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

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

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

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

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

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

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

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

Effects of implementation intentions on subthreshold binge eating.

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

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

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

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

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

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

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

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

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

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

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

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

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

Changing automatic behavior through self-monitoring: does overt change also imply implicit change?

BACKGROUND AND OBJECTIVES: Self-monitoring of unwanted behavior is a common component of effective cognitive-behavioral therapy. Self-monitoring has often shown to lead to decreases in undesirable behavior. To investigate the underlying mechanisms of these 'reactive effects', we investigated whether behavioral changes as a result of self-monitoring were accompanied by changes in explicit and implicit evaluation. For this purpose, monitoring of snack-eating was compared to monitoring of alcohol-drinking, since reactive effects are found absent in alcohol-drinking. METHODS: Implicit evaluations (Affective Priming Task), estimated frequency and satisfaction of consumption (Snacks and Drinks Questionnaire) were assessed before and after a 15-day self-monitoring period. Consumption was measured using self-monitoring forms. Participants were randomly assigned to a group that either monitored snack-eating behavior (experimental group) or to a group that monitored alcohol-drinking behavior (control group). RESULTS: After self-monitoring, consumption only decreased in the experimental group, although both groups estimated their snack-eating frequency to be higher after self-monitoring. Explicit satisfaction of the habit remained the same but self-monitoring did result in a slightly more implicit negative evaluation of the monitored substance in both groups. In both groups, participants were less satisfied with their snack-eating behavior than with their alcohol-drinking behavior. CONCLUSIONS: Self-monitoring reduced snack-eating but not alcohol-drinking. In both groups, self-monitoring appeared to be accompanied by small implicit, but not explicit changes in evaluation. Changes in evaluation apparently do not lead to actual behavioral change on their own. Other factors are expected to be involved as well, such as dissatisfaction at the start of monitoring.

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

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

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

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

Face value: eye movements and the evaluation of facial crowds in social anxiety.

Scientific evidence is equivocal on whether Social Anxiety Disorder (SAD) is characterized by a biased negative evaluation of (grouped) facial expressions, even though it is assumed that such a bias plays a crucial role in the maintenance of the disorder. To shed light on the underlying mechanisms of face evaluation in social anxiety, the eye movements of 22 highly socially anxious (SAs) and 21 non-anxious controls (NACs) were recorded while they rated the degree of friendliness of neutral-angry and smiling-angry face combinations. While the Crowd Rating Task data showed no significant differences between SAs and NACs, the resultant eye-movement patterns revealed that SAs, compared to NACs, looked away faster when the face first fixated was angry. Additionally, in SAs the proportion of fixated angry faces was significantly higher than for other expressions. Independent of social anxiety, these fixated angry faces were the best predictor of subsequent affect ratings for either group. Angry faces influence attentional processes such as eye movements in SAs and by doing so reflect biased evaluations. As these processes do not correlate with explicit ratings of faces, however, it remains unclear at what point implicit attentional behaviors lead to anxiety-prone behaviors and the maintenance of SAD. The relevance of these findings is discussed in the light of the current theories.

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

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

The effects of brief cognitive-behaviour therapy for pathological skin picking: A randomized comparison to wait-list control.

Thirty-four college students suffering from pathological skin picking were randomly assigned to a four-session cognitive-behavioural treatment (n=17) or a waiting-list condition (n=17). Severity of skin picking, psycho-social impact of skin picking, strength of skin-picking-related dysfunctional cognitions, and severity of skin injury were measured at pre-, post-, and two-months follow-up assessment. Participants in the treatment condition showed a significantly larger reduction on all measured variables in comparison to the waiting-list condition. The obtained effect sizes for the outcome measures were large, ranging from .90 to 1.89. Treatment effects were maintained at follow-up. In conclusion, cognitive-behavioural therapy, even in brief form, constitutes an adequate treatment option for pathological skin-picking behaviour.

Agoraphobic cognitions in old and young patients with panic disorder.

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

Habituation of premonitory sensations during exposure and response prevention treatment in Tourette's syndrome.

Exposure to premonitory sensations and response prevention of tics (ER) has been shown to be a promising new treatment for Tourette's syndrome (TS). The present study tested the hypothesis that habituation to unpleasant premonitory sensations associated with the tic is an underlying mechanism of change in ER. Patients rated the severity of sensations and urges at 15-minute intervals during ten 2-hour ER sessions. Multilevel models using multiple time trend analyses showed significant reductions of the sensory severity ratings both within and between sessions. The decrease of these severity ratings was related to the frequency of tics exhibited during sessions, regardless of tic severity at baseline. These results support the hypothesis that habituation may be at least part of the underlying working mechanism of exposure in the treatment of tics in TS and that effective tic suppression during sessions is an important factor in this habituation process.

Tic suppression in the treatment of Tourette's syndrome with exposure therapy: the rebound phenomenon reconsidered.

Exposure and response prevention (ER), a behavioral treatment program consisting of exposure to premonitory sensory experiences during prolonged tic suppression, was shown to be a promising new treatment for tics in Tourette's syndrome (TS). In this study, the commonly reported paradoxical increase in tic frequency following voluntary tic suppression, i.e., rebound phenomenon, was examined. Tic frequency was rated in 20 TS patients during 15-minute videotaped conversations taken both before and following 10 ER sessions. In addition, tic frequency was obtained at home by family members of the patients during 15-minute daily tic frequency registrations. Ratings following ER sessions were compared with ratings obtained before the sessions. Neither the ratings at the institute nor the ratings at home supported a rebound effect following ER tic suppression.