Self-hate, dissociation, and suicidal behavior in bulimia nervosa.

BACKGROUND: Individuals with eating disorders (EDs) often struggle with markedly low self- esteem and are at risk for suicidal behavior. Dissociation and perceived burdensomeness are often cited as facilitators of suicidal outcomes. Specifically, perceived burdensomeness is comprised of self-hate and liability on others, although it remains unclear which variables most heavily influence suicidal behavior in EDs. METHODS: In a sample of 204 women with bulimia nervosa, the present study examined the potential impact of self-hate and dissociation on suicidal behavior. We hypothesized that suicidal behavior would be equally, and potentially more strongly, related to self-hate than dissociation. Regression analyses investigated the unique effects of these variables on suicidal behavior. RESULTS: Consistent with our hypothesis, a significant relationship emerged between self-hate and suicidal behavior (B = 0.262, SE = 0.081, p < .001, CIs = 0.035-0.110, R-squared =0.07) but not between dissociation and suicidal behavior (B = 0.010, SE = 0.007, p = .165, CIs = -0.389-2.26, R-squared =0.010). Additionally, when controlling for one another, both self-hate (B = 0.889, SE = 0.246, p < .001, CIs = 0.403-1.37) and capability for suicide (B = 0.233, SE = 0.080, p = .004, CIs = 0.076-0.391) were uniquely and independently associated with suicidal behavior. LIMITATIONS: Future work should include longitudinal analyses to understand temporal relationships among study variables. CONCLUSIONS: In sum, when considering suicidal outcomes, these findings support a view that highlights personal loathing rooted in self-hate rather than de-personalizing aspects of dissociation. Accordingly, self-hate may emerge as a particularly valuable target for treatment and suicide prevention in EDs.

Congruence/genuineness: A meta-analysis.

Congruence or genuineness is a relationship element with an extensive and important history within psychotherapy. Congruence is an aspect of the therapy relationship with two facets, one intrapersonal and one interpersonal. Mindful genuineness, personal awareness, and authenticity characterize the intrapersonal element. The capacity to respectfully and transparently give voice to ones' experience to another person characterizes the interpersonal component. Although most fully developed in the person-centered tradition, congruence is highly valued in many theoretical orientations. In this article, we define and provide clinical examples of congruence. We also present an original meta-analysis of its relation with psychotherapy improvement. An analysis of 21 studies (k), representing 1,192 patients (N), resulted in a weighted aggregate effect size (r) of .23 (95% confidence interval = [.13, .32]) or an estimated d of .46. Moderators of the association between congruence and outcome are also investigated. In closing, we address patient contributions, limitations of the extant research, diversity considerations, and therapeutic practices that might promote congruence and improve psychotherapy outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Effects of Cognitive Behavioral Stress Management on Negative Mood and Cardiac Autonomic Activity in ICD Recipients.

BACKGROUND: Behavioral intervention studies in patients with an implantable cardioverter-defibrillator (ICD) show promise in improving psychosocial outcomes but inconclusive effects on cardiovascular outcome. We assessed the effects of cognitive behavioral stress management (CBSM) on mood state and potentially arrhythmogenic cardiovascular responses to mental stress in ICD patients, in support of further larger scale arrhythmia trials. METHODS: A total of 103 ICD recipients were randomly assigned to 10-week programs of CBSM or "Patient Education" (ED). Of these, 83 patients continued to either CBSM (n = 44) or ED (n = 39) intervention. Study end points were mood change, heart rate variability (HRV), double product elevation (DP = heart rate × systolic blood pressure) by math and anger-recall stress, and arrhythmia up to 6 months follow-up. RESULTS: Adjusting for multiple testing, CBSM was associated with moderate effect size reductions in tension/anxiety (P = 0.010), anger/hostility (P = 0.020), perceived stress (P = 0.037), and total mood disturbance (P = 0.025), greatest immediately following intervention (P < 0.05), and partially attributable to increased negative mood following ED (P < 0.01). No significant intervention effects on high frequency or low frequency spectral power of HRV, DP responses, or cardiac arrhythmias were demonstrated. CONCLUSIONS: CBSM intervention in ICD recipients resulted in reduced anxiety, anger, and perceived stress, not sustained at 6 months follow-up, and without conclusive effect on cardiac autonomic or hemodynamic responses to mental stress, or arrhythmia. Findings support conduct of larger behavioral intervention arrhythmia trial, with consideration of reinforcement training and targeting of subgroup responders to therapy.

Increased prefrontal cortex activity during negative emotion regulation as a predictor of depression symptom severity trajectory over 6 months.

IMPORTANCE: Emotion regulation is critically disrupted in depression, and the use of paradigms that tap into these processes may uncover essential changes in neurobiology during treatment. In addition, because neuroimaging outcome studies of depression commonly use only baseline and end-point data-which are more prone to week-to-week noise in symptomatology-we sought to use all data points over the course of a 6-month trial. OBJECTIVE: To examine changes in neurobiology resulting from successful treatment. DESIGN, SETTING, AND PARTICIPANTS: Double-blind trial examining changes in the neural circuits involved in emotion regulation resulting from 1 of 2 antidepressant treatments during a 6-month trial. Twenty-one patients with major depressive disorder and without other Axis I or Axis II diagnoses were scanned before treatment and 2 and 6 months into treatment at the university's functional magnetic resonance imaging facility. INTERVENTIONS: Venlafaxine hydrochloride extended release (with doses of up to 300 mg) or fluoxetine hydrochloride (with doses of up to 80 mg). MAIN OUTCOMES AND MEASURES: Neural activity, as measured using functional magnetic resonance imaging during performance of an emotion regulation paradigm, as well as regular assessments of symptom severity using the Hamilton Depression Rating Scale. For use of all data points, slope trajectories were calculated for rate of change in depression severity and for rate of change in neural engagement. RESULTS: The depressed individuals who showed the steepest decrease in depression severity over the 6-month period were the same individuals who showed the most rapid increases in activity in Brodmann area 10 and the right dorsolateral prefrontal cortex activity when regulating negative affect over the same time frame. This relationship was more robust when using only the baseline and end-point data. CONCLUSIONS AND RELEVANCE: Changes in prefrontal cortex engagement when regulating negative affect correlate with changes in depression severity over 6 months. These results are buttressed by calculating these statistics, which are more reliable and robust to week-to-week variation than are difference scores.

Relationships between changes in sustained fronto-striatal connectivity and positive affect in major depression resulting from antidepressant treatment.

OBJECTIVE Deficits in positive affect and their neural bases have been associated with major depression. However, whether reductions in positive affect result solely from an overall reduction in nucleus accumbens activity and fronto-striatal connectivity or the additional inability to sustain engagement of this network over time is unknown. The authors sought to determine whether treatment-induced changes in the ability to sustain nucleus accumbens activity and fronto-striatal connectivity during the regulation of positive affect are associated with gains in positive affect. METHOD Using fMRI, the authors assessed the ability to sustain activity in reward-related networks when attempting to increase positive emotion during performance of an emotion regulation paradigm in 21 depressed patients before and after 2 months of antidepressant treatment. Over the same interval, 14 healthy comparison subjects underwent scanning as well. RESULTS After 2 months of treatment, self-reported positive affect increased. The patients who demonstrated the largest increases in sustained nucleus accumbens activity over the 2 months were those who demonstrated the largest increases in positive affect. In addition, the patients who demonstrated the largest increases in sustained fronto-striatal connectivity were also those who demonstrated the largest increases in positive affect when controlling for negative affect. None of these associations were observed in healthy comparison subjects. CONCLUSIONS Treatment-induced change in the sustained engagement of fronto-striatal circuitry tracks the experience of positive emotion in daily life. Studies examining reduced positive affect in a variety of psychiatric disorders might benefit from examining the temporal dynamics of brain activity when attempting to understand changes in daily positive affect.

Reduced right ventrolateral prefrontal cortex activity while inhibiting positive affect is associated with improvement in hedonic capacity after 8 weeks of antidepressant treatment in major depressive disorder.

BACKGROUND: Anhedonia, a reduced ability to experience pleasure, is a chief symptom of major depressive disorder and is related to reduced frontostriatal connectivity when attempting to upregulate positive emotion. The present study examined another facet of positive emotion regulation associated with anhedonia-namely, the downregulation of positive affect-and its relation to prefrontal cortex (PFC) activity. METHODS: Neuroimaging data were collected from 27 individuals meeting criteria for major depressive disorder as they attempted to suppress positive emotion during a positive emotion regulation task. Their PFC activation pattern was compared with the PFC activation pattern exhibited by 19 healthy control subjects during the same task. Anhedonia scores were collected at three time points: at baseline (time 1), 8 weeks after time 1 (i.e., time 2), and 6 months after time 1 (i.e., time 3). Prefrontal cortex activity at time 1 was used to predict change in anhedonia over time. Analyses were conducted utilizing hierarchical linear modeling software. RESULTS: Depressed individuals who could not inhibit positive emotion-evinced by reduced right ventrolateral prefrontal cortex activity during attempts to dampen their experience of positive emotion in response to positive visual stimuli-exhibited a steeper anhedonia reduction slope between baseline and 8 weeks of treatment with antidepressant medication (p < .05). Control subjects showed a similar trend between baseline and time 3. CONCLUSIONS: To reduce anhedonia, it may be necessary to teach individuals how to counteract the functioning of an overactive pleasure-dampening prefrontal inhibitory system.

Congruence/genuineness.

Congruence or genuineness is a relational quality that has been highly prized throughout the history of psychotherapy, but of diminished research interest in recent years. In this article, we define and provide examples of this attribute of the therapy relationship and present an original meta-analytic review of the empirical literature showing its relation to improvement. Analysis of 16 studies (k), representing 863 patients (N), resulted in a weighted aggregate ES (r) of .24 (p = .003; 95% CI = .12 to .36). Moderators of the association between congruence and treatment outcome are examined, and limitations of the extant research are discussed as well. In closing, we advance several therapist practices that are likely to foster congruence and thus improve psychotherapy outcomes.

Using functional magnetic resonance imaging in psychotherapy research: a brief introduction to concepts, methods, and task selection.

Functional magnetic resonance imaging (fMRI) has become an increasingly important methodology in the study of psychotherapy outcome and process. In this article, the authors offer a brief introduction to the use of fMRI in psychotherapy research aimed primarily at the informed clinician or investigator and with the goal of facilitating an understanding of study design and interpretation of research findings. After introducing the method and offering a rationale for its use in the study of psychotherapy, the authors outline major issues in fMRI data collection and analysis and emphasize the central role of the tasks used during the imaging session as critical to the interpretation of findings. They discuss how task selection influences the conclusions that can be drawn from fMRI studies of psychotherapeutic intervention and close with recommendations and caveats for the consumer of fMRI/psychotherapy research.

Reduced capacity to sustain positive emotion in major depression reflects diminished maintenance of fronto-striatal brain activation.

Anhedonia, the loss of pleasure or interest in previously rewarding stimuli, is a core feature of major depression. While theorists have argued that anhedonia reflects a reduced capacity to experience pleasure, evidence is mixed as to whether anhedonia is caused by a reduction in hedonic capacity. An alternative explanation is that anhedonia is due to the inability to sustain positive affect across time. Using positive images, we used an emotion regulation task to test whether individuals with depression are unable to sustain activation in neural circuits underlying positive affect and reward. While up-regulating positive affect, depressed individuals failed to sustain nucleus accumbens activity over time compared with controls. This decreased capacity was related to individual differences in self-reported positive affect. Connectivity analyses further implicated the fronto-striatal network in anhedonia. These findings support the hypothesis that anhedonia in depressed patients reflects the inability to sustain engagement of structures involved in positive affect and reward.

Universal session-level change processes in an early session of psychotherapy: path models.

The authors used structural equation modeling to investigate universal change processes identified in the generic model of psychotherapy (GMP). Three path models of increasing complexity were examined in Study 1 in dynamic therapy. The best fitting model from Study 1 was replicated in Study 2 for participants receiving either cognitive or interpersonal therapy. Findings provided support for the universality of the GMP constructs in different types of therapy. Positive influences for therapeutic bond, openness, and realizations were observed, as was a surprising negative impact for one aspect of bond. Discussion highlights a complex conception of the therapy relationship that underscores the importance of investigating the multiple functions that the therapy relationship might serve in different psychotherapies.

Self-system therapy as an intervention for self-regulatory dysfunction in depression: a randomized comparison with cognitive therapy.

Self-system therapy (SST) is a new therapy based on regulatory focus theory (E. T. Higgins, 1997) for depressed individuals unable to pursue promotion goals effectively. The authors conducted a randomized trial comparing SST with cognitive therapy (CT) in a sample of 45 patients with a range of depressive symptoms to test 2 hypotheses: that SST would be more efficacious for depressed individuals characterized by inadequate socialization toward pursuing promotion goals and that SST would lead to greater reduction in dysphoric responses to priming of promotion goals. There was no overall difference in efficacy between treatments, but patients whose socialization history lacked an emphasis on promotion goals showed significantly greater improvement with SST. In addition, SST patients showed a greater reduction in dysphoric responses to promotion goal priming than did CT patients. The results illustrate the value of a theory-based translational approach to treatment design and selection.

Early psychotherapy process and cluster B and C personality pathology: similarities and differences in interactions with symptomatic and interpersonal distress.

Abstract In a prior study (Kolden & Klein, 1996), the authors found that the relationships between global personality pathology and early psychotherapy change processes (as defined by the Generic Model of Psychotherapy) were moderated by the extent of the patient's acute symptomatic and interpersonal distress. In the current study, the authors reanalyzed the same data to examine similarities and differences between personality disorder Clusters B (dramatic, emotional, or erratic) and C (anxious or fearful) in therapy process. In general, we found that more distressed patients reported greater defensiveness. There were no significant interactions between symptomatic distress and personality pathology in the prediction of any of the process variables. However, interpersonal distress moderated relationships between Clusters B and C and some therapy processes. Patients high in Cluster B felt more open and involved in the session when they were less distressed by their interpersonal problems at the start of therapy. In contrast, openness and insight were impeded among patients high in Cluster C when they were less distressed interpersonally. Therapists generally used more direct interventions and exploration of past experiences when working with patients higher in Cluster C pathology. However, therapists used direct interventions more specifically when patients with more severe Cluster B pathology were also higher in interpersonal distress. The discussion considers implications for the facilitation of productive early therapy process in patients suffering from Cluster B or C personality pathology.

A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefits.

Evidence is accumulating for physical activity as an effective, well-tolerated, highly rewarding complementary behavioral intervention for enhancing quality of life (QOL) as well as fitness among individuals with chronic and even terminal illnesses. However, relatively few studies have examined the feasibility and potential health benefits of supervised, structured exercise programs for sedentary women with primary breast cancer. Forty women over the age of 45 with primary breast cancer participated in a course of group exercise training (GET) delivered in a structured format three times per week for 16 weeks. GET emphasizes physical activities that promote aerobic fitness, strength, and flexibility. Assessments of fitness/vigor and QOL were conducted prior to, during, and upon completion of the program. Results demonstrated that GET was feasible, safe, and well-tolerated. Moreover, the participants experienced significant health benefits over the course of the intervention in multiple dimensions of fitness/vigor (aerobic capacity, strength, flexibility) as well as QOL (increased positive affect, decreased distress, enhanced well-being, and improved functioning). Discussion highlights the need for inclusion of physical activity programs in comprehensive, complementary treatment regimes for breast cancer patients.