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Background With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments. Objective To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT). Method Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8–18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child’s baseline sociodemographic and clinical characteristics, and parent’s psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups. Results At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile. Conclusions The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (, HIGHLIGHTS Given the time-limited significance of differential treatment effects on outcome, brevity and large effect size for EMDR and cognitive-behavioural writing therapy for paediatric PTSD, future focus should be on enhancing delivery of these treatments, rather than tailoring them.

Trials of virtual reality exposure therapy (VRET) for anxiety-related disorders have proliferated in number and diversity since our previous meta-analysis that examined 13 total trials, most of which were for specific phobias (Powers & Emmelkamp, 2008). Since then, new trials have compared VRET to more diverse anxiety and related disorders including social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and panic disorder (PD) with and without agoraphobia. With the availability of this data, it is imperative to re-examine the efficacy of VRET for anxiety. A literature search for randomized controlled trials of VRET versus control or in vivo exposure yielded 30 studies with 1057 participants. Fourteen studies tested VRET for specific phobias, 8 for SAD or performance anxiety, 5 for PTSD, and 3 for PD. A random effects analysis estimated a large effect size for VRET versus waitlist (g = 0.90) and a medium to large effect size for VRET versus psychological placebo conditions (g = 0.78). A comparison of VRET and in vivo conditions did not show significantly different effect sizes (g = -0.07). These findings were relatively consistent across disorders. A meta-regression analysis revealed that larger sample sizes were associated with lower effect sizes in VRET versus control comparisons (β = -0.007, p

Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence-outcome association. The current study aims to examine whether therapists' interpersonal behaviours and patients' active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness-based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater's explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory-II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients' active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists' interpersonal skills, and patients' active engagement did not predict posttreatment depressive symptom reduction. Patients' active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient's in-session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.

Cognitive biases have been suggested to play a crucial role in the etiology and maintenance of social anxiety disorder (SAD). The aim of the present study was to investigate the effects of exposure therapy on attention- and approach-avoidance bias in SAD. In a randomized controlled trial, we compared changes from pre- to posttreatment in both biases in patients receiving stand-alone exposure therapy to a waiting-list control condition comprising 60 participants (Mage = 36.9 years) with SAD with heterogeneous social fears. Before and after treatment, attention bias was assessed using the dot probe task and approach-avoidance bias using the approach avoidance task. Results revealed that pre- to posttreatment changes in attention bias and approach-avoidance bias in exposure therapy did not significantly differ from changes in the waiting-list condition. Limitations and potential implications of the current results are discussed.

Although effective treatments for obsessive compulsive disorder (OCD) are increasingly available, a considerable percentage of patients fails to respond or relapses. Predictors associated with improved outcome of OCD were identified. However, information on interpersonal determinants is lacking. This study investigated the contribution of attachment style and expressed emotion to the outcome of exposure and response prevention (ERP), while accounting for previously documented intrapersonal (i.e., symptom severity and personality pathology) predictors. Using logistic regression analyses and multi-level modeling, we examined predictors of treatment completion and outcome among 118 adult OCD patients who entered ERP. We assessed outcome at post treatment, and at four and 13 months from treatment completion. OCD baseline severity and fearful attachment style emerged as the main moderators of treatment outcome. Severe and fearfully attached patients were more likely to dropout prematurely. The improvement of fearful clients was attenuated throughout treatment and follow-up compared to non-fearful clients. However, their symptom worsening at the long-term was also mitigated. Severe OCD patients had a more rapid symptom reduction during treatment and at follow-up, compared to less severe clients. The findings suggest that both baseline OCD severity and fearful attachment style play a role in the long-term outcome of ERP.

AIMS: The objective of this study is to investigate whether type of depressive symptoms (i.e. cognitive-affective or somatic) is related to a patient-perceived need for professional psychological care in individuals with diabetes.METHODS: In total 2266 participants were recruited as part of the screening procedure for a multi-center randomized controlled trial on the treatment of depressive symptoms among individuals with diabetes. Individuals were invited to complete Beck Depression Inventory-II (BDI-II). Patients with elevated depressive symptoms (BDI-II ≥14) were interviewed about their psychological care need. Based on their care needs patients were categorized into: unmet need, no need, met need and unclear need. These groups were compared on type of depressive symptoms, as categorized into cognitive-affective symptoms and somatic symptoms.RESULTS: 568 eligible individuals had elevated depressive symptoms, of whom 519 were reached. Among these depressed individuals, 19.7% (102 of 519) had an unmet need for psychological care. Participants with an unmet need were younger (pCONCLUSIONS: Cognitive-affective symptoms of depression-but not somatic symptoms-were associated with an unmet need for psychological care among depressed individuals with diabetes. Future research is needed to reveal better predictors explaining the discrepancy between distress and low care needs in order to optimize screening procedures.

Ample evidence supports the use of Virtual Reality (VR) for anxiety disorders. Nonetheless, currently there is no evidence about moderators or potential negative effects of VR treatment strategies. An Individual Patient Data (IPD) approach was employed with 15 retrieved datasets. The current study sample was composed of 810 patients. Randomized control trials (RCTs) for each primary outcome measure were performed, in addition to moderator analyses of the socio-demographic variables. Deterioration rates were 14 patients (4.0%) in VR, 8 (2.8%) in active control conditions, and 27 (15%) in the WL condition. With regard to receiving treatment, patients in a waiting list control condition had greater odds of deteriorating than in the two active conditions, odds ratios (ORs) 4.87, 95% confidence interval (CI) [0.05, 0.67]. In the case of the socio-demographic variables, none of them were associated with higher or lower odds of deterioration, with the exception of marital status in the WL condition; married people presented a significantly lower probability of deterioration, OR 0.19, 95% CI [0.05, 0.67]. Finally, when comparing pooled effects of VR versus all control conditions, the OR was 0.61 (95% CI 0.31–1.23) in favor of VR, although this result was not statistically significant. This study provides evidence about the deterioration rates of a therapeutic VR approach, showing that the number of deteriorated patients coincides with other therapeutic approaches, and that deterioration is less likely to occur, compared to patients in WL control groups.

This meta-analysis investigated the efficacy of technology-assisted interventions for individuals with social anxiety disorder (SAD). A systematic literature search in the databases Medline, PsychInfo, and Web of Science revealed 37 randomized controlled trials (2991 participants) that were grouped into internet delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials). Patients undergoing ICBT and VRET showed significantly less SAD symptoms at postassessment than passive control conditions (g=0.84 and 0.82, respectively). Compared to active control conditions, ICBT had a small advantage (g=0.38) and VRET showed comparable effects (p>0.05). CBM was not more effective than passive control conditions, except when delivered in the laboratory (g=0.35). While the efficacy of CBM was limited, substantial evidence for ICBT and preliminary evidence for VRET suggests that both can effectively reduce SAD symptoms indicating the potential of technology-assisted interventions for SAD.

Anxiety disorders are highly prevalent worldwide and engender substantial economic costs and disability. The World Health Organization is currently developing the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), which represents the first opportunity to improve the validity, clinical utility, and global applicability of the classification in more than 25 years. This article describes changes in the organization and diagnostic guidelines for anxiety and fear-related disorders proposed by the ICD-11 Working Group on the Classification of Mood and Anxiety Disorders and the rationale and evidence base for the proposals. In ICD-11, anxiety and fear-related disorders that manifest across the lifespan are brought together under a new grouping, and are partly distinguished by their focus of apprehension. The focus of apprehension is the stimulus or situation that triggers the fear or anxiety and may be highly specific as in specific phobia or relate to a broader class of situations as in social anxiety disorder. The guidelines also clarify the relationship between panic disorder and agoraphobia and a qualifier is provided for panic attacks in the context of other disorders. A standardized format emphasizing essential features of anxiety disorders is intended to improve clinical utility. Guidelines will be further refined based on findings from two types of field studies: those using a case-controlled vignette methodology disseminated via the Internet to practitioners worldwide (http://gcp.network) and clinic-based field trials implemented globally at participating field study centers.

This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposure intervention comprising verbal interaction with virtual humans to target heterogeneous social fears in participants with social anxiety disorder. Sixty participants (Mage = 36.9 years; 63.3% women) diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analyses revealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms, speech duration, perceived stress, and avoidant personality disorder related beliefs when compared to the waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation, speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. The iVET condition was further superior to the VRET condition regarding decreases in social anxiety symptoms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up. At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stress was significant. VRET containing extensive verbal interaction without any cognitive components can effectively reduce complaints of generalized social anxiety disorder. Future technological and psychological improvements of virtual social interactions might further enhance the efficacy of VRET for social anxiety disorder.

Objective: To compare the effectiveness between parent-child interaction therapy (PCIT) and methylphenidate in preschool children with attention-deficit/hyperactivity disorder (ADHD) symptoms and disruptive behaviors who had remaining significant behavior problems after previous behavioral parent training. Methods: We included 35 preschool children, ranging in age between 3.4 and 6.0 years. Participants were randomized to PCIT (n=18) or methylphenidate (n=17). Outcome measures were maternal ratings of the intensity and number of behavior problems and severity of ADHD symptoms. Changes from pretreatment to directly posttreatment were compared between groups using two-way mixed analysis of variance. We also made comparisons of both treatments to a nonrandomized care as usual (CAU) group (n=17) regarding intensity and number of behavior problems. All children who started one of the treatments were included in the analyses. Results: Mothers reported a significantly more decreased intensity of behavior problems after methylphenidate (pre-post effect size d=1.50) compared with PCIT (d=0.64). ADHD symptoms reduced significantly over time only after methylphenidate treatment (d=0.48) and not after PCIT. Changes over time of children in the CAU treatment were nonsignificant. Conclusions: Although methylphenidate was more effective than PCIT, both interventions may be effective in the treatment of preschool children with disruptive behaviors. Our findings are preliminary as our sample size was small and the use of methylphenidate in preschool children lacks profound safety data as reflected by its off-label status. More empirical support is needed from studies with larger sample sizes.

Background: Practice guidelines for childhood posttraumatic stress disorder (PTSD) recommend trauma-focused psychotherapies, mainly cognitive behavioral therapy (CBT). Eye movement desensitization and reprocessing (EMDR) therapy is a brief trauma-focused, evidence-based treatment for PTSD in adults, but with few well-designed trials involving children and adolescents. Methods: We conducted a single-blind, randomized trial with three arms (n = 103): EMDR (n = 43), Cognitive Behavior Writing Therapy (CBWT; n = 42), and wait-list (WL; n = 18). WL participants were randomly reallocated to CBWT or EMDR after 6 weeks; follow-ups were conducted at 3 and 12 months posttreatment. Participants were treatment-seeking youth (aged 8–18 years) with a DSM-IV diagnosis of PTSD (or subthreshold PTSD) tied to a single trauma, who received up to six sessions of EMDR or CBWT lasting maximally 45 min each. Results: Both treatments were well-tolerated and relative to WL yielded large, intent-to-treat effect sizes for the primary outcomes at posttreatment: PTSD symptoms (EMDR: d = 1.27; CBWT: d = 1.24). At posttreatment 92.5% of EMDR, and 90.2% of CBWT no longer met the diagnostic criteria for PTSD. All gains were maintained at follow-up. Compared to WL, small to large (range d = 0.39–1.03) intent-to-treat effect sizes were obtained at posttreatment for negative trauma-related appraisals, anxiety, depression, and behavior problems with these gains being maintained at follow-up. Gains were attained with significantly less therapist contact time for EMDR than CBWT (mean = 4.1 sessions/140 min vs. 5.4 sessions/227 min). Conclusions: EMDR and CBWT are brief, trauma-focused treatments that yielded equally large remission rates for PTSD and reductions in the severity of PTSD and comorbid difficulties in children and adolescents seeking treatment for PTSD tied to a single event. Further trials of both treatments with PTSD tied to multiple traumas are warranted.

This study examined whether patients' expectations of treatment outcome predict treatment completion, homework compliance, and depressive symptom improvement in cognitive behavior therapy (CBT) and mindfulness-based cognitive therapy (MBCT). Study participants were patients with diabetes and comorbid depressive symptoms who were randomized to 8 sessions of either CBT (n = 45) or MBCT (n = 46), both individually delivered. The results showed that high outcome expectations were predictive of post-treatment depressive symptoms in CBT and MBCT, but not of early and mid-treatment symptoms. Patients' outcome expectations predicted treatment completion in CBT and MBCT as well as homework compliance in MBCT. Homework compliance did not mediate the association between patients' outcome expectations and post-treatment depressive symptom improvement. The findings do not support the hypothesis that patients' expectations have an immediate impact on patients' mental state and partially support the notion that patients are less involved in treatment when they hold low expectations for improvement.

Controlled studies on the effectiveness of inpatient psychotherapy with patients with personality disorders (PD) are rare. This study aims to compare 3-month short-term inpatient psychotherapy based on transactional analysis (STIP-TA) with other psychotherapies (OP) up to 36-month follow-up. PD patients treated with STIP-TA were matched with OP patients using the propensity score. The primary outcome measure was general psychiatric symptomatology; secondary outcomes were psychosocial functioning and quality of life. In 67 pairs of patients, both STIP-TA and OP showed large symptomatic and functional improvements. However, STIP-TA patients showed more symptomatic improvement at all time points compared to OP patients. At 36 months, 68% of STIP-TA patients were symptomatically recovered compared to 48% of OP patients. STIP-TA outperformed OP in terms of improvements in general psychiatric symptomatology and quality of life. Superiority of STIP-TA was most pronounced at 12-month follow-up, but remained intact over the course of the 3-year follow-up.

BACKGROUND AND OBJECTIVES: Research on virtual reality exposure therapy (VRET) has demonstrated good treatment efficacy with regards to several anxiety disorders. Yet, there is lack of knowledge about the value of integrating interaction between clients and virtual humans in VRET. Such interaction might prove effective in treating psychological complaints that involve social interactions, such as social anxiety.METHODS: A VRET system specifically designed to expose clients with social anxiety disorder to anxiety provoking social situations was applied to 16 and 18 individuals with high and low levels of social anxiety, respectively. Participants engaged in two exposure sessions in several free speech dialogues with virtual humans while being monitored by a therapist.RESULTS: Participants with high levels of social anxiety reported significantly lower levels of social anxiety three months after exposure to two virtual reality interaction sessions than before treatment (p < 0.01). In the group with low levels of social anxiety, no significant change of social anxiety was reported between pre-treatment and follow-up. Additionally, participants in both groups reported higher self-efficacy three months after treatment than before treatment (ps ≤ 0.001).CONCLUSION: These findings indicate that virtual reality technology that incorporates social interactions may be successfully applied for therapeutic purposes.

The development of borderline personality disorder (BPD) has been associated with parenting styles and parental psychopathology. Only a few studies have examined current parental rearing styles and parental psychopathology in relationship to BPD symptoms in adolescents. Moreover, parenting stress has not been examined in this group. The current study examined 101 adolescents (14-19 years old) with BPD symptoms and their mothers. Assessments were made on severity of BPD symptoms, youth-perceived maternal rearing styles, and psychopathology and parenting stress in mothers. Multiple regression analyses were used to examine potential predictors of borderline severity. No correlation was found between severity of BPD symptoms in adolescents and parenting stress. Only youth-perceived maternal overprotection was significantly related to BPD severity. The combination of perceived maternal rejection with cluster B traits in mothers was significantly related to BPD severity in adolescents. This study provides a contribution to the disentanglement of the developmental pathways that lead to BPD.

Background: The current study presents the results of a meta-analysis of 39 randomized controlled trials on the efficacy of acceptance and commitment therapy (ACT), including 1,821 patients with mental disorders or somatic health problems. Methods: We searched PsycINFO, MEDLINE and the Cochrane Central Register of Controlled Trials. Information provided by the ACBS (Association of Contextual Behavioral Science) community was also included. Statistical calculations were conducted using Comprehensive Meta-Analysis software. Study quality was rated using a methodology rating form. Results: ACT outperformed control conditions (Hedges' g = 0.57) at posttreatment and follow-up assessments in completer and intent-to-treat analyses for primary outcomes. ACT was superior to waitlist (Hedges' g = 0.82), to psychological placebo (Hedges' g = 0.51) and to treatment as usual (TAU) (we defined TAU as the standard treatment as usual; Hedges' g = 0.64). ACT was also superior on secondary outcomes (Hedges' g = 0.30), life satisfaction/quality measures (Hedges' g = 0.37) and process measures (Hedges' g = 0. 56) compared to control conditions. The comparison between ACT and established treatments (cognitive behavioral therapy) did not reveal any significant differences between these treatments (p = 0.140). Conclusions: Our findings indicate that ACT is more effective than treatment as usual or placebo and that ACT may be as effective in treating anxiety disorders, depression, addiction, and somatic health problems as established psychological interventions. More research that focuses on quality of life and processes of change is needed to understand the added value of ACT and its transdiagnostic nature.

This study aims to explore the influence of paternal variables on outcome of behavioral parent training (BPT) in children with attention-deficit/hyperactivity disorder (ADHD). 83 referred, school-aged children with ADHD were randomly assigned to BPT plus ongoing routine clinical care (RCC) or RCC alone. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Moderator variables included paternal ADHD symptoms, depressive symptoms, and parenting self-efficacy. We conducted repeated measures analyses of variance (ANOVA) for all variables, and then analyzed the direction of interaction effects by repeated measures ANOVA in high and low scoring subgroups. Paternal ADHD symptoms and parenting self-efficacy played a moderating role in decreasing behavioral problems, but not in decreasing ADHD symptoms. Paternal depressive symptoms did not moderate either treatment outcome. BPT is most beneficial in reducing children's behavioral problems when their fathers have high levels of ADHD symptoms or high-parenting self-efficacy.

ObjectiveCognitive Behavior Therapy (CBT) and Mindfulness-Based Cognitive Therapy (MBCT) have shown to be effective interventions for treating depressive symptoms in patients with diabetes. However, little is known about which intervention works best for whom (i.e., moderators of efficacy). The aim of this study was to identify variables that differentially predicted response to either CBT or MBCT (i.e., prescriptive predictors).MethodsThe sample consisted of 91 adult outpatients with type 1 or type 2 diabetes and comorbid depressive symptoms (i.e., BDI-II >= 14) who were randomized to either individual 8-week CBT (n = 45) or individual 8-week MBCT (n = 46). Patients were followed for a year and depressive symptoms were measured at pre-treatment, post-treatment, and at 9-months follow-up. The predictive effect of demographics, depression related characteristics, and disease specific characteristics on change in depressive symptoms was assessed by means of hierarchical regression analyses.ResultsAnalyses showed that education was the only factor that differentially predicted a decrease in depressive symptoms directly after the interventions. At post-treatment, individuals with higher educational attainment responded better to MBCT, as compared to CBT. Yet, this effect was not apparent at 9-months follow-up.ConclusionsThis study did not identify variables that robustly differentially predicted treatment effectiveness of CBT and MBCT, indicating that both CBT and MBCT are accessible interventions that are effective for treating depressive symptoms in broad populations with diabetes. More research is needed to guide patient-treatment matching in clinical practice.

Objective: Although personality disorder not otherwise specified (PDNOS) is highly prevalent and associated with a high burden of disease, only a few treatment studies in this patient group exist. This study is the first to investigate the effectiveness of different modalities of psychotherapy in patients with PDNOS, i.e., short-term (up to 6 months) and long-term (more than 6 months) outpatient, day hospital, and inpatient psychotherapy. Method: A total of 205 patients with PDNOS were assigned to one of six treatment modalities. Effectiveness was assessed over 60 months after baseline. The primary outcome measure was symptom severity, and the secondary outcome measures included psychosocial functioning and quality of life. The study design was quasi-experimental, and the multiple propensity score was used to control for initial differences between treatment groups. Results: All treatment modalities showed positive outcomes, especially in terms of improvements of symptom severity and social role functioning. At 12-month follow-up, after adjustment for initial differences between the treatment groups, short-term outpatient psychotherapy and short-term inpatient psychotherapy showed most improvement and generally outperformed the other modalities concerning symptom severity. At 60 months after baseline, effectiveness remained but observed differences between modalities mostly diminished. Conclusion: Patients with PDNOS benefit from psychotherapy both at short-term and long-term follow-up. Short-term outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

Objectives: Worry and depressive rumination have been found to be involved in the onset and maintenance of a range of psychological disorders. The development of brief screening measures for excessive worry and depressive rumination is therefore desirable to facilitate the assessment of worry and rumination in prevention and treatment settings where routine administration of full questionnaires is not practical due to time-related constraints.Design and methods: Using the Penn State Worry Questionnaire (PSWQ) and the Ruminative Response Scale (RRS) as gold standard starting points, brief versions of these measures were developed in a large sample of adolescents (N = 1,952) and results were cross-validated in two independent samples (N = 1,954; N = 457).Results: The brief versions demonstrated acceptable to high internal consistency (brief PSWQ: α = .84-.91; brief RRS: α = .78-.81) and correlated highly with the full questionnaires (brief PSWQ: r = .91-.94; brief RRS: r = .88-.91). In addition, they showed high sensitivity (brief PSWQ: .90-.92; brief RRS: .90-.93), and high specificity (brief PSWQ: .88-.90; brief RRS: .80-.87) to detect excessive worry and rumination. The validity of the brief measures was further supported by demonstrating that the brief measures showed similar differences in scores between males and females as the full measures as well as substantial relationships to other measures of repetitive negative thinking and symptom measures of anxiety and depression. Finally, the brief measures predicted future symptoms of anxiety and depression.Conclusions: The brief versions of the PSWQ and RRS are time-efficient and valid instruments for the screening of worry and depressive rumination. Their use in clinical practice is recommended to inform treatment and/or to select individuals at risk for development of psychological disorders who may benefit from preventive interventions.

Background and objectives Control of obsessive thoughts in Obsessive Compulsive Disorder (OCD) involves both avoidance and removal of undesirable intrusive thoughts. Thought suppression tasks tap both of these processes but experimental results have been inconsistent. Experimental tasks allowing more focused study of the processes involved in controlling intrusive thoughts may be needed. In two experiments, control over neutral, standardized intrusive and personal intrusive thoughts was investigated as participants attempted to replace them with neutral thoughts. Methods Non-selected university students (Experiment 1: N = 61) and university students scoring high and low on self-report measure of OC symptoms (Experiment 2: N = 40) performed a computerized thought replacement task. Results In experiment 1 replacing personal intrusive thoughts took longer than replacing neutral thoughts. Self-reports showed that intrusive thoughts were rated more difficult to replace and were associated with greater thought reoccurrence during replacement, larger emotional reaction and more discomfort. These results were largely replicated in experiment 2. Furthermore, the high OC symptom group experienced greater overall difficulty controlling thoughts on the replacement task, experienced more reoccurrences of personal intrusive thoughts, larger emotional reactions and discomfort associated with them, and felt a greater urge to remove them. Limitations All participants were non-clinical university students, and older adults with OCD should be tested. Conclusions The findings are in line with cognitive behavioural theories of OCD. They support the usefulness of thought replacement as a research paradigm to study thought control in OCD and possibly other psychological conditions characterized by repetitive thoughts.

Substance use disorders and intimate partner violence (IPV) perpetration frequently co-occur, and it has been hypothesized that alcohol use and IPV perpetration are causally related. This led to the development of an Integrated treatment for Substance abuse and Partner violence (I-StoP). This case study describes the treatment of Henry, who repeatedly abused his partner and was diagnosed with alcohol and cannabis dependence. Treatment with I-StoP was highly successful with respect to IPV: At posttreatment and 6 months follow-up, no IPV had taken place. However, Henry had not changed substance use. This can be explained by the spurious model that states that a third variable, such as inadequate problem-solving skills (which was addressed in I-StoP), may be responsible for both IPV and substance abuse. In addition, Henry’s partner was involved in treatment and became more assertive and, in contrast, he did change substance use. This case study illustrates that IPV is a very complex problem and that it is important to involve the partner.

The general assumption has been that male batterers from clinical samples were mostly insecurely attached as compared to non-batterers. Recently, a large group was found (39.4 % of batterers in a clinical sample) whose main attachment style was secure. No previous studies have examined specifically the securely attached batterer. The aim of the present study was to test whether antisocial personality disorder (ASPD) and narcissistic personality disorder (NPD), but not borderline personality disorder (BPD), traits may be related to battering among securely attached individuals. Twenty-seven securely attached batterers, 45 insecurely attached batterers, 40 securely attached controls, and 22 insecurely attached controls who lived in the Netherlands, filled in self-report measures of personality disorder traits (i.e., antisocial, narcissism, borderline) and attachment (i.e., avoidant and anxious). Results showed that ASPD traits explained 19 % of the variance of battering in securely attached individuals. NPD and BPD traits are related to battering among securely attached individuals when NPD and BPD traits were entered alone in the equation.

Posttraumatic stress disorder (PTSD) is highly prevalent in adult survivors of childhood sexual and/or physical abuse. However, intervention studies focusing on this group of patients are underrepresented in earlier meta-analyses on the efficacy of PTSD treatments. The current meta-analysis exclusively focused on studies evaluating the efficacy of psychological interventions for PTSD in adult survivors of childhood abuse. Sixteen randomized controlled trials meeting inclusion criteria could be identified that were subdivided into trauma-focused cognitive behavior therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing, and other treatments (interpersonal, emotion-focused). Results showed that psychological interventions are efficacious for PTSD in adult survivors of childhood abuse, with an aggregated uncontrolled effect size of g = 1.24 (pre- vs. post-treatment), and aggregated controlled effect sizes of g = 0.72 (post-treatment, comparison to waitlist control conditions) and g = 0.50 (post-treatment, comparison with TAU/placebo control conditions), respectively. Effect sizes remained stable at follow-up. As the heterogeneity between studies was large, we examined the influence of two a priori specified moderator variables on treatment efficacy. Results showed that trauma-focused treatments were more efficacious than non-trauma-focused interventions, and that treatments including individual sessions yielded larger effect sizes than pure group treatments. As a whole, the findings are in line with earlier meta-analyses showing that the best effects can be achieved with individual trauma-focused treatments.Keywords: Meta-analysis, PTSD, Childhood trauma, Abuse, Treatment

The present study investigated whether (combinations of) specific substance use disorders predicted any and severe perpetration and victimization in males and females entering substance abuse treatment. All patients (N = 1799) were screened for IPV perpetration and victimization; almost one third of the sample committed or experienced any IPV in the past year. For males, an alcohol use disorder in combination with a cannabis and/or cocaine use disorder significantly predicted any IPV (perpetration and/or victimization) as well as severe IPV perpetration. For females, alcohol and cocaine abuse/dependence predicted both any IPV (perpetration and/or victimization) and severe IPV perpetration. Results from the present study emphasize the importance of routinely assessing IPV in patients in substance abuse treatment and demonstrate that clinicians should be particularly alert for IPV in patients with specific substance use disorder combinations.

Worry and rumination are two types of Repetitive Negative Thinking (RNT) that have been shown to be related to the development and maintenance of emotional problems. Whereas these two forms of RNT have traditionally been regarded as distinct and differentially related to psychopathology, researchers have recently argued that worry and rumination share the same process and show a very similar relationship to different forms of psychopathology. In a series of three studies, we employed a structural equation modelling approach to compare these competing hypotheses. Results showed that a bi-factor model (representing RNT by one latent factor with two uncorrelated method factors) provided a better fit to the data than a two-factor model (with worry and rumination represented by separate factors). In addition, the shared variance within the bi-factor model fully accounted for changes in symptom levels of depression and anxiety in two prospective studies. These findings support a transdiagnostic account of RNT. Implications for theory, measurement and clinical practice are discussed.

Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom-based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state-of-the-art in psychotherapy treatment research, “component analyses” aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large-scale public health strategies and treatments that can be applied to more patients in a simpler and cost-effective way. Increased research on efficacy and moderators of Internet-based treatments and e-mental health tools (e.g. to support “real time” clinical decision-making to prevent treatment failure or relapse) might be one promising way forward.

Psychology as a science offers an enormous diversity of theories, principles, and methodological approaches to understand mental health, abnormal functions and behaviours and mental disorders. A selected overview of the scope, current topics as well as strength and gaps in Psychological Science may help to depict the advances needed to inform future research agendas specifically on mental health and mental disorders. From an integrative psychological perspective, most maladaptive health behaviours and mental disorders can be conceptualized as the result of developmental dysfunctions of psychological functions and processes as well as neurobiological and genetic processes that interact with the environment. The paper presents and discusses an integrative translational model, linking basic and experimental research with clinical research as well as population-based prospective-longitudinal studies. This model provides a conceptual framework to identify how individual vulnerabilities interact with environment over time, and promote critical behaviours that might act as proximal risk factors for ill-health and mental disorders. Within the models framework, such improved knowledge is also expected to better delineate targeted preventive and therapeutic interventions that prevent further escalation in early stages before the full disorder and further complications thereof develop. In contrast to conventional "personalized medicine" that typically targets individual (genetic) variation of patients who already have developed a disease to improve medical treatment, the proposed framework model, linked to a concerted funding programme of the "Science of Behaviour Change", carries the promise of improved diagnosis, treatment and prevention of health-risk behaviour constellations as well as mental disorders.

The Dimensional Obsessive Compulsive Scale (DOCS) is a self-report instrument to assess severity of OC symptoms along four thematically distinct symptom dimensions. This may carry benefits; both in assessment and for studying the link between OC related beliefs and symptoms. The validity and factor structure of the Icelandic version of the DOCS was investigated in a sample of 547 university students and the congruence between OC related beliefs and symptoms was also compared across different symptom measures (DOCS and OCI-R). Confirmatory factor analysis supported the proposed four-factor structure and a model with a higher-order general severity factor accounting for the inter-relations between the factors. Convergent validity of the scale was supported with moderate to strong correlations with the OCI-R and the Y-BOCS-Self Report version and its symptom checklist. Divergent validity was supported with low to moderate correlations with measures of general anxiety, depression and worry. Regression analyses partly replicated previous results regarding congruence between beliefs and DOCS symptom dimensions. Results did not depend on the symptom measure used. The DOCS has good psychometric properties and may be a useful assessment instrument in both research and clinical settings, although its advantages compared to other self-report measures are not clear.

We tested whether suppressing disgust related thoughts, compared with no suppression, differentially affected target thought frequency and emotional responses, and whether this was related to participants' cognitive inhibition abilities. We also tested whether different control instructions during a thought control task would affect performance on a subsequent behavioural avoidance task involving disgust related stimuli. Sixty university students, pre-selected on their level of disgust propensity/sensitivity, were instructed to either suppress or not to suppress all target-related thoughts following viewing of a disgust-related film fragment. Thought suppression immediately reduced target thought frequency, but only for participants with good inhibitory control. Thought suppression led to sustained thought frequency and levels of disgust after suppression was lifted, whereas a significant drop was observed for these measures in the no-suppression group. Thought control instructions did not affect performance on the behavioural avoidance task at the group level. However, regression analyses showed that changes in thought frequency during thought suppression interacted with beliefs concerning importance of thoughts and thought control when predicting fear and disgust reactions during the behavioural task.

Virtual reality (VR) technology provides a way to conduct exposure therapy with patients with social anxiety. However, the primary limitation of current technology is that the operator is limited to pre-programed avatars that cannot be controlled to interact/converse with the patient in real time. The current study piloted new technology allowing the operator to directly control the avatar (including speaking) during VR conversations. Using an incomplete repeated measures (VR vs. in vivo conversation) design and random starting order with rotation counterbalancing, participants (N = 26) provided ratings of fear and presence during both VR and in vivo conversations. Results showed that VR conversation successfully elevated fear ratings relative to baseline (d = 2.29). Participants also rated their fear higher during VR conversation than during in vivo conversation (d = 0.85). However, in vivo conversation was rated as more realistic than VR conversation (d = 0.74). No participants dropped out and 100% completed both VR and in vivo conversations. Qualitative participant comments suggested that the VR conversations would be more realistic if they did not meet the actor/operator and if they were not in the same room as the participant. Overall, the data suggest that the novel technology allowing real time interaction/conversation in VR may prove useful for the treatment of social anxiety in future studies.

Short-term inpatient psychotherapy based on transactional analysis (STIP-TA) in patients with personality disorders (PD) has shown to be more effective than comparable other specialized psychotherapies (OP). The aim of this study was to assess whether the higher effectiveness of STIP-TA also results in a better cost-effectiveness. Patients treated with STIP-TA were matched with patients treated with OP by the propensity score. Healthcare costs and lost productivity costs were measured over 3 years and from the societal perspective. Cost-effectiveness was represented by costs per quality adjusted life years (QALYs). Uncertainty was assessed using bootstrapping. Mean 3-year costs were 59,834 for STIP-TA and 69,337 for OP, a difference of -(sic)9,503, 95% CI [-32,561, 15,726]. QALYs were 2.29 for STIP-TA and 2.05 for OP, a difference of .24, 95% CI [.05, .44]. STIP-TA is a dominant treatment compared to OP: less costly and more effective. We conclude that STIP-TA is a cost-effective treatment in PD patients.

This article gives an overview of research into psychological treatments for concurrent posttraumatic stress disorder (PTSD) and substance used disorder (SUD), with a special focus on the effectiveness of treatments addressing both disorders compared to treatments addressing one of the disorders alone. In addition, a distinction is made between trauma-focused versus non-trauma-focused therapies for concurrent PTSD and SUD. The databases Embase, Psychinfo, Medline and Web of science were searched for relevant articles. In total, seventeen studies were identified evaluating ten treatments protocols (six trauma-focused and four non-trauma-focused treatment approaches). In general, the studies showed pre-post reductions for PTSD and/or SUD symptoms. Although most treatments for concurrent PTSD and SUD did not prove to be superior to regular SUD treatments, there are some promising preliminary results suggesting that some patients might benefit from trauma-focused interventions. However, the lack of methodologically sound treatment trials makes it difficult to draw firm conclusions. Methodological limitations are discussed, along with recommendations for future research.

Background: Research suggests that yohimbine hydrochloride (YOH), a noradrenaline agonist, can facilitate fear extinction. It is thought that the mechanism of enhanced emotional memory is stimulated through elevated noradrenaline levels. This randomized placebo-controlled trial examined the potential exposure-enhancing effects of YOH in a clinical sample of participants meeting DSM-IV criteria for a specific phobia (fear of flying). Methods: Sixty-seven participants with fear of flying were randomized to 4 sessions of virtual reality exposure therapy (VRET) combined with YOH (10 mg), or 4 sessions of VRET combined with a placebo. Treatment consisted of 4 weekly 1-hour exposure sessions consisting of two 25-minute virtual flights. At pre- and post- treatment, fear of flying was assessed. The YOH or placebo capsules were administered 1 h prior to exposures. The manipulation of the noradrenaline activity was confirmed by salivary α-amylase (sAA) samples taken pre-, during and post-exposure. Results: Forty-eight participants completed treatment. Manipulation of noradrenaline levels with YOH was successful, with significantly higher levels of sAA in the YOH group when entering exposure. Results showed that both groups improved significantly from pre- to post-treatment with respect to anxiety reduction. However, although the manipulation of noradrenaline activity was successful, there was no evidence that YOH enhanced outcome. Conclusions: Participants improved significantly on anxiety measures independently of drug condition, after 4 sessions of VRET. These data do not support the initial findings of exposure-enhancing effects of YOH in this dosage in clinical populations.

The aim of this article is to review the literature on aetiology, epidemiology and course, assessment and treatment of the obsessive-compulsive personality disorder (OCPD). OCPD is a rather prevalent personality disorder, being one of the most prevalent personality disorders in the general population. OCPD is associated with moderate Axis I and Axis II co-occurrence and functional impairment is stable over time but generally mild. There is some evidence that the economic burden of OCPD may be considerable. Psychological treatment studies on patients with OCPD are rare, consisting of a few case studies and two open studies. Only one randomized controlled study on pharmacotherapy and no controlled study on psychological treatment directly focusing on OCPD as primary complaint have been reported. Finally, future areas of research are discussed. Copyright © 2010 John Wiley & Sons, Ltd.

Background: To compare the effectiveness of second-step treatment with cognitive therapy (CT) versus fluvoxamine in patients with obsessive-compulsive disorder (OCD) who are nonresponsive to exposure in vivo with response prevention (ERP). Methods: A 12-week randomized controlled trial at an outpatient clinic in the Netherlands comparing CT with fluvoxamine in OCD. Of 118 subjects with OCD treated with 12 weeks of ERP, 48 appeared to be nonresponders (Y-BOCS improvement score of less than one third). These nonresponders were randomized to CT (n = 22) or fluvoxamine (n = 26). The main outcome measure was the Y-BOCS severity scale. Statistical analyses were conducted in the intention-to-treat sample (n = 45) on an ‘as randomized basis’ and in the per-protocol sample (n = 30). Due to selective dropout in the fluvoxamine group, two additional sensitivity analyses were performed. Results: Complete data could be obtained from 45 subjects (94%) after 12 weeks. Fifty percent of the patients refused fluvoxamine after randomization compared to 13% who refused CT [χ2(1) = 7.10; p = 0.01]. CT as a second-step treatment did not appear to be effective in this sample of nonresponders. Fluvoxamine was significantly superior to CT in the intention-to-treat sample, in the per-protocol sample and in the two separately defined samples in which the sensitivity analyses were performed. Conclusions: OCD patients who are nonresponsive to ERP may benefit more from a switch to treatment with an antidepressant instead of switching to CT. In clinical practice, it may be important to motivate this subgroup of patients to undergo psychopharmacological treatment, as this may improve their outcome considerably.

Patients’ self-reports of explanatory models (EMs) are sensitive to distortions, particularly as a result of social desirability, uncertainty towards one’s own beliefs, and ethnic disparities with the interviewer. In contrast, reaction-time-based indirect measures are thought to be less sensitive to such factors. This article reports on two studies that applied direct (interview) and indirect (reaction-time-based association task) measures of EMs. Study 1 found evidence for the convergent validity of the direct and indirect measures, indicating that the two measures were essentially related. Furthermore, social desirability and uncertainty towards one’s beliefs affected the association between the measures on two categories of EMs. Study 2 showed that, unlike the self-reports of EMs, indirect measures were less sensitive to the ethnicity of the interviewer. The nature of the indirect measure, and the construct that it measures, are discussed.

This is the first study that compared different types of offenders in forensic outpatient treatment (i.e., offenders of general violence [GV], intimate partner violence [IPV], sex crimes, and “other offenses” such as drug smuggling and property crimes) regarding the prevalence of substance use disorders at the time of the offense. In total, 35.8% of participants ( n = 187) were diagnosed with any substance use disorder. Specifically, 61.5% of GV perpetrators, 30.9% of IPV perpetrators, 9.1% of sex offenders, and 26.7% of “other offenders” were diagnosed with substance abuse or dependence. More GV offenders and less sex offenders fulfilled diagnostic criteria for a substance use disorder. Furthermore, 29.9% of the offenders were intoxicated by substances at the moment they committed the offense (48.5% of GV perpetrators, 25.0% of IPV perpetrators, 17.4% of sex offenders, and 21.0% of other offenders). More GV perpetrators were intoxicated during the offense. As there is a clear association between substance abuse and criminal behavior, substance abuse in offenders should be assessed and, if present, be treated.

In clinical practice, the combination of brief, cost effective, valid and reliable assessment of personality disorders (PDs) is highly important. Substantial budget cuts require optimal use of the clinician's time. PDs are related with high axis I comorbidity, poorer therapy outcome and increased health service costs. In an effort to find a screening questionnaire that meets both the demands of cost-effectiveness and methodological soundness, we investigated the use of the Personality Diagnostic Questionnaire 4+ (PDQ-4+) as a first step in a two-step diagnostic procedure. As the second step, we used the Structured Clinical Interview of DSM-IV Axis II Personality Disorders (SCID-II) as criterion measure. Our results show that the positive predictive power of the PDQ-4+ is rather low, resulting in a large number of false positives. Therefore, its added value is poor in comparison with administering the SCID-II in the first place. Also, the value of the two validity scales of the PDQ-4+ is highly questionable. We therefore conclude that the PDQ-4+ should not be used in clinical practice as a screening instrument for PD assessment.

Substance abuse has often been associated with committing sex offenses. In this article, the following will be reviewed: 1) studies that assessed substance abuse in sex offenders; 2) differences in substance abuse among different types of sex offenders; 3) differences in substance abuse between sex offenders and nonsexual offenders and substance abuse in the normal population; 4) sex offenders’ intoxication at the time of the offense; and 5) differences in intoxication at the time of the offense among different types of sex offenders. Studies will be discussed according to the method they used to assess substance abuse, i.e., file research, screening instruments or semi-structured interviews. This review shows that about half of the sex offenders has a history of substance abuse, a quarter to half of the sex offenders has a history of alcohol misuse and that about one fifth to a quarter of the sex offenders has a history of drug misuse. Furthermore, about a quarter to half of the sex offenders appeared to be intoxicated at the time of the offense. The review results in recommendations for future research. Because of the high prevalence of substance abuse in sex offenders it is advisable to routinely screen for substance abuse and, if necessary, to treat substance abuse.

Objective: Children with attention deficit hyperactivity disorder (ADHD) who participated in a randomized clinical trial, which compared a brief intensive multimodal behaviour therapy combined with optimally titrated methylphenidate to optimally titrated methylphenidate alone (n = 45), were reassessed at adolescence in a naturalistic follow‐up 4.5 to 7.5 years after treatment. Also a matched normal control group was recruited (n = 23). Methods: Assessments at follow‐up included diagnostic status, ADHD symptoms, oppositional and conduct behaviour, substance abuse symptoms and parenting stress. Results: Of the 24 adolescents participating in the follow‐up study, 50% still met diagnostic criteria for ADHD. There were no significant differences between adolescents at follow‐up and those lost for follow‐up. At follow‐up, adolescents in the combined treatment condition used significantly less medication than children in the methylphenidate condition; there were no other significant differencesbetween the treatment conditions. The adolescents showed a significant decline in hyperactivity/impulsivity, oppositional and conduct disorder symptoms from post‐test to follow‐up. Only inattention symptoms increased from post‐test to follow‐up but not to pre‐test levels. The adolescents originally diagnosed with ADHD fared significantly worse than the matched controls on all outcomes, except on conduct disorder and substance abuse symptoms. Conclusions: Our study shows in adolescents, diagnosed with ADHD in childhood, age‐dependent decline of ADHD symptoms, although they still fared significantly worse than matched normal controls. Implications of results are restricted by small samples size, and the results may be subject to chance findings and need replication before firm conclusions can be drawn.