Bettina K. Doering

Utilizing placebo mechanisms for dose reduction in pharmacotherapy

The knowledge and systematic application of the placebo effect remains limited, although its importance to the treatment of various medical conditions has increasingly been recognized. A possible application of the placebo effect to pharmacotherapy is seen in conditioning processes that aim at a placebo-controlled dose reduction of drugs while maintaining the efficacy of the medical treatment. The pairing of a placebo and a pharmacological agent may achieve satisfactory treatment outcomes in combination with a lower dose of medication. This procedure includes classic and instrumental conditioning processes that involve both conscious and non-conscious information processing. Although recent studies have gathered preliminary evidence for the efficacy of placebo-controlled dose reduction (e.g. in psoriasis and attention deficit hyperactivity disorder [ADHD]), they have also illustrated the difficulties that are inherent to this approach. We critically review previous approaches and discuss designs for clinical trials that seem appropriate to the investigation of conditioned placebo effects in pharmacotherapy.

Drug treatment of primary insomnia: a meta-analysis of polysomnographic randomized controlled trials.

ContextAlthough insomnia is a frequent health complaint that is often treated with drugs, little is known about differences in treatment efficacy of various drug classes on objective versus subjective outcome measures.ObjectiveOur aim was to compare treatment efficacy of classical benzodiazepines, benzodiazepine receptor agonists (zopiclone, zolpidem and zaleplon), antidepressants (including low-dose doxepin), neuropeptides, progesterone receptor antagonists, hormones, melatonin receptor agonists, antihistamines, antiepileptics, and narcotics addressing primary insomnia.Data SourcesWe conducted a comprehensive literature search (up to 5 April 2013) using PubMed, Cochrane Clinical Trials, PQDT OPEN, OpenGREY, ISI Web of Knowledge, PsycINFO, PSYNDEX, and the WHO International Clinical Trials Registry Platform.Eligibility CriteriaOnly polysomnographic, parallel-group, randomized controlled drug trials were included; eligibility was determined by two independent authors.Data SynthesisWe used a random effects model, based on 31 studies reporting 80 treatment conditions, covering 3,820 participants.ResultsEffect size estimates for the total sample of pooled drug classes suggest that there is a small-to-moderate, significant, and robust effect for objective outcomes (sleep onset latency g = −0.36, total sleep time g = 0.27) and subjective outcomes (sleep onset latency g = −0.24, total sleep time g = 0.21). Results indicate higher effect sizes for benzodiazepine receptor agonists and classical benzodiazepines compared with antidepressants (including low-dose doxepin) and for classical benzodiazepines compared with benzodiazepine receptor agonists. Benzodiazepine receptor agonists demonstrated higher effect sizes for objective outcomes.LimitationsData on drug safety were not analyzed.ConclusionsFuture studies should use objective and subjective assessment. Focusing on efficacy, clinicians should favor benzodiazepine receptor agonists and classical benzodiazepines over antidepressants (including low-dose doxepin) for primary insomnia treatment, but the additional consideration of different side effect profiles can lead to alternative treatment decisions.

Looking beyond the importance of life goals. The personal goal model of subjective well-being in neuropsychological rehabilitation

Objective: To identify subjective importance, attainability and success of life goals and their predictive value for subjective well-being in patients with acquired brain injury. Design: Cross-sectional, descriptive. Setting: Two inpatient neurological rehabilitation centres. Participants: Patients with non-progressive neurological disorders. Interventions: Survey using questionnaires. Measures: Life goal characteristics were assessed using a life goal questionnaire (GOALS). Subjective well-being (composite score) was measured using the Center of the Epidemic Studies Depression Scale (CES-D), the Positive and Negative Affect Schedule (PANAS) and the Satisfaction With Life Scale (SWLS). Results: Fifty-nine patients participated in the study. The most important life goals are intimacy (4.59/5), achievement (3.96/5) and altruism (3.89/5). The intimacy goals are considered most attainable (4.19/5) and patients feel most successful in this domain (3.98/5). Two important predictions of the personal goal model of subjective well-being could be confirmed. First, goal attainability moderates the relation between goal importance and goal success. Second, the influence of goal importance on subjective well-being is mediated by experienced success. The most powerful predictors for subjective well-being are success in the achievement domain (β = 0.404) and discrepancy between importance and success in the intimacy domain (β = —0.276). Conclusions: The subjective well-being of neurological patients depends not only on the appraised importance of life goals but also on their attainability and success.

Treatment for complicated grief: State of the science and ways forward

Purpose of review There is increasing recognition that a minority of bereaved persons experiences persistent and disabling grief symptoms, also termed complicated grief. We review currently proposed criteria for complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11), highlight controversies with regard to establishing complicated grief as a psychiatric disorder, summarize recent complicated grief treatment research within a cognitive behavioral treatment framework, and establish a novel and systematic research agenda for complicated grief treatment. Recent findings Clinicians should be wary of overdiagnosis and misdiagnosis of complicated grief. Recent changes to definitions of complicated grief may threaten generalizability and clinical application of research findings. Universal treatment, treatment for at-risk groups and preventive complicated grief treatment appear ineffective. Although medication is often prescribed to bereaved persons, evidence for its effectiveness is equivocal. Face-to-face and internet-based cognitive behavioral therapy techniques appear most effective in targeting complicated grief. However, little is known about what, how, and for whom treatment works best. Summary In light of these findings, we recommend systematic investigation of: what works best in complicated grief treatment, by conducting well designed, stepped effectiveness trials and treatment component dismantling studies; how it works, by conducting investigations on therapeutic theories and examining mediators of therapeutic change; and for whom it works, by examining potential moderators of treatment effects.

Decline in attainability of communion and agency life goals over 2 years following acquired brain injury and the impact on subjective well-being.

Acquired brain injury (ABI) confronts patients with sudden and possibly permanent functional impairments which disrupt or block the attainment of important life goals and reduce subjective well-being (SWB). This longitudinal study aimed at investigating changes in the importance and the attainability of communion and agency life goals and their impact on SWB. Self-report measures of life goals, functional status and SWB were assessed in 42 patients during acute rehabilitation two months following ABI (baseline) and reassessed 19 months following discharge (follow up). Results indicate a significant longitudinal decrease of the general attainability of life goals and of the present success in achieving communal and agentic life goals. Life goal importance remained stable. After controlling for baseline SWB and follow up functional status the attainability of communal life goals significantly predicted SWB at follow up whereas agentic life goals failed to predict SWB. The present findings show long-term deterioration of life goal attainability. They highlight that more emphasis should be given to realistic attainability attributions during rehabilitation processes. Moreover, the results stress the need for outpatient treatment to promote disengagement from unobtainable life goals and to offer means for the engagement in alternative life goals in order to maintain or regain SWB.

The many faces of somatosensory amplification: The relative contribution of body awareness, symptom labeling, and anxiety:

The questionnaire study aimed to evaluate the relative contribution of body awareness, subjective symptoms, and anxiety to the construct of somatosensory amplification in both healthy controls (n = 475) and patients visiting their general practitioner (n = 236). Regression analysis explained 52.0 percent of total variance of the somatosensory amplification scale scores. Body awareness was the most influential predictor (β = 0.489, p < 0.001) when considering all predictors simultaneously. The results suggest that dispositional interoceptive focus, as indicated by body awareness, may be an important aspect of somatosensory amplification, over and above dispositional anxiety or subjective symptom report.

Psychosocial Stress Increases Salivary Alpha-Amylase Activity Independently from Plasma Noradrenaline Levels

Salivary alpha-amylase activity (sAA) and plasma noradrenaline (NA) concentrations are often considered to be surrogate markers of sympathetic activation in response to stress. However, despite accumulating evidence for a close association between sAA and noradrenaline and other indicators of sympathetic activity, reliability and generality of this relation remains unclear. We employed the Trier Social Stress Test (TSST) in order to directly compare the responses in sAA and NA to psychological stress in healthy volunteers (n = 23). The TSST significantly increased sAA and NA plasma levels with no significant differences in females and males. However, when subjects were divided according to their NA responses into low versus high responders, both groups did not significantly differ in their sAA before, during or after stress exposure. These data suggest that in response to acute psychological stress both plasma NA levels and sAA reflect sympathetic activity, however seemed to increase independently from each other.

Combining neuropsychological and cognitive-behavioral approaches for treating psychological sequelae of acquired brain injury.

Purpose of review Acquired brain injury (ABI) does not only result in physical and cognitive impairments, but may also entail behavioral–emotional difficulties and mental disorders. Although neuropsychological approaches target the rehabilitation of cognitive deficits, the treatment of emotional and behavioral sequelae has received less consideration. This review argues for the integration of cognitive–behavioral approaches into the rehabilitation process and examines respective recent research. Recent findings Cognitive–behavioral interventions have been investigated in the treatment of behavioral disturbances and mental disorders after ABI. They have also been targeted at supporting adaptive coping with chronic injury-related impairments. Problem-solving approaches of cognitive behavioral therapy may work as meta-models or framework for the rehabilitative process. Unfortunately, most studies reviewed employed methodologically weak designs, which limit convincing conclusions. Still, positive intervention effects have been demonstrated concerning specific outcome measures. Whether these changes also translate into increased psychosocial functioning or quality of life remains unclear. Summary Methodologically sound evidence for cognitive–behavioral interventions after ABI is limited, but preliminary results support the effectiveness of these interventions in the treatment of behavioral disorders and emotional disturbances after ABI. Integrating neuropsychological and cognitive–behavioral approaches may therefore prove beneficial to the rehabilitation process.

Dispositional aspects of body focus and idiopathic environmental intolerance attributed to electromagnetic fields (IEI‐EMF)

Body focus is often considered an undesirable characteristic from medical point of view as it amplifies symptoms and leads to higher levels of health anxiety. However, it is connected to mindfulness, well-being and the sense of self in psychotherapy. The current study aimed to investigate the contribution of various body focus related constructs to acute and chronic generation and maintenance of medically unexplained symptoms (MUS). Thirty-six individuals with idiopathic environmental intolerance to electromagnetic fields (IEI-EMF) and 36 controls were asked to complete questionnaires assessing negative affect, worries about harmful effects of EMFs, health anxiety (HA), body awareness, and somatosensory amplification (SSA), and to report experienced symptoms evoked by a sham magnetic field. Body awareness, HA, SSA, and EMF-related worries showed good discriminative power between individuals with IEI-EMF and controls. Considering all variables together, SSA was the best predictor of IEI-EMF. In the believed presence of a MF, people with IEI-EMF showed higher levels of anxiety and reported more symptoms than controls. In the IEI-EMF group, actual symptom reports were predicted by HA and state anxiety, while a reverse relationship between symptom reports and HA was found in the control group. Our findings show that SSA is a particularly important contributor to IEI-EMF, probably because it is the most comprehensive factor in its aetiology. IEI-EMF is associated with both a fear-related monitoring of bodily symptoms and a non-evaluative body focus. The identification of dispositional body focus may be relevant for the management of MUS.

Is somatosensory amplification a risk factor for an increased report of side effects? Reference data from the German general population

OBJECTIVE The study investigates the association between somatosensory amplification and the reporting of side effects. It establishes a German version of the Somatosensory Amplification Scale and examines its psychometric properties in a representative sample of the German population. METHODS Sample size was 2.469, with 51% taking any medication. Participants answered the Somatosensory Amplification Scale, Generic Assessment of Side Effects Scale, and indicated whether they were taking any medication and the type of medication. Correlational analysis and binary logistic regression were performed. RESULTS When examining a subsample reporting both medication intake and general bodily symptoms, participants higher in somatosensory amplification rated more of their general bodily symptoms as medication-attributed side effects. However, somatosensory amplification scores were not associated with the intake of any type of medication. In the overall sample, higher somatosensory amplification scores were associated with an increased report of bodily symptoms. Additionally, participants with higher somatosensory amplification reported intake of a greater number of different medications. The psychometric properties of the translated scale were good, and previously established associations of somatosensory amplification with demographic variables (age, sex) were replicated. CONCLUSION Results suggest a possible attributional bias concomitant to somatosensory amplification which in turn may increase the reporting of side effects after medication intake.