Predicting response to cognitive therapy and interpersonal therapy, with or without antidepressant medication, for major depression: a pragmatic trial in routine practice

BACKGROUND

Identifying patient characteristics that predict response within treatments (prognostic) or between treatments (prescriptive) can inform clinical decision-making. In this study, we sought to identify predictors of response to evidence-based treatments in a sample of depressed patients seeking help in routine practice.

METHODS

Data come from a pragmatic trial of 174 patients with major depression who received an evidence-based treatment of their own choice: cognitive therapy (CT), interpersonal therapy (IPT), antidepressant medication (ADM) alone or in combination with either of the two psychotherapies. Patient characteristics measured at baseline were examined to see if they predicted subsequent response as measured with the Beck Depression Inventory (BDI) over the course of 26 weeks of treatment, using mixed regression modeling.

RESULTS

Higher agoraphobia scores at baseline predicted more change in depression scores across treatments, irrespective of the treatment received. Physical functioning moderated the response to treatment: patients with high physical functioning fared better in combined treatment than patients with low physical functioning, whereas physical functioning did not predict a differential response in the psychotherapy group. Moreover, the lowest levels of physical functioning predicted an increase of depressive symptoms in combined treatment.

LIMITATIONS

A relatively small sample size, and selection of several predictors that were less theory-driven, which hampers the translation to clinical practice.

CONCLUSIONS

If replicated, the prognostic and prescriptive indices identified in this study could guide decision-making in routine practice. Development of more uniform requirements for the analysis and reporting of prediction studies is recommended.

Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy

BACKGROUND

Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy.

METHOD

In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point.

RESULTS

Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037).

CONCLUSIONS

In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.

Brief communication: investigating the relationship between psychopathy and interoceptive awareness

Psychopathy is a disorder that is characterized by marked emotional deficiencies. Because previous studies suggest that an individual's sensitivity to bodily signals--or "interoceptive awareness"--is associated with various components of emotional functioning, the authors expected this capacity to be reduced in psychopathic individuals. Therefore, the current study examined the relationship between psychopathy and interoceptive awareness by assessing heartbeat detection abilities in a group of 75 male personality disordered offenders, varying in their degree of psychopathy, as assessed with the Hare Psychopathy Checklist-Revised (PCL-R; Hare, 2003). Regression analyses revealed that PCL-R Facet 4, which reflects antisocial behavior, was predictive of reduced interoceptive awareness. These findings suggest that the expression of psychopathic behavior might be influenced by an attenuated sensitivity to one's own bodily signals.

Preliminary evaluation of psychometric properties of the Finnish Borderline Personality Disorder Severity Index: Oulu-BPD-Study

BACKGROUND

Borderline personality disorder (BPD) is a severe disorder decreasing the functional ability of the patient and places an extensive burden on the healthcare system. There is a need for a reliable and valid instrument with which unstable recent BPD symptoms can be assessed in a short-term perspective, and which is applicable for clinical evaluations and treatment-outcome research.

AIMS

We evaluated the psychometric properties of the Borderline Personality Disorder Severity Index IV (BPDSI-IV) interview in a sample of Finnish BPD patients. Our study is a part of the randomized, monocentre Oulu-BPD trial, which compares the effectiveness of treatment by experts with treatment as usual.

METHODS

Patients (n = 71) were enrolled in a 2-year randomized controlled trial. The BPDSI-IV was used to assess recent manifestations of BPD. The internal consistency of the BPDSI-IV in the Finnish patient sample was analysed with Cronbach's alpha coefficient and mean item-total correlation. Discriminant validity was examined by comparing the Finnish BPD patient sample with the Dutch BPD patient and non-patient samples.

RESULTS

The Cronbach's alphas ranged from 0.58 to 0.79 being highest in Dissociation and lowest in Relationships. A total of five subscales out of nine exceeded the acceptable limit (≥ 0.70). With respect to mean item-total correlation, seven out of nine subscales had an acceptable correlation ≥ 0.30.

CONCLUSIONS

The BPDSI-IV interview was applied for the first time in a Finnish sample of BPD patients. It appears to be a useful instrument for measuring and following the severity and the change of symptoms of patients with BPD.

Rejection sensitivity is a mediator between borderline personality disorder features and facial trust appraisal

Individuals with borderline personality disorder (BPD) fear abandonment and exhibit instability in their close relationships. These interpersonal difficulties may be influenced by the propensity to interpret neutral social stimuli (e.g., nonemotional faces) as untrustworthy. This study evaluated the hypothesis that BPD features are associated with attributions of untrustworthiness to neutral faces. Additionally, the authors hypothesized that the trait of rejection sensitivity (RS) is also associated with BPD features and mediates the relationship between BPD features and untrustworthy facial trait appraisal. An undergraduate, nonclinical sample (N = 95) was assessed for BPD features, RS, and trust appraisal of neutral faces. Higher BPD features were associated with lower ratings of trustworthiness of the faces and higher scores on RS. Furthermore, as hypothesized, the association between BPD features and trust appraisal was mediated by RS. Results are discussed in the context of a proposed model of the social cognitive mechanisms of interpersonal hypersensitivity in BPD.

Short-term group schema cognitive-behavioral therapy for young adults with personality disorders and personality disorder features: associations with changes in symptomatic distress, schemas, schema modes and coping styles

The aim of this pilot study was to document the effects of a group schema cognitive-behavioral therapy intervention (SCBT-g; van Vreeswijk & Broersen, 2006) on global symptomatic distress in young adults with personality disorders or personality disorder features. We also sought to determine the stability of maladaptive schemas, schema modes, and coping responses throughout treatment as well as relations among these variables with improvement in symptomatic distress during treatment. Twenty-six young adults (mean age 22.5 years; range: 18-29 years) with a primary diagnosis of a DSM-IV Cluster-B or Cluster-C personality disorder or with personality disorder features participated in the 20-session SCBT-g protocol. Global symptomatic distress decreased substantially from pre-treatment to post-treatment (d = 0.81). Maladaptive schemas, schema modes and dysfunctional coping responses decreased with medium to large effect sizes (d's = 0.56 and 0.98, respectively), however decrease in maladaptive schemas was not significant after controlling for symptomatic distress. Adaptive schema modes increased slightly (d = 0.40) throughout treatment. Baseline levels of maladaptive schemas predicted symptomatic distress concurrently and at mid-treatment but not at post-treatment. Our findings provide preliminary evidence that SCBT-g might be an effective treatment for young adults with personality disorders or personality disorder features in terms of improvements in global symptomatic distress and underlying vulnerability.

Initial validation of the Spanish childhood trauma questionnaire-short form: factor structure, reliability and association with parenting

The present study examines the internal consistency and factor structure of the Spanish version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) and the association between the CTQ-SF subscales and parenting style. Cronbach's α and confirmatory factor analyses (CFA) were performed in a female clinical sample (n = 185). Kendall's ι correlations were calculated between the maltreatment and parenting scales in a subsample of 109 patients. The Spanish CTQ-SF showed adequate psychometric properties and a good fit of the 5-factor structure. The neglect and abuse scales were negatively associated with parental care and positively associated with overprotection scales. The results of this study provide initial support for the reliability and validity of the Spanish CTQ-SF.

Imagery Rescripting as treatment for complicated PTSD in refugees: a multiple baseline case series study

This study tested the effectiveness of Imagery Rescripting (ImRs) for complicated war-related PTSD in refugees. Ten adult patients in long-term supportive care with a primary diagnosis of war-related PTSD and Posttraumatic Symptom Scale (PSS) score > 20 participated. A concurrent multiple baseline design was used with baseline varying from 6 to 10weeks, with weekly supportive sessions. After baseline, a 5-week exploration phase followed with weekly sessions during which traumas were explored, without trauma-focused treatment. Then 10 weekly ImRs sessions were given followed by 5-week follow-up without treatment. Participants were randomly assigned to baseline length, and filled out the PSS and the BDI on a weekly basis. Data were analyzed with mixed regression. Results revealed significant linear trends during ImRs (reductions of PSS and BDI scores), but not during the other conditions. The scores during follow-up were stable and significantly lower compared to baseline, with very high effect sizes (Cohen's d = 2.87 (PSS) and 1.29 (BDI)). One patient did clearly not respond positively, and revealed that his actual problem was his sexual identity that he couldn't accept. There were no dropouts. In conclusion, results indicate that ImRs is a highly acceptable and effective treatment for this difficult group of patients.

Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial

BACKGROUND

Behavioural activation might be a viable alternative to antidepressant medication for major depressive disorder.

AIMS

To compare the effectiveness of behavioural activation and treatment as usual (TAU, antidepressant medication) for major depressive disorder in routine clinical practice in Iran.

METHOD

Patients with major depressive disorder (n = 100) were randomised to 16 sessions of behavioural activation (n = 50) or antidepressant medication (n = 50) (IRCT138807192573N1). The main outcome was depression, measured with the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD), assessed at 0, 4, 13 and 49 weeks.

RESULTS

Symptom reduction was greater in the behavioural activation group than in the TAU group on both the BDI and the HRSD at 13 and 49 weeks in multilevel analysis. Baseline depression severity was a moderator, with relatively better effects for behavioural activation in individuals who were more severely depressed. Also, there was better retention in the behavioural activation than in the TAU group.

CONCLUSIONS

Behavioural activation is a viable and effective treatment for people with major depressive disorder, especially for those who are more severely depressed, and it can successfully be disseminated into routine practice settings in a non-Western country such as Iran.

The relationship between adult reactive and proactive aggression, hostile interpretation bias, and antisocial personality disorder

Reactive aggression (RA) refers to angry responses to provocation or frustration, while proactive aggression (PA) denotes nonemotional, instrumental, and unprovoked aggression. The current study examined personality-related and cognitive correlates of both aggressive types. Respectively, the predictive values of antisocial personality disorder (ASPD), and of hostile interpretation bias, which is the tendency to interpret ambiguous stimuli in a hostile manner, were studied. The sample consisted of n = 37 male adult patients with mixed diagnoses and n = 29 male nonpatients that responded to vignettes and pictures of ambiguous situations, using both open and closed answer formats. ASPD was assessed by means of the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II), and the Reactive Proactive Questionnaire (RPQ) measured RA and PA. Results showed that although both RA and PA types were predicted by ASPD traits, RA was additionally predicted by a hostile interpretation bias. These findings suggest that reducing hostile bias is a promising avenue for clinical treatment of ASPD-patients high in RA.

Neither dichotomous nor split, but schema-related negative interpersonal evaluations characterize borderline patients

Cognitive models explain extreme thoughts, affects, and behaviors of patients with Borderline Personality Disorder (BPD) by specific mal-adaptive schemas and dichotomous thinking. Psychodynamic theories ascribe these to splitting. This study expanded the study of Veen and Arntz (2000) and investigated whether extreme evaluations in BPD are (1) dichotomous, negativistic, or split; (2) limited to specific (schema-related) interpersonal situations; and (3) related to traumatic childhood experiences. BPD (n = 18), cluster C personality disorder (n = 16), and nonpatient (n = 17) groups were asked to judge 16 characters portrayed in film fragments in a specific or nonspecific context and with negative, positive, or neutral roles on visual analogue scales. These scales were divided in negative-positive trait opposites related to BPD schemas, negative-positive trait opposites unrelated to BPD schemas, and neutral trait opposites. Interpersonal evaluations of patients with BPD were (1) negativistic; (2) schema related; and (3) partially related to traumatic childhood experiences. Negative evaluations of caring characters in an intimate context particularly characterized BPD. No evidence was found for dichotomous thinking or splitting in BPD.

Psychometric properties of the German version of the borderline personality disorder severity index--version IV

BACKGROUND

Although the borderline personality disorder severity index--version IV (BPDSI-IV) has already been used in several studies, psychometric properties are only known from two developing studies.

SAMPLING AND METHODS

To examine item characteristics, reliability, and validity indicators, a large sample including subjects with borderline personality disorder (n = 163), a mixed psychiatric group (n = 58), and a healthy control group (n = 43) were interviewed with the German version of the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) as well as the BPDSI-IV.

RESULTS

The indices for interrater reliability as well as internal consistency of the BPDSI-IV were excellent to good. The total score and the subscales of the BPDSI-IV discriminated between diagnostic subgroups. As expected, its subscales were associated with the scores in the SCID-II and applied self-rating measures.

CONCLUSIONS

In a subsequent version, subscales might have to be adapted to the proposed traits of the borderline type in DSM-V.

Schema therapy for borderline personality disorder: a comprehensive review of its empirical foundations, effectiveness and implementation possibilities

Borderline personality disorder is a serious psychiatric disorder for which the effectiveness of the current pharmacotherapeutical and psychotherapeutic approaches has shown to be limited. In the last decades, schema therapy has increased in popularity as a treatment of borderline personality disorder; however, systematic evaluation of both effectiveness and empirical evidence for the theoretical background of the therapy is limited. This literature review comprehensively evaluates the current empirical status of schema therapy for borderline personality disorder. We first described the theoretical framework and reviewed its empirical foundations. Next, we examined the evidence regarding effectiveness and implementability. We found evidence for a considerable number of elements of Young's schema model; however, the strength of the results varies and there are also mixed results and some empirical blanks in the theory. The number of studies on effectiveness is small, but reviewed findings suggest that schema therapy is a promising treatment. In Western-European societies, the therapy could be readily implemented as a cost-effective strategy with positive economic consequences.

A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia

BACKGROUND

Interpersonal psychotherapy (IPT) seems to be as effective as cognitive behavioral therapy (CBT) in the treatment of major depression. Because the onset of panic attacks is often related to increased interpersonal life stress, IPT has the potential to also treat panic disorder. To date, a preliminary open trial yielded promising results but there have been no randomized controlled trials directly comparing CBT and IPT for panic disorder.

METHOD

This study aimed to directly compare the effects of CBT versus IPT for the treatment of panic disorder with agoraphobia. Ninety-one adult patients with a primary diagnosis of DSM-III or DSM-IV panic disorder with agoraphobia were randomized. Primary outcomes were panic attack frequency and an idiosyncratic behavioral test. Secondary outcomes were panic and agoraphobia severity, panic-related cognitions, interpersonal functioning and general psychopathology. Measures were taken at 0, 3 and 4 months (baseline, end of treatment and follow-up).

RESULTS

Intention-to-treat (ITT) analyses on the primary outcomes indicated superior effects for CBT in treating panic disorder with agoraphobia. Per-protocol analyses emphasized the differences between treatments and yielded larger effect sizes. Reductions in the secondary outcomes were equal for both treatments, except for agoraphobic complaints and behavior and the credibility ratings of negative interpretations of bodily sensations, all of which decreased more in CBT.

CONCLUSIONS

CBT is the preferred treatment for panic disorder with agoraphobia compared to IPT. Mechanisms of change should be investigated further, along with long-term outcomes.

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

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

Relationships between childhood maltreatment, parenting style, and borderline personality disorder criteria

This study examines the relationship of different types of childhood maltreatment and the perceived parenting style with borderline personality disorder (BPD) criteria. Kendall's Tau partial correlations were performed controlling for the effect of simultaneous adverse experiences and Axis I and II symptoms in a sample of 109 female patients (32 BPD, 43 other personality disorder, and 34 non-personality disorder). BPD criteria were associated with higher scores on emotional and sexual abuse, whereas parenting style did not show a specific association with BPD. Findings of the present study help clarify the effects of overlapping environmental factors that are associated with BPD.

The state dependency of cognitive schemas in antisocial patients

Patients with antisocial personality disorder (ASPD) typically report little psychopathology. Recent findings also showed this group to report high levels of healthy cognitions. Such a non-deviant cognitive profile might merely characterize ASPD under neutral assessment conditions. Indeed, hardly anything is known about how emotional states alter ASPD patients' cognitions. The current study therefore assessed the impact of autobiographical anger recollection on state cognitions. In a sample of N=147 participants, ASPD patients' (n=21) self-reported schema modes were assessed before and after an anger interview, and compared with those of borderline (n=45) and cluster-C patients (n=46) and non-patients controls (n=35). Results showed that ASP -patients' high baseline levels of healthy cognitions dropped drastically following the anger recollection. This finding suggests that reviving past anger-eliciting events breaks down the healthy veneer of ASPD patients and that their healthy cognitions are unstable. These findings underscore the importance of pathology assessment under emotional conditions in ASPD samples.