in two independent studies, analyzed separately, urge caution regarding the interpretation of promising prediction results based on neuroimaging data from small samples and emphasizes that some of the prediction accuracies from previous studies may result from overestimation due to homogeneous data and weak cross-validation schemes. The promise of resting-state neuroimaging data to play an important role in the prediction of CBT treatment outcomes in patients with anxiety disorders remains yet to be delivered.

Improving Exposure Therapy: Rationale and Design of an International Consortium.

The Exposure Therapy Consortium (ETC) was established to advance the science and practice of exposure therapy. To encourage participation from researchers and clinicians, this article describes the organizational structure and activities of the ETC. Initial research working group experiences and a proof-of-principle study underscore the potential of team science and larger-scale collaborative research in this area. Clinical working groups have begun to identify opportunities to enhance access to helpful resources for implementing exposure therapy effectively. This article discusses directions for expanding the consortium's activities and its impact on a global scale.

Clinicians diagnosing virtual patients with the classification algorithm for chronic pain in the ICD-11 (CAL-CP) achieve better diagnoses and prefer the algorithm to standard tools: An experimental validation study.

BACKGROUND: The ICD-11 classification of chronic pain comprises seven categories, each further subdivided. In total, it contains over 100 diagnoses each based on 5-7 criteria. To increase diagnostic reliability, the Classification Algorithm for Chronic Pain in the ICD-11 (CAL-CP) was developed. The current study aimed to evaluate the CAL-CP regarding the correctness of assigned diagnoses, utility and ease of use. METHODS: In an international online study, n = 195 clinicians each diagnosed 4 out of 8 fictitious patients. The clinicians interacted via chat with the virtual patients to collect information and view medical histories and examination findings. The patient cases differed in complexity: simple patients had one chronic pain diagnosis; complex cases had two. In a 2 × 2 repeated-measures design with the factors tool (algorithm/standard browser) and diagnostic complexity (simple/complex), clinicians used either the algorithm or the ICD-11 browser for their diagnoses. After each case, clinicians indicated the pain diagnoses and rated the diagnostic process. The correctness of the assigned diagnoses and the ratings of the algorithm's utility and ease of use were analysed. RESULTS: The use of the algorithm resulted in more correct diagnoses. This was true for chronic primary and secondary pain diagnoses. The clinicians preferred the algorithm over the ICD-11 browser, rating it easier to work with and more useful. Especially novice users benefited from the algorithm. CONCLUSIONS: The use of the algorithm increases the correctness of the diagnoses for chronic pain and is well accepted by clinicians. The CAL-CP's use should be considered in routine care and research contexts. SIGNIFICANCE STATEMENT: The ICD-11 has come into effect in January 2022. Clinicians and researchers will soon begin using the new classification of chronic pain. To facilitate clinicians training and diagnostic accuracy, a classification algorithm was developed. The paper investigates whether clinicians using the algorithm-as opposed to the generic tools provided by the WHO-reach more correct diagnoses when they diagnose standardized patients and how they rate the comparative utility of the diagnostic instruments available.

The future of psychological treatments: The Marburg Declaration.

Although psychological treatments are broadly recognized as evidence-based interventions for various mental disorders, challenges remain. For example, a substantial proportion of patients receiving such treatments do not fully recover, and many obstacles hinder the dissemination, implementation, and training of psychological treatments. These problems require those in our field to rethink some of our basic models of mental disorders and their treatments, and question how research and practice in clinical psychology should progress. To answer these questions, a group of experts of clinical psychology convened at a Think-Tank in Marburg, Germany, in August 2022 to review the evidence and analyze barriers for current and future developments. After this event, an overview of the current state-of-the-art was drafted and suggestions for improvements and specific recommendations for research and practice were integrated. Recommendations arising from our meeting cover further improving psychological interventions through translational approaches, improving clinical research methodology, bridging the gap between more nomothetic (group-oriented) studies and idiographic (person-centered) decisions, using network approaches in addition to selecting single mechanisms to embrace the complexity of clinical reality, making use of scalable digital options for assessments and interventions, improving the training and education of future psychotherapists, and accepting the societal responsibilities that clinical psychology has in improving national and global health care. The objective of the Marburg Declaration is to stimulate a significant change regarding our understanding of mental disorders and their treatments, with the aim to trigger a new era of evidence-based psychological interventions.

The Inventory of Social Expectations in Bereavement: Development and psychometric validation of a new instrument.

Negative expectations concerning social interactions contribute to feelings of loneliness. Since loneliness is one of the most pronounced challenges for bereaved individuals, we investigated grief-specific social expectations and its association with loneliness and grief severity. Initially, we developed an Inventory of Social Expectations in Bereavement (ISEB). Its factorial and psychometric validity was then tested in a bereaved sample (N = 344; 28.3 ± 11.1 years; 74.4% female). A two-factor solution for the scale fit the data best (factor 1: "relationship to others," factor 2: "relationship to the deceased") and demonstrated good psychometric validity. Higher ISEB-levels were associated with higher levels in grief severity and loneliness. The results suggest that individual social expectations affect the experience of loneliness after the loss of a significant other. The ISEB assesses these expectations time-efficiently and provides a basis for therapeutic interventions. Expressing expectations as probabilistic beliefs about the future renders them amenable for corrective experiences in clinical practice.

Hype or hope? High placebo response in major depression treatment with ketamine and esketamine: a systematic review and meta-analysis.

Background: Ketamine and esketamine offer a novel approach in the pharmacological treatment of major depressive disorder (MDD). This meta-analysis aimed to investigate the placebo response in double-blind, randomized controlled studies (RCTs) on patients with MDD receiving ketamine or esketamine. Methods: For this systematic review and meta-analysis Medline (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), PsycInfo and Embase databases were systematically searched for citations published up to March 17, 2023. A total number of 5017 abstracts was identified. Quality of the included trials was assessed with the Cochrane risk-of-bias tool. The meta-analysis was performed using a restricted maximum likelihood model. This study is registered with PROSPERO, number CRD42022377591. Results: A total number of 14 studies and 1100 participants (593 in the medication group and 507 in the placebo group) meeting the inclusion criteria were selected. We estimated the pooled effect sizes of the overall placebo (d pl = -1.85 [CI 95%: -2.9 to -0.79] and overall treatment (dtr = -2.57; [CI 95% -3.36 to -1.78]) response. The overall placebo response accounts for up to 72% of the overall treatment response. Furthermore, we performed subgroup analysis of 8 studies for the for the 7 days post-intervention timepoint. Seven days post-intervention the placebo response (d pl 7d = -1.98 [CI 95%: -3.26 to -0.69]) accounts for 66% of the treatment response (d tr 7d = - 3.01 [CI 95%, -4.28 to -1.74]). Conclusion: Ketamine and esketamine show large antidepressant effects. However, our findings suggest that the placebo response plays a significant role in the antidepressant response and should be used for the benefit of the patients in clinical practice. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022377591.

EFFects of Exposure and Cognitive behavioral Therapy for chronic BACK pain ("EFFECT-BACK"): study protocol for a randomized controlled trial.

INTRODUCTION: Chronic back pain is a widespread medical condition associated with high socioeconomic costs and increasing prevalence. Despite the advanced implementation of multidisciplinary approaches, providing a satisfactory treatment offer for those affected is often not possible. Exposure therapy (EXP) promises to be an effective and economical form of treatment and in a previous pilot study showed to be superior to cognitive behavioral therapy (CBT) in reducing perceived limitations of movement. The current study aims to further compare the efficacy of both treatment methods and identify those patient groups that particularly benefit from EXP. METHODS: The general objective of this randomized multicenter clinical trial (targeted N = 380) is to improve and expand the range of treatments available to patients with chronic back pain. As the primary objective of the study, two different psychological treatments (EXP and CBT) will be compared. The primary outcome measure is a clinically significant improvement in pain-related impairment, measured by the QPBDS, from baseline to 6-month follow-up. Secondary outcome measures are absolute changes and clinically significant improvements in variables coping, psychological flexibility, depressiveness, catastrophizing, exercise avoidance and fear of exercise, and intensity of pain. Participants are recruited in five psychological and medical centers in Germany and receive ten sessions of manualized therapy by trained licensed CBT therapists or clinical psychologists, who are currently in their post-gradual CBT training. Potential predictors of each treatment's efficacy will be explored with a focus on avoidance and coping behavior. CONCLUSION: This study will be the first RCT to compare CBT and EXP in chronic back pain in a large sample, including patients from different care structures due to psychological and medical recruitment centers. By identifying and exploring potential predictors of symptom improvement in each treatment group, this study will contribute to enable a more individualized assignment to treatment modalities and thus improves the care situation for chronic back pain and helps to create a customized treatment program for subgroups of pain patients. If our findings confirm EXP to be an efficacious and efficient treatment concept, it should gain more attention and be further disseminated. TRIAL REGISTRATION: ClinicalTrials.gov NCT05294081. Registered on 02 March 2022.

Does subjective social status affect pain thresholds? - an experimental examination.

Past research regarding the relationship between different constructs of social status and different aspects of pain has yielded divergent results. So far, there are few experimental studies to investigate the causal relationship between social status and pain. Therefore, the present study aimed to examine the effect of perceived social status on pain thresholds by experimentally manipulating participants' subjective social status (SSS). 51 female undergraduates were randomly assigned to a low- or high-status condition. Participants' perceived social standing was temporarily elevated (high SSS condition) or reduced (low SSS condition). Before and after experimental manipulation participants' pressure pain thresholds were assessed. The manipulation check confirmed that participants in the low-status condition reported significantly lower SSS than participants in the high-status condition. A linear mixed model revealed a significant group x time interaction for pain thresholds: Whereas participants' pain thresholds in the low SSS condition increased post manipulation, pain thresholds of participants in the high SSS condition decreased post manipulation (ß = 0.22; 95% CI, 0.002 to 0.432; p < .05). Findings suggest that SSS may have a causal effect on pain thresholds. This effect could either be due to a change in pain perception or a change in pain expression. Future research is needed to determine the mediating factors.

Pre-treatment expectations and their influence on subjective symptom change in Crohn's disease.

BACKGROUND: Treatment expectations reportedly shape treatment outcomes, but have not been studied in the context of multimodal therapy in Crohn's disease (CD). Therefore, the current study investigated the role of treatment expectations for subjective symptom changes in CD patients who have undergone an integrative multimodal therapy program. METHODS: Validated questionnaires were completed at the start of the treatment program and post intervention. Pre-treatment expectations and experienced symptom change were assessed with the Generic Rating Scale for Previous Treatment Experiences, Treatment Expectations, and Treatment Effects (GEEE); stress levels were quantified with the Perceived Stress Scale (PSS-10) and disease specific quality of life was quantified with the disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ). We performed multiple linear and Bayesian regression to determine how expectations related to symptom change. RESULTS: N = 71 CD patients (66.2% female) were included. Stronger expectations regarding symptom improvement (b = 0.422, t = 3.70, p < .001) were associated with higher experienced symptom improvement. Additionally, Bayesian analysis provided strong evidence for including improvement expectations as a predictor of improvement experience (BFinclusion = 13.78). CONCLUSIONS: In line with research in other disorders, we found that positive treatment expectations were associated with experienced symptom improvement. In contrast, we found no indication that an experience of symptom worsening was associated with positive or negative baseline treatment expectations. Induction of positive expectations might be a potential avenue for improving treatment outcomes in CD therapy.