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17 maart 2023, Item does not contain fulltext, Anxiety-related disorders are characterized by high levels of avoidance, but experimental research into avoidance learning in patients is scarce. To fill this gap, we compared healthy controls (HC, n = 47) with patients with obsessive-compulsive disorder (OCD, n = 33), panic disorder with agoraphobia (PDA, n = 40), and post-traumatic stress disorder (PTSD, n = 66) in a computer-based avoidance learning task, in order to examine (1) differences in rates of avoidance responses, (2) differences in action-safety learning during avoidance, and (3) differences in subjective relief following successful avoidance. The task comprised aversive negative pictures (unconditional stimulus, US) that followed pictures of two colored lamps (conditional stimuli, CS+), but not a third colored lamp (safety stimulus, CS-), and could be avoided by pressing a button during one CS+ (CS+ avoidable) but not the other (CS+ unavoidable). Participants rated their US-expectancy and level of relief on a trial-by-trial basis. Compared to the HC group, patient groups displayed higher levels of avoidance to the safety stimulus, and higher levels of US-expectancy and relief following the safety and avoidable danger stimulus. We propose that patients with anxiety disorders have low confidence in the safety consequences of avoidance actions, which induces increased relief during US omissions that reinforce the avoidance action.

Radboud University, 10 november 2023, Promotor : Roelofs, K. Co-promotores : Kampman, M., Kleine, R.A. de, Item does not contain fulltext

Contains fulltext : 296241.pdf (Publisher’s version ) (Open Access), Social avoidance has been associated with more persistent social anxiety disorder (SAD) symptoms and low testosterone levels in individuals with SAD. We tested whether pre-treatment avoidance tendencies moderate the efficacy of testosterone-augmented exposure therapy. Fifty-five females with SAD received two exposure sessions during which fear levels were assessed. Session 1 was augmented with testosterone (0.50 mg) or placebo. Avoidance tendencies and symptom severity were assessed pre- and post-exposure. Participants showed stronger avoidance for social versus non-social stimuli and this tendency remained stable over time. Stronger pretreatment avoidance tendencies were associated with larger fear reduction in the testosterone but not the placebo condition. This effect did not transfer to the second non-enhanced session or symptom severity. The findings support the hypothesis that individuals suffering from SAD with relatively stronger pretreatment avoidance tendencies benefit more from testosterone-augmentation, pointing to a potential behavioral marker for testosterone enhancement of exposure therapy.

Item does not contain fulltext, Family accommodation in obsessive compulsive disorder (OCD) consists of participation in symptoms and modification of family routines in order to reduce patients' anxiety and impairment, manage relatives' own distress, and maintain family functioning. Higher levels of accommodation are associated with increased symptom severity and worse treatment outcome. However, this has not been investigated for adults with OCD receiving intensive cognitive behavioral therapy (iCBT). The aim of this study was to examine if change in family accommodation during the intensive phase of iCBT predicted treatment outcome. Within an observational study design, 52 adult patients received iCBT with pre-, between- and post-treatment measurements. Results showed that family accommodation was reported by 94% of relatives of OCD patients and was associated with self-reported OCD symptoms but not global functioning. Family accommodation was significantly reduced from pre-to post-treatment. Greater reductions in family accommodation were associated with lower levels of OCD symptom severity and better global functioning at post-treatment, and greater likelihood of achieving remission status. However, changes on the outcome measures from pre-to post-treatment were not dependent on the magnitude of change in family accommodation during the intensive phase of treatment. Therefore, findings are inconclusive in supporting that targeting family accommodation might directly affect treatment outcome for adults with OCD receiving iCBT.

Item does not contain fulltext, Angststoornissen, obsessieve-compulsieve stoornis (OCS) en posttraumatische stressstoornis (PTSS) kunnen een chronisch beloop hebben en dermate ernstig zijn dat zij binnen het bereik van het EPA-domein komen. Naast rehabilitatie en zelfmanagement zijn regelmatige evaluaties met betrekking tot nieuwe behandelmogelijkheden of een veranderde situatie van de patiënt belangrijk. Er bestaat een grote comorbiditeit tussen ernstige psychiatrische stoornissen als psychotische stoornissen en bipolaire stoornissen en angststoornissen, OCS en PTSS. Bij deze groep worden deze comorbide stoornissen vaak niet herkend en is er sprake van onderbehandeling. Een (semi)gestructureerd interview is noodzakelijk om (comorbide) angststoornissen, OCS en PTSS te herkennen en te evalueren. Enkele gecontroleerde en ongecontroleerde studies laten zien dat de behandeling van angststoornissen, OCS en PTSS bij mensen binnen het EPA-domein veilig is, klachtenvermindering geeft en de kwaliteit van leven verbetert.

Item does not contain fulltext, The Dimensional Obsessive-Compulsive Scale (DOCS) is a self-report questionnaire aimed to measure the severity of obsessive-compulsive symptoms on four thematically different symptom dimensions (contamination, responsibility for harm, unacceptable thoughts, and symmetry and completeness). The DOCS was developed in the US in response to the insufficiency of existing OCD measures. The 20-item scale is used in research and clinical settings. We translated the DOCS into Dutch and examined the psychometric properties in a clinical sample. In addition, we further examined the US version of DOCS with respect to measurement invariance between patient and non-patients and also between the US and the Dutch version of the DOCS. The analyses showed that the Dutch version is a valid and reliable version of the DOCS. Measurement invariance tests indicated that patient scores can be validly compared with non-patient scores. Therefore, the DOCS is a good instrument to monitor the development of OCD, for example, during treatment. The same result was found for the US DOCS and the Dutch DOCS, hence US scores and Dutch scores can be validly compared. With these two studies we have extended our knowledge of the DOCS, beyond the common psychometric properties.

Contains fulltext : 236341.pdf (Publisher’s version ) (Open Access), Individuals with a social anxiety disorder (SAD) show hypofunctioning of the hypothalamus–pituitary-gonadal (HPG) axis, which is linked to social fear and avoidance behavior. As testosterone administration has been shown to facilitate social-approach behavior in this population, it may enhance the effectiveness of exposure treatment. In this proof-of-concept study, we performed a randomized clinical assay in which 55 women diagnosed with SAD received two exposure therapy sessions. Session 1 was supplemented with either testosterone (0.50 mg) or placebo. Next, transfer effects of testosterone augmentation on within-session subjective fear responses and SAD symptom severity were assessed during a second, unenhanced exposure session (session 2) and at a 1-month follow-up, respectively. The participants having received testosterone showed a more reactive fear pattern, with higher peaks and steeper reductions in fear levels in session 2. Post-hoc exploration of moderating effects of endogenous testosterone levels, revealed that this pattern was specific for women with high basal testosterone, both in the augmented and in the transfer session. In contrast, the participants with low endogenous testosterone showed reduced peak fear levels throughout session 1, again with transfer to the unenhanced session. Testosterone did not significantly affect self-reported anxiety. The effects of testosterone supplementation on fear levels show transfer to non-enhanced exposure, with effects being modulated by endogenous testosterone. These first preliminary results indicate that testosterone may act on important fear mechanisms during exposure, providing the empirical groundwork for further exploration of multi-session testosterone-enhanced exposure treatment for SAD.

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Contains fulltext : 219370.pdf (publisher's version ) (Closed access), Background: Comorbid personality disorders are assumed to negatively interfere with the treatment outcome of affective disorders. Data on late-life panic disorder remain unknown. We examined the association of personality pathology and treatment outcome related to age and treatment modality. Methods: An observational study on the effectiveness of cognitive-behavioral therapy (CBT) for panic disorder with agoraphobia among patients 18 to 74 years of age and randomized controlled comparison of paroxetine and CBT in older patients (60 y of age or older) were performed. The diagnosis of panic disorder was confirmed by the Anxiety Disorder Interview Schedule-Revised (ADIS-IV) and personality features were assessed with the Personality Diagnostic Questionnaire. The impact of personality features on either agoraphobic cognitions (Agoraphobic Cognitions Questionnaire) or avoidance behavior (Mobility Inventory Avoidance Scale) was examined by multiple linear regression analyses adjusted for sex, level of education, duration of illness, comorbid psychopathology, and baseline severity. The interaction between personality and age was examined among those treated with CBT (n=90); the interaction between personality and treatment modality was examined among the older subgroup (n=34). Results: Cluster B personality pathology (evaluated on the basis of either Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria depending on the date of assessment) was negatively associated with outcomes of CBT in both younger and older adults with panic disorder and agoraphobia. Older adults with a higher number of features of any personality pathology or cluster A pathology had worse treatment outcomes when treated with paroxetine compared with CBT. Conclusions: Cluster B pathology had a detrimental effect on CBT treatment outcome for panic disorder in b

Contains fulltext : 221419.pdf (publisher's version ) (Open Access), Stepped-care (SC) models for anxiety disorders are implemented on a large scale and are assumed to be as effective for the greater majority of patients as more intensive treatment schemes. To compare the outcomes of SC and international guideline-based treatment (Treatment as Usual: TAU) for panic disorder, a total of 128 patients were randomized to either SC or TAU (ratio 2: 1, respectively) using a computer generated algorithm. They were treated in four mental health care centres in the Netherlands after therapists had been trained in SC by a senior expert therapist. SC comprised 10-week guided self-help (pen-and-paper version) followed, if indicated, by 13-week manualized face-to-face cognitive behavioural therapy (CBT), with medication- if prescribed- kept constant. TAU consisted of 23-week regular face-to-face CBT (RCBT) with medication -when prescribed- also kept constant. The means of the attended sessions in the SC condition was 5.9 (SD = 4.8) for ITT and 9.6 (SD = 9.6) for the RCBT condition. The difference in the number of attended sessions between the conditions was significant (t(126) = -3.87, p < .001). Remission rates between treatment conditions did not differ significantly (SC: 44.5%; RCBT: 53.3%) and symptom reduction was similar. Stepping up SC treatment to face-to-face CBT showed a minimal additional effect. Importantly, drop-out rates differed significantly for the two conditions (SC: 48.2%; RCBT: 26.7%). SC was effective in the treatment of panic disorder in terms of symptom reduction and remission rate, but dropout rates were twice as high as those seen in RCBT, with the second phase of SC not substantially improving treatment response. However, SC required significantly less therapist contact time compared to RCBT, and more research is needed to explore predictors of success for guided self-help interventions to allow treatment intensity to be tailored to patients' needs and preferences.

Contains fulltext : 205890.pdf (publisher's version ) (Open Access), Background: An adequate frequency of treatment might be a prerequisite for a favorable outcome. Unfortunately, there is a diversity of factors that interfere with an adequate frequency of sessions. This occurs especially in the first phase of treatment, while the first phase seems vital for the rest of treatment. The aim of this naturalistic study was to explore the impact of the initial frequency of treatment sessions on treatment outcome in a diverse mental health care population. Methods: Anonymized data were analyzed from 2,634 patients allocated for anxiety disorders, depressive disorders, and personality disorders to outpatient treatment programs in a large general mental health care facility. Patients' treatment outcome was routinely monitored with the Outcome Questionnaire-45 (OQ-45.2), every 12 weeks. Frequency of sessions was assessed for the first three months of treatment. Using Cox-proportional-hazard models, we explored the associations between initial frequency and improvement (reliable significant change) and recovery (reliable and clinically significant change). Results: Improvement and recovery were associated with symptom severity and functional impairment at start of treatment, the year the treatment started, number of measurements, the treatment program (anxiety disorders, depressive disorders, and personality disorders) and receiving group therapy other than psychotherapy. In all diagnostic groups, both improvement and recovery were associated with a higher frequency of sessions during the first three months of treatment. For improvement, this effect diminished after three years in treatment; however, for recovery this association was sustained. Conclusions: In addition to severity at start of treatment and other predictors of outcome, a low frequency of initial treatment sessions might lead to a less favorable outcome and a more chronic course of the mental disorder. This association seems not to be limited to a specific diagnostic group, but

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Supplement 3, Meeting Abstract: P986

Item does not contain fulltext, BACKGROUND: Digital technology (e-health or 'blended' care), combined with evidence-based face-to-face CBT, is becoming increasingly implemented into mental health care and is expected to result in improved effectiveness and efficiency. AIM: To explore the feasibility of blended CBT for patients with a panic disorder. METHOD: Nine face-to-face sessions of blended CBT (n = 18), supplemented with the digital support of a tabletcomputer and three e-mail contacts, were compared with 12 weekly sessions of regular CBT (n = 18). Primary outcomes were panic frequency and avoidance behaviour; the secondary outcome was general functioning. Patients' experiences of the treatment were collected in the form of a structured interview. RESULTS: The effect sizes found in both the regular and the blended CBT were medium to high (Cohen's d 0.42-1.60). In both types of treatment there was a significant reduction in patients' symptoms. There were no big differences in patient satisfaction regarding the treatment received. The therapists registered 39 face-to-face minutes in the blended treatment but they registered in total 41 fewer face-to-face minutes; this represented a time reduction of 4%. CONCLUSION: Blended CBT with help of a tablet computer seems to be a suitable method for treating panic disorder psychologically, although the time saved is only moderate. Much more research is needed to ascertain the feasibility and the cost effectiveness of blended CBT.