Mechanisms of change during group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder.

Repetitive negative thinking (RNT) is a transdiagnostic process that serves to maintain emotional disorders. Metacognitive theory suggests that positive and negative metacognitive beliefs guide the selection of RNT as a coping strategy which, in turn, increases psychological distress. The aim of this study was to test the indirect effect of metacognitive beliefs on psychological distress via RNT. Patients (N=52) with primary and non-primary generalized anxiety disorder attended a brief, six-week group metacognitive therapy program and completed measures of metacognitive beliefs, RNT, and symptoms at the first and final treatment sessions, and at a one-month follow-up. Prospective indirect effects models found that negative metacognitive beliefs (but not positive metacognitive beliefs) had a significant indirect effect on psychological distress via RNT. As predicted by metacognitive theory, targeting negative metacognitions in treatment appears to reduce RNT and, in turn, emotional distress. Further research using alternative measures at multiple time points during therapy is required to determine whether the absence of a relationship with positive metacognitive beliefs in this study was a consequence of (a) psychometric issues, (b) these beliefs only being relevant to a subgroup of patients, or (c) a lack of awareness early in treatment.

Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: an effectiveness trial.

BACKGROUND: Generalized anxiety disorder (GAD) is a common and highly comorbid anxiety disorder characterized by repetitive negative thinking (RNT). Treatment trials tend to exclude individuals with non-primary GAD, despite this being a common presentation in real world clinics. RNT is also associated with multiple emotional disorders, suggesting that it should be targeted regardless of the primary disorder. This study evaluated the acceptability and effectiveness of brief group metacognitive therapy (MCT) for primary or non-primary GAD within a community clinic. METHODS: Patients referred to a specialist community clinic attended six, two-hour weekly sessions plus a one-month follow-up (N=52). Measures of metacognitive beliefs, RNT, symptoms, positive and negative affect, and quality of life were completed at the first, last, and follow-up sessions. RESULTS: Attrition was low and large intent-to-treat effects were observed on most outcomes, particularly for negative metacognitive beliefs and RNT. Treatment gains increased further to follow-up. Benchmarking comparisons demonstrated that outcomes compared favorably to longer disorder-specific protocols for primary GAD. LIMITATIONS: No control group or independent assessment of protocol adherence. CONCLUSIONS: Brief metacognitive therapy is an acceptable and powerful treatment for patients with primary or non-primary GAD.

Does enhanced cognitive behaviour therapy for eating disorders improve quality of life?

Quality of life (QOL) is the degree of enjoyment and satisfaction experienced in life, and embraces emotional well-being, physical health, economic and living circumstances, and work satisfaction. QOL recovery with eating disorder treatment has received sparse attention, and until now, no study has investigated QOL recovery with enhanced cognitive behaviour therapy (CBT-E). Patients (n = 196) admitted to a specialist eating disorders outpatient programme and receiving CBT-E completed measures of QOL, eating disorder psychopathology, depression, anxiety and self-esteem, before and after treatment. QOL at intake was compared with community norms, and QOL below the norm was predicted from sociodemographic and clinical correlates with logistic regression. Baseline QOL below the norm was associated with depression and anxiety Axis I comorbidity, and severity of depressive symptoms. Predictors of post-treatment QOL were baseline QOL and level of depressive symptoms and self-esteem at post-treatment. CBT-E was associated with gains in QOL over the course of treatment, in addition to eating disorder symptom relief.

The role of perfectionism, dichotomous thinking, shape and weight overvaluation, and conditional goal setting in eating disorders.

This study examined the role of perfectionism (self-oriented and socially prescribed), shape and weight overvaluation, dichotomous thinking, and conditional goal setting in eating disorder psychopathology. Perfectionism and shape and weight overvaluation have had longstanding implication in the development and maintenance of eating disorders. A leading evidence-based theory of eating disorders (Fairburn, Cooper & Shafran, 2003) outlines perfectionism as a maintaining mechanism of eating disorder psychopathology and as a proximal risk factor for the development of shape and weight overvaluation. These constructs have been linked to other cognitive processes relevant to eating disorders, specifically, dichotomous thinking and conditional goal setting. Women with DSM-IV eating disorders (N=238) were compared to women in the general community (N=248) and, as hypothesised, scores on measures of these constructs were pronounced in the clinical sample. Hierarchical regression analyses predicting eating disorder psychopathology showed that for both groups, dichotomous thinking and conditional goal setting significantly improved model fit beyond perfectionism and shape and weight overvaluation alone. Self-oriented perfectionism, but not socially prescribed perfectionism, was relevant to eating disorder psychopathology. We discuss the implications for current treatment protocols and early intervention.

Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity.

OBJECTIVES: To compare quality of life (QoL) in mental health outpatients to non-clinical norms, and examine the associations between QoL and principal diagnosis, number of comorbid Axis I diagnoses, and type of comorbidity. METHODS: Consecutively referred and assessed patients (n = 2024) formed the study sample pool. Of these, 1486 individuals who had completed a QoL instrument at intake and had a principal diagnosis amenable to comparison by group analysis were included in the study. Principal diagnoses were unipolar mood disorder (n = 687), eating disorder (n = 226), bipolar disorder (n = 165), social anxiety disorder (n = 165), generalized anxiety disorder (n = 125), and panic disorder (n = 118). QoL for psychiatric groups was compared to non-clinical norms using a valid and reliable measure. RESULTS: QoL was significantly impaired in all psychiatric groups compared to nonclinical norms. There was a significant interaction between principal diagnosis and number of comorbid Axis I disorders, controlling for age, sex, marital status, employment, and years of school. The addition of one comorbidity significantly attenuated QoL in social anxiety disorder, panic disorder, and bipolar disorder. For all other conditions, a significant loss in QoL occurred with two or more comorbidities. Axis I depressive and anxiety comorbidity significantly attenuated QoL across all diagnostic groups. CONCLUSIONS: QoL is significantly impaired in psychiatric outpatients and diagnostic groups vary in the extent to which they experience additional QoL burden with increasing comorbidities.

Mediators between perfectionism and eating disorder psychopathology: shape and weight overvaluation and conditional goal-setting.

OBJECTIVE: To examine mediators of the relationship between perfectionism and eating disorder (ED) psychopathology in a clinical sample. METHOD: Participants were 201 women with a DSM-IV diagnosed ED consecutively referred to a specialist outpatient treatment clinic. Participants completed measures of perfectionism, ED psychopathology, shape and weight overvaluation, and conditional goal-setting (CGS). RESULTS: Evaluation of a multivariate mediator model using Baron and Kenny's (1986) four-step mediation methodology showed that shape and weight overvaluation and CGS significantly and uniquely mediated the relation between self-oriented perfectionism (SOP) and restraint, eating concern, shape concern, and weight concern. The mediator model furthered the proportion of explained variance in outcomes beyond the direct effects model by 28-49%. DISCUSSION: The findings support the conclusion that the relationship between SOP and ED psychopathology in women with a clinically diagnosed ED is mediated by shape and weight overvaluation and CGS.

Reliability and validity of the Conditional Goal Setting in Eating Disorders Scale (CGS-EDS) among adults with eating disorders.

The aim of this study was to develop and validate a self-report measure of Conditional Goal Setting (CGS) for use among individuals with eating disorders, the Conditional Goal Setting in Eating Disorders Scale (CGS-EDS). The CGS-EDS assesses the degree to which an individual believes that the achievement of happiness is contingent upon the attainment of body shape and weight goals. Women with a DSM-IV diagnosed eating disorder consecutively referred to a specialist outpatient clinic (N=238) completed the CGS-EDS and self-report measures of theoretically related constructs. Exploratory factor analysis indicated a one-factor solution, which accounted for 65% of the variance. The CGS-EDS correlated positively with theoretically related measures of overvaluation of shape and weight, concern with shape and weight, dichotomous thinking, and depression. The alpha reliability of the scale was .92. The CGS-EDS is a valid and reliable measure of CGS in eating disorders and is relevant to cognitive and behavioral models of maintenance and intervention.

Quality of life in depression: an important outcome measure in an outpatient cognitive-behavioural therapy group programme?

Studies have shown that psychiatric patients have significantly impaired quality of life (QOL) in comparison to community samples who are not suffering a mental illness. Despite an increase in research in the mental health field, there still remains little consensus as to the merit of using such questionnaires within a mental health population. There is a concern that QOL is redundant with affective state and symptomatology. We investigated the usefulness of the Quality of Life Enjoyment and Satisfaction Questionnaire-short form (QLESQ-SF) in a depressed outpatient sample receiving time-limited, standardized group cognitive-behavioural therapy. QLESQ-SF ratings were examined at admission and 10-week endpoint in an intention-to-treat (N = 212) and completers (N = 164) sample. QLESQ-SF ratings and symptom ratings (Beck Depression Inventory-II; Beck Anxiety Inventory) improved significantly over time. Hierarchical regression analyses revealed that, although affective state and change in symptomatology were significantly correlated with QOL and change in QOL, a large proportion of variance was unexplained. These results are inconsistent with the theory of measurement redundancy. QOL appears to be a useful measure that provides additional treatment outcome information distinct from affective state and symptomatology.

Role of gender in depressive disorder outcome for individual and group cognitive-behavioral treatment.

Gender in cognitive-behavioral therapy (CBT) for outcome for depression has been inadequately examined in previous research. Thirty-five men and 55 women diagnosed with a depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) completed individual CBT at an outpatient community mental health clinic and 56 men and 105 women completed group CBT. Depression severity was measured before treatment and at endpoint using the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996) along with secondary outcomes of anxiety (Beck Anxiety Inventory; Beck, Epstein, Brown, & Steer, 1988) and quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire; Endicott, Nee, Harrison, & Blumenthal, 1993). Men and women demonstrated equivalent pretreatment and posttreatment illness severity, a comparable gradient of improvement on outcomes, and attainment of clinically meaningful benchmarks.

The reliability and validity of the dichotomous thinking in eating disorders scale.

The Dichotomous Thinking in Eating Disorders Scale (DTEDS) is a short, self-report measure that can be used to assess the presence of a rigid, "black-and-white" cognitive thinking style. It was originally developed for use in a study of psychological predictors of weight regain in obesity. The DTEDS consists of two subscales. Items on the Eating subscale assess dichotomous thinking with regards to eating, dieting or weight, and items on the General subscale assess dichotomous thinking more generally. This study aimed to examine the factor structure and psychometric properties of the DTEDS in a sample of treatment-seeking eating disordered (N=87) and overweight/obese (N=111) women. Confirmatory factor analysis demonstrated that a two-factor model provided a better fit to the data than a one-factor model. The psychometric properties of the final scale were excellent, with evidence being provided for the reliability and validity of the two subscales. Overall, the results indicated that the DTEDS is a reliable instrument that can be used to assess eating-specific as well as more general aspects of dichotomous thinking.

The association between depressive personality and treatment outcome for depression following a group cognitive-behavioral intervention.

The present study investigated the association of depressive personality traits to treatment outcome for depression. One hundred and nineteen patients with a primary diagnosis of major depression were divided into high- and low-depressive personality groups, and depression symptomatology was assessed pre- and postparticipation in a standardized group cognitive-behavioral intervention. Analyses revealed poorer pre-state and end-state functioning for the high-depressive personality group. However, rate of improvement pre- to posttreatment was comparable between the two groups. Subsequent multiple regression analyses revealed that when controlling for pretreatment depression severity, depressive personality was not a predictor of depression treatment outcome. Within the methodological parameters of the current study, depressive personality traits were not associated with a poorer response to cognitive-behavioral treatment for depression.

Relationship between homework completion and outcome in cognitive behaviour therapy.

Homework or between-session learning has long been considered an essential aspect of effective cognitive behaviour therapy. However, it has received relatively less empirical attention than other components of cognitive behaviour therapy. In general, studies have found that homework completion is predictive of outcome in psychotherapy. However, the amount of homework completed by a patient represents only one aspect of this important therapeutic component. This study investigated both the quantity and the quality of homework completed during a 10-week group cognitive and behavioural treatment program for anxious and depressed patients. It explored the relationship between various aspects of homework completion and outcomes on several different variables. A total of 94 patients were included in the analysis. It was found that both quantity and quality of homework completed predicted outcome on measures of depression, anxiety and quality of life at post-treatment and at 1-month follow-up. The results were strongest for the amount of homework completed, suggesting that clinicians should encourage patients to complete homework even if the homework content is not entirely accurate. The results of this study highlight the importance of homework as a central part of effective cognitive and behavioural treatment.