An investigation of different aspects of overgeneralization in patients with major depressive disorder and borderline personality disorder.

OBJECTIVE: The aim of this study was to investigate whether (a) overgeneralization is restricted to negative attributions directed at the self; or whether it also extends to positive self-attributions and to attributions of situations in the outside world, and (b) whether the valence and direction (positively or negatively, to the self- or across situations) of overgeneralization processes vary among different patient populations. METHODS: Patients with major depressive disorder (MDD, n = 34), borderline personality disorder (BPD, n = 18), or both (n = 35), and never-depressed non-patients (NPs; n = 50) completed various measures of overgeneralization. RESULTS: Patients with MDD show higher levels of negative overgeneralization but lower levels of positive overgeneralization to the self- and across situations than NPs. Patients with MDD show more negative than positive overgeneralization to the self: a negative bias. They, however, do show higher levels of positive than negative overgeneralization across situations. Patients with BPD show the same pattern for overgeneralization to the self, but their higher levels of negative overgeneralization across situations are not exceeded by their positive counterpart. CONCLUSIONS: Results indicate that patient groups differ from NPs not only with respect to negative, but also with respect to positive overgeneralization. Furthermore, the valence and direction of overgeneralization processes vary among MDD and BPD patient populations. More specifically, findings suggest that, as compared to never-depressed individuals, patients with BPD and patients with MDD alike, lack a buffer against negative overgeneralization directed at the self. In patients with BPD, not only the high level of overgeneralization to the self, but also the high level of overgeneralization across situations seems to be problematic, since both types of overgeneralization appear not to be buffered by their positive counterparts.

Shared decision-making: increases autonomy in substance-dependent patients.

This study examines the effect of a shared decision-making intervention (SDMI) on patients' and clinicians' self-perceived interpersonal behavior. Clinicians (n = 34) in three addiction treatment centers in the Netherlands were randomly assigned to SDMI or treatment decision-making as usual. Patients receiving inpatient treatment in 2005-2006 were included (n = 212). Baseline characteristics were measured by the European Addiction Severity Index (EuropASI) and the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM). Treatment goals were assessed using the Goals of Treatment Questionnaire (GoT-Q) plus a Q-sort ranking procedure. Interpersonal behavior was measured by Interpersonal Checklist-Revised (ICL-R) at baseline, end of treatment, and 3-month follow-up. Repeated measures analyses of variance and multiple hierarchical linear regression analysis were used. The key finding of this study was that SDMI is associated with an increase of patient autonomy (independent behavior) and control behavior. The study limitations have been noted.

Opioid detoxification: from controlled clinical trial to clinical practice.

Controlled clinical trials have high internal validity but suffer from difficulties in external validity. This study evaluates the generalizability of the results of a controlled clinical trial on rapid detoxification in the everyday clinical practice of two addiction treatment centers. The results show that rapid detoxification in everyday practice differs with regard to patient characteristics, enrolment, and completion rates (86.8% vs. 100%). However, abstinence rates after rapid detoxification in the controlled clinical trial (61.8%) were generalizable to everyday clinical practice (59.0%). Implementation factors that may have influenced the results, such as referral problems and treatment delivery, are discussed.

The psychological mindedness assessment procedure - validation study of a Dutch version.

OBJECTIVE: The Psychological Mindedness Assessment Procedure [PMAP; McCallum, M. & Piper, W. E. (1990)] operationalizes psychological mindedness as a participant's understanding of the problem presented by two videotaped enacted patients. To possibly enhance predictive power for psychotherapy outcome, we added two video scenarios with emotionally high-impact. This article describes psychometric properties of the Dutch translation of the PMAP and the extended version, the PMAP-plus. DESIGN: A therapy-analogue study with non-clinical participants (N = 100). METHODS: In individual sessions, participants watched the four video-scenarios and responded to the PMAP-question 'What seems to be troubling this woman?'. Emotional reactions were measured using the Positive And Negative Affect Schedule [PANAS; Watson, D., Clark, L. E. & Tellegen, A. (1988)]. RESULTS: The PMAP and the PMAP-plus had good interrater reliability. As expected, PMAP-levels were lower for the newly added high-emotional scenarios. Validity was further supported by a negative relation of PMAP-scores with the Negative Affect subscale. CONCLUSIONS: The Dutch translation of the PMAP and the added scenarios of the PMAP-plus are reliable instruments. The predictive power for psychotherapy outcome needs to be investigated in a patient group. The variation in presented clinical problems could also make it a useful instrument to assess psychological mindedness in psychotherapists.

Prediction of withdrawal symptoms during opioid detoxification.

OBJECTIVE: The severity of self-reported withdrawal symptoms varies during detoxification of opioid-dependent patients. The aim of this study is to identify subgroups of withdrawal symptoms within the detoxification trajectory and to predict the severity of withdrawal symptoms on the basis of drug-related and sociodemographic characteristics. DESIGN AND SETTING: A prospective study carried out in an in-patient setting in four addiction treatment centres in the Netherlands. PARTICIPANTS: Two hundred opioid-dependent patients who participated in a randomized controlled trial and completed more than 75 percent of the administrations of the subjective opioid withdrawal scales during rapid detoxification. INTERVENTION AND MAIN OUTCOME MEASURE: Main outcome measure was the severity of opioid withdrawal as measured by the subjective opioid withdrawal scale during detoxification (18 measurements). Predictor baseline data were obtained on sociodemographic background, severity of addiction, psychopathology, personality disorder, and craving. STATISTICS: Those variables found to be statistically significant in univariate analyses were entered into multivariate regression models to predict the severity of subjective withdrawal. RESULTS: No distinct subgroups could be identified despite substantial individual variability throughout the detoxification trajectory. The multiple regression results showed only four variables to predict the severity of withdrawal symptoms: baseline withdrawal symptoms, intravenous heroin use in the last 30 days, anxiety, and cluster C personality disorder. The variance explained by these sociodemographic variables was low while the largest amount of variance was explained by baseline withdrawal symptoms (27percent). CONCLUSIONS: The results of the present study provide evidence that the severity of withdrawal symptoms during detoxification treatment is moderately predicted by the baseline severity of their withdrawal symptoms and not by drug- and patient-related characteristics.

Prediction of abstinence in opioid-dependent patients.

OBJECTIVES: : Opioid detoxification with subsequent naltrexone is found to be an effective method as the first step in an abstinence-oriented approach. The aim of this study is to investigate the predictive value of variables for abstinence in opioid-dependent patients. METHODS: : Opioid-dependent patients were followed up to 1 month after detoxification. Predictor variables were assessed at baseline, during detoxification, and at discharge. Primary outcome was abstinence assessed by analyzing urine samples and self-reports. Logistic regression was used to identify predictors of abstinence. RESULTS: : Of 272 participants, 211 could be rated as abstinent (59.2%) or nonabstinent (40.8%) at 1 month follow-up. Significant baseline predictors were severity score of justice/police (ASI) and physical quality of life (SF-36); discharge predictors were general quality of health (SF-36) and sleeping problems (SCL-90); change in sleeping problems (SCL-90) during detoxification was also a predictor. The explained variance of these predictors was very low and clinical significance was limited. CONCLUSIONS: : Considering the results it seems not possible to predict who will be abstinent or not 1 month after detoxification. Because rapid detoxification is found to be an effective detoxification method in selected patients, it seems warranted to recommend that patients with similar characteristics (ie, patients motivated for an abstinence-based treatment and low non-drug-related severity scores on the ASI) should be regarded as eligible for rapid detoxification.

Does naltrexone affect craving in abstinent opioid-dependent patients?

Naltrexone blocks the opioid receptors that modulate the release of dopamine in the brain reward system and therefore blocks the rewarding effects of heroin and alcohol. It is generally assumed that naltrexone leads to reduction of craving, but few studies have been performed to prove this. The purpose of the present study was to examine the effect of the administration of naltrexone on craving level after rapid opioid detoxification induced by naltrexone. A naturalistic study was carried out in which patients were followed during 10 months after rapid detoxification. Data about abstinence, relapse, and naltrexone use were collected by means of urine specimens. Craving was measured by the visual analogue scale craving, the Obsessive Compulsive Drug Use Scale, and the Desires for Drug Questionnaire. Results showed that patients who relapsed in opioid use experienced obviously more craving than abstinent people. Patients who took naltrexone did not experience significant less craving than those who did not. These results suggest that the use of opioids is associated with increased craving and that abstinence for opioids is associated with less craving, independent of the use of naltrexone. This is in contrast to the general opinion. Because of the naturalistic design of the study, no firm conclusions can be drawn, but the results grounded the needs of an experimental study.

Psychometric evaluation of the Dutch version of the Subjective Opiate Withdrawal Scale (SOWS).

AIM: To evaluate the psychometric properties of the Dutch version of the 16-item Subjective Opiate Withdrawal Scale (SOWS). The SOWS measures withdrawal symptoms at the time of assessment. METHODS: The Dutch SOWS was repeatedly administered to a sample of 272 opioid-dependent inpatients of four addiction treatment centers during rapid detoxification with or without general anesthesia. Examination of the psychometric properties of the SOWS included exploratory factor analysis, internal consistency, test-retest reliability, and criterion validity. RESULTS: Exploratory factor analysis of the SOWS revealed a general pattern of four factors with three items not always clustered in the same factors at different points of measurement. After excluding these items from factor analysis four factors were identified during detoxification (temperature dysregulation, tractus locomotorius, tractus gastro-intestinalis and facial disinhibition). The 13-item SOWS shows high internal consistency and test-retest reliability and good validity at different stages of withdrawal. CONCLUSION: The 13-item SOWS is a reliable and valid instrument to assess opioid withdrawal during rapid detoxification. Three items were deleted because their content does not correspond directly with opioid withdrawal symptoms.

Static and dynamic patient characteristics as predictors of criminal recidivism: A prospective study in a Dutch forensic psychiatric sample.

If clinicians in forensic psychiatry want to reduce risk of reoffending in their patients, they require insight into dynamic risk factors, and evidence that these add predictive power to static risk indicators. Predictors need to be evaluated under clinically realistic circumstances. This study aimed to validate dynamic and static variables as predictors of reconviction in a naturalistic outcome study. Data on static and dynamic risk factors were collected for 151 patients discharged from Dutch forensic psychiatric hospitals. Community follow-up was prospective, with a 5.5 year minimum. A prediction model was developed using Cox regression analysis. The magnitude of the predictive power of this model was estimated using receiver operating characteristic (ROC) analysis. The final prediction model contained four static and no dynamic predictors. The model's ROC area under the curve was .79 (95% CI .69-.89). Clinical risk ratings were non-predictive. Post hoc analyses exploring the influence of subgroups of patients did not yield better models. It is concluded that a small set of static predictors yielded a good estimate of future reconvictions; inclusion of dynamic predictors did not add predictive power.

The structural coherence of clinically derived dynamic indicators of reoffending risk.

BACKGROUND: Forensic psychiatrists aim to reduce the risk of reoffending through treatment. With few exceptions, research evidence tends to favour risk assessment aids reliant on fixed historical rather than clinical data, but transparency in the making of clinical judgements is lacking. AIMS: To evaluate further a clinically derived 47-item dynamic risk assessment checklist; specifically to test first whether it has a meaningful dimensional structure and, second, the extent to which items and underlying dimensions are associated with a separate, direct clinical judgement of risk of reoffending. METHODS: Data sets from four previous studies on the reliability and validity of the Clinical Inventory of Dynamic Reoffending Risk Indicators (CIDRRI) were merged, yielding 370 cases. The resulting data set was analysed using principal axis (common) factor analysis, with orthogonal (varimax) rotation. In addition, receiver operating characteristic (ROC) curves were calculated. RESULTS: The model of best fit depended on treatment stage; for those in residential treatment it was a six- factor model (responsibility, self-reliance, antisocial/narcissistic traits, treatment compliance, goal attainment and avoidance); for those back in the community a five-actor model in which, effectively, the compliance and goal attainment factors became one, provided a better fit. These dimensions and some individual scale items were associated with clinical judgement of risk of reoffending. CONCLUSIONS AND CLINICAL IMPLICATIONS: This study provides evidence that the CIDRRI is an adequate operationalization of underpinnings of clinical risk assessment, and that these underpinnings are part of meaningful higher-order dimensions. The CIDRRI is a viable instrument for clinical use, taking only 15 minutes to complete and identifying dynamic risk factors, the validity of which needs to be further established.

Personality disorders, depression, and coping styles in Argentinean bulimic patients.

This study investigates the coping styles of bulimic patients with personality disorders (PDs) and the effects of the level of depression on the relations between PDs and coping. The sample consisted of 75 Argentinean bulimic outpatients engaged in treatment. Patients completed the SCID II (Structural Interview for DSM IV-Personality Disorders), COPE (Coping Inventory), and the SCL-90-R (Symptom Checklist-90-Revised). No differences in the coping styles of bulimic patients with or without a PD were found. However, when three specific PDs were considered-Avoidant, Obsessive-Compulsive, or Borderline PDs-clear differences in the coping styles of the bulimics were found. However, the differences disappeared when depression was controlled. Regarding the severity of the three specific PDs, coping styles were only found to be associated with the Avoidant PD. Depression showed to affect the relations between coping styles and two specific PDs-Avoidant and Borderline PDs-in bulimic patients.

The role of core beliefs in the specific cognitions of bulimic patients.

Cognitive models of bulimia nervosa have stressed the importance of self-beliefs in the maintenance of the disorder. However, new findings show a deeper and more general level of beliefs also to play a role in eating disorders. These beliefs are long-standing, absolute, and unconditional. In the present study, the relations between such core beliefs and specific cognitions regarding eating, shape, and weight were examined. The sample consisted of 75 bulimic outpatients who started treatment. The patients completed the Schema Questionnaire, the Eating Disorders Inventory-2, the SCL-90-R, and the Mizes Anorectic Cognitions Questionnaire at intake. Strong relations between some core beliefs and the specific cognitions regarding shape, weight, and eating were found. The modification of core beliefs appears to be a very important issue to incorporate into treatment.

Treatment motivation: An attempt for clarification of an ambiguous concept.

Although the concept of treatment motivation is generally regarded as highly relevant, it has since long been surrounded by conceptual confusion, resulting in miscommunication, ambiguous measures, and contradictory conclusions of research. This article provides an analysis of three major sources of confusion in the conceptualization of treatment motivation: (a) negligence of the concepts' intrinsic relationship with behavior, (b) entanglement of the concept with its determining factors and behavioral consequences, and (c) conceptualization in a stage model. Following the conceptual analysis, causes of the problems and implications for clinical praxis and research are considered. Finally, a more adequate conceptualization of treatment motivation is proposed and suggestions for future research are made.

Tendency toward overeating and restraint as predictors of food consumption.

Restrained eaters have repeatedly been found to overeat following a preload, which phenomenon is called the disinhibition effect. Remarkably, the disinhibition effect is only found when the restraint scale (RS) is used, and never when other measures of restraint, like the three-factor eating questionnaire (TFEQ) or the Dutch eating behavior questionnaire (DEBQ) are applied. Recent research has shown that tendency toward overeating appears to be a better predictor of food consumption than dietary restraint. The present study examines the predictive value of preload, tendency toward overeating and dietary restraint. An experiment was carried out with 209 female participants with the aim to evaluate whether the results of the study [Int J Eating Disorders 28 (2000) 333] are robust. In addition to the RS, the TFEQ and DEBQ were used to measure restraint and tendency toward overeating. Again, no disinhibition effect occurred, confirming the results of the previous study. Restraint, as measured by the three questionnaires, was not related to food consumption. In contrast, tendency toward overeating was significantly related to food consumption. Restraint theory's contentions that dieting leads to overeating might be valid for only some dieters, namely those with a high tendency toward overeating.

Cross-cultural replication of the five-factor model and comparison of the NEO-PI-R and MMPI-2 PSY-5 scales in a Dutch psychiatric sample.

The authors investigated cross-cultural replicability of the five-factor model (FFM) of personality as represented by the revised NEO Personality Inventory (NEO-PI-R; P. T. Costa & R. R. McCrae, 1992) in a sample of 423 Dutch psychiatric patients. Also, NEO-PI-R domain scales were compared with the Personality Psychopathology Five (PSY-5; A. R. Harkness & J. L. McNulty, 1994) scales of the Minnesota Multiphasic Personality Inventory-2 (J. N. Butcher, W. G. Dahlstrom, J. R. Graham, A. Tellegen, & B. Kaemmer, 2002). Principal-components analysis with procrustean rotation confirmed the hypothesized structural similarity of the present sample with the U.S. normative factor scores. All of the hypothesized relations between NEO-PI-R and PSY-5 scales were confirmed. The results provide evidence for cross-cultural replicability of the FFM and for validity of the NEO-PI-R and PSY-5 constructs in the psychological assessment of psychiatric patients.

Absence of a disinhibition effect of alcohol on food consumption.

Alcohol is frequently mentioned as a disinhibitor of restrained eating behavior although only a small number of studies have investigated this disinhibition effect. The present study was conducted to fill this gap. A total of 116 female college students participated in a questionnaire-based assessment and a taste-test experiment. Before the taste test, half of the participants consumed a preset amount of alcohol-laced orange juice, the other half were given plain orange juice. The dependent variable was the amount of savory crackers eaten during the taste test. The Dutch Eating Behavior Questionnaire (DEBQ), the Three-Factor Eating Questionnaire (TFEQ), and the Restraint Scale (RS) were used to measure eating behavior dimensions, which formed the independent variables in various regression analyses. No disinhibition effect was found. On the contrary, participants scoring high on restraint (DEBQ, TFEQ) proved to consume even less food than those having lower scores. Participants that rated high on the scales measuring tendency toward overeating consumed more food than participants with low scores. These results support earlier contentions that the validity of the Restraint Theory's statement that dieting leads to overeating is questionable.