The change process in adult anorexia nervosa inpatient treatment: a path model.

PURPOSE: Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment. METHODS: We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model. RESULTS: The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/m2 (SD = 1.6 kg/m2). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2. CONCLUSIONS: The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

Aggregating factors of the change process in the treatment of anorexia nervosa.

PURPOSE: We aimed to reduce the large body of factors which may be associated with the change process in treatments for Anorexia Nervosa (AN) into a clinically and scientifically useful number of higher-rank dimensions. In addition, we examined the associations between the identified factors and eating disorder psychopathology and body mass index (BMI) in exploratory analyses. METHODS: Within a naturalistic multicenter study we administered the Change Process Questionnaire (CPQ-AN) to inpatients with AN upon admission. The factorial structure of the CPQ-AN was explored via factor analysis. Multiple regression analyses were performed to examine the associations with BMI and eating disorder symptomatology (EDI-2). RESULTS: In total 233 female inpatients with AN (mean BMI=14.9 kg/m(2), SD=1.7) participated. The factor analysis yielded four latent factors: basic need satisfaction, AN-specific cognitions and behavior, emotional involvement and commitment to treatment, and alliance and treatment confidence. Furthermore, greater basic need satisfaction and less AN-specific cognitions and behavior predicted lower EDI-2 scores. Higher alliance and treatment confidence were associated with higher BMI as well as a lower EDI-2 score. CONCLUSION: The associations between the newly derived dimensions and BMI and AN-psychopathology provide evidence to support the clinical relevance of the identified change process dimensions. Future investigations could provide further insights to deepen our understanding of the change process in AN.

Effects of therapeutic relationship, expectancy, and credibility in breathing therapies for anxiety.

The authors investigated the effects of the quality of the therapeutic alliance, expectancy of improvement, and credibility of treatment on the outcome of two breathing therapies for anxiety and panic. Data were collected during a randomized clinical trial evaluating the efficacy of two theoretically opposing, end-tidal pCO2 feedback-assisted breathing therapies for patients experiencing anxiety attacks. In this study, five weekly individual breathing therapy sessions were administered for the patients who were experiencing anxiety attacks as symptoms of various anxiety disorders. The outcome of this trial indicated that regardless of the opposing breathing instructions (raise or lower pCO2) used in the two breathing therapies, patients in both treatment groups improved equally after treatment. Nonspecific factors rather than the different directions of pCO2 changes could have played a role in the improvement. Regression analyses showed that for both therapies patient-rated therapeutic alliance was predictive of improvement at the 1-month follow-up, and that patient-rated confidence that the therapy would produce improvement, an aspect of its credibility, accounted for almost half of the variance in improvement at the 6-month follow-up. Thus, two factors usually considered nonspecific were identified to be potent predictors of treatment outcome.

Psychological and interactional characteristics of patients with somatoform disorders: Validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population.

OBJECTIVE: The new DSM-5 Somatic Symptom Disorder (SSD) emphasizes the importance of psychological processes related to somatic symptoms in patients with somatoform disorders. To address this, the Somatic Symptoms Experiences Questionnaire (SSEQ), the first self-report scale that assesses a broad range of psychological and interactional characteristics relevant to patients with a somatoform disorder or SSD, was developed. This prospective study was conducted to validate the SSEQ. METHODS: The 15-item SSEQ was administered along with a battery of self-report questionnaires to psychosomatic inpatients. Patients were assessed with the Structured Clinical Interview for DSM-IV to confirm a somatoform, depressive, or anxiety disorder. Confirmatory factor analyses, tests of internal consistency and tests of validity were performed. RESULTS: Patients (n=262) with a mean age of 43.4 years, 60.3% women, were included in the analyses. The previously observed four-factor model was replicated and internal consistency was good (Cronbach's α=.90). Patients with a somatoform disorder had significantly higher scores on the SSEQ (t=4.24, p<.001) than patients with a depressive/anxiety disorder. Construct validity was shown by high correlations with other instruments measuring related constructs. Hierarchical multiple regression analyses showed that the questionnaire predicted health-related quality of life. Sensitivity to change was shown by significantly higher effect sizes of the SSEQ change scores for improved patients than for patients without improvement. CONCLUSION: The SSEQ appears to be a reliable, valid, and efficient instrument to assess a broad range of psychological and interactional features related to the experience of somatic symptoms.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder: prospective 1-year follow-up study.

OBJECTIVE: To compare the predictive validity and clinical utility of DSM-IV somatoform disorders and DSM-5 Somatic Symptom Disorder (SSD) at 12-month follow-up. METHODS: In a sample of psychosomatic inpatients (n=322, mean age=45.6 years (SD 10.0), 60.6% females) we prospectively investigated DSM-IV somatoform disorders and the DSM-5 diagnosis of SSD plus a variety of psychological characteristics, somatic symptom severity, and health-related quality of life at admission, discharge, and follow-up. RESULTS: DSM-IV diagnoses and DSM-5 SSD similarly predicted physical functioning at follow-up; SSD also predicted mental functioning at follow-up. Bodily weakness, intolerance of bodily complaints, health habits, and somatic attribution at admission were significant predictors of physical functioning at follow-up. The change in physical functioning during inpatient therapy was a significant predictor for the course of physical functioning until follow-up. CONCLUSIONS: Psychological symptoms appear to be predictively valid diagnostic criteria for the 12-month functional outcome in patients with SSD. Mental functioning can be better predicted by the DSM-5 diagnosis than by DSM-IV diagnoses. Not the change in single psychological features but in physical functioning during the treatment interval predicted the change in physical functioning until follow-up.

[Remission, response, and its prediction in depressive inpatients]. / Remission, Response und deren Prädiktion bei stationären Depressionspatienten.

Using mean comparisons and effect sizes to report effects of inpatient treatment, this not reveals, how many inpatients benefit from treatment and which characteristics predict the positive outcome. Several characteristics were collected from 1 533 consecutive inpatients with an episode of depression. The pre-post-effect size in the Beck Depression Inventory was 1.29 (95%-CI: 1.23; 1.36). The rate of remission was 39.5%. The rate of response was 57.8% based on the reliable change index (RCI) and 72.4% based on the percental symptom improvement. The regression model with the RCI as outcome variable was stabile in the cross-validation. A negative predictive impact was demonstrated by the depressive symptoms at treatment beginning, whereas higher assessment of physical health and higher level of education were found to be positively associated. A consistent definition of response seems essential for cross-study and cross-methodological comparisons.

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5.

OBJECTIVE: Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample. METHODS: Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity. RESULTS: Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD. CONCLUSIONS: The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.

Psychological change mechanisms in anorexia nervosa treatments: how much do we know?

OBJECTIVE: Anorexia nervosa (AN) is a debilitating and often chronic and treatment-resistant disorder. Despite decades of theoretical progress and research, many questions remain with regard to the psychological mechanisms explaining why and how some AN patients respond to treatment whereas others do not. Based on the premise that the broader, noneating disorders psychotherapy research literature, and particularly the common factors literature, can inform AN treatment development efforts, we review a set of selected psychological change mechanisms and describe how they might be relevant in the context of AN treatment response. Specifically, we suggest that a systematic consideration of constructs such as basic psychological needs, expectancies, the therapeutic alliance, experiential avoidance, and patient motivation for change might help illuminate how patients do or do not benefit from AN treatment. We briefly describe an ongoing multicenter trial in which the constructs introduced here are being measured on a weekly basis and are examined as potential mediators of treatment response. The article aims to contribute to the AN literature by introducing a set of potentially important change constructs that we think ought to be studied in greater depth by AN researchers.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder--comparison with DSM-IV somatoform disorders and additional criteria for consideration.

OBJECTIVE: Major changes to the diagnostic category of somatoform disorders are being proposed for DSM-5. The effect of e.g. the inclusion of psychological criteria (criterion B) on prevalence, predictive validity, and clinical utility of "Somatic Symptom Disorder" (SSD) remains unclear. A prospective study was conducted to compare current and new diagnostic approaches. METHODS: In a sample of N=456 psychosomatic inpatients (61% female, mean age=44.8±10.4 years) diagnosed with somatoform, depressive and anxiety disorders, we investigated the current DSM-5 proposal (SSD) plus potential psychological criteria, somatic symptom severity, and health-related quality of life at admission and discharge. RESULTS: N=259 patients were diagnosed with DSM-IV somatoform disorder (56.8%). With a threshold of 6 on the Whiteley Index to assess psychological criteria, the diagnosis of SSD was similarly frequent (51.8%, N=230). However, SSD was a more frequent diagnosis when we employed the recommended threshold of one subcriterion of criterion B. Patients diagnosed with only SSD but not with DSM-IV somatoform disorder showed greater psychological impairment. Both diagnoses similarly predicted physical functioning at discharge. Bodily weakness and somatic and psychological attributions at admission were among significant predictors of physical functioning at discharge. Reduction of health anxiety, bodily weakness, and body scanning significantly predicted an improvement of physical functioning. CONCLUSIONS: Psychological symptoms enhance predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder compared to DSM-IV somatoform disorders. The SSD diagnosis identifies more psychologically impaired patients than its DSM-IV precursor. The currently suggested diagnostic threshold for criterion B might increase the disorder's prevalence.

Opposing breathing therapies for panic disorder: a randomized controlled trial of lowering vs raising end-tidal P(CO2).

BACKGROUND: Teaching anxious clients to stop hyperventilating is a popular therapeutic intervention for panic. However, evidence for the theory behind this approach is tenuous, and this theory is contradicted by an opposing theory of panic, the false-suffocation alarm theory, which can be interpreted to imply that the opposite would be helpful. OBJECTIVE: To test these opposing approaches by investigating whether either, both, or neither of the 2 breathing therapies is effective in treating patients with panic disorder. METHOD: We randomly assigned 74 consecutive patients with DSM-IV-diagnosed panic disorder (mean age at onset = 33.0 years) to 1 of 3 groups in the setting of an academic research clinic. One group was trained to raise its end-tidal P(CO2) (partial pressure of carbon dioxide, mm Hg) to counteract hyperventilation by using feedback from a hand-held capnometer, a second group was trained to lower its end-tidal P(CO2) in the same way, and a third group received 1 of these treatments after a delay (wait-list). We assessed patients physiologically and psychologically before treatment began and at 1 and 6 months after treatment. The study was conducted from September 2005 through November 2009. RESULTS: Using the Panic Disorder Severity Scale as a primary outcome measure, we found that both breathing training methods effectively reduced the severity of panic disorder 1 month after treatment and that treatment effects were maintained at 6-month follow-up (effect sizes at 1-month follow-up were 1.34 for the raise-CO(2) group and 1.53 for the lower-CO(2) group; P < .01). Physiologic measurements of respiration at follow-up showed that patients had learned to alter their P(CO2) levels and respiration rates as they had been taught in therapy. CONCLUSIONS: Clinical improvement must have depended on elements common to both breathing therapies rather than on the effect of the therapies themselves on CO(2) levels. These elements may have been changed beliefs and expectancies, exposure to ominous bodily sensations, and attention to regular and slow breathing. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00183521.

Effects of breathing training on voluntary hypo- and hyperventilation in patients with panic disorder and episodic anxiety.

Anxiety disorders are associated with respiratory abnormalities. Breathing training (BT) aimed at reversing these abnormalities may also alter the anxiogenic effects of biological challenges. Forty-five Panic Disorder (PD) patients, 39 Episodic Anxiety patients, and 20 non-anxious controls underwent voluntary hypoventilation and hyperventilation tests twice while psychophysiological measures were recorded. Patients were randomized to one of two BT therapies (Lowering vs. Raising pCO(2)) or to a waitlist. Before treatment panic patients had higher respiration rates and more tidal volume instability and sighing at rest than did non-anxious controls. After the Lowering therapy, patients had lower pCO(2) during testing. However, neither reactivity nor recovery to either test differed between patients and controls, or were affected by treatment. Although the two treatments had their intended opposite effects on baseline pCO(2), other physiological measures were not affected. We conclude that baseline respiratory abnormalities are somewhat specific to PD, but that previously reported greater reactivity and slower recovery to respiratory challenges may be absent.

Methodological considerations in ambulatory skin conductance monitoring.

Little is known how much skin conductance (SC) recordings from the fingers are affected by factors such as electrode site deterioration, ambient temperature (TMP), or physical activity (ACT), or by age, sex, race, or body mass index. We recorded SC, TMP, and ACT in 48 healthy control subjects for a 24-hour period, and calculated SC level (SCL), its standard deviation, the coefficient of SC variation, and frequency and amplitude of non-specific SC fluctuations. One method of assessing electrode site deterioration showed an average decline of 20%, while a second method found no significant change. All SC measures were higher during waking than sleep. Other factors influenced different measures in different ways. Thus, 24-hour SC recording outside the laboratory is feasible, but some measures need to be corrected for the influence of confounding variables.

Goal setting in psychotherapy: the relevance of approach and avoidance goals for treatment outcome.

The present study is the first aimed at investigating the influence of goal definition on treatment outcome in a sample of depressed patients. Data from 657 inpatients admitted to a psychosomatic clinic in Germany being treated in a cognitive-behavioral therapy program were analyzed. Treatment goals were identified as either approach or avoidance, and the sample was classified accordingly. Patients who identified approach goals only were placed in the approach group, and those who identified at least one avoidance goal were placed in the avoidance group. Results showed that framing goals using avoidance terms was associated with less symptomatic improvement but did not affect goal attainment. Findings from this research should be utilized in practice not only for process management such as individual treatment planning but also to control outcome quality. Furthermore, goal definition should be considered as a control variable in research on depression.

Twenty-four hour skin conductance in panic disorder.

Skin conductance, physical activity, ambient temperature and mood were recorded for 24 h in 22 panic disorder (PD) patients and 29 healthy controls. During the day, subjects performed standardized relaxation tests (ARTs). We hypothesized that tonically elevated anticipatory anxiety in PD during waking and sleeping would appear as elevated skin conductance level (SCL) and greater skin conductance (SC) variability. Mean SCL was higher during both usual waking activities and sleeping in PD, but not during the ARTs. Group SC variability differences did not reach significance, perhaps because of variance unrelated to anxiety. Analyses indicated that in the PD group, antidepressant medication reduced mean SCL whereas state anxiety had the opposite effect during the day. Depressive symptoms reported during the day were related to elevated mean SCL on the night of the recording. The rate and extent of SCL deactivation over the night was equal in the two groups. However, PD patients had more frequent interruptions of deactivation that could have arisen from conditioned arousal in response to threat cues during sleep.

End-tidal versus transcutaneous measurement of PCO2 during voluntary hypo- and hyperventilation.

Recent studies have shown that end-tidal PCO(2) is lower during anxiety and stress, and that changing PCO(2) by altering breathing is therapeutic in panic disorder. However, end-tidal estimation of arterial PCO(2) has drawbacks that might be avoided by the transcutaneous measurement method. Here we compare transcutaneous and end-tidal PCO(2) under different breathing conditions in order to evaluate these methods in terms of their comparability and usability. Healthy volunteers performed two hypoventilation (slow vs. paused breathing) and two hyperventilation tests (25 mm Hg at 18 vs. 30 breaths per minute). Three measurements of PCO(2) (two end-tidal and one transcutaneous device), tidal volume, and respiration rate were recorded. Before and after each test, subjects filled out a symptom questionnaire. The results show that PCO(2) estimated by the two methods was comparable except that for transcutaneous measurement registration of changes in PCO(2) was delayed and absolute levels were much higher. Both methods documented that paused breathing was effective for raising PCO(2), a presumed antidote for anxious hyperventilation. We conclude that since the two methods give comparable results choosing between them for specific applications is principally a matter of whether the time lag of the transcutaneous method is acceptable.

Sympathetic activation in broadly defined generalized anxiety disorder.

The definition of generalized anxiety disorder (GAD) has been narrowed in successive editions of DSM by emphasizing intrusive worry and deemphasizing somatic symptoms of hyperarousal. We tried to determine the clinical characteristics of more broadly defined chronically anxious patients, and whether they would show physiological signs of sympathetic activation. A group whose chief complaint was frequent, unpleasant tension over at least the last six weeks for which they desired treatment, was compared with a group who described themselves as calm. Participants were assessed with structured interviews and questionnaires. Finger skin conductance, motor activity, and ambient temperature were measured for 24h. Results show that during waking and in bed at night, runs of continuous minute-by-minute skin conductance level (SCL) declines were skewed towards being shorter in the tense group than in the calm group. In addition, during waking, distributions of minute SCLs were skewed towards higher levels in the tense group, although overall mean SCL did not differ. Thus, the tense group showed a failure to periodically reduce sympathetic tone, presumably a corollary of failure to relax. We conclude that broader GAD criteria include a substantial number of chronically anxious and hyperaroused patients who do not fall within standard criteria. Such patients deserve attention by clinicians and researchers.

Psychophysiological reactions to two levels of voluntary hyperventilation in panic disorder.

Panic disorder (PD) patients usually react with more self-reported distress to voluntary hyperventilation (HV) than do comparison groups. Less consistently PD patients manifest physiological differences such as more irregular breathing and slower normalization of lowered end-tidal pCO(2) after HV. To test whether physiological differences before, during, or after HV would be more evident after more intense HV, we designed a study in which 16 PD patients and 16 non-anxious controls hyperventilated for 3 min to 25 mmHg, and another 19 PD patients and another 17 controls to 20 mmHg. Patients reacted to HV to 20 mmHg but not to 25 mmHg with more self-reported symptoms than controls. However, at neither HV intensity were previous findings of irregular breathing and slow normalization of pCO(2) replicated. In general, differences between patients and controls in response to HV were in the cognitive-language rather than in the physiological realm.

Psychophysiological effects of breathing instructions for stress management.

Stressed and tense individuals often are recommended to change the way they breathe. However, psychophysiological effects of breathing instructions on respiration are rarely measured. We tested the immediate effects of short and simple breathing instructions in 13 people seeking treatment for panic disorder, 15 people complaining of daily tension, and 15 controls. Participants underwent a 3-hour laboratory session during which instructions to direct attention to breathing and anti-hyperventilation instructions to breathe more slowly, shallowly, or both were given. Respiratory, cardiac, and electrodermal measures were recorded. The anti-hyperventilation instructions failed to raise end-tidal pCO(2) above initial baseline levels for any of the groups because changes in respiratory rate were compensated for by changes in tidal volume and vice versa. Paying attention to breathing significantly reduced respiratory rate and decreased tidal volume instability compared to the other instructions. Shallow breathing made all groups more anxious than did other instructions. Heart rate and skin conductance were not differentially affected by instructions. We conclude that simple and short instructions to alter breathing do not change respiratory or autonomic measures in the direction of relaxation, except for attention to breathing, which increases respiratory stability. To understand the results of breathing instructions for stress and anxiety management, respiration needs to be monitored physiologically.

Physiological evaluation of psychological treatments for anxiety.

Classification of mental disorders has been greatly influenced by a medical model postulating biological abnormalities that underlie its divisions. Particularly in anxiety disorders, physiological symptoms are part of the Diagnostic and Statistical Manual criteria. Therefore, successful therapy should influence physiological as well as cognitive-verbal expressions of anxiety. Nevertheless, despite the well-known limitations of self-report, physiological outcome measures have only occasionally been employed. We searched the literature for treatment studies that attempted to make a physiological argument for the efficacy of a psychological treatment for anxiety. Our search found only a few methodologically sound examples, where normalization of self-report and physiological measures corresponded. The most convincing studies dealt with the treatment of specific phobias and post-traumatic stress disorder.