Acknowledging religion in cognitive behavioural therapy: The effect on alliance, treatment expectations and credibility in a video-vignette study.

OBJECTIVES: Developing mental health services which are accessible and acceptable to those from minority backgrounds continues to be a priority. In the United Kingdom, individuals who identify with a religion are underrepresented in Talking Therapies services as compared to those with no religion. This necessitates an understanding of how therapy is perceived. This online study explored the impact of explicitly acknowledging religion on anticipated alliance, treatment credibility and expectations of therapy in a non-clinical sample of British Muslims. METHODS: A video-vignette experimental design was used in which participants who self-reported as either high or low in religiosity were randomly allocated to receiving information about cognitive behavioural therapy either with or without an explicit mention of religion as a value in the therapeutic process. RESULTS: One hundred twenty-nine British Muslim adults aged 18-70+ years from various ethnic backgrounds participated in the study. Between-subjects ANOVAs showed that scores on the perceived credibility of therapy and treatment expectations were significantly higher when religion was explicitly mentioned by the 'therapist', but that acknowledging religion did not impact upon anticipated alliance. CONCLUSIONS: These findings suggest that mentioning religion as a value to be considered in therapy has some positive impacts upon how therapy is perceived by British Muslims. Although video vignettes do not provide insight into the complexity of actual therapeutic encounters, acknowledging religion in mental health services more broadly remains an important consideration for improving equity of access and may bear relevance to other minoritized groups.

Sleep disruption in adolescent inpatients: prevalence, associations with clinical outcomes, and clinician perspectives.

Sleep problems are common for adolescents with psychiatric disorders, and sleep treatment may aid mental health recovery. Inpatient admissions are likely a particularly challenging time for sleep. Despite this little is known about the nature of sleep problems, and how sleep treatments could be optimised for this setting. This mixed-methods study set out to better understand sleep disturbances in adolescent inpatients. Study 1 examined the prevalence of Sleep Condition Indicator-assessed insomnia at admission and associations with psychiatric symptoms and admission length in 100 inpatients (aged 11-17 years) on one unit in Oxford. Data were gathered from admission routine measures and medical records. Associations were analysed using linear regressions. Half of the inpatients (n = 50) screened positive for insomnia at admission. Moderate-large significant associations were observed between more severe insomnia and more severe depression (ß = -0.56), anxiety (ß = -0.51), self-harm (ß = -0.49), psychotic experiences (ß = -0.32), and conduct problems (ß = -0.30), but not admission length. Study 2 gained 12 clinicians' perspectives on sleep problems on the unit via a focus group and semi-structured interviews, analysed using thematic analysis. Ward staff observed insomnia and excessive daytime sleepiness in adolescent inpatients and a reciprocal relationship with mental health symptoms. Ward processes were barriers (e.g., night-time observations) and facilitators (e.g., regular routines) of sleep. Cognitive behavioural therapy for insomnia was not routinely offered but viewed as potentially helpful. Insomnia may be a common problem for adolescent inpatients, associated with greater psychopathology, but not admission length. The possible benefits of psychological sleep interventions for adolescents admitted to psychiatric units now require testing.

The Effectiveness and Feasibility of Psychological Interventions for Populations Under Ongoing Threat: A Systematic Review.

Current views of psychological therapies for trauma typically assume the traumatic event to be in the past. Yet, individuals who live in contexts of ongoing organized violence or experience intimate partner violence (IPV) may continue to be (re)exposed to related traumatic events or have realistic fears of their recurrence. This systematic review considers the effectiveness, feasibility, and adaptations of psychological interventions for individuals living with ongoing threat. PsychINFO, MEDLINE, and EMBASE were searched for articles that examined psychological interventions in contexts of ongoing threat of either IPV or organized violence and used trauma-related outcome measures. The search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on study population, ongoing threat setting and design, intervention components, evaluation methods, and outcomes were extracted, and study quality was assessed using the Mixed-Method Appraisal Tool. Eighteen papers featuring 15 trials were included (12 on organized violence and 3 on IPV). For organized violence, most studies showed moderate to large effects in reducing trauma-related symptoms when compared to waitlists. For IPV, findings were varied. Most studies made adaptations related to culture and ongoing threat and found that providing psychological interventions was feasible. The findings, albeit preliminary with mixed methodological quality, showed psychological treatments can be beneficial and should not be withheld in the context of ongoing organized violence and IPV. Clinical and research recommendations are discussed.

Do they really care? Specificity of social support issues in hoarding disorder and obsessive-compulsive disorder.

OBJECTIVES: Unmet interpersonal needs may play a role in excessive emotional attachments to objects for people with hoarding disorder (HD). Previous research indicates that social support (but not attachment difficulties) may be specific to HD. The study aimed to evaluate social networks and support in HD relative to clinical controls with obsessive-compulsive disorder (OCD) and healthy controls (HC). The secondary aim was to explore the extent of loneliness and thwarted belongingness. Potential mechanisms for deficits in social support were also considered. DESIGN: A cross-sectional between-groups design was used to compare scores on measures in those with HD (n = 37); OCD (n = 31); and HCs (n = 45). METHODS: Participants completed a structured clinical interview by telephone (to assign diagnostic categories) followed by online questionnaires. RESULTS: Whilst individuals with HD and OCD both report smaller social networks than HC, lower levels of perceived social support appear to be specific to HD. The HD group also showed higher levels of loneliness and thwarted belonging compared to OCD and HC. No differences were found between groups for perceived criticism or trauma. CONCLUSIONS: The results support previous findings of lower levels of self-reported social support within HD. Loneliness and thwarted belongingness also appear significantly elevated within HD compared with OCD and HC. Further research is required to explore the nature of felt support and belonging, direction of effect and to identify potential mechanisms. Clinical implications include advocating and promoting support systems (both personal supporters and professionals) for individuals with HD.

Responses to autobiographical memories involving being a victim or perpetrator of betrayal in people with OCD and community controls.

Mental contamination in people with OCD has been linked to the perceived impact of being betrayed and betraying others. In this study, participants with OCD (N = 56) and community controls (N = 37) were randomised to an induction involving eliciting autobiographical memories of either being betrayed by someone they trusted or betraying someone that trusted them. The OCD group experienced greater increases in state mental contamination and anxiety than the control group, but no differences were observed between groups in urges to wash or drink. Both betrayal conditions elicited similar levels of mental contamination and anxiety. The results of this study suggest that people with OCD experience similar increases in mental contamination and anxiety not only when recalling memories of being a victim of betrayal but also when recalling being a perpetrator. People with OCD are therefore more sensitive to betrayal experiences than community controls. Clinical implications and implications for future research are discussed.

Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability.

Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond.

BACKGROUND: Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however. AIMS: In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment. METHOD: The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general. CONCLUSION: Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

What Is the Common Ground for Modern Psychotherapy? A Discussion Paper Based on EACLIPT's 1st Webinar.

Psychotherapy as it is implemented today, can be seen as the composition of unconnected groups of practitioners and scientists pursuing different theories. The idea of finding a common "umbrella" for all evidence-based treatments in the field of psychotherapy is gaining more interest. Based on this background, experts in clinical psychology from various backgrounds led a fundamental discussion about modern psychotherapy and its basic mechanisms. Process-Based Therapy (PBT) was presented by Stefan Hofmann as a possible novel approach to clinical research and practice. In this article we present the different perspectives of the four panelists on PBT and in how far the model builds a common ground for different treatment approaches. Learning mechanisms and the therapeutic alliance were almost unanimously considered as indispensable factors in a global model of psychotherapy. In conclusion, the panelists emphasized a much-needed focus on characteristics and competencies of therapists themselves e.g., in communication, listening and empathy. These core competencies should be trained and promoted independently of the therapeutic approach.

Different cognitive behavioural processes underpinning reassurance seeking in depression and obsessive-compulsive disorder.

BACKGROUND AND OBJECTIVES: It has been suggested that reassurance seeking may play an important role in the development and maintenance of common mental health problems such as OCD and depression. We considered the extent of reassurance seeking in depression and OCD relative to a healthy comparison group and tested the hypothesis that reassurance seeking is primarily motivated by threat in those suffering from OCD and by interpersonal concerns in those suffering from depression. METHODS: The frequency and intensity of reassurance seeking and the motivation for seeking reassurance was measured using the reassurance seeking questionnaire in 28 people with OCD, 18 people with depression and 29 healthy controls. RESULTS: The OCD group sought reassurance more and at a higher intensity than both the depression group and healthy controls. For the OCD group, reassurance seeking was found to be linked to threat concern motivation. The depression group were not motivated by threat or interpersonal concerns. LIMITATIONS: The OCD group did not significantly differ from the depression group on the measure of depression, most likely due to secondary depression in the OCD group. CONCLUSIONS: For people suffering from OCD, reassurance is motivated by threat concern. For the depression group, levels of reassurance seeking were not substantially increased relative to controls, and the motivation to seek reassurance is less clear but interpersonal concern may not be a distinct motivational factor.

How women with obsessive compulsive disorder experience maternity care and mental health care during pregnancy and postpartum: A systematic literature review.

INTRODUCTION: Obsessive Compulsive Disorder has a higher prevalence in pregnancy and postpartum than in the general population. Experiences of maternity care and mental health care can impact the health and wellbeing of perinatal women. The aim of this review was to synthesize evidence on the experiences of maternity care and mental health care for women with OCD during pregnancy and postpartum. METHODS: Studies were systematically reviewed by two independent reviewers after identification in MEDLINE, Embase, PsycINFO, Global Health, CINAHL, the Cochrane Library, Web of Science and grey literature searches (last searched October 2021). Papers meeting pre-specified inclusion criteria were extracted using a pre-determined extraction sheet and were quality assessed. Thematic synthesis was conducted. RESULTS: 19 papers reporting 18 studies describing 33 participants were included. Three descriptive themes were found: experiences of barriers to treatment and care, experiences of treatment/care decision making and experiences of treatment and care. Three analytic themes were found demonstrating tensions: keeping baby healthy vs keeping mother healthy, keeping baby safe vs keeping mother safe, and normal perinatal experience vs not normal perinatal experience. LIMITATIONS: Despite an inclusive search strategy, available data was limited. 17 of the studies were case studies that were poor in quality. Synthesis and subsequent findings were limited. CONCLUSIONS: There were significant literature gaps for all aspects of care but particularly around experiences of maternity and pharmacological care. Tensions that could impact the experience of care need to be carefully balanced to ensure that women with OCD get the care that they need.

Sensitivity to being betrayed and betraying others in obsessive compulsive disorder and depression.

OBJECTIVES: Mental contamination (MC) describes subjective internal feelings of 'dirtiness', which are experienced in the absence of direct physical contact/contaminants. There is evidence of a link between MC in obsessive compulsive disorder (OCD) and the experience of past betrayals. However, it has also been noted that 'perpetrators' also experience MC. We aimed to replicate the previous finding of specificity of OCD for sensitivity to being betrayed by comparing with those suffering from depression, and to extend this by evaluating whether people with high MC OCD are also relatively more sensitive to the idea that they might betray others compared to those with low levels of MC OCD. DESIGN: A cross-sectional, between-groups design was used. METHOD: Four groups, high MC OCD (N = 60), low MC OCD (N = 61), depression (N = 28), and non-clinical controls (N = 46) completed online questionnaires. Participants were recruited through the National Health Service (NHS) and social media. RESULTS: Relative to all groups, the high MC OCD group had significantly higher scores both for betrayal sensitivity and sensitivity to betraying others. The depression group showed similar levels to low MC OCD in betrayal sensitivity but were significantly lower (and comparable to non-clinical controls) in sensitivity to betraying others. CONCLUSIONS: Betrayal sensitivity occurs trans-diagnostically. There may be a specific link between the development of OCD and the perception of betraying others, perhaps linked to the trauma of being betrayed making those so affected more likely to worry about their own responsibility for betraying others. PRACTITIONER POINTS: Clinicians should, across diagnoses, attend to sensitivity to being betrayed and the experiences which may have led to this. Current treatments for MC OCD recommend working with historical experiences of 'betrayal'. This study suggests that people with OCD also have an increased sensitivity to the idea of being a 'perpetrator' of betrayal linked to high responsibility beliefs. Specifically for OCD, it is possible that the experience of previously being betrayed results in increased current sensitivity to being responsible for being a 'betrayer'. It may, therefore, also be useful for therapists to consider if patients with MC OCD are concerned about potentially betraying others and to consider this within the formulation. The focus of clinical work could be to redefine these difficulties by reappraising beliefs regarding experience of betrayal and the likelihood of betraying others. Elevated levels of betrayal sensitivity were found in people with depression, and this may need to be considered in treatment approaches.

Abstract thinking as a risk factor for the development of posttraumatic stress disorder symptoms in student paramedics.

cognitive processing is characterized by "why?" and "what if?" questions and associated with processes such as rumination and worry. The tendency to think abstractly in response to stress has not been examined as a longitudinal risk factor for later stress reactions. The present study evaluated the extent to which an abstract thinking style could represent a risk factor for posttraumatic stress disorder (PTSD) symptoms in student paramedics over a 6-month follow-up period. Student paramedics (N = 89) recruited from universities in the United Kingdom were assessed for baseline symptoms, abstract thinking, and cognitive responses to stressful memories; a follow-up assesment was conducted 6 months later in their training. All participants were exposed to a potentially traumatic event between baseline and follow-up. Baseline symptoms and trauma history accounted for 45% of the variation in follow-up posttraumatic symptoms, with abstract thinking style explaining an additional 2.5% over and above what could be predicted from initial symptom levels. Abstract thinking was moderately related to rumination in response to stressful memories, r = .45, and correlated with follow-up symptoms of PTSD, r = .49; anxiety, r = .40; and depression, r = .27. This study builds on previous work suggesting that abstract processing mode and abstract rumination are risk factors for PTSD. Abstract thinking in response to stress represents a potentially modifiable risk factor that could be targeted by a resilience-focused intervention for individuals likely to encounter traumatic events.

"I'm So Tired": Fatigue as a Persistent Physical Symptom among Working People Experiencing Exhaustion Disorder.

Fatigue is widespread in the population, particularly among working people. Exhaustion disorder (ED), a clinical manifestation of burnout, is common, but, after treatment, about one-third still experience fatigue and other physical symptoms. We propose that in some instances, fatigue as a persistent physical symptom (PPS) might be a more appropriate formulation of ED patients' fatigue problems, and we suggest that ED patients who meet fatigue PPS criteria will differ from other ED patients in terms of psychological distress, non-fatigue PPSs and functional impairment. Questionnaires were sent to 10,956 members of a trade union of which 2479 (22.6%) responded. Of 1090 participants who met criteria for ED, 106 (9.7%) met criteria for fatigue as a PPS. Participants who met fatigue PPS criteria scored on average higher on measures of depression, anxiety and functional impairment and were more likely to have clinically significant scores. Moreover, they had 27 times higher odds of meeting other PPS subtypes and reported more non-fatigue PPS subtypes, suggesting a more complex health problem. Specific evidence-based interventions are available for both ED and PPSs, and therefore, it is crucial to accurately formulate the fatigue problem reported by patients to provide appropriate treatment.

Negative interpretations of ambiguous 'psychosis-like' and 'anxiety-like' experiences in recovery from psychosis or anxiety.

OBJECTIVES: Fear of relapse (FOR) after experiencing psychosis has been found to predict actual relapse; however, potential mechanisms underlying this relationship have not been investigated. Negative appraisals of 'prodromal symptoms' are believed to play an important role in both psychosis and mental health anxiety (MHA). This study aimed to explore whether people in recovery from psychosis or anxiety disorders show an enduring tendency to negatively interpret ambiguous experiences both related and less related to their previous mental health difficulty relative to controls. DESIGN: Cross-sectional between-groups questionnaire design. METHODS: Participants self-reported as in recovery from psychosis (n = 33) or anxiety (n = 77) or without previous experience of mental health problems (n = 61) were recruited online or via NHS services. Interpretations of psychosis-like, anxiety-like, and external-control experiences were measured using the newly developed Experiences Interpretation Questionnaire (EIQ). MHA and FOR were measured using self-report questionnaires. RESULTS: People in recovery from psychosis interpreted psychosis-like experiences significantly more negatively than the other groups. Negative interpretations of anxiety-like experiences were greater than controls but comparable between mental health groups. Contrary to predictions, FOR was not significantly different between the mental health groups. MHA and FOR did not significantly predict negative interpretations of psychosis-like items in the psychosis group, however, MHA predicted negative interpretations of anxiety-like items in the anxiety group. The EIQ subscales demonstrated good test-retest reliability. CONCLUSIONS: People in self-defined recovery from psychosis or anxiety are more likely to negatively interpret ambiguous experiences relating to their previous mental health difficulties. Clinical and future research implications are outlined. PRACTITIONER POINTS: People in recovery from psychosis or anxiety appraise possible symptoms of their previous difficulties negatively/catastrophically (as indicating relapse) relative to those without prior MH problems. Clinicians should consider attending to how people in recovery appraise possible symptoms when encouraging early signs monitoring as part of relapse prevention. This may be important to ensure that self-monitoring leads to helpful responses rather than being counterproductive, with catastrophic interpretations leading to anxiety and thus increasing the risk of relapse. Interventions drawing on CBT principles to address catastrophic interpretations of possible symptoms may potentially be a useful addition to relapse prevention work; in psychosis this may also include symptoms of anxiety.

Cognitive analysis of specific threat beliefs and safety-seeking behaviours in generalised anxiety disorder: revisiting the cognitive theory of anxiety disorders.

BACKGROUND: Generalised anxiety disorder (GAD) has been an uneasy member of the anxiety disorders group since its inclusion in the third edition of the DSM. Multiple theories and treatment protocols for GAD and its defining symptom, excessive worry, have comparable efficacy in treating GAD symptoms. Crucially, these theories of GAD and excessive worry fail to explain when and why worry is excessive and when it is adaptive. AIMS: In this paper we propose a cognitive behavioural account of the difference between excessive and adaptive states of worry and explore the theme of threat and the function of safety-seeking behaviours as seen in GAD. Specifically, we incorporate the concept of inflated responsibility in a cognitive behavioural analysis of threat appraisal and safety-seeking behaviours in excessive worry and GAD. CONCLUSION: It is proposed that when worry is used as a strategy intended to increase safety from perceived social or physical threat then it should be conceptualised as a safety-seeking behaviour. However, when worry is used as a strategy to solve a problem which the person realistically can resolve or to deal explicitly with the feeling of anxiety then it functions as an adaptive coping behaviour. We also propose that the theme of threat in GAD centres on an inflated sense of responsibility for external everyday situations, and the function of safety-seeking behaviours is to attain certainty that responsibility has been fulfilled. The clinical implications of this cognitive behavioural analysis of excessive worry are discussed, as well as future research directions.

[Prevalence of persistent physical symptoms and association with depression, anxiety and health anxiety in Iceland].

INTRODUCTION: Persistent physical symptoms that are medically unexplained can result in significant functional impairment. The aim of this study was to estimate the prevalence of persistent physical symptoms among people seeking primary healthcare in Reykjavík, Iceland, how they relate to functional impairment, symptoms of depression, general anxiety and health anxiety, and estimate the proportion of people with such symptoms who would likely benefit from psychological treatment. MATERIALS AND METHODS: Questionnaires measuring persistent physical symptoms, functional impairment, and symptoms of depression, general anxiety and health anxiety were administered to 106 patients attending two primary healthcare clinics. RESULTS: The prevalence of persistent physical symptoms was 27.4% among the primary care patients and they had a strong relationship to symptoms of mental disorders. Participants with persistent physical symptoms were 8 times more likely to have clinical levels of depression and general anxiety than participants without such symptoms, 4 times more likely to have clinical levels of health anxiety and 13 times more likely to have clinical levels of functional impairment. At least two-thirds of participants with persistent physical symptoms would likely benefit from psychological treatment. CONCLUSION: The prevalence of persistent physical symptoms among health care patients in the capital area of Iceland is in line with previous studies. Similarly, the strong relationship between persistent physical symptoms and symptoms of depression and anxiety corresponds to previous studies. It is likely that at least two out of three patients with persistent physical symptoms would benefit from psychological treatment. Transdiagnostic cognitive behavioural therapy for persistent physical symptoms might be particularly useful as is focuses on the interplay between physical and mental symptoms.

Evaluation of mechanism of change in transdiagnostic cognitive behaviour therapy using single case experimental design.

BACKGROUND AND OBJECTIVES: Transdiagnostic mechanisms of change (txMOC) specific to cognitive behaviour therapy are poorly understood. Salkovskis (1996) proposed one such mechanism in terms of the shift towards an alternative, less negative view of their problems or cognitive flexibility. This hypothesis has been described as involving a shift in beliefs, from "theory A″ to "theory B". The objective of this research was to evaluate this hypothesis. METHODS: Effectiveness of a novel txCBT and temporal changes in process and symptom measures were evaluated using a non-concurrent multiple baseline design and Tau-U calculations with thirteen participants (five with obsessive-compulsive disorder, two with panic disorder with agoraphobia and six with major depressive disorder). As a secondary analysis authors calculated Kendall's - Tau correlation between process and symptom measures, performed the Wilcoxon signed-rank test to assess treatment modules effect on negative thought and calculated Reliable change index (RCI). RESULTS: The txCBT was clearly effective for eight participants. The results varied dependent on the stimuli evaluated as negative or threatening. Level and trend of the ratings of belief in theory A followed the level and trend of symptom measures to a greater extent than the (inverse) level and trend of belief in theory B. LIMITATIONS: Only thirteen participants were recruited and evaluated. CONCLUSIONS: The results are consistent with the view that effective treatment may involve a txMOC characterized by the ability to shift from a relatively fixed negative view of their experience to a less negative psychologically focused alternative.