Charlotte E. Wittekind

Psychotic-like cognitive biases in borderline personality disorder.

Whereas a large body of research has linked borderline personality disorder (BPD) with affective rather than psychotic disorders, BPD patients frequently display psychotic and psychosis-prone symptoms, respectively. The present study investigated whether cognitive biases implicated in the pathogenesis of psychotic symptoms, especially delusions, are also evident in BPD. A total of 20 patients diagnosed with BPD and 20 healthy controls were administered tasks measuring neuropsychological deficits (psychomotor speed, executive functioning) and cognitive biases (e.g., one-sided reasoning, jumping to conclusions, problems with intentionalizing). Whereas BPD patients performed similar to controls on standard neuropsychological tests, they showed markedly increased scores on four out of five subscales of the Cognitive Biases Questionnaire for Psychosis (CBQp) and displayed a one-sided attributional style on the revised Internal, Personal and Situational Attributions Questionnaire (IPSAQ-R) with a marked tendency to attribute events to themselves. The study awaits replication with larger samples, but we tentatively suggest that the investigation of psychosis-related cognitive biases may prove useful for the understanding and treatment of BPD.

Do it yourself? Self-help and online therapy for people with obsessive-compulsive disorder

Purpose of review In spite of advances in the understanding and treatment of obsessive-compulsive disorder (OCD), for most patients some symptoms persist even after therapeutic intervention. Another large subgroup does not seek treatment at all, particularly due to shame or fear of stigma. The treatment gap in OCD is large and self-help is increasingly seen as a low-threshold form of intervention for individuals with minor symptoms or who are currently treatment-reluctant. Our review summarizes the expanding but still small literature on self-help and Internet interventions for OCD and provides advice on how to conduct (Internet) studies on self-help. Strategies to deal with methodological problems that notoriously plague Internet research are discussed. Recent findings Despite methodological limitations inherent in most studies considered for the current review, as well as the unreplicated nature of some of the more recent findings, self-help tools hold some promise. In particular, self-help interventions that are rooted in evidence-based concepts may be helpful as an add-on to standard interventions and as (initial) therapeutic strategies for those who are presently reluctant to participate in face-to-face treatment. Summary The current review identifies self-help, which is based on evidence-based concepts, as a promising clinical tool for the treatment of OCD. The current literature suggests that self-help can be a facilitator and aid to standard face-to-face interventions, rather than a rival.

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.

Effects of chronic posttraumatic stress disorder on metabolic risk, quality of life, and stress hormones in aging former refugee children.

It is still unclear whether the association between traumatic stress and physical disease is mediated by posttraumatic stress disorder (PTSD). Therefore, we examined the long-term consequences of PTSD on cardiovascular risk, stress hormones, and quality of life in a sample of former refugee children who were severely traumatized more than six decades ago. In 25 subjects with chronic PTSD and 25 trauma-controlled subjects, we measured the variables of metabolic syndrome supplemented by the ankle-brachial index and highly sensitive C-reactive protein. Quality of life was assessed using the 36-item Short-Form Health Survey. Cortisol, adrenocorticotropin-releasing hormone (ACTH), and dehydroepiandrosterone (DHEA) were measured using the low-dose-dexamethasone suppression test. In addition, salivary cortisol was assessed at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. We found a significant group effect between participants with and without PTSD regarding quality of life but not in any metabolic parameter including the ankle-brachial index or cortisol, ACTH, and DHEA in plasma before and after dexamethasone or salivary cortisol. The postulated association between traumatic stress and physical illness does not appear to be mediated by PTSD in this population. Nevertheless, the search for subgroups of PTSD patients with childhood traumatization leading to different metabolic and endocrine long-term consequences in aging PTSD patients is needed.

Langzeitfolgen von in der Kindheit am Ende des II. Weltkrieges erlebter Flucht und Vertreibung

Little is known about long-term consequences of flight and expulsion during childhood. The aim of this study was to interview aging former refugee children about their recollection of traumatic experiences and to screen for full and partial posttraumatic stress disorder (PTSD) and their differential impact on todays quality of life and mental health. In 502 participants from the former German eastern territories who were displaced as children at the end of World War II (at the age of 5-12 years) we examined traumatic experiences, posttraumatic stress symptoms (PDS), comorbid symptoms (SCL-90-R), depressive symptoms (BDI) and quality of life (SF-36). 31.5% participants reported posttraumatic stress symptoms indicating current full PTSD, and 33.7% fulfilled the criteria of a current partial PTSD. Participants with full and partial PTSD reported a significantly reduced quality of life, often depressive and comorbid symptoms and were compromised in their well-being compared to participants without PTSD. The study demonstrates the long-term consequences of flight and expulsion during childhood in aging former refugee children more than 60 years later. Posttraumatic stress symptoms play a prominent role for quality of life and well-being in this population.

Intergenerational transmission of biased information processing in posttraumatic stress disorder (PTSD) following displacement after World War II

An attentional bias for trauma-related stimuli has been demonstrated in individuals with posttraumatic stress disorder (PTSD). However, few studies have investigated how biological relatives of individuals with PTSD process trauma-relevant information. To investigate whether parental PTSD is associated with an attentional bias for trauma-related stimuli in adult offspring, we compared performance of individuals displaced after World War II with (n=22) and without PTSD (n=24) to a non-displaced healthy control group (n=11) and their respective offspring as to their processing of trauma-related stimuli in an emotional Stroop task. Evidence for biased information processing was neither found in individuals with PTSD nor their offspring. Possible explanations for the findings and implications for future studies are discussed.

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

Harnessing the Web: Internet and Self-Help Therapy for People with Obsessive–Compulsive Disorder and Posttraumatic Stress Disorder

Notwithstanding advances in the treatment of anxiety disorders, many patients show incomplete symptom remission following even state-of-the-art (psycho)therapy. Moreover, many people suffering from anxiety do not seek treatment at all. Self-help is increasingly regarded as a low-threshold approach to fill the apparent treatment gap. Our review summarizes the expanding but still small literature on self-help and Internet interventions for obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) suggesting that self-help rooted in evidence-based concepts is a promising clinical tool that may aid and facilitate face-to-face treatment.

Depression, not PTSD, is associated with attentional biases for emotional visual cues in early traumatized individuals with PTSD

Using variants of the emotional Stroop task (EST), a large number of studies demonstrated attentional biases in individuals with PTSD across different types of trauma. However, the specificity and robustness of the emotional Stroop effect in PTSD have been questioned recently. In particular, the paradigm cannot disentangle underlying cognitive mechanisms. Transgenerational studies provide evidence that consequences of trauma are not limited to the traumatized people, but extend to close relatives, especially the children. To further investigate attentional biases in PTSD and to shed light on the underlying cognitive mechanism(s), a spatial-cueing paradigm with pictures of different emotional valence (neutral, anxiety, depression, trauma) was administered to individuals displaced as children during World War II (WWII) with (n = 22) and without PTSD (n = 26) as well as to non-traumatized controls (n = 22). To assess whether parental PTSD is associated with biased information processing in children, each one adult offspring was also included in the study. PTSD was not associated with attentional biases for trauma-related stimuli. There was no evidence for a transgenerational transmission of biased information processing. However, when samples were regrouped based on current depression, a reduced inhibition of return (IOR) effect emerged for depression-related cues. IOR refers to the phenomenon that with longer intervals between cue and target the validity effect is reversed: uncued locations are associated with shorter and cued locations with longer RTs. The results diverge from EST studies and demonstrate that findings on attentional biases yield equivocal results across different paradigms. Attentional biases for trauma-related material may only appear for verbal but not for visual stimuli in an elderly population with childhood trauma with PTSD. Future studies should more closely investigate whether findings from younger trauma populations also manifest in older trauma survivors.

Attentional bias for affective visual stimuli in posttraumatic stress disorder and the role of depression

An attentional bias for trauma-related verbal cues was frequently demonstrated in posttraumatic stress disorder (PTSD) using variants of the emotional Stroop task (EST). However, the mechanisms underlying the Stroop-effect are ill-defined and it is yet unclear how the findings apply to different paradigms and stimulus modalities. To address these open questions, for the first time a spatial-cuing task with pictorial cues of different emotional valence was administered to trauma-exposed individuals with and without PTSD, and non-trauma-exposed controls. Groups did not show different response profiles across affective conditions. However, a group effect was evident when comparing depressed with non-depressed individuals: Those with depression showed delayed attending towards trauma-related cues and faster attending away from negative cues. In correlational analyses, attentional avoidance was associated with both depression and PTSD symptom severity. These findings highlight the need for research on trauma populations and anxiety in general to pay closer attention to depression as an important confound in the study of emotional information processing.