The role of expectations in mental disorders and their treatment

The role of expectancies and selective interrogation of information in trait anxiety-linked affect when approaching potentially stressful future events

The present study examined cognitive mechanisms underpinning the increased tendency of individuals with high trait anxiety to experience inflation of negative affect when approaching potential stressors. Specifically, the roles of (1) disproportionately negative relative to positive expectancies (i.e., negative expectancy bias) and (2) disproportionately interrogating negative relative to positive information (i.e., negative interrogation bias), each concerning the potential stressor, were examined. High and low trait anxiety participants (N = 286) completed the experimental session, in which they were informed they may view a potentially stressful film. As participants approached the putative film viewing, participants' negative and positive affect, as well as their negative and positive expectancies were assessed. Additionally, negative interrogation bias was assessed by providing participants the opportunity to selectively interrogate information from a larger pool of negative and positive information concerning the putative film viewing. Our findings provide evidence indirect associations between trait anxiety and inflation of negative affect is serially mediated via negative interrogation bias and, in turn, negative expectancy bias. Findings are discussed with regards to limitations and potential implications for public health campaigns, and cognitive interventions for anxiety, highlighting the utility of further examining negative interrogation bias as an avenue for improving the efficacy of each.

The future of psychological treatments: The Marburg Declaration

Although psychological treatments are broadly recognized as evidence-based interventions for various mental disorders, challenges remain. For example, a substantial proportion of patients receiving such treatments do not fully recover, and many obstacles hinder the dissemination, implementation, and training of psychological treatments. These problems require those in our field to rethink some of our basic models of mental disorders and their treatments, and question how research and practice in clinical psychology should progress. To answer these questions, a group of experts of clinical psychology convened at a Think-Tank in Marburg, Germany, in August 2022 to review the evidence and analyze barriers for current and future developments. After this event, an overview of the current state-of-the-art was drafted and suggestions for improvements and specific recommendations for research and practice were integrated. Recommendations arising from our meeting cover further improving psychological interventions through translational approaches, improving clinical research methodology, bridging the gap between more nomothetic (group-oriented) studies and idiographic (person-centered) decisions, using network approaches in addition to selecting single mechanisms to embrace the complexity of clinical reality, making use of scalable digital options for assessments and interventions, improving the training and education of future psychotherapists, and accepting the societal responsibilities that clinical psychology has in improving national and global health care. The objective of the Marburg Declaration is to stimulate a significant change regarding our understanding of mental disorders and their treatments, with the aim to trigger a new era of evidence-based psychological interventions.

Cancer patients' expectations of advance care planning: A typological content analysis of qualitative interviews

BACKGROUND

Advance care planning (ACP) can help to elicit cancer patients' preferences in a discussion process to promote person-centred medical decision-making. Expectations are known to be highly relevant determinants of decisional processes. So far, however, little is known about cancer patients' expectations of ACP that lead to acceptance or refusal of the programme. The presented study, therefore, aims to explore cancer patients' expectations of ACP.

METHODS

Semi-structured interviews were conducted with a purposeful sample of 27 cancer patients consenting to or refusing a newly implemented ACP programme in a German university hospital. Data were analysed using typological content analysis.

RESULTS

We identified five different expectation clusters in relation to ACP. Consenting participants held expectations about the impact of ACP that were either 'ego-centred' or 'family-centred'. Refusers had expectations based on ignorance and misinformation, or-if they had already completed an advance directive-expectations to avoid unpleasant redundancy, perceiving no additional benefit but a burden from ACP. Finally, refusers in particular expressed expectations of delegated responsibility at the end of life, including anticipation of proxy decision-making.

CONCLUSION

Our study results suggest that expectation-modifying measures could be taken to positively influence cancer patients' expectations and thus the acceptance of ACP. In this respect, reducing ignorance and misguided expectations plays a decisive role. Especially in family constellations with expected delegation of responsibility and dependence at the end of life, it might be important to promote ACP as a family-intervention to improve family outcomes.

Assessing Dysfunctional Expectations in Posttraumatic Stress Disorder: Development and Validation of the Posttraumatic Expectations Scale (PTES)

Dysfunctional expectations are a particularly important subset of cognitions that influence the development and maintenance of various mental disorders. This study aimed to develop and validate a scale to assess dysfunctional expectations in posttraumatic stress disorder (PTSD), the "Posttraumatic Expectations Scale" (PTES). In a cross-sectional study, 70 PTSD patients completed the PTES, the Posttraumatic Cognitions Inventory (PTCI), as well as measures of the severity of symptoms of PTSD and depression. The results show that the PTES has excellent internal consistency and correlates significantly with the PTCI and PTSD symptom severity. A regression analysis revealed that the PTES explained variance of PTSD symptom severity above the PTCI, supporting the incremental validity of the PTES. While the original version of the PTES comprises 81 items, short scales were constructed using the BISCUIT (best items scales that are cross-validated, unit-weighted, informative and transparent) method. The current findings provide preliminary psychometric evidence suggesting that the PTES is an internally consistent and valid novel self-report measure in patients with PTSD. However, conclusions about the psychometric properties of the PTES are limited because of the absence of criterion-related validity, factor structure evidence, variability over time/response to intervention, and test-retest reliability. Future research should use the PTES in large-scale longitudinal studies to address these aspects to further validate the scale.

Neurobiological mechanisms of dialectical behavior therapy and Morita therapy, two psychotherapies inspired by Zen

Psychotherapy is a learning process. Updating the prediction models of the brain may be the mechanism underlying psychotherapeutic changes. Although developed in different eras and cultures, dialectical behavior therapy (DBT) and Morita therapy are influenced by Zen principles, and both emphasize the acceptance of reality and suffering. This article reviews these two treatments, their common and distinct therapeutic factors, and their neuroscientific implications. Additionally, it proposes a framework that includes the predictive function of the mind, constructed emotions, mindfulness, therapeutic relationship, and changes enabled via reward predictions. Brain networks, including the Default Mode Network (DMN), amygdala, fear circuitry, and reward pathways, contribute to the constructive process of brain predictions. Both treatments target the assimilation of prediction errors, gradual reorganization of predictive models, and creation of a life with step-by-step constructive rewards. By elucidating the possible neurobiological mechanisms of these psychotherapeutic techniques, this article is expected to serve as the first step towards filling the cultural gap and creating more teaching methods based on these concepts.

Expectation focused and frequency enhanced cognitive behavioural therapy for patients with major depression (EFFECT): a study protocol of a randomised active-control trial

INTRODUCTION

The effectiveness of psychotherapy in depression is subject of an ongoing debate. The mechanisms of change are still underexplored. Research tries to find influencing factors fostering the effect of psychotherapy. In that context, the dose-response relationship should receive more attention. Increasing the frequency from one to two sessions per week seems to be a promising start. Moreover, the concept of expectations and its influence in depression can be another auspicious approach. Dysfunctional expectations and the lack of their modification are central in symptom maintenance. Expectation focused psychological interventions (EFPI) have been investigated, primarily in the field of depression. The aim of this study is to compare cognitive behavioural therapy (CBT) once a week with an intensified version of CBT (two times a week) in depression as well as to include a third proof-of-principle intervention group receiving a condensed expectation focused CBT.

METHODS AND ANALYSIS

Participants are recruited through an outpatient clinic in Germany. A current major depressive episode, diagnosed via structured clinical interviews should present as the main diagnosis. The planned randomised-controlled trial will allow comparisons between the following treatment conditions: CBT (one session/week), condensed CBT (two sessions/week) and EFPI (two sessions/week). All treatment arms include a total dose of 24 sessions. Depression severity applies as the outcome variable (Beck Depression Inventory II, Montgomery Asberg Depression Rating Scale). A sample size of n=150 is intended.

ETHICS AND DISSEMINATION

The local ethics committee of the Department of Psychology, Philipps-University Marburg approved the study (reference number 2020-68 v). The final research article including the study results is intended to be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00023203).

A tale of tails: Nonlinear effects of ability rank on adolescent psychological well-being

Previous literature has documented the effect of cognitive ability on adolescent psychological well-being. This study extends this line of research by revealing the nonlinear effect of a student's ability rank within the peer group on adolescent depression. Using a nationally representative longitudinal survey of U.S. adolescents, we leverage a quasi-experimental research design to show that controlling for absolute ability, students with lower ability ranks are more likely to develop depressive symptoms. Moreover, this effect is nonlinear and more pronounced at the top and bottom of the ability distribution. We further examine two mediation mechanisms: social comparison and social relations. Results show that social comparison partly mediate the ability rank effect on depression at the top and bottom of the ability distribution; social relations, particularly care from teachers, partly mediate the rank effect at the top of the ability distribution. Findings may help design targeted initiatives to address adolescent depression.

Expectations do not need to be accurate to be maintained: Valence and need for cognitive closure predict expectation update vs. persistence

Expectations about us and our environment serve to successfully anticipate the future, make accurate predictions, and guide behavior and decisions. However, when expectations are not accurate, individuals need to resolve or minimize incongruence. Coping is especially important when expectations affect important domains such as students' academic self-concept. Whether expectations are adjusted after expectation violation (accommodation), maintained by denying the discrepancy (immunization), or whether individuals modify behavior to minimize the likelihood of future expectation violations (assimilation) depends on situational and dispositional predictors. In our experiment, we examined valence of expectation violation (positive vs. negative) as a situational predictor together with need for cognitive closure (NCC) as a dispositional predictor with N = 297 participants in a word riddle study. MANCOVA revealed that students tended to assimilate and accommodate more strongly after worse-than-expected achievement, and also NCC promoted both stronger accommodation and assimilation. NCC interacted with the valence of expectation violation: individuals with high NCC reported more assimilation and accommodation only after worse-than-expected achievement. The results replicate and extend previous findings: individuals do not always strive to have the most accurate expectations possible. Instead, both affective (valence) and cognitive (NCC) predictors appear to affect which coping strategy is preferred by the individual.

Exploring service users experiences of remotely delivered CBT interventions in primary care during COVID-19: An interpretative phenomenological analysis

Primary Care Mental Health Services (PMHCS) aim to provide accessible and effective psychological interventions. However, there is a scarcity of qualitative research focused on patients' experiences. Service users' experience can inform development of accessible, high-quality mental health services. Nine semi-structured interviews were analysed from Primary Care Mental Health users in Northern Scotland using Interpretative Phenomenological Analysis (IPA). Four superordinate themes were generated: Orientating to treatment, Intervention features, Change enablers, and Impact. The results identified both facilitators and barriers associated with access and psychological change; and narratives around CBT acceptability, outcomes and remote delivery. The role of GPs emerged as a key determinant of access to PMHCS. The therapeutic relationship contributed to person-centred care provision, idiosyncratic change processes and self-empowerment. A personal commitment to engage with homework was described as a crucial change enabler. Findings are discussed in relation to existing literature, practical implications and suggestions for future research.

Changing attitudes towards psychotherapy via social observations: are similarities more important than discrepancies?

OBJECTIVES

Therapy expectations and attitudes towards psychotherapy contribute substantially to the outcome, process and duration of psychotherapy. The a priori use of role model videos seems to be promising for changing expectations and attitudes towards psychotherapy. In contrast, underlying mechanisms, like identifying with the role model, have been sparsely investigated in studies so far. For instance, the effects of similarities and differences between the role model and the observer are not clear yet.

METHODS

A total of 158 persons were recruited and randomly assigned to four groups. In one of three experimental groups, participants watched an expectation-optimised video with patients giving information about their mostly positive therapy outcomes (positive model). Two further experimental groups saw the same video, but either received instructions to focus on similarities (similarity group) or on differences (discrepancy group) between the patients and themselves. A further control group watched a video with patients who gave information about their symptoms. As the primary outcome variable, we assessed attitudes towards psychotherapy using the Questionnaire on Attitudes towards Psychotherapy (QAPT). It was filled in before and after watching the video and after a two-week follow-up period.

RESULTS

Contrary to the hypotheses, the discrepancy group and the experimental group without further intervention (positive model) showed significant improvements in their attitudes towards psychotherapy after watching the video, while such an effect was not found in the similarity group or control group.

CONCLUSION

Focusing on similarities between patient examples and the observer does not support a change in therapy expectations or attitudes through observation, while a positive video model without instructions, or with the instruction to focus on differences does. Attentional interference and depth of cognitive evaluation are discussed as possible reasons.

TRIAL REGISTRATION

Ethical approval (2018-19k) was obtained from the ethics committee of the Psychological Department, University of Marburg, and the trial was registered at Aspredicted.org (#22,205; 16.04.2019).

Using expectation violation models to improve the outcome of psychological treatments

Expectations are a central maintaining mechanism in mental disorders and most psychological treatments aim to directly or indirectly modify clinically relevant expectations. Therefore, it is crucial to examine why patients with mental disorders maintain dysfunctional expectations, even in light of disconfirming evidence, and how expectation-violating situations should be created in treatment settings to optimize treatment outcome and reduce the risk of treatment failures. The different psychological subdisciplines offer various approaches for understanding the underlying mechanisms of expectation development, persistence, and change. Here, we convey recommendations on how to improve psychological treatments by considering these different perspectives. Based on our expectation violation model, we argue that the outcome of expectation violation depends on several characteristics: features of the expectation-violating situation; the dynamics between the magnitude of expectation violation and cognitive immunization processes; dealing with uncertainties during and after expectation change; controlled and automatic attention processes; and the costs of expectation changes. Personality factors further add to predict outcomes and may offer a basis for personalized treatment planning. We conclude with a list of recommendations derived from basic psychology that could contribute to improved treatment outcome and to reduced risks of treatment failures.

Motive-Oriented, Personalized, Internet-Based Interventions for Depression: Nonclinical Experimental Study

Background

The low level of adherence in internet-based self-help interventions for depression suggests that in many existing programs, the motivational fit between the program and the user is unsatisfactory (eg, the user seeks autonomy, but the program provides directive guidance). Personalized, motive-oriented, self-help interventions could enable participants who interact with a program and its contents to have more engaging and less aversive experiences and thus increase adherence.

Objective

In an experimental study with a nonclinical analogue sample, we aimed to test the hypotheses that a better motivational person-program fit is linked with higher anticipated adherence, working alliance, and satisfaction with the program.

Methods

Motivational person-program fit was examined with respect to the 2 contrasting motives being autonomous and being supported. The hypotheses were tested by specifically varying the motivational person-program fit in a nonclinical sample (N=55), where participants were asked to work on, and subsequently evaluate, a limited set of individual pages of a self-help program with guidance (in the form of text messages) for depression. The sections of the self-help program were redesigned to either particularly address the autonomy motive or the support motive. For the quasi-experimental variation of the motivational person-program characteristics, we divided the 55 participants into 2 groups (autonomy group: n=27, 49%; support group: n=28, 51%) by screening method (using the Inventory of Approach and Avoidance Motivation), corresponding to the 2 motives. Both groups evaluated (in randomized order) 2 excerpts of the program—one that matched their motive (fit) and one that was contrary to it (no fit). Immediately after the evaluation of each excerpt, anticipated adherence, working alliance, and treatment satisfaction were assessed.

Results

Regarding being supported, the satisfaction with or violation of this motive had an impact on (optimal) anticipated adherence as well as working alliance and satisfaction with the intervention; a congruent person-program fit resulted in significantly higher anticipated adherence (t₂₇=3.00; P=.006), working alliance (t₂₇=3.20; P=.003), and satisfaction (t₂₇=2.86; P=.008) than a noncongruent fit. However, a similar impact could not be found for the motive being autonomous. Several correlations were found that supported our hypotheses (eg, for the congruent person-program fit autonomy motive and autonomy group, support satisfaction negatively correlated with optimal anticipated adherence).

Conclusions

This first experimental study gives reason to assume that motive orientation may have a positive influence on adherence, working alliance, and satisfaction in internet-based self-help interventions for depression and other mental disorders. Future studies should conduct randomized controlled trials with clinical samples and assess clinical outcomes.

Predictors of Coping with Health-related Expectation Violations among University Students

Objectives: Individuals often experience expectation violations related to the consumption of healthy food and physical activity and they may cope with expectation-disconfirming information by (1) ignoring the discrepancy (immunization), (2) increasing efforts to fulfill them (assimilation), or (3) changing their expectations (accommodation). We investigated whether valence, discrepancy magnitude, and controllability of the expectation disconfirming event predicted coping with expectation violations. Methods: A 2 (valence: positive vs negative) x 2 (discrepancy: larger vs smaller) x 2 (controllability: control vs no control) experimental design was implemented. Overall, we presented 297 university students with vignettes describing expectation violations and present different combinations of predictor levels. Results: Regarding physical activity, participants showed significantly higher accommodation when experiencing a better-than-expected event and showed significantly higher immunization when experiencing a worse-than-expected event. Regarding food consumption and physical activity, individuals experiencing lower discrepancy showed significantly higher immunization; individuals with control over the source of expectation disconfirmation showed significantly higher assimilation; and individuals without control over the source of expectation disconfirmation showed significantly higher accommodation.Conclusions: To promote the maintenance of healthy expectations, despite expectation violations, interventions could foster the perception of control as well as assimilative behavior.

Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

Perceived Course of Illness on the Desire for Social Distance From People Suffering From Symptoms of Schizophrenia in India

BACKGROUND

Stigmatization of people with schizophrenia remains a highly relevant topic worldwide, particularly in low- and middle-income countries like India. It is crucial to identify the determinants of the desire for social distance as a proxy for discriminatory behavior in a socio-cultural context to indicate ways to reduce stigma. This study aims to explore whether the public perception of the perceived course of an illness concerning people with symptoms of schizophrenia has an impact on the desire for social distance.

SUBJECTS AND METHODS

Data collection took place in five cities in India. The sample (N = 447) was stratified for gender, age, and religion. Desire for social distance was sampled based on a self-reported questionnaire using unlabelled vignettes for schizophrenia. First, factor analysis was conducted to identify the main factors underlying the perception of the perceived course of the illness. Subsequently, a regression analysis was conducted to examine the impact of the perception of those prognostic factors on the desire for social distance.

RESULTS

Factor analysis revealed two independent factors of the perceived course of an illness: (1) life-long dependency on others and loss of social integration and functioning and (2) positive expectations toward treatment outcome. This second factor was significantly associated with a less desire for social distance toward persons with schizophrenia.

CONCLUSION

The desire for social distance toward people with schizophrenia reduces with the expectation of positive treatment outcomes which underlines the need to raise public mental health awareness and provide psychoeducation for affected people and their family members in India. Help-seeking behaviors can be promoted by directing those needing treatment toward locally available, affordable and credible community-based services rather than facility-based care. Strikingly, lifelong dependency and the inability to socially integrate do not increase the desire for social distance, reflecting the Indian nation's socio-relational values and insufficiency of public mental health services. This indicates the suitability of systemic therapy approaches in public mental healthcare services to support the family's involvement and family-based interventions in caregiving for mentally ill people across the lifespan.

Dispositional and situational predictors of coping with violated achievement expectations

Most students experience expectation violations during their academic career, such as unexpected failed tests. However, contradictory evidence does not always result in expectation change (accommodation). Expectations often persist through stronger efforts to fulfil the expectation (assimilation) or ignoring the discrepancy (immunisation). Our study addresses possible situational and dispositional predictors that may be decisive influences on the use of the three coping strategies. We conducted an experimental study with n = 439 students who experienced an expectation violation in an achievement test. Dispositional coping tendencies, valence of expectation violation, and the interaction of valence and degree of expectation violation were found to predict situational coping. Furthermore, higher need for cognitive closure predicted stronger accommodation, and a large degree of expectation violation predicted stronger immunisation. Thus, our study provides initial evidence on which situational and dispositional factors predict coping with expectation violations in an educational context. Expectation violation in a performance context mainly resulted in stronger efforts to protect positive achievement expectations.

Mechanisms of change in acceptance and commitment therapy for primary headaches

BACKGROUND

Despite the demonstrated effectiveness of behavioural headache interventions, it is not yet known which intervention processes account for treatment responses. Acceptance and commitment therapy (ACT), an emerging behavioural intervention for headaches, proposes psychological flexibility (PF) processes as the mechanisms via which intervention change occurs. This is the first study examining these processes of change variables on headache-related disability and quality of life (treatment outcome).

METHODS

Data originated from a Randomized Clinical Trial evaluating the efficacy of ACT for primary headaches. Ninety-four individuals with primary headaches (M = 43 y; 84% females; M headache frequency/month = 9.30) were randomized to either an ACT-based or a Wait-list control group (N = 47 in each). Participants completed questionnaires related to their headache experiences and PF processes at pre- (T1), post-treatment (T2), and 3-month follow-up (T3).

RESULTS

Following a bootstrapped cross product of coefficients approach, results demonstrated mediating effects of headache acceptance, cognitive defusion, avoidance of headache, and mindfulness in the ACT group compared to control on parameters of headache-related disability and quality of life at post and 3-month follow-ups.

CONCLUSIONS

These findings demonstrate that changes in certain PF processes lower disability and improve quality of life in headache sufferers, supporting that ACT works via its proposed mechanisms of change. Interventions for headache management may be optimized if they target increases in headache acceptance, defusion from thoughts, and mindfulness.

SIGNIFICANCE

Psychological flexibility (PF) guides the ACT approach, an emerging behavioral headache intervention that focuses on optimizing head pain adjustment via flexible responses to pain. It targets at increasing daily functioning rather than preventing or controlling headache episodes. Pain acceptance, cognitive defusion, and mindfulness act as processes of functional change in ACT, lowering disability and increasing daily functioning and quality of life. These components can upgrade the established effectiveness of behavioral headache interventions with personalized, modularized therapeutic targets that can help headache sufferers re-establish optimal daily functioning even in fluctuating and persistent headache episodes.

TRIAL REGISTRATION

clinical trials.gov registry (NCT02734992).

Health behaviors of German university freshmen during COVID-19 in association with health behaviors of close social ties, living arrangement, and time spent with peers

Objective

The start of university is a critical period for health risk behavior (i.e. eating, physical activity, alcohol use) which can be influenced by expectations and by environmental factors such as living arrangement, health behaviors of close social ties (i.e. parents, partners, peers), and time spent with peers. We investigated associations between environmental factors and current/expected health behaviors of German freshmen during the COVID-19 pandemic.

Method

A cross-sectional survey design was used. A total of N = 208 students (82.7% female; M age = 20.90, SD = 4.10) completed an online questionnaire assessing health behaviors and environmental factors at the beginning of their first semester.

Results

Current and expected physical activity was associated to that of all social ties, current and expected alcohol use to partner's and peers' alcohol use, while current and expected eating was only associated to peers' eating. The relationship between partner's or peers' and participant's alcohol use was moderated by coresidence, with a greater probability of engaging in these behaviors observed in case of coresidence. Perceived peer encouragement for alcohol consumption moderated the relationship between peer alcohol use and the number of drinks consumed by participants per month. Participants who spend more time with peers were more likely to consume higher amounts of alcohol. No differences were found regarding present and expected behaviors of participants who moved out of their parents' home and those who did not.

Conclusion

Partners and peers significantly influence students' health behaviors, particularly alcohol use. Interventions to prevent health risk behaviors among freshmen should therefore address these social ties' influence.

Prospective mental imagery in depression: Impact on reward processing and reward-motivated behaviour

Background

Mental imagery has long been part of cognitive behavioural therapies. More recently, a resurgence of interest has emerged for prospective mental imagery, i.e. future-directed imagery-based thought, and its relation to reward processing, motivation and behaviour in the context of depression.

Method

We conducted a selective review on the role of prospective mental imagery and its impact on reward processing and reward-motivated behaviour in depression.

Results

Based on the current literature, we propose a conceptual mechanistic model of prospective mental imagery. Prospective mental imagery of engaging in positive activities can increase reward anticipation and reward motivation, which can transfer to increased engagement in reward-motivated behaviour and more experiences of reward, thereby decreasing depressive symptoms. We suggest directions for future research using multimodal assessments to measure the impact of prospective mental imagery from its basic functioning in the lab to real-world and clinical implementation.

Conclusion

Prospective mental imagery has the potential to improve treatment for depression where the aim is to increase reward-motivated behaviours. Future research should investigate how exactly and for whom prospective mental imagery works.

This review provides a selected update of the literature on prospective mental imagery.

Prospective mental imagery might decrease depression via reward processing and reward-motivated behaviours.

Suggestions for future research to investigate these hypotheses are provided.

Combat Experience, New-Onset Mental Health Conditions, and Posttraumatic Growth in U.S. Service Members

Objective: Studies examining posttraumatic growth (PTG) rely on surveys evaluating PTG in relation to prior traumatic experiences, resulting in psychometric problems due to the linkage of the dependent and independent variables. Few studies have assessed PTG following combat deployment while also controlling for mental health problems.Method: Longitudinal data on PTG, combat experience, and mental health were examined among U.S. Millennium Cohort Study deployers (n = 8732). Scores from a short-form (SF) version of the PTG inventory assessing current-state beliefs (C-PTGI-SF) independent of any predictor variables were assessed at time 1 (T1), before deployment, and change in scores were assessed approximately 3 years later after deployment at time 2 (T2). All participants screened negative for posttraumatic stress disorder (PTSD) and depression at T1.Results: Combat deployment severity was associated with a worsening of C-PTGI-SF scores at T2 among participants with moderate C-PTGI-SF scores at T1. A positive screen for comorbid PTSD/depression was associated with a worsening of C-PTGI-SF scores at T2 among participants with moderate or high C-PTGI-SF scores at T1. At T2, a strong inverse correlation was found between C-PTGI-SF scores and PTSD (r = -0.38) and depression (-0.41). Only 5% of participants who screened positive for a mental health problem at T2 (23/517) also experienced positive growth.Conclusions: These results challenge the clinical utility of the PTG construct. While PTG may be a useful framework for supporting trauma recovery on an individual basis, PTG does not appear to be distinct and independent from the negative psychological impact of traumatic experiences.

When Beliefs Face Reality: An Integrative Review of Belief Updating in Mental Health and Illness

Belief updating is a relatively nascent field of research that examines how people adjust their beliefs in light of new evidence. So far, belief updating has been investigated in partly unrelated lines of research from different psychological disciplines. In this article, we aim to integrate these disparate lines of research. After presenting some prominent theoretical frameworks and experimental designs that have been used for the study of belief updating, we review how healthy people and people with mental disorders update their beliefs after receiving new information that supports or challenges their views. Available evidence suggests that both healthy people and people with particular mental disorders are prone to certain biases when updating their beliefs, although the nature of the respective biases varies considerably and depends on several factors. Anomalies in belief updating are discussed in terms of both new insights into the psychopathology of various mental disorders and societal implications, such as irreconcilable political and societal controversies due to the failure to take information into account that disconfirms one’s own view. We conclude by proposing a novel integrative model of belief updating and derive directions for future research.

No1LikesU! – A pilot study on an ecologically valid and highly standardised experimental paradigm to investigate social rejection expectations and their modification

Background

Dysfunctional expectations have been suggested as core features in the development and maintenance of mental disorders. Thus, preventing development and promoting modification of dysfunctional expectations through intervention might improve clinical treatment. While there are well-established experimental procedures to investigate the acquisition and modification of dysfunctional performance expectations in major depression, paradigms for investigating other important types of dysfunctional expectations (e.g. social rejection expectations) are currently lacking. We introduce an innovative associative learning paradigm, which can be used to investigate the development, maintenance, and modification of social rejection expectations.

Method

A pilot sample of 28 healthy participants experienced manipulated social feedback after answering personal questions in supposed webcam conferences. While participants repeatedly received social rejection feedback in a first phase, differential feedback was given in a second phase (social rejection vs. social appreciation). In a third phase, explicit social feedback was omitted.

Results

Participants developed social rejection expectations in the first phase. For the second phase, we found an interaction effect of experimental condition; i.e. participants adjusted their expectations according to the differential social feedback. In the third phase, learned social expectations remained stable in accordance to the social feedback in the second phase.

Conclusion

Results indicate that the paradigm can be used to investigate the development, maintenance, and modification of social rejection expectations in healthy participants. This offers broad applications to explore the differential acquisition and modification of social rejection expectations in healthy vs. clinical samples. Further, the paradigm might be used to investigate therapeutic strategies to facilitate expectation change.

Dopamine: from prediction error to psychotherapy

Dopamine, one of the main neurotransmitters in the mammalian brain, has been implicated in the coding of prediction errors that govern reward learning as well as fear extinction learning. Psychotherapy too can be viewed as a form of error-based learning, because it challenges erroneous beliefs and behavioral patterns in order to induce long-term changes in emotions, cognitions, and behaviors. Exposure therapy, for example, relies in part on fear extinction principles to violate erroneous expectancies of danger and induce novel safety learning that inhibits and therefore reduces fear in the long term. As most forms of psychotherapy, however, exposure therapy suffers from non-response, dropout, and relapse. This narrative review focuses on the role of midbrain and prefrontal dopamine in novel safety learning and investigates possible pathways through which dopamine-based interventions could be used as an adjunct to improve both the response and the long-term effects of the therapy. Convincing evidence exists for an involvement of the midbrain dopamine system in the acquisition of new, safe memories. Additionally, prefrontal dopamine is emerging as a key ingredient for the consolidation of fear extinction. We propose that applying a dopamine prediction error perspective to psychotherapy can inspire both pharmacological and non-pharmacological studies aimed at discovering innovative ways to enhance the acquisition of safety memories. Additionally, we call for further empirical investigations on dopamine-oriented drugs that might be able to maximize consolidation of successful fear extinction and its long-term retention after therapy, and we propose to also include investigations on non-pharmacological interventions with putative prefrontal dopaminergic effects, like working memory training.

Cortisol response to stress: The role of expectancy and anticipatory stress regulation

An exacerbated physiological response to stress is associated with the development of stress-related disorders (e.g., depression and anxiety disorders). Recently, it has been proposed that individuals with high expectancies of being able to deal with stressful situations will activate regulatory mechanisms during the anticipation of the stressful event that would improve stress regulation. To test this hypothesis, 52 women in young adulthood (M = 21.06; SD = 2.58) anticipated and performed a laboratory-based stress task after receiving positive or negative bogus feedback on their abilities to deal with stressful events. Heart rate variability and salivary cortisol were assessed throughout the experimental protocol. Participants receiving positive bogus feedback (i.e., High Expectancy group) showed a more positive anticipatory cognitive stress appraisal (i.e., they anticipated the stress task as less threatening/challenging, and they perceived that they were more able to deal with it), and they showed a lower cortisol response to stress. Moreover, a more positive anticipatory cognitive stress appraisal was associated with better anticipatory stress regulation (indexed as less decrease in heart rate variability), leading to a lower cortisol response. Our results indicate that people with positive expectancy initiate mechanisms of anticipatory stress regulation that enhance the regulation of the physiological stress response. Expectancy and anticipatory stress regulation may be key mechanisms in the development and treatment of stress-related disorders.

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

BACKGROUND

People with depression differ from healthy people in the extent to which they use novel positive information to adjust negative expectations. In this study, we examined whether the two groups also differ in updating positive expectations after receiving unexpectedly negative information.

METHODS

Examining 76 people with depressive symptoms and 81 healthy controls, we used an adapted version of a previously validated paradigm. After the initial establishment of positive performance expectations, participants worked on the TEMINT performance test, whereupon half of the participants received standardized feedback that confirmed previous positive expectations while the other half received disconfirming negative feedback. Subsequently, participants' performance expectations were assessed again. Additionally, we assessed participants' appraisal of the feedback, particularly whether they tended to disregard it.

RESULTS

Results indicated that healthy subjects had overall more positive expectations than people with depressive symptoms, but the two samples did not differ in updating their expectations: both groups changed their expectations in a negative direction after receiving negative feedback; similarly, there were no differences between the two samples after receiving confirmatory positive feedback. Both people with and without depressive symptoms were more likely to disregard the feedback received if the feedback was negative, and such a negative appraisal of the feedback was associated with smaller expectation update.

CONCLUSIONS

In combination with prior work, the current findings suggest that people with depressive symptoms do not over-sensitively react to unexpectedly negative information; rather, the main problem of depression seems to be the integration of novel positive information, as shown previously.

Examining the Effectiveness of a Web-Based Intervention for Depressive Symptoms in Female Adolescents: Applying Social Cognitive Theory

BACKGROUND

Depression is a serious mental health illness among adolescents especially girls. Web-based treatment can possibly become a solution for reducing mental health problems in adolescents. This study is one of the first trials aimed to evaluate the efficiency of web-based depression improvement program among female adolescents based on the Social Cognitive Theory (SCT).

STUDY DESIGN

Randomized Controlled Trial.

METHODS

A six-month randomized controlled trial based on the SCT was implemented in female schools in Hamadan City, west of Iran in 2018 on 128 female students with mild to moderate depressive symptoms (CES-D =10-45). They were randomly assigned to either intervention or control group (n= 64 in each group). Depression improvement program was implemented through the website via short videos, animations and Power-Point slides. Depression was evaluated using Center for Epidemiologic Depression Scale. A researcher-made questionnaire based on the sheerer and Perceived-Social-Support-Scale-Revised (PSSS-R) questionnaires were used to evaluate the SCT constructs. The data were analyzed using SPSS software.

RESULTS

The intervention program resulted in the improvement of depression in 12 wk based on Intent-to-treat analyses. Nevertheless, these achievements seem to have decreased by 24 wk in intervention group. The intervention increased the mean scores of the constructs of social support and self-regulation from baseline to 12 wk in the intervention group (P<0.05). The intervention had no effect on outcome expectations and self-efficacy. There were no statistically significant associated between theory constructs changes and changes in depression (P>0.05).

CONCLUSION

The web-based intervention improved depression in female students. Future training using strategies for the sustainable improvement of depression in female students are needed.

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

BACKGROUND

Research has revealed that negative expectations impact depressive symptoms. However, research on the change of dysfunctional expectations in depression is lacking so far. Therefore, the present research aimed to fill this gap by testing the hypothesis that people with the major depressive disorder (MDD), contrary to healthy individuals, maintain their expectations despite experiences that positively disconfirm expectations. Further, it was hypothesized that cognitive immunization (a cognitive reappraisal of the disconfirming evidence) is a mechanism underlying the persistence of expectations.

METHOD

In Study 1, we compared individuals with MDD (N = 58) to healthy individuals (N = 59). Participants worked on the same performance test and received standardized feedback that either confirmed or disconfirmed their initial performance expectations. In Study 2, we investigated the effects of cognitive immunization on expectation change among 59 individuals reporting elevated levels of depression by varying the appraisal of expectation-disconfirming feedback.

RESULTS

Results from Study 1 show that in the expectation-disconfirming condition, healthy individuals changed their expectations, whereas individuals with MDD did not. No such difference between the two groups was found for expectation-confirming feedback. Results from Study 2 indicated that varying cognitive immunization impacted expectation change, thus suggesting a crucial role of cognitive immunization in expectation change.

CONCLUSIONS

These two studies indicated that individuals suffering from depression have more difficulties in changing their expectations after disconfirming experiences than do healthy individuals, and cognitive immunization might be a core mechanism underlying expectation persistence. Therefore, psychotherapeutic interventions should aim to inhibit cognitive immunization processes to enhance expectation change.

Comorbidity of Obsessive-Compulsive Disorder and Schizotypal Personality Disorder: Clinical Response and Treatment Resistance to Pharmacotherapy in a 3-Year Follow-Up Naturalistic Study

The present study aims to analyze the clinical and socio-demographic characteristics of patients with obsessive-compulsive disorder (OCD) in comorbidity with schizotypal personality disorder (SPD), as well as the response rate to pharmacological treatments. OCD+SPD patients had a younger age at onset, a higher probability to have more severe obsessive-compulsive symptoms, a higher rate of schizophrenia spectrum disorders in their first-degree relatives, and a poorer insight compared to OCD patients. During the 3-year follow-up period, these patients showed a lower rate of recovery, thus requiring augmentation with different psychotropic medications, including low doses of antipsychotics. Our findings suggest that the comorbidity of OCD and SPD causes a poor treatment response, and a reduced probability to recover using standard pharmacological treatment strategies. Further investigations are needed to identify alternative strategies, including psychoeducation and cognitive behavioral therapy, to manage such frequent comorbidity in clinical practice.

Revisiting the Cognitive Model of Depression: The Role of Expectations

The cognitive model of depression was highly stimulating for a better understanding and development of treatment for depression. However, the concept of “cognition” is rather broad and unspecific, and we suggest to focus on the cognitive subset of expectation.

We conducted a narrative review on the role of expectations, and present an expectation-focused model of explaining why depression tends to persist despite the occurrence of positive events.

Several results from basic neuroscience to effects in clinical interventions indicate that expectations play a special role not only for the understanding of the development of mental disorders and the effects of treatment approaches, but especially for an improved understanding of the persistence of mental disorders. If expectations are a major mechanism of depression, the treatment of depression must maximize the violation of dysfunctional expectations. We also introduce the concept of immunization that describes any cognitive or behavioral strategies to reduce the effect of expectation violation experiences, and hereby contributing to expectation maintenance despite expectation contradicting events. We postulate that the development of immunization strategies could help to better understand the transition from episodic to chronic depression.

While in early periods of depression development, a focus on expectation change might be sufficient in treatment, the treatment of patients with chronic depression requires addressing these cognitive and behavioral immunization strategies more intensively. Further implications for treatment and research are outlined that are derived from this balance between expectation violation and cognitive immunization in depression.

A focus on “expectations” helps to better understand the maintenance of depression

We offer a model that explains why depression persists even in the presence of positive experiences.

Many psychological treatments focus on the violation of negative expectations, but cognitive immunization can hinder treatment success.

We suggest strategies on how to improve psychological treatments for depression by maximizing expectation violation, and minimizing cognitive immunization.

Influence of depressed patients' expectations prior to electroconvulsive therapy on its effectiveness and tolerability (Exp-ECT): a prospective study

Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive disorders. Though there are known clinical predictors of response (e.g., higher age, presence of psychotic symptoms), there is a lack of knowledge concerning the impact of patients' expectations on treatment outcome and tolerability in terms of possible placebo/nocebo effects. In 31 patients with unipolar or bipolar depressive disorder, we used a questionnaire to investigate the patients' expectations of ECT effectiveness and tolerability prior to and in the course of the treatment. Additionally, the questionnaire was used after the ECT course for a final assessment. Depressive symptoms and putative side-effects were measured at each time point. General linear models were used to analyze the course of depressive symptoms and patients' expectation of ECT effectiveness and tolerability. ECT significantly reduced depressive symptoms with large effect sizes. Patients' rating of ECT effectiveness decreased in parallel: While responders' rating of ECT effectiveness remained stable on a high level, non-responders' rating decreased significantly. Group difference was significant after, but not prior to and during the treatment. Regarding tolerability, there was a (temporary) significant increase in the severity of self-rated symptoms such as headache and memory impairment. In contrast, patients' expectation and assessment of ECT tolerability remained unchanged, and their expectations prior to ECT had no impact on the occurrence of side-effects. These findings contradict the presence of relevant placebo/nocebo effects in the context of ECT when investigating a population of mostly chronic or treatment resistant patients with moderate to severe depressive disorder.

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

BACKGROUND

Dysfunctional expectations are considered to be core features of mental disorders and, in particular, major depression. The aim of the present study was to integrate two important types of expectations into the cognitive model of depression: situation-specific dysfunctional expectations (SDE) and dispositional optimism (DO). It was hypothesized that the influence of both DO and intermediate beliefs (IB) on depressive symptoms would be mediated via SDE.

METHODS

We examined 95 individuals (age M = 40.7, 68.1% female) with a diagnosed major depressive disorder from two inpatient clinics and one outpatient clinic. Measurements used in the study included the Depressive Expectations Scale, Dysfunctional Attitudes Scale, Life Orientation Test Revised, and Beck's Depression Inventory-II. Relationships between the constructs were analyzed using path-analytic models with bias-corrected bootstrapping confidence intervals.

RESULTS

Results indicate that the effect of IB on depressive symptoms was fully mediated via SDE, while the effect of DO on depressive symptoms was partly mediated via SDE. IB and DO moderately correlated with each other.

LIMITATIONS

Due to the cross-sectional design of the study, it is not possible to draw unambiguous conclusions regarding the causality of the suggested relationships.

CONCLUSIONS

The present study stresses the crucial role of dysfunctional expectations for major depression. Moreover, it reveals that SDEs as expectations with a high level of situational specificity may pose an important link between global cognitions and depressive symptoms. Given this situational specificity, SDEs are amenable to disconfirmation through behavioral experiments and may therefore be a promising target for cognitive-behavioral interventions.

Optimizing expectations and distraction leads to lower cortisol levels after acute stress

BACKGROUND

A new approach of psychological interventions prior to stress aiming to optimize expectations may have beneficial effects on a person's health status by reducing physiological stress. The purpose of this experiment was to determine whether a brief psychological intervention designed to optimize personal control expectations prior to acute stress would affect perceived and biological stress responsiveness in comparison to two more established interventions (fostering gratitude or distraction) in a healthy sample.

METHODS

74 healthy participants were randomized to one of three psychological interventions prior to stress: (i) writing about ways to influence stress to optimize personal control expectations (EXPECTATION), (ii) writing a gratitude-letter (GRATITUDE) (iii) or a distraction writing task (DISTRACTION). After completing the intervention, the Maastricht acute stress test was administered to induce (psychosocial and physiological) stress. Assessments took place at baseline, post-intervention (15 min writing task) and after stress induction (additional salivary assessments: 15 and 30 min after stress). Main outcomes were expectations, emotions, perceived stress, salivary cortisol and alpha-amylase. Personality traits (eg, optimism) were assessed at baseline.

RESULTS

EXPECTATION specifically increased personal control expectations (p = .016, d = .72) and GRATITUDE specifically increased gratitude (p = .026, d = .68). EXPECTATION and DISTRACTION led to lower cortisol concentrations after stress induction than GRATITUDE (time x group interaction: p < .001, d = .88). We detected no intervention effects on alpha-amylase or perceived stress. Optimism moderated intervention effects on cortisol (p = .023, d = .74).

CONCLUSIONS

Brief psychological interventions aiming to optimize expectations or distraction prior to stress reduce the cortisol response in healthy participants after an acute stressor.

The role of depression pharmacogenetic decision support tools in shared decision making

Patients discontinue antidepressant medications due to lack of knowledge, unrealistic expectations, and/or unacceptable side effects. Shared decision making (SDM) invites patients to play an active role in their treatment and may indirectly improve outcomes through enhanced engagement in care, adherence to treatment, and positive expectancy of medication outcomes. We believe decisional aids, such as pharmacogenetic decision support tools (PDSTs), facilitate SDM in the clinical setting. PDSTs may likewise predict drug tolerance and efficacy, and therefore adherence and effectiveness on an individual-patient level. There are several important ethical considerations to be navigated when integrating PDSTs into clinical practice. The field requires greater empirical research to demonstrate clinical utility, and the mechanisms thereof, as well as exploration of the ethical use of these technologies.