Understanding cognitive behaviour therapy: A retrieval competition account

Brief report: Reduced anxiety following Pivotal Response Treatment in young children with Autism Spectrum Disorder

Up to 40% of children with Autism Spectrum Disorder (ASD) exhibit co-occurring anxiety symptoms. Despite recent success in mitigating anxiety symptoms in school-aged children with ASD (mean age >9 years) using adapted versions of Cognitive Behavioural Therapy, little is known about potential treatment outcomes for younger children. To address the gap in the literature, this open-label study evaluated change in anxiety following a 16-week open-label trial of Pivotal Response Treatment (PRT) in children with ASD aged 4-8 years. PRT is a behavioural treatment based on the principles of Applied Behaviour Analysis and has a primary aim of increasing social communication skills in children with ASD through natural reinforcements. To minimise conflation of anxiety and other co-occurring symptoms such as disruptive behaviour and attention-deficit hyperactivity disorder, we measured anxiety using the autism anxiety subscale of the Child and Adolescent Symptom Inventory (CASI) devised by Sukhodolsky et al. (2008). We observed significant anxiety reduction over 16-weeks of PRT. Furthermore, anxiety reduction was independent of changes in autism symptom severity. This study shows promising results for PRT as an intervention for reducing anxiety in young children with ASD.

Physiological and psychological effects of imagery techniques on health anxiety

Previous research has shown that intrusions are part of the psychopathology of mental disorders. Imagery techniques seem to be an effective treatment of negative intrusions. Since negative mental imagery is part of health anxiety, the present study investigated the impact of imagery techniques on health anxiety. A total of 159 students with elevated scores in a health anxiety questionnaire watched an aversive film concerning a cancer patient and were randomly allocated to one of three interventions (positive imagery, imagery reexperiencing, imagery rescripting) or the control group. The intervention lasted 9 min. Physiological data (heart rate and cortisol) as well as psychological measures, such as mood ratings, health anxiety scores, and intrusions, were assessed during the appointment, while psychological measures were assessed over a period of 1 week after the intervention. Cortisol levels changed over time depending on the intervention. Heart rate changed during the 9-min interventions as well, with the fastest decrease during imagery rescripting. Moreover, negative mood and distress decreased after the intervention, while intrusions were reduced 1 week after the intervention in all groups equally. The results suggest that imagery rescripting is a promising technique that seems to activate a process of deep elaboration. Therefore, it might be an adequate way to target health anxiety symptoms such as anxiety, intrusions, and avoidance or safety-seeking behavior. Further studies should focus on imagery rescripting in clinical samples with health anxiety and target individual intrusive images to increase effectiveness. Nevertheless, the development of a long-term explanatory model of rescripting is needed.

Effectiveness of Multidisciplinary Group-Based Intervention versus Individual Physiotherapy for Improving Chronic Low Back Pain in Nursing Staff: A Clinical Trial with 3- and 6-Month Follow-Up Visits from Tehran, Iran

Study Design

Clinical trial.

Purpose

To evaluate the effectiveness of a multidisciplinary group-based intervention on improving pain and disability among Iranian nurses with chronic low back pain in Tehran, Iran.

Overview of Literature

Although low back pain (LBP) is one of the most important health problems, the challenge remains on how to find an effective intervention to reduce pain and related disabilities.

Methods

Overall, 136 eligible nurses with chronic mechanical LBP were classified into two groups. The intervention group (n=66 participants) participated in a physiotherapy educational program (for 120 minutes) plus a health educational program based on predictive constructs of the social cognitive theory (for 120 minutes). These interventions were delivered by a physiotherapist and a health education specialist. The control group (n=70 participants) participated in a physiotherapy educational program (for 120 minutes). Disability rate, pain severity, and back pain prevention behavior were measured initially and at 3- and 6-month follow-up visits using the visual analogue scale, Roland-Morris Disability, and Nursing Low Back Pain Preventive Behaviors Questionnaire. Data were analyzed by SPSS ver. 16.

Results

There were statistically significant differences between the two groups in the main outcome measures immediately after the educational program and at 3- and 6-month follow-up visits. Preventive behaviors of participants in the intervention group were improved at 3- and 6- month follow-up visits (p<0.001). The mean scores of predictive constructs regarding LBP preventive behaviors in the intervention group were improved after 3 and 6 months (p<0.001). Finally, in the intervention group, pain severity and disability were decreased significantly.

Conclusions

This study showed that a multidisciplinary educational program intervention can be an effective approach for reducing LBP and related disabilities among nurses.

Pathways from Trauma to Psychotic Experiences: A Theoretically Informed Model of Posttraumatic Stress in Psychosis

In recent years, empirical data and theoretical accounts relating to the relationship between childhood victimization and psychotic experiences have accumulated. Much of this work has focused on co-occurring Posttraumatic Stress Disorder or putative causal mechanisms in isolation from each other. The complexity of posttraumatic stress reactions experienced in psychosis remains poorly understood. This paper therefore attempts to synthesize the current evidence base into a theoretically informed, multifactorial model of posttraumatic stress in psychosis. Three trauma-related vulnerability factors are proposed to give rise to intrusions and to affect how people appraise and cope with them. First, understandable attempts to survive trauma become habitual ways of regulating emotion, manifesting in cognitive-affective, behavioral and interpersonal responses. Second, event memories, consisting of perceptual and episodic representations, are impacted by emotion experienced during trauma. Third, personal semantic memory, specifically appraisals of the self and others, are shaped by event memories. It is proposed these vulnerability factors have the potential to lead to two types of intrusions. The first type is anomalous experiences arising from emotion regulation and/or the generation of novel images derived from trauma memory. The second type is trauma memory intrusions reflecting, to varying degrees, the retrieval of perceptual, episodic and personal semantic representations. It is speculated trauma memory intrusions may be experienced on a continuum from contextualized to fragmented, depending on memory encoding and retrieval. Personal semantic memory will then impact on how intrusions are appraised, with habitual emotion regulation strategies influencing people's coping responses to these. Three vignettes are outlined to illustrate how the model accounts for different pathways between victimization and psychosis, and implications for therapy are considered. The model is the first to propose how emotion regulation and autobiographical memory may lead to a range of intrusive experiences in psychosis, and therefore attempts to explain the different phenomenological associations observed between trauma and intrusions. However, it includes a number of novel hypotheses that require empirical testing, which may lead to further refinement. It is anticipated the model will assist research and practice, in the hope of supporting people to manage the impact of victimization on their lives.

Upward counterfactual thinking and depression: A meta-analysis

This meta-analysis examined the strength of association between upward counterfactual thinking and depressive symptoms. Forty-two effect sizes from a pooled sample of 13,168 respondents produced a weighted average effect size of r=.26, p<.001. Moderator analyses using an expanded set of 96 effect sizes indicated that upward counterfactuals and regret produced significant positive effects that were similar in strength. Effects also did not vary as a function of the theme of the counterfactual-inducing situation or study design (cross-sectional versus longitudinal). Significant effect size heterogeneity was observed across sample types, methods of assessing upward counterfactual thinking, and types of depression scale. Significant positive effects were found in studies that employed samples of bereaved individuals, older adults, terminally ill patients, or university students, but not adolescent mothers or mixed samples. Both number-based and Likert-based upward counterfactual thinking assessments produced significant positive effects, with the latter generating a larger effect. All depression scales produced significant positive effects, except for the Psychiatric Epidemiology Research Interview. Research and theoretical implications are discussed in relation to cognitive theories of depression and the functional theory of upward counterfactual thinking, and important gaps in the extant research literature are identified.

Tackling maladaptive memories through reconsolidation: From neural to clinical science

Behavioral neuroscience has greatly informed how we understand the formation, persistence, and plasticity of memory. Research has demonstrated that memory reactivation can induce a labile period, during which previously consolidated memories are sensitive to change, and in need of restabilization. This process is known as reconsolidation. Such findings have advanced not only our basic understanding of memory processes, but also hint at the prospect of harnessing these insights for the development of a new generation of treatments for disorders of emotional memory. However, even in simple experimental models, the conditions for inducing memory reconsolidation are complex: memory labilization appears to result from the interplay of learning history, reactivation, and also individual differences, posing difficulties for the translation of basic experimental research into effective clinical interventions. In this paper, we review a selection of influential animal and human research on memory reconsolidation to illustrate key insights these studies afford. We then consider how these findings can inform the development of new treatment approaches, with a particular focus on the transition of memory from reactivation, to reconsolidation, to new memory formation, as well as highlighting possible limitations of experimental models. If the challenges of translational research can be overcome, and if reconsolidation-based procedures become a viable treatment option, then they would be one of the first mental health treatments to be directly derived from basic neuroscience research. This would surely be a triumph for the scientific study of mind and brain.

How can the recall of early affiliative memories with peers influence on disordered eating behaviours?

The present study aimed to explore the role of early affiliative memories with peers on the adoption of disordered eating attitudes and behaviours through the mechanisms of external shame and self-judgment. The sample used in the current study comprised 632 women from the community, aged between 18 and 60 years old.The tested model explained 22 % of eating psychopathology's variance and showed excellent model fit indices. Results indicated that the impact of the recall of early positive memories with peers on eating psychopathology was fully carried through the mechanisms of external shame and self-judgment. In fact, these findings seem to suggest that the lack of warm and safe affiliative memories with peers is linked to higher levels of shame (e.g., feelings of inferiority and inadequacy), and also to higher vulnerability to engage in maladaptive emotional strategies (such as self-judgmental attitudes), which appears to explain the increase of disordered eating behaviours.These findings contribute to the understanding of the impact of peer-related early affiliative memories in the engagement in disordered eating. Furthermore, this study has significant clinical implications, emphasizing the importance of targeting shame and maladaptive emotional strategies, especially in a context involving early adverse emotional experiences with peers.

Cognitive restructuring and imagery modification for posttraumatic stress disorder (CRIM-PTSD): A pilot study

BACKGROUND AND OBJECTIVES

Cognitive restructuring and imagery modification for PTSD (CRIM-PTSD) is a new short intervention. It consists of the cognitive restructuring of core trauma-related dysfunctional beliefs about the self and the use of imagery to encourage more functional beliefs. A randomized controlled trial showed that CRIM was effective for reducing posttraumatic stress disorder (PTSD) in survivors of childhood sexual abuse (CSA) when it focused on the feeling of being contaminated. For this study, CRIM was adapted to treat PTSD symptoms more generally and after various types of trauma by addressing the patients' negative self-concept.

METHODS

Ten patients with PTSD received two assessment sessions, two treatment sessions, and a booster session. The Clinician-Administered PTSD Scale (CAPS) was administered prior to and four weeks after treatment. Self-ratings, e.g., the Posttraumatic Diagnostic Scale (PDS) and the Posttraumatic Cognitions Inventory (PTCI), were administered at baseline, immediately posttreatment, and four weeks after treatment.

RESULTS

The participants showed significant improvements in both clinician-rated (d = 2.55; p < 0.01) and self-reported PTSD symptoms (d = 1.47; p < 0.01). One month after treatment, 9 patients no longer fully met the diagnostic criteria for PTSD.

LIMITATIONS

The results are limited by the small sample size and the lack of a control group.

CONCLUSIONS

This pilot study suggests that addressing the negative self-concept of PTSD patients using a combination of cognitive techniques and imagery modification can effectively reduce PTSD symptoms. Further research is needed to assess the treatment's effects and stability in a randomized controlled trial.

Autobiographical episodic memory-based training for the treatment of mood, anxiety and stress-related disorders: A systematic review and meta-analysis

We review evidence for training programmes that manipulate autobiographical processing in order to treat mood, anxiety, and stress-related disorders, using the GRADE criteria to judge evidence quality. We also position the current status of this research within the UK Medical Research Council's (2000, 2008) framework for the development of novel interventions. A literature search according to PRISMA guidelines identified 15 studies that compared an autobiographical episodic memory-based training (AET) programme to a control condition, in samples with a clinician-derived diagnosis. Identified AET programmes included Memory Specificity Training (Raes, Williams, & Hermans, 2009), concreteness training (Watkins, Baeyens, & Read, 2009), Competitive Memory Training (Korrelboom, van der Weele, Gjaltema, & Hoogstraten, 2009), imagery-based training of future autobiographical episodes (Blackwell & Holmes, 2010), and life review/reminiscence therapy (Arean et al., 1993). Cohen's d was calculated for between-group differences in symptom change from pre- to post-intervention and to follow-up. We also completed meta-analyses for programmes evaluated across multiple studies, and for the overall effect of AET as a treatment approach. Results demonstrated promising evidence for AET in the treatment of depression (d=0.32), however effect sizes varied substantially (from -0.18 to 1.91) across the different training protocols. Currently, research on AET for the treatment of anxiety and stress-related disorders is not yet at a stage to draw firm conclusions regarding efficacy as there were only a very small number of studies which met inclusion criteria. AET offers a potential avenue through which low-intensity treatment for affective disturbance might be offered.

Changes in the self during cognitive behavioural therapy for social anxiety disorder: A systematic review

A consistent feature across cognitive-behavioural models of social anxiety disorder (SAD) is the central role of the self in the emergence and maintenance of the disorder. The strong emphasis placed on the self in these models and related empirical research has also been reflected in evidence-based treatments for the disorder. This systematic review provides an overview of the empirical literature investigating the role of self-related constructs (e.g., self-beliefs, self-images, self-focused attention) proposed in cognitive models of SAD, before examining how these constructs are modified during and following CBT for SAD. Forty-one studies met the inclusion criteria. Guided by Stopa's (2009a, b) model of self, most studies examined change in self-related content, followed by change in self-related processing. No study examined change in self-structure. Pre- to post-treatment reductions were observed in self-related thoughts and beliefs, self-esteem, self-schema, self-focused attention, and self-evaluation. Change in self-related constructs predicted and/or mediated social anxiety reduction, however relatively few studies examined this. Papers were limited by small sample sizes, failure to control for depression symptoms, lack of waitlist, and some measurement concerns. Future research directions are discussed.

Family-Based Cognitive–behavioral Therapy for an Intelligent, Elementary School-Aged Child With Generalized Anxiety Disorder

This case study follows an 8-year-old Caucasian female who presented with symptoms of Generalized Anxiety Disorder (GAD). Given this child’s age but advanced cognitive skills, careful selection of an appropriate treatment was made. In the current case study, a family-based cognitive–behavioral therapy intervention (Wood & McLeod, 2008) was implemented to treat this child’s symptoms of GAD. Following completion of the intervention, the child demonstrated significant decreases in her symptoms. In addition, she demonstrated a thorough understanding of coping skills, successfully applied and generalized her skills to a variety of situations, and took pride in teaching her skills to others. This child showed quantitative improvements on objective self-report measures as well as qualitative improvements in her overall emotional and behavioral functioning. This case study suggested that cognitive–behavioral therapy interventions, particularly when used in a family-based approach, are effective for children with symptoms of GAD.

Reconsolidation versus retrieval competition: Rival hypotheses to explain memory change in psychotherapy

I suggest it is premature to assume memory reconsolidation provides a unifying model of psychotherapeutic change given our current state of knowledge, and that other basic memory mechanisms, also supported by neuroscience, have a stronger claim at present. In particular, I propose that retrieval competition provides a more plausible alternative to memory reconsolidation.

The efficacy of imagery rescripting compared to cognitive restructuring for social anxiety disorder

Imagery rescripting (IR) aims to alter negative meanings associated with distressing autobiographical memories. The current study aimed to extend demonstrated benefits of IR for social anxiety disorder (SAD), including direct comparison of IR with cognitive restructuring (CR) to assess the relative impact of these interventions on symptoms and processes. SAD individuals (N=60) were randomly allocated to IR, CR or Control conditions, and completed two speech tasks (before and after) their assigned intervention. Participants completed measures of symptomatology and state affective/cognitive variables in relation to the intervention and speech tasks. Results support the benefits of IR for SAD, with both IR and CR yielding large and equivalent reductions in trait social anxiety. However, IR and CR may function via differing pathways. Outcomes suggest that IR may be most effective in the treatment of SAD when delivered across multiple sessions or preceded by CR to target verbal and imaginal self-representations.

Reward memory relieves anxiety-related behavior through synaptic strengthening and protein kinase C in dentate gyrus

Anxiety disorders are presumably associated with negative memory. Psychological therapies are widely used to treat this mental deficit in human beings based on the view that positive memory competes with negative memory and relieves anxiety status. Cellular and molecular processes underlying psychological therapies remain elusive. Therefore, we have investigated its mechanisms based on a mouse model in which food reward at one open-arm of the elevated plus-maze was used for training mice to form reward memory and challenge the open arms. Mice with the reward training showed increased entries and stay time in reward open-arm versus neutral open-arm as well as in open-arms versus closed-arms. Accompanying with reward memory formation and anxiety relief, glutamatergic synaptic transmission in dentate gyrus in vivo and dendritic spines in granule cells became upregulated. This synaptic up-regulation was accompanied by the expression of more protein kinase C (PKC) in the dendritic spines. The inhibition of PKC by chelerythrine impaired the formation of reward memory, the relief of anxiety-related behavior and the up-regulation of glutamate synapses. Our results suggest that reward-induced positive memory relieves mouse anxiety-related behavior by strengthening synaptic efficacy and PKC in the hippocampus, which imply the underlying cellular and molecular processes involved in the beneficial effects of psychological therapies treating anxiety disorders.

A systematic review and meta-analysis on controlled treatment trials of metacognitive therapy for anxiety disorders

Background:

To conduct a systematic review and meta-analysis on controlled treatment trials of meta-cognitive therapy for anxiety disorders.

Materials and Methods:

Studies were included if they employed controlled methodology and treated people above 18 years with anxiety disorders. Case studies (with less than 4 cases) and single case designed studies were excluded. A comprehensive literature search identified 15 trials for systematic review.

Results:

All included studies showed better treatment results in the MCT arms compared to the control groups. We also statistically pooled the results across studies (when possible). The meta-analyses also showed that MCT had statistically significant better results compared to the control groups in GAD (both immediately post-treatment and 12 months post-therapy results), OCD, and PTSD (p-values ranged <0.0001-0.025).

Conclusion:

Based on the results of our systematic review, MCT seems to be an effective treatment for anxiety disorders and can effectively control their psychological problems.

The impact of imagery rescripting on memory appraisals and core beliefs in social anxiety disorder

Negative mental images in social anxiety disorder (SAD) are often rooted in autobiographical memories of formative, distressing life events. In the present study, 25 participants with SAD retrieved an idiosyncratic negative mental image and associated autobiographical memory. Participants were then randomly assigned either to a single-session of imagery rescripting (IR) targeting the retrieved autobiographical memory or to a non-intervention control condition (no-IR). Outcomes were assessed one week later. Compared to control participants, those who received IR experienced substantial reduction in SAD symptoms accompanied by more positive and less negative appraisals of their autobiographical memories. Moreover, IR relative to no-IR participants reported marked shifts in the content, validity, and accuracy of their memory-derived negative core beliefs about self and others, but not about the world. Results support the promise of IR as a stand-alone intervention for SAD and suggest important directions for future research to enhance our understanding of the cognitive mechanisms that underlie its effects.

Imagery Rescripting as stand-alone treatment for posttraumatic stress disorder related to childhood abuse

OBJECTIVE

This case series tested the feasibility and explored the efficacy of Imagery Rescripting (ImRs) as a stand-alone treatment for PTSD related to childhood physical and/or sexual abuse (CA).

METHOD

Participants (6 women and 2 men) were patients with PTSD related to CA who entered an 8 week treatment program with 16 twice-weekly ImRs sessions. Blind assessments took place at pre- and post-treatment and at 3 month follow-up.

RESULTS

Participants showed improvement in both self-reported and clinician-rated PTSD symptoms. Gains were maintained at 3-month follow-up. At post-treatment, 50% of participants no longer met criteria for PTSD, and this number increased to 75% at 3 month follow-up.

LIMITATIONS

The main limitation is the small sample size and the selective nature of the sample, which limits the generalizability of the findings.

CONCLUSIONS

This pilot study suggests that Imagery Rescripting as stand-alone treatment is feasible and effective without prior stabilization in an outpatient population with CA-related PTSD. Further replication is needed in form of a randomized controlled trial.

Bringing the "self" into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of "self" (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis

Objectives

To assess whether cognitive behavioural (CB) approaches improve disability, pain, quality of life and/or work disability for patients with low back pain (LBP) of any duration and of any age.

Methods

Nine databases were searched for randomised controlled trials (RCTs) from inception to November 2014. Two independent reviewers rated trial quality and extracted trial data. Standardised mean differences (SMD) and 95% confidence intervals were calculated for individual trials. Pooled effect sizes were calculated using a random-effects model for two contrasts: CB versus no treatment (including wait-list and usual care (WL/UC)), and CB versus other guideline-based active treatment (GAT).

Results

The review included 23 studies with a total of 3359 participants. Of these, the majority studied patients with persistent LBP (>6 weeks; n=20). At long term follow-up, the pooled SMD for the WL/UC comparison was -0.19 (-0.38, 0.01) for disability, and -0.23 (-0.43, -0.04) for pain, in favour of CB. For the GAT comparison, at long term the pooled SMD was -0.83 (-1.46, -0.19) for disability and -0.48 (-0.93, -0.04) for pain, in favour of CB. While trials varied considerably in methodological quality, and in intervention factors such as provider, mode of delivery, dose, duration, and pragmatism, there were several examples of lower intensity, low cost interventions that were effective.

Conclusion

CB interventions yield long-term improvements in pain, disability and quality of life in comparison to no treatment and other guideline-based active treatments for patients with LBP of any duration and of any age.

Systematic Review Registration

PROSPERO protocol registration number: CRD42014010536.

Cognitive Bias Modification: Past Perspectives, Current Findings, and Future Applications

Research conducted within the general paradigm of cognitive bias modification (CBM) reveals that emotional biases in attention, interpretation, and memory are not merely associated with emotional disorders but contribute to them. After briefly describing research on both emotional biases and their modification, the authors examine similarities between CBM paradigms and older experimental paradigms used in research on learning and memory. The techniques and goals of CBM research are compared with other approaches to understanding cognition-emotion interactions. From a functional perspective, the CBM tradition reminds us to use experimental tools to evaluate assumptions about clinical phenomena and, more generally, about causal relationships between cognitive processing and emotion.

Are 60-minute prolonged exposure sessions with 20-minute imaginal exposure to traumatic memories sufficient to successfully treat PTSD? A randomized noninferiority clinical trial

The study aims to determine whether 60-minute sessions of prolonged exposure (PE) that include 20 minutes of imaginal exposure (IE) are noninferior to the standard 90-minute sessions that include 40 minutes of IE in treating posttraumatic stress disorder (PTSD) and to explore the relationship of treatment outcome to within- and between-session habituation and change in negative cognitions. Thirty-nine adult veterans with chronic PTSD were randomly assigned to 90-minute (n=19) or 60-minute (n=20) sessions of PE. PTSD symptoms were assessed by an unaware independent evaluator before and after treatment and at 6-month follow-up. Self-reports of depression and negative cognitions were assessed before and after treatment. Participants in both conditions showed significant reductions in PTSD symptoms. Sixty-minute sessions were found to be noninferior to 90-minute sessions in reducing PTSD symptoms, as the upper bound of the 95% confidence interval for the difference between conditions in the PTSD Symptom Scale-Interview (posttreatment: 6.00; follow-up: 6.77) was below the predefined noninferiority margin (7.00). Participants receiving shorter sessions showed less within- and between-session habituation than those receiving longer sessions, but no group differences in reductions in negative cognitions were found. The current findings indicate that the outcomes of 60-minute sessions of PE do not differ from those of 90-minute sessions. In addition, change in trauma-related cognitions and between-session habituation are both potential mechanisms of PE.

A randomised controlled trial of positive memory training for the treatment of depression within schizophrenia

BACKGROUND

Depression is highly prevalent within individuals diagnosed with schizophrenia, and is associated with an increased risk of suicide. There are no current evidence based treatments for low mood within this group. The specific targeting of co-morbid conditions within complex mental health problems lends itself to the development of short-term structured interventions which are relatively easy to disseminate within health services. A brief cognitive intervention based on a competitive memory theory of depression, is being evaluated in terms of its effectiveness in reducing depression within this group.

METHODS/DESIGN

This is a single blind, intention-to-treat, multi-site, randomized controlled trial comparing Positive Memory Training plus Treatment as Usual with Treatment as Usual alone. Participants will be recruited from two NHS Trusts in Southern England. In order to be eligible, participants must have a DSM-V diagnosis of schizophrenia or schizo-affective disorder and exhibit at least a mild level of depression. Following baseline assessment eligible participants will be randomly allocated to either the Positive Memory Training plus Treatment as Usual group or the Treatment as Usual group. Outcome will be assessed at the end of treatment (3-months) and at 6-month and 9-month post randomization by assessors blind to group allocation. The primary outcome will be levels of depression and secondary outcomes will be severity of psychotic symptoms and cost-effectiveness. Semi-structured interviews will be conducted with all participants who are allocated to the treatment group so as to explore the acceptability of the intervention.

DISCUSSION

Cognitive behaviour therapy is recommended for individuals diagnosed with schizophrenia. However, the number of sessions and length of training required to deliver this intervention has caused a limit in availability. The current trial will evaluate a short-term structured protocol which targets a co-morbid condition often considered of primary importance by service users. If successful the intervention will be an important addition to current initiatives aimed at increasing access to psychological therapies for people diagnosed with severe mental health problems.

TRIAL REGISTRATION

Current Controlled Trials. ISRCTN99485756 . Registered 13 March 2014.

Self-imagery in individuals with high body dissatisfaction: the effect of positive and negative self-imagery on aspects of the self-concept

BACKGROUND AND OBJECTIVES

Cognitive behavioural models of eating disorders highlight low self-esteem as a maintaining factor. This study explored the impact of positive and negative self-imagery on aspects of the working self (implicit and explicit self-esteem and self-concept clarity) in individuals with high body dissatisfaction (an important aspect of eating disorders). The impact of these images on state body satisfaction and affect was also explored.

METHOD

A group of participants with high body dissatisfaction completed measures of explicit self-esteem, self-concept clarity, state body satisfaction and affect prior to completing a negative (n = 33) or positive (n = 33) self-imagery retrieval task. Following this they completed the baseline measures and a measure of implicit self-esteem.

RESULTS

Holding a negative self-image in mind had a negative effect on explicit self-esteem, whilst holding a positive self-image had a beneficial effect. There were no effects of imagery on implicit self-esteem. Holding a negative image in mind led to a significant reduction in self-concept clarity; however, positive self-imagery did not affect self-concept clarity. Holding a negative self-image in mind led to a decrease in body satisfaction and state affect. The opposite was found for the positive self-imagery group.

LIMITATIONS

Implicit self-esteem was not measured at baseline.

CONCLUSIONS

Imagery techniques which promote positive self-images may help improve aspects of the working self, body satisfaction and affect in individuals with high levels of body dissatisfaction. As such, these imagery techniques warrant further investigation in a clinical population.

Impact of cognitive behavioral therapy on observed autism symptom severity during school recess: a preliminary randomized, controlled trial

This study compared cognitive behavioral therapy (CBT) and treatment-as-usual (TAU) in terms of effects on observed social communication-related autism symptom severity during unstructured play time at school for children with autism spectrum disorders (ASD). Thirteen children with ASD (7-11 years old) were randomly assigned to 32 sessions of CBT or community-based psychosocial treatment (TAU) for 16 weeks. The CBT program is based on the memory retrieval competition model and emphasizes the development of perspective-taking through guided behavioral experimentation supplemented with reflective Socratic discussion and supported by parent training and school consultation to promote generalization of social communication and emotion regulation skills. Trained observers blind to treatment condition observed each child during recess on two separate days at baseline and again at posttreatment, using a structured behavioral observation system that generates frequency scores for observed social communication-related autism symptoms. CBT outperformed TAU at posttreatment on the frequency of self-isolation, the proportion of time spent with peers, the frequency of positive or appropriate interaction with peers, and the frequency of positive or appropriate peer responses to the target child (d effect size range 1.34-1.62). On average, children in CBT were engaged in positive or appropriate social interaction with peers in 68.6% of observed intervals at posttreatment, compared to 25% of intervals for children in TAU. Further investigation of this intervention modality with larger samples and follow-up assessments is warranted.

Psychological impact of identifying character strengths in people with psychosis

A one group pre–post test design investigated the impact of identifying character strengths using the Values In Action Inventory of Strengths (VIA-IS) with individuals with early psychosis (N = 29). Post-test improvements in positive affect and cognitive performance were observed. Neither self-esteem nor self-efficacy improved. The technique appears feasible for use within early intervention services. Adverse consequences should be monitored and additional components considered to enhance benefits.

Out of my real body: cognitive neuroscience meets eating disorders

Clinical psychology is starting to explain eating disorders (ED) as the outcome of the interaction among cognitive, socio-emotional and interpersonal elements. In particular two influential models—the revised cognitive-interpersonal maintenance model and the transdiagnostic cognitive behavioral theory—identified possible key predisposing and maintaining factors. These models, even if very influential and able to provide clear suggestions for therapy, still are not able to provide answers to several critical questions: why do not all the individuals with obsessive compulsive features, anxious avoidance or with a dysfunctional scheme for self-evaluation develop an ED? What is the role of the body experience in the etiology of these disorders? In this paper we suggest that the path to a meaningful answer requires the integration of these models with the recent outcomes of cognitive neuroscience. First, our bodily representations are not just a way to map an external space but the main tool we use to generate meaning, organize our experience, and shape our social identity. In particular, we will argue that our bodily experience evolves over time by integrating six different representations of the body characterized by specific pathologies—body schema (phantom limb), spatial body (unilateral hemi-neglect), active body (alien hand syndrome), personal body (autoscopic phenomena), objectified body (xenomelia) and body image (body dysmorphia). Second, these representations include either schematic (allocentric) or perceptual (egocentric) contents that interact within the working memory of the individual through the alignment between the retrieved contents from long-term memory and the ongoing egocentric contents from perception. In this view EDs may be the outcome of an impairment in the ability of updating a negative body representation stored in autobiographical memory (allocentric) with real-time sensorimotor and proprioceptive data (egocentric).

Autobiographical memory distributions for negative self-images: memories are organised around negative as well as positive aspects of identity

The relationship between developmental experiences, and an individual's emerging beliefs about themselves and the world, is central to many forms of psychotherapy. People suffering from a variety of mental health problems have been shown to use negative memories when defining the self; however, little is known about how these negative memories might be organised and relate to negative self-images. In two online studies with middle-aged (N = 18; study 1) and young (N = 56; study 2) adults, we found that participants' negative self-images (e.g., I am a failure) were associated with sets of autobiographical memories that formed clustered distributions around times of self-formation, in much the same pattern as for positive self-images (e.g., I am talented). This novel result shows that highly organised sets of salient memories may be responsible for perpetuating negative beliefs about the self. Implications for therapy are discussed.

The effect of acutely administered MDMA on subjective and BOLD-fMRI responses to favourite and worst autobiographical memories

3,4-methylenedioxymethamphetamine (MDMA) is a potent monoamine-releaser that is widely used as a recreational drug. Preliminary work has supported the potential of MDMA in psychotherapy for post-traumatic stress disorder (PTSD). The neurobiological mechanisms underlying its putative efficacy are, however, poorly understood. Psychotherapy for PTSD usually requires that patients revisit traumatic memories, and it has been argued that this is easier to do under MDMA. Functional magnetic resonance imaging (fMRI) was used to investigate the effect of MDMA on recollection of favourite and worst autobiographical memories (AMs). Nineteen participants (five females) with previous experience with MDMA performed a blocked AM recollection (AMR) paradigm after ingestion of 100 mg of MDMA-HCl or ascorbic acid (placebo) in a double-blind, repeated-measures design. Memory cues describing participants' AMs were read by them in the scanner. Favourite memories were rated as significantly more vivid, emotionally intense and positive after MDMA than placebo and worst memories were rated as less negative. Functional MRI data from 17 participants showed robust activations to AMs in regions known to be involved in AMR. There was also a significant effect of memory valence: hippocampal regions showed preferential activations to favourite memories and executive regions to worst memories. MDMA augmented activations to favourite memories in the bilateral fusiform gyrus and somatosensory cortex and attenuated activations to worst memories in the left anterior temporal cortex. These findings are consistent with a positive emotional-bias likely mediated by MDMA's pro-monoaminergic pharmacology.

Visual mental imagery in psychopathology--implications for the maintenance and treatment of depression

Negative mental images are a common feature in a range of mental disorders as well as in healthy subjects. Intrusive negative mental images have only recently become a focus of attention in clinical research on depression. Research so far indicates that they can be an important factor regarding the onset and chronicity of affective disorders. This article is the first to provide an extensive overview of the current state of research in the field of visual mental images in depression. It aims to investigate disorder-specific characteristics, as well as the role of imagery as a maintaining factor. A detailed definition and description of empirical results about mental images in depressive disorders is followed by a presentation and analysis of treatment studies using imagery techniques in depressed samples. Additionally, methodological issues like small sample sizes and the lack of control groups are pointed out and implications for future research are discussed. Case vignettes are included in the appendix to exemplify the importance of negative mental images in patients suffering from depression.

Imagery rescripting as a stand-alone treatment for patients with social phobia: a case series

BACKGROUND AND OBJECTIVES

The majority of patients with social phobia reports experiencing negative images, usually linked to memories of earlier aversive social experiences. Several studies have indicated that such negative self-imagery appears to have a causal role in maintaining social phobia, which suggests that interventions aimed at dealing with these images could be beneficial in the treatment of social phobia. One potentially powerful approach is imagery rescripting (IR), a clinical intervention that focuses on changing the meaning and impact of unpleasant memories. In the treatment of social phobia IR was only used as part of a broader cognitive-behavioral treatment package. However, we propose that IR alone might also be an effective treatment for this anxiety disorder. The present study reports an initial evaluation of the application of IR as a stand-alone treatment for six adult outpatients presenting with social phobia.

METHODS

A single case series using an A-B replication across patients design was employed. Following a no-treatment baseline period, IR was delivered weekly and patients were followed up for 3 and 6 months.

RESULTS

For all patients, substantial reductions were obtained on all outcome measures at post-treatment, and gains were largely maintained at 6-months follow-up.

LIMITATIONS

The generalizability of the effects of IR for social phobia is limited by the small number of patients treated by only one therapist.

CONCLUSIONS

The results of this preliminary case series suggest that IR as a stand alone treatment is an apparently effective intervention in the treatment of patients with social phobia, and indicate that controlled evaluation of its efficacy might be worthwhile.

Experimental single-session imagery rescripting of distressing memories in bowel/bladder-control anxiety: a case series

Bowel and bladder obsession [bowel/bladder-control anxiety (BBCA)] is a viscerally centered phobic syndrome involving a specific concern about losing control of bowel or bladder functioning in a public place. Like other anxiety disorders, BBCA is characterized by intrusive imagery. We have previously described the nature of intrusive mental imagery in BBCA and found imagery themes to be linked to actual experiences of loss of control or to "near misses." A causal role for imagery in symptom maintenance can be inferred by examining the effects of imagery rescripting. Moreover, successful rescripting may point to a potentially efficacious avenue for treatment development. Three cases of imagery rescripting are described here with pre-, post-, and follow-up (1-week) data reported. After rescripting, two participants experienced pronounced reductions in imagery vividness, distress, shame, disgust, and belief conviction. Most importantly, all three participants experienced a reduction in fear-associated bladder and/or bowel sensations. The results support a causal role for mental imagery in bowel-bladder-control anxiety and suggest that rescripting of distressing intrusive memories linked to recurrent images may be a useful avenue for development of cognitive-behavioral treatments of bladder/bowel-control anxiety.

Measuring slips and lapses when they occur - ambulatory assessment in application to cognitive failures

Cognitive failures are lapses in attention, cognition, and actions that everybody experiences in everyday life. Self-reports are mainly used for assessment but those instruments are memory-biased and more related to personality aspects than to actual behavior. Ambulatory assessment is already used for capturing emotions or addictive behavior, but not yet for cognitive failures. The newly developed Questionnaire for Cognitive Failures in Everyday Life (KFA) was applied via mobile phones (electronic KFA) wherein an acoustic signal asked participants (N=91, 60-76 years) 4 times daily to answer 13 questions for 1 week. The new instrument showed satisfying reliability and was compared with a self-report method (Cognitive Failures Questionnaire; Broadbent, Cooper, Fitzgerald, and Parkes, 1982) in terms of correlations with cognitive abilities (working memory capacity, short-term memory, switching ability, and reasoning), personality traits, and demographical aspects. Although further validation is needed, first results are promising and eKFA enriches cognitive failures research.

Within the mind's eye: Negative mental imagery activates different emotion regulation strategies in high versus low socially anxious individuals

BACKGROUND AND OBJECTIVES

The link between social anxiety (SA) and maladaptive emotion regulation has been clearly established, but little is known about the spontaneous regulation strategies that may be activated during social stress by negative involuntary mental images and whether the nature of such strategies might distinguish individuals with high vs. low trait SA.

METHODS

Participants with high (n = 33) or low (n = 33) trait SA performed an evaluative speech and reported whether they experienced an involuntary negative mental image during the task. They also rated their negative affect (NA) and positive affect (PA) and the extent to which they viewed their image as being controllable and malleable. Finally, they described the types of strategies they spontaneously used to try to control or change their image intrusions. Reported strategies were then subjected to a content analysis and categorized by blinded coders.

RESULTS

Among high SA participants, image controllability was both diminished overall and positively correlated with PA. Whereas 90% of low SA individuals reported that they spontaneously self-regulated by altering the content or perceptual features of their images, only about half of the high SA participants used this strategy, with the other 50% reporting that they either suppressed their images or succumbed passively to them in whatever form they took.

LIMITATIONS AND CONCLUSIONS

Although these initial findings require replication in future experimental studies on clinical samples, they also help to enrich our understanding of the strategies that are commonly used by high and low SA individuals to manage their image intrusions during in-vivo stress and suggest potential avenues for future research on the role of imagery in adaptive and maladaptive emotion regulation.

Cognitive behavioral therapy for children with autism: review and considerations for future research

OBJECTIVE

Cognitive behavioral therapy (CBT) is now commonly used for high-functioning children with an autism spectrum disorder. The objective of this article was to describe the methods and results of cognitive behavioral interventions for children with autism.

METHOD

This article reviews CBT programs targeting anxiety, disruptive behavior, and core autism symptoms for children with autism.

RESULTS

There is emerging evidence suggesting that CBT is possibly efficacious for anxiety and autism symptoms, but methodological weaknesses must be addressed before clear conclusions can be drawn.

CONCLUSION

More research needs to be conducted to examine the effectiveness of CBT for children with autism. Specifically, future research should use more stringent methodology and assess the effectiveness of specific cognitive strategies and autism-related adaptations.