Emotion Regulation and Social Cognition as Functional Targets of Mechanism-Based Psychotherapy in Major Depression With Comorbid Personality Pathology

Algorithm-based modular psychotherapy vs. cognitive-behavioral therapy for patients with depression, psychiatric comorbidities and early trauma: a proof-of-concept randomized controlled trial

Effect sizes of psychotherapies currently stagnate at a low-to-moderate level. Personalizing psychotherapy by algorithm-based modular procedures promises improved outcomes, greater flexibility, and a better fit between research and practice. However, evidence for the feasibility and efficacy of modular-based psychotherapy, using a personalized treatment algorithm, is lacking. This proof-of-concept randomized controlled trial was conducted in 70 adult outpatients with a primary DSM-5 diagnosis of major depressive disorder, a score higher than 18 on the 24-item Hamilton Rating Scale for Depression (HRSD-24), at least one comorbid psychiatric diagnosis according to the Structured Clinical Interview for DSM-5 (SCID-5), a history of at least "moderate to severe" childhood maltreatment on at least one domain of the Childhood Trauma Questionnaire (CTQ), and exceeding the cut-off value on at least one of three measures of early trauma-related transdiagnostic mechanisms: the Rejection Sensitivity Questionnaire (RSQ), the Interpersonal Reactivity Index (IRI), and the Difficulties in Emotion Regulation Scale-16 (DERS-16). Patients were randomized to 20 sessions of either standard cognitive-behavioral therapy alone (CBT) or CBT plus transdiagnostic modules according to a mechanism-based treatment algorithm (MoBa), over 16 weeks. We aimed to assess the feasibility of MoBa, and to compare MoBa vs. CBT with respect to participants' and therapists' overall satisfaction and ratings of therapeutic alliance (using the Working Alliance Inventory - Short Revised, WAI-SR), efficacy, impact on early trauma-related transdiagnostic mechanisms, and safety. The primary outcome for efficacy was the HRSD-24 score at post-treatment. Secondary outcomes included, among others, the rate of response (defined as a reduction of the HRSD-24 score by at least 50% from baseline and a score <16 at post-treatment), the rate of remission (defined as a HRSD-24 score ≤8 at post-treatment), and improvements in early trauma-related mechanisms of social threat response, hyperarousal, and social processes/empathy. We found no difficulties in the selection of the transdiagnostic modules in the individual patients, applying the above-mentioned cut-offs, and in the implementation of MoBa. Both participants and therapists reported higher overall satisfaction and had higher WAI-SR ratings with MoBa than CBT. Both approaches led to major reductions of depressive symptoms at post-treatment, with a non-significant superiority of MoBa over CBT. Patients randomized to MoBa were nearly three times as likely to experience remission at the end of therapy (29.4% vs. 11.4%; odds ratio, OR = 3.2, 95% CI: 0.9-11.6). Among mechanism-based outcomes, MoBa patients showed a significantly higher post-treatment effect on social processes/empathy (p<0.05) compared to CBT patients, who presented an exacerbation on this domain at post-treatment. Substantially less adverse events were reported for MoBa compared to CBT. These results suggest the feasibility and acceptability of an algorithm-based modular psychotherapy complementing CBT in depressed patients with psychiatric comorbidities and early trauma. While initial evidence of efficacy was observed, potential clinical advantages and interindividual heterogeneity in treatment outcomes will have to be investigated in fully powered confirmation trials.

What Are the Neural Correlates of Impaired Awareness of Social Cognition and Function in Dementia? A Systematic Review

Deficits in social cognition and function are characteristic of dementia, commonly accompanied by a loss of awareness of the presence or extent of these deficits. This lack of awareness can impair social relationships, increase patients' and carers' burden, and contribute to increased rates of institutionalization. Despite clinical importance, neural correlates of this complex phenomenon remain unclear. We conducted a systematic search of five electronic databases to identify functional and structural neuroimaging studies investigating the neural correlates of impaired awareness of social cognition and function in any dementia type. We rated study quality and conducted a narrative synthesis of the results of the eight studies that met the predefined eligibility criteria. Across these studies, deficits in awareness of impairments in social cognition and function were associated with structural or functional abnormalities in the frontal pole, orbitofrontal cortex, temporal pole, middle temporal gyrus, inferior temporal gyrus, fusiform gyrus, amygdala, hippocampus, parahippocampal gyrus, and insula. Several identified regions overlap with established neural correlates of social cognition. More research is needed to understand awareness of social cognition and function and how this becomes impaired in dementia to improve neuroscientific understanding, aid the identification of this problematic symptom, and target interventions to reduce burden and improve care.

Impaired empathic functioning in chronic depression: Behavioral evidence for the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) model

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) model proposes preoperational functioning as a core feature of persistent depressive disorders (PDD). Empathy deficits comprise one aspect. Resulting from childhood maltreatment, empathy deficits may aggravate social isolation, a key factor in the maintenance of depression. CBASP targets empathy by teaching patients to disengage from past experiences and to engage successfully in present social interactions. However, behavioral evidence for empathy deficits in PDD has remained elusive. We reasoned that deficits become apparent only under stress and that these deficits improve after CBASP-treatment. Twenty-two patients and 21 controls performed two parallel versions of the Multifaceted Empathy Test. For stress induction, a negative autobiographical event was presented before performing the task. A neutral event served as control. Fifteen patients performed the experiment twice, before and after a 12-week inpatient CBASP-treatment. Supporting our hypotheses, patients showed reduced empathy under stress, while no group difference was found in the absence of stress. Reduced empathy correlated with the level of re-experiencing negative memories. Pre-post-treatment comparison revealed that the stress-induced empathy deficit improved in patients over time. Post-treatment empathic capacity correlated positively with clinical improvement. Our findings provide empirical support for the CBASP model, but highlight an important new aspect: Empathy is not generally deficient in PDD but becomes impaired under stress. In real-life situations, stress-induced empathy impairments may exacerbate interpersonal conflicts. CBASP's interpersonal focus improved empathy, accompanied by clinical improvement as the model predicts.

Modular-based psychotherapy (MoBa) versus cognitive-behavioural therapy (CBT) for patients with depression, comorbidities and a history of childhood maltreatment: study protocol for a randomised controlled feasibility trial

INTRODUCTION

In depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms, and a high rate of comorbid disorders. Personalised treatments targeting comorbidities as well as underlying transdiagnostic mechanisms and factors like early childhood maltreatment may lead to better outcomes. A modular-based psychotherapy (MoBa) approach provides a treatment model of independent and flexible therapy elements within a systematic treatment algorithm to combine and integrate existing evidence-based approaches. By optimally tailoring module selection and application to the specific needs of each patient, MoBa has great potential to improve the currently unsatisfying results of psychotherapy as a bridge between disorder-specific and personalised approaches.

METHODS AND ANALYSIS

In a randomised controlled feasibility trial, N=70 outpatients with episodic or persistent major depression, comorbidity and childhood maltreatment are treated in 20 individual sessions with MoBa or standard cognitive-behavioural therapy for depression. The three modules of MoBa focus on deficits associated with early childhood maltreatment: the systems of negative valence, social processes and arousal. According to a specific questionnaire-based treatment algorithm, elements from cognitive behavioural analysis system of psychotherapy, mentalisation-based psychotherapy and/or mindfulness-based cognitive therapy are integrated for a personalised modular procedure.As a proof of concept, this trial will provide evidence for the feasibility and efficacy (post-treatment and 6-month follow-up) of a modular add-on approach for patients with depression, comorbidities and a history of childhood maltreatment. Crucial feasibility aspects include targeted psychopathological mechanisms, selection (treatment algorithm), sequence and application of modules, as well as training and supervision of the study therapists.

ETHICS AND DISSEMINATION

This study obtained approval from the independent Ethics Committees of the University of Freiburg and the University of Heidelberg. All findings will be disseminated broadly via peer-reviewed articles in scientific journals and contributions to national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00022093.

Towards a mechanistic understanding of mindfulness-based stress reduction (MBSR) using an RCT neuroimaging approach: Effects on regulating own stress in social and non-social situations

Although much research has shown that mindfulness-based interventions (MBIs) can reduce psychological stress, it is less clear if effects generalize to everyday social situations, which range among the largest stress triggers. Furthermore, mechanisms of MBIs have not been fully established. Emotion regulation (ER) has been suggested as one key mechanism, yet the role of cognitive reappraisal and acceptance strategies is still under debate. To address these questions, a neuroimaging-based randomized controlled trial (RCT) was performed (n=68), comparing mindfulness-based stress reduction (MBSR) with a reading/listening intervention (READ), using a novel dyadic paradigm for self and other emotion regulation under stress as primary outcome on behavior and brain levels and established empathy measures (clinicatrials.gov NCT03035669). Compared to READ, MBSR led to self-reported stress reduction through both cognitive reappraisal and acceptance only when regulating self and not when regulating others' distress. In addition, MBSR led to increased brain activation over time for regulating own (parietal cortex) and others' (precuneus, TPJ) emotions through cognitive reappraisal and acceptance, albeit this effect was also seen for the reading intervention for regulating own stress via reappraisal. Brain changes did not scale with subjective stress reduction and amount of meditation practice. More distant generalization effects of MBSR on socio-emotional functioning (cognitive empathy and compassion) could also not be shown. This study identified both cognitive reappraisal and acceptance as two ER mechanisms of MBSR, but indicates that effects do not extend to social settings.

Lessening of the pervasiveness of interpersonal patterns in borderline personality disorder explains symptom decrease after treatment: A process analysis

Background

Problematic interpersonal patterns, as defined by the core conflictual relationship theme (CCRT) method, are part of the clinical presentation of clients with borderline personality disorder (BPD). So far, we do not know whether the pervasiveness of interpersonal patterns changes and if this change explains therapy outcome.

Methods

In a secondary analysis of a randomized controlled trial on a brief version of psychiatric treatment for BPD, a treatment with a psychodynamic focus, the present study included N = 39 clients. One early session and one late session of the treatment were transcribed and analyzed using the CCRT method.

Results

It appeared that pervasiveness of the predominant CCRT decreased over the course of the brief treatment; this effect was robust across treatment conditions. Change in pervasiveness in any CCRT component explained a small portion of variance of the decrease in borderline symptoms observed at the end of treatment.

Discussion

Lessening of pervasiveness of problematic in‐session interpersonal patterns may be hypothesized as potential mechanism of effective treatment for BPD which should be tested in controlled designs.

A Longitudinal Analysis of Social Skills and Adolescent Depression: A Multivariate Latent Growth Approach

Ample research has shown that the link between social skills and adolescent depression is significant. However, how the changes in different domains of social skills influence the change in depression from early to middle adolescence remains largely unknown. To address this gap in knowledge, the current research used longitudinal data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (N = 1061) to examine the influences of the changes in cooperation, assertion, responsibility, and self-control on the change in depression from early to middle adolescence. Univariate latent growth modeling showed that, from early to middle adolescence, adolescents experience decreases in cooperation and assertion, increases in responsibility and depression, and stability in self-control. Multivariate latent growth modeling suggested that adolescents who had more increases in responsibility and self-control tended to experience a slower increase in depression from early to middle adolescence; while adolescents who had more decreases in cooperation and assertion tended to experience a faster increase in depression from early to middle adolescence. The results suggested that promoting adolescents social skills might be particularly salient for the prevention of adolescent depression.

How Personality Disorders Change in Psychotherapy: a Concise Review of Process

PURPOSE OF REVIEW

The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective.

RECENT FINDINGS

The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.

Childhood adversity and depressive symptoms among young adults: Examining the roles of individuation difficulties and perceived social support

AIM

While childhood adversity is a known risk for depressive symptoms, little is known about the contributing role of individuation difficulties among young adults. The present study examined individuation difficulties and perceived social support-and their interaction-as moderators of the relationship between childhood adversity exposure and depressive symptoms.

METHODS

Young adults (N = 119; M = 20.8 years) completed self-report assessments of childhood adversity, depressive symptoms, individuation difficulties, and perceived social support. Regression analyses were used to examine interaction effects regarding depressive symptom severity.

RESULTS

A significant moderated moderation effect was found whereby individuation difficulties interacted with adversity exposure as perceived social support was reduced. Thus, at high levels of individuation difficulties, young adults with exposure to childhood adversity reported elevated depressive symptoms. This effect was buffered by social support such that when individuation difficulties were high, the association between adversity and depressive symptoms decreased from low to moderate and high support.

CONCLUSION

Individuation difficulties and social support are important factors in the development of depressive symptoms from exposure to childhood adversity among young adults.

[Impact of early life maltreatment of women on the mother-child relationship : Data from mother-child dyads from Heidelberg and Berlin]

Early life maltreatment can have severe and long-lasting consequences for the directly affected individual as well as for the next generation. Data from our research including mother-child dyads from Heidelberg and Berlin show that early life maltreatment is associated with behavioral and neural changes including personality traits and attachment style of the affected mothers that negatively affect their relationship with their child. The children of these mothers affected by early life maltreatment have an elevated risk to be maltreated and to develop mental disorders. They also show a heightened cortisol concentration and a reduced inhibition control. It seems to be of importance whether the mother has experienced early life maltreatment but is resilient, meaning that she has not developed a mental disorder (up to the time of examination) or whether in addition to the early life maltreatment she has developed a mental disorder later in life. Children of mothers with early life maltreatment and a lifetime mental disorder seem to be especially exposed to stress and show the greatest impairments and risks. Based on the existing data from our research practical and clinical implications are discussed and one possible intervention in the form of a training of mentalization competencies for parents is presented.

Developing an assessment of epistemic trust: a research protocol

Epistemic trust (ET) describes the willingness to accept new information from another person as trustworthy, generalizable, and relevant. It has been recently proposed that a pervasive failure to establish epistemic trust may underpin personality disorders. Although the introduction of the concept of ET has been inspiring to clinicians and is already impacting the field, the idea that there may be individual differences in ET has yet to be operationalized and tested empirically. This report illustrates the development of an Epistemic trust assessment and describes the protocol for its validation. The sample will include 60 university students. The Trier Social Stress Test for Groups will be administered to induce a state of uncertainty and stress, thereby increasing the relevance of information for the participants. The experiment will entail asking information from the participants about their performance and internal states during a simulated employment interview, and then tracking how participants are able to revise their own judgments about themselves in light of the feedback coming from an expert committee. To control for social desirability and personality disorder traits, the short scale for social desirability (Kurzskala Soziale Erwunschtheit-Gamma) and the Inventory of Personality Organization are utilized. After the procedure, the participants will complete an app-based Epistemic trust questionnaire (ETQ) app. Confirmatory Factor Analysis will be utilized to investigate the structure and dimensionality of the ETQ, and ANOVAs will be used to investigate mean differences within and between persons for ET scores by item category. This study operationalizes a newly developed ET paradigm and provides a framework for the investigation of the theoretical assumptions about the connection of ET and personality functioning.

Mechanisms of Change in Treatments of Personality Disorders: Introduction to the Special Section

The present introduction to the Special Section on Mechanisms of Change in Treatments of Personality Disorders explains the value of research focusing on processes of change in psychotherapy by referring to a variety of methodologies. Whereas outcome for these treatments has been repeatedly demonstrated, it remains an open question what the core psychobiological features of change are. Taking a radically empirical perspective, this introduction focuses on patient and therapeutic relationship variables, such as emotional and socio-cognitive processing. The six empirical articles of the Special Section are introduced, as are the three discussions of the Special Section.

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section

Considerable progress has been made in the psychotherapeutic treatment of patients with personality disorders (PDs). Once engendering a pervasive therapeutic nihilism, PDs are starting to be viewed as treatable with a much better prognosis than previously thought. Evidence from several randomized controlled trials demonstrating the effectiveness of various forms of psychotherapy, coupled with findings from several longitudinal studies, suggests that such increased clinical optimism is warranted. However, the persistent focus on treatment brands obscures our understanding of the mechanisms through which benefits are actually realized. This article considers emerging trends in PD treatment research, exemplified by the series of articles contained within this special section, that attempt to identify more precisely the mechanisms of therapeutic change. It is only through such work that we will be able to accomplish further refinement of effective strategies, create possibilities for true integration of therapies, and achieve real progress in the field for the betterment of our patients.

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section

Ueli Kramer has assembled an eclectic and original set of articles on mechanisms of change in the treatment of borderline personality disorder. They largely focus on patient variables. Several authors make the point that developmentally based variables may have more predictive power than symptom-based variables. Several other articles illustrate that changes occur early in treatments and studying their mechanisms is a promising approach that could have longer term significance. These articles document the variety of research methodologies that can be used to study mechanisms of change and the potential clinical significance of doing this. For showing the field the potential of such research, we owe Dr. Kramer our gratitude.

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section

Personality disorders (PDs) come in a large variety of presentations, severely affect the individual's social and emotional functioning, and are notoriously complex to treat. To make treatments for individuals with PDs more potent, there is a need to better understand how and why these treatments work. The articles assembled for this special section propose potential mechanisms of change within PD patients that may be addressed in future process-outcome research. Although the studies are exploratory and were limited by their scope and heterogeneity of their samples, they illustrate the importance of process research as nomothetic and idiographic building blocks toward a multifaceted understanding of change processes in PDs and their treatment. In this discussion, the authors aim to foster interest in the potential mechanisms of change in PD treatments and inspire further research by providing several methodological considerations for future process-outcome research and its potential clinical implications.

Neurobiological Mechanisms Mediating Emotion Dysregulation as Targets of Change in Borderline Personality Disorder

Emotion dysregulation is a hallmark of borderline personality disorder (BPD). Most interventions for patients with BPD, therefore, aim at the improvement of emotion regulation. In the current paper, we provide an overview of studies investigating the effects of psychotherapeutic or pharmacological interventions on neurobiological correlates of various aspects of emotion regulation. In fact, studies suggest that the prefrontal-limbic circuit may play a major role in mediating effects of clinically efficacious psychotherapeutic treatments, i.e., they lead to clinical improvement via modulating the function and structure of the amygdala, the insula, and the dorsal anterior cingulate cortex, as well as prefrontal areas involved in the cognitive regulation of emotions, and enhancing the coupling of limbic and prefrontal areas. Oxytocin as a promising pharmacological approach to emotion dysregulation in BPD was shown to dampen amygdala activity in response to emotional stimuli. Understanding the brain mechanisms that mediate treatment effects will harness further development of targeted mechanism-based interventions for patients with BPD.