Sudden gains in routine clinical care: application of a permutation test for trauma-focused cognitive behavioural therapy

Background: Sudden gains, defined as large and stable improvements of psychopathological symptoms, are a ubiquitous phenomenon in psychotherapy. They have been shown to occur across several clinical contexts and to be associated with better short-term and long-term treatment outcome. However, the approach of sudden gains has been criticized for its tautological character: sudden gains are included in the computation of treatment outcomes, ultimately resulting in a circular conclusion. Furthermore, some authors criticize sudden gains as merely being random fluctuations.Objective: Use of efficient methods to evaluate whether the amount of sudden gains in a given sample lies above chance level.Method: We used permutation tests in a sample of 85 patients with posttraumatic stress disorder (PTSD) treated with trauma-focused cognitive behaviour therapy in routine clinical care. Scores of self-reported PTSD symptom severity were permuted 10.000 times within sessions and between participants to receive a random distribution.Results: Altogether, 18 participants showed a total of 24 sudden gains within the first 20 sessions. The permutation test yielded that the frequency of sudden gains was not beyond chance level. No significant predictors of sudden gains were identified and sudden gains in general were not predictive of treatment outcome. However, subjects with early sudden gains had a significantly lower symptom severity after treatment.Conclusions: Our data suggest that a significant proportion of sudden gains are due to chance. Further research is needed on the differential effects of early and late sudden gains.

Prevalence of suicidal ideation in German psychotherapy outpatients: A large multicenter assessment

BACKGROUND

Suicidal ideation is a major concern in clinical practice. Yet, little is known about prevalence rates of suicidal ideation in patients undergoing outpatient psychotherapeutic treatment. Therefore, the aim of the current study is to assess the prevalence of suicidal ideation in a large sample of psychotherapy outpatients in Germany. The data analyzed in this study is taken from the KODAP-project on the coordination of data collection and analysis at German university-based research and training outpatient clinics for psychotherapy.

METHODS

A total of N = 10,357 adult outpatients (64.4 % female; age: M(SD) = 35.94 (13.54), range: 18-92 years of age) starting cognitive-behavioral therapy at one of 27 outpatient clinics in Germany were included in the current study. Prevalence of suicidal ideation was assessed with the Suicide Item (Item 9) of the Beck-Depression Inventory II.

RESULTS

Suicidal ideation was reported by 36.7 % (n = 3795) of the participants. Borderline Personality Disorder, Posttraumatic Stress Disorder, and recurrent Major Depression were the diagnoses most strongly associated with the presence and severity of suicidal ideation.

LIMITATION

Suicide ideation was assessed only with the respective item of the Beck Depression Inventory II.

CONCLUSION

Suicidal ideation is very common among adult patients who start psychotherapy in Germany. A well-founded knowledge of risk assessment in suicidal patients and suicide-specific treatment options is therefore highly relevant.

Alcohol does not influence trust in others or oxytocin, but increases positive affect and risk-taking: a randomized, controlled, within-subject trial

BACKGROUND

Alcohol consumption to facilitate social interaction is an important drinking motive. Here, we tested whether alcohol influences trust in others via modulation of oxytocin and/or androgens. We also aimed at confirming previously shown alcohol effects on positive affect and risk-taking, because of their role in facilitating social interaction.

METHODS

This randomized, controlled, within-subject, parallel group, alcohol-challenge experiment investigated the effects of alcohol (versus water, both mixed with orange juice) on perceived trustworthiness via salivary oxytocin (primary and secondary endpoint) as well as testosterone, dihydrotestosterone, positive affect, and risk-taking (additional endpoints). We compared 56 male participants in the alcohol condition (1.07 ± 0.18 per mille blood alcohol concentration) with 20 in the control condition.

RESULTS

The group (alcohol versus control condition) × time (before [versus during] versus after drinking) interactions were not significantly associated with perceived trustworthiness (η2 < 0.001) or oxytocin (η2 = 0.003). Bayes factors provided also substantial evidence for the absence of these effects (BF01 = 3.65; BF01 = 7.53). The group × time interactions were related to dihydrotestosterone (η2 = 0.018 with an increase in the control condition) as well as positive affect and risk-taking (η2 = 0.027 and 0.007 with increases in the alcohol condition), but not significantly to testosterone.

DISCUSSION

The results do not verify alcohol effects on perceived trustworthiness or oxytocin in male individuals. However, they indicate that alcohol (versus control) might inhibit an increase in dihydrotestosterone and confirm that alcohol amplifies positive affect and risk-taking. This provides novel mechanistic insight into social facilitation as an alcohol-drinking motive.

Getting specific: participation preference in urooncological decision-making

BACKGROUND

Shared decision-making is the gold standard for good clinical practice, and thus, psychometric instruments have been established to assess patients' generic preference for participation (e.g., the Autonomy Preference Index, API). However, patients' preferences may vary depending on the specific disease and with respect to the specific decision context. With a modified preference index (API-Uro), we assessed patients' specific participation preference in preference-sensitive decisions pertaining to urological cancer treatments and compared this with their generic participation preference.

METHODS

In Study 1, we recruited (N = 469) urological outpatients (43.1% urooncological) at a large university hospital. Participation preference was assessed with generic measures (API and API case vignettes) and with the disease-specific API-Uro (urooncological case vignettes describing medical decisions of variable difficulty). A polychoric exploratory factor analysis was used to establish factorial validity and reduce items. In Study 2, we collected data from N = 204 bladder cancer patients in a multicenter study to validate the factorial structure with confirmatory factor analysis. Differences between the participation preference for different decision contexts were analyzed.

RESULTS

Study 1: Scores on the specific urooncological case vignettes (API-Uro) correlated with the generic measure (r = .44) but also provided incremental information. Among the disease-specific vignettes of the API-Uro, there were two factors with good internal consistency (α ≥ .8): treatment versus diagnostic decisions. Patients desired more participation for treatment decisions (77.8%) than for diagnostic decisions (22%), χ²(1) = 245.1, p ≤ .001. Study 2: Replicated the correlation of the API-Uro with the API (r = .39) and its factorial structure (SRMR = .08; CFI = .974). Bladder cancer patients also desired more participation for treatment decisions (57.4%) than for diagnostic decisions (13.3%), χ²(1) =84, p ≤ .001.

CONCLUSIONS

The desire to participate varies between treatment versus diagnostic decisions among urological patients. This underscores the importance of assessing participation preference for specific contexts. Overall, the new API-Uro has good psychometric properties and is well suited to assess patients' preferences. In routine care, measures of participation preference for specific decision contexts may provide incremental, allowing clinicians to better address their patients' individual needs.

Do changes in dysfunctional posttraumatic cognitions differentially predict PTSD symptom clusters?

OBJECTIVE

In recent years, it has been suggested that the modification of dysfunctional posttraumatic cognitions plays a central role as a mechanism of change in cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD). Indeed, several studies have shown that changes in dysfunctional posttraumatic cognitions precede and predict symptom change. However, these studies have investigated the influence on overall symptom severity-despite the well-known multidimensionality of PTSD. The present study therefore aimed to explore differential associations between change in dysfunctional conditions and change in PTSD symptom clusters.

METHOD

As part of a naturalistic effectiveness study evaluating trauma-focused cognitive behavioral therapy for PTSD in routine clinical care, 61 patients with PTSD filled out measures of dysfunctional posttraumatic cognitions and PTSD symptom severity every five sessions during the course of treatment. Lagged associations between dysfunctional cognitions and symptom severity at the following timepoint were examined using linear mixed models.

RESULTS

Over the course of therapy, both dysfunctional cognitions and PTSD symptoms decreased. Posttraumatic cognitions predicted subsequent total PTSD symptom severity, although this effect was at least partly explained by the time factor. Moreover, dysfunctional cognitions predicted three out of four symptom clusters as expected. However, these effects were no longer statistically significant when the general effect for time was controlled for.

CONCLUSION

The present study provides preliminary evidence that dysfunctional posttraumatic cognitions predict PTSD symptom clusters differentially. However, different findings when employing a traditional versus a more rigorous statistical approach make interpretation of findings difficult. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

When attitudes and beliefs get in the way of shared decision-making: A mediation analysis of participation preference

INTRODUCTION

Certain sociodemographic characteristics (e.g., older age) have previously been identified as barriers to patients' participation preference in shared decision-making (SDM). We aim to demonstrate that this relationship is mediated by the perceived power imbalance that manifests itself in patients' negative attitudes and beliefs about their role in decision-making.

METHODS

We recruited a large sample (N = 434) of outpatients with a range of urological diagnoses (42.2% urooncological). Before the medical consultation at a university hospital, patients completed the Patients' Attitudes and Beliefs Scale and the Autonomy Preference Index. We evaluated attitudes as a mediator between sociodemographic factors and participation preference in a path model.

RESULTS

We replicated associations between relevant sociodemographic factors and participation preference. Importantly, attitudes and beliefs about one's own role as a patient mediated this relationship. The mediation path model explained a substantial proportion of the variance in participation preference (27.8%). Participation preferences and attitudes did not differ for oncological and nononcological patients.

CONCLUSION

Patients' attitudes and beliefs about their role determine whether they are willing to participate in medical decision-making. Thus, inviting patients to participate in SDM should encompass an assessment of their attitudes and beliefs. Importantly, negative attitudes may be accessible to change. Unlike stable sociodemographic characteristics, such values are promising targets for interventions to foster more active participation in SDM.

PATIENT OR PUBLIC CONTRIBUTION

This study was part of a larger project on implementing SDM in urological practice. Several stakeholders were involved in the design, planning and conduction of this study, for example, three authors are practising urologists, and three are psychologists with experience in patient care. In addition, the survey was piloted with patients, and their feedback was integrated into the questionnaire. The data presented in this study is based on patients' responses. Results may help to empower our patients.

Training machine learning algorithms for automatic facial coding: The role of emotional facial expressions' prototypicality

Automatic facial coding (AFC) is a promising new research tool to efficiently analyze emotional facial expressions. AFC is based on machine learning procedures to infer emotion categorization from facial movements (i.e., Action Units). State-of-the-art AFC accurately classifies intense and prototypical facial expressions, whereas it is less accurate for non-prototypical and less intense facial expressions. A potential reason might be that AFC is typically trained with standardized and prototypical facial expression inventories. Because AFC would be useful to analyze less prototypical research material as well, we set out to determine the role of prototypicality in the training material. We trained established machine learning algorithms either with standardized expressions from widely used research inventories or with unstandardized emotional facial expressions obtained in a typical laboratory setting and tested them on identical or cross-over material. All machine learning models' accuracies were comparable when trained and tested with held-out dataset from the same dataset (acc. = [83.4% to 92.5%]). Strikingly, we found a substantial drop in accuracies for models trained with the highly prototypical standardized dataset when tested in the unstandardized dataset (acc. = [52.8%; 69.8%]). However, when they were trained with unstandardized expressions and tested with standardized datasets, accuracies held up (acc. = [82.7%; 92.5%]). These findings demonstrate a strong impact of the training material's prototypicality on AFC's ability to classify emotional faces. Because AFC would be useful for analyzing emotional facial expressions in research or even naturalistic scenarios, future developments should include more naturalistic facial expressions for training. This approach will improve the generalizability of AFC to encode more naturalistic facial expressions and increase robustness for future applications of this promising technology.

Automatic facial coding predicts self-report of emotion, advertisement and brand effects elicited by video commercials

Introduction

Consumers' emotional responses are the prime target for marketing commercials. Facial expressions provide information about a person's emotional state and technological advances have enabled machines to automatically decode them.

Method

With automatic facial coding we investigated the relationships between facial movements (i.e., action unit activity) and self-report of commercials advertisement emotion, advertisement and brand effects. Therefore, we recorded and analyzed the facial responses of 219 participants while they watched a broad array of video commercials.

Results

Facial expressions significantly predicted self-report of emotion as well as advertisement and brand effects. Interestingly, facial expressions had incremental value beyond self-report of emotion in the prediction of advertisement and brand effects. Hence, automatic facial coding appears to be useful as a non-verbal quantification of advertisement effects beyond self-report.

Discussion

This is the first study to measure a broad spectrum of automatically scored facial responses to video commercials. Automatic facial coding is a promising non-invasive and non-verbal method to measure emotional responses in marketing.

State anxiety by itself does not change political attitudes: A threat of shock experiment

Previous research suggests that state anxiety may sway political attitudes. However, previous experimental procedures induced anxiety using political contexts (e.g., social or economic threat). In a pre-registered laboratory experiment, we set out to examine if anxiety that is unrelated to political contexts can influence political attitudes. We induced anxiety with a threat of shock paradigm, void of any political connotation. All participants were instructed that they might receive an electric stimulus during specified threat periods and none during safety periods. Participants were randomly assigned to one of two conditions: Political attitudes (implicit and explicit) were assessed under safety in one condition and under threat in the other. Psychometric, as well as physiological data (skin conductance, heart rate), confirmed that anxiety was induced successfully. However, this emotional state did not alter political attitudes. In a Bayesian analytical approach, we confirmed the absence of an effect. Our results suggest that state anxiety by itself does not sway political attitudes. Previously observed effects that were attributed to anxiety may be conditional on a political context of threat.

Time is a great healer: Peak-end memory bias in anxiety - Induced by threat of shock

Recently, we demonstrated that the peak-end memory bias, which is well established in the context of pain, can also be observed in anxiety: Retrospective evaluations of a frightening experience are worse when peak anxiety is experienced at the end of an episode. Here, we set out to conceptually replicate and extend this finding with rigorous experimental control in a threat of shock paradigm. We induced two intensity levels of anxiety by presenting visual cues that indicated different strengths of electric stimuli. Each of the 59 participants went through one of two conditions that only differed in the order of moderate and high threat phases. As a manipulation check, orbicularis-EMG to auditory startle probes, electrodermal activity, and state anxiety confirmed the effects of the specific threat exposure. Critically, after some time had passed, participants for whom exposure had ended with high threat reported more anxiety for the entire episode than those for whom it ended with moderate threat. Moreover, they ranked their experience as more aversive when compared to other unpleasant everyday experiences. This study overcomes several previous limitations and speaks to the generalizability of the peak-end bias. Most notably, the findings bear implications for exposure therapy in clinical anxiety.

How are you getting by? Coping in developmental coordination disorder versus attention-deficit/hyperactivity disorder

Objective

Developmental Coordination Disorder (DCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) persist into adulthood; however, little research exists to describe how adults with DCD and/or ADHD cope with their symptoms. Therefore, the purpose of this study was to investigate coping mechanisms reported by adults with DCD, ADHD, or both conditions. We expected there would be strategies specific to each condition and a broader scope of mechanisms reported by those with co-occurring DCD+ADHD.

Method

N = 161 participants completed the online survey, including n = 31 with DCD only, n = 116 with ADHD only, and n = 14 with DCD+ADHD.

Results

Most participants reported adaptive strategies. Of these, behavioral adaptations were most relevant to ADHD, while environmental modifications were common in DCD. Cognitive reframing and social support were similarly relevant to those with DCD and DCD+ADHD. Coping strategy categories were most uniform for the DCD+ADHD group.

Conclusions

Coping profiles highlight several noteworthy differences between DCD and ADHD which may be relevant for treatment.

The adult developmental coordination disorders/dyspraxia checklist - German: adapted factor structure for the differentiation of DCD and ADHD

BACKGROUND

The Adult Dyspraxia/DCD Checklist (ADC) is the only existing self-report questionnaire to screen adults for potential Developmental Coordination Disorder (DCD). It was developed in English and Hebrew, however, its factor structure has not yet been assessed.

AIMS

The goals of the current study were to (1) develop and refine a German translation, (2) explore the emerging factors in a new and restructured ADC in German and apply this structure to an English ADC, and (3) explore its potential for distinguishing DCD versus ADHD.

METHOD

In a series of three studies, we assessed comprehensibility of the translation and revisions to the questionnaire. We further examined subscale structure in a sample of N = 148 individuals with DCD or ADHD and retested it in an English-speaking sample (N = 134).

RESULTS

Overall, we found decent reliability and construct validity for the German ADC. Three components emerged with themes of fine motor coordination, gross motor coordination, and executive functions which had strong psychometric properties in German and English.

CONCLUSIONS

The studies collectively highlight the German translation is effective and has strong potential to differentiate DCD and ADHD. Most notably, there are unique symptom profiles in motor and executive functioning difficulties in adults with DCD or ADHD. WHAT THIS PAPER ADDS?: The translation and preliminary validation of the German ADC in this study has the potential to screen for probable DCD in German-speaking adults for the first time. In addition, the new subscale structure can be generalized to the English version as well and allows for the potential assessment of several key symptomatic patterns in the realms of gross motor, fine motor, and executive functioning skills that differ between adults with DCD and ADHD. These differences were fairly consistent between English- and German-speaking samples, indicating potential for more widespread assessment and differentiation of DCD and ADHD.

Fear one, fear them all: A systematic review and meta-analysis of fear generalization in pathological anxiety

It is a defining feature of anxiety disorders that fear is elicited by a circumscribed class of stimuli rather than by only one specific exemplar of that class. Therefore, fear generalization, a mechanism by which associative fear extends from one conditioned stimulus to similar cues, has been central to theories on anxiety. Yet, experimental evidence for the link between generalization and pathological anxiety, as well as its moderators, has not been formally integrated. This systematic review and meta-analysis of empirical findings clarifies the relationship between fear generalization and pathological anxiety. In conclusion, enhanced fear generalization is associated with several anxiety disorders and stress-related disorders, which is supported statistically by a small, but robust effect size of g = 0.44 for risk ratings as an index of fear generalization. However, empirical results are inconsistent across disorders and they rarely allow for conclusions on their causality in the disorders' etiology. Therefore, based on theoretical considerations, we recommend directions for intensified research, especially on the causal relationship between overgeneralization and pathological fear.

Different patients, different preferences: A multicenter assessment of patients' personality traits and anxiety in shared decision making

OBJECTIVE

Patient-centered care and shared decision making (SDM) are generally recognized as the gold standard for medical consultations, especially for preference-sensitive decisions. However, little is known about psychological patient characteristics that influence patient-reported preferences. We set out to explore the role of personality and anxiety for a preference-sensitive decision in bladder cancer patients (choice of urinary diversion, UD) and to determine if anxiety predicts patients' participation preferences.

METHODS

We recruited a sample of bladder cancer patients (N = 180, primarily male, retired) who awaited a medical consultation on radical cystectomy and their choice of UD. We asked patients to fill in a set of self-report questionnaires before this consultation, including measures of treatment preference, personality (BFI-10), anxiety (STAI), and participation preference (API and API-Uro), as well as sociodemographic characteristics.

RESULTS

Most patients (79%) indicated a clear preference for one of the treatment options (44% continent UD, 34% incontinent UD). Patients who reported more conscientiousness were more likely to prefer more complex methods (continent UD). The majority (62%) preferred to delegate decision making to healthcare professionals. A substantial number of patients reported elevated anxiety (32%), and more anxiety was predictive of higher participation preference, specifically for uro-oncological decisions (β = 0.207, p < 0.01).

CONCLUSIONS

Our findings provide insight into the role of psychological patient characteristics for SDM. Aspects of personality such as conscientiousness influence treatment preferences. Anxiety contributes to patients' motivation to be involved in pertinent decisions. Thus, personality and negative affect should be considered to improve SDM.

Effect of Cleft Lip on Adolescent Evaluation of Faces: An Eye-Tracking Study

PURPOSE

Adolescence is a delicate phase during life in which self-stigmatization increases and acceptance by peers becomes more important. However, little is known about how adolescents with cleft lip and/or palate experience this stage of life. Therefore, the purpose of this study was to investigate how cleft lip and/or palate (CLP) adolescents are looked at by their peers and how they look at others with/without CLP.

METHODS

In this prospective, cross-sectional study 54 observers (CLP versus control) performed an eye-tracking task and gave attractiveness/ valence ratings. For this purpose, they were shown pictures of patients with and without CLP with neutral or smiling facial expressions.

RESULTS

Adolescents with CLP were looked at differently compared to their unaffected peers, with shorter fixations of the eyes and longer fixations of the nose and mouth. Smiling altered the scan path toward the mouth for all faces. Contrary to the control group, adolescents with CLP tended to spend less time fixating the eyes. In the attractiveness/valence ratings, CLP adolescents were rated more negatively.

CONCLUSIONS

Adolescents with cleft lip and/or palate look differently at peers and are also viewed with an alternate scan path.

Girls' Stuff? Maternal Gender Stereotypes and Their Daughters' Fear

One of the most robust findings in psychopathology is the fact that specific phobias are more prevalent in women than in men. Although there are several theoretical accounts for biological and social contributions to this gender difference, empirical data are surprisingly limited. Interestingly, there is evidence that individuals with stereotypical feminine characteristics are more fearful than those with stereotypical masculine characteristics; this is beyond biological sex. Because gender role stereotypes are reinforced by parental behavior, we aimed to examine the relationship of maternal gender stereotypes and children’s fear. Dyads of 38 mothers and their daughters (between ages 6 and 10) were included. We assessed maternal implicit and explicit gender stereotypes as well as their daughters’ self-reported general fearfulness, specific fear of snakes, and approach behavior toward a living snake. First, mothers’ fear of snakes significantly correlated with their daughters’ fear of snakes. Second, mothers’ gender stereotypes significantly correlated with their daughters’ self-reported fear. Specifically, maternal implicit gender stereotypes were associated with daughters’ fear of snakes and fear ratings in response to the snake. Moreover, in children, self-reported fear correlated with avoidance of the fear-relevant animal. Together, these results provide first evidence for a potential role of parental gender stereotypes in the development and maintenance of fear in their offspring.

Behavioural and functional evidence revealing the role of RBFOX1 variation in multiple psychiatric disorders and traits

Common variation in the gene encoding the neuron-specific RNA splicing factor RNA Binding Fox-1 Homolog 1 (RBFOX1) has been identified as a risk factor for several psychiatric conditions, and rare genetic variants have been found causal for autism spectrum disorder (ASD). Here, we explored the genetic landscape of RBFOX1 more deeply, integrating evidence from existing and new human studies as well as studies in Rbfox1 knockout mice. Mining existing data from large-scale studies of human common genetic variants, we confirmed gene-based and genome-wide association of RBFOX1 with risk tolerance, major depressive disorder and schizophrenia. Data on six mental disorders revealed copy number losses and gains to be more frequent in ASD cases than in controls. Consistently, RBFOX1 expression appeared decreased in post-mortem frontal and temporal cortices of individuals with ASD and prefrontal cortex of individuals with schizophrenia. Brain-functional MRI studies demonstrated that carriers of a common RBFOX1 variant, rs6500744, displayed increased neural reactivity to emotional stimuli, reduced prefrontal processing during cognitive control, and enhanced fear expression after fear conditioning, going along with increased avoidance behaviour. Investigating Rbfox1 neuron-specific knockout mice allowed us to further specify the role of this gene in behaviour. The model was characterised by pronounced hyperactivity, stereotyped behaviour, impairments in fear acquisition and extinction, reduced social interest, and lack of aggression; it provides excellent construct and face validity as an animal model of ASD. In conclusion, convergent translational evidence shows that common variants in RBFOX1 are associated with a broad spectrum of psychiatric traits and disorders, while rare genetic variation seems to expose to early-onset neurodevelopmental psychiatric disorders with and without developmental delay like ASD, in particular. Studying the pleiotropic nature of RBFOX1 can profoundly enhance our understanding of mental disorder vulnerability.

A Smarter Way to Use Your Smartphone: An Intervention to Limit Smartphone-Related Distractions Reduces Hyperactivity but Not Inattention Symptoms

INTRODUCTION

Smartphones are often helpful in our everyday lives. Yet, they also tend to interrupt us during other activities. It has been argued that such distractions contribute to attention-deficit/hyperactivity disorder-like symptoms. However, since there are mostly correlational studies, the causal nature of this relationship is unclear. Our aim was to test whether reducing smartphone-related distractions might have a beneficial effect on inattention and hyperactive symptoms.

METHODS

We conducted a 1-week field experiment with 37 healthy undergraduates and quasi-randomly assigned them to an intervention or control group (CG). The intervention group was given theory-based specific instructions that aimed at reducing smartphone-related distractions, whereas the CG received no intervention. The outcomes of interest were inattention level, hyperactive symptoms, and working memory accuracy.

RESULTS

Compared to those in the control condition, participants who limited their smartphone use showed considerable reductions in hyperactive symptoms after 1 week - particularly those who displayed high problematic smartphone use. However, there were no group differences regarding inattention symptoms and working memory accuracy.

DISCUSSION

The results give a first hint that strategically reducing smartphone-related distractions via specific but simple use modifications can mitigate hyperactive symptoms. Especially people with problematic smartphone use seem to profit from such an intervention. Remaining questions and directions are discussed.

Mechanisms of Change in Trauma-Focused Treatment for PTSD: The Role of Rumination

OBJECTIVE

Cognitive behavioral therapy (CBT) has been well established in the treatment of posttraumatic stress disorder (PTSD). In recent years, researchers have begun to investigate its underlying mechanisms of change. Dysfunctional cognitive content, i.e. excessively negative appraisals of the trauma or its consequences, has been shown to predict changes in PTSD symptoms over the course of treatment. However, the role of change in cognitive processes, such as trauma-related rumination, needs to be addressed. The present study investigates whether changes in rumination intensity precede and predict changes in symptom severity. We also explored the extent to which symptom severity predicts rumination.

METHOD

As part of a naturalistic effectiveness study evaluating CBT for PTSD in routine clinical care, eighty-eight patients with PTSD completed weekly measures of rumination and symptom severity. Lagged associations between rumination and symptoms in the following week were examined using linear mixed models.

RESULTS

Over the course of therapy, both ruminative thinking and PTSD symptoms decreased. Rumination was a significant predictor of PTSD symptoms in the following week, although this effect was at least partly explained by the time factor (e.g., natural recovery or inseparable treatment effects). Symptom severity predicted ruminative thinking in the following week even with time as an additional predictor.

CONCLUSIONS

The present study provides preliminary evidence that rumination in PTSD is reduced by CBT for PTSD but does not give conclusive evidence that rumination is a mechanism of change in trauma-focused treatment for PTSD.

Evaluation of a new screening instrument for psychological distress in postacute rehabilitation in older person

PURPOSE

Although psychological distress has a negative impact on functional recovery, institutionalisation and mortality rates, there is typically no established procedure to screen for psychological distress in geriatric rehabilitation. The aim of the study was to evaluate a brief single-item Verbal Numerical Rating Scale (VNRS-PD) as a screening tool for psychological distress in multimorbid geriatric rehabilitation patients.

METHODS

In this cross-sectional study, N = 132 geriatric rehabilitation in-patients (M = 82 years old; 70.5% female) completed a verbal numerical rating scale (VNRS-PD) on satisfaction with their mood as well as the Hospital Anxiety and Depression Scale (HADS) and the short-form of the Geriatric Depression Scale (GDS). Based on the questionnaire data, the rehabilitation patients were classified as high or low in psychopathology. Using receiver-operating characteristic (ROC) curve analysis, optimal cutoff scores of the VNRS-PD were calculated for each questionnaire to detect significant psychological distress.

RESULTS

Between 28.8% (HADS ≥ 18) and 43.9% (GDS ≥ 6) of the sample had above-cutoff questionnaire scores. The area under the curve (AUC) of the VNRS-PD varied from 0.785 (95%-CI 0.709-0.861) (GDS ≥ 6) and 0.790 (95%-CI 0.716-0.864) (HADS ≥ 18) to 0.807 (95%-CI 0.734-0.880) (GDS ≥ 7). A score of ≤ 5 in the VNRS-PD proved to be the cutoff with an optimal trade-off between sensitivity (0.776-0.867) and specificity (0.638-0.703).

CONCLUSION

The VNRS-PD may be a suitable screening instrument to detect patients with psychological distress in inpatient geriatric rehabilitation for and to initiate further diagnostics within a graduated psychodiagnostic scheme. This first step may help to identify older patients with psychological distress and mental disorders, to initiate targeted interventions. Further research is needed to replicate these findings in a larger sample.

Interactions with Standardized Patients to Evaluate Students’ Psychotherapy-Competencies

Abstract. The use of standardized patients (SPs) in the training of prospective practitioners is a well-established didactic tool in medical schools. Only recently have simulations of patients in psychotherapy been introduced into the training of psychologists. By integrating psychotherapy training into university-level master’s programs, German law now requires licensing exams for psychotherapists (i. e., Approbationsprüfung) to include an assessment of therapeutic competencies in simulated interactions with SPs. Yet, it has not been examined whether these simulations are useful for a reliable assessment of competencies in psychotherapy trainees. Also, we need to develop standardized instruments to evaluate competencies in entry-level psychotherapists. As part of a university course, we trained master’s-level students from three cohorts in clinical interviewing techniques (course title: Klinisch-psychologische Gesprächsführung). We analyzed videotaped 20-min sequences of N = 104 students while they interviewed one of N = 38 trained SPs. The students’ task was to interview the SP, conduct a brief case history, and use the interviewing skills they had learned in class. Two independent raters evaluated their psychotherapeutic competencies with an adapted version of the German Cognitive Therapy Scale (CTS). Raters evaluated students’ performance on two subscales and the total score with satisfactory interrater agreement (intraclass correlations). In general, students performed well in the interviews: They structured the sessions sufficiently, and their global psychotherapeutic competencies were satisfactory. However, the psychotherapeutic competencies of master’s students fell short of the benchmark derived from experienced psychotherapists. This pilot study provides first evidence that simulated interviews with SPs may be a reliable tool in the assessment of practical competencies in psychotherapy trainees at an early stage of their training. Moreover, we found that the CTS, which has demonstrated validity to quantify competencies of psychotherapists, is applicable and reliable in this training context as well. In sum, this suggests that simulated interviews with SPs may be useful for evaluating psychotherapeutic competencies of psychotherapy trainees.

Automatic Facial Expression Recognition in Standardized and Non-standardized Emotional Expressions

Emotional facial expressions can inform researchers about an individual's emotional state. Recent technological advances open up new avenues to automatic Facial Expression Recognition (FER). Based on machine learning, such technology can tremendously increase the amount of processed data. FER is now easily accessible and has been validated for the classification of standardized prototypical facial expressions. However, applicability to more naturalistic facial expressions still remains uncertain. Hence, we test and compare performance of three different FER systems (Azure Face API, Microsoft; Face++, Megvii Technology; FaceReader, Noldus Information Technology) with human emotion recognition (A) for standardized posed facial expressions (from prototypical inventories) and (B) for non-standardized acted facial expressions (extracted from emotional movie scenes). For the standardized images, all three systems classify basic emotions accurately (FaceReader is most accurate) and they are mostly on par with human raters. For the non-standardized stimuli, performance drops remarkably for all three systems, but Azure still performs similarly to humans. In addition, all systems and humans alike tend to misclassify some of the non-standardized emotional facial expressions as neutral. In sum, emotion recognition by automated facial expression recognition can be an attractive alternative to human emotion recognition for standardized and non-standardized emotional facial expressions. However, we also found limitations in accuracy for specific facial expressions; clearly there is need for thorough empirical evaluation to guide future developments in computer vision of emotional facial expressions.

Transfer of exposure therapy effects to a threat context not considered during treatment in patients with panic disorder and agoraphobia: Implications for potential mechanisms of change

Further developments of exposure-based therapy (EBT) require more knowledge about transfer of treatment to non-trained everyday contexts. However, little is known about transfer effects of EBT. Using a standardized EBT protocol in 275 patients with panic disorder and agoraphobia we investigated the transfer of EBT to a highly standardized context during a Behavioral Avoidance Test (BAT; being entrapped in a small and dark test chamber) and not part of the exposure sessions. Patients of a treatment group underwent the BATs before treatment (t1), after a preparatory treatment phase (t2), and after an agoraphobic exposure phase (t3) and were compared with wait-list control patients, who repeated BAT assessments across the same time period. We found stronger reductions in avoidance behavior, reported fear, and autonomic arousal during the BAT from t1 to t3 in the treatment group patients who were anxious during t1 relative to the anxious but untreated patients. Fear reduction was related to treatment outcome indicating the contribution of transfer effects to successful EBT. Interestingly, reduction varied for different fear response systems suggesting different processes to may be involved in transfer effects. Importantly, final BAT assessment still evoked residual fear in the treatment group as compared to BAT non-anxious control patients, suggesting limited transfer effects - one possible reason for the return of symptoms in new situations.

Decision Aids for Shared Decision-making in Uro-oncology: A Systematic Review

CONTEXT

Decision aids (DAs) aim to support patients in the process of shared decision-making for complex treatment decisions. To improve patient-centered care in uro-oncology, it is essential to evaluate the availability and quality of existing DAs.

OBJECTIVE

To assess the quality of existing DAs for patients across the most prevalent uro-oncological entities.

EVIDENCE ACQUISITION

This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. A systematic literature search (MedLine, Cochrane Library, Web of Science Core Collection, and CCMed) was conducted to identify DAs for treatment decisions for patients with prostate, renal, or bladder cancer. All studies reporting on the development or evaluation of DAs were included. The DAs were examined based on the International Patient Decision Aid Standards (IPDAS) and the evaluation studies were compared in accordance with Standards for Universal reporting of a patient Decision Aid Evaluations (SUNDAE).

EVIDENCE SYNTHESIS

The literature search identified 1995 potentially relevant publications. Thirty-two studies reporting on 25 DAs met the inclusion criteria. Twenty-two DAs address prostate cancer, two renal tumor, and one bladder cancer. In the majority of DAs (n = 20), patients can enter individual data. A few (n = 6) DAs allow for personalization using a risk-adapted presentation of treatment options. The percentage of IPDAS criteria met in DAs ranged between 50% and 100% (median 87.5%), and the studies' adherence to the SUNDAE checklist was between 62% and 96% (median 86.6%). Evaluation studies suggest that interventions are likely efficacious. However, a preliminary meta-analysis revealed no significant difference between "DA" and "usual care" for decisional conflict or decisional regret.

CONCLUSIONS

This review highlights that a number of well-developed DAs exist in urology. However, there is a need for specific instruments targeting kidney and bladder cancer. Personalization of tools and adherence to international standards of DAs should be further improved.

PATIENT SUMMARY

The majority of uro-oncological decision aids target prostate cancer, whereas fewer address kidney or bladder cancer. The quality of the existing instruments is high, but can be increased further to better address specific needs of individual patients.

Predicting decisional conflict: Anxiety and depression in shared decision making

OBJECTIVES

Emotional distress can be a potential barrier to shared decision making (SDM), yet affect is typically not systematically assessed in medical consultation. We examined whether urological patients report anxiety or depression prior to a consultation and if emotional distress predicts decisional conflict thereafter.

METHODS

We recruited a large sample of urological outpatients (N = 397) with a range of different diagnoses (42 % oncological). Prior to a medical consultation, patients filled in questionnaires, including the Hospital Anxiety and Depression Scale. After the consultation, patients completed the Decisional Conflict Scale. We scored the rate of anxiety and depression in our sample and conducted multiple regression analysis to examine if emotional distress before the consultation predicts decisional conflict thereafter.

RESULTS

About a quarter of patients reported values at or above cut-off for clinically relevant emotional distress. Emotional distress significantly predicted a higher degree of decisional conflict. There were no differences in emotional distress between patients with and without uro-oncological diagnosis.

CONCLUSIONS

Emotional distress is common in urology patients - oncological as well as non-oncological. It predicts decisional conflict after physician consultation.

PRACTICE IMPLICATIONS

Emotional distress should be systematically assessed in clinical consultations. This may improve the process and outcome of SDM.

Effects of affective content and motivational context on neural gain functions during naturalistic scene perception

Visual scene processing is modulated by semantic, motivational, and emotional factors, in addition to physical scene statistics. An open question is to what extent those factors affect low-level visual processing. One index of low-level visual processing is the contrast response function (CRF), representing the change in neural or psychophysical gain with increasing stimulus contrast. Here we aimed to (a) establish the use of an electrophysiological technique for assessing CRFs with complex emotional scenes and (b) examine the effects of motivational context and emotional content on CRFs elicited by naturalistic stimuli, including faces and complex scenes (humans, animals). Motivational context varied by expectancy of threat (a noxious noise) versus safety. CRFs were measured in 18 participants by means of sweep steady-state visual evoked potentials. Results showed a facilitation in visuocortical sensitivity (contrast gain) under threat, compared with safe conditions, across all stimulus categories. Facial stimuli prompted heightened neural response gain, compared with scenes. Within the scenes, response gain was smaller for scenes high in emotional arousal, compared with low-arousing scenes, consistent with interference effects of emotional content. These findings support the notion that motivational context alters the contrast sensitivity of cortical tissue, differing from changes in response gain (activation) when visual cues themselves carry motivational/affective relevance.

Better safe than wealthy: Dysfunctional risk avoidance in spider-fearful individuals

Previous research has documented that fearful individuals avoid fear-relevant cues even if they incur costs in doing so. Paradigms that were previously used to study avoidance in the lab, manipulated reward contingencies in favor of selecting either fear-relevant or neutral cues, e.g., spiders versus butterflies. We, thus, developed a paradigm where the chance of monetary gains was linked with increasing probability of a fear-relevant or a neutral outcome. To this end, we modified the well-established Balloon Analogue Risk Task (BART) to include fear-relevant outcomes. Individuals with and without fear of spiders (N = 35) were offered the chance to inflate balloons, with more pumps resulting in larger gains. However, if the balloon exploded, this resulted in a loss of money - and at the same time in the presentation of a picture, either a fear-relevant spider or a neutral butterfly (emotional Balloon Analogue Risk Task; eBART). We operationalized risk aversion as the number of pumps and dysfunctionality of decision strategy as the amount of money that participants earned. In addition, decisional conflict was measured by response times for each decision. The data indicate, that spider-fearful individuals were generally more risk-averse and much more so in trials with fear-relevant stimuli as part of the negative outcome. Overall, this resulted in smaller amount of money that spider-fearful individuals earned compared to spider non-fearful individuals. Interestingly, spider-fearful compared to spider non-fearful individuals generally responded more hesitantly on all trials, and more so when they feared to encounter a spider. This research introduces a new paradigm and provides ecologically valid evidence for costly avoidance behavior in spider-fearful individuals. The eBART may be a promising new research tool to examine risk avoidance with emotionally relevant stimuli.

Shared Decision Making during the COVID-19 Pandemic

OBJECTIVE

The COVID-19 pandemic pushed some of the most well-developed health care systems to their limits. In many cases, this has challenged patient-centered care. We set out to examine individuals' attitudes toward shared decision making (SDM) and to identify predictors of participation preference during the pandemic.

METHODS

We conducted an online survey with a large convenience sample (N = 1061). Our main measures of interest were participants' generic and COVID-19-related participation preference as well as their acceptance and distress regarding a triage vignette. We also assessed anxiety, e-health literacy, and aspects of participants' health. We conducted group comparisons and multiple linear regression analyses on participation preference as well as triage acceptance.

RESULTS

In generic decision making, most participants expressed a strong need for information and a moderate participation preference. In the hypothetical case of COVID-19 infection, most preferred physician-led decisions. Generic participation preference was the strongest predictor of COVID-19-related participation preference, followed by age, education, and anxiety. Furthermore, both higher generic and COVID-19-related participation preferences predicted lower triage acceptance.

CONCLUSION

Our findings demonstrate potential health care recipients' attitudes toward SDM during a severe health care crisis and emphasize that participation preference varies according to the context.

Automatic facial coding versus electromyography of mimicked, passive, and inhibited facial response to emotional faces

Decoding someone's facial expressions provides insights into his or her emotional experience. Recently, Automatic Facial Coding (AFC) software has been developed to provide measurements of emotional facial expressions. Previous studies provided first evidence for the sensitivity of such systems to detect facial responses in study participants. In the present experiment, we set out to generalise these results to affective responses as they can occur in variable social interactions. Thus, we presented facial expressions (happy, neutral, angry) and instructed participants (N = 64) to either actively mimic, to look at them passively (n = 21), or to inhibit their own facial reaction (n = 22). A video stream for AFC and an electromyogram (EMG) of the zygomaticus and corrugator muscles were registered continuously. In the mimicking condition, both AFC and EMG differentiated well between facial expressions in response to the different emotional pictures. In the passive viewing and in the inhibition condition AFC did not detect changes in facial expressions whereas EMG was still highly sensitive. Although only EMG is sensitive when participants intend to conceal their facial reactions, these data extend previous findings that Automatic Facial Coding is a promising tool for the detection of intense facial reaction.

Evoked Potentials Differentiate Developmental Coordination Disorder From Attention-Deficit/Hyperactivity Disorder in a Stop-Signal Task: A Pilot Study

Developmental Coordination Disorder and Attention-Deficit/Hyperactivity Disorder are unique neurodevelopmental disorders with overlaps in executive functions and motor control. The conditions co-occur in up to 50% of cases, raising questions of the pathological mechanisms of DCD versus ADHD. Few studies have examined these overlaps in adults with DCD and/or ADHD. Therefore, to provide insights about executive functions and motor control between adults with DCD, ADHD, both conditions (DCD + ADHD), or typically developed controls, this study used a stop-signal task and parallel EEG measurement. We assessed executive performance via go accuracy and go reaction time, as well as motor response inhibition via stop-signal reaction time. This was complemented with analysis of event-related potentials (ERPs). Based on existing investigations of adults with DCD or ADHD, we expected (1) groups would not differ in behavioral performance on stop and go trials, but (2) differences in ERPs, particularly in components N200 (index of cognitive control) and P300 (index of attention and inhibition) would be evident. The sample included N = 50 adults with DCD (n = 12), ADHD (n = 9), DCD + ADHD (n = 7), and control participants (n = 22). We replicated that there were no between-group differences for behavioral-level executive performance and motor response inhibition. However, on a physiological level, ERP components N200 and P300 differed between groups, particularly during successful response inhibition. These ERPs reflect potential endophenotypic differences not evident in overt behavior of participants with ADHD and/or DCD. This suggests a disorder specific employment of inhibition or general executive functions in groups of adults with DCD, DCD + ADHD, ADHD, or control participants.

Therapygenetic effects of 5-HTTLPR on cognitive-behavioral therapy in anxiety disorders: A meta-analysis

There is a recurring debate on the role of the serotonin transporter gene linked polymorphic region (5-HTTLPR) in the moderation of response to cognitive behavioral therapy (CBT) in anxiety disorders. Results, however, are still inconclusive. We here aim to perform a meta-analysis on the role of 5-HTTLPR in the moderation of CBT outcome in anxiety disorders. We investigated both categorical (symptom reduction of at least 50%) and dimensional outcomes from baseline to post-treatment and follow-up. Original data were obtained from ten independent samples (including three unpublished samples) with a total of 2,195 patients with primary anxiety disorder. No significant effects of 5-HTTLPR genotype on categorical or dimensional outcomes at post and follow-up were detected. We conclude that current evidence does not support the hypothesis of 5-HTTLPR as a moderator of treatment outcome for CBT in anxiety disorders. Future research should address whether other factors such as long-term changes or epigenetic processes may explain further variance in these complex gene-environment interactions and molecular-genetic pathways that may confer behavioral change following psychotherapy.

Stress Makes the Difference: Social Stress and Social Anxiety in Decision-Making Under Uncertainty

Stress and anxiety can both influence risk-taking in decision-making. While stress typically increases risk-taking, anxiety often leads to risk-averse choices. Few studies have examined both stress and anxiety in a single paradigm to assess risk-averse choices. We therefore set out to examine emotional decision-making under stress in socially anxious participants. In our study, individuals (N = 87) high or low in social anxiety completed an expanded variation of the Balloon Analogue Risk Task (BART). While inflating a balloon to a larger degree is rewarded, a possible explosion leads to (a) a loss of money and (b) it is followed by an emotional picture (i.e., a calm vs. an angry face). To induce stress before this task, participants were told that they would have to deliver a speech. We operationalized risk-taking by the number of pumps during inflation and its functionality by the amount of monetary gain. In addition, response times were recorded as an index of decisional conflict. Without the stressor, high socially anxious compared to low socially anxious participants did not differ in any of the dependent variables. However, under stress, the low socially anxious group took more risk and earned more money, while high socially anxious individuals remained more cautious and did not change their risk-taking under social stress. Overall, high socially anxious individuals made their decisions more hesitantly compared to low socially anxious individuals. Unexpectedly, there were no main effects or interactions with the valence of the emotional faces. This data shows that stress affects socially anxious individuals differently: in low socially anxious individuals stress fosters risk-taking, whereas high socially anxious individuals did not alter their behavior and remained risk-averse. The novel eBART is a promising research tool to examine the specific factors that influence decision-making.

Dealing With the COVID-19 Infodemic: Distress by Information, Information Avoidance, and Compliance With Preventive Measures

In the ongoing coronavirus disease 2019 (COVID-19) pandemic, media reports have caused anxiety and distress in many. In some individuals, feeling distressed by information may lead to avoidance of information, which has been shown to undermine compliance with preventive health behaviors in many health domains (e.g., cancer screenings). We set out to examine whether feeling distressed by information predicts higher avoidance of information about COVID-19 (avoidance hypothesis), and whether this, in turn, predicts worse compliance with measures intended to prevent the spread of COVID-19 (compliance hypothesis). Thus, we conducted an online survey with a convenience sample (N = 1,059, 79.4% female) and assessed distress by information, information avoidance, and compliance with preventive measures. Furthermore, we inquired about participants' information seeking behavior and media usage, their trust in information sources, and level of eHealth literacy, as well as generalized anxiety. We conducted multiple linear regression analyses to predict distress by information, information avoidance, and compliance with preventive measures. Overall, distress by information was associated with better compliance. However, distress was also linked with an increased tendency to avoid information (avoidance hypothesis), and this reduced compliance with preventive measures (compliance hypothesis). Thus, distress may generally induce adaptive behavior in support of crisis management, unless individuals respond to it by avoiding information. These findings provide insights into the consequences of distress by information and avoidance of information during a global health crisis. These results underscore that avoiding information is a maladaptive response to distress by information, which may ultimately interfere with effective crisis management. Consequently, we emphasize the need to develop measures to counteract information avoidance.

An investigation of genetic variability of DNA methyltransferases DNMT3A and 3B does not provide evidence for a major role in the pathogenesis of panic disorder and dimensional anxiety phenotypes

While DNA methylation patterns have been studied for a role in the pathogenesis of anxiety disorders, the role of the enzymes establishing DNA methylation-DNA methyltransferases (DNMTs)-has yet to be investigated. In an effort to investigate DNMT genotype-specific effects on dimensional anxiety traits in addition to the categorical phenotype of panic disorder, 506 panic disorder patients and 3112 healthy participants were assessed for anxiety related cognition [Agoraphobic Cognitions Questionnaire (ACQ)], anxiety sensitivity [Anxiety Sensitivity Index (ASI)] as well as pathological worry [Penn State Worry Questionnaire (PSWQ)] and genotyped for five single nucleotide polymorphisms (SNPs) in the DNMT3A (rs11683424, rs1465764, rs1465825) and DNMT3B (rs2424932, rs4911259) genes, which have previously been found associated with clinical and trait-related phenotypes. There was no association with the categorical phenotype panic disorder. However, a significant association was discerned between DNMT3A rs1465764 and PSWQ scores in healthy participants, with the minor allele conveying a protective effect. In addition, a marginally significant association between questionnaire scores (PSWQ, ASI) in healthy participants and DNMT3B rs2424932 was detected, again with the minor allele conveying a protective effect. The present results suggest a possible minor role of DNMT3A and DNMT3B gene variation in conveying resilience towards anxiety disorders. As the observed associations indicated a protective effect of two SNPs particularly with pathological worry, future studies are proposed to explore these variants in generalized anxiety disorder rather than panic disorder.

Read My Face: Automatic Facial Coding Versus Psychophysiological Indicators of Emotional Valence and Arousal

Facial expressions provide insight into a person's emotional experience. To automatically decode these expressions has been made possible by tremendous progress in the field of computer vision. Researchers are now able to decode emotional facial expressions with impressive accuracy in standardized images of prototypical basic emotions. We tested the sensitivity of a well-established automatic facial coding software program to detect spontaneous emotional reactions in individuals responding to emotional pictures. We compared automatically generated scores for valence and arousal of the Facereader (FR; Noldus Information Technology) with the current psychophysiological gold standard of measuring emotional valence (Facial Electromyography, EMG) and arousal (Skin Conductance, SC). We recorded physiological and behavioral measurements of 43 healthy participants while they looked at pleasant, unpleasant, or neutral scenes. When viewing pleasant pictures, FR Valence and EMG were both comparably sensitive. However, for unpleasant pictures, FR Valence showed an expected negative shift, but the signal differentiated not well between responses to neutral and unpleasant stimuli, that were distinguishable with EMG. Furthermore, FR Arousal values had a stronger correlation with self-reported valence than with arousal while SC was sensitive and specifically associated with self-reported arousal. This is the first study to systematically compare FR measurement of spontaneous emotional reactions to standardized emotional images with established psychophysiological measurement tools. This novel technology has yet to make strides to surpass the sensitivity of established psychophysiological measures. However, it provides a promising new measurement technique for non-contact assessment of emotional responses.

Emotional sounds guide visual attention to emotional pictures: An eye-tracking study with audio-visual stimuli

For the realm of visual cues, it has been well documented that attention is preferentially oriented toward emotionally relevant cues. Preliminary evidence suggests that emotional cues from other sensory modalities may also steer visual attention toward emotional pictures. However, more research is needed to elucidate the mechanisms that are involved. Therefore, a novel design was used to investigate whether emotional sounds promote attentional orientation toward emotional pictures. To this end, 48 participants viewed pairs of pictures with either neutral or unpleasant content in a free-viewing paradigm. In addition, neutral or unpleasant sounds were presented either on the left-hand or on the right-hand side of the monitor. Eye movements were recorded as an index of visual spatial attention toward the pictures. Most interestingly, position and valence of the sounds independently modulated visual orienting towards unpleasant pictures. For initial capture and sustained attention, orienting towards unpleasant pictures was significantly enhanced when any sound was heard on the same side as the unpleasant picture. In addition, unpleasant sounds (irrespective of the side) boosted leftward bias of initial attention toward emotionally congruent pictures. Taken together, this study clearly shows that emotional auditory cues guide visual spatial allocation of attention specifically to emotionally congruent pictures. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An instrument for quality assurance in work capacity evaluation: development, evaluation, and inter-rater reliability

Background

Employees insured in pension insurance, who are incapable of working due to ill health, are entitled to a disability pension. To assess whether an individual meets the medical requirements to be considered as disabled, a work capacity evaluation is conducted. However, there are no official guidelines on how to perform an external quality assurance for this evaluation process. Furthermore, the quality of medical reports in the field of insurance medicine can vary substantially, and systematic evaluations are scarce. Reliability studies using peer review have repeatedly shown insufficient ability to distinguish between high, moderate and low quality. Considering literature recommendations, we developed an instrument to examine the quality of medical experts’ reports.

Methods

The peer review manual developed contains six quality domains (formal structure, clarity, transparency, completeness, medical-scientific principles, and efficiency) comprising 22 items. In addition, a superordinate criterion (survey confirmability) rank the overall quality and usefulness of a report. This criterion evaluates problems of inner logic and reasoning. Development of the manual was assisted by experienced physicians in a pre-test. We examined the observable variance in peer judgements and reliability as the most important outcome criteria. To evaluate inter-rater reliability, 20 anonymous experts’ reports detailing the work capacity evaluation were reviewed by 19 trained raters (peers). Percentage agreement and Kendall’s W, a reliability measure of concordance between two or more peers, were calculated. A total of 325 reviews were conducted.

Results

Agreement of peer judgements with respect to the superordinate criterion ranged from 29.2 to 87.5%. Kendall’s W for the quality domain items varied greatly, ranging from 0.09 to 0.88. With respect to the superordinate criterion, Kendall’s W was 0.39, which indicates fair agreement. The results of the percentage agreement revealed systemic peer preferences for certain deficit scale categories.

Conclusion

The superordinate criterion was not sufficiently reliable. However, in comparison to other reliability studies, this criterion showed an equivalent reliability value. This report aims to encourage further efforts to improve evaluation instruments. To reduce disagreement between peer judgments, we propose the revision of the peer review instrument and the development and implementation of a standardized rater training to improve reliability.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4387-4) contains supplementary material, which is available to authorized users.

What's the Risk? Fearful Individuals Generally Overestimate Negative Outcomes and They Dread Outcomes of Specific Events

Although it is an adaptive mechanism that danger usually elicits fear, it seems that fearful individuals overestimate the danger associated with their feared objects or situations. Previous research has not systematically distinguished between the estimated risk of an encounter with fear-relevant stimuli and the expected unpleasant outcomes of such encounters. Furthermore, it is not clear if biased risk perception is specific to an individual's fear or generalized to all negative events. In an online-survey (N = 630) we assessed the estimated risk to encounter fear-relevant stimuli and the expectations of negative outcomes of such encounters. Items contained three domains (spiders, snakes, and everyday fear triggers). In regression analyses we examined the specific associations between fear and risk estimations. In addition, we compared subgroups with specific fears and low fearful individuals. While an individual's fear score was not related to the estimated risk of an encounter with fear-specific stimuli, it was related to an overestimation of negative outcomes in all domains. The perceived risk of aversive outcomes was most pronounced for an individual's specific fear. Furthermore, an individual's specific fear was most predictive of the estimated risk of a negative fear-relevant outcome. Highly fearful individuals overestimate the risk of negative outcomes of fear-relevant encounters. Specifically, they dread outcomes of encounters with their feared object. Differentiating fear-relevant components of risk perception provides insights into the cognitions which may motivate maladaptive avoidance behavior.

All's Bad That Ends Bad: There Is a Peak-End Memory Bias in Anxiety

The peak-end memory bias has been well documented for the retrospective evaluation of pain. It describes that the retrospective evaluation of pain is largely based on the discomfort experienced at the most intense point (peak) and at the end of the episode. This is notable because it means that longer episodes with a better ending can be remembered as less aversive than shorter ones; this is even if the former had the same peak in painfulness and an overall longer duration of pain. Until now, this bias has not been studied in the domain of anxiety despite the high relevance of variable levels of anxiety in the treatment of anxiety disorders. Therefore, we set out to replicate the original studies but with an induction of variable levels of anxiety. Of 64 women, half watched a clip from a horror movie which ended at the most frightening moment. The other half watched an extended version of this clip with a moderately frightening ending. Afterward, all participants were asked to rate the global anxiety which was elicited by the video. When the film ended at the most frightening moment, participants retrospectively reported more anxiety than participants who watched the extended version. This is the first study to document that the peak-end bias can be found in the domain of anxiety. These findings require replication and extension to a treatment context to evaluate its implications for exposure therapy.

A genome-wide association meta-analysis of prognostic outcomes following cognitive behavioural therapy in individuals with anxiety and depressive disorders

Major depressive disorder and the anxiety disorders are highly prevalent, disabling and moderately heritable. Depression and anxiety are also highly comorbid and have a strong genetic correlation (rg ≈ 1). Cognitive behavioural therapy is a leading evidence-based treatment but has variable outcomes. Currently, there are no strong predictors of outcome. Therapygenetics research aims to identify genetic predictors of prognosis following therapy. We performed genome-wide association meta-analyses of symptoms following cognitive behavioural therapy in adults with anxiety disorders (n = 972), adults with major depressive disorder (n = 832) and children with anxiety disorders (n = 920; meta-analysis n = 2724). We estimated the variance in therapy outcomes that could be explained by common genetic variants (h2SNP) and polygenic scoring was used to examine genetic associations between therapy outcomes and psychopathology, personality and learning. No single nucleotide polymorphisms were strongly associated with treatment outcomes. No significant estimate of h2SNP could be obtained, suggesting the heritability of therapy outcome is smaller than our analysis was powered to detect. Polygenic scoring failed to detect genetic overlap between therapy outcome and psychopathology, personality or learning. This study is the largest therapygenetics study to date. Results are consistent with previous, similarly powered genome-wide association studies of complex traits.

Orexin in the anxiety spectrum: association of a HCRTR1 polymorphism with panic disorder/agoraphobia, CBT treatment response and fear-related intermediate phenotypes

Preclinical studies point to a pivotal role of the orexin 1 (OX₁) receptor in arousal and fear learning and therefore suggest the HCRTR1 gene as a prime candidate in panic disorder (PD) with/without agoraphobia (AG), PD/AG treatment response, and PD/AG-related intermediate phenotypes. Here, a multilevel approach was applied to test the non-synonymous HCRTR1 C/T Ile408Val gene variant (rs2271933) for association with PD/AG in two independent case-control samples (total n = 613 cases, 1839 healthy subjects), as an outcome predictor of a six-weeks exposure-based cognitive behavioral therapy (CBT) in PD/AG patients (n = 189), as well as with respect to agoraphobic cognitions (ACQ) (n = 483 patients, n = 2382 healthy subjects), fMRI alerting network activation in healthy subjects (n = 94), and a behavioral avoidance task in PD/AG pre- and post-CBT (n = 271). The HCRTR1 rs2271933 T allele was associated with PD/AG in both samples independently, and in their meta-analysis (p = 4.2 × 10^-7), particularly in the female subsample (p = 9.8 × 10^-9). T allele carriers displayed a significantly poorer CBT outcome (e.g., Hamilton anxiety rating scale: p = 7.5 × 10^-4). The T allele count was linked to higher ACQ sores in PD/AG and healthy subjects, decreased inferior frontal gyrus and increased locus coeruleus activation in the alerting network. Finally, the T allele count was associated with increased pre-CBT exposure avoidance and autonomic arousal as well as decreased post-CBT improvement. In sum, the present results provide converging evidence for an involvement of HCRTR1 gene variation in the etiology of PD/AG and PD/AG-related traits as well as treatment response to CBT, supporting future therapeutic approaches targeting the orexin-related arousal system.

Impaired Interparental Relationships in Families of Children With Attention-Deficit/Hyperactivity Disorder (ADHD)

Abstract. Research on attention-deficit/hyperactivity disorder (ADHD) in children and adolescents has traditionally focused on the genetic and neurobiological aspects of the disorder, but the role of family relationships has been much less systematically examined. There is growing evidence that the quality of interparental relationships and a child’s ADHD symptoms are reciprocally related. Because the literature appears to be inconsistent, this meta-analysis aims to summarize previous research and assess whether there are robust differences in the quality of interparental relationships between parents of children with ADHD and parents of healthy children. This meta-analysis of 15 studies with 43 effect sizes revealed a small but significant difference ( d = .24), which indicates that parents of a child with ADHD report poorer relationship quality than parents of healthy children. This effect was moderated by the child’s age and did not depend on whether the child had a comorbid oppositional defiant disorder (ODD) or conduct disorder (CD). The causality of this relationship has yet to be determined.

Dissociation in victims of childhood abuse or neglect: a meta-analytic review

Childhood abuse and neglect are associated with dissociative symptoms in adulthood. However, empirical studies show heterogeneous results depending on the type of childhood abuse or neglect and other maltreatment characteristics. In this meta-analysis, we systematically investigated the relationship between childhood interpersonal maltreatment and dissociation in 65 studies with 7352 abused or neglected individuals using the Dissociative Experience Scale (DES). We extracted DES-scores for abused and non-abused populations as well as information about type of abuse/neglect, age of onset, duration of abuse, and relationship to the perpetrator. Random-effects models were used for data synthesis, and meta-regression was used to predict DES-scores in abused populations from maltreatment characteristics. The results revealed higher dissociation in victims of childhood abuse and neglect compared with non-abused or neglected subsamples sharing relevant population features (MAbuse = 23.5, MNeglect = 18.8, MControl = 13.8) with highest scores for sexual and physical abuse. An earlier age of onset, a longer duration of abuse, and parental abuse significantly predicted higher dissociation scores. This meta-analysis underlines the importance of childhood abuse/neglect in the etiology of dissociation. The identified moderators may inform risk assessment and early intervention to prevent the development of dissociative symptoms.

Verbal instructions override the meaning of facial expressions

Psychological research has long acknowledged that facial expressions can implicitly trigger affective psychophysiological responses. However, whether verbal information can alter the meaning of facial emotions and corresponding response patterns has not been tested. This study examined emotional facial expressions as cues for instructed threat-of-shock or safety, with a focus on defensive responding. In addition, reversal instructions were introduced to test the impact of explicit safety instructions on fear extinction. Forty participants were instructed that they would receive unpleasant electric shocks, for instance, when viewing happy but not angry faces. In a second block, instructions were reversed (e.g., now angry faces cued shock). Happy, neutral, and angry faces were repeatedly presented, and auditory startle probes were delivered in half of the trials. The defensive startle reflex was potentiated for threat compared to safety cues. Importantly, this effect occurred regardless of whether threat was cued by happy or angry expressions. Although the typical pattern of response habituation was observed, defense activation to newly instructed threat cues remained significantly enhanced in the second part of the experiment, and it was more pronounced in more socially anxious participants. Thus, anxious individuals did not exhibit more pronounced defense activation compared to less anxious participants, but their defense activation was more persistent.

Social and monetary incentives counteract fear-driven avoidance: Evidence from approach-avoidance decisions

BACKGROUND AND OBJECTIVES

The reduction of avoidance behavior is a central target in the treatment of anxiety disorders, but it has rarely been studied how approach of fear-relevant stimuli may be initiated. In two studies, the impact of hypothetical monetary and symbolic social incentives on approach-avoidance behavior was examined.

METHODS

In Study 1, individuals high or low on fear of spiders (N = 84) could choose to approach a fear-relevant versus a neutral stimulus, which were equally rewarded. In a subsequent micro-intervention, approaching the fear-relevant stimulus was differentially rewarded either by monetary or social incentives. In Study 2 (N = 76), initial incentives for approach were discontinued to investigate the stability of approach.

RESULTS

Hypothetical monetary and symbolic social incentives reduced or eliminated initial avoidance, even in highly fearful individuals. Approach resulted in a decrease of self-reported aversiveness towards the fear-relevant stimulus. However, even after successful approach, fearful individuals showed significant avoidance behavior when incentives for approach were discontinued.

LIMITATIONS

Future research should investigate the long-term effects of prolonged approach incentives on multiple levels of fear (e.g., self-report, behavioral, physiological). It should also be tested if such an intervention actually improves compliance with exposure based interventions.

CONCLUSIONS

The present findings highlight that incentives are useful to initiate initial approach towards a feared stimulus. Although incentive-based approach may neither fully eliminate avoidance nor negative feelings towards the feared stimulus, such operant interventions may set the stage for more extensive extinction training.