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COGNITIVE FACTORS IN FIBROMYALGIA: THE ROLE OF SELF-CONCEPT AND IDENTITY RELATED CONFLICTS

Fibromyalgia is a syndrome characterized by the presence of diffuse and chronic musculoskeletal pain of unknown etiology. Clinical diagnosis and the merely palliative treatments considerably affect the patients experience and the chronic course of the disease. Therefore, several authors have emphasized the need to explore issues related to self in these patients. The repertory grid technique (RGT), derived from personal construct theory, is a method designed to assess the patients construction of self and others. A group of women with fibromyalgia (n = 30) and a control group (n = 30) were assessed using RGT. Women with fibromyalgia also completed the Fibromyalgia Impact Questionnaire and a visual-analogue scale for pain, and painful tender points were explored. Results suggest that these women had a higher present self–ideal self discrepancy and a lower perceived adequacy of others, and it was more likely to find implicative dilemmas among them compared to controls. These dilemmas are a type of cognitive conflict in which the symptom is construed as “enmeshed” with positive characteristics of the self. Finally, implications of these results for the psychological treatment of fibromyalgia are suggested to give a more central role to self-identity issues and to the related cognitive conflicts.

Cognitive conflicts in major depression: Between desired change and personal coherence

Objectives The notion of intrapsychic conflict has been present in psychopathology for more than a century within different theoretical orientations. However, internal conflicts have not received enough empirical attention, nor has their importance in depression been fully elaborated. This study is based on the notion of cognitive conflict, understood as implicative dilemma (ID), and on a new way of identifying these conflicts by means of the Repertory Grid Technique. Our aim was to explore the relevance of cognitive conflicts among depressive patients. Design Comparison between persons with a diagnosis of major depressive disorder and community controls. Methods A total of 161 patients with major depression and 110 non-depressed participants were assessed for presence of IDs and level of symptom severity. The content of these cognitive conflicts was also analysed. Results Repertory grid analysis indicated conflict (presence of ID/s) in a greater proportion of depressive patients than in controls. Taking only those grids with conflict, the average number of IDs per person was higher in the depression group. In addition, participants with cognitive conflicts displayed higher symptom severity. Within the clinical sample, patients with IDs presented lower levels of global functioning and a more frequent history of suicide attempts. Conclusions Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity. Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics. Practitioner points Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence about its relevance due to the lack of methods to measure them. We developed a method for identifying conflicts using the Repertory Grid Technique. Depressive patients have higher presence and number of conflicts than controls. Conflicts (implicative dilemmas) can be a new target for intervention in depression. Cautions/Limitations A cross-sectional design precluded causal conclusions. The role of implicative dilemmas in the causation or maintenance of depression cannot be ascertained from this study.

Bibliometric Review of the Repertory Grid Technique: 1998–2007

This bibliometric review covers the scientific production with or about the repertory grid technique (RGT; Kelly, 1955/1991) between 1998 and 2007. An analysis of previous reviews suggests the need for a more careful and broad process of bibliographic research. With this aim, 24 bibliographic sources were used to cover a wide range of specialties. We began by drawing up an explicit protocol in which the research terms were detailed. Then we consulted the bibliographic sources, taking into account a specification of inclusion and exclusion criteria. As a result of this process, 973 references were obtained: 468 journal papers, 335 book chapters, 108 doctoral theses, and 62 books. The review also evaluates the types of documents found, the evolution of the number of works published, the repertory grids fields of application, and the degree of openness to other disciplines. The most relevant authors, their affiliations, countries, and the publication language are also revealed in this article, as well as the major journals contributing to dissemination of the work done with this technique.

Implicative Dilemmas and Symptom Severity in Depression: A Preliminary and Content Analysis Study

An implicative dilemma, a type of cognitive conflict, is found in a subjects repertory grid whenever a personal construct on which change is desired is associated with another construct on which change is undesirable. We studied dilemmas in 57 participants who met criteria for depressive spectrum disorders and compared them to 496 nonclinical controls. Almost 60% of the clinical sample presented with at least one implicative dilemma in their grids, as compared to 39% of controls. Participants with dilemma(s) showed higher levels of depressive symptoms and general distress (SCL-90-R) than those without any implicative dilemma in their grids. Also, the number of implicative dilemmas was associated with symptom severity. An analysis of the specific content of the personal constructs forming such dilemmas revealed that congruent constructs were mostly of moral nature, whereas discrepant constructs were related to emotional balance. Further studies may investigate whether an intervention targeted to the resolution of such dilemmas could be incorporated into existing treatments for depression to enhance their efficacy.

Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

BackgroundDepression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence.Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression.DesignA therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions).MethodParticipants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used.DiscussionWe expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression.Trial registrationISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Systemic Couple Therapy for dysthymia.

We examined the effect of Systemic Couple Therapy on a patient diagnosed with dysthymic disorder and her partner. Marge and Peter, a middle-aged married couple, showed significant and meaningful changes in their pattern of interaction over the course of the therapy and, by the end of it, Marge no longer met the diagnostic criteria for dysthymic disorder. Her scores on the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and Beck Depression Inventory, Second Edition (BDI-II) were in the clinical range before treatment and in the nonclinical one at the end of therapy. Although scores on Dyadic Adjustment Scale showed different patterns, both members reported significant improvement. The analysis of change in the alliance-related behaviors throughout the process concurred with change in couples pattern of interaction. Treatment effects were maintained at 12-month follow-up. Highlights in the therapy process showed the importance of relational mechanisms of change, such as broadening the therapeutic focus into the couples pattern of interaction, reducing expressed emotion and resentment, as well as increasing positive exchanges. The results of this evidence-based case study should prompt further investigation of couple therapy for dysthymia disorder. Randomized clinical trial design is needed to reach an evidence-based treatment status.

Self-Construction, Cognitive Conflicts, and Disordered Eating Attitudes in Young Women

The aim of this study is to identify cognitive variables that predict disordered eating attitudes in a nonclinical sample composed of 50 female university students. Repertory grid technique was used to assess cognitive features of self-construing and cognitive conflicts. Drive for Thinness and Body Dissatisfaction scales from the Eating Disorder Inventory–2 were used as dependent variables, as previous studies suggested that high scores on these scales are associated with the risk of developing or aggravating eating syndromes. Results suggest that drive for thinness can be associated with cognitive conflicts, whereas body dissatisfaction may be higher for those who construct themselves as inadequate and similar to others. In addition, both dependent variables were predicted by being younger and having a higher body mass index.

A DILEMMA-FOCUSED INTERVENTION FOR DEPRESSION: A MULTICENTER, RANDOMIZED CONTROLLED TRIAL WITH A 3-MONTH FOLLOW-UP.

Since long ago it has been asserted that internal conflicts are relevant to the understanding and treatment of mental disorders, but little research has been conducted to support the claim. The aim of this study was to test the differential efficacy of group cognitive behavioral therapy (CBT) plus an intervention focused on the dilemma(s) detected for each patient versus group individual CBT plus individual CBT for treating depression. A comparative controlled trial with a 3‐month follow‐up was conducted.

Dilemma-focused intervention for unipolar depression: a treatment manual.

BackgroundThis article introduces a new treatment protocol for depression. Based on previous research which indicated the presence of cognitive conflicts in depression, this study created an intervention manual to address these conflicts.MethodThe therapy manual for depressive patients followed the guideline for inclusion in clinical trials (stage II), which has received high recognition. A preliminary version (stage I) of this manual was formulated based on other, more general dilemma-focused therapy publications, inspired by personal construct theory (PCT), and input from clinical experience. The resulting version was then applied during the 8-session format of a pilot study with patients diagnosed with major depressive disorder or dysthymia. Finally, feedback was requested from seasoned and highly respected therapists, some of whom were familiar with PCT.ResultsAccording to the mentioned guideline, the intervention manual selected the theoretical framework, in this case PCT, to include its conceptualization of depression and resolution of dilemmas (to foster clinical improvement) as a main treatment goal. The manual was then contrasted with psychoanalytic psychotherapy, cognitive-behavior therapy (CBT), motivational interviewing (MI), and other similar approaches such as cognitive-analytic therapy and coherence therapy. Following these conceptual clarifications, the specific interventions included in the manual were defined according to both categories: their unique and essential components and those conceived as common psychotherapeutic factors. Next, the general structure and content for each session were presented. The structure consisted of seven well-defined individual sessions with an additional session, which could complement any of the former sessions to address the patient’s issues in greater depth, if needed.ConclusionsThis Dilemma-Focused Intervention manual aimed to improve the treatment outcome for depression by offering an intervention that could be combined with other general approaches. At its present level of definition, it allows for inclusion in controlled trials (eg, the current RCT combining group CBT with this intervention). Thus, this manual added to the existing resources in psychotherapeutic research and practice for treatment of depression.

Maltrato y reconstrucción de la identidad en la psicoterapia constructivista de la fibromialgia

espanolRecientemente ha crecido el interes de los tratamientos psicologicos en Fibromialgia (FM). Hay pocas evidencias de como el maltrato afecta al proceso psicoterapeutico. El objetivo es investigar si el maltrato afecta de manera diferencial al desarrollo de una terapia constructivista. 20 mujeres con FM fueron evaluadas antes y despues de la terapia utilizando la Tecnica de Rejilla y otras medidas clinicas. Las 13 pacientes que habian sufrido maltrato presentaban antes del tratamiento mayor severidad de sintomas y una construccion mas negativa de los otros. Despues de la terapia, este grupo reduce los sintomas de manera significativa y se ven mas similares a los otros. La historia de maltrato parece ser un factor relevante en la terapia constructivista en fibromialgia. EnglishInterest in psychological treatments in Fibromyalgia (FM) has increased lately. Little evidences are available about whether having experienced maltreatment affects psychotherapy outcome. Our aim is to investigate the effect of maltreatment on outcome during constructivist therapy in FM. 20 women were assessed before and after therapy using Repertory Grid Technique and clinical measures of which 13 had suffered maltreatment. Those with a history of maltreatment had higher levels of symptoms and a negative construction of others at pre-treatment assessment in comparison to those with no report of maltreatment. After therapy, only those who had been maltreated reduced symptoms and achieved a more integrated construction of others. Maltreatment seemed to affect differently the outcome in constructivist therapy in FM.