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Contains fulltext : 214849.pdf (Publisher’s version ) (Open Access) Whereas sudden gains and losses (large shifts in symptom severity) in patients receiving psychotherapy appear abrupt and hence may seem unexpected, hypotheses from complex-systems theory suggest that sudden gains and losses are actually preceded by certain early-warning signals (EWSs). We tested whether EWSs in patients' daily self-ratings of the psychotherapeutic process predicted future sudden gains and losses. Data were collected from 328 patients receiving psychotherapy for mood disorders who completed daily self-ratings about their therapeutic process using the Therapy Process Questionnaire (TPQ). Sudden gains and losses were classified from the Problem Intensity scale of the TPQ. The other items of the TPQ were used to compute the EWSs. EWSs predicted an increased probability for sudden gains and losses in a 4-day predictive window. These results show that EWSs can be used for real-time prediction of sudden gains and losses in clinical practice. 11 p.

For patients with Obsessive-Compulsive Disorder (OCD), whose triggers are highly idiosyncratic, individual stimulus material has been used in several fMRI studies. This study aims at comparing individual to standardized picture sets and at investigating a possible overlap of the former with the self-referential neuronal network. During fMRI-scanning, 17 inpatients with OCD and 17 healthy controls were exposed to pictures of their personal triggers, photographed in their domestic environments, to standardized pictures designed to provoke OCD symptoms, and to neutral pictures. Whole-brain analyses were calculated and the pictures were rated by both patients and controls with respect to valence, arousal, and coping. Patients rated the individualized stimuli lower in valence and coping and higher in arousal compared to controls, and also compared to standardized OCD- and neutral stimuli. The individual stimuli elicited neuronal activity in the cingulate cortex, hippocampus, insula, middle frontal/precentral gyrus, superior/inferior parietal lobe, and precuneus, while no group difference was detected by the standardized OCD-stimuli. In conclusion, individual picture sets facilitate the detection of neuronal activity, but the results might be confounded due to the overlap with the network of self-referential processing and memory retrieval. The use of individual symptom-provoking and individual neutral stimuli would therefore be optimal.

Background While considerable progress has been made in exploring the psychological, the neural, and the neurochemical dimensions of OCD separately, their interplay is still an open question, especially their changes during psychotherapy. Methods Seventeen patients were assessed at these three levels by psychological questionnaires, fMRI, and venipuncture before and after inpatient psychotherapy. Seventeen controls were scanned at comparable time intervals. First, pre/post treatment changes were investigated for all three levels separately: symptom severity, whole-brain and regional activity, and the concentrations of cortisol, serotonin, dopamine, brain-derived neurotrophic factor (BDNF), and immunological parameters (IL-6, IL-10, TNFα). Second, stepwise linear modeling was used to find relations between the variables of the levels. Results The obsessive-compulsive, depressive, and overall symptom severity was significantly reduced after psychotherapy. At the neural level, the activity in the anterior cingulate cortex (ACC), in frontal regions, in the precuneus, and in the putamen had significantly decreased. No significant changes were found on the neurochemical level. When connecting the levels, a highly significant model was found that explains the decrease in neural activity of the putamen by increases of the concentrations of cortisol, IL-6, and dopamine. Conclusion Multivariate approaches offer insight on the influences that the different levels of the psychiatric disorder OCD have on each other. More research and adapted models are needed.

OBJECTIVE: Home-based treatment of families with low socio-economic status and multiple psychosocial problems (multi-problem families, MPFs) is gaining importance in clinical social epidemiology and health services research. The sustainability of the treatment is of special importance in order to breach transgenerational effects. METHODS: We examined outcome, effect size, and clinical significance of home-based treatment for 84 multi-problem families in a naturalistic setting. 48 of the families were available for a follow-up after 3 years. The baseline characteristics of these family systems included low collaboration, an increased family adversity index, minors with high rates of child psychiatric disorders, a high prevalence of comorbidity, low relational family functioning, and adolescents who refused any form of treatment or had unilaterally terminated different forms of treatment before. The home-based family therapy consisted of one or two face-to-face counseling sessions per week over an average of 28.8 months (SD = 19.2). The symptoms and competence of the adolescents, the caregivers, and the family structure were assessed with 13 variables. RESULTS: All variables showed significant improvement rates (pre- vs. post- treatment) with medium to high effect sizes (mean of Cohen’s d = 1.04, range = .34 – 2.18). All variables showed a sustained or even further improvement at follow-up. CONCLUSION: This study provides evidence of statistically (p), practically (d), and clinically (RCI) significant changes in symptom and competence-related variables among adolescents and caregivers in MPFs with sustainable long-term effects in the 3-year follow-up period.

Background Promoting well-being and preventing poor mental health in young people is a major global priority. Building emotional competence (EC) skills via a mobile app may be an effective, scalable and acceptable way to do this. However, few large-scale controlled trials have examined the efficacy of mobile apps in promoting mental health in young people; none have tailored the app to individual profiles. Method/design The Emotional Competence for Well-Being in Young Adults cohort multiple randomised controlled trial (cmRCT) involves a longitudinal prospective cohort to examine well-being, mental health and EC in 16–22 year olds across 12 months. Within the cohort, eligible participants are entered to either the PREVENT trial (if selected EC scores at baseline within worst-performing quartile) or to the PROMOTE trial (if selected EC scores not within worst-performing quartile). In both trials, participants are randomised (i) to continue with usual practice, repeated assessments and a self-monitoring app; (ii) to additionally receive generic cognitive-behavioural therapy self-help in app; (iii) to additionally receive personalised EC self-help in app. In total, 2142 participants aged 16 to 22 years, with no current or past history of major depression, bipolar disorder or psychosis will be recruited across UK, Germany, Spain, and Belgium. Assessments take place at baseline (pre-randomisation), 1, 3 and 12 months post-randomisation. Primary endpoint and outcome for PREVENT is level of depression symptoms on the Patient Health Questionnaire-9 at 3 months; primary endpoint and outcome for PROMOTE is emotional well-being assessed on the Warwick-Edinburgh Mental Wellbeing Scale at 3 months. Depressive symptoms, anxiety, well-being, health-related quality of life, functioning and cost-effectiveness are secondary outcomes. Compliance, adverse events and potentially mediating variables will be carefully monitored. Conclusions The trial aims to provide a better understanding of the causal role of learning EC skills using interventions delivered via mobile phone apps with respect to promoting well-being and preventing poor mental health in young people. This knowledge will be used to develop and disseminate innovative evidence-based, feasible, and effective Mobile-health public health strategies for preventing poor mental health and promoting well-being. Trial registration ClinicalTrials.gov (www.clinicaltrials.org). Number of identification: NCT04148508 November 2019.

Objective: fMRI scans of patients with obsessive-compulsive disorder (OCD) consistently show a hyperactivity of the insular cortex, a region responsible for disgust-processing, when confronted with symptom-triggering stimuli. This asks for an investigation of the role of disgust and the insula in OCD patients. Methods: Seventeen inpatients with OCD and 17 healthy controls (HC) underwent fMRI scanning. Whole-brain contrasts were calculated for "Disgust vs. Neutral" for both groups, plus an analysis of variance (ANOVA) to assess the interaction between group and condition. Additionally, the emotional dimensions of valence and arousal, along with the ability to cope, were assessed by picture ratings. Results: The picture ratings confirmed the patients' heightened sensitivity to disgust with higher values for arousal and inability to cope, but not for valence. fMRI scans revealed no hyperactivity of the insula in patients compared to controls for the condition "Disgust vs. Neutral," indicating no basic hypersensitivity to disgusting stimuli. Increased activity in the precuneus in controls for this condition might correspond to the downregulation of arousal. Conclusions: The absent differences in neural activity of the insula in patients compared to controls for the disgust-condition, but heightened activity for symptom-provoking conditions, suggests that the illness is due to an erroneous recruitment of the insula cortex for OCD-stimuli. The finding is interpreted within the framework of the neural reuse hypothesis.

CONTEXT: Families with high rates of childhood adversities (CAs) (Multi-problem-families-MPF) have an increasing importance in public health-policy. OBJECTIVE: The present study addresses the relationship between risk- and protective factors and the severity and treatment-outcome of mental disorders. SETTING: Family-therapeutic home-based treatment for MPF. We examined a clinical sample (N = 1031) of children between the age of 4 to 17, and a non-clinical sample of 148 children. We hypothesized that of all children of the clinical group have a predominance of risk factors and a higher number of psychopathological symptoms. Furthermore, we hypothesized that children with a predominance of protective factors benefit stronger from psychotherapy. MAIN RESULTS: In the clinical sample, most children met the criteria of a psychopathological diagnosis (95.7%, as compared to 21.6% in the non-clinical sample) and showed significant higher rates of childhood adversities and significant less protective factors as compared to the non-clinical sample. The clinical group showed a significant reduction of psychopathological symptoms and benefitted equally well from treatment. The number of risk factors was a significant predictor for a child from the non-clinical sample to meet the criteria of a psychopathological diagnosis, while the number of protective factors significantly predicted the absence thereof. CONCLUSION: Children and adolescents with high scores of CAs show significant associations with child psychiatric symptoms (d = 0.35; including all ICD-diagnosis such as e.g. Asperger-Syndrome, ADHD etc. with a higher rate of genetic etiology). Early life stressors however do not trigger an irreversible fate, as psychotherapy with young people with high numbers of risk factors does help to reduce psychopathological symptoms significantly (range of 5 outcome parameters: d = 0.31 – 0.72).

OBJECTIVE: The present study validates the Multiproblem Family (MPF)-Collaboration Scale), which measures the development of goal-directed collaboration of patients in the treatment of families with multiple problems (MPF) and its relation to drop-out rates and treatment outcome. METHOD: Naturalistic study of symptom and competence-related changes in children of ages 4-18 and their caregivers. SETTING: Integrative, structural outreach family therapy. MEASURES: The data of 5 different groups of goal directed collaboration (deteriorating collaboration, stable low collaboration, stable medium collaboration, stable high collaboration, improving collaboration) were analyzed in their relation to treatment expectation, individual therapeutic goals, family adversity index, severity of problems and global assesment of functioning of caregiver, child and relational aspects. RESULTS: From N = 810 families, 20% displayed stable high collaboration (n = 162) and 21% had a pattern of improving collaboration. These families with stable high or improving collaboration had significant more progress throughout therapy in terms of treatment outcome expectancy (d = 0.96; r = 0.43), achieving individual therapeutic goals (d = 1.17; r = 0.50), family adversities (d = 0.55; r = 0.26), and severity of psychiatric symptoms (d = 0.31; r = 0.15). Furthermore, families with stable high or improving collaboration maintained longer treatments and had a bigger chance of finishing the therapy as planned. The odds of having a stable low or deteriorating collaboration throughout treatment were significantly higher for subjects that started treatment with low treatment expectation or high family-related adversities. CONCLUSIONS: The positive outcomes of homebased interventions for multi-problem families are closely related to “stable high” and an “improving” collaboration as measured with the MPF-Collaboration Scale. Patients falling into these groups have a high treatment outcome expectancy and reduce psychological stress. For therapeutic interventions with multiproblem families it seems beneficial to maintain a stable high collaboration or help the collaboration, e.g. by fostering treatment expectation.

Objective. The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder. Methods. A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the client’s dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the client’s individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions. Results. For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy. Conclusion. By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and towards a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.