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Karoline Körfer,1 Lea Schemer,2 Tobias Kube,2 Julia A Glombiewski2 1Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany; 2Department of Clinical Psychology and Psychotherapy, University of Koblenz – Landau, Landau, GermanyCorrespondence: Karoline KörferDepartment of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, GermanyEmail karoline.koerfer@uni-marburg.deObjective: Novel suggestions derived from the inhibitory learning model on how to optimize exposure therapy have been debated with enthusiasm in the last few years, particularly with respect to the focus on expectancy violations. However, little is known about how this new approach directly compares to the traditional habituation rationale of exposure therapy. In the present study, we examined these two competing therapeutic instructions among healthy female participants in an experimental heat pain paradigm.Design and Methods: Participants (N= 116) received a therapeutic instruction derived from either a habituation-based approach or the inhibitory learning model (expectation violation). Participants were repeatedly exposed to painful thermal stimulations until a predefined exposure goal was reached.Results: The expectation violation instruction led to faster goal attainment and higher response rates than the habituation instruction. Both instructions led to increased pain tolerance in the short and long term (one-week follow-up).Conclusion: Our results suggest that exposure treatments using an expectation violation instruction are especially time-effective. Although the findings from this analogue design cannot be directly generalized to populations with clinically relevant levels of chronic pain, they do point to some important theoretical and clinical implications for the treatment of pain.Keywords: exposure therapy, inhibitory learning model, expectation violation, dose-response relationship

Lea Schemer,1 Winfried Rief,2 Julia A Glombiewski1 1Department of Clinical Psychology and Psychotherapy, University Koblenz - Landau, Landau 76829, Germany; 2Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg 35032, GermanyCorrespondence: Lea SchemerDepartment of Clinical Psychology and Psychotherapy, University Koblenz – Landau, Ostbahnstraße 10, Landau 76829, GermanyTel +49 6341 280-35627Email schemer@uni-landau.dePurpose: Accumulating evidence suggests an association between patient expectations and treatment success across various types of pain treatments. Expectations among treatment caregivers, however, are often neglected. Despite international treatment guidelines, only a small minority of chronic pain patients undergo psychological interventions. Therefore, our aim was to explore expectations among treatment receivers and caregivers especially concerning their attitudes towards psychological pain treatments.Methods: Two hundred ten (potential) treatment receivers (n=85 individuals suffering from chronic low back pain (CLBP); n=125 healthy controls) and 237 caregivers (n=75 physicians; n=64 psychotherapists; n=98 physiotherapists) provided ratings of expected treatment success for standardized vignettes describing patients suffering from CLBP and undergoing a pharmacological, psychological, or multimodal pain management program.Results: Individuals suffering from CLBP generally had lower treatment expectations than healthy controls. Both psychotherapists and physicians had higher treatment expectations from their own individual treatment approach. All participants expected the multimodal approach to be most effective. The psychological approach was expected to be more effective than the pharmacological approach – except for the physicians, who expected both treatment approaches to be equally effective.Conclusion: There is an urgent need to clarify, under which circumstances and how patient expectations can be altered among individuals suffering from CLBP. Our results appear to encourage the implementation of multimodal and psychological pain management approaches across various settings. We invite clinicians to reflect whether their own expectations are in line with the recommendations in international treatment guidelines.Keywords: treatment expectations, chronic pain management approaches, psychological pain treatments, attitudes of treatment receivers and caregivers

Robert Sielski,1 Julia Anna Glombiewski,1 Winfried Rief,1 Geert Crombez,2 Antonia Barke1 1Department for Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany; 2Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium Abstract: According to the dual process model of coping, assimilative or accommodative strategies can be applied to deal with aversive life situations. In people with chronic pain, the tenacious focus on achieving analgesia is often referred to as assimilative coping and associated with more disability and catastrophic thinking. In contrast, accommodative coping (accepting one’s pain and setting new goals) appears to have beneficial effects. To assess how people with chronic pain use these different coping strategies, questionnaires measuring these concepts are needed. Following international guidelines, a German version of the Pain Solutions Questionnaire (PaSol) was prepared. A sample of 165 participants with chronic low back pain (CLBP; 60% women; age 53 ± 8.4 years) filled in the questionnaire and measures for pain-related disability, affective distress, catastrophic thinking, and attention to pain. Item analyses, an exploratory factor analysis, and correlations with pain-related measures were calculated. In addition, data from 98 participants who received psychological treatment were examined to investigate the PaSol’s sensitivity to change. The exploratory factor analysis reproduced the original questionnaire’s four-factor structure. Internal consistencies for the subscales ranged from Cronbach’s α=0.72 to α=0.84. Mean item difficulties for the subscales ranged from pi=0.62 to pi=0.79. The highest correlations were found for Meaningfulness with catastrophic thinking (r=−0.58) and affective distress (r=−0.36). The PaSol subscale Meaningfulness predicted pain-related disability; the subscales Meaningfulness and Solving Pain predicted affective distress. Furthermore, the PaSol was found to be sensitive to detect changes over time. The German version of the PaSol is a reliable and valid instrument in the measurement of assimilative and accommodative coping strategies in people suffering from CLBP. It may provide a useful tool when examining temporal dynamics of the changing coping strategies in the transition from acute to chronic pain as well as during pain treatments. Keywords: acceptance, back pain, coping, problem-solving, German, validation

Jenny Riecke,1 Sebastian Holzapfel,1 Winfried Rief,1 Harald Lachnit,2 Julia A Glombiewski1 1Department for Clinical Psychology and Psychotherapy, 2Department for Associative Learning, University of Marburg, Marburg, Germany Study design: Cross-cultural translation and psychometric testing. Objective: The purpose of the present study was to examine reliability and validity of a cross-cultural adaption of the German Quebec Back Pain Disability Scale (QBPDS) in a context of a randomized controlled trial evaluating the effectiveness of graded in vivo exposure in chronic low back pain patients. Background: The QBPDS is one of the most widely used disease-specific disability questionnaires. In particular, for cognitive behavioral treatments with a clear focus on behavioral aspects such as graded in vivo exposure, the QBPDS provides an ascertained strategy with a sound conceptual basis and excellent quality criteria. Nevertheless, there is conflicting evidence concerning factor structure and a German adaption is missing. Methods: The cross-cultural adaption followed international guidelines. Psychometric testing was performed using data from 180 participants with chronic low back pain. The psychometric analyses included internal consistency, convergent, and divergent validity. Exploratory factor analysis was used to determine the underlying factor structure. Results: The QBPDS showed strong psychometric properties, with high internal consistency for the full scale (α=0.94) and good convergent and divergent validity. The factor analysis revealed a four-factor solution (bending, ambulation, brief effortful movements, and long-lasting postures). Conclusion: The translation and cross-cultural adaption of the QBPDS into German was successful. The German version proved to be a valid and reliable instrument and is well suited for use in the context of an exposure-based psychological treatment. Keywords: Chronic pain, back pain, questionnaire, functional disability, German, validation

Our objective is to implement a single-case experimental design (SCED) infrastructure in combination with experience-sampling methods (ESM) into the standard diagnostic procedure of a German outpatient research and training clinic. Building on the idea of routine outcome monitoring, the SCED infrastructure introduces intensive longitudinal data collection, individual effectiveness measures, and the opportunity for systematic manipulation to push personalization efforts further. It aims to empower psychotherapists and patients to evaluate their own treatment (idiographic perspective) and to enable researchers to analyze open questions of personalized psychotherapy (nomothetic perspective). Organized around the principles of agile research, we plan to develop, implement, and evaluate the SCED infrastructure in six successive studies with continuous stakeholder involvement: In the project development phase, the business model for the SCED infrastructure is developed that describes its vision in consideration of the context (Study 1). Also, the infrastructure's prototype is specified, encompassing the SCED procedure, ESM protocol, and ESM survey (Study 2 and 3). During the optimization phase, feasibility and acceptability are tested and the infrastructure is adapted accordingly (Study 4). The evaluation phase includes a pilot implementation study to assess implementation outcomes (Study 5), followed by actual implementation using a within-institution A-B design (Study 6). The sustainability phase involves continuous monitoring and improvement. We discuss to what extent the generated data could be used to address current questions of personalized psychotherapy research. Anticipated barriers and limitations during the implementation processes are outlined., (© 2024. The Author(s).)

Abstract: This is the first study to empirically determine the potential for data-driven personalization in the context of chronic primary pain (CPP). Effect sizes of psychological treatments for individuals with CPP are small to moderate on average. Aiming for better treatment outcomes for the individual patient, the call to personalize CPP treatment increased over time. However, empirical evidence that personalization of psychological treatments can optimize treatment outcomes in CPP is needed. This study seeks to estimate heterogeneity of treatment effect for cognitive behavioral therapy (CBT) as the psychological treatment approach for CPP with the greatest evidence base. For this purpose, a Bayesian variance ratio meta-regression is conducted using updated data from 2 recently published meta-analyses with randomized controlled trials comparing CBT delivered face-to-face to treatment-as-usual or waiting list controls. Heterogeneity in patients with CPP would be reflected by a larger overall variance in the post-treatment score compared with the control group. We found first evidence for an individual treatment effect in CBT compared with the control group. The estimate for the intercept was 0.06, indicating a 6% higher variance of end point values in the intervention groups. However, this result warrants careful consideration. Further research is needed to shed light on the heterogeneity of psychological treatment studies and thus to uncover the full potential of data-driven personalized psychotherapy for patients with CPP.A Bayesian variance ratio meta-regression indicates empirical evidence that data-driven personalized psychotherapy for patients with chronic primary pain could increase effects of cognitive behavioral therapy., (Copyright © 2024 International Association for the Study of Pain.)

Objective: Research suggests that some therapists achieve better outcomes than others. However, an overlooked area of study is how institution differences impact patient outcomes independent of therapist variance. This study aimed to examine the role of institution and therapist differences in adult outpatient psychotherapy., Method: The study included 1428 patients who were treated by 196 therapists at 10 clinics. Two- and three-level hierarchical linear regression models were employed to investigate the effects of therapists and institutions on three dependent patient variables: (1) symptom change, (2) treatment duration, and (3) dropout. Level three explanatory variables were tested., Results: The results showed that therapist effects (TE) were significant for all three types of treatment outcome (7.8%-18.2%). When a third level (institution) was added to the model, the differences between therapists decreased, and significant institution effects (IE) were found: 6.3% for symptom change, 10.6% for treatment duration, and 6.5% for dropout. The exploratory analyses found no predictors able to explain the systematic variation at the institution level., Discussion: TE on psychotherapy outcomes remain a relevant factor but may have been overestimated in previous studies due to not properly distinguishing them from differences at the institution level.

Objective: Exposure with response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD). However, refusals, dropouts and the required high time and logistic effort constitute barriers to the use of ERP. In a non-inferiority randomized controlled trial, we compared metacognitive therapy (MCT) to exposure with response prevention (ERP) as treatments for OCD., Method: 74 outpatients received 12 weekly sessions of either manualized MCT or ERP, with primary outcomes assessed by blinded assessors using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at pre-treatment, mid-treatment, post-treatment, and 6-month follow-up. Secondary outcomes included measures of depression and anxiety. Non-inferiority margin was specified at no less than d = 0.38 below the improvement reached by ERP, corresponding to a difference of about 3 points on the Y-BOCS., Results: Drop-out rates were low (<14%) and similar in both groups. Linear models indicated non-inferiority of MCT to ERP at post-treatment, but not at 6-month follow-up. While both groups showed comparable Y-BOCS improvements, the MCT group demonstrated a significantly greater reduction in state anxiety scores at post-treatment and follow-up., Conclusions: Overall, MCT was not inferior to ERP, especially at post-treatment, suggesting it could be a treatment alternative. However, further research is needed to explore differential treatment indications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Open-label placebos (OLP) prescribed without deception and with a convincing rationale have been shown to evoke powerful treatment effects. Patients' treatment expectations seem to influence the magnitude of the effect., Objective: We examined if two different OLP rationales increased pain tolerance and reduced pain intensity and unpleasantness in a standardized heat pain experiment., Methods: Participants (N = 71) who self-reported reoccurring pain for at least the last 3 months were randomly assigned to one of three groups. We compared a personal-emotional and a scientific-matter-of-fact rationale with a control group (CG) that received the same placebo without any rationale. The rationale suggested a desensitizing effect on pain perception and improved pain coping of the placebo, whereas in the CG it was introduced as an ointment for measurement. The primary outcomes were pre-post changes in pain tolerance, expected and experienced pain intensity and unpleasantness., Results: Participants showed a decrease in expected pain intensity, but not expected pain unpleasantness for both rationales. There were no differences in pain tolerance and experienced pain intensity and unpleasantness., Conclusions: Our study suggests that evoking positive treatment expectations is not sufficient to elicit an OLP response. Possibly, the magnitude of expectations change in this study was not powerful enough to evoke an OLP effect. Additionally, it is possible that OLP effects in pain are unrelated to positive treatment expectations. The failure of OLP in our study is in contrast to a number of previous studies examining the effects of OLP in experimental and clinical pain., Significance: This study provides evidence that positive treatment expectations are not sufficient to evoke an open-label placebo effect in a standardized heat pain experiment. We showed that two different rationales improved participants treatment expectations, but failed to evoke a placebo effect in comparison to a control group that received the same placebo, labelled as an ointment to improve measurement quality., (© 2023 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation ‐ EFIC ®.)

Background: Relations among psychological variables are assumed to be complex and to vary over time. Personalized networks can model multivariate complex interactions. The development of time-varying networks allows to model the variation of parameters over time. Objectives: We aimed to determine the value of time-varying networks for clinical practice. Methods: We applied time-varying mixed graphical models (TV-MGM) and time-varying vector autoregressive models (TV-VAR) to intensive longitudinal data of nine participants with depressive symptoms ( n  = 6) or anxiety ( n  = 3). Results: Most of the participants showed temporal changes in network topology within the assessment period of 30 days. Time-varying networks of participants with small, medium, and large time variability in edge parameters clearly show the different temporal evolvements of dynamic interactions between variables. The case example indicates clinical utility but also limitations to the application of time-varying networks in clinical practice. Conclusion: Time-varying network models provide a data-driven and exploratory approach that could complement current diagnostic standards by reflecting interacting, often mutually reinforcing processes of mental health problems and by accounting for variation over time. They can be used to generate hypotheses for further confirmatory and clinical testing.

Introduction: Chronic back pain is a widespread medical condition associated with high socioeconomic costs and increasing prevalence. Despite the advanced implementation of multidisciplinary approaches, providing a satisfactory treatment offer for those affected is often not possible. Exposure therapy (EXP) promises to be an effective and economical form of treatment and in a previous pilot study showed to be superior to cognitive behavioral therapy (CBT) in reducing perceived limitations of movement. The current study aims to further compare the efficacy of both treatment methods and identify those patient groups that particularly benefit from EXP., Methods: The general objective of this randomized multicenter clinical trial (targeted N = 380) is to improve and expand the range of treatments available to patients with chronic back pain. As the primary objective of the study, two different psychological treatments (EXP and CBT) will be compared. The primary outcome measure is a clinically significant improvement in pain-related impairment, measured by the QPBDS, from baseline to 6-month follow-up. Secondary outcome measures are absolute changes and clinically significant improvements in variables coping, psychological flexibility, depressiveness, catastrophizing, exercise avoidance and fear of exercise, and intensity of pain. Participants are recruited in five psychological and medical centers in Germany and receive ten sessions of manualized therapy by trained licensed CBT therapists or clinical psychologists, who are currently in their post-gradual CBT training. Potential predictors of each treatment's efficacy will be explored with a focus on avoidance and coping behavior., Conclusion: This study will be the first RCT to compare CBT and EXP in chronic back pain in a large sample, including patients from different care structures due to psychological and medical recruitment centers. By identifying and exploring potential predictors of symptom improvement in each treatment group, this study will contribute to enable a more individualized assignment to treatment modalities and thus improves the care situation for chronic back pain and helps to create a customized treatment program for subgroups of pain patients. If our findings confirm EXP to be an efficacious and efficient treatment concept, it should gain more attention and be further disseminated., Trial Registration: ClinicalTrials.gov NCT05294081. Registered on 02 March 2022., (© 2024. The Author(s).)

Introduction: Depressive symptoms have been linked to difficulties in revising established negative beliefs in response to novel positive information. Recent predictive processing accounts have suggested that this bias in belief updating may be related to a blunted processing of positive prediction errors at the neural level. In this proof-of-concept study, pupil dilation in response to unexpected positive emotional information was examined as a psychophysiological marker of an attenuated processing of positive prediction errors associated with depressive symptoms., Methods: Participants ( N = 34) completed a modified version of the emotional Bias Against Disconfirmatory Evidence (BADE) task in which scenarios initially suggest negative interpretations that are later either confirmed or disconfirmed by additional information. Pupil dilation in response to the confirmatory and disconfirmatory information was recorded., Results: Behavioral results showed that depressive symptoms were related to difficulties in revising negative interpretations despite disconfirmatory positive information. The eye tracking results pointed to a reduced pupil response to unexpected positive information among people with elevated depressive symptoms., Discussion: Altogether, the present study demonstrates that the adapted emotional BADE task can be appropriate for examining psychophysiological aspects such as changes in pupil size along with behavioral responses. Furthermore, the results suggest that depression may be characterized by deviations in both behavioral (i.e., reduced updating of negative beliefs) and psychophysiological (i.e., decreased pupil dilation) responses to unexpected positive information. Future work should focus on a larger sample including clinically depressed patients to further explore these findings., 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 © 2024 Spaeth, Koenig, Everaert, Glombiewski and Kube.)

Placebo interventions generate mismatches between expected pain and sensory signals from which pain states are inferred. Because we lack direct access to bodily states, we can only infer whether nociceptive activity indicates tissue damage or results from noise in sensory channels. Predictive processing models propose to make optimal inferences using prior knowledge given noisy sensory data. However, these models do not provide a satisfactory explanation of how pain relief expectations are translated into physiological manifestations of placebo responses. Furthermore, they do not account for individual differences in the ability to endogenously regulate nociceptive activity in predicting placebo analgesia. The brain not only passively integrates prior pain expectations with nociceptive activity to infer pain states (perceptual inference) but also initiates various types of actions to ensure that sensory data are consistent with prior pain expectations (active inference). We argue that depending on whether the brain interprets conflicting sensory data (prediction errors) as a signal to learn from or noise to be attenuated, the brain initiates opposing types of action to facilitate learning from sensory data or, conversely, to enhance the biasing influence of prior pain expectations on pain perception. Furthermore, we discuss the role of stress, anxiety, and unpredictability of pain in influencing the weighting of prior pain expectations and sensory data and how they relate to the individual ability to regulate nociceptive activity (endogenous pain modulation). Finally, we provide suggestions for future studies to test the implications of the active inference model of placebo analgesia., (Copyright © 2023 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: There is a significant research gap with respect to the long-term sustainability of psychological treatment effects in chronic pain patients. This study aimed to investigate long-term treatment effects of two psychological treatments: cognitive behavioural therapy (CBT) as a broad-spectrum approach and exposure as a specific intervention for fear-avoidant pain patients., Methods: Patients with chronic low back pain were randomized to CBT or exposure in vivo. Long-term follow-up (LTFU) data were available for 64 patients up to 8 years after treatment, with a response rate of 73%. The primary outcomes were pain-related disability and pain intensity and secondary outcomes were emotional distress, psychological flexibility, catastrophizing and pain-related fear. The data analysis was performed with longitudinal multilevel modelling., Results: Multilevel analyses showed improvements in all primary outcomes as well as all secondary outcomes from pre-treatment to LTFU for both treatments. The mean proportion of cases meeting reliable and clinical improved criteria in all primary outcome was 36% (range: 22%-46%) in the exposure group and 50% (range: 33%-60%) in the CBT group. Dropout analyses revealed significantly higher deterioration rates over time. Pre-treatment to LTFU effect sizes of the primary outcomes ranged from 0.54 to 1.59., Conclusions: Our results indicate that the effects of psychological treatments might be stable over several years. Treatment gains for exposure as a stand-alone treatment seem to be of shorter duration than a general CBT intervention. Thus, psychological treatments might offer a promising and sustainable long-term perspective for patients with chronic back pain., Significance: The long-term stability of treatment effects is a highly neglected issue despite its inherent importance in the context of chronic pain. This study is the first to investigate treatment effects of cognitive behavioural therapy and in vivo exposure in chronic back pain sufferers up to 8 years after treatment. The findings contribute to an understanding of the sustainability of psychological cognitive behavioural therapy-based intervention effects., (© 2023 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®.)

Background: Research has shown that patients with somatoform disorders (SFD) have difficulty using medical reassurance (i.e. normal results from diagnostic testing) to revise concerns about being seriously ill. In this brief report, we investigated whether deficits in adequately interpreting the likelihood of a medical disease may contribute to this difficulty, and whether patients' concerns are altered by different likelihood framings., Methods: Patients with SFD ( N = 60), patients with major depression ( N = 32), and healthy volunteers ( N = 37) were presented with varying likelihoods for the presence of a serious medical disease and were asked how concerned they are about it. The likelihood itself was varied, as was the format in which it was presented (i.e. negative framing focusing on the presence of a disease v. positive framing emphasizing its absence; use of natural frequencies v. percentages)., Results: Patients with SFD reported significantly more concern than depressed patients and healthy people in response to low likelihoods (i.e. 1: 100 000 to 1:10), while the groups were similarly concerned for likelihoods ⩾1:5. Across samples, the same mathematical likelihood caused significantly different levels of concern depending on how it was framed, with the lowest degree of concern for a positive framing approach and higher concern for natural frequencies (e.g. 1:100) than for percentages (e.g. 1%)., Conclusions: The results suggest a specific deficit of patients with SFD in interpreting low likelihoods for the presence of a medical disease. Positive framing approaches and the use of percentages rather than natural frequencies can lower the degree of concern.

Objective: The causes of the long-term persistence of symptoms after a severe acute respiratory syndrome coronavirus 2 infection (i.e., post-COVID syndrome) remain elusive. Although previous research identified demographic and medical risk factors for the development of post-COVID, the present prospective study is the first to investigate the role of psychological factors., Methods: The interview and survey data of polymerase chain reaction-positive participants ( n = 137; 70.8% female) were assessed in the acute, subacute (3 months after symptom onset), and chronic phases (6 months after symptom onset) of COVID., Results: After controlling for medical (body mass index, disease score) and demographic factors (sex, age), psychosomatic symptom burden (measured by the Somatic Symptom Disorder-B Criteria Scale) predicted higher odds and magnitude of COVID-related symptom impairment in the post-COVID phases. Fear of COVID-related health consequences (measured by the Fear of COVID Scale) also predicted higher odds of reporting any COVID symptoms in the subacute and chronic phases, whereas it only predicted a higher magnitude of COVID-related symptom impairment in the subacute phase. In subsequent exploratory analyses, we found that other psychological factors were associated with an overall increase (i.e., chronic stress and depression) or decrease (i.e., trait positive affect) in the odds and magnitude of COVID-related symptom impairment., Conclusions: We conclude that psychological factors can fuel or temper the experience in post-COVID syndrome, opening new possibilities for psychological interventions., Trial Registration: The study protocol was preregistered in the Open Science Framework ( https://osf.io/k9j7t )., (Copyright © 2023 by the American Psychosomatic Society.)

This is the first study to disentangle associations of within- and between-person fluctuations in loneliness and their effect on evening mood during a nationwide lockdown due to COVID-19. To contribute to the development of personality-tailored risk profiles, we additionally explored the moderating role of trait neuroticism and extraversion on the association of within- and between-person loneliness and mood. We employed an ambulatory assessment design during 21 days of nationwide lockdown in Germany (13/04/2020-03/05/2020) with two interval-based assessments. The final sample comprised 322 participants (74.5% women) aged between 15 and 82 years (M = 30.7, SD = 14.9) providing 6,084 evening assessments. Linear mixed models were used to evaluate the effects of within- and between-person fluctuations in loneliness on evening mood while controlling for unspecific effects of time, sex, and age. Moderation analysis was used to investigate the influence of neuroticism and extraversion on the relation between loneliness and mood, respectively. Results indicate that especially higher between-person loneliness (i.e. participants felt lonelier compared to the average participant) but also higher within-person loneliness (i.e. participants felt lonelier compared to their individual mean) were associated with a more unpleasant mood. Neuroticism augmented the effect of within-person loneliness, while extraversion seemed to buffer the effect of between-person loneliness on mood. Our findings underline the importance of carefully monitoring loneliness during COVID-19. The findings contribute towards the development of personality-tailored risk profiles (e.g. among newly arising risk groups for loneliness due to COVID-19). We discuss how the differential consideration of within- and between-psychological processes might help to elucidate currently mixed findings on psychological coping during the COVID-19 pandemic.

Background and Aims: For the first time, the ICD-11 provides the diagnosis compulsive sexual behavior disorder (CSBD) that can be assigned for pornography use disorder (PUD). This study aimed to estimate the prevalence of PUD and associated consequences in Germany, to identify the psychotherapy demand among likely PUD (lPUD) cases and the treatment supply in different psychotherapeutic settings, to survey psychotherapists' level of expertise regarding PUD, and to identify predictors for psychotherapy demand., Methods: Four studies were conducted: 1. Online study in the general population (n = 2070; m = 48.9%, f = 50.8%, d = 0.2%), 2. Survey among practicing psychotherapists (n = 983), 3. Survey of psychotherapists in psychotherapeutic outpatient clinics (n = 185), 4. Interviews with psychotherapeutic inpatient clinics (n = 28)., Results: The estimated prevalence of lPUD in the online study was 4.7% and men were 6.3 times more often affected than women. Compared to individuals without PUD, individuals with lPUD more often indicated negative consequences in performance-related areas. Among lPUD cases, 51.2% of men and 64.3% of women were interested in a specialized PUD treatment. Psychotherapists reported 1.2%-2.9% of lPUD cases among their patients. 43.2%-61.5% of psychotherapists stated to be poorly informed about PUD. Only 7% of psychotherapeutic inpatient clinics provided specific treatments to patients with PUD. While, among other factors, negative consequences attributed to lPUD were predictive for psychotherapy demand, weekly pornography consumption, subjective well-being, and religious attachment were not., Discussion and Conclusions: Although PUD occurs quite often in Germany, availability of mental health care services for PUD is poor. Specific PUD treatments are urgently needed.

With the steadily growing importance of psychotherapeutic care, there is also an increasing need for high-quality training. We analyze the literature published between 2009 and 2022 on the effectiveness of training in cognitive behavioral therapy. The review addresses current gaps in the literature by focusing on the description of specific training components and their associated costs, as well as examining therapist-level predictors of training effectiveness. Our findings confirm the effect of additional supervision on both therapist competence and patient outcomes. Instructor-led training and self-guided web-based training seem to moderately increase competence, especially when targeting specific and highly structured treatments or skills. The level of prior training and experience of a therapist appears to predict the strength of training-related gains in competence. Few studies analyzed the differential effect of certain elements of training (e.g., the amount of active learning strategies) and training costs were generally not reported. Future studies should replicate or expand the existing evidence on active ingredients and therapist-level predictors of training effectiveness. Costs should be systematically reported to enhance the comparability of different training strategies., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Increasing the access to and improving the impact of pain treatments is of utmost importance, especially among youths with chronic pain. The engagement of patients as research partners (in contrast to research participants) provides valuable expertise to collaboratively improve treatment delivery., Objective: This study looked at a multidisciplinary exposure treatment for youths with chronic pain through the lens of patients and caregivers with the aim to explore and validate treatment change processes, prioritize and develop ideas for improvement, and identify particularly helpful treatment elements., Methods: Qualitative exit interviews were conducted with patients and caregivers at their discharge from 2 clinical trials (ClinicalTrials.gov NCT01974791 and NCT03699007). Six independent co-design meetings were held with patients and caregivers as research partners to establish a consensus within and between groups. The results were validated in a wrap-up meeting., Results: Patients and caregivers described that exposure treatment helped them better process pain-related emotions, feel empowered, and improve their relationship with each other. The research partners developed and agreed upon 12 ideas for improvement. Major recommendations include that pain exposure treatment should be disseminated more not only among patients and caregivers but also among primary care providers and the general public to facilitate an early referral for treatment. Exposure treatment should allow flexibility in terms of duration, frequency, and delivery mode. The research partners prioritized 13 helpful treatment elements. Most of the research partners agreed that future exposure treatments should continue to empower patients to choose meaningful exposure activities, break long-term goals into smaller steps, and discuss realistic expectations at discharge., Conclusions: The results of this study have the potential to contribute to the refinement of pain treatments more broadly. At their core, they suggest that pain treatments should be disseminated more, flexible, and transparent., (©Lea Schemer, Courtney W Hess, Amanda R Van Orden, Kathryn A Birnie, Lauren E Harrison, Julia A Glombiewski, Laura E Simons. Originally published in Journal of Participatory Medicine (https://jopm.jmir.org), 09.03.2023.)

Background: In two experimental studies, we tested the hypothesis that negative mood would hinder the revision of negative beliefs in response to unexpectedly positive information in depression, whereas positive mood was expected to enhance belief updating., Methods: In study 1 ( N = 101), we used a subclinical sample to compare the film-based induction of sad v. happy mood with a distraction control group. Subsequently, participants underwent a well-established paradigm to examine intra-individual changes in performance-related expectations after unexpectedly positive performance feedback. In study 2, we applied the belief-updating task from study 1 to an inpatient sample ( N = 81) and induced sad v. happy mood via film-clips v. recall of autobiographic events., Results: The results of study 1 showed no significant group differences in belief updating; the severity of depressive symptoms was a negative predictor of belief revision, though, and there was a non-significant trend suggesting that the presence of sad mood hindered belief updating in the subgroup of participants with a diagnosed depressive episode. Study 2 revealed that participants updated their expectations significantly less in line with positive feedback when they underwent the induction of negative mood prior to feedback, relative to positive mood., Conclusions: By indicating that the presence of negative mood can hinder the revision of negative beliefs in clinically depressed people, our findings suggest that learning from new experiences can be hampered if state negative mood is activated. Thus, interventions relying on learning from novel positive experiences should aim at reducing state negative mood in depression.

Background: We examined whether the difficulties of patients with somatoform disorders (SFDs) in integrating medical reassurance can be altered by preventing patients from devaluing reassuring information through defensive cognitive strategies., Method: Patients with SFD ( n = 60), patients with major depression ( n = 32), and healthy volunteers ( n = 37) watched a videotaped doctor's report, which provided medical reassurance for gastroenterological complaints. Subsequently, participants were asked about their perception of the report. In the SFD sample, patients' appraisal of the reassuring was experimentally modulated: In one condition, doubts about the validity of the doctor's diagnostic assessment were triggered; in another condition, the devaluation of medical reassurance was blocked through underscoring the validity of the doctor's diagnostic assessment; and a control condition received no manipulation., Results: As evident on all outcome variables, patients with SFD had more difficulty integrating medical reassurance than depressed and healthy people. Within the SFD sample, participants from the experimental condition blocking the devaluation of medical reassurance rated the likelihood of an undetected serious disease to be significantly lower than the other two conditions. They also reported less emotional concern and a lower desire to seek the opinion of another doctor., Conclusions: By comparing patients with SFD to both a healthy and a clinical control group, the current study suggests that the difficulty in processing reassuring medical information is a specific psychopathological feature of SFD. Furthermore, our results suggest that the integration of medical reassurance can be improved by preventing patients from devaluing reassuring information through dismissive cognitive strategies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

After traumatic experiences, intrusive memories can flash back and evoke significant distress. Here, we investigated whether the frequency and severity of intrusions can be reduced by the provision of placebo. After the (online) exposure to the trauma-film paradigm, healthy participants (N = 112) received deceptive placebo (DP), open-label placebo (OLP), or no treatment. In the DP group, participants were led to believe to receive a dopamine-modulating drug, which was supposed to disrupt the consolidation of traumatic memories, although they in fact received the same placebo tablets as the OLP group for one week. The results show that the groups did not differ in the frequency of intrusive memories after one week. However, participants receiving OLP reported a significantly reduced intensity of intrusions as compared to DP. Across groups, negative expectations about the intensity and controllability of intrusions were associated with a higher frequency of intrusions, higher distress, higher burden, and more negative appraisal. The results suggest that expectations play an important role in the emergence of intrusive memories and that some of the disabling aspects of intrusive memories can be reduced by placebo. This may carry clinical potential because placebos are an accessible, cost-effective intervention to reduce the risk of intrusive memories., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: Placebos being prescribed with full honesty and disclosure (i.e., open-label placebo [OLP]) have been shown to reduce symptom burden in a variety of conditions. With regard to allergic rhinitis, previous research provided inconclusive evidence for the effects of OLP, possibly related to a separate focus on either symptom severity or symptom frequency. Overcoming this limitation of previous research, the present study aimed to examine the effects of OLP on both the severity and frequency of allergic symptoms., Methods: In a randomized-controlled trial, patients with allergic rhinitis ( N = 74) were randomized to OLP or treatment as usual (TAU). Because of the COVID-19 pandemic, OLP was administered remotely in a virtual clinical encounter. Participants took placebo tablets for 14 days. The primary outcomes were the severity and frequency of allergic symptoms. The secondary end point was allergy-related impairment., Results: OLP did not significantly improve symptom severity over TAU ( F (1,71) = 3.280, p = .074, η2 = 0.044) but did reduce symptom frequency ( F (1,71) = 7.272, p = .009, η2 = 0.093) and allergy-related impairment more than TAU ( F (1,71) = 6.445, p = .013, η2 = 0.083), reflecting medium to large effects. The use of other antiallergic medication did not influence the results., Conclusions: Although OLP was able to lower the frequency of allergic symptoms and allergy-related impairment substantially, its effects on symptom severity were weaker. The remote provision of OLP suggests that physical contact between patients and providers might not be necessary for OLP to work., (Copyright © 2022 by the American Psychosomatic Society.)

Background: Expectations of painful sensations constitute a core feature of chronic pain. An important clinical question is whether such expectations are revised when disconfirming experiences are made (e.g., less pain than expected). This study examined how people adjust their pain expectations when the experience of decreasing pain is expected vs. unexpected., Methods: In a novel randomized between-subjects design, a subclinical sample of people who frequently experience pain was provided with painful thermal stimulations. Unbeknownst to participants, the temperature applied was decreased from trial to trial. Based on the experimental instructions provided, this experience of decreasing pain was expected in one condition (expectation-confirmation; n = 34), whereas it was unexpected in another (expectation-disconfirmation; n = 39)., Results: Perceived pain intensity was lower in the expectation-confirmation condition than in the expectation-disconfirmation condition (p = .014, η p 2  = 0.083). The expectation-confirmation condition also showed a greater adjustment of their pain expectations than the expectation-disconfirmation condition (p = .046, η p 2  = 0.047). Across groups, large expectation violations (i.e., less pain than expected) were associated with increases in pain tolerance and the ability to cope with pain at a one-week follow-up., Conclusions: In terms of assimilation, perceived pain intensity was shaped in the direction of pain expectations. The greater adjustment of expectations in the expectation-confirming condition is consistent with a confirmation bias in pain perception. Though participants who experienced large discrepancies between expected and experienced pain were hesitant to adjust their pain expectations immediately, expectation violations increased their ability to cope with pain one week later, suggesting some beneficial longer-term effects of expectation violations., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: The aim of our study was to determine and enhance physicians' acceptance, performance expectancy and credibility of health apps for chronic pain patients. We further investigated predictors of acceptance., Design: Randomised experimental trial with a parallel-group repeated measures design., Setting and Participants: 248 physicians working in various, mainly outpatient settings in Germany., Intervention and Outcome: Physicians were randomly assigned to either an experimental group (short video about health apps) or a control group (short video about chronic pain). Primary outcome measure was acceptance. Performance expectancy and credibility of health apps were secondary outcomes. In addition, we assessed 101 medical students to evaluate the effectiveness of the video intervention in young professionals., Results: In general, physicians' acceptance of health apps for chronic pain patients was moderate (M=9.51, SD=3.53, scale ranges from 3 to 15). All primary and secondary outcomes were enhanced by the video intervention: A repeated-measures analysis of variance yielded a significant interaction effect for acceptance ( F (1, 246)=15.28, p = 0.01), performance expectancy ( F (1, 246)=6.10, p = 0.01) and credibility ( F (1, 246)=25.61, p < 0.001). The same pattern of results was evident among medical students. Linear regression analysis revealed credibility (β=0.34, p < 0.001) and performance expectancy (β=0.30, p < 0.001) as the two strongest factors influencing acceptance, followed by scepticism (β=-0.18, p < 0.001) and intuitive appeal (β=0.11, p = 0.03)., Conclusions and Recommendations: Physicians' acceptance of health apps was moderate, and was strengthened by a 3 min video. Besides performance expectancy, credibility seems to be a promising factor associated with acceptance. Future research should focus on ways to implement acceptability-increasing interventions into routine care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cognitive immunisation against disconfirmatory evidence (i.e., devaluing expectation-disconfirming information through cognitive mechanisms) has recently been discussed as an obstacle to the revision of dysfunctional beliefs in mental disorders such as depression. Yet, it is unclear whether cognitive immunisation is also involved in belief updating in non-clinical samples., Methods: Using a three-group modulation protocol (promotion vs. inhibition of cognitive immunisation vs. control group), we examined how cognitive immunisation influences belief updating in response to performance feedback in three non-clinical samples. In Experiments 1 ( N  = 99) and 2 ( N  = 93), participants received unexpectedly negative feedback, whereas participants from Experiment 3 ( N  = 118) received unexpectedly positive feedback. Depressive symptoms and dispositional optimism were examined as additional predictors of belief updating., Results: In all experiments, participants adjusted their expectations in line with the feedback received, but this effect was not influenced by the cognitive immunisation manipulation. In Experiment 3, expectation change remained stable over 2 weeks. Depressive symptoms were associated with a reduced integration of positive feedback, but not with an increased sensitivity to negative feedback., Conclusions: Whereas previous research has shown that cognitive immunisation contributes to persistent beliefs in clinical populations, the present findings suggest that it does not affect belief updating in non-clinical samples., Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-021-10256-y., Competing Interests: Conflict of InterestTobias Kube and Julia Anna Glombiewski declare that they have no conflicts of interest., (© The Author(s) 2021.)

Objective Ecological momentary assessment (EMA) and network analysis are promising empirical developments for psychotherapy research and practice, but they lack a therapeutic rationale that could guide case conceptualization and treatment planning. We developed an assessment strategy that aims to assess functional analysis with EMA. Method: The assessment strategy was applied to a series of three N-of-1 assessments in a proof-of-concept study. After selecting a personalized set of items, EMA was implemented with three measurement time points per day for a period of 30 days. The participants evaluated feasibility and acceptance. Practicing psychotherapists discussed clinical implications in a focus group. Results: The implementation of the assessment strategy seemed feasible and accepted; participants did not report any side effects. Principal component and network analyses indicated interpretable components (e.g., participant 1: hopelessness, procrastination, coping, avoidance). The focus group pointed out potentials (e.g., efficient profit of the waiting time, empowering patients) and challenges (e.g., prioritize and interpret all the information). Conclusion: The presented assessment strategy may enhance the scientific quality of case conceptualization empowering therapists' decision-making regarding treatment planning. At the same time, it is a concrete demonstration of the challenges that need to be addressed in future research.

Background: Polyregulation-the concurrent or sequential use of multiple strategies to regulate affect or cope with stressors-is a frequent but understudied phenomenon., Objectives: We aimed to identify patterns of daily coping and individuals' coping repertoires (i.e., range of coping patterns employed across situations) during a COVID-19 pandemic lockdown. We investigated day-level covariates (appraisals, worrying, mood) of daily coping patterns and person-level covariates (psychopathology, average mood) of coping repertoires. Design: A non-representative community sample ( n  = 322, 15-82 years old) participated in a 21-day ambulatory assessment study., Methods: We applied multilevel latent class analysis.., Results: We identified seven daily coping patterns and ten classes of individuals differing in the size of their coping repertoire and their propensity for polyregulation. Daily coping patterns differed in daily perceived controllability and mood (but not in daily worrying or stress). At the person level, individuals with a higher level of average coronavirus-related worrying more frequently engaged in a high degree of polyregulation. The size of individuals' coping repertoire was unrelated to psychopathology and average mood., Conclusion: The findings provide insights into the composition of daily coping patterns and individuals' coping repertoires during crisis periods and contribute to a new polyregulation perspective on coping.

Behavior therapy of obsessive-compulsive disorder (OCD) aims to reduce avoidance, rituals, and discomfort in OCD-relevant situations. The Behavioral Avoidance Test (BAT) measures these behavior-related outcomes in individually challenging OCD-related situations. The association of the BAT with OCD severity measures and its relevance for treatment outcome is, however, still unclear. The current study investigates with a retrospective analysis of a subsample of a pilot study, (1) if reactions on the BAT are related to OCD severity measures in an OCD sample ( n = 28), (2) if treatment with two variants of cognitive-behavior therapy (exposure and response prevention vs. metacognitive therapy) changes the BAT scores and (3) if these changes as well as pretreatment BAT avoidance are relevant for OCD treatment outcome as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Participants rated avoidance, ritual, and discomfort in three individually challenging OCD-related situations before and after therapy. For one of these situations, BAT dimensions were rated by the therapist and an independent rater in addition to the patients' ratings. Correlational analyses found significant correlations between BAT discomfort and OCD severity measures like the Y-BOCS. A repeated measures ANOVA with pre- and posttest scores showed that all three BAT dimensions significantly decreased during both treatments. Hierarchical regression analyses (controlling for Y-BOCS pretest scores) revealed that changes in BAT discomfort as well as pretreatment BAT avoidance scores predicted the Y-BOCS posttest score. These findings suggest that the BAT is a distinct measure of behavior-related outcomes partly being relevant for OCD treatment outcome., 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 Hansmeier, Haberkamp, Glombiewski and Exner.)

Metacognitive therapy (MCT) has been shown to be a promising treatment approach for obsessive-compulsive disorder (OCD). The changeability of metacognitions by (metacognitive) treatment and its relevance to treatment outcome is, however, still unclear. The current study investigates, (1) if treatment with MCT or exposure and response prevention (ERP) in a randomized-controlled pilot trial ( n = 24 patients with OCD) changes OCD-specific metacognitions of thought fusion beliefs, beliefs about rituals and stop signals, and (2) if these changes are relevant for the treatment outcome in terms of patient- and therapist-rated OCD symptoms. ANOVA with pretest, posttest and follow-up scores could show that all three metacognitions significantly decreased during both treatments. Regarding thought fusion beliefs, a significant interaction effect indicated a higher decrease after MCT than ERP treatment. In hierarchical regression analyses, changes in stop signals from pre- to post-treatment significantly predicted patient-rating OCD symptoms at post-treatment and follow-up at 3 months after treatment. These changes were even predictive of post-treatment outcome after controlling for general metacognitions and dysfunctional cognitive beliefs. These findings support the assumption that metacognitions can change during both treatments and that changes in stop signals might be relevant for the treatment outcome on the symptom level in OCD., 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 Hansmeier, Haberkamp, Glombiewski and Exner.)

Differences in fear conditioning between individuals suffering from chronic pain and healthy controls may indicate a learning bias that contributes to the acquisition and persistence of chronic pain. However, evidence from lab-controlled conditioning studies is sparse and previous experiments have produced inconsistent findings. Twenty-five participants suffering from chronic back pain and twenty-five controls not reporting chronic pain took part in a differential fear conditioning experiment measuring attention (eye tracking) and autonomic arousal (pupil dilation and skin conductance) elicited by visual cues predicting the presence or absence of electric shock. In contrast to the healthy control group, participants with chronic pain did not acquire differential autonomic responding to cues of threat and safety and specifically failed to acquire any attentional preference for the safety cue over irrelevant contextual cues (while such preference was intact for the threat cue). We present simulations of a reinforcement learning model to show how the pattern of data can be explained by assuming that participants with chronic pain might have experienced less positive emotion (relief) when the electric shock was absent following safety cues. Our model shows how this assumption can explain both, reduced differential responding to cues of threat and safety as well as less selective attention to the safety cue., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The ability to differentiate between negative emotional states [negative emotion differentiation (NED)] has been conceptualized as a trait that facilitates effective emotion regulation and buffers stress reactivity. In the present research, we investigated the role of NED in within-person processes of daily affect regulation and coping during times of stress (the first COVID-19-related pandemic lockdown in April 2020). Using intensive longitudinal data, we analyzed whether daily stress had an indirect effect on sleep quality through calmness in the evening, and we tested whether NED moderated this within-person indirect effect by buffering the link between daily stress and calmness in the evening. A non-representative community sample ( n = 313, 15-82 years old) participated in a 21-day ambulatory assessment with twice-daily surveys. The results of multilevel mediation models showed that higher daily stress was related to within-day change in calmness from morning to evening, resulting in less calmness in the evening within persons. Less calmness in the evening, in turn, was related to poorer nightly sleep quality within persons. As expected, higher NED predicted a less negative within-person link between daily stress and calmness in the evening, thereby attenuating the indirect effect of daily stress on nightly sleep quality through calmness. This effect held when we controlled for mean negative emotions and depression. The results provide support for a diathesis-stress model of NED, and hence, for NED as a protective factor that helps to explain why some individuals remain more resilient during times of stress than others., 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 Lischetzke, Schemer, Glombiewski, In-Albon, Karbach and Könen.)

Objectives: Although several questionnaires assessing fear of movement exist, it is still a challenge to identify individuals who might benefit more from exposure for chronic pain than from other psychological approaches and vice versa. Psychological approaches to chronic pain cannot advance toward the often called-for "tailored approaches" because of limited knowledge about treatment predictors. Our aim was to evaluate the additional predictive value of avoidance behavior based on behavioral observation., Methods: This study examined pretreatment self-report and behavioral measures as predictors of treatment outcome for n=43 patients experiencing disabling chronic low back pain, who took part in a randomized controlled trial in which they received 10 to 15 sessions of exposure treatment. Only patients with elevated fear avoidance based on self-report measures were included. Data were analyzed using regression analyses and classification and regression trees., Results: Regression analyses showed that higher avoidance behavior at pretreatment as measured by the Behavioral Avoidance Test-Back Pain (BAT-Back) significantly predicted reduction in global disability (with a small to medium effect), but not in specific disability. Self-report measures failed to predict treatment success for both outcome measures. Classification and regression trees divide subgroups who might benefit from exposure treatment through a BAT-Back score of >22 for Pain Disability Index., Discussion: There is some preliminary evidence that pretreatment avoidance behavior might be an indicator for reduction in global disability after exposure treatments in patients experiencing disabling chronic low back pain and elevated fear avoidance. We identified preliminary cutoff scores that need further investigation., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Placebos can reduce physical symptoms even when provided with full honesty and disclosure. Yet, the precise mechanisms underlying the effects of "open-label placebos" (OLPs) have remained subject of debate. Furthermore, it is unclear whether OLPs are similarly effective when provided remotely, as is sometimes required e.g. in the current COVID-19 pandemic., Methods: In a randomized-controlled trial, we examined the effects of OLP plus treatment as usual (TAU) compared to TAU alone on symptom reduction in people with allergic rhinitis (N = 54) over the course of two weeks. Due to the COVID-19 pandemic, OLP was provided remotely (i.e. sent via postal service). To investigate the potential influence of the clinical encounter on the effects of OLP, we manipulated the perception of the virtual clinical encounter, both with respect to verbal and nonverbal factors (augmented vs. limited encounter)., Results: The results of the manipulation check confirmed that the augmented clinical encounter was evaluated more positively than the limited encounter, in terms of perceived warmth of the provider. Participants from all treatment groups showed significant symptom reduction from baseline to two weeks later, but OLP had no incremental effect over TAU. Participants benefitted more from OLP when they did not take any other medication against allergic symptoms than when taking medication on demand. When controlling for baseline symptoms, a significant treatment by encounter interaction was found, pointing to greater symptom improvement in the OLP group when the encounter was augmented, whereas the control group improved more when the encounter was limited., Discussion: The study demonstrates that providing OLP and enhancing the encounter remotely is possible, but their effectiveness might be lower in comparison to previous studies relying on physical patient-provider interaction. The study raises questions for future research about the potential and challenges of remote placebo studies and virtual clinical encounters. The study has been registered as a clinical trial at ISRCTN (record number: 39018)., Competing Interests: The authors have declared that no competing interests exist.

Self-compassion is associated with disability, pain-related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self-compassion versus other concepts such as psychological flexibility and self-esteem is unknown. The present study therefore aimed to clarify these relationships. Individuals with chronic pain (N CP  = 872) and without chronic pain (N NP  = 356) took part in a longitudinal study. Participants completed self-report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS-20), Patient Health Questionnaire (PHQ-9), State Trait Anger Expression Inventory (STAXI), Self-Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self-Esteem Scale (RSES). Assessments were repeated after 8 weeks. We found differences in baseline levels of all relevant variables except for anger-out and anger-control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (N CP ), addressing the predictive value of reduced uncompassionate self-responding (RUS), compassionate self-responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self-esteem (RSES) regarding pain-related (PDI, PCS, PASS) and emotional variables (PHQ-9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain-related anxiety. Self-esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%-72.1% of the variance in pain-related variables, 68.7% of the variance in depression and 38.7%-60.7% in the variance of anger-related variables. In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self-compassion. Future research should focus on subgroups and tailored-treatment approaches. SIGNIFICANCE: Applying a longitudinal design, this study examined the predictive value of self-compassion regarding pain, depression and anger. The relevance of self-compassion was compared to psychological flexibility and self-esteem. We can conclude that psychological flexibility, in terms of avoidance behaviour, is the most relevant predictor concerning pain., (© 2020 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation ‐ EFIC®.)

Background: Exposure treatments are shown to be effective in reducing pain-related fear and the perceived harmfulness of physical activities. However, due to the fragility of extinction its stability is questionable. We investigated the generalizability of exposure effects in chronic low back pain (CLBP) patients by integrating a behavioral test in the context of an intervention study., Methods: The study is an additional analysis of a randomized controlled trial investigating the efficacy of exposure in vivo. A total of 67 CLBP patients were randomly assigned to one of the three groups: Exposure-short (EXP-S); exposure-long (EXP-L) and cognitive behavioral therapy (CBT). Participants rated the expected harmfulness of daily activities (Photograph Series of Daily Activities) before and after therapy. Post-treatment participants were confronted with an individually tailored, threatening movement in a new context. Harm and pain expectations before the exposure were compared to the actual experience after exposure., Results: We found that EXP leads to more strongly reduced harm expectations (F(2,50) = 11.37, p < .001, η 2  = 0.31) compared to CBT, regardless of the duration of EXP. After therapy, patients expected less harm (F(2,50) = 3.61, p = .034, η 2  = 0.13) but not less pain (F(2,50) = 3.61, p = .034, η 2  = 0.13) when confronted with a novel movement., Conclusions: Exposure successfully reduced harm but not pain expectations in patients with CLBP. Further, preliminary results showed that these specific exposure effects were generalized to a novel activity in a different context outside therapy., Significance: This study investigats the generalizability and stability of exposure effects in patients with CLBP by combining a behavioral test with an intervention study. We found strong and stable effects on harm expectations but not on pain expectations. Results show promising preliminary evidence that reduced harm expectations can be generalized to a novel threatening activity in a new context. Clinical implications of our findings suggest that exposure treatment would benefit from a clear focus on harm expectations., (© 2020 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation -EFIC ®.)

Background: Meta-analyses demonstrate that placebo effects play an important role in antidepressant treatment. Expectations seem to constitute a highly relevant placebo mechanism in this context. This study investigated whether an expectation manipulation combined with the intake of an active placebo could reduce acute sadness in depressed participants following a sadness-inducing mood manipulation., Methods: Women who suffered from a major depressive episode (N = 94) were randomly allocated to the drug expectation group (expectation to receive a fast-operating antidepressant), the placebo expectation group (expectation to receive a placebo) or the no treatment group (no expectation, no placebo). The drug expectation and the placebo expectation group received a placebo. All participants watched a sadness-inducing film. Sadness was assessed at baseline, after randomization and after placebo intake and mood induction. Data were analyzed by a 3 × 3 analysis of variance., Results: There were significant between-group differences in sadness change from the baseline after mood induction. While sadness increased in the no treatment group, it did not change in the placebo expectation group. In the drug expectation group, sadness even decreased., Limitations: Only a single medication intake was simulated. Effects on acute sadness do not allow inferences about depression symptoms., Conclusion: This experimental study found a placebo effect on sadness in clinically depressed participants. The effects were even larger than expected. Future research must investigate placebo effects on depression symptoms as well as long-term placebo intake., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest associated with this publication to declare and there has been no significant financial support for this work that could have influenced its outcome., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The cognitive model of depression has significantly influenced the understanding of distorted cognitive processes in major depression; however, this model's conception of cognition has recently been criticized as possibly too broad and unspecific. In this review, we connect insights from cognitive neuroscience and psychiatry to suggest that the traditional cognitive model may benefit from a reformulation that takes current Bayesian models of the brain into account. Appealing to a predictive processing account, we explain that healthy human learning is normally based on making predictions and experiencing discrepancies between predicted and actual events or experiences. We present evidence suggesting that this learning mechanism is distorted in depression: current research indicates that people with depression tend to negatively reappraise or disregard positive information that disconfirms negative expectations, thus resulting in sustained negative predictions and biased learning. We also review the neurophysiological correlates of such deficits in processing prediction errors in people with depression. Synthesizing these findings, we propose a novel mechanistic model of depression suggesting that people with depression have the tendency to predominantly expect negative events or experiences, which they subjectively feel confirmed due to reappraisal of disconfirming evidence, thus creating a self-reinforcing negative feedback loop. Computationally, we consider too much precision afforded to negative prior beliefs as the main candidate of pathology, accompanied by an attenuation of positive prediction errors. We conclude by outlining some directions for future research into the understanding of the behavioral and neurophysiological underpinnings of this model and point to clinical implications of it., (Copyright © 2019 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objectives: Recent research has shown that placebos can be effective even if they are openly prescribed to participants. Yet, it is unclear how such "open-label placebos" (OLPs) compare to deceptive placebo (DP) and what the mechanisms of actions are. In this study, we therefore compared 2 versions of OLP to DP and no treatment (NT)., Materials and Methods: Using a standard heat pain paradigm, 117 healthy volunteers underwent a baseline and a posttreatment pain assessment. With the exception of NT, all groups received an inert placebo cream after the first assessment. OLP was administered by either evoking positive expectancies or by raising hope for placebo analgesia, thus distinguishing for the first time conceptually between expectancy and hope in experimental pain research. The primary outcome was pre-post change in pain tolerance., Results: Increase in pain tolerance was larger in the 3 treatment groups compared with NT, whereas the treatment groups did not differ from each other. Further results showed that participants receiving DP reported a large reduction of subjective pain intensity and unpleasantness, whereas no such reduction was found for the 2 OLP groups. The 2 OLP versions did not differ in terms of their analgesic effects., Discussion: The study provided evidence for traditional placebo analgesia on the basis of deception. For OLP, we found that OLP indeed increased pain tolerance; however, participants receiving OLP were reluctant to report any subjective analgesic effects. Combined with previous studies, the present findings suggest that the effects of OLP are weaker in healthy volunteers than in clinical samples.

Background: People with depression differ from healthy people in the extent to which they use novel positive information to adjust negative expectations. In this study, we examined whether the two groups also differ in updating positive expectations after receiving unexpectedly negative information., Methods: Examining 76 people with depressive symptoms and 81 healthy controls, we used an adapted version of a previously validated paradigm. After the initial establishment of positive performance expectations, participants worked on the TEMINT performance test, whereupon half of the participants received standardized feedback that confirmed previous positive expectations while the other half received disconfirming negative feedback. Subsequently, participants' performance expectations were assessed again. Additionally, we assessed participants' appraisal of the feedback, particularly whether they tended to disregard it., Results: Results indicated that healthy subjects had overall more positive expectations than people with depressive symptoms, but the two samples did not differ in updating their expectations: both groups changed their expectations in a negative direction after receiving negative feedback; similarly, there were no differences between the two samples after receiving confirmatory positive feedback. Both people with and without depressive symptoms were more likely to disregard the feedback received if the feedback was negative, and such a negative appraisal of the feedback was associated with smaller expectation update., Conclusions: In combination with prior work, the current findings suggest that people with depressive symptoms do not over-sensitively react to unexpectedly negative information; rather, the main problem of depression seems to be the integration of novel positive information, as shown previously., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Research has revealed that negative expectations impact depressive symptoms. However, research on the change of dysfunctional expectations in depression is lacking so far. Therefore, the present research aimed to fill this gap by testing the hypothesis that people with the major depressive disorder (MDD), contrary to healthy individuals, maintain their expectations despite experiences that positively disconfirm expectations. Further, it was hypothesized that cognitive immunization (a cognitive reappraisal of the disconfirming evidence) is a mechanism underlying the persistence of expectations., Method: In Study 1, we compared individuals with MDD (N = 58) to healthy individuals (N = 59). Participants worked on the same performance test and received standardized feedback that either confirmed or disconfirmed their initial performance expectations. In Study 2, we investigated the effects of cognitive immunization on expectation change among 59 individuals reporting elevated levels of depression by varying the appraisal of expectation-disconfirming feedback., Results: Results from Study 1 show that in the expectation-disconfirming condition, healthy individuals changed their expectations, whereas individuals with MDD did not. No such difference between the two groups was found for expectation-confirming feedback. Results from Study 2 indicated that varying cognitive immunization impacted expectation change, thus suggesting a crucial role of cognitive immunization in expectation change., Conclusions: These two studies indicated that individuals suffering from depression have more difficulties in changing their expectations after disconfirming experiences than do healthy individuals, and cognitive immunization might be a core mechanism underlying expectation persistence. Therefore, psychotherapeutic interventions should aim to inhibit cognitive immunization processes to enhance expectation change.

Background: Research has shown that negative expectations in major depressive disorder (MDD) often persist despite positive disconfirming experiences. To explain this phenomenon, the concept of cognitive immunization has been introduced: that is, individuals with MDD reappraise disconfirming positive evidence in such a way that negative expectations are maintained. In this study, we examined whether it is possible to inhibit cognitive immunization to facilitate expectation update., Methods: We examined 113 people with MDD being treated in an inpatient psychosomatic hospital. Using a previously validated paradigm, participants worked on a standardized performance test; we examined changes in negative performance-related expectations after positive expectation-disconfirming feedback. One experimental group received additional information increasing the value of the positive feedback ('INFORMATION'). Another group was instructed to recall the feedback after completing the task ('RECALL'). In a third group, participants' attention was shifted to potential expectation-disconfirming feedback ('ATTENTION'). In addition, a control group underwent the standard procedure of the paradigm., Results: The results showed significant group differences in the change in generalized performance expectations, with the largest changes in participants from the INFORMATION group. All experimental groups had lower values for cognitive immunization than the control group., Limitations: Given that this proof-of-concept study was the first to examine strategies to inhibit cognitive immunization, the findings need to be replicated in future studies., Conclusions: The present study confirms that cognitive immunization in MDD can be inhibited, thus facilitating adjusting negative expectations. The most promising results were found for the INFORMATION group, providing information to emphasize the relevance of expectation-disconfirming information., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: To improve treatment outcomes, it is essential to understand the processes involved in therapeutic change. The aim of this study was to investigate the processes involved in treatment of individuals with chronic lower back pain (CLBP) and high fear-avoidance. Graded in vivo exposure (Exposure), a specific treatment, and cognitive-behavioural therapy (CBT), a general treatment, were compared., Methods: Our study used data from a three-arm randomized controlled trial. The sample comprised 61 CLBP patients (pain duration >3 months; sufficient level of fear-avoidance). Assessments of session-by-session processes were done weekly for a maximum 14 weeks. The primary outcome, functional disability, was assessed at pre-treatment, post-treatment and 6-months follow-up. First, two-level models were used to test for treatment-related similarities and differences in the changes in session-by-session measures (i.e., common and unique treatment processes respectively). Second, we analysed treatment processes as predictors of treatment outcome., Results: Contrary to our expectations, we found no evidence of unique treatment processes. Our results indicate that Exposure and CBT share some treatment processes. Specifically, patients reported a reduction in fear of movement and improvements in their ability to relax, to distract themselves, to manage their pain, to confront feared movements, to be active and to enjoy things despite their pain. Changes in fear of movement, relaxation, distraction, confrontation, activity and pain-related self-efficacy were also related to disability reduction., Conclusions: Despite conceptual differences, Exposure and CBT may share common treatment processes. Future research needs to address, however, whether these processes need to be targeted directly or can be supported indirectly., Significance: We identified several treatment processes (e.g., reduction of fear of movement, enhancement of self-efficacy), which were associated with disability reduction during the management of chronic pain and fear-avoidance. These processes appeared to be equally important for Exposure and CBT. Practitioners should optimize these processes to improve their patients' functioning., (© 2018 European Pain Federation - EFIC®.)

Purpose of Review: Recent research suggests that expectations might be a particularly important subgroup of cognitions in major depression. The present study aimed to further specify the role of situation-specific dysfunctional expectations (SDEs) in the development of depressive symptoms. It was hypothesized that the effects of intermediate beliefs and dispositional optimism on depressive symptoms would be mediated via SDEs., Recent Findings: We examined 125 students (age M = 22.05, SD = 4.00, 74.6% women) using a longitudinal design with a 1-year follow-up. Questionnaires used in the study included the Depressive Expectations Scale, Dysfunctional Attitudes Scale, Life Orientation Test and Beck's Depression Inventory. When considering SDEs at baseline as mediator variable, neither intermediate beliefs nor dispositional optimism had significant direct effects on depressive symptoms. Instead, their effects were fully mediated via SDEs. When considering SDEs at the follow-up as the mediator variable, SDEs partly mediated the effects of intermediate beliefs and dispositional optimism on depressive symptoms., Summary: The study provides further evidence for a cognitive mediational model, suggesting that SDEs mediate the effects of rather global beliefs (such as intermediate beliefs and dispositional optimism) on depressive symptoms. Due to their high level of situational specificity, SDEs might be an effective target for cognitive-behavioural interventions.

Our aim was to evaluate isolated elements of psychological pain treatments and explore treatment effects on biological stress markers. We employed a single-case experimental design with multiple baselines. Matching pairs of twelve participants (chronic low back pain >6 months; elevated pain-related fear) were randomly assigned to graded in vivo exposure (EXP) or cognitive-behavioral therapy (CBT) in a yoked design. Primary assessments were taken during baseline (7-26 days), treatment (23-44 days) and at 6-months follow-up (11-30 days) including changes in pain symptoms, disability, pain-related fear, acceptance, body confidence, self-efficacy, and positive thoughts. Psycho-educational, behavioral, cognitive, and exposure interventions were compared to baseline. EXP exhibited immediate middle-to-large effects; CBT's small-to-middle effects were delayed. Within the EXP approach, change mainly occurred during exposure but not during psycho-educational sessions. Overall cortisol was lower in EXP than CBT at post-treatment. We recommend integrating exposure elements in the management of CLBP to increase its efficacy. Psycho-educational sessions might not be necessary or should be adapted, e.g. with stronger focus on motivational aspects. Since CBT seemed to produce delayed effects, core CBT interventions such as cognitive restructuring might be added after exposure treatment to sustain therapeutic effects., (Copyright © 2018 Elsevier Ltd. All rights reserved.)