Attachment scales predict outcome in a randomized controlled trial of two group therapies for binge eating disorder: An aptitude by treatment interaction

Attachment style to body dissatisfaction, restrained eating, and disordered eating in adolescent girls: Differential weight communication mediators

Body dissatisfaction and eating behaviors are disproportionately elevated amongst adolescent girls. Family relationships represent a context in which adolescent girls' body image issues emerge. Thus, we integrated attachment and confirmation theories to examine whether weight related supportive messages (i.e., acceptance and challenge) mediated the relationship between attachment style (i.e., anxiety and avoidance) and body image outcomes (i.e., body dissatisfaction (BD), restrained eating (RE), and disordered eating (DE)). Acceptance refers to weight related support that is characterized by warmth and accepting messages; challenge refers to weight related support that is characterized by instrumental assistance and problem-solving messages. A sample of 106 adolescent girls, ages 11 to 21, completed self-report measures on attachment (Relationship Structures Questionnaire), acceptance and challenge (weight related Parental Behavior Questionnaire), body dissatisfaction (Eating Disorders Inventory), and eating behaviors (Dutch Eating Behavior Questionnaire; Eating Disorder Diagnostic Scale). Attachment anxiety directly related to all body image outcomes, whereas attachment avoidance only directly related to RE. Attachment avoidance only related to BD and DE indirectly through perceived acceptance. Those with high anxiety endorsed lower perceived challenge, whereas avoidant individuals endorsed lower perceived acceptance and challenge. We concluded that attachment dimension characteristics to be either hyperactivated regarding relationships (i.e., anxiety), or deactivated and distant (i.e., avoidance), are associated with how individuals perceive support, and in turn, are related to body image and eating behavior outcomes. Further, we clarify the differential roles of acceptance and challenge. Although both supportive, acceptance encompasses a layer of warmth that is more meaningful in body image, particularly for avoidantly attached individuals. By integrating qualities of attachment and supportive weight communication, we reveal that potential pathways of attachment to body image and eating behaviors.

The equivalence of psychodynamic therapy and cognitive behavioral therapy for depressive disorders in adults: A meta-analytic review

BACKGROUND

Meta-analyses on the relative efficacy of psychodynamic psychotherapy (PDT) and cognitive behavioral therapy (CBT) for depressive disorders are limited by heterogeneity in diagnostic samples and comparators and a lack of equivalence testing.

OBJECTIVE

We addressed this through a meta-analytic test of the equivalence of manualized PDT and CBT in treating adults with depressive disorders as determined by diagnostic interviews. Sensitivity analyses evaluated the impact of pretreatment differences, mixed diagnostic samples, author allegiance, study quality, year of publication and outliers on findings.

METHOD

A comprehensive literature search across multiple databases using reliable screening methods identified nine randomized controlled trials directly comparing manualized PDT and CBT for diagnosed depressive disorders in adults. Following pre-registration, we employed random effect models for our meta-analyses and two one-sided test procedures for equivalence testing.

RESULTS

Independent raters determined that all studies were of adequate quality. Immediately posttreatment, depressive symptoms were statistically equivalent across PDT and CBT (k = 9; g = -0.11, 90% confidence interval [90% CI]: -0.24 to 0.02, pequivalence = .048, pNHST = .212, I2 = 32.7). At follow-up, the longest time point within a year, depressive symptoms were neither statistically equivalent nor statistically different (k = 6; g = -0.16, 90% CI: -0.31 to -0.02, pequivalence = .184, pNHST = .126, I2 = 0.00).

CONCLUSION

The efficacy of manualized PDT is equal to manualized CBT immediately at posttreatment for depressive disorders in the adult general population. Nevertheless, insufficient data exists to reach a conclusion regarding equivalence at follow-up.

Group member attachment style interacts with actor and partner helping alliance to predict decreasing binge eating episodes

OBJECTIVE

An individual's attachment style may impact how they interact with their therapy group. This study examined the moderating role of a group member's attachment on the dynamic relationships between that group member's (actor) and other group members' (partner) therapeutic alliances and symptom outcomes. Method: This is a secondary analysis of data from a trial testing the outcome of emotionally-focused group therapy for binge-eating disorder. The sample consisted of 2,360 sessions nested within 118 group members who attended a 20-session treatment. Patients recorded binge eating episodes (BEE), their body weight and an alliance measure session-by-session.

RESULTS

Dynamic structural equation modelling showed decreases in BEE and weight over the therapy. When attachment style was not included in the model, higher-than-average partner's alliance scores in the previous session were related to decreases in BEE in the current session. Attachment style moderated these actor and partner effects. For patients with preoccupied attachments, higher-than-average actor alliance in the previous session was related to subsequent decreases in BEE. For patients with dismissing or disorganized attachments, higher partner alliance in the previous session was related to subsequent decreases in BEE.

CONCLUSION

Group members' attachment characteristics can play a role in the development of alliance-outcome patterns in group therapy.

Attachment as a predictor of dropout in mentalization-based treatment

OBJECTIVES

Although treatments of patients with borderline personality disorder (BPD) were historically associated with relatively high dropout rates, dropout rates in contemporary evidence-based treatments for BPD are typically substantially lower. However, only a few studies have investigated dropout rates in mentalization-based treatment (MBT), and even fewer have investigated predictors of dropout in this type of treatment. In this study, we investigated dropout rates in two types of MBT (day hospital MBT [MBT-DH] and intensive outpatient MBT [MBT-IOP]) using data from a recent multicenter randomized clinical trial. Given the central importance of attachment considerations in MBT, we also investigated the relationship between dropout in these two treatments and attachment dimensions.

DESIGN

Within a multicenter randomized clinical trial, 114 BPD patients were randomized to MBT-DH (n = 70) or MBT-IOP (n = 44).

METHODS

Dropout in both types of MBT was investigated using descriptive analyses, and its association with attachment anxiety and attachment avoidance, as measured by the Experiences in Close Relationships questionnaire at baseline, was investigated using regression analyses.

RESULTS

Dropout rates were relatively low (10.5% across both types of MBT) and did not significantly differ between groups (11.4% in MBT-DH, 9.1% in MBT-IOP). Attachment avoidance and attachment anxiety did not impact dropout, nor did their interaction or the interaction with the type of MBT.

CONCLUSIONS

Low dropout rates in both types of MBT indicate a high level of engagement of patients in both programmes. Attachment dimensions were not associated with dropout, consistent with the principle that MBT is tailored to each individual's needs. More research is needed, however, to investigate to what extent attachment is a dynamic context-bound adaptive process rather than a static personality feature.

Exploring effectiveness of CBT in obese patients with binge eating disorder: personality functioning is associated with clinically significant change

BACKGROUND

Binge eating disorder (BED), as the most prevalent eating disorder, is strongly related to obesity and other somatic and psychiatric morbidity. Despite evidence-based treatments a considerable number of BED patients fail to recover. There is preliminary evidence for the association between psychodynamic personality functioning and personality traits on treatment outcome. However, research is limited and results are still contradictory. Identifying variables associated with treatment outcome could improve treatment programs. The aim of the study was to explore whether personality functioning or personality traits are associated with Cognitive Behavioral Therapy (CBT) outcome in obese female patients with BED or subthreshold BED.

METHODS

Eating disorder symptoms and clinical variables were assessed in 168 obese female patients with DSM-5 BED or subthreshold BED, referred to a 6-month outpatient CBT program in a pre-post measurement design. Personality functioning was assessed by the Developmental Profile Inventory (DPI), personality traits by the Temperament and Character Inventory (TCI). Treatment outcome was assessed by the Eating Disorder Examination-Questionnaire (EDE-Q) global score and self-reported binge eating frequency. According to the criteria of clinical significance, 140 treatment completers were categorized in four outcome groups (recovered, improved, unchanged, deteriorated).

RESULTS

EDE-Q global scores, self-reported binge eating frequency and BMI significantly decreased during CBT, where 44.3% of patients showed clinically significant change in EDE-Q global score. Treatment outcome groups showed significant overall differences on the DPI Resistance and Dependence scales and the aggregated 'neurotic' scale. Significant overall differences were found between groups on TCI Harm avoidance, although post hoc t-tests were non-significant. Furthermore, multiple logistic regression analysis, controlling for mild to moderate depressive disorder and TCI harm avoidance showed that 'neurotic' personality functioning was a significant negative predictor of clinically significant change.

CONCLUSION

Maladaptive ('neurotic') personality functioning is significantly associated with a less favorable outcome after CBT in patients with binge eating. Moreover, 'neurotic' personality functioning is a predictor of clinically significant change. Assessment of personality functioning and personality traits could support indication for more specified or augmented care, tailored towards the patients' individual strengths and vulnerabilities.

TRIAL REGISTRATION

This study protocol was retrospectively evaluated and approved on 16-06-2022 by the Medical Ethical Review Committee (METC) of the Amsterdam Medical Centre (AMC). Reference number W22_219#22.271.

Attachment insecurity predicts outcomes in an ACT-CBT group therapy for adults in a physical rehabilitation centre

Adapting to chronic illness or disability is accompanied by acute and ongoing illness stressors. Psychological factors such as emotional distress and low self-efficacy are common experiences in chronic illness and disability and interfere with adaptation and psychosocial outcomes such as health-related quality of life. Transdiagnostic group psychotherapy may provide a parsimonious approach to psychological treatment in rehabilitation care by targeting shared illness stressors across mixed chronic illnesses and disabilities, and shared processes that maintain psychological symptoms. Attachment theory may explain individual differences in outcomes and help identify individuals at risk of poor health-related quality of life trajectories. Adults (N=109) participated in an 8-week process-based ACT-CBT psychotherapy group at a tertiary care physical rehabilitation centre between 2016 and 2020. Participants completed measures of emotional distress, self-efficacy, health-related quality of life, and attachment at pre- and post-treatment. Multilevel analyses indicated that patients improved on most outcomes at post-treatment. Attachment anxiety at pre-treatment was associated with more positive outcomes. Reliable change indices suggest clinically meaningful change for the majority of participants, but most were not recovered. Results provide proof-of-concept for the transdiagnostic group intervention and suggest that a longer course of treatment may be clinically indicated. Results warrant replication with larger and more diverse samples, and more robust designs.

Attachment insecurity predicts worse outcome in patients with eating disorders treated with enhanced cognitive behavior therapy: A one-year follow-up study

OBJECTIVE

This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions.

METHOD

In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor.

RESULTS

After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses.

DISCUSSION

The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues.

PUBLIC SIGNIFICANCE STATEMENT

Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of outcome predictors is of considerable clinical interest. This study demonstrated that attachment insecurity was associated with worse longitudinal trends of ED psychopathology and body uneasiness in patients with AN and BN treated with CBT-E, highlighting the importance of personalizing treatment programs taking into account a developmental perspective on these disorders.

Online group psychodynamic psychotherapy-The effectiveness and role of attachment-The results of a short study

The role of remote treatment, including psychotherapy, has increased during the COVID-19 pandemic. The results of research in this area are promising, initially pointing to similar effectiveness for online psychotherapy as that of face-to-face psychotherapy. A significantly smaller amount of research has been conducted on online group psychotherapy, in particular, in the psychodynamic paradigm. Many authors have drawn attention to the need to conduct further research, considering specific patient features, for example, personality traits, attachment style, age, and other demographic variables. This study conducted pre- and post-treatment (10 weeks) and a 6-week follow-up, on the effectiveness of online synchronous group psychodynamic psychotherapy (via Zoom) taking into account patients' attachment styles. Four main hypotheses were tested: H1: Patients will obtain a lower score in the attachment's dimensions of anxiety and avoidance; H2: Patients will get a lower level of symptoms and sense of loneliness; H3: Patients will have increased self-esteem; and H4: The anxiety and avoidance dimensions of the attachment will be predictors for the effectiveness of online psychodynamic group psychotherapy. Twenty-two outpatients participated in the study, out of which 18 suffered from neurotic, stress-related, and somatoform disorders (F40-F48), and four suffered from a depressive episode (F32.0, F32.1) according to ICD-10. The results of the pre-treatment test showed a reduction in the global severity of psychiatric symptoms (d = -0.526) and depressive symptoms (d = -0.5), as well as an increase in self-esteem (d = 0.444) and feelings of loneliness (d = 0.46). A change in the attachment dimension, anxiety (d = -0.557) and avoidance (d = -0.526), was also observed. The above results were maintained in the follow-up test conducted after 6 weeks. Additionally, a reduction in the symptoms of social phobia was observed. Attachment dimensions were not a predictor of the effectiveness of psychotherapy, but a decrease in avoidance during therapy was a predictor of increased symptoms of pain. The results of the research are promising in terms of psychiatric symptoms and increased self-esteem. During therapy, there may be a favorable change in attachment dimensions, but this variable was not shown to be a predictor of results. These results suggest that more controlled research is required.

Psychological Mindedness, Personality Structure, and Outcomes in Short-Term Group Analytic Psychotherapy

The present study investigated the treatment effects of focused short-term group analytic psychotherapy and examined whether outcomes were predicted by the client's psychological mindedness and personality structure as measured by the Operationalized Psychodynamic Diagnosis (OPD). Treatment foci were formulated according to the OPD for 66 student counseling clients across nine groups. Two observers independently rated client psychological mindedness and personality structure. The pre-post Cohen's d effect sizes were large on the Global Severity Index (GSI) and the Inventory of Interpersonal Problems (IIP-64) and moderate on the Social Adjustment Scale Self Report, including all 66 clients starting treatment. Psychological mindedness significantly predicted two outcomes (GSI, IIP), and personality structure predicted one outcome (GSI). These measures could be helpful when selecting clients for short-term group analytic psychotherapy. We discuss study limitations and implications for future research and practice.

Change in Defensive Functioning Following Group Psychodynamic-Interpersonal Psychotherapy in Women With Binge-Eating Disorder

We examined change in defensive functioning following group psychodynamic-interpersonal psychotherapy (GPIP) for binge-eating disorder (BED) compared to a waitlist control. We hypothesized that defensive functioning will improve to a greater extent at posttreatment for those in GPIP compared with those in a waitlist control condition. Participants were women with BED assigned to GPIP (n = 131) or a waitlist control (n = 44) condition in a quasi-experimental design. Those who received GPIP had significantly greater improvements in defensive functioning from pretreatment to six months posttreatment compared to the control group. GPIP may be effective for improving defensive functioning in individuals with BED. A randomized controlled trial is needed to confirm that GPIP is efficacious for addressing defensive functioning among women with BED.

Adult attachment anxiety is associated with night eating syndrome in UK and US-based samples: Two cross-sectional studies

Previous research has shown that "attachment anxiety" is a robust predictor of disinhibited eating behaviours and that this relationship is underpinned by difficulties in managing emotion. Night eating syndrome (NES), a proposed eating disorder characterized by evening hyperphagia, nocturnal awakenings to eat, and morning anorexia, is also associated with eating to manage emotion. Across two studies (N = 276 &N = 486), we considered a relationship between attachment anxiety and NES. In Study 1, we hypothesised (pre-registered) that attachment anxiety would predict NES score and that this relationship would be mediated by disinhibited eating. Participants were asked to complete questionnaire measures of attachment orientation, disinhibited eating (emotional and uncontrolled eating) and NES. Our parallel mediation model confirmed a direct relationship between attachment anxiety and NES (p < .001) and showed an indirect path via both emotional (95% CI: 0.15-0.63) and uncontrolled eating (95% CI: 0.001-0.36). In Study 2, we showed that fear of negative evaluation of eating significantly mediated a reversed relationship between attachment anxiety and NES (95% CI: 0.02-0.04). Finally, across both studies we used a novel tool to assess "eating to cope". We showed a relationship with emotional eating but failed to show a robust relationship with NES. Attachment orientation may represent a potential intervention target for night eating syndrome. Future research should consider a longitudinal approach to strengthen our understanding of directionality amongst these factors.

COVID-19 Related Traumatic Distress in Psychotherapy Patients during the Pandemic: The Role of Attachment, Working Alliance, and Therapeutic Agency

The early months of the COVID-19 pandemic have been a challenging time for many psychotherapy patients. To understand why certain patients were more resilient, we examined the role of patients' attachment anxiety and attachment avoidance, as well as collaborative therapy experiences (perceived working alliance and therapeutic agency) in their online sessions on their COVID-related traumatic distress over a three-month period. A total of 466 patients in online psychotherapy completed a survey during the first weeks of the pandemic, and 121 of those completed a follow-up survey three months later. Lower distress at follow-up was predicted by patients' lower attachment anxiety and higher therapeutic agency in their online sessions after controlling for baseline distress and time of survey completion. Higher working alliance predicted less distress at follow-up only for patients with high attachment anxiety. For patients with low attachment avoidance (i.e., more securely attached), higher therapeutic agency predicted less distress. These findings suggest that patients' attachment anxiety and therapeutic agency may play significant roles also in online therapy during COVID-19 in patient's experienced traumatic distress, and that working alliance and therapeutic agency may be differentially important for patients with different levels of attachment anxiety and avoidance.

Reconsidering a role for attachment in eating disorder management in the context of paediatric diabetes

We suggest a reconsideration of the role of 'attachment orientation' in the context of eating disorders and paediatric diabetes. Attachment orientation is a psychological construct that describes a relatively stable set of expectations and behaviours an individual relies upon in managing relationships. There is considerable evidence of an association between attachment orientation and the development and maintenance of disordered eating in individuals without diabetes, though evidence is more scant in populations with diabetes. We discuss the underpinning theory and critically examine the existing literature for the relationship between attachment orientation and disordered eating in paediatric diabetes. Finally, we draw on adjacent literatures to highlight potential future directions for research should this area be revisited. Overall, we contextualise our discussion in terms of patient-centred, holistic care that addresses the mind and body (i.e., our discussion of attachment orientation assumes a psycho-biological approach).

Effectiveness of interpersonal psychotherapy for community living depressed women involved with the justice system

BACKGROUND

Despite the prevalence of depression among women in the justice system, and its potentially significant consequences, there is a dearth of studies investigating psychological treatments for depression in this context, especially outside prison.

AIMS

Our aim was to gather preliminary data on whether individual interpersonal psychotherapy (IPT) is an acceptable and effective treatment for depression in women at an early stage in the justice system.

METHOD

In this pilot study, IPT was offered to 24 depressed women following their first or second contact with the justice system. The women were assessed using a range of scales to quantify depression, anxiety, post-traumatic stress disorder (PTSD) and social support. Multilevel models were used to explore interactions between change in depression and other features given the multiplicity and complexity of problems. Details on engagement and attrition were also collected.

RESULTS

Therapy attrition was low, despite challenging life-circumstances and depression scores followed a linear trajectory with scores significantly decreasing over the time (β = -0.59, SE = 0.07, p < 0.001). Participants with more adverse life events, attachment related anxiety and lower social support had poorer outcomes.

CONCLUSIONS AND IMPLICATIONS

Results are encouraging. More than half of the hard-to-reach women who were eligible did engage, and retention rates suggest the therapy was acceptable to them. Depression scores improved, and potential factors affecting treatment outcome were identified. A randomised controlled trial is now warranted, ensuring adequate supplementary support for women with dependants living on their own and without employment.

The feasibility of emotion-focused therapy for binge-eating disorder: a pilot randomised wait-list control trial

BACKGROUND

Research into psychotherapy for binge-eating disorder (BED) has focused mainly on cognitive behavioural therapies, but efficacy, failure to abstain, and dropout rates continue to be problematic. The experience of negative emotions is among the most accurate predictors for the occurrence of binge eating episodes in BED, suggesting benefits to exploring psychological treatments with a more specific focus on the role of emotion. The present study aimed to explore the feasibility of individual emotion-focused therapy (EFT) as a treatment for BED by examining the outcomes of a pilot randomised wait-list controlled trial.

METHODS

Twenty-one participants were assessed using a variety of feasibility measures relating to recruitment, credibility and expectancy, therapy retention, objective binge episodes and days, and binge eating psychopathology outcomes. The treatment consisted of 12 weekly one-hour sessions of EFT for maladaptive emotions over 3 months. A mixed model approach was utilised with one between effect (group) using a one-way analysis of variance (ANOVA) to test the hypothesis that participants immediately receiving the EFT treatment would demonstrate a greater degree of improvement on outcomes relating to objective binge episodes and days, and binge eating psychopathology, compared to participants on the EFT wait-list; and one within effect (time) using a repeated-measures ANOVA to test the hypothesis that participation in the EFT intervention would result in significant improvements in outcome measures from pre to post-therapy and then maintained at follow-up.

RESULTS

Recruitment, credibility and expectancy, therapy retention outcomes indicated EFT is a feasible treatment for BED. Further, participants receiving EFT demonstrated a greater degree of improvement in objective binge episodes and days, and binge eating psychopathology compared to EFT wait-list control group participants. When participants in the EFT wait-list control group then received treatment and outcomes data were combined with participants who initially received the treatment, EFT demonstrated significant improvement in objective binge episodes and days, and binge eating psychopathology for the entire sample.

CONCLUSIONS

These findings provide further preliminary evidence for the feasibility of individual EFT for BED and support more extensive randomised control trials to assess efficacy.

TRIAL REGISTRATION

The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12620000563965 ) on 14 May 2020.

Meta-analysis on the long-term effectiveness of psychological and medical treatments for binge-eating disorder

OBJECTIVE

Long-term effectiveness is a critical aspect of the clinical utility of a treatment; however, a meta-analytic evaluation of psychological and medical treatments for binge-eating disorder (BED), including weight loss treatments, is outstanding. This meta-analysis sought to provide a comprehensive evaluation of the long-term effectiveness in diverse treatments for BED regarding a range of clinically relevant outcomes.

METHOD

Based on a systematic search up to February 2018, 114 published and unpublished randomized-controlled (RCTs), nonrandomized, and uncontrolled treatment studies, totaling 8,862 individuals with BED (DSM-IV, DSM-5), were identified and analyzed using within-group random-effect modeling.

RESULTS

Effectiveness (regarding binge-eating episodes and abstinence, eating disorder and general psychopathology) up to 12 months following treatment was demonstrated for psychotherapy, structured self-help treatment, and combined treatment, while the results regarding body weight reduction were inconsistent. These results were confirmed in sensitivity analyses with RCTs on the most common treatments-cognitive-behavioral therapy and self-help treatment based on this approach. Follow-up intervals longer than 12 months were rarely reported, mostly supporting the long-term effectiveness of psychotherapy. Few follow-up data were available for pharmacotherapy, and behavioral and self-help weight loss treatment, while follow-up data were lacking for pharmacological and surgical weight loss treatment. Study quality varied widely.

DISCUSSION

This comprehensive meta-analysis demonstrated the medium-term effectiveness of psychotherapy, structured self-help treatment, and combined treatment for patients with BED, and supported the long-term effectiveness of psychotherapy. The results were derived from uncontrolled comparisons over time. Further long-term high quality research on psychological and medical treatments for BED is required.

Wechselseitige Effekte von Gruppenkohäsion und Symptomen

Kohäsion ist ein bedeutsamer Teil gruppentherapeutischer Beziehungen und stellt einen potenziell kurativen Faktor dar, der nachfolgende Symptomverbesserungen erklären kann. Trotz der häufig belegten Korrelation zwischen erlebter Kohäsion und der Symptomschwere fehlen longitudinale Studien, in denen sowohl die zeitliche Abfolge von Kohäsion und Symptomveränderungen angemessen berücksichtigt und zusätzlich zwischen dem mittleren Level der Kohäsion einzelner Gruppenteilnehmer („between-person effect“) und der individuellen Veränderung („within-person effect“) differenziert wird. Diese Studie untersucht das Kohäsionserleben zur Patientengruppe auf einer Psychotherapiestation mit integrierter Tagesklinik. Vierzig depressive Patienten wurden im Rahmen einer randomisierten kontrollierten Studie zum Vergleich tagesklinischer und stationärer Psychotherapie rekrutiert. Alle Patienten gaben wöchentlich Auskunft über die Therapiebeziehungen (einschließlich Kohäsion) und die aktuelle Symptombelastung; für die Auswertung der Multilevel Daten wurde ein autoregressives cross-lagged Modell verwendet. Die Ergebnisse deuten auf eine wechselseitige Beeinflussung hin. Ein individueller Anstieg der Kohäsion war ein signifikanter Prädiktor für verbesserte Symptome, auch wenn für die vorherige Symptombelastung kontrolliert wurde. Umgekehrt war auch eine Symptomverbesserung prädiktiv für ein höheres Kohäsionserleben im Verlauf. Damit zeigt die Studie die Bedeutung der Beziehungsqualität zur Gruppe der Mitpatienten und weist auf eine wechselseitige Beeinflussung von Kohäsion und Symptomen hin. Allerdings müssen die Ergebnisse aufgrund der kleinen Stichprobe mit Vorsicht interpretiert werden.

An Integrative Approach to Clinical Decision-Making for Treating Patients With Binge-Eating Disorder

Transtheoretical integrative decision-making models help clinicians to use patient factors that are known to predict outcomes in order to inform individualized treatment. Patient factors with a strong evidence base include: functional impairment, social support and interpersonal functioning, complexity and comorbidity, coping style, level of resistance, and level of subjective distress. Among those with binge-eating disorder (BED), patient factors have not been extensively characterized relative to norms or other clinical samples. We used an integrative decision-making model of these six patient factor domains related to patient outcomes to characterize a sample of 424 adults seeking treatment for BED. Data were from medical charts, a demographics questionnaire, and validated psychometric scales. We then compared these data to published data from normative and other eating disorder (ED) samples. Results showed that the average patient with BED: (1) was significantly more functionally impaired compared to non-clinical norms but somewhat less impaired than other patients with ED, (2) demonstrated clinically significant problems in social support and interpersonal functioning, (3) presented with complex comorbid pathology and high levels of chronicity, (4) used a more internalizing coping style compared to the norm and other ED samples, (5) had low levels of resistance to interventions, and (6) experienced a moderately high level of subjective distress indicating good motivation for treatment. Corresponding recommendations to these findings are that the average patient with BED should be provided higher intensity treatment that is longer in duration, interpersonally focused, directive in nature, and emphasizing self-reflection and insight. Despite the nomothetic nature of the findings, clinicians are encouraged to assess these patient domains when developing an ideographic case conceptualization and to tailor precision treatment to the individual patient with BED.

Vom Sinn des Verfahrenskonzepts und der Verfahrensvielfalt – und warum das Baukasten-System in der Psychotherapie nicht funktioniert

Why the concept of distinct psychotherapeutic approaches is indispensable - and why the tool box concept of psychotherapy cannot work Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.

Persistence of friendly and submissive interpersonal styles among those with binge-eating disorder: Comparisons with matched controls and outcomes after group therapy

Interpersonal problems play a prominent role in the development of binge-eating disorder (BED), so reducing their intensity may be a key focus of many psychological interventions. In recent years, several interpersonal treatments for BED were developed, which posit that binge eating arises to manage relational problems. However, few studies have evaluated the prototypical interpersonal problems, and no studies evaluated the longitudinal changes in interpersonal functioning after treatment within this population. We investigated the severity and prototypicality of interpersonal problems of 101 overweight women with BED from pre-group psychodynamic-interpersonal psychotherapy (GPIP) to 12 months post-GPIP. At baseline, we compared patients' interpersonal problems with two groups of matched controls (46 overweight and 49 normal weight women without a diagnosis of BED) and examined circular correlations between relational problems, depressive symptoms, and binge-eating frequency. Results showed that participants with BED had significantly higher levels of interpersonal problems compared with the matched control samples, with predominantly nonassertive and exploitable styles. Depressive symptoms were related to the presence of friendly-submissive interpersonal problems only among those with BED. Although the intensity of nonassertive interpersonal problems of patients with BED decreased post-group treatment, their profiles remained prototypically nonassertive and exploitable across all time points. Women with BED experience higher levels of interpersonal difficulties exemplified by an exploitable/nonassertive style that significantly improve but continue to prevail even after treatment. Clinicians might modify interventions to focus on increasing interpersonal skills and decreasing interpersonal dysfunctions among those with BED.

Testing a stepped care model for binge-eating disorder: a two-step randomized controlled trial

BACKGROUND

A stepped care approach involves patients first receiving low-intensity treatment followed by higher intensity treatment. This two-step randomized controlled trial investigated the efficacy of a sequential stepped care approach for the psychological treatment of binge-eating disorder (BED).

METHODS

In the first step, all participants with BED (n = 135) received unguided self-help (USH) based on a cognitive-behavioral therapy model. In the second step, participants who remained in the trial were randomized either to 16 weeks of group psychodynamic-interpersonal psychotherapy (GPIP) (n = 39) or to a no-treatment control condition (n = 46). Outcomes were assessed for USH in step 1, and then for step 2 up to 6-months post-treatment using multilevel regression slope discontinuity models.

RESULTS

In the first step, USH resulted in large and statistically significant reductions in the frequency of binge eating. Statistically significant moderate to large reductions in eating disorder cognitions were also noted. In the second step, there was no difference in change in frequency of binge eating between GPIP and the control condition. Compared with controls, GPIP resulted in significant and large improvement in attachment avoidance and interpersonal problems.

CONCLUSIONS

The findings indicated that a second step of a stepped care approach did not significantly reduce binge-eating symptoms beyond the effects of USH alone. The study provided some evidence for the second step potentially to reduce factors known to maintain binge eating in the long run, such as attachment avoidance and interpersonal problems.

Emotion-focused therapy for binge-eating disorder: A review of six cases

OBJECTIVE

This study aimed to provide preliminary evidence of the usefulness of emotion-focused therapy (EFT) for binge-eating disorder (BED).

METHODS

We used a single-subject design in which 12 weeks of individual EFT were applied nonconcurrently to six female adult participants with BED, following three weekly baseline sessions. Participants were assessed for binge-eating psychopathology and emotion regulation difficulties on a weekly basis during baseline and treatment. They were assessed on a 2-, 4-, and 8-week basis during posttreatment, and they were assessed for binge-eating episodes, eating disorder attitudes, alexithymia, and psychiatric comorbidity at pretreatment and posttreatment.

RESULTS

All cases experienced reliable recovery from binge-eating psychopathology and a significant decrease in binge-eating frequency. For all cases, there was reliable improvement or recovery on eating and shape concerns, and there was improvement on weight concern for the majority of cases. For all cases, reliable recovery or improvement occurred in overall emotion regulation. Most cases that were in the clinical range pretreatment recovered for anxiety, and reliable improvement in or recovery from depression occurred for all cases. There was reliable recovery or improvement in alexithymia for half of the cases; however, the other half experienced no change or deteriorated. There were no treatment dropouts.

CONCLUSION

Individual EFT demonstrates potential as a psychological treatment for BED. The current study provides preliminary evidence to guide the development of a more extensive trial to test the efficacy of individual EFT for BED as well as to identify possible mechanisms of change.

Rates of abstinence following psychological or behavioral treatments for binge-eating disorder: Meta-analysis

OBJECTIVE

Standardized effect sizes reported in previous meta-analyses of binge-eating disorder (BED) treatment are sometimes difficult to interpret and are criticized for not being a useful indicator of the clinical importance of a treatment. Abstinence from binge eating is a clinically relevant component of a definition of a successful treatment outcome. This meta-analysis estimated the prevalence of patients with BED who achieved binge eating abstinence following psychological or behavioral treatments.

METHOD

This meta-analysis included 39 randomized controlled trials, with 65 treatment conditions and 2,349 patients. Most conditions comprised cognitive-behavioral therapy (n = 40). Pooled event rates were calculated at posttreatment and follow-up using random effects models.

RESULTS

The total weighted percentage of treatment-completers who achieved abstinence at posttreatment was 50.9% (95% CI = 43.9, 57.8); this estimate was almost identical at follow-up (50.3%; 95% CI = 43.6, 56.9). The total weighted percentage of patients who achieved abstinence at posttreatment in the intention-to-treat analysis (all randomized patients) was 45.1% (95% CI =40.7, 49.5), and at follow-up it was 42.3% (95% CI =37.5, 47.2). Interpersonal psychotherapy (IPT) produced the highest abstinence rates. Clinician-led group treatments produced significantly higher posttreatment (but not follow-up) abstinence estimates than guided self-help treatments. Neither timeframe for achieving abstinence, assessment type (interview/questionnaire), number of treatment sessions, patient demographics, nor trial quality, moderated the abstinence estimates.

DISCUSSION

The present findings demonstrate that 50% of patients with BED do not fully respond to treatment. Continued efforts toward improving eating disorder treatments are needed.

Attachment and therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

We examine associations between client attachment style and therapeutic alliance in a 3-arm randomized controlled trial of brief motivational interviewing and cognitive-behavioural therapy compared with longer term motivational interviewing and cognitive-behavioural therapy or standard care alone. Client self-report measures of attachment style were completed at baseline, and both clients and therapists in the treatment arms of the trial completed alliance measures 1 month into therapy. We found that insecure-anxious attachment was positively associated with therapist-rated alliance, whereas clients with insecure-avoidant attachment were more likely to report poorer bond with therapist. There was no evidence that client attachment significantly predicted clinical or substance misuse outcomes either directly or indirectly via alliance. Nor evidence that the length of therapy offered interacted with attachment to predict alliance.

Reliability and validity of the Experiences in Close Relationships Scale-12: Attachment dimensions in a clinical sample with eating disorders

OBJECTIVE

Attachment insecurity is a potential risk factor for the development and maintenance of eating disorders (EDs). To date, there are multiple psychometrically sound questionnaires for the evaluation of attachment in both clinical and healthy populations, such as the Experience in Close Relationships (ECR) scale. Composed by two subscales (i.e., attachment anxiety and avoidance), the ECR scale was recently adapted to a shorter, 12-item version (ECR-12). However, a validation of the ECR-12 among patients with EDs is still lacking. The present study sought to investigate the psychometric properties of the ECR-12, when used in a treatment-seeking sample with EDs.

METHOD

A total of 1,262 treatment-seeking patients with various ED diagnoses completed the ECR-12, together with a commonly used measure of ED psychopathology (Eating Disorder Inventory-2). Subsamples also completed the Attachment Style Questionnaire (n = 66) or underwent a Day Hospital Program (n = 128).

RESULTS

A multigroup confirmatory factor analysis indicated that the ECR-12 maintained its two-factor structure across the ED diagnostic groups. In addition, the scale demonstrated good convergent validity, internal consistency, concurrent, and incremental validity. Finally, both ECR-12 subscales demonstrated adequate test-retest reliability.

DISCUSSION

Our results provide preliminary evidence of the psychometric properties of ECR-12 in assessing attachment anxiety and avoidance among patients with EDs. This short scale could help clinicians tailor interventions for EDs that take into account attachment dimensions.

Group psychotherapy for eating disorders: A meta-analysis

OBJECTIVE

In the current meta-analysis, we review the effect of group psychotherapy compared to both wait-list controls and other active treatments for adults with eating disorders (EDs).

METHOD

Twenty-seven randomized controlled trials (RCTs) that provide direct comparisons with a total of 1,853 participants were included.

RESULTS

Group psychotherapy is significantly more effective than wait-list controls at achieving abstinence rates of binge eating and/or purging (RR = 5.51, 95% CI: 3.73, 8.12), decreasing the frequency of binge eating and/or purging (g = 0.70, 95% CI: 0.51, 0.90), and reducing related ED psychopathology (g = 0.49, 95% CI: 0.32, 0.66) after treatment. The effects of group psychotherapy and other active treatments (e.g., behavioral weight loss, self-help, individual psychotherapy) did not differ on any outcome at post-treatment or at follow-ups. Group cognitive behavioral therapy (CBT) and other forms of group psychotherapy did not differ significantly on outcomes at any time point.

DISCUSSION

Additional research is needed to evaluate other group psychotherapy approaches, along with CBT, to provide more evidence-based treatment options for individuals with an ED. Group psychotherapy appears as effective as other common treatments and is perhaps more cost-effective than the most popular treatment, individual psychotherapy. Only 8.33% of comparisons in the current meta-analysis had at least 80% power to detect a moderate effect (d = .50) and we recommend that future RCTs be adequately powered.

Change in attachment states of mind of women with binge-eating disorder

Insecure and unresolved/disorganized attachment states of mind may impact affect regulation and interpersonal functioning that contribute to binge eating in women with binge-eating disorder (BED). Group psychological treatment may facilitate changes from insecure to secure and from unresolved-disorganized to non-unresolved/disorganized attachment states of mind. This study used attachment theory to understand better the psychopathology of BED and co-morbid overweight status and to understand better the treatment response of patients with BED who receive group psychotherapy. Women with BED attended group psychodynamic interpersonal psychotherapy and completed the Adult Attachment Interview pretreatment and 6 months posttreatment. Matched samples of overweight women without BED and normal-weight women without BED completed the Adult Attachment Interview at 1 time point. Women with BED had significantly higher rates of preoccupied and unresolved/disorganized attachment states of mind compared to normal-weight women without BED and had similar rates of insecure and unresolved/disorganized attachment states of mind compared to overweight women without BED. Of the women with BED who had an insecure and/or unresolved/disorganized attachment states of mind at pretreatment, about 60% demonstrated clinically relevant changes to secure and to non-unresolved/disorganized states of mind at 6 months post group psychodynamic interpersonal psychotherapy. Results indicated that some women with BED may benefit from interventions that help them regulate hyperactivated affect and create coherent narratives. Both women with BED and overweight women without BED may benefit from treatments that help them develop more adaptive affect regulation strategies related to unresolved/disorganized attachment states of mind.

Secure Attachment Moderates the Relation of Sexual Trauma With Trauma Symptoms Among Adolescents From an Inpatient Psychiatric Facility

Experiencing sexual trauma has been linked to internalizing and externalizing psychopathologies. Insecure attachment has been shown to moderate the relation between sexual trauma and trauma symptoms among adults. However, few studies have explored relations among sexual trauma, attachment insecurity, and trauma symptoms in adolescence, and none have used developmentally appropriate measures. The present study sought to examine attachment security as a potential moderator of the relation between having a history of sexual trauma (HST) and trauma symptoms among adolescents at an inpatient psychiatric facility. Attachment to caregivers was measured by the Child Attachment Interview (CAI) and trauma symptoms by the Trauma Symptoms Checklist for Children (TSCC). HST was assessed with responses to two separate interviews that asked about traumatic experiences: the Computerized Diagnostic Interview Schedule for Children (C-DISC) and the CAI. Moderation analyses were conducted using univariate General Linear Modeling (GLM). Of the 229 study participants, 50 (21.8%) had a HST. The relation between HST and trauma symptoms was significantly moderated by insecure attachment with both mother, F(1, 228) = 4.818, p = .029, and father, F(1, 228) = 6.370, p = .012. Specifically, insecurely attached adolescents with a HST exhibited trauma symptoms at levels significantly greater than securely attached adolescents with a HST and adolescents with no HST. Results are consistent with previous research that suggests secure attachment may protect against the development of trauma symptoms among those who have experienced a sexual trauma.

The role of coherence of mind and reflective functioning in understanding binge-eating disorder and co-morbid overweight

Coherence of mind and reflective functioning may impact negative affect and interpersonal functioning over and above the effects of symptoms of depression and interpersonal problems that contribute to symptoms of binge-eating disorder (BED) and overweight/obesity. Matched samples of overweight women with BED and overweight and normal weight women without BED completed the Adult Attachment Interview, a measure of depressive symptoms, and a measure of interpersonal problems. Greater symptoms of depression distinguished women with BED from the matched comparison samples. Greater interpersonal problems differentiated women with BED from overweight women without BED. Coherence of Mind scores did not differentiate the samples. However, lower Reflective Functioning scores did distinguish both women with BED and overweight women without BED from normal weight women. Lower reflective functioning may lead to binge eating independent of depressive symptoms and interpersonal problems.

Feeling Worse Before Feeling Better: A Case of Increased Disorganized Mental States Following Group Psychotherapy

Is group therapy effective if it results in members revealing greater unresolved/disorganized mental states related to childhood trauma? That is, do patients have to more fully experience partially disavowed trauma before they get better? We found a small proportion of patients whose pre-treatment Adult Attachment Interview (AAI) transcripts were not coded as Unresolved/Disorganized at the start of group treatment, but were coded as such at the end. In one case report, we examined pre- and six months post-AAI transcripts and group therapy interactions to document the emergence of an unresolved/disorganized mental state. Despite the increase in disorganization, the patient showed some symptom improvement and improved reflective functioning. The 16-week psychodynamic group therapy allowed the patient to reflect on her traumatic experiences and their impact on her life. However, this also resulted in a disorganizing effect on her mental state. Longer-term therapy may be necessary to improve interpersonal functioning and affect regulation in patients who experienced early trauma.

A comprehensive review of psychodynamic treatments for eating disorders

PURPOSE

To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic.

METHODS

Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RESULTS

A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available.

CONCLUSIONS

The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

Does the interpersonal model apply across eating disorder diagnostic groups? A structural equation modeling approach

BACKGROUND

Interpersonal model has been validated with binge-eating disorder (BED), but it is not yet known if the model applies across a range of eating disorders (ED).

PURPOSE

The goal of this study was to investigate the validity of the interpersonal model in anorexia nervosa (restricting type; ANR and binge-eating/purge type; ANBP), bulimia nervosa (BN), BED, and eating disorder not otherwise specified (EDNOS).

PROCEDURE

Data from a cross-sectional sample of 1459 treatment-seeking women diagnosed with ANR, ANBP, BN, BED and EDNOS were examined for indirect effects of interpersonal problems on ED psychopathology mediated through negative affect.

RESULTS

Findings from structural equation modeling demonstrated the mediating role of negative affect in four of the five diagnostic groups. There were significant, medium to large (.239, .558), indirect effects in the ANR, BN, BED and EDNOS groups but not in the ANBP group. The results of the first reverse model of interpersonal problems as a mediator between negative affect and ED psychopathology were nonsignificant, suggesting the specificity of these hypothesized paths. However, in the second reverse model ED psychopathology was related to interpersonal problems indirectly through negative affect.

CONCLUSION

This is the first study to find support for the interpersonal model of ED in a clinical sample of women with diverse ED diagnoses, though there may be a reciprocal relationship between ED psychopathology and relationship problems through negative affect. Negative affect partially explains the relationship between interpersonal problems and ED psychopathology in women diagnosed with ANR, BN, BED and EDNOS. Interpersonal psychotherapies for ED may be addressing the underlying interpersonal-affective difficulties, thereby reducing ED psychopathology.

The empirical status of psychodynamic psychotherapy - an update: Bambi's alive and kicking

BACKGROUND

The Task Force on Promotion and Dissemination of Psychological Procedures proposed rigorous criteria to define empirically supported psychotherapies. According to these criteria, 2 randomized controlled trials (RCTs) showing efficacy are required for a treatment to be designated as 'efficacious' and 1 RCT for a designation as 'possibly efficacious'. Applying these criteria modified by Chambless and Hollon, this article presents an update on the evidence for psychodynamic therapy (PDT) in specific mental disorders.

METHODS

A systematic search was performed using the criteria by Chambless and Hollon for study selection, as follows: (1) RCT of PDT in adults, (2) use of reliable and valid measures for diagnosis and outcome, (3) use of treatment manuals or manual-like guidelines, (4) adult population treated for specific problems and (5) PDT superior to no treatment, placebo or alternative treatment or equivalent to an established treatment.

RESULTS

A total of 39 RCTs were included. Following Chambless and Hollon, PDT can presently be designated as efficacious in major depressive disorder (MDD), social anxiety disorder, borderline and heterogeneous personality disorders, somatoform pain disorder, and anorexia nervosa. For MDD, this also applies to the combination with pharmacotherapy. PDT can be considered as possibly efficacious in dysthymia, complicated grief, panic disorder, generalized anxiety disorder, and substance abuse/dependence. Evidence is lacking for obsessive-compulsive, posttraumatic stress, bipolar and schizophrenia spectrum disorder(s).

CONCLUSIONS

Evidence has emerged that PDT is efficacious or possibly efficacious in a wide range of common mental disorders. Further research is required for those disorders for which sufficient evidence does not yet exist.

Short-term intensive psychodynamic group therapy versus cognitive-behavioral group therapy in day treatment of anxiety disorders and comorbid depressive or personality disorders: study protocol for a randomized controlled trial

BACKGROUND

Psychodynamic and cognitive-behavioral group therapies are frequently applied in day hospitals for the treatment of anxiety disorders and comorbid depressive or personality disorders in Poland and other Eastern European countries. Yet there is not enough evidence as to their effectiveness in this environment; this study addresses this gap. The aim of the study is to determine the effectiveness of these two kinds of day treatment care consisting of intensive, short-term group psychodynamic and cognitive-behavioral therapy, for patients with anxiety disorders and/or comorbid depressive or personality disorders. Our objectives are to: 1) show the effectiveness of each treatment in a day-care setting relative to the wait-list control group; 2) demonstrate the relative short- and long-term effectiveness of the two active treatments; 3) carry out a preliminary examination of the predictors and moderators of treatment response; 4) carry out a preliminary examination of the mediators of therapeutic change; and 5) compare the impact of both methods of treatment on the outcome of the measures used in this study.

METHODS/DESIGN

In this randomized controlled trial, a total of 199 patients with anxiety disorders and comorbid depressive and/or personality disorders will be assigned to one of three conditions: 1) psychodynamic group therapy; 2) cognitive-behavioral group therapy; or 3) wait-list control group. The therapy will last 12 weeks. Both treatments will be manualized (the manuals will address comorbidity). Primary outcome measures will include self-reported symptoms of anxiety, observer-rated symptoms of anxiety, global improvement, and recovery rate. Secondary outcome measures will include the number of pathological personality traits, depression, self-esteem, defense mechanisms, beliefs about self and others, interpersonal problems, object relations, parental bonding, meta-cognition, and quality of life. Measures will be taken at baseline, post-treatment, and at six months following the end of therapy.

DISCUSSION

The rationale is to investigate how effectively anxiety disorders and/or comorbid depressive or personality disorders can be treated in a day hospital setting, typical of the Polish health care system, during a three-month treatment period.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02126787 , registered on 28 April 2014.

QUINT: A tool to detect qualitative treatment-subgroup interactions in randomized controlled trials

OBJECTIVE

The detection of subgroups involved in qualitative treatment-subgroup interactions (i.e., for one subgroup of clients treatment A outperforms treatment B, whereas for another the reverse holds true) is crucial for personalized health. In typical Randomized Controlled Trials (RCTs), the combination of a lack of a priori hypotheses and a large number of possible moderators leaves current methods insufficient to detect subgroups involved in such interactions. A recently developed method, QUalitative INteraction Trees (QUINT), offers a solution. However, the paper in which QUINT has been introduced is not easily accessible for non-methodologists. In this paper, we want to review the conceptual basis of QUINT in a nontechnical way, and illustrate its relevance for psychological applications.

METHOD

We present a concise introduction into QUINT along with a summary of available evidence on its performance. Subsequently, we subject RCT data on the effect of motivational interviewing in a treatment for substance abuse disorders to a reanalysis with QUINT. As outcome variables, we focus on measures of retention and substance use.

RESULTS

A qualitative treatment-subgroup interaction is found for retention. By contrast, no qualitative interaction is detected for substance use.

CONCLUSIONS

QUINT may lead to insightful and well-interpretable results with straightforward implications for personalized treatment assignment.

Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria

Psychodynamic therapy (PDT) is an umbrella concept for treatments that operate on an interpretive-supportive continuum and is frequently used in clinical practice. The use of any form of psychotherapy should be supported by sufficient evidence. Efficacy research has been neglected in PDT for a long time. In this review, we describe methodological requirements for proofs of efficacy and summarise the evidence for use of PDT to treat mental health disorders. After specifying the requirements for superiority, non-inferiority, and equivalence trials, we did a systematic search using the following criteria: randomised controlled trial of PDT; use of treatment manuals or manual-like guidelines; use of reliable and valid measures for diagnosis and outcome; adults treated for specific mental problems. We identified 64 randomised controlled trials that provide evidence for the efficacy of PDT in common mental health disorders. Studies sufficiently powered to test for equivalence to established treatments did not find substantial differences in efficacy. These results were corroborated by several meta-analyses that suggest PDT is as efficacious as treatments established in efficacy. More randomised controlled trials are needed for some mental health disorders such as obsessive-compulsive disorder and post-traumatic stress disorder. Furthermore, more adequately powered equivalence trials are needed.

The effectiveness of psychodynamic psychotherapies: An update

This paper provides a comprehensive review of outcome studies and meta-analyses of effectiveness studies of psychodynamic therapy (PDT) for the major categories of mental disorders. Comparisons with inactive controls (waitlist, treatment as usual and placebo) generally but by no means invariably show PDT to be effective for depression, some anxiety disorders, eating disorders and somatic disorders. There is little evidence to support its implementation for post-traumatic stress disorder, obsessive-compulsive disorder, bulimia nervosa, cocaine dependence or psychosis. The strongest current evidence base supports relatively long-term psychodynamic treatment of some personality disorders, particularly borderline personality disorder. Comparisons with active treatments rarely identify PDT as superior to control interventions and studies are generally not appropriately designed to provide tests of statistical equivalence. Studies that demonstrate inferiority of PDT to alternatives exist, but are small in number and often questionable in design. Reviews of the field appear to be subject to allegiance effects. The present review recommends abandoning the inherently conservative strategy of comparing heterogeneous "families" of therapies for heterogeneous diagnostic groups. Instead, it advocates using the opportunities provided by bioscience and computational psychiatry to creatively explore and assess the value of protocol-directed combinations of specific treatment components to address the key problems of individual patients.