Katharine A. Rimes

Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial

BACKGROUND About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). AIMS To test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. METHOD Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150). RESULTS Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. CONCLUSIONS This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

Incidence, Prognosis, and Risk Factors for Fatigue and Chronic Fatigue Syndrome in Adolescents: A Prospective Community Study

OBJECTIVE. The objective of this study was to describe the incidence, prevalence, risk factors, and prognosis of fatigue, chronic fatigue, and chronic fatigue syndrome in 11- to 15-year-olds. METHODS. A random general population sample (n = 842) of British adolescents and their parents were assessed at baseline and 4 to 6 months later. The main outcomes were fatigue, chronic fatigue, and chronic fatigue syndrome, operationally defined. RESULTS. The incidence over 4 to 6 months was 30.3% for fatigue, 1.1% for chronic fatigue, and 0.5% for chronic fatigue syndrome. The point prevalence was 34.1% and 38.1% for fatigue, 0.4% and 1.1% for chronic fatigue, and 0.1% and 0.5% for chronic fatigue syndrome at time 1 and time 2, respectively. Of participants who were fatigued at time 1, 53% remained fatigued at time 2. The 3 cases of chronic fatigue and 1 case of chronic fatigue syndrome at time 1 had recovered by time 2. Higher risk for development of chronic fatigue at time 2 was associated with time 1 anxiety or depression, conduct disorder, and maternal distress; in multivariate analysis, baseline anxiety or depression remained a significant predictor of chronic fatigue. Increased risk for development of fatigue at time 2 was associated with time 1 anxiety or depression, conduct disorder, and older age; in multivariate analyses, these factors and female gender all were significant predictors of fatigue. CONCLUSIONS. The incidence rates for chronic fatigue and chronic fatigue syndrome in this adolescent sample were relatively high, but the prognosis for these conditions was good. This prospective study provides evidence for an association between emotional/behavioral problems and subsequent onset of fatigue/chronic fatigue.

Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome

OBJECTIVES. Difficulties in processing emotional states are implicated in the aetiology and maintenance of diverse health conditions, including anorexia nervosa (AN) and chronic fatigue syndrome (CFS). This study sought to explore distress tolerance, self-silencing, and beliefs regarding the experience and expression of emotions in individuals diagnosed with AN and CFS. These conditions were chosen for this study because their clinical presentation is characterized by physical symptoms, yet cognitive behavioural models suggest that emotional processing difficulties contribute to the aetiology and maintenance of both. DESIGN. A between-subjects cross-sectional design was employed. METHODS. Forty people with AN, 45 with CFS, and 48 healthy controls (HCs) completed the Distress Tolerance Scale (DTS), Silencing the Self Scale (STSS), Beliefs about Emotions Scale (BES), and measures of clinical symptomatology. RESULTS. Initial group comparisons found that both AN and CFS participants scored higher than HCs on a subscale measuring difficulties in distress tolerance. AN and CFS participants were also more likely to judge themselves by external standards, endorse statements reflecting a tendency to put the needs of others before themselves, and present an outwardly socially compliant image of themselves whilst feeling hostile within. Relative to HCs, AN participants reported more maladaptive beliefs regarding the experience of having negative thoughts and feelings and revealing these emotions to others, with CFS participants showing a non-significant trend in the same direction. After controlling for differences in age, anxiety, and depression the only significant difference to remain was that observed for the STSS care as self-sacrifice subscale. More maladaptive beliefs about the experience and expression of emotions were associated with greater degree of eating disorder symptomatology in the AN group. CONCLUSIONS. Differences in emotional processing are present in AN and CFS compared to HCs, with some disorder-specific variation, and may be associated with greater clinical symptomatology. These findings support current explanatory models of both AN and CFS, and suggest that emotional processing should be addressed in the assessment and treatment of individuals with these illnesses.

The neural correlates of fatigue: an exploratory imaginal fatigue provocation study in chronic fatigue syndrome

BACKGROUND Fatigue is the central symptom in chronic fatigue syndrome (CFS) and yet very little is known about its neural correlates. The aim of this study was to explore the functional brain response, using functional magnetic resonance imaging (fMRI), to the imaginal experience of fatigue in CFS patients and controls. METHOD We compared the blood oxygen level dependent (BOLD) responses of 12 CFS patients and 11 healthy controls to a novel fatigue provocation procedure designed to mimic real-life situations. A non-fatiguing anxiety-provoking condition was also included to control for the non-specific effects of negative affect. RESULTS During the provocation of fatigue, CFS patients reported feelings of both fatigue and anxiety and, compared to controls, they showed increased activation in the occipito-parietal cortex, posterior cingulate gyrus and parahippocampal gyrus, and decreased activation in dorsolateral and dorsomedial prefrontal cortices. The reverse pattern of findings was observed during the anxiety-provoking scenarios. CONCLUSIONS The results may suggest that, in CFS patients, the provocation of fatigue is associated with exaggerated emotional responses that patients may have difficulty suppressing. These findings are discussed in relation to the cognitive-behavioural model of CFS.

The Beliefs about Emotions Scale: Validity, reliability and sensitivity to change

OBJECTIVE Beliefs about the unacceptability of experiencing or expressing negative emotions have been noted in individuals with a range of problems, including chronic fatigue syndrome (CFS), irritable bowel syndrome, somatization disorder, depression, eating disorders, social phobia, posttraumatic stress disorder, and borderline personality disorder. These beliefs are likely to have implications for emotion regulation and processing, and are addressed explicitly or implicitly within many therapies including cognitive behavior therapy (CBT), mindfulness-based cognitive therapy (MBCT), and Acceptance and Commitment Therapy (ACT). This article describes the development, validation, and internal reliability of the Beliefs about Emotions Scale (BES), a self-report questionnaire to assess such beliefs. METHODS The new scale was completed by people with CFS (n=121) and healthy controls (n=73). Twenty-two individuals with CFS completed the scale before and after CBT. RESULTS People with CFS had significantly higher scores on this new questionnaire than healthy controls. Principal components analysis identified one factor, and the scale had high internal consistency (0.91). Scores on the BES were most highly correlated with a measure of negative perfectionism (r=0.59) and also showed significant correlations with measures of dysfunctional attitudes, self-sacrifice, depression, anxiety, and fatigue. When completed before and after CBT for CFS, the questionnaire was sufficiently sensitive to detect a significant reduction in endorsement of unhelpful beliefs about emotions. CONCLUSION The new Beliefs about Emotions Scale showed good internal reliability, validity and sensitivity to change.

Probing the working memory system in chronic fatigue syndrome: a functional magnetic resonance imaging study using the n-back task.

Objective: Up to 90% of patients with chronic fatigue syndrome (CFS) report substantial cognitive difficulties. However, objective evidence supporting these claims is inconsistent. The present functional magnetic resonance imaging study examined the neural correlates of working memory in patients with CFS compared with controls. Methods: Seventeen patients with CFS and 12 healthy control subjects were scanned while performing a parametric version of the n-back task (0-, 1-, 2-, and 3-back). Results: Both groups performed comparably well and activated the verbal working memory network during all task levels. However, during the 1-back condition, patients with CFS showed greater activation than control subjects in medial prefrontal regions, including the anterior cingulate gyrus. Conversely, on the more challenging conditions, patients with CFS demonstrated reduced activation in dorsolateral prefrontal and parietal cortices. Furthermore, on the 2- and 3-back conditions, patients but not control subjects significantly activated a large cluster in the right inferior/medial temporal cortex. Trend analyses of task load demonstrated statistically significant differences in brain activation between the two groups as the demands of the task increased. Conclusions: These results suggest that patients with CFS show both quantitative and qualitative differences in activation of the working memory network compared with healthy control subjects. It remains to be determined whether these findings stay stable after successful treatment. CFS = chronic fatigue syndrome; fMRI = functional magnetic resonance imaging; PASAT = Paced Auditory Serial Addition Test; WM = working memory; SPECT = single photon emission computed tomography; CDC = Centers for Disease Control and Prevention; BOLD = blood oxygen level dependent; BA = Brodmanns area; TR = repetition time; TE = echo time; SSQratio = sum of squares ratio.

Obsessive–compulsive disorder, anxiety disorders, and self-esteem: an exploratory study

In a preliminary investigation of the link between self-esteem and obsessional problems, patients with OCD were compared with people suffering from other anxiety disorders and non-anxious controls. A questionnaire was devised which allowed the reliable coding of open ended responses focussed on issues surrounding self-worth; standardized measures of self-esteem and clinical symptomatology were also administered. Results indicated that both clinical groups differed significantly from non-clinical controls on generalized self-esteem assessments. There was some evidence of OCD specific effects; obsessionals were more likely than anxious controls to link their self-worth to other people and their relationships. They also regarded the possibility of causing harm as likely to result in other people making extreme negative and critical judgements of them; the other groups expected the responses of others towards them to be more lenient. The implications for future research and for treatment of OCD are discussed.

Pilot Study of Mindfulness-Based Cognitive Therapy for Trainee Clinical Psychologists

BACKGROUND It is recommended that Mindfulness-Based Cognitive Therapy (MBCT) instructors should undertake MBCT themselves before teaching others. AIM To investigate the impact of MBCT (modified for stress not depression) on trainee clinical psychologists. METHOD Twenty trainees completed questionnaires pre- and post-MBCT. RESULTS There was a significant decrease in rumination, and increases in self-compassion and mindfulness. More frequent home practice was associated with larger decreases in stress, anxiety and rumination, and larger increases in empathic concern. Only first-year trainees showed a significant decrease in stress. Content analysis of written responses indicated that the most commonly reported effects were increased acceptance of thoughts/feelings (70%), increased understanding of what it is like to be a client (60%), greater awareness of thoughts/feelings/behaviours/bodily sensations (55%) and increased understanding of oneself and ones patterns of responding (55%). Participants reported increased metacognitive awareness and decentring in relation to negative thoughts. Eighty-five percent reported an impact on their clinical work by the end of the course. CONCLUSIONS Trainee psychologists undergoing MBCT experienced many of the psychological processes/effects that they may eventually be helping to cultivate in clients using mindfulness interventions, and also benefits in their general clinical work.

Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study.

UNLABELLED Cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS; sometimes known as myalgic encephalomyelitis). However, only a minority of patients fully recover after CBT; thus, methods for improving treatment outcomes are required. This pilot study concerned a mindfulness-based cognitive therapy (MBCT) intervention adapted for people with CFS who were still experiencing excessive fatigue after CBT. The study aimed to investigate the acceptability of this new intervention and the feasibility of conducting a larger-scale randomized trial in the future. Preliminary efficacy analyses were also undertaken. Participants were randomly allocated to MBCT or waiting list. Sixteen MBCT participants and 19 waiting-list participants completed the study, with the intervention being delivered in two separate groups. Acceptability, engagement and participant-rated helpfulness of the intervention were high. Analysis of covariance controlling for pre-treatment scores indicated that, at post-treatment, MBCT participants reported lower levels of fatigue (the primary clinical outcome) than the waiting-list group. Similarly, there were significant group differences in fatigue at 2-month follow-up, and when the MBCT group was followed up to 6 months post-treatment, these improvements were maintained. The MBCT group also had superior outcomes on measures of impairment, depressed mood, catastrophic thinking about fatigue, all-or-nothing behavioural responses, unhelpful beliefs about emotions, mindfulness and self-compassion. In conclusion, MBCT is a promising and acceptable additional intervention for people still experiencing excessive fatigue after CBT for CFS, which should be investigated in a larger randomized controlled trial. KEY PRACTITIONER MESSAGE Only about 30% of people with chronic fatigue syndrome (CFS) recover after cognitive behaviour therapy (CBT); thus, methods for improving treatment outcomes are needed. This is the first pilot randomized study to demonstrate that a mindfulness-based intervention was associated with reduced fatigue and other benefits for people with CFS who were still experiencing excessive fatigue after a course of CBT. Levels of acceptability, engagement in the intervention and rated helpfulness were high. A larger-scale randomized controlled trial is required.

Predictive genetic testing: Psychological factors

Advances in medical technology such as those linked to the human genome project are increasing the potential for predictive testing for a wide range of health threats. There have not been comparable advances in understanding of the psychological factors involved in such testing. These factors and issues relating to them are examined, and it is suggested that a cognitive-behavioral approach to the understanding and management of adverse reactions to testing is likely to be particularly fruitful. The use of such an approach should result in the development of effective pre- and posttest interventions to prevent, minimize, and manage distress associated with screening.