Brooke C. Schneider

The approach-avoidance task as an online intervention in cigarette smoking: a pilot study.

BACKGROUND AND OBJECTIVES Dual-process models posit that addictive behaviors are characterized by strong automatic processes that can be assessed with implicit measures. The present study investigated the potential of a cognitive bias modification paradigm, the Approach-Avoidance Task (AAT), for retraining automatic behavioral tendencies in cigarette smoking. METHODS The study was set up as an online intervention. After completing an online survey, 257 smokers were randomly allocated either to one of two experimental conditions (AAT) or a waitlist control group. Participants responded to different pictures by pushing or pulling the computer mouse, depending on the format of the picture. Pictures in portrait format depicted smoking-related items and were associated with pushing, pictures in landscape format depicted neutral items and were associated with pulling. One version of the AAT provided individual feedback after each trial whereas the standard version did not. After four weeks, participants were re-assessed in an online survey. RESULTS Analyses revealed that the standard AAT, in particular, led to a significant reduction in cigarette consumption, cigarette dependence, and compulsive drive; no effect was found in the control group. LIMITATIONS Interpretability of the study is constrained by the fact that no active control condition was applied. CONCLUSIONS Notwithstanding the limitations, our findings indicate that the AAT might be a feasible instrument to reduce tobacco dependence and can be applied as an online intervention. Future studies should investigate whether the effects of behavior therapy can be augmented when combined with retraining interventions.

Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis

INTRODUCTION Self-help is increasingly accepted for the treatment of mental disorders, including psychosis, as both a provisional first step and a way to bridge the large treatment gap. Though mindfulness-based interventions do not belong to first line treatment strategies in psychosis and randomized controlled trials are lacking, encouraging preliminary findings speak for the usefulness of this approach. For the present study, we examined whether patients with psychosis benefit from mindfulness bibliotherapy. METHODS A sample of 90 patients with psychosis (including a subsample with a verified diagnosis of schizophrenia) took part in the study via the Internet. Following baseline assessment, participants were randomized to either a mindfulness group or a Progressive Muscle Relaxation (PMR) control group and received the respective self-help manual including accompanying audio files. Symptom change was measured six weeks after the baseline assessment with self-rating scales including the Paranoia Checklist. The retention rate was 71%. The quality of the online dataset was confirmed by various strategies (e.g., psychosis lie scale; examination of response biases). The trial was registered at the ISRCTN registry (ISRCTN86762253). RESULTS No changes across time or between groups were noted for the Paranoia Checklist. Both conditions showed a decline in depressive and obsessive-compulsive symptoms at a medium effect size (per protocol and intention to treat analyses). DISCUSSION/CONCLUSION The study provided partial support for the effectiveness of self-help mindfulness and PMR for depression in psychosis. Whether mindfulness delivered by a licensed therapist might lead to improved treatment adherence and a superior outcome relative to PMR remains to be established. The results underscore that bibliotherapy is a worthwhile approach to narrow the large treatment gap seen in psychosis.

Neurocognitive deficits in schizophrenia. Are we making mountains out of molehills

BACKGROUND Most original studies and all meta-analyses conducted to date converge on the conclusion that patients with schizophrenia display rather generalized neurocognitive deficits. For the present study, we reopen this seemingly closed chapter and examine whether important influences, such as lack of motivation and negative attitudes towards cognitive assessment, result in poorer secondary neuropsychological performance. METHOD A sample of 50 patients with an established diagnosis of schizophrenia were tested for routine neurocognitive assessment and compared to 60 nonclinical volunteers. Before and after the assessment, subjective momentary influences were examined (e.g. motivation, concerns about assessment, fear about poor outcome) for their impact on performance using a new questionnaire called the Momentary Influences, Attitudes and Motivation Impact (MIAMI) on Cognitive Performance Scale. RESULTS As expected, patients performed significantly worse than controls on all neurocognitive domains tested (large effect size, on average). However, patients also displayed more subjective momentary impairment, as well as more fears about the outcome and less motivation than controls. Mediation analyses indicated that these influences contributed to (secondary) poorer neurocognitive performance. Differences in neurocognitive scores shrank to a medium effect size, on average, when MIAMI scores were accounted for. CONCLUSIONS The data argue that performance on measures of neurocognition in schizophrenia are to a considerable extent due to secondary factors. Poor motivation, fears and momentary impairments distinguished patients from controls and these variables heavily impacted performance. Before concluding that neurocognitive deficits in psychiatric patients are present, clinicians should take these confounding influences into account. Although patients with schizophrenia achieved, on average, worse test scores than controls, a large subgroup displayed spared performance.

Efficacy of Metacognitive Training for Depression: A Randomized Controlled Trial

cruited shortly after admission to a psychosomatic outpatient day clinic (RehaCentrum Hamburg) according to the following inclusion criteria: diagnosis of a single episode or recurrent major depressive disorder or dysthymia (verified by the Mini International Psychiatric Interview) and age between 18 and 65 years. The exclusion criteria were lifetime psychotic symptoms (i.e. hallucinations, delusions, or mania), suicidality (Suicidal Behaviors Questionnaire Revised score ≥ 7), or intellectual disability (estimated IQ <70). Personality disorders and (changes in) medication were tolerated. All participants provided written informed consent prior to participation. The study was approved by the Ethics Committee of the German Psychological Association and was registered at the German Clinical Trials Register (No. DRKS00007907). The following instruments were administered at baseline (t0), 4 weeks (t1) and 6 months later (t2) by raters blind to diagnostic status: primary outcome measure: Hamilton Depression Rating Scale (HDRS) and secondary outcome measures: Beck Depression Inventory (Cronbach’s α at t0 = 0.88), Dysfunctional Attitudes Scale (α = 0.84), Rosenberg Self-Esteem Scale (α = 0.86), World Health Organization Quality of Life Assessment (α = 0.81). At t1, patients additionally filled out the Client Satisfaction Questionnaire (ZUF-8), measuring ‘general satisfaction’ with overall treatment. All patients participated in a standard intensive psychosomatic outpatient treatment program (=treatment as usual, TAU) 5 days a week for 8 h a day, which included a wide range of physical, occupational, and psychological interventions. The frequency and duration of sessions for adjunct interventions (D-MCT/HT) were equivalent across conditions (8 sessions of 60 min over a period of 4 weeks). For D-MCT, a treatment manual is available in German; materials in other languages can be downloaded at no cost via www.uke.de/depression. HT consisted of one walking and one psychoeducation session on health topics (e.g. stress reduction) per week. We conducted 2 intention-to-treat (ITT) and 1 complete-case (CC) analysis. To address missing data, last observation carried forward and multiple imputation (20 imputations) were utilized. For the CC analysis, only patients who completed assessments at all visits were considered. For all analyses, difference scores (t0 to t1 and t0 to t2, respectively) served as dependent variables, and baseline scores were entered as a covariate. Effect sizes are expressed as η p 2 (with η p 2 ≈ 0.01, η p 2 ≈ 0.06, and η p 2 ≈ 0.14 corresponding to small, medium, and large effects and a Cohen’s d of ≈ 0.2, ≈ 0.5, and ≈ 0.8, respectively). The ITT sample ( fig. 1 ) consisted of 84 patients (62 women and 22 men) with a mean age of 45.5 years (SD = 9.89). Almost two thirds of the patients (n = 49, 58.33%) were currently in a relationship. Thirty-six patients (43%) were diagnosed with a single episode of major depressive disorder, 47 (56%) with recurrent depression, and 1 with dysthymia (1%). The mean illness duration was approximately 96 months (SD = 104.96). On average, patients exEffective pharmacological and psychological treatments for depression exist. However, even if optimal treatment were accessible to all patients, the burden of depression would be reduced by only 30% [1] , partly due to dropout [2] and relapse rates after treatment [3] . Improving treatment for depression is crucial and is less a question of developing novel treatments than of determining how existing treatments can be enhanced and applied in a more straightforward and cost-effective manner. For example, low-intensity variants could be delivered by individuals without formal health care training instead of highly trained personnel [4] . To meet this need, metacognitive training for depression (DMCT) has been developed as a low-threshold, easy-to-administer, cognitive behavioral therapy-based group intervention. The aim of D-MCT is to reduce depressive symptoms by changing the patient’s cognitive biases through a metacognitive perspective. In addition to depressive thought patterns typically targeted in cognitive behavioral therapy (e.g. overgeneralization), a number of general cognitive biases, which have been identified by basic cognitive research, form the core of D-MCT (e.g. mood-congruent memory [5] ). As in metacognitive therapy according to Wells [6] , dysfunctional coping strategies are targeted (i.e. thought suppression, rumination). D-MCT also addresses the content of depressive thought patterns. Modeled after metacognitive training for psychosis [7] , D-MCT challenges cognitive biases through creative and engaging exercises (e.g. insight elicited by ‘aha experiences’). However, the content of the training is based on empirical findings in depressive patients. Use of standardized multimedia presentations reduces the time needed for preparation and administration; moreover, this packaging increases D-MCT’s accessibility to a wide range of health care providers. Safety, feasibility and effectiveness of a beta version were confirmed in an open-label pilot study [8] . The aim of the current study was to investigate the efficacy of D-MCT as an add-on intervention. We conducted a parallel, accessor-blind randomized controlled trial comparing two add-on group interventions: D-MCT (experimental group) and health training (HT, active control group). Between 2012 and 2013, patients were consecutively reReceived: August 17, 2015 Accepted: December 29, 2015 Published online: May 27, 2016

The other side of “madness”: frequencies of positive and ambivalent attitudes towards prominent positive symptoms in psychosis

Background: Phenomenological descriptions of psychosis traditionally emphasize the subjective burden that psychosis inflicts on patients. However, a growing body of work suggests that in a subgroup of patients, psychotic symptoms are appraised as positive. The present study set out to explore the frequency of positive, negative and ambivalent attitudes towards positive symptoms. We were also interested in characterizing the phenomenological structure of positive symptoms. Method: Participants were recruited over the Internet via specialized psychosis forums. Among other questionnaires, participants completed the Community Assessment of Psychic Experiences (CAPE) scale. In addition, we administered a novel scale called Subjective Perception of Positive Symptoms (SUPPOSY) that assesses core positive symptoms along various dimensions (e.g. emotional appraisal, impact on daily life). Results: For all symptom clusters, the majority of participants expressed ambivalence. Psychotic symptoms were associated with both self-reported positive and negative emotions. Experiencing regret should positive symptoms disappear was associated with prior medication noncompliance. Discussion: The present study indicates that symptoms are neither regarded as an “emotional hell” nor as a “preferred reality”. Thus, for a symptom to become a target of treatment, various aspects of the symptom have to be carefully weighed.

Neurocognitive deficits are relevant for the jumping-to-conclusions bias, but not for delusions: A longitudinal study

Patients with delusions exhibit an increased tendency to arrive at decisions based on very limited evidence (jumping-to-conclusions; JTC), making this reasoning bias relevant for the treatment of delusions. Neurocognitive deficits contribute to JTC, but it is not known whether this has any bearing on the clinical syndrome of delusions. We addressed this question by reanalyzing data from an efficacy study of non-pharmacological interventions as adjunctive treatments in schizophrenia. We investigated the longitudinal associations of cognitive functioning, JTC and delusions in patients with psychotic disorders receiving either a metacognitive intervention addressing reasoning biases (n = 59), or cognitive remediation (n = 58). Both interventions improved JTC; in the cognitive remediation group, tentative evidence suggested that better neurocognitive performance contributed to this improvement. However, JTC gains were associated with delusion improvement only in the metacognitive intervention group, suggesting a content-specific mechanism of action.

Competitive Memory Training (COMET) for OCD: A Self-treatment Approach to Obsessions

Competitive Memory Training (COMET) is a cognitive intervention that aims to change the maladaptive cognitive-emotional networks underlying obsessive-compulsive disorder (OCD). COMET has not been previously tried as a self-help intervention. The present study tested the preliminary feasibility, acceptability, and effectiveness of COMET for OCD implemented as a self-help intervention. Sixty-five participants with OCD recruited through online OCD self-help fora completed an online baseline assessment including measures of OCD symptoms, self-esteem, and depression. Participants were randomly assigned to either COMET or a wait-list control group. All participants were approached 4 weeks later to complete an online post-assessment. There was no evidence for a greater decline of OCD symptoms or depression under COMET. When analyses were limited to only those participants who reported reading the entire manual at least once, self-esteem was higher at post-assessment in the COMET group. Although 78.1% of patients in the COMET group rated it as appropriate for self-administration, only 56.5% performed COMET exercises regularly and 26.4% read the entire manual at least once. The feasibility and effectiveness of COMET as a self-help internet intervention for OCD was not supported in this study. Further work is needed to better understand if modifications to our implementation of COMET may yield improved outcomes.

Association Splitting: A randomized controlled trial of a new method to reduce craving among inpatients with alcohol dependence

Association Splitting, a novel cognitive intervention, was tested in patients with alcohol dependence as an add-on intervention in an initial randomized controlled trial. Preliminary support for Association Splitting has been found in patients with obsessive-compulsive disorder, as well as in an online pilot study of patients with alcohol use disorders. The present variant sought to reduce craving by strengthening neutral associations with alcohol-related stimuli, thus, altering cognitive networks. Eighty-four inpatients with verified diagnoses of alcohol dependence, who were currently undergoing inpatient treatment, were randomly assigned to Association Splitting or Exercise Therapy. Craving was measured at baseline, 4-week follow-up, and six months later with the Obsessive-Compulsive Drinking Scale (primary outcome) and the Alcohol Craving Questionnaire. There was no advantage for Association Splitting after three treatment sessions relative to Exercise Therapy. Among Association Splitting participants, 51.9% endorsed a subjective decline in craving and 88.9% indicated that they would use Association Splitting in the future. Despite high acceptance, an additional benefit of Association Splitting beyond standard inpatient treatment was not found. Given that participants were concurrently undergoing inpatient treatment and Association Splitting has previously shown moderate effects, modification of the study design may improve the potential to detect significant effects in future trials.

Self-Reported Symptoms of Attention-Deficit/Hyperactivity Disorder: Rate of Endorsement and Association with Neuropsychological Performance in an Adult Psychiatric Sample

The lack of specificity of attention-deficit/hyperactivity disorder (ADHD) symptoms represents a diagnostic challenge, especially when assessing psychiatric patients reporting a wide range of complaints. Rate of endorsement of ADHD symptoms, and their association with neuropsychological performance, was examined in a psychiatric sample of 71 adults, who had been referred for a neuropsychological evaluation. Patients completed two self-report measures of ADHD symptoms, the ADHD Self-Report Scale (ADHD-SR) and the Wender Utah Rating Scale-Short Form, as well as measures of attention, executive functioning, visuoconstructional ability, and verbal learning and memory. On the ADHD-SR, 74.6% of the sample met the cutoff for inattention or hyperactivity, while 81.7% met the cutoff for impulsivity. Neuropsychological performance was weakly associated with self-reported symptoms. Our results suggest that psychiatric patients commonly report symptoms of inattention, hyperactivity, and impulsivity. Assessment utilizing multiple sources is necessary to confirm whether self-reported symptoms are indicative of ADHD or reflect other causes.

An Investigation of Module-Specific Effects of Metacognitive Training for Psychosis

Metacognitive training for psychosis (MCT) is a group training program that targets cognitive biases, which play a role in the pathogenesis of delusions. It remains unclear to what extent individual MCT modules lead to within- or between-session changes in positive symptoms, sadness, cognitive biases, or theory of mind (ToM) distortions. A one-armed open-label intervention study was conducted with 176 psychiatric inpatients with psychotic symptoms. Patients were asked to fill out a questionnaire on cognitive biases, symptoms, and ToM distortions before and after each session. Multilevel (ML) modeling was used to assess associations between participation in a respective module and subsequent changes in self-reported symptoms. ML analyses indicated an overall improvement in all outcomes as well as within-session decreases in positive symptoms for a module addressing ToM distortions with a small effect. Two MCT modules addressing cognitive biases (jumping to conclusions, a bias against disconfirmatory evidence) were associated with reductions in the module-specific bias with a small and small to medium effect, respectively. The study provides initial evidence regarding module-specific associations with positive symptoms, cognitive biases, and ToM distortions in MCT.