Previous studies have been inconsistent in demonstrating a relationship between delusion proneness and induced stress on reasoning biases. The present study was an experimental investigation of the role of stress in the form of feeling rushed, which has previously been shown to be related to the jumping-to-conclusions reasoning bias for delusion-prone individuals, on the reasoning of delusion-prone individuals. University students (n = 133) completed a measure of delusion proneness and were randomly assigned to either receive or not receive a stress induction in the form of a speeded subtraction task. All participants engaged in four trials of a probabilistic reasoning task. Delusion-prone and not delusion-prone participants performed similarly when there was no stress induction, but delusion-prone individuals demonstrated reasoning biases relative to not delusion-prone individuals when stress was induced. The reasoning of delusion-prone individuals may be particularly vulnerable when they feel rushed and in stressful conditions.
Given the importance of reflective practice within clinical psychology and a lack of empirical research, this study aimed to investigate the personal and professional impact of reflective practice groups (RPGs) for former trainees.
This study followed an analytic survey design utilizing a convenience sample of qualified clinical psychologists from a UK training programme.
A RPG questionnaire (RPGQ) was developed for the purposes of the study. Following initial pilot work, 297 qualified psychologists were invited to complete the RPGQ.
One hundred and twenty-four psychologists (42%) completed the RPGQ. Factor analysis yielded two underlying constructs labelled 'value' and 'distress'. The RPGQ demonstrated significant internal and test-retest reliability. The majority rated the RPGs as valuable for personal and professional development and learning about group processes. Just under half however reported distress as a result of the groups. Whilst some trainees, who reported distress, were able to view the challenges positively, one-sixth were not. Potency of facilitation and group size significantly predicted levels of perceived value and distress.
In view of the ethical issues raised by compulsory RPGs, recommendations were made to keep group sizes within an average of 10-13, utilize facilitators with sufficient training in group processes and ensure additional methods of reflective practice development are available. Further suggestions and recommendations for future research in relation to coping and personal learning style were also made.
OBJECTIVE. 'What is narrative therapy and how do you do it?' is a question that is repeatedly asked of narrative therapy, with little consistent response. This study aimed to explore and distil out the 'common themes' of practitioner definitions of White and Epston's approach to narrative therapy. DESIGN. This was an Internet-based study involving current UK practitioners of this type of narrative therapy using a unique combination of a Delphi Panel and Q methodology. METHOD. A group of experienced practitioners were recruited into the Delphi Poll and were asked two questions about what narrative therapy is and is not, and what techniques are and are not employed. These data combined with other information formed the statements of a Q-sort that was then administered to a wider range of narrative practitioners. FINDINGS. The Delphi Panel agreed on a number of key points relating to the theory, politics and practice of narrative therapy. The Q-sort produced eight distinct accounts of narrative therapy and a number of dimensions along which these different positions could be distinguished. These included narrative therapy as a political stance and integration with other approaches. CONCLUSIONS. For any therapeutic model to demonstrate its efficacy and attract proponents, an accepted definition of its components and practice should preferably be established. This study has provided some data for the UK application of White and Epston's narrative therapy, which may then assist in forming a firmer base for further research and practice.
Chronic pain and depression are coexisting entities with high simultaneous prevalence. Both are linked with early adversities. Early maladaptive schemas (EMS) can be seen as a reflection of these adversities. EMSs extensively indicate underlying psychic patterns and provide a good opportunity to detect covert processes and psychic shapes (latent factors), which create the basis of how people rate their schemas. The purpose of this study was to explore these latent, higher order schema factors (SF) and to find out how they are associated with pain intensity or depression in chronic pain patients and a control sample. The study subjects consisted of 271 first-visit pain patients and 331 control participants. Sociodemographic and pain data were gathered by questionnaire; 18 EMSs were measured with the Young Schema Questionnaire (short form) and depressiveness was measured with the Beck Depression Inventory, Version II. Exploratory factor and regression analyses were used. The chronic pain patient group showed two SFs. The first SF showed a shameful, defective, socially isolated, failure, emotionally inhibited, deprived, submissive and resigned pattern. The second SF showed a demanding, approval seeking, self-sacrificing and punitive pattern. SF1 predicted more than half of the depressiveness in the pain patient sample. A three-factor structure was found in the control sample, and SFs 1 and 3 together predicted almost one-third of depressiveness. The pain patient and the control groups had a different, higher order factor structure. We assume that SF1 in the pain patients reflected a rather serious, undefined early psychic trauma and was also associated with their depressiveness.
Monitoring psychotherapeutic progress requires valid and economic measures to detect change of clinical relevance. We addressed validity and sensitivity to change of the 'Klinisch Psychologisches Diagnosesystem 38' (KPD-38, Clinical Psychological Diagnosis System), an instrument for outcome monitoring and quality assurance.
Data from an inpatient sample (n = 1.377) were used to investigate the concurrent validity, the sensitivity to change, and the criterion validity of the KPD-38 in comparison to the Outcome Questionnaire (OQ-45) and the Brief Symptom Inventory (BSI).
Sensitivity-specificity analyses showed similar sensitivity and higher specificity for the KPD-38 scales compared with the BSI and OQ total scores. Change rates on the KPD-38 distress scale (DIS) were found to be lower than on the BSI (KPD-38 DIS: 36.6%, GSI: 67.7%) and the OQ-45 (KPD-38 DIS: 44.3%, OQ tot: 57.1%) total scores. Concordance was low with the BSI ([κ = 0.24] and moderate with the OQ-45 [κ = 0.45]).
Implications for applications in the field of outcome assessment and the challenge of further validation are discussed. The relation between sensitivity to change and criterion validity is highlighted.
In this article, the authors study the factorial structure of the Italian translation of the Outcome Questionnaire 45 (OQ-45) in a sample of college students (n = 522) and psychiatric outpatients (n = 301). The relative goodness of fit of six competing models of the OQ-45 was examined using confirmatory factor analysis (CFA). Specifically, the study examined the relative fit of the most frequently presented models in the literature and three alternative models. Results of the CFA provided support for the four factor bi-level solution, suggesting that the OQ-45 is a multidimensional instrument that contains one general factor and multiple unique subscale factors.
Previous research indicates that the content of psychotic symptoms is of significant importance for the individual who experiences them. However, there are limitations concerning the use of self-report instruments for capturing experiences that are of highly personal nature. The aim of this study was to provide a deeper understanding of how individuals with psychosis make sense of the content of their psychotic symptoms.
Semi-structured interviews were conducted with 12 individuals, some of whom were experiencing active symptoms and some of whom had experienced symptoms within the last 12 months. The interviews explored the individuals' understanding of psychotic symptoms in terms of the content and the possible meaning of the content. All participants were patients at a unit specializing in psychosis. The study applied interpretive phenomenological analyses to highlight the subjective understanding of the content of psychotic symptoms.
Interpersonal experiences were a consistent theme in participants' understanding of the content of their psychotic symptoms. Grandiose content was understood as being related to lack of relationships and helplessness, whereas harassing content was related to experiences of being abused. Commanding content was linked to emotional consequences of intrusive relationships and to distressing life events. Supportive content was viewed as a substitute for real-life persons.
These results support previous findings suggesting that the content of psychotic symptoms is related to interpersonal experiences. The study highlights the importance of validating the patient's own knowledge and interpretations of symptoms.
This study investigated short-term re-experiencing and avoidance after elective surgical abortion. In addition, it was prospectively investigated whether peritraumatic dissociation and pre-abortion dissociative tendencies and alexithymia predict re-experiencing and avoidance.
In a prospective observational design, Dutch-speaking women presenting for first trimester elective surgical abortion completed self-report measures for dissociative tendency and alexithymia. Peritraumatic dissociation was measured immediately post-abortion. Re-experiencing and avoidance were measured 2 months post-abortion.
Participants reported moderately elevated levels of re-experiencing and avoidance that exceeded a clinical cut-off point for 19.4% of the participants. Peritraumatic dissociation predicted intrusion and avoidance at 2 months. In addition, avoidance was predicted by the alexithymic aspect of difficulty describing feelings.
Re-experiencing and avoidance after elective surgical abortion represent a significant clinical problem that is predicted by peritraumatic dissociation and alexithymia. Psychological screening and intervention might be a useful adjunct to elective abortion procedures.
Cognitive-behaviour therapy (CBT) is efficacious in reducing symptoms of generalized anxiety disorders (GAD). The question is whether it is also efficient, i.e., whether there are also enduring effects with respect to improving utilization of medication and psychotherapy, or occupational functioning and sick leave after the end of treatment.
The study was based on 44 outpatients (age 18-65 years; HAM-A score ≥18; GAD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as assessed by standardized interview) who were treated with 25 sessions of CBT (treatment by 12 state-licensed behaviour therapists in office-based practice; no psychotropic treatment for the duration of the therapy). The rate of medication treatment, occupational functioning and sick leave was assessed for 8 months before and after the end of treatment.
In the comparison of the pre-treatment and post-treatment periods, 46.5% versus 7.2% of patients used psychotropic medication for at least 4 weeks and had been 3.1 versus 1.1 days on sickness absence per month, respectively. About 70% of patients showed impairment in occupational role performance during the pre-treatment phase compared with 5% to 20%, depending on the dimension, in the follow-up period.
The data suggest that CBT is not only efficacious in terms of symptom reduction but also efficient in terms of reducing inappropriate medication intake and improving occupational functioning.
Self-concept literature and literature on childhood sexual abuse (CSA) suggests that women with a history of CSA may have particular ways of perceiving themselves, which, as well as impacting upon relationships within their everyday lives, may also have implications for therapy; whether this is on an individual basis or within a group. This research investigated self-concept and attributions about other women using an adapted version of the self-concept sorting task. Three groups of women were compared: women with a history of CSA, women experiencing depressed mood but without a history of CSA and a healthy non-clinical comparison group of hospital staff. To some extent the current findings supported previous studies indicating that women attempting to cope with the consequences of a history of CSA have a negative self-concept. However, there was evidence to suggest that certain self-aspects are protective or protected. Similarly, there is some support for previous evidence of difficult relationships with mothers. Possible explanations for these findings were discussed and areas for future research suggested.
The risk of adverse psychological outcomes in adult victims of childhood and adolescent sexual abuse (CSA) has been documented; however, research on possible mediating variables is still required, namely with a clinical perspective. The attachment literature suggests that secure interpersonal relationships may represent such a variable. Twenty-eight women who had experienced episodes of CSA, and 16 control women, were interviewed using Bremner's Early Trauma Inventory and the DSM-IV Global Assessment of Functioning; they also responded to Collins' Relationship Scales Questionnaire, evaluating adult attachment representations in terms of Closeness, Dependence and Anxiety. Subjects with an experience of severe abuse reported significantly more interpersonal distance in relationships (low index of Closeness) than other subjects. The index of psychopathological functioning was correlated with both the severity of abuse and attachment (low index of Closeness). Regression analysis on the sample of abused women revealed that attachment predicted psychopathology when abuse was controlled for, whereas abuse did not predict psychopathology when attachment was controlled for. Therefore, preserving a capacity for closeness with attachment figures in adulthood appears to mediate the consequences of CSA on subsequent psychopathological outcome.
Bullying has been considered as a traumatic experience that can lead to paranoid ideation in students (Campbell and Morrison, 2007). This study aimed to explore differences concerning experiences of childhood trauma, the display of social anxiety behaviours, paranoid ideation, and aggressive traits and behaviour in a mixed clinical population with and without persecutory delusions, between individuals who reported being victims of bullying versus those who did not.
A total of 61 individuals with diagnoses of paranoid schizophrenia and social anxiety disorder were given a battery of questionnaires that measured bullying experiences, childhood abuse and experiences of threat and subordination, paranoid ideation, social anxiety behaviours, shame, and aggressive traits and behaviours.
Data on the differences between the victims of bullying and non-victims, in terms of recalling being bullied, showed higher scores on childhood abuse, experiences of threat and subordination within the family, aggressive traits and higher display of persecutory symptoms and less social anxiety behaviours.
Bullying is a traumatic phenomenon that is reported by people who suffer from persecutory delusions to a higher degree than those who do not. This study, thus, gives support to the idea that childhood abuse within the family is associated with bullying experiences and that a traumatic infancy may lead to the use of aggressive traits and behaviours to deal with a threatening environment (Bentall and Fernyhough,). This argument raises clinical issues regarding anger management and addressing bullying experiences in individuals with persecutory ideation.
Early maladaptive schemas, defined as cognitive and behavioural patterns of viewing oneself and the world that cause considerable distress, are increasingly being recognized as an important underlying correlate of mental health problems. Recent research has begun to examine early maladaptive schemas among individuals seeking treatment for substance abuse. Unfortunately, there is limited research on whether substance abusers score higher on early maladaptive schemas than non-clinical controls. Thus, the current study examined whether a sample of young adult female substance abuse treatment seekers (n = 180) scored higher than a non-clinical group of female college students (n = 284) on early maladaptive schemas. Results demonstrated that the substance abuse group scored higher than the non-clinical group on 16 of the 18 early maladaptive schemas. In addition, a number of differences in early maladaptive schemas were large in effect size. Implications of these findings for future research and substance abuse treatment programmes are discussed.
Key practitioner message:
Young adult female substance users have a number of early maladaptive schemas that may be contributing to the onset and maintenance of substance use. Findings from the current study suggest that early maladaptive schemas are more prevalent among young adult female substance abusers than a non-clinical control group, even after controlling for demographic differences between groups. The treatment of substance abuse among young adults should consider targeting early maladaptive schemas.
Although current treatments help to alleviate some of the symptoms of schizophrenia, people with schizophrenia often continue to experience residual symptoms. An emotion-focused treatment approach may help to improve well-being in this population by increasing positive experiences and resources. In this article, we discuss the feasibility and acceptability of a skills-based group treatment for people schizophrenia or schizoaffective disorder. As part of the Awareness and Coping with Emotion in Schizophrenia (ACES) intervention, group members learned eight empirically supported cognitive and behavioural skills covering emotional awareness and coping. Group member feedback and three case illustrations illuminate participants' experiences with the group, as well as the potential benefits and challenges of this treatment approach. These data suggest that ACES is a feasible and acceptable group intervention. Future research is needed to examine whether ACES has a selective impact on well-being, but these initial findings point to the promise of this intervention to improve quality of life for individuals with schizophrenia and schizoaffective disorder, thus filling a void in existing treatments options.
Key practitioner message:
There is a void in existing treatments for schizophrenia with few interventions focusing on increasing well-being in this population. Awareness and Coping with Emotion in Schizophrenia (ACES) is a skills-based group intervention that teaches cognitive and behavioural interventions to promote awareness and coping with emotion. Preliminary evidence demonstrates the feasibility and acceptance of the ACES group intervention in increasing well-being in those with schizophrenia. Future studies should extend this work by systematically evaluating the efficacy of this treatment approach.
The present study explores whether specific subgroups of patients could be identified based on Chronic Pain Acceptance Questionnaire scores. A battery of self-report questionnaire was used to assess acceptance of pain, self-compassion and psychopathology in 103 participants with chronic pain, from Portuguese health care units. K-Means cluster were performed and the results supported three subgroups of patients (low acceptance subgroup; high acceptance subgroup; intermediate subgroup with activity engagement near to the mean and low willingness to pain). One-way ANOVA's showed that the three subgroups identified differed significantly from each other on psychopathology and self-compassion. Results indicated that the intermediate subgroup presented less depression and stress, compared with the low acceptance subgroup. In what concerns self-compassion, the low acceptance subgroup reported higher self-judgment, isolation and over identification, compared with the intermediate subgroup. These subgroups also differed from each other in common humanity and mindfulness. Implications and clinical utility of the results were discussed, suggesting the increase of willingness to pain as an important key in chronic pain interventions.
Over 116 million Americans experience chronic pain, incurring an annual cost of $635 bn in healthcare and lost work. Acceptance-based therapies have gained increasing recognition for improving functional outcomes. In our online chronic pain sample, we predicted that (1) patients would cluster into low, medium and high groups of chronic pain acceptance and (2) positive affect, negative affect and perceived disability scores would differ overall by cluster, with the most positive outcomes found in the high cluster and the least found in the low cluster. Participants completed the Chronic Pain Acceptance Questionnaire, Positive and Negative Affect Scales and the Pain Disability Index. A k-means cluster analysis was conducted using activity engagement (AE) and pain willingness (PW) totals from the Chronic Pain Acceptance Questionnaire. As predicted, cluster analysis specified three groups: low AE/low PW, high AE/high PW and medium AE/medium PW. Significant multivariate analysis of covariance results were obtained according to Wilks' λ (0.55), F(6,266) = 15.39, p < 0.01, and indicated differences in positive affect, negative affect and perceived disability within each cluster. Follow-up analyses of covariance revealed mean differences in the predicted directions: the high-high group showed the most positive affect and the least negative affect and perceived disability. Conversely, the low-low group displayed the least positive affect (M = 20.28, SD = 7.86), the most negative affect (M = 28.05, SD = 9.33) and perceived disability (M = 49.57, SD = 9.46). The presence of these clusters introduces key questions about the possibility of creating tailored interventions based on cluster profiles.
Key practitioner message:
Higher levels of Acceptance are associated with better functional and affective outcomes for chronic pain patients. Lower Acceptance is associated with poorer functional and affective outcomes. Tailoring interventions using Acceptance-based profiling may improve chronic pain therapies.
A specific psychotherapeutic strategy for increasing psychological well-being and resilience, well-being therapy (WBT), based on Ryff's conceptual model, has been developed and tested in a number of randomized controlled trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one's self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage effectively one's life and a sense of self-determination. A decreased vulnerability to depression, mood swings and anxiety has been demonstrated after WBT in high-risk populations. School interventions based on the principles of WBT have been found to yield both promotion of well-being and decrease of distress compared with control groups. The differential technical characteristics and indications of WBT are described, with a special reference to the promotion of an individualized and balanced path to achieve optimal human functioning, avoiding the polarities in positive psychological dimensions.
The diversity of patients, problems, beliefs and cultures mandates the need to educate, match, negotiate and integrate psychological interventions. This is necessary in all cultures and in every setting. Many schools of psychotherapy offer specific theories and particular techniques, yet they share many common approaches. Their individual techniques allow therapists form and structure to treat different clinical problems, discuss diverse content and use them in varied settings and among people with assorted cultural backgrounds. The heterogeneity within cultures, regions and populations demands that therapists understand the local and individual reality. The apparent contradictions between standard psychological therapies and their use across cultures, when viewed through a form-content framework, allow for matching strategies for specific individuals and their distress, and for choosing the best treatment options from a diverse therapeutic armamentarium. Psychotherapies are at their weakest when they attempt to provide explanations across cultures and are at their strongest when they are used as vehicles for engagement with patients. The challenge is to find a common psychotherapeutic language, which attempts to bridge the divide between the issues facing the patient and the armamentarium of the therapist. The form-content paradigm at least partly explains the complexity of the issues within psychotherapy. It also allows the therapist to move from the therapy-centric orientation of Western approaches to the patient-centric orientations required for success in psychological therapies.
To explore the psychometric properties of the Cross-Cultural Questionnaire (CCQ), a new self-report tool for assessing factors of risk and maintenance for eating disorders (ED).
Data was collected during a multi-centre case-control study. The sample included 854 ED patients and 784 healthy participants from the UK, Spain, Austria, Slovenia and Italy. Exploratory factor analyses examined the factor structure of each section of the CCQ, and Cronbach's alpha coefficients valued the internal consistency of each derived scale score. Logistic regression and receiver operating characteristic (ROC) curve procedure assessed the screening accuracy and predictive validity of the empirical factors.
Based on a total of 127 items, nine dimensions emerged, with satisfactory internal consistency and high congruence between countries. CCQ scores demonstrated satisfactory accuracy for discriminating between ED cases and controls (area under the ROC curve = 0.88). Most of the items achieved discriminative accuracy.
This study offers preliminary evidence that the CCQ, available in five languages, is a useful and valid tool to assess factors of risk and maintenance for EDs.
It is still an open question whether psychotherapists adhere to their therapeutic conceptions in routine practice (clinician's treatment adherence) and thus to what extent the two most common approaches, cognitive-behavioural (CBT) and psychodynamic therapy (PDT), differ from each other as theoretically expected (treatment differentiation). This holds true especially in case of group therapy.The study compares essential process components of CBT and PDT group treatments under clinically representative conditions using non-participating observer ratings. Results demonstrate that CBT group therapists use more cognitive, behavioural and psychoeducational strategies, foster self-efficacy to a larger extent and are more supporting and empathetic. PDT group therapists use more interpretative and confrontative interventions and focus on interactional and dynamic aspects. The results strongly support that not only in individual psychotherapy-as shown in prior research-but also in the group setting do CBT and PDT reveal very distinct profiles and that therapists primarily abide by their theoretical training also in clinical practice. They allow one to identify differential process components of the group setting and to trace back parameters of outcome to the process of CBT and PDT for clinical routines.
In this article, we describe an investigation into the diagnostic activities of practicing clinical psychologists. Two questionnaires were filled in by 313 psychologists. One group of psychologists (N = 175) judged the necessity of diagnostic activities; the other group (N = 138) selected the activities they would actually perform. Results showed that more participants thought that diagnostic activities were necessary than there were participants who intended to actually perform those activities. Causal analysis, by generating and testing diagnostic hypotheses to form an integrated client model with an explanation for the problem, was judged least necessary and would not be performed. We conclude that a discrepancy exists between the number and types of activities psychologists judged to be necessary and they intend to actually perform. The lack of attention for causal analysis is remarkable as causal explanations are crucial to effective treatment planning.
Despite evidence from a number of long-term follow-up studies of anorexia nervosa that nearly 50% of patients eventually make a full recovery, controlled trials of psychotherapy for anorexia nervosa are lacking. Those with severe and enduring problems represent a considerable therapeutic challenge. Thirty-four consecutive adult referrals to the inpatient treatment unit who fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for anorexia nervosa were examined pre-admission, post-discharge and 4 years after admission. Characteristics of remitted and non-remitted patients were examined. Secondary analyses considered the differences between patients with anorexia nervosa, restricting type and anorexia nervosa binging/purging type. The findings highlight a number of differences between patients with anorexia nervosa (restricting type) versus anorexia nervosa (binging/purging type) as well as remitted versus non-remitted patients. The use of a comprehensive battery of assessments found that resolution of eating disorder symptomatology was paralleled by improvements in emotional and psychological distress and improvement in body image perception and coping skills. Better results were obtained for those who had continuity of care on an outpatient basis. This pattern is particularly significant given the more 'chronic' nature of the sample that were older, with a higher incidence of binge-eating and purging than previous samples. Results provide some encouragement for the treatment of those adults with anorexia nervosa who typically have less favourable outcomes.
Generalized anxiety disorder (GAD) is one of the most prevalent psychiatric presentations; however, GAD has the lowest diagnostic reliability of the anxiety disorders and is poorly recognized in clinical practice. A more reliable assessment of GAD could lead to earlier detection and treatment of the disorder, which has an otherwise debilitating course and significant associated impairment. The 7-item GAD Scale (GAD-7) has shown promise as a measure with good clinical utility and strong psychometric properties in primary care and community settings but has yet to be assessed in acute psychiatric populations. This study examined the validity of the GAD-7 in a sample of 232 patients enrolled in a partial hospital programme. Patients completed a diagnostic interview and a battery of self-report measures before and after treatment. Findings suggest that the GAD-7 has good internal consistency and good convergent validity with worry, anxiety, depression and stress, and the measure was sensitive to change over the course of a short intensive cognitive-behavioural therapy partial hospital programme. However, the confirmatory analysis failed to support the hypothesized unidimensional factor structure; and although the GAD-7 demonstrated good sensitivity (.83), specificity was poor (.46) in identifying patients with GAD. Overall, the GAD-7 appears to be a valid measure of generalized anxiety symptoms in this sample, on the basis of good internal consistency, convergent validity and sensitivity to change, but does not perform well as a screener for GAD.
Key practitioner message:
The GAD-7 Scale is an easy-to-score, self-report measure of core generalized anxiety disorder symptoms. The GAD-7 Scale has good internal consistency and convergent validity with depression, anxiety, stress and worry, and is sensitive to change. The GAD-7 Scale appears to be a good measure of generalized anxiety symptoms in an acute psychiatric sample. The GAD-7 Scale does not perform well as a screener for GAD and should not be used to identify cases of GAD in acute psychiatric samples.
The contributions of disorder severity, comorbidity and interpersonal variables to therapists' adherence to a cognitive-behavioural treatment (CBT) manual were tested.Method
Thirty-eight patients received panic control therapy (PCT) for panic disorder. Trained observers watching videotapes of the sixth session of a 24-session protocol rated therapists' adherence to PCT and their use of interventions from outside the CBT model. Different observers rated patients' behavioural resistance to therapy in the same session using the client resistance code. Interview measures obtained before treatment included the Panic Disorder Severity Scale, the anxiety disorders interview schedule for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the structured clinical interview for DSM-IV, Axis II. Questionnaire measures were the anxiety sensitivity index at intake, and, at session 2, the therapist and client versions of the working alliance inventory—short form.ResultsThe higher the patients' resistance and the more Axis II traits a patient had, the less adherent the therapist. Moreover, the more resistant the client, the more therapists resorted to interventions from outside the CBT model. Stronger therapist and patient alliance was also generally related to better adherence, but these results were somewhat inconsistent across therapists. Pretreatment disorder severity and comorbidity were not related to adherence.Conclusions
Interpersonal variables, particularly behavioural resistance to therapy, are related to therapists' ability to adhere to a treatment manual and to their use of interventions from outside of the CBT model.
This narrative review draws upon a broad range of literature, including theory and empirical research, to argue that positive emotions are a useful adjunct to therapy when working with individuals who self-harm. The review highlights how self-harm is often employed as a method of emotion regulation and may be both negatively and positively reinforced. It is suggested that individuals who self-harm have potential difficulty in experiencing positive and negative emotions. The compatibility of an emotion focused approach to therapy for individuals who self-harm is therefore deemed an appropriate one. However, current therapeutic models predominantly focus on unpleasant or negative emotions and largely tend to neglect positive emotions, such as happiness. Broaden and build theory indicates that positive emotions can reduce the effects of negative emotions and aid recovery from intolerable negative emotions that may underpin self-harming behaviours. Therefore, the incorporation of positive emotions into therapy is likely to be helpful. In addition, if cultivated over time, positive emotions can build resilience that may enable individuals to cope better with events that precipitate self-injurious behaviours. The review emphasizes how positive emotions represent a valuable addition to therapeutic work but also highlights that the negatively valenced and painful emotions often experienced by those who self-injure must still be addressed.
Key practitioner message:
When working with individuals who self-harm it may be beneficial for practitioners to consider clients' experiences of positive emotions, and how to cultivate these, in addition to targeting the negative emotions which tend to underpin self-harming behaviours.
Exposures to a high-ropes course are introduced as an adjunct intervention in the therapy of psychotherapy patients. A controlled study was conducted to investigate the effectiveness of high-ropes exposures as an add-on to inpatient treatment in a naturalistic setting. In a sample of 247 patients, depressive symptoms, trait anxiety, locus of control and self-efficacy were assessed at admission and discharge of treatment and at 24-month follow-up. Follow-up data were available for 104 patients who attended the ropes courses and 53 control patients who underwent an inpatient treatment programme as usual. At the end of treatment, more high-rope participants showed clinically significant change on trait anxiety than controls but not regarding depressive symptoms. High-rope participants showed better follow-up outcomes than controls in trait anxiety and self-efficacy but not in depressive symptoms and external locus of control. Moreover, during follow-up, in the high-rope group, more patients showed reliable improvements and fewer patients showed reliable deteriorations in trait anxiety as compared with controls. The study gives a preliminary indication that the high-rope interventions are a feasible and valuable add-on to inpatient psychotherapy. The study design, sample composition and loss to follow-up are discussed as potential limitations of the study.
This study investigated the psychometric properties of the first clinician-administered semi-structured interview for assessing the severity of hypochondriacal symptoms. The Hypochondriasis Yale-Brown Obsessive-Compulsive Scale (H-YBOCS) consisted of three a priori dimensions: hypochondriacal obsessions, compulsions and avoidance.
The 16-item interview was conducted with 112 participants with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, hypochondriasis. We analysed factor analytic structure, reliability, construct validity and sensitivity to change.
Factor analysis supported a three-factor model similar to the a priori dimensions. Internal consistency ranged from satisfactory to good. Inter-rater reliability was excellent. The construct validity was low to moderate. The H-YBOCS was sensitive for measuring changes in symptom severity.
The H-YBOCS is a (factorially) valid and coherent interview with a high level of agreement across different raters. The relatively low discriminant validity could be due to co-morbid anxiety and depressive disorders. Overall, the H-YBOCS seems to be a promising contribution to the assessment of hypochondriasis. KEY PRACTITIONER MESSAGE: *The hypochondriasis Y-BOCS is a feasible clinician rated interview to assess the severity of hypochondriacal complaints.
The Panic Disorder Severity Scale (PDSS) is a seven-item scale designed to assess overall severity of panic disorder symptoms. Although the PDSS is widely used, there have been limited independent studies confirming reliability and validity, particularly of the self-report version of the PDSS, and even fewer studies directly comparing the two versions. Given the need for psychometrically sound measures that comprehensively assess the main features of panic disorder, this study examined the psychometric properties of both the clinician-administered and self-report versions of the PDSS. As the PDSS targets symptom severity across a number of specific domains, PDSS items were compared to several scales designed to measure similar constructs, including the Anxiety Sensitivity Index, Illness Intrusiveness Ratings Scale, Mobility Inventory for Agoraphobia and Agoraphobic Cognitions Questionnaire. Results indicated acceptable reliability for both the clinician-administered and self-report versions. Results indicated acceptable validity for the clinician-administered PDSS and promising validity for the self-report. However, correlations between both versions of the PDSS and comparison measures were lower than predicted. Results also indicated that scores on the self-report and clinician-administered versions were significantly associated, although correlations between specific PDSS items on the two versions were also lower than expected. Results suggest that total scores on each of the PDSS versions provide a useful indication of panic-related severity. However, clinicians and researchers are cautioned against relying on scores from individual items to measure specific constructs due to their poor specificity.
Relationships between temperament, coping, depressive and aggressive mood in 8-12-year-old boys (n = 185) and girls (n = 219) were investigated, with a focus on gender differences. Children completed two self-report questionnaires: the Early Adolescent Temperament Questionnaire-Revised and Children's Coping Strategies Checklist-Revised1. Comparing boys and girls on three temperament dimensions, positive affectivity, negative affectivity and effortful control, girls scored higher than boys on the first two dimensions. Girls also scored higher than boys on avoidant coping and depressive mood. For both boys and girls, aggressive and depressive mood were predicted by negative affectivity. Coping did not add towards this prediction. Gender specific models of temperament, coping and depressive mood were tested. For girls, both effortful control and active problem solving, accounted for the variability in depressive mood. For boys, only effortful control accounted for variance in depressive mood. Results showed that gender specific vulnerability to depression in girls is apparent before adolescence and can be linked to temperament and coping.
Over the past two decades, Interpersonal Psychotherapy (IPT) has shown itself to be one of only two evidence-based psychotherapies for the treatment of depression in adolescence-an age group where the prescribing of antidepressant medication is limited and where morbidity and recurrence are high. We review the literature on the development and research studies of the IPT model for depressed adolescent patients, as well as recent developments expanding its use to other cultures and different diagnostic areas. An overview is provided of the model in action, using a fictionalized case vignette. Finally, we consider the future of IPT for the treatment and prevention of affective disorders in the under 18 age group and in the context of other generations in vulnerable families.
Children with attention deficit hyperactivity disorder (ADHD) who participated in a randomized clinical trial, which compared a brief intensive multimodal behaviour therapy combined with optimally titrated methylphenidate to optimally titrated methylphenidate alone (n = 45), were re-assessed at adolescence in a naturalistic follow-up 4.5 to 7.5 years after treatment. Also a matched normal control group was recruited (n = 23).
Assessments at follow-up included diagnostic status, ADHD symptoms, oppositional and conduct behaviour, substance abuse symptoms and parenting stress.
Of the 24 adolescents participating in the follow-up study, 50% still met diagnostic criteria for ADHD. There were no significant differences between adolescents at follow-up and those lost for follow-up. At follow-up, adolescents in the combined treatment condition used significantly less medication than children in the methylphenidate condition; there were no other significant differences between the treatment conditions. The adolescents showed a significant decline in hyperactivity/impulsivity, oppositional and conduct disorder symptoms from post-test to follow-up. Only inattention symptoms increased from post-test to follow-up but not to pre-test levels. The adolescents originally diagnosed with ADHD fared significantly worse than the matched controls on all outcomes, except on conduct disorder and substance abuse symptoms.
Our study shows in adolescents, diagnosed with ADHD in childhood, age-dependent decline of ADHD symptoms, although they still fared significantly worse than matched normal controls. Implications of results are restricted by small samples size, and the results may be subject to chance findings and need replication before firm conclusions can be drawn.
The aim of this study was to investigate whether depressed adolescents differed from non-depressed adolescents in terms of constructs consistent with those that are proposed to underpin interpersonal psychotherapy. In particular, it was hypothesized that compared with non-depressed adolescents, depressed adolescents would demonstrate a greater number of negative life events associated with interpersonal loss and major life transitions, a more insecure attachment style and poorer communication skills, interpersonal relationships and social support. Thirty-one clinically diagnosed depressed adolescents were matched with 31 non-depressed adolescents on age, gender and socio-economic status. The 62 participants were aged between 12 and 19years and comprised 18 male and 44 female adolescents. On a self-report questionnaire, depressed adolescents reported a greater number of negative interpersonal life events, a less secure attachment style and scored higher on all insecure attachment styles compared with the non-depressed adolescents. In addition, depressed adolescents demonstrated lower levels of social skill (on both adolescent and parent report), a poorer quality of relationship with parents (on both adolescent and parent report) and lower social competence (adolescent report only). Parents of depressed adolescents also reported more negative parental attitudes and behaviours towards their adolescent compared with parents of non-depressed adolescents. Thus, the results of this study are consistent with the constructs underlying interpersonal psychotherapy and suggest their usefulness in the assessment, conceptualization and treatment of adolescent depression. Clinical implications are discussed.
Quality of life (QoL) of children with chronic conditions has received increasing attention in recent years. While frequent paediatric health conditions and life-threatening conditions are in the foreground, QoL of children with rare diseases such as haemophilia is scarce. While haemophilia-specific instruments to assess QoL in children have been developed, cross-cultural comparison of QoL and its determinants has not been addressed so far. QoL and potential psychosocial determinants such as coping were assessed in 298 paediatric haemophilia patients from six European countries demonstrating significant differences in QoL between countries. Results indicated that psychosocial predictors varied across countries, although life satisfaction and social support explained the highest proportion of variance and, moreover, superseded clinical characteristics. These findings suggest that intervention programmes should be geared towards enhancing psychosocial resources in children and adolescents with haemophilia.
The association between disordered eating and depression has been established, but less is known about the temporal relations between these two disturbances. Accordingly, the current study examined the reciprocal relations between depressive and bulimic symptoms over an 8-year period, with longitudinal data from a community sample of 496 female adolescents. Depressive symptoms predicted future increases in bulimic symptoms, and bulimic symptoms likewise predicted increases in depressive symptoms, controlling for earlier levels of symptoms for each outcome. These results provide evidence consistent with the hypothesis that the two disorders contribute reciprocally to each other, and indicate that successful prevention or treatment of one disorder may yield effects for the other. However, the relatively small predictive effect sizes imply that some third variable may contribute to both conditions (e.g., temperamental negative affectivity).
Within the European Screening for and Promotion of Health-Related Quality of Life in Children and Adolescents-A European Public Health Perspective (KIDSCREEN) Study, emotional well-being and behaviour was examined in national representative samples of 22 000 children and adolescents aged 8 to 18.The proportion of children and adolescents showing signs of mental health problems (Strengths and Difficulties Questionnaire-SDQ) varied across countries and socio-demographic and socio-economic subgroups. Risk factors examined included adverse family climate, low socio-economic status, poor social support and decreased mental well-being of the parents. When several risk factors occur simultaneously, the prevalence of mental health problems increases markedly. Children and adolescents with mental health problems display distinctly impaired health-related quality of life (KIDSCREEN-10).Cross-cultural differences in the observed patterns of mental health problems were discussed. High-risk groups are cross-culturally characterized by poor social support and mental distress of parents. Strengthening social and familial resources should be a key objective, both in prevention and in interventions.
A significant minority of bereaved adults develops prolonged grief disorder (PGD), a syndrome encompassing debilitating symptoms of grief distinct from depression and anxiety. Few studies have examined the phenomenology and correlates of PGD among children and adolescents. In part, this is due to the lack of a psychometrically sound questionnaire to assess PGD symptoms in these groups. Based on an adult measure of PGD, we developed two questionnaires of PGD symptoms for children and adolescents named the Inventory of Prolonged Grief for Children (IPG-C) and Inventory of Prolonged Grief for Adolescents (IPG-A), respectively. Psychometric properties of these measures were examined in three samples, including mostly parentally bereaved children (aged 8-12 years, total sample n = 169) and adolescents (aged 13-18 years, total sample n = 153). First, findings showed that items of the IPG-C and IPG-A represented one underlying dimension. Second, the internal consistency and temporal stability of both questionnaires were adequate. Third, findings supported the concurrent validity (e.g., significant correlations with measures of depression and post-traumatic stress-disorder [PTSD]), convergent and divergent validity (stronger correlations with similar questionnaires of 'traumatic grief' than with two dissimilar questionnaires of 'ongoing presence' and 'positive memories') and incremental validity (significant correlations with an index of functional impairment, even when controlling for concomitant depression and PTSD) of the IPG-C and IPG-A. This report provides further evidence of the clinical significance of PGD symptoms among children and adolescents and promising psychometric properties of questionnaires that can be used to assess these symptoms.
Key practitioner message:
The Inventory of Prolonged Grief for Children (IPG-C) and Inventory of Prolonged Grief for Adolescents (IPG-A) were developed to be able to assess symptoms of Prolonged Grief Disorder (PGD) among children and adolescents. In different samples, the internal consistency, temporal stability, and concurrent and construct validity of these questionnaires were found to be adequate. The IPG-C and the IPG-A can be used in research examining causes and consequences of PGD, and the effectiveness of bereavement interventions for children and adolescents. This study provides further evidence of the existence and clinical significance of PGD symptoms among children and adolescents and supports the inclusion of a new category for bereavement-related disorders in DSM-5.
In the past years, there is growing recognition of a syndrome of disturbed grief referred to as prolonged grief disorder (PGD). Although mostly studied in adults, clinically significant PGD symptoms have also been observed in children and adolescents. To date, no effective treatment for childhood PGD yet exists. We recently developed a nine-session cognitive-behavioural treatment for childhood PGD combined with five sessions of parental counselling. In the current article, we present outcomes of treatment of 10 consecutive children and adolescents turning to our university clinic with elevated PGD symptoms as their primary problem and main reason to seek therapy. Patients were significantly improved at post-treatment, with large improvements in self-rated PGD and post-traumatic stress (effect sizes > 0.8) and small to moderate improvement in depression and parent-rated internalizing and externalizing problems (0.2 < effect sizes < 0.8). Additional predictor analysis of outcomes suggested that, among other things, this treatment approach is less efficacious for children and adolescents further removed from loss and those confronted with suicidal loss. That said, the treatment appears promising, and controlled evaluation is clearly indicated.
A negative self-generated image is thought to play a role in the development and maintenance of social anxiety. Video feedback (VF) is an effective therapeutic technique for correcting this distorted image with adults during stressful social tasks. This study investigated the effectiveness of VF with adolescents.
Thirty-six highly socially anxious adolescents (13 to 17-year-olds) were randomly assigned to one of two groups: VF or no VF. Both groups gave two brief speeches to a video camera. Self-rated measures of anticipatory anxiety, predicted performance and actual performance during the speeches were completed at several time points. The speeches were also rated by two independent observers.
Adolescents who received VF, in comparison with control participants, developed more positive appraisals of their performance during the first speech. Predictions of their performance on the second speech also improved, and a reduction in state anxiety was observed. Furthermore, a more positive appraisal of performance was generalized to the second speech. The independent observers could not distinguish between the participants who received VF and those who did not.
When used with socially anxious adolescents, VF may be a beneficial therapeutic technique in correcting a distorted self-perception of performance, reducing anxiety prior to entering a stressful social task and enhancing predictions of performance for future tasks.
The Clark and Wells' cognitive model of social phobia suggests that self-focused attention, negative observer-perspective images of oneself and safety behaviours maintain anxiety in subjects with SP. Empirical research among adults supports the model, but limited evidence for it has been obtained in other age groups or in the general population. We examined automatic thoughts, imagery, safety behaviours and general coping of adolescents with social anxiety and phobia. These were elicited by a thought listing procedure in a recalled, distressing social situation. The target variables were compared between adolescents with high versus normal self-reported social anxiety (HSA/NSA) and between adolescents with clinical/subclinical SP (SP/SSP) versus no diagnosis. Adolescents with HSA reported overall negative thoughts, negative observer-perspective images and safety behaviours more frequently than adolescents with NSA. The SP/SSP group displayed the same difference, and clearer, relative to the no diagnosis group, but additionally reported negative thoughts focused more often on self. Minor differences in coping were found between the groups. The study suggests that adolescents with SP already display the negative self-focused cognitions, observer-perspective imagery and behavioural pattern found among adults with SP.
Key practitioner message:
Social anxiety associates with observer-perspective imagery and safety behaviours in adolescence. Adolescents with clinical social phobia report frequent negative self-focused thoughts. However, such negative cognitions focused on self do not associate to self-reported social anxiety. The cognitive model of social phobia (Clark & Wells, 1995) is applicable to adolescents.
Social recovery has become a prominent aspect of mental health service design and delivery in the past decade. Much of the literature on social recovery is derived from first-person accounts or primary research with adult service users experiencing severe mental illness. There is a lack of both theoretical and empirical work that could inform consideration of how the concept of social recovery might apply to adolescents experiencing common (non-psychotic) mental health problems such as anxiety and depression. The current study was conducted to understand the process of experiencing anxiety and depression in young people. Semi-structured interviews were conducted with nine adolescents with anxiety and depression (seven girls and two boys aged 14-16 years) and 12 mothers who were recruited from a specialist Child and Adolescent Mental Health Service in the South of England. Thematic analysis indicated that young people do experience a process of 'recovery'; the processes participants described have some congruence with the earlier stages of adult recovery models involving biographical disruption and the development of new meanings, in this case of anxiety or depression, and changes in sense of identity. The accounts diverge with regard to later stages of adult models involving the development of hope and responsibility. The findings suggest that services should attend to social isolation and emphasise support for positive aspirations for future selves whilst also attending to young people's and parents' expectations about change. Methodological challenges face enquiry about 'recovery' given its connotations with cure in everyday language.
Key practitioner message:
Theoretical and empirical work on social recovery in young people and families is lacking. Using interviews, this study sought to understand the relevance of social recovery for adolescents with anxiety and depression and their mothers. Findings suggest some congruence with the earlier stages of adult recovery models involving meaning and identity. Findings diverge with regard to later stages of adult recovery models involving hope and responsibility. Social recovery in mental health services for young people needs significant empirical attention and critical debate.
Mental health problems affect approximately 20% of adolescents. Traditionally, the principal focus has been on vulnerability and risk factors and less on protective factors. The study, therefore, explores the relation between frequent psychiatric symptoms and resilience factors among older adolescents.
The Resilience Scale for Adolescents (READ) was completed by 307 Norwegian high school students (M = 16.4 years) along with the Depression Anxiety Stress Scales, and the Obsessive-Compulsive Inventory-Revised.
Higher resilience scores predicted lower scores on levels of depression, anxiety, stress and obsessive-compulsive symptoms after controlling for age and gender.
This study provides further evidence that it may be fruitful for clinicians and researchers to attend to resilience factors in relation to psychological symptoms among older adolescents.