Francesco Pagnini

Relaxation training for anxiety: a ten-years systematic review with meta-analysis

BackgroundRelaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.MethodsAll studies (1997–2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobsons progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.Results27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohens d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.ConclusionThe results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

Internet-Based Behavioral Interventions for Obesity: An Updated Systematic Review

The objective of this systematic review is to update a previous systematic review on the effectiveness of internet-based interventions for weight loss and weight loss maintenance in overweight and obese people with new or additional studies. A literature search from 2008 to March 2010 was conducted. Studies were eligible for inclusion if: participants were adults with a body mass index ≤ 25, at least one study arm involved an internet-based intervention and the primary aims were weight loss or maintenance. Eight additional studies over the eighteen included in the previous review met the inclusion criteria. Data were extracted on sample characteristics, attrition, weight loss, duration of treatment and maintenance of weight loss. Effect sizes (Hedges g) and relative 95% confidence intervals were calculated for all two-way comparisons within each study. No attempt was made to pool the data in a meta-analysis because of the great heterogeneity of designs among studies. An examination of effect sizes show that the higher significant effects pertain studies that found a superiority of behavioral internet-based programs enhanced by features such as tailored feedback on self-monitoring of weight, eating and activity over education only internet-based interventions. However, control groups are very different among studies and this heterogeneity probably accounts for much of the variance in effect sizes. Hence, questions still remain as to the effectiveness of web-based interventions in achieving weight loss or maintenance. Implications for further research include using a “real” control group in order to make meta-analysis possible and developing multi-factorial design in order to separate components of interventions and identify which of them or patterns of them are keys to success.

Can Relaxation Training Reduce Emotional Eating in Women with Obesity? An Exploratory Study with 3 Months of Follow-Up

Stress and negative emotions have been shown to be critical factors in inducing overeating as a form of maladaptive coping in some patients with obesity. We evaluated the efficacy of a 3-week relaxation protocol enhanced by virtual reality and portable mp3 players in reducing emotional eating in a sample of 60 female inpatients with obesity who report emotional eating, using a three-arm exploratory randomized controlled trial with 3 months of follow-up. The intervention included 12 individual relaxation training sessions provided traditionally (imagination condition) or supported by virtual reality (virtual reality condition). Control participants received only standard hospital-based care. Weight, behavior and psychological data were collected and analyzed. Relaxation training was effective in reducing emotional eating episodes, depressive and anxiety symptoms, and in improving perceived self-efficacy for eating control at 3-month follow-up after discharge. The virtual reality condition proved better than the imagination condition in the reduction of emotional eating. Weight decreased in subjects in all three conditions without significant differences between them, probably due to the common treatment all inpatients received. We conclude that relaxation training supported by new technologies could be a useful tool for reducing emotional eating episodes and thereby reducing weight and obesity.

Psychological wellbeing and quality of life in amyotrophic lateral sclerosis: A review

Amyotrophic lateral sclerosis is a fatal neurodegenerative disease with a progressive and rapid course that, so far, cannot be stopped or reversed. The psychological impact of the disease is huge, on both patients and caregivers. This review summarizes studies that have investigated quality of life, depression, anxiety, pain, spiritual and existential issues, hope, and hopelessness in the ALS field, with attention to both patients and their caregivers. Psychological support and the possible role of psychologists in the ALS field are also discussed.

Existential well-being and spirituality of individuals with amyotrophic lateral sclerosis is related to psychological well-being of their caregivers

Abstract Existential well-being (EWB) and spirituality issues are important factors in determining quality of life (QoL) in amyotrophic lateral sclerosis (ALS) patients. No conclusive data among the relation between patients EWB, their spirituality and caregivers’ QoL are available. In the mainframe of a longitudinal study, we performed a cross-sectional analysis aimed to investigate EWB and spirituality issues in sporadic ALS (SALS) patients and the relations with caregivers’ psychological features. Thirty-seven SALS patients, together with their caregivers, consecutively recruited at NEuroMuscular Omnicentre, in Milan, were included in this study. EWB and spirituality questions were administrated to patients and caregivers. Caregivers also completed questionnaires about quality of life (MQoL-SI), care burden (ZBI), depression (BDI) and anxiety (STAI). Both EWBs and questions about spirituality of SALS patients showed a positive correlation with MQoL-SI and EWBs in their caregivers. Conversely, SALS patients’ EWB and spirituality were negatively correlated with caregivers’ STAI, BDI and ZBI scores. In conclusion, existential well-being, as well as spirituality issues, perceived by SALS patients seems to be directly related with quality of life, severity of mood disturbance and burden experienced by their caregivers.

Amyotrophic lateral sclerosis: Time for research on psychological intervention?

Abstract The literature on psychological aspects of amyotrophic lateral sclerosis (ALS) has explored quality of life, depression, anxiety, spirituality, hopelessness, and other constructs in an attempt to understand the patients grief and other psychological responses to the disease. However, there is a lack of research on the efficacy of psychological interventions. We believe it is important to develop ‘best practices’ for the improvement of quality of life and the reduction of psychological distress related to ALS.

Pain in Amyotrophic Lateral Sclerosis: a psychological perspective

Pain in Amyotrophic Lateral Sclerosis is often underestimated and untreated by clinicians and few studies have investigated its specific features and impact. Pain experience was investigated with the Italian Questionnaire of Pain, together with the McGill Quality of Life Questionnaire for quality of life (QoL), at a baseline and at a 4-month follow-up. About half of ALS patients reported pain, described as nagging, sore, annoying, boring and exhausting, with periodic but enduring episodes. Pain was related with QoL and its intensity was able to predict QoL worsening. Obtained results indicate the importance of clinical investigation of pain in ALS patients and of the intervention with anti-pain treatment whenever necessary.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams. Objectives: To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases. Methods: A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions. Results: The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive—Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post—Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache. Conclusions: Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

Being mindful about mindfulness

288 www.thelancet.com/psychiatry Vol 2 April 2015 The results of more than three decades of research have shown the many positive eff ects that mindfulness can have on health, improving quality of life both in the general population and in clinical populations. A mindful outlook helps people to avoid automatic behaviours that rely on pre-existing or underlying assumptions and evaluations that might not be applicable to the current situation. Despite a resurgence of interest in mindfulness as shown in academic publications (fi gure), and in the published work directed at the general public, this method continues to be much misunderstood. Our view is that a broad array of clinical applications exists for an increased understanding of the diff erent approaches to mindfulness, and we focus here on the details of two well known and diff erent conceptual frameworks. There are two major theoretical frameworks defi ning mindfulness, one developed by Ellen Langer in the mid1970s and the other by Jon Kabat-Zinn in the late 1970s. Ellen Langer’s concept of mindfulness is characterised by the process of actively making new distinctions about a situation and its environment, rather than relying on automatic categorisations from the past. This process of paying attention to novelty and to the context of the current situation can lead an individual to approach the scenario from many possible perspectives, reframing events in more than one way. Processing information within this framework might result in positive healthrelated outcomes. For example, being mindful about ageing enables us to understand that our preconceived notions about the apparently inevitable course of ageing is a function of our mindset, a refl ection of the view that growing older automatically coincides with a substantial reduction in the pleasures associated with youth. If, instead, we free ourselves of the conventional limitations imposed on ageing, we might add years to our lives or at least add more life to our years. Mindfulness is the reverse of mindlessness, in which a person takes a perspective about an event or a situation and relies on automatic or repetitive thought processes, judgments and behaviour. When mindless, people rely on previously established distinctions and categories, which in turn can lead to maladaptive behaviours. Examples of mindlessness include preju dice, stereotypes, and automatic behaviours (eg, driving somewhere and not remembering how we got there). In Jon Kabat-Zinn’s theory, mindfulness focuses on paying attention in a purposeful manner, in the present moment, and non-judgmentally: without moral and emotional assessments, as if no bad or good exists. In this approach, mindfulness is promoted by meditation, particularly a westernised version of Buddhist Vipassana meditation. The community of clinical psychologists in Europe and the USA tends to rely on the Kabat-Zinn construct as illustrated in two well known mindfulnessbased interventions: mindfulness-based stress reduction, and mindfulness-based cognitive therapy. In our view, it is inconsistent with mindfulness as a way of life to defi ne it as equating to or necessitating meditation; such an approach might be deemed mindless in its requirement to follow a particular process to achieve mindfulness. The concept of mindfulness, regardless of one’s theoretical approach, refers more to a psychological construct and is not rooted in any particular mechanism or set of exercises to achieve. In this sense, we see the function that meditation has in the construct of mindfulness as analogous to the role an antidepressant drug has in relation to depression, as a mechanism infl uencing a psychological variable. Moreover, just as an antidepressant drug is not the only way to reduce depressive symptoms, meditation is not the only method to establish a state of mindfulness. We fully agree that meditation training can be powerful in the improvement of psychological well being and quality of life, as articulated in the increased focus of academic studies. However, less than 10% of the general population of the USA engages in a regular practice of meditation. Although many people might not be aware of meditation’s benefi ts, clinical experience suggests Being mindful about mindfulness

Psychological Considerations in the Assessment and Treatment of Pain in Neurorehabilitation and Psychological Factors Predictive of Therapeutic Response: Evidence and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: In order to provide effective care to patients suffering from chronic pain secondary to neurological diseases, health professionals must appraise the role of the psychosocial factors in the genesis and maintenance of this condition whilst considering how emotions and cognitions influence the course of treatment. Furthermore, it is important not only to recognize the psychological reactions to pain that are common to the various conditions, but also to evaluate how these syndromes differ with regards to the psychological factors that may be involved. As an extensive evaluation of these factors is still lacking, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) aimed to collate the evidence available across these topics. Objectives: To determine the psychological factors which are associated with or predictive of pain secondary to neurological conditions and to assess the influence of these aspects on the outcome of neurorehabilitation. Methods: Two reviews were performed. In the first, a PUBMED search of the studies assessing the association between psychological factors and pain or the predictive value of these aspects with respect to chronic pain was conducted. The included papers were then rated with regards to their methodological quality and recommendations were made accordingly. In the second study, the same methodology was used to collect the available evidence on the predictive role of psychological factors on the therapeutic response to pain treatments in the setting of neurorehabilitation. Results: The first literature search identified 1170 results and the final database included 189 articles. Factors such as depression, anxiety, pain catastrophizing, coping strategies, and cognitive functions were found to be associated with pain across the various conditions. However, there are differences between chronic musculoskeletal pain, migraine, neuropathy, and conditions associated with complex disability with regards to the psychological aspects that are involved. The second PUBMED search yielded 252 studies, which were all evaluated. Anxiety, depression, pain catastrophizing, coping strategies, and pain beliefs were found to be associated to different degrees with the outcomes of multidisciplinary programs, surgery, physical therapies, and psychological interventions. Finally, sense of presence was found to be related to the effectiveness of virtual reality as a distraction tool. Conclusions: Several psychological factors are associated with pain secondary to neurological conditions and should be acknowledged and addressed in order to effectively treat this condition. These factors also predict the therapeutic response to the neurorehabilitative interventions.