Stefan Westermann

Moving from Efficacy to Effectiveness in Cognitive Behavioral Therapy for Psychosis: A Randomized Clinical Practice Trial.

OBJECTIVE Randomized controlled trials have attested the efficacy of cognitive behavioral therapy (CBT) in reducing psychotic symptoms. Now, studies are needed to investigate its effectiveness in routine clinical practice settings. METHOD Eighty patients with schizophrenia spectrum disorders who were seeking outpatient treatment were randomized to a specialized cognitive behavioral intervention for psychosis (CBTp; n = 40) or a wait list (n = 40). The CBTp group was assessed at baseline, posttreatment, and 1-year follow-up. The wait list group was assessed at baseline, after a 4-month waiting period, at posttreatment, and after 1 year. The primary outcome measure was the Positive and Negative Syndrome Scale (PANSS). RESULTS The CBTp group showed significant improvement over the wait list group for the total PANSS score at posttreatment-postwaiting. CBTp was also superior to the wait list group in regard to the secondary outcomes positive symptoms, general psychopathology, depression, and functioning, but not in regard to negative symptoms. The number of dropouts during the treatment phases was low (11.3%). Participants perceived the treatment as helpful (98%) and considered themselves improved (92%). Significant pre- and posttreatment effect sizes varied between 0.77 for general psychopathology and 0.38 for delusional conviction. The positive effects of treatment could be maintained at 1-year follow-up, although the number of patients who had deteriorated was higher than at postassessment. CONCLUSIONS Large proportions of patients in clinical practice settings benefit from CBTp. The efficacy of CBTp can be generalized to clinical practice despite the differences in patients, therapists, and deliverance.

Being deluded after being excluded? How emotion regulation deficits in paranoia-prone individuals affect state paranoia during experimentally induced social stress.

Emotion regulation (ER) has become a relevant construct to understanding paranoia. While the ER strategy called expressive suppression (e.g., poker face) may foster state paranoia by increasing arousal, another strategy called reappraisal (e.g., changing the perspective on situations) may reduce negative emotions and state paranoia when adaptively used. However, if reappraisal fails, this could increase paranoia. The aim of this study was to test the proposed effects of the ER strategies on state paranoia in the socially stressful situation of being excluded in paranoia-prone individuals. We conducted an experimental online study with N=116 participants who were randomized to a social inclusion or an exclusion condition using a virtual Cyberball ball-tossing game. They completed questionnaires on paranoia proneness and habitual ER strategies. Before and after the Cyberball task, participants rated their level of state paranoia. The impact of habitual ER strategies, paranoia proneness, and social stress on changes in state paranoia was investigated using linear regression analysis. The three-way interaction of social stress, paranoia proneness, and habitual reappraisal use significantly predicted state paranoia, t(114)=2.62, p=0.010. The decomposition of the interaction term revealed that in the social stress condition, the impact of reappraisal on state paranoia was moderated by the level paranoia proneness. Specifically, in high paranoia-prone individuals the use of reappraisal predicted higher state paranoia. The findings regarding habitual use of suppression were not significant. Although reappraisal is generally considered a functional strategy, its use in distressing social situations seems to be impaired in persons with higher paranoia proneness. A working model of emotion dysregulation in delusions is presented and possible implications for cognitive therapy of psychosis are discussed.

Emotion regulation difficulties are relevant to persecutory ideation

OBJECTIVES Persecutory delusions are preceded and accompanied by negative emotions, which may be prolonged or even amplified by difficulties in the ability to regulate negative emotions. This study aims to gain insight into emotion regulation difficulties in persecutory ideation. DESIGN AND METHOD A correlational approach was adopted to explore bivariate and multivariate associations between emotion regulation difficulties and persecutory ideation in a subclinical sample. Furthermore, general psychopathology as well as positive symptoms of schizophrenia were assessed in order to estimate the specificity of emotion regulation difficulties. Data from 151 participants acquired via an Internet-based survey were analyzed. RESULTS There were substantial bivariate correlations between paranoid ideation and emotion regulation difficulties. However, only impulse control difficulties were specific to persecutory ideation after controlling for general psychopathology. Additionally, a multivariate analysis revealed unexpected positive associations between the acceptance of emotional responses and paranoid ideation as well as positive symptoms. CONCLUSIONS Besides the general difficulties in regulating emotion that are common to many clinical disorders and were associated with overall psychopathology, subclinical psychotic symptoms seem to be specifically associated with certain aspects of emotion regulation. Emotion regulation difficulties are likely to contribute to symptom formation and maintenance in persecutory delusions and might therefore present a valuable treatment target.

On the distinction of empathic and vicarious emotions

In the introduction to the special issue “The Neural Underpinnings of Vicarious Experience” the editors state that one “may feel embarrassed when witnessing another making a social faux pas”. In our commentary we address this statement and ask whether this example introduces a vicarious or an empathic form of embarrassment. We elaborate commonalities and differences between these two forms of emotional experiences and discuss their underlying mechanisms. We suggest that both, vicarious and empathic emotions, originate from the simulation processes mirroring and mentalizing that depend on anchoring and adjustment. We claim the term “empathic emotion” to be reserved exclusively for incidents where perceivers and social targets have shared affective experience, whereas “vicarious emotion” offers a wider scope and also includes non-shared affective experiences. Both are supposed to be highly functional in social interactions.

Specificity of emotion regulation deficits in social anxiety: An internet study

OBJECTIVES There is evidence for an association between social anxiety and emotion regulation difficulties. This study investigates that emotion regulation difficulties are specific to two domains of social anxiety. DESIGN AND METHOD An explorative study was conducted to examine the associations between emotion regulation facets and social anxiety in the normal population. N= 149 healthy volunteers participated in an internet-based survey. MEASURES Emotion regulation deficits were measured by the Difficulties in Emotion Regulation Scale which consists of six subscales. Social anxiety was measured by the Social Phobia Scale and the Social Interaction Anxiety Scale. RESULTS Hierarchical regression analyses showed that anxiety of interactive social situations is associated with non-acceptance of negative emotions, impulse control difficulties, and lack of functional emotion regulation strategies over and above the impact of age and general psychopathology. In contrast, anxiety of being observed by others was not specifically associated with emotion regulation strategies. CONCLUSION The results support the hypothesis that specific emotion regulation deficits are relevant to specific aspects of social anxiety. Implications for further research and therapy are discussed.

Using signal detection theory to test the impact of negative emotion on sub-clinical paranoia

A novel experimental paradigm for measuring state paranoia by means of signal detection theory was evaluated. A liberal response bias, indicating the tendency to recognize facial expressions as threatening, was expected to reflect paranoia. Against theoretical expectations, heightened paranoia questionnaire scores were associated with a non-liberal bias, which was not affected by negative emotion per se. However, subsequent analyses revealed that, if anxious, participants with heightened paranoia adopted a comparatively more liberal response bias. These findings corroborate the eminent role of anxiety in paranoia and demonstrate that state paranoia can be captured with the presented paradigm.

Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis

This study investigates the predictors of outcome in a secondary analysis of dropout and completer data from a randomized controlled effectiveness trial comparing CBTp to a wait-list group (Lincoln et al., 2012). Eighty patients with DSM-IV psychotic disorders seeking outpatient treatment were included. Predictors were assessed at baseline. Symptom outcome was assessed at post-treatment and at 1-year follow-up. The predictor×group interactions indicate that a longer duration of disorder predicted less improvement in negative symptoms in the CBTp but not in the wait-list group whereas jumping-to-conclusions was associated with poorer outcome only in the wait-list group. There were no CBTp specific predictors of improvement in positive symptoms. However, in the combined sample (immediate CBTp+the delayed CBTp group) baseline variables predicted significant amounts of positive and negative symptom variance at post-therapy and 1-year follow-up after controlling for pre-treatment symptoms. Lack of insight and low social functioning were the main predictors of drop-out, contributing to a prediction accuracy of 87%. The findings indicate that higher baseline symptom severity, poorer functioning, neurocognitive deficits, reasoning biases and comorbidity pose no barrier to improvement during CBTp. However, in line with previous predictor-research, the findings imply that patients need to receive treatment earlier.

When does jumping-to-conclusions reach its peak? The interaction of vulnerability and situation-characteristics in social reasoning

BACKGROUND AND OBJECTIVES Persons with delusions tend to display a jumping-to-conclusions (JTC) bias which is considered relevant to delusion formation. However, its contribution in real life social scenarios is unknown. This study investigates whether JTC increases when decisions have to be made in delusion-relevant situations and whether the increase is uniquely moderated by delusion-proneness. METHODS JTC was assessed by a social reasoning paradigm in 92 healthy participants that were classified as high, medium or low in paranoid ideation and social anxiety. Decisions had to be made for emotionally salient scenarios without direct self-relevance, self-relevant scenarios and delusion-relevant scenarios, by successively drawing pieces of information. RESULTS All participants drew less information in the scenarios that were self-relevant and delusion-relevant compared to non-self-relevant scenarios. Participants with higher paranoid ideation generally drew less information than persons with medium or low levels of paranoid ideation. However, the hypothesized interaction of delusion-proneness and type of scenario was not significant. Social anxiety had no effect on draws to decision in any of the task types. LIMITATIONS The description of social encounters in the task does still not capture the full perceptual experience in real life encounters. CONCLUSIONS The data support the assumption that the formation of persecutory delusions might arise as a function of a delusion-specific JTC-bias in combination with a normal and functional tendency to collect less information in self-relevant situations.

Emotion regulation in delusion‐proneness: Deficits in cognitive reappraisal, but not in expressive suppression

OBJECTIVES Although anxiety plays a key role in delusions, its downregulation using specific emotion regulation (ER) strategies has not been investigated. Reappraisal has been shown to be one of the most effective strategies for healthy individuals. However, individuals with delusions might have difficulties in successfully applying reappraisal. This study therefore tests the effectiveness of reappraisal compared to expressive suppression in individuals with varying levels of delusion-proneness. DESIGN An experimental design with the independent variables ER strategy (within subject) and delusion-proneness (between subject; quasi-experimental) was used. The dependent variables were subjective ER success and physiological arousal, as well as state delusional ideation. METHODS Eighty-six healthy participants with different levels of delusion-proneness were instructed to respond to anxiety-inducing stimuli by either using reappraisal or expressive suppression. RESULTS Overall, reappraisal was more effective than expressive suppression in regulating anxiety. However, delusion-prone individuals were less successful in applying reappraisal (interaction effect: F(2,158) = 3.70, p = .027). In addition, lower success in reappraising threat was accompanied by higher state delusional ideation (r = -0.20, p = .013). CONCLUSIONS Delusion-proneness is accompanied by difficulties in reappraising threat that might contribute to the formation and maintenance of clinically relevant delusions. Preliminary implications for the improvement of cognitive behaviour therapy for delusions are discussed.

Increased soluble interleukin-2 receptor levels are related to somatic but not to cognitive-affective features in major depression.

Cell-mediated immune activation may play a role in the pathogenesis of depression as indicated by findings of increased soluble tumor necrosis factor receptor (sTNF-R) levels and meta-analytic evidence for elevated soluble interleukin-2 receptor (sIL-2R) concentrations. However, little research has been done on how these soluble cytokine receptors are differently related to specific features in patients with depression. We measured levels of the soluble cytokine receptors sIL-2R, sTNF-R1 and sTNF-R2 in 25 non-medicated patients with major depression (DSM-IV) and 22 healthy controls. Psychometric measures included cognitive-affective depressive symptoms, somatoform symptoms, somatic and cognitive dimensions of anxiety and current mood states. While patients with depression showed increased levels of sIL-2R (p<0.01), differences in sTNF-R1 (p=0.09) and sTNF-R2 (p=0.08) marginally failed to reach significance. Increased concentrations of sIL-2R were related to somatic measures such as the severity of somatoform symptoms and somatic anxiety symptoms but not to cognitive-affective measures or current mood states. Our findings may suggest some specificity in the relationship between sIL-2R and symptom dimensions and highlight potential pathways by which T cell mediated immune activation may underpin somatic symptoms in depression.