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

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

Leveraging Single-Case Experimental Designs to Promote Personalized Psychological Treatment: Step-by-Step Implementation Protocol with Stakeholder Involvement of an Outpatient Clinic for Personalized Psychotherapy.

Our objective is to implement a single-case experimental design (SCED) infrastructure in combination with experience-sampling methods (ESM) into the standard diagnostic procedure of a German outpatient research and training clinic. Building on the idea of routine outcome monitoring, the SCED infrastructure introduces intensive longitudinal data collection, individual effectiveness measures, and the opportunity for systematic manipulation to push personalization efforts further. It aims to empower psychotherapists and patients to evaluate their own treatment (idiographic perspective) and to enable researchers to analyze open questions of personalized psychotherapy (nomothetic perspective). Organized around the principles of agile research, we plan to develop, implement, and evaluate the SCED infrastructure in six successive studies with continuous stakeholder involvement: In the project development phase, the business model for the SCED infrastructure is developed that describes its vision in consideration of the context (Study 1). Also, the infrastructure's prototype is specified, encompassing the SCED procedure, ESM protocol, and ESM survey (Study 2 and 3). During the optimization phase, feasibility and acceptability are tested and the infrastructure is adapted accordingly (Study 4). The evaluation phase includes a pilot implementation study to assess implementation outcomes (Study 5), followed by actual implementation using a within-institution A-B design (Study 6). The sustainability phase involves continuous monitoring and improvement. We discuss to what extent the generated data could be used to address current questions of personalized psychotherapy research. Anticipated barriers and limitations during the implementation processes are outlined.

Change in pain expectations but no open-label placebo analgesia: An experimental study using the heat pain paradigm.

BACKGROUND: Open-label placebos (OLP) prescribed without deception and with a convincing rationale have been shown to evoke powerful treatment effects. Patients' treatment expectations seem to influence the magnitude of the effect. OBJECTIVE: We examined if two different OLP rationales increased pain tolerance and reduced pain intensity and unpleasantness in a standardized heat pain experiment. METHODS: Participants (N = 71) who self-reported reoccurring pain for at least the last 3 months were randomly assigned to one of three groups. We compared a personal-emotional and a scientific-matter-of-fact rationale with a control group (CG) that received the same placebo without any rationale. The rationale suggested a desensitizing effect on pain perception and improved pain coping of the placebo, whereas in the CG it was introduced as an ointment for measurement. The primary outcomes were pre-post changes in pain tolerance, expected and experienced pain intensity and unpleasantness. RESULTS: Participants showed a decrease in expected pain intensity, but not expected pain unpleasantness for both rationales. There were no differences in pain tolerance and experienced pain intensity and unpleasantness. CONCLUSIONS: Our study suggests that evoking positive treatment expectations is not sufficient to elicit an OLP response. Possibly, the magnitude of expectations change in this study was not powerful enough to evoke an OLP effect. Additionally, it is possible that OLP effects in pain are unrelated to positive treatment expectations. The failure of OLP in our study is in contrast to a number of previous studies examining the effects of OLP in experimental and clinical pain. SIGNIFICANCE: This study provides evidence that positive treatment expectations are not sufficient to evoke an open-label placebo effect in a standardized heat pain experiment. We showed that two different rationales improved participants treatment expectations, but failed to evoke a placebo effect in comparison to a control group that received the same placebo, labelled as an ointment to improve measurement quality.

How negative mood hinders belief updating in depression: results from two experimental studies.

BACKGROUND: In two experimental studies, we tested the hypothesis that negative mood would hinder the revision of negative beliefs in response to unexpectedly positive information in depression, whereas positive mood was expected to enhance belief updating. METHODS: In study 1 (N = 101), we used a subclinical sample to compare the film-based induction of sad v. happy mood with a distraction control group. Subsequently, participants underwent a well-established paradigm to examine intra-individual changes in performance-related expectations after unexpectedly positive performance feedback. In study 2, we applied the belief-updating task from study 1 to an inpatient sample (N = 81) and induced sad v. happy mood via film-clips v. recall of autobiographic events. RESULTS: The results of study 1 showed no significant group differences in belief updating; the severity of depressive symptoms was a negative predictor of belief revision, though, and there was a non-significant trend suggesting that the presence of sad mood hindered belief updating in the subgroup of participants with a diagnosed depressive episode. Study 2 revealed that participants updated their expectations significantly less in line with positive feedback when they underwent the induction of negative mood prior to feedback, relative to positive mood. CONCLUSIONS: By indicating that the presence of negative mood can hinder the revision of negative beliefs in clinically depressed people, our findings suggest that learning from new experiences can be hampered if state negative mood is activated. Thus, interventions relying on learning from novel positive experiences should aim at reducing state negative mood in depression.

Feeling lonely during the pandemic: Towards personality-tailored risk profiles.

This is the first study to disentangle associations of within- and between-person fluctuations in loneliness and their effect on evening mood during a nationwide lockdown due to COVID-19. To contribute to the development of personality-tailored risk profiles, we additionally explored the moderating role of trait neuroticism and extraversion on the association of within- and between-person loneliness and mood. We employed an ambulatory assessment design during 21 days of nationwide lockdown in Germany (13/04/2020-03/05/2020) with two interval-based assessments. The final sample comprised 322 participants (74.5% women) aged between 15 and 82 years (M = 30.7, SD = 14.9) providing 6,084 evening assessments. Linear mixed models were used to evaluate the effects of within- and between-person fluctuations in loneliness on evening mood while controlling for unspecific effects of time, sex, and age. Moderation analysis was used to investigate the influence of neuroticism and extraversion on the relation between loneliness and mood, respectively. Results indicate that especially higher between-person loneliness (i.e. participants felt lonelier compared to the average participant) but also higher within-person loneliness (i.e. participants felt lonelier compared to their individual mean) were associated with a more unpleasant mood. Neuroticism augmented the effect of within-person loneliness, while extraversion seemed to buffer the effect of between-person loneliness on mood. Our findings underline the importance of carefully monitoring loneliness during COVID-19. The findings contribute towards the development of personality-tailored risk profiles (e.g. among newly arising risk groups for loneliness due to COVID-19). We discuss how the differential consideration of within- and between-psychological processes might help to elucidate currently mixed findings on psychological coping during the COVID-19 pandemic.

Effects of a video intervention on physicians' acceptance of pain apps: a randomised controlled trial.

OBJECTIVES: The aim of our study was to determine and enhance physicians' acceptance, performance expectancy and credibility of health apps for chronic pain patients. We further investigated predictors of acceptance. DESIGN: Randomised experimental trial with a parallel-group repeated measures design. SETTING AND PARTICIPANTS: 248 physicians working in various, mainly outpatient settings in Germany. INTERVENTION AND OUTCOME: Physicians were randomly assigned to either an experimental group (short video about health apps) or a control group (short video about chronic pain). Primary outcome measure was acceptance. Performance expectancy and credibility of health apps were secondary outcomes. In addition, we assessed 101 medical students to evaluate the effectiveness of the video intervention in young professionals. RESULTS: In general, physicians' acceptance of health apps for chronic pain patients was moderate (M=9.51, SD=3.53, scale ranges from 3 to 15). All primary and secondary outcomes were enhanced by the video intervention: A repeated-measures analysis of variance yielded a significant interaction effect for acceptance (F(1, 246)=15.28, p=0.01), performance expectancy (F(1, 246)=6.10, p=0.01) and credibility (F(1, 246)=25.61, p<0.001). The same pattern of results was evident among medical students. Linear regression analysis revealed credibility (ß=0.34, p<0.001) and performance expectancy (ß=0.30, p<0.001) as the two strongest factors influencing acceptance, followed by scepticism (ß=-0.18, p<0.001) and intuitive appeal (ß=0.11, p=0.03). CONCLUSIONS AND RECOMMENDATIONS: Physicians' acceptance of health apps was moderate, and was strengthened by a 3 min video. Besides performance expectancy, credibility seems to be a promising factor associated with acceptance. Future research should focus on ways to implement acceptability-increasing interventions into routine care.

Coping under a COVID-19 lockdown: patterns of daily coping and individual differences in coping repertoires.

BACKGROUND: Polyregulation-the concurrent or sequential use of multiple strategies to regulate affect or cope with stressors-is a frequent but understudied phenomenon. OBJECTIVES: We aimed to identify patterns of daily coping and individuals' coping repertoires (i.e., range of coping patterns employed across situations) during a COVID-19 pandemic lockdown. We investigated day-level covariates (appraisals, worrying, mood) of daily coping patterns and person-level covariates (psychopathology, average mood) of coping repertoires. Design: A non-representative community sample (n = 322, 15-82 years old) participated in a 21-day ambulatory assessment study. METHODS: We applied multilevel latent class analysis.. RESULTS: We identified seven daily coping patterns and ten classes of individuals differing in the size of their coping repertoire and their propensity for polyregulation. Daily coping patterns differed in daily perceived controllability and mood (but not in daily worrying or stress). At the person level, individuals with a higher level of average coronavirus-related worrying more frequently engaged in a high degree of polyregulation. The size of individuals' coping repertoire was unrelated to psychopathology and average mood. CONCLUSION: The findings provide insights into the composition of daily coping patterns and individuals' coping repertoires during crisis periods and contribute to a new polyregulation perspective on coping.

No Evidence for the Involvement of Cognitive Immunisation in Updating Beliefs About the Self in Three Non-Clinical Samples.

BACKGROUND: Cognitive immunisation against disconfirmatory evidence (i.e., devaluing expectation-disconfirming information through cognitive mechanisms) has recently been discussed as an obstacle to the revision of dysfunctional beliefs in mental disorders such as depression. Yet, it is unclear whether cognitive immunisation is also involved in belief updating in non-clinical samples. METHODS: Using a three-group modulation protocol (promotion vs. inhibition of cognitive immunisation vs. control group), we examined how cognitive immunisation influences belief updating in response to performance feedback in three non-clinical samples. In Experiments 1 (N = 99) and 2 (N = 93), participants received unexpectedly negative feedback, whereas participants from Experiment 3 (N = 118) received unexpectedly positive feedback. Depressive symptoms and dispositional optimism were examined as additional predictors of belief updating. RESULTS: In all experiments, participants adjusted their expectations in line with the feedback received, but this effect was not influenced by the cognitive immunisation manipulation. In Experiment 3, expectation change remained stable over 2 weeks. Depressive symptoms were associated with a reduced integration of positive feedback, but not with an increased sensitivity to negative feedback. CONCLUSIONS: Whereas previous research has shown that cognitive immunisation contributes to persistent beliefs in clinical populations, the present findings suggest that it does not affect belief updating in non-clinical samples. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10608-021-10256-y.

An attentional perspective on differential fear conditioning in chronic pain: The informational value of safety cues.

Differences in fear conditioning between individuals suffering from chronic pain and healthy controls may indicate a learning bias that contributes to the acquisition and persistence of chronic pain. However, evidence from lab-controlled conditioning studies is sparse and previous experiments have produced inconsistent findings. Twenty-five participants suffering from chronic back pain and twenty-five controls not reporting chronic pain took part in a differential fear conditioning experiment measuring attention (eye tracking) and autonomic arousal (pupil dilation and skin conductance) elicited by visual cues predicting the presence or absence of electric shock. In contrast to the healthy control group, participants with chronic pain did not acquire differential autonomic responding to cues of threat and safety and specifically failed to acquire any attentional preference for the safety cue over irrelevant contextual cues (while such preference was intact for the threat cue). We present simulations of a reinforcement learning model to show how the pattern of data can be explained by assuming that participants with chronic pain might have experienced less positive emotion (relief) when the electric shock was absent following safety cues. Our model shows how this assumption can explain both, reduced differential responding to cues of threat and safety as well as less selective attention to the safety cue.

Distorted Cognitive Processes in Major Depression: A Predictive Processing Perspective.

The cognitive model of depression has significantly influenced the understanding of distorted cognitive processes in major depression; however, this model's conception of cognition has recently been criticized as possibly too broad and unspecific. In this review, we connect insights from cognitive neuroscience and psychiatry to suggest that the traditional cognitive model may benefit from a reformulation that takes current Bayesian models of the brain into account. Appealing to a predictive processing account, we explain that healthy human learning is normally based on making predictions and experiencing discrepancies between predicted and actual events or experiences. We present evidence suggesting that this learning mechanism is distorted in depression: current research indicates that people with depression tend to negatively reappraise or disregard positive information that disconfirms negative expectations, thus resulting in sustained negative predictions and biased learning. We also review the neurophysiological correlates of such deficits in processing prediction errors in people with depression. Synthesizing these findings, we propose a novel mechanistic model of depression suggesting that people with depression have the tendency to predominantly expect negative events or experiences, which they subjectively feel confirmed due to reappraisal of disconfirming evidence, thus creating a self-reinforcing negative feedback loop. Computationally, we consider too much precision afforded to negative prior beliefs as the main candidate of pathology, accompanied by an attenuation of positive prediction errors. We conclude by outlining some directions for future research into the understanding of the behavioral and neurophysiological underpinnings of this model and point to clinical implications of it.

Self-compassion predicting pain, depression and anger in people suffering from chronic pain: A prospective study.

Self-compassion is associated with disability, pain-related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self-compassion versus other concepts such as psychological flexibility and self-esteem is unknown. The present study therefore aimed to clarify these relationships. Individuals with chronic pain (NCP = 872) and without chronic pain (NNP = 356) took part in a longitudinal study. Participants completed self-report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS-20), Patient Health Questionnaire (PHQ-9), State Trait Anger Expression Inventory (STAXI), Self-Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self-Esteem Scale (RSES). Assessments were repeated after 8 weeks. We found differences in baseline levels of all relevant variables except for anger-out and anger-control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (NCP), addressing the predictive value of reduced uncompassionate self-responding (RUS), compassionate self-responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self-esteem (RSES) regarding pain-related (PDI, PCS, PASS) and emotional variables (PHQ-9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain-related anxiety. Self-esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%-72.1% of the variance in pain-related variables, 68.7% of the variance in depression and 38.7%-60.7% in the variance of anger-related variables. In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self-compassion. Future research should focus on subgroups and tailored-treatment approaches. SIGNIFICANCE: Applying a longitudinal design, this study examined the predictive value of self-compassion regarding pain, depression and anger. The relevance of self-compassion was compared to psychological flexibility and self-esteem. We can conclude that psychological flexibility, in terms of avoidance behaviour, is the most relevant predictor concerning pain.

Belief updating in depression is not related to increased sensitivity to unexpectedly negative information.

BACKGROUND: People with depression differ from healthy people in the extent to which they use novel positive information to adjust negative expectations. In this study, we examined whether the two groups also differ in updating positive expectations after receiving unexpectedly negative information. METHODS: Examining 76 people with depressive symptoms and 81 healthy controls, we used an adapted version of a previously validated paradigm. After the initial establishment of positive performance expectations, participants worked on the TEMINT performance test, whereupon half of the participants received standardized feedback that confirmed previous positive expectations while the other half received disconfirming negative feedback. Subsequently, participants' performance expectations were assessed again. Additionally, we assessed participants' appraisal of the feedback, particularly whether they tended to disregard it. RESULTS: Results indicated that healthy subjects had overall more positive expectations than people with depressive symptoms, but the two samples did not differ in updating their expectations: both groups changed their expectations in a negative direction after receiving negative feedback; similarly, there were no differences between the two samples after receiving confirmatory positive feedback. Both people with and without depressive symptoms were more likely to disregard the feedback received if the feedback was negative, and such a negative appraisal of the feedback was associated with smaller expectation update. CONCLUSIONS: In combination with prior work, the current findings suggest that people with depressive symptoms do not over-sensitively react to unexpectedly negative information; rather, the main problem of depression seems to be the integration of novel positive information, as shown previously.

How to modify persisting negative expectations in major depression? An experimental study comparing three strategies to inhibit cognitive immunization against novel positive experiences.

BACKGROUND: Research has shown that negative expectations in major depressive disorder (MDD) often persist despite positive disconfirming experiences. To explain this phenomenon, the concept of cognitive immunization has been introduced: that is, individuals with MDD reappraise disconfirming positive evidence in such a way that negative expectations are maintained. In this study, we examined whether it is possible to inhibit cognitive immunization to facilitate expectation update. METHODS: We examined 113 people with MDD being treated in an inpatient psychosomatic hospital. Using a previously validated paradigm, participants worked on a standardized performance test; we examined changes in negative performance-related expectations after positive expectation-disconfirming feedback. One experimental group received additional information increasing the value of the positive feedback ('INFORMATION'). Another group was instructed to recall the feedback after completing the task ('RECALL'). In a third group, participants' attention was shifted to potential expectation-disconfirming feedback ('ATTENTION'). In addition, a control group underwent the standard procedure of the paradigm. RESULTS: The results showed significant group differences in the change in generalized performance expectations, with the largest changes in participants from the INFORMATION group. All experimental groups had lower values for cognitive immunization than the control group. LIMITATIONS: Given that this proof-of-concept study was the first to examine strategies to inhibit cognitive immunization, the findings need to be replicated in future studies. CONCLUSIONS: The present study confirms that cognitive immunization in MDD can be inhibited, thus facilitating adjusting negative expectations. The most promising results were found for the INFORMATION group, providing information to emphasize the relevance of expectation-disconfirming information.

Exposure and cognitive-behavioural therapy for chronic back pain: An RCT on treatment processes.

BACKGROUND: To improve treatment outcomes, it is essential to understand the processes involved in therapeutic change. The aim of this study was to investigate the processes involved in treatment of individuals with chronic lower back pain (CLBP) and high fear-avoidance. Graded in vivo exposure (Exposure), a specific treatment, and cognitive-behavioural therapy (CBT), a general treatment, were compared. METHODS: Our study used data from a three-arm randomized controlled trial. The sample comprised 61 CLBP patients (pain duration >3 months; sufficient level of fear-avoidance). Assessments of session-by-session processes were done weekly for a maximum 14 weeks. The primary outcome, functional disability, was assessed at pre-treatment, post-treatment and 6-months follow-up. First, two-level models were used to test for treatment-related similarities and differences in the changes in session-by-session measures (i.e., common and unique treatment processes respectively). Second, we analysed treatment processes as predictors of treatment outcome. RESULTS: Contrary to our expectations, we found no evidence of unique treatment processes. Our results indicate that Exposure and CBT share some treatment processes. Specifically, patients reported a reduction in fear of movement and improvements in their ability to relax, to distract themselves, to manage their pain, to confront feared movements, to be active and to enjoy things despite their pain. Changes in fear of movement, relaxation, distraction, confrontation, activity and pain-related self-efficacy were also related to disability reduction. CONCLUSIONS: Despite conceptual differences, Exposure and CBT may share common treatment processes. Future research needs to address, however, whether these processes need to be targeted directly or can be supported indirectly. SIGNIFICANCE: We identified several treatment processes (e.g., reduction of fear of movement, enhancement of self-efficacy), which were associated with disability reduction during the management of chronic pain and fear-avoidance. These processes appeared to be equally important for Exposure and CBT. Practitioners should optimize these processes to improve their patients' functioning.

Why dysfunctional expectations in depression persist - Results from two experimental studies investigating cognitive immunization.

BACKGROUND: Research has revealed that negative expectations impact depressive symptoms. However, research on the change of dysfunctional expectations in depression is lacking so far. Therefore, the present research aimed to fill this gap by testing the hypothesis that people with the major depressive disorder (MDD), contrary to healthy individuals, maintain their expectations despite experiences that positively disconfirm expectations. Further, it was hypothesized that cognitive immunization (a cognitive reappraisal of the disconfirming evidence) is a mechanism underlying the persistence of expectations. METHOD: In Study 1, we compared individuals with MDD (N = 58) to healthy individuals (N = 59). Participants worked on the same performance test and received standardized feedback that either confirmed or disconfirmed their initial performance expectations. In Study 2, we investigated the effects of cognitive immunization on expectation change among 59 individuals reporting elevated levels of depression by varying the appraisal of expectation-disconfirming feedback. RESULTS: Results from Study 1 show that in the expectation-disconfirming condition, healthy individuals changed their expectations, whereas individuals with MDD did not. No such difference between the two groups was found for expectation-confirming feedback. Results from Study 2 indicated that varying cognitive immunization impacted expectation change, thus suggesting a crucial role of cognitive immunization in expectation change. CONCLUSIONS: These two studies indicated that individuals suffering from depression have more difficulties in changing their expectations after disconfirming experiences than do healthy individuals, and cognitive immunization might be a core mechanism underlying expectation persistence. Therefore, psychotherapeutic interventions should aim to inhibit cognitive immunization processes to enhance expectation change.

Situational expectations mediate the effect of global beliefs on depressive symptoms: a 1-year prospective study using a student sample.

PURPOSE OF REVIEW: Recent research suggests that expectations might be a particularly important subgroup of cognitions in major depression. The present study aimed to further specify the role of situation-specific dysfunctional expectations (SDEs) in the development of depressive symptoms. It was hypothesized that the effects of intermediate beliefs and dispositional optimism on depressive symptoms would be mediated via SDEs. RECENT FINDINGS: We examined 125 students (age M = 22.05, SD = 4.00, 74.6% women) using a longitudinal design with a 1-year follow-up. Questionnaires used in the study included the Depressive Expectations Scale, Dysfunctional Attitudes Scale, Life Orientation Test and Beck's Depression Inventory. When considering SDEs at baseline as mediator variable, neither intermediate beliefs nor dispositional optimism had significant direct effects on depressive symptoms. Instead, their effects were fully mediated via SDEs. When considering SDEs at the follow-up as the mediator variable, SDEs partly mediated the effects of intermediate beliefs and dispositional optimism on depressive symptoms. SUMMARY: The study provides further evidence for a cognitive mediational model, suggesting that SDEs mediate the effects of rather global beliefs (such as intermediate beliefs and dispositional optimism) on depressive symptoms. Due to their high level of situational specificity, SDEs might be an effective target for cognitive-behavioural interventions.

Exposure and CBT for chronic back pain: An RCT on differential efficacy and optimal length of treatment.

OBJECTIVE: Our aim was to establish whether Exposure, a specialized tailored treatment for chronic low back pain, has any advantages over cognitive-behavioral therapy (CBT) among individuals with high fear-avoidance levels. Second, we planned to compare short and long versions of Exposure. Third, we aimed to investigate whether Exposure can be delivered in an outpatient psychological setting. METHOD: A total of 88 Caucasian participants (55% women) were randomized to three different psychological treatment conditions, Exposure-long, Exposure-short, and CBT. All participants were suffering from chronic pain and elevated levels of pain-related anxiety and disability. The primary outcomes were disability (assessed using two different questionnaires, QBPDS and PDI) and average pain intensity; secondary outcomes included pain-related anxiety, psychological flexibility, coping strategies, and depression. Assessments took place at pretreatment, midtreatment, posttreatment, and 6-month follow-up. RESULTS: Exposure was more effective than CBT at reducing movement-related disability assessed with the QBPDS. Exposure and CBT did not differ in reduction of pain intensity or disability assessed using the PDI. Exposure-short outperformed Exposure-long after 10 sessions, meaning that individuals improved faster when they were offered fewer sessions. Exposure could be safely delivered in the psychological setting. Concerning secondary outcomes, Exposure led to greater improvements in psychological flexibility relative to CBT. CBT was more effective than Exposure at enhancing coping strategies. In Exposure, significantly more participants dropped out. CONCLUSIONS: Although being more challenging to patients, Exposure is an effective treatment, which can be delivered in a psychological treatment setting and should be offered as a short-term treatment. (PsycINFO Database Record

Using Different Expectation Mechanisms to Optimize Treatment of Patients With Medical Conditions: A Systematic Review.

OBJECTIVE: Patients' expectations have been shown to predict the course and treatment success of a variety of medical conditions. Therefore, expectation-focused psychological interventions (EFPIs) have been developed to use these expectation effects clinically. Importantly, EFPI differ with regard to the particular expectation mechanism being addressed, i.e., expectation optimization or expectation violation. The aims of this systematic review were to give an overview of the application of these expectation interventions and to evaluate their effectiveness. METHODS: Several databases were searched to identify clinical trials or experimental studies that conducted EFPI among participants with various medical conditions. Risk of bias was evaluated using the Cochrane Risk of Bias tool. RESULTS: Eleven studies (N = 944) investigating different medical conditions (coronary heart disease, cancer, chronic pain) were included. Qualitative synthesis revealed positive effects of EFPI on clinical outcome variables in all studies. Expectation optimization approaches yielded particularly promising results. Because of the large heterogeneity of outcome measures, quantitative synthesis was not possible. CONCLUSION: This review highlights the potential of EFPI for optimizing treatment of patients with medical conditions. However, it seems that different expectation mechanisms might have different application possibilities. Therefore, we provide suggestions for further developing EFPI to tailor treatment and develop personalized psychological interventions. We argue that for this purpose, it is important to consider both disease-specific aspects and patients' personality traits. In addition, we discuss future challenges such as implementing EFPI into routine medical care.

Integrating situation-specific dysfunctional expectations and dispositional optimism into the cognitive model of depression - A path-analytic approach.

BACKGROUND: Dysfunctional expectations are considered to be core features of mental disorders and, in particular, major depression. The aim of the present study was to integrate two important types of expectations into the cognitive model of depression: situation-specific dysfunctional expectations (SDE) and dispositional optimism (DO). It was hypothesized that the influence of both DO and intermediate beliefs (IB) on depressive symptoms would be mediated via SDE. METHODS: We examined 95 individuals (age M = 40.7, 68.1% female) with a diagnosed major depressive disorder from two inpatient clinics and one outpatient clinic. Measurements used in the study included the Depressive Expectations Scale, Dysfunctional Attitudes Scale, Life Orientation Test Revised, and Beck's Depression Inventory-II. Relationships between the constructs were analyzed using path-analytic models with bias-corrected bootstrapping confidence intervals. RESULTS: Results indicate that the effect of IB on depressive symptoms was fully mediated via SDE, while the effect of DO on depressive symptoms was partly mediated via SDE. IB and DO moderately correlated with each other. LIMITATIONS: Due to the cross-sectional design of the study, it is not possible to draw unambiguous conclusions regarding the causality of the suggested relationships. CONCLUSIONS: The present study stresses the crucial role of dysfunctional expectations for major depression. Moreover, it reveals that SDEs as expectations with a high level of situational specificity may pose an important link between global cognitions and depressive symptoms. Given this situational specificity, SDEs are amenable to disconfirmation through behavioral experiments and may therefore be a promising target for cognitive-behavioral interventions.

Cross-cultural adaptation of the German Pain Solutions Questionnaire: an instrument to measure assimilative and accommodative coping in response to chronic pain.

According to the dual process model of coping, assimilative or accommodative strategies can be applied to deal with aversive life situations. In people with chronic pain, the tenacious focus on achieving analgesia is often referred to as assimilative coping and associated with more disability and catastrophic thinking. In contrast, accommodative coping (accepting one's pain and setting new goals) appears to have beneficial effects. To assess how people with chronic pain use these different coping strategies, questionnaires measuring these concepts are needed. Following international guidelines, a German version of the Pain Solutions Questionnaire (PaSol) was prepared. A sample of 165 participants with chronic low back pain (CLBP; 60% women; age 53 ± 8.4 years) filled in the questionnaire and measures for pain-related disability, affective distress, catastrophic thinking, and attention to pain. Item analyses, an exploratory factor analysis, and correlations with pain-related measures were calculated. In addition, data from 98 participants who received psychological treatment were examined to investigate the PaSol's sensitivity to change. The exploratory factor analysis reproduced the original questionnaire's four-factor structure. Internal consistencies for the subscales ranged from Cronbach's α=0.72 to α =0.84. Mean item difficulties for the subscales ranged from pi=0.62 to pi=0.79. The highest correlations were found for Meaningfulness with catastrophic thinking (r=-0.58) and affective distress (r=-0.36). The PaSol subscale Meaningfulness predicted pain-related disability; the subscales Meaningfulness and Solving Pain predicted affective distress. Furthermore, the PaSol was found to be sensitive to detect changes over time. The German version of the PaSol is a reliable and valid instrument in the measurement of assimilative and accommodative coping strategies in people suffering from CLBP. It may provide a useful tool when examining temporal dynamics of the changing coping strategies in the transition from acute to chronic pain as well as during pain treatments.