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Accepted manuscript version, licensed CC BY-NC-ND 4.0. Final version published in Schizophrenia Research, 211, 79-85, is available at https://doi.org/10.1016/j.schres.2019.06.022. To mitigate the often chronic course of schizophrenia and improve functional outcome, researchers are increasingly interested in prodromal states and psychological risk factors that may predict the outbreak of psychotic symptoms, but are also amenable to change. In recent years, depressive symptoms have been proposed as precursors of psychosis and some interventional studies indicate that the amelioration of depressive symptoms and depression-related thinking styles (e.g., worrying) improves positive symptoms, thereby “killing two birds with one stone”. Yet, in a prior study, we were unable to find a strong specific predictive role of depression on paranoia over three years, which may have been due to the use of a nonclinical sample with minimal/mild symptom fluctuations. To address this further, in the present study we adopted a similar methodological approach but assessed a large patient sample with a schizophrenia spectrum disorder at three assessment points; baseline (N = 250), 6 weeks later (n = 207, 82.8% retention) and 6 months after baseline (n = 185, 74% retention). Using cross-lagged modeling, we assessed paranoia with the respective items from the Positive and Negative Syndrome Scale (PANSS) and the Psychosis Rating Scales (PSYRATS) delusions subscale. Depression was measured using the Patient Health Questionnaire-9 (PHQ-9) and the Calgary Depression Scale for Schizophrenia (CDSS). We could identify a significant pathway from depression to paranoia from baseline to post (negative association) but not from post to follow-up. Paranoia significantly predicted depressive symptoms for both intervals. Our findings do not refute claims that depression may precede or even predict psychosis, but such a linkage does not seem to be ubiquitous.

Introduction: Imaginal retraining is a self-help technique that adapts the principles of approach bias modification to the imagination. Imaginal retraining has been shown to reduce craving and addictive behaviours in 3 randomized controlled trials (RCTs) on problematic alcohol consumption, overweight, and tobacco use. To date, there have been no studies evaluating the long-term efficacy of the intervention. The aim of the present study was to generate first hypotheses on the long-term efficacy of imaginal retraining in smokers in a controlled 1-year follow-up study. Materials and Methods: We recontacted the 345 participants who had taken part in an RCT on imaginal retraining for smokers 1 year later. The survey was carried out online and assessed craving for tobacco (primary outcome), smoking behaviour, well-being, and subjective appraisal. Individuals who applied the technique at least once during the previous year were categorized as the training group, whereas participants who never performed the training were categorized as the no-training group. Data were analysed using linear mixed models (LMMs). The study was preregistered as DRKS00021044. Results: The completion rate was 45.5%. Less than 40% used the intervention at least once in the previous 12 months. LMM analyses showed a significant reduction in craving for tobacco for the training compared to the no-training group after 1 year. No significant group differences emerged in smoking behaviour, depressive symptoms, or quality of life. Subjective appraisal of the intervention was favorable, similar to the initial study. Conclusion: The present study provides preliminary support for the long-term efficacy of imaginal retraining on craving for tobacco but not on smoking behaviour, highlighting the importance of multimodal treatment concepts in smoking cessation that target a variety of maintaining factors. Future studies need to investigate the long-term efficacy of the intervention in prospective RCTs that test alternative ways of conveying the technique to improve adherence.

Accepted manuscript version, licensed CC BY-NC-ND 4.0. Published version available at https://doi.org/10.1016/j.psychres.2018.08.113. Depressive symptoms are common, yet only a subgroup of individuals receive adequate treatment. To reduce the treatment gap, several online self-help programs have been developed, yielding small to moderate effects. We developed a smartphone self-help application addressing depressive symptoms. We sought to evaluate its feasibility and efficacy in participants reporting a subjective need for help (a diagnosis of depression was not mandatory). We conducted a randomized controlled trial (N = 90). The primary outcome was a reduction of depressive symptoms measured with the Patient Health Questionnaire-9 (PHQ-9). Secondary outcomes included improved self-esteem (Rosenberg Self-Esteem Scale) and quality of life (WHOQOL-BREF). The intervention group obtained access to the application for four weeks, the wait-list group received access after the post assessment. No group differences emerged in either outcome in intention-to-treat analyses. Per protocol analyses with frequent users (i.e., several times a week or more) yielded a small effect size (η2p = 0.049) at trend level on the reduction of depressive symptoms in favor of the treatment group. However, 39% of the participants did not use the application frequently. Mobile self-help applications represent a promising addition to existing treatments, but it is important to increase patients’ motivation to use them.

Background Psychological online interventions (POIs) reduce depression but we know little about factors influencing their effectiveness. We evaluated a new, brief POI for depression and conducted exploratory moderator analyses. Methods In this online trial (German Clinical Trials Register; DRKS00011045), we allocated participants to treatment as usual (TAU; n = 67) or POI (n = 65). At first, we randomized participants; later we allocated participants based on depression severity in order to counter baseline differences. The unguided POI addressed behavioral activation and depressive thinking in a single module with 25 webpages (including a smartphone application). We did one assessment at baseline and a post-assessment four weeks later. Results At post-assessment, depression (p = .586), behavioral activation (p = .332), and dysfunctional attitudes (p = .499) did not differ between groups. When concurrent treatments (medication/psychotherapy) remained constant/decreased, the POI outperformed TAU (p = .031). POI-participants with lower willingness to change (p = .030) or higher education (p = .017) were less likely to worsen (i.e., experience increased depressive symptoms) compared to TAU. Discussion The targeted sample size was not reached, measurements were self-reported, and randomization failed. The POI's content may have been too limited. Concurrent treatments, which were more often sought out by TAU participants, diminished group differences and should be considered in future studies. Brief POIs may protect against worsening of depressive symptoms among highly educated participants or those with low willingness to change., Highlights • Psychological online interventions (POIs) reduce depression but little is known about moderators of their effectiveness • We conducted a controlled online trial to evaluate a newly developed, brief POI in comparison treatment as usual (TAU) • Exploratory moderator analyses were conducted • No group differences were found for depression, behavioral activation, and dysfunctional attitudes at post-assessment • Concurrent treatments moderated the effect of the POI on depression compared to TAU • Education and willingness to change moderated the effect of the POI on worsening of depressive symptoms compared to TAU

Background Psychological online interventions (POIs) could represent a promising approach to narrow the treatment gap in psychosis but it remains unclear whether improving mindfulness functions as a mechanism of change in POIs. For the present study, we examined if mindfulness mediates the effect of a comprehensive POI on distressing (auditory) hallucinations. Methods We conducted a secondary analysis on voice hearers (n = 55) from a randomized controlled trial evaluating a POI for psychosis (EviBaS; trial registration NCT02974400, clinicaltrials.gov). The POI includes a module on mindfulness and we only considered POI participants in our analyses who completed the mindfulness module (n = 16). Results Participants who completed the mindfulness module reported higher mindfulness (p = 0.015) and lower hallucinations (p = 0.001) at post assessment, compared to controls, but there was no effect on distress by voices (p = 0.598). Mindfulness mediated the POI’s effect on hallucinations (b = −1.618, LLCI = −3.747, ULCI = −0.054) but not on distress by voices (b = −0.057, LLCI = −0.640, ULCI = 0.915). Limitations and Discussion Completion of the mindfulness module was not randomized. Hence, we cannot draw causal inferences. Even if we assumed causality, it remains unclear which contents of the POI could have resulted in increased mindfulness and reduced hallucinations, as participants completed other modules as well. In addition, confounding variables could explain the mediation and the sample size was small. Nonetheless, the overall pattern of results indicates that the POI is likely to improve mindfulness, and that increased mindfulness could partially explain the POI’s efficacy. Keywords: mindfulness-based intervention, auditory verbal hallucinations, mediation analysis, schizophrenia, internet intervention

Accepted manuscript version, licensed CC BY-NC-ND 4.0. Jumping to conclusions (JTC) is the best established cognitive bias in schizophrenia and is increasingly targeted in interventions aimed to improve positive symptoms. To address shortcomings of the standard measure to capture JTC, the beads task, we developed a new variant—the box task—which was subsequently validated in people with elevated psychotic-like experiences. For the first time, the box task was administered in a sample of individuals with manifest schizophrenia. We hypothesized that patients with schizophrenia would display an elevated JTC bias relative to controls. Method - We recruited a large sample of 101 patients with schizophrenia and matched them to an online sample recruited from the general population. In the box task, participants must decide which of two kinds of colored balls are presented more often. Participants are told that the task may end prematurely, and that task performance will be counted as an error if no decision had been made before that point. The primary measure was the number of draws to decision (DTD), where fewer DTD corresponds to greater JTC. Results - In contrast to expectations, participants with schizophrenia showed significantly higher DTD (i.e., reduced JTC). Consistent with our previous findings, patients also displayed a lowered decision threshold compared to controls. Response confidence for the final decision was lower in patients and correlated with self-esteem and positive symptoms. While there was evidence that previous knowledge of the box task lowered DTD, exclusion of participants with experience on the box task did not substantially change results. Discussion - The study fits a growing body of experiments casting doubt on the generalizability of the JTC effect in schizophrenia across different tasks. While the study tentatively supports a liberal acceptance account of psychosis, caution is warranted and we recommend that research should explore and control for potentially important mediators (e.g., task difficulty, stress, test-taking attitudes).

Background Depressive symptoms are one of the most common and ever-increasing mental health problems among students worldwide. Conventional treatment options, particularly psychotherapy, do not reach all students in need of help. Internet- and mobile-based interventions are promising alternatives for narrowing the treatment gap. Objective In the framework of a randomized controlled trial, we aim to investigate the effectiveness, acceptance, and side effects of a self-help smartphone app (MCT & More) based on cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and metacognitive training in a sample of students with self-reported depressive symptoms. Furthermore, we were interested in examining the influence of treatment expectations and attitudes toward internet- and mobile-based interventions on treatment adherence and effectiveness. Methods A total of 400 students were recruited via open access websites and randomized to either the intervention group (n=200), who received access to the self-help smartphone app MCT & More for a period of 4 weeks, or to a wait-list control group (n=200). The Patient Health Questionnaire-9 (depression) served as the primary outcome parameter, and the Rosenberg Self-esteem Scale (self-esteem) and the global item of the World Health Organization Quality of Life-abbreviated version (quality of life) served as the secondary outcome parameters. The Attitudes Towards Psychological Online Interventions was used to measure attitudes toward internet- and mobile-based interventions. Outcome expectations were assessed using the Patient Questionnaire on Therapy Expectation and Evaluation, and side effects were assessed using the Inventory for Assessing Negative Effects of Psychotherapy. Results Per-protocol (PP), complete-case, and intention-to-treat analyses showed a significantly higher reduction in depressive symptoms (PP: F1,222=3.98; P=.047; d=0.26) and a significantly higher increase in self-esteem (PP: F1,220=8.79; P=.003; d=0.40) in the intervention group than in the wait-list control group. Most participants regularly used the self-help smartphone app (91/120, 75.8%, at least once a week). The more positive the attitude toward internet- and mobile-based interventions (r=0.260; P=.004) and the more positive the outcome expectation (r=0.236; P=.009), the more frequently the self-help smartphone app was used. Conclusions The effectiveness of the self-help smartphone app MCT & More was demonstrated among students with depressive symptoms compared with a wait-list control group. The app could be offered regularly as a low-threshold intervention to enhance students’ health. Trial Registration German Clinical Trials Register DRKS00020941; https://tinyurl.com/pr84w6er

Objective Psychotic episodes have long been conceptualized as inevitable incidents triggered by endogenous biological impairments. It is now well-accepted that the ability of an individual to deal with social and environmental challenges plays an important role in regard to whether or not a vulnerability to psychosis translates into symptoms. For the present study, we examined symptomatic correlates of dysfunctional coping in psychosis and aimed to elucidate a profile of coping strategies that distinguishes patients with schizophrenia from those with depression. Method The newly devised Maladaptive and Adaptive Coping Styles Scale (MAX) was administered to 75 individuals with psychosis, 100 individuals with depression and 1100 nonclinical controls. Results Schizophrenia patients showed compromised coping abilities relative to nonclinical controls, particularly a lack of engaging in adaptive coping. Depression was more closely tied to dysfunctional coping than were positive symptoms as indicated by group comparisons and correlational analyses. Correlations between positive symptoms, particularly paranoid symptoms, and avoidance and suppression remained significant when depression was controlled for. Conclusions Although maladaptive and adaptive coping are unlikely to represent proximal mechanisms for the pathogenesis of positive symptoms, fostering coping skills may reduce positive symptoms via the improvement of depressive symptoms, which are increasingly regarded as risk factors for core psychotic symptoms. Furthermore, the reduction of avoidance and suppression may directly improve positive symptoms.

In the past few decades, sex differences have been identified in a number of clinical, cognitive and functional outcomes in patients with schizophrenia spectrum disorders. However, to date, sex differences in higher-order cognitive biases have not been systematically studied. The present study aimed to examine sex differences in jumping-to-conclusions and evidence integration impairment based on data collected in two previous studies in patients with schizophrenia spectrum disorders and healthy controls. For this purpose, data from n = 58 patients and n = 60 healthy controls on the Fish Task (as a measure of jumping to conclusions) and bias against disconfirmatory evidence (BADE; as a measure of evidence integration) task were analyzed. Results indicated a lack of sex differences in jumping-to-conclusions and evidence integration impairment both in patients with schizophrenia spectrum disorders and healthy controls. Although the present study was adequately powered to detect sex differences of a low medium effect size, larger studies are warranted to exclude differences of a smaller magnitude between men and women regarding delusion-associated cognitive biases.

Source at https://doi.org/10.1186/s12888-018-1644-8. Licensed CC BY-NC-ND 4.0. Background: Evidence shows that internet-based self-help interventions are effective in reducing symptoms for a wide range of mental disorders. To date, online interventions treating psychotic disorders have been scarce, even though psychosis is among the most burdensome disorders worldwide. Furthermore, the implementation of cognitive-behavioral therapy (CBT) for psychosis in routine health care is challenging. Internet-based interventions could narrow this treatment gap. Thus, a comprehensive CBT-based online self-help intervention for people with psychosis has been developed. The aim of this study is the evaluation of the feasibility and efficacy of the intervention compared with a waiting list control group. Methods: The intervention includes modules on delusion, voice hearing, social competence, mindfulness, and seven other domains. Participants are guided through the program by a personal moderator. Usage can be amended by an optional smartphone app. In this randomized controlled trial, participants are allocated to a waiting list or an intervention of eight weeks. Change in positive psychotic symptoms of both groups will be compared (primary outcome) and predictors of treatment effects will be assessed. Discussion: To our knowledge, this project is one of the first large-scale investigations of an internet-based intervention for people with psychosis. It may thus be a further step to broaden treatment options for people suffering from this disorder. Trial registration: NCT02974400 (clinicaltrials.gov), date of registration: November 28th 2016.

Objectives: It is textbook knowledge that individuals with alcohol use disorder (AUD) show large neurocognitive deficits. However, these patients display a number of additional impairments (e.g., lack of drive and motivation) that may contribute to poor test results. The impact of these secondary mediators has not been explored systematically. Based on prior findings that low performance motivation, a negative attitude toward cognitive assessment, and momentary symptoms compromise neuropsychological test results in depression, schizophrenia, and obsessive-compulsive disorder, we examined the possibility that impaired test results in AUD partially represent an epiphenomenon. Methods: Fifteen patients with AUD and 20 matched nonclinical individuals underwent a comprehensive neuropsychological test battery. The neurocognitive assessment was flanked by the Momentary Influences, Attitudes and Motivation Impact on Cognitive Performance Scale (MIAMI), which captures momentary influences affecting performance. Results: Patients with AUD performed worse than nonclinical controls on most test parameters. Group differences achieved a very large effect size for parameters tapping speed and accuracy. Patients with AUD showed deviant scores, particularly on the post version of the MIAMI (retrospective assessment of symptoms and influences during testing) and the total scores. For accuracy, the MIAMI scores represented a partial mediator. For speed, significant group effect sizes were rendered nonsignificant when the MIAMI was taken into account. Conclusion: Like other psychiatric patients, patients with AUD show marked neurocognitive impairments that seem to be aggravated by, for example, distraction and lack of effort. This tentatively suggests that performance only partly reflects cortical impairments in areas hosting neurocognitive faculties. Contextual factors deserve greater attention in patients with addiction. The cross-sectional design of our study limits conclusions relating to causality.

This is the peer-reviewed but unedited manuscript version of the following article: Moritz, S., Ludtke, T., Pfuhl, G., Balzan, R. P. & Andreou, C. (2017). Liberale akzeptanz als kognitiver mechanismus bei psychose: Eine 2-stufen-theorie der pathogenese schizophrener positivsymptome. Verhaltenstherapie (Basel), 27(2), 108-118. http://doi.org/10.1159/000464256. The final, published version is available at http://www.karger.com/?doi=10.1159/000464256. Positivsymptome wie Wahn und Halluzinationen stellen definierende Symptome einer (schizophrenen) Psychose dar. In dieser Übersichtsarbeit wird ein 2-stufiges heuristisches Modell für die Entstehung und Aufrechterhaltung psychotischer Positivsymptome vorgelegt. Im Kern der Theorie steht die Hypothese, dass von Psychose betroffene Menschen eine erniedrigte Entscheidungsschwelle aufweisen, die zu einer frühzeitigen Annahme von Hypothesen führt (liberale Akzeptanz). Im Unterschied zu nichtpsychotischen Personen ist die Konfidenz in falsche Urteile bei Betroffenen, als Folge dieser liberalen Akzeptanz, erhöht. Postuliert werden 2 Stufen der Wahnentwicklung. Auf Stufe 1 (Wahnentstehung) ist die subjektive Wahrscheinlichkeit für akzeptierte Hypothesen bei Menschen mit Psychose zunächst vergleichsweise gering. Wahnhafte Ideen sind in diesem Stadium häufig nicht voll entfaltet bzw. fragil und können zwischen 2 sich gegenseitig ausschließenden Ansichten oszillieren («doppelte Buchführung»). Im Zuge der 2. Stufe (Überzeugung, Aufrechterhaltung) verfestigen sich die flüchtigen wahnhaften Ideen zu falschen Überzeugungen aufgrund eines 2-gliedrigen Konsolidierungsprozesses – indem einerseits Gegenbeweise ignoriert und andererseits Belege zugunsten der Leithypothese einen Verarbeitungsvorteil erhalten (Bestätigungstendenz). Alternative Hypothesen rü- cken in den Hintergrund. Aufrechterhaltend für eine Wahnidee sind vielfältige psychologische Faktoren und Motive, wie die Kongruenz des Wahns mit dem emotionalen Befinden, persönliche Bedeutsamkeit und die temporäre Steigerung des Selbstwertgefühls sowie das Spannen eines Erklärungsrahmens für ein breites Spektrum von Beschwerden zur Reduktion kognitiver Dissonanz. Aus unserer Sicht können viele Formen von Halluzinationen und Erstrangsymptomen (z.B. Gedankeneingebung) ebenfalls durch liberale Akzeptanz erklärt werden. Diese Symptome basieren unseres Erachtens nicht zwingend auf fehlerhaften oder abnormalen Wahrnehmungen, sondern repräsentieren eine Fehlinterpretation von (teilweise) normalen sensorischen Phänomenen, die sich von einem (normalen) «Als-ob»-Gefühl bis hin zu einer wahnhaften Überzeugung steigern. Im Einklang mit dem erläuterten Modell werden Positivsymptome durch Interventionen wie das metakognitive Training (MKT) verringert, die Betroffene dazu anhalten, mehr Informationen zu sammeln und ihre Urteilssicherheit zu reduzieren (Säen von Zweifel). Die antipsychotische Wirkung von Antipsychotika/Neuroleptika wird im Rahmen der Theorie zum Teil durch ihre Eigenschaft erklärt, Zweifel zu induzieren. Die Bedeutung der Emotionsregulation bei der Reduktion von Positivsymptomen wird ebenfalls aufgezeigt, und zukünftige Forschungsrichtungen sowie offene Fragen diskutiert. Liberal Acceptance as a Cognitive Mechanism in Psychosis: A 2-Step-Therory on the Pathogenesis of Positive Symptoms in Schizophrenia Positive symptoms, such as delusions and hallucinations, are defining features of psychosis and schizophrenia, respectively. In this review article, we present a 2-stage heuristic model for the formation and maintenance of psychotic positive symptoms. At the heart of our theory is the assumption that individuals with psychosis have a lowered decision threshold resulting in the liberal acceptance of hypotheses. In contrast to non-psychotic persons, confidence in errors is enhanced as a result of liberal acceptance. Two stages are put forward here. At stage 1 (delusion formation), the subjective probability of an accepted hypothesis is relatively low. Delusional ideas at this stage are often fragile and may oscillate between mutually exclusive views (‘double book keeping’). During the 2. stage (conviction, maintenance), flighty delusional ideas crystallize due to a 2-fold consolidation process: a) counter-evidence is ignored and b) cues in favor of the dominant hypothesis have a processing advantage (confirmation bias). Alternative hypotheses are degraded in the course of this process. A number of psychological factors and motifs act as maintenance factors, for example the congruence between the delusion and present emotional states, personal importance and the temporary elevation of self-esteem, as well as a superstructure that may explain a broad range of impairments to reduce cognitive dissonance. From our point of view, some forms of hallucinations and first-rank symptoms (e.g., thought broadcasting) can be explained by liberal acceptance as well. These symptoms are not necessarily based on erroneous or abnormal perception but on the misinterpretation of (partially) normal sensory phenomena which evolve from an ‘as if’ feeling to delusional conviction. In accordance with the model, positive symptoms are decreased by interventions such as metacognitive training (MCT) which encourage individuals with psychosis to search for more information and to reduce their level of certainty (i.e., ‘sowing the seeds of doubt’). The antipsychotic properties of antipsychotics/neuroleptics are explained by their potential to induce doubt. The role of emotion regulation for the amelioration of positive symptoms is demonstrated, and further research directions and open questions are outlined.

Source:http://www.sciencedirect.com/science/article/pii/S0005791616301203 Objectives: We outline a two-stage heuristic account for the pathogenesis of the positive symptoms of psychosis. Methods: A narrative review on the empirical evidence of the liberal acceptance (LA) account of positive symptoms is presented. Hypothesis: At the heart of our theory is the idea that psychosis is characterized by a lowered decision threshold, which results in the premature acceptance of hypotheses that a nonpsychotic individual would reject. Once the hypothesis is judged as valid, counterevidence is not sought anymore due to a bias against disconfirmatory evidence as well as confirmation biases, consolidating the false hypothesis. As a result of LA, confidence in errors is enhanced relative to controls. Subjective probabilities are initially low for hypotheses in individuals with delusions, and delusional ideas at stage 1 (belief formation) are often fragile. In the course of the second stage (belief maintenance), fleeting delusional ideas evolve into fixed false beliefs, particularly if the delusional idea is congruent with the emotional state and provides “meaning”. LA may also contribute to hallucinations through a misattribution of (partially) normal sensory phenomena. Interventions such as metacognitive training that aim to “plant the seeds of doubt” decrease positive symptoms by encouraging individuals to seek more information and to attenuate confidence. The effect of antipsychotic medication is explained by its doubt-inducing properties. Limitations: The model needs to be confirmed by longitudinal designs that allow an examination of causal relationships. Evidence is currently weak for hallucinations. Conclusions: The theory may account for positive symptoms in a subgroup of patients. Future directions are outlined.