Emotion Regulation and Mentalization in Patients With Depression and Anxiety.

OBJECTIVE: Theoretical conceptualizations of emotion and affect regulation have a considerable common ground. However, mentalization theory considers the ability to regulate affects as being contingent on the ability to mentalize. The aim of the present study is to examine the association between emotion regulation and mentalization, operationalized as reflective functioning, in a sample of patients with depression and/or anxiety. METHODS: The study used data from the TRAns-diagnostic Cognitive behavioural Therapy versus standard cognitive behavioural therapy (TRACT-RCT) trial. Patients with depression and/or anxiety (N = 291; 64.4% female; Mage = 32.2; SD = 11.0) completed the Emotion Regulation Strategies Questionnaire (ERSQ) and the Reflective Functioning Questionnaire (RFQ-6). Correlation and regression analyses were performed to determine associations of the measures of ERSQ and RFQ-6 in relation to the outcome variables, global well-being (World Health Organization Well-being Index; WHO-5) and social functioning (Work and Social Adjustment Scale; WSAS). RESULTS: Overall, the patients had a reduced level of emotion regulation (MERSQ_Total = 1.77; SD = 0.59). However, only mildly impaired reflective functioning was found (MRFQ-6 = 3.57; SD = 1.26). ERSQ correlated significantly with RFQ-6 (r = -0.31), that is, more frequent use of emotion regulation strategies was associated with less hypomentalization. ERSQ was a stronger predictor of well-being and social function than RFQ-6. CONCLUSION: In patients with anxiety and/or depression, hypomentalization as measured by the RFQ-6 is not a major problem, but emotion regulation is. It seems that these two, theoretically related constructs, do not necessarily co-occur. Alternatively, the RFQ-6 scale might not capture the mentalization construct in a valid way. Emotion regulation strategies are highly related to symptomatology; therefore, they are likely to be an important target for psychotherapy.

Transdiagnostic psychopathology in the light of robust single-trial event-related potentials.

Recent evidence indicates that event-related potentials (ERPs) as measured on the electroencephalogram (EEG) are more closely related to transdiagnostic, dimensional measures of psychopathology (TDP) than to diagnostic categories. A comprehensive examination of correlations between well-studied ERPs and measures of TDP is called for. In this study, we recruited 50 patients with emotional disorders undergoing 14 weeks of transdiagnostic group psychotherapy as well as 37 healthy comparison subjects (HC) matched in age and sex. HCs were assessed once and patients three times throughout treatment (N = 172 data sets) with a battery of well-studied ERPs and psychopathology measures consistent with the TDP framework The Hierarchical Taxonomy of Psychopathology (HiTOP). ERPs were quantified using robust single-trial analysis (RSTA) methods and TDP correlations with linear regression models as implemented in the EEGLAB toolbox LIMO EEG. We found correlations at several levels of the HiTOP hierarchy. Among these, a reduced P3b was associated with the general p-factor. A reduced error-related negativity correlated strongly with worse symptomatology across the Internalizing spectrum. Increases in the correct-related negativity correlated with symptoms loading unto the Distress subfactor in the HiTOP. The Flanker N2 was related to specific symptoms of Intrusive Cognitions and Traumatic Re-experiencing and the mismatch negativity to maladaptive personality traits at the lowest levels of the HiTOP hierarchy. Our study highlights the advantages of RSTA methods and of using validated TDP constructs within a consistent framework. Future studies could utilize machine learning methods to predict TDP from a set of ERP features at the subject level.

Robust single-trial event-related potentials differentiate between distress and fear disorders.

Recent evidence indicates that measures of brain functioning as indexed by event-related potentials (ERPs) on the electroencephalogram align more closely to transdiagnostic measures of psychopathology than to categorical taxonomies. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a transdiagnostic, dimensional framework aiming to solve issues of comorbidity, symptom heterogeneity, and arbitrary diagnostic boundaries. Based on shared features, the emotional disorders are allocated into subfactors Distress and Fear. Evidence indicates that disorders that are close in the HiTOP hierarchy share etiology, symptom profiles, and treatment outcomes. However, further studies testing the biological underpinnings of the HiTOP are called for. In this study, we assessed differences between Distress and Fear in a range of well-studied ERP components. In total, 50 patients with emotional disorders were divided into two groups (Distress, N = 25; Fear, N = 25) according to HiTOP criteria and compared against 37 healthy comparison (HC) subjects. Addressing issues in traditional ERP preprocessing and analysis methods, we applied robust single-trial analysis as implemented in the EEGLAB toolbox LIMO EEG. Several ERP components were found to differ between the groups. Surprisingly, we found no difference between Fear and HC for any of the ERPs. This suggests that some well-established results from the literature, e.g., increased error-related negativity in OCD, are not a shared neurobiological correlate of the Fear subfactor. Conversely, for Distress, we found reductions compared to Fear and HC in several ERP components across paradigms. Future studies could utilize HiTOP-validated psychopathology measures to more precisely define subfactor groups.

Utility of the Work and Social Adjustment Scale (WSAS) in predicting long-term sick-leave in Danish patients with emotional disorders.

BACKGROUND: The Work and Social Adjustment Scale (WSAS) is a self-administered measure designed to assess the level of inability to function socially as a consequence of a defined problem or disorder. METHODS: A total of 230 patients with emotional disorders completed the Danish translation of the WSAS, measures of anxiety and depression, the Level of Personality Functioning Brief Form, the Personality Inventory for DSM-5 Short Form, and the World Health Organization Five-Item Well-Being Index (WHO-5). We conducted a confirmatory factor analysis of the previously suggested factor structure of the instrument. We furthermore evaluated the construct validity of the WSAS by means of its relationship with depression, anxiety, personality functioning, and overall well-being. Finally, we evaluated the utility of the WSAS to identify those on long-term sick-leave by conducting receiver operating characteristic (ROC) curves. RESULTS: The instrument had a poor to average fit with the previously reported single-factor structure, but a better fit to a modified single-factor structure. Cronbach's alpha and McDonald's omega showed good internal scale reliability (α = .79, ωtotal = .85). WSAS was positively correlated with measures of anxiety (r = .33), depression (r = .44), and personality functioning (r = .23 and r = .20), and negatively correlated with WHO-5 wellbeing (r = -.57). The optimal cut-off point in the ROC-analyses was 23, which yielded a sensitivity of 74% and a specificity of 55% in the prediction of sick-leave status. DISCUSSION: The Danish WSAS shows promising psychometric properties, but has limited external validity insofar as predicting long-term sick leave in psychiatric patients with emotional disorders.

Affectivity in danish patients with emotional disorders: assessing the validity of the Positive and Negative Affect Schedule (PANAS).

BACKGROUND: The Positive and Negative Affect Schedule (PANAS) was designed to measure trait positive affect (PA) and trait negative affect (NA). METHODS: The Danish PANAS was administered to outpatients with depression and anxiety disorders. Internal consistency was assessed using Cronbach's alpha and McDonald's omega and factorial structure was evaluated using confirmatory factor analysis (CFA). Convergent validity was evaluated by means of correlations with the negative affectivity and the detachment domain of the Personality Inventory for DSM-5 Short Form (PID-5-SF), the Hamilton Anxiety Rating Scale 6 (HARS-6) and the Hamilton Depression Rating Scale 6 (HDRS-6). RESULTS: PANAS Scores of 256 patients were analyzed. Cronbach's alpha and McDonald's omega showed good internal consistency for both the PA score (alpha = .84 and omega = .89) and the NA score (alpha = .86 and omega = .90). CFA analysis confirmed a structure with two factors corresponding to the PA and NA factors. PA was negatively correlated with the detachment domain of PID-5 (r = -.47), HARS-6 (r = -.15) and HDRS-6 (r = -.37). NA was positively correlated with PID-5-SF negative affectivity domain (r = .43), HARS-6 (r = .51) and HDRS-6 (r = .52). DISCUSSION: The Danish PANAS has promising internal consistency and construct validity, which are comparable to other studies of the instrument.

Social phobia and evasiveness: trial protocol for a randomized controlled feasibility and superiority trial of the effect of Modified Collaborative Assessment vs. standard assessment on patients' readiness for psychotherapy (CO-ASSM-RCT).

BACKGROUND: Evasive personality disorder (AvPD) and social phobia (SP) have substantial costs for patients and their families and great economic costs to the society. While psychotherapy can be an efficacious treatment, many patients drop out during treatment. Increased knowledge on how to decrease dropout from psychotherapy is warranted, including how to increase a patient's readiness for psychotherapy. METHODS: We describe a randomized controlled feasibility and superiority trial of 42 individuals with a clinical diagnosis of either SP or AvPD, who are to initiate psychotherapeutic treatment in Danish outpatient mental health services. They will be randomized in a 1:1 ratio to either assessment-as-usual and receive no further assessment or to a Modified Collaborative Assessment (MCA) provided as a pre-treatment intervention before psychotherapy initiation. MCA will include a battery of psychological tests designed to thoroughly assess the patients' psychopathology. The tests are administered in collaboration with the patient, including detailed oral and written feedback. We hypothesize that the intervention is feasible regarding patient's acceptance and adherence. We further hypothesize that patients randomized to MCA will reach higher levels of readiness for psychotherapy as assessed with the University of Rhode Island Change Assessment Scale (URICA). DISCUSSION: This protocol assesses the feasibility, efficacy, acceptability, and safety of an intervention aimed at changing the readiness for participation in psychotherapy of patients with SP and AvPD. Results from this feasibility study could guide the development of future large-scale trials of MCA and procedures for MCA treatment fidelity assessment. TRIAL REGISTRATION: NCT2021001.

"The Depressed" and "People with Anxiety" therapists' discursive representations of patients with depression and anxiety in Danish Psychiatry.

Stigmatization within mental health care has previously been identified, and some diagnoses have been shown to be particularly exposed to negative attitudes and stigma. However, no previous studies have explored practitioners' discursive construction of patients with different diagnoses within a transdiagnostic group context. We performed discourse analysis on 12 interviews with Danish mental health practitioners, who had been conducting either transdiagnostic psychotherapy (The Unified Protocol) or standard group cognitive behavioral therapy (CBT) with patients treated for anxiety disorders or major depressive disorder. The purpose of this study was to identify how patients with anxiety and depression were represented by therapists. We identified a "training discourse," within which patients were evaluated through perceived motivation, responsibility, active participation, and progression. We argue that this training discourse can be related to a broader neoliberal order of discourse valuing efficiency and agency. The analysis indicated that patients with anxiety were sometimes "favorized" over patients with depression, and it is argued that the neoliberal order of discourse and pre-assumptions related to the diagnoses are contributing to this. The interviews indicate that multiple discourses were applied when describing patients, and ambivalence was often detectable. We discuss the findings of the analysis in relation to therapists' general critical attitudes toward the psychiatric system and in relation to broader societal tendencies.

Trait and symptom change in group cognitive behaviour therapy for anxiety and depression.

Personality traits underlying both anxiety disorders and depression are more malleable than previously presumed. This study examined associations between changes in personality traits (i.e. negative affectivity and detachment) and alleviation of anxiety and depression symptoms following cognitive behaviour therapy (CBT). We hypothesized that decreases in negative affectivity would predict alleviation of depression and anxiety symptoms and decreases in detachment would predict decreases in depression and, to a lesser degree, anxiety symptoms. Data (N = 156) were collected in a randomized controlled trial comparing transdiagnostic and diagnosis-specific group CBT for patients with major depressive disorder, social anxiety disorder, panic disorder or agoraphobia. We assessed personality traits using the Personality Inventory for DSM-5 (PID-5) and symptoms with the Hopkins Symptom Checklist 25-item scale (SCL). Prediction was based on regression analyses. We found that decreases in negative affectivity predicted lower levels of depression and anxiety symptoms while decreases in detachment only predicted lower levels of depression symptoms. The findings substantiate current efforts to explicate the dynamic interplay between personality traits and symptoms and support the existing focus on targeting negative affectivity and detachment in therapy for anxiety disorders and depression. The trial is registered at clinicaltrials.gov (ID NCT02954731).

Patient-reported outcome measures in depression.

AIM: Patient-reported outcome measures (PROMs) are increasingly important as a mean for quality assurance. Feasible estimates of recovery can be achieved through the application of Jacobson plots, which is a simple demonstration of the outcome of each case, recommended for clinical use. We applied this approach with PROMs collected regarding group psychotherapy in a mental health service (MHS) setting. We hypothesized a recovery rate of above 50% of all cases, expecting a lower recovery rate amongst patients with severe depression. METHODS: We made a secondary sub-sample analysis of data from patients with unipolar depression (N = 171) within a pragmatic, non-inferiority, randomized controlled clinical trial comparing two cognitive behavior therapy (CBT) group interventions. The treatment consisted of 14 2-hours weekly group CBT sessions. We collected depression PROMs with the Becks Depression Inventory-II and functional levels PROMs with the Work and Social Adjustment Scale at baseline, end-of-treatment, and at a 6-months follow-up. RESULTS: At follow-up, 35% (N = 43/123) of cases with moderate or severe depression (BDI > 19) at baseline reached scores below the cut-off for moderate depression. Recovery rates in severe cases were significantly lower (26.5 vs 52.5%; p = 0.0004). We observed severe functional impairment in 36% of the patients at baseline (52/144) and observed no changes or worsening in scores at a 6-months follow-up in 44% of the patients (64/144). CONCLUSION: We achieved satisfactory remission rates for patients with moderate depression. Patients with severe depression and patients with functional impairment reached recovery rates below the standard of comparable MHSs. Improved MHSs for these patients are needed.

What is the effect of using collaborative assessment on symptomatology as an intervention in the treatment of mental illness? A systematic review and meta-analysis protocol.

BACKGROUND: Clinicians usually conduct diagnostic assessments in order to establish a diagnosis or to evaluate the effect of treatment. Two meta-analyses suggest that diagnostic assessment administered in collaboration with the patient and personalized feedback might have a therapeutic effect. METHODS: We aim to conduct a systematic review and meta-analysis of the effect on symptomatology when using assessment as a therapeutic intervention for patients with psychiatric illnesses. We will search in five relevant electronic databases. Two reviewers will independently select papers following pre-defined eligibility criteria, extract data, and assess the quality of included studies. Randomized controlled trials comparing the effect of psychological assessment with other psychotherapeutic interventions in populations of patients will be included in the meta-analysis. We will extract data on symptom-related outcomes, quality of life, dropout, and re-diagnosis and use meta-analysis techniques to compute the effect size of interventions using assessment as a psychotherapeutic intervention. The review will be conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Risk of bias will be assessed by using the Risk of Bias tool RoB 2.0 of the Cochrane Collaboration, and the certainty of the body of evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. DISCUSSION: THE RESULTS WILL BE ABLE TO INFORM CLINICIANS AND POLICYMAKERS ON THE EFFECT OF ASSESSMENT AND, DEPENDING ON THE RESULTS, COULD LEAD TO A RECOMMENDATION FOR MODIFIED ASSESSMENT PROCEDURES AND APPROACHES IN MENTAL HEALTH SERVICES. ULTIMATELY, IT MIGHT IMPROVE THE TREATMENT OUTCOME IN MENTAL HEALTH SERVICES.: SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021270567.

[Transdiagnostic cognitive behaviour therapy for anxiety disorders].

Evidence-based diagnosis specific cognitive behaviour therapy (CBT) protocols for anxiety disorders, currently recommended in national clinical guidelines, have shortcomings in relation to the application of group therapy in the mental health service. Transdiagnostic CBT is theory-driven, targeting common personality traits and emotion-driven behaviour observed in all of the anxiety disorders. This review recapitulates the theory and the evidence base. More head-to-head comparison studies are needed, in particular concerning group therapy. The current evidence is, however, very promising.

Transdiagnostic versus Diagnosis-Specific Group Cognitive Behavioral Therapy for Anxiety Disorders and Depression: A Randomized Controlled Trial.

INTRODUCTION: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a group format could facilitate the implementation of evidence-based psychological treatments. OBJECTIVE: This study compared the efficacy of group UP and diagnosis-specific cognitive behavioral therapy (dCBT) for anxiety and depression in outpatient mental health services. METHODS: In this pragmatic, multi-center, single-blinded, non-inferiority, randomized controlled trial (RCT), we assigned 291 patients with major depressive disorder, social anxiety disorder, panic disorder, or agoraphobia to 14 weekly sessions in mixed-diagnosis UP or single-diagnosis dCBT groups. The primary test was non-inferiority, using a priori criteria, on the World Health Organisation 5 Well-Being Index (WHO-5) at the end of the treatment. Secondary outcomes were functioning and symptoms. We assessed outcomes at baseline, end-of-treatment, and at a 6-month follow-up. A modified per-protocol analysis was performed. RESULTS: At end-of-treatment, WHO-5 mean scores for patients in UP (n = 148) were non-inferior to those of patients in dCBT (n = 143; mean difference -2.94; 95% CI -8.10 to 2.21). Results were inconclusive for the WHO-5 at the 6-month follow-up. Results for secondary outcomes were non-inferior at end-of-treatment and the 6-month follow-up. Client satisfaction and rates of attrition, response, remission, and deterioration were similar across conditions. CONCLUSIONS: This RCT demonstrated non-inferior acute-phase outcomes of group-delivered UP compared with dCBT for major depressive disorder, social anxiety disorder, panic disorder, and agoraphobia in outpatient mental health services. The long-term effects of UP on well-being need further investigation. If study findings are replicated, UP should be considered a viable alternative to dCBT for common anxiety disorders and depression in outpatient mental health services.

"Despite the Differences, We Were All the Same". Group Cohesion in Diagnosis-Specific and Transdiagnostic CBT Groups for Anxiety and Depression: A Qualitative Study.

Group cohesion refers to a sense of belonging, mutual support and identification with other group members. Group cohesion has been associated with better outcomes, lower drop-out rates, more interpersonal support and better participation in psychotherapy. Nevertheless, the role of group cohesion in CBT has not yet received much attention. The rationale for delivering CBT in groups is that patients can model themselves through each other due to their similarities in symptoms. However, there has recently been a shift towards transdiagnostic CBT protocols, in which patients with varied diagnoses participate in the same groups. This shift challenges the rationale of delivering CBT in groups, and it is therefore highly important to understand if and how group cohesion develops in mixed diagnoses CBT groups. The current study used a qualitative comparative framework to investigate the patients' experiences of group cohesion in diagnosis-specific versus transdiagnostic CBT groups. Twenty-three patients were interviewed with semi-structured interviews upon completion of the treatment. Participants had a primary diagnosis of MDD, panic disorder, agoraphobia or social anxiety disorder. A comparative thematic analysis was carried out. Three themes were found: the move from differences to similarities, the role of group cohesion in group CBT and factors helpful and hindering to group cohesion. Group cohesion developed across groups and was considered highly important in both diagnosis-specific and transdiagnostic CBT groups.

Transdiagnostic group CBT vs. standard group CBT for depression, social anxiety disorder and agoraphobia/panic disorder: Study protocol for a pragmatic, multicenter non-inferiority randomized controlled trial.

BACKGROUND: Transdiagnostic Cognitive Behavior Therapy (TCBT) manuals delivered in individual format have been reported to be just as effective as traditional diagnosis specific CBT manuals. We have translated and modified the "The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders" (UP-CBT) for group delivery in Mental Health Service (MHS), and shown effects comparable to traditional CBT in a naturalistic study. As the use of one manual instead of several diagnosis-specific manuals could simplify logistics, reduce waiting time, and increase therapist expertise compared to diagnosis specific CBT, we aim to test the relative efficacy of group UP-CBT and diagnosis specific group CBT. METHODS/DESIGN: The study is a partially blinded, pragmatic, non-inferiority, parallel, multi-center randomized controlled trial (RCT) of UP-CBT vs diagnosis specific CBT for Unipolar Depression, Social Anxiety Disorder and Agoraphobia/Panic Disorder. In total, 248 patients are recruited from three regional MHS centers across Denmark and included in two intervention arms. The primary outcome is patient-ratings of well-being (WHO Well-being Index, WHO-5), secondary outcomes include level of depressive and anxious symptoms, personality variables, emotion regulation, reflective functioning, and social adjustment. Assessments are conducted before and after therapy and at 6 months follow-up. Weekly patient-rated outcomes and group evaluations are collected for every session. Outcome assessors, blind to treatment allocation, will perform the observer-based symptom ratings, and fidelity assessors will monitor manual adherence. DISCUSSION: The current study will be the first RCT investigating the dissemination of the UP in a MHS setting, the UP delivered in groups, and with depressive patients included. Hence the results are expected to add substantially to the evidence base for rational group psychotherapy in MHS. The planned moderator and mediator analyses could spur new hypotheses about mechanisms of change in psychotherapy and the association between patient characteristics and treatment effect. TRIAL REGISTRATION: Clinicaltrials.gov NCT02954731 . Registered 25 October 2016.

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services.

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.

Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: a systematic review and meta-analysis of published outcome studies.

Transdiagnostic approaches to cognitive behaviour therapy (TCBT) of anxiety disorders have drawn increasing interest and empirical testing over the past decade. In this paper, we review evidence of the overall efficacy of TCBT for anxiety disorders, as well as TCBT efficacy compared with wait-list, treatment-as-usual, and diagnosis-specific cognitive behaviour therapy (CBT) controls. A total of 11 studies reporting 12 trials (n = 1933) were included in the systematic review. Results from the meta-analysis of 11 trials suggest that TCBT was generally associated with positive outcome; TCBT patients did better than wait-list and treatment-as-usual patients, and treatment gains were maintained through follow-up. The pooled estimate showed a moderate treatment effect, however with large heterogeneity suggesting differences in treatment effects between the studies. Also, all the included trials, apart from one, were judged to be associated with a high risk of bias. Only one study compared TCBT with diagnosis-specific CBT suggesting treatment effect of TCBT to be as strong as diagnosis-specific CBT. This study not only cautiously supports evidence for the efficacy of TCBT, but also suggests the need for more high-quality, large-scaled studies in this area. Transdiagnostic treatments offer great clinical promise as an affordable and pragmatic treatment for anxiety disorders and as a specialized treatment for co-morbid and other-specified anxiety disorders.

Posttraumatic stress disorder among bereaved relatives of cancer patients.

The aim of this study was to assess post-traumatic stress disorder (PTSD) and predictors of PTSD in individuals who experienced the loss of a close relative to cancer. A total of 251 bereaved relatives ages 14 to 76 (M = 41.3, SD = 16.8) were recruited at a counseling service for cancer patients and their relatives. The prevalence of current probable PTSD was 40% in the bereaved sample. A hierarchical logistic regression analysis indicated that full-time employment, perceived control, and a secure attachment style moderated the risk for PTSD. Moreover, a long period of caretaking, high levels of somatization, and dissociation were all associated with an increased risk of PTSD.