The phase model of psychotherapy outcome: Domain-specific trajectories of change in outpatient treatment.

OBJECTIVE: The Phase model of psychotherapy outcome assumes a log-linear trajectory of change and allows predictions about the three outcome domains of Well-being, Symptoms, and Interpersonal functioning. Although the model has been partly validated, little is known about the types of trajectories in the specific domains and about the transferability of the model to treatments of longer duration. This study tested whether the domain-specific change trajectories followed a log-linear curve as postulated by the Phase model. Furthermore, it was examined whether the speed of change differed between the domains. METHOD: Growth curves were modeled using hierarchical linear modeling on an outpatient sample (N = 351), with treatment duration averaging 52 sessions. RESULTS: A log-linear curve best explained the change trajectories of the domains Well-being and Symptoms as well as the Global score of psychopathology, whereas Interpersonal functioning tends to improve in a linear pattern. Estimated slopes were biggest for Well-being and smallest for Interpersonal functioning. CONCLUSIONS: In the present study, the predictions of the Phase model concerning multidimensional phases were validated. The finding that trajectories of change are not uniformly log-linear, but either log-linear or linear in a domain-specific manner, is partly inconsistent with the model. Clinical or methodological significance of this article: This article extends previous research in the field of psychotherapeutic change by providing results from the modeling of change trajectories in psychotherapeutic treatments with larger amounts of sessions (i.e., more than 20 sessions). Our findings of domain-specific different shapes (i.e., log-linear for Well-Being and Symptoms and linear for Interpersonal functioning) and speed (i.e., fastest for Well-Being and slowest for Interpersonal function) of trajectories of psychotherapeutic change may be clinically applied by means of guidelines for therapists to plan and adapt their treatments. In addition to content-related aspects of a continuous adjustment of treatment goals (e.g., merely symptom-oriented or focusing on interpersonal change) and interventions, this adaptive planning is also related to health care considerations (e.g., may justify longer treatments if therapy goals target several domains of change).

Effects of a cognitive-behavioral exposure-based body image therapy for overweight females with binge eating disorder: a pilot study.

BACKGROUND: Although not part of the diagnostic criteria of the DSM-5, body image disturbance seems to be a relevant feature of Binge Eating Disorder (BED) as well as of other eating disorders such as Anorexia Nervosa (AN) or Bulimia Nervosa (BN). Hence, the aim of the present pilot study was to assess the changeability of body image disturbance in a sample of overweight females with BED by a cognitive-behavioral treatment, directly addressing body image disturbance. METHOD: Overweight females (N = 34) with BED were randomized to a manualized body image therapy or a waiting-list control group. The final sample consisted of n = 15 participants in the intervention group and n = 19 in the control group due to two drop-outs in the control condition. Before and after the intervention or the waiting period, respectively, participants filled out a questionnaire battery assessing several body image and eating disorder related features. To quantify the perceptual component of body image disturbance, a digital photo distortion technique based on a picture of each participant taken in a standardized suit was applied. RESULTS: In a two-way ANOVA, significant Time × Group interactions were found for eating and shape concerns, drive for thinness, body dissatisfaction, depressiveness and low self-esteem. Follow-up t-tests indicated a significant symptom reduction of a generally high magnitude in the intervention group. No significant changes concerning body checking and the estimations of one's own "real", "felt" and "ideal" body dimensions were found. CONCLUSION: The strong symptom reduction in the cognitive-affective component of body image disturbance indicates that an exposure-based cognitive-behavioral body image intervention is a promising treatment module for overweight females with BED, but future research with a larger sample size is needed to quantify possible changes in all components of body image.

Immediate Effects of Body Checking Behaviour on Negative and Positive Emotions in Women with Eating Disorders: An Ecological Momentary Assessment Approach.

OBJECTIVES: Cognitive-behavioural models of eating disorders state that body checking arises in response to negative emotions in order to reduce the aversive emotional state and is therefore negatively reinforced. This study empirically tests this assumption. METHODS: For a seven-day period, women with eating disorders (n = 26) and healthy controls (n = 29) were provided with a handheld computer for assessing occurring body checking strategies as well as negative and positive emotions. Serving as control condition, randomized computer-emitted acoustic signals prompted reports on body checking and emotions. RESULTS: There was no difference in the intensity of negative emotions before body checking and in control situations across groups. However, from pre- to post-body checking, an increase in negative emotions was found. This effect was more pronounced in women with eating disorders compared with healthy controls. DISCUSSION: Results are contradictory to the assumptions of the cognitive-behavioural model, as body checking does not seem to reduce negative emotions.

Internet-based motivation program for women with eating disorders: eating disorder pathology and depressive mood predict dropout.

BACKGROUND: One of the main problems of Internet-delivered interventions for a range of disorders is the high dropout rate, yet little is known about the factors associated with this. We recently developed and tested a Web-based 6-session program to enhance motivation to change for women with anorexia nervosa, bulimia nervosa, or related subthreshold eating pathology. OBJECTIVE: The aim of the present study was to identify predictors of dropout from this Web program. METHODS: A total of 179 women took part in the study. We used survival analyses (Cox regression) to investigate the predictive effect of eating disorder pathology (assessed by the Eating Disorders Examination-Questionnaire; EDE-Q), depressive mood (Hopkins Symptom Checklist), motivation to change (University of Rhode Island Change Assessment Scale; URICA), and participants' age at dropout. To identify predictors, we used the least absolute shrinkage and selection operator (LASSO) method. RESULTS: The dropout rate was 50.8% (91/179) and was equally distributed across the 6 treatment sessions. The LASSO analysis revealed that higher scores on the Shape Concerns subscale of the EDE-Q, a higher frequency of binge eating episodes and vomiting, as well as higher depression scores significantly increased the probability of dropout. However, we did not find any effect of the URICA or age on dropout. CONCLUSIONS: Women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program. Interventions such as ours need to address the specific needs of women with more severe eating disorder pathology and depressive mood and offer them additional support to prevent them from prematurely discontinuing treatment.

Maintaining lasting improvements: one-year follow-up of children with severe chronic pain undergoing multimodal inpatient treatment.

OBJECTIVE: To investigate the long-term effectiveness of a 3-week multimodal inpatient program for children and adolescents with chronic pain. METHODS: 167 adolescents were evaluated at pretreatment baseline, 3-, and 12-month follow-up. Long-term effectiveness was investigated for pain-related variables (pain-related disability, school absence, pain intensity) and emotional distress. RESULTS: We found statistically and clinically significant changes in all variables. After 1 year, the majority (56%) showed overall improvement as indexed by decreased pain-related disability or school absence. 22% had an unsuccessful treatment outcome. Those showing only short-term improvements had higher levels of emotional distress at baseline. CONCLUSIONS: 1 year after completing a multimodal inpatient program adolescents report less chronic pain, disability, and emotional distress. Clinically significant changes remain stable. Adolescents with high levels of emotional distress at admission may require special attention to maintain positive treatment outcomes. Specialized inpatient therapy is effective for children with chronic pain.

Psychometric properties of the German version of the borderline personality disorder severity index--version IV.

BACKGROUND: Although the borderline personality disorder severity index--version IV (BPDSI-IV) has already been used in several studies, psychometric properties are only known from two developing studies. SAMPLING AND METHODS: To examine item characteristics, reliability, and validity indicators, a large sample including subjects with borderline personality disorder (n = 163), a mixed psychiatric group (n = 58), and a healthy control group (n = 43) were interviewed with the German version of the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) as well as the BPDSI-IV. RESULTS: The indices for interrater reliability as well as internal consistency of the BPDSI-IV were excellent to good. The total score and the subscales of the BPDSI-IV discriminated between diagnostic subgroups. As expected, its subscales were associated with the scores in the SCID-II and applied self-rating measures. CONCLUSIONS: In a subsequent version, subscales might have to be adapted to the proposed traits of the borderline type in DSM-V.

[Development and validation of a German questionnaire assessing motivation to change in eating disorders - the Stages of Change Questionnaire for Eating Disorders (SOCQ-ED)]. / Entwicklung und Validierung einer deutschsprachigen Skala zur Erfassung der Veränderungsmotivation bei Essstörungen - The Stages of Change Questionnaire for Eating Disorders (SOCQ-ED).

The present study describes the development and validation of a German questionnaire assessing motivation to change in individuals with eating disorders (Stages of Change Questionnaire-Eating Disorders, SOCQ-ED). The SOCQ-ED measures stages of change separately for each eating disorder symptom domain. Psychometric properties were assessed in a sample of N=63 women with Anorexia Nervosa or Bulimia Nervosa. Test-retest reliability ranged from rtt=0.42 to 0.78 (Mdn=0.56), correlations with the University of Rhode Island Change Assessment were between r=0.21 and 0.32 and correlations with measurements of eating pathology ranged from r=0.19 to 0.46. The results provide initial support for the reliability and validity of the SOCQ-ED.

Emotion dysregulation as a core feature of borderline personality disorder: comparison of the discriminatory ability of two self-rating measures.

BACKGROUND/AIMS: There is growing evidence that emotion dysregulation (ED) is a core feature of borderline personality disorder (BPD). The present study examines whether a self-rating measure, the ED Scale, lets us distinguish between individuals with BPD and those diagnosed with other mental disorders in a way similar to that of a borderline-related screening measure, the German version of the McLean Screening Instrument for Borderline Personality Disorders (MSI-BPD). METHOD: Based on the signal detection theory, receiver operating characteristics as well as reliability and validity indicators are determined in a heterogeneous outpatient sample (n = 168). RESULTS: The values of internal consistency and the validity indicators turned out to be in the expected range. The area under the curve (AUC) for the ED Scale was 0.86, and therefore emerged on a par with the AUC = 0.90 of the MSI-BPD. As required, analyses for both measures revealed equal and high values for sensitivity, as well as corresponding low negative predictive values. There was, however, a lower degree of specificity on the ED Scale as compared to the MSI-BPD. CONCLUSION: The results support the assumption that ED is a core feature of BPD, but should also be taken into account in the assessment and treatment of other mental disorders.

Specialized multimodal outpatient treatment for children with chronic pain: treatment pathways and long-term outcome.

OBJECTIVE: Despite the increased recognition of paediatric chronic pain, centres for providing appropriate treatment are scarce, and much remains unknown about optimal treatment approaches. The purpose of this study was to investigate effectiveness of multimodal outpatient treatment (MOT) through the examination of treatment pathways and long-term outcomes. METHODS: Within an observational longitudinal study, 275 children (4-18years) formed the study group and received MOT. Over a 12-month period, we followed the progress of the study group to identify how many children completed treatment, how many continued treatment and how many were stepped-up to more intensive treatment. To investigate significant and clinically relevant changes in primary and secondary outcomes the study group was assessed at three consecutive treatment sessions (initial session, 3-, 6-month visit) and 12months following the initial session. RESULTS: Analysis of treatment pathways showed that 1/3 of the children did not attend the prescribed second and third visit to the clinic. Cessation of treatment correlated with significant improvement. Only a small number of children were still in treatment at 12-month follow-up (12%) or needed more intensive treatment (11%). At 12-month follow-up, almost 70% of children in the study group were able to attend school regularly. Pain intensity, pain-related disability and inappropriate coping strategies were significantly reduced at 3-month visit and remained stable at the subsequent time points. CONCLUSIONS: MOT appears to be beneficial for children with chronic pain. A short intensive intervention (comprising of a total of 2.5-h) can lead to substantial improvements even for severely affected children.

Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling.

OBJECTIVE: At present, the most frequently investigated psychosocial intervention for borderline personality disorder (BPD) is dialectical behavior therapy (DBT). We conducted a meta-analysis to examine the efficacy and long-term effectiveness of DBT. METHOD: Systematic bibliographic research was undertaken to find relevant literature from online databases (PubMed, PsycINFO, PsychSpider, Medline). We excluded studies in which patients with diagnoses other than BPD were treated, the treatment did not comprise all components specified in the DBT manual or in the suggestions for inpatient DBT programs, patients failed to be diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, and the intervention group comprised fewer than 10 patients. Using a mixed-effect hierarchical modeling approach, we calculated global effect sizes and effect sizes for suicidal and self-injurious behaviors. RESULTS: Calculations of postintervention global effect sizes were based on 16 studies. Of these, 8 were randomized controlled trials (RCTs), and 8 were neither randomized nor controlled (nRCT). The dropout rate was 27.3% pre- to posttreatment. A moderate global effect and a moderate effect size for suicidal and self-injurious behaviors were found, when including a moderator for RCTs with borderline-specific treatments. There was no evidence for the influence of other moderators (e.g., quality of studies, setting, duration of intervention). A small impairment was shown from posttreatment to follow-up, including 5 RCTs only. CONCLUSIONS: Future research should compare DBT with other active borderline-specific treatments that have also demonstrated their efficacy using several long-term follow-up assessment points.

The pain provocation technique for adolescents with chronic pain: preliminary evidence for its effectiveness.

OBJECTIVE: This study aims to investigate the effectiveness of the "pain provocation technique" (PPT)--a focused treatment strategy incorporating interoceptive exposure (i.e., imagining increases in pain intensity), bilateral stimulation (tactile stimulation), and implementation of pain-related coping to decrease pain intensity--for adolescents suffering from chronic pain. DESIGN: Prospective observational comparative study. METHODS: Adolescents utilizing PPT (19 boys and 21 girls) within multimodal inpatient treatment were compared with adolescents in standard multimodal inpatient treatment matched for age, gender, and diagnosis. Core outcome variables (pain intensity, disability, emotional distress) were assessed at admission and 3 months posttreatment. RESULTS: Adolescents in the PPT group demonstrated a sharper decrease in pain intensity and school aversion. Both groups demonstrated significant reductions in disability and emotional distress. CONCLUSIONS: Results are discussed in terms of the importance of focused treatment strategies such as interoceptive exposure for adolescents suffering from disabling chronic pain. Future studies are warranted to carefully investigate the effectiveness and possible process of change during the PPT such as sensory, cognitive, emotional, and memory aspects.

Changes in pain-related coping strategies and their importance for treatment outcome following multimodal inpatient treatment: does sex matter?

UNLABELLED: While sex differences in pain-related coping have been widely reported, little is known on sex differences in changes in coping following multimodal pain treatment and how these changes relate to treatment outcome. The present prospective study therefore aimed to investigate sex differences in coping strategies between boys and girls with chronic pain prior to multimodal inpatient treatment and at 3-month follow-up. Sixty-four boys and 103 girls with various pain disorders were evaluated. Core outcomes (pain intensity and pain-related disability) and coping were assessed via validated questionnaires. At admission, boys and girls used similar coping strategies. Three months following treatment, boys and girls decreased passive pain coping and seeking social support while they maintained the degree of positive self-instruction. Girls displayed higher seeking social support than boys and of importance, only for girls, a reduction in seeking social support was related to decreases in pain intensity. In both groups, the changes in coping were related to positive treatment outcome. Results suggest that both groups may benefit from reductions in passive pain coping and seeking social support. The causal quality of this relationship remains to be determined in future studies. Gender-role expectations and family interactions may account for the sex differences demonstrated for seeking social support. PERSPECTIVE: Boys and girls with chronic pain show profound similarities in pain-related coping strategies prior and after multimodal pain treatment. The changes in coping are related to positive treatment outcomes. Sex-specific treatment strategies for changing seeking social support may need to be developed and tested for their differential efficacy in boys and girls.

[Screening measure for borderline personality disorder]. / Screening-Instrument für die Borderline-Persönlichkeitsstörung. Diagnostische Effizienz der deutschen Version des McLean Screening Instrument for Borderline Personality Disorder.

Borderline personality disorder (BPD) is a life-threatening mental disorder. To date, there is no German screening tool available. To examine the psychometric properties of a German version of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). A heterogeneous outpatient sample (N=168) was used to examine discriminatory ability, diagnostic efficiency as well as indicators for internal consistency and convergent validity. The area under the curve was AUC=0.90 (CI 95%: 0.85

Effectiveness of a multimodal inpatient treatment for pediatric chronic pain: a comparison between children and adolescents.

OBJECTIVES: To evaluate short and long-term treatment outcome of children (7-10 years) in comparison to adolescents (11-18 years) with disabling chronic pain following multimodal inpatient pain treatment. PATIENTS AND METHODS: Thirty-three children and 167 adolescents underwent multimodal inpatient pain treatment. Standardized assessment of pain-related variables, disability, coping, and use of analgesics was performed at admission, 3- and 12-month follow-up. RESULTS: Children and adolescents displayed similar pain-characteristics at admission. Adolescents demonstrated significantly higher disability and passive pain coping. Children relied more on others when in pain. All core variables (i.e., pain intensity, pain-related disability, school absence and pain-related coping) decreased significantly in both children and adolescents after 3 months. Both groups maintained this decline 12 months later. More than half of the children and adolescents demonstrated a 50%-reduction in pain intensity after 3 months, and almost 60% after 12 months. Use of analgesics was significantly reduced at 3-month follow-up with no additional changes after 12 months. While age did not exert any impact on results, there were significant gender differences in pain intensity and school absence. Girls demonstrated higher pain intensity and higher school absence 1 year following treatment. CONCLUSIONS: Children display similar pain-characteristics to adolescents when entering inpatient treatment. A multimodal inpatient program appears to stop the the long-term vicious cycle of disability and pain for both children and adolescents. The demonstrated gender differences raise issues for further research and the possibility of additional pain management strategies for girls.

Sex differences in pain intensity in adolescents suffering from cancer: differences in pain memories?

UNLABELLED: Although sex differences have been investigated in chronic pain populations, little is known about sex differences in the pain experience of paediatric oncology patients and also whether their parents rate the pain experience differently for boys and girls. The aim of the present study was to determine if (1) boys and girls with cancer differ in current perception and past recollection of cancer-related pain and (2) if adolescents' and parents' pain ratings differ in relation to the sex of the adolescent. One hundred twelve adolescents with malignant diagnoses (12 to 18 years) and their parents participated in the study. Girls reported higher pain intensity within the last 7 days and 4 weeks despite similar diagnosis, physical status, duration of diagnoses, and main pain causes. When asked for pain intensity that dated back in time, parent and adolescent ratings diverged, with a trend for parents to reporting higher pain intensity in boys and lower pain intensity in girls, particularly for pain in the preceding 7 days. The present study provides preliminary evidence for sex differences in the recalled pain experience of adolescents with malignant diagnoses. Although boys and girls experience present pain similarly and hence should be treated similarly, girls recall higher pain intensity than boys. Future studies should address whether negative memories in girls play a significant role and may have an impact on girls' well-being and pain-related distress. Additionally, psychosocial factors such as gender role expectations may need to be investigated. Parental variables and their impact on parents' pain ratings, especially for ratings of precedent pain, warrants further investigation. PERSPECTIVE: Girls with malignant diagnoses differ from boys in their recalled pain intensity ratings, with girls reporting higher pain intensity. Additional pain management strategies referring to the memory of pain may need to be implemented.

Effectiveness of a 3-week multimodal inpatient pain treatment for adolescents suffering from chronic pain: statistical and clinical significance.

OBJECTIVE: The present study aimed to investigate the effectiveness of a 3-week multimodal inpatient pain program for children and adolescents with chronic pain. METHODS: Effectiveness was investigated for pain-related variables (pain intensity, pain-related disability) and emotional distress in 3 ways: (1) in terms of statistically significant changes; (2) in terms of the clinical significance of these changes by creating post-hoc outcome groups for pain-related variables and emotional distress; and (3) in terms of the clinically significant overall amelioration generalizing the outcome over 3 variables (ie, pain intensity, pain-related disability, and school absence). One hundred sixty-seven adolescents (aged between 11 and 18 y) with various pain disorders (50% with headache) who met inpatient criteria were evaluated at baseline and 3 months posttreatment. RESULTS: Patients demonstrated statistically significant changes in all variables with large to medium effect sizes. Seventy-two percent and 45% of the patients demonstrated clinically significant changes in pain intensity and pain-related disability, respectively. The percentages of patients demonstrating clinically significant change in emotional distress ranged from 13% to 26%. Seventy-seven adolescents demonstrated overall amelioration. DISCUSSION: Results of the study are promising in at least 2 ways: (1) a multimodal inpatient program might stop the negative effects of chronic pain, disability, and emotional distress in children and adolescents, and (2) the exploration of clinical significance testing has demonstrated utility and can be applied to future effectiveness studies in pediatric pain.

[Change in psychological distress of cancer in-patients attending a structured psychooncological care program]. / Veränderung der psychischen Belastung von Krebspatienten im Rahmen einer strukturierten psychoonkologischen Versorgung.

The aim of this health service research study was to investigate the change in the psychological distress of cancer in-patients. According to the structured psychooncological care program Case Management Psychoonkologie (CMP) the patients received psychological treatment during the acute cancer therapy. The CMP was implemented in routine healthcare practice of 6 hospitals. The improvement in the patient's symptoms of anxiety and depression was analyzed as an indication for the effectiveness of the CMP. In order to assess the psychological distress, quality of life, and the functional status the German version of the Hospital Anxiety and Depression Scale (HADS) and a checklist of single-item-scales were administered at hospital admission (t1), 120 days later (t2) and one year after the hospital admission (t3). According to the HADS, the pre-post effect sizes of the psychooncological care program for 258 patients were 0.35 at t2 and 0.46 at t3. The effect sizes of 1.05 at t2 and 1.38 at t3 were calculated for the sub-group of patients with high psychological distress at t1. In 34.4 % of these patients clinical significant improvements in symptoms of anxiety and depression could be identified at t2 and in 45.3 % of the cases at t3. Symptom changes were significantly influenced by the patient's age and the intensity of psychooncological interventions. Symptom improvement was most evident for patients with a high use of psychooncological care. The correlation between HADS and single Item scales is in the moderate to high range. This is an indication of improvement not only in the psychological domain but also in the quality of life and functional status one year after the beginning of cancer treatment. These findings implicate that this study is one of the first to demonstrate the potential effectiveness of structured psychooncological care interventions in routine hospital care.

Does habitual body avoidance and checking behavior influence the decrease of negative emotions during body exposure in eating disorders?

The aim of the present study was to assess whether habitual body avoidance and body-checking behavior influences the decrease of negative emotions during body exposure. Twenty-one eating-disordered female participants completed the Body Image Avoidance Questionnaire and the Body Checking Questionnaire. On another day, a 40-min body exposure session was conducted under standardized conditions. Every 10 min, negative emotions were assessed. It was shown that the extent of decrease in negative emotions during the body exposure session could be predicted by a lower degree of body checking. Results indicate that habitual checking behavior seems to negatively influence the effect of body exposure. Therefore, an adaptation of body exposure to patients with a higher degree of body-checking behavior might be promising.

Look at yourself: can body image therapy affect the cognitive and emotional response to seeing oneself in the mirror in eating disorders?

The study examined whether the extent of negative body-related thoughts and emotions evoked by looking in a mirror can be changed by cognitive-behavioural body image therapy (BIT) and whether any remaining cognitive and affective responses dropped faster after the treatment. Females with eating disorders (n = 17) looked in a mirror for 40 minutes under standardised conditions before and after BIT. A control group (CG) (n = 24) was also exposed to their own bodies twice. Cognitive and affective reactions were assessed four times during the session. Hierarchical Linear Modelling revealed that among eating-disordered patients, the entrance levels of negative thoughts and feelings were lower at post compared to pre-BIT, whereas they remained stable in the CG. The extent of reduction of the remaining body image distress was not changed after the treatment. BIT seems to be a potent treatment of negative emotions and cognitions in an in vivo situation.

What happens in the course of body exposure? Emotional, cognitive, and physiological reactions to mirror confrontation in eating disorders.

OBJECTIVE: Though body exposure seems to enhance outcome in cognitive-behavioural therapy of anorexia and bulimia nervosa, the underlying mechanisms are still unknown. METHODS: Participants with eating disorders (ED; n = 21) and normal controls (NC; n = 28) were exposed to their own bodies in front of a mirror for 40 minutes under standardized conditions. Emotions, cognitions, and saliva cortisol were assessed every 10 minutes during body exposure. Heart rate and skin conductance were recorded continuously. RESULTS: ED showed higher negative emotional and cognitive responses to body exposure compared to NC, whereas no group differences were found for physiological reactions. In the course of body exposure, the extent of negative emotions and cognitions decreased significantly with medium effects for emotions and low effects for cognitions. Physiological parameters remained stable during the task. CONCLUSION: Body exposure is a promising technique to overcome negative body-related emotions, but additional cognitive techniques are necessary.