Changes in Intrapersonal Factors of Participants in the Pregnancy Remote Monitoring Study Who Are at Risk for Pregnancy-Induced Hypertension: Descriptive Quantitative Study.

BACKGROUND: The peripartum period, defined as the period from the beginning of the gestation until 1 year after the delivery, has long been shown to be potentially associated with increased levels of stress and anxiety with regard to one's transition to the status of parent and the accompanying parental tasks. Yet, no research to date has investigated changes in intrapersonal factors during the peripartum period in women at risk for pregnancy-induced hypertension (PIH). OBJECTIVE: The aim of this study is to explore and describe changes in intrapersonal factors in participants at risk for PIH. METHODS: We used an explorative design in which 3 questionnaires were sent by email to 110 participants the day following enrollment in the Pregnancy Remote Monitoring program for pregnant women at risk for PIH. Women were invited to complete the questionnaires at the beginning of their participation in the Pregnancy Remote Monitoring project (mostly at 14 weeks of gestation) and after approaching 32 weeks of gestational age (GA). The Generalized Anxiety Disorder-7 Scale (GAD-7) and the Patient Health Questionnaire-9 were used to assess anxiety and depression, and adaptation of the Pain Catastrophizing Scale was used to measure trait pain catastrophizing. RESULTS: Scores were significantly higher at 32 weeks of GA than at the moment of enrollment (GAD-7 score=7, range 4-11 vs 5, range 3-8; P=.01; and Patient Health Questionnaire-9 score=6, range 4-10 vs 4, range 2-7; P<.001). The subscale scores of the Pain Catastrophizing Scale were all lower at 32 weeks of GA compared with 14 weeks of GA (rumination: 4, range 1-6 vs 5, range 2-9.5; P=.11; magnification: 3, range 1-5.5 vs 4, range 3-7; P=.04; and helplessness: 5, range 2-9 vs 6, range 3.5-12; P=.06). The proportion of women with a risk for depression (GAD-7 score >10) was 13.3% (10/75) at enrollment and had increased to 35.6% (26/75) at 32 weeks of GA. CONCLUSIONS: This study shows that pregnant women at risk for PIH have higher levels of stress and anxiety at 32 weeks of GA than at the moment of enrollment. Further research is recommended to investigate potential strategies to help pregnant women at risk for PIH manage feelings of stress and anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/study/NCT03246737.

Generalization of fear of movement-related pain and avoidance behavior as predictors of work resumption after back surgery: a study protocol for a prospective study (WABS).

BACKGROUND: Previous studies indicated that about 20% of the individuals undergoing back surgery are unable to return to work 3 months to 1 year after surgery. The specific factors that predict individual trajectories in postoperative pain, recovery, and work resumption are largely unknown. The aim of this study is to identify modifiable predictors of work resumption after back surgery. METHODS: In this multisite, prospective, longitudinal study, 300 individuals with radicular pain undergoing a lumbar decompression will be followed until 1-year post-surgery. Prior to surgery, participants will perform a computer task to assess fear of movement-related pain, avoidance behavior, and their generalization to novel situations. Before and immediately after surgery, participants will additionally complete questionnaires to assess fear of movement-related pain, avoidance behavior, optimism, expectancies towards recovery and work resumption, and the duration and severity of the pain. Six weeks, 3 months, 6 months, and 12 months after surgery, they will again complete questionnaires to assess sustainable work resumption, pain severity, disability, and quality of life. The primary hypothesis is that (generalization of) fear of movement-related pain and avoidance behavior will negatively affect sustainable work resumption after back surgery. Second, we hypothesize that (generalization of) fear of movement-related pain and avoidance behavior, negative expectancies towards recovery and work resumption, longer pain duration, and more severe pain before the surgery will negatively affect work resumption, pain severity, disability, and quality of life after back surgery. In contrast, optimism and positive expectancies towards recovery and work resumption are expected to predict more favorable work resumption, better quality of life, and lower levels of pain severity and disability after back surgery. DISCUSSION: With the results of this research, we hope to contribute to the development of strategies for early identification of risk factors and appropriate guidance and interventions before and after back surgery. Trial registration The study was preregistered on ClinicalTrials.gov: NCT04747860 on February 9, 2021.

Relationship Between Adherence to Remote Monitoring and Patient Characteristics: Observational Study in Women With Pregnancy-Induced Hypertension.

BACKGROUND: Pregnancy-induced hypertension (PIH) is associated with high levels of morbidity and mortality in mothers, fetuses, and newborns. New technologies, such as remote monitoring (RM), were introduced in 2015 into the care of patients at risk of PIH in Ziekenhuis Oost-Limburg (Genk, Belgium) to improve both maternal and neonatal outcomes. In developing new strategies for obstetric care in pregnant women, including RM, it is important to understand the psychosocial characteristics associated with adherence to RM to optimize care. OBJECTIVE: The aim of this study was to explore the role of patients' psychosocial characteristics (severity of depression or anxiety, cognitive factors, attachment styles, and personality traits) in their adherence to RM. METHODS: Questionnaires were sent by email to 108 mothers the day after they entered an RM program for pregnant women at risk of PIH. The Generalized Anxiety Disorder Assessment-7 and Patient Health Questionnaire-9 (PHQ-9) were used to assess anxiety and the severity of depression, respectively; an adaptation of the Pain Catastrophizing Scale was used to assess cognitive factors; and attachment and personality were measured with the Experiences in Close Relationships-Revised Scale (ECR-R), the Depressive Experiences Questionnaire, and the Multidimensional Perfectionism Scale, respectively. RESULTS: The moderate adherence group showed significantly higher levels of anxiety and depression, negative cognitions, and insecure attachment styles, especially compared with the over adherence group. The low adherence group scored significantly higher than the other groups on other-oriented perfectionism. There were no significant differences between the good and over adherence groups. Single linear regression showed that the answers on the PHQ-9 and ECR-R questionnaires were significantly related to the adherence rate. CONCLUSIONS: This study demonstrates the relationships between adherence to RM and patient characteristics in women at risk of PIH. Alertness toward the group of women who show less than optimal adherence is essential. These findings call for further research on the management of PIH and the importance of individual tailoring of RM in this patient group. TRIAL REGISTRATION: ClinicalTrials.gov NCT03509272; https://clinicaltrials.gov/ct2/show/NCT03509272.

How to Train Experienced Therapists in a New Method: A Qualitative Study into Therapists' Views.

BACKGROUND: Implementation of new effective treatments involves training, supervision and quality control of therapists, who are used to utilize other methods. Not much is known about therapists' views on how new psychotherapy methods should be taught. OBJECTIVE: The purpose of this study is to get insight in how experienced therapists experience the training in a new method so that training methods for experienced therapists can be improved. METHOD: Qualitative research using focus groups. For an RCT on the effectiveness of schema therapy (ST) for six personality disorders more than 80 therapists were trained in ST. They applied the ST-protocol after 4-day training, with peer supervision and limited expert supervision. Sixteen of these trained ST therapists from seven health institutions participated in the focus groups. The transcripts and records of the focus groups were analyzed on repeating themes and subthemes and in terms of higher order categories. RESULTS: Therapists appreciated didactical learning methods but particularly valued experiential learning. Especially, novice ST therapists missed role plays, feedback to learn required skills and attitudes, and attention to their resistance to new techniques (e.g., empathic confrontation and imagery). Peer supervision gave emotional recognition, but therapists lacked regular advice from an ST-expert. CONCLUSIONS: In teaching a new therapeutic method didactic teaching is necessary, but experiential learning is decisive. Experiential learning includes practicing the new therapy and reflecting on one's experiences, including resistance against new methods. Emphatic confrontation, case conceptualization, role play, peer supervision and opportunities to ask an expert supervisor during peer supervision are found to be helpful. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Especially by Eperiential learning besides didactic learning. By practicing with many role plays including feedback. By reflecting on one's experiences including resistance against ingredients of the new method. By peer supervision with opportunities to ask an expert supervisor.

Schema Therapy for Personality Disorders: a Qualitative Study of Patients' and Therapists' Perspectives.

BACKGROUND: Several studies have evaluated the (cost) effectiveness of schema therapy for personality disorders, but little research has been done on the perspectives of patients and therapists. AIM: The present study aims to explore patients' and therapists' perspectives on schema therapy. METHOD: Qualitative data were collected through in-depth semi-structured interviews with 15 patients and a focus group of 8 therapists. A thematic analysis was performed. RESULTS: Most patients and therapists agreed that helpful aspects in schema therapy were the highly committed therapeutic relationship, the transparent and clear theoretical model, and the specific schema therapy techniques. About unhelpful aspects, several patients and some therapists shared the opinion that 50 sessions was not enough. Furthermore, patients lacked clear advance information about the possibility that they might temporarily experience stronger emotions during therapy and the possibility of having telephone contact outside session hours. They missed practical goals in the later stage of therapy. With regard to imagery, patients experienced time pressure and they missed a proper link between the past and the present. For therapists, it was hard to manage the therapeutic relation, to get used to a new kind of therapy and to keep the treatment focused on personality problems. CONCLUSIONS: Patients and therapists found some aspects of the schema therapy protocol helpful. Their views about which aspects are unhelpful and their recommendations need to be taken into consideration when adjusting the protocol and implementing schema therapy.

Economic evaluation of schema therapy and clarification-oriented psychotherapy for personality disorders: a multicenter, randomized controlled trial.

PURPOSE: To compare from a societal perspective the cost-effectiveness and cost-utility of schema therapy, clarification-oriented psychotherapy, and treatment as usual for patients with avoidant, dependent, obsessive-compulsive, paranoid, histrionic, and/or narcissistic personality disorder. METHOD: A multicenter, randomized controlled trial, single-blind parallel design, was conducted between May 2006 and December 2011 in 12 Dutch mental health institutes. Data from 320 patients (diagnosed according to DSM-IV criteria) randomly assigned to schema therapy (n = 145), treatment as usual (n = 134), or clarification-oriented psychotherapy (n = 41) were analyzed. Costs were repeatedly measured during 36 months by interview and patient registries. Primary outcome measures were proportion of recovered patients as measured with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders for the cost-effectiveness analysis, and quality-adjusted life-years (QALYs) for the cost-utility analysis. Bootstrap replications in the cost-effectiveness and the cost-utility planes were used to estimate the probability that one treatment was more cost-effective than the other. Mixed gamma regression on net monetary benefit for different levels of willingness to pay for extra effects was used as sensitivity analysis. Additional sensitivity analyses were done to assess robustness of the results. RESULTS: Due to higher clinical effects and lower costs, schema therapy was dominant over the other treatments in the cost-effectiveness analyses. Schema therapy has the probability of being the most cost-effective treatment (78% at €0 to 96% at €37,500 [$27,375] willingness to pay per extra recovery). Treatment as usual was more cost-effective than clarification-oriented psychotherapy due to lower costs. In the cost-utility analysis, schema therapy had a stable 75% probability of being cost-effective. Sensitivity analyses confirmed these findings. CONCLUSIONS: The results support the cost-effectiveness of schema therapy but not of clarification-oriented psychotherapy. TRIAL REGISTRATION: Netherlands Trial Register NTR566.

The impact of comorbid depression on recovery from personality disorders and improvements in psychosocial functioning: results from a randomized controlled trial.

Depressive disorders often co-occur with personality disorders. The extent to which depressive disorders influence treatment outcome in personality disorders remains unclear. The aim of this study was to determine the impact of co-morbid depression on recovery from personality disorders and improvements in psychosocial functioning. This study drew data from a randomized-controlled trial in which patients (N = 320) with cluster-c (92%), paranoid, histrionic and/or narcissistic personality disorders received schema-therapy, treatment-as-usual, or clarification-oriented psychotherapy. Recovery from personality disorders at three-year follow-up and improvements in psychosocial functioning over a course of three years was predicted by the diagnostic status of depressive disorders at baseline using mixed model regression analyses. Based on the number of axis-I and axis-II disorders, personality disorder severity and global symptomatic distress and functioning a baseline severity index was computed and included in subsequent analyses to test the specificity of baseline depression in predicting outcomes. Patients with co-occurring depression reported higher baseline severity compared to patients without co-occurring depression. Depression at baseline was associated with lower recovery rates at three-year follow-up (p = 0.01) but this effect disappeared after controlling for baseline severity. Patients with depression at baseline reported higher psychosocial impairments throughout treatment (p < 0.001). Depression at baseline did not moderate treatment effects except for one psychosocial outcome measure. In conclusion, depression is associated with lower recovery rates from personality disorders but this effect disappears when general severity is taken into account. Patients with primarily cluster-c personality disorders and co-occurring depression might benefit from additional depression treatment in terms of improved psychosocial functioning.

Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders.

OBJECTIVE: The authors compared the effectiveness of 50 sessions of schema therapy with clarification-oriented psychotherapy and with treatment as usual among patients with cluster C, paranoid, histrionic, or narcissistic personality disorder. METHOD: A multicenter randomized controlled trial, with a single-blind parallel design, was conducted between 2006 and 2011 in 12 Dutch mental health institutes. A total of 323 patients with personality disorders were randomly assigned (schema therapy, N=147; treatment as usual, N=135; clarification-oriented psychotherapy, N=41). There were two cohorts of schema therapy therapists, with the first trained primarily with lectures and the second primarily with exercises. The primary outcome was recovery from personality disorder 3 years after treatment started (assessed by blinded interviewers). Secondary outcomes were dropout rates and measures of personality disorder traits, depressive and anxiety disorders, general psychological complaints, general and social functioning, self-ideal discrepancy, and quality of life. RESULTS: A significantly greater proportion of patients recovered in schema therapy compared with treatment as usual and clarification-oriented psychotherapy. Second-cohort schema therapists had better results than first-cohort therapists. Clarification-oriented psychotherapy and treatment as usual did not differ. Findings did not vary with specific personality disorder diagnosis. Dropout was lower in the schema therapy and clarification-oriented psychotherapy conditions. All treatments showed improvements on secondary outcomes. Schema therapy patients had less depressive disorder and higher general and social functioning at follow-up. While interview-based measures demonstrated significant differences between treatments, differences were not found with self-report measures. CONCLUSIONS: Schema therapy was superior to treatment as usual on recovery, other interview-based outcomes, and dropout. Exercise-based schema therapy training was superior to lecture-based training.

Consistency of reporting sexual and physical abuse during psychological treatment of personality disorder: an explorative study.

The objective of this study was to assess the prevalence of decreasing, consistent and increasing reports of sexual and physical abuse after 12 months of long-term psychological treatment of personality disorders, to investigate demographic and clinical characteristics predictive of inconsistency of reporting abuse, and to explore whether autobiographical memory may account for this inconsistency. In 229 clinical participants with an SCID II diagnosed personality disorder, 180 (78.6%) reported the same instances of invasive sexual and/or physical abuse on a trauma questionnaire (SPAQ) at baseline and follow-up, 25 (10.9%) decreased and 24 (10.4%) increased their abuse reports. Consistency of reporting abuse did not differ between schema-focused therapy, clarification-oriented psychotherapy and treatment-as-usual. Current depressive episode (SCID-I) and decreased capacity to produce specific negative memories on the Autobiographical Memory Test were characteristic of decreasing abuse reporters, while increasing abuse reporters showed higher levels of Cluster A personality pathology (in particular schizotypal traits) on the Assessment of DSM-IV Personality Disorders (ADP-IV). These results suggest that even in treatment procedures directed at exploring someone's personal past with abuse-related imagery consistency of reporting abuse is quite stable. However, certain clinical characteristics may make some persons more likely to change their trauma reports. Moreover, reduced negative memory specificity may represent an avoidant strategy associated with no longer reporting instances of abuse.

Changes in natural language use as an indicator of psychotherapeutic change in personality disorders.

Word use has been shown to reflect various psychological processes and psychological change. This study examines the self-view in personality disorders (PDs) and its change over the course of therapy using the Linguistic Inquiry and Word Count analysis procedure. A sample of 299 participants with PDs and 108 community control participants wrote short essays about their lives. Patients repeated the assignment three times over two years and completed assessments of PD-pathology, general psychopathology, PD-beliefs, and quality of life. Results show that as hypothesized the use of words in the 1st Person Singular Pronouns, Negative Emotion, Causation, Past and Future Tense Verbs categories significantly declines over the course of treatment, while the use of Present Tense Verbs and Positive Emotion increases. These categories tend to distinguish patients from non-patients prior to treatment. We also found 12 additional word categories changing over time, including Word Count and Negations. Change in word use statistically predicts better treatment outcome on all outcome measures (p < .001). Reductions in the use of Negative Emotion Words and Negations are the strongest predictors of outcome. The non-hypothesized role of Negations was explored and seemed to reflect that PD-patients miss a lot in their lives. Reduction of what they miss seems central to recovery. This issue seems relatively neglected in theoretical and treatment models of PDs. An increased focus on what patients miss in their lives might improve our understanding and treatment of PDs. In sum, Negative Emotion and Negation word categories appear to reflect key treatment targets.

Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders.

BACKGROUND: Despite international guidelines describing psychotherapy as first choice for people with personality disorders (PDs), well-designed research on the effectiveness and cost-effectiveness of psychotherapy for PD is scarce. Schema therapy (ST) is a specific form of psychological treatment that proved to be effective for borderline PD. Randomized controlled studies on the effectiveness of ST for other PDs are lacking. Another not yet tested new specialized treatment is Clarification Oriented Psychotherapy (COP). The aim of this project is to perform an effectiveness study as well as an economic evaluation study (cost effectiveness as well as cost-utility) comparing ST versus COP versus treatment as usual (TAU). In this study, we focus on avoidant, dependent, obsessive-compulsive, paranoid, histrionic and narcissistic PD. METHODS/DESIGN: In a multicentered randomized controlled trial, ST, and COP as an extra experimental condition, are compared to TAU. Minimal 300 patients are recruited in 12 mental health institutes throughout the Netherlands, and receive an extensive screening prior to enrolment in the study. When eligible, they are randomly assigned to one of the intervention groups. An economic evaluation and a qualitative research study on patient and therapist perspectives on ST are embedded in this trial. Outcome assessments (both for clinical effectiveness and economic evaluation) take place at 6,12,18,24 and 36 months after start of treatment. Primary outcome is recovery from PD; secondary measures include general psychopathological complaints, social functioning and quality of life. Data for the cost-effectiveness and cost-utility analyses are collected by using a retrospective cost interview. Information on patient and therapist perspectives is gathered using in-depth interviews and focus groups, and focuses on possible helpful and impeding aspects of ST. DISCUSSION: This trial is the first to compare ST and COP head-to-head with TAU for people with a cluster C, paranoid, histrionic and/or narcissistic PD. By combining clinical effectiveness data with an economic evaluation and with direct information from primary stakeholders, this trial offers a complete and thorough view on ST as a contribution to the improvement of treatment for this PD patient group. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR566.

Extended Schema Mode conceptualizations for specific personality disorders: an empirical study.

The aim of this study was to investigate newly formulated schema mode models for cluster-C, paranoid, histrionic and narcissistic personality disorders. In order to assess 18 hypothesized modes, the Schema Mode Inventory (SMI) was modified into the SMI-2. The SMI-2 was administered to a sample of 323 patients (with a main diagnosis on one of the PDs mentioned) and 121 nonpatients. The SMI-2 was successful in distinguishing patients and controls. Newly formulated modes proved to be appropriate for histrionic, avoidant, and dependent PD. The modification of the Overcontroller mode into the Perfectionistic and Suspicious Overcontroller mode was valuable for characterizing paranoid and obsessive-compulsive PD. The results support recent theoretical developments in Schema Therapy, and are useful for application in clinical practice.

Word use of outpatients with a personality disorder and concurrent or previous major depressive disorder.

In a recent study, Rude, Gortner, and Pennebaker (2004) found word use to be related to depression and vulnerability to depression in the essays of college students. We sought to replicate and extend these findings in a clinical sample. Written essays of 304 psychiatric outpatients with a personality disorder and a mixed psychiatric profile on DSM-IV axis-I and 108 healthy controls were examined with word count software. Data on the tendency to be discrepant about the current self compared to a more ideal self were also gathered. We found that psychiatric outpatients in general used more words referring to the self and negative emotion words and fewer positive emotion words, compared to healthy controls. However, word-use proved unrelated to depression specifically. Actual-ideal self discrepancies were related to patient status and to current depression. Contrary to our hypothesis, these discrepancies did not correlate with the use of words referring to the self. We conclude that the negative content and self-focus of written essays and high levels of discrepancy reflect a negative thinking style that is common to a range of psychiatric disorders rather than being specific to depression.

Reduced specificity of autobiographical memory in Cluster C personality disorders and the role of depression, worry, and experiential avoidance.

The study objective was to investigate whether, compared with nonclinical controls, participants with an avoidant, dependent, or obsessive-compulsive Cluster C personality disorder (PD) manifested reduced levels of memory specificity and whether the association of Cluster C PDs with memory specificity is mediated by repetitive negative thoughts and experiential avoidance. The Autobiographical Memory Test (R. J. McNally, N. B. Lasko, M. L. Macklin, & R. K. Pitman, 1995) was administered along with self-report measures (translated into Dutch) for repetitive, uncontrollable, and negative thinking in the form of worry (Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990) and experiential avoidance (Acceptance and Action Questionnaire; S. C. Hayes et al., 2004) to 294 clinical participants diagnosed with Axis I disorders (assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I]; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1994) and Axis II disorders (assessed with the SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1997)--202 with avoidant, 49 with dependent, and 120 with obsessive-compulsive PD--and to 108 matched nonclinical controls. Participants with a Cluster C PD showed lower levels of memory specificity than did nonclinical controls. Depression and worry mediated the effect of Cluster C PDs on memory specificity. Besides depression severity, repetitive, uncontrollable, and negative thinking may constitute a general mechanism mediating the association of various Axis I and II disorders with memory specificity.