Cognitive Behavioral Psychotherapy as an Add-on in Comprehensive Outpatient Care of Non-affective Psychoses: A Multicenter Randomized-Controlled Effectiveness Trial in a Naturalistic Setting.

BACKGROUND AND HYPOTHESIS: Non-affective psychoses (NAP) are associated with severe consequences with regard to social functioning, physical health, employment, and suicidality. Treatment guidelines recommend cognitive behavioral therapy for psychosis (CBTp) as an effective additional treatment strategy to psychopharmacology. We hypothesized that outpatient CBTp has an add-on effect in individuals with NAP who already receive comprehensive outpatient care (COC) in Germany. STUDY DESIGN: In a randomized-controlled effectiveness trial, 6 months of COC + CBTp were compared to COC. The primary outcomes were change of symptom severity as assessed by the Positive and Negative Symptom Scale (pre-/post-treatment and 6-month follow-up). Mixed linear models and effect sizes were used to compare changes across treatment groups. Additionally, the number of readmissions was compared. STUDY RESULTS: N = 130 individuals with chronic NAP were recruited (COC + CBTp: n = 64, COC: n = 66). COC + CBTp participants significantly improved more regarding positive symptom severity (estimated mean difference at follow-up: -2.33, 95% CI: -4.04 to -0.61, P = .0083, d = 0.32) and general psychopathology (estimated mean difference at follow-up: -4.55, 95% CI: -7.30 to -1.81, P = .0013, d = 0.44) than the COC group. In both groups, negative symptom severity did not change significantly over time nor did groups differ regarding readmissions. CONCLUSION: The results underline an add-on benefit of CBTp in chronically ill individuals with NAP. Superiority of CBTp was demonstrated in comparison with high-quality comprehensive care and may also be true in different comprehensive care settings. CLINICAL TRIALS REGISTRATION: DRKS00015627.

[Gender-Related Differences Regarding Aggressive Behaviour and Coercive Measures in Psychiatric Inpatients]. / Geschlechtsspezifische Unterschiede aggressiven Verhaltens und der Anwendung von Zwangsmaßnahmen bei stationär psychiatrischen Patienten und Patientinnen.

OBJECTIVE: Examination of gender-related differences of aggressive incidents and the use coercive measures within a whole psychiatric hospital with a catchment area of 339.000 inhabitants over a period of fifteen years. METHODS: Recording of aggressive incidents using the Staff Observation Aggression Scale-Revised (SOAS-R) as well as coercive measures by a clinically developed record sheet and analysing gender-related differences from 2005 to 2019. RESULTS: 82 833 inpatients (male: 55.3 %; female: 44.7 %) are included. Between 2005 and 2019, 60.1 % of the aggressive events involved male patients and 39.9 % involved female patients; however, regarding cases of treatment no gender-related difference existed (odds ratio: 1.1). The SOAS-R-severity score of women was significantly higher, while aggressive incidents of men were subjectively graded more serious by staff. The number of coercive measures and the mean duration of restraint and seclusion episodes were significantly higher and longer, respectively, in male inpatients. CONCLUSION: Differences in frequency and duration of coercive measures between male and female patients could be influenced by the subjective perception of staff that male patients behave more aggressively.

Neural correlates of emotion acceptance and suppression in borderline personality disorder.

Background: Emotion dysregulation is a central feature of borderline personality disorder (BPD). Since impaired emotion regulation contributes to disturbed emotion functioning in BPD, it is crucial to study underlying neural activity. The current study aimed at investigating the neural correlates of two emotion regulation strategies, namely emotion acceptance and suppression, which are both important treatment targets in BPD. Methods: Twenty-one women with BPD and 23 female healthy control participants performed an emotion regulation task during functional magnetic resonance imaging (fMRI). While watching fearful movie clips, participants were instructed to either accept or to suppress upcoming emotions compared to passive viewing. Results: Results revealed acceptance-related insular underactivation and suppression-related caudate overactivation in subjects with BPD during the emotion regulation task. Conclusion: This is a first study on the neural correlates of emotion acceptance and suppression in BPD. Altered insula functioning during emotion acceptance may reflect impairments in emotional awareness in BPD. Increased caudate activity is linked to habitual motor and cognitive processes and therefore may accord to the well-established routine in BPD patients to suppress emotional experiences.

Caudate hyperactivation during the processing of happy faces in borderline personality disorder.

BACKGROUND: Emotion dysfunction and anhedonia are main problems in borderline personality disorder (BPD). In the present functional magnetic resonance imaging (fMRI) study, we investigated neural activation during the processing of happy faces and its correlates with habitual emotion acceptance in patients with BPD. METHODS: 22 women with BPD and 26 female healthy controls watched movie clips of happy and neutral faces during fMRI without any instruction of emotion regulation. To associate neural activation with habitual emotion acceptance, we included individual scores of the Emotion Acceptance Questionnaire (EAQ) as a covariate in brain data analysis. RESULTS: All participants showed amygdala, temporal and occipital activation during the processing of happy compared to neutral faces. Compared with healthy controls, patients with BPD showed significantly more activation within the bilateral caudate. We did not find significant correlations with emotion acceptance. CONCLUSIONS: Our results indicate caudate hyperactivation in patients with BPD during the processing of happy faces. Although patients reported significantly less emotion acceptance of positive emotions, an association with neural activation was not detectable.

[Supporting Interventions for Families with Children of Mentally Ill Parents: An Overview of Family-Oriented Complex Interventions in German-Speaking Countries]. / Familien mit Kindern psychisch kranker Eltern: Ein Überblick über ambulante, familienorientierte Komplexangebote im deutschsprachigen Raum.

OBJECTIVE: The aim of the present review was to identify all outpatient, family-oriented complex interventions for children of mentally ill parents known in the German-speaking countries on the basis of defined minimum requirements and to give an overview of their structure, content and proof of effectiveness. METHODOLOGY: The interventions were identified by means of internet and literature research. If the defined criteria were met, the providers were contacted and asked to participate in a written survey. RESULTS: A total of 512 offers could be identified, 46 of which were to be classified as family-oriented complex interventions. Only a few interventions have been systematically evaluated so far. CONCLUSION: There is a large number of interventions for the children of mentally ill parents, but family-oriented complex interventions are rare. There is also a considerable need for evaluation studies.

Nonacceptance of negative emotions in women with borderline personality disorder: association with neuroactivity of the dorsal striatum

Background: Emotion dysfunction is a key symptom in patients with borderline personality disorder (BPD) and is considered a consequence of dysfunctional emotion regulation (e.g., reduced emotion acceptance). In the present functional MRI (fMRI) study, we investigated the neural correlates of habitual emotion acceptance in individuals with BPD. Methods: Female patients with BPD and female healthy controls passively viewed negative and neutral movie clips of faces during fMRI. We assessed emotion acceptance using the Emotion Acceptance Questionnaire (EAQ). To examine brain activation associated with habitual emotional acceptance of negative stimuli, the EAQ score was included as a regressor of interest in brain data analyses of activation intensity during negative compared with neutral movies. Results: We included 20 women with BPD and 20 heatlhy controls in our analysis. Compared with healthy controls, patients with BPD showed significantly more activation in frontostriatal brain regions (i.e., left superior frontal gyrus, right caudate) as well as in the left precuneus, left precentral gyrus, left posterior cingulate cortex and left hippocampus when confronted with negative (v. neutral) stimuli. Patients with BPD reported decreased emotion acceptance compared with healthy controls, and habitual emotion acceptance was inversely associated with activation of striatal areas (i.e., left putamen, left caudate) in patients with BPD. Limitations: Causal conclusions are not possible. Comorbid diagnoses were not excluded, and only female participants were investigated. Stimuli were not rated immediately and may not be generalizable to all negative emotions. We cannot make any statements about other emotion-regulation strategies that may have been applied here. Conclusion: Data indicate that striatal hyperactivation during the processing of negative stimuli in women with BPD is related to their decreased disposition to accept unpleasant emotional states. Thus, individuals with BPD may benefit from therapy approaches that focus on emotion acceptance in order to normalize emotional reactions.

Breath Versus Emotions: The Impact of Different Foci of Attention During Mindfulness Meditation on the Experience of Negative and Positive Emotions.

Mindfulness meditation yields beneficial effects on the processing of emotions. However, it is still unclear whether the focus of attention during meditation influences these effects. In the present study we aimed at comparing the effects of breathing meditation and emotion-focused meditation on the immediate and delayed processing of negative and positive emotions. The study included 65 adult novice meditators who were exposed to positively and negatively valenced film clips. Participants were randomly assigned to three conditions. While watching the films at t1, they were asked to mindfully focus on their breath (condition 1), on emotions (condition 2), or on nothing in particular (condition 3). Ten minutes later at t2, comparable film clips were shown but all participants watched them without taking up a mindful attitude. Dependent measures were emotional states at t1 and t2. Participants of both meditation conditions particularly showed a more preferable delayed emotional reaction to negative stimuli than participants of the control condition. Breathing meditation and emotion-focused meditation may constitute effective emotion regulation strategies to deal with negatively valenced emotional states.

Effects of cortisol on the memory bias for emotional words? A study in patients with depression and healthy participants using the Directed Forgetting task.

Mood congruent alterations in information processing such as an impaired memory bias for emotional information and impaired inhibitory functions are prominent features of a major depressive disorder (MDD). Furthermore, in MDD patients hypothalamic-pituitary-adrenal axis dysfunctions are frequently found. Impairing effects of stress or cortisol administration on memory retrieval as well as impairing stress effects on cognitive inhibition are well documented in healthy participants. In MDD patients, no effect of acute cortisol administration on memory retrieval was found. The current study investigated the effect of acute cortisol administration on memory bias in MDD patients (N = 55) and healthy controls (N = 63) using the Directed Forgetting (DF) task with positive, negative and neutral words in a placebo controlled, double blind design. After oral administration of 10 mg hydrocortisone/placebo, the item method of the DF task was conducted. Memory performance was tested with a free recall test. Cortisol was not found to have an effect on the results of the DF task. Interestingly, there was significant impact of valence: both groups showed the highest DF score for positive words and remembered significantly more positive words that were supposed to be remembered and significantly more negative words that were supposed to be forgotten. In general, healthy participants remembered more words than the depressed patients. Still, the depressed patients were able to inhibit intentionally irrelevant information at a comparable level as the healthy controls. These results demonstrate the importance to distinguish in experimental designs between different cognitive domains such as inhibition and memory in our study.

[Attentional bias and emotional suppression in borderline personality disorder]. / Aufmerksamkeitsbias und Emotionssuppression bei der Borderline-Persönlichkeitsstörung.

OBJECTIVE: Emotion regulation dysfunctions marked by negative affectivity are a core feature of borderline personality disorder (BPD). In addition, patients with BPD show disturbed attentional processes which become particularly apparent in the domain of selective attention when emotional stimuli are presented (negative attentional bias). Assuming that emotion regulation is linked to attentional deployment processes, this study aimed (1) to determine whether a negative attentional bias is established by using film clips of fearful faces and (2) to investigate the association between dysfunctional emotion regulation strategies (emotional suppression) and negative attention bias in BPD. METHODS: We investigated 18 inpatients with BPD and 18 healthy control participants using the modified version of the fearful face-paradigm to assess the inhibition of emotional stimuli. We also administered self-report emotion regulation questionnaires. RESULTS: Compared to the healthy controls, patients with BPD showed significant longer reaction times during the emotional versus the neutral film stimuli in the modified fearful face-paradigm. With regard to the second hypothesis, we failed to find an association between the negative attentional bias and the habitual use of emotional suppression in BPD. CONCLUSIONS: In this study, we could confirm an attentional bias for negative stimuli, using complex, dynamic material. Future studies need to address the impact of confounding variables (e. g. comorbid disorders) on the relationship between maladaptive emotion regulation and selective attentional bias.

The impact of self-reported childhood trauma on emotion regulation in borderline personality disorder and major depression.

Early life stress is said to play a critical role in the development of borderline personality disorder (BPD) and major depressive disorder (MDD), but the underlying mediating factors remain uncertain. This study aimed to investigate self-reported childhood trauma, emotion regulation difficulties, and their associations in a sample of BPD (n = 49) and MDD (n = 48) patients and healthy control participants (n = 63). Multiple regressions were used to evaluate the impact of the quality and severity of self-reported childhood trauma on self-reported emotion regulation. The results supported an association between self-reported maltreatment experiences, especially emotional abuse and neglect, and emotion regulation difficulties. Additional analyses showed that emotion regulation difficulties influence the association between self-reported emotional abuse and acute symptomatology in the BPD subgroup. Emotion regulation difficulties may be 1 pathway through which early life stress, particularly emotional abuse, increases the risk for developing BPD symptomatology.

Acute glucocorticoid effects on response inhibition in borderline personality disorder.

INTRODUCTION: Growing evidence suggests inhibition dysfunctions in borderline personality disorder (BPD). Moreover, abnormalities in hypothalamic-pituitary-adrenal (HPA) axis functioning have also been found in BPD patients. In healthy individuals, response inhibition has been sensitive to acute stress, and previous research indicates that effects mediated by the HPA axis become particularly apparent when emotional stimuli are processed. This study aimed to explore the influence of acute hydrocortisone administration on response inhibition of emotional stimuli in BPD patients compared to healthy control participants. METHODS: After a single administration of 10mg hydrocortisone or placebo, 32 female BPD patients and 32 healthy female participants performed an adapted emotional go/no-go paradigm to assess response inhibition for emotional face stimuli in a cross-over study. RESULTS: Acute cortisol elevations decreased the reaction times to target stimuli in both BPD patients and healthy controls. Patients and controls did not differ in task performance; however, BPD patients with comorbid posttraumatic stress disorder (PTSD) displayed longer reaction times than patients without PTSD. In contrast, the occurrence of comorbid eating disorder had no significant impact on go/no-go performance. No significant interaction effect between the treatment condition and the emotional valence of the face stimuli was found. CONCLUSIONS: Acute hydrocortisone administration enhances response inhibition of face stimuli in BPD patients and healthy controls, regardless of their emotional valence. Our results agree with the suggestion that moderate cortisol enhancement increases the inhibition of task-irrelevant distracters.

Increased attempts to suppress negative and positive emotions in Borderline Personality Disorder.

Patients with Borderline Personality Disorder (BPD) show evidence of disturbed emotion regulation. In particular, patients may try to suppress their emotions with possibly negative effects on mental health. We investigated the suppression of both negative and positive emotions in BPD patients and healthy participants. Thirty BPD patients and 30 matched healthy controls were assessed for emotion suppression using the Emotion Acceptance Questionnaire (EAQ). In addition, we administered additional questionnaires to validate emotion suppression findings. BPD patients reported increased attempts to suppress both negative and positive emotions. These findings indicate that BPD patients are not simply acting out negative emotions. Therapeutic approaches that focus on emotion acceptance of emotions are supported by our study data. Apart from negative emotions, treatment programs should consider positive emotions as well.

Cortisol effects on autobiographic memory retrieval in PTSD: an analysis of word valence and time until retrieval.

In healthy participants, cortisol administration has been found to impair autobiographic memory retrieval. We recently reported that administration of 10 mg of hydrocortisone had enhancing effects on autobiographical memory retrieval, i.e. more specific memory retrieval, in patients with posttraumatic stress disorder (PTSD), while in healthy controls the impairing effects were replicated. We here report a re-analysis of these data with respect to cue-word valence and retrieval time. In a placebo-controlled cross-over study, 43 patients with PTSD and 43 age- and sex-matched healthy controls received either placebo or hydrocortisone orally before the autobiographical memory test was performed. We found that the effects of cortisol on memory retrieval depended on cue-word valence and group (significant interaction effects of drug by group and drug by valence by group). The enhancing effect of cortisol on memory retrieval in PTSD seemed to be relatively independent of cue-word valence, while in the control group the impairing effects of cortisol were only seen in response to neutral cue-words. The second result of the study was that in patients as well as in controls, cortisol administration led to faster memory retrieval compared to placebo. This was seen in response to positive and (to lesser extend) to neutral cue-words, but not in response to negative cue-words. Our findings illustrate that the opposing effects of cortisol on autobiographical memory retrieval in PTSD patients and controls are further modulated by the emotionality of the cue-words.

Effects of acute cortisol administration on response inhibition in patients with major depression and healthy controls.

Glucocorticoids (GCs) have repeatedly been shown to impair hippocampus-mediated, declarative memory retrieval and prefrontal cortex-based working memory in healthy subjects. However, recent experimental studies indicated that patients with major depressive disorder (MDD) lack these impairing effects. These missing effects have been suggested to result from dysfunctional brain GC receptors. The purpose of the present study was to investigate whether response inhibition, an executive function relying on the integrity of the prefrontal cortex, would be impaired after cortisol administration in patients with MDD. In a placebo-controlled, double blind crossover study, 50 inpatients with MDD and 54 healthy control participants conducted an emotional go/no-go task consisting of human face stimuli (fearful, happy, and neutral) after receiving a dose of 10 mg hydrocortisone and after placebo. GC administration had an enhancing effect on inhibitory performance in healthy control participants, indicated by faster responses, while no GC effect was revealed for the patients group. Moreover, patients showed an overall worse performance than healthy participants. In conclusion, this study further supports the hypothesis of impaired central glucocorticoid receptor function in MDD patients. Regarding the importance of inhibitory functioning for daily living, further studies are needed to examine the impact of glucocorticoids on response inhibition.

Increased suppression of negative and positive emotions in major depression.

BACKGROUND: Patients with major depression (MDD) show increased suppression of negative emotions. Emotion suppression is related to depressive symptoms such as depressive mood and anhedonia. It is not clear whether MDD patients also suppress positive emotions. In the present study we aim to investigate suppression of both negative and positive emotions in MDD patients as well as the relation between emotion suppression and depressive symptoms. In addition, we suggest that emotion suppression might be associated with fear of emotions. METHODS: 39 MDD patients and 41 matched healthy control subjects were investigated for emotion suppression and fear of emotions with the Emotion Acceptance Questionnaire (EAQ). In addition, we applied additional questionnaires to validate emotion suppression findings and to assess depressive symptoms. RESULTS: MDD patients reported increased suppression of both negative and positive emotions. Suppression of negative and positive emotions was related to depressive symptoms. Patients also reported more fear of emotions than healthy subjects and this fear was related to emotion suppression in both study samples. LIMITATIONS: Due to the cross-sectional and correlational study design, causal directions between the variables tested cannot be stated. CONCLUSIONS: Fear of emotion might be one reason why MDD patients suppress emotions. With regard to positive emotions, our results strongly suggest that therapeutic approaches should not only encourage patients to participate in potentially enjoyable situations but that patients may also benefit from practicing the allowance of pleasant emotions.

Associations of childhood trauma with hypothalamic-pituitary-adrenal function in borderline personality disorder and major depression.

BACKGROUND: Alterations of the hypothalamus-pituitary-adrenal (HPA) axis are hallmarks in major depressive disorder (MDD) and there is some evidence about similar patterns in borderline personality disorder (BPD). This study examines HPA axis abnormalities with respect to clinical characteristics in both BPD (n=24) and MDD patients (n=33) as well as in healthy control participants (n=41). METHOD: A 0.5mg dexamethasone suppression test was administered to evaluate basal cortisol release and HPA feedback sensitivity via salivary cortisol. Traumatic experiences in childhood as well as severity of borderline and depressive symptom severity and dissociation were obtained by self-report questionnaires. RESULTS: Compared to the healthy control group, BPD and MDD patients exhibited both enhanced cortisol concentrations before and after the administration of 0.5mg dexamethasone. Higher cortisol levels were positively correlated to a history of childhood trauma, current dissociative symptoms and severity of borderline and depressive symptoms. Regression analyses revealed that some aspects of early trauma were associated with cortisol release before and after dexamethasone, whereas psychopathology did not contribute to the regression model. CONCLUSIONS: HPA dysfunctions appear to be related rather to childhood trauma than to psychopathology in adulthood. Exposure to childhood trauma may contribute to long-lasting alterations in HPA activity and might enhance the risk for the development of later mental disorder.

Cortisol has enhancing, rather than impairing effects on memory retrieval in PTSD.

BACKGROUND: In the present study, we aimed to compare the effect of exogenous cortisol on memory retrieval in posttraumatic stress disorder (PTSD) with the effects in healthy controls. In healthy participants, administration of cortisol impairs declarative memory retrieval. Only a few studies have investigated these effects in PTSD yielding mixed results. METHODS: In a placebo-controlled crossover study, 44 patients with PTSD and 65 healthy controls received either placebo or 10mg of hydrocortisone orally before memory testing. In addition to declarative memory retrieval (word list learning), we also tested autobiographical memory retrieval specificity. RESULTS: In both tasks opposing effects of cortisol on memory were observed when comparing patients with controls. In controls, cortisol had impairing effects on memory retrieval, while in PTSD patients cortisol had enhancing effects on memory retrieval in both memory domains. CONCLUSIONS: The present results suggest beneficial effects of acute cortisol elevations on hippocampal mediated memory processes in PTSD. Possible neurobiological mechanisms underlying these findings are discussed.

Effects of acute hydrocortisone administration on declarative memory in patients with major depressive disorder: a placebo-controlled, double-blind crossover study.

OBJECTIVE: Major depressive disorder (MDD) has been associated with hypercortisolism, reduced glucocorticoid feedback sensitivity, and impaired memory function. In healthy subjects, administration of hydrocortisone impairs declarative memory. The aim of this study was to examine the effects of acute hydrocortisone administration on memory retrieval in MDD patients and healthy controls. We further tested whether the enhancing or impairing effects of hydrocortisone would prevail when it was given after encoding and when delayed retrieval was tested at a time point when glucocorticoid levels were still elevated. METHOD: In a placebo-controlled, double-blind crossover study, 44 patients with DSM-IV MDD and 51 healthy control participants received either placebo or 10 mg of hydrocortisone orally before memory testing. A word list paradigm and the Logical Memory Test from the Wechsler Memory Scale were applied. The study was conducted from April 2008 until April 2010 at sites in Bielefeld and Hamburg, Germany. RESULTS: In both memory tests, patients with MDD performed worse than controls. Healthy controls showed impaired memory performance after hydrocortisone administration compared to placebo. In contrast, hydrocortisone had no effects on memory in MDD patients. Furthermore, in healthy controls we found that administration of hydrocortisone immediately after learning did not lead to an enhanced free recall during increased cortisol levels. CONCLUSIONS: It appears that the impairing effects of hydrocortisone on memory performance are missing in patients with MDD. This might be interpreted in the context of reduced central glucocorticoid receptor functioning.

Hydrocortisone impairs working memory in healthy humans, but not in patients with major depressive disorder.

OBJECTIVE: Several studies have shown that stress or the administration of glucocorticoids can impair hippocampus-based declarative memory retrieval and prefrontal dependent working memory performance in healthy subjects. Major Depressive Disorder (MDD) is often characterized by memory impairment and increased cortisol secretion. Studies indicate that the impairing effects of glucocorticoids on declarative memory performance are missing in patients with MDD. The purpose of our study was to investigate whether the finding of missing effects of acute cortisol administration on memory performance in MDD is also seen when examining prefrontal-based working memory. METHODS: In a placebo-controlled study, 57 patients with MDD and 56 sex- and age-matched healthy control subjects received either placebo or 10 mg of hydrocortisone orally before memory testing. To test the verbal modality of working memory, the Word Suppression Test was applied with one negative and one neutral test part. RESULTS: After hydrocortisone intake, healthy subjects showed a significantly poorer working memory performance compared to placebo treatment when negative interference words were administered. In contrast, memory performance of MDD patients was not affected by hydrocortisone treatment. CONCLUSIONS: The missing effects of glucocorticoid administration on working memory in MDD might be interpreted in the context of reduced central glucocorticoid receptor function.

Self-reported emotional dysregulation but no impairment of emotional intelligence in borderline personality disorder: an explorative study.

Emotional dysfunction is a key feature of patients with borderline personality disorder (BPD) but emotional intelligence (EI) has rarely been investigated in this sample. This study aimed at an investigation of ability EI, general intelligence, and self-reported emotion regulation in BPD. We included 19 patients with BPD and 20 healthy control subjects in the study. EI was assessed by means of the Mayer-Salovey-Caruso emotional intelligence test and the test of emotional intelligence. For the assessment of general intelligence, we administered the multidimensional "Leistungsprüfsystem-Kurzversion." The emotion regulation questionnaire and the difficulties in Emotion Regulation Scale were used to assess emotion regulation. The patients with BPD did not exhibit impairments of ability EI and general intelligence but reported severe impairments in emotion regulation. Ability EI was related both to general intelligence (patients and controls) and to self-reported emotion regulation (patients). In conclusion, emotional dysfunction in BPD might primarily affect self-perceived behavior rather than abilities. Intense negative emotions in everyday life may trigger dysfunctional emotion regulation strategies in BPD although patients possess sufficient theoretical knowledge about optimal regulation strategies.