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Daniel Campos,1 Adriana Mira,1,2 Juana Bretón-López,1,3 Diana Castilla,1,3 Cristina Botella,1,3 Rosa Maria Baños,3,4 Soledad Quero1,3 1Department of Basic Psychology, Universitat Jaume I, Castellón, Spain; 2Department of Psychology and Sociology, Facultad de Ciencias Sociales y Humanas, Universidad de Zaragoza, Campus Universitario de Teruel, Teruel, Spain; 3CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Barcelona, Spain; 4Department of Personality, Evaluation and Psychological Treatment, Universitat de València, Valencia, Spain Purpose: Internet-based treatments have been tested for several psychological disorders. However, few studies have directly assessed the acceptability of these self-applied interventions in terms of expectations, satisfaction, treatment preferences, and usability. Moreover, no studies provide this type of data on Internet-based treatment for flying phobia (FP), with or without therapist guidance. The aim of this study was to analyze the acceptability of an Internet-based treatment for FP (NO-FEAR Airlines) that includes exposure scenarios composed of images and real sounds. A secondary aim was to compare patients’ acceptance of two ways of delivering this treatment (with or without therapist guidance).Patients and methods: The sample included 46 participants from a randomized controlled trial who had received the self-applied intervention with (n = 23) or without (n = 23) therapist guidance. All participants completed an assessment protocol conducted online and by telephone at both pre- and posttreatment.Results: Results showed good expectations, satisfaction, opinion, and usability, regardless of the presence of therapist guidance, including low aversiveness levels from before to after the intervention. However, participants generally preferred the therapist-supported condition.Conclusion: NO-FEAR Airlines is a well-accepted Internet-based treatment that can help enhance the application of the exposure technique, improving patient acceptance and access to FP treatment. Keywords: Internet-based exposure, expectations, satisfaction, treatment preferences, usability, flying phobia

Adriana Mira,1 Juana Bretón-López,1,2 Azucena García-Palacios,1,2 Soledad Quero,1,2 Rosa María Baños,2,3 Cristina Botella1,2 1Department of Basic, Clinical Psychology and Psychobiology, Labpsitec, Universitat Jaume I, Castellón de la Plana, Spain; 2CIBER of Physiopathology of Obesity and Nutrition CIBERobn, CB06/03 Instituto de Salud Carlos III, Santiago de Compostela, Spain; 3Department of Personality, Evaluation and Psychological Treatment, Universidad de Valencia, Valencia, Spain Purpose: The purpose of this study was to analyze the efficacy of an Internet-based program for depressive symptoms using automated support by information and communication technologies (ICTs) and human support. Patients and methods: An Internet-based program was used to teach adaptive ways to cope with depressive symptoms and daily problems. A total of 124 participants who were experiencing at least one stressful event that caused interference in their lives, many of whom had clinically significant depressive symptoms, were randomly assigned into either an intervention group with ICT support (automated mobile phone messages, automated emails, and continued feedback through the program); an intervention group with ICT support plus human support (brief weekly support phone call without clinical content); or a waiting-list control. At pre-, post-, and 12-month follow-up, they completed depression, anxiety, positive and negative effect, and perceived stress measures. Results were analyzed using both intention-to-treat and completers data. The majority were women (67.7%), with a mean age of 35.6 years (standard deviation =9.7). Results: The analysis showed that the two intervention groups improved significantly pre- to posttreatment, compared with the control group. Furthermore, improvements were maintained at the 12-month follow-up. Adherence and satisfaction with the program was high in both conditions. Conclusion: The Internet-based program was effective and well accepted, with and without human support, showing that ICT-based automated support may be useful. It is essential to continue to study other ICT strategies for providing support. Keywords: online intervention, types of support, depressive symptomatology, adherence, satisfaction

Cristina Botella,1,2 Adriana Mira,1 Inés Moragrega,2,3 Azucena García-Palacios,1,2 Juana Bretón-López,1,2 Diana Castilla,1,2 Antonio Riera López del Amo,1 Carla Soler,1 Guadalupe Molinari,1 Soledad Quero,1,2 Verónica Guillén-Botella,2,3 Ignacio Miralles,1,2 Sara Nebot,1 Berenice Serrano,1,2 Dennis Majoe,4 Mariano Alcañiz,2,5 Rosa María Baños2,31Department of Basic, Clinical Psychology and Psychobiology, Universitat Jaume, Castellón, Spain; 2CIBER Physiopathology of Obesity and Nutrition, CIBERobn, Instituto de Salud Carlos III, Santiago de Compostela, Spain; 3Department of Personality, Evaluation and Psychological Treatment, Universidad de Valencia, Valencia, Spain; 4Native Systems Institute, ETH Zurich, Zurich, Switzerland; 5Human-Centered Technology Institute, Universidad Politécnica de Valencia, Valencia, Spain Purpose: Computerized cognitive behavioral therapy (CCBT) has been shown to be efficacious. Moreover, CCBT can be enhanced by using physiological and activity sensors, but there is no evidence about the acceptability of all these tools. The objective of this study is to examine the efficacy, expectations, satisfaction, and ease of use of an Internet-based CCBT program for preventing depression, with and without sensors (electroencephalography, electrocardiograhpy ECG, and actigraphy), in a high-risk population (unemployed men).Patients and methods: Sixty participants at risk of depression (unemployed men) were randomly assigned to three experimental conditions: 1) intervention program (N=22), 2) intervention program plus sensors (N=19), and 3) control group (N=19). Participants completed depression, anxiety, positive and negative affect, and perceived stress measures. Furthermore, they also completed the measures for expectation, satisfaction, and the ease of use of the program.Results: Results showed that the two intervention groups improved significantly more than the control group on the clinical variables, and the improvements were greater in the group that used sensors than in the group that did not use them. Furthermore, participants in both intervention groups scored high on expectations and satisfaction with the CCBT program (with and without sensors). The mean score for usability was 88 out of 100 (standard deviation =12.32). No significant differences were found between groups on any of these variables.Conclusion: This is the first study to analyze the efficacy, expectations, satisfaction, and ease of use of an Internet-based program using physiological and activity sensors. These results suggest that an Internet program for depression with or without physiological and activity sensors is effective, satisfactory, and easy to use. Keywords: depression, ease of use, efficacy, Internet, sensors, satisfaction

Cristina Botella,1 Berenice Serrano,1 Rosa M Baños,2 Azucena Garcia-Palacios1 1Universitat Jaume I, Castellón de la Plana, Spain; 2Universitat de Valencia, Valencia, Spain Introduction: The essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. According to evidence-based intervention guidelines and empirical evidence, one of the most extensively researched and validated treatments for PTSD is prolonged exposure to traumatic events; however, exposure therapy can present some limitations. Virtual reality (VR) can help to improve prolonged exposure because it creates fictitious, safe, and controllable situations that can enhance emotional engagement and acceptance. Objective: In addition to carrying out a review to evaluate the efficacy of VR exposure-based therapy (VR-EBT) for the treatment of PTSD, the aim of this study was to contribute to analyzing the use of VR-EBT by: first, evaluating the adequacy of psychological treatment protocols that use VR-EBT to treat PTSD; and second, analyzing the acceptability of VR-EBT. Method: We performed a replica search with descriptors and databases used in two previous reviews and updated to April 2015. Next, we carried out an evaluation of the efficacy, adequacy, and acceptability of VR-EBT protocols. Results: Results showed that VR-EBT was effective in the treatment of PTSD. The findings related to adequacy showed that not all studies using VR-EBT reported having followed the clinical guidelines for evidence-based interventions in the treatment of PTSD. Regarding acceptability, few studies evaluated this subject. However, the findings are very promising, and patients reported high acceptability and satisfaction with the inclusion of VR in the treatment of PTSD. Conclusion: The main weaknesses identified in this review focus on the need for more controlled studies, the need to standardize treatment protocols using VR-EBT, and the need to include assessments of acceptability and related variables. Finally, this paper highlights some directions and future perspectives for using VR-EBT in PTSD treatment. Keywords: evidence-based intervention, prolonged exposure, treatment efficacy

Introduction: The Dutch Eating Behaviour Questionnaire for children was developed by Van Strien and Oosterveld (2008) to measure three different eating behaviors (emotional eating, restrained eating and external eating); it is an adaptation of the DEBQ for adults. Objective: The purpose of this study is to analyze the psychometric properties of the Dutch Eating Behavior Questionnaire for Children (DEBQ-C) with a Spanish sample. Method: The DEBQ-C was administered to 473 children (240 boys and 233 girls), from 10 to 14 years old. The sample included a Clinical Overweight Group (COG; n = 81) comprising children who were receiving weight loss treatments, a Non Clinical Overweight Group (NCOG, n = 31) comprising children who were overweight but not in treatment, and a Normal Weight Group (NWG, n = 280). Results: Results showed that the DEBQ-C had acceptable internal consistency (a = 0.70). Temporal stability was good for 'External Eating' and 'Restrained Eating' scales. Confirmatory factor analysis showed that the three-factor solution had good fit indices. Furthermore, the clinical overweight participants scored significantly higher on 'External Eating' and 'Restrained Eating' compared to the normal weight children. Conclusion: The DEBQ-C proved to be an effective instrument for researching children's eating behaviors. [ABSTRACT FROM AUTHOR]

This article discusses the development of the first totally self-administered online CBT program for the treatment of a specific social phobia (fear of public speaking) called talk to me. The online program includes three parts. The assessment protocol gives the patient information about the problem, including impairment, severity, and the degree of fear and avoidance regarding the main feared situations. The structured treatment protocol ensures that the patient does not skip any steps in the treatment. The treatment protocol is a CBT program that provides exposure to the feared situation using videos of real audiences. Finally, the control protocol assesses treatment efficacy, not only at posttreatment, but also at every intermediate step. In this work we describe talk to Me and its practical application through a case study. [ABSTRACT FROM AUTHOR]

When it comes to coping with stress, positive emotion upregulation is of utmost importance. Positive emotions have been suggested to be an important resource during stressful times since people try to create and upregulate pleasant emotional states when feeling stressed. Accordingly, individual differences in the ability to generate and savor positive emotional states could also affect one's skills in dealing with stress. In this regard, an important factor might be depression, which is associated with impaired positive emotion regulation. To disentangle the reciprocal influence between perceived stress and positive emotion upregulation, we conducted an Ecological Momentary Assessment study ( n = 92) in which we assessed participants' stress levels and use of positive upregulating strategies (attentional deployment, cognitive change, and response modulation) three times a day over 2 weeks. Results from linear mixed-effects models showed that higher levels of perceived stress at one point predicted increased use of positive upregulating strategies from this point to the next which, in turn, resulted in subsequent diminished stress levels. Interaction analyses indicated that participants with higher depressive symptoms implemented upregulating strategies to a lower extent when experiencing intense stress. Furthermore, attentional deployment was less effective in decreasing stress in individuals higher in depression, whereas the other strategies showed comparable or even higher efficacy. Overall, positive emotion upregulation might be regarded as an adaptive tool that helps cope with stress. This mechanism might be altered in people higher in depression, who specifically struggle to implement positive upregulating strategies during times of stress. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The objectives of this study were (a) to explore the preliminary cross-cultural validity of a visual-perceptual method to assess body image; (b) to examine potential differences and similarities in body image phenomena between women from two Western countries (i.e., Canada and Spain). 201 self-identified women participated in this cross-sectional study. Ideal, normal, and self-perceived body sizes were assessed using a visual-perceptual method, whereas body dissatisfaction was measured using both a visual-perceptual method and a questionnaire. Visual-perceptual body dissatisfaction was significantly correlated with questionnaire body dissatisfaction, suggesting a preliminary convergent validity between the two assessment methods. Women in both countries were dissatisfied with their bodies. Compared to their self-perceived body, all women chose a significantly thinner visual representation of their "normal" and ideal body. These results may suggest a shift towards the "thin" body as not only ideal, but also normative. This study provides the first evidence for the cross-cultural validity of a visual-perceptual body image assessment tool. The results of the current study confirm the presence of "normative discontent", and suggest more cross-country similarities than differences among women from these two Western societies., (© 2024 The Authors. European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.)

Objectives: To examine the cross-sectional association between baseline depressive symptoms and the presence of type 2 diabetes (T2D), and its association with glycated hemoglobin (HbA1c) and other metabolic variables, and the prospective association of depressive symptoms and HbA1c after 1 year of follow-up., Methods: n = 6224 Mediterranean older adults with overweight/obesity and metabolic syndrome (48% females, mean age 64.9 ± 4.9 years) were evaluated in the framework of the PREDIMED-Plus study cohort. Depressive symptoms were assessed using the Beck Depression Inventory-II and HbA1c was used to measure metabolic control., Results: The presence of T2D increased the likelihood of higher levels of depressive symptoms (χ 2  = 15.84, p = 0.001). Polynomial contrast revealed a positive linear relationship (χ 2  = 13.49, p = 0.001), the higher the depressive symptoms levels, the higher the prevalence of T2D. Longitudinal analyses showed that the higher baseline depressive symptoms levels, the higher the likelihood of being within the HbA1c ≥ 7% at 1-year level (Wald-χ 2  = 24.06, df = 3, p < .001, for the full adjusted model). Additionally, depressive levels at baseline and duration of T2D predicted higher HbA1c and body mass index, and lower physical activity and adherence to Mediterranean Diet at 1 year of follow-up., Conclusions: This study supports an association between T2D and the severity of depressive symptoms, suggesting a worse metabolic control from mild severity levels in the short-medium term, influenced by lifestyle habits related to diabetes care. Screening for depressive symptoms and a multidisciplinary integrative therapeutic approach should be ensured in patients with T2D., (© 2024. The Author(s).)

Background: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression., Objective: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments., Methods: We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables., Results: Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005)., Conclusions: To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance., Trial Registration: ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573., International Registered Report Identifier (irrid): RR2-10.1186/s13063-016-1511-1., (©Asmae Doukani, Matteo Quartagno, Francesco Sera, Caroline Free, Ritsuko Kakuma, Heleen Riper, Annet Kleiboer, Arlinda Cerga-Pashoja, Anneke van Schaik, Cristina Botella, Thomas Berger, Karine Chevreul, Maria Matynia, Tobias Krieger, Jean-Baptiste Hazo, Stasja Draisma, Ingrid Titzler, Naira Topooco, Kim Mathiasen, Kristofer Vernmark, Antoine Urech, Anna Maj, Gerhard Andersson, Matthias Berking, Rosa María Baños, Ricardo Araya. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 31.05.2024.)

Background: There has been an increased interest in understanding social anxiety (SA) and SA disorder (SAD) antecedents and consequences as they occur in real time, resulting in a proliferation of studies using ambulatory assessment (AA). Despite the exponential growth of research in this area, these studies have not been synthesized yet., Objective: This review aimed to identify and describe the latest advances in the understanding of SA and SAD through the use of AA., Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic literature search was conducted in Scopus, PubMed, and Web of Science., Results: A total of 70 articles met the inclusion criteria. The qualitative synthesis of these studies showed that AA permitted the exploration of the emotional, cognitive, and behavioral dynamics associated with the experience of SA and SAD. In line with the available models of SA and SAD, emotion regulation, perseverative cognition, cognitive factors, substance use, and interactional patterns were the principal topics of the included studies. In addition, the incorporation of AA to study psychological interventions, multimodal assessment using sensors and biosensors, and transcultural differences were some of the identified emerging topics., Conclusions: AA constitutes a very powerful methodology to grasp SA from a complementary perspective to laboratory experiments and usual self-report measures, shedding light on the cognitive, emotional, and behavioral antecedents and consequences of SA and the development and maintenance of SAD as a mental disorder., (©Javier Fernández-Álvarez, Desirée Colombo, Juan Martín Gómez Penedo, Maitena Pierantonelli, Rosa María Baños, Cristina Botella. Originally published in JMIR Mental Health (https://mental.jmir.org), 04.04.2024.)

Background: Body compassion is a protective factor in the field of eating disorders (ED) that has been associated with higher body appreciation and lower body shame. However, more studies are needed in order to disentangle the protective role of compassion in regard to the risk of ED. The study’s aims were to (1) analyze the psychometric properties of the Spanish adaptation of the Body Compassion Scale (BCS) and (2) determine whether body appreciation and body shame were mediators in the relationship between body compassion and the risk of ED., Method: 288 women (range: 18-40 years old; M = 24.65 ± 5.02) from the general Spanish population completed online questionnaires., Results: The Spanish adaptation of the BCS was reliable and valid. Results of a serial and parallel mediation model confirmed the protective role of body compassion and body appreciation on body shame and the risk of ED, accounting for 68.88% of the variance., Conclusions: Findings indicate that women who present higher body compassion tend to show higher body appreciation, which in turn leads to lower internal body shame and lower risk of ED. These results support the need to develop a positive and compassionate relationship with one’s body, in order to prevent ED.

Introduction: Interoceptive deficits are associated with difficulties in identifying and regulating emotions. However, research on interoception after acquired brain injury (ABI) is scarce, and its relationship with emotional difficulties in this population is unknown. This study aimed to (1) examine differences in self-reported alexithymia, performance-based emotional awareness, emotion regulation, depression, and interoceptive sensibility between ABI and control individuals; and (2) analyze the role of adaptive interoceptive dimensions in these emotional processes after ABI., Methods: Forty-three individuals with ABI and 42 matched control individuals completed the Multidimensional Assessment of Interoceptive Awareness-2, the Toronto Alexithymia Scale, the Levels of Emotional Awareness Scale, the Difficulties in Emotion Regulation Scale, and the Hospital Anxiety and Depression Scale., Results: Compared to the control group, individuals with ABI showed reduced tendency to ignore unpleasant sensations increased severity of depressive symptoms, as well as tendencies to have greater difficulties in emotion regulation and lower emotional awareness. Additionally, interoceptive dimensions such as trusting, as well as not-distracting from and not-worrying about bodily sensations, played a relevant role in explaining lower alexithymia and difficulties in emotion regulation. Moreover, lower alexithymia and emotion dysregulation were related to less depressive symptoms. These relationships were invariant across ABI and control individuals., Discussion: Although individuals with ABI may have different levels of emotional abilities compared to non-ABI individuals, the relationship patterns between interoceptive and emotional processes appear to be similar between the two groups. This study suggests the potential benefit of addressing both interoceptive and emotional difficulties in treatments targeting such prevalent sequelae of ABI as depressive symptoms., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer RET declared shared affiliation with the authors to the handling editor at the time of review. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Desdentado, Miragall, Llorens, Navarro and Baños.)

Background: Although it has been suggested that family members of persons suffering from Borderline Personality Disorder (BPD) endure high levels of burden, however, the process and the impact of this burden in their lives, and specifically the relation between the burden and emotional regulation has not been broadly investigated among this population. The main objective of this study is to examine the impact of burden on quality of life and depression, anxiety and stress, as mediated by difficulties in emotional regulation in family members of persons diagnosed with BPD., Method: Participants were 167 family members of persons diagnosed with BPD. The Burden Assessment Scale, Difficulties in Emotion Regulation Scale, Multicultural Quality of Life Index, and Depression Anxiety Stress Scale-21 were filled out. Mediation analysis was conducted using the Maximum Likelihood estimator, bootstrap method and listwise deletion for missing data., Results: Burden showed a significant, negative effect on quality of life and positive on depression, anxiety and stress. Difficulties in emotion regulation significantly mediated these relations. After accounting for the mediating role of difficulties in emotion regulation, burden still had an impact on quality of life, depression, anxiety and stress. Women showed a higher level in both burden and stress than men. The caregivers with secondary and higher studies showed higher levels in burden than those with no studies. Not significant differences in burden, emotion regulation, depression, anxiety and stress were found related to marital status., Conclusion: Difficulties in emotion regulation mediate the relations between burden and quality of life, depression, anxiety, and stress. Family members could engage in group interventions designed specifically for family members of people with BPD, oriented toward understanding the disorder or learning skills., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Fonseca-Baeza, García-Alandete, Marco, Pérez Rodríguez, Baños and Guillén.)

Background: Children with growth hormone deficiency face the prospect of long-term recombinant human growth hormone (r-hGH) treatment requiring daily injections. Adherence to treatment is important, especially at treatment initiation, to achieve positive health outcomes. Historically, telenursing services embedded in patient support programs (PSPs) have been a valid approach to support r-hGH treatment initiation and patient education and facilitate adherence by identifying and optimizing appropriate injection techniques. The development of mobile phones with augmented reality (AR) capabilities offers nurses new tools to support patient education., Objective: To investigate experiences among nurses of a new mobile phone app developed to support patient training with a phone-based PSP for r-hGH treatment., Methods: In 2020, the Easypod AR mobile app was launched to support nurse-driven telehealth education for patients initiating r-hGH therapy with the Easypod electromechanical auto-injector device. Nurses who were part of PSPs in countries where the Easypod AR app had been launched or where training was provided as part of an anticipated future launch of the app were invited to participate in an online survey based on the Mobile App Rating Scale to capture their feedback after using the app., Results: In total, 23 nurses completed the online questionnaire. They positively rated the quality of the app across multiple dimensions. The highest mean scores were 4.0 for engagement (ie, adaptation to the target group; SD 0.74), 4.1 (SD 0.79) for functionality (navigation) and 4.1 (SD 0.67) for aesthetics (graphics). Responses indicated the potential positive impact of such a tool on enhancing patient education, patient support, and communication between patients and PSP nurses. Some participants also suggested enhancements to the app, including gamification techniques that they felt have the potential to support the formation of positive treatment behaviors and habits., Conclusions: This study highlights the potential for new digital health solutions to reinforce PSP nurse services, including patient education. Future studies could explore possible correlations between any behavioral and clinical benefits that patients may derive from the use of such apps and how they may contribute to support improved patient experiences and treatment outcomes., (©Rosa Maria Baños, Laura-Maria Peltonen, Blaine Martin, Ekaterina Koledova. Originally published in JMIR Nursing (https://nursing.jmir.org), 21.04.2023.)

Background: Food addiction (FA) is characterised by symptoms such as loss of control over food consumption, inability to reduce consumption despite the desire to do so, and continued consumption despite negative consequences. The modified Yale Food Addiction Scale 2.0 (mYFAS 2.0) is a widely used instrument to assess FA., Objectives: To validate the Spanish mYFAS 2.0; to analyse the relationships between FA with other eating behaviours, sociodemographic variables, and Body Mass Index (BMI); and to test the eating-related variables that account for the variance in FA., Methods: The sample consisted of 400 university students (M age  = 24.16, SD age  = 6.12; 51% female), who completed the mYFAS 2.0 and measures of eating-related constructs., Results: A confirmatory factor analysis (CFA) supported the one-factor structure of the mYFAS 2.0. The scale showed good internal consistency (α = .78), and good convergent validity with the mYFAS. FA was related to eating styles, binge eating, and bulimia. No differences in FA were observed between males and females, and there was no association between FA and BMI. In addition, younger participants scored higher on FA than older participants. The eating-related variables explain 54.7% of the variance in FA., Conclusions: The mYFAS 2.0 is a valid and reliable scale to assess FA in the Spanish population. The positive and significant relationship of variables related to eating (eating styles, binge eating and bulimia) with FA was demonstrated. These variables were indicated by those at high risk of FA., (© 2023. The Author(s).)

(1) Background: The 'Living Better' web-based programme has shown short- and long-term benefits for body composition and psychological variables in obese patients with hypertension by promoting a healthier lifestyle. To further explore the potential of this programme, in this work we aimed to explore the possible effect of the patient's 'own doctor' appearing in the video content of the Living Better intervention. (2) Methods: A total of 132 patients were randomly assigned either to the experimental (EG, n = 70) or control (CG, n = 62) group (with a doctor the patient knew as 'their own' or an 'unknown doctor', respectively). The body mass index (BMI), motivation towards physical activity (PA), PA levels, motivation to change one's eating habits, adherence to the Mediterranean diet, and eating behaviour were all assessed and compared at baseline and post-intervention (12 weeks). (3) Results: The results of this study confirmed the positive effects of the Living Better programme on BMI and external eating style, with significant improvements in these variables in both groups. In addition, in the EG there was higher intrinsic motivation to change eating behaviour (mean difference of 0.9, 95% CI [0.1, 1.6], p = 0.032) and lower amotivation (mean difference of -0.6, 95% CI [-1.2, -0.1], p = 0.027) compared to the CG. (4) Conclusions: This study suggests that the presence of the patients' own doctor in the audiovisual content of the Living Better intervention did not have significant additional benefits in terms of BMI or external eating style. However, their presence did improve intrinsic motivation and amotivation related to eating habits.

Introduction: Online interventions have long been shown to be an effective means to promote a healthy lifestyle, thereby helping to control body weight and blood pressure figures. Likewise, using video modeling is also considered an effective way to guide patients through behavioral interventions. Nonetheless, to the best of our knowledge, this study is the first to analyze how the presence of patients' "own doctor" in the audiovisual content of a web-based lifestyle program (" Living Better" ) aimed at promoting regular physical exercise and healthy eating behavior, compared with an "unknown doctor," influences the outcomes of adults with obesity and hypertension., Materials and Methods: A total of 132 patients were randomly assigned either to the experimental ( n = 70) or control ( n = 62) group ("own doctor" or "unknown doctor", respectively). The body mass index, systolic and diastolic blood pressure, number of antihypertensive drugs used, physical activity level, and quality of life was assessed and compared at baseline and post-intervention (12 weeks)., Results: The intention-to-treat analysis showed intragroup significant improvements in both groups in terms of the body mass index (control group: mean difference -0.3, 95% CI [-0.5, -0.1], p = 0.002; experimental group: -0.4 [-0.6, -0.2], p < 0.001) and systolic blood pressure (control group: -2.3 [-4.4, -0.2], p = 0.029; experimental group: -3.6 [-5.5, -1.6], p < 0.001). In addition, there were also significant improvements in the experimental group for the diastolic blood pressure (-2.5 [-3.7, -1.2], p < 0.001), physical activity (479 [9, 949], p = 0.046), and quality of life (5.2 [2.3, 8.2], p = 0.001). However, when comparing the experimental with the control group, no between-group significant differences were found in these variables., Conclusions: This study suggests that the presence of patients' "own doctor" in the audiovisual content of a web-based intervention, aimed at promoting a healthy lifestyle among adults with obesity and hypertension, do not show significant additional benefits over the efficacy of e-counseling., Trial Registration: ClinicalTrials.gov NCT04426877. First Posted: 11/06/2020. https://clinicaltrials.gov/ct2/show/NCT04426877., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Múzquiz-Barberá, Ruiz-Cortés, Herrero, Vara, Escrivá-Martínez, Baños, Rodilla and Lisón.)

The presence of meaning in life (PML) and the search for meaning in life (SML) are crucial when facing difficult times. Although several theoretical frameworks have tried to explain the dynamics of meaning in life during adversity, empirical evidence about interactions among both constructs using longitudinal designs is scarce. This study examined the trajectories of both PML and SML during the COVID-19 lockdown period in Spain. In total, 220 adults fulfilled an online survey during two periods: a strict and a relaxed lockdown period. Latent growth models showed that both PML and SML declined slightly during the strict lockdown, but they reached a plateau during the relaxed lockdown. Results also showed that age and having a partner predicted higher PML and lower SML at baseline, whereas being male predicted higher scores on PML. PML and SML were negatively associated at baseline, higher SML at baseline was related to a steeper decreasing PML slope during the strict lockdown, and the PML and SML slopes in the relaxed lockdown period were negatively related. This study contributes to better understanding longitudinal fluctuations of meaning in life in situations of adversity., (© The Author(s) 2022.)

Background: Chronic medical illnesses significantly and negatively affect the quality of life of individuals who suffer them and represent one of the most important challenges faced by healthcare providers and policy-makers due to its rising prevalence and high rates of comorbidity. Compassion-based interventions delivered over the Internet may be a useful approach to facilitate illness management and improve the quality of life of individuals with chronic medical conditions., Objectives: The purpose of this study is to describe a protocol for a randomized controlled trial to test the efficacy of the Internet Attachment-Based Compassion Therapy (iABCT) to improve the quality of life and well-being of patients with chronic medical illnesses., Method: A two-arm, parallel-group, randomized controlled trial (RCT) will be carried out, with three assessment points (baseline, 3-month, and 6-month) under two conditions: intervention group and control group (waiting list). The primary outcomes include the quality of life on the EuroQol 5-Dimensions Questionnaire (EQ-5D) and the Pemberton Happiness Index (PHI). Secondary outcomes, such as compassion, self-care behaviors, illness interference, self-criticism, symptomatology, attachment styles, social support, and illness perception, will be considered. Moreover, an assessment on satisfaction and usability will be carried out. A total of 68 participants as minimum will be recruited (34 per arm). Intent-to-treat mixed-model analyses without any ad hoc imputations will be conducted., Conclusions: Findings of this study will provide new insights into the potential of self-applied compassion-based interventions (CBI) delivered online in the context of chronic medical illnesses, considering aspects of their implementation (e.g., facilitators, barriers) and mechanisms of change., Trial Registration: The study is registered under Clinicaltrials.gov (NCT04809610) and it is currently in the participant recruitment phase., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Martínez-Sanchis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The prevalence of emotional disorders has increased in recent times. Emotional Reasoning (ER), which is a transdiagnostic process, occurs when feelings, rather than objective evidence, are used as a source of information to make judgements about the valence of a situation. Differences in ER may explain the existence and maintenance of emotional disorders. The objective is to systematically review the role of ER in the occurrence and severity of emotional disorders. Following PRISMA guidelines, we searched through: PubMed, PsycInfo, Scopus and The Cochrane Library. Search terms were "Emotional Reasoning", "ex-consequentia reasoning", "Affect-as-information"; and "emotional disorders", "anxiety", "depression", "depressive". Nine articles were included. An association was demonstrated between ER and a greater degree of anxious symptomatological severity. In depressive symptomatology, no significant differences were found. One study reported the effect of Cognitive Behavioural Therapy on ER bias, finding no changes after the intervention. Finally, another study evaluated the efficacy of computerised experiential training in reducing ER bias, showing significant differences. There are few studies on ER and its evolution in research has not been uniform over time. Encouragingly, though, research to date suggests that ER is a transdiagnostic process involved in several anxiety disorders. More investigation is needed to dilucidate whether ER also underlies the onset and maintenance of depressive disorders., Competing Interests: Declarations of interestThe authors have no conflicts of interest to declare., (© The Author(s) 2022.)

Background: Patients with chronic disease represent an at-risk group in the face of the COVID-19 crisis as they need to regularly monitor their lifestyle and emotional management. Coping with the illness becomes a challenge due to supply problems and lack of access to health care facilities. It is expected these limitations, along with lockdown and social distancing measures, have affected the routine disease management of these patients, being more pronounced in low- and middle-income countries with a flawed health care system., Objectives: The purpose of this study is to describe a protocol for a randomized controlled trial to test the efficacy of the Adhera® MejoraCare Digital Program, an mHealth intervention aimed at improving the quality of life of patients with chronic diseases during the COVID-19 outbreak in Paraguay., Method: A two-arm randomized controlled trial will be carried out, with repeated measures (baseline, 1-month, 3-month, 6-month, and 12-month) under two conditions: Adhera® MejoraCare Digital Program or waiting list. The primary outcome is a change in the quality of life on the EuroQol 5-Dimensions 3-Levels Questionnaire (EQ-5D-3L). Other secondary outcomes, as the effect on anxiety and health empowerment, will be considered. All participants must be 18 years of age or older and meet the criteria for chronic disease. A total of 96 participants will be recruited (48 per arm)., Conclusions: It is expected that the Adhera® MejoraCare Digital Program will show significant improvements in quality of life and emotional distress compared to the waiting list condition. Additionally, it is hypothesized that this intervention will be positively evaluated by the participants in terms of usability and satisfaction. The findings will provide new insights into the viability and efficacy of mHealth solutions for chronic disease management in developing countries and in times of pandemic., Trial Registration: ClinicalTrials.gov NCT04659746., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Escrivá-Martínez et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The study aimed to analyze the longitudinal change in mental health during the third wave of COVID-19 infections in Spain. Negative (e.g., emotional distress) and positive (e.g., positive functioning variables) outcomes were analyzed. Protective factors (e.g., resilience) as predictors of psychological adjustment (i.e., positive mental health, openness to the future, and low burden due to COVID-19) after ten months of the pandemic were also examined. The sample consisted of 164 participants, and self-reported questionnaires were administered at the beginning of the lockdown (March 2020), at the end of the lockdown (June 2020), and during the third wave (January 2021). Linear mixed models showed that individuals' emotional distress increased, and positive functioning variables (i.e., meaning in life, gratitude, resilience, and life satisfaction) decreased over time, but an increase was observed in some dimensions of posttraumatic growth. Regression analyses showed that resilience scores at all three data collection time points were significant predictors of positive mental health, openness to the future, and burden during the third wave. Mediation analyses showed that positive mental health and openness to the future were mediators of the effect of resilience on burden. The prolonged situation of the COVID-19 crisis had an important impact on positive and negative mental health. However, resilience may help to build up resources that can act as a buffer against adverse psychological effects., Competing Interests: Conflict of interestOn behalf of all the authors, the corresponding author states that there are no conflicts of interest., (© The Author(s) 2022.)

Background: COVID-19 confinement affected lifestyles. There is inconclusive evidence about changes in eating patterns, and there are few studies on the impact on body mass index (BMI), the occurrence of dysfunctional behaviors (binge eating, fat intake), and the predictive role of maladaptive eating styles (emotional, external, and restrained eating)., Objectives: (1) To analyze the differences in binge eating, fat intake, BMI, and maladaptive eating styles before and during COVID-19 confinement, and (2) to analyze whether maladaptive eating styles (before confinement) predicted binge eating, fat intake, and BMI during confinement., Methods: The sample consisted of 146 Spanish college students, divided into 104 females (71.2%; age: M = 22.20, SD = 2.97) and 42 males (28.8%; age: M = 24.74; SD = 3.53). All completed several dietary measures and BMI twice: before COVID-19 confinement (T1, November 2019) and during COVID-19 confinement (T2, April 2020)., Results: BMI and maladaptive eating styles did not change in T2 (vs. T1). However, binge eating and fat intake decreased in T2. Emotional eating at T1 positively predicted BMI and binge eating at T2. External eating at T1 positively (and marginally) predicted fat intake at T2. Restrained eating at T1 positively predicted binge eating at T2, and negatively (and marginally) predicted BMI and fat intake at T2. The model explained 80.5% of the variance in BMI, 41.5% of the variance in binge eating, and 25.8% of the variance in fat intake during COVID-19 confinement., Conclusions: The COVID-19 confinement had a positive impact on some eating behaviors. Future policies should focus part of their prevention on maladaptive eating styles to curb dysfunctional eating behaviors and BMI problems in times of stress., (© 2022. The Author(s).)

Background: Meaning-Centered Psychotherapy (MCP) is effective in improving meaning in life, hope, optimism, self-efficacy, well-being, and quality of life, and in reducing stress in people with cancer. However, all the studies on the application of MCP in cancer patients have been carried out in Anglo-Saxon samples. Therefore, it is necessary to adapt and verify the efficacy of MCP in populations that speak languages other than English, such as Spanish. Moreover, to expand the data supporting the efficacy of MCP for cancer patients, it would be necessary to compare MCP to other active therapies such as Cognitive Behavioral Therapy (CBT)., Methods: The aims of the proposed study are: the first objective is to verify the efficacy of the MCP intervention for Spanish participants with cancer in a randomized control trial (RCT) comparing it to CBT. The second objective is to analyze the feasibility and acceptance of MCP in Spanish participants with cancer. The third objective is to analyze whether the changes produced in the meaning in life dimensions (presence, search, comprehension, purpose, and mattering) will predict changes in anxiety, depression, quality of life, etc. Our research team adapted MCP for Spanish participants with cancer. This paper presents the study protocol. The study design consists of a two-arm RCT with two conditions: MCP and CBT, where participants will be randomized to one of the two groups. Eligible participants will be adults with stage I, II, and III cancer who were treated with curative intent and had completed their main medical treatment (surgery, radiotherapy, or chemotherapy). Participants will be assessed at pretreatment, post-treatment, and 6-month follow-up. The intention-to-treat principle will be used when analyzing data, using mixed-effects models with full information and maximum likelihood estimation., Discussion: This study will provide results that confirm the efficacy of the MCP in Spanish participants with cancer., Trial Registration: ClinicalTrials.gov; https://register.clinicaltrials.gov/prs/app/template/Home.vm?uid=U0005WS9&ts=4&sid=S000BOTT&cx=bvr2ue, identifier NCT05197348., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Marco, Llombart, Guillén, Baños, Romero, Garcia-Conde and Pérez Rodríguez.)

Purpose: The aim of the present study was to confirm the original factor structure of the Multicultural Quality of Life Index (MQLI) and analyze its psychometric properties in a sample of caregivers of people with borderline personality disorder (BPD)., Methods: The MQLI was administered to 233 relatives of people with BPD. Participants completed the MQLI, the Depression, Anxiety and Stress Scale (DASS-21), and the Connor-Davidson Resilience Scale (CD-RISC)., Results: Factor analysis of the relatives indicated that the MQLI generated a one-factor solution. The MQLI showed good internal consistency, ϖ = 0.91 [95% CI (0.90, 0.93)] and correlated significantly and positively with the CD-RISC ( r s = 0.576) and negatively with the DASS-21 ( r s = -0.583)., Conclusion: Consistent with other studies, the MQLI demonstrated feasibility, strong internal consistency, and good convergent and discriminant validity, which means it is a psychometrically robust measure for the assessment of quality of life in relatives of people with BPD. Along with other validation studies, this measure will be a useful tool for assessing quality of life in relatives of people with mental disorders., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Marco, Fernandez-Felipe, García-Alandete, Fonseca-Baeza, Baños, Garcia-Palacios, Pérez Rodríguez and Guillén.)

‘Living Better’, a self-administered web-based intervention, designed to facilitate lifestyle changes, has already shown positive short- and medium-term health benefits in patients with an obesity−hypertension phenotype. The objectives of this study were: (1) to examine the long-term (3-year) evolution of a group of hypertensive overweight or obese patients who had already followed the ‘Living Better’ program; (2) to analyze the effects of completing this program a second time (reintervention) during the COVID-19 pandemic. A quasi-experimental design was used. We recruited 29 individuals from the 105 who had participated in our first study. We assessed and compared their systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI), eating behavior, and physical activity (PA) level (reported as METs-min/week), at Time 0 (first intervention follow-up), Time 1 (before the reintervention), and Time 2 (post-reintervention). Our results showed significant improvements between Time 1 and Time 2 in SBP (−4.7 (−8.7 to −0.7); p = 0.017), DBP (−3.5 (−6.2 to −0.8); p = 0.009), BMI (−0.7 (−1.0 to −0.4); p < 0.001), emotional eating (−2.8 (−5.1 to −0.5); p = 0.012), external eating (−1.1 (−2.1 to −0.1); p = 0.039), and PA (Time 1: 2308 ± 2266; Time 2: 3203 ± 3314; p = 0.030, Z = −2.17). Statistical analysis showed no significant differences in SPB, DBP, BMI, and eating behavior between Time 0 and Time 1 (p > 0.24). Implementation of the ‘Living Better’ program maintained positive long-term (3-year) health benefits in patients with an obesity−hypertension phenotype. Moreover, a reintervention with this program during the COVID-19 pandemic produced significant improvements in blood pressure, BMI, eating behavior, and PA.

The sense of embodiment refers to the set of sensations related to having (i.e., ownership), being located in (i.e., location), and controlling (i.e., agency) a virtual body. Recently, 360-degree video-based Virtual Reality (VR) has been used to manipulate the sense of embodiment, generating the body-swap illusion, that is, the illusionary switch from the real body to a virtual one. However, the psychological mechanisms involved in this illusion are still unknown. The present study is a secondary analysis of the study by Ventura et al. (2021) investigating the feasibility of 360-degree video to induce the body swap from a male's real body to a female virtual body in a sexual harassment virtual environment. In addition, the study explores whether the sense of presence and psychological trait variables related to sexual harassment (i.e., machismo, chivalry, alexithymia, empathic abilities) predict the illusion of owning the body of a female victim of sexual harassment. Forty-four men participated in the study, and the results indicate that the 360-degree video is able to induce the body-swap illusion for location and ownership, but not for agency. Multiple regression analyses showed that the sense of presence was a predictor of the three dimensions of embodiment, but specific psychological traits (i.e., low scores on machismo, high scores on difficulties expressing feelings, and high scores on perspective taking) were also predictor variables of experiencing a greater sense of location and agency in the female virtual body. This study shows that both technological issues and participants' psychological traits are involved in the experience of the body-swap illusion in a sexual harassment scenario using 360-degree video-based VR., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ventura, Miragall, Cardenas and Baños.)

Background: Although major depressive disorder (MDD) is characterized by a pervasive negative mood, research indicates that the mood of depressed patients is rarely entirely stagnant. It is often dynamic, distinguished by highs and lows, and it is highly responsive to external and internal regulatory processes. Mood dynamics can be defined as a combination of mood variability (the magnitude of the mood changes) and emotional inertia (the speed of mood shifts). The purpose of this study is to explore various distinctive profiles in real-time monitored mood dynamics among MDD patients in routine mental healthcare., Methods: Ecological momentary assessment (EMA) data were collected as part of the cross-European E-COMPARED trial, in which approximately half of the patients were randomly assigned to receive the blended Cognitive Behavioral Therapy (bCBT). In this study a subsample of the bCBT group was included ( n = 287). As part of bCBT, patients were prompted to rate their current mood (on a 1-10 scale) using a smartphone-based EMA application. During the first week of treatment, the patients were prompted to rate their mood on three separate occasions during the day. Latent profile analyses were subsequently applied to identify distinct profiles based on average mood, mood variability, and emotional inertia across the monitoring period., Results: Overall, four profiles were identified, which we labeled as: (1) "very negative and least variable mood" ( n = 14) (2) "negative and moderate variable mood" ( n = 204), (3) "positive and moderate variable mood" ( n = 41), and (4) "negative and highest variable mood" ( n = 28). The degree of emotional inertia was virtually identical across the profiles., Conclusions: The real-time monitoring conducted in the present study provides some preliminary indications of different patterns of both average mood and mood variability among MDD patients in treatment in mental health settings. Such varying patterns were not found for emotional inertia., Competing Interests: DE has served as a consultant to/on the scientific advisory boards of Sanofi, Novartis, Minddistrict, Lantern, Schoen Klinike, Ideamed and German health insurance companies BARMER, Techniker Krankenkasse and a number of federal chambers for psychotherapy. He is also stakeholder of the Institute for health training online formerly GET.ON/ now HelloBetter, which aims to implement scientific findings related to digital health interventions into routine care. IT reports to have received fees for lectures/workshops in the e-mental-health context from training institutes for psychotherapists. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 van Genugten, Schuurmans, Hoogendoorn, Araya, Andersson, Baños, Berger, Botella, Cerga Pashoja, Cieslak, Ebert, García-Palacios, Hazo, Herrero, Holtzmann, Kemmeren, Kleiboer, Krieger, Rogala, Titzler, Topooco, Smit and Riper.)

The prevalence of mental disorders continues to increase, especially with the advent of the COVID-19 pandemic. Although we have evidence-based psychological treatments to address these conditions, most people encounter some barriers to receiving this help (e.g., stigma, geographical or time limitations). Digital mental health interventions (e.g., Internet-based interventions, smartphone apps, mixed realities -virtual and augmented reality) provide an opportunity to improve accessibility to these treatments. This article summarizes the main contributions of the different types of digital mental health solutions. It analyzes their limitations (e.g., drop-out rates, lack of engagement, lack of personalization, lack of cultural adaptations) and showcases the latest sophisticated and innovative technological advances under the umbrella of precision medicine (e.g., digital phenotyping, chatbots, or conversational agents). Finally, future challenges related to the need for real world implementation of these interventions, the use of predictive methodology, and hybrid models of care in clinical practice, among others, are discussed.

Background: To assess three dimensions of Meaning in Life (comprehension, purpose, and mattering) the Multidimensional Existential Meaning Scale (MEMS) was developed, however, the MEMS's factorial structure has not yet been confirmed in a Spanish-speaking sample. A question that remains unanswered is which of the three dimensions of MiL are associated with psychopathology in clinical samples., Aims: (1) to analyze the psychometric properties of the MEMS in a Spanish non-clinical population, and (2) to identify which of the three dimensions of MiL shows the strongest relationship with depression, anxiety and positive affect in a clinical population., Method: The non-clinical sample, consisted of N = 1106 Spanish adults, and the clinical sample consisted of 88 adults diagnosed with mental disorders. A Confirmatory Factor Analysis and regression analysis were carried out., Results: The three-factor model for the MEMS showed an acceptable fit, and full invariance across gender groups. In the clinical sample, the mattering dimension had the highest association with depression and anxiety, and purpose with positive affect., Conclusion: The MEMS is an adequate instrument to assess the three dimensions of meaning in Spanish-speaking participants. These results support the importance of evaluating the MiL construct from a multidimensional perspective in clinical samples., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Marco, García-Alandete, Pérez Rodríguez, Guillén, Baños and Tormo-Irun.)

Disturbances in eating behaviors have been widely related to obesity. However, little is known about the role of obesity-related biomarkers in shaping habitual patterns of eating behaviors (i.e., eating styles) in childhood. The objective of the present study was to explore the relationships between several biomarkers crucially involved in obesity (ghrelin, insulin resistance, and leptin/adiponectin ratio) and eating styles in children and adolescents with obesity. Seventy participants aged between 8 and 16 (56.2% men) fulfilled the Spanish version of the Dutch Eating Behavior Questionnaire for Children to measure external, emotional, and restrained eating styles. In addition, concentrations of ghrelin, leptin, adiponectin, insulin, and glucose were obtained through a blood test. Hierarchical multiple regression analyses controlling for age and sex were computed for each eating style. Results indicated that individuals with higher ghrelin concentration levels showed lower scores in restrained eating (β = -0.61, p < 0.001). The total model explained 32% of the variance of the restrained pattern. No other relationships between obesity-related biomarkers and eating behaviors were found. This study highlights that one of the obesity-risk factors, namely lower plasma ghrelin levels, is substantially involved in a well-known maladaptive eating style, restraint eating, in childhood obesity.

The outbreak of COVID-19 and national restrictions to slow down its spread have significantly changed people's everyday lives. Many people engage in intensive social media use (SMU) to stay up-to-date about the pandemic. The present study investigated the extent of SMU as source of COVID-19 information, and its relationship with anxiety and the experienced burden caused by the pandemic in Spain. Of the 221 participants, 52.5% reported to frequently use SM as information source. The use of other information sources such as print and online newspaper reports, television reports, and official governmental online sites was not associated with anxiety and burden caused by the current COVID-19 situation. However, SMU was significantly positively linked to both variables. Moreover, anxiety significantly mediated the relationship between SMU and the experienced burden. The findings show the potential negative effect of SMU on individual emotional state and behavior during the pandemic. They emphasize the significance of an accurate and conscious use of SM specifically during extraordinary circumstances such as the COVID-19 outbreak., Competing Interests: Conflicts of Interest/Competing InterestsOn behalf of all authors, the corresponding author states that there are no conflicts of interest or competing interests., (© The Author(s) 2021.)

COVID-19 pandemic-related confinement may be a fruitful opportunity to use individual resources to deal with it or experience psychological functioning changes. This study aimed to analyze the evolution of different psychological variables during the first coronavirus wave to identify the different psychological response clusters, as well as to keep a follow-up on the changes among these clusters. The sample included 459 Spanish residents (77.8% female, M age  = 35.21 years, SD age  = 13.00). Participants completed several online self-reported questionnaires to assess positive functioning variables (MLQ, Steger et al. in J Loss Trauma 13(6):511-527, 2006. 10.1080/15325020802173660; GQ-6, McCullough et al. in J Person Soc Psychol 82:112-127, 2002. 10.1037/0022-3514.82.1.112; CD-RISC, Campbell-Sills and Stein in J Traum Stress 20(6):1019-1028, 2007. 10.1002/jts.20271; CLS-H, Chiesi et al. in BMC Psychol 8(1):1-9, 2020. 10.1186/s40359-020-0386-9; SWLS; Diener et al. in J Person Assess, 49(1), 71-75, 1985), emotional distress (PHQ-2, Kroenke et al. in Med Care 41(11):1284-1292, 2003. 10.1097/01.MLR.0000093487.78664.3C; GAD-2, Kroenke et al. in Ann Internal Med 146(5):317-325, 2007. 10.7326/0003-4819-146-5-200703060-00004; PANAS, Watson et al. in J Person Soc Psychol 47:1063-1070, 1988; Perceived Stress, ad hoc), and post-traumatic growth (PTGI-SF; Cann et al. in Anxiety Stress Coping 23(2):127-137, 2010. 10.1080/10615800903094273), four times throughout the 3 months of the confinement. Linear mixed models showed that the scores on positive functioning variables worsened from the beginning of the confinement, while emotional distress and personal strength improved by the end of the state of alarm. Clustering analyses revealed four different patterns of psychological response: "Survival", "Resurgent", "Resilient", and "Thriving" individuals. Four different profiles were identified during mandatory confinement and most participants remained in the same cluster. The "Resilient" cluster gathered the largest number of individuals (30-37%). We conclude that both the heterogeneity of psychological profiles and analysis of positive functioning variables, emotional distress, and post-traumatic growth must be considered to better understand the response to prolonged adverse situations., Supplementary Information: The online version contains supplementary material available at 10.1007/s10902-021-00469-z., Competing Interests: Conflict of interestAll authors declare that they have no conflict of interest., (© The Author(s) 2021.)

The use of virtual reality (VR) and mixed reality (MR) technology in clinical psychology is growing. Efficacious VR-based treatments for a variety of disorders have been developed. However, the field of technology-assisted psychotherapy is constantly changing with the advancement in technology. Factors such as interdisciplinary collaboration, consumer familiarity and adoption of VR products, and progress in clinical science all need to be taken into consideration when integrating virtual technologies into psychotherapies. We aim to present an overview of current expert opinions on the use of virtual technologies in the treatment of anxiety and stress-related disorders. An anonymous survey was distributed to a select group of researchers and clinicians, using an analytic framework known as Strengths, Weaknesses, Opportunities, and Threats (SWOT). Overall, the respondents had an optimistic outlook regarding the current use as well as future development and implementation of technology-assisted interventions. VR and MR psychotherapies offer distinct advantages that can overcome shortcomings associated with traditional therapy. The respondents acknowledged and discussed current limitations of VR and MR psychotherapies. They recommended consolidation of existing knowledge and encouraged standardisation in both theory and practice. Continued research is needed to leverage the strengths of VR and MR to develop better treatments. Abbreviations: AR: Augmented Reality; MR: Mixed Reality; RCT: Randomised Controlled Trial; SWOT: Strengths, Weaknesses, Opportunities, and Threats; VR: Virtual Reality; VR-EBT: Virtual Reality Exposure-Based Therapy.

Background: Adolescence is a developmental stage when there is a high risk of engaging in non-suicidal self-injury (NSSI). There is recent interest in the study of thwarted belongingness and perceived burdensome as variables associated with the frequency of NSSI in adolescents. Meaning in life (MIL) might be negatively associated with thwarted belongingness and perceived burdensomeness. To date, no studies have analyzed the buffering role of MIL in the association between thwarted belongingness and perceived burdensomeness and the frequency of lifetime NSSI in Spanish adolescents., Aims: (a) To test whether thwarted belongingness and perceived burdensomeness are associated with frequency of lifetime NSSI; (b) to test whether MIL moderates the association between thwarted belongingness and frequency of lifetime NSSI; and (c) to test whether MIL moderates the association between perceived burdensomeness and frequency of lifetime NSSI., Method: The sample consisted of N = 1531 participants ( n = 736, 48.1%, were men, and n = 795, 51.9%, were women) between 12 and 18 years old from Spain. The participants filled out the Inventory of Statements about Self-Injury, Purpose-In-Life Test-Adolescent Version, and Interpersonal Needs Questionnaire. Moderation analyses were performed., Results: No statistically significant differences were found in the frequency of lifetime NSSI in the adolescents based on gender. Thwarted belongingness and perceived burdensomeness were positively associated with the frequency of lifetime NSSI in Spanish adolescents. MIL was a moderating variable between thwarted belongingness and the frequency of lifetime NSSI, and between perceived burdensomeness and the frequency of lifetime NSSI., Conclusions: Thwarted belongingness and perceived burdensomeness might be positively associated with the frequency of lifetime NSSI, and MIL might be negatively associated with the frequency of lifetime NSSI. Thus, adding these variables to current descriptive theories of NSSI in adolescents would allow us to improve assessment and treatment protocols for adolescents with NSSI.

Background: The current COVID-19 coronavirus pandemic is an emergency on a global scale, with huge swathes of the population required to remain indoors for prolonged periods to tackle the virus. In this new context, individuals' health-promoting routines are under greater strain, contributing to poorer mental and physical health. Additionally, individuals are required to keep up to date with latest health guidelines about the virus, which may be confusing in an age of social-media disinformation and shifting guidelines. To tackle these factors, we developed Elena+, a smartphone-based and conversational agent (CA) delivered pandemic lifestyle care intervention. Methods: Elena+ utilizes varied intervention components to deliver a psychoeducation-focused coaching program on the topics of: COVID-19 information, physical activity, mental health (anxiety, loneliness, mental resources), sleep and diet and nutrition. Over 43 subtopics, a CA guides individuals through content and tracks progress over time, such as changes in health outcome assessments per topic, alongside user-set behavioral intentions and user-reported actual behaviors. Ratings of the usage experience, social demographics and the user profile are also captured. Elena+ is available for public download on iOS and Android devices in English, European Spanish and Latin American Spanish with future languages and launch countries planned, and no limits on planned recruitment. Panel data methods will be used to track user progress over time in subsequent analyses. The Elena+ intervention is open-source under the Apache 2 license (MobileCoach software) and the Creative Commons 4.0 license CC BY-NC-SA (intervention logic and content), allowing future collaborations; such as cultural adaptions, integration of new sensor-related features or the development of new topics. Discussion: Digital health applications offer a low-cost and scalable route to meet challenges to public health. As Elena+ was developed by an international and interdisciplinary team in a short time frame to meet the COVID-19 pandemic, empirical data are required to discern how effective such solutions can be in meeting real world, emergent health crises. Additionally, clustering Elena+ users based on characteristics and usage behaviors could help public health practitioners understand how population-level digital health interventions can reach at-risk and sub-populations., Competing Interests: JO, PS, AA, DR, CB, OK, EF, FW, and TK are affiliated with the Centre for Digital Health Interventions www.c4dhi.org, a joint initiative of the Department of Management, Technology and Economics at ETH Zurich and the Institute of Technology Management at the University of St. Gallen, which was funded in part by the Swiss health insurer CSS Versicherung. EF and TK are also cofounders of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, neither CSS nor Pathmate Technologies are involved in the Elena+ project or this article. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer AR declared a past co-authorship with several of the authors AS and RB to the handling editor., (Copyright © 2021 Ollier, Neff, Dworschak, Sejdiji, Santhanam, Keller, Xiao, Asisof, Rüegger, Bérubé, Hilfiker Tomas, Neff, Yao, Alattas, Varela-Mato, Pitkethly, Vara, Herrero, Baños, Parada, Agatheswaran, Villalobos, Keller, Chan, Mishra, Jacobson, Stanger, He, von Wyl, Weidt, Haug, Schaub, Kleim, Barth, Witt, Scholz, Fleisch, Wangenheim, Car, Müller-Riemenschneider, Hauser-Ulrich, Asomoza, Salamanca-Sanabria, Mair and Kowatsch.)

Body image (BI) disturbance is a relevant factor in the etiology and treatment of eating disorders (ED). Although progress has been made in recent decades in understanding BI and its relationship with ED, the efficacy of BI disturbance prevention and intervention programs is still limited. In order to reach deeper understanding of BI disturbance and clarify the interactions between some protective and risk factors related to this construct, we carried out a literature review on some specific BI-related factors that so far have been analyzed independently. We specifically examined positive and negative BI; embodiment and its role in the development of positive and negative BI; and self-compassion as a protective factor that promotes positive embodiment (vs. disembodiment) and protection against body shame. We conclude that integrating the available evidence on these factors into BI models may be used to enhance our understanding of BI and improve the efficacy of prevention and intervention programs to help fight negative BI (by reducing body shame and disembodiment) and promote positive BI (by increasing self-compassion and positive embodiment)., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background : The adverse consequences of the COVID-19 pandemic on mental health have been widely studied in recent months. However, few studies have examined the protective psychological factors that may explain how individuals are coping with the COVID-19 pandemic and its forced confinements. Objective : This study analyzes the impact of confinement due to the COVID-19 pandemic on positive functioning variables (resilience, meaning of life, gratitude, compassion, life satisfaction), emotional distress (depression, anxiety, perceived stress, affect), and posttraumatic growth (PTG). The impact was measured during and after the first month of strict and obligatory confinement in Spain. Methods : The sample was composed of 438 Spanish residents (78.3% women) between the ages of 18 and 68 ( M = 35.68; SD  = 13.19) during the first stage (first two weeks) of confinement. The sample was reduced to 197 participants during the second stage (fifth week) of confinement. Several online self-reported questionnaires were administered to assess positive functioning variables, emotional distress, and PTG. Results : Women, youths, individuals without a partner, with lower monetary incomes, or diagnosed with a mental disorder or chronic illness experienced lower scores in positive functioning variables and greater emotional distress during the first stage of confinement. Linear mixed models showed that scores on positive functioning variables, emotional distress, and PTG worsened in the second stage of confinement. Nevertheless, a structural equations model showed that increases in positive functioning variables in the second stage were associated with increases in life satisfaction ( R 2   = .450) and related to decreases in emotional distress ( R 2   = .186), leading in turn to increases in PTG ( R 2   = .061). Conclusions : Individuals could experience PTG during strict and mandatory confinement. The increase in PTG during this adverse event was indirectly associated with increases in positive functioning variables (i.e. gratitude, presence of meaning, resilience), through improvements in life satisfaction and emotional distress., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Physical exercise declines during adolescence due to several factors, such as lack of intrinsic motivation or enjoyment, high physical exercise anxiety, and so on. The objectives of this study were to validate the psychometric structure of the Behavioral Regulation in Exercise Questionnaire-2 to confirm the existence of five levels of motivation toward physical exercise in adolescent population, as well as to analyze the differences in motivation according to sex and age, and the role of age and sex in the relationship between motivation and enjoyment. To do so, 666 students between 10 and 16 years old completed the Behavioral Regulation in Exercise Questionnaire-2 and questionnaires related to enjoyment and physical exercise anxiety. The confirmatory factor analysis of the Behavioral Regulation in Exercise Questionnaire-2 showed a five-factor structure. However, a more parsimonious four-factor structure with a single intrinsic-identified regulation emerged through an exploratory factor analysis. The more self-determined types of motivation were positively associated with enjoyment and negatively with anxiety, the type of physical exercise motivation fluctuated depending on age and sex, and the age moderated the relationship between motivation and enjoyment. This study highlights the importance of fostering specific types of motivation to improve the physical exercise and the relevance of age and sex when developing interventions.

The study investigated the influence of resilience and dispositional optimism on, first, emotional distress and, second, the intention to self-isolate, experienced by people with a lower and higher illness risk, during the lockdown imposed in Spain during the first COVID-19 wave. These effects were investigated against the background of the Health Belief Model (HBM). A convenience sample of N = 325 participants completed an online survey including an ad-hoc questionnaire measuring the HBM core factors: Perceived health threat (susceptibility and severity of getting infected), and perceived quarantine benefits and costs. Self-efficacy and perceived social pressure were also measured. Based on reviews regarding pandemic outbreaks, quarantine benefits were conceptualized as the perceived effectiveness and solidary contribution of self-isolating in line with the quarantine protocols. Quarantine "psychosocial" costs were conceptualized as a composite of perceived boredom, loneliness, and economic concerns. Findings revealed an asymmetrical pattern of results so that (i) people at higher risk were more distressed by the perceived severity of getting infected whereas people at lower risk were more distressed by the psychosocial costs. Moreover, (ii) resilience and optimism were more "protective" against distress within the lower and higher risk groups, respectively. In addition, (iii) quarantine benefits and self-efficacy promoted the intention to self-isolate within both groups. However, (iv) optimism hindered such intention. This finding is discussed in the light of links between dispositional optimism and optimistic bias; the underestimation of experiencing negative events, which can relax the perceived health risk. Based on these findings, communication campaigns should prioritize information about the effectiveness of the implemented preventive behaviors rather than the costs of not implementing them, and be cautionary in encouraging excessive optimism., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Cervera-Torres, Ruiz-Fernández, Godbersen, Massó, Martínez-Rubio, Pintado-Cucarella and Baños.)