Fritz Renner

Early maladaptive schemas in depressed patients: Stability and relation with depressive symptoms over the course of treatment

BACKGROUND Early maladaptive schemas (EMSs) are hypothesized to be stable, trait-like, enduring beliefs underlying chronic and recurrent psychological disorders. We studied the relation of EMSs with depressive symptom severity and tested the stability of EMSs over a course of evidence-based outpatient treatment for depression in a naturalistic treatment setting. METHODS The sample consisted of depressed outpatients (N=132) treated at a specialized mood disorders treatment unit in The Netherlands. Participants completed measures of depressive symptom severity and maladaptive schemas before treatment and 16-weeks after starting with treatment. RESULTS Specific maladaptive schemas (failure, emotional deprivation, abandonment/instability) were cross-sectionally related to depressive symptom severity. Moreover, the schema domain impaired autonomy & performance at pre-treatment related positively to depression levels at the 16-week follow-up assessment, whereas the schema domain overvigilance & inhibition at pre-treatment related negatively to depression levels at the follow-up assessment when controlling for pre-treatment depression severity. Finally, all EMSs demonstrated good relative stability over the course of treatment. CONCLUSIONS Our results suggest that specific EMSs are related to depressive symptom severity in clinically depressed patients, that specific schema domains predict treatment outcome, and that schemas are robust to change over time, even after evidence-based outpatient treatment for depression.

Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial

BACKGROUND Behavioural activation might be a viable alternative to antidepressant medication for major depressive disorder. AIMS To compare the effectiveness of behavioural activation and treatment as usual (TAU, antidepressant medication) for major depressive disorder in routine clinical practice in Iran. METHOD Patients with major depressive disorder (n = 100) were randomised to 16 sessions of behavioural activation (n = 50) or antidepressant medication (n = 50) (IRCT138807192573N1). The main outcome was depression, measured with the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD), assessed at 0, 4, 13 and 49 weeks. RESULTS Symptom reduction was greater in the behavioural activation group than in the TAU group on both the BDI and the HRSD at 13 and 49 weeks in multilevel analysis. Baseline depression severity was a moderator, with relatively better effects for behavioural activation in individuals who were more severely depressed. Also, there was better retention in the behavioural activation than in the TAU group. CONCLUSIONS Behavioural activation is a viable and effective treatment for people with major depressive disorder, especially for those who are more severely depressed, and it can successfully be disseminated into routine practice settings in a non-Western country such as Iran.

Extended Schema Mode Conceptualizations for Specific Personality Disorders: An Empirical Study

The aim of this study was to investigate newly formulated schema mode models for cluster-C, paranoid, histrionic and narcissistic personality disorders. In order to assess 18 hypothesized modes, the Schema Mode Inventory (SMI) was modified into the SMI-2. The SMI-2 was administered to a sample of 323 patients (with a main diagnosis on one of the PDs mentioned) and 121 nonpatients. The SMI-2 was successful in distinguishing patients and controls. Newly formulated modes proved to be appropriate for histrionic, avoidant, and dependent PD. The modification of the Overcontroller mode into the Perfectionistic and Suspicious Overcontroller mode was valuable for characterizing paranoid and obsessive-compulsive PD. The results support recent theoretical developments in Schema Therapy, and are useful for application in clinical practice.

Self-reported psychotic-like experiences are a poor estimate of clinician-rated attenuated and frank delusions and hallucinations.

Background: One reason for the decision to delay the introduction of an Attenuated Psychosis Syndrome in the main text of the fifth edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders was the concern that attenuated psychotic symptoms (APS) might in fact be common features in adolescents and young adults from the general population of no psychopathological significance in themselves. This concern was based on reports of high prevalence rates of psychotic-like experiences (PLEs) in the general population and the assumption that PLEs are a good estimate of APS. Although the criterion validity of self-reported PLEs had already been studied with respect to clinician-rated psychotic symptoms and found insufficient, it had been argued that PLEs might in fact be more comparable with mild, subclinical expressions of psychotic symptoms and, therefore, with APS. The present paper is the first to specifically study this assumption. Sampling and Methods: The sample consisted of 123 persons seeking help at a service for the early detection of psychosis, of whom 54 had an at-risk mental state or psychosis, 55 had a nonpsychotic mental disorder and 14 had no full-blown mental disorder. PLEs were assessed with the Peters Delusion Inventory and the revised Launay-Slade Hallucination Scale, and psychotic symptoms and APS were assessed with the Structured Interview for Prodromal Syndromes. Results: At a level of agreement between the presence of any PLE (in 98.4% of patients) and any APS (in 40.7%) just exceeding chance (κ = 0.022), the criterion validity of PLEs for APS was insufficient. Even if additional qualifiers (high agreement or distress, preoccupation and conviction) were considered, PLEs (in 52.8%) still tended to significantly overestimate APS, and agreement was only fair (κ = 0.340). Furthermore, the group effect on PLE prevalence was, at most, moderate (Cramers V = 0.382). Conclusions: The prevalence of APS cannot be deduced from studies of PLEs. Thus, the high population prevalence rate of PLEs does not allow the conclusion that APS are common features of no pathological significance and would lack clinical validity as an Attenuated Psychosis Syndrome in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Rather, the population prevalence rate of APS has to be assumed to be largely unknown at present but is likely lower than indicated by epidemiological studies of PLEs. Therefore, dedicated studies are warranted, in which APS are assessed in a way that equates to their clinical evaluation.

Effects of a best-possible-self mental imagery exercise on mood and dysfunctional attitudes

Dispositional optimism has been related to positive physical and mental health outcomes, increased positive mood ratings and cognitions about the future. In order to determine the causal relation between optimism and mood and cognitions optimism should be manipulated experimentally. The current study tested the effects of a best-possible-self mental imagery exercise on affect and mood ratings and dysfunctional cognitions following a sad mood induction in undergraduate students (N=40). Participants in the experimental condition wrote about their best possible self in the future for 15 min and engaged in a mental imagery task about their best possible self in the future for 5 min in order to experimentally induce optimism. Participants in the control condition wrote about a typical day for 15 min and engaged in mental imagery about a typical day for 5 min. We assessed affect, mood and dysfunctional cognitions before and after the experimental manipulation. Participants in the experimental condition had higher positive mood ratings and higher positive affect compared to participants in the control condition. Participants in the control condition reported decreased dysfunctional cognitions whereas dysfunctional cognitions in the experimental group remained unchanged. Future studies should replicate these findings in clinical groups with more profound levels of negative affect and dysfunctional cognitions.

Looking at food in sad mood: do attention biases lead emotional eaters into overeating after a negative mood induction?

BACKGROUND Emotional eating is associated with overeating and the development of obesity. Yet, empirical evidence for individual (trait) differences in emotional eating and cognitive mechanisms that contribute to eating during sad mood remain equivocal. AIM The aim of this study was to test if attention bias for food moderates the effect of self-reported emotional eating during sad mood (vs neutral mood) on actual food intake. It was expected that emotional eating is predictive of elevated attention for food and higher food intake after an experimentally induced sad mood and that attentional maintenance on food predicts food intake during a sad versus a neutral mood. METHOD Participants (N = 85) were randomly assigned to one of the two experimental mood induction conditions (sad/neutral). Attentional biases for high caloric foods were measured by eye tracking during a visual probe task with pictorial food and neutral stimuli. Self-reported emotional eating was assessed with the Dutch Eating Behavior Questionnaire (DEBQ) and ad libitum food intake was tested by a disguised food offer. RESULTS Hierarchical multivariate regression modeling showed that self-reported emotional eating did not account for changes in attention allocation for food or food intake in either condition. Yet, attention maintenance on food cues was significantly related to increased intake specifically in the neutral condition, but not in the sad mood condition. DISCUSSION The current findings show that self-reported emotional eating (based on the DEBQ) might not validly predict who overeats when sad, at least not in a laboratory setting with healthy women. Results further suggest that attention maintenance on food relates to eating motivation when in a neutral affective state, and might therefore be a cognitive mechanism contributing to increased food intake in general, but maybe not during sad mood.

Interpersonal problems, dependency, and self-criticism in major depressive disorder.

OBJECTIVES The goal of the present research was the examination of overlap between 2 research traditions on interpersonal personality traits in major depression. We hypothesized that Blatts (2004) dimensions of depressive experiences around the dimensions of relatedness (i.e., dependency) and self-definition (i.e., self-criticism) are associated with specific interpersonal problems according to the interpersonal circumplex model (Leary, 1957). In addition, we examined correlations of interpersonal characteristics with depression severity. METHOD Analyses were conducted on 283 patients with major depressive disorder combined from 2 samples. Of the patients, 151 participated in a randomized controlled trial in the United States, and 132 patients were recruited in an inpatient unit in Germany. Patients completed measures of symptomatic distress, interpersonal problems, and depressive experiences. RESULTS Dependency was associated with more interpersonal problems related to low dominance and high affiliation, while self-criticism was associated with more interpersonal problems related to low affiliation. These associations were independent of depression severity. Self-criticism showed high overlap with cognitive symptoms of depression. CONCLUSION The findings support the interpersonal nature of Blatts dimensions of depressive experiences. Self-criticism is associated with being too distant or cold toward others as well as greater depression severity, but is not related to the dimension of dominance.

Negative mood-induction modulates default mode network resting-state functional connectivity in chronic depression

BACKGROUND The aim of this study was to investigate the effects of sad mood on default mode network (DMN) resting-state connectivity in persons with chronic major depressive disorder (cMDD). METHODS Participants with a diagnosis of cMDD (n=18) and age, gender and education level matched participants without a diagnosis of depression (n=18) underwent a resting-state fMRI scan, before and after a sad mood induction. The posterior cingulate cortex (PCC) was used as a seed for DMN functional connectivity across the two resting-state measurements. RESULTS Mood ratings decreased in both groups following the sad mood induction procedure. PCC connectivity with the parahippocampal gyrus, the superior temporal gyrus and the anterior inferior temporal cortex increased in cMDD patients following the sad mood induction, whereas it decreased in non-patient controls. PCC connectivity with the anterior prefrontal cortex and the precuneus decreased in cMDD patients following the sad mood induction, whereas it increased in non-patient controls. LIMITATIONS Limitations of this study include the relatively small sample size and lack of a clinical control group. CONCLUSIONS These findings are in line with neurobiological models of depression suggesting that the observed changes in DMN connectivity following the sad mood induction might reflect a failure to exert cognitive control over negative memory retrieval in patients with cMDD.

Two-year stability and change of neuroticism and extraversion in treated and untreated persons with depression: findings from the Netherlands Study of Depression and Anxiety (NESDA)

BACKGROUND The personality dimensions neuroticism and extraversion likely represent part of the vulnerability to depression. The stability over longer time periods of these personality dimensions in depressed patients treated with psychological treatment or medication and in untreated persons with depression in the general population remains unclear. Stability of neuroticism and extraversion in treated and untreated depressed persons would suggest that part of the vulnerability to depression remains stable over time. The current study addressed the question whether treatment in depressed patients is related to changes in neuroticism and extraversion. METHODS Data are from 709 patients with major depressive disorder participating in a cohort study (Netherlands Study of Depression and Anxiety; NESDA). We determined the 2-year stability of extraversion and neuroticism in treated and untreated persons and related change in depression severity to change in personality over time. RESULTS Neuroticism decreased from baseline to 2-year follow-up (d=0.73) in both treated and untreated persons. Extraversion did not change significantly after controlling for neuroticism and depression severity at baseline and follow-up. Decreased depressive symptoms over time were related to decreased neuroticism (d=1.91) whereas increased depressive symptoms over time were unrelated to neuroticism (d=0.06). LIMITATIONS Patients were not randomized to treatment conditions and the groups are therefore not directly comparable. CONCLUSIONS Treated patients with depression in the general population improve just as much on depression severity and neuroticism as untreated persons with depression. This suggests that changes in neuroticism in the context of treatment likely represent mood-state effects rather than direct effects of treatment.

Neural correlates of self-referential processing and implicit self-associations in chronic depression

BACKGROUND Patients with depression tend to process negative information with regard to the self (i.e. self-referential processing). A better understanding of the neural underpinnings of self-referential processing in patients with depression is clinically important as it can inform on potential treatment targets. METHOD This fMRI study sought to study the neural correlates of self-referential processing in patients with chronic major depressive disorder (cMDD) (n=17) and non-patient controls (n=18) using a passive processing paradigm. Stimuli consisted of positive, negative, negative depression related and neutral personality trait words or non-words. Participants were instructed to indicate whether a presented word was an existing word or a non-word while undergoing an fMRI scan. Participants also completed an explicit and an implicit measure of positive and negative self-associations outside the scanner. RESULTS Non-patient controls had relatively increased activity in the medial prefrontal cortex (mPFC) during processing of negative depression related vs. neutral words whereas patients with cMDD had relatively decreased activity. Non-patient controls had relatively increased dorsolateral prefrontal cortex (dlPFC) activity during processing of positive vs. neutral words whereas patients with cMDD had relatively decreased activity. Explicit but not implicit self-associations with depression related words were associated with neural activity in the mPFC and the dlPFC. LIMITATIONS The study did not include a clinical control group and therefore the specificity of findings remains unknown. CONCLUSIONS The distinct neural processing of emotional self-relevant stimuli in the mPFC and the dlPFC in patients with cMDD might represent an emotional blunting response towards negative self-relevant stimuli.