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Prevalence of suicidal ideation in German psychotherapy outpatients: A large multicenter assessment. J Affect Disord 2024; 351:971-976. [PMID: 38346649 DOI: 10.1016/j.jad.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/30/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024]
Abstract
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.
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Words count in psychotherapy: Differentiating language characteristics of cognitive behavioral therapy and focal psychodynamic therapy for anorexia nervosa. Psychotherapy (Chic) 2023; 60:488-496. [PMID: 37824236 DOI: 10.1037/pst0000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
It is generally assumed that psychodynamic therapy and cognitive behavioral therapy (CBT) differ in terms of applied techniques and processes. To date, however, little is known about whether and how such differences can actually be observed at a basic linguistic level and in what the two treatment approaches differ most strongly (i.e., how psychodynamic and CBT therapists differ in what they actually say word-by-word in therapy sessions). Building on theoretical models and previous research that used observer ratings, we formulated specific hypotheses regarding which word categories psychodynamic and CBT therapists who treat patients with an eating disorder should differ in. To investigate these hypotheses, we used verbatim transcripts from 297 therapy sessions of a randomized controlled trial in which patients with anorexia nervosa (n = 88) received either focal psychodynamic therapy (FPT) or CBT. These transcripts were then examined using computerized quantitative text analysis. In line with our hypotheses, we found that CBT therapists overall spoke more than their FPT counterparts and that they used more words related to eating. Also in line with our hypotheses, FPT therapists used more words related to social processes. Contrary to our expectations, CBT therapists did not show a stronger focus on the future but talked more about emotions than FPT therapists. The latter effect, however, appears to be driven by a stronger focus on positive emotions. These findings suggest that computerized quantitative text analysis can differentiate meaningful language characteristics of CBT and FPT on spoken-word level and that it holds potential as a tool for researchers and therapists. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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The role of general change mechanisms in sudden gains in the treatment of anorexia nervosa. Behav Res Ther 2023; 163:104285. [PMID: 36913844 DOI: 10.1016/j.brat.2023.104285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
Previous research has shown a robust association between sudden gains (SGs) and treatment outcome in psychotherapy for various mental disorders including anorexia nervosa (AN). However, little is known about factors contributing to SGs. This study investigated the role of general change mechanisms in body-weight related SGs in AN. Data were drawn from a randomized-controlled trial on cognitive-behavioral therapy (CBT) and focal psychodynamic therapy (FPT) for adult outpatients with AN. Session-level data on the general change mechanisms 'clarification' (insight), 'mastery' (coping), and 'therapeutic relationship' were analyzed. Pre-gain sessions were compared with control (pre-pre-gain) sessions in 99 patients with a SG in body weight. Additionally, propensity score matching was used to compare data from pre-gain sessions from 44 patients with SG and data from the corresponding session from 44 patients without SG. In the pre-gain session, patients experienced higher levels of clarification and mastery but not therapeutic relationship. Compared to patients without a SG, patients with a SG likewise experienced more clarification and mastery but not a better therapeutic relationship in the pre-gain/corresponding session. CBT and FPT did not differ regarding these effects. The findings suggest that general change mechanisms contribute to SGs in CBT and FPT for AN.
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Language style matching and treatment outcome in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2023; 31:110-120. [PMID: 35962959 DOI: 10.1002/erv.2943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Psychotherapy is the treatment of choice for anorexia nervosa (AN) but mechanisms of action are still largely unknown. Growing research suggests that synchrony between patient and therapist contributes to treatment success. Adding to this literature, this study examined the association between language style matching (LSM) among patient and therapist as an indicator of interpersonal (verbal) synchrony and treatment outcome in AN. METHOD Audio recordings of mid-treatment therapy sessions (n = 25) in a multi-centre randomized controlled trial on the Maudsley Model of Anorexia Nervosa Treatment for Adults were transcribed and used to calculate LSM for each patient-therapist dyad. These scores were used to predict treatment outcome at 12-month follow-up. RESULTS LSM did not predict body mass index (primary outcome) at follow-up. However, higher LSM (M = 0.87, SD = 0.04) was associated with lower eating disorder psychopathology (accounting for 11% of the variance) and higher recovery rates (accounting for 28% of variance) at follow-up. CONCLUSIONS These preliminary findings suggest that verbal synchrony between patients with AN and their therapists contributes to favourable treatment outcomes. High levels of LSM may reflect therapeutic empathy, cooperation, or mutual positive perception. Further research should explore the mechanisms of linguistic synchrony with larger samples to allow for stronger conclusions.
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Patient and mentor language style matching as a predictor of working alliance, engagement with treatment as usual, and eating disorders symptoms over the course of an online guided self-help intervention for anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2023; 31:135-146. [PMID: 35983983 PMCID: PMC10087304 DOI: 10.1002/erv.2948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/29/2022] [Accepted: 08/07/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors. METHOD 87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention. RESULTS Both early (1st session) and late (6th session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads. CONCLUSIONS These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome.
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Cognitive flexibility, central coherence, and quality of life in anorexia nervosa. J Eat Disord 2022; 10:22. [PMID: 35168670 PMCID: PMC8845392 DOI: 10.1186/s40337-022-00547-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/01/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Anorexia nervosa (AN) has consistently been found to be associated with poor cognitive flexibility and central coherence. These two cognitive functions have been considered important maintenance factors in AN and are addressed by specific treatment approaches such as cognitive remediation therapy. While there is clear empirical evidence that difficulties in such cognitive functions are related to impaired daily functioning in schizophrenia and bipolar disorder, this potential association has received only little attention in AN research so far. Therefore, the aim of this study was to examine potential relationships between weak cognitive flexibility, central coherence, and poor quality of life (QoL) in AN. METHODS Cognitive flexibility and central coherence were measured by both neuropsychological (i.e., performance based) and self-report measures alongside with self-reported QoL in a sample of 138 adult patients with AN. RESULTS Self-report but not performance based measures of cognitive flexibility and central coherence were associated with QoL. Weaker cognitive flexibility and central coherence were correlated with poorer QoL. These associations were independent of comorbid depression. The link between weak central coherence and poor QoL was particularly strong in patients with the restricting subtype of AN. The link between cognitive flexibility and QoL, however, was independent of AN subtype. CONCLUSIONS Weak cognitive flexibility and central coherence are associated with low QoL in AN, especially in patients with the restrictive subtype. However, this relationship is dependent on the method of measurement, where self-report measures seem to be more relevant than performance based measures.
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Cognitive remediation therapy in anorexia nervosa-A randomized clinical trial. J Consult Clin Psychol 2021; 89:805-815. [PMID: 34807656 DOI: 10.1037/ccp0000675] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Especially for adult patients with anorexia nervosa (AN), treatment response is generally low to moderate. The present study aimed to evaluate the efficacy of cognitive remediation therapy (CRT) as adjunctive treatment for AN regarding clinical and cognitive outcomes. Method: In this randomized controlled superiority trial, 167 adult and adolescent (≥17 years) patients with AN were randomly allocated (1:1) to 10 weekly sessions of group therapy of either CRT (n = 82) or art therapy (ART; n = 85) as an adjunct to inpatient treatment-as-usual (TAU). Outcomes were assessed at baseline, end-of-treatment (10 weeks), and 6-month follow-up. Change in body mass index (BMI), eating disorder psychopathology, and health-related quality of life (QoL) from baseline to 6-month follow-up served as primary outcomes. Improvements in motivation to change and several indices of set-shifting and central coherence between baseline and end-of-treatment and between baseline and 6-month follow-up served as secondary outcomes. Analysis was by intention to treat. Results: Treatment groups did not differ regarding change in BMI, eating disorder psychopathology, and health-related QoL from baseline to 6-month follow-up. Likewise, groups neither differed regarding improvements in these outcomes between baseline and end-of-treatment nor in motivation to change, set-shifting, and central coherence at any time, except for greater short-term improvements in one measure of set-shifting in the CRT group. Conclusions: CRT as an adjunct to inpatient TAU for AN was not efficacious in improving clinical and cognitive outcomes. The results do not support routine employment of CRT in inpatient treatment for AN. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Participants' experience of approach bias modification training with transcranial Direct Current Stimulation as a combination treatment for binge eating disorder. EUROPEAN EATING DISORDERS REVIEW 2021; 29:969-984. [PMID: 34460140 DOI: 10.1002/erv.2859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/25/2021] [Accepted: 08/09/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study explored participants' experience of approach bias modification training (ABM) with transcranial Direct Current Stimulation (tDCS) for binge eating disorder (BED) within a randomised controlled trial (RCT). A subset of participants who completed the RCT were interviewed to attain feedback on treatment experience and outcomes. METHOD 15 participants with BED who completed the RCT were recruited, using purposive sampling. Participants received six sessions of concurrent ABM training with either real or sham tDCS. Semi-structured interviews relating to study experience and treatment outcomes were conducted and data were analysed thematically. RESULTS The combined ABM and tDCS intervention was deemed acceptable and worthwhile by participants interviewed across both intervention groups. Negative preconceptions of tDCS were an initial deterrent to study participation for some, yet the brain stimulation experience was found to be tolerable. Minor and transient sensations and side effects attributed to tDCS were reported by most participants during and after stimulation, in addition to less pleasant aspects of ABM training, with no significant adverse effects reported by interviewees. Positive outcomes were described by participants across both intervention groups, relating to changes in BED symptoms and to broader beneficial effects on associated cognitive and emotional factors. Two participants experienced a shift in autonomy, attributed to tDCS and the combined intervention respectively. CONCLUSIONS Adults with symptoms of BED found concurrent ABM and tDCS sessions to be acceptable, despite initial apprehension about the safety of tDCS. Findings are relevant to the neuroethics literature and may inform science communication strategies on neuromodulation treatments.
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Reduced emotion recognition from nonverbal cues in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2021; 29:868-878. [PMID: 34431168 DOI: 10.1002/erv.2860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/23/2021] [Accepted: 08/09/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Recent models of anorexia nervosa (AN) emphasise the role of reduced emotion recognition ability (ERA) in the development and maintenance of the disorder. However, methodological limitations impede conclusions from prior research. The current study tries to overcome these limitations by examining ERA with an audio-visual measure that focuses strictly on multimodal nonverbal cues and allows to differentiate between ERA for different emotion categories. METHOD Forty women with AN and 40 healthy women completed the Geneva Emotion Recognition Test. This test includes 83 video clips in which 10 actors express 14 different emotions while saying a pseudo-linguistic sentence without semantic meaning. All clips contain multimodal nonverbal cues (i.e., prosody, facial expression, gestures, and posture). RESULTS Patients with AN showed poorer ERA than the healthy control group (d = 0.71), particularly regarding emotions of negative valence (d = 0.26). Furthermore, a lower body weight (r = 0.41) and longer illness duration (ρ = -0.32) were associated with poorer ERA in the AN group. CONCLUSIONS Using an ecologically valid instrument, the findings of the study support illness models emphasising poor ERA in AN. Directly addressing ERA in the treatment of AN with targeted interventions may be promising.
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No effect of very brief exposure to masked food pictures on fear of food in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2021; 29:645-656. [PMID: 33951241 DOI: 10.1002/erv.2835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Very brief exposure to masked images of spider stimuli can facilitate approach behaviour towards spiders in fearful subjects. We hypothesized that a similar effect might occur for fear of food in patients with anorexia nervosa (AN), possibly offering a new treatment approach, with advantages over other methods of food exposure. METHODS Patients with AN (n = 60) were randomly assigned to one of three experimental conditions and received a single session of exposure to either masked and very briefly presented food images, clearly visible food images, or masked non-food images (i.e. household items). Effects of the three exposure conditions on fear of food and food avoidance were examined. RESULTS Contrary to our expectations, very brief food cue exposure was not superior to the control conditions regarding fear of food and approach behaviour towards food immediately after the intervention and body mass index four weeks later. CONCLUSION This finding suggests important differences between fear of food in AN and specific phobias such as fear of spiders. The absence of an effect reveals limitations of the very brief exposure method, which might be better suited for evolutionarily relevant threat stimuli.
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Approach avoidance training to curb consumption of sugar-sweetened beverages - A pilot randomized controlled trial in healthy volunteers. Appetite 2021; 162:105194. [PMID: 33705891 DOI: 10.1016/j.appet.2021.105194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 11/29/2022]
Abstract
Elevated consumption of sugar-sweetened beverages (SSBs) contributes to overweight and obesity. Automatic action tendencies like an approach bias might promote the consumption of SSBs. We investigated whether an Approach-Avoidance Training (AAT) reduces this approach bias and related behaviors like craving for and consumption of SSBs. Fifty-six healthy participants, with a self-reported SSB consumption of at least 330 ml per day, were randomized to 6 sessions of real or sham AAT. In the real AAT condition, participants were trained to react with avoidance movements to pictures of SSBs in an implicit learning paradigm (i.e. participants were instructed to respond to a task-irrelevant feature), whereas in the sham AAT condition the same pictures were used but no systematic (avoidance) reaction was trained. Approach bias, craving for SSB and SSB intake in a bogus taste test were assessed. Real AAT was not superior to sham AAT in any outcome measure. AAT in its current form and as a stand-alone intervention does not appear to be effective in reducing SSB consumption.
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Time to make a change: A call for more experimental research on key mechanisms in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2020; 28:361-367. [PMID: 32567176 DOI: 10.1002/erv.2754] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 01/15/2023]
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Improving emotion recognition in anorexia nervosa: An experimental proof-of-concept study. Int J Eat Disord 2020; 53:945-953. [PMID: 32277519 DOI: 10.1002/eat.23276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Previous research has found increasing evidence for difficulties in emotion recognition ability (ERA) and social cognition in anorexia nervosa (AN), and recent models consider these factors to contribute to the development and maintenance of the disorder. However, there is a lack of experimental studies testing this hypothesis. Therefore, the present proof-of-concept study examined whether ERA can be improved by a single session of a computerized training in AN, and whether this has short-term effects on eating disorder symptoms. METHOD Forty inpatients (22.20 ± 7.15 years) with AN were randomly assigned to receive a single session of computerized training of ERA (TERA) or a sham training (training the recognition of different types of clouds). ERA, self-reported eating disorder symptoms, and body mass index (BMI) were assessed within 3 days before and after training. RESULTS After training, both groups showed improved ERA, reduced self-reported eating disorder symptoms, and an increased BMI. As compared to patients in the control group, patients who received TERA showed greater improvements in ERA and self-reported eating disorder symptoms. DISCUSSION ERA can be effectively trained in patients with AN. Moreover, short-term improvements in self-reported eating disorder symptoms provide tentative support for the hypothesis that difficulties in ERA contribute to the maintenance of AN, and that specific trainings of ERA hold promise as an additional component in AN treatment. Future studies are needed to replicate these findings in larger samples, and to investigate long-term effects and transfer into real-world settings.
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Approach and avoidance bias for thin-ideal and normal-weight body shapes in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2020; 28:536-550. [PMID: 32431093 DOI: 10.1002/erv.2744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/06/2020] [Accepted: 04/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The two studies aimed to examine implicit affective evaluations of thin-ideal and normal-weight body shapes in women with anorexia nervosa (AN), taking identification with body shapes into account. METHOD In study 1, approach-avoidance bias for thin-ideal and normal-weight bodies was assessed in 40 women with AN and 40 healthy women by using an Approach-Avoidance Task and female avatar bodies with a standard face as stimuli. In study 2, 39 women with AN and 38 healthy women underwent a similar task but identification with bodies was manipulated by presenting bodies once with the participant's own face and once with another woman's face. RESULTS In study 1, patients with AN did not differ from healthy participants in their automatic approach-avoidance tendencies towards thin-ideal and normal-weight bodies. In study 2, no definite approach bias for a thin self and no avoidance bias for thin other women or for a normal-weight self were found. However, as compared to healthy women, those with AN showed a less positive implicit evaluation of thin other women, and an implicit preference for thin bodies depicted as themselves over thin bodies depicted as another woman. CONCLUSIONS The findings suggest that intra-sexual competition for being slim is increased in AN.
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Approach bias modification training to increase physical activity: A pilot randomized controlled trial in healthy volunteers. J Health Psychol 2020; 26:2470-2486. [DOI: 10.1177/1359105320913936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Regular physical activity is associated with better physical and mental health outcomes as well as higher quality of life. This pilot randomized controlled trial examined whether approach bias modification, an economical and easily accessible computerized cognitive training, could increase objectively and subjectively measured physical activity in individuals aiming for more physical activity. Forty healthy volunteers of normal weight were randomly allocated to six sessions of approach bias modification or no treatment. The approach bias modification adopted an implicit learning paradigm that trained participants to show approach behavior in response to visual cues of physical activity. Approach bias modification did not increase objectively and subjectively measured physical activity.
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Sudden Gains in Cognitive Behavioural Therapy and Focal Psychodynamic Therapy for Anorexia Nervosa: Findings from the ANTOP Study. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 88:241-243. [PMID: 30991398 DOI: 10.1159/000499118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/24/2019] [Indexed: 11/19/2022]
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Combining cognitive bias modification training (CBM) and transcranial direct current stimulation (tDCS) to treat binge eating disorder: study protocol of a randomised controlled feasibility trial. BMJ Open 2019; 9:e030023. [PMID: 31640997 PMCID: PMC6830595 DOI: 10.1136/bmjopen-2019-030023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Binge eating disorder (BED) is a common mental disorder, closely associated with obesity. Existing treatments are only moderately effective with high relapse rates, necessitating novel interventions. This paper describes the rationale for, and protocol of, a feasibility randomised controlled trial (RCT), evaluating the combination of transcranial direct current stimulation (tDCS) and a computerised cognitive training, namely approach bias modification training (ABM), in patients with BED who are overweight or obese. The aim of this trial is to obtain information that will guide decision-making and protocol development in relation to a future large-scale RCT of combined tDCS+ABM treatment in this group of patients, and also to assess the preliminary efficacy of this intervention. METHODS AND ANALYSIS 66 participants with Diagnostic and Statistical Manual-5 diagnosis of BED and a body mass index (BMI) of ≥25 kg/m2 will be randomly allocated to one of three groups: ABM+real tDCS; ABM+sham tDCS or a wait-list control group. Participants in both intervention groups will receive six sessions of ABM+real/sham tDCS over 3 weeks; engaging in the ABM task while simultaneously receiving bilateral tDCS to the dorsolateral prefrontal cortex. ABM is based on an implicit learning paradigm in which participants are trained to enact an avoidance behaviour in response to visual food cues. Assessments will be conducted at baseline, post-treatment (3 weeks) and follow-up (7 weeks post-randomisation). Feasibility outcomes assess recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments. Other outcomes include eating disorder psychopathology and related neurocognitive outcomes (ie, delay of gratification and inhibitory control), BMI, other psychopathology (ie, mood), approach bias towards food and surrogate endpoints (ie, food cue reactivity, trait food craving and food intake). ETHICS AND DISSEMINATION This study has been approved by the North West-Liverpool East Research Ethics Committee. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN35717198.
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Measuring approach-avoidance tendencies towards food with touchscreen-based arm movements. PSYCHOLOGICAL RESEARCH 2019; 84:1789-1800. [PMID: 31055649 PMCID: PMC7479004 DOI: 10.1007/s00426-019-01195-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/25/2019] [Indexed: 12/11/2022]
Abstract
Most tasks for measuring automatic approach-avoidance tendencies do not resemble naturalistic approach-avoidance behaviors. Therefore, we developed a paradigm for the assessment of approach-avoidance tendencies towards palatable food, which is based on arm and hand movements on a touchscreen, thereby mimicking real-life grasping or warding movements. In Study 1 (n = 85), an approach bias towards chocolate-containing foods was found when participants reached towards the stimuli, but not when these stimuli had to be moved on the touchscreen. This approach bias towards food observed in grab movements was replicated in Study 2 (n = 60) and Study 3 (n = 94). Adding task features to disambiguate distance change through either corresponding image zooming (Study 2) or emphasized self-reference (Study 3) did not moderate this effect. Associations between approach bias scores and trait and state chocolate craving were inconsistent across studies. Future studies need to examine whether touchscreen-based approach-avoidance tasks reveal biases towards other stimuli in the appetitive or aversive valence domain and relate to relevant interindividual difference variables.
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Approach bias modification training in bulimia nervosa and binge-eating disorder: A pilot randomized controlled trial. Int J Eat Disord 2019; 52:520-529. [PMID: 30689229 DOI: 10.1002/eat.23024] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/13/2018] [Accepted: 01/07/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with poorly controlled approach behavior toward food resulting in binge eating. Approach bias modification (ABM) may reduce these automatic action tendencies (i.e., approach bias) toward food and may thus decrease binge eating and related symptoms. METHOD A total of 56 patients with BN/BED participated in this double-blind, randomized controlled trial (RCT) comparing real and sham ABM. The real ABM condition adopted an implicit learning paradigm in which participants were trained to show avoidance behavior in response to food cues. Participants in the sham condition used a similar task but were not trained to avoid food cues. Both conditions comprised 10 training sessions within 4 weeks. RESULTS Participants in both groups experienced significant reductions in binge eating, eating disorder symptoms, trait food craving, and food cue reactivity. Real ABM tended to result in greater reductions in eating disorder symptoms than sham ABM. Food intake, approach bias, and attention bias toward food did not change. DISCUSSION This is the first RCT on ABM in eating disorders. The findings provide limited support for the efficacy of ABM in BN/BED and pose questions regarding its active ingredients and its usefulness as a stand-alone treatment for eating disorders.
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Blunted emotion-modulated startle reflex in anorexia nervosa. Int J Eat Disord 2019; 52:270-277. [PMID: 30653688 DOI: 10.1002/eat.23022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 12/13/2018] [Accepted: 01/04/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Patients with anorexia nervosa (AN) often show difficulties in the perception, expression, and regulation of emotions and a strong avoidance of aversive feelings. According to psychobiological models, dietary restraint and accompanying weight loss may serve as a maladaptive mechanism of emotion regulation by attenuating aversive emotional states in AN, thereby contributing to the maintenance of the disorder. METHOD Twenty-seven women with AN and 26 age-matched healthy women were shown short film-clips to elicit fear, sadness, amusement, and neutral emotional states. Eyeblink startle response was measured by electromyography in reaction to startle-eliciting acoustic stimuli presented 12 times binaurally during each film-clip. RESULTS As compared to healthy controls, patients with AN showed a blunted startle response to the fear- but not to the sadness-eliciting stimulus. DISCUSSION The findings support the assumption that underweight is associated with attenuated emotional reactivity to fear-eliciting material in AN. This is in line with the hypothesis that starvation and low body weight constitute a maladaptive mechanism of emotion regulation in AN, contributing to the maintenance of the disorder.
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Food cue-induced craving in individuals with bulimia nervosa and binge-eating disorder. PLoS One 2018; 13:e0204151. [PMID: 30212574 PMCID: PMC6136823 DOI: 10.1371/journal.pone.0204151] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/04/2018] [Indexed: 01/09/2023] Open
Abstract
Individuals with bulimia nervosa (BN) or binge-eating disorder (BED) experience more frequent and intense food cravings than individuals without binge eating. However, it is currently unclear whether they also show larger food cue-induced increases in craving (i.e., food cue reactivity) than those without binge eating, as suggested by conditioning theories of binge eating. A group of individuals with BN or BED (binge-eating group, n = 27) and a group of individuals with low trait food craving scores and without binge eating (control group, n = 19) reported their current food craving before and after a food cue exposure. Although food craving intensity significantly increased in both groups, this increase was significantly stronger in the binge-eating group than in the control group. This result is in line with conditioning models of binge eating that propose that food cues are conditioned stimuli that elicit a conditioned response (e.g., food craving) and that this association is stronger in individuals with binge eating. As food craving increased in individuals with low trait food craving scores as well-although to a lesser extent-previous null results might be explained by methodological considerations such as not screening control participants for trait food craving.
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Abstract
BACKGROUND Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments. METHODS We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials. RESULTS We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation. CONCLUSIONS Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.
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Measurement of food-related approach–avoidance biases: Larger biases when food stimuli are task relevant. Appetite 2018; 125:42-47. [DOI: 10.1016/j.appet.2018.01.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/07/2018] [Accepted: 01/26/2018] [Indexed: 01/22/2023]
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Body image related negative interpretation bias in anorexia nervosa. Behav Res Ther 2018; 104:69-73. [DOI: 10.1016/j.brat.2018.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 03/05/2018] [Accepted: 03/12/2018] [Indexed: 11/28/2022]
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Emotional Expression Predicts Treatment Outcome in Focal Psychodynamic and Cognitive Behavioural Therapy for Anorexia Nervosa: Findings from the ANTOP Study. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:108-110. [PMID: 28183091 DOI: 10.1159/000453582] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 11/17/2016] [Indexed: 01/02/2023]
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Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis. Front Psychiatry 2018; 9:158. [PMID: 29765338 PMCID: PMC5939188 DOI: 10.3389/fpsyt.2018.00158] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/09/2018] [Indexed: 12/17/2022] Open
Abstract
Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods:The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat*/therap* and controlled trial. Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.
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Reward-related decision making and long-term weight loss maintenance. Physiol Behav 2017; 181:69-74. [DOI: 10.1016/j.physbeh.2017.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/20/2017] [Accepted: 09/08/2017] [Indexed: 01/07/2023]
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Meaningful Memory in Acute Anorexia Nervosa Patients-Comparing Recall, Learning, and Recognition of Semantically Related and Semantically Unrelated Word Stimuli. EUROPEAN EATING DISORDERS REVIEW 2016; 25:89-97. [PMID: 28032373 DOI: 10.1002/erv.2496] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/17/2016] [Accepted: 11/14/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE It is unclear whether observed memory impairment in anorexia nervosa (AN) depends on the semantic structure (categorized words) of material to be encoded. We aimed to investigate the processing of semantically related information in AN. METHOD Memory performance was assessed in a recall, learning, and recognition test in 27 adult women with AN (19 restricting, 8 binge-eating/purging subtype; average disease duration: 9.32 years) and 30 healthy controls using an extended version of the Rey Auditory Verbal Learning Test, applying semantically related and unrelated word stimuli. RESULTS Short-term memory (immediate recall, learning), regardless of semantics of the words, was significantly worse in AN patients, whereas long-term memory (delayed recall, recognition) did not differ between AN patients and controls. DISCUSSION Semantics of stimuli do not have a better effect on memory recall in AN compared to CO. Impaired short-term versus long-term memory is discussed in relation to dysfunctional working memory in AN. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
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The ABBA study - approach bias modification in bulimia nervosa and binge eating disorder: study protocol for a randomised controlled trial. Trials 2016; 17:466. [PMID: 27670138 PMCID: PMC5037622 DOI: 10.1186/s13063-016-1596-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 08/30/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The core symptoms of bulimia nervosa (BN) and binge eating disorder (BED) are recurrent episodes of binge eating. Despite negative psychological and physical consequences, BN/BED patients show uncontrollable approach tendencies towards food. This cognitive bias occurs at an early stage of information processing. Cognitive bias modification (CBM) directly targets such biases and has been shown to be effective in treating several mental disorders. In alcohol addiction, automatic action tendencies towards alcohol cues and relapse rates were successfully reduced by a specific form of CBM, termed approach bias modification. Based on these findings and data from a proof-of-concept study in people with high levels of food craving, CBM is considered a promising new treatment approach for BN/BED. Given the similarities between BN/BED and addictive disorders, the rationale for using approach bias modification appears to be particularly strong. The aim of the present study is to examine whether, compared to a sham training, computerised approach bias modification (10 sessions) can reduce binge-eating episodes in BN/BED patients from pre-treatment to follow-up. Additionally, we will investigate whether this CBM programme also reduces global eating disorder psychopathology, trait and cue-elicited food craving, food intake as well as approach and attentional bias towards visual food cues. Treatment acceptance will be determined by attrition rates and responses on a feedback form. METHODS This is a double-blind, randomised, placebo-controlled, parallel-group superiority trial with two parallel arms. A total of 54 BN/BED patients will be recruited. Approach bias towards food will be retrained by a computer task adopting an implicit learning paradigm. Patients in the control condition (sham) will conduct a similar task but will not be trained to avoid food cues. Methods against bias include public registration, randomisation by a central study office, standardisation of the treatments and blinding of assessors. Furthermore, the session number and duration will be equivalent in the two conditions. DISCUSSION This is the first registered randomised controlled trial of approach bias modification in a clinical BN/BED sample. Results from this study will provide an indication of the efficacy of approach bias modification training for BN/BED and the potential mechanisms of action underlying this treatment. TRIAL REGISTRATION DRKS00010231 (retrospectively registered on 24 March 2016; first version).
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Social cognition in anorexia nervosa: Specific difficulties in decoding emotional but not nonemotional mental states. Int J Eat Disord 2016; 49:883-90. [PMID: 27315544 DOI: 10.1002/eat.22574] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Building on recent models of anorexia nervosa (AN) that emphasize the importance of impaired social cognition in the development and maintenance of the disorder, the present study aimed at examining whether women with AN have more difficulties with inferring other people's emotional and nonemotional mental states than healthy women. METHOD Social cognition was assessed in 25 adult women with AN and 25 age-matched healthy women. To overcome limitations of previous research on social cognition in AN, the processing of social information was examined in a more complex and ecologically valid manner. The Movie for the Assessment of Social Cognition (MASC) reflects complex real-life social interaction and allows for disentangling emotional and non-emotional mental state inference as well as different types of errors in mentalizing. RESULTS Women with AN showed poorer emotional mental state inference, whereas non-emotional mental state inference was largely intact. Groups did not differ in undermentalizing (overly simplistic theory of mind) and overmentalizing (overly complex or over-interpretative mental state reasoning). Performance in the MASC was independent of levels of eating disorder psychopathology and symptoms of depression and anxiety. DISCUSSION The findings suggest that AN is associated with specific difficulties in emotional mental state inference despite largely intact nonemotional mental state inference. Upon replication in larger samples, these findings advocate a stronger emphasis on socio-emotional processing in AN treatment. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:883-890).
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Brain effects of computer-assisted cognitive remediation therapy in anorexia nervosa: A pilot fMRI study. Psychiatry Res Neuroimaging 2016; 249:52-56. [PMID: 27000307 DOI: 10.1016/j.pscychresns.2016.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/07/2016] [Accepted: 02/20/2016] [Indexed: 10/22/2022]
Abstract
Poor cognitive-behavioral flexibility is considered a trait marker in anorexia nervosa (AN) that can be improved by cognitive remediation therapy (CRT). The present pilot study aimed at identifying changes in brain function potentially associated with CRT in AN. Data was obtained from a randomized, controlled trial. Twenty-four patients were assessed before and after 30 sessions of either CRT or a non-specific neurocognitive therapy. Voxel-wise analysis of whole brain functional magnetic resonance imaging was applied. Brain activation was measured during response inhibition and task switching. Although results did not reach significance, we found tentative support for CRT-related increases in brain activation in the dorsal putamen during task switching and in the dorsolateral prefrontal, sensorimotor and temporal cortex during response inhibition. These pilot findings provide viable pathways for future research on brain changes underlying CRT in AN.
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First-person Pronoun Use in Spoken Language as a Predictor of Future Depressive Symptoms: Preliminary Evidence from a Clinical Sample of Depressed Patients. Clin Psychol Psychother 2016; 24:384-391. [PMID: 26818665 DOI: 10.1002/cpp.2006] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 12/30/2015] [Accepted: 01/04/2016] [Indexed: 11/11/2022]
Abstract
Several theories suggest that self-focused attention plays an important role in the maintenance of depression. However, previous studies have predominantly relied on self-report and laboratory-based measures such as sentence completion tasks to assess individual differences in self-focus. We present a prospective, longitudinal study based on a sample of 29 inpatients with clinical depression, investigating whether an implicit, behavioural measure of self-focused attention, i.e., the relative frequency of first-person singular pronouns in naturally spoken language, predicts depressive symptoms at follow-up over and above initial depression. We did not find a significant cross-sectional association between depressive symptoms and first-person singular pronoun use. However, first-person singular pronoun use significantly predicted depressive symptoms approximately 8 months later, even after controlling for depressive symptoms at baseline or discharge. Exploratory analyses revealed that this effect was mainly driven by the use of objective and possessive self-references such as 'me' or 'my'. Our findings are in line with theories that highlight individual differences in self-focused attention as a predictor of the course of depression. Moreover, our findings extend previous work in this field by adopting an unobtrusive approach of non-reactive assessment, capturing naturally occurring differences in self-focused attention. We discuss possible clinical applications of language-based assessments and interventions with regard to self-focus. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE Naturally occurring individual differences in first-person singular pronoun use provide an unobtrusive way to assess patients' automatic self-focused attention. Frequent use of first-person singular pronouns predicts an unfavourable course of depression. Self-focused language might offer innovative ways of tracking and targeting therapeutic change.
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Inhibitory Control and Hedonic Response towards Food Interactively Predict Success in a Weight Loss Programme for Adults with Obesity. Obes Facts 2016; 9:299-309. [PMID: 27701173 PMCID: PMC5644782 DOI: 10.1159/000447492] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/01/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Low inhibitory control and strong hedonic response towards food are considered to contribute to overeating and obesity. Based on previous research, the present study aimed at examining the potentially crucial interplay between these two factors in terms of long-term weight loss in people with obesity. METHODS BMI, inhibitory control towards food, and food liking were assessed in obese adults prior to a weight reduction programme (OPTIFAST® 52). After the weight reduction phase (week 13) and the weight loss maintenance phase (week 52), participants' BMI was re-assessed. RESULTS Baseline BMI, inhibitory control and food liking alone did not predict weight loss. As hypothesised, however, inhibitory control and food liking interactively predicted weight loss from baseline to week 13 and to week 52 (albeit the latter effect was less robust). Participants with low inhibitory control and marked food liking were less successful in weight reduction. CONCLUSION These findings underscore the relevance of the interplay between cognitive control and food reward valuation in the maintenance of obesity.
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Reward-related decision making in eating and weight disorders: A systematic review and meta-analysis of the evidence from neuropsychological studies. Neurosci Biobehav Rev 2015; 61:177-96. [PMID: 26698021 DOI: 10.1016/j.neubiorev.2015.11.017] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/30/2015] [Indexed: 02/02/2023]
Abstract
Eating disorders (EDs) and overweight/obesity (OW/OB) are serious public health concerns that share common neuropsychological features and patterns of disturbed eating. Reward-related decision making as a basic neurocognitive function may trans-diagnostically underlie both pathological overeating and restricted eating. The present meta-analysis synthesizes the evidence from N=82 neuropsychological studies for altered reward-related decision making in all ED subtypes, OW and OB. The overall effect sizes for the differences between currently-ill ED patients and OW/OB people and controls were Hedge's g=-0.49 [CI: -0.63; -0.35], and Hedge's g=-0.39 [CI: -0.53; -0.25], respectively. Decision making was found to be altered to similar degrees in all ED subtypes and OB. Effect sizes, however, diverged for the different measures of decision making. Adolescents appear to be less affected than adults. When foods were used as rewarding stimuli, decision making was found to be intact in OB. The findings support that altered general reward-related decision making is a salient neuropsychological factor across eating and weight disorders in adulthood.
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Approach bias and cue reactivity towards food in people with high versus low levels of food craving. Appetite 2015; 95:197-202. [DOI: 10.1016/j.appet.2015.07.013] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/30/2015] [Accepted: 07/12/2015] [Indexed: 11/25/2022]
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Mood-incongruent processing during the recall of a sad life event predicts the course and severity of depression. J Affect Disord 2015; 187:91-6. [PMID: 26322713 DOI: 10.1016/j.jad.2015.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/29/2015] [Accepted: 08/04/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Previous studies suggest that mood-incongruent processing constitutes an adaptive mood regulation strategy, and that difficulties in this process may contribute to the maintenance of depression. However, no study has yet examined whether mood-incongruent processing predicts the course and severity of clinical depression. METHODS To address this question, the present study used a prospective, longitudinal design to examine the effects of mood-incongruent processing in a sample of 59 clinically depressed patients. At baseline, participants were asked to recall and describe a sad and a happy life event. Participants' utterances were transcribed and analysed using computerized text analysis. Negated emotion words were excluded. The proportion of positive emotion words during sad memory recall was used as an indicator of mood-incongruent processing. After 6 months, participants were re-assessed for symptom levels and the criteria of major depressive disorder (MDD) during the follow-up period. RESULTS Higher relative frequency of positive emotion words during sad memory recall was associated with less symptoms of depression at follow-up and shorter time to recovery from MDD, over and above baseline symptoms of depression. The effect was not just due to increased general positivity in emotional expression or emotional expressiveness per se. LIMITATIONS The sample size and the timeframe for the follow-up assessment were limited. Furthermore, it is unknown to which degree word use reflects the actual experience of the expressed emotions. CONCLUSIONS The findings highlight the role of mood-incongruent processing in the maintenance of depression and advocate a stronger focus on mood-incongruent processing in the treatment of depression.
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Me, myself, and I: self-referent word use as an indicator of self-focused attention in relation to depression and anxiety. Front Psychol 2015; 6:1564. [PMID: 26500601 PMCID: PMC4598574 DOI: 10.3389/fpsyg.2015.01564] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/28/2015] [Indexed: 11/13/2022] Open
Abstract
Self-focused attention (SFA) is considered a cognitive bias that is closely related to depression. However, it is not yet well understood whether it represents a disorder-specific or a trans-diagnostic phenomenon and which role the valence of a given context is playing in this regard. Computerized quantitative text-analysis offers an integrative psycho-linguistic approach that may help to provide new insights into these complex relationships. The relative frequency of first-person singular pronouns in natural language is regarded as an objective, linguistic marker of SFA. Here we present two studies that examined the associations between SFA and symptoms of depression and anxiety in two different contexts (positive vs. negative valence), as well as the convergence between pronoun-use and self-reported aspects of SFA. In the first study, we found that the use of first-person singular pronouns during negative but not during positive memory recall was positively related to symptoms of depression and anxiety in patients with anorexia nervosa with varying levels of co-morbid depression and anxiety. In the second study, we found the same pattern of results in non-depressed individuals. In addition, use of first-person singular pronouns during negative memory recall was positively related to brooding (i.e., the assumed maladaptive sub-component of rumination) but not to reflection. These findings could not be replicated in two samples of depressed patients. However, non-chronically depressed patients used more first-person singular pronouns than healthy controls, irrespective of context. Taken together, the findings lend partial support to theoretical models that emphasize the effects of context on self-focus and consider SFA as a relevant trans-diagnostic phenomenon. In addition, the present findings point to the construct validity of pronoun-use as a linguistic marker of maladaptive self-focus.
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Social organization and space use of a wild mandrill (Mandrillus sphinx) group. Am J Primatol 2015; 77:1036-48. [PMID: 26235675 DOI: 10.1002/ajp.22439] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 05/22/2015] [Accepted: 05/23/2015] [Indexed: 11/09/2022]
Abstract
Mandrills (Mandrillus sphinx) are enigmatic Old World primates whose social organization and ecology remain poorly known. Previous studies indicated, for example, that groups are composed of only adult females and their young or that several units composed of one adult male and several females make up larger permanent social units. Here, we present the first data on group composition and male ranging patterns from the only habituated wild mandrill group and examine how home range size and daily path length varied with environmental and demographic factors over a 15-month period. Our study site is located in southern Gabon where we followed the group on a daily basis, collecting data on presence, ranging, behavior, and parasite load of its individual members. Throughout the study, the group was made up of about 120 individuals, including several non-natal and natal adult and sub-adult males. One-male units were never observed. The mandrills traveled an estimated 0.44-6.50 km/day in a home range area of 866.7 ha. Exploratory analyses revealed that precipitation, the number of adult males present, and the richness of protozoan parasites were all positively correlated with daily path length. These results clarify the social system of mandrills and provide first insights into the factors that shape their ranging patterns.
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Approach Bias Modification in Food Craving-A Proof-of-Concept Study. EUROPEAN EATING DISORDERS REVIEW 2015; 23:352-60. [DOI: 10.1002/erv.2382] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/11/2015] [Accepted: 06/08/2015] [Indexed: 11/06/2022]
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Differentiating early-onset chronic depression from episodic depression in terms of cognitive-behavioral and emotional avoidance. J Affect Disord 2015; 175:418-23. [PMID: 25679196 DOI: 10.1016/j.jad.2015.01.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 01/16/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although chronic depression is associated with lower global functioning and poorer treatment response than episodic depression, little is known about the differences between these two forms of depression in terms of psychological factors. Thus, the present study aimed at differentiating chronic and episodic depression regarding cognitive-behavioral and emotional avoidance that have been proposed as important risk factors for depression and promising targets for the treatment of depression. METHODS Thirty patients with early onset chronic depression were compared with 30 patients with episodic depression and 30 healthy, never-depressed controls in terms of self-reported cognitive-behavioral (social and non-social) and emotional avoidance. RESULTS Chronically depressed patients reported more avoidance than healthy controls in each of the measures. Moreover, they reported more cognitive-nonsocial and behavioral-nonsocial as well as behavioral-social and emotional avoidance (in the form of restricted emotional expression to others) than patients with episodic depression. This kind of emotional avoidance also separated best between chronically and episodically depressed patients. Furthermore, general emotion avoidance and behavioral-social avoidance were positively correlated with levels of depression in chronically depressed patients. LIMITATIONS The results are based on self-report data and should thus be interpreted with caution. Additionally, the cross-sectional design limits any causal conclusions. CONCLUSIONS The findings underscore the relevance of cognitive-behavioral and emotional avoidance in differentiating chronic from episodic depression and healthy controls and advocate a stronger focus on maladaptive avoidance processes in the treatment of chronic depression.
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The temporal dynamics of cognitive reactivity and their association with the depression risk: an exploratory study. Psychopathology 2015; 48:114-9. [PMID: 25720814 DOI: 10.1159/000368782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 10/01/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cognitive reactivity is the change in depressive thinking in response to negative mood. Previous research indicates that cognitive reactivity is an important variable in the etiology and course of depression. The present study tested which time interval after a negative mood induction is critical for the prediction of the depression risk. METHODS Participants suffering from a major depressive disorder were recruited when entering inpatient treatment. At the end of inpatient treatment they completed an experimental procedure to assess their depressive thinking once before and twice after a negative mood induction. Subsequently, patients were followed up for 26 weeks. RESULTS The immediate change in depressive thinking in response to the negative mood induction was negatively associated with future depression. The delayed change did not predict the depression risk. CONCLUSION The negative association between the immediate change in depressive thinking and the depression risk is not in line with results from previous studies on cognitive reactivity. Previous research on emotion context insensitivity and the avoidance of negative thoughts offers hypotheses which could account for this result. Further research is needed to shed light on the processes underlying cognitive reactivity.
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Corrigendum: Impaired cross-talk between mesolimbic food reward processing and metabolic signaling predicts body mass index. Front Behav Neurosci 2014. [PMCID: PMC4264505 DOI: 10.3389/fnbeh.2014.00433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Set-shifting ability across the spectrum of eating disorders and in overweight and obesity: a systematic review and meta-analysis. Psychol Med 2014; 44:3365-3385. [PMID: 25066267 DOI: 10.1017/s0033291714000294] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In this meta-analysis we review the findings from neuropsychological studies on set-shifting in people with eating disorders (EDs) or overweight/obesity. METHOD Four databases (PubMed, PsycINFO, PSYNDEX and Web of Science) were searched for eligible studies. Effect sizes (ESs) were pooled using random-effects models. Moderator analyses were conducted for ED and overweight/obese subgroups, adult/adolescent samples and measures of set-shifting. RESULTS Sixty-four studies with a total of 1825 ED patients [1394 anorexia nervosa (AN), 376 bulimia nervosa (BN) and 55 binge eating disorder (BED)] and 10 studies with a total of 449 overweight/obese individuals were included. The meta-analysis revealed a small to medium ES for inefficient set-shifting across all three ED diagnoses (Hedges' g = -0.45). Subgroup analyses yielded small to medium ESs for each ED subtype (g = -0.44 for AN, -0.53 for BED, -0.50 for BN), which did not differ significantly. There was a medium ES for restricting type AN (ANR; g = -0.51) but no significant ES for binge/purge type AN (AN/BP; g = -0.18). A medium ES was found across obesity studies (g = -0.61). The ES across overweight studies was not significant (g = -0.07). Adult samples did not differ from adolescent samples in either ED or overweight/obesity studies. The different set-shifting measures were associated with largely varying ESs. CONCLUSIONS The meta-analysis provides strong support that inefficient set-shifting is a salient neuropsychological phenomenon across ED subtypes and obesity, but is less prominent in AN/BP and overweight. Compulsivity seems to be a common underlying factor supporting a dimensional and transdiagnostic conceptualization of EDs and obesity.
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[Mealtime support for patients with eating disorders: a survey on the clinical practice in German eating disorders centers]. Psychother Psychosom Med Psychol 2014; 65:112-8. [PMID: 25401216 DOI: 10.1055/s-0034-1389960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Mealtime support is a cornerstone of eating disorders (ED) inpatient and day-care treatment but has received only little attention in research so far and no valid recommendations are available for this type of intervention. Thus, the aim of the present study was to gather a comprehensive picture of how mealtime support is currently practiced in Germany. In a nationwide survey, 97 staff members from 66 ED centers across Germany completed a survey-form that covered 4 broad topics: (a) setting, (b) general conditions, (c) specific interventions, and (d) treatment providers' perspective. For the most part, mealtime support is delivered by nurses. Two thirds of the centers provide at least one therapeutically supported meal per day. Most centers offer their patients a kitchen and/or a guided cooking group. Patient eating behavior and amount of food eaten is documented by three quarters of staff members. Most staff members offer some kind of role modeling by eating their own meals at the same table. Food exposure is provided by a minority. Whereas two thirds use sanctions when patients did not achieve their eating goals, only one third use positive reinforcement when patients achieved their goals. Less than one half offer some kind of post-meal support. The results provide important insights into the current practice of mealtime support and will thus inform future studies that examine the efficacy of different types and interventions of mealtime support.
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Impaired Cross-Talk between Mesolimbic Food Reward Processing and Metabolic Signaling Predicts Body Mass Index. Front Behav Neurosci 2014; 8:359. [PMID: 25368558 PMCID: PMC4201102 DOI: 10.3389/fnbeh.2014.00359] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 09/27/2014] [Indexed: 12/20/2022] Open
Abstract
The anticipation of the pleasure derived from food intake drives the motivation to eat, and hence facilitate overconsumption of food, which ultimately results in obesity. Brain imaging studies provide evidence that mesolimbic brain regions underlie both general as well as food-related anticipatory reward processing. In light of this knowledge, the present study examined the neural responsiveness of the ventral striatum (VS) in participants with a broad BMI spectrum. The study differentiated between general (i.e., monetary) and food-related anticipatory reward processing. We recruited a sample of volunteers with greatly varying body weights, ranging from a low BMI (below 20 kg/m(2)) over a normal (20-25 kg/m(2)) and overweight (25-30 kg/m(2)) BMI, to class I (30-35 kg/m(2)) and class II (35-40 kg/m(2)) obesity. A total of 24 participants underwent functional magnetic resonance imaging while performing both a food and monetary incentive delay task, which allows to measure neural activation during the anticipation of rewards. After the presentation of a cue indicating the amount of food or money to be won, participants had to react correctly in order to earn "snack points" or "money coins," which could then be exchanged for real food or money, respectively, at the end of the experiment. During the anticipation of both types of rewards, participants displayed activity in the VS, a region that plays a pivotal role in the anticipation of rewards. Additionally, we observed that specifically anticipatory food reward processing predicted the individual BMI (current and maximum lifetime). This relation was found to be mediated by impaired hormonal satiety signaling, i.e., increased leptin levels and insulin resistance. These findings suggest that heightened food reward motivation contributes to obesity through impaired metabolic signaling.
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Difficulties in emotion regulation across the spectrum of eating disorders. Compr Psychiatry 2014; 55:565-71. [PMID: 24411653 DOI: 10.1016/j.comppsych.2013.12.001] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/14/2013] [Accepted: 12/01/2013] [Indexed: 10/25/2022] Open
Abstract
Theoretical models consider difficulties in emotion regulation (ER) as central trans-diagnostic phenomena across the spectrum of eating disorders (ED). However, there is a lack of studies directly comparing ED subtypes regarding ER problems. Furthermore, patients with anorexia nervosa-restricting type (AN-R) and patients with AN-binge/purge type (AN-BP) have usually been merged into one overall AN group in previous research on ER. In order to overcome these limitations of previous studies, the present study investigated specific ER difficulties in 120 patients with different ED subtypes, including AN-R, AN-BP, bulimia nervosa (BN), and binge-eating disorder (BED). As compared to 60 healthy normal-weight controls (NWC) and 29 healthy over-weight controls (OWC), all ED subtypes reported greater difficulties in ER. ED subtypes did not differ regarding most domains of ER except BED showing less severe ER difficulties in some domains. In addition, AN-BP but not BN reported greater impulse control difficulties than AN-R and BED. The findings underscore the relevance of ER difficulties in ED and support the trans-diagnostic view of ER difficulties being present across the whole spectrum of ED. In addition, the present results suggest that certain domains of ER may be linked more closely to certain ED subtypes than to others.
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[The short form of the NMR scale (NMR-SF) as an instrument for measuring the self-rated ability for negative mood regulation: review and construct validity]. Psychother Psychosom Med Psychol 2014; 64:108-14. [PMID: 24343311 DOI: 10.1055/s-0033-1361153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The NMR-SF is the short form of the NMR Scale. The NMR-SF is a self-rating instrument to measure negative mood regulation expectancies. This construct is an important variable in the etiology and psychotherapy of mental disorders. The present study investigates the construct validity of the NMR-SF in 2 non-clinical samples and a sample of depressed patients. The NMR-SF was positively correlated with adaptive strategies of mood regulation and negatively with maladaptive strategies. High scores on the NMR-SF were associated with less psychopathology. There was a small positive correlation with social desirability. The results of the current study support the construct validity of the NMR-SF and indicate that its psychometric properties are good. Due to its efficiency, the NMR-SF is well applicable in clinical samples, especially when using repeated measurements designs.
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Preliminary Evidence for a Nexus between Rumination, Behavioural Avoidance, Motive Satisfaction and Depression. Clin Psychol Psychother 2014; 22:232-9. [DOI: 10.1002/cpp.1885] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 12/06/2013] [Accepted: 12/09/2013] [Indexed: 11/09/2022]
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Training cognitive flexibility in patients with anorexia nervosa: a pilot randomized controlled trial of cognitive remediation therapy. Int J Eat Disord 2014; 47:24-31. [PMID: 24166941 DOI: 10.1002/eat.22206] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/04/2013] [Accepted: 09/14/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Inefficient cognitive flexibility is considered a neurocognitive trait marker involved in the development and maintenance of anorexia nervosa (AN). Cognitive Remediation Therapy (CRT) is a specific treatment targeting this cognitive style. The aim of this study was to investigate the feasibility and efficacy (by estimating the effect size) of specifically tailored CRT for AN, compared to non-specific cognitive training. METHOD A prospective, randomized controlled, superiority pilot trial was conducted. Forty women with AN receiving treatment as usual (TAU) were randomized to receive either CRT or non-specific neurocognitive therapy (NNT) as an add-on. Both conditions comprised 30 sessions of computer-assisted (21 sessions) and face-to-face (9 sessions) training over a 3-week period. CRT focused specifically on cognitive flexibility. NNT was comprised of tasks designed to improve attention and memory. The primary outcome was performance on a neuropsychological post-treatment assessment of cognitive set-shifting. RESULTS Data available from 25 treatment completers were analyzed. Participants in the CRT condition outperformed participants in the NNT condition in cognitive set-shifting at the end of the treatment (p = 0.027; between-groups effect size d = 0.62). Participants in both conditions showed high treatment acceptance. DISCUSSION This study confirms the feasibility of CRT for AN, and provides a first estimate of the effect size that can be achieved using CRT for AN. Furthermore, the present findings corroborate that neurocognitive training for AN should be tailored to the specific cognitive inefficiencies of this patient group.
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