Hansjörg Znoj

Emotion-regulation skills as a treatment target in psychotherapy.

BACKGROUND Deficits in emotion-regulation skills have been shown to be integral to the development and maintenance of a wide range of mental disorders. AIM To evaluate the importance of these skills as a treatment target in psychotherapeutic interventions. METHOD Nine specific emotion-regulation skills were assessed in a sample of 289 inpatients before and after cognitive-behavioural treatment. Self-reports of success in pretreatment skills application were first compared to those of 246 non-clinical controls. Pretreatment skills application and change in skills application during therapy were then related to a variety of outcome measures. Finally, the effects of integrating a brief training of general emotion-regulation skills into the CBT-based treatment were evaluated in a controlled trial. RESULTS Uni- and multivariate analyses identified the skills of acceptance, tolerance, and active modification of negative emotions as particularly important for current mental health and treatment outcome. Replacing parts of the standard CBT treatment with the emotion-regulation training enhanced the effects of the CBT treatment on skills application and on other measures of mental health. CONCLUSION Incorporating interventions that directly target general emotion-regulation skills may improve the effectiveness of psychotherapeutic interventions.

Entwicklung und Validierung eines Fragebogens zur standardisierten Selbsteinschätzung emotionaler Kompetenzen (SEK-27)

Theoretischer Hintergrund: Defizite und Ressourcen im Bereich der allgemeinen Emotionsregulation spielen eine wichtige Rolle bei Entstehung, Aufrechterhaltung und Behandlung psychischer Storungen. Fragestellung: Um moglichst viele Bereiche des konstruktiven Umgangs mit negativen Emotionen okonomisch erfassen zu konnen, wurde der Fragebogen zur Selbsteinschatzung Emotionaler Kompetenzen (SEK-27) entwickelt und validiert. Methode: Anhand von zwei nicht-klinischen (N = 952) und drei klinischen Stichproben (N = 238) wurden verschiedene Indikatoren der Testgute bestimmt. Ergebnisse: Die Befunde sprechen fur die ausreichende bis sehr gute Reliabilitat, Validitat und Veranderungssensitivitat des Fragebogens. Schlussfolgerungen: Mit dem SEK-27 steht ein okonomischer Fragebogen mit angemessenen psychometrischen Eigenschaften zur Selbsteinschatzung des konstruktiven Umgangs mit negativen Emotionen zur Verfugung.

Heart rate recovery after exercise in chronic heart failure: Role of vital exhaustion and type D personality

OBJECTIVE Vital exhaustion and type D personality previously predicted mortality and cardiac events in patients with chronic heart failure (CHF). Reduced heart rate recovery (HRR) also predicts morbidity and mortality in CHF. We hypothesized that elevated levels of vital exhaustion and type D personality are both associated with decreased HRR. METHODS Fifty-one patients with CHF (mean age 58+/-12 years, 82% men) and left ventricular ejection fraction (LVEF) < or = 40% underwent standard exercise testing before receiving outpatient cardiac rehabilitation. They completed the 9-item short form of the Maastricht Vital Exhaustion Questionnaire and the 14-item type D questionnaire asking about negative affectivity and social inhibition. HRR was calculated as the difference between heart rate at the end of exercise and 1 min after abrupt cessation of exercise (HRR-1). Regression analyses were adjusted for gender, age, LVEF, and maximum exercise capacity. RESULTS Vital exhaustion explained 8.4% of the variance in continuous HRR-1 (p=0.045). For each point increase on the vital exhaustion score (range 0-18) there was a mean+/-SEM decrease of 0.54+/-0.26 bpm in HRR-1. Type D personality showed a trend toward statistical significance for being associated with lower levels of HRR-1 explaining 6.5% of the variance (p<0.08). The likelihood of having HRR-1 < or = 18 bpm was significantly higher in patients with type D personality than in those without (odds ratio=7.62, 95% CI 1.50-38.80). CONCLUSIONS Elevated levels of vital exhaustion and type D personality were both independently associated with reduced HRR-1. The findings provide a hitherto not explored psychobiological explanation for poor cardiac outcome in patients with CHF.

Higher emotional distress in female partners of cancer patients: prevalence and patient–partner interdependencies in a 3-year cohort

Assessment and treatment of psychological distress in cancer patients was recognized as a major challenge. The role of spouses, caregivers, and significant others became of salient importance not only because of their supportive functions but also in respect to their own burden. The purpose of this study was to assess the amount of distress in a mixed sample of cancer patients and their partners and to explore the dyadic interdependence.

Gender Differences in Cardiac Rehabilitation Outcomes: Do Women Benefit Equally in Psychological Health?

BACKGROUND Psychological factors are important in the etiology and prognosis of coronary heart disease (CHD). Cardiac rehabilitation (CR) aims to reduce psychological distress, besides other somatic risk factors. Studies have shown that CR is effective in reducing psychological distress, but little is known about gender-specific outcome differences. Our objective was to examine whether women and men benefit equally from outpatient CR in terms of reduction in psychological distress and whether women show more impaired psychological health at baseline of CR than do men. METHODS We enrolled 441 CHD patients (mean age 58+/-11 years, 79.8% men) who underwent a 12-week outpatient CR program. Psychological dimensions, namely, anxiety, depression, vital exhaustion, social inhibition, and negative affect, were assessed at baseline and post-CR. Multivariate analysis of variance (MANOVA), controlling for age, disease severity, and exercise capacity, was applied to test for gender-specific differences at baseline and change between baseline and post-CR. In addition, gender-specific effect sizes were calculated for the change on psychological dimensions. RESULTS Women and men did not differ on any psychological measure at baseline of CR. The effect sizes show small to moderate treatment effects on the psychological dimensions assessed. Gender had a significant impact on change on the dimensions vital exhaustion (F=5.040(df=1), p<0.05) and social inhibition (F=5.74(df=1), p<0.05). Women showed larger change on social inhibition and smaller change on vital exhaustion than men. CONCLUSIONS Women and men do not differ in the extent of psychological distress at baseline of CR, which could be explained also by the exclusion of highly distressed women from treatment. CR is less effective among women with regard to vital exhaustion and more effective with regard to social inhibition compared with men in a sample of low distressed patients.

The younger sibling of PTSD: similarities and differences between complicated grief and posttraumatic stress disorder.

Just as traumatic experiences may lead to posttraumatic stress disorder (PTSD) in some individuals, grief may also be a serious health concern for individuals who have experienced bereavement. At present, neither the DSM-IV nor the ICD-10 recognizes any form of grief as a mental disorder. The aim of this review is to summarize recent advances in definition, assessment, prevention, and treatment of complicated grief disorder (CGD) and to compare CGD with PTSD. Four areas are identified to be of importance to clinicians and researchers: (a) the recently proposed consensus criteria of CGD for DSM-V and ICD-11, (b) available assessment instruments, (c) recent prevention and treatment techniques and related effectiveness studies, and (d) emerging disorder models and research on risks and protective factors. This review focuses on the similarities and differences between CGD and PTSD and highlights how a PTSD-related understanding aids the investigation and clinical management of CGD. For the abstract or full text in other languages, please see Supplementary files under Reading Tools online

Perceived responsibility for change as an outcome predictor in cognitive-behavioural group therapy

PURPOSE The study of control beliefs in psychotherapy research has been neglected in the past years. Based on the evidence that some patients do not benefit enough from therapy because of inadequate expectancies regarding the responsibility and the mechanisms of therapeutic change, assessing control beliefs specific to the psychotherapy context and linking them to therapy outcome can help highlighting this specific aspect and reactivating a neglected field of clinical research. METHOD Using a new validated instrument (Questionnaire on Control Expectancies in Psychotherapy, TBK), this study investigated whether and how perceived responsibility for change predicts favourable response to group cognitive-behavioural therapy in a sample of 49 outpatients with social anxiety disorder (SAD). Patient engagement and therapy-related self-efficacy were assessed as possible process variables. RESULTS Among therapy-related control beliefs, low powerful others expectancies (towards the therapist) were found to be the strongest predictor for clinical improvement at follow-up. At a process level, analyses of mediation showed that powerful others expectancies predicted therapy engagement, which then influenced the degree of clinical improvement on social anxiety levels and global symptoms. The association between therapy-specific internality and outcome was confirmed for social anxiety at follow-up and was partially mediated by therapy-related self-efficacy. CONCLUSIONS Findings confirm that therapy-related control beliefs predict psychotherapy process (patient engagement and therapy-specific self-efficacy) and outcome in cognitive-behavioural group therapy for SAD. Implications for clinicians and for future research are discussed.

Association of fatigue and psychological distress with quality of life in patients with a previous venous thromboembolic event

Health-related quality of life (QoL) has been associated with several social and medical conditions in patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). To the best of our knowledge, there is no study investigating the relationship of QoL with psychological variables in this patient population. We assumed as a hypothesis an association between heightened levels of fatigue and psychological distress, as well as decreased QoL in patients with an objectively diagnosed venous thromboembolic event. Study participants were 205 consecutively enrolled out-patients (47.4 years, 54.6% men) with DVT and/or PE. Approximately 10 days before blood collection for thrombophilia work-up, QoL, fatigue, and psychological distress were assessed using the Short Form Health Survey (SF-12), the Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF) as well as the Hospitality Anxiety and Depression scale (HADS). After controlling for demographic and medical factors, fatigue (p < 0.01) but not psychological distress (p>0.05) was negatively associated with physical QoL, explaining 11.0% of the variance. Fatigue (p < 0.001) and psychological distress (p < 0.001) were significant predictors of mental QoL, explaining an additional 36.2% and 3.6% of the variance. Further analyses revealed that all subscales of the HADS (e.g. anxiety and depression) and of the MFSI-SF (e.g. general fatigue, physical fatigue, emotional fatigue, mental fatigue and vigor) were significant predictors of mental QoL. MFSI-SF subscales also predicted physical QoL. The findings suggest that fatigue and psychological distress substantially predict QoL in patients with a previous venous thromboembolic event above and beyond demographic factors.

Who cares, who bears, who benefits? Female spouses vicariously carry the burden after cancer diagnosis

Background and aim: Among couples coping with cancer diagnosis, the effects of gender, role (patient vs. spouse) and patient relationship status (single vs. partnered) on quality of life (QoL) have been investigated with inconsistent results. The present study examined the impact of gender, role and relationship status on male and female patients, their spouses and non-partnered patients. Method: A representative sample of 218 patients with a new primary cancer diagnosis (any type and stage) and their spouses (n = 137), were assessed within 8 weeks of diagnosis. Measures assessed multiple QoL dimensions including health-related and dyadic QoL as well as symptoms of distress: (anxiety, depression, intrusion, avoidance and hyperarousal). Results: Multivariate analyses of covariance revealed lower QoL for women versus men, and for spouses versus patients on a number of measures (health-related QoL, satisfaction with dyadic coping, anxiety and intrusions). Conclusions: Female spouses of cancer patients are at high risk of deteriorated QoL immediately after diagnosis, and require special attention to their psychosocial care needs.

Time-Series Panel Analysis (TSPA) - Multivariate modeling of temporal associations in psychotherapy process.

OBJECTIVE Processes occurring in the course of psychotherapy are characterized by the simple fact that they unfold in time and that the multiple factors engaged in change processes vary highly between individuals (idiographic phenomena). Previous research, however, has neglected the temporal perspective by its traditional focus on static phenomena, which were mainly assessed at the group level (nomothetic phenomena). To support a temporal approach, the authors introduce time-series panel analysis (TSPA), a statistical methodology explicitly focusing on the quantification of temporal, session-to-session aspects of change in psychotherapy. TSPA-models are initially built at the level of individuals and are subsequently aggregated at the group level, thus allowing the exploration of prototypical models. METHOD TSPA is based on vector auto-regression (VAR), an extension of univariate auto-regression models to multivariate time-series data. The application of TSPA is demonstrated in a sample of 87 outpatient psychotherapy patients who were monitored by postsession questionnaires. Prototypical mechanisms of change were derived from the aggregation of individual multivariate models of psychotherapy process. In a 2nd step, the associations between mechanisms of change (TSPA) and pre- to postsymptom change were explored. RESULTS TSPA allowed a prototypical process pattern to be identified, where patients alliance and self-efficacy were linked by a temporal feedback-loop. Furthermore, therapists stability over time in both mastery and clarification interventions was positively associated with better outcomes. CONCLUSIONS TSPA is a statistical tool that sheds new light on temporal mechanisms of change. Through this approach, clinicians may gain insight into prototypical patterns of change in psychotherapy.