Originalbeiträge (Originals). Network meta-analysis: science or alchemy? ­What works best in generalized anxiety disorder?

Recently Papola et al. (2023) published a network meta-analysis (NMA) on psychotherapy of generalized anxiety disorder (GAD) and concluded that cognitive-behavioral therapy (CBT) should be considered the first-line treatment for GAD. However, there are several concerns with regard to the procedures and the conclusions of this NMA and of NMA in general. We show that these concerns question the conclusions by Papola et al. Furthermore, we place concerns about thisNMAin a broader context and question whether existing evidence is consistent with the notion that one form of psychotherapy can be regarded as the gold standard for mental disorders and for all patients and therapists.

Psychological interventions for interoception in mental health disorders: A systematic review of randomized-controlled trials.

Disturbed interoception (i.e., the sensing, awareness, and regulation of internal body signals) has been found across several mental disorders, leading to the development of interoception-based interventions (IBIs). Searching PubMed and PsycINFO, we conducted the first systematic review of randomized-controlled trials (RCTs) investigating the efficacy of behavioral IBIs at improving interoception and target symptoms of mental disorders in comparison to a non-interoception-based control condition [CRD42021297993]. Thirty-one RCTs fulfilled inclusion criteria. Across all studies, a pattern emerged with 20 (64.5%) RCTs demonstrating IBIs to be more efficacious at improving interoception compared to control conditions. The most promising results were found for post-traumatic stress disorder, irritable bowel syndrome, fibromyalgia and substance use disorders. Regarding symptom improvement, the evidence was inconclusive. The IBIs were heterogenous in their approach to improving interoception. The quality of RCTs was moderate to good. In conclusion, IBIs are potentially efficacious at improving interoception for some mental disorders. In terms of symptom reduction, the evidence is less promising. Future research on the efficacy of IBIs is needed.

Borderline Personality Disorder: A Review.

Importance: Borderline personality disorder (BPD) affects approximately 0.7% to 2.7% of adults in the US. The disorder is associated with considerable social and vocational impairments and greater use of medical services. Observations: Borderline personality disorder is characterized by sudden shifts in identity, interpersonal relationships, and affect, as well as by impulsive behavior, periodic intense anger, feelings of emptiness, suicidal behavior, self-mutilation, transient, stress-related paranoid ideation, and severe dissociative symptoms (eg, experience of unreality of one's self or surroundings). Borderline personality disorder is typically diagnosed by a mental health specialist using semistructured interviews. Most people with BPD have coexisting mental disorders such as mood disorders (ie, major depression or bipolar disorder) (83%), anxiety disorders (85%), or substance use disorders (78%). The etiology of BPD is related to both genetic factors and adverse childhood experiences, such as sexual and physical abuse. Psychotherapy is the treatment of choice for BPD. Psychotherapy such as dialectical behavior therapy and psychodynamic therapy reduce symptom severity more than usual care, with medium effect sizes (standardized mean difference) between -0.60 and -0.65. There is no evidence that any psychoactive medication consistently improves core symptoms of BPD. For discrete and severe comorbid mental disorders, eg, major depression, pharmacotherapy such as the selective serotonin reuptake inhibitors escitalopram, sertraline, or fluoxetine may be prescribed. For short-term treatment of acute crisis in BPD, consisting of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger a patient or others, crisis management is required, which may include prescription of low-potency antipsychotics (eg, quetiapine) or off-label use of sedative antihistamines (eg, promethazine). These drugs are preferred over benzodiazepines such as diazepam or lorazepam. Conclusions and Relevance: Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.

[Love is all around? - On dealing with eroticism and infatuation in three different psychotherapeutic approaches]. / Love is all around? ­ Über den Umgang mit Erotik und Verliebtheit in drei verschiedenen Therapieschulen: Ein Scoping Review.

How do therapists react when their patients or they themselves develop erotic feelings in the therapeutic setting? Conceptual differences of different therapy approaches (psychoanalytic therapy, cognitive behavioral therapy and client-centered therapy), specific attitudes of therapists and possibilities of intervention will be shown. The literature search in several databases revealed that in comparison to the abundance of psychoanalytic literature on the topic, little (but relevant) information can be found in the two other approaches. These publications point to the regular occurrence of feelings of infatuation in behavioral therapy and client-centered psychotherapy and to a need to engage with the topic as therapists. The consensus of the publications presented here is that therapists want to accept and work with feelings of infatuation in patients and in themselves, while maintaining abstinence. It is considered especially important not to shame disclosing patients by rejecting them. Treatment discontinuation should be avoided whenever possible. More research on erotic feelings in behavioral and client-centered psychotherapy is encouraged, as well as ideas for education and training.

To Be or Not to Be Improved: Patients' Perception of Symptom Improvement - Linking the SCL-90-R to Patient-Rated Global Improvement in a Large Real-World Treatment Sample.

INTRODUCTION: From both a clinical and research perspective, it is important to determine what constitutes a perceivable change in commonly used outcome measures. OBJECTIVE: We aimed to do so for the Symptom Checklist-90-Revised (SCL-90-R). METHODS: Patients from a large real-world sample treated with inpatient psychotherapy (n = 4,791) rated improvements in symptoms on a global 5-point Likert scale at discharge. These ratings were related to pre-post changes in the Global Severity Index (GSI) of the SCL-90-R by use of equipercentile linking. RESULTS: A patient rating of 5 ("clearly improved") was found to be equivalent to an absolute pre-post difference in the GSI of 0.67 or to a percentage improvement of 54%, with the latter corresponding to the common definition of response as a 50% reduction in symptoms. A rating of 1 ("clearly worse") was equivalent to an increase in the GSI >0.50 and to a percentage worsening >55%. "Slightly improved" or "slightly worse" (ratings of 4 or 2) corresponded to pre-post changes in the GSI of 0.07 and 0.50. For severely disordered patients, larger changes were required for ratings of improvement, and for less severely disordered patients, larger changes were required for ratings of worsening. Results for depressive, anxiety, and personality disorders were widely consistent with those of the total sample. CONCLUSIONS: This study is the first to link patient ratings of improvement or worsening to changes in the SCL-90-R. Results are relevant to both the interpretation of changes in individual patients and of effect sizes in outcome research. Results require replication.

Let's Distinguish Relative and Absolute Efficacy to Move Psychotherapy Research Forward.

Objective: Background regarding a recent debate between Cuijpers et al. (2019a, b) and the authors (Munder et al. 2019) about the efficacy of psychotherapy for depression is given. Method: A main reason for the discrepancy in Cuijpers et al.'s and our conclusions is discussed. Results: In our view the discrepancy is due, among other things, to a blurred distinction between questions of relative and absolute efficacy of psychotherapy. Although the efficacy of psychotherapy vis-à-vis alternative treatments may be ambiguous, there can be little doubt about the benefits of psychotherapy relative to no treatment. Conclusion: We do not think that raising fundamental concerns about the value of psychotherapy is a service to the field. We argue that moving the field forward requires a focus on how psychotherapy works and how the access to psychotherapy can be increased.

Vom Sinn des Verfahrenskonzepts und der Verfahrensvielfalt ­ und warum das Baukasten-System in der Psychotherapie nicht funktioniert.

Why the concept of distinct psychotherapeutic approaches is indispensable - and why the tool box concept of psychotherapy cannot work Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.

Cognitive-Behavioral and Psychodynamic Therapy in Adolescents with Social Anxiety Disorder: A Multicenter Randomized Controlled Trial.

BACKGROUND: Although social anxiety disorder (SAD) has an early onset and is frequently found in adolescence, evidence for psychotherapeutic treatments of SAD in adolescents is rather scarce. Within the Social Phobia Psychotherapy Research Network (SOPHO-NET), we examined the efficacy of cognitive-behavioral (CBT) and psychodynamic therapy (PDT) compared to a waiting list (WL) in these patients. METHODS: In a multicenter randomized controlled superiority trial, 107 patients, aged 14-20 years, were randomized to CBT (n = 34), PDT (n = 34), or WL (n = 39). Assessments were made at baseline, at the end of treatment, and 6 and 12 months after termination. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA) applied by raters masked to the treatment condition was used as the primary outcome. As secondary outcomes, rates of response and remission and the Social Phobia Anxiety Inventory (SPAI) were used. RESULTS: Both treatments were superior to WL in the LSAS-CA (CBT: p = 0.0112, d = 0.61, 95% CI 0.14-1.08; PDT: p = 0.0261, d = 0.53, 95% CI 0.06-1.00). At the end of treatment, response rates were 66, 54, and 20% for CBT, PDT, and WL. The corresponding remission rates were 47, 34, and 6%, respectively. CBT and PDT were significantly superior to WL regarding remission (CBT: p = 0.0009, h = 1.0; PDT: p = 0.0135, h = 0.74), response (CBT: p = 0.0004, h = 0.97; PDT: p = 0.0056, h = 0.72), and the SPAI (CBT: p = 0.0021, d = 0.75, 95% CI 0.27-1.22; PDT: p = 0.0060, d = 0.66, 95% CI 0.19-1.13). Treatment effects were stable at 6- and 12-month follow-ups. CONCLUSIONS: These results are comparable to the large SOPHO-NET trial in adults (n = 495). Early treatments for social anxiety are needed in order to prevent chronic manifestation of SAD.

On Mechanisms of Change in Psychodynamic Therapy.

BACKGROUND: There is a growing body of evidence for the efficacy of psychodynamic therapy. Some representatives of other approaches, however, have repeatedly questioned its efficacy. Recently, another line of argumentation emerged, claiming that psychodynamic therapy may work, but that the mechanisms of change underlying its effects were not clear or even could not be tested empirically at all. OBJECTIVE: The present article critically reviews these allegations. RESULTS: The allegations put forward were shown to be mostly untenable. Mechanisms of change of psychodynamic therapy are testable and have been tested empirically. CONCLUSIONS: There is evidence for both the efficacy of psychodynamic therapy and for the assumed mechanisms of change. The repeatedly presented critique by representatives of other approaches seems to be motivated more by political than by scientific reasons. However, further research on both the outcome and process of psychodynamic therapy is required.

The Effects of Waiting for Treatment: A Meta-Analysis of Waitlist Control Groups in Randomized Controlled Trials for Social Anxiety Disorder.

Social anxiety disorder (SAD) is a highly prevalent mental disorder. However, little is known about how SAD changes in subjects who do not receive treatment. Waitlist control groups (WLCGs) are frequently included in randomized controlled trials (RCTs) on the treatment of mental disorders. Data from WLCGs are of value as they provide information on the untreated short-term course of a disorder and may serve as disorder-specific norms of change (benchmarks) against which treatment outcomes of SAD can be compared. Thus, we performed a meta-analysis focusing on the effects occurring in WLCGs of RCTs for SAD. Our study was conducted along the PRISMA guidelines. Thirty RCTs (total n = 2460) comprising 30 WLCGs and 47 treatment groups were included. Mean waiting time was 10.6 weeks. The pooled effect of waiting on SAD measures was g = 0.128 (95% CI: 0.057-0.199). Effects regarding other forms of anxiety, depression and functioning were of similarly small size. In contrast, change in the treatment groups was large, both within (g = 0.887) and between groups (g = 0.860). Our results show that for SAD, changes occurring in WLCGs of RCTs are small. The findings may serve as benchmarks in pilot studies of a new treatment or as an additional comparison in studies comparing two active treatments. For psychotherapy research in general, the small effect sizes found in WLCGs confirm that testing a treatment against a waiting list is not a very strict test. Further research on WLCGs in specific mental disorders is required, for example examining the expectancies of patients randomized to waiting. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: In clinical practice, patients suffering from a mental disorder often have to wait for treatment. By analyzing data from waitlist control groups we can gain estimates of symptom change that occur during waiting. It could be seen that waiting for treatment only results in a negligible effect. Thus, in the short-term (i.e., 10.6 weeks) time is no healer in social anxiety disorder. Our results are similar to previous meta-analyses on the effects of waiting in other disorders, e.g., depression and posttraumatic stress disorder.

Psychoanalytic-Interactional Therapy versus Psychodynamic Therapy by Experts for Personality Disorders: A Randomized Controlled Efficacy-Effectiveness Study in Cluster B Personality Disorders.

BACKGROUND: With regard to cluster B personality disorders, most psychotherapeutic treatments focus on borderline personality disorder. Evidence-based treatments for patients with other cluster B personality disorders are not yet available. Psychoanalytic-interactional therapy (PIT) represents a transdiagnostic treatment for severe personality disorders. PIT has been applied in clinical practice for many years and has proven effective in open studies. In a randomized controlled trial, we compared manual-guided PIT to nonmanualized pychodynamic therapy by experts in personality disorders (E-PDT) in patients with cluster B personality disorders. METHODS: In an inpatient setting, patients with cluster B personality disorders were randomly assigned to manual-guided PIT (n = 64) or nonmanualized E-PDT (n = 58). In addition, a quasi-experimental control condition was used (n = 46) including both patients receiving treatment as usual and patients waiting for treatment. Primary outcomes were level of personality organization and overall psychological distress. As secondary outcomes, depression, anxiety and interpersonal problems were examined. RESULTS: No significant improvements were found in the control patients. Both PIT and E-PDT achieved significant improvements in all outcome measures and were superior to the control condition. No differences were found between PIT and E-PDT in any outcome measure at the end of treatment. The type of cluster B personality disorder had no impact on the results. CONCLUSIONS: In an inpatient setting, both PIT and E-PDT proved to be superior to a control condition in cluster B personality disorders. In a head-to-head comparison, both treatments appeared to be equally effective. Further research on the treatment of cluster B personality disorders is required.

[Short-Term Psychodynamic Therapy in Depression - An Evidence-Based Unified Protocol]. / Psychodynamische Kurzzeittherapie der Depression - ein evidenzbasiertes vereinheitlichtes Therapieprotokoll.

With a lifetime prevalence of about 17% depression is the most common mental disorder. Psychotherapy is efficacious in the treatment of depression, with no significant differences between different forms of psychotherapies. For psychodynamic therapy (PDT) various models proved to be efficacious in randomized controlled trials (RCTs). As a consequence the evidence for PDT is scattered between different forms or orientations of PDT entailing problems regarding psychotherapy training and the transfer of research into clinical practice. Thus, our aim was to develop a unified protocol for the dynamic treatment of depression that is based on those models of PDT that proved efficacious in randomized controlled trials (RCTs). As a first step we conducted a systematic search of RCTs investigating manualized or manual-based individual psychodynamic therapy for depressive disorders in adults that proved to be efficacious compared to comparison conditions. 11 studies fulfilled our inclusion criteria. In a second step we systematically reviewed the studies with regard to the treatment concepts they had applied. 7 highly consistent treatment components could be identified. We conceptualized them in the form of 7 interrelated treatment modules which constitute the unified psychodynamic protocol for depression. The protocol may enhance the empirical status of PDT and facilitate both psychotherapy training as well as the transfer of research to clinical practice. Through the focused use of techniques that proofed efficacious it is expected to bring more benefit to depressed patients and therefore also have a positive impact on the health care system.

Psychotherapy Versus Pharmacotherapy of Depression: What's the Evidence?

OBJECTIVES: Depression may be treated by psychotherapy or pharmacotherapy or their combination. There is an ongoing debate whether one of these approaches is possibly superior. A recent meta-analysis reported results in favour of pharmacotherapy. METHODS: Individual studies and meta-analyses on the comparative efficacy of psychotherapy vs. pharmacotherapy were reviewed. RESULTS: Evidence suggests that psychotherapy and pharmacotherapy are equally efficacious in the short-term, but psychotherapy is superior in the long-term. For the recently stated hypothesis that pharmacotherapy is superior to psychotherapy in studies without a pill placebo condition, which implies equally including a positive expectancy effect for both pharmacotherapy and psychotherapy no evidence was found. CONCLUSION: Depression may be treated by psychotherapy or pharmacotherapy with equivalent results in the short-term and advantages for psychotherapy in the long-term. As the rates of response and remission are still limited in both treatments, further improvement of treatments is required.

Developing a prototype for short-term psychodynamic (supportive-expressive) therapy: An empirical study with the psychotherapy process Q-set.

OBJECTIVE: A Psychotherapy Process Q-set (PQS) prototype characteristic of short-term psychodynamic therapy (STPP) does not yet exist. METHOD: Experts in supportive-expressive (SE) therapy used the 100-Item PQS questionnaire to rate an ideal short-term SE therapy. RESULTS: Agreement between raters was high (Cronbach's alpha = 0.94). The prototype for SE therapy showed a significant correlation with the psychoanalytic prototype, but with 28% of variance explained, the majority of variance of the former was not explained by the latter or vice versa. Furthermore, the SE prototype showed significant correlations with the cognitive-behavioral prototype and the prototype of interpersonal therapy by Ablon and Jones (r = 0.69, 0.43). CONCLUSIONS: We recommend using the PQS prototype presented here for future process research on STPP.

The empirical status of psychodynamic psychotherapy - an update: Bambi's alive and kicking.

BACKGROUND: The Task Force on Promotion and Dissemination of Psychological Procedures proposed rigorous criteria to define empirically supported psychotherapies. According to these criteria, 2 randomized controlled trials (RCTs) showing efficacy are required for a treatment to be designated as 'efficacious' and 1 RCT for a designation as 'possibly efficacious'. Applying these criteria modified by Chambless and Hollon, this article presents an update on the evidence for psychodynamic therapy (PDT) in specific mental disorders. METHODS: A systematic search was performed using the criteria by Chambless and Hollon for study selection, as follows: (1) RCT of PDT in adults, (2) use of reliable and valid measures for diagnosis and outcome, (3) use of treatment manuals or manual-like guidelines, (4) adult population treated for specific problems and (5) PDT superior to no treatment, placebo or alternative treatment or equivalent to an established treatment. RESULTS: A total of 39 RCTs were included. Following Chambless and Hollon, PDT can presently be designated as efficacious in major depressive disorder (MDD), social anxiety disorder, borderline and heterogeneous personality disorders, somatoform pain disorder, and anorexia nervosa. For MDD, this also applies to the combination with pharmacotherapy. PDT can be considered as possibly efficacious in dysthymia, complicated grief, panic disorder, generalized anxiety disorder, and substance abuse/dependence. Evidence is lacking for obsessive-compulsive, posttraumatic stress, bipolar and schizophrenia spectrum disorder(s). CONCLUSIONS: Evidence has emerged that PDT is efficacious or possibly efficacious in a wide range of common mental disorders. Further research is required for those disorders for which sufficient evidence does not yet exist.

Do personality traits predict outcome of psychodynamically oriented psychosomatic inpatient treatment beyond initial symptoms?

OBJECTIVES: Whether personality characteristics have an impact on treatment outcome is an important question in psychotherapy research. One of the most common approaches for the description of personality is the five-factor model of personality. Only few studies investigated whether patient personality as measured with the NEO-Five-Factor Inventory (NEO-FFI, Costa & McCrae [1992b]. Revised NEO-PI-R and NEO-FFI. Professional manual. Odessa, FL: Psychological Assessment Recources) predicts outcome. Results were inconsistent. Studies reporting personality to be predictive of outcome did not control for baseline symptoms, while studies controlling initial symptoms could not support these findings. We hypothesized that after taking into account baseline symptoms, the NEO-FFI would not predict outcome and tested this in a large sample of inpatients at a psychosomatic clinic. DESIGN: Naturalistic, non-controlled study using patients' data for multiple regression analysis to identify predictors of outcome. METHODS: Data of 254 inpatients suffering primarily from depressive, anxiety, stress, and somatoform disorders were analysed. Personality was assessed at the beginning of therapy. For psychotherapy outcome, changes in anxiety and depression (Hospital Anxiety and Depression Scale; HADS), overall psychopathology (Symptom Checklist-90-R Global Severity Index [GSI]), and interpersonal problems (Inventory of Interpersonal Problems; IIP) were measured. RESULTS: The treatment resulted in significant decreases on all outcome measures corresponding to moderate to large effect sizes (HADS: d = 1.03; GSI: d = 0.90; IIP: d = 0.38). Consistent with our hypothesis, none of the personality domains predicted outcome when baseline symptoms were controlled for. CONCLUSIONS: Personality assessment at baseline does not seem to have an added value in the prediction of inpatient psychotherapy outcome beyond initial symptoms. PRACTITIONER POINTS: Clinical implications Personality dimensions overlap with symptomatic distress. Rather than serve as predictors of outcome, the domains tapped by the NEO-FFI reflect current psychological symptomatology in inpatients with depressive, anxiety, stress or somatoform disorders. From a clinician's point of view monitoring individual progress by using actuarial measures is more valuable than trying to predict who will benefit from treatment using personality assessments. Limitations of the study Diagnostic assessment was solely based on clinical evaluation rather than structured interviews. Twenty-five per cent of the original sample had to be excluded due to missing data. There was a focus on only one set of client characteristics (i.e., five-factor model personality traits). Assessment of personality domains in the acute phase of a mental disorder may be problematic and could have influenced findings.