Mathijs Deen

Does cognitive behavioral therapy strengthen the effect of bariatric surgery for obesity? Design and methods of a randomized and controlled study

BACKGROUND (Extreme) obesity is a chronic harmful condition with high risk of medical comorbidities and negative social and emotional consequences. Bariatric surgery is an effective intervention for obesity, but approximately 20 to 30% of the patients experience adverse outcomes after surgery and there is a need for augmentation of current treatment strategies. This study examines the added value of pre-operative cognitive behavioral therapy (CBT) focused on modification of thoughts and behaviors in terms of eating behavior and physical exercise as well as preparation for surgery and postoperative life style. We hypothesize that pre-operative CBT will result in better weight loss maintenance, reduction of maladaptive eating behavior and better adherence to postoperative lifestyle on the long term as compared to bariatric surgery alone. METHODS One hundred and twenty eight patients that are on a waiting list for bariatric surgery are randomly assigned to the control or treatment condition. Patients in the treatment condition receive 10 sessions of CBT before surgery aimed at modifying dysfunctional eating habits and behaviors and developing more rational weight and body-related beliefs in order to enable long term maintenance of a healthier lifestyle after surgery. Weight loss, eating behavior, eating disorders, depression, quality of life and psychological distress are assessed before and after treatment, as well as 1, 3, and 5 year following surgery.

A masked negative self-esteem? Implicit and explicit self-esteem in patients with Narcissistic Personality Disorder

The mask model of narcissism states that the narcissistic traits of patients with NPD are the result of a compensatory reaction to underlying ego fragility. This model assumes that high explicit self-esteem masks low implicit self-esteem. However, research on narcissism has predominantly focused on non-clinical participants and data derived from patients diagnosed with Narcissistic Personality Disorder (NPD) remain scarce. Therefore, the goal of the present study was to test the mask model hypothesis of narcissism among patients with NPD. Male patients with NPD were compared to patients with other PDs and healthy participants on implicit and explicit self-esteem. NPD patients did not differ in levels of explicit and implicit self-esteem compared to both the psychiatric and the healthy control group. Overall, the current study found no evidence in support of the mask model of narcissism among a clinical group. This implicates that it might not be relevant for clinicians to focus treatment of NPD on an underlying negative self-esteem.

Negative Beliefs about Voices in Patients with Borderline Personality Disorder Are Associated with Distress: A Plea for Cognitive-Behavioural Therapy?

Background: Auditory verbal hallucinations (AVH) are experienced by 21-54% of patients diagnosed with a borderline personality disorder (BPD), and ensuing distress is often high. Little is known about the beliefs these patients foster about their voices, and the influence thereof on distress and need for hospitalisation. Methods: In a convenience sample of 38 BPD outpatients with AVH, data were collected with the aid of the Psychotic Symptom Rating Scales (PSYRATS), Beliefs about Voices Questionnaire (BAVQ), Social Comparison Rating Scale (SCRS), and Voice Power Differential Scale (VPDS). Results: The majority of patients with BPD who experience AVH rate their voices as malevolent and omnipotent, and higher in social rank than themselves. Moreover, their resistance against them tends to be high. These parameters correlate positively and significantly with high levels of distress experienced in relation to these AVH. The need for hospitalisation, in turn, is associated with high scores for omnipotence of the voices and distress due to AVH. However, these findings could not be confirmed in regression analyses. Conclusions: As negative beliefs can be altered with cognitive-behavioural therapy (CBT), we expect CBT to be beneficial in the treatment of AVH in BPD patients, whether or not in combination with antipsychotic medication.

Self-esteem and peer-perceived social status in early adolescence and prediction of eating pathology in young adulthood

Abstract Objective Self‐esteem is implied as a factor in the development of eating disorders. In adolescence peers have an increasing influence. Support for the role of self‐esteem in eating disorders is ambiguous and little is known about the influence of social status as judged by others. The present study investigates whether self‐esteem and peer status in early adolescence are associated with eating pathology in young adulthood. Method This study is part of TRAILS, a longitudinal cohort study on mental health and social development from preadolescence into adulthood. At age 11, participants completed the Self‐Perception Profile for Children, assessing global self‐esteem and self‐perceptions regarding social acceptance, physical appearance, and academic competence. At age 13, peer status among classmates was assessed regarding likeability, physical attractiveness, academic performance, and popularity in a subsample of 1,007 participants. The Eating Disorder Diagnostic Scale was administered at age 22. The present study included peer‐nominated participants with completed measures of self‐perception at age 11 and eating pathology at age 22 (N = 732; 57.8% female). Results In a combined model, self‐perceived physical attractiveness at age 11 and peer popularity at age 13 were inversely correlated with eating pathology at 22 years, while likeability by peers at age 13 was positively related to eating pathology. Discussion Both self‐perceptions and peer status in early adolescence are significant predictors of eating pathology in young adults. Specific measures of self‐esteem and peer‐perceived status may be more relevant to the prediction of eating pathology than a global measure of self‐esteem.

The Attribution of Mental Health Problems to Jinn: An Explorative Study in a Transcultural Psychiatric Outpatient Clinic

Background Among Muslim patients, a common cultural concept of distress is the notion that jinn may be the cause of mental health problems, especially in the presence of hallucinations. Objective This study examines the frequency with which this attribution style is manifest in a specific psychiatric outpatient population with a Muslim background. Methods Of all patients registered at an outpatient clinic specialized in transcultural psychiatry, data were collected on folk belief, religion, hallucinations (if present), and medical diagnosis. Through a search in the electronic medical files, the notes made during the first contact and first psychiatric examination were screened for the keywords “evil eye,” “magic,” “voodoo,” and “jinn.” In addition, new eligible cases were accepted. Results From all 551 patients thus screened, 118 were eligible for participation. Of these, 49 (41.5%) were interviewed using a semi-structured questionnaire. Among them, 21 (43%) were positive that their psychiatric symptoms were caused by jinn, whereas 13 (27%) thought not, and 15 (31%) were in doubt. No less than 87.2% had experienced hallucinations during their lives. Among the relatively large proportion of eligible patients who did not participate (58.5%), many expressed a fear for stigmatization or metaphysical repercussions if they spoke about jinn. Conclusion The phenomenon of attributing mental health symptoms to jinn was much more common in this population of Muslim patients than previously assumed. This underscores the need for proper knowledge of Muslim explanatory models of disease and for the use of culturally sensitive interviewing techniques in this population.

Comorbid Diagnosis of Psychotic Disorders in Borderline Personality Disorder: Prevalence and Influence on Outcome

Background A diagnosis of psychotic disorder is traditionally considered incompatible with borderline personality disorder (BPD), even though patients sometimes fulfill the diagnostic criteria for both disorders. How often this happens is barely known, as is the influence of comorbid psychotic disorders on the outcome of BPD. Since studies on isolated auditory verbal hallucinations in patients with BPD indicate that these perceptual symptoms have severe consequences and are associated with suicidal behavior and hospitalization, patients with comorbid psychotic disorders are unlikely to fare better. Objective To examine the point prevalence of psychotic disorders in patients with BPD, their association with the outcome of BPD, and their predictive value for outcome. Methods In a cross-sectional design, 84 female outpatients diagnosed with BPD were interviewed with the aid of the MINI-International Neuropsychiatric Interview to establish the point prevalence of comorbid psychotic and other comorbid disorders. After termination of their treatment at a specialized outpatient clinic, the type of referral was considered to be a “good” outcome when they were referred to their general practitioner or to basic psychiatric care for noncomplex patients, and a “poor” outcome when referred to a specialized psychiatric department or to a psychiatric district team for patients with severe psychiatric disorders. Results Psychotic disorders were present in 38% of the patients with BPD. With a prevalence of 20%, psychotic disorder not otherwise specified (NOS) was the most common subtype; the least common types were schizophrenia (2%), substance-induced psychotic disorder (2%), and brief psychotic disorder (1%). Among six types of comorbid disorders, only psychotic disorders were associated with a poor outcome; they were also predictors for a poor outcome, along with comorbid mood disorders, eating disorders, and somatoform disorders, as well as the severity of BPD, and, counterintuitively, more years of education. Conclusion Psychotic disorders, notably of the psychotic disorder NOS subtype, are common among patients with BPD, and their presence is associated with a poor outcome. This implies that adequate diagnosis and treatment of both disorders is warranted in this subgroup with a dual diagnosis.

Temperament and character in men with autism spectrum disorder: A reanalysis of scores on the Temperament and Character Inventory by individual case matching

Background Interest in autism spectrum disorders (ASD) in adulthood is increasing. Although a person may be diagnosed with ASD, the diagnosis reveals little about the individuals temperament, character, and personality. Also, relatively little is known about the personality of adults with ASD. Method A reanalysis of scores on the Temperament and Character Inventory (TCI) administered to a group of 66 normally intelligent men aged 18–63 years, diagnosed with ASD, by individual case matching to a comparison group of 66 men from the general population drawn from the TCI manual. Results Compared to the comparison group, men with ASD scored significantly higher on the scale for Harm Avoidance, and lower on Novelty Seeking, Reward Dependence, Self-Directedness, and Cooperativeness. Conclusions In this study the score pattern for temperament and character found in men with ASD by individual case matching confirms and strengthens earlier general group matching findings emerging from our 2012 study and from studies from Sweden and the Netherlands.