A randomized controlled trial of an internet-based posttreatment care for patients with eating disorders.

BACKGROUND: Despite effective treatment approaches, relapses are frequent in eating disorders. Posttreatment care is essential to enhance continuous recovery and prevent deterioration. This study evaluated the effects of an Internet-based intervention following routine care. MATERIALS AND METHODS: One hundred five women who received treatment for bulimia nervosa and related eating disorders not otherwise specified were randomly assigned either to an immediate Internet-based support program (EDINA) over 4 months or to a 4-month waiting-list treatment as usual (TAU) control condition. The primary outcome was eating disorder-related attitudes at baseline and after 4 months assessed by the Eating Disorder Examination Questionnaire (EDE-Q). RESULTS: The program proved feasible and was well accepted. A significant reduction in eating disorder-related attitudes could be shown for both groups at the end of the 4 months. There was a tendency for participants of the aftercare intervention to show better results on all outcome measures. In total, 40.6% (13/32) of the EDINA participants and 24.4% (10/41) of the TAU participants showed statistically reliable improvement on the EDE-Q total score by the end of the intervention period [χ(2)(1)=2.195, p=0.138]. CONCLUSIONS: The Internet-based support program was feasible and well accepted but did not prove efficacious in a heterogeneous sample of patients following routine care.

[Eating disorders on the internet: an experimental study on the effects of pro-eating disorders websites and self-help websites]. / Essstörungen im Internet: Eine experimentelle Studie zu den Auswirkungen von Pro-Essstörungs- und Selbsthilfewebsites.

Pro-eating disorders (ED) websites are assumed to have a negative impact on internet users because these sites promote ED as a lifestyle, and present an extreme thin ideal as well as extreme weight loss measures. We tested the impact of reading pro-ED contents in a sample of 421 women. The participants were randomly assigned to one of 3 conditions in which they were exposed to either a pro-ED blog, a self-help blog, or a neutral control blog. Post-exposure negative affect was higher in participants of the pro-ED and the self-help conditions compared to the neutral blog condition. Participants with an elevated risk for developing an ED had a lower appearance self esteem after exposure to the pro-ED, or the self-help blog. According to the study, a subgroup of high risk individuals might be affected by ED-related internet content. The implications of this study are discussed in the context of the ongoing controversy around pro-ED websites.

Attentional bias in depressive patients and the moderating effect of concurrent anxiety.

BACKGROUND: Most previous studies finding positive results in the emotional Stroop test did not control for concurrent anxiety symptoms. This study investigated depressive patients without comorbid anxiety disorders in order to clarify existing inconsistent findings. Furthermore, we examined the relationship between anxiety level and the emotional Stroop effect in patients and healthy subjects. SUBJECTS AND METHODS: Twenty-three depressive patients without comorbid anxiety disorder and 27 healthy subjects performed a mixed computerized version of the emotional Stroop test (attentional bias test). We assessed the state and trait anxiety and examined its correlation with the emotional Stroop effect. RESULTS: We failed to find evidence for attentional bias in the patients as measured by longer reaction times to the emotional stimuli. However, there was a positive correlation between state anxiety and attentional bias in depressed patients. On the other hand, in healthy subjects the trait anxiety correlated negatively with attentional bias. CONCLUSIONS: Attentional bias is not found in depressed patients if only patients without comorbid anxiety disorders are included. Furthermore, healthy subjects with high trait anxiety levels may be vulnerable to affective disorders because they use avoidance strategies when encountering negative information.

Quality of marital relationship and depression: results of a 10-year prospective follow-up study.

BACKGROUND: Although the long-term course of depression has been intensively examined, there are only few studies on the long-term development of depressed patients' spousal relationships. The aim of the study was to assess the quality and stability of depressed patients' spousal relationships in the long-term course of depression and to identify predictors of relationship outcome. METHODS: In the study, 50 inpatients with Major Depression were followed-up one, two and ten years after discharge from hospital and compared to a healthy control group matched by age and sex. Marital satisfaction was measured by the Terman item. Expressed Emotion (EE) was assessed with the Five-Minute Speech Sample (FMSS) and the Perceived Criticism Index (PC). RESULTS: In the follow-up period of ten years, 26 patients (56.5%) had a recurrence. Ten years after discharge from hospital 8 couples were separated, 11 were unhappy and 26 couples were happy with their spousal relationship. The quality of marital relationship decreased over the follow-up period. In comparison to a healthy control group, patients showed a significantly worse quality of marital relationship at follow-up. Besides age and course of depression, the spousal EE status was a prognostic factor for the quality of the relationship after 10 years. CONCLUSIONS: The results confirm the decrease of marital satisfaction over time in the long-term course of depression. Identified interpersonal predictors of the quality of spousal relationship in major depression could be used as indication criteria for couple therapy.

Intra-individual variability in high-functioning patients with schizophrenia.

Intra-individual variability of reaction times (IIV) can be employed as a measure of the stability of information processing, which has been proposed to be fundamentally disturbed in schizophrenia. However, the theoretical and clinical significance of IIV is not clear, in part because it has previously been investigated in subject groups with generalized cognitive impairment. Therefore, the purpose of the study was to assess IIV in high-functioning patients with schizophrenia and relatively preserved cognitive performance. 28 high-functioning patients with schizophrenia and 28 controls performed a Go/Nogo task and a Continuous Performance Test. In contrast to average measures of task performance, IIV differentiated consistently and with large effect size between groups. Modelling with an Ex-Gaussian distribution revealed that patients have a higher proportion of slow responses reflected by an increased tau parameter. The tau parameter was correlated with work capability in the sample with schizophrenia. In conclusion, IIV is an easily obtained measure, which is highly sensitive to fundamental cognitive deficits not directly visible in a high-functioning patient group. The response pattern with more exceedingly slow reactions could reflect a core deficit in the stability of information processing. The relationship with work capability suggests investigation of IIV as a clinical measure.

Initial orienting to emotional faces in female adolescents with borderline personality disorder.

BACKGROUND: Previous research has implicated a general hypervigilance for negative emotional words in adults with borderline personality disorder (BPD) as compared to healthy controls. The purpose of this study was to assess initial orienting to negative and positive emotional faces in female adolescents with BPD. METHOD: Adolescent patients with BPD (n = 30), adolescent patients with other psychiatric diagnoses (n = 29) and adolescent healthy comparison subjects (n = 29) were tested with the visual dot probe task to examine attentional orienting to emotional and neutral faces. RESULTS: In contrast to the adolescent healthy comparison subjects, both the adolescent patients with BPD and the adolescent patients with other psychiatric diagnoses showed a stronger orienting to negative emotional stimuli. However, no differences were found between the clinical groups. Data regarding positive stimuli showed that BPD is not associated with a specific orienting to positive faces. CONCLUSIONS: These findings suggest that attentional orienting to negative faces is not specific to adolescent patients with BPD but also affects adolescent patients with other psychiatric diagnoses. Furthermore, no distortion in information processing concerning positive cues was observed in adolescent patients with BPD. If these findings were confirmed, further BPD research could no longer assume that BPD is specifically associated with distortions in initial orienting processes.

Attentional bias in later stages of emotional information processing in female adolescents with borderline personality disorder.

BACKGROUND: Bias in emotional information processing has been described in patients with borderline personality disorder (BPD). This study investigates whether adolescent patients with a diagnosis of BPD demonstrate abnormalities in attentional maintenance in viewing emotional faces. SAMPLING AND METHODS: Thirty female adolescents with a diagnosis of BPD, 29 female adolescents with mixed psychiatric diagnoses, and 30 healthy participants were tested with the visual dot probe task. The task involved showing photographs of actors with faces depicting neutral, negative, and positive expressions for 1,500 ms each. RESULTS: Attentional bias to negative faces was not generally associated with BPD, but patients with BPD did show a strong correlation between current mood and attentional bias to negative faces. Only in adolescents with BPD did attention to negative faces narrow when they were currently in a state of negative mood. Conversely, both control groups avoided negative faces in conjunction with a decline in positive mood. CONCLUSIONS: This study indicates that borderline pathology is linked to an inability to disengage attention from negative facial expressions during attentional maintenance when in a negative mood. Based on these findings, mood-dependent therapeutic interventions focusing on attentional processes may represent a useful add-on to established therapies in patients with BPD.

Slow cortical potentials in human aversive trace conditioning.

The aim of the present study was to better understand the cortical structures and neuronal processes involved in aversive differential trace conditioning in healthy subjects. According to previous findings in literature, we tested whether the stimulus preceding negativity (SPN) in an emotional trace-conditioning paradigm shows a frontocentral maximum reflecting affective anticipation, e.g. in the anterior cingulate, or a centroparietal maximum reflecting time estimation and sensory anticipation. Two distinct SPN intervals were analyzed, one during the presentation of the CS (comparable to delay conditioning) and another one after CS offset (trace conditioning). In the CS+ condition, where subjects anticipated the onset of an aversive electrical stimulus after CS+ offset, a significantly larger negativity than in the unpaired (CS-) condition was present. SPN revealed a sustained midcentral and posterior parietal negativity during both SPN intervals. Differences between the two analyzed SPN intervals pointed towards occipital activity being found in the first interval (delay), but not in the second (trace). Aversive conditioning paradigms with longer trace intervals seem to rely upon a similar activation pattern as cognitive stimulus anticipation.

Expressed emotion, perceived criticism and 10-year outcome of depression.

Outcome studies of patients suffering from depression indicate a high relapse rate and a tendency towards chronicity. A family atmosphere characterised by expressed emotion (EE) and perceived criticism (PC) was reported to be a robust predictor of outcome in affective disorders. The aim of the study was to analyze the association between EE, PC and long-term outcome of depression. Fifty inpatients with major depression were followed up 1, 2 and 10 years after discharge from the hospital. After 10 years, 26 patients (56.5%) had at least one recurrence. Spousal EE, assessed with the Five-Minute Speech Sample (FMSS), and the Perceived Criticism Index (PCI) were not significant prognostic factors for depression outcome. The significance of EE and PC for the long-term course of depression has to be questioned. The findings indicate a need to examine factors that may partly mediate the effect of EE and PC on the outcome of depression.

[Perception of emotional facial expressions in female adolescents with borderline personality disorder]. / Wahrnehmung und Bewertung von emotionalen Gesichtsausdrücken bei weiblichen Jugendlichen mit einer Borderline-persönlichkeitsstörung.

OBJECTIVES: Investigation of the perception of emotional and neutral facial expressions in female adolescents with borderline personality disorder (BPD). METHODS: Emotional and neutral facial expressions from the set of Ekman and Friesen were presented to 30 adolescent patients with a diagnosis of BPD, to 29 adolescent patients with other psychiatric diagnoses, and to a control group of 30 healthy subjects. All participants in the study were female. The subjects were asked to name the displayed emotion and to estimate the perceived intensity, negativity and pleasantness by means of a self-developed questionnaire on the perception of emotions in facial expressions. RESULTS: Female adolescents with BPD demonstrated no deficits in naming the displayed emotions. Nor did they differ from the clinical and healthy control groups regarding the subjective ratings of the negative and neutral facial expressions. However, female adolescents with BPD rated the pleasantness and intensity of positive facial expressions lower, and the negativity of positive facial expressions higher than did either the clinical or the healthy control group. CONCLUSIONS: The findings suggest the need for further research on the processing of positive stimuli and its role in the regulation of emotion in adolescents with borderline personality disorder. Due to the dysfunctional interpretation of positive emotional stimuli, therapeutic efforts should also rely on the possible biases in emotional information processing.

Marital interaction in depression: a comparison of structural analysis of social behavior and the Kategoriensystem für Partnerschaftliche Interaktion.

BACKGROUND: A number of studies have shown that marital interaction plays an important role regarding etiology, maintenance, and course of depression. The Kategoriensystem fur Partnerschaftliche Interaktion (KPI; 'Coding System for Marital/Family Interaction') and the Structural Analysis of Social Behavior (SASB) are both widely used to describe and quantify the interactional behavior of patients and their relatives. To evaluate the validity of extrapolating research findings from one system to another, especially in the field of depressive disorders, the two coding systems were compared in an empirical analysis. SAMPLING AND METHODS: Videotaped marital problem-solving interaction tasks of 29 married couples with a depressed spouse were coded by means of both systems by separate teams of observers. RESULTS: Between-system comparisons revealed that convergent validity on the level of SASB clusters and KPI verbal categories were moderate and differentiated between the behavior of patients and that of spouses. The KPI nonverbal positive and negative categories were not simply correlated with the SASB affiliation dimension. CONCLUSION: The results underline the importance of undertaking validation studies with different samples.

IREL - A psychometric instrument for measuring life themes.

BACKGROUND: Although biographical narratives and work involving the meaning of biographical episodes is a central focus in any psychotherapy, there remains a lack of psychometric instruments for measuring the autobiographical construction as such. We will be presenting a theoretical model of an autobiographical construction of life themes and the Interview of Retrospective Exploration of Life themes (IREL) will be used as the basis of a psychometric instrument. The IREL takes about 90-120 min. The interrater reliability and test-retest reliability will be examined. METHODS: Two samples of 21 and 23 mentally healthy subjects were recruited. In addition to the IREL, the Beck Depression Inventory (BDI) and SCID were also used to control for psychopathological status and depressive mood. RESULTS: According to our data, biographical events can be explored objectively and reliably using the IREL. Minor test-retest variability of the affective valence of life themes is not state-dependent. CONCLUSIONS: Setting aside limitations due to the small sample sizes, the results suggest that the proposed interview is an objective and reliable instrument for measuring central issues within the subjective biographical construction (life themes).

Stroop performance in depressive patients: a preliminary report.

BACKGROUND: The Stroop interference test requires executive control functions, in particular inhibition of a learned routine (in this case word reading). Depressive patients show deficits on tests of executive function. However, the impact of confounding variables like type of depression and anxiety level is not yet elucidated for depressive patients. This is of clinical importance, since executive functions seem to play an important role in predicting treatment response and functional outcome. METHODS: 23 depressive patients and 27 healthy subjects performed a computerized mixed trial Stroop task. Depressive patients were divided according to DSM-IV diagnosis into melancholic and non-melancholic subgroups. Furthermore the level of anxiety was assessed in all subjects. RESULTS: When depressed patients were analyzed as a whole group, they showed only a trend towards higher Stroop interference effect at the beginning of the task. When analysis was performed using according to DSM-IV defined melancholic and non-melancholic subgroups, only non-melancholic patients were impaired in the Stroop task compared to melancholic patients and healthy subjects. LIMITATIONS: The sample size was small resulting in low statistical power. Furthermore, the patients were medicated. CONCLUSIONS: The unexpected result that melancholic patients perform better than non-melancholic ones may be due to their more pronounced rigidity, which makes them more resistant against distraction. Hence, more detailed psychopathological assessment is desirable for future investigations in executive functions of melancholic patients.

[The exploration of the depressive personality disorder]. / Zur Erfassung der depressiven Persönlichkeitsstörung -- Validierung einer deutschen Version des "Depressive-Persönlichkeitsstörungs-Inventars" (DPSI).

Lately the concept of the depressive personality disorder has been regarded more often again in the context of chronic and subthreshold forms of depression. The purpose of the present study was the psychometric evaluation of a German version of the "Depressive Personality Disorder Inventory" (DPDI), which is a questionnaire for the exploration of the depressive personality disorder. A total of 138 depressive patients and controls were included in the study. The inter-rater-reliability as well as the internal consistency and the test-retest-reliability of the DPDI revealed satisfactory and good results. A short version of the DPDI was developed by means of a factor analysis. Medium correlations were found between the DPDI and two interviews for the depressive personality disorder. These results are discussed and it is concluded that the DPDI as well as its short version are reliable, valid and economic self-rating instruments for the exploration of the depressive personality disorder.

Dimensions of the Typus melancholicus personality type.

The Typus melancholicus personality type (TMP) is characterised by orderliness, conscientiousness and interpersonal dependence. Several standardised instruments have been developed for the assessment of the Typus melancholicus personality. To date there has been no systematic comparison of these instruments and in particular it has been unclear whether TMP represents a single trait or a personality trait constellation. The aim of this study was the comparison of four TMP questionnaires and the investigation of the dimensionality of the personality as revealed by these questionnaires. The factorial validity of four TMP questionnaires was examined based on a sample of n = 264 psychiatric inpatients and normal controls. In a factor analysis of the items of the TMP questionnaires, four dimensions could be differentiated: Dependence, Intolerance of Ambiguity, Norm-Orientation, and Perfectionism. Psychometric evaluation showed good values for the individual items and the new TMP scales. The four subscales had a differential correlation profile in relation to the dimensions of the five-factor model of personality. The TMP scales could distinguish a group of depressed patients from a group of normal controls. The results show that TMP personality is not a single trait but consists of four related but separate traits. These can be clearly distinguished from those of the five-factor model of personality. The analysis of the TM concept therefore also represents a theoretical perspective for the integration of the personality characteristics which are relevant for depression. Based on this analysis, we constructed a multidimensional TMP inventory which forms the basis for the investigation of the effect of TM personality on clinical outcome and on psychotherapeutic treatment.

Prefrontal-cingulate activation during executive control: which comes first?

The Stroop test requires executive control functions, in particular inhibition of a learned routine (in this case, word reading). The spatiotemporal analysis of brain activation during Stroop task execution was performed in 16 healthy subjects using high-density event-related potentials (ERPs) and dipole source modeling (BESA software). Scalp ERP analysis revealed the neurophysiological substrate of the interference effect: first, a greater negativity in the incongruent as compared to the congruent and neutral conditions was found between 350 and 450 ms poststimulus over left frontocentral scalp regions. Source analysis of the difference wave (incongruent-congruent) indicated that a generator localized in left prefrontal cortex (PFC) contributed to this effect. Second, immediately after the first effect, a greater positivity in the incongruent as compared to the congruent and neutral conditions developed between 450 and 550 ms poststimulus over midline frontocentral scalp regions. A generator of this effect was located in right anterior cingulate cortex (ACC). ACC activation seems to follow the activation of PFC with some overlap between the two components. Possible interpretation of this finding is that PFC signals ACC when executive control is required and ACC implements the control.

Expressed emotion in relatives of first-episode and chronic patients with schizophrenia and major depressive disorder-a comparison.

Relatives of first-episode and chronic schizophrenic and depressed patients were examined with respect to their expressed emotion (EE) status. The two aims of the study were to (1) investigate whether relatives of first-episode patients differed from family members of chronic patients, and (2) whether EE indices of relatives of schizophrenic patients were comparable to those of depressed subjects. Twenty patients of each diagnostic group (DSM-III-R and DSM-IV) were included, i.e. a total of 80 patients. The EE status of key relatives was assessed with the Five-Minute Speech Sample on the basis of critical comments and emotional overinvolvement. Additionally, the new criterion 'covert criticism' was applied to detect indirect expressions of critique. Relatives of first-episode and chronic patients of both diagnostic groups did not differ significantly regarding their EE status; in first-episode patients, 52.5% of relatives were classified high EE; in chronic patients, 45%. Moreover, EE indices of relatives of schizophrenic and depressed patients were comparable. Analysis revealed 52.5 and 45% high-EE relatives in the depression and the schizophrenia subsamples, respectively. Thus, the overall incidence of high-EE relatives was comparable to numbers reported in the literature. In our study EE status of relatives was not disease-specific, and it was independent of chronicity of illness.

Typus melancholicus personality type and the five-factor model of personality.

Personality traits are significant factors in the development and course of depression. Apart from the classical five-factor model of personality, other personality constellations, such as Tellenbach's Typus melancholicus, have been described in association with depressive disorder. Several instruments have been developed to assess the Typus melancholicus personality (TMP). A systematic comparison of these instruments has not been done to date. The goal of this study was the comparison of four questionnaires used in assessing TMP. Four TMP questionnaires were compared and their relationship to the five-factor model of personality was examined among 264 psychiatric patients and normal controls. It was found that the TMP type represents a trait distinct from those of the five-factor model. TMP inventories had only moderate concurrent validity. The single TMP scales focus on different aspects of the TMP, despite their common core. Both the five-factor personality traits and the TMP scales were able to differentiate a group of depressed patients from control groups. The results show that TMP is not one trait but a personality trait constellation. This leads to the conclusion that a number of dimensions must be taken into consideration in the construction of a TMP inventory. This multidimensionality contributes to the refinement of the TMP concept and differentiates its therapeutic implications.

Um encontro com Heidelberg: personalidade pré-mórbida e interaçåo conjugal observada de pacientes deprimidos endógenos / Premorbid personality and observed marital interaction of endogenous depressive patients

O conceito do tipo melancólico em depressäo é uma importante contribuiçäo da escola fenomenológica de Heidelberg. Esse tipo de personalidade se caracteriza por um excesso de orientaçäo à norma e a à ordem, e por aspiraçäo a uma harmonia interpessoal. Uma medida sociométrica, "Structural Analysis of Social Behavior - SASB", permite testar empiricamente esse conceito e, portanto, preencher a lacuna entre abordagens fenomenológicas e empíricas . 26 pacientes deprimidos foram divididos, após remissäo, em pertencentes ao tipo melancólico ou näo. Amostras de 15 minutos de diálogo entre pacientes e seus cônjuges - metódo: "Partner-Conflict Dialogue" - forneceram dados interacionais diretamente observáveis que foram subsequentemente analisados pela SASB. No geral, os dados empricos da SASB baseados em distribuiçäo de frequências däo suporte ao conceito do tipo melancólico. Esses pacientes parecem, de fato, procurar harmonia nos seus relacionamentos ao evitarem interaçöes crítico-negativas abertas e controladoras-negativas. No entanto, resultados de análises em sequência parecem contradizer esses achados: dada uma interaçäo afetiva negativa do paciente do tipo melancólico ou do se esposo, o respectivo parceiro tende a reagir numa maneira ofensiva, crítico-negativa ou controladora-negativa. Assim, embora na avaliaçäo geral evitem conflitos, pares com paciente do tipo melancólico se envolvem mais rapidamente num estilo de interaçäo negativa na rara ocasiäo em que uma interaçäo crítico-negativa ou controladora-negativa é iniciada por um dos cônjuges. Dados de personalidade do Maudsley Personality Inventory (MPI) sugerem que o tipo melancólico näo é homogêneo, o que pode levar aos dados inconsistentes. Trabalho conceitual e empírico ulterior visando uma quantificaçäo da extensäo na qual outros aspectos de personalidade se misturam com o tipo melancólico (por exemplo bipolaridade ou narcisismo) é desejável.

Um encontro com Heidelberg: personalidade pre-morbida e interacao conjugal observada de pacientes deprimidos endogenos

O conceito do tipo melancolico em depressao e uma importante contribuicao da escala fenomenologica de Heidelberg. Esse tipo de personalidade se caracteriza por um excesso de orientacao a norma e a ordem, e por aspiracao a uma harmonia interpessoal. Uma medida sociometrica, 'Structural Analysis of Social Behavior - SASB', permite testar empiricamente esse conceito e, portanto, preencher a lacuna entre abordagens fenomenologicas e empiricas. 26 pacientes deprimidos foram divididos, apos remissao, em pertecentes ao tipo melancolico ou nao. Amostras de 15 minutos de dialogo entre pacientes e seus conjuges - metodo: 'Partner-Conflict Dialogue' - forneceram dados interacionais diretamente abservaveis que foram subsequentemente analisados pela SASB. No geral, os dados empiricos da SASB baseados em distribuicao de frequencias dao suporte ao conceito do tipo melancolico. Esse pacientes parecem, de fato, procurar harmonia nos seus relacionamentos ao evitarem interacoes critico-negativas abertas e controladoras-negativas. No entanto, resultados de analises em sequencia parecem contradizer esses achados: dada uma interacao afetiva negativa do paciente do tipo melancolico ou do seu esposo, o respectivo parceiro tende a reagir numa maneira afensiva, critico-negativa ou controladora-negativa. Assim, embora na avaliacao geral evitem conflitos, pares com paciente do tipo melancolico se envolvem mais rapidamente num estilo de interacao negativa na rara ocasiao em que uma interacao critico-negativa ou controladora-negativa e iniciada por um dos conjuges. Dados de personalidade do Maudsley Personality Inventory (MPI) sugerem que o tipo melancolico nao e homogeneo, o que pode levar aos dados inconsistentes. Trabalho conceitual e empirico ulterior visando uma quantificacao da extensao na qual outros aspectos de personalidade se misturam com o tipo melancolico (por exemplo bipolaridade ou narcisismo) e desejavel.