Rainer Leonhart

Working Alliance Inventory‐Short Revised (WAI‐SR): psychometric properties in outpatients and inpatients

The Working Alliance Inventory-Short Revised (WAI-SR) is a recently refined measure of the therapeutic alliance that assesses three key aspects of the therapeutic alliance: (a) agreement on the tasks of therapy, (b) agreement on the goals of therapy and (c) development of an affective bond. The WAI-SR demonstrated good psychometric properties in an initial validation in psychotherapy outpatients in the USA. The generalizability of these findings is limited because in some countries a substantial portion of individual psychotherapy is delivered in inpatient settings. This study investigated and compared the psychometric properties of the WAI-SR in German outpatients (N = 88) and inpatients (N = 243). In both samples reliability (alpha > 0.80) and convergent validity with the Helping Alliance Questionnaire were good (r > 0.64). Confirmatory factor analysis showed acceptable to good model fit for the proposed Bond-Task-Goal model in both samples. Multi-group analysis demonstrated that the same constructs were measured across settings. Alliance ratings of outpatients and inpatients differed regarding the overlap of alliance components and the magnitude of the alliance ratings: The differentiation of the alliance components was poorer in inpatients and they reported lower alliances. Unique aspects of the alliance in inpatient treatment are discussed and a need for further research on the alliance in inpatient settings is pointed out. Overall, the WAI-SR can be recommended for alliance assessment in both settings.

Researcher allegiance in psychotherapy outcome research: An overview of reviews

Researcher allegiance (RA) is widely discussed as a risk of bias in psychotherapy outcome research. The relevance attached to RA bias is related to meta-analyses demonstrating an association of RA with treatment effects. However, recent meta-analyses have yielded mixed results. To provide more clarity on the magnitude and robustness of the RA-outcome association this article reports on a meta-meta-analysis summarizing all available meta-analytic estimates of the RA-outcome association. Random-effects methods were used. Primary study overlap was controlled. Thirty meta-analyses were included. The mean RA-outcome association was r=.262 (p=.002, I(2)=28.98%), corresponding to a moderate effect size. The RA-outcome association was robust across several moderating variables including characteristics of treatment, population, and the type of RA assessment. Allegiance towards the RA bias hypothesis moderated the RA-outcome association. The findings of this meta-meta-analysis suggest that the RA-outcome association is substantial and robust. Implications for psychotherapy outcome research are discussed.

Planning Abilities and the Tower of London: Is This Task Measuring a Discrete Cognitive Function?

The Tower of London (ToL) test is widely used for measuring planning and aspects of problem solving. The primary focus of this study was to assess the relationship among different performance measures on the ToL. A secondary purpose was to examine the putative relationship between intelligence and working memory with that of ToL performance. Analyses of the interrelation of several ToL parameters indicated that better ToL performance was associated with longer preplanning time and shorter movement execution time. Good performers showed a stronger increase in preplanning duration with task difficulty than intermediate or poor planners. Stepwise multiple regression analysis yielded fluid intelligence as the only significant predictor of ToL performance. These results suggest that the Tower of London assesses predominantly planning and problem solving and could not be sufficiently explained by other cognitive domains.

The Tower of London: the impact of instructions, cueing, and learning on planning abilities

The Tower of London (ToL) is a well-known test of planning ability, and commonly used for the purpose of neuropsychological assessment and cognitive research. Its widespread application has led to numerous versions differing in a number of respects. The present study addressed the question whether differences in instruction, cueing, and learning processes systematically influence ToL performance across five difficulty levels (three to seven moves). A total of 81 normal adults were examined in a mixed design with the between-subject factor instruction (online versus mental preplanning) and the within-subject factors cueing (cue versus non-cue test version) and learning processes (first block and second block). We also assessed general intelligence for further analyses of differences between instruction groups. In general, there was a significant main effect across the difficulty levels indicating that the rate of incorrect solutions increased with problem difficulty. The participants who were instructed to make full mental plans before beginning to execute movements (preplanning) solved significantly more problems than people who started immediately with task-related movements (online). As for the cueing conditions, participants with the minimum number of moves predetermined (cue) could solve more trials than people who were only instructed to solve the problems in as few moves as possible (non-cue). Participants generally increased performance in the second part of the test session. However, an interaction of presentation order of the cueing condition with learning indicated that people who started the tasks with the non-cue version showed significantly better performance in the following cue condition, while participants who started with the cue condition stayed at the same performance level for both versions. These findings suggest that instruction, cueing conditions, and learning processes are important determinants of ToL performance, and they stress the necessity of standardized application in research and clinical practice.

Time course of anger and other emotions in women with borderline personality disorder: A preliminary study

Borderline personality disorder (BPD) is characterized by emotional dysregulation including strong emotional reactions to emotional stimuli and a slow return to baseline emotions. Difficulties controlling anger are particularly prominent in BPD. To experimentally test emotional dysregulation with a special focus on anger, we investigated whether a standardized anger induction by a short story caused stronger and prolonged anger reactions in women with BPD (n=27) as compared to female healthy controls (n=26) and whether other emotions were affected by the anger induction. Although the anger reaction was not stronger in the BPD group, it was significantly prolonged. The BPD group showed also stronger negative emotions over the whole experiment. The study is the first to demonstrate prolonged anger reactions in BPD patients in an experimental setting.

Auxiliary variables in multiple imputation in regression with missing X: a warning against including too many in small sample research

BackgroundMultiple imputation is becoming increasingly popular. Theoretical considerations as well as simulation studies have shown that the inclusion of auxiliary variables is generally of benefit.MethodsA simulation study of a linear regression with a response Y and two predictors X1 and X2 was performed on data with n = 50, 100 and 200 using complete cases or multiple imputation with 0, 10, 20, 40 and 80 auxiliary variables. Mechanisms of missingness were either 100% MCAR or 50% MAR + 50% MCAR. Auxiliary variables had low (r=.10) vs. moderate correlations (r=.50) with X’s and Y.ResultsThe inclusion of auxiliary variables can improve a multiple imputation model. However, inclusion of too many variables leads to downward bias of regression coefficients and decreases precision. When the correlations are low, inclusion of auxiliary variables is not useful.ConclusionMore research on auxiliary variables in multiple imputation should be performed. A preliminary rule of thumb could be that the ratio of variables to cases with complete data should not go below 1 : 3.

How to make your own response boxes: A step-by-step guide for the construction of reliable and inexpensive parallel-port response pads from computer mice.

Psychological research is based in large parts on response latencies, which are often registered by keypresses on a standard computer keyboard. Recording response latencies with a standard keyboard is problematic because keypresses are buffered within the keyboard hardware before they are signaled to the computer, adding error variance to the recorded latencies. This can be circumvented by using external response pads connected to the computer’s parallel port. In this article, we describe how to build inexpensive, reliable, and easy-to-use response pads with six keys from two standard computer mice that can be connected to the PC’s parallel port. We also address the problem of recording data from the parallel port with different software packages under Microsoft’s Windows XP.

Validation of patient health questionnaire (PHQ) for major depression in Chinese outpatients with multiple somatic symptoms: A multicenter cross-sectional study

BACKGROUND Despite the high co-morbidity of depressive symptoms in patients with multiple somatic symptoms, the validity of the 9-item Patient Health Questionnaire (PHQ-9) has not yet been investigated in Chinese patients with multiple somatic symptoms. METHODS The multicenter cross-sectional study was conducted in ten outpatient departments located in four cities in China. The psychometric properties of the PHQ-9 were examined by confirmative factor analysis (CFA). Criterion validation was undertaken by comparing results with depression diagnoses obtained from the Mini International Neuropsychiatric Interview (MINI) as the gold standard. RESULTS Overall, 491 patients were recruited of whom 237 had multiple somatic symptoms (SOM+ group, PHQ-15≥10). Cronbach׳s α of the PHQ-9 was 0.87, 0.87, and 0.90 for SOM+ patients, SOM- patients, and total sample respectively. All items and the total score were moderately correlated. The factor models of PHQ-9 tested by CFA yielded similar diagnostic performance when compared to sum score estimation. Multi-group confirmatory factor analysis based on unidimensional model showed similar psychometric properties over the groups with low and high somatic symptom burden. The optimal cut-off point to detect depression in Chinese outpatients was 10 for PHQ-9 (sensitivity=0.77, specificity=0.76) and 3 for PHQ-2 (sensitivity=0.77, specificity=0.74). LIMITATIONS Potential selection bias and nonresponse bias with applied sampling method. CONCLUSIONS PHQ-9 (cut-off point=10) and PHQ-2 (cut-off point=3) were reliable and valid to detect major depression in Chinese patients with multiple somatic symptoms.

Development of Planning Abilities in Normal Aging: Differential Effects of Specific Cognitive Demands.

In line with the frontal hypothesis of aging, the ability to plan ahead undergoes substantial change during normal aging. Although impairments on the Tower of London planning task were reported earlier, associations between age-related declines and specific cognitive demands on planning have not been studied. Here we investigated the impact of search depth and goal ambiguity on planning, which impose demands on the depth and breadth of look-ahead processes, respectively. Besides an overall age-related decline in planning accuracy of 106 healthy older adults, differential search depth effects were found: Whereas planning accuracy of subjects in the early 60s was not affected by variations in search depth, between the ages of 65 and 76 years, accuracy was significantly decreased for high versus low levels of search depth. For subjects older than 76, different search depth levels did not further impact on accuracy, which was lowest overall. This nonlinear pattern may reflect differential impairments in fluid abilities and working memory capacity across various stages of older age. As no age-related effects of goal ambiguity were found, normal aging seems to be specifically sensitive to planning demands on the depth but not the breadth of anticipatory search processes. Hence, cognitive functions subserved by the prefrontal cortex experience differential development over the course of normal aging.

Psychological and behavioral variables associated with the somatic symptom severity of general hospital outpatients in China

OBJECTIVE In high-income countries, the number and severity of somatic symptoms - irrespective of etiology--are associated with adverse psychobehavioral and functional characteristics. This study aimed to assess these key features among Chinese general hospital outpatients with high levels of somatic symptoms. METHODS This multicenter, cross-sectional study evaluated four outpatient departments of internal medicine and Traditional Chinese Medicine in Beijing and Kunming and enrolled a total of 281 consecutive patients. The patients answered questionnaires concerning somatic symptom severity [Patient Health Questionnaire (PHQ-15)], illness perception (Brief Illness Perception Questionnaire), illness behavior (Scale for the Assessment of Illness Behavior), emotional distress (Hospital Anxiety and Depression Scale) and health-related quality of life (12-Item Short Form Health Survey). Subsamples reporting high scores of somatic symptom severity (PHQ-15 ≥10, SOM+) versus low scores (PHQ-15 <10, SOM-) were compared. RESULTS Twenty-eight percent (79/281) of all outpatients showed high somatic symptom severity. The strongest correlations between high somatic symptom severity and psychobehavioral variables were found for high emotional distress, female gender, living alone, low physical quality of life and high dysfunctional illness behavior. The proportion of the explained variance was 36.1%. CONCLUSION In Chinese outpatients, high somatic symptom severity is frequent and associated with psychobehavioral characteristics. With the PHQ-15 cutoff of 10, SOM+ patients could be differentiated from SOM- patients using these characteristics.