The mediating effect of mindful non-reactivity in exposure-based cognitive behavior therapy for severe health anxiety

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.

Understanding the relationship between negative emotional eating and binge eating: The moderating effects of acting with awareness and non-reactive mindfulness

OBJECTIVES

Negative emotional eating and binge eating are positively related, occur in diverse populations, and may be driven by similar mechanisms. Mindfulness facets such as acting with awareness, describe, non-judgement, non-reactive, and observe may moderate the relationship between these maladaptive eating phenotypes.

METHOD

A cross-sectional study assessed emotional eating-depression (Emotional Eating Scale-Revised, depression subscale), trait mindfulness facets (Five Facet Mindfulness Questionnaire-Short Form), and binge eating severity (Binge Eating Scale) in adults (N = 258).

RESULTS

Emotional eating-depression was less strongly associated with binge eating severity in participants with higher acting with awareness mindfulness. Emotional eating-depression was more strongly associated with binge eating severity in participants with higher non-reactive mindfulness.

CONCLUSIONS

Acting with awareness and non-reactive mindfulness may be important treatment targets in concurrent presentations of emotional eating-depression and binge eating.

The Differential Role of Coping, Physical Activity, and Mindfulness in College Student Adjustment

Research has examined the function of stress management techniques, including coping, physical activity, and mindfulness on college students’ adjustment. The present study examined the differential contributions of three stress management techniques to students’ maladaptation (perceived stress, depression, anxiety, and loneliness) and adaptation (self-esteem). Undergraduate students (N = 1185) responded to an online survey. Hierarchical linear regression results indicated that all three stress management techniques – coping, physical activity, and mindfulness – were related to the five outcomes as predicted. Higher levels of disengagement coping strategies were related to higher perceived stress, anxiety, and depression. Components of mindfulness emerged as a strong predictor of adaptation.

Mediators of treatment effect in minimal-contact cognitive behaviour therapy for severe health anxiety: A theory-driven analysis based on a randomised controlled trial

Cognitive behaviour therapy (CBT) is efficacious for severe health anxiety, but little is known about mechanisms. We analysed putative mediators of change based on 13 weekly assessments in a randomised controlled trial (N = 132) of exposure-based minimal-contact CBT (guided Internet-delivered CBT, unguided Internet-delivered CBT and bibliotherapy) vs. a waitlist control for severe health anxiety. We hypothesised that the effect of CBT on health anxiety would be mediated by non-reactivity to inner experiences, health anxiety behaviours and perceived competence. We also explored somatosensory amplification. In parallel process growth models, non-reactivity, health anxiety behaviours and perceived competence - but not somatosensory amplification - were influenced by CBT and associated with health anxiety. Random intercepts cross-lagged panel models were used to study within-individual ordering of change. None of the putative mediators systematically predicted subsequent changes in health anxiety. Rather, changes in health anxiety predicted subsequent changes in all putative mediators. In summary, CBT influenced health anxiety behaviours, non-reactivity to inner experiences and perceived competence, and these variables were associated with the outcome. However, their role as mediators was not corroborated because we found no evidence that changes in these variables predicted subsequent changes in health anxiety. We encourage further research into mediators of CBT for health anxiety.

Who Can Get More Benefits? Effects of Mindfulness Training in Long-Term and Short-Term Male Prisoners

The aim of the present study was to examine the effects of a 6-week mindfulness training program on mental health, anxiety, depression, aggression, sleep quality, mood states, total mood disturbance, and perceived stress among male Chinese prisoners, and to explore whether the intervention effects differed in long-term and short-term prisoners. Eighty-three male prisoners completed the study, including 39 in the mindfulness training group and 44 in the waitlist control group. Results showed that, compared with the waitlist control group, mindfulness training group showed a significant improvement in mindfulness level (p < .0l), Symptom Checklist-90 (SCL-90; p < .00l), aggression (p < .05), sleep quality (p < .05), and total mood disturbance (p < .0l). Moreover, compared with the short-term prisoners, mindfulness training was more effective on the long-term prisoners in mindfulness level (p < .05), SCL-90 (p < .001), anxiety (p < .05), depression (p < .05), aggression (p < .05), total mood disturbance (p < .0l), and perceived stress (p < .0l). Given the study's innovation, we discussed its significance and limitations.

Accuracy of self-referral in health anxiety: comparison of patients self-referring to internet-delivered treatment versus patients clinician-referred to face-to-face treatment

BACKGROUND

Severe health anxiety is a chronic and costly disorder if untreated. Patient self-referral may lower barriers to treatment and decrease diagnostic delay.

AIMS

This study evaluated the accuracy of self-referral for severe health anxiety and compared characteristics of patients self-referred to internet-delivered treatment with patients referred by a clinician to face-to-face treatment.

METHOD

Two trials in the same clinic employed different referral methods for health anxiety, namely self-referral and clinician-referral (trial registration: clinicaltrials.gov: NCT01158430 and NCT02735434). The trials were conducted at different time points but with largely comparable eligibility criteria. The accuracy of the recruitment methods was compared by looking at the number of eligible patients in the two trials. Patients completed a baseline questionnaire and subsequently underwent a diagnostic interview by experienced clinicians. Mean differences in self-report and clinical data explored between-group demographic and clinical characteristics.

RESULTS

In total, 101/151 (67%) self-referred patients were eligible compared with 126/254 (50%) clinician-referred patients (P = 0.001). Self-referred patients were 3.4 years older (P = 0.008) and had a somewhat higher educational level (P = 0.030). Patients who self-referred reported significantly higher levels of health anxiety, emotional distress and somatic symptoms compared with clinician-referred patients. Yet, they had less clinician-assessed comorbid anxiety disorders (P<0.001) and better physical health-related quality of life (P<0.001) suggesting a more distinct symptom profile.

CONCLUSIONS

Self-referral was found to be an accurate method to recruit highly relevant patients with treatment-demanding health anxiety. Thus, both self-referral and clinician-referral seem feasible and valid referral methods, but they may recruit patients with slightly different characteristics.

DECLARATION OF INTEREST

None.

The Effect of a Brief Mindfulness Training on Distress Tolerance and Stress Reactivity

Poor distress tolerance (DT) is considered an underlying facet of anxiety, depression, and a number of other psychological disorders. Mindfulness may help to increase DT by fostering an attitude of acceptance or nonjudgment toward distressing experiences. Accordingly, the present study examined the effects of a brief mindfulness training on tolerance of different types of distress, and tested whether trait mindfulness moderates the effect of such training. Undergraduates (n = 107) naïve to mindfulness completed a measure of trait mindfulness and underwent a series of stress tasks (cold pressor, hyperventilation challenge, neutralization task) before and after completing a 15-minute mindfulness training or a no-instruction control in which participants listened to relaxing music. Participants in the mindfulness condition demonstrated greater task persistence on the hyperventilation task compared to the control group, as well as a decreased urge to neutralize the effects of writing an upsetting sentence. No effect on distress ratings during the tasks were found. Overall trait mindfulness did not significantly moderate task persistence, but those with lower scores on the act with awareness facet of mindfulness demonstrated greater relative benefit of mindfulness training on the hyperventilation challenge. Mediation analyses revealed significant indirect effects of mindfulness training on cold pressor task persistence and urges to neutralize through the use of the nonjudge and nonreact facets of mindfulness. These results suggest that a brief mindfulness training can increase DT without affecting the subjective experience of distress.

Severe Illness Anxiety Treated by Integrating Inpatient Psychotherapy With Medical Care and Minimizing Reassurance

Illness anxiety disorder (IAD, formerly hypochondriasis) is characterized by preoccupation with fear of serious illness despite medical reassurance. IAD is common, debilitating, challenging to treat, and results in high healthcare utilization. Outpatient management of IAD is challenging because patients can compulsively seek reassurance from numerous providers, which interferes with learning more productive coping skills. We present the case of a woman with severe IAD who presented to the emergency room with increasing frequency over several months, despite regular outpatient medical visits and escalating psychiatric care. We made the unusual decision to hospitalize her for IAD for 1 month, in the absence of typical hospitalization criteria. This hospitalization allowed us to consolidate all medical and psychiatric care into a single provider team and train all staff and family to communicate with her in a consistent manner. We successfully treated her by integrating a general cognitive-behavioral therapy (CBT) protocol into medical care and decision-making. In response to her numerous health concerns, we minimized medical work-up, reassurance, and reactive medication changes, and instead used the concerns as opportunities to reinforce the psychotherapy. This approach allowed us to simplify her medication regimen and manage her co-morbid hypertension and vitamin deficiencies. Though inpatient hospitalization is likely infeasible in most cases of IAD, outpatient providers may create similar treatment plans based on the example of our case report, without needing highly specialized expertise. Such a plan would require a straightforward understanding of IAD psychology, which we review here, combined with readily accessible tools including a universal CBT protocol, online CBT courses, and clinical symptom scales. We discuss our approach for responding to health concerns, maintaining therapeutic alliance, integrating CBT principles into patient interactions, and managing medications. Since patients with IAD share health concerns with all providers, staff, and family, we also include our own IAD communication guide, appropriate for a general audience, that demonstrates how to respond in these conversations.

The Effectiveness of Internet-Based Cognitive Behavioral Therapy in Treatment of Psychiatric Disorders

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (ICBT) in the treatment of psychiatric disorders. ICBT’s effectiveness has been investigated in treating and managing conditions like depression, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. ICBT’s role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. Furthermore, this study elaborates on its cost-effectiveness and its impact in rural areas. We conducted a thorough literature search using PubMed and Google Scholar with no restrictions on the date. ICBT's role in treating and controlling psychiatric illnesses has been established in the literature. From the data compiled, we conclude that ICBT is useful in treating mental health and medical illnesses with psychiatric comorbidities. It has also been found to be cost-effective for patients and society. ICBT is a potential tool emerging with modern day technological advancements and is useful in rural and urban settings, across various languages and cultures, and on a global scale. Larger randomized control trials on its use in clinical practice and in reaching rural populations are bound to shed more light on the effectiveness of this tool along with spreading awareness among physician and patient communities.