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Page 1
Vth World Congress of Behavioural and Cognitive Therapies
Table of Contents
Abstracts are grouped into topic areas and then into categories (invited addresses,
symposia and open papers). Within each category abstracts are presented in the order in
which they are likely to occur during the congress. Abstracts of the poster sessions are
reproduced in a different booklet.
English Language Abstracts
Addictive Disorders
Invited Address:
Translational Research on Craving: Promises, Problems and Potential
Peter Monti, Brown University, USA
Symposium 11:
Symposium 25:
Symposium 39:
Symposium 72:
Symposium 87:
Symposium 100:
Symposium 115:
Open Papers 17:
Adolescent brain development and vulnerability for substance use disorders: Implications for early interventions
Addictive Behaviours in Young People and Adolescents: Cognitive-Behavioural Predictors and Preventive Applications
Advances in Treatment for Amphetamine Use Problems
Cannabis Use Disorders: Cross-cultural Trends in Epidemiology, Comorbidity and Treatment Development
Mental Health and Substance Use Comorbidity: Innovative, Integrated CBT Treatments
Delivering Alcoholism Treatment in Novel Ways: Challenges and Solutions
New developments in Cognitive Behaviour Therapy of Substance Misuse; the UK experience.
Issues in Addiction
Anxiety Disorders
Invited Addresses
Maximizing Useful Knowledge From Psychotherapy Research: Strategies For the More Rapid Development of Effective Interventions
Thomas Borkovec, Penn State University, USA
Developing and Disseminating Effective Cognitive Therapies for Anxiety Disorders
David M Clark, Institute of Psychiatry at Kings College London, UK
Anxiety Disorders; what now
Paul Salkovskis, Institute of Psychiatry, UK.
Twenty Years of White Bears: An Update on the Clinical Implications of Thought Suppression
Daniel Wegner, Harvard University, USA
Symposium 7:
Symposium 21:
Symposium 34:
Symposium 51:
Symposium 64:
Symposium 80:
Symposium 84:
Symposium 93:
Symposium 97:
Symposium 109;
Symposium 156:
Symposium 172:
Panel Debate 9:
Open Papers 32:
Open Papers 40:
Open Papers 44:
Innovations In The Treatment of Anxiety Disorders
Social Anxiety disorder: New developments in models and treatment
Cognitive Factors in the treatment of social phobia
Unraveling interpersonal factors from a cognitive-behavioral perspective in Social Anxiety Disorder
New ideas in OCD: The influence and inspiration of S. Rachman
Role of cognition in treatment of OCD
CBT on late-life anxiety disorders: empirical findings from recently conducted studies on treatment and phenomenology
Disentangling the roles of safety and neutralizing behaviours: Helpful, harmful, both or neither?
Beliefs of patients and therapists in social phobia: are they true?
OCD: Treatment outcome in specialized populations and mechanisms of action
Never mind the quality, feel the width - broadening our understanding of the treatment of obsessive-compulsive disorder
Disgust and Anxious Psychopathology
Anxiety Disorders Across the Lifespan: Multiple perspectives on predictors of symptom development and maintenance
Cognitive Mechanisms in Anxiety Disorders
Outcome in CBT for Anxiety
CBT For Social Anxiety: Symptom Focus and Group Format
Adult Depression
Invited Address:
Cognitive Therapy in the Treatment and Prevention of Depression
Steven Hollon, Vanderbilt University, USA
Symposium 60:
Symposium 76:
Symposium 90:
Symposium 105:
Symposium 124:
Symposium 140:
Symposium 155:
Symposium 171:
Open Papers 9:
Open Papers 13:
Open Papers 18:
Psychological and psychobiological processes in vulnerability to depression
Methodological Advances in the Study of Cognitive Vulnerability to Depression
Depressive rumination: Nature, origins, and maintenance
Ruminative processes across depression and anxiety
Further frontiers in CBT for the Prevention of Relapse and Recurrence of Depression
CBT for primary prevention & prevention of relapse in bipolar disorder, unipolar depressive disorder and suicidal depression
Treatment-resistant depression|
Mindfulness for Anxiety & Depression
Depression, Cognition and Relationships
CBT Interventions for Depression
Cognitive Processes in Depression
'Adult Psychosis
Invited Addresses:
Cognitive Processes Related to Mania and Depression within Bipolar Disorder
Sheri Johnson, University of Miami, USA
The psychology of bipolar disorder
Richard Bentall, University of Manchester, UK
Recent advances in cognitive models of psychosis
Philippa Garety, Institute of Psychiatry, UK
Psychosis in an interpersonal context: issues in familial and therapeutic relationships
Theory and Practice in Social Recovery Based Interventions in Psychosis
The PRP Trial Results: The Psychological Prevention of Relapse in Psychosis
Cognitive behavioural approaches to the prevention of psychosis
Symposium 135:
Symposium 180:
Roundtable 2:
Panel Debate 6:
Open Papers 16:
Open Papers 19:
Open Papers 43:
Page 2
CBT in Early Psychosis:what should the focus be?
New developments in the psychology of bipolar disorder
Enahnced Relapse Prevention for Bipolar Disorder
Cognitive Remediation Therapy In The Treatment of Schizophrenia
Advances in the understanding of paranoia
It's the thought that counts: Appraisals in psychosis
Cognitive behavioral approach to the psychology on symptoms of psychosis
Certificate 18: the right to be lost to the system
Innovations in Schizophrenia Treatment: New Concepts in CBT and Implementation Difficulties
Issues in Psychosis
Cognitive and Interpersonal Processes in Psychosis
Advances in CBT with Pyschosis and Severe Mental Health Problems
Adult Trauma
Invited Addresses:
Scientific Principles of CBT: Retrieval competition between multiple memories
Chris Brewin, University College London, UK
The Phenomenology, Theory and Treatment of Posttraumatic Stress Disorder
Edna Foa, University of Pennsylvania, USA
Symposium 33:
Symposium 50:
Symposium 62:
Symposium 78:
Symposium 91:
Symposium 107:
Symposium 122:
Symposium 138:
Symposium 157:
Open Papers 49:
Individual differences in vulnerability to Posttraumatic Stress symptoms
Cognitive Mechanisms of Traumatic Experiences
Cognitive processes in PTSD: Integrating and expanding cognitive models
Intrusions as a transdiagnostic symptom: Recent developments on the etiology of intrusions in PTSD and other disorders
Cognitive processes in posttraumatic stress disorder
Enhancing Cognitive Behaviour Therapy of Posttraumatic Stress Disorder
Integrating Imagery Interventions in Cognitive Therapy of Posttraumatic Stress Disorder
Psychological treatment for severe, complex and chronic Posttraumatic Stress Disorder
The role of case studies in the refinement of evidence-based practice in the treatment of posttraumatic stress disorder
PTSD Interventions
Applied Behaviour Analysis & Acceptance and Commitment Therapy
Invited Address:
The Implications of ACT and RFT for CBT
Steven Hayes, University of Nevada, USA
Symposium 14:
Symposium 28:
Symposium 40:
Basic processes underlying the expansion and treatment of anxiety disorders
Experimental analysis of several strategies to cope with aversive private experiences. Implications in the clinical context.
Application of Acceptance and Commitment Therapy (ACT) to the prevention and treatment of health problems.
Basic Processes
Invited Addresses:
Uncertainty in OCD
Marcel van den Hout, Utrecht University, The Netherlands
Metacognitive Therapy: Nature and effectiveness across disorders
Adrian Wells, University of Manchester, UK
Cognitive and Neural Systems Underlying the Control of Intrusive Memories: Implications for theories of thought suppression
Michael C. Anderson, University of Oregon, USA
Symposium 5:
Symposium 12:
Symposium 13:
Symposium 26:
Symposium 27:
Symposium 42:
Symposium 43:
Symposium 112:
Symposium 121:
Symposium 137:
Symposium 154:
Symposium 166:
Symposium 169:
Symposium 179:
Panel Debate 2:
Open Papers 2:
Open Papers 4:
Open Papers 28:
Open Papers 37:
Open Papers 38:
New advances in understanding key cognitive processes that maintain anxiety and depression
Information-processing of emotion in depression: clinically relevant insights from cognitive neuroscience
Why can't I stop thinking about it': The role of post-event processing in social anxiety
Human fear conditioning: an excellent paradigm to study the basic processes of behaviour change.
Dismantling Ruminative Thinking
The Role of Mood in Perseverative Psychopathologies
The Therapeutic, Organisational, and Conceptual Implications of Understanding the Nature of Perceptual Control
The identification and modification of attentional bias to threat in anxiety: From cognitive science to clinical applications
Metacognitive processes in OCD: theoretical and clinical perspectives.
Information processing research in OCD: New advances and future directions
Metacognition Across Disorders : Theory And Evidence
Implicit cognitive processing in substance abuse and eating disorders
Basic Processes in the Eating Disorders
Maladaptive perfectionism: Recent developments in conceptualization, assessment and treatment
When is Thought Suppression Dysfunctional?
Basic Cognitive Processing in Anxiety and Trauma
Personality and Emotional Regulation
Basic Processes and Impulse Control Across Disorders
Cognitive Biases in Anxiety and Depression
Metacognition and Avoidance
Behavioural Medicine
Invited Addresses:
CBT in Behavioural Medicine in the 21st Century
Neil Schneiderman, University of Miami, USA
Insomnia: Bridging the Gaps Between Research Evidence and Clinical Practice
Charles Morin, Laval University, Canada
Symposium 71:
Symposium 86:
Symposium 99:
Symposium 114:
Symposium 123:
Symposium 139:
Symposium 158:
Symposium 178:
Open Papers 5:
Open Papers 10:
Open Papers 14:
Using cognitive behaviour therapy self-help: what works in practice?
Advances in clinical interventions for sleep disturbance: Recent findings across disorders
Are we pushing the right buttons? Recommendations for cognitive behaviour therapy in patients with chronic somatic complaints.
Cognitive and behavioral interventions for family caregivers of stroke and dementia patients
Gaining No Pain?: Cutting Edge Approaches to Chronic Pain and Disability
Mindfulness & Health
Tailored Cognitive Behavioural Therapy for Somatic Illnesses
Cognitive Behavioural models and treatment of dizziness and syncope
Health Problems and Insomnia
CBT for Pain and Fatigue
CBT for Nerve and Blood Disorders
Page 3
Challenging Behaviour and Personality Disorder
Invited Address:
Cognitive Therapy for Borderline Personality Disorder
Judith Beck, Beck Institute, Philadelphia, USA
Symposium 57:
Symposium 74:
Symposium 102:
Symposium 117:
Symposium 120:
Symposium 136:
Symposium 159:
Symposium 175:
Roundtable 8:
Open Papers 50:
Measurement, Etiology and Treatent of Borderline Personality Disorder
Early Maladaptive Schemas: from theory to empirical assessment
Borderline Persoanlity Disorder: Connecting basic research to cognitive-behavioral treatment
Comparing direct and indirect assessment of cognitions and emotions in patients with personality disorders and depression.
Cognitive-Behavioral Therapies for Forensic Patients with Personality Disorders: Toward Evidence-Based Clinical Practice
Recent developments in antisocial and borderline personality disorder: experimental and intervention studies
Interventions for Anger and Violence
Schema-focused therapy for borderline personality disorder
State of the art of research into CBT treatment for personality disorders
CBT, Forensic Issues and Drug Addiction
Children and Adolescent Mental Health
Invited Addresses:
Evidence-Based Clinical Practice with Children and Adolescents: The Delicate Dance
Tom Ollendick, Virginia Polytechnic Institute and State University, USA
How Effective Are Interventions for Autism Spectrum Disorders
Patricia Howlin Institute of Psychiatry at Kings College London, UK
On the etiology of anxiety disorders: What can we learn from childhood studies?
Silvia Schneider, University of Basel, Switzerland.
Symposium 1:
Symposium 9:
Symposium 16:
Symposium 23:
Symposium 29:
Symposium 30:
Symposium 45:
Symposium 46:
Symposium 58:
Symposium 75:
Symposium 89:
Symposium 103:
Symposium 118:
Symposium 134:
Symposium 152:
Symposium 153:
Symposium 168:
Symposium 170:
Symposium 182:
Open Papers 12:
Open Papers 22:
Open Papers 23:
Open Papers 25:
Open Papers 29:
Open Papers 34:
Open Papers 39:
Child Anxiety; Theory and Treatment (CATTs) Epidemiology and acquisition
Prevention and treatment of externalizing disorders in children and adolescents
Child Anxiety; Theory and Treatment (CATTs): Understanding and treating anxiety disorders in children
Mind Yourself”: A Strength Focused and Community Based Adolescent Suicide Prevention Project.
New developments in research on the etiology of childhood anxiety disorders
Evaluation of international research trials of the FRIENDS for Life program implemented as a universal prevention program
Cognitive-behavioral therapy for children with anxiety disorders: The involvement and influence of parents.
Impacting Children and Families Using Population-Based Intervention Strategies
Obsessive compulsive disorder in children and adolescents: Issues in treatment
Cognitive distortions in anxious children and adolescents
Vulnerability to Depression in Adolescents
The role of the father in the etiology, prevention and treatment of child psychopathology
Recent Innovations in the Treatment of Child and Adolescent Anxiety Disorders
What Research is Telling Us About the Treatment of Adolescent Depression
Sleep problems in childhood and adolescence
Prevention and Early Intervention in Child Anxiety - the role of parenting re-visited
Cognitive-emotional factors in the development of childhood conduct problems: Implications for existing and innovative treatments
Current trends in the treatment of social anxiety disorder for children and adolescents
"Using computer and gaming technology to improve childhood disorders treatments."
Dissemination of CBT, Parenting and Child Behaviour
Child and Adult Mental Health: Risk of Anxiety and Depression
Cogntive Behaviour Therapy Developments and Adolescent Problems
Children and Adolescents: Treament of Anxiety and Depression
Parenting and Schemas
Parenting Cognition and Behaviour Problems
Children and Adolescents: Health and Wellbeing
Cross Cultural and Global Issues
Invited Address:
Cultural Contexts of Psychotherapy: A Good Therapy is Like a Good Japanese Restaurant
Gordon Nagayama Hall, University of Oregon, USA
Symposium 70:
Symposium 85:
Symposium 98:
Symposium 113:
Symposium 127:
Symposium 144:
Symposium 161:
Open Papers 47:
Social Anxiety around the World - Cultural Aspects of Social Anxiety Disorder
Social Anxiety and Taijin Kyofusho in Adolescents and in Young Adults.
A Cross-Cultural Perspective on Obsessions and Other Unwanted Intrusive Thoughts
Cognitive behavioral therapies: theoretical and empiric aspects in focus
What are health psychologists doing in Brazil and Portugal?
Dissemination and maintenance of the spirit of motivational interviewing in non English speaking populations and in different contexts
How Can We Train Competent Cognitive Behaviour Therapists? A Cross-Cultural Perspective
Anxiety Across Cultures and CBT with Immigrant People
Eating Disorders
Invited Address:
Trans-diagnostic Cognitive Behaviour Therapy for Eating Disorders: Clinical Experience and Research Findings
Chris Fairburn, Oxford University, UK
Symposium 2:
Symposium 17:
Symposium 31:
Symposium 47:
Symposium 73:
Symposium 88:
Symposium 101:
Symposium 116:
Symposium 165:
Open Papers 51:
Revolutionizing the treatment of eating disorders and obesity: the contribution of G. Terry Wilson
Guided self-help for bulimia nervosa and binge eating disorder
Predicting and Preventing Relapse in Eating Disorders
Automatic approach-avoidance tendencies in anxiety, eating disorders, and addiction: Theoretical meaning and clinical implications.
Core cognitive beliefs: are they still interesting? A symposium about perfectionism, control, and worry in eating disorders
Attentional strategies and implications for treatment in eating disorders and body image disorders
Food reward and reward sensitivity: Implications for understanding eating disorders and obesity
Neuroimaging Approaches to Body Image Disturbances in Eating Disorders
New developments in Body Dysmorphic Disorder
Eating Disorders and CBT Interventions
Intellectual and Developmental Disabilities
Invited Address:
Mindfulness-Based Therapy and Caregiving in Developmental Disabilities
Nirbhay N Singh, ONE Research Institute, USA
Symposium 10:
Symposium 24:
Symposium 38:
Symposium 55:
Symposium 67:
Symposium 95:
Panel Debate 4:
Innovations in Formulation and Application of CBT for People with Intellectual Disabilities
Therapy with people with intellectual disabilities: Models and evidence
Mindfulness and Acceptance in Developmental Disabilities
CBT,social cognition and motivation in sex offenders with intellectual disabilties.
Challenges Associated with Providing CBT to Dually Diagnosed Individuals In Community Settings
Trauma, PTSD and other psychological disorders, and effectiveness of treatment in people with IDD
Can Residential/Institutional Treatment Be a Viable Part of the Continuum of Treatment for Individuals with Intellectual Deficits
Page 4
New Developments in Cognitive Behaviour Therapy
Invited Address::
The training of attentional and interpretive bias in anxiety: A new approach to the advancement of theoretical understanding and the
enhancement of therapeutic intervention.
Colin Macleod, University of Western Australia, Australia
Symposium 19:
Symposium 92:
Symposium 130:
Symposium 131:
Symposium 148:
Symposium 149;
Symposium 151:
Symposium 167:
Symposium 173:
Symposium 174:
Symposium 181:
Panel Debate 1:
From the Laboratory to the Clinic: Experimental Findings Informing Treatment Innovations Across Clinical Disorders
Recent developments in research on Mindfulness-Based Cognitive Therapy (MBCT)
Facilitating Therapeutic Contexts: The Application of D-Cycloserine for the Treatment of Anxiety Disorders.
Putting a halt to negative thoughts, memories and emotions? New directions in thought suppression research
New developments in the treatment of trichotillomania
Personal meaning: Its disruption and re-establishment following major stressful life events
Clinical cognitions and their modification in depression and worry
Refining and enhancing methods of inducing more benign cognitive biases in anxiety
Metacognitive Therapy : Outome Across Disorders
International Negotiation and Psychotherapy
Training of Information Processing Biases in Anxiety
Self reported cognition in clinical psychology: Progressive or regressive?'
Sex, Marital and Family Relationships
Invited Address:
Marriage Matters: Why and how we should help couples strengthen their relationships
Kim Halford, Griffiths University, Australia
Symposium 15:
Symposium 44:
Symposium 69:
Symposium 129:
Symposium 147:
Symposium 164:
Roundtable 4:
Roundtable 6:
The Restructuring of Family Schemas: A Cognitive-Behavioral Perspective
The Long-Term Effects of Couple Education and Therapy
Psychological Vulnerability Factors for The Development of Sexual Dysfunction: New Empirical Data
Recent developments in aetiology and treatment of primary vaginismus
Cognitive Processes and Sexual Dysfunction
Recognition and treatment of sexual dysfunction within a CBT framework
Extending Principles of Couple Interactions to Specific Populations
Bridging the gap between family therapy research and treatment: A clinical roundtable discussion.
Therapeutic and Applied Issues
Invited Addresses::
Symposium 6:
Symposium 20:
Symposium 37:
Symposium 41:
Symposium 49:
Symposium 54:
Symposium 56:
Symposium 59:
Symposium 63:
Symposium 104:
Symposium 108:
Symposium 128:
Symposium 132:
Symposium 145:
Symposium 150:
Symposium 162:
Open Papers 26:
Open Papers 30:
Open Papers 33:
Open Papers 35:
Open Papers 41:
Open Papers 48:
Panel Debate 3:
Panel Debate 5
Beyond Rationality: Using Emotion in Cognitive Therapy
Robert Leahy, American Institute for Cognitive Therapy, USA
Cognitive therapy for depression: Towards a new synthesis?
Melanie Fennell, Oxford Cognitive Therapy Centre, UK
New Advances in Schema Therapy for Personality Disorder
Jeff Young, Cognitive Therapy Center of New York, UK.
New applications of Mindfulness-based Cognitive Therapy
Is Laughter the Best Medicine: Using humor in Psychotherapy
Increasing openness to empirically supported treatments
Computer-assisted self-help in the treatment of psychological disorders
Imagery, emotion and motivation: some research findings.
Repeated Assessment and Modeling of Psychopathology and Treatment
Using cognitive behaviour therapy self-help: what works in practice?
Cognitive-behavioural Case Formulation: What can we learn from emerging research?
The Therapeutic Relationship In Cognitive-Behavioral Psychotherapy
The Cognitive Model of Aaron T. Beck: Its Impact and Future Direction
Mindfulness and Meditation in various religious traditions to promote positive mental health
Working Alliance and Restoration of Morale in CBT
Cognitive Behaviour Therapy in the Acute Psychiatric Inpatient Unit.
Implicit self-esteem in anxiety and depression
Corpus delicti. Bodily preoccupations across psychopathological disorders
Self-esteem as a predictor of improvement in Cognitive and Behavioural Treatment (CBT) with complex cases
Mindfulness Based Cognitive Therapy Outcome
Transdiagnostic Psychological Mechanisms
Applying CBT in New Populations and Formats
Extending Access to CBT
Religion, Beliefs and CBT
Causal Attributions and CBT Outcome Factors
Cognitive-behavioural Case Formulation: Is the emperor clothed?
The Importance of Theory to Stabilize the Science and Practice of Cognitive Therapy.
Training, Supervision and International Standards
Invited Addresses:
Power Supervision: Training the next generation of CBT clinicians to excel in both technical merit and artistic impression
Corey Newman, University of Pennsylvania, USA
The Next Frontier: Building Positive Qualities with CBT
Christine Padesky, Center for Cognitive Therapy, USA
Symposium 68:
Symposium 96:
Symposium 133:
Symposium 146:
Symposium 163:
Symposium 177:
Panel Debate 8:
Roundtable 7:
Roundtable 9:
Open Papers 7:
Developing Interpersonal Competencies in Cognitive Behavioural Therapy: The Challenges for Trainers
Training Cognitive Therapists Self-Experientially: The Theoretical and Empirical Case for incorporating Personal
CBT Training - Meeting the Challenge
Therapeutic Convergences And Divergences Of Cognitive Models: Implications For Training
Let a hundred flowers bloom: varieties of training in CBT
Supervision and Training in Cognitive Behavioural Psychotherapy: An International Structural Perspective
How is personal experiential work and/or personal therapy best incorporated into the training of cognitive therapists?
Cognitive-Behavioural Case Formulation: Strategies for Training, Supervision and Professional Development?
The formation process for cognitive therapist
Issues in CBT Training
SCRiTC Symposium & Invited Speakers
Invited Addresses:
CBT progress in delivering self-help and in developing a common language
Issac Marks, Institute of Psychiatry, London, UK
Symposium 79:
Noves Fronteres en Teràpia Cognitiva i Conductual
New Frontiers in Cognitive Behaviour Therapy
Page 5
Spanish Language Abstracts
Addictive Disorders
Symposium 126:
Symposium 142:
Open Papers 15:
Aplicaciones de las técnicas cognitivo-conductuales en la prevención y tratamiento de las adicciones
Eficacia del tratamiento psicológico en adicciones
Conductas Adictivas
Adult Anxiety
Symposium 66:
Symposium 82:
Panel Debate 7:
Nuevos planteamientos y avances en el campo de la ansiedad social
Evaluación de la ansiedad social en España y Latinoamérica con implicaciones para su prevención y tratamiento
Propuesta para un modelo de consenso sobre el papel y la definición de los subtipos en el trastorno de ansiedad social
Adult Psychosis
Symposium 160:
Intervención familiar en la esquizofrenia:
Behaviour Analysis & Acceptance and Commitment Therapy
Symposium 53:
Open Papers 20:
Componentes básicos de ACT: Evaluación funcional e intervenciones eficaces para pacientes con problemas crónicos.
Procesos Basicos
Behavioural Medicine
Psicologia de la Salud
Psicología de la actividad física y el deporte
Medicina Conductual (1)
Medicina Conductual (2)
Challenging Behaviour and Personality Disorders
Symposium 35:
Symposium 52:
Mujeres víctimas de violencia doméstica: Realidad actual y líneas de actuación
Innovaciones recientes en la aplicación del modelo de la terapia de esquemas
Child and Adolescent Mental Health
Symposium 65:
Symposium 111:
Symposium 125:
Symposium 141:
Roundtable 10:
Open Papers 21:
Open Papers 24:
Nuevas estrategias en la intervencion cognitiva-comportamental con niños y adolescentes
Hospitalizacion parcial de niños y adolescentes desde un modelo cognitivo-conductual
Desarrollo y Evaluación de Programas de Intervención Breve en Adolescentes Consumidores de Alcohol
Avances en la aplicación y depuración de la Intervención en Adolescentes Españoles con Fobia Social Generalizada
La intervención cognitivo conductual para el tratamiento de la ansiedad infantil
Salud Mental en Ninos y Adolocentes 1
Salud Mental en Ninos y Adolocentes 2
Cross Cultural and Global Issues
Symposium 22:
Roundtable 1:
Open Paper 46:
Avances en latinoamerica de la terapia cognitivo-comportamental aplicada a los problemas afectivo-emocionales y adaptativos
Aplicación de tratamientos cognitivos en la Argentina.
Aspectos socioculturales
Eating Disorders
Symposium 143:
Factores de riesgo específicos para Trastornos Alimentarios o Trastornos Relacionados con el peso
Intellectual and Developmental Disabilities
Symposium 110:
Panorámica actual de los tratamientos en población infanto-juvenil con discapacidades
Sex, Marital and Family Relationships
Symposium 81:
Symposium 94:
Roundtable 3:
Open Papers 45:
Abordajes en la terapia sexual cognitivo-comportamental: contribuciones latinoamericanas
Avances de la terapia cognitivo-comportamental para los problemas de pareja en latinoamérica
La aplicación de la terapia de aceptación y compromiso en la superación de barreras psicológicas en la sexualidad
Relaciones de pareja y familia
Therapeutic and Applied Issues
Symposium 8:
Symposium 36:
Symposium 83:
Symposium 176:
Open Paper 8:
Open Papers 27:
Open Papers 31:
Open Papers 36:
Open Papers 42:
Aportaciones de las nuevas tecnologías en el campo de la Psicología Clínica y de la Salud
Flexibilidad de los tratamientos cognitivos-conductuales manualizados y alcance a nuevas poblaciones y lugares de tratamiento
Desarrollo del estilo personal del terapeuta
Identificación de Cogniciones Disfuncionales en Profesionales de Educación Media Superior
Salud Mental Adultos
Desarrollos Terapéuticos (1)
Desarrollos Terapéuticos (2)
Desarrollos Terapéuticos (3)
Desarrollos Terapéuticos (4)
Training, Supervision and International Standards
Roundtable 5:
Formación y entrenamiento de psicoterapeutas cognitivos
Invited addresses
La promoción del envejecimiento activo: la contribución de la Psicología de la Salud - Rocio Fernández-Ballesteros,
VOLVER A LAS RAÍCES Y SEGUIR NAVEGANDO A ÍTACA - Miguel Costa, Ayuntamiento de Madrid, España
Page 7
Addictive Disorders
Invited Addresses
Translational Research on Craving: Promises, Problems and Potential
Peter Monti, Brown University, USA
This plenary session will review contemporary empirical research on craving for alcohol and tobacco with particular emphasis on craving's determinants,
phenomenology, and neurobiological underpinnings. Cue exposure treatment, coping skills approaches, pharmacological approaches (i.e., naltrexone, nicotine
replacement therapy) and combined behavioral and pharmacological approaches to craving will be presented and critiqued. Potential methods for enhancing
these existing treatments as well as promising new treatments for adult and adolescent substance abusers will be discussed. More generally, the talk will
highlight the need for transdisciplinary research that clarifies the genetic and neurobiological bases of craving and meaningfully translates these more basic
advances into novel clinical approaches and enhanced clinical care.
Symposium 11
Adolescent brain development and vulnerability for substance use disorders: Implications for early
Convenor: Reinout Wiers, Maastricht University, The Netherlands, The Netherlands
Adolescent Brain Maturation: A Period of Vulnerabilities and Opportunities
Ronald E. Dahl, M.D., University of Pittsburgh, U.S.A.
This presentation provides an overview and conceptual framework for considering key aspects of adolescent brain maturation with an emphasis on
understanding developmental pathways to substance use problems. Adolescent development is a period of special opportunities as well as vulnerabilities
with respect to a wide range of behavioural and emotional health problems in youth. More specifically there are unique brain/behaviour/social-context
interactions during pubertal maturation that can influence these developmental trajectories in positive and negative ways. A model will be described that
focuses on neurobehavioral changes at puberty that lead to an increase tendency toward risk-taking and sensation-seeking in adolescence. These
biologically-based changes in drives, emotions and motivations (“igniting passions”) often emerge early in adolescence. In contrast, the gradual and
relatively prolonged maturation of self-regulatory skills and judgment continue to develop through late adolescence. This may be particularly relevant to
individuals who enter adolescence with previous vulnerabilities, including those at biological, familial, or social risk-particularly youth living in social contexts
that create challenges to the gradually emerging skills in self-control. Key features of the model will be illustrated through a consideration of
brain/behaviour/social-context interactions in sleep/wake regulation in adolescence. The clinical and social policy implications of this model-and its relevance
to early intervention and prevention of behavioural and emotional problems in youth, with an emphasis on early interventions for substance use problems-will
be discussed.
MRI Research on Adolescent Brain Development and Substance Use
Susan F. Tapert, Ph.D., University of California, San Diego, U.S.A.
Alcohol and marijuana are commonly used among adolescents worldwide. Technological advances in neuroimaging have facilitated an appreciation of
ongoing neuromaturation during this developmental stage, and have provided tools for assaying brain functioning features associated with risk for substance
use and the neural consequences of such behaviors. Dr. Tapert will describe the results of several functional magnetic resonance imaging (fMRI) studies
conducted in adolescents aimed at uncovering these bidirectional relationships. First, she will review fMRI findings in adolescents with substance use
disorder risk factors, including family history of alcoholism, positive alcohol expectancies, and low levels of response to alcohol. fMRI cue exposure
paradigms in heavy drinking youth will be presented, showing that neural response to substance-specific stimuli appears to be a function of personal
drinking. Next, she will review a set of fMRI studies, conducted with over 100 youths, that examine how heavy alcohol or marijuana use during adolescence
may be linked to abnormalities in thinking and memory abilities and strategies. Heavy drinking during adolescence has been linked to abnormalities in brain
response during working memory tasks, with indications of compensation and neural reorganization in frontal and parietal areas. Females appear somewhat
more affected than males, and concomitant marijuana use is linked to further abnormalities, especially in prefrontal and temporal regions. Longitudinal
studies are underway to evaluate abnormalities in conjunction with substance use changes across adolescence. Implications for prevention and intervention
will be discussed, including dissemination of factual information to teens, motivational enhancement, and expectancy challenges.
A developmental neurobiological model and substance use problems
Monique Ernst, M.D., Ph.D., NIMH, Bethesda, USA
Mature behavior requires the harmonious development of modular systems that underlie affective and cognitive function, along, of course, the elementary
units of action linking sensory-perceptual input with motor-executive output. Adolescence is a prime period when affective and cognitive control systems
show dramatic changes. These changes reflect plasticity and might augur vulnerabilities as well as opportunities for intervention. A developmental
neurobiological model based on equilibrium among and within functional neural systems will be discussed and implications for age-appropriate safeguard
policies as well as preventive interventions for the development of substance use problems will be addressed.
Acute sensitivity to alcohol in young adults: impulsivity and substance abuse risk
Mark T. Fillmore, Ph.D., University of Kentucky, U.S.A
Impulsivity and under-controlled behavior are common characteristics associated with early-onset (i.e., adolescent) substance abuse. Although our
understanding of the relationship between impulsivity and adolescent substance use remains unclear, there is growing evidence that prolonged drug
exposure during adolescence could impede the formation of frontal lobe circuitry, resulting in impairments in the regulation and control of behavior.
Moreover, such adverse effects might contribute to the maintenance and escalation of drug use. Adolescent drug users often develop alcohol use problems
(e.g., binge drink) as young adults and are at greater risk for alcohol dependence. Alcohol is well-known for its acute disinhibiting effects on behavior and its
chronic use is associated with sustained states of under-controlled behavior often described as impulsivity. Thus it is important to determine how prior drug
exposure during adolescence might alter alcohol sensitivity in young adults. Lasting neurocognitive impairments owing to a history of adolescent drug use
could increase the vulnerability of these individuals to the acute disruptive effects of alcohol. In this presentation, Dr. Mark Fillmore describes studies that
examine the acute neurocognitive and subjective rewarding effects of alcohol in groups of young adults as a function of prior adolescent drug use history
and other substance abuse risk factors, such as childhood Attention Deficit/Hyperactivity Disorder (ADHD). Dose-response studies are described that
examine the magnitude of acute behavioral impairment and acute subjective rewarding effects in groups of young adults with and without histories of
adolescent drug use and childhood ADHD.
Adolescent brain development and vulnerability for substance use disorders: Implications for early interventions?
Susan L. Ames, Ph.D. & Alan W. Stacy, Ph.D., University of Southern California, U.S.A
Various associative memory measures have been used to assess processes that probably operate implicitly on behavior. These implicit processes are
revealed on indirect measures of addictive behavior that tap into and activate pre-existing associations in memory. A review of findings on associative
memory work in at-risk youth is presented including involvement of confounding and moderator effects. One study evaluated the mediating role of
associative memory in the prediction of substance use among at-risk youth, examining relationships among dissociative experiences, sensation seeking, and
spontaneous cognitions in the analyses. Findings from latent variable models revealed spontaneous cognitions independently predicted alcohol and
marijuana use and mediated the predictive effects of sensation seeking on drug use. A second study compared indirect measures in an attempt to quantify
the level of marijuana associations among at-risk adolescents. Automatic drug-relevant associations were assessed with a word association index, IAT and
EAST. Measures of working memory capacity, sensation seeking, and explicit cognitions were also included in analyses as potential confounders. The word
association index and IAT excited D-measure were significant predictors of marijuana use. Another study evaluated the interaction between working memory
capacity and implicit cognition in the prediction of alcohol and cigarette use among at-risk youth, controlling for gender, ethnicity, and acculturation.
Consistent with dual-process cognitive theories, drug-related associations in memory predicted drug use more strongly in youth with lower levels of working
memory capacity. These findings add to the growing research that implicates the importance of implicit associative processes in risk and health behaviors in
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A Model for the Development of Problematic Alcohol and Drug Use in Adolescence.
Reinout W. Wiers (1, 2, 3), Carolien Thush (1), Jerry Grenard (4) Susan L. Ames (4) & Alan W. Stacy (4), (1) Maastricht University, The Netherlands
(2) Radboud University Nijmegen; (3) IVO Addiction Research Institute Rotterdam; (4) University of Southern California
A model is presented, which describes the development of addictive behaviors in (human) adolescents, with a focus on alcohol (Wiers et al., in press,
Pharmacol, Biochem, Behav, available online). In essence, the model proposes that addictive behaviors develop as the result of an imbalance between two
systems: an appetitive, approach-oriented system that becomes sensitized with repeated alcohol use and a regulatory executive system that is not fully
developed and that is compromised by exposure to alcohol. Self-regulation critically depends on two factors: ability and motivation to regulate the appetitive
response tendency. The motivational aspect is often still weak in heavy drinking adolescents, who typically do not recognize their drinking as problematic.
Motivation to regulate use often develops only years later, after the individual has encountered serious alcohol-related problems. Unfortunately, at that point
behavioral change becomes harder due to several neurocognitive adaptations that result from heavy drinking. As we document, there is preliminary support
for the central elements of the model (appetitive motivation vs. self-regulation), but there is a paucity of research directly addressing these mechanisms in
human adolescents. I will present data from two recent studies which both found that executive functions moderate the impact of automatic appetitive
responses to addiction-related stimuli on behavior. In both studies we found that spontaneous appetitive reactions to addiction-related stimuli better predicted
substance use in adolescents with relatively poor executive skills, as compared with individuals with relatively well developed executive skills. Finally, I will
discuss implications of the model for interventions.
Symposium 25
Addictive Behaviours in Young People and Adolescents: Cognitive-Behavioural Predictors and Preventive
Convenor: Jose P. Espada, Spain
The Motivation-Skills-Decision Making Model of Drug abuse Prevention
Steven Sussman, University of Southern California, USA
This presentation asserts that young people at risk for substance abuse will not use substances if they: 1) are motivated to quit through being aware of
misleading information that facilitates substance use, reconciling their own equivocation about their substance use, and appreciate the consequences that
substance use may have on their own and others lives, 2) have skills that help them lower their risk for use, including awareness of cessation strategies,
and 3) have decision making skills to make personal commitments not to use substances. This is known as the Motivation, Skills, Decision- Making (MSD)
Model. Motivation exists as a distance between what is and what could be, and people desire to reduce such discrepancies. For example, most youth plan
to continue to attend school or job training. When prompted as part of a critical-thinking-like sequence one sees that drug use could interfere with achieving
life goals. It is important for prevention programs to help youth connect the importance of health as a value to obtaining their life goals, and develop a
sequenced plan so that they know how to proceed on step-by-step. Behavioral skills can buffer against the impact of risk factors, and permits the
establishment of new pro-health social and other life options, if well-directed from motivational guides. For example, one type of behavioral skill is that of
self-control. In self-control programming, youth learn to assess their self-control, particularly in social contexts. They learn the importance of thinking ahead
and anticipating problem situations so that they are prepared beforehand to deal with problems that may arise. They also learn the importance of context
(e.g., not laughing at a funeral). Finally, they learn assertiveness and anger management to help them better control their reactions in social settings. It is
most wise to include behavioral skills training in conjunction with material addressing motivation and decision-making. Motivations regarding drug use need
to be addressed, so behaviors learned are not misdirected. With motivational guides, and new behavioral options, one can decide how to act in specific
situations through additional use of decision making and making a personal commitment not to abuse drugs. Training in decision-making operates on
variables that are intermediate in the causal process, and thereby strengthen self-control abilities so that they are more resilient in the face of proximal risk
factors for drug use such as life stresses and peer pressures.
Integrating Cognitive, Behavioral, and Affective Skills Training As A Drug Abuse Prevention Approach
Kenneth W. Griffin, Cornell University, New York, USA
School-based drug abuse prevention programs for early adolescents are an efficient way to deliver prevention services to young people before they become
heavy substance users or abusers. Contemporary prevention programs include social refusal skills training with training in more generic "life skills" using
cognitive, behavioral, and affective skills training techniques. This type of programming typically teaches young people principles of cognitive reframing,
behavioral self-control, coping, and relaxation skills, and how to apply these skills outside of the classroom in high risk situations. This presentation will
review the concepts and empirical findings from the "Life Skills Training" prevention program, including short and long-term effects of substance use and
related risk behaviors. One goal of the presentation is to suggest that broad-based competence enhancement prevention programs may be an efficient and
effective way to prevent a variety of negative outcomes during adolescence.
Substance use patterns and social phobia in Spanish adolescents
José A. Piqueras, José Olivares, Luis-Joaquín García-López, Jose P. Espada and Mireia Orgilés., Universidad de Alicante, Spain
This study aimed to analyze the comorbidity of different substance use problems and social phobia and study the relationship between social phobia,
substance use patters and other related variables (social anxiety, comorbidity with other disorders, self-steem, etc).. The sample consisted of 116 Spanish
adolescents ranged between 14 and 18 years, attending 15 high-schools in rural and urban areas of the south of Spain. After a screening assessment, 69
(59.5%) subjects fulfilled the criteria for the diagnosis of Social Phobia, 24 (20.7%) that for specific social phobia and 23 (19.8%) did not. Among them, 55
(47.4%) met criteria for substance use problems and 61 (52.6%) did not. Substance users took cannabis, cigarettes, or any other drugs. We selected two
conditions in order to study the differences: substance users and non-substance users. To carry out the comparisons among them a one-way analysis of
variance (ANOVA) for the quantitative information, and tests ?2 for the dichotomic data. Comparisons in psychopathological and demographic variables
showed statistically significant differences among substance users and non-substance users in mean age, age of onset and chronicity of the disorder.
Specifically, we found that substance users were more often older adolescents, had an early age of onset and a higher chronicity of social phobia. The
current study establishes preliminary support for the relationship between social phobia and substance use problems in a Spanish sample of adolescents.
Chronic cannabis use and cognitive performance.
Daniel Lloret and M. Carmen Segura, Universidad Miguel Hernández, Spain
Cognitive impairment due to the psychological residual effects of chronic cannabis use have not been yet clearly demonstrated. To determine whether such
consequences occurred, this work compares the cognitive performance of college students cannabis users (n=28) and non users, in a battery of six tests of
maintained attention, observation and reasoning. Mean of age was 20,7 years. Users had a regular consumption of cannabis for at least six months up to
10 years (73% more than 1 year of consumption). Users were tested after a period of abstinence of at least 1 day. Controls had neither current nor past
experience with cannabis. Both, users and controls, were matched for age, educational level, sex, intellectual activity and labour activity. Other psychoactive
drugs chronic experience, including alcohol, recent consumption of any abuse drug or psychiatric diagnosis was considered as exclusion criteria. The
group of users was two-folded in heavy and light users. Heavy smokers were considered by using cannabis at least seven times per week. Preliminary
findings suggest that light users of cannabis show no significant differences in the test scores. Further analysis are needed for heavy users.
Comparison between two applications of LST program applied by experts vs teachers
Jose P. Espada, Mónica Gázquez and Jose A. Garcia del Castillo, Universidad Miguel Hernandez, Spain
In recent years advances have been made in the evaluation of substance abuse preventive programs at school. Researchers have centered their efforts in
assessing the outcomes of preventive programs, concluding that generally they are effective in preventimg substance use and abuse. A strategy in the
evaluation of behavioral interventions is the variation of the intervention parameters, as the characteristics of the therapist. Many studies indicate that the
data on the differential effectiveness of the programs based on the applicators (expert versus teacher), are contradictory. The aim of this work was to
compare the outcomes of the application of a program based on improving general skills of the adolescent (social skills, self-esteem, information, problem
solving, etc.), comparing the effects when it is carried out by experts or teachers. A quasi experimental group design was used with a nonequivalent control
group, repeated measures pretest, postest and follow up. The program was applied with a scholar sample of adolescents of secondary. The sample was
composed by 324 students with an average age of 12,5 years. Experimental group received the intervention based on Life Skills Training program, whereas
a control group didn´t received the intervention. The dependent variables were substance use, attitude towards drugs, intention of future use and abuse, and
the level of information. Instruments were self reports. Inter-group and intra-group changes are analyzed. Preliminary results point at a greater effectiveness
when the programs are applied by the experts. The benefits and limitations of the application of the programs by teachers and the implications for future
preventive interventions will be discussed.
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Symposium 39
Advances in Treatment for Amphetamine Use Problems
Convenor: Frances Kay-Lambkin, Centre for Mental Health Studies, University of Newcastle, Australia, Australia
The effectiveness of cognitive behaviour therapy for amphetamine use problems
Amanda Baker1, Nicole Lee2, Frances Kay-Lambkin1, Melissa Claire1, Linda Jenner3, 1 The University of Newcastle, Australia 2; Turning Point
Drug and Alcohol Centre, Melbourne, Australia3 The University of Queensland, Brisbane, Australia
This study sought to replicate and extend a small pilot study conducted by Baker, Boggs and Lewin (2001) which demonstrated that brief interventions
consisting of motivational interviewing and cognitive-behaviour therapy (CBT) were feasible and associated with better outcomes compared with a control
condition. Methods: This was a randomised controlled trial conducted in the Greater Brisbane Region of Queensland and Newcastle, NSW, among 214
regular amphetamine users. Results: The main finding of this study was that there was a significant increase in the likelihood of abstinence from
amphetamines among those receiving two or more treatment sessions. In addition, the number of treatment sessions attended had a significant short-term
beneficial effect on level of depression. Overall, there was a marked reduction in amphetamine use among this sample over time and, apart from abstinence
rates and short-term effects on depression level, this was not differential by treatment group. Reduction in amphetamine use was accompanied by significant
improvements in stage of change, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behaviour, criminal activity level, and psychiatric
distress and depression level. Discussion: On the basis of these findings, a stepped care approach is recommended. The first step in providing an effective
intervention among many regular amphetamine users, particularly those attending non-treatment settings, may include provision of: a structured assessment
of amphetamine use and related problems; self-help material; and regular monitoring of amphetamine use and related harms. Regular amphetamine users
who present to treatment settings could be offered two sessions of CBT, whilst people with moderate to severe levels of depression may best be offered four
sessions of CBT for amphetamine use from the outset, with further treatment for amphetamine use and/or depression depending on response.
Initial findings of a prospective study into amphetamine use and psychosis
Sharon Dawe, Griffith University, Australia
No abstract available
Stepped care of cognitive behaviour therapy CBT for people with comorbid amphetamine use problems and depression
Frances Kay-Lambkin1, 2, Amanda Baker1, Rebecca McKetin2, Maree Teesson2, Nicole Lee3, Robert Batey4, 1 University of Newcastle, Australia
2 National Drug and Alcohol Research Centre, University of NSW, Australia3 Turning Point Drug and Alcohol Centre, Melbourne, Australia4 Centre
for Drug and Alcohol, NSW Health, Australia
There is clear evidence to suggest that amphetamine use is common and increasing both in Australia and internationally, and has also been associated with
increased psychological and social problems. An Australian study, found high rates of mood disorder among amphetamine users, with at least three
quarters of the sample reporting symptoms of anxiety or depression. Depressive symptoms are higher among amphetamine users than cocaine and other
drug users and depressive symptoms persist longer in amphetamine users compared to cocaine users. Despite this, very few treatment options exist that
cater to the specific, cyclical and interactive nature of co-occurring mental health and amphetamine use problems. The net result is poorer outcomes,
increased likelihood of psychiatric and amphetamine-related relapse, along with increased costs of care for the individual, families, services, etc. Significant
research conducted previously by the members of this Symposium has attempted to develop a menu of cognitive behavioural treatment options for people
with depression and AOD use comorbidity, including amphetamine use problems, with each treatment approach providing evidence for at least some benefit
among the comorbid study participants. However, while encouraging, these results again raise the issue of how treatment may be incorporated into existing
services (mental health, AOD use, primary care, etc.). A stepped care approach to treatment of comorbidity has been suggested as one model for the
dissemination of such evidence-based treatments. Although stepped care approaches have received attention in recent commentaries within the research
literature, almost no evidence exists to suggest how they might be implemented and evaluated in clinical practice. This paper will report on a pilot study of a
stepped care approach to the treatment of amphetamine use and depression.
The relationship between positive symptoms, impulsivity, and amphetamine use on aggressive behaviour.
Kely Lapworth1, Sharon Dawe1, Penny Davis1, David Kavanagh2, 1 Griffith University, Australia; 2 The University of Queensland, Brisbane,
No abstract available
Symposium 72
Cannabis Use Disorders: Cross-cultural Trends in Epidemiology, Comorbidity and Treatment Development
Convenor: Eva Hoch, Technische Universität Dresden, Germany, Germany
From Epidemiological Evidence to Defining Priorities for Intervention in CUD
Hans-Ulrich Wittchen & Silke Behrendt, Technische Universität Dresden, Germany
There is an abundance of descriptive cross-sectional epidemiological studies that have highlighted that since the mid 80ies up to 50% of all adolescents
have tried a cannabis product at least once in their life (lifetime users). There is also evidence that 20-45% of all lifetime users report a pattern of regular use
for at least some time and that up to 10% of all lifetime users met criteria for cannabis use disorders. It is estimated that among 14-24 years olds about 5%
of all adolescents meet lifetime criteria for either abuse or dependence. The prevalence of cannabis dependence is estimated to be 1.4% for the past 12
months and 3.1% for lifetime.Longitudinal studies have further started to describe the transitions from use to CUD also highlighting a wide range of variables
that influence the probability of transitions from use to cannabis use disorders and vice versa from use to non use. Core variables that are associated with
an unfavourable course are: access and availability, frequency and duration of use, concomitant use of other legal and illegal drugs, peer pressure, and preexisting as well as subsequent psychopathology (externalizing and internalizing disorders).In sharp contrast to these well established findings, the
description of cannabis users needs for intervention remains incomplete. Although there is little doubt that there is a substantially increase in treatment
demands among people with cannabis problems, the type and nature of their needs for intervention is unclear. The paper will present recent findings on
problem profiles of cannabis users and those with cannabis disorders and will highlight to what degree community services are meeting the needs of these
patients.This project was funded by the National Ministry for Education and Research.
The Adolescent Cannabis Check-up
Jan Copeland & Greg Martin, University of New South Wales, Australia
Cannabis is the illicit drug most commonly used by adolescents in Europe, the US and Australia. There are, however, few interventions developed
specifically for this group. This study assesses the efficacy of the Australian Adolescent Cannabis Check-up (ACCU); a brief intervention targeting non
treatment-seeking adolescent cannabis users in a randomised controlled trial. The ACCU includes a single educational session for concerned parents;
assessment and structured feedback sessions for young cannabis users. There were a total of 298 contacts to the study; 86 concerned parents and 126
young people were successfully screened and 40 young people randomised. The final three month follow-up rate was 80%. Data analyses showed
significantly greater reductions in frequency of cannabis use and number of cannabis dependence symptoms reported for the participants in the active
treatment group compared with the delayed treatment condition. Self-reported cannabis use in the preceding 30 days was validated by urinalysis. The
intervention was acceptable to participants with a large majority rating the intervention as helpful and useful.This project was funded by the National Health
and Medical Research Council.
CANDIS- Targeted Treatment for Cannabis Disorders
Eva Hoch, Heike Rohrbacher, René Noack & Jana Henker, Technische Universität Dresden, Germany
In Europe the demand for treatment due to cannabis-related physical, mental, social, and legal problems has been rising in the past decade. Anyhow, there
is still a considerably lack of treatment programs with established efficacy, that meet the specific poblems and needs of these patients. From January 2006
to March 2007 a randomized controlled intervention study was conducted at Dresden University, Germany. The three armes were 1.) a modular standardized
treatment ST, including motivational enhancement, cognitive behavioural, and psychosocial problem solving components; 2.) a targeted standardized
Page 10
treatment, including the same components as the ST but being individually matched to the patients' specific problem profile; and (c) a delayed treatment
control group. There were a total of 150 contacts to the study. 122 adolescents and adults participated at an information session, 102 subjects were
successfully screened at baseline examination and 92 entered treatment. The majority of participantes were males, who used cannabis on a daily basis.
Three out of four subjects met the criteria for cannabis abuse or cannabis dependence according to DSM-IV (last four weeks) (M-CIDI). Comorbid disorders
were also frequent, especially affective disorders, anxiety disorders, alcohol dependence, nicotine dependence and dependence from illegal substances
other than cannabis.CANDIS intervention was well accepted by patients and study therapists. Every second treatment completer (currently n=72) reported
complete abstinence (self reports & urine sreenings), 33% reduced, 3% increased their cannabis use, 13% reported no change. This project was funded by
the National Ministry for Research and Education.
Symposium 87
Mental Health and Substance Use Comorbidity: Innovative, Integrated CBT Treatments
Convenor: Amanda Baker, Centre for Mental Health Studies, University of Newcastle, Australia, Australia
A review of the evidence for the treatment of comorbid psychotic disorders and substance misuse problems
David Kavanagh, The University of Queensland, Australia
No abstract available
Randomised controlled trial of computerised cognitive behaviour therapy for depression and substance use comorbidity
Frances Kay-Lambkin1, 4, Amanda Baker, Brian Kelly, Terry Lewin1, Vaughan Carr1, 3., 1 The University of Newcastle, Australia; 2 The University
of Queensland, Australia; 3 Neuroscience Institute for Schizophrenia and Allied Disorders;4 University of NSW, Australia; 5 Centre for Rural and
Remote Mental Health, Orange, Australia
This paper will report on the 12-month outcomes of the SHADE project (Self-Help for Alcohol/other drug use and DEpression), which offered integrated
cognitive behaviour therapy to people with co-existing depression and alcohol and other drug (AOD) problems.Background: Despite the high co-occurrence
of depression and AOD problems, an effective program of treatment is yet be developed and tested for people experiencing this comorbidity. In addition,
access to psychological treatment for people with such co-existing problems is typically difficult. As such, it is important to focus efforts on developing
treatments that not only target these problems, but that also address the important issue of treatment accessibility.Methods: 300 people with current
depression and co-existing problematic use of alcohol, cannabis or amphetamines were recruited from the general community. Following a comprehensive
assessment, participants received a one-session brief intervention, and were subsequently randomised to one of three treatment conditions: 9 sessions of
SHADE therapy conducted by a psychologist, 9 sessions of SHADE therapy conducted via a therapist assisted computer program (CD-Rom), or 9 sessions
of person-centre supported counselling. Blind follow-up interviews were conducted at post-treatment, 6- and 12-months.Results: Reductions in depression
and AOD use were evident at the post-treatment assessment. Improvements were maintained at 6- and 12-months in the two active SHADE therapy
conditions. Conclusions: People with co-existing depression and AOD use problems will attend a program of psychological treatment and report benefit from
therapy that integrates depression and AOD-related strategies. Therapist assisted computerised treatment may help people to reduce levels of depression
and AOD use. Further implications will be discussed.
The Effectiveness of an Integrated CBT Intervention for Co-Occurring Depression and Substance Misuse in Young People: A
Pilot Study
Leanne Hides1, Dan I. Lubman1, Steve Carroll1 , Lisa Catania1, Frances Kay-Lambkin2, Amanda Baker2, & Nicholas Allen1, 1 University of
Melbourne, Australia; 2 University of Newcastle, Australia
Adolescents with a substance use disorder are at two to three times the risk of experiencing concurrent anxiety or mood disorders. Whilst there is a wellestablished evidence base for the use of CBT in the treatment of depression in young people, the majority of these studies exclude adolescents with drug
and alcohol problems, despite increasing evidence for the efficacy of CBT for such problems amongst young people. More recently, there has been an
emphasis on the need for more integrated approaches to the treatment of young people with co-existing depression and substance use problems, and
preliminary evidence from two studies has reported positive outcomes for integrated CBT interventions for depression and alcohol dependence in
adolescents. The aim of this study was to determine the effectiveness of an integrated cognitive behaviour therapy (CBT) intervention for co-occurring
depression and substance misuse in young people.Methods: Participants consisted of 61 young people aged 15 to 25, with a major depressive disorder and
concurrent substance misuse. Participants were provided with 10 sessions of CBT for co-occurring depression and substance misuse and case
management over a maximum of 20 weeks. Partial or non-responders were provided with a randomised 10-week double-blind, placebo-controlled trial of
sertraline.Results: Pre and post treatment and 6 month data on depressive and substance use symptoms will be presented. Preliminary results indicated
positive outcomes on functioning and depression/anxiety symptoms but not substance use outcomes post treatment. Predictors of treatment response to
the integrated CBT intervention at mid and post treatment will also be reported.Conclusions: Preliminary evidence from recently published pilot studies have
demonstrated the efficacy of integrated CBT interventions in alcohol dependent adolescents with co-existing depression. The current paper reports
preliminary support for the effectiveness of integrated treatment for depression and substance misuse amongst young people.
Combined versus single focused interventions for co-morbid depression and alcohol problems: the DAISI project.
Amanda Baker1, David Kavanagh2, Frances Kay-Lambkin1, Sally Hunt1, Terry Lewin1, Vaughan Carr1, 3, 1 The University of Newcastle,
Australia; 2 The University of Queensland, Australia;3 Neuroscience Institute for Schizophrenia and Allied Disorders, Australia
It has long been known that the co-morbidity of alcohol problems and depression is common, and that people experiencing these conditions concurrently
have poorer treatment outcomes than those experienced by people with single disorders, resulting in greater use of services and medications. Despite this,
effective evidenced-based treatments have yet to be developed and fully tested for this unique group. There is a need to explore interventions which
acknowledge the co-morbidity and actively work to minimise the effect of both conditions. The DAISI study is one of the first to explore whether an
intervention that integrates treatment for depression and alcohol would be superior in reducing alcohol use and symptoms of depression, when compared
with a treatment that focuses on alcohol alone or depression alone. Participants will be randomly allocated to one of four treatment conditions which
combine CBT and Motivational Interviewing strategies. The first three conditions offer 10 sessions which focus on a) depression; b) alcohol use; or c)
integrated depression and alcohol focus. The remaining group will receive a single case formulation and assessment feedback session. Interim outcomes
will be presented for a sub-sample, assessed prior to treatment, and again 3-months post initial assessment. It is predicted that this research will result in
the development of an effective treatment program for people with alcohol and depressive disorders, and further, that the integrated CBT will produce
greater, more sustainable reductions in both depressive and alcohol use outcomes relative to the other treatment conditions at the post-treatment follow-up
Neuropsychological functioning in people with co-morbid depression and alcohol use.
Sally Hunt1, Amanda Baker1, David Kavanagh2, Frances Kay-Lambkin1, 4, Terry Lewin1, Vaughan Carr1, 3., 1 The University of Newcastle,
Australia; 2 The University of Queensland, Australia; 3 Neuroscience Institute for Schizophrenia and Allied Disorders;4 University of NSW,
As awareness of the complex needs of people with depression and alcohol use co-morbidity have increased, so too has the need to allocate clients to
appropriate and effective treatments. Clinicians are often asked to predict whether a client will benefit from a psychological intervention such as Cognitive
Behaviour Therapy (CBT) based on the client's level of cognitive functioning. Unfortunately, there is little empirical evidence for them to draw on in making
this assessment, and therapeutic tools and strategies are often decided on after a process of trial and error. The DAISI study aims to clarify these issues by
examining the neuropsychological profile of a sample of participants who are currently experiencing both depression and alcohol use above non-hazardous
levels. Participants undergo neuropsychological testing prior to treatment, and again 12-months after baseline testing. Participants are randomly allocated to
one of four treatments, the first three conditions offer 10 sessions of CBT and Motivational Interviewing (MI) which focus on a) depression; b) alcohol use; or
c) integrated depression and alcohol focus. The remaining group will receive a single session of case formulation and assessment feedback. It is anticipated
that the baseline neuropsychological test results will predict responsiveness to treatment and that the 12-month follow-up assessments will detect a
relationship between change in cognitive functioning and change in symptom and/or alcohol use. Methodology and interim results will be discussed.
Page 11
Screening and integrated treatment of depression, anxiety and substance use disorders in a real world setting
Nicole Lee, Jacqui Cameron, Tracey Brooke, Sandra Roeg, Turning Point Drug and Alcohol Centre, Melbourne, Australia
Integrated treatment is now the recommended practice for patients with comorbid mental health and alcohol and drug disorders. Up to 80% of patients
present to alcohol and drug services with mental health problems, primarily the higher prevalence disorders (anxiety and depression). Alcohol and drug
workers do not always have extensive mental health experience and the focus of research and clinical programs is often on the more acute disorders, such
as psychosis, meaning that few programs have been developed for this population. In order to provide truly integrated treatment, there is an urgent need to
upskill alcohol and drug workers to both screen and intervene with both clinical and subclinical mental health disorders.The PsyCheck Project has
proceeded in three phases: 1) the development of screening and intervention tools, 2) the evaluation of the implementation of mental health screening and
cognitive behavioural intervention within a range of drug and alcohol settings, and 3) the best practice dissemination of the program. Each phase has
undergone extensive evaluation. This presentation will overview the outcomes of Phases 1 and 2 and outline the dissemination strategy including early
evaluation results.
Symposium 100
Delivering Alcoholism Treatment in Novel Ways: Challenges and Solutions
Convenor: Peter Miller, Medical University of South Carolina, USA
Computer based treatment documentation and feedback system for alcohol use disorders
Gerhard Bühringer 1) 2)Johannes Lindenmeyer 3), 1) IFT Institut für Therapieforschung, Munich, Germany;
2) Technischen Universität, Dresden, Germany; 3) Salus Klinik, Lindow, Germany
In Germany, the post-acute treatment of alcohol dependence is the responsibility of the Pension Insurance Scheme. About 28.800 cases are treated
annually in inpatient centres; treatment standards are high and monitored by the funding agency. Aims: To describe (1) the video- and computer-based
documentation system for all patient and treatment related information, (2) the utilisation by staff members and (3) the problems in the implementation
period. Method: The intranet system covers the following components: (1) Standardised data collection of all relevant patient information during the total stay
of 8-12 weeks. No further step in treatment is possible without the timely completion of all details. (2) Compiling a patient report after the 3rd day (history,
test results, treatment targets). (3) Patient specific allocation of 45 possible treatment components, reaching from behaviour therapy programmes like stress
management, to social or health related activities. The therapist "books" specific components in the system which helps the management to provide the
necessary resources in time. (4) Access to relevant information by all staff members who are involved in the treatment of a specific patient. (5) Automatic
creation of a final report for the funding agency. Conclusions: The system avoids traditional paper-based patient files, reduces time for staff meetings,
improves the implementation of a highly individualised treatment programme, reduces the work for final responds and contributes to a quality assurance
system. Problems in the implementation period had to be solved related to deficits of the staff to handle the system, and to find a balance between
standardisation and individual freedom for the staff in the treatment process.
Prevention of High-Risk Drinking among College Students: A Harm-Reduction Approach
G. Alan Marlatt, University of Washington, USA
Alcohol problems associated with high-risk drinking represent a leading health concern among college students. A variety of harmful consequences are
reported, especially among students who engage in “binge drinking” (5 or more drinks on a single occasion for males, 4 or more for females), including
blackouts, losing consciousness (“passing out”), sexual and aggressive problems, and in some cases, loss of life due to either injuries and accidents or
alcohol overdose fatalities. Although abstinence is a legal requirement for underage drinkers (e.g., those under 21 years of age in the USA), the majority of
students do engage in at least some alcohol consumption, with about 20% classified as frequent binge drinkers. Harm reduction is an alternative goal that
may reduce the risks and harmful consequences of excessive drinking on college campuses. Two programs developed at the University of Washington
(Seattle, USA) will be described: Alcohol Skills-Training Program, a six-session course that can be delivered in a group format, and BASICS (Brief Alcohol
Screening and Intervention for College Students) that is designed to be delivered in two face-to-face interviews with a counselor trained in BASICS skills.
Results from randomized clinical trials evaluating both programs will be presented, showing that the harm-reduction approach is associated with significant
reductions in both consumption rates and negative consequences associated with drinking.
Implementation of Screening and Brief Interventions for alcohol at a health systems level in Catalonia. Outcomes and pitfalls.
Antoni Gual 1,2, Lidia Segura 1, Joan Colom 1, 1 Health Department, Government of Catalonia, Spain; 2 Neurosciences Institute, IDIBAPS.
Barcelona, Spain
There is consistent evidence on the efficacy of Screening and Brief Interventions (SBI) to identify hazardous drinkers and to reduce their consumption. Yet,
dissemination of SBI at a population level has proven to be difficult. In the frame of the WHO Collaborative Study on Alcohol and Primary Health Care (PHC)
we undertook the dissemination of SBI to all PHC centres, targeting 340 Centres that provide health care to the population of Catalonia (7.000.000
inhabitants).Aim: To evaluate if a training package (5 hours) based on the Skills for Change Module (WHO) improved knowledge, attitudes and clinical
performance of PHC professionals concerning alcohol.Methods: A representative sample of the Centres (n=28) was randomly selected. Data on knowledge,
attitudes and clinical behaviour were obtained before and 3 months after training through 3 different sources: interviews to professionals, audit of medical
records and exit-poll interviews to patients.Results: The training package was highly valued by both trainers and trainees, and more than 80% of
professionals attended at least 4 out of 5 sessions. Training increased the knowledge of PHC professionals and improved their willingness to treat alcohol
problems (from 62,5% to 84,7%; p<0.05) but screening rates remained low both measured through the exit poll questionnaires (never screened: from 51,1%
to 53,4%: p=ns) and the medical records audit (3,2% to 4,6%; p=ns).Discussion: Training appears to be not enough to increase SBI use in PHC settings.
Structural and cultural barriers seem to play an important role.
Using Electronic Medical Records to Increase Implementation and Documentation of Alcohol Screening and Intervention in
Primary Care
P.M. Miller, S. Ornstein, H. Liszka, P. Neitert, A. Wessell, L. Nemeth, R. Jenkins, Medical University of South Carolina, USA
The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol
problems in hypertensive (HTN) patients by primary care practitioners. The AA-TRIP intervention model includes didactic training, on-site academic detailing,
electronic medical record (EMR) templates and prompts, quarterly practice feedback, and yearly “best practices” meetings and discussion groups. Ten
experimental group practices received AA-TRIP training over a 2-year period while 10 control group practices received written alcohol screening guidelines
and quarterly practice feedback only. All primary care practices used the same EMR system and EMR templates for prompting and documenting screening.
At the end of a 2-year training period, primary care practices receiving the alcohol-focused training screened an average of 77% of their HTN patients
compared to 26% by control practices. Making alcohol diagnoses and providing brief intervention was more challenging, although implementation of brief
interventions was significantly higher in the experimental group. EMR alcohol screening templates facilitated screening and documentation, with accurate
documentation a key element in health services studies since physicians often report more screening and intervention than is actually documented. Early
adopters and high performing practices served as valuable role models to facilitate improvement in other practices. The significance of this study is that it
provides an evidence-based intervention to facilitate the routine use of alcohol screening with patients whose hypertension may be exacerbated by
excessive alcohol consumption.
Symposium 115
New developments in Cognitive Behaviour Therapy of Substance Misuse; the UK experience.
Convenor: Christos Kouimtsidis, St. George's, University of London, U.K.
Brief interventions for alcohol misuse: research and practice.
Colin Drummond, St George's, University of London, U.K.
Alcohol misuse is prevalent in western countries and places a considerable burden on society through health and social care, and criminal justice costs.
Alcohol misuse is the third leading cause of ill health in Europe, after smoking and hypertension. Alcohol misusers commonly present to medical and criminal
justice settings, often with the consequences of excessive drinking, but are seldom identified. Opportunistic screening and brief intervention is a cost
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effective means of reducing excessive drinking in medical settings. However, there are considerable challenges to implementing brief interventions in
practice, not least overcoming attitudinal barriers in health professionals, and at least in the UK, a lack of political will. Widespread implementation of brief
alcohol interventions would have a major public health impact and result in significant cost savings in health care and criminal justice agencies. This paper
will review the evidence base for screening and brief intervention, and examine methods of improving implementation. Recent research on stepped care
intervention provides a new method of specialists and non specialists working together with practical clinical algorithms to meet the diverse needs of a
spectrum of alcohol misusers. Finally a new programme of research on implementation of screening and brief interventions will be described.
Social Behaviour and Network Therapy and the United Kingdom Alcohol Treatment Trial
Alex Copello, The University of Birmingham & Birmingham and Solihull Mental Health Trust, UK
This paper will describe Social Behaviour and Network Therapy (SBNT), an intervention package developed by integrating strategies found to be effective in
other substance misuse treatment approaches and built upon the premise that social network support for change is central to the resolution of addictive
behaviour. SBNT has been tested as part of the large randomised multi centre United Kingdom Alcohol Treatment Trial and found to be as effective and
cost-effective as Motivational Enhancement Therapy. SBNT has also been implemented and evaluated in drug use services in the UK. The core principle of
SBNT is that positive change is promoted by support from a close network of family members and/or friends (referred to as 'network members') who provide
a person who wishes to abstain from or reduce substance use with positive social support for change. The intervention uses a number of strategies built
around communication, behavioural interactions and relapse prevention to attempt to create the right conditions to support and encourage change in the
substance user's social environment. The paper will describe key principles and skills of SBNT as well as the main results of the United Kingdom Alcohol
Treatment Trial
Cognitive behavioural therapy for opioid dependence; The experience of the United Kingdom Cognitive Behaviour Therapy in
Methadone Maintenance study (UKCBTMM)
Christos Kouimtsidis, St. George's, University of London, U.K.
Evidence from USA suggests that psychosocial interventions improve methadone maintenance treatment outcome. There is evidence to support the
effectiveness of CBT with cannabis, stimulant and alcohol users. There are major differences in philosophy and practice of services between USA and UK.
This paper will present the results of the UKCBTMM study and discuss the experience of therapists and implementation issues. The main aim of the study
was to evaluate the effectiveness and cost effectiveness of CBT as an adjunct to standard Methadone maintenance treatment (MMT). This was a pragmatic,
randomised, multi-centre, parallel group design study comparing CBT plus MMT with MMT alone. Outcome assessment was in 1 year with interim
assessment at 6 months. It took place in 10 community methadone maintenance clinics in 3 regions in England. Therapists and key-workers were recruited
from existing staff. Therapists were trained with an intensive 10 working days programme, accredited and received regular supervision. CBT was delivered
weekly according to a purpose designed manual. Quality and adherence to manual were assessed. MMT was offered every 2 weeks (also manual guided).
The study was underpowered therefore results did not reach levels of significance. Intention to treat analysis showed that at six months CBT group had
more days of abstinence to MMT group (16%vs 9%; Standarised Effect Sizes difference of 0.28); difference maintained at 12 months. For both groups there
was reduction in use of health services in 6 and 12 months. The estimated annual resource saving compared to study treatment costs was 15:1 ratio for
CBT compared to 14:1 ratio for MMT.
Integrated motivational interviewing and cognitive behaviour therapy for psychosis and substance misuse
Christine Barrowclough 1; Sarah Nothard 2,, 1 University of Manchester, UK ; 2 Manchester Mental Health and Social Care Trust
Despite high rates of problematic substance use in psychosis and the associated problems, there is a very limited evidence base available as to how best to
help this client group. In Manchester UK, we have developed a therapeutic intervention that combines motivational interviewing (MI) and cognitive behaviour
therapy (CBT). We described an earlier form of this therapy in a small published RCT. We have now further developed the therapy and are currently
evaluating it in a large trial: MIDAS (Motivational Interventions for Drug and Alcohol use in Schizophrenia). MIDAS is a large multi-site randomised
controlled trial funded by the Medical Research Council and the Department of Health and is currently running in the UK from the Universities of Manchester
and London in collaboration with local NHS mental health trusts. The integrated CBT- MI is delivered over 12 months alongside the client's routine care and
aims to take account of the dual and interactive nature of substance use and psychosis problems and the motivational stage of the patient.This presentation
aims to briefly review the therapy literature for substance use & psychosis, illustrate MIDAS integrated therapy, discuss key therapy issues for people with
psychosis and substance use and report on progress with the trial.
Open Paper Symposium 17
Issues in Addiction
Presenting a Dynamic Model of Relapse: Non-normality and Divergence in Post-Treatment Alcohol Use
Katie Witkiewitz, University of Illinois, USA.
Alcohol lapses are the modal outcome following treatment for alcohol use disorders, yet many alcohol researchers have encountered limited success in the
prediction and prevention of relapse. One hypothesis is that lapses are unpredictable, but another possibility is the complexity of the relapse process is not
captured by traditional linear models of behavior. This paper provides an introduction to the revised cognitive behavioral model of relapse (Witkiewitz &
Marlatt, 2004) and empirical evidence supportive of the revised model. Implications for the treatment of alcohol use and future research directions are also
discussed. Data from Project MATCH, a multi-site alcohol treatment study, were re-analyzed using two statistical methodologies: catastrophe modeling and
two-part growth mixture modeling. Project MATCH included 1,726 participants who were randomly assigned to receive one of three manualized treatments
for alcohol use disorders: cognitive-behavioral therapy, motivation enhancement therapy, or twelve-step facilitation therapy. The participants received
treatment over 12 weeks and were then assessed every 3-months for the first 15 months following treatment. Project MATCH was designed to test 16
specific patient-treatment matching hypotheses and the results from the original analysis provided little support for the study hypotheses: all three treatments
were equally effective in reducing alcohol use and only one of the 16 primary hypotheses was supported. The current study was designed to test two
different, but complementary, statistical methods for analyzing the Project MATCH data. More specifically this study examined whether using analyses that
treated the relapse process as a nonlinear dynamical system would improve our ability to test one of the proposed matching hypotheses.
Swiss and US Alcohol Use Disorder Treatment Programs: Program Characteristics and One-Year Outcomes
Franz Moggi, University Hospital of Psychiatry Bern, Rudolf H. Moos, Veterans Affairs and Stanford University Medical Centers, Anna Giovanoli,
University Hospital of Psychiatry Bern, Caroline Buri, University Hospital of Psychiatry Bern, Bernice S. Moos, Veterans Affairs and Stanford
University Medical Centers, Switzerland
Although there is an ever-growing body of research on the association between alcohol use disorder (AUD) treatment processes and patients' outcomes,
virtually all of it focuses only on selected patients drawn from one country at a time, especially the United States (US) (Berglund et al., 2003; Miller &
Wilbourne, 2002). Some reviews have examined patient characteristics and outcomes by comparing studies conducted in different countries; however,
these studies typically used different assessment procedures (Swearingen et al., 2003; Süss, 1995). Moreover, we do not know of any study that has
compared the relationship between treatment program characteristics and patients' outcomes in samples of patients drawn from different countries. This
study compared Swiss and US AUD patients and residential treatment programs, and the relationship of program characteristics to patients' substance use
and psychosocial functioning at a 1-year follow-up. The study utilized a prospective, naturalistic design to compare patients and program characteristics in a
sample of 10 programs in the German-speaking part of Switzerland and 15 US public, government-run treatment programs. A total of 358 male patients in
Swiss programs were matched on age, marital status, and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care
staff members also participated. In the two countries, patients completed the same inventories at admission, discharge, and 1-year follow-up that assessed
their substance use and psychological functioning and receipt of aftercare. Staff members reported on program characteristics and their beliefs about
substance use. Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and, although they did not
differ on abstinence and remission at the 1-year follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and
included more individual cognitive-behavioral oriented treatment sessions; US programs focused more on group sessions and were more oriented toward
12-step treatment and a disease model of treatment. This evaluation capitalized on representative treatment conditions and typical treatment orientations in
a selected sample of Swiss and US treatment programs. Such an approach augments the external validity; however, the data were only based on male
patients and, in the US, on only one system of care. Overall, length of program, treatment intensity, and 12-step orientation were associated with better 1year outcomes for patients in both countries. The Swiss and US programs sampled here differed substantially in their patient and treatment characteristics;
however, in general, program characteristics in the two sets of programs showed comparable associations with patients' 1-year outcomes. Associations
between treatment processes and patients' outcomes may generalize from one cultural context to another.
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Acamprosate and Integrated Behaviour Therapy in the Outpatient Treatment of Alcohol Dependents
Wolfgang H. Strauss, Psychiatric Clinic of thre University Duesseldorf, Nicole Frommann, Psychiatric Clinic of thre University Duesseldorf,
Wolfgang Wölwer, Psychiatric Clinic of thre University Duesseldorf, Germany
Alcohol dependence treatment may include medications, behavioural therapies or both. It is unknown how combining these treatments may impact their
effectiveness Based on a previous study where 120 patients were randomly assigned to 3 different outpatient treatment programs in which was shown that
patients undergoing behaviour therapy showed significantly higher success rates compared with supportive therapy 372 patients in five therapy centres
were randomly as-signed after detoxification to three therapy groups: Integrated behavioural therapy (IBT) in combination with the anticraving medication
Acamprosate (ACA), IBT with placebo, and therapy as usual (TAU) with Acamprosate. As the study is not unblinded regarding the medication at this point of
time preliminary results show that the rates of improved and abstinent patients in the groups with IBT is significant higher than in the TAU-ACA-group. The
results of the study will have considerable consequences for further strategies of relapse prevention in alcohol dependents in outpatient treatment.
Training Addiction Counselors in Group CBT for Depression
Kimberly Hepner, RAND Corporation, Stephanie Woo, Pepperdine University, Kathryn Watkins, RAND Corporation
Co-morbid depression is common in addicted populations; however, access and acceptability of empirically supported, behavioral interventions for
depression are limited. We sought to train addiction counselors in group CBT for depression, an intervention that is traditionally only provided by trained
mental health professionals, and evaluate whether addiction counselors could achieve acceptable levels of adherence and competence to the CBT model.
Outpatient addiction counselors were selected and trained to provide a manualized group CBT intervention for depression. The group was provided in a
residential substance abuse setting as part of a multi-site, community-based treatment outcome study. Selected counselors were required to express an
interest in learning CBT and be employed at the substance abuse setting for at least one year. Counselors were not required to have any prior knowledge
about depression or CBT. Counselors were provided with two days of didactic training, ongoing weekly group supervision with a licensed cognitive
behavioral therapist, and a one day booster training after leading the treatment once. All treatment sessions were audio taped and reviewed during group
supervision. Selected sessions were coded for fidelity (adherence and competence) by external raters. Adherence was coded on a 4-point scale (0-3)
based on how adequately group leaders covered essential elements of each structured session. A score of 2 or higher indicated acceptable adherence.
Competence was coded using an adapted version of the Cognitive Therapy Adherence and Competence Scale. Each item was coded on a 7-point scale (06), with an average score of 4.0 indicating competent CBT. These fidelity ratings were also used to inform supervisors of issues to be addressed in ongoing
supervision. The average rate of adherence to treatment was 84% across the coded sessions, while the average competence score (Mean = 4.1) indicated
that counselors were delivering competent CBT. Our work demonstrates the feasibility of disseminating group CBT for depression to addicted populations
through training of addiction counselors. Addiction counselors demonstrated acceptable adherence and competence in delivering group CBT for depression.
Challenges in training addiction counselors in group CBT for depression will be discussed. These challenges included 1) differences in the structure and
approach of the CBT group intervention compared to usual substance abuse groups, 2) managing competing demands and allocating adequate preparation
time, 3) expanding the counselors' “scope of practice” to include depression, and 4) changing counselor values regarding the importance of empirically
supported treatments and continued adherence to the treatment model. Specific suggestions for successfully training addiction counselors and addressing
these challenges will be provided.
Improving the Odds - Internet-based Treatment for Problem Gambling
Leanne Casey, Griffith University, Tian Oei, University of Queensland, Namrata Raylu, Northern Sydney Central Coast Health Service, Hui Lim,
Griffith University, Australia
Problem gambling is increasingly recognized as a serious disorder in many countries. In addition to causing substantial impairment for individuals in
personal, vocational and relationship domains, problem gambling also costs society in the form of lost productivity, lost employment, and criminal activities
(Blaszczynski, Walker, Sagris, & Dickerson, 1997). Furthermore, of those who experience significant problems as a result of their gambling, it appears that
only a small proportion, approximately 1 in 10, seek treatment (Ladouceur, 2005). Examining the reasons that problem gamblers may delay seeking
treatment, Tavares and his colleagues (Tavares, Martins, Zilberman, & el Guebaly, 2002) found that shame and secrecy regarding gambling were amongst
the strongest predictors of delay. Of particular relevance to increasing treatment acceptance and engagement in problem gamblers is the observation that
some individuals may prefer the internet to other methods of delivering and receiving mental health interventions because of its anonymity (Griffiths &
Cooper, 2003). Improving the Odds is an internet-based treatment program based on cognitive-behavioural principles that has been developed to assist
problem gamblers to either control or abstain from gambling. Using a randomised control design, the program is offered via six online sessions on a fixed
weekly schedule. Participants are asked to complete a range of pre-treatment questionnaires and a telephone-based diagnostic interview at the beginning
of the program and again at three, six and 12 month intervals after its completion. Preliminary results of the program are discussed in terms of impact on
frequency and duration of gambling, urge to gamble, level of control over gambling behaviour, gambling cognitions and quality of life Internet-based
treatment for problem gambling appears to be a promising form of treatment that may enable many more individuals with this disabling condition to access
psychological treatment.
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Anxiety Disorders
Invited Addresses
Maximizing Useful Knowledge From Psychotherapy Research: Strategies For the More Rapid Development of
Effective Interventions
Thomas Borkovec, Penn State University, USA
The presenter has spent nearly four decades conducting therapy outcome efficacy investigations. He is now convinced that he has made a big mistake. Such
investigations will continue to be worthwhile, if they involve the use of powerful, rather than weak, experimental designs, but therapy research also needs to
be broadened beyond these efficacy studies to emphasize the more frequent use of (a) short-duration analog therapy experiments, on the one hand, and (b)
large-scale therapy investigations within the context of Practice Research Networks involving hundreds of therapists and thousands of clients, on the other
hand. This presentation will elaborate on each of these points, and a special emphasis will be placed on the deployment of catalytic designs that allow us to
identify cause-and-effect relationships that better reflect the nonlinear dynamical nature of human functioning.
Developing and Disseminating Effective Cognitive Therapies for Anxiety Disorders
David M Clark, Institute of Psychiatry at Kings College London, UK
Anxiety disorders are common, persistent, under-diagnosed, and under-treated. A cognitive science approach to developing more effective treatments is
outlined. The approach attempts to identify factors that prevent patients' excessively negative appraisals of danger from self-correcting and targets these
factors in specialized cognitive therapy programmes. Illustrations of the key maintaining factors and the way they can be reversed in therapy will be presented
with a particular focus on PTSD and social phobia. Surprise findings and the way these have influenced practice will be highlighted. A review of controlled trials
and the substantial effect sizes that can currently be expected for cognitive therapy programmes in anxiety disorders will lead on to a discussion of two types
of future challenge. First, how can treatments be made more effective and efficient? Second, what are the obstacles to more widespread dissemination of the
treatments and how can these be overcome?
Anxiety Disorders; what now
Paul Salkovskis, Institute of Psychiatry, UK.
We should congratulate ourselves. Tremendous progress has been made in Cognitive-behavioural understanding and treatment of anxiety disorders.
Congratulations are due in terms of what we know (which is a great deal) and what we can do (which is also a great deal). Too much self congratulation would,
however, be premature. The reality is that there is much that we do not know, and although we can do a great deal to help those suffering from anxiety disorders,
the reality is that most people suffering from anxiety do not receive effective help. Sadly, it is clear that, despite the considerable progress made, we have yet
to achieve the most important target of all, which is to change the epidemiology and natural history of anxiety disorder. Most patients are treated wrongly, badly
or not at all. Even our finest efforts do not meet with complete success, and unfortunately few people experience our finest efforts.
The factors underpinning our successes and failures will be considered in the context of specific disorders, and this analysis used to suggest how things should
be progressed in order to maintain our successes and minimise further failures and dead-ends. Some new directions for both research and clinical services
will also be suggested.
Twenty Years of White Bears: An Update on the Clinical Implications of Thought Suppression
Daniel Wegner, Harvard University, USA
The inner life of mental disorder is often painful, unpleasant, a focus of suffering-something a person might not want to think about. People who are troubled
might thus suppress thoughts of their sorrows, their symptoms, their fears, their abnormalities, or the voices in their heads. This reaction could be very broad,
a standard and stereotypical response to mental turmoil in every form of psychopathology in which a person remains conscious and experiences distress. Such
suppression of thoughts may seem to be an effective solution, but a wide range of research indicates otherwise. Dating from the initial finding that trying not
to think about a white bear can bring this creature back to mind repeatedly (Wegner, Schneider, Carter, & White, 1987), two decades of research has revealed
that the strategy of suppression can have profound and unexpected consequences in the unwanted magnification of the psychological influences of the
suppressed thought. Spontaneous thought suppression may complicate psychological disorders, expand their damage, prolong their course, and render them
more resistant to treatment. This talk reviews the evidence to date for a role of thought suppression across a variety of anxiety, mood, and impulsive disorders,
and suggests how treatment plans may be devised in light of this discovery.
Symposium 7
Innovations In The Treatment of Anxiety Disorders
Convenor: Robert Leahy, American Institute for Cognitive Therapy, USA
Emotional Schemas and the Treatment of Anxiety Disorders
Emily A. Holmes, University of Oxford, Department of Psychiatry, UK
Fundamental reasons to use mental imagery in innovative treatments for anxiety disorders will be proposed, based on the assertion that imagery has a
special relationship with emotion. The role of 'micro-formulation' in unravelling how specific types of imagery may contribute to an individual client's
difficulties will be illustrated. A draft framework will be discussed for selecting the different types of imagery techniques that might be used.
Emotional Schemas and the Treatment of Anxiety Disorders
Robert L. Leahy, American Institute for Cognitive Therapy, U.S.A
Cognitive-behavioral treatment of anxiety disorders invariably involves experiential exposure to situations that provoke anxiety. Individuals differ in their
conceptualization and evaluation of their anxiety and the strategies (avoidance, escape, reassurance-seeking) that they utilize to cope. The Emotional
Schema Model allows the clinician to assess specific conceptualizations of anxiety (e.g., escalation, duration, incomprehensibility) and evaluation (shame,
guilt, uniqueness) to assist the patient in normalizing, compartmentalizing and temporizing anxiety. Specific interventions for obsessive-compulsive disorder
and other anxiety disorders will be described. These provide the patient an opportunity to utilize behavioural and emotional experiments to modify
dysfunctional schemas that may interfere with exposure treatment and maintenance of improvement.
Looming vulnerability targeted Cognitive Therapy
John H. Riskind and Neil A. Rector*, George Mason University, U.S.A.; * University of Toronto, Canada
The looming vulnerability model has recently emerged as a cognitive model that is uniquely distinguished by a greater emphasis on the importance of
temporal representations of threat (e.g., Riskind & Williams, 2005). The keystone of the looming model is the premise that anxiety is not just characterized
by appraisals of the odds of noxious events but of the extent the odds are rapidly escalating. A threat is an event in time and space rushing forward
towards a dreaded end. Importantly, looming vulnerability illusions can be found in the distortions of thoughts and images of anxious patients. For example,
individuals with motor vehicle trauma may have illusions that automobiles are moving in collision courses, while spider phobics may exaggerate spider
movement. In Generalized Anxiety, cognitive overload can result from illusions that multiple threats are moving forward “all at once.” We argue that these
illusions must be addressed, either directly or indirectly, to most fully treat anxiety pathology as well as the risk of relapse of anxiety disorder. Recently, we
have developed a treatment manual that describes clinical interventions for a cognitive approach for looming vulnerability targeted cognitive therapy
(Riskind, Rector, & Taylor, 2007). This treatment approach is described and illustrated with case studies of patients with GAD, Social Anxiety, and other
disorders. Such interventions are devised for looming vulnerability problems that are domain specific, or even concrete (e.g., in spiders or motor vehicle
movement), or problems that involve more abstract phenomenology where events are rushing forward in time.
Page 15
Metacognitively Delivered Exposure
Adrian Wells, The University of Manchester, U.K.
Exposure is a component of Metacognitive Therapy (MCT). But it is different from exposure in CBT. Metacognitively delivered exposure (MCDE)
manipulates the cognitive style of individuals to promote belief and emotional change, and it also targets metacognitive beliefs. All exposure experiments that
aim to change beliefs are essentially metacognitive since they elicit the appraisal of cognition. However, the metacognitive element is largely unspecified.
Experiments can be improved by manipulating how patients process before, during and after exposure. Data from three experimental studies of MCDE will
be presented. In the first (Wells & Papageorgiou, 1998) instructions to focus attention on the external social environment significantly enhanced exposure
effects in social phobic patients. In the second (Fisher & Wells, 2005) loop-tape exposure with a metacognitive rationale was more effective than exposure
with a habituation rationale in obsessive-compulsive patients. In the third (Roussis & Wells, submitted), engaging in detached mindfulness in response to
intrusions after exposure to a stressful stimulus leads to lower intrusions than a control condition. These results suggest MCDE could be an efficient means
of inducing cognitive-emotional change without the need of repeated or prolonged exposure.
Symposium 21
Social Anxiety disorder: New developments in models and treatment
Convenor: Hans M Nordahl, NTNU, Norway, Norway
Sensory-Processing Sensitivity in Social Anxiety Disorder: Relationship to Harm Avoidance and Diagnostic Subtypes
Stefan G. Hofmann and Stella Bitran, Boston University, USA
Sensory-processing sensitivity is assumed to be a heritable vulnerability factor to develop shyness. The present study is the first to examine sensoryprocessing sensitivity among individuals with social anxiety disorder. The results showed that the construct is separate from social anxiety, but it is highly
correlated with harm avoidance and agoraphobic avoidance. Individuals with a generalized subtype of social anxiety disorder reported higher levels of
sensory-processing sensitivity than individuals with a non-generalized subtype. These preliminary findings are consistent with the notion that sensoryprocessing sensitivity may represent a unique vulnerability factor for social anxiety disorder. Recommendations for future research are discussed.
Self-imagery and autobiographical memory in social anxiety
Andy Jenkins & Lusia Stopa, University of Southampton, UK
The cognitive model of social phobia by Clark and Wells (1995) implies that individuals with social phobia adopt a negative self-imagery of themselves which
can activate the retrieval of autobiographical memories (negative), both before, during and after a social situation.This study examined the effects of selfimagery, during a speech task, on the retrieval of autobiographical memories. Participants rated their anxiety at baseline and rated their predicted
performance before the speech task. After the speech task, they rated their anxiety levels and actual performance during the speech, and then completed a
behaviour checklist. They then completed the autobiographical memory task. This procedure was repeated (counterbalanced image condition) one week
later. Positive memories in response to positive cue words took longer to retrieve in the negative condition and negative memories in response to negative
cue words took longer to retrieve in positive condition. High socially anxious individuals also reported higher levels of anxiety and rated their performance
worse if they held a negative image in mind compared to positive image. The valence of these self-images also affected ratings of behaviour by an
independent assessor. The results are discussed in relation to current theory and previous research.
Understanding the process of change in cognitive versus attention treatment of social phobia
Marisol Voncken & Susan Bögels, University of Maastricht & University of AmsterdamThe Netherlands
In cognitive models of social phobia (Clark, 2001; Rapee and Heimberg, 1997) two processes are believed to be essential in the maintenance of this
invalidating problem: cognitive distortions and attention problems, e.g., the inability to direct attention outward during distressing social events. A body of
studies have shown that both processes are present in the maintenance of social phobia, and changes in both processes are related to recovery during
treatment (Hirsch and Clark, 2004; Bögels and Mansell, 2004). Unclear is yet which of these two mechanisms are more important in the recovery of social
phobia, and to what extent cognitive and attention interventions influence these processes differentially. In this study 95 referred patients with social phobia
were treated with either cognitive therapy (n = 47) or mindfulness-based task concentration training (n = 48). Assessment of social anxiety, self-focussed
attention and distorted cognitions took place at pre-, post- and 2 month follow-up of treatment. A regression analysis in which decrease in social anxiety was
predicted by decreased self-focussed attention and cognitive distortions was conducted. Results and implications for treatment will be presented.
What influences distorted self-image in patients with Social phobia?
Hans M Nordahl, Tore C Stiles & Patrick A Vogel, Dept. of Psychology, NTNU, Norway
The way patients with social phobia see themselves in social situations seems to be an important part of their problems in social situations. In Clark & Wells'
(1995) model the distorted self-image is crucial in both the development and in the maintenance of social phobia. This is also supported in recent empirical
studies, which have shown that negative and distorted images play a causal or crucial role in maintenance of social anxiety. However, it is not yet clear what
influences the way the patients see themselves in social situations. Is it the arousal or the body state information in an anxiety-provoking situation, or is it
characteristics of their social perceptions, such as the current perspective taking in the social situation? This can be considered a test of the bottom-up vs
top-down processing models of social anxiety. Knowing what is the most important for distorted self-image, the body-state processing or perspective taking,
could have implications for the way negative distorted self-images are challenged in the Clark and Wells' model. A group of 50 patients underwent psychophysiological assessment as part of a RCT on generalised social phobia, looking at the effects of cognitive therapy, drugs (paroxetine) and their
combination. All patients were assessed on SCID-I and ADIS-IV criteria for social phobia. They were investigated using a multi-modal approach with psychophysiological recordings, self-report questionnaires and clinical observations during anxiety provoking tasks. Results from this study and potential
implications will be presented
Cognitive Factors in the treatment of social phobia
Convenor: Thomas Heidenreich, University of applied sciences Esslingen, Germany, Germany
Cognitive therapy vs. Interpersonal Psychotherapy in the treatment of social phobia: long-term results from a randomized
controlled trial
Ulrich Stangier:, Friedrich Schiller University, Jena, Germany
The efficacy of cognitive-behavioral therapy for social phobia based on the model by Clark and Wells has been repeatedly demonstrated. In addition,
Interpersonal Psychotherapy has proven to be an effective treatment of depression and also might be a promising alternative in social phobia. The efficacy
of both treatment approaches was compared in a randomized controlled trial.121 patients meeting DSM IV criteria for social phobia were randomly allocated
to Cognitive Therapy (CT), Interpersonal Psychotherapy (IPT), or waiting list control group (WCL). In addition, assignment to treatments was stratified by
comorbid depression to allow a systematic comparison over treatment conditions. Treatments included 16 weekly sessions and a two month booster
session. Assessments included independent ratings of the Liebowitz Social Anxiety Scale and the Hamilton Rating Scale as well as self-ratings of social
phobia questionnaires.108 patients completed treatment or waiting period. At post-treatment, both treatments archieved significantly better results in all
outcome variables than WCL. CT was significantly superior to IPT with respect to clinician-rated social phobic symptoms. Preliminary analyses of 1 year
follow-up indicate that, again, there was a highly significant difference between CT and IPT with regard to primary outcome. Based on in the independent
ratings of social phobic symptoms, CT was significantly superior to IPT. As compared to short-term effects after termination of treatment, patients in CT
maintained their short-term gains whereas patients IPT more showed a reduced response rate. The results suggest that CT is more effective than IPT in
reducing social phobic symptoms on short- and long-term.
Mindfulness-based task concentration training vs structured cognitive therapy for social phobia: A randomised clinical trial
Susan Bögels:, Maastricht UniversityThe Netherlands
Next to interpretation biases, heightened self-focused attention, hypervigilance, attentional avoidance, and mindless rumination, maintain social phobia.
Mindfulness approaches may directly change these dysfunctional attention processes and help patients with social phobia to be more fully present in the
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here and now, and as a result change their interpretation biases.To test this hypothesis, we compared the effects of mindfulness-based task concentration
training with structured cognitive therapy for social phobia. 60 clinical patients were randomised to MBTCT or SCT. Both treatments consisted of 8 sessions
and were delivered in group format. Changes were assessed in the following areas: personal goals, social anxiety symptoms, general psychopathology,
actual social behavior during a speech and interaction task, social interpretation biases, and psychophysiological responses (cheek blood flow and cheek
temperature to assess blushing, skin conductance). Assessments took place before and after waitlist, after the 2 month treatment, and at 2 months, 1 year, 2
year and 3 year follow-up. Results will be presented at the conference.
What procedures are effective in cognitive therapy for social phobia? Experimental analyses.
David M Clark, Kings College, London, United Kingdom
Randomized controlled trials have shown that individual cognitive therapy is an effective treatment for social phobia that compares favourably with
medication and several alternative psychological treatments. However, the treatment is a complex intervention utilizing many therapeutic manoeuvres, some
of which build on each other. The later feature means complicates component analyses. This presentation reports three single session therapy experiments
that investigated specific components of the treatment in order to determine whether they have significant effects on their own. Patients meeting DSM-IV
criteria for social phobia who were in the early stages of cognitive therapy participated in the experiments. The components were: 1) the self-focused
attention and safety behaviours experiential exercise, 2) video feedback, 3) re-scripting of early experiences linked to intrusive images. All three components
received empirical support.
Sudden Gains During Therapy of Social Phobia
Stefan G. Hofmann, Boston University, U.S.A.
In recent years, psychotherapy researchers have investigated the phenomenon of large, rapid and stable decreases in symptomatology during treatment,
which has been referred to as sudden gains. The present study investigated the phenomenon of sudden gains in 107 participants with social phobia (social
anxiety disorder) who received either cognitive behavioral group therapy or exposure group therapy without explicit cognitive interventions. Twenty-two out of
967 session-to-session intervals met criteria for sudden gains, which most frequently occurred in session 5. Individuals with sudden gains showed similar
improvements in the two treatment groups. Although cognitive behavioral therapy was associated with more cognitive changes than exposure therapy,
cognitive changes did not precede sudden gains. In general, the results of this study question the clinical significance of sudden gains in social phobia
Temperament and character dimensions in patients with social phobia: Patterns of change following treatments?
Ewa Mörtberg:, Karolinska Institute, Sweden
The aim of this study was to examine Temperament and Character Inventory (TCI) profiles in patients with social phobia (DSM-IV) and to outline patterns of
change following intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU). One hundred patients recruited
by advertisements in local papers were randomized to IGCT, ICT and TAU. Patients (n=59) who completed diagnostic evaluation and TCI assessments at
baseline and 1-year follow-up were examined in this study. Patients differed from healthy controls in novelty seeking (NS), harm avoidance (HA), selfdirectedness (SD), cooperativeness (C) and self-transcendence (ST). Treatments overall were associated with decrease in HA, while increase in SD was
observed after psychotherapy only. Reduced social anxiety was correlated with decrease in HA and increase in SD. High HA at baseline was related to poor
treatment outcome in all treatments. To conclude, patients with social phobia show a temperamental vulnerability for developing anxiety and character traits
associated with personality disorders. Successful treatment is related to decrease in HA and increase in SD. High HA at baseline may suggest a need for
extensive treatment in order to achieve remission.
Symposium 51
Unraveling interpersonal factors from a cognitive-behavioral perspective in Social Anxiety Disorder
Convenor: Marisol Voncken, Maastricht University, the Netherlands
Closer to home: How do individuals with elevated social anxiety respond with close others?
J. Gayle Beck, State University of New York at Buffalo, USA
Although people with social anxiety often experience interpersonal impairment, many are able to form close relationships, particularly with romantic partners.
Unfortunately, we know very little about the behavior of individuals with social anxiety within their close relationships. Current theories of SA almost
completely neglect a focus on close relationships, an omission that potentially could enrich our models of the psychopathology and treatment of this
disorder. In this talk, I will present observational data from women with and without elevated social anxiety in interaction with their romantic partners when
placed under a social-evaluative threat. Unexpectedly, no differences were noted between socially anxious (SA) and non-anxious (NSA) women and their
partners with respect to support behaviors. However, when relationship satisfaction was considered, it was noted that the more satisfied SA women
displayed more negative behaviors towards their partner when stressed. Furthermore, the more positively the partner behaved, the greater was the distress
reported by the SA woman. These findings contrast with earlier self-report data suggesting greater levels of negative styles of relating to close others among
individuals with elevated SA. Implications for understanding the role of close relationships in SA will be discussed, with particular attention to understanding
the role of the partner as “safety”. Additional discussion will be given to potential self-reporting biases among individuals with SA, as these impact
perceptions of behavior within close relationships.
Why are Social Phobic Patients disliked? The role of social performance, similarity and evoked emotions.
Marisol Voncken and Lynn E. Alden, Maastricht University, the Netherlands; University of British Columbia, Canada
Patients with social phobia are afraid of being disliked. Sadly, socially anxious people have shown to elicit negative responses form others (Melesko &
Alden, 1993; Jones & Russell, 1982, Pilkonis, 1977; Creed & Funder, 1998; Alden & Wallace, 1995). This negative relation between social anxiety and
likeability might be mediate by social performance deficits. There is mounting evidence that social phobic patients show deficits in social performance (Baker
& Edelmann, 2002; Fydrich, Chambless, Perry, Buergener, & Beazley, 1998; Stopa & Clark, 1993). In turn these social performance deficits might produce
two essential interpersonal feelings that are intertwined with likeability. First people tend to like individuals more, when they perceive them similar to
themselves (Byrne, 1971; Papsdorf & Alden, 1993). Social awkward behavior might decrease feelings of similarity. Second, social performance deficits may
evoke negative emotions in interaction partners. Coyne (1976) demonstrated that depressed patients were able to evoke negative feelings in others in a
conversation of only 5 minutes. The same process could play a role in social phobia. In this study Social Phobic Patients (n = 63) and normal controls (n =
26) were observed during a conversation of 5 minutes with two confederates. The confederates rated social performance, three video observers rated
similarity, and evoked emotions and three other video observers rated likeability of the participants. The results showed, as expected, a relation between
social anxiety and likeability (r = -.47). A LISREL analysis revealed that social anxiety was related to social performance deficits (r = .43), which in turn
related to evoked negative emotions (r = .66). No relation was found between social performance deficits and similarity but evoked negative emotions
related strongly with similarity (r = -.70), which both related to likeability (resp.: r = -.37: r = .47). Thus, social performance deficits in social phobia seem to
play a crucial role in the likeability of socially anxious individuals. Not only do these behaviors evoke negative emotions in their interaction partners but also
these negative emotions lead others to perceive them as less similar. These two processes are essential when we evaluate how much we like one another.
Implications of these findings for the cognitive model and treatment of social phobia will be discussed.
An Interpersonal-Cognitive Behavioral Treatment Program for Social Anxiety Disorder: Mediators of Treatment Response
Lynn E. Alden and Charles T. Taylor, University of British Columbia
A treatment outcome evaluation of a cognitive-behavioral version of interpersonal therapy (I-CBT) demonstrated that the program was highly effective for
patients with Social Anxiety Disorder (SAD). In this paper, we examine possible mediators of treatment response in that regimen. Recent research indicates
that changes in judgmental biases regarding the probability and cost of negative social outcomes mediate outcome in CBT regimens (Hofmann, 2004).
However, judgments of negative social outcomes are a function of two factors: judgments about one's own behavior and judgments about others' responses
(interpersonal judgments). The goal of this study was to determine whether changes in self- or interpersonal- judgments mediated outcome. To do this, we
constructed a version of the Probability and Cost Questionnaire (PCQ) that distinguished the likelihood and cost of negative outcomes related to self and
others. The instrument yielded four scores: Interpersonal probability (What is the likelihood that others would respond negatively in this situation?),
Interpersonal cost (How bad would it be if they responded negatively?), Self probability (What is the likelihood that you would handle this situation poorly?)
and self cost: (How bad would it be if you handled it poorly?). Subjects were 36 patients with SAD who completed a 12-week I-CBT program. Self-report and
interviewer ratings of social anxiety symptoms and impairment were collected at pre- and post- assessment. Change in judgmental biases were assessed
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through residualized pre to mid treatment PCQ scores. A series of regression analyses were conducted to determine which, if any, of the PCQ scores would
mediate treatment outcome. Results indicated that the mechanism underlying response to the I-CBT regimen was change in patients' judgments of the
likelihood that others would respond negatively to them and the emotional cost should they do so. Discussion will consider whether changes in interpersonal
judgments must ultimately lead to change in self-judgments to accomplish lasting improvement.
Cognitive therapy vs. Interpersonal Psychotherapy in the treatment of social phobia: comparison of treatment process
Stangier, U. (1), Heidenreich, T (2)., Schramm, E. (3), Berger, M. (3). Clark, D.M. (4), (1) University of Jena, Germany; (2) Department of Psychology,
University of Applied Science, Esslingen(3)
Department of Psychiatry, University of Freiburg(4)Institute of Psychiatry, University of
Cognitive therapy (CT) of social phobia includes exposure to critical social situations and modification of dysfunctional cognitive processing and beliefs. In
contrast, Interpersonal Psychotherapy (IPT) focuses on the improvement of social relationships than on problematic aspects of cognitions and behaviour.
Within the framework of generic psychotherapy, it is expected that the treatment process in CT might be characterized by a stronger focus on activation of
problems and coping, whereas IPT therapists might put more emphasis on insight and activation of personal resources. We assessed these dimensions
using self-ratings of therapists and patients after each treatment session. In addition, patients weekly symptom ratings served as a measure for changes in
social phobic symptoms over treatment.Results indicate that CT therapists reported to focus more on coping with the problems, and, contrary to our
expectations, also reported to use more resource activating interventions and to put more emphasis on insight. In addition, our results indicate that a
stronger reduction in social phobic symptoms occurred during the second half of the sessions in CT as compared to IPT. There were no significant
differences between patients receiving CT and IPT with regard to these dimensions. In addition, no significant difference was observed between both
treatment conditions in the quality of therapeutic relationship, as rated by therapists and patients.To conclude, our results indicate that besides techniques
and interventions specific for CT, cognitive therapists, as compared to IPT therapists, also make more often use of interventions that might be effective
components of psychotherapy in general.
Predictors of Residential Cognitive and Interpersonal Treatment for social phobia
Borge, F-M., Hoffart, A., Sexton, H., Modum Bad, Norway
The purpose of his study wa to examine the predictors of Residential Cognitive (RCT) and Interpersonal Treatment (RIPT) for social phobia. 80 patients
were randomised to cognitive or interpersonal psychotherapy for 10 weeks of residential treatment. One specific hypothesis was tested: (1) Sotsky et al.
(1991) found differential effects of cognitive (CT) and interpersonal (IPT) treatment for depression, suggesting that low dysfunction patients of the
characteristic ingredient of that particular treatment (social or cognitive) profited more than high dysfunction patients. We wanted to investigate if similar
differential effects arised during RCT and RIPT of social phobic patients. Other predictors investigated included symptom severity, concurrent anxiety and
mood disorders, body dysmorphic disorder, avoidant personality disorder traits, age at onset of social phobia and treatment expectancy/credibility.
Symposium 64
New ideas in OCD: The influence and inspiration of S. Rachman
Convenor: Roz Shafran, St. Mary's Hospital and Reading University, U.K
Intrusions, Obsessions, and Other Mental Treacheries: Navigating the Stream of Consciousness with Professor Jack Rachman
David A Clark, University of New Brunswick, Canada
As reflected in a distinguished life of clinical research on the nature and treatment of anxiety, especially obsessive-compulsive disorder (OCD), Professor
Jack Rachman has contributed immensely not only to our knowledge of the human condition, but he has promoted a methodological perspective on
psychological inquiry that has proven most fruitful in advancing research and practice in clinical psychology. The fundamentals of this methodology include
(a) astute clinical observation, (b) translation of well-defined phenomenological deductions into innovative experimental investigation, (c) development of
coherent theoretical systems, (d) innovative treatment derived from empirical research, and (e) dedication to the inherent continuity between normal and
abnormal human function. In this paper the substantial insights offered by this applied experimental perspective will be illustrated in Professor Rachman's
theoretical and research contributions to our understanding of the stream of consciousness. The presentation will focus on research into normal and
abnormal obsessions or unwanted intrusive thoughts, the role of cognitive appraisal in the persistence of disruptive thoughts, and the boundaries of
intentional mental control of unwanted cognition. Research conducted by the author as well as other investigators will be reviewed with reference to
Professor Rachman's writings on intrusions, obsessions and the control of unwanted thoughts. The presentation will conclude with a consideration of future
directions and various issues that remain unresolved in research and treatment of persistent, unwanted distressing cognition.
Responsibility and obsessive-compulsive disorder: An experimental test
Arnoud Arntz, University of Maastricht, The Netherlands
Although Freud was earlier to suggest that obsessive-compulsive disorder (OCD) had something to do with guilt and responsibility, Jack Rachman was the
first to highlight the special role of responsibility in the context of cognitive-behavioral theory. The idea greatly inspired Paul Salkovskis to formulate a theory
of OCD with a central role for responsibility. However, most of the evidence relied on clinical observations and correlational evidence with some exceptions
by Rachman and coworkers. Nevertheless, there was no proof for a causal role of a heightened sensitivity to responsibility in the development of new
checking behavior.To test the causal status of responsibility in obsessive-compulsive disorder (OCD), an experiment was done in which responsibility was
experimentally manipulated. OCD patients, non-OCD anxiety controls, and non-patients executed a classification task in either a high or a low responsibility
condition. Subjective ratings related indicated that the manipulation was successful. Subjective OCD-like experiences and checking behaviors were higher in
OCD patients in the high responsibility condition than in all other groups. Thus, only OCD patients when given a highly responsible task developed new
OCD-like phenomena. Although the checking subscale of the Padua Inventory correlated with subjective ratings in the OCD patients in the HiRes condition,
it was not associated with checking behaviors. Thus, the development of new checking behaviors was not restricted to checkers; all types of OCD patients
displayed it. The results confirm the hypothesis, derived from Jack Rachman's early work, that responsibility plays a causal role in OCD.
Developing specificity in cognitive models of OCD: Or: “Every good idea I thought I had had about OCD, Jack had actually had
it 15 years or so before”
Mark H Freeston, Newcastle University & Newcastle Centre for Cognitive and Behaviour Therapies, UK.
During the 1970's, Rachman (71, 76, 78, Rachman & Hodgson 80) described many of the key features that we find in contemporary models of obsessional
thoughts and OCD. Further, he advanced a series of hypotheses about how some of these factors may interact in the aetiology and maintenance of OCD.
The intervening years have seen the study of a wide range of single factors that have now been clearly linked to at least a subset of OCD. Further, there
has been a great deal of work examining the relative proportion of variance accounted for in measures of OC symptoms. There is, however, an even more
important thread of research emerging, that which looks at how some of these factors interact together. Examples of recent research will briefly illustrate key
themes that may be found in Rachman's early work and which have since been developed further by him and colleagues over the last 15 or so years and by
the many researchers who have been influenced by his work. The themes that will be illustrated are 1) the importance of clinical phenomenology in
developing theory and treatment, 2) that the expression of OCD can be understood as on a continuum with normal behaviour, and 3) that the combined
effects of contributory factors provide us with the best chance of understanding why OCD develops, what maintains it and how it may be treated.
Rachman showed that in OCD the solution becomes the problem: an update on how the solution to the problem can best be
solved to deal with the problem.
Paul M. Salkovskis, University of London
Early work by the team led by Rachman showed the importance ofcompulsive behviour in the maintenance of OCD. From the patient'sperspective,
ritualising was the solution to their fears; Rachman showedthat ritualising worsened their fears in the longer term, indicatingthat "the solution has become the
problem". The evolution of theseconcepts is mapped, and the accumulation of evidence elaborating on thisearly conceptualistion is described. More recent
work, includingtreatment outcome research, identifies the importance of cognitive andmotivational issues in understanding the role of neutralising in
OCD.However, careful consideration and checking indicates that thisaparrently new work has already been contaminated by Rachman, and noamount of
attention can eliminate traces of where he has been. Severalresearchers have sought to check his work, but have been unable to do sowith any satisfactory
degree of perfection. It is concluded that Duracis less relevant that many believe.
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Symposium 80
Role of cognition in treatment of OCD
Convenor: Sheila Woody, University of British Columbia, Canada
The Role of Magical Thinking in Obsessive-Compulsive Disorder
Danielle Einstein and Ross G. Menzies (presenter), Institute of Psychiatry, UK
The aim of the present research was to explore the role of magical thinking in the mediation of obsessive-compulsive behaviour. Several authors have
suggested that the ability to suspend culturally accepted laws of causality may underlie many obsessive- compulsive symptoms. It can be argued, for
example, that certain compulsive behaviours (eg. tapping, blinking, touching, and counting rituals) require a tendency toward magical thinking. Magical
Ideation was examined in 71 individuals across four groups matched for gender and age. These groups were: (1) Obsessive-Compulsive Disorder (OCD)
patients with cleaning compulsions (n=11); (2) OCD patients with checking compulsions (n=20); (3) Panic Disorder patients with minimal obsessivecompulsive symptoms (n=19); (4) a 'normal' control group with minimal obsessive-compulsive symptoms (n=21). The Magical Ideation Scale (MI, Eckblad &
Chapman, 1983), the Obsessive Compulsive Inventory Short Version (OCI-SV; Foa et al., 2002) and the Maudsley Obsessional-Compulsive Inventory
(MOCI, Hodgson & Rachman, 1977) were administered to all participants. As expected, the OCD groups obtained magical ideation scores higher than
control subjects. Similarly, OCD participants obtained a mean magical ideation score significantly higher than the Panic Disorder group. Of note, Panic
Disorder and control group means on MI did not differ significantly. The findings are consistent with cognitive models emphasizing magical thinking in OCD.
Magical thinking appears to be a clinical feature of OCD that can distinguish it from other anxiety disorders and non-anxious groups. As previously argued,
magical thinking may be an essential component of many presentations of the disorder. The present findings, in combination with earlier findings of strong
positive correlations between MI scores and OCD severity, suggest that targeting magical thinking could advance treatment outcomes in OCD. Possible
clinical strategies for targeting MI will be described. A cognitive model of OCD that integrates magical thinking will be presented.
Reduction in Cognitive Biases Associated With Successful Symptom Reduction in Treatment of Primary Obsessions
Sheila Woody, Maureen Whittal, Peter McLean, & S.J. Rachman, University of British Columbia, Canada
Despite recent theoretical and clinical advances in the treatment of OCD, the active factors in treatment change remain poorly understood. Cognitive
therapy takes a direct approach to changing appraisals and beliefs, but other treatment approaches may also lead to cognitive change. Data from a recently
completed trial of psychological treatments for primary obsessions will be used to examine the degree to which cognitive change predicts successful
symptom reduction. Patients received either cognitive therapy, which focused on reducing appraisals of such thoughts as important or personally significant,
or a comparison treatment - stress management training - designed to improve interpersonal, organizational, and relaxation skills. The cognitive therapy
specifically targeted cognitive change through logical analysis and deliberate behavioural experiments, whereas cognition was not explicitly addressed
during stress management training. In a 2 x 2 design, patients were randomly assigned to receive one of these two treatments either immediately or after a
12-week delay. Cognitive biases were repeatedly assessed using measures designed to assess metacognition relevant to obsessions, including
responsibility related to the experience of the thoughts, perfectionism, importance or personal significance of the thoughts, and desirability of controlling the
thoughts. Of interest is the degree to which cognitive and symptom change covary in these two disparate treatments.
Prediction of outcome following cognitive-behavior therapy for Obsessive-Compulsive Disorder
Kyrios, M. 1; Hordern, C. 1, 2; Nedeljkovic M. 1; Bhar, S. 3; Moulding, R. 1 & Doron, G. 1, 1 Swinburne University of Technology, Australia; 2.
University of Melbourne, Australia; 3 University of Pennsylvania, USA
Research has supported the efficacy of cognitive-behaviour therapy (CBT) in treating Obsessive-Compulsive Disorder (OCD). However, relatively little
research has examined outcome prediction and treatment processes. This paper reports on 79 participants with OCD undertaking a 16-week manualised
CBT intervention. Symptomatic, cognitive and functional measures were administered at 4 time points (at initial presentation, at pre-treatment following a
waitlist period, at the conclusion of treatment, and at 6-to-12 month follow-up). The major outcome was the self-rated YBOCS. Intention-to-treat analyses
for the total sample indicated no YBOCS or cognitive changes during the waitlist period, significant reductions on all measures from pre- to post- treatment,
and maintenance of gains over the follow-up period. Two thirds of participants responded to treatment, with few relapsers at follow-up. YBOCS severity at
assessment and pre-treatment was the most consistent predictor of end-treatment and follow-up outcome. Anxiety also featured in the prediction of
outcomes. Pre-to-post treatment YBOCS change was predicted by initial and pre-treatment OCD severity levels, initial and pre-treatment anxiety levels, and
initial depression levels. Pre-post treatment symptomatic change exhibited moderate to high magnitude correlations with changes in anxiety, depression,
and cognitions. After controlling for pre-treatment OCD severity, a regression with change indices found that pre-post YBOCS change was predicted by prepost changes in anxiety and perfectionism/intolerance for uncertainty. Non-responders were more anxious, while relapsers could not be distinguished on the
basis of pre-treatment variables or treatment changes. There were few differences in findings for selected OCD subgroups. Implications for assessment
and treatment are discussed.
Cognitive Behavioural Treatment for Obsessional Ruminations and Rituals: How Do They Compare?
Paul Salkovskis, Institute of Psychiatry, London
In the presentation two trials will be described. In the first, cognitive behaviour therapy was compared with behaviour therapy and a waiting list in patients
whose compulsive behaviour was primarily overt. In the second, the comparison was CBT, stress management and wait list in a group whose compulsive
behaviour is predominantly covert. Scores on symptoms and beliefs will be contrasted. Implications for the debate on sub-typing and the focus of treatment
will be considered.
Symposium 84
Cognitive-behavioural therapy on late-life anxiety disorders: empirical findings from recently conducted studies
on treatment and phenomenology
Convenor: Gert-Jan Hendriks, Mental Health Hospital GGz Nijmegen & Radboud University Nijmegen, The Netherlands,
Treatment of late-life panic disorder: a randomised controlled trial with paroxetine versus cognitive behavioural therapy
Gert-Jan Hendriks, Ger Keijsers, Mirjam Kampman, Marc Verbraak, Kees Hoogduin, Mental Health Hospital GGz Nijmegen & Radboud University
Nijmegen, The Netherlands
Late-life anxiety disorders are the most prevalent psychiatric disorders in elderly people with a 12-month prevalence up to 10%. Randomised controlled trials
with cognitive behavioural therapy (CBT) or antidepressants are relatively scarce in later life and mostly conducted on generalised anxiety disorder. Results,
however, are comparable with trials at younger age. The current study is, to our knowledge, the first RCT on the treatment of late-life panic disorder with
CBT or an antidepressant, i.c. paroxetine (a Selective Serotonin Re-uptake Inhibitor (SSRI)). Aim of the study was to determine efficacy of CBT and
paroxetine compared with a waiting list control.Methods:30 women and 19 men (mean age = 67.8 years, SD = 4.2) with panic disorder (with or without
agoraphobia) were randomised into individual treatment with CBT or paroxetine, or a waiting-list control condition. The main outcome measures for
treatment response at post-treatment (14 weeks) and at follow-up were frequency of panic attacks, Agoraphobic Questionnaire, the Mobility Inventory.
Results:Treatment with CBT or paroxetine was significantly effective, as compared to a waiting-list control, in reducing panic attacks, avoidance behaviour
and anxiety cognitions. CBT was more effective in reducing avoidance behaviour whereas paroxetine was more effective in reducing anxiety cognitions.
Conclusions:Treatment with CBT or paroxetine are both effective treatments in late-life panic disorder.
The phenomenology of anxiety in older adults
Schuurmans, J., Weijnen, I.J.C., Comijs, H.C., Emmelkamp, P.M.G., van Dyck, R., & van Hout, M.A., VU University Amsterdam, The Netherlands
Differences in the phenomenology of anxiety between older and younger adults may contribute to difficulties in the recognition and treatment of late-life
anxiety. In order to examine differential aspects of late-life anxiety, young adults, middle-aged adults and older adults with and without an anxiety disorder
were compared with respect to differences in fear evoking stimuli (CS) and cognitive contents of anxiety (UCS). Data are available for two separate studies:
The first study was aimed at the general population. The second was aimed at a clinical population, suffering from anxiety disorders. For the first study, we
conducted a mail survey in a sample of 513 representative participants in the Netherlands, divided equally in three age groups of 18-44 years, 45-64 years
and 65 years and over. For the second study, we recruited approximately 200 patients from various mental health care centres in the Netherlands. Fear-
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evoking stimuli were measured with the Fear Survey Schedule (FSS). Cognitive contents were measured by the Worry Domains Questionnaire-Revised
(WDQ-R) and a newly devised instrument, the Senior Anxiety Scale (SAS). ANCOVA's and post-hoc Bonferroni corrected t-tests were conducted on all total
scores and subscale scores to test for differences between age groups. Data from the clinical study are currently being analysed and will be available for
presentation at the WCBCT conference. The mail survey showed that older adults scored higher than young adults on two factors on the Senior Anxiety
Scale, one representing the fear of decline of physical and mental health, and one representing the fear of life-threatening situations.
Cognitive behaviour therapy for panic disorder: a comparison between younger adults and elderly people
Mirjam Kampman, Gert-Jan Hendriks, Ger Keijsers, Marc Verbraak, and Kees Hoogduin, Mental Health Hospital “GGz Nijmegen” & Radboud
University Nijmegen, The Netherlands
Cognitive behaviour therapy (CBT) for panic disorder has widely been accepted as one of the most successful evidence based treatments for adults under
60 years old. Surprisingly, not many studies have been carried out into the effects of CBT for the elderly panic disorder patient. The present study made a
comparison of the pretreatment symptom severity, the effectiveness of CBT on panic disorder symptoms, dropout, and treatment motivation in the elderly
patient versus the younger adults.Methods:Data of 157 panic disorder patients under 60 years from a different study (Kampman, Keijsers, Hoogduin, &
Hendriks, 2003) were compared with CBT in 30 elderly panic disorder patients. In both studies treatment was manualised and lasted 14 weeks. Panic
disorder symptoms (panic attacks, catastrophic agoraphobic cognitions, agoraphobic avoidance) were assessed with the Agoraphobic Cognitions
Questionnaire and the Mobility Inventory. Furthermore, depressive symptoms were measured with the Beck Depression Inventory. Motivation was assessed
with the Nijmegen Motivation List-2.Results:Concerning pretreatment symptom severity: elderly patients had significant less catastrophic agoraphobic
cognitions. Other pretreatment symptoms were not significantly different.Ancova's were carried out on posttreatment symptom severity. Elderly patients had
significantly less avoidance behaviour. Other posttreatment symptoms did not differ significantly.Dropout rates differed significantly between both groups, the
group of elderly patients had less dropout. Pretreatment motivation did not differ between both groupsConclusions:Symptom severity in elderly panic
disorder patients and panic disorder patients under 60 years are comparable or even better on several symptoms.
Internet-based cognitive behavioural therapy for sub-threshold depression in people over 50 years old.
Viola Spek, Ivan Nyklícek, Niels Smits, Pim Cuijpers, Heleen Riper, Jules Keyzer, Victor Pop, Tilburg University, The Netherlands
Subthreshold depression is a highly prevalent condition and a risk factor for developing a major depressive episode. Internet-based cognitive behaviour
therapy may be a promising approach for the treatment of sub-threshold depression. The current study had two aims: (1) to determine whether an internetbased cognitive behaviour therapy intervention and a group cognitive behaviour therapy intervention are more effective than a waiting-list control group (2) to
determine whether the effect of the internet-based cognitive behaviour therapy differs from the group cognitive behaviour therapy intervention.Methods: 191
women and 110 men (mean age = 55 years, SD = 4.6) with subthreshold depression were randomized into internet-based treatment, group cognitive
behaviour therapy (Lewinsohn's Coping With Depression Course), or a waiting-list control condition. The main outcome measure was treatment response
after ten weeks, defined as the difference in pre and post-treatment scores on the Beck Depression Inventory. Missing data were imputed using the Multiple
Imputation procedure Data Augmentation.Results: In the waiting-list control group, we found a pre to post improvement effect size of 0.45, which was 0.65 in
the group cognitive behaviour therapy condition and 1.00 within the internet-based treatment condition. Helmert contrasts showed a significant difference
between the waiting-list condition and the two treatment conditions (p = 0.04) and no significant difference between both treatment conditions (p =
0.62).Conclusions: An internet-based intervention may be at least as effective as a commonly used group cognitive behaviour therapy intervention for
subthreshold depression in people over 50 years.
Symposium 93
Disentangling the roles of safety and neutralizing behaviours: Helpful, harmful, both or neither?
Convenor: Adam S. Radomsky, Concordia University, Canada
How Do Safety Behaviors Impede Fear Reduction During Exposure Therapy?: A Test of the Threat Disconfirmation Hypothesis
Michael J. Telch, Ph.D., University of Texas at Austin, USA
There is a growing body of data showing that repeated checking of both computerized and real stoves leads to decreased memory confidence.
Consequently, research has begun to examine the conditions under which this decrease occurs. This talk will present results of two studies testing potential
moderators of the impact of repeated checking on memory confidence. First, we tested the impact of perceived threat. Eighty-one undergraduates
completed checks of both threatening and non-threatening objects (a real stove and a fake stove made of plywood). Memory characteristics and personal
responsibility were assessed before and after either 2 checks or 15 checks. Results replicated the basic finding that repeated checking (15 checks) lead to
decreased memory confidence. However, perceived threat was not found to moderate the impact of repeated checking. Participants that performed 15
checks of the fake stove showed decrements in memory confidence parallel to those observed for participants that performed 15 checks of the real stove. In
our second study, we will replicate and extend these initial findings. We will extend the previous study by also examining the potential impact of perceived
responsibility on changes in memory confidence. Participants will again be randomly assigned to check either a threat or non-threat object (real or fake
stove). However, in this study they will also be randomly assigned to perform the checks under conditions of high or low responsibility. Following from
cognitive models of checking it is hypothesized that heightened responsibility will intensify the impact of repeated checking on memory confidence.
Probing threatening memory associations in panic disorder.
Mark B. Powers, Ph.D., University of Amsterdam; Jasper Smits, Ph.D., Southern Methodist University; Alexander Bystritsky, M.D., University of
California at Los Angeles; Michael J. Telch, Ph.D., University of Texas at Austin, University of Amsterdam, The Netherlands
One of the central assumptions of cognitive models of panic disorder is that patients interpret bodily symptoms in a threatening/catastrophic way. These
negative interpretations are assumed to further fuel the 'threatening' symptoms. Studies employing self-rating scales like the Body Sensations Interpretation
Questionnaire (BSIQ) have provided support for this interpretation bias. Theoretically, these effects can be explained by assuming that - for panic patients in long term memory the associations between representations of bodily symptoms (e.g., breathlessness) are more strongly associated with representations
of threatening outcomes (e.g., suffocation). So, when confronted with a relevant bodily symptom, the catastrophic outcomes are more readily activated. To
test this model more directly, we employed a lexical decision task in a modified semantic priming paradigm. The study included 31 panic patients, 25
anxious controls and two nonanxious control groups. There were 4 types of prime-target combinations. The crucial combinations consisted of a 'bodily
symptom prime' followed by a 'threatening interpretation target' (panic-panic; e.g. chest pain - heart attack). Additionally there were three types of control
pairs (a) panic-neutral (e.g. chest pain - study), (b) neutral-panic (e.g. garden chair - heart attack) or (c) neutral - neutral (e.g. garden chair - study).
Consistent with predictions, there was a significant interaction between Group and Trial Type. For the panic group responses were significantly faster for
panic-panic trials compared to control trials. Interestingly, a similar pattern was observed for mental health workers without a history of panic disorder.
Results support and at the same time challenge information processing models of panic disorder.
Attentional Bias to Ideographically Selected Threat Relevant Information in Individuals with Obsessive Compulsive Symptoms
Roz Shafran, Ph.D., Warneford Hospital; University of Oxford, UK, Warneford Hospital, University of Oxford, UK
Individuals with Obsessive-Compulsive disorder (OCD) tend to focus on disorder-related information in their environment. Moreover, some studies suggest
that in the laboratory, these individuals pay particular attention to OCD-related information. However, researchers have not examined the extent to which
ideographically selected OCD-related information captures the attention of individuals with and without obsessive-compulsive symptoms. We asked
individuals with OCD symptoms to complete an ideographic word selection task where they rated the emotional valence of OCD-related (e.g., germs) and
neutral (e.g., chair) words. They then completed a probe detection task. In this task participants see two words on a computer screen. Words were
presented if the participant had previously rated them as either negative or neutral. These words then disappear and a probe (i.e., the letter “E” or “F”)
appears in the location of one of the words. Participants are asked to press a corresponding key on the mouse to indicate whether they saw “E” or “F.”
Faster response latency in identifying probes replacing threat words compared to probes replacing neutral words suggests attention deployment toward
threat words. Slower response latency differences suggest avoidance of threat words. Preliminary data suggest that individuals with OCD symptoms
showed significant avoidance of ideographically selected OCD-related words compared to non-anxious controls. This is in contrast to previous research
examining this question in OCD. However, because our participants selected words that were relevant to their own concerns, they may have been more
motivated to avoid them.
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Memory bias for threatening information that was neutral at encoding: Implications for anxiety disorders with delayed onset
Irena Milosevic, M.A., & Adam S. Radomsky, Ph.D., Concordia University, Canada
Memory bias for threatening information, demonstrated by the preferential recall of threat-related information has been observed in association with a
number of different anxiety disorders. However, all studies demonstrating a memory bias have compared memory for encoded information that was
threatening against encoded information that was not threatening. The objective of the current project is to investigate a memory bias for threatening
information in a novel way by having participants encode only neutral information, half of which is made threatening following encoding. Undergraduate
participants were read a vignette about two individuals in a benign situation. Participants were then asked to recall all of the information remembered from
the vignette (pre-test). The researcher then presented the participants with new threatening information about one of the characters in the story.
Participants were then asked to recall once more all of the information remembered from the vignette (post-test). It was hypothesized that participants would
remember more threatening information than non-threatening information from the vignette at post-test. Preliminary analyses indicated that participants
recalled significantly more threatening information than non-threatening information at post-test, and recalled significantly more threatening information for
the 'threatening' individual compared to the 'nonthreatening' individual. These results support the presence of a memory bias for information made
threatening only after it has been encoded. The results of this study will be discussed in terms of cognitive approaches of understanding OCD, information
processing, and psychopathology with delayed onset.
Symposium 97
Beliefs of patients and therapists in social phobia: are they true?
Convenor: Maartje Vroling, University of Groningen, The Netherlands
What characterizes social phobic patients the most: poor social performance or cognitive discrepancies?
M. J. Voncken S. M. Bögels, Maastricht Univeristy, the Netherlands; University of Amsterdam, the Netherlands
Cognitive models emphasize that social phobia is mainly characterized by biased estimations of their anxious appearance and social skills. In addition, there
is a growing body of evidence showing that social phobic patients actually appear more anxious and suffer from social skills problems as well. This study
aims to unravel what characterizes social phobic patients the most, cognitive discrepancies or actual problems in anxious appearance and social skills.
Observed anxious appearance and social skills as well as cognitive discrepancies regarding anxious appearance and social skills were examined in referred
patients with social phobia (n = 48) and normal controls (n = 27) during two situations: a speech and a conversation. The results showed that social phobia
patients are mainly characterized by cognitive discrepancies during the speech and by actual impairment in social skills and anxious appearance during the
conversation. The theoretical and clinical implications of these findings will be discussed.
Cognitive Biases in Fear of Blushing
Corine Dijk Marisol Voncken *Peter de Jong, University of Groningen, the Netherlands; Maastricht University, the Netherlands
Cognitive biases are assumed to play a role in social anxiety and fear of blushing. However, results in prior studies, which investigated cognitions via written
vignettes, are not straight forward. Some studies did find blushing phobics to show more negative cognitions concerning blushing than non fearful
participants, others did not. The use of written scripts in these studies might have accounted for these conflicting results. In this study we therefore used an
in vivo approach; a 5 minute conversation with two confederates. Participants that were high (n=50) and low (n=50) in fear of blushing received the feedback
of an increase in blush intensity. A control group did not receive feedback about their blush. The confederates rated their social performance and participants
estimated how well the confederates would judge their social performance. The idea that blushing fearfuls overestimate the negative interpersonal effects of
blushing was tested, as well as the discrepancy between the participants in these four groups and the confederate ratings (as estimation of cognitive
biases). The results will be presented.
Impact of Alcohol Consumption on Interpersonal Rumination
Alexander L. GerlachNina Heinrichs Silvia Henke, Technical University Carolo-Wilhelmina, Brunswick, Germany
Socially anxious individuals often attempt to reduce their fears by consuming alcohol prior to social situations. The appraisal disruption model (Sayette,
1993) explains the anxiolytic effect of alcohol by assuming that the substance impedes the evaluation of threatening information. Findings by Gerlach et al.
(2006) suggest that alcohol may also reduce the consolidation of fear-relevant aspects of social situations in memory. We currently recruit 30 high and 30
low socially anxious individuals with interaction anxiety. The assessment is conducted twice: once directly after a social interaction (party conversation) and
once one to three days later. Prior to the social situation, all participants receive orange juice: for half of the participants in each group the juice contained
alcohol (vodka). Dependent variables are social anxiety and post-event processing measures as well as depressive and state symptom questionnaires. We
expect (1) that independent of the alcohol consumption condition the high socially anxious group will report similar levels of social anxiety prior to the
interaction situation (first assessment point) and (2) that the high socially anxious (but not the low socially anxious) individuals who consumed alcohol at the
first assessment point will report less anxiety and less rumination about the social event one to three days later (assessment point 2). The implications of the
results will be discussed.
Social anxiety and reasoning bias
Maartje S. VrolingPeter J. de Jong, University of Groningen, the Netherlands
It is well known that many socially anxious' beliefs concerning social situations are erroneous. In cognitive therapy, we target the erroneous beliefs in order
to help patients realize that they are incorrect. By doing so, we aim to diminish the patients fear. How come these patients cannot diminish their own fear?
How come they do not see that what they believe is untrue, even though disconfirming evidence is available? In this presentation we will focus on the role of
reasoning in maintaining dysfunctional beliefs. Questions are whether socially anxious individuals are characterized by a reasoning style that confirms rather
than disconfirms what they believe, and whether this reasoning style is characteristic of socially anxious individuals.We recently conducted a study in which
high and low socially anxious individuals performed a syllogistic reasoning task. The results support the notion the reasoning biases contribute in maintaining
social anxiety. The findings and the implications will be discussed.
Cognitions and symptoms during residential cognitive and interpersonal therapy for social phobia: week-to-week and phaseto-phase relationships
A. Hoffart F.M. BorgeH. Sexton, Research Institute at Modum Bad, Vikersund, Norway
The purpose of this study was to examine the mediating role of cognitions in residential cognitive and interpersonal therapy for social phobia. Eighty social
phobic patients were randomized to 10-week residential cognitive (RCT) or interpersonal psychotherapy (RIPT). They completed cognitive and symptom
measures at pre-, mid-, and posttreatment and at follow-up one year after end of treatment. They also completed short-form cognitive measures every
Thursday and a symptom measure every Monday. For both time levels, the ratings were analysed with mixed models. The following research questions
were addressed: What were the predictive relationships between the cognitive variables and the symptom variables?Did the predictive cognitive variables
influence the symptoms differentially in the two treatments or are the relationships general in both treatments?Which of the cognitive variables (a) changed
their level during treatment and (b) was this change more influenced by one of the treatments?
Symposium 109
OCD: Treatment outcome in specialized populations and mechanisms of action
Convenor: Maureen Whittal, University of British Columbia, Canada
Cognitive Treatment of Obsessions: A Controlled Trial
Maureen L. Whittal, Sheila R. Woody, Peter D. McLean, S. Jack Rachman, University of British Columbia, Canada
Classic obsessions typically involve egodystonic intrusions of sex, violence or blasphemy. To date, these individuals have largely been ignored in treatment
studies and were once thought untreatable. Traditionally, as with other OCD subtypes, treatments were behavioral in their focus. Exposure-based treatment
of obsessions consist of repeated imaginal exposure to the intrusion, which is highly anxiety provoking. Although potentially helpful, it is difficult to tolerate
and may lead to drop out. Contemporary cognitive treatments that focus on reappraising the meaning associated with the intrusion (e.g., mad, bad or
dangerous) and do not use imaginal exposure therefore hold promise. 84 participants were randomized to either cognitive therapy (CT) or stress
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management (SMT) offered immediately or following a 3-month waiting period. Treatment consisted of twelve 50-60 minute individual sessions. The
majority of the sessions were weekly with the remaining 2-3 fortnightly. Data from 67 treatment completers was available for analysis. Respondents rated
both treatments were rated as equally plausible after the first session. At post-treatment both CT and SMT demonstrated significant declines of greater than
50% in YBOCS, with no between group differences. Similarly, SMT and CT resulted in comparable declines on measures of depression and anxiety during
treatment. However, the meaning of intrusions did differ between groups at post treatment. Participants in CT had a significantly lower score on the
negative meanings associated with obsessions compared to participants in the SMT group. Follow-up data are currently being collected and will be
discussed at the time of presentation.
Cognitive-Behavioral Therapy for Compulsive Hoarding: Results from Open and Controlled Trials
Randy O. Frost, Gail Steketee, David F. Tolin, Cristina Sorrentino, Jessica Rasmussen, Amanda Gibson, Sarah Carlson, Robert Brady, Smith
College, MA, USA
Compulsive hoarding has traditionally been conceptualized as a subtype of obsessive-compulsive disorder (OCD). However, treatments found effective for
OCD (e.g., serotonergic antidepressants, ERP) have shown less promise for hoarding. A cognitive-behavioral model of compulsive hoarding posits that
hoarding stems from deficits in information processing, maladaptive beliefs about and attachments to possessions, and avoidance behaviors. In addition,
positive emotional responses to saving and acquiring directly reinforce these behaviors. A cognitive-behavioral treatment based on this model was tested
first in an open trial in with 10 patients. This 26-session treatment consisted of in-home and office assessments, motivational enhancement, collaborative
model-building, training in organizing skills and problem solving, practice sorting objects, non-acquisition exposure exercises, cognitive therapy, and relapse
Findings from the open trial showed significant reductions in hoarding severity and in specific hoarding behaviors, as well as in
observational measures of clutter. Both therapist and client rated the client as "much improved" or "very much improved" in 57% of treatment completers. A
subsequent controlled trial compared treated patients with a 12-week waitlist group. Of 43 clients who entered the program, only 7 (16%) dropped out.
Treated clients showed significant reductions in hoarding symptoms even by week 12, outperforming waitlisted patients with a large effect sizes on most
measures. After 26 sessions, 83% of patients and 69% of therapists rated patients as “much” or “very much” improved. Clinically significant change was
observed in 46% of patients. Although CBT was effective, genuine remission of hoarding behaviors was infrequent, and substantial residual symptoms
The process of change in treatment of obsessive compulsivedisorder: Cognitive versus behavior therapy
Gideon E. Anholt, Pieter Kempe, Else de Haan, Patricia van Oppen, Danielle C. Cath, Johannes H. Smit, Anton J. L. M. van Balkom, VU-University
Medical Center and GGZ Buitenamstel, The Netherlands
Behavior therapy (exposure and response prevention, ERP) and cognitive therapy (CT) have been found to be effective treatments for obsessive-compulsive
disorder (OCD). Direct comparisons between these treatment modalities have detected little differences in efficacy. However, research of the differential
change process between ERP and CT is scarce. The present investigation is a first attempt to study change as a continuous process rather than at specific
points of treatment and follow up. Methods: Weekly measured obsessions and compulsions severity (measured by the Yale-Brown Obsessive-Compulsive
Scale; Y-BOCS) of 61 treatment completers following either CT or ERP were compared to assess whether the process of change in CT and ERP is indeed
differential. We expected ERP to primarily affect behavior, therefore reduce compulsions first, and CT to primarily affect thought, therefore reduce
obsessions first. Results: No differences in the change process of obsessions and compulsions between ERP and CT were detected. Further, compulsions
were found more explanatory than obsessions to all treatment effects. Conclusions: These results suggest that behavior change is the change process by
which both ERP and CT affect change. These results are further discussed.
Cognitive, symptomatic and functional changes following cognitive-behavior therapy for Obsessive-Compulsive Disorder
M. Kyrios, C. Hordern, S. Bhar, M. Nedeljkovic, R. Moulding, & G. Doron, Swinburne University, Australia
Research has consistently supported the efficacy of cognitive-behaviour therapy (CBT) in ameliorating symptoms of Obsessive-Compulsive Disorder (OCD),
although not always across all OCD subtypes. For instance, there has been equivocation about the efficacy of CBT for depressed and obsessional
presentations of OCD patients. Furthermore, little research has examined treatment-related changes in cognitions, self-representations, and quality of life,
and whether improvements in these are seen across different OCD subtypes. Changes in cognitions and self-representations are important because of their
relevance to vulnerability. Improvement in quality of life is of particular relevance to patients and their carers. In the present study, seventy-nine participants
presenting with OCD underwent a 16-week manualised CBT intervention. Just over half the participants were medication-free (53%) and 44% presented with
current major depression. A range of symptomatic, cognitive and functional measures were administered at 5 time points (at initial presentation, at pretreatment following an average 10 week waitlist period, at mid-treatment, at the conclusion of treatment, and at 6-to-12 month follow-up). Intention-to-treat
analyses were conducted, as were analyses for treatment completers. No changes were found over the waitlist period. Large magnitude changes were
found in measures of symptoms, cognitions, self-ambivalence, and quality of life at post-treatment. Gains were maintained over the follow-up period. Overall,
two thirds of participants responded to treatment, while only eight (10%) relapsed following treatment. There were generally no differences in outcome for
the OCD subtypes examined, although some exceptions were noted with respect to increase in depression levels at follow-up for some subtypes.
Implications for the management of OCD and the dissemination of CBT are discussed.
Symposium 156
Never mind the quality, feel the width - broadening our understanding of the treatment of OCD
Convenor: Dr Elizabeth Forrester, Centre for Anxiety Disorders & Trauma, South London & Maudsley NHS Trust, UK
OCD-CTS: the development of the Cognitive Therapy Scale for Obsessive-Compulsive Disorder
Dr Elizabeth Forrester (1), Dr Victoria Bream Oldfield (1), Professor Paul Salkovskis (2), 1) South London & Maudsley NHS Trust, UK; 2)
Institute of Psychiatry, King's College, London, UK
Measures of competence in cognitive-behaviour therapy have been in existence from 1980, most notably those of Young and Beck (1980, 1988) and more
recently by Blackburn, James, Milne, Baker, Standart, Garland, and Reichelt (2001). Whilst the Young and Beck measures were devised for assessing
competency in the cognitive treatment of depression, it has been used as a disorder-wide measure of general cognitive-behaviour therapy (CBT) skill.
Blackburn et al. have taken this shortcoming into account and have demonstrated reliability across the spectrum of psychological disorders. Whilst such
measures may provide a useful means of assessing developing skills of therapists undergoing training in CBT, it may be argued that they are not sufficiently
sensitive to the discrete skills and techniques which may be unique to the treatment of a particular disorder. In particular, it is argued by many researchers
(eg. Startup, Jackson, and Pearce, 2002) that there is a need for measures of therapist skill and competence that is specific to individual disorders in order
to further enhance the claims of several randomised control trials which offer evidence that CBT is the most effective treatment (eg. For panic disorder
(Clark, Salkovskis, Hackmann, Middleton, Anastasiades, & Gelder, 1994), in schizophrenia (eg. Thornicroft & Susser, 2001; Haddock, Tarrier, Spaulding,
Yusupoff, Kinney, & McCarthy, E, 1998), obsessive-compulsive disorder (eg. Abramowitz, 1997).This study describes the development of a new scale to
measure integrity of the treatment of obsessive-compulsive disorder (OCD-CTS) and tests its reliability. Video-tapes of therapy sessions were obtained from
therapists experienced in the cognitive-behavioural treatment of OCD and assessed using this measure. As a control group, a selection of video-tapes
considered to be of 'good quality' behaviour therapy (exposure and response prevention) from the participating therapists were also assessed. The results
will be discussed.
Intensive vs. weekly CBT for OCD: A quantitative and qualitative study of treatment completers
Anna Bevan (1), Victoria Bream Oldfield (2), Paul Salkovskis (1), 1) Institute of Psychiatry, Kings College London, UK;.2) Centre for Anxiety
Disorders & Trauma, Maudsley Hospital, UK
Time-intensive and weekly CBT for OCD are compared with significant treatment effects found in both groups. On a range of self-report measures, the two
treatment conditions were found to be equally effective at the end of treatment and at three-month follow-up. Uncontrolled effect sizes show that the
treatment is comparable to other trials of CBT for OCD. Patients in each condition took part in qualitative interviews. Although quantitative methods provide
reliable measures of symptom change over time, and hence of treatment effectiveness, qualitative methods offer uniquely useful insights into factors
affecting change, such as clients' engagement with treatment, or motivation to undertake difficult homework tasks. Thus incorporating client perspectives
can enrich traditional methods of treatment evaluation. A better understanding of client perspectives may assist the development of highly acceptable
services, and in turn, impact on service effectiveness. Six treatment completers in each group (time-intensive and weekly; matched for age, gender, and
symptom change over the course of treatment) were asked to reflect on helpful and unhelpful aspects of treatment, and to consider the differences between
treatment formats. The interviews were transcribed and analysed in detail using Interpretative Phenomenological Analysis. Results indicated that contrary to
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the beliefs of clients who had completed weekly treatment, those who undertook intensive treatment valued the high pressure and pace and felt that it
improved motivation, engagement and eventual outcome. Although there may be individual differences in preference for OCD treatment format, clients who
choose an intensive format perceive important benefits from it.
Onset of OCD: Early onset, recent onset.
Claire Lomax (1), Paul Salkovskis (1), andVictoria Bream Oldfield *(2), 1) Institute of Psychiatry, Kings College London, UK.2) Centre for Anxiety
Disorders & Trauma, Maudsley Hospital, UK
The etiology of OCD remains poorly understood. Two areas of interest are introduced. Firstly, whether CBT is effective in a rapid reduction of obsessional
beliefs, symptoms and interference in recent onset obsessional problems. It has been proposed that briefer duration of psychological symptoms should
mean that the difficulties are more straightforward to treat, and therefore may require fewer sessions of treatment. To investigate this hypothesis, two
patients with OCD of recent clinical onset (within previous 4 months) were treated with cognitive-behaviour therapy (CBT) on an outpatient basis. It was
proposed that, in line with the aims of the stepped care model, these individuals would require fewer sessions of treatment than patients who had
experienced OCD symptoms of longer duration. However, these expectations were not realised as the patients required approximately the same number of
sessions of treatment as would be given in a normal course of treatment. The implications of this finding are discussed.Secondly, is outcome in CBT is
related to age of onset of OCD? Research has indicated that individuals who report an early onset of the disorder report greater severity and persistence of
symptoms, although few studies have investigated whether there are differences in treatment response. The present study represents a preliminary
investigation in the setting of a specialist OCD clinic, using the analysis of case records. The study found that individuals with early onset of OCD reported
more severe symptoms at assessment, but that there was no difference in treatment response between the groups.
Belief change in OCD treatment: a pilot study
Blake Stobie, Centre for Anxiety South London & Maudsley NHS Trust, UK
Despite advances in CBT, many obsessional patients still fail to make or maintain substantial improvements following therapy. Many patients are not offered
cognitive behavioural treatment and a substantial proportion that are refuse or discontinue therapy prematurely. Rasmussen and Eisen (1997) note that 2030% of OCD patients treated in treatment trials remain refractory. Findings concerning factors involved when patients do not accept or benefit from treatment
have been influential in the development of cognitive behavioural therapies (Foa, 1979). However, the basis of “treatment resistance” in OCD remains an
under-researched area - historically, clinicians and researchers have attributed OCD treatment failure to factors such as poor patient motivation, “symptom
substitution”, secondary gain, comorbidity and so forth. In this pilot study, a sample of OCD patients was administered a 21 item questionnaire at set points
over the course of cognitive behaviour therapy treatment sessions. The questionnaire examined patient beliefs about OCD treatability and aetiology, their
progress and what they attributed this to. Respondents were also administered treatment outcome measures at the same time points. It was hypothesised
that treatment responders would demonstrate a significantly higher shift in belief ratings relative to treatment non-responders. This hypothesis was only
partly supported by the findings. Clinical and research implications, including adapting the questionnaire to determine therapist beliefs about OCD treatment,
are discussed.
Symposium 172
Disgust and Anxious Psychopathology
Convenor: Graham Davey, University of Sussex, UK
Analogue Studies On Behavioral Avoidance of Disgust In Contamination-Based OCD
Bunmi O. Olatunji, Vanderbilt University USA
The fear of contamination is the most common theme observed in Obsessive-compulsive disorder. Recent theoretical developments have highlighted the
complex, powerful, and potentially persistent role of disgust in this fear. However, empirical evidence in support of the relation between disgust and
contamination fear has been largely descriptive. The present studies attempts to address this limitation by examining the disgust-contamination fear
relationship in the context of behavioral avoidance tasks (BATS). This approach may contribute to our understanding of the role of disgust in OCD by
broadening the parameters in which the experience of disgust is typically assessed.
Vaginismus: The Role Of Disgust And Fear Of Contamination
Peter De Jong, University Of Groningen, The Netherlands
Current explanations of vaginismus focus on the role of fear of pain to explain the persistent difficulties to allow vaginal entry of a penis, a finger, and/or
object, despite the women's expressed wish to do so. In this presentation I will argue that disgust and fear of contamination rather than fear of pain may be
critically involved in the etiology of the characteristic defensive responses in vaginismus. On the basis of two recent studies it will be illustrated how a disgust
conceptualization of vaginismus may help explain this “most perplexing condition”. Clinical implications will be discussed.
The Disgust Propensity And Sensitivity Scale: A Valuable Addition To Research?
Mark Van Overveldt University Of Maastricht, The Netherlands, P.J. De Jong & M.L. Peters,
The Disgust Propensity and Sensitivity Scale - Revised (DPSS-R) is a recently devised questionnaire, measuring both disgust propensity (tendency to
experience disgust more rapidly) and disgust sensitivity (how negatively does the individual evaluate this disgust experience). It will be demonstrated that
disgust propensity and disgust sensitivity are differentially associated to various forms of psychopathology, e.g., emetophobia, obsessive compulsive
disorders, and specific fears. Theoretical and methodological impications wil be discussed
Habituation to Disgust: Experimental Findings and Clinical Implications
Dean Mckay & Erica Chin, Fordham University, USA
Recent findings have convincingly tied disgust to many different anxiety problems. These include phobias to insects and certain small animals, blood-injuryinjection (BII), and contamination fears. Other research has implicated disgust in more complex clinical phenomena, such as sexual dysfunction and eating
disorders. In light of this wide diversity of clinical problems where disgust is involved, the habituation pattern for disgust is an important area of investigation.
Recent investigations suggest that habituation to disgust may be detected using psychophysiological assessments of respiration, muscle tension, heart rate,
blood pressure, and skin response. Disgust is associated with parasympathetic activation, leading to decreases in the aforementioned psychophysiological
domains. This presentation will summarize prior research examining the psychophysiological reactivity to disgust. Also, one study examining the changes in
response to disgust cues, and its generalization, will be summarized (Tsao & McKay, 2006). Finally, an examination of habituation for disgust in a group of
BII phobics is presented. This most recent study has important implications for treatment, where individuals with BII phobia reported significantly less
anxiety for blood cues (video of a blood draw from a human arm) following exposure for unrelated disgust information (video of a person vomiting). Further,
there was no difference between individuals with BII phobia who were exposure to the blood cue compared to those exposed to the disgust cue. BII phobics
showed significant decreases in facial muscle tension associated with disgust (levator labii region) following exposure for blood and disgust cues. The
importance of these findings for intervention will be considered.
A Causal Model Of Disgust In Anxious Psychopathology
Graham Davey & Benie Macdonald, University of Sussex, UK
The findings from three experiments indicate that (1) inducing disgust causes an interpretation bias by which participants interpret ambiguous stimuli more
threateningly, (2) inducing disgust does not immediately maintain or facilitate experienced anxiety unless the individual has experienced the interpretation
bias in action, and (3) elevated disgust causes any ambiguous stimulus to be interpreted more negatively regardless of whether that stimulus has a disgustrelevant status or not. These findings help to explain a number of paradoxical findings in the disgust and psychopathology literature, and suggest that
disgust may be a significant risk factor for a range of psychopathologies independently of other dispositional factors such as trait anxiety.
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Panel Debate 9
Anxiety Disorders Across the Lifespan: Multiple perspectives on predictors of symptom development and
Convenor: Meredith Coles , Binghamton University, USA,
Anxiety Disorders Across the Lifespan: Multiple perspectives on predictors of symptom development and maintenance
University of New Brunswick, Canada; Macquarie University, Australia Northwestern University, USAUniversity of Western Australia, Australia
Much is known about the treatment of anxiety. However, much less is known regarding predictors of symptom development and maintenance. Additional
information regarding malleable risk factors will improve efforts to refine treatments and prevent the development of anxiety disorders. Therefore, recent
work has taken multiple perspectives towards elucidating predictors of symptom changes over time. The members of this panel represent many of these
perspectives and the interaction of the panel members will provide a unique opportunity to 1) educate audience members regarding current thinking in this
field, and 2) advance this field by integrating typically disparate literatures. Ronald Rapee, from Macquarie University in Australia is an international expert
in the etiology and prevention of childhood anxiety. His work examining the impact of parenting styles and temperament in the development of anxiety will be
discussed. Colin MacLeod, from the University of Western Australia will discuss his recent work showing that training of information processing biases (e.g.,
teaching subjects to look away from threatening information) predicts subsequent anxiety responses. This work represents a unique perspective regarding
the role of information-processing biases in the etiology of anxiety. David Clark, from the University of New Brunswick, Canada, will provide a complimentary
perspective on the role of cognition in anxiety disorders. Dr. Clark is an international expert in the role of maladaptive beliefs in anxiety and depression.
Finally, Sue Mineka, from Northwestern University, USA, will discuss her recent work examining specific and non-specific risk factors for anxiety such as
neuroticism, anxiety sensitivity, and information-processing style. The 1.5 hour panel will address the following issues: 1) what are the primary predictors of
symptom development and maintenance in the anxiety disorders, 2) do the predictors differ for etiology versus maintenance, 3) what are the shared
predictors across the anxiety disorders, 4) what are the unique predictors for specific anxiety disorders. The Chair, Meredith Coles, will elicit position
statements from the panelists, facilitate debate between the panelists, and integrate comments and questions from the audience members.
Open Paper Symposium 32
Cognitive Mechanisms in Anxiety Disorders
The Effects of Group Cognitive Behavioral Therapy on Cognitive Changes in Panic Disorder Patients
Yongrae Cho, Hallym University, Republic of Korea; Yeon Sook Choi, Catholic University, Republic of Korea; Yang Soo, Catholic University,
Republic of Korea; Young Hee Choi, Mettaa Institution of Cognitive Behavior Therapy, Republic of Korea
The present study purposed to examine the effects of group cognitive behavioral therapy (GCBT) on improvement in panic disorder patients' major clinical
symptoms and changes in their cognition and behavior. The authors compared the degree of depression, the severity of panic and agoraphobic symptoms,
interpretation of bodily sensation and abilities to cope with anxiety before and after GCBT. The subjects of this study were patients diagnosed with panic
disorder with or without agoraphobia by psychiatrists according to the diagnosis criteria of DSM-? during the period from April 2006 to January 2007. The
experimental group of 44 patients was selected from Mettaa Institute of Cognitive Behavioral Therapy, and the control group of 38 patients was selected
from two university hospitals and one psychiatric clinic. 12 sessions of group cognitive behavioral therapy were applied to the subject group once a week
along with medication, and supportive psychotherapy with medication were applied to the control group. Clinical symptoms and changes in cognitive and
behavioral indicators were measured using BDI (Beck's Depression Inventory), PAS (Panic and Agoraphobic Scale), BBSIQ (Brief Body Sensation
Interpretation Questionnaire) and ACQ (Anxiety Control Questionnaire). Collected data were analyzed using the SAS program through ?2test, Fisher's exact
test, t-test and repeated measures ANOVA. The effect of the group cognitive behavioral therapy was tested through comparing depression, body sensation
interpretation, anxiety control, panic and agoraphobic symptoms and medication use before and after the scheduled program, and correlations among the
variables were analyzed through Pearson's correlation coefficient. In addition, stepwise multiple regression was used to identify factors related to the effect
of cognitive changes and relevant behavioral changes. 1. Panic and agoraphobic symptoms decreased significantly in both group but only during the early
period of therapy in the control group.2. As to the catastrophic misinterpretation of bodily sensation, the subjects of the group cognitive behavioral therapy
showed significant decreases in the rank of and belief in panic bodily sensation and in the rank score and belief score of external events. On the contrary,
the control group showed a significant decrease only in the rank scores of panic body sensation. 3. The perceived control of anxiety increased significantly
in the experimental group but not in the control group. 4. Most influential cognitive factor on the subjects' improvement in panic and agoraphobic symptoms
was perceived control, explaining around 31% of the improvement.5. In terms of medications, 63.6% stopped completely, 29.6% lowered the dosage by half,
and 6.8% showed no change in the experimental group. On the contrary, none of the control group stopped medication, 50% lowered the dosage by half,
and 50% showed no change. Panic disorder patients are assumed to make cognitive errors such as catastrophic thinking and overestimation. This research
showed that such cognitive errors could be modified through cognitive behavioral therapy and the patients could interpret their bodily sensation more
positively and control anxiety better. As a result, the patients' suffering was reduced and it was easier for them to stop or taper their medication.
The effects of cognitive-behavioral treatment on disorder-specific negative affective associations in generalized anxiety
disorder measured with the EAST task
Andrea Reinecke, Dresden University of Technology, Germany, Mike Rinck, Radboud University Nijmegen, The Netherlands, Eni S. Becker,
Radboud University Nijmegen, The Netherlands
According to cognitive theories of anxiety (e.g. Mathews & Mackintosh, 1998; Williams, Watts, MacLeod, & Mathews, 1997), cognitive processes play a
significant role in the etiology and maintenance of anxiety disorders. Previous studies revealed disorder-specific cognitive biases in generalized anxiety
disorder (GAD), for instance, biased attention (Martin, Williams, & Clark, 1991). It is unclear, however, whether GAD is also related to biased affective
associations and whether these biases are modifiable through cognitive-behavioral intervention. Forty patients with GAD and 20 healthy controls were tested
twice. Half of the patients were randomly assorted to a no-treatment waiting group, the other half received cognitive-behavioral intervention between
diagnostics. Distances between diagnostics were held constantly at 3 months in all the three groups. In each diagnostic session, participants performed an
EAST task. In this paradigm, two reaction keys are associated with extrinsic valence by first sorting generally pleasant and unpleasant words. During the test
phase, participants use these same keys to categorize GAD-related vs. GAD-irrelevant words on the basis of their printing color as either red or green.
Recent research with spider phobics revealed prolonged reaction times when spider words and pleasant words require the same response (Ellwart, Becker,
& Rinck, 2005). In addition, we assessed direct self-reports of worry with the Penn State Worry Questionnaire at all test times. We will first assess whether
GAD is related to disorder-specific biases of negative affective associations. Afterwards, we will compare changes during the waiting time to the effects
gained during treatment, once for the implicit and once for the explicit parameter. Data will point to the parameters sensitive to treatment. If biased negative
affective associations turn out to be modifiable through treatment, this result indicates relevance of the parameter for etiology and maintenance of GAD.
The study of some functional relations involved in the obsessive-compulsive behavior
Roberto Alves Banaco, Pontifícia Universidade Católica de São Paulo, Joana Singer Vermes, Paradigma, Núcleo de Análise do Comportamento,
Specialized literature establishes that obsessive-compulsive responses may be reinforced by elimination of conditioned aversive stimuli and anxiety, by
social attention, and by avoidance of aversive situations The present study intends to test that hypothesis through analysis of single cases. Method: After
interviews and a preference test, three children with washing compulsion were submitted to twelve sessions of 15 minutes each, conducted in a room with a
washbasin and other matters that might be used in the activities and in ritual's performance. Each child was submitted to the following conditions: toys of
medium preference; toys of medium preference and dirt; toys of low preference; toys of low preference and dirt; toys of high preference; toys of high
preference and dirt; aversive tasks; aversive tasks and dirt. Sessions were videotaped and duration of each behavior was registered. Results show a
relationship between these behaviors and the experimental conditions. Subject 1, for instance, presented more duration of obsessive-compulsive behavior
and had a higher duration at the aversive task condition and at the toys of low preference conditions, confirming the hypothesis of literature that suggests
the multiple operant function of obsessive-compulsive behavior. Also in Subject 2, data indicates that the behaviors of washing hands, and of rubbing hands
as well (on clothes or other surfaces) were displayed in two sessions: the one in which the low-preference toys were presented along with the anxiogenic
stimulus; and the one where aversive activities were proposed together with the anxiogenic stimulus (session 11). Data from Subject 3 indicates that the
behaviors related to the obsessive-compulsive problem were presented when the anxiogenic stimulus were available, even when high preference toys were
in the session, suggesting that for Subject 3, obsessive-compulsive behavior are more related to dirt that to availability of potential reinforcers in the
environment. But the session with low preference toys and dirt was observed as the one with higher frequence of cleaning behavior, suggesting that yhe
behavior can be related to destituiton of activities. The study confirms the hypothesis of literature that suggests the multiple operant function of obsessive-
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compulsive behavior. The increase in the number of responses related to anxiety by the three subjects corroborates the hypotheses presented by some
authors, such as Banaco (1997), Graña & Bayon (2000), Sidman (1995), and Zamignani (2000) as regards how the abundance of aversive stimulation might
favor the obsessive-compulsive problem if the subjects do not have in their repertoire other avoidance responses or coping skills for managing aversive
situations. This information also leads to the supposition that aversive situations tend do bring out typical responses to anxiety. These data indicate that,
although the stimulus used for conjuring up anxiety and for discriminating the performance of rituals might increase the likelihood of obsessive-compulsive
behaviors for some individuals, other variables might be operating on the behavior in question, leading individuals to display rituals also when the
conditioned aversive stimulus is lacking. This study leads to the statement that the work of the behavior analysts, on their turn, must be focused on what
they are in fact set to do: the changing of the environmental contingencies.
Attentional biases towards threatening and positive stimuli in older adults: the role of trait- and induced anxiety
Ignacio Montorio, Universidad Autónoma de Madrid, Spain; Isabel Cabrera, Universidad Autónoma de Madrid, Spain; Roberto Nuevo, Hospital
Unversitario de La Princesa, Spain; María Izal, Universidad Autónoma de Madrid, Spain; María Márquez-González, Universidad Autónoma de
Madrid, Spain
Diverse studies support the presence of attentional biases towards threatening information in non-clinical people with high levels of trait anxiety. Studies
have typically used samples of younger adults, and knowledge regarding the presence of anxiety-related attentional biases in the elderly population remains
sparse. However, age-related changes in cognitive (i.e., inhibitory deficit) and emotional functioning allow to hypothesize that the pattern on attentional
biases might be somewhat different in the elderly. The present study explores the presence of attentional biases towards emotional (threatening and
positive) stimuli in a sample of high- and low- trait anxious older adults in conditions of induced anxiety. One hundred and eleven volunteers aged 60 and
over were preselected on the basis of their STAI-T scores (high: > percentile 66th; low: < percentile 33th) and randomly allocated to one of 2 conditions:
anxiety induction condition (AIC) and control (C). Anxious mood was induced in half of the sample using a Mood Induction Procedure (MIP) consisting of the
reading of self-referent statements with anxious content and the listening of anxiogenic music. STAI-T and a 10-point visual analogue scale (VAS) were used
to assess, respectively, trait and state anxiety. Attentional biases were measured with a Dot Probe Task employing pictorial stimuli selected mainly from the
IAPS. Threatening pictures varied in their content (physical-danger, health problems and socioemotional concerns). Stimulus duration was varied (100
versus 500 milliseconds). The MIP was successful in inducing anxiety (F=16.0; p<.001). A mixed design analysis of variance (ANOVA) was carried out on
reaction time (RT) data, with 2 between-subjects factors (trait anxiety: high vs. low; and condition: induction vs. no induction), and 3 within-subjects factors:
emotional stimulus duration (100 vs. 500 ms) type of emotional stimuli (threat, positive and neutral) and emotional cue-dot consistency (consistent vs.
inconsistent). Only a main effect was found for emotional stimulus duration (subjects were slower in trials of 100 ms), together with two complex interactions
(Stimulus duration x condition x trait anxiety; and Stimulus duration x cue-dot consistency x Trait anxiety). No effect of trait-anxiety was found. However,
univariate ANOVAs analyzing the effect of Trait-Anxiety and Induced Anxiety on diverse attentional bias scores revealed a main effect of Trait-Anxiety on
attentional bias towards threatening stimuli (F=3.74; p<0.05) and, specifically, stimuli with social content (F=6.5;p<.05) in trials of 500 ms: high-anxious
subjects tended to orient their attention away from, and not towards, these type of stimuli. The pattern of anxiety-related attentional biases towards
emotional information found for older adults is different from that found for younger ones. Possible explanations and potential implications of this finding are
What happens when we try to stop worrying? Does it just seem to make things worse?
Andrew McLean, University of Glasgow, UK; Niall Broomfield, University of Glasgow, UK
A piece of advice that we give to one another is, "just don't worry about it!". Well, if we actually attempted to employ this advice by suppressing any
worrisome thoughts, what would happen? According to Wells' metacognitive model of Generalised Anxiety Disorder (GAD; Wells, 1995, Behavioural and
Cognitive Psychotherapy, 23, 301-320), GAD patients sometimes attempt to suppress intrusions that trigger worry. Wells postulates that these attempts are
rarely effective and may increase the frequency of worry triggers. These apparent failures are interpreted as evidence for loss of mental control, thereby
exacerbating beliefs about worry uncontrollability. So, the advice, "just don't worry about it!", may well be making things worse for people with problematic
worry. The current study tested these predictions. Sixty-two high worriers (score>56 on the Penn State Worry Questionnaire) completed a naturalistic
experiment comprising two sessions separated by one week. In Session 1, participants recorded their beliefs about worry in general, including its
uncontrollability. They then selected a current worry and recorded how often it came to mind over the following week. The Suppression group (N=32)
suppressed their chosen worry during the week. The Mention group (N=30) simply monitored its occurrence. In Session 2, Session 1 measures were
repeated. Contrary to prediction, the Suppression group reported a significant increase in worry controllability in general. No shift was demonstrated by the
Mention group. In addition, relative to the Mention group, the Suppression group reported more success at suppressing their chosen worries, spent less time
thinking about them, and found them more controllable and less distressing. Suppression was seen to bestow some relative benefit for people with
significant worry. This raises obvious practical interest. The findings are also discussed within the context of Wells' model of GAD. In some respects, the
findings are supportive of the model and its implications for treatment; attempts to suppress amongst high worriers proved relatively successful, in turn
promoting a beneficial adjustment in beliefs about uncontrollability of worry. The latter effect (resultant belief change) is entirely in keeping with Wells' model.
However, where Wells' model has more difficulty relates to its assumption regarding the ineffectiveness of suppression. Limitations of the present study are
discussed, as are possibilities for future research.
Open Paper Symposium 40
Outcome in CBT for Anxiety
Prevention of panic disorder: Results from a Randomised Controlled Trial
Peter Meulenbeek, GGNet, Godelief Willemse, Trimbos-instituut, Filip Smit, Trimbos-instituut, Pim Cuijpers, Vrije Universiteit van Amsterdam, the
Panic disorder (PD), is a serious DSM-IV axis I disorder affecting 2.2% of the Dutch population each year. It is associated with a large burden of disease,
considerable medical consumption and extensive loss of productivity. A substantial proportion of the population suffers from subsyndromal PD and are at risk
of developing a full-blown PD. The first author has developed a preventive intervention for panic symptoms, called the No panic! course. This intervention
can be used as a first step in a stepped-care model in mental health. The intervention consists of eight, weekly group sessions of two hours. It contains
psycho-education about anxiety and panic attacks, changing life-style, managing stress, relaxation training, cognitive restructuring, interoceptive exposure,
'in vivo' exposure and relapse prevention.
Aim of the study: To examine primary the reduction of the incidence of PD (DSM-IV using the MINI), secondary the reduction of symptoms of panic (PDSS,
HADS-anxiety, POL, MI) and improvement of quality of life (EuroQuol EQ-5D), and tertiary the costs per avoided case (TIC-P) and costs per 'quality adjusted
life year' (QALY). In addition, we examined the influence on depressive symptoms (BDI-II). Methods: A pragmatic, not-blinded, multi-site randomised trial (the
course 'No Panic!' versus waiting list control group), with a baseline measurement and two follow-up measurements (at the end of the intervention and 6
months later). Subjects were recruited from the general population by advertisements in regional newspapers, information brochures at general practices,
physiotherapist practices and public libraries. Potential participants had a psychiatric interview with a clinician from a Community Mental Health Centre. The
clinician used a list with inclusion and exclusion criteria. They also were interviewed centrally using the MINI. Consenting subjects were then randomized
(block-randomization, stratified to presence/absence of agoraphobic symptoms; conducted centrally). A total of 217 subjects entered the study and were
randomised to the experimental group (N=109) and the control group (N=108). Clinicians and prevention workers from 17 community mental health centres
offered the No panic! course. Analyses were conducted on an intention-to-treat basis. In all analysis, we controlled for the clustering of data caused by the
multi-site character of the study. Preliminary results are promising. Final results of this trial will be presented at the WCBCT2007 conference. The
effectiveness of the preventive intervention in preventing the development of a full-blown panic disorder and other implications of the findings will be
Perceived help and hindrance to remission in dysthymia and panic disorder at 9-year follow-up
Cecilia Svanborg, Clinical Neuroscience, St Göran's hospital, Karolinska Institute, Sofie Bäärnhielm, Transcultural Centre, Stockholm County
Counsil, Anna Åberg Wistedt, St Göran's hospital, Karolinska Institute, Kim Lützen, Ersta Sköndal University College, Sweden
Nine years after entry into two naturalistic studies with psychotherapy and antidepressant medication about 50 % of 23 patients with dysthymia and 15
patients with panic disorder were in full or partial remission. The aim of the study was to examine the phenomenon remission by exploring convergence of
different outcome measures and variations of perceived helpful and hindering factors to remission of these 38 patients. A concurrent quantitative and
qualitative method was used including diagnostic assessments according to DSM-IV, quantitative measures (SCL-90), Life-charting developed from the
NIMH Life Chart Methodology, and open-ended, semi-structured interviews. The interviews were analysed with qualitative content analysis. The main
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hindrance for all participants was difficulties in negotiating requested treatments. Remitted had overcome the obstacles, whereas many non-remitted with
greater disabilities and personality disorders had failed to obtain requested treatments. Common helpful factors for both diagnoses were self-understanding,
antidepressive medications, confidence in the therapist, learning to reason with one self and important relations. Participants with panic disorder and
dysthymia described different helpful relationships to the therapist: 'As a coach' or 'As a parent', and respectively different central areas for change:
awareness and handling of feelings versus self-acceptance and resolution of relational problems. The divergence between subjective and objective outcome
measures for two patients could be understood in terms of 'safety-seeking behaviours'. Overcoming access problems, shared decision making and
diagnostic differentiation are essential for empowerment and long-term remission.The findings will be discussed from the perspective of the patient as the
expert on what works (Bohart, 2000) and the common and specific factors leading to endurable remission.
Combining an interpersonal approach to the treatment of social phobia with medication: short-term effects
Ariel Stravynski, University of Montreal, Danielle Amado, University of Montreal, Paul Sidoun, Louis-H. Lafontaine Hospital, Lise Lachance,
University of Quebec at Chicoutimi, Canada
Clinical-lore favors the combination of medication with psychological treatments of social phobia. The evidence for the superiority of such combinations
however is sparse, as few studies have attempted them and typically with equivocal results. The goal of the current study was to assess the value of such a
combination. Fifty-nine social phobic patients were randomly assigned to either an interpersonal approach to the treatment of social phobia aiming to
improve social functioning or to a combined treatment also including paroxetine; 24 in each condition completed treatment. Seven patients dropped out from
the interpersonal condition alone and four from the combined regimen. An experienced clinical psychologist assisted by a trainee co-therapist administered
the therapy aiming to improve social functioning in small groups (5-6 participants) over 12 consecutive 2-hour weekly sessions. A psychiatrist oversaw
pharmacotherapy in the combined condition over 5 sessions (1, 2, 6, 10, 12) with dosages starting at 10-20mg and increased up to 50mg. Medication was
discontinued in gradually diminishing dosages at the end of treatment. Anxious distress and avoidance as well as social functioning were assessed before
and after the end of treatment. Patients in both conditions significantly benefited from their respective treatments, reporting less anxious distress, a weaker
tendency to avoid and correspondingly an improved social functioning in various areas of social life. Overall, patients in the combined regimen reported
greater gains. In summary, medication somewhat enhanced the effects of an interpersonal approach to the treatment of social phobia - in the short-term. A
one-year follow-up is currently in progress.
To consult …or not to consult the problem: the help-seeking dilemma of obsessive-compulsive disorder patients
Carmen Morillo, Faculty of Psychology, University of Valencia, Spain, Gema del Valle, Outpatients Mental Health Clinic, Burjassot, Valencia
(Spain), Amparo Belloch, Faculty of Psychology, University of Valencia, Spain, Carme Carrio, Outpatients Mental Health Clinic, Burjassot, Valencia
(Spain), Elena Cabedo, Outpatients Mental Health Clinic, Foios, Valencia, Spain
Obsessive-Compulsive Disorder (OCD) is a chronic and disabling mental health problem, associated with considerable distress and interference in daily
functioning. Despite this fact, data from different community-based survey studies indicate that only a reduced percentage of subjects suffering OCD (34% to
40 %) seek professional help for their problem. Additionally, it has been reported that OCD patients do not seek mental health treatment for a considerable
time after initial onset of symptoms. The specific factors influencing this tendency to delay the help-seeking remain still unclear. The purpose of the present
study was to explore the variables evolved in the help-seeking process among OCD patients. To that end, 26 OCD patients (principal diagnosis, Axis I DSMIV criteria) completed the Structured Interview of Help-Seeking (SIH-S), a new instrument specifically designed for this study. The SIH-S assesses to what
extent OCD patients delay in seeking treatment for their problem, throughout three groups of questions: factors influencing the recognition of the problem,
reasons for delaying the treatment-seeking (i.e., barriers to help-seeking), and reasons for consulting the problem (i.e. motivators to help-seeking).
Participants also completed OCD, depression and worry measures. The mean length of delay in seeking treatment was of 39.38 (± 50.95) months, and a
great variety of reasons for delaying were observed. The OCDs who delayed the longest to consult, in comparison with patients with lower delay rates, had
more worry proneness, greater duration of OCD symptoms, and were less aware about the interference and behavioural changes associated with the
problem. Differences between “Pure obsessives” and “Ritualizers” were also examined. Although both groups were comparable on their overall delay rates,
remarkable between-group differences emerged on several variables concerning the help-seeking process. “Pure obsessives” decided to consult the
problem because of dysfunctional beliefs about their obsessions (catastrophic interpretations). “Ritualizers” delayed to seek help because of a tendency to
minimize the importance and interference of the symptoms, which reveals a poor insight about their obsessions and compulsions. A different balance
between the reasons to consult or not to consult the problem may be operating in both types of OCD. The consequences of these reasons for the early
detection of the OCD, as well as for their clinical course and response to the treatment should be further investigated.
A comparison of individual vs. group cognitive-behavioural treatment for obsessive-compulsive disorder: a 1 year follow-up
Nuria Jaurrieta, OCD Unit, University Hospital of Bellvitge, Susana Jiménez-Murcia, OCD Unit, University Hospital of Bellvitge, José Manuel
Menchón, OCD Unit, University Hospital of Bellvitge, Maria del Pino Alonso, OCD Unit, University Hospital of Bellvitge, Spain
Introduction: The first controlled-trial that analyse individual vs. group cognitive-behavioural treatment (CBT) was conducted by Fals-Stewart, Marks &
Schafer (1993). They noted that although patients in the individual treatment (IT) initially show faster rates of improvement than those in group treatment
(GT), by the post-treatment neither condition was superior to the other and the same at the follow-up. In this study, in the 6 month follow-up the obsessivecompulsive symptomatology increase slightly. A recent study observed that IT is associated with more rapid response but that both treatments had
equivalents of recovered participants by brief follow-up (Anderson & Rees, 2007). At the previous controlled pilot study compared IT, GT and CG, the IT
seems to be more effective than GT and both than the CG at the end of the treatment (Jaurrieta, et al. in press).
Objective: To compare the effectiveness of two modalities of cognitive-behavioural treatment (CBT) (group and individual) in a sample of patients with
obsessive-compulsive disorder (OCD) at 6 and 12 month follow-up period Method: Thirty-eight subjects meeting DSM-IV-TR OCD criteria completed 20
sessions of individual and group CBT and were assessed with the Y-BOCS and the Hamilton Anxiety and Depression Scales at baseline, post-treatment and
at 6 and 12 month follow-up period. Results: The clinical improvement obtained at the end of the treatment was maintained at 6 and 12 month follow-up.
Clinical outcome did not differ between the individual treatment (IT) and group treatment (GT). At 6 month follow-up the presence of hoarding obsessions or
compulsions was associated with lower improvement in depressive and anxiety symptoms. Older onset was associated with less improvement in depressive
symptoms. Patients with checking obsessions and compulsions and early onset were associated with less improvement in obsessive-compulsive symptoms.
At 12 month follow-up the presence of ordering-symmetry and checking obsessions was associated with more improvement in depressive symptoms, and
the presence of checking obsessions presented less improvement. Finally, the presence of slowness and older age of onset was associated with less
improvement in obsessive-compulsive symptoms, and the presence of to be employed and hoarding obsessions was associated with more improvement.
The drop-out rates were significantly higher in women in comparison to men. However, the drop-out rates were similar in IT and GT. Conclusions: CBT is
effectiveness for a sample OCD patients. Individual and group CBT were showed similar results at 6 and 12 month follow-up. Clinical implications at these
findings will be discussed.
Open Paper Symposium 44
CBT For Social Anxiety: Symptom Focus and Group Format
Short-term group therapy for fear of blushing - an open trial
Samia Chaker, Technische Universität Dresden, Jürgen Hoyer, Technische Universität Dresden, Germany
The aim of this trial was to test the effectiveness of an economic short-term and time-intensive group format for patients whose primary concern is fear of
blushing. We developed a short-term group treatment program with subsequent self-help instructions to serve the specific treatment needs of this group. The
program was based upon a combination of the cognitive model of social phobia by Clark and Wells (1995) and the task concentration training by Bögels,
Mulkens and de Jong (1997). The study was designed as an open trial without a control group. A total of N = 31 patients fulfilling DSM-IV criteria for social
phobia with fear of blushing as predominant complaint were treated within one weekend in groups of up to 12 patients. Assessments took place twice before
therapy, after therapy, and at 6-week and 6-month follow up. The evaluation of treatment effects included questionnaire measures such as the Blushing,
Trembling and Sweating Questionnaire (Bögels & Reith, 1999) and the Social Phobia Diagnostic Questionnaire (Newman et al., 2003), and an evaluation
sheet in an open format. Three patients (10%) dropped out during treatment. A significant reduction of fear of blushing was found after treatment (d = 1.9). A
portion of this effect was due to a reduction between first and second pre-treatment measurement. Significant reductions of behavioural problems, negative
cognitions, the use of safety behaviours, and in the physical reactions of blushing were shown, furthermore positive cognitions about blushing increased
significantly. Indicators of social phobia also decreased significantly after treatment. Nevertheless, at 6-week follow-up 71% of participants still lay above the
cut-off score for social phobia. 6-month data are about to be completed. The open-ended evaluative questions revealed a high degree of contentment
although often a second therapy weekend was requested. The new treatment format of weekend-therapy was well accepted by the patients and led to
reductions in fear of blushing and related problems as well as in social anxiety. The subsequent self-help instructions seemed to work quite well regarding
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the further improvement between results directly after treatment and at 6-week follow-up. As an unspecific factor, the decision to cooperate in a group
treatment explains in part the reduction in symptom measures even before treatment start. However, one weekend did not seem to be sufficient to cover the
underlying features of social phobia as well. The new format for treating fear of blushing is promising because it is highly cost-effective and also
therapeutically effective. It can serve as a means to more easily disseminate specifically indicated treatment for social phobia into practice even for those
patients who would not believe that social phobia - as opposed to fear of blushing - describes their main problem.
An experimental clinical trial of a CBT package for chronic stuttering
Ross Menzies, The University of Sydney, Sue O'Brian, The University of Sydney, Mark Onslow, The University of Sydney, Tamsen McColl, The
University of Sydney, Ann Packman, The University of Sydney, Australia
For the past 40 years, behavioural treatment for stuttering in adults has been dominated by speech restructuring procedures derived from Goldiamond's
(1965) initial work (see Packman, Onslow & Menzies, 2000). These treatments rely on the replacement of stuttered speech with a novel speech pattern that
is incompatible with stuttering. However, it is now evident that speech-related social anxiety is also a clinical consideration that cannot be overlooked in the
management of chronic stuttering. The evidence for a relationship between anxiety and stuttering is considerable. For example, adults who stutter have
reported high levels of trait, state, and social evaluative anxiety on standard tests (Hancock & Craig, 1998). During periods of high general stress, persons
who stutter show greater increases in salivary cortisol than controls (Blood, Blood, Bennett, Simpson & Susman, 1994). The aims of the present research
were to: (1) study the effects of speech restructuring treatment on speech-related social anxiety in adults who stutter; (2) study the effects on anxiety of a
CBT package specifically designed for clients who stutter, and; (3) determine whether CBT treatment alone, or in addition to direct speech restructuring
treatment, reduces stuttering severity in those with severe social anxiety. Thirty adults with chronic stuttering were randomly allocated to receive either: (1)
speech restructuring combined with a CBT package for social anxiety (focussing on stuttering-related graded exposure, cognitive restructuring, and
behavioural experiments) or; (2) speech restructuring alone. Ten outcome measures were assessed at pre-treatment, post-treatment and 12 month followup. Results obtained question the effectiveness of speech restructuring in reducing social anxiety, negative thoughts about stuttering, mood impairment and
improving general psychological functioning. At 12 months post-treatment, participants who received the CBT package for speech-related social anxiety,
compared to those who did not, showed greater improvements in: (1) Global Assessment of Functioning (GAF) scores; (2) Behavioural Avoidance Test
scores, and; (3) Social Phobia diagnostic status. Non-significant trends favouring the CBT combined condition were obtained at 12 month follow-up on the
Social Phobia Anxiety Inventory (SPAI), Social Avoidance and Distress scale (SAD), Fear of Negative Evaluation scale (FNE), Beck Depression Inventory
(BDI), Beck Anxiety Inventory (BAI), and a new measure of unhelpful thoughts and beliefs about stuttering (UTBAS). However, of note, the addition of the
CBT package did not lead to greater improvements in fluency rates among participants. In summary, CBT for social anxiety appears a critical addition to
traditional speech restructuring for stuttering. It increases psychological wellness, and increases engagement in everyday speaking tasks.
Effectiveness of Cognitive Behavior Group Therapy (CBGT) for Social Phobia (SP) in People who Stutter (PWS) with Social
Phobia (SP)
Ruth Ezrati-Vinacour, Tel Aviv University, Speech, Language and Hearing, Eva Gilboa-Shechtman, , Bar Ilan University, , Israel;, Gideon Anholt,
Geha Mental Health Center, Sackler Faculty of Medicine, Tel Aviv University, Israel, Abraham Weizman, Geha Mental Health Center, Sackler
Faculty of Medicine, Tel Aviv University, Israel, Haggai Hermesh, Sackler Faculty of Medicine, Tel Aviv University, Israel
SP is the third most common psychiatric disorder, characterized by persistent and excessive fear of social or performance situations where embarrassment
may occur (Heimberg & Becker, 2002). Stuttering is a DSM-IV communication disorder and is characterized by disfluency of speech. Both disorders cause
anxiety, worsen in social situations, cause avoidance of social situations and significant impairment in inter-actional aspects of life. The DSM-IV provides
stuttering and Parkinsonian tremor, as examples of disorders in which SP diagnosis should be avoided , if the SP is related to these apparently
embarrassing disorders. Thus, a person who stutters is not eligible to be diagnosed with SP if his fear of stuttering occurs in public (Stein et al. 2006).
Efficacy of CBGT for SP has received robust empirical support (Juster & Heimberg, 1995). The two aims of the study were: 1. assessing the utility of CBGT
for SP in stuttering comorbid with SP, for both disorders, 2. examining the validity of DSM-IV excluding criteria. Participants consisted of 13 outpatients
suffering from both diagnoses. Patients underwent a psychiatric structured interview (MINI). Measures for SP and depression consisted of self
questionnaires: Liebowitz (LSAS) questionnaire(Liebowitz, 1987) and Beck Depression Inventory (BDI) (Beck, 1987). Measures of stuttering consisted of:
% of stuttered syllables (SS%) (Bloodstein, 1995), Speech Situation Checklist (SSC) (Brutten, 1985; Ezrati & Levin, 2004) and Stuttering Severity Instrument
(SSI) (Riley, 1972). Stuttering measures were recorded and taken by an experienced senior speech therapist. Recorded tapes of speech samples assessed
blindly. CBGT consisted of 18 weekly 1.5 hour sessions. All psychiatric and speech measures were taken twice: prior to and at termination of CBGT. There
was a significant reduction in LSAS following the completion of CBGT. There were no significant changes in SS% nor in SSI following CBGT but SSC
improved significantly at termination of CBGT. 1. CBGT for SP in PWS with SP, is an effective intervention for the SP and the depression. 2. CBGT can also
lead to an improvement in SP+PWS patients' subjective emotional reactions towards their own speech difficulties. 3. CBGT is not beneficial for the
stuttering per-se, even in combined cases. 4. It is warranted to include patients who stutter, whose fear is of speaking in public, into the DSM-V SP
category. This inclusion will enable those patients suffering from the dual diagnoses to benefit from efficacious CBGT for SP and their exaggerated emotional
reaction towards their stuttering. 5. A psychopharmacological study of an established anti-SP agent for SP+PWS patients seems warranted.
Factors affecting treatment efficacy in social phobia: The use of video feedback and individual vs. group formats
Idan Aderka, Psychology Department, Bar-Ilan University, Ramat-Gan, Israel
Social Phobia (SP) is a common anxiety disorder with an estimated lifetime prevalence rate of 7-13% in western countries (Furmark, 2002). The most
common psychological treatment for SP, and the one considered the "gold standard" is cognitive behavioral group treatment (CBGT - Hofmann & Bogels
2006). CBGT has received robust empirical support (Rodebaugh, Holaway, & Heimberg, 2004), but has known limitations such as that 40-50% of individuals
suffering from SP show little or no improvement (Hofmann & Bogels 2006) and many individuals no not reach good end-state functioning after termination of
treatment (Mattick & Peters 1988). Because of these limitations, several techniques have been developed in order to enhance the efficacy of CBGT. The
most important and influential of these is video feedback.
Video feedback was found to be beneficial for individuals suffering from SP (Rapee & Hayman, 1996, Harvey, Clark, Ehlers, & Rapee 2000). However,
Rodebaugh (2004) found mixed effects for video feedback, and Smits, Powers, Buxkamper, & Telch (2006) found no added beneficial effect when using
video feedback. Despite the controversy in the literature, video feedback is now widely used in the treatment of social phobia. The present study was aimed
at assessing the efficacy of video feedback by using meta-analysis.
Another controversial issue in the treatment of SP is whether treatments held in group format are superior to individual treatments. As mentioned, the
prominent opinion is that group treatment is the treatment of choice in the case of SP. However, evidence of the superiority of individual treatment is
accruing rapidly. Individual CBT has been recently found to be superior to Fluoxetine and to placebo (Clark et al. 2003), superior to waiting list and to
exposure and applied relaxation (Clark et al. 2006), and superior to CBGT (Stangier et al. 2003). As there is only one study directly comparing CBGT to
individual CBT (Stangier et al. 2003), and many conflicting studies which indirectly support each treatment, the present study investigated group vs.
individual formats across studies. Studies in treatment outcome of SP that were published between the years 2000-2006 were located. The main inclusion
criteria were using only clinical samples diagnosed according to DSM-IV criteria, using validated outcome measures, and treating adults. Nineteen studies
conducting 31 trials (conditions) fit our inclusion criteria and were included in the meta-analysis. Of these 31 trials, 8 used video feedback, 14 used individual
format, 15 used group format, and 2 trials used a combination of individual and group formats. Effect sizes (Cohen's d's) were calculated for each trial while
correcting for measurement error (Hunter & Schmidt, 2004). The Q statistic was used to test heterogeneity across trials and to test potential moderators. No
differences were found between trials using video feedback (d=0.96) and other trials (d=1.00). In addition, No differences were found between studies using
group treatment (d=0.93) and studies using individual treatment (d=1.05). However, group treatment was associated with higher attrition rates. In the
discussion we delineate the implications of these findings on treatment and on current theories of SP.
Intensive Group Cognitive Treatment and Individual Cognitive Therapy versus Treatment as Usual in Social Phobia: A
Randomized Controlled Trial
Ewa Mörtberg, Karolinska Institute, , St Göran, Sweden, David M. Clark, Kings College London, Institute of Psychiatry, London, UK, Örjan Sundin,
Karolinska Institute, , Anna Åberg Wistedt, Karolinska Institute, , St Göran, Sweden
The aim of the study was to examine the effects of a brief intensive group cognitive treatment (IGCT) compared with individual cognitive therapy (ICT) and
treatment as usual (TAU) in patients suffering from social phobia. 100 patients meeting DSM-IV criteria for social phobia were randomized to IGCT, ICT and
TAU. IGCT involved 16 group sessions spread over three weeks. ICT involved 16 shorter weekly sessions in 4 months. TAU involved an indicated SSRI and
emotional support with therapy sessions as required for 1 year. The main outcome measure was the Social Phobia Composite that combined several
standardised self-report measures. Diagnostic assessment was repeated at 1-year follow-up. Significant improvements were observed with all treatments.
ICT was superior to IGCT and TAU, which did not differ in overall effectiveness. The study confirms and extends previously reported findings that ICT is
more effective than group cognitive treatment and treatment with SSRIs. IGCT works fast, showing most of its benefits after only 3 weeks, and is at least as
effective as more protracted treatment as usual.
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Adult Depression
Invited Addresses
Cognitive Therapy in the Treatment and Prevention of Depression
Steven Hollon, Vanderbilt University, USA
Depression is a chronic and recurrent disorder that is often easier to treat than it is to prevent. Antidepressant medication is relatively safe and efficacious but
does little to reduce risk for symptom return once its use is discontinued. Cognitive therapy is a cognitive behavioral intervention that targets the negative beliefs
and maladaptive information processing that underlies ineffectual problem solving and untoward distress inherent in depression. A series of studies conducted
over the last thirty years suggests that cognitive therapy has an enduring effect that lasts beyond the end of treatment. These studies show that patients treated
to remission with cognitive therapy are about half as likely to relapse following treatment termination than patients treated to remission with ADM and no more
likely to relapse than patients who are kept on medications. Moreover, there are indications that this enduring effect may be mediated by changes in stable
underlying information processing proclivities, that these changes are best achieved by therapist behaviors specific to a cognitive behavioral approach, and
that these effects are moderated by patient characteristics and possibly medication type. There are indications that these enduring effects also may extend to
more purely behavioral interventions and to the prevention of initial onset in children and adolescents at risk. This presentation will provide an overview of these
indications and highlight what is known about the moderators and mediators of this enduring effect.
Symposium 60
Psychological and psychobiological processes in vulnerability to depression
Convenor: Thomas Ehring, University of Bielefeld, Germany
Characteristics of emotion regulation in individuals vulnerable to depression
Thomas Ehring, Silke Fischer & Jewgenija Schnülle, University of Bielefeld, Germany
Currently depressed patients show a number of emotion regulation deficits, i.e., they do not succeed in modulating their emotion experience, expression and
behaviour in a way that is consistent with their individual goals and the situational demands. Some authors suggest that these deficits are not confined to
current episodes of depression, but are also a risk factor for the development of future episodes. From this point of view, currently euthymic individuals who
are vulnerable to depression should also show deficits in emotion regulation. The presentation describes the results of two studies testing this hypothesis. In
Study 1, n = 42 recovered depressed individuals were compared with matched controls on a number of self-report questionnaires assessing characteristics
of emotion regulation. In Study 2, negative mood was experimentally induced in n = 35 recovered depressed subjects and n = 38 controls. The groups were
compared regarding the type of spontaneously used emotion regulation strategies as well as the effects of experimentally induced emotion suppression vs.
reappraisal on emotional and physiological responses to the mood induction. Results showed that recovered depressed individuals (a) reported significantly
more emotion regulation problems, (b) reported using more avoidant emotion regulation strategies, (c) showed stronger negative effects of experimentally
induced emotion suppression und (d) were less successful using reappraisal to regulate their emotions. Implications for future research as well as possible
implications for relapse prevention strategies in depression will be discussed.
The effects of trait rumination and past depression on problem solving ability and confidence
Dorothea Quack & Thomas Ehring,, University of Bielefeld, Germany
Earlier studies have found that experimentally induced rumination in negative mood impairs problem solving abilities and confidence. Theories of depressive
rumination and results into pathological worry suggest that high trait ruminators should also generally show less problem solving confidence in comparison to
controls. However, this hypothesis has not been thoroughly tested to date. This study aimed to test the relationship between trait rumination, past depression
and problem solving ability and confidence in euthymic as well as induced negative mood. N = 68 female college students were divided into four groups
based on their scores on the Response Style Questionnaires (RSQ) and the presence vs. absence of past depression. The groups were then compared on
problem solving abilities and problem solving confidence before and after a negative mood induction. Current levels of depression were controlled.
Compared to low ruminators, high ruminators showed significantly lower problem solving confidence in both mood states. However, the groups did not
significantly differ in problem solving abilities. Having experienced past major depressive episodes was found to be significantly related to lower problemsolving abilities, independent of trait rumination scores. The manipulation of mood state did not have any significant effect on problem solving abilities and
confidence in any of the groups. The findings are consistent with the idea that low problem solving confidence might in part maintain rumination and support
the role of problem solving deficits in depression vulnerability. Implications for theoretical models of rumination and depression vulnerability as well as future
research will be discussed.
Repeated recreational use of MDMA ('XTC') and cognitive vulnerability to depression
Willem van der Does, Janet Van den Berg, Seline Muchall and Linda Booij, University of Leiden, The Netherlands
3,4-methylenedioxymethamphetamine (MDMA) or 'ecstasy' (XTC) has been shown to cause long term damage to serotonergic cerebral neurons in animals.
The neurotoxic effects in humans are less clear and there is mixed evidence concerning the functional consequences. Some studies suggest that MDMA
use poses a risk for developing brain serotonin injury. Since depression is associated with decreased brain serotonin function, we investigated the possibility
that MDMA-users are putting themselves at risk of developing depressive disorders, by investigating the relationship between repeated recreational use of
MDMA and cognitive vulnerability to depression.Methods: Twenty-five ecstasy users and a control group (n= 17) were compared. Both groups were from the
same subculture and no participant was depressed at the time of the study. Vulnerability to depression was assessed by means of questionnaires that
measure dysfunctional attitudes, cognitive reactivity, rumination and thought suppression. Several information processing tests, including stroop interference,
visual memory and executive function tests were also administered. Results: Ecstasy users who did not meet criteria for dependency of other substances
than MDMA appear to be no more vulnerable to depression than controls. However, polydrug users scored higher than the other groups on some measures
of cognitive reactivity and on negative affectivity.Conclusions: The present study found little evidence for a direct relationship between repeated use of
MDMA and cognitive vulnerability to depression. However, repeated use of multiple substances was associated with a number of cognitive deficits. These
results do not rule out the possibility of longer-term deleterious effects of ecstacy use, or of subtle deficits not picked up by our selection of instruments.
State effects of short meditation interventions on prefrontal alpha-asymmetry
Thorsten Barnhofer, Catherine Crane, Helen Nightingale, Claire Visser & J. Mark G. Williams, University of Oxford, UK
Recent research on Mindfulness-Based Cognitive Therapy (MBCT), an eight-week group program combining meditation-based and cognitive interventions,
has increased interest in the use of meditation techniques to target cognitive and biological vulnerability factors fordepression. While the MBCT training has
been shown to successfully reduce rates of relapse, relatively little is known about the differential effects and indications of the meditation techniques that
are often combined in mindfulness programs. This study compared state effects of breathing and loving kindness (Metta) meditations on prefrontal alphaasymmetry in resting EEG, a global biological indicator of approach vs. withdrawal motivation and related affect. Thirty previously depressed individuals were
randomly assigned to either of the meditation techniques and prefrontal asymmetry was assessed before and after. We hypothesized that loving kindness,
but not breathing meditation would produce changes in prefrontal asymmetry. Results will be presented at the conference.
Symposium 76
Methodological Advances in the Study of Cognitive Vulnerability to Depression
Convenor: John Abela, Department of Psychology / McGill University, Canada
Cognitive Vulnerability to Depression in Adolescents in Urban and Rural China: A Multi-Wave Longitudinal Study
John Abela, McGill University, Canada
Epidemiological studies suggest that the prevalence of depression in China has risen in recent decades - particularly among adolescents. With respect to
adolescents, China has the second highest suicide rate in the world. Despite such alarming statistics, little research has examined models of the etiology of
depression in China. Further, of the studies conducted, the majority are cross-sectional providing little insight into causal mechanisms. The current multiwave longitudinal study examined the applicability of several prevailing cognitive theories of vulnerability to depression to samples of adolescents in urban
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and rural China. Participants included 558 adolescents in Changsha - an industrial city - and 588 adolescents in Liuyang - a rural town. Participants
completed measures assessing cognitive vulnerability factors, negative events, and anxious/depressive symptoms. During a series of follow-up
assessments, occurring once a month for six months, participants completed measures assessing negative events and anxious/depressive symptoms. The
use of a multi-wave longitudinal design allowed us to take an idiographic approach towards examining our hypotheses. More specifically, we examined
whether the slope of the relationship between negative events and depressive/anxious symptoms within adolescents varied across adolescents as a function
of cognitive vulnerability. In both samples, results from HLM analyses provided support for the vulnerability hypotheses of the cognitive theories. At the
same time, a comparison of the pattern of findings obtained at our urban and rural sites with respect to depressive and anxious symptoms suggests that the
differing cultural contexts of these sites likely impact symptom manifestation.
Negative Inferential Styles: Mediator or Moderator of Stress in the Development of Children's Depressive Symptoms
Brandon Gibb, Binghamton University, NY, USA
Providing a developmental extension to the hopelessness theory of depression (Abramson et al., 1989), theorists have suggested that during early to
middle childhood, inferential styles may mediate rather than moderate the association between negative life events and the development of depression. The
primary goal of this study was to test this hypothesis using a multi-wave prospective study of children aged 8-12 years. Method: Participants were 100
children and their mothers assessed at baseline as well as 2, 4, and 6-month follow-ups. At each assessment point, we assessed children's inferential
styles, negative interpersonal events, and depressive symptoms. Results: Preliminary analyses based on data from the initial assessment provide some
support for the hypothesis that the three inferential styles (causes, consequences, self-characteristics), as well as children's weakest inferential link, partially
mediate the relation between negative interpersonal events (Expressed Emotion-Criticism and verbal victimization) and children's depressive symptoms. In
addition, however, there was also some evidence for the moderating role of inferential styles regarding self-characteristics. Discussion: Although based on
preliminary data, these results add to the growing body of research supporting the mediating role of inferential styles in the link between childhood negative
events and their levels of depressive symptoms. This said, the results also suggest that stronger support for moderation may be observed for some
inferential styles (e.g., inferences for self-characteristics) than for others in this age range.
The Structure of the Self-Schema in Depression: Theoretical Advances and Methodological Issues
David Dozois, University of Western Ontario, Canada
Three primary levels of cognition are emphasized in Beck's theory of depression: Cognitive products (e.g., negative automatic thoughts, dysfunctional
attitudes), processes (e.g., memory and attention biases) and structures (i.e., well-organized and interconnected internal representations of self). Although
cognitive structure is conceptually pivotal to cognitive theories of depression, most researchers have relied on self-report and information-processing indices
to assess the self-schema. This presentation will highlight some of the different strategies (e.g., self-complexity, compartmentalization, prime-target
relatedness, measures of interstimulus distance) utilized to study cognitive structure in depression. A program of research will also be described that has
used the Psychological Distance Scaling Task (Dozois & Dobson, 2001) to assess cognitive organization of self-referent content. This measure has
demonstrated sensitivity, specificity and temporal stability. Pilot data will also be presented, however, showing that cognitive therapy may change these
cognitive structures (suggestive of the possibility that the prophylactic effects of cognitive therapy, relative to pharmacotherapy, may be due to the alteration
of these deeper cognitive mechanisms). The conceptual and clinical implications of these findings will be discussed. Issues pertinent to how depressive selfschemas are conceptualized and operationalized will also be addressed
A Cross-Cultural Comparison of Canadian and Chinese Adolescents:Examination of Coping, Stress, and Depressive Symptoms
Randy Auerbach, McGill University, Canada
In Western countries, depression is one of the most prevalent mental health problems among youth with up to 25% of adolescents experiencing at least one
major depressive episode by the age of 18 (Clarke et al., 1993). Similarly, epidemiological studies conducted in mainland China suggest that the prevalence
rate of adolescent depression has risen dramatically over the past two decades (Dennis, 2004). Despite such alarming statistics, researchers have only
recently begun to examine theories of the etiology of depression in adolescents. The goal of the current study was to examine whether coping deficits are
associated with increases in depressive symptoms following the occurrence of stressors in adolescent samples from Canada and China. Coping deficits
were operationalized as exhibiting a greater tendency to utilize maladaptive coping strategies in response to stressors than adaptive strategies (e.g., ratio of
maladaptive to adaptive). At Time 1, 161 adolescents from Montreal, Canada and 411 adolescents from Yue Yang, China completed self-report measures
assessing coping strategies, depressive symptoms, and the occurrence of negative events. Follow-up assessments occurred every month for four and six
months in Canada and China, respectively. At each follow-up, participants completed measures assessing depressive symptoms and the occurrence of
negative events. Hierarchical linear modeling analyses indicated that Canadian and Chinese adolescents who exhibited high levels of coping deficits were
more likely than adolescents possessing low levels to report increases in depressive symptoms following the occurrence of negative events.
Symposium 90
Depressive rumination: Nature, origins, and maintenance
Convenor: Costas Papageorgiou, University of Lancaster, UK
A clinical metacognitive model of rumination and depression
Costas Papageorgiou, University of Lancaster, UK
Several theories have been advanced to account for the role of rumination in depression. Wells and Matthews' (1994) Self-Regulatory Executive Function
(S-REF) theory of emotional disorders accounts for the information processing mechanisms that initiate and maintain perseverative thinking. Grounded on
the S-REF theory, Papageorgiou and Wells (2003) proposed a clinical metacognitive model of rumination and depression. In this model, positive
metacognitive beliefs about rumination are likely to motivate individuals to engage in sustained rumination. Once rumination is activated, individuals may
appraise this process as both uncontrollable and harmful and likely to lead to negative interpersonal and social consequences. The activation of negative
metacognitive beliefs about rumination contributes to the experience of depression. Moreover, decreases in metacognitive confidence and efficiency may be
an important depressogenic byproduct, which contributes to negative beliefs about the interpersonal and social consequences of rumination and maintains
the activation of positive beliefs concerning the need to ruminate in order to facilitate effective coping. Therefore, a number of vicious cycles of rumination
and metacognition may be responsible for the perpetuation of depression. Cross-sectional, prospective and experimental evidence supporting the role of
metacognition in depressive rumination will be presented together with data supporting the implementation of a metacognitive-focused cognitive therapy of
depressive rumination.
A factor analytic study of measures of rumination and worry in depressed participants
Hannah J. Goring and Costas Papageorgiou, University of Lancaster, UK
Rumination has featured in psychological models of depression whereas worry is considered to be an important feature of anxiety disorders, particularly
generalized anxiety disorder. Similarities between these two types of processes have led researchers to compare them and investigate the relationships
between rumination, worry, depression, and anxiety. However, most studies have recruited non-clinical samples. This study aimed to examine the
relationship between rumination and worry through joint exploratory factor analysis of measures of rumination (the Ruminative Response Scale) and worry
(the Penn State Worry Questionnaire) in a sample of 216 participants with depression (183 women and 33 men). The results of factor analyses suggested
that rumination and worry can be distinguished in individuals with depression, as items from the two measures loaded on separate factors. This finding is
consistent with Wells and Matthews' (1994) suggestion that different forms of perseverative negative thinking are associated with different forms of
On the links between self-discrepancies, rumination, metacognitions, and symptoms of depression in undergraduates
Jeffrey Roelofs, Maastricht University, The Netherlands, Costas Papageorgiou, University of Lancaster, UK, Ralph D. Gerber, Maastricht
University, The Netherlands, Marcus Huibers, Maastricht University, The Netherlands, Frenk Peeters, University Hospital Maastricht, The
Netherlands, and Arnoud Arntz, Maastricht University, The Netherlands, Maastricht University, The Netherlands
In this paper, a study will be presented aimed to test the central components of Papageorgiou and Wells' (2003) non-clinical metacognitive model of
rumination and depression that is grounded on the Self-Regulatory Executive Function (S-REF) model of emotional disorders (Wells & Matthews, 1994). A
second aim was to extend the non-clinical model with the concept of self-discrepancy in line with the S-REF model. Data of the current study were collected
in a large sample of non-clinical Dutch undergraduates (N = 196), who completed a battery of questionnaires including measures of rumination, positive and
negative metacognitions, depressive symptoms, and self-discrepancy (i.e., actual-ideal, actual-ought, and actual-feared discrepancies). Hypothesized
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relationships among these variables were tested by means of structural equation modelling. Following some theoretically consistent modifications, the model
was an adequate fit to the data. With respect to the second aim of the study, self-discrepancies were directly linked to symptoms of depression as well as
indirectly via the cognitive processes involved in the metacognitive model of rumination and depression. Evidence was found for positive beliefs about
rumination to partially mediate the relation between self-discrepancy and rumination. Clinical implications of the findings, including implementation of a
metacognitive-focused cognitive therapy of depression, and suggestions for future research will be discussed.
Metacognitive beliefs and perceptions of parental responses to low mood as predictors of rumination in women
Anwen Woodcock and Costas Papageorgiou, University of Lancaster, UK
In this study, we explored one of the processes through which rumination may develop in women. By linking the response styles theory of depression
(Nolen-Hoeksema, 1987), transgenerational theories of depression, and metacognitive approaches to depression (Papageorgiou & Wells, 2003; Wells &
Matthews, 1994), we considered the role that social learning may have on the development of rumination in women. Female volunteers anonymously
completed a series of five questionnaires measuring self-reported use of rumination, perceived use of rumination in male and female parent figures, and
metacognitive beliefs about rumination. We found that positive beliefs about rumination and perceptions of female parent figure's use of brooding responses
when depressed significantly predicted rumination in women. The findings contribute to current understanding of the origins of rumination by exploring social
learning theory as an important process involved in the development of coping responses. The results add further support to the metacognitive theory (Wells
& Matthews, 1994) and clinical model (Papageorgiou & Wells, 2003) of rumination and depression. The results have potential implications for parent training,
the role of psycho-education in pre-adolescent females to expand coping repertoires, and metacognitive-focused cognitive therapy for depression.
Symposium 105
Ruminative processes across depression and anxiety
Convenor: Stephen Barton, Newcastle University, UK
Does anxious worry reflect depressive goal investment?
Stephen Barton, Tanyah Womersley, Mark Freeston & Dave Lee, Newcastle University, UK
This paper reports an analogue study of worry processes and goal investment in a normal sample. The participants had above average levels of negative
affect and below average levels of positive affect, but did not reach clinical levels of depression or GAD. Worry is known to maintain the overestimation of
threat concerning future events, and is characteristic of people with GAD. Narrow goal investment is known to maintain the over-valuation of particular
social roles or goals, and is characteristic of people who are vulnerable to depression. The prediction was that naturally occurring worries would be tend to
be concentrated on overvalued goals, and this would provide analogue evidence for a specific functional linkage between depression and GAD. In other
words, overvalued goals create the setting conditions for worry, and conversely worried-about-events tend to become overvalued. Sixteen participants
chained down three of their naturally occurring worries, that is, they explored and described the consequences of worried-about-events actually occurring.
Each of these consequences was classified for the life-goal domain it most closely mapped onto, and this was done by blind raters. A significant association
was observed between worry consequences and life-goal investment, providing preliminary evidence for functional linkage at the proposed level.
Implications for treating co-morbid depression and GAD are discussed.
Rumination as a transdiagnostic process
Ed Watkins, University of Exeter, UK
Rumination has been demonstrated to be a core process in the onset and maintenance of depression. However, recent evidence has suggested that
rumination may also be involved in the onset and maintenance of other psychological disorders, particularly anxiety disorders, leading to the suggestion that
negative repetitive thought is a transdiagnostic process (Harvey, Watkins, Mansell, & Shafran, 2004). This presentation will review recent studies indicating a
role for rumination in other disorders (e.g., Nolen-Hoeksema et al., 2007) and then consider evidence from several recent studies investigating the role of
rumination in other disorders. First, data will be presented from a clinically depressed sample indicating the relationship between rumination and co-morbid
Axis I and II disorders. Second, data from a randomized controlled trial will be presented to examine the effect of treating rumination with a focused CBT
intervention on disorders co-morbid to depression - both sets of data indicate that rumination contributes to anxiety as well as depression and, in particular,
is associated with generalized anxiety disorder.
Obsessions and worries: A replication and some thoughts on extension to other classes of intrusive thoughts
Pablo Romero, Aurora Gavino, Antonio Godoy, Raquel Nogueira, University of Malaga, Spain
Worry is the central characteristic of Generalized Anxiety Disorder (GAD) and obsessions are a central feature of Obsessive-Compulsive Disorder (OCD).
There are strong similarities between these disorders: repetitive cognitive intrusions, negative emotions, difficulty dismissing the intrusion and finally, loss of
mental control. This study attempted to replicate in Spanish population in the studies by Langlois, Freeston & Ladouceur (2000a, b), and to specify the
differences between obsessive intrusive thoughts and worry in a non-clinical population across a series of variables drawn from current models (appraisal,
general descriptors and emotional reactions). 285 university students participated in the study. They first identified an obsession-like intrusion of the YaleBrown Obsessive-Compulsive Scale, self report (Y-BOCS-SR; Goodman et al., 1989; Steketee, Frost, & Bogart, 1996) and a worry of the Worry and Anxiety
Questionnaire (WAQ; Dugas, Freeston, Lachance, Provencher, & Ladouceur, 1995), and then evaluated them with the Cognitive Intrusion Questionnaire
(CIQ; Freeston, Ladouceur, Thibodeau & Gagnon, 1992). Within-subject comparisons demonstrated significant differences on several variables, and
generally support the differences postulated in Langlois, Freeston & Ladouceur (2000a, b). The egodystonic-egosyntonic dimension emerged as an
important variable in understanding obsessions and worry.
Conceptualizing and measuring ego-dystonicity in obsessive thinking: a preliminary study
Mark Freeston & Nicola Wright, Newcastle University, UK
Current models suggest that obsessive thinking, worry, and depressive rumination will share a number of common processes. Both classical psychiatry and
cognitive models of OCD assign a central role to ego-dystonicity in the presentation and understanding of obsessive thinking. Surprisingly, there have been
few attempts to measure this key construct. This study examined in the construct among 182 16-18 year olds from the North East of England. They
completed a battery of questionnaires including a 19-item questionnaire measuring appraisals of their most distressing intrusive thought that they had
selected from a 13-item list. The six items measuring ego-dystonicity had excellent internal consistency (.90). The scale was specifically associated with
items measuring shame and guilt, likelihood and moral thought-action fusion, and the desire to avoid or remove the thought. Further, hierarchical regression
indicates that the scale was specifically associated with a measure of obsessive thoughts over and above relationships to depression, worry-like concerns.
These findings suggest that although there may be overlapping features and common processes between worry, depressive rumination, and obsessive
thinking, specific patterns of appraisal may be involved. This study provides preliminary evidence that ego-dystonic appraisals can be measured in way that
reflects the common understanding of the term and that this measure links meaningfully both to other appraisals and symptom measures.
Symposium 124
Further frontiers in CBT for the Prevention of Relapse and Recurrence of Depression
Convenor: Willem Kuykens, University of Exeter, UK
Cognitive therapy in the treatment and prevention of depression
Steven D. Hollon, Ph.D., Vanderbilt University, USA
Depression is a chronic and recurrent disorder that is often easier to treat than it is to prevent. Antidepressant medication (ADM) is relatively safe and
efficacious but does little to reduce risk for symptom return once its use is discontinued. CT is a cognitive behavioural intervention that targets the negative
beliefs and maladaptive information processing that underlies ineffectual problem solving and untoward distress inherent in depression. A series of studies
conducted over the last thirty years suggests that cognitive therapy (CT) has an enduring effect that lasts beyond the end of treatment. These studies show
that patients treated to remission with CT are about half as likely to relapse following treatment termination than patients treated to remission with ADM and
no more likely to relapse than patients who are kept on medications. Moreover, there are indications that this enduring effect may be mediated by changes
in stable underlying information processing proclivities, that these changes are best achieved by therapist behaviours specific to a cognitive behavioural
Page 30
approach, and that these effects are moderated by patient characteristics and possibly medication type. Finally, there are indications that these enduring
effects may extend to more purely behavioural interventions and to the prevention of initial onset in children and adolescents at risk. This presentation will
provide an overview of these indications and highlight what is known about the moderators and mediators of this enduring effect.
Can activation alone prevent relapse in the treatment of depression?
Christopher Martell, Ph.D. and Sona Dimidjian, Ph.D., University of Washington, USA; 2 Sona Dimidjian is at the University of Colorado, Boulder)
A resurgence of interest in behavioural approaches in the treatment of depression has led to several studies of the efficacy of activation. These studies,
both large and small, have suggested that behavioural activation is sufficient in the treatment of major depressive disorder and that treatment gains are
maintained over time. While there is not a specific relapse prevention strategy, the treatment focuses on teaching clients to engage in activities despite
negative affect and lethargy. In this presentation the literature on treatment outcome in behavioural activation will be briefly reviewed. Data from follow-up
of a randomised clinical trial will be presented. The authors will also make suggestions for improving long-term outcomes and relapse prevention
Preventing depression relapse in “real-world health care settings” using Mindfulness-based Cognitive Therapy (MBCT):
Preliminary data from a randomized controlled trial
Willem Kuyken, Ed Watkins, Rod Taylor, Emily Holden and Kat White on behalf of the Exeter MRC MBCT Trial Group, University of Exeter, UK
Whilst existing antidepressant interventions are reasonably effective in treating acute depression, there are still high levels of recurrence and relapse,
especially if antidepressants are discontinued. Furthermore, many patients express a preference for psychosocial interventions yet do not have access to
psychosocial treatments. There is a pressing need to develop cost-effective psychosocial interventions to prevent the recurrence of depression within nontraditional delivery systems that can significantly increase accessibility to treatment. A recently developed treatment, Mindfulness-based Cognitive Therapy
(MBCT) shows potential for meeting these priorities as a brief group relapse prevention programme Two randomized controlled trials suggest that
Mindfulness-based Cognitive Therapy (MBCT) halves the rates of depression relapse compared to treatment as usual (Ma & Teasdale, 2004; Teasdale et
al., 2000).In the Exeter MRC MBCT Trial we asked “How does MBCT compare against maintenance anti-depressants in preventing depression relapse in
terms of (a) relapse rates, (b) residual depressive symptoms and (c) quality of life.” One hundred and twenty three people with a history of three or more
episodes of major depression were randomised either to continuation anti-depressants or to MBCT and discontinuation of antidepressants. Patients were
followed up for one year. This paper will present the preliminary outcome data from the trial.
Rumination-focussed cognitive therapy for residual depression
Edward Watkins, University of Exeter, UK
In recent years, there has been growing recognition that depression is a chronic and recurring condition, with improved relapse/recurrence prevention
identified as a priority for future treatment research (e.g., Hollon et al., 2002). An important risk factor for relapse and recurrence is partial remission, that is,
the maintenance of residual symptoms following acute treatment for depression. Residual depression is a common problem, with one third of patients not
responding fully to acute treatments, most commonly antidepressant medication. Randomised controlled trials suggest the value of CBT interventions for
residual symptoms, whilst indicating that there is significant scope for improvements in therapeutic efficacy (e.g. Paykel et al., 1999). One potential way to
improve the efficacy of CBT for residual depression is to adapt CBT to specifically address core processes in residual depression. Rumination has been
identified as a core process in the development and maintenance of depression, which remains elevated in fully and partially recovered depressed groups.
Treatments targeting ruminative processes may therefore be particularly helpful for treating chronic and recurrent depression. The development of a brief
cognitive behavioural treatment that explicitly focuses on reducing rumination is presented, outlining the main components of the therapy. This treatment is
theoretically and empirically derived from recent cognitive-experimental research in depression. The results of an initial case series for patients with residual
depression suggest that this approach may be beneficial. The development and results of a pilot randomized controlled trial to further investigate this
therapy are outlined.
Symposium 140
New forms of cognitive therapy for primary prevention and prevention of relapse in bipolar disorder, unipolar
depressive disorder and suicidal depression
Convenor: Claudi Bockting, AMC de Meren/University of Amsterdam, The Netherlands
New forms of cognitive therapy for primary prevention and prevention of relapse in bipolar disorder, unipolar depressive
disorder and suicidal depression
J.M.G.Williams, University of Oxford
There are large differences from one person to another in the extent to which suicidal ideation and behaviour can be triggered by mood or by difficult
circumstances. Our research investigates the hypothesis that suicidal cognitions are not the problem: it is how people react to them that creates the
conditions in which they persist and escalate. Although some people take comfort from suicidal feelings, most people either try to suppress these feelings, or
ruminate about what it means to have them. Both ways of coping with suicidal feelings can backfire: the feelings become stronger.What is happening here?
Our work suggests that people are doing the best they can, but they are using a mode of mind that, while it works in many situations to cope with external
stress, cannot work for dealing with ideas in the mind. This is the 'doing ' mode of mind, a mode that is good for goal striving but can be tragically counterproductive in dealing with difficult emotional states.Mindfulness training teaches people to recognize when the doing mode is being activated, and to shift to
'being' mode of mind, a mode that is associated with self-acceptance and flexibility of response, rather than with running off old habits.Data from a pilot trial
of patients with a history of unipolar and bipolar disorder who become suicidal when depressed shows that MBCT reduces residual symptoms of depression,
reduces reactivity and experiential avoidance, consistent with our model of vulnerability, and promising for further investigation of its longer term effects.
MBCT and depressive relapse prevention: a randomized controlled study on its efficacy and the implication of cognitive and
biological mechanisms
F. Jermann1, Jean-Michel Aubry1, M. Van der Linden2, G. Bertschy1, G. Bondolfi1, Dpt of Psychiatry, Geneva University Hospital, Switzerland
MBCT and depressive relapse prevention: a randomized controlled study on its efficacy and the implication of cognitive and biological mechanisms Two
studies showed the efficacy of Mindfulness-Based Cognitive Therapy (MBCT) to reduce relapses among unipolar depressive patients with 3 or more
previous episodes (Segal et al., 2002; Ma & Teasdale, 2004). Only few studies focused on cognitive and/or biological mechanisms that might be modified
through MBCT (Williams et al., 2000). The primary aim of the present study was to investigate, using a randomized controlled design, whether MBCT would
prevent depressive relapse/recurrence in a French speaking population, without direct intervention of the founders of the method. The secondary aims were
to evaluate a) whether some cognitive mechanisms could be modified by MBCT and b) whether the HPA (hypothalamic-pituitary-adrenal) system
dysregulation observed in remitted depressed patients could be modified through MBCT. Two groups were compared, one benefiting from MBCT (MBCT
group) and one allocated to a treatment-as-usual procedure (TAU group).The possible occurrence of a depressive relapse/recurrence was monitored over a
period of one year. At three times, a cognitive evaluation was proposed to the participants, that triggered among others the specificity of autobiographical
memories recall, shifting capacities, amount of dysfunctional attitudes or rumination habits. Additionally, awakening salivary cortisol was collected every three
months.Results regarding the efficacy of MBCT in a French speaking sample, as well as findings bearing on the implication of cognitive and biological
mechanisms, will be presented.
Preventing relapse using CBT in bipolar disorder
Thomas D. Meyer 1) & 2) & Martin Hautzinger 1), University of Tuebingen & Newcastle University
Despite the fact that a mood stabilizing medication is inevitable and remains the first choice in treating bipolar affective disorders, the relevance of additional
psychosocial interventions is, however, more and more recognized. Looking at the empirical evidence, the efficacy of adjunctive psychotherapy has been
shown in uncontrolled and controlled studies. Several controlled studies explicitly tested the efficacy of Cognitive Behavior Therapy (CBT), and CBT proved
to be effective compared to standard medical treatment CBT concerning relapse prevention and functional outcome. However, all of these studies compared
CBT to either a waiting list control group or standard treatment (Meyer & Hautzinger, 2002, 2004). We therefore can conclude that that CBT works better
than no or standard treatment. But we do not know, if the effect of CBT goes beyond the effects of supportive therapy (ST) of equal intensity and
frequency.Methods: We planned a randomized controlled trial. Each therapy condition consisted of 20 sessions (lasting about 50 minutes) within nine
months. Both treatments involve psychoeducation and a monitoring of symptoms. While CBT focuses on the identification of warning signs for episodes and
on cognitive and behavioral factors individually involved in relapse, the ST focuses on coping and crises intervention with current issues the patient reports.
We randomized 38 patients. 65 patients can be considered “completers” (> 15 sessions). Eleven subjects dropped out. The primary efficacy assessment is
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symptomatic and functional status in the 12-month-follow-up period (e.g. SCID I).Results: Prior analyses showed that at the 3- and 6-month follow-up there
were no significant differences in relapse rates between treatment conditions. The question remains if CBT is superior to ST if one looks at the 12-month
follow-up.. These results will be presented.
Preventing relapse using diverse combinations with new forms of cognitive therapy in remitted recurrently depressed
Dr Claudi Bockting (The Netherlands):,
No abstract available
Symposium 155
Treatment-resistant depression
Convenor: Pétur Hauksson, Reykjalundur Rehabilitation Centre, Iceland
Comparison of Individual and Group Cognitive Behaviour Therapy and Rehabilitation for Treatment-resistant Depression
Pétur Hauksson, Sylvía Ingibergsdóttir, Thorunn Gunnarsdóttir, Inga Hrefna Jónsdóttir., Reykjalundur Rehabilitation Centre, Iceland
Depressed patients do not all respond sufficiently to conventional therapy. Medication, psychotherapy or inpatient treatment do not allways sufficiently
ameliorate the symptoms and consequences of depression. This lack of response puts a long-term burden on both the individual, family and society. Data
will be presented on the results of individual and group CBT and control treatment for 204 patients with depressive disorder who had not responded to a full
course of conventional therapy. They were all admitted to a rehabilitation centre and received 6 weeks of in-patient treatment, offering a wide range of
treatment options, including supportive therapy or counselling as needed, individualised physical training and a progressive behaviour-modification
programme. In addition, they were randomly allocated to individual, group or no CBT. CBT was provided by a multidisciplinary team. There was a 1 and 2year follow-up. CBT was manual-based, the same manual being used for individual and group therapy. There were 12 sessions, 2 per week. Group sessions
were 90 minutes, individual sessions 50 minutes. Groups had 12-15 participants and 2 therapists. Results indicated that individual CBT was superior to
group CBT and control treatment. Group CBT, however, was not statistically superior to control treatment and thus did not add significantly to the relatively
intensive and programmed inpatient treatment at a rehabilitation establishment, although individual CBT did. Limitations are the large and diverse groups
and incomplete randomization. The importance of the therapeutic relationship formed in individual CBT is evident, especially as regards decreasing
hopelessness and automatic thoughts.
Cognitive Behaviour Group Therapy for Depressed Inpatients: Outcome Related to Comorbidity.
Inga Hrefna Jónsdóttir, Sylvía Ingibergsdóttir, Thórunn Gunnarsdóttir, Pétur Hauksson, Reykjalundur Rehabilitation Centre, Iceland
Depression resistant to treatment is a persistent problem for many patients suffering from medical and psychiatric conditions. Cognitive behaviour group
therapy is a cost-effective choice to be considered in an inpatient setting as well as for outpatients. To be able to choose effectively who will benefit most
from a CBT group therapy versus individual therapy, it can be useful to look into the comorbidity of depression. Cognitive behaviour therapy has wellestablished efficacy for depression but less is known about its efficacy for chronic or treatment-resistant depression with psychiatric comorbidity. In the
current study, inpatients at a rehabilitation centre, meeting full criteria for major depression, either received CBT in groups or individually. The treatment
included 12 sessions of manual-based CBT, delivered by an interdisciplinary team of therapists trained in CBT; psychologists, psychiatrists, nurses, social
workers and occupational therapists. All the patients also received conventional interdisciplinary rehabilitation treatment-as-usual for 6 weeks including
supportive therapy/counselling, physical endurance and fitness training, psycho-education, and physical- and occupational therapy. Outcome measures were
analysed at the start of treatment and at the end, after six weeks of rehabilitation. Follow-up was at one and two years. Preliminary results suggest a high
rate of comorbidity in this sample. In an effort to examine the relationship between depression and multiple comorbidity, the pattern of comorbidity and
outcome will be studied and compared to outcome data obtained from group versus individual CBT treatment. The treatment implication of these results will
be discussed.
Effect of Cognitive Behavioural Therapy on Hopelessness in Depressed Patients
Rósa M. Gudmundsdóttir, Marga Thome, Pétur Hauksson, Reykjalundur Rehabilitation Centre. University of Iceland, Iceland
There is scarce evidence on the effects of cognitive behavioural therapy (CBT) on hopelessness in depressed patients, despite a well established link
between hopelessness and suicidal behaviour. The study was carried out in an open-ward rehabilitation institute offering a wide range of treatment options
and training, individualised for each patient. CBT was provided by a multidisciplinary team. The purpose of this study is to evaluate the effect of individual
and group CTB on hopelessness in patients who have a history of treatment-resistant depression. After obtaining informed consent, a sample of inpatients
(n= 170) was allocated randomly to three treatment modalities: 1) individual CBT , 2) group CBT and 3) control: usual rehabilitation. The Icelandic version of
Beck´s Hopelessness Scale (BHS) was filled in before and after treatment. Demographic information was obtained from patients' records. Results showed
that the majority of patients (71%) were moderately to severely hopeless (M = 12,06, SD = 5,53). The number of diagnoses had a significant effect on the
severity of hopelessness. A significant association was found between the severity of hopelessness and age, r = -0,239, p<0,05, and hopelessness was
lower among people who had children. Patients receiving individual CBT improved significantly more in comparison to those who received group CBT or
control treatment.
Comparison of Cognitive Behavioural Group Therapy, Rehabilitation, and Wait-list Control for Treatment-resistant Depression
Ragnhildur Gu_mundsdóttir1, Inga Hrefna Jónsdóttir2, Sylvía Ingibergsdóttir2, _órunn Gunnarsdóttir2, Pétur Hauksson2, 1 Leiden University, The
Netherlands; 2 Reykjalundur rehabilitation centre, Iceland
This study seeks to compare the effects of different forms of treatment on treatment-resistant depression. We assessed and compared the effects of
outpatient group CBT and inpatient treatment at the psychiatric department of a rehabilitation centre, of depressed patients who had not responded
sufficiently to other treatment. The course of depression was followed in three groups of patients i.e. two treatment groups (outpatients who exclusively
received group CBT, and inpatients who received rehabilitation but no CBT) and one control group (patients on a waiting list). The sample was created by
screening patients on a waiting list for depression. They were then randomly divided into two groups, a CBT group and a control group, and were asked to
participate in the study. Results were compared with the results of inpatient rehabilitation without CBT. Treatment, either outpatient CBT or inpatient
rehabilitation, gave significantly lower scores on all scales at the end of treatment, than at the start of treatment. Symptoms of depression and anxiety
decreased significantly more during CBT, than in the control group. Symptoms of depression, anxiety, and automatic thoughts decreased significantly more
during rehabilitation, than in the control group. Both treatments, outpatient group CBT and inpatient rehabilitation, seem to be effective in reducing symptoms
of anxiety and depression. Outpatient CBT group therapy could be an effective alternative to inpatient rehabilitation or could prepare patients for the
rehabilitation program.
Comparison of the Effect of Cognitive Behavioural Therapy Carried out by Nurses and by Other Psychiatric Team Members
Sylvía Ingibergsdóttir, Marga Thome, Pétur Hauksson, University of Iceland, Iceland;2 Reykjalundur Rehabilitation Centre
This study is part of a larger project comparing the results of different forms of CBT for treatment resistant depression that was carried out by a
multidisciplinary team at the psychiatric unit of a rehabilitation centre. Nurses working in psychiatric establishments have usually not received training in CBT
and are often not regarded as therapists. However, they comprise a significant part of staff of most psychiatric units, and their contribution to treatment might
be developed further in order to achieve better treatment results. In this study the treament team carrying out CBT was comprised of nurses, occupational
therapists, a psychologist, a social worker and a psychiatrist. All therapists underwent 1.5 years training in CBT and received regular supervision. 61 patients
received individual CBT. In 70% of these cases, the treatment was carried out by nurses, and in 30% by the other team members. CBT was manual based,
with 12 individual sessions. All patients were inpatients at a rehabilitation centre and all received individualised physical training, education, counselling and
support sessions as needed, in addition to CBT. This study tests the hypothesis that the effect of CBT carried out by nurses is not different from the results
of CBT carried out by other team members. Results will be presented at the symposium.
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Symposium 171
Mindfulness for Anxiety & Depression
Convenor: Dolores Foley, Macquarie University, Australia, Australia
Mindfulness For Anxiety and Depression: Rationale, Preliminary Research and a Manualised Programme For GAD.
Malcolm Huxter, Charles Stuart University, & North Coast Area Health Service, NSW Australia
In 2001 preliminary research was conducted assessing the effectiveness of an eight-session stress management programme based on Mindfulness. The
programme aimed at reducing the severity of anxiety and depressive symptoms with heterogenous clinical populations of a rural mental health service. The
programme was supported under the Australian Second National Health Plan: 1998-2003. The method of evaluation involved an open clinical trial with
comparison to another established stress management programme in an urban setting. The established CBT programme used conventional cognitive
restructuring and not mindfulness. The results of the Mindfulness-Based (MB) programme were comparable to the successful CBT programme. With the MB
programme severity of symptoms of participants reduced significantly over the period of participation and at two-month follow up. Currently, various MB
programmes are being utilised in the rural mental health service to help patients cope with: Generalised Anxiety disorder (GAD), Panic, Bipolar Disorder,
Depression and dysthymia, stress related emotional disorder and emotional dysfunction as part of personality disorder. Following the preliminary research in
2001, a 12-session MB programme specifically for GAD was written. This programme was utilised in more rigorous research conducted by Macquarie
University, Australia in 2005 and 2006, with favourable results. Mr Mal Huxter will present the background rationale for using mindfulness with anxiety and
depression and the results of the preliminary research conducted in 2001. He will also present a very brief overview of the 12-session programme, which
will serve as an introduction to the next presentation given in this symposium by Dr Maree Abbott.
A randomized control trial comparing Mindfulness training and CBT in the treatment of generalized anxiety disorder.
Dr Maree Abbott, Prof Ronald Rapee & Ms Lexine Stapinski, University of Sydney, Australia
Generalized Anxiety Disorder (GAD) is a common and complex disorder that has proved difficult to treat, with meta-analyses showing relatively poor
outcomes. The present study sought to compare contemporary cognitive-behavioural treatment with Mindfulness meditation training for GAD; the active
treatments were compared to a waitlist control group. Both treatments were presented in a group format of 12 sessions. All participants were assessed using
the ADIS-IV and met the principal diagnostic criteria for GAD. Participants were assessed using self-report questionnaires and the ADIS-IV at pre
treatment/waitlist, post treatment/waitlist, 6 and 18 month follow-up. 96 participants completed the study. Data collection for self-report and diagnostic
measures has been completed for the pre, post and 6 month follow-up data waves; 18 month follow-up data collection is continuing. Both active treatments
made significant improvements in treating GAD, showing enhanced outcomes that were maintained at follow-up. However, mindfulness training produced
significantly stronger outcomes in terms of diagnostic severity levels, the proportion of participants entering the non-clinical range and in reducing co-morbid
depression. In addition, the active treatments showed no significant differences in drop-out rates or on levels of non-specific therapy factors endorsed by
Cognitive Behaviour Therapy plus mindfulness for depression and anxiety outside model programs: A randomized clinical trial
Foley, D., Baillie, A, Renner, P. & Hayes, S., Macquarie University, Australia
This study evaluated the effectiveness of a Cognitive Behaviour Therapy (CBT) treatment program verses a program including mindfulness training in
addition to CBT. Participants met diagnosis for a mixture of depressive and/or anxiety related disorders according the Anxiety Disorders Interview Schedule.
Minimum exclusion criteria were applied. Participants were randomly allocated to CBT or CBT plus mindfulness conditions and attend 8 weekly group
therapy sessions of equivalent duration. Continuous measures included the Hamilton Depression Rating Scale, the Depression, Anxiety Stress Scale and
measures of mindfulness. Treatment gains and relapse rates were monitored over an 8 month treatment and follow-up period. Results based on 16
treatment groups will be presented and implications for future research discussed.
MBCT in Treatment resistant depression: a positive and potentially lasting effect.
Dr Maura Kenny & Professor Mark Williams, Centre for the Treatment of Anxiety and Depression, South Australia
Mindfulness-based Cognitive Therapy (MBCT) is a class-based program designed for use in the prevention of relapse of Major Depression. Its aim is to
teach participants mindfulness meditation techniques to disengage from those cognitive processes that may render them vulnerable to future episodes.
These same cognitive processes are also known to maintain depression once established, hence a clinical audit was conducted to explore the use of MBCT
in patients who were currently actively depressed, and who had not responded fully to standard treatments. The study showed that it was acceptable to
these patients and resulted in an improvement in depression scores (Pre-Post Effect Size = 1.04), with a significant proportion of patients returning to normal
or near-normal levels of mood. Follow-up data will also be presented and discussed.
Open Paper Symposium 9
Depression, Cognition and Relationships
Cognitive Mechanism of Familial Transmission of Depression
Tian P.S. Oei, The University of Queensland, Anna Salzgeber, The University of Queensland, Australia
The present study investigated the cognitive mechanism of the familial transmission of depression in a sample of 103 young adults and one of their parents.
Structural equation modelling (SEM) was used to compare eight models of the transmission of parent cognitions and depressive symptoms to offspring
cognitions and depressive symptoms. Offspring and one of their parents completed a questionnaire battery consisting of the Depression Anxiety and Stress
Scale (DASS), the Dysfunctional Attitudes Scale (DAS), and the Automatic Thoughts Questionnaire (ATQ). Four of the models provided adequate fits for the
data. The results suggested the importance of the pathway between parent and offspring automatic thoughts as a mode of familial transmission of
depression. These findings support cognitive mechanism of familiar transmission of depression. These findings have implications for the prevention and
treatment of depression.
Representations of significant others and the activation of interpersonal scripts
Le Roux Van der Westhuizen, Stellenbosch University, South-Africa
Despite the general assumption in psychology that people are influenced by the mental representation of others and in particular the significant other people
in their lives, relatively little empirical studies have been done on how such “inner audiences” are invoked and on the cognitive mechanisms that underlie
their influence (Shah, 2003). The present study extended the work by Baldwin (1992), as well as Andersen and Cole (1990) and empirically investigated the
linkages between past experiences with significant others, significant other representations and the current processing of interpersonal information. In a
2x3x4 experimental design the influence of chronic accessibility and subliminal priming on the accuracy and speed of processing scripted interpersonal
information were investigated. One hundred and thirteen university students took part in two sessions. In the first they completed the Attachment Style
Questionnaire (Feeny, Noller & Hanrahan, 1994) and provided the names of positive and negative significant others. According to a median split of the
Confidence Scale of the ASQ, they were assigned to the chronic positive or chronic negative group. In session two, an individual computer task; (a) they
were subliminally primed (33 ms) with a control word or the name of the positive or negative significant other; (b) asked to read a positive, negative, mixed
or ambiguous script of an interpersonal event; and (c) complete a memory test of 36 interpersonal statements (9 positive, negative, ambiguous and filler
statements). The accuracy and response time for every statement was recorded and the response times of accurate responses of positive and negative
scripts were included in the main analysis. Separate univariate analyses of the difference between positive and negative priming per polarity of chronic
group and script supported the priming hypothesis. The results of a two-way analysis of variance for chronic group and script showed a highly significant
interaction effect between chronic group and script (p = .000). When the primes were congruent to the scripts, the chronic groups were significantly faster in
recognising statements from a congruent script. The results supported the conjunctive model of priming. People with a history of particular relationship
experiences, processed congruent relationship information more efficiently when they were primed with information from a significant other with whom they
share some of these relationship experiences. The results supported the notion of Baldwin (1992) that relational schemas are based on repeated
interactions with significant others and are constituted by three interrelated elements (self-schema, person-schema and interpersonal script). It also
demonstrated that the person-schema and interpersonal script are connected. The study satisfied the requirement of Higgins and Bargh (1987) that one
element of a hypothesised schema must be primed and measures taken demonstrating that the activation has spread to another element, before the
existence of a schema can be claimed. The study demonstrated that significant other representations could be activated outside of awareness to facilitate
the subsequent conscious processing of interpersonal information. The therapeutic applications of the findings will also be discussed.
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A Good Woman. Suppression and Rumination in Romantic Relationships.
Kumari Fernando, Christchurch School of Medicine and Health Sciences, University of Otago, New Zealand
According to the World Health Organisation, depression will be the second leading contributor to global disability in 2020. Women are two to three times
more likely than men to develop depression. This presentation examines two theories explaining women's greater vulnerability to depression: Silencing the
Self (Jack (1991) and Rumination (Nolen-Hoeksema, e.g., 1989). Silencing the Self describes schema about, and behaviour within, romantic relationships
that involve suppression of thoughts and feelings. Rumination, in contrast, refers to a focus on thoughts and feelings. Using Wegner's (e.g., 1994), Ironic
Process Model, the author suggests that the two processes are related and that the combination of the two processes is a better predictor of depressive
symptoms than either predictor alone. Wegner's model is a cognitive explanation of what happens when information is consciously suppressed. According to
Wegner, suppression makes information more accessible both unconsciously and consciously. Data from three studies are presented, including a large
correlational study, an experimental investigation and a longitudinal study. All three studies involved university undergraduate students. In the correlational
study, participants completed measures of rumination, self-silencing and depressive symptoms. All three measures were positively associated, supporting
the hypothesis that a tendency to suppress information is associated with rumination. The experimental investigation involved manipulating mood and
rumination. Participants were asked to describe a typical or negative relationship event. In addition, participants were asked to write factually or to ruminate
about these events. Participants' mood was measured before and after the writing task. In addition, their self-silencing tendencies were measured before the
writing task. Results showed that the combination of having a high tendency to self-silence and ruminating resulted in a dramatic decrease in mood.
The longitudinal investigation utilised a novel email paradigm to obtain participant reports of daily mood, relationship functioning, self-silencing and
rumination over the course of one month. Results showed that participants daily accounts of their rumination and suppression (that occurred within a
romantic relationship) predicted depressive symptoms one month later. The three studies together support the hypothesis that rumination and self-silencing
are related to each other, and that the combination of the two processes predicts short term depressed mood and longer term depressive functioning.
Recent clinically oriented theories have focussed on problems with suppressing thoughts and feelings. This programme of investigation adds to the literature
about suppression and the paradoxical finding that the more one tries to suppress one's thoughts and feelings, the more one thinks about them.
Development of a Group Cognitive Therapy Program Focused on Cognition regarding Relationships with Significant Others in
Female Patients with Depression in Japan
Yoshie Okada, St. Luke's College of Nursing, Graduate School, Japan
Introduction: The objective of this study was to evaluate the practicality of the group cognitive therapy program, which focuses on the cognition of female
patients with depression in Japan, with regard to their relationships with significant others, to modify and refine the program. Method: Subjects were 13
women with unipolar depression. Data was collected from interviews and questionnaires. Three nurses, not including the study area staff, conducted
interviews before the start of and after the end of the program. In addition, questionnaires were conducted using the Beck Depression Inventory-Second
Edition (BDI-II), Automatic Thoughts Questionnaire-Revised (ATQ-R) and Dysfunctional Attitude Scale 24-Japanese Version (DAS24-J) at either the start or
end of each session. Interview data was qualitatively analyzed using the grounded theory approach and integrated with the results of data analysis from
questionnaires, followed by the Wilcoxon signed-rank test. Results:Integration of the results revealed that during the course of the present program, female
patients with depression experienced “a pre-participation state in which they had problems relating to their relationships with significant others.” Then,
“changes in themselves during group cognitive therapy,” and ultimately “improvements in their social lives with regard to relationships with significant others.”
In addition, “improvements in their social lives with regard to relationships with significant others” were characterized by “change toward adaptive cognition
regarding relationships,” “recovery of behavioral control,” “improvements in problems relating to relationships with significant others,” “improvements in mood
states,” and “alleviation of somatic symptoms.” These changes and improvements indicate the effectiveness of experiences such as “acquisition of
knowledge and techniques regarding cognition and behavior” and “comfort through sharing of common experiences” in groups, which contributed to
“changes in themselves during group cognitive therapy” in the present program. Discussion:Because participation in the program resulted in cognitive and
behavioral changes and improvements in mood states and relationships with significant others, the present program can be considered useful as a program
that targets the characteristics of female patients with depression. In addition, possible interventions for promoting changes among patients include
implementation in the learning of cognitive therapy techniques that were shown herein to be effective for solving problems, efforts to promote therapeutic
experiences in groups, and providing feedback in response to realizations and changes among patients. Conclusion: The present group cognitive therapy
program which focuses on the cognition of female patients with depression may be useful for changing and improving their cognition, behavior, mood and
somatic symptoms regarding their relationships with significant others.
A factorial categorization of depressive and anxious symptoms, depressive vulnerability factors and cultural beliefs among
youth in urban and rural Hunan, China
Carolyn Parkinson, McGill University, Canada; Randy Auerbach, McGill University, Canada; John Abela, McGill University, Canada
While early epidemiological studies suggested that depression rates were lower in China than in Western countries (Murray & Lopez, 1996), recent research
suggests they are now higher (Zhou et al., 2006). Although epidemiological studies have only looked at adults, this trend appears to be mirrored among
youth (Wang, 2004). Increased psychopathology may be attributed to stress stemming from rapid urbanization and increased academic pressure (Wang,
2004). As the magnitude of associations between stress and depression varies across studies, moderating variables are of interest. Cognitive models of
depression posit that certain individuals possess thinking styles and belief systems that make them more likely than others to engage in negative thought
patterns following stress. Interpersonal vulnerability models posit that protective factors buffer individuals against the development of depression after the
occurrence of negative life events. Research points to the applicability of these models to Chinese samples (Li & Qian, 2002). While these theories focus on
vulnerability factors within the individual or his immediate environment, culture-related beliefs have also been found to be associated with depression.
China's collectivist value orientation buffers individuals against depression via collectivist coping strategies, social cohesion, and stable self-ingroup relations
(Triandis et al., 1988). Further, extrinsic values and independent self-construal may confer vulnerability to depression (Kasser & Ryan, 1996; Markus &
Kitayama, 1991). The current study examined the factorial categorization of depression-related constructs in urban and rural samples of Hunan adolescents.
Before studying vulnerability to depression in Chinese youth using variables put forth as predicting depression, these variables must be shown to be distinct
from each other and from symptoms. It was hypothesized that distinct factors for cognitive vulnerability factors, interpersonal vulnerability factors and culturerelated beliefs would be obtained, and that components of these factors would be associated with depression. The participants, 558 adolescents (ages 1419) from two urban Changsha public schools and 592 adolescents (ages 14-19) from one rural Liuyang public school, completed measures of depressed
and anxious symptoms, stress, culture-related beliefs, cognitive and interpersonal vulnerability factors, and neuroticism. Exploratory factor analysis (EFA)
was carried out in the Changsha sample. In the Liuyang sample, confirmatory factor analysis (CFA) was performed to assess the adequacy of the solution.
In line with our hypotheses, a six-factor model was obtained, accounting for 62.7% of the variance. Distinct factors were obtained for symptoms, familial
relationships, collectivism, hopelessness, individualism and peer support. The results of CFA indicated a moderate fit for this model. The results of CFA
support the proposed categories in a very different sample. A dual effect of individualism and collectivism was found, suggesting that both the elimination of
old cultural beliefs and the introduction of new ones may be associated with depression. While the model fit the Liuyang data well, individualism was not
associated with depression there, suggesting that higher levels of collectivism could buffer adolescents against negative effects of individualism, or that
healthy levels of individualism exist below the threshold at which it becomes harmful. Investigating the nature of correlations between factors constitutes a
valuable direction for future research.
Open Paper Symposium 13
CBT Interventions for Depression
Combined Cognitive Therapy and Family Therapy for Severely Depressed Patients
Ivan Miller, Psychosocial Research Program, Butler Hospital and Brown University, Christopher Beevers, Department of Psychology, University of
Texas, Austin, USA
Despite their high morbidity, poor response to usual treatments, and high treatment costs, depressed inpatients have been markedly under-studied in
clinical trials. While previous studies have suggested that combined psychosocial + pharmacological treatment maybe the most efficacious treatment, these
studies have been limited in several respects and have not explored the parameters of the most effective combined treatments.
To address these issues, we conducted a clinical trial investigating the efficacy of combined psychosocial + medication treatments for post-discharge
treatment of depressed inpatients. In addition to the basic comparison of combined treatment versus pharmacotherapy, we investigated whether or not
adding a family therapy component increases the efficacy of combined treatment. 135 hospitalized patients with major depression were randomly assigned
to one of three treatment conditions: 1) Pharmacotherapy Alone (medication + clinical management), 2) Combined Individual (cognitive therapy +
medication + clinical management, and 3) Combined Individual + Family (cognitive therapy + family therapy + medication + clinical management). Number of
therapy contacts were constrained to be equivalent in the two Combined conditions. Patients were recruited while in the hospital and treated for 24 weeks
on an outpatient basis. Initial HLM analyses suggested that while both Combined treatment conditions had a better response to treatment than
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Pharmacotherapy Alone, there were no differences between Combined Individual and Combined Individual + Family treatment groups. Preliminary analyses
suggest that the addition of a psychosocial intervention improves outcome relative to pharmacotherapy alone for severely depressed patients. However, both
individual cognitive therapy and cognitive therapy + family therapy were equally efficacious. Further analyses and discussion will be presented at the
Urinary catecholamines and response to group cognitive behaviour therapy for depression.
Genevieve Dingle, University of Queensland, Tian-Po Oei, University of Queensland, Molly McCarthy, University of Queensland, Australia
The treatment specificity hypothesis proposes that when psychological or biological factors can be identified, depression will be best remediated by a
treatment that targets the identified factor. For example, it has generally been accepted that cognitive behaviour therapy (CBT) is unlikely to benefit
individuals with melancholic (or biological) depression. However, most investigations into this hypothesis have been indirect, using measures of melancholic
symptoms or depression severity rather than direct markers of biological dysfunction. Thus the current study was designed to test the treatment specificity
hypothesis directly with the use of a measure of biological dysfunction, namely the presence of elevated urinary levels of catecholamines. It was
hypothesised that participants whose urinary catecholamines were elevated would respond less well to a course of group CBT than depressed patients
without this biological marker. A sample of 70 depressed volunteers provided measures of depressive symptoms, cognitions, and 24-hour urine samples at
pre- and post-treatment. A cut-off one standard deviation above a published mean for urinary catecholamines was used to designate elevated catecholamine
output, and participants were divided into three conditions: “Low” (below the cutoff at both pre- and post-treatment; N=33), “High” (elevated catecholamine
excretion at both pre- and post-treatment; N=10) and “Mixed” (below the cutoff at one assessment and above the cutoff at the other; N=27). Treatment was
a 12 week course of group CBT. Results of the BDI and Zung depression measures showed that participants in the High condition started and finished
treatment significantly more depressed than those in the Mixed and Low conditions. Despite this, all groups improved significantly in mood during the
treatment, and improved at similar rates. All three groups improved in measures of negative cognitions also, indicating that the CBT had an impact on the
cognitive functioning of participants, regardless of their biological status. The treatment specificity hypothesis was not supported by results of this study.
Results indicate that depressed patients with evidence of catecholamine dysfunction can benefit from a group CBT program.This finding is consistent with a
previous report that depressed patients with and without another biological marker (decreased REM sleep latency) responded equally well to 20 sessions of
group CBT (Thase et al., 1991).
Internet-based cognitive behavioural therapy for sub-threshold depression in people over 50 years old.
Viola Spek, Tilburg University, Ivan Nyklícek, Tilburg University, Niels Smits, Vrije Universiteit Amsterdam, Pim Cuijpers, Vrije Universiteit
Amsterdam, Heleen Riper, Trimbos-institute, Netherlands Institute of Mental Health and Addiction, Netherlands
Sub-threshold depression is a highly prevalent condition and a risk factor for developing major depression. Internet-based cognitive behaviour therapy may
be a promising approach for the treatment of sub-threshold depression. The low-threshold accessibility of the internet makes it very suitable for offering and
receiving non-stigmatizing help for psychological problems in large population samples. The objectives of this study were (1) to determine whether an
internet-based cognitive behaviour therapy intervention and a group cognitive behaviour therapy intervention were more effective than a waiting-list control
group, and (2) to determine whether the efficacy of the internet-based cognitive behaviour therapy differed from the group cognitive behaviour therapy
intervention. Participants were 191 women and 110 men (mean age = 55 years, SD = 4.6) with sub-threshold depression. They were randomized into one of
three groups receiving an internet-based cognitive behaviour therapy intervention, group cognitive behaviour therapy, or a waiting-list control condition. The
main outcome measure was treatment response, defined as the difference in pre and post-treatment scores on the Beck Depression Inventory. For
improvement within the waiting-list control group, we found a moderate improvement effect size of 0.39. The group cognitive behaviour therapy condition
had a large improvement effect size: 0.67, while an even larger improvement effect size of 0.94 was found within the internet-based treatment condition.
Helmert contrasts were fitted to test hypotheses about the differences between conditions. The first fitted contrast showed a significant difference between
the waiting-list condition on the one hand and the two cognitive behaviour therapy conditions on the other hand (p = 0.04). The two treatment conditions did
not differ significantly (p = 0.62). Furthermore, clinically significant change in functional status from moderate to serious symptoms (BDI = 20) at baseline to
minimal to light symptoms (BDI = 20) at post-treatment was found for both treatment groups (McNemar, p < .01). The waiting-list group did not show a
significant change in status (McNemar, p = .103). These results suggest that an internet-based cognitive behaviour therapy intervention may be at least as
effective as group cognitive behaviour therapy for sub-threshold depression in people over 50 years. This supports the idea that internet-based therapy
might help to prevent and treat this highly prevalent disorder.
Multicultural Information on Depression online (MIDonline): Development and evaluation of a multilingual depression
information website
Kathryn Gilson, Department of General Practice, Monash University, Litza Kiropoulos, Department of General Practice, Monash University,
Low levels of depression literacy and stigma associated with mental disorder appear to be barriers to help-seeking in the Australian community, yet these
are two issues that have not been examined in mid to older culturally and linguistically diverse (CALD) populations living in Australia. This is of particular
importance because by 2026 it is projected that one in four people aged 70 and over will be from CALD backgrounds (with Italy and Greece being the most
common regions of origin for those aged 70 and over living in Melbourne, Australia) (Gibson et al., 2001). Additionally, higher levels of depression and
anxiety in mid to older Greek-born and Italian-born immigrants have been found compared to their Anglo-Australian counterparts (Kiropoulos, 2004; Klimidis
and Minas, 1998) and CALD groups have been found to underutilize the appropriate mental health care (Hickie, 2001). Currently, there is no culturally
relevant and appropriate depression information available via the internet targeted at CALD consumers, carers and health professionals in Australia.
The aim of the current study is to discuss the development and evaluation of a culturally relevant and appropriate depression information website aimed to
increase knowledge of depression and related conditions and decrease stigmatising attitudes towards mental disorders in Greek and Italian-born people
living in Australia. MIDonline is targeted to the needs of CALD people experiencing depression and in general provides comprehensive multilingual online
information for CALD people relating to symptoms and types of depression, associated disorders, and CBT treatment and management of depression by
mental health professionals. The depression specific website can be viewed in English, Greek and Italian and has been developed for use by mental health
professionals, carers and consumers.
Participants were randomly allocated to the intervention group (n = 30) (viewing of the MIDonline intervention) or the control condition (n = 30) (taking part in
a depression schemas interview). All participants were assessed at pre, post and 1 week follow up periods. This paper reports the preliminary findings which
examine differences in the following variables after having viewed the MIDonline intervention or taking part in a depression shemas interview (i.e., control):
sociodemographics, level of depression, level of anxiety, depression literacy, depression related stigma (personal and perceived), cognitive impairment,
substance abuse, number of chronic conditions, english language proficiency, level of acculturation, receiving treatment, user satisfaction and quality of life.
The results of the current study will have implications for future policy and development in relation to the design and delivery of mental health care services
to mid to older CALD populations living in Australia. The current study will provide important data about the effectiveness of providing depression related
information, including the CBT treatment of depression, to increasing knowledge of depression via the internet to people of a CALD background.
Development of an Integrative, Interactive Self-Help Intervention for Depression: The Therapeutic Dialog (Theralog) Program
Björn Meyer, City University, London & GAIA AG, Hamburg, Mario Weiss, GAIA AG, Hamburg & Ashridge Business School, Germany
Evidence suggests that computerized self-help interventions, such as Beating the Blues (Proudfoot et al., 2004) or Overcoming Depression (Whitfield et al.,
2006) can be effective in the treatment of mild to moderate depression. However, current programs are limited in the sense that they are not specifically
tailored to individual patient characteristics, are utilizing a relatively narrow repertoire of CBT interventions, and are not optimally responsive to fluctuating
user needs and preferences. This paper describes the development of a novel, integrative, computerized self-help program for depression-the Therapeutic
Dialog (Theralog) program-that aims to overcome these limitations. The program is available in English and German and consists of 12 user-tailored
modules that are presented in individualized sequences, depending on the needs and preferences identified in an initial module. The program includes a
broad range of CBT and related interventions that are established or promising in their efficacy (e.g., behavioural activation, cognitive modification, social
skills training, relaxation exercises, lifestyle modification, acceptance/mindfulness, schema-work, problem-solving, positive psychology interventions). The
modules are individualized in content and tone to suit the needs and preferences of a variety of user- and depression-subtypes (e.g., depression following
relationship dissolution, chronic/endogenous, postpartum, seasonal). Additional user-characteristics considered for module-individualization are, for example,
gender, age, motivation, internalizing versus externalizing tendency, and degree of experiential avoidance. The program simulates a series of dialogues
between client/user and expert/computer, such that the user is continuously presented with options and subsequently receives content that acknowledges,
and is responsive to, his or her choices. Content is presented as a combination of text and visual illustrations, with the option of augmenting the program
with additional audio- and video components in future versions. This presentation provides an overview of the rationale, development and structure of the
program as well as initial results concerning effectiveness. In an initial (ongoing) study, 120 mildly depressed participants (Beck Depression Inventory [BDI] >
12 and < 25) are randomized to either 9 weeks of online-treatment followed by 9 weeks follow-up or, reversed, 9 weeks of initial wait-list control followed by
9 weeks of online-treatment. Symptom severity (BDI), depressive cognitions (Dysfunctional Attitudes Scale), social/occupational functioning (Work and Social
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Adjustment Scale), and mood (Positive and Negative Affects Schedule) are assessed at baseline, post-treatment, and follow-up, and a brief symptom
checklist is completed prior to each session. Critics have argued that current computerized self-help programs are inadequately user-tailored and neglect the
'common factors' that underlie therapeutic effectiveness, such as therapist responsiveness and the patient-therapist alliance (e.g., Richardson & Richards,
2006). New interactive programs, such as the one described herein, aim to simulate and maximize therapeutic responsiveness by engaging the user in a
series of highly individualized dialogues. Even though computerized self-help programs are unlikely to replace face-to-face therapies-and such replacement
would be a misguided goal-it is hoped that interactive, user-responsive programs can facilitate and augment other interventions, free up human resources,
and enable persons who otherwise would not have access to CBT to benefit from such interventions.
Open Paper Symposium 18
Cognitive Processes in Depression
De Novo postnatal depression' versus 'Recurrent depression': are there subtypes of postnatal mood disturbance?
Jane Phillips, University of Sydney, Louise Sharpe, University of Sydney, Stephen Matthey, Sydney South West Area Health Service, Australia
Postnatal depression (PND) effects up to 15% of new mothers and can have devastating impacts on the developing mother-infant relationship and thus on
the child's subsequent development. There has been a suggestion that PND may not be homogenous and that women who become depressed for the first
time post-natally ('De Novo') might differ from those with a history of depression ('Recurrent') (Cooper & Murray, 1995). The current study aimed to
determine whether there were any identifiable phenomenological differences between these two groups of women. Specifically, it was hypothesized that (i)
'Recurrents' would display a greater degree of dysfunctional attitudes in comparison to 'De Novos' and 'Controls'; whereas 'De Novos' would display more
negative maternal specific dysfunctional attitudes than 'Recurrents' and 'Controls'; and that (ii) 'Recurrents' would be more likely than 'De Novos' and
'Controls' to have a vulnerable personality and an insecure adult attachment style. One hundred and sixty women with infants under 12 months were
recruited from the Karitane Residential Family Care Unit in Sydney, Australia. Participants completed a semi-structured, diagnostic interview for current and
lifetime mood and anxiety disorders, from which they were allocated to one of four groups: (i) 'De Novos', (ii) 'Recurrents', (iii) 'No depression controls' (no
current or lifetime history of depression) and (iv) 'History of depression controls' (history of non-postnatal depression but not currently depressed).
Participants also completed questionnaires relating to dysfunctional attitudes, attitudes towards motherhood, personality style, infant temperament, life
stressors and adult attachment style. Results of ANCOVA analyses showed there were no significant differences between 'Recurrents' and 'De Novos' in
terms of symptom severity or dysfunctional attitudes (general or maternally specific), suggesting that PND is characterised by a negative cognitive style,
irrespective of whether the depression developed De Novo or as a recurrence of a previous depressive disorder. However, while those women who had
been previously depressed were no different from the 'Recurrent' group in their generally negative attitudes, they demonstrated more positive maternally
specific attitudes. In line with the study's second hypothesis, women in the 'Recurrent' depression group displayed a greater degree of personality
vulnerability than 'De Novos' or 'Controls'. The current paper will consider these results in relation to previous literature and will discuss implications for the
provision of specifically tailored cognitive-behavioural treatments for PND.
Depression related schemata and relapse:Comparison between first episode, several episodes and never depressed subjects
Fereshteh Mootabi, Shahid Beheshti University, Alireza Jazayeri, University of Welfare & Rehabilitation, Parvaneh Mohammadkhani, University of
Welfare & Rehabilitation, Abbas Pourshahbaz, University of Welfare & Rehabilitation, Iran
There are different views about relapse of depression in CBT, for example Beck's model and Teasdale's "depression about depression". This research aimed
to combine these models by investigating the existing of "depression related schemata". 93 subjects were assigned in 3 groups: first-episode depressed
subjects (N=29), several episode depressed subjects (N=34), and nonclinical subjects (N=30). All subjects' depression related beliefs were assessed before
and after mood induction and after distraction, by "Depression-related Belief Scale". Results showed no difference between the two depressed groups, but a
significant difference between nonclinical group and both depressed groups was found (p<0.05). When subjects with less than 4 episodes were excluded
from the several episodes group, the difference between two depressed groups was found to be significant (p<0.05). It seems that the depression-related
schemata are developed during several episodes of depression, and can contribute to the new episodes of depression. The results of this research propose
that Beck's model of depression can explain relapse of depression. In other words, "depression related beliefs" are core beliefs, which can be activated by
every thing that is like signs and symptoms of depression. Activation of these schemata can produce depressed mood and lead to an episode of depression.
Trajectories of Overgeneral Memory: The Impact of Self-Esteem and Depressive Rumination
John Roberts, University at Buffalo, The State University of New York, USA and Filip Raes, University of Leuven, Belgium
Overgeneral autobiographical memory (OGM) has been repeatedly demonstrated among depressed patients and individuals with a history of trauma. These
studies are based on the Autobiographical Memory Test (AMT), which asks participants to retrieve specific personal memories to a series of cue words.
Investigators typically create an aggregate score on the AMT by summing the number of OGM's retrieved by each participant. However, recent research
suggests that it may prove useful to disaggregate performance and examine OGM on a trial-by-trial basis. For example, Roberts et al. (2005) found that
performance systematically changed over the course of the trial sequence in the form of a quadratic function; the probability of retrieving OGMs steadily
increased through the first half of the trial sequence, plateaued, and then decreased. Furthermore, self-esteem moderated the shape of these trajectories,
such that individuals with low self-esteem tended to have steadily increasing OGM without any deflection. The present research was designed to replicate
these effects and test the combined effects of self-esteem and depressive rumination on trajectories of OGM. We also attempted rule out the possibility that
individual differences in conscientiousness contribute to patterns of declining performance. Participants were 314 students (69 males) at University of
Leuven who completed a paper-and-pencil version of the AMT with a total of 10 cue words, as well as measures of conscientiousness, rumination and selfesteem. AMT data were treated as having a nested structure (2545 observations nested in 314 participants) and were analyzed with multilevel modeling.
Results indicated a statistically significant quadratic effect (z=4.16, p<.001) that took the same inverted-U form as seen in the Roberts et al. (2005) study.
Consistent with this past investigation, there was a significant interaction between the quadratic effect and self-esteem (z=2.21, p<.05). Furthermore, there
was a significant Self-esteem x Rumination x Trial2 interaction (z=1.98, p<05), suggesting a synergistic effect between self-esteem and depressive
rumination in shaping trajectories of OGM. Importantly, conscientiousness did not moderate either the linear or quadratic trend, suggesting that these
trajectories were not the result of less conscientious participants disengaging as the task progressed. Given that these data originated in a different lab and
are based on a different instrument, they provide a strong conceptual replication of our previous findings. Furthermore, these results suggest that the
combined effects of low self-esteem and depressive rumination influence one's ability to maintain specificity in situations requiring the generation of multiple
and sequential concrete autobiographical memories, for example during the course of complex problem solving. Future research should directly test whether
or not trajectories of OGM are associated with impairments in problem solving, which in turn contribute to stress generation.
Effects of training contextual thinking on vulnerability to a mood challenge in a dysphoric sample
Natalie Jacoby, University College London, Chris Brewin, University College London, UK
Previous studies have suggested that cognitive biases have a causal impact on anxiety. Training of attentional and interpretational biases has been found to
correspond with increases and reductions in anxious mood. For the present study we developed a new form of training designed to correct the
overgeneralisation bias associated with depression, and investigated whether this training method could protect individuals exposed to triggers that would
normally exacerbate a sad mood. Contextual training, which encourages participants to see negative events as distinct and temporary, was predicted to
reduce sad responses to negative memories. Dysphoric participants were forced to give contextual interpretations to different negative events. Participants
read pre-written diary entries of negative events. The entries contained numbered gaps throughout, which they filled with one of two correspondinglynumbered words or phrases. Using the rule “complete the gap with the word or phrase containing a capital vowel, not a capital consonant”, the contextual
group were forced to choose contextual options and reject general ones, whereas the control group's choices were neutral. Participants were then faced with
an autobiographical memory challenge task, where they wrote about a time where they had felt disappointed. Sad mood scores were recorded throughout
the study. As expected, after describing a negative autobiographical memory sad mood was attenuated in the contextual group. Importantly, there were no
group differences in mood after the training, suggesting that its effects were indeed on thinking patterns rather than directly on mood. The advantage to the
experimental group was only evident when they were challenged with recall of a negative autobiographical memory, a task which as predicted led to
significantly worse mood among the controls. The results of this study suggest for the first time that knowledge about cognitive biases in depression can, like
corresponding knowledge about anxiety, be applied to the development of training tasks designed to manipulate vulnerable thinking styles. The results add
to the previous findings of Watkins et al. (2003) by confirming that requiring participants to process contextual information concerning negative events and
moods appears to have a positive impact on sadness. This supports cognitive models of depression, indicating negative generalised self-representations are
a significant factor in maintaining depression. These initial results show promise for the application of cognitive bias training to different mood states
including anxiety and depression. Even at this early stage of the research, the existence of effects such as that found in this study strengthens the
theoretical basis of cognitive-behaviour therapy by helping to confirm the casual impact of thinking styles on mood. In the longer term, it is possible that such
tasks may become a useful adjunct to traditional forms of therapy, either in enhancing resiliency to future stressors or in directly combating negative moods.
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Investigation of the Indulgence Cycles Hypothesis of Suppression on Experimentally-Induced Visual Intrusions in Dysphoria
Alishia Williams, University of New South Wales, Australia; Michelle Moulds, University of New South Wales, Australia;
Within the thought control literature, Wegner (1989) referred to the combined initial suppression and expression phases of thought control as an indulgence
cycle which results in the rebound effect typically observed in suppression studies. Based on Ironic Process Theory (Wegner, 2004), this rebound leads to
further attempts to suppress which is difficult due to the hyperaccessibility of the target thought which subsequently leads to a secondary rebound effect
through a positive feedback system of indulgence cycles. Because real-life suppression is likely to occur in a cyclical manner, detection of a rebound effect
may require repetition of periods of suppression followed by permitted expression rather than singular or isolated periods of suppression followed by
expression in the laboratory. Additionally, although thought suppression is a commonly employed strategy used by depressed individuals to avoid the
pervasive negative intrusions that typify depressive thinking, suppression of spontaneous intrusions has only been minimally assessed in the context of
depression. A growing body of literature suggests that unwanted intrusions in the form of negative autobiographical memories are particularly associated
with mental control strategies such as suppression (Starr & Moulds, 2006) and that this association is more marked in depressed individuals (Williams &
Moulds, 2006). The current study investigated the effects of repeated suppression and opportunities for expression by using a novel method to index the
frequency, duration, and associated levels of distress of an experimentally-induced visual intrusion. The current study also assessed whether any observed
effects were differentially linked to depressive symptomatology in an analogue sample of low dysphoric and high dysphoric participants, and whether any
mental control strategies could discriminate between successful and unsuccessful suppressors. Results of a 2 (Depression status: low, high) x 5 (Condition:
Baseline, Suppression 1, Expression 1, Suppression 2, Expression 2) mixed ANOVA revealed a main effect of condition, supporting the occurrence of
secondary indulgence-based rebound effect. Paradoxically, results also supported a secondary rebound effect in those participants most successful at
suppressing target intrusions. A main effect of depression status was not observed although the data indicated a trend for high dysphoric participants to
report intrusions of longer duration that were rated as more distressing than those reported by low dysphoric participants. The findings offer an important
extension to the indulgence-cycle hypothesis of intrusion maintenance and highlight the relationship between maladaptive mental control strategies and the
potential for elevated distress to perpetuate continued use of such strategies. Research using clinical samples is an obvious and necessary step in
understanding the effects of suppression on depression and on intrusive memory development and re-occurrence.
Adult Psychosis
Invited Addresses
Cognitive Processes Related to Mania and Depression within Bipolar Disorder
Sheri Johnson, University of Miami, USA
Theories of bipolar disorder have focused on the idea that the neurobiological vulnerability to this disorder might be expressed in dysregulation in brain regions
involved in processing and responding to reward cues. Consistent with this idea, recent research suggests that mania relates to a set of problems in how people
cope with and think about the steps in goal pursuit. In particular, even during remitted periods, bipolar disorder appears to involve heightened ambitions and
an oversensitivity to life events involving success. During good moods, people with bipolar disorder exhibit more pronounced increases in confidence and goal
engagement than do others. Not only are deficits in goal regulation evident among people with bipolar disorder, but these deficits predict higher levels of manic
symptoms over time. These findings suggest four potential treatment targets: reward sensitivity, heightened ambition, confidence fluctuations, and excessive
goal engagement. The GOALS program, a mania prevention intervention, was developed to target these issues. Findings of a small open trial will be
summarized. .
The psychology of bipolar disorder
Richard Bentall, University of Manchester, UK
Richard Bentall, University of Manchester/ University of Wales, Bangor, UK
The symptoms of bipolar disorder present many puzzles for researchers who have begun to map out their underlying psychological and biological mechanisms.
Part of the problem is that the basic structure of bipolar symptoms has not been adequately described. For example, there is increasing evidence from our own
research and from the research of others, that mania, far from existing at the opposite pole to depression on a single dimension of affect, varies independently
of depression, and may be the product of different mechanisms. Another difficulty is the inherently dynamic nature of the phenomena. Recent studies conducted
by our group have examined bipolar patients using both longitudinal and cross-sectional designs, and has pointed to three kinds of abnormal psychological
functioning: instability of affect and self-esteem, abnormal coping styles and excessive sensitivity to reward stimuli. These processes appear to be only loosely
inter-related and are important in different phases of the disorder, explaining why patients experience dramatic shifts in symptoms over time.
Recent advances in cognitive models of psychosis
Philippa Garety, Institute of Psychiatry, London, UK
Psychosis is a complex disorder resulting from multiple interacting causes. Cognitive models of the positive symptoms of psychosis specify the cognitive,
emotional and social processes held to contribute to their occurrence and persistence. Over the past five years, the predictions of cognitive models have
been tested in many empirical studies. Converging evidence has also been emerging from epidemiological, genetic and neurobiological studies. In this
address, a cognitive model of psychosis will be presented (Garety et al, 2001) and recent research findings testing some of its key predictions will be
described. This will include research into reasoning biases, negative beliefs about self and others, anxiety-related processes, social relationships and the
urban environment. The current evidence base for each of the hypothesised processes, in terms of making a causal contribution to symptoms, will be
discussed. The implications of these recent findings for refining cognitive behavioural therapy for psychosis will be considered, and potential new treatment
developments will be outlined.
Symposium 3
Psychosis in an interpersonal context: issues in familial and therapeutic relationships
Convenor: Christine Barrowclough, University of Manchester, UK
Does Expressed Emotion need to be understood within a more systemic framework?
Fiona Lobban, University of Manchester, UK
To examine the relationship between discrepancies in beliefs about schizophrenia and Expressed Emotion (EE) in family dyads.Method Illness beliefs were
assessed in patients with a diagnosis of schizophrenia and their relatives. The degree and direction of discrepancy was calculated and comparisons were
made between dyads in which the relative was rated as high EE and dyads in which the relative was rated as low EE Results There was greater
discrepancy between illness models of schizophrenia in dyads involving a high EE relative than in dyads involving a low EE relative. This difference was not
accounted for by differences in either relatives' or patient beliefs alone.Conclusions Further research is needed to understand EE in the context of
discrepancies in beliefs between patients and relatives rather than focussing on relatives' beliefs alone.
Adult attachment theory and psychosis: A framework for understanding interpersonal problems and difficulties in therapeutic
Katherine Berry, Alison Wearden, Christine Barrowclough, University of Manchester, UK
Attachment theory provides a useful framework for understanding the development of interpersonal difficulties in psychosis and the influence of interpersonal
relationships on its development and course. However, there is limited research investigating attachment styles and their correlates in clinical samples.
Method. We administered self- and informant-report versions of the Psychosis Attachment Measure (PAM) in a sample of 96 patients with psychosis and
psychiatric staff. Using a cross-sectional design, we investigated associations between attachment dimensions, interpersonal difficulties and engagement in
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therapeutic relationships. We also explored associations between patient and staff perceptions of interpersonal difficulties and the influence of discrepancies
on therapeutic alliance. Results. Predicted associations between high levels of attachment anxiety and avoidance and interpersonal problems were partially
supported, with specific associations between attachment avoidance and interpersonal hostility and attachment anxiety and overly demanding behaviour. As
predicted, high levels of attachment avoidance were associated with difficulties in therapeutic relationships. Key workers identified more significant
interpersonal problems than patients identified themselves. Discrepancies in ratings of interpersonal problems were not significantly associated with poorer
alliance, but staff who identified patients as having more problems than patients identified themselves reported poorer alliance. The majority of effects were
maintained when controlling for the influence of severity of symptoms. Conclusions. Findings suggest that adult attachment style may be an important
predictor of interpersonal problems and difficulties in therapeutic relationships in psychosis over and above the severity of psychiatric symptoms. Attachment
theory has clinical implications, which may be particularly useful in developing more therapeutic relationships between psychiatric staff and patients.
Attachment dimensions and core beliefs about the self and others in undergraduate students.
Wearden A., Peters I., Berry K., Barrowclough C., and Liversidge T., University of Manchester, U.K.
According to attachment theory, early experiences with caregivers lead to the formation of working models of the self and others in relationships. Anxiously
attached people have a negative view of the self in relationships while those with avoidant attachment have a negative view of others in relationships. Our
study aimed to examine how reports of parental care-giving and anxious and avoidant attachment dimensions relate to the more general, core beliefs about
oneself and others that are implicated in cognitive models of psychopathology. Methods:In a cross-sectional study, undergraduate students at the University
of Manchester (n=389; 283 [73%] female; mean age 21.9 years, s.d. 5.25) completed the following questionnaires on a university web-site: the Psychosis
Attachment Measure (PAM; Berry et al., 2006), the Brief Core Schema Scale (BCSS; Fowler et al., 2006), the Descriptions of Parental Care-giving Style
scale (DCPS; Hazan & Shaver, 1986), the Positive and Negative Affectivity Scale (PANAS: Watson, Clark & Tellegen, 1988). Results:As hypothesised,
anxious attachment was correlated with negative core beliefs about the self (r=.592, p<.001) and with reports of anxious/ambivalent maternal care-giving
(r=.251, p<.001). Avoidant attachment was weakly correlated with negative core beliefs about others (r=.176, p=.001). Anxious attachment partially mediated
a significant association between anxious/ambivalent maternal care-giving and negative core beliefs about the self. Relationships between variables
remained significant when negative affectivity was controlled for. Conclusions:Attachment representations contribute to core beliefs about the self and
others. This finding both informs our understanding of psychopathology and may have implications for therapeutic relationships.
The effects of mood state on statements relating to behaviour change and informal reasoning processes in people with
psychosis and co-morbid substance abuse undergoing motivational interviewing.
Patricia Gooding and Christine Barrowclough*, University of Manchester, UK
The vast majority of studies investigating motivational interviewing (MI) have focused on comparing MI with other therapies on key outcome measures,
assessing the effectiveness of MI on such measures, and investigating which aspects of therapist competence are associated with successful outcome. To
date, there appears to be no published work exploring the interplay between cognitive-emotional processes and MI techniques in producing positive
behaviour change. A body of evidence indicates that negative emotional states narrow the range of cognitive processing, and that conversely, positive
emotional states broaden that range. Two cognitive processes are important in MI which may generalise to other therapeutic settings. First, given that MI
relies on exploring ambivalence to change with the client and facilitating them in producing their own rationale for behaviour change, then 'everyday' or
informal reasoning ability is essential. Second, the processes underlying commitment to change statements, and ensuing behaviour are central to MI. The
main goal of the proposed study was to investigate the effect of the emotional state of clients on the frequency and level of commitment to change
statements expressed by clients, and the type and frequency of arguments and evidence generated by clients. It is important to address this in all major
client groups, but particularly in those groups where cognitive processing may be particularly compromised, and where clients may experience a degree of
emotional lability. Hence, the focus of the present work was with clients who had a dual diagnosis of substance abuse and psychosis.
Determinants of the therapeutic relationship in the treatment of patients with psychosis and substance use
Petra Meier, Christine Barrowclough, University of Sheffield, UK;University of Manchester
There is good evidence that the quality of the therapeutic relationship (alliance) predicts treatment retention and outcomes. Findings on the determinants of
successful relationships are inconsistent, and as yet there is little evidence regarding factors influencing the therapeutic alliance in dual diagnosis patients.
The aim of the current study is to investigate the determinants of successful patient-therapist relationships in dual diagnosis treatment for psychosis and
substance use. 200 psychosis patients in the treatment arm of a randomised controlled trial on motivational interviewing were assessed at intake, covering
demographics, drug use, psychiatric morbidity, psychosocial resources, motivation for treatment, and treatment attitudes. Patients and therapists provided
alliance ratings after the second or third session of treatment. In this presentation, we explore a) which pre-treatment factors predict the quality of the
alliance, b) whether therapist and patient ratings of the alliance are predicted by a similar set of variables, c) the degree of concordance between therapist
and patient views on the alliance, d) therapist differences in alliance ratings
Symposium 4
Theory and Practice in Social Recovery Based Interventions in Psychosis
Convenor: David Fowler, University of East Anglia, United Kingdom
The Importance of Schizotypy in Recovery from Early Psychosis
Jo Hodgekins & David Fowler, 1University of East Anglia, United Kingdom
The symptom-disability gap in psychosis has long been established. Thus, even when psychotic symptoms remit, individuals still experience difficulties in
returning to premorbid levels of social functioning. It therefore appears likely that other factors are having an impact upon the recovery phase of the
disorder. It is important that the nature and role of such factors are highlighted, in order to design focused therapeutic interventions to target deficits in social
recovery.The main aim of this paper is to report on the association of time use (as a measure of social recovery) with clinical, psychological and
neuropsychological variables. This will be done using data from two studies: first a prospective study of over 100 consecutive referrals to a UK early
intervention service; and second, a study of over 70 cases who have entered an MRC funded randomised controlled trial of social recovery in early
psychosis: the Improving Social Recovery in Early Psychosis (ISREP) trial. These studies suggest that levels of non-psychotic, but distressing symptoms (in
particular schizotypal symptoms, paranoia and social anxiety); as well as appraisals of negative beliefs about the self and others; combined with
hopelessness and stigmatisation, may be associated with a lack of social recovery.Successful interventions to address social recovery in early psychosis
need to be based on psychological understanding of ongoing low-level symptoms, and also take into account the emotional impact and meaning of social
recovery to the person. The person can then be effectively prepared to make best of any social opportunities which can be provided. Early outcome data
from the ISREP trial, examining the effectiveness of such an intervention, will be discussed.
Possible selves, schema, and beliefs about illness in recovery from first episode psychosis
Lawrence Howells1, Gavin Taylor1, David Fowler2, 1Norfolk and Waveney Mental Health Partnership NHS Trust 2University of East Anglia, UK
Recovery from an initial psychotic episode is often measured by a reduction in the experience of positive symptoms. However, social, emotional and
behavioural adjustment is also vital for pre-morbid levels of functioning to be attained. The present study aims to further the understanding of associations
between psychological processes, depression and social recovery in first episode psychosis. Two measures of beliefs about the self and others were
conducted with a cohort of consecutive referrals to an early intervention service. The Brief Core Schema Scale (Fowler et al, 2006) is a self-report tool that
measures positive and negative beliefs about the self and others. The Possible Selves Interview examines hopes and fears for the future, and their relation
to the current self. These data will be used to explore the relationship between beliefs about the self and others with symptomatic and social recovery 3 - 6
months post referral to the service. It will also examine any longitudinal relationship using longer-term recovery data. The presentation will suggest that
negative beliefs about the self and others are associated with a lack of symptomatic recovery whereas poorly balanced possible selves are associated with a
lack of social recovery. References:Fowler, D., Freeman, D., Smith, B., Kuipers, E., Bebbington, P., Bashforth, H., Coker, S., Hodgekins, J., Gracie, A., Dunn,
G., & Garety, P. (2006). The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and
psychosis samples. Psychological Medicine, 36 (6). pp. 749-759.
The impact of trauma exposure and PTSD on social recovery in early psychosis
Corinna Hackmann & David Fowler, University of East Anglia, UK
Evidence suggests that environmental factors, such as childhood abuse, influence the development and course of severe psychiatric disorders. Research
suggests that levels of trauma and abuse are high in clinical populations (Read et al, 2006). Studies into the impact of trauma on psychosis have mainly
Page 38
focussed on associations with positive and negative psychotic symptoms (e.g. Read and Argyle, 1999). However, less is known about trauma and social
recovery in psychosis. This study utilises service outcome data from an Early Intervention in Psychosis service in Norfolk, to investigate the impact of lifetime
exposure to trauma and PTSD on social recovery following a first acute psychotic episode.
The role of attributional biases in vocational functioning: findings from an early psychosis sample
Miriam Fornells-Ambrojo1, Tom Craig2 & Philippa A. Garety2, 1 University College London, UK 2 Institute of Psychiatry, London, UK
Occupational functioning is severely impaired in people with psychosis, even at the early stages of illness. Poor vocational functioning is predicted by
neurocognitive deficits (memory, attention, executive functioning, problem solving), social factors (stigma and labour market), and by negative and positive
symptoms of psychosis. Attributional style has been shown to influence vocational behaviour in healthy volunteers. However, there has been no research
looking at the impact of attributions on the vocational functioning of people with psychosis. This is surprising given that people with psychosis have been
shown to have a bias for external attributions for negative events. The paper reports data from a study investigating if externalising attributional biases that
are typically associated with positive symptoms of psychosis play a role in the poor vocational functioning of people with early psychosis. A cross-sectional
design was used. Fifty participants with early psychosis completed measures on attributional style, executive functioning, dysfunctional attitudes, subjective
satisfaction with vocational status and symptom severity. Vocational functioning was assessed using case notes and interview. Although poor executive
functioning and positive symptoms were associated with poor vocational functioning, the externalising attributional style for failures emerged as a stronger
predictor of level of functioning in a sample of people with early psychosis. Further research is needed to investigate the direction of the relationship
between attributional style and vocational behaviour and the former's potential role in mediating the impact of symptoms and cognitive impairment on
Using virtual reality to measure community function in psychosis: the relationship with cognition and symptoms
KE Greenwood1, V White1, R Morris1, T Wykes1, 1 Institute of Psychiatry, London, UK
New pharmacological and rehabilitation interventions aim to improve cognition and in turn also social and community function in psychosis. There is a need
for brief standardised measures of community function which can be used to assess the outcome of these interventions. These should be validated against
real life function and its underlying cognitive processes.
People with psychosis were assessed on the same measures of community function (accuracy,
efficiency and redundancy) in two different supermarket shopping tasks(1)
A Real-Life Test (2)
A novel Virtual Reality Test All participants were
also assessed on cognitive measures that are known to associate with real-life community function (IQ, working memory, strategy use, response initiation),
as well as on social cognition which may differentially associate with the real-life compared to the virtual reality task. Measures of shopping correlated well
across the two types of assessment and some underlying cognitive processes correlated with shopping in both real-life and virtual reality. The role of
symptoms, including paranoia and anxiety, on functioning was also explored.
The virtual reality test provides a good estimate of functioning in real life
and is underpinned by some of the same cognitive processes. The use of virtual reality enables greater standardisation of the community environment and
so greater reliability of measurement of recovery.
Symposium 18
The PRP Trial Results: The Psychological Prevention of Relapse in Psychosis
Convenor: Philippa Garety, King's College London, Institute of Psychiatry, UK
Introducing the PRP trial: Methodology
Freeman, D., Garety, P., Kuipers, E., Fowler, D., Kuipers, E., Bebbington, P., Dunn, G., Institute of Psychiatry, King's College London, U.K.
The PRP Trial is a UK multi-centre randomised controlled trial of cognitive behaviour therapy and family intervention for psychosis, designed to answer
questions both about outcome and the psychological processes associated with psychosis. The trial ran from 2001 to 2006. Three hundred and one
patients with a relapse of psychosis took part. In this presentation the key questions, design, and methodology of the trial will be outlined. It will be
highlighted how the trial is a methodologically robust evaluation: all patients with a relapse of psychosis in the trial centres were approached to participate;
randomisation was conducted by an independent centre; therapy and assessments were closely monitored; assessors were blind to allocation; and very
high follow-up rates were obtained (96% for the key outcome variable).
An overview of the PRP trial results
Garety, P.A., Fowler, D.G.,, Freeman, D., Bebbington, P., Dunn, G., & Kuipers, E., Institute of Psychiatry, King's College London, U.K.
The preliminary PRP trial results will be summarised in this presentation, together with a discussion of their interpretation. The outcome measures for the
trial were independent blinded assessments of relapse and rehospitalisation at the end of treatment (12 months) and at 24 months, and symptoms and
social functioning assessed pre-treatment (0 months) at end of treatment (12 months) and at 24 months. There was a total sample of 301 participants in two
arms (for those with carers and those without carers). A total of 133 were allocated from both arms to CBT and 28 to Family Intervention (carer arm only),
while the remaining 140 participants were allocated to treatment as usual. Those allocated to CBT received a mean of 14.4 sessions (s.d. 7.8) and to FI 13.9
sessions (s.d. 7.5) The majority of participants had a full 'dose' of therapy, defined as at least 12 sessions; this applied to 66.2% of CBT and 71% of FI
allocations. The interpretation and implications of the outcome findings for the future delivery of CBT and FI will be discussed. The discussion will consider
stage of illness (acute, relapsing, stable), selection and motivation for psychological treatment, therapy targets (relapse, distress and depression, positive
symptoms, functioning), choice of CBT or FI, and the intriguing possibility of superior outcomes for those with carers.
Studies of the process of therapy within the PRP trial of CBT for relapse prevention
Fowler, D., Rollinson, R., Jolley S., Smith, B., Freeman, D., Garety, P., Kuipers, E., Bebbington, P., Dunn, G, University of East Anglia, U.K.
This paper will describe preliminary results from studies of therapy process conducted during the course of the PRP trial. These studies involved the
refinement and development of tools to assess adherence and competence of CBT and therapists and patients experience of sessions. We will use the
results from these instruments to describe the therapy undertaken in the trial in depth. A further aim of these studies was to undertake a sophisticated
statistical analysis of the association between therapy dose and type and outcome. Most existing methods which attempt simply to examine associations
between therapy process and outcome fail to take full account of the influence of confounding factors such as pre-existing patient characteristics on
outcome. In this paper we report the results of an analysis of associations between therapy process and outcome in the PRP trial which is based on CACE
(instrumental variable IV) methodology which may provide a better estimate of the effect of therapy on outcome taking account of such confounds.
Outcomes in those with carers in PRP.
Elizabeth Kuipers, Paul Bebbington, David Fowler, Daniel Freeman, Graham Dunn & Philippa Garety., Institute of Psychiatry, London, U.K.
In the carer arm of the study we recruited 83 carers and participants and compared family intervention (FI) (N=28), cognitive behavioural therapy (CBT)
(N=27) and treatment as usual (TAU) (N=27). Across the whole trial 132 participants had carers (some of whom had not given consent to their carer's
participation in the trial). We did an exploratory analysis on this combined group. The implication of these analyses for clinical work in psychosis will be
Life events: a confounding effect on treatment?
Paul Bebbington, Graham Dunn, David Fowler, Daniel Freeman, Philippa Garety & Elizabeth Kuipers, University College London, U.K.
The main features of the design and methods of the PRP (Prevention of Relapse in Psychosis) have been described in detail in this symposium. There is
considerable evidence that stressful life events are associated with relapse and symptom exacerbation in psychosis. We therefore included an assessment
of life events occurring to participants during the course of the trial. Events were assessed retrospectively at the 12 and 24 month assessment points. We
used the Life Events and Difficulties Schedule of Brown & Harris, and rated events in terms of stressfulness, loss, danger, humiliation and intrusiveness.The
impact of events on symptoms rated as 12 and 24 months will be presented, together with an indication of any confounding of treatment effects.
Changing illness perceptions in CBT for psychosis: a case example from both the client's and therapist's perspective
Ben Smith, Brendan O'Sullivan, Philip Watson, Daniel Freeman, Elizabeth Kuipers, David Fowler, Paul Bebbington & Philippa Garety, University
College London & North East London Mental Health Trust, U.K.
This paper describes a case example of CBT for psychosis with a focus on changing illness perceptions. The case is described from both the client's and
therapist's perspective in order to explore what both parties believe changed in CBT. The outcome of this case example is then linked to theoretical accounts
of the role of illness perceptions in psychosis. For instance, cognitive models of psychosis propose that appraisals concerning the nature of the psychosis
Page 39
will influence the maintenance or recurrence of symptoms through coping responses, emotional impact and cognitive processes (e.g. Garety et al, 2001).
Furthermore, one possible origin of emotional dysfunction in psychosis is from a psychological reaction to the psychosis itself (Birchwood, 2003). Finally,
clinical implications are discussed again from both the perspective of the client and the therapist. CBT should emphasise that having a psychotic disorder
does not necessarily equate to a lifetime of uncontrollable illness, but that steps can be taken to improve coping and reduce the impact of symptoms.
Symposium 32
Cognitive behavioural approaches to the prevention of psychosis
Convenor: Mike Startup University of Newcastle, Australia
Cannabis use as a complication in psychological treatments for people at ultra-high risk of psychosis: early findings from the
DEPTh trial.
Mike Startup, Vaughan Carr, Amanda Baker, and Ulrich Schall, Helen Stain, Sean Halpin & Sandra Bucci,, University of Newcastle, Australia
The DEPTh project is a randomised controlled trial comparing the effectiveness of cognitive behaviour therapy (CBT) and person-centred therapy for the
prevention of psychosis among young people who are at ultra-high risk. It is being conducted on two sites in New South Wales: the Hunter Valley and the
Greater Western Area. The CBT is modelled on the manual developed by Paul French and Tony Morrison in the UK. That form of CBT has been shown in
one trial to be effective in preventing transition to psychosis. However, it does not include any techniques that specifically focus on the reduction of
substance abuse even though such abuse, especially of cannabis, is known to be very high among people who are at ultra-high risk, and cannabis use has
been found in prospective studies to be associated with the later onset of psychosis. Therefore, we have adapted French & Morrison's CBT by integrating it
with a manual for motivational interviewing (MI) with young cannabis users. The ways in which CBT and MI are integrated in the DEPTh project will be
illustrated with case material.
Comparison of CBT with Neuroleptic Medication
Lisa Phillips & Shona Francey, University of Melbourne, Australia
The first trial to directly compare the relative benefits of cognitive-behavioural therapy (CBT) with those of neuroleptic medication is being conducted at the
PACE Clinic, Melbourne, Australia. Previous trials conducted at PACE and elsewhere have demonstrated benefits of CBT and medication alone and in
combination. 116 young people meeting PACE UHR criteria consented to involvement in the trial and were randomly assigned to one of three treatment
groups: low-dose risperidone (up to 2mg) and intensive CBT versus placebo and intensive CBT versus placebo and supportive therapy. Treatment was
provided for 12 months followed by a 12 month follow-up phase. Another 46 young people who met UHR criteria did not consent to involvement in the trial
but did consent to regular assessments to determine if full-blown psychosis developed. Six months after commencement of treatment there were no
differences between the groups in transition rate to psychosis but the combined treatment group reported lower levels of functioning and higher levels of
negative symptoms than the other groups. Further data analysis is required but these early results suggest a possible advantage of the two types of
psychological treatment (CBT and supportive therapy) alone compared to combined CBT and neuroleptic medication. These early results will be discussed
in light of changes in the nature of referrals to the PACE Clinic in more recent years, and the implications of these changes for the types of interventions
offered to young people at heightened risk of psychosis.
Access, Detection and Psychological Treatments (ADAPT) for those at clinical high risk of psychosis
J Addington, I, Epstein & R. Zipursky, University of Toronto, Canada
There is evidence that psychological interventions may have an impact on conversion to psychosis. The aim of the ADAPT study is to determine the
effectiveness of different psychological treatments. ADAPT study, funded by the Ontario Mental Health Foundation (Canada), compares two psychological
treatments for people at risk of developing a psychotic illness (CBT versus a control treatment).Specific aims are to determine (i) whether these treatments
delay or even prevent the onset of psychosis for those who are at risk for psychosis; (ii) whether these treatments are helpful in treating the symptoms and
concerns for which clients seek help;( iii) the pathways that people take when they are trying to get help and the obstacles that may get in their way; and (iv)
the economic and psychological costs to the family. In this large randomized control trial participants are randomized to cognitive-behaviour therapy based
on the French & Morrison Manual from the EDIE trial or supportive therapy for 6 months. During the course of the therapy we will monitor symptoms monthly
and then at three monthly interviews. Participants will be followed for one year after therapy to determine the benefits. Individuals who participate in this
study have access to case management and psychiatric management. Educating communities, recruiting participants, training therapists in this manualized
approach and determining outcome with respect to treating young people who appear to be at risk will be discussed. Baseline and preliminary follow-up data
for the first 50 subjects will be presented.
Cognitive therapy for the prevention of psychosis in people at ultra-high risk: results of a randomised controlled trial
Anthony P. Morrison, University of Manchester, U.K.
There have been recent advances in the ability to identify people at high risk of developing psychosis. This has led to interest in the possibility of preventing
the development of psychosis, although there are clearly ethical dilemmas associated with such a preventative approach. A randomised controlled trial
compared cognitive therapy (CT) with treatment as usual in 58 patients at ultra-high risk of developing a first episode of psychosis. CT was provided within
the first six months, and all patients were monitored on a monthly basis for 12 months. Logistic regression demonstrated that CT significantly reduced the
likelihood of making progression to psychosis as defined on a semi-structured psychiatric interview over one year. In addition, it significantly reduced the
likelihood of being prescribed antipsychotic medication and of meeting criteria for a DSM-IV diagnosis of a psychotic disorder. Participants were also
followed up over a three-year period (follow up rate at 3 years was 47%). Logistic regression demonstrated that CT significantly reduced likelihood of being
prescribed antipsychotic medication over a three-year period, but it did not affect transition to psychosis defined using the PANSS or probable DSM-IV
diagnosis. However, exploratory analyses revealed that CT significantly reduced the likelihood of making progression to psychosis as defined on the PANSS
over 3 years after controlling for baseline cognitive factors. There appear to be some enduring benefits of CT over both one and three years, suggesting it is
an efficacious intervention for people at high risk of developing psychosis. The design of a new multi-centre trial will also be described.
Preventing Transition to Psychosis in a Community Mental Health Setting: The experience of ED:IT, Birmingham, UK
Amanda Skeate, Paul Patterson, Max Birchwood,, University of Birmingham, UK
Since 2002, the Birmingham Early Detection & Intervention Team (ED:IT) have utilized the criteria developed by the PACE clinic, Melbourne, Australia (Yung
et al., 1996) to detect individuals at ultra high risk (UHR) of developing a psychotic disorder. The experience of ED:IT confirms that young people at
imminent risk of psychosis describe high levels of emotional distress, with 35.7% of clients reporting at least one previous suicide attempt and 65%
complaining of suicidal ideation at baseline assessment. Furthermore, in spite of traditional mental health services often perceiving these clients as 'not ill
enough' to require treatment, clients rate as having (on average) a moderate to substantial level of disability on the Global Assessment of Functioning scale,
and 68% of clients assessed had one or more co-morbid diagnosis. The type of treatment offered needs to be carefully considered, balancing uncertainties
around diagnosis with a need for intervention to prevent worsening of symptoms and reduction of distress in this client group. Birmingham ED:IT provides
an individually tailored cognitive behavioural approach based on the protocol developed and evaluated by Morrison et al. (2002) in a randomised controlled
trial. Operating within a moderated Assertive Outreach model, this intervention appears to be acceptable to many young people referred to ED:IT. In this
presentation the service will be described with particular reference to intervention and preliminary outcome data will be reported.
Symposium 48
CBT in Early Psychosis:what should the focus be?
Convenor: Anna Meneghelli, Ospedale Niguarda Milano, Italy
The challenge of engagement in first episode psychosis: positive symptomatology and case formulation.
Bislenghi,L., Meneghelli,A., Caprin, C., Cocchi, A., Ospedale Niguarda Milano
Cognitive-Behavioural Therapy with attenuated positive symptoms in persons with ultra-risk of psychosis.
Lemos, S.*, Vallina, O.**, Fernández, P.*, García, P. **, Gutiérrez, A. ** & Ortega J.A.**, University of Oviedo, Italy
Page 40
Depression, negative symptoms and social dysfunctioning. Evaluation and CBT procedures in a multidimensional program.
Meneghelli, A., Caprin, C., Cocchi A.,
The effects of CBT in improving social recovery in early psychosis: the results of ISREP trial.
Fowler D., Hodgekins, J., PainterM., Reilly, T., Crayne,C., Croudace, T., Jones, P., University of East Anglia, Norfolk
Social phobia in early psychosis:incidence and preliminary outcomes with computer-aided self-help.
Gega, L. and Fowler, D.,
No abstracts available
Symposium 61
New developments in the psychology of bipolar disorder
Convenor: Steven Jones, University of Manchester, UK
Self-dispositional appraisal, approach motivation and affect in hypomanic personality
Steven Jones, David Ankers, University of Manchester, UK
The presentation will describe studies which have explored the relationships between a new measure of positive self dispositional appraisal and mood and
self esteem in individuals at behavioural risk of hypomania In the first study 870 participants completed the Hypomanic Personality Scale as a measure of
behavioural risk. They also completed measures of normal and pathological mood, self esteem and positive self dispositional appraisals. In a second study
30 participants at high behavioural risk and 30 participants at low behavioural risk of hypomania were study over a week long period. These participants, in
addition to the above measures, completed seven day actigraphic recordings to provide sleep and circadian activity data. They also recorded daily events
experienced and daily mood. Actigraphic data was also used to explore behavioural responses to particular events. These studies indicate the importance of
both cognitive and motivational approaches to the understanding of risk of hypomania. The data will illustrate the relative importance of self dispositional
appraisal and behavioural activation and behavioural inhibition system sensitivity in predicting mood instability and responses to daily events. The relation
between both variables and objective and subjective markers of circadian rhythm disruptions will also be reported. These results are pertinent both to
developing theories of bipolar disorder and to understanding more about how to further refine psychological approaches to treatment
Specific Cognitive Vulnerabilities in remitted Bipolar I Disorder versus remitted Unipolar Depression and Non-Clinical Controls
Warren Mansell, Gemma Paszek, Rebecca Pedley, University of Manchester, UK
A recent model (Mansell, Morrison, Reid, Lowens & Tai, 2007) proposes that people with bipolar disorders hold a multiple, extreme, personal, conflicting
(e.g. positive and negative) beliefs about changes in their internal state that bias their processing and behaviour in ways that make them vulnerable to mood
swings. This study assessed the specificity of cognitive vulnerabilities using both remitted bipolar and unipolar participants, in addition to healthy controls:
hypomanic attitudes (HAPPI; Mansell, 2006; Mansell & Jones, 2006, e.g. “When I feel really good, people don't understand me”, “When I feel restless, the
world is full of unlimited opportunities for me”), selective attention to words varying in level of valence and intensity (e.g. 'relaxed' - 'dynamic'; 'lifeless' 'domineering'); and use of video-presented advice during a goal directed task (extending Mansell & Lam, 2006, who found rejection of advice in high moods
to be specific to bipolar disorder). Measures were taken before and after a high video mood induction. Participants were followed up for one month to assess
predictors of mood variation and onset of mood episodes. Early findings are largely consistent with the model. For example, preliminary analyses indicate
that the bipolar group scored higher than both other groups on the HAPPI even when controlling for age, gender and level of education. When also
controlling for level of current depression, this effect held only for certain classes of items on the scale. The findings are aimed to inform future developments
of the HAPPI, and help improve cognitive behavioural interventions.
Cognition in Bipolar Disorder: Ambitious life goals
Sheri Johnson, Charles Carver, Lori Eisner, University of Miami, USA
Theory and data have suggested that bipolar disorder is characterized by heightened sensitivity to rewards. Less is known about cognitive processes that
are related to reward sensitivity. Our research is focused on understanding how people with bipolar disorder think about rewards and successes, and how
this influences life ambitions. We developed a scale to assess unrealistically high life ambitions, the WASSUP. In three studies, we found that
undergraduate students at risk for bipolar disorder endorse extremely high life ambitions compared to control participants. Life ambitions were particularly
high for extrinsically-oriented goals, such as earning wealth and becoming famous. In a fourth study, mood disorders were diagnosed on the basis of the
Structured Clinical Interview for DSM-IV. Persons with bipolar spectrum disorder (n = 21) endorsed significantly higher life ambitions on the WASSUP
compared to those with major depression (n = 21) and those with no disorder (n = 42). These results suggest that people with bipolar disorder aspire to
success in domains involving public recognition, consistent with the goal dysregulation model of mania.
The Role of Instability of Affect and Self-Esteem in Bipolar Disorder (Working Title TBC)
Richard Bentall, University of Manchester, UK
Richard Bentall will present data from his work evaluating the role of instability of affect and self esteem in bipolar disorder
Symposium 77
Enahnced Relapse Prevention for Bipolar Disorder
Convenor: Fiona Lobban, University of Manchester, UK, England
Feasibility study of training Care Coordinators to offer Enhanced Relapse Prevention (ERP) for Bipolar Disorder - rationale and
study design
Fiona Lobban, Carrol Gamble, Peter Kinderman, Lee Taylor, Claire Chandler, Elizabeth Tyler, Sarah Peters, Eleanor Pontin, William Sellwood, &
Richard K. Morriss, University of Manchester, UK
Bipolar Disorder is a common and severe form of mental illness characterised by repeated relapses of mania or depression. Pharmacotherapy is the main
treatment currently offered, but this has only limited effectiveness. A recent Cochrane review has reported that adding psycho-social interventions that train
people to recognise and manage the early warning signs of their relapses is effective in increasing time to recurrence, improving social functioning and in
reducing hospitalisations. However, the review also highlights the difficulties in offering these interventions within standard mental health services due to the
need for highly trained therapists and extensive input of time. There is a need to explore the potential for developing Early Warning Sign (EWS) interventions
in ways that will enhance dissemination.This presentation describes a cluster-randomised trial to assess the feasibility of training care coordinators in
community mental health teams (CMHTs) to offer ERP to people with Bipolar Disorder. CMHTs in the North West of England are randomised to either
receive training in ERP and to offer this to their clients, or to continue to offer treatment as usual (TAU). The main aims of the study are (1) to determine the
acceptability of the intervention, training and outcome measures (2) to assess the feasibility of the design as measured by rates of recruitment, retention,
attendance and direct feedback from participants (3) to estimate the design effect of clustering for key outcome variables (4) to estimate the effect size of the
impact of the intervention on outcome.
Enhanced Relapse Prevention manual, training and supervision
Lee Taylor, Fiona Lobban, Peter Kinderman, & Richard Morriss, Pennine Care NHS Trust, Manchester, UK
The training manual was designed as an easy to use booklet, divided into four chapters: 'Understanding Relapse Prevention'; 'How to do it'; 'All the Materials
you will Need'; 'Further Help'. The chapter, 'How to do it' was divided into six sections, outlining each of the intervention sessions. To facilitate the learning
process, the training followed the same 6-session format. This session will provide an outline of ERP manual, a description of the how the training was
implemented, and a reflection on the supervision process. Key issues to be covered will include linking theory to practice, techniques to ensure a positive
and practical learning experience, practicalities of training NHS staff, and ensuring adherence to the manual.
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How feasible is it to train Care Coordinators in Enhanced Relapse Prevention?
Claire Chandler, William Sellwood, Lee Taylor, Fiona Lobban, Peter Kinderman, Carol Gamble, Elizabeth Tyler & Richard Morris, University of
Liverpool, UK
The feasibility of training care coordinators in community mental health teams to offer ERP to people with Bipolar Disorder was assessed in a number of
ways including (1) rates of recruitment and retention of Care Coordinators, people with Bipolar Disorder and their relatives into the study; (2) Care
Coordinator feedback on the quality and impact of the training and supervision on their work with people with Bipolar Disorder; (3) Assessment of Care
Coordinator competency in offering ERP following training and supervision. The results from each of these will be presented and discussed. The impact of
ERP on relapse rates for people with BD was also explored. This study is ongoing but an outline of the methods used to assess this will be presented.
The story behind the numbers - a qualitative exploration of the barriers and solutions to offering Enhanced Relapse
Prevention in the NHS.
Ellie Pontin, Sarah Peters, Fiona Lobban, Anne Rogers, & Richard Morriss, University of Liverpool, UK
The aim of our qualitative study was to explore, from the perspectives of case managers, service users and relatives, the value of, and barriers to
implementation and effectiveness of ERP. Using a qualitative methodology, semi-structured interviews were conducted with a purposive sample of 50
participants including service users, relatives and case managers. Data were analysed using an iterative approach to develop conceptual categories from
the dataset. All groups perceived ERP to have value in reducing the severity and number of relapses. Not only did the intervention increase awareness and
recognition of early warning signs, triggers and coping strategies it also enhanced the relationship and communication between case managers, service
users and relatives by offering a collaborative and structured approach to their time together. A range of barriers to the implementation and effectiveness of
ERP were identified. Service users found components of the intervention emotionally and cognitively challenging and engagement was influenced by their
understanding of bipolar disorder. ERP was perceived as increasing the complexity of the case manager's role and their workload and added to their
balance of other work demands and service user needs. Consequences were problems of dissemination and concerns over long term maintenance.
Recommendations to overcoming individual and organisational barriers to delivery of ERP will be discussed along with implications for future training of case
Enhanced Relapse Prevention - discussion and conclusions
Richard Morriss, University of Nottingham, UK
To be drawn from the content of the symposium.
Symposium 106
Cognitive Remediation Therapy In The Treatment of Schizophrenia
Convenor: Rafael Penadés, Clinical Institute Of Neurosciences, Hospital Clinic, Barcelona (Spain), Spain
Developing a metacognitive theory for how cognitive change impacts behaviour following Cognitive Remediation Therapy
(CRT) for people with a diagnosis of schizophrenia
Clare H. Reeder, Ph.D., Institute of Psychiatry, Kings College, UK
There is an increasing drive to demonstrate that CRT leads to improvements not only in cognition, but also in social functioning and symptoms. However,
there is no well-established theory of how cognitive changes might impact behaviour. There is preliminary evidence that not all cognitive changes lead to
functioning improvements, and that this depends on the specific cognitive targets and whether the cognitive change has been achieved in the context of
CRT. This study investigates (a) the association between specific executive function and memory improvements and improvements in social functioning and
symptoms, and (b) the moderating role of CRT. 85 people with schizophrenia and cognitive inefficiency were assessed on executive and memory measures,
the PANSS and the Social Behaviour Schedule. They were randomised to receive 40 sessions of individual CRT or treatment-as-usual and re-assessed
immediately post-therapy. Cognitive change was assessed using three executive/working memory factors, (i) 'verbal working memory', (ii) 'response
inhibition' and (iii) 'schema generation'; and composite verbal and visuo-spatial long-term memory measures. Improvements in only the 'schema generation'
scores were predictive of improved social functioning and negative and disorganised symptoms, regardless of treatment group. There was no evidence for a
moderating effect of CRT. The ability to generate new schemas seems therefore to be a good target for intervention in order to achieve improved social
functioning and symptoms. It is argued that this ability relies on metacognitive functioning, and a new model will be presented in which metacognition plays a
key role in explaining how cognitive change impacts behaviour.
Specificity of Cognitive Remediation Therapy in the treatment of chronic Schizophrenia
Rafael Penades, Clinical Institute of Neurosciences, Barcelona, Spain
Cognitive Remediation Therapy (CRT) is a novel treatment based on the errorless learning approach designed to improve adaptative functioning by using
cognitive compensatory strategies to bypass the cognitive deficits associated with schizophrenia. Cognitive Behavioural Therapy (CBT) is a useful treatment
for psychotic symptoms and emotional problems that is not expected to have effects on neurocognition. The effect of both treatments were tested on
neurocognition, symptomatology and psychosocial functioning. A total of 40 chronic patients with DSM-IV schizophrenia disorder, cognitive impairments and
prominent negative symptoms were randomly assigned for 4 months to one of the two treatment conditions: 1) standard medication plus CRT, 2) standard
medication plus CBT. Comprehensive assessments were conducted before and after the treatments (CRT or CBT) and at the end of a follow-up period of 6
months. CRT has a specific treatment effect on Psychomotor Speed, Verbal and Non-verbal Memory, and Executive Function. Patients receiving CRT
showed greater mean differences and more large effect-size changes (Mean effect size = 0.5) than did patients receiving CBT. CBT only showed a little nonspecific improvement in Working Memory. Patients receiving CRT achieved improvements in social functioning, showing that cognitive improvements are
clinically meaningful. These gains were not vanished after the 6 month follow-up. These results support the specificity of CRT in improving neurocognition
and social functioning. CBT was useful in improving emotional symptoms. This study adds to the growing evidence of the efficacy of cognitive remediation
treatments in improving neurocognition and the complementary function of CBT in chronic and negative schizophrenia
Training of mnemonic strategies in schizophrenia
Gudrun Sartory, University of Wuppertal, Germany
Patients with schizophrenia were found to show different neural activity during encoding of word lists compared to healthy controls (Heinze et al., 2006).
Whereas the latter recalled words that were associated with parietal activation during learning, patients with schizophrenia recalled words whose encoding
was accompanied by occipital activation, indicative of a visualizing strategy. The present study aimed at comparing the success of training a visualization
strategy with that of rehearsal. Thirty-three patients with chronic schizophrenia of a mean duration of 11 years were randomly allocated to either the
visualization or the rehearsal group. All patients were clinically stabilized and on medication during training. During training patients were presented with 7
lists of words. Patients of the visualization group were asked to imagine the words and consider the colours, size and context of the named objects. The
rehearsal group was asked to silently repeat the words. Each list was recalled immediately. A final test list was presented after a rest period.
Neuropsychological tests were given the day before training and the test list was to be recalled again the day after. Visualization conferred a marginal
benefit during recall of the training lists not, however, during recall of the test list. The day after, patients recalled either none or one of the words of the test
list. The results suggest either that a brief training such as the present one is insufficient or that visualization does not improve memory performance in
schizophrenia. Heinze, S., Sartory, G., Müller, B. et al. (2006) Neural activation during successful verbal learning in schizophrenia. Schizophrenia Res. 83,
Empirical evidence for integrated group therapy in schizophrenia: the Integrated Psychological Therapy (IPT) and the
Integrated Neurocognitive Therapy (INT)
Daniel R. Mueller, PhD, Marc Laechler, PhD, and Volker Roder, PhD, University Hospital of Psychiatry Bern, Switzerland
Currently it seems to be a generally accepted therapeutic goal to enhance neurocognitive functions in schizophrenia patients by cognitive remediation
approaches. Group-based integrated therapy represents one of these approachesThe Integrated Psychological Therapy (IPT) is one of the first
comprehensive integrated treatment approaches for schizophrenia patients. This cognitive behavioural group therapy focuses on neurocognition, social
cognition and social competence. Over the past 25 years, research groups in Europe, America and Asia have conducted 33 independent evaluation studies
on IPT including 1476 patients. A meta-analysis found superior effects of IPT in neurocognition and social cognition, social behaviour and psychopathology
compared to control conditions. The combination of neurocognitive and social cognitive IPT sub-programs showed higher effects than the neurocognitive
sub-program alone.During the past two years we designed a cognitive-behavioural group therapy program (INT) as further development of the cognitive part
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of IPT. INT is partly computer based and intends to restitute and compensate neuro- and social cognitive (dys)functions. The program is embedded in the
daily living context of the patients and starts from their resources with a special focus on facilitating intrinsic motivation. The INT-manual contains exercises
to improve neurocognitive and social cognitive functioning. Currently we evaluate INT in a randomized international multi-centre study. INT is compared with
standard care of outpatients. First results show better outcome of INT in neurocognitive variables, emotion perception, self-rated motivation and selfefficacy.Results of IPT and INT evaluations confirm the importance of group-based integrated therapy to optimize rehabilitation.
The Efficacy of Cognitive Remediation in the Treatment of Schizophrenia: Conclusions from Meta-Analyses
Mario Pfammatter, Ulrich Martin Junghan & Hans Dieter Brenner, University Hospital of Psychiatry Bern, Switzerland
Over the past decade several cognitive training approaches have been developed to improve cognitive deficits in schizophrenia patients. However, health
care systems are challenged by serious financial constraints. Therefore, decisions about what treatment to provide for whom must be based on evidence. A
series of meta-analyses have evaluated the benefits of cognitive remediation in schizophrenic patients. The present contribution aims to provide a
comprehensive survey of the evidence for the efficacy of cognitive remediation as derived from these meta-analyses and the findings from an own recent
meta-analysis of all existing randomized controlled trials. Relevant meta-analyses and randomized controlled trials were identified by searching several
electronic databases and by hand-searching of reference lists. In order to compare the findings of the existing meta-analyses the reported effect sizes were
extracted and transformed into an uniform effect size measure. For the own meta-analysis weighted mean effect size differences between comparison
groups regarding various types of outcome were estimated. Their significance was tested by confidence intervals and heterogeneity tests were applied to
examine the consistency of the effects. There are marked discrepancies between the findings of the existing meta-analyses depending on the rigor of the
study inclusion criteria as well as the homogeneity of the included approaches with regard to their contents and targets. The present meta-analysis provides
support for short-term improvements in attention, executive functioning and social cognition. It demonstrates small to medium, but robust beneficial effects
on these functions. It also indicates small reductions in negative symptoms and a moderate transfer effect on social functioning. However, follow-up data are
entirely lacking. There is sound evidence for the short-term efficacy of cognitive remediation regarding certain cognitive functions. This evidence is based on
numerous studies that have been summarized in a series of meta-analyses over the past two decades. However, several important questions are still
awaiting an answer. Since the available studies on cognitive remediation are based on short periods of observation, the durability of these achievements in
cognitive functions remains unclear. Moreover, the strategies and techniques of the different cognitive remediation approaches vary considerably. Therefore,
it may not be justified to summarize them under the same label. For future research there is a clear need to evaluate the functional relevance of specific
cognitive profiles for certain instrumental and social requirements of daily life. This may help define the corresponding treatment targets and identify the
essential common therapeutic components regarding the strategies and techniques of cognitive remediation that relate to these contents. Further questions
arise regarding the synergistic effects of cognitive remediation and other therapy or rehabilitation approaches.
Symposium 119
Advances in the understanding of paranoia
Convenor: Miriam Fornells-Ambrojo, (1) Institute of Psychiatry & (2) University College London, UK
Theories of paranoia: All are winners and all must have prizes
Richard Bentall1 (speaker), Rhiannon Corcoran2, Peter Kinderman3, Georgina Rouse4, Nick Shryane1, Nigel Blackwood5 and Rob Howard5,
Universities of Manchester, UK; Nottingham2, Liverpool3, Sheffield4 and the Institute of Psychiatry, London5
Apparently competing models of paranoia suggest that it may be related to (a) abnormal attributions; (b) a tendency to jump to conclusions (JTC bias); and
(c) theory of mind (ToM) deficits. Previous research into these processes has often been confounded by failure to consider delusions in non-schizophrenia
groups and also comorbid symptoms such as depression. We measured attributions, self-esteem, mood, JTC bias, ToM and other variables (sometimes
using multiple measures) in schizophrenia patients with paranoia, schizophrenia patients who had recovered from paranoid delusions, paranoid depressed
patients, non-paranoid depressed patients, elderly patients with late onset psychosis, depressed elderly patients, and controls matched to both the young
and old patients. We used structural equation modelling to examine relationships between the variables. The best model implicated all of these variables.
JTC and ToM seemed to be closely associated with more general executive dysfunction.
Covariation Assessment for Neutral and Emotional Stimuli, Attributional Biases and Symptom Severity in Persecutory
Carmelo Vázquez, Ph.D.Cristina Díez-Alegría, Ph.D.María J. Hernández-Lloreda, Ph.D. Carmen Valiente, Ph.D., Universidad Complutense Spain;
School of Psychology
The aim of this study were to explore whether patients with persecutory delusions would show biases when judging covariation of emotionally threatening
stimuli and to what extent those biases would be related both to attributional biases and symptom severity. We assessed estimations of covariation in acute
deluded paranoid patients, remitted deluded patients, and a normal control group. Our results show that all participants made precise estimations of
covariation when judging covariation in neutral sentences. Yet, when using sentences related to social threat, the acute deluded patients were the only group
showing a bias consisting of overestimating the number of sentences that were related to themselves. Mediational analyses of the relationships among
covariation, attributional biases, and psychopathological symptoms showed that both covariation biases and attributional biases were directly associated to
the severity of participants' delusions. The implications for understanding of the role of self-referent information processing biases in delusion formation are
New experimental studies of persecutory ideation.
Dr Daniel Freeman, Institute of Psychiatry, King's College London, UK
Paranoia denotes the fear that others intend to cause you harm. It occurs most dramatically as delusions of persecution, but is related to suspicious
thoughts that occur in 10-20% of the general population. In this talk recent advances in the psychological understanding of paranoid thoughts carried out by
the presenter and colleagues will be described. In particular, studies of paranoia in the laboratory using virtual reality will be presented. Emphasised in the
psychological understanding of paranoia are: affective processes, especially anxiety, worry, and inter-personal sensitivity; anomalous experiences, such as
hallucinations, which may be caused by contextual processing difficulties and street drug use; reasoning biases, particularly the belief confirmation bias,
jumping to conclusions, and belief inflexibility; and social factors, such as isolation and trauma. This work has been used to inform the first self-help book on
the topic, Overcoming Paranoid and Suspicious Thoughts (Freeman et al, 2006).
Understanding attributional biases, emotions and self-esteem in paranoia: findings from an early psychosis sample
Miriam Fornells-Ambrojoa & Philippa A Garetyb, aUniversity College London, UK;b Institute of Psychiatry, London, UK
Trower & Chadwick (1995) proposed an understanding of persecutory beliefs in the context of an interpersonal theory of the self. Their theory of two types of
paranoia ('poor me' and 'bad me') highlights the potential role of anger and guilt.The current study investigates attributions and emotions in a sample of
people with early psychosis who have persecutory delusions. 'Poor me' paranoia has been found to be more frequent than 'bad me' paranoia in the early
stages of psychosis. Anger and a tendency to blame other people are hypothesised to characterise 'poor me' paranoia. Twenty individuals with early
psychosis with 'poor me' persecutory delusions, 21 clinical controls with depression and 32 healthy volunteers completed a thorough assessment of
emotions and attributions. The 'poor me' paranoia group showed high levels of anger, anxiety, depression and a tendency to blame others but not
themselves. Self-esteem and guilt were preserved. Anger, but not self-esteem, was associated with an attributional bias characterised by blaming other
people instead of oneself. In conclusion, anger, a previously overlooked emotion in the study of persecutory delusions, warrants further attention. The otherdirected nature of this emotion highlights the potential role of interpersonal schemas in understanding paranoia.
Aversive learning mechanisms relevant to the development and maintenance of persecutory syndromes
Michael Moutoussis & Richard P. Bentall (In collaboration with Jonathan Williams and Peter Dayan), University of Manchester, UK
Theories of delusions often underplay the role of their content, possibly due to the historical bias in thinking of the form of thoughts as more important than
their content. Recent research, however, has established that content is important. People suffering from persecutory ideation display specific abnormalities
in considering and predicting aversive, threatening events even if affective and heuristic variables are controlled for. With respect to persecutory delusions,
taking threat as fundamental suggests that models of threat-related, aversive learning, such as the Conditioned Avoidance Response (CAR) task, might offer
valid insights into the underlying normal and abnormal processes. Temporal-difference models have made significant contributions to the understanding of
the role of brain mechanisms in appetitive learning, thus bridging biological and psychological aspects of learning. However, understanding of the
corresponding mechanisms in aversive learning is rather less advanced. These mechanisms are likely to be involved in the psychology and biology of
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human psychotic fears and hence have great clinical importance. We developed temporal-difference based models of a variety of qualitative phenomena
observed in the Conditioned Avoidance Response. These models accounted for normal Conditioned Avoidance learning and, given adequate acquisition, for
the persistence of responding in the absence of further reinforcement ('in extinction'). Such persistence was vulnerable to the experience of no-avoidance no-shock contingency. Dopamine agonism resulted in more persistent responding. Models also accounted for critical effects of dopamine blockade,
including the counter-intuitive acquisition of responding when both shocks and dopamine blockade are removed. In our models dopamine reports betterthan-expected outcomes and is involved in changing policies. Its role in these processes can thus account for many of the effects of dopaminergic
modulation in laboratory models of psychopathological processes. We draw detailed implications of the CAR findings and discuss some directions for further
research into clinical persecutory syndromes.
Symposium 135
It's the thought that counts: Appraisals in psychosis
Convenor: Emmanuelle Peters, Institute of Psychiatry, UK
Comparing appraisals of psychotic-like experiences between people with and without a need for care
Brett, C.M.C, Peters, E.P., McGuire, P., Canterbury Christ Church University, UK
Data will be presented from a study which examined anomalous experiences in people with and without a need for care. Two groups of age- and gendermatched participants were recruited: a group who had been diagnosed and treated for a psychotic disorder (n = 35), and a group who reported anomalies
associated with psychosis, but who had never received a diagnosis or treatment for psychosis (n = 36). The participants were assessed using a novel semistructured interview (the Appraisals of Anomalous Experiences (AANEX) interview). Cross-sectional comparisons were made to assess the predictive value
of different types of appraisal on (a) anomaly-related distress and (b) diagnostic status. A qualitative analysis of the participants' views of the impact of the
anomalies on their view of the world and themselves was also performed.The non-clinical individuals were differentiated from those diagnosed with a
psychotic disorder by several variables, including the types of appraisals they made of their experiences. 'Paranoid' appraisals appeared to form an
independent dimension of variation from the presence and frequency of psychotic-like anomalous experiences. More specifically, appraising experiences as
being caused by other people strongly predicted distress and diagnostic status, but externalising appraisals per se did not predict distress. The non-clinical
group were more likely to make 'spiritual' or normalising appraisals of their experiences.In the qualitative analysis, the non-clinical participants largely
reported that their experiences had been highly salient for their worldview and self-image, primarily in a positive direction.
Virtual Reality and Paranoid Ideations in people with an 'At Risk Mental State' for psychosis
Lucia R. Valmaggia, Daniel Freeman, Catherine Green, Philippa Garety, Elizabeth Kuipers, Paul Bebbington, Matthew Broome,Philip McGuire,
Institute of Psychiatry, UK
Appraisal of anomalous experiences plays a central role in the cognitive model of psychosis (Garety et al 2001). Virtual reality provides a useful tool to
manipulate a life-like environment while observing spontaneous responses to different stimuli. Pilot data has confirmed that virtual characters can elicit
unfounded paranoid thoughts in healthy controls (Freeman at al., 2003; 2005). This paper describes the results a study to examine: whether individuals with
an at risk mental state (ARMS) have persecutory thoughts about virtual reality characters; and to explore which emotional and cognitive processes are
associated with paranoid thoughts. Methods: Twenty-one ARMS participants entered a virtual underground train populated by computer-generated people.
The participants completed dimensional assessments of items related to psychiatric symptoms (Paranoia Scale; Persecutory Thoughts Scale; Launay Slade
Hallucination Scale; Depression, Anxiety, Stress Scale; Interpersonal sensitivity scale); of their thoughts about the virtual characters (VR-Paranoia); and the
Beads task and Wisconsin Card Sorting Test.Results: The results show that individuals attribute mental states to virtual reality characters. The majority of
participants (57%) endorsed at least one persecutory item. Individuals who had persecutory thoughts about the virtual characters had significantly higher
levels of anxiety (rho=.57, p<.01), perceived stress (rho=.50, p<.05), and a fragile inner self (rho=.46, p<.05). Jumping to conclusions (beads task) did not
correlate with persecutory ideations.Conclusion: VR methodology can be used with a clinical group, it is realistic, not distressing and non-intrusive. The
virtual environment triggers persecutory ideations which are associated with emotional and cognitive processes predicted by a cognitive model.
Anomalous Interpersonal Schemata among People with First-Episode Psychosis and Co-morbid Social Anxiety
Dr Maria Michail & Prof. Max Birchwood, University of Birmingham, UK
Social anxiety disorder has been identified as a co-morbid diagnosis in schizophrenia (17%; Cossof & Hafner, 1998). However, its pathogenesis remains
unclear. This research explored the notion that social anxiety may be a psychological response to psychosis. Shame cognitions arising from a diagnosis of
mental illness were suggested to contaminate social interaction leading to social avoidance and withdrawal. Developmental risk factors and adult attachment
problems were also investigated.Method: Three groups of participants, aged 16-35, constitute the sample: a) social anxiety group, b) first-episode psychotic
group and c) control group. A clinical interview using the SCAN (WHO, 1999) was conducted to establish diagnoses of social anxiety and/or schizophrenia
based on the ICD-10 criteria. A battery of measures was also administered to identify shame related cognitions and risk factors underlying their emergence.
Results: Findings reported high levels of social anxiety in individuals with psychosis (26.2%). Shamefulness about the mental illness and fear of discovery
were found to contaminate social interaction giving rise to symptoms of social anxiety and avoidance. Developmental anomalies posed a significant risk
factor for the emergence of social anxiety in people with first-episode psychosis. Findings also pointed towards a specific association between insecure adult
attachment style and social anxiety in psychosis.Implications: Providing a pathway for the nature and origins of social anxiety in psychosis will have further
implications for the understanding and treatment of emotional dysfunction in psychosis.
It's not what you hear, it's the way you think about it: beliefs about voice power in voice-hearers
Emmanuelle Peters , Sally Williams, Michael Cooke & Elizabeth Kuipers, Institute of Psychiatry, UK
Recent advances in understanding the emotional impact of auditory hallucinations have been made by applying cognitive theories to such phenomena.
Chadwick and Birchwood (1994) first suggested that beliefs about voices mediate the relationship between actual voice experience and behavioural and
affective response. Beliefs about voice power (omnipotence) and voice purpose (malevolence/benevolence), together with emotional and behavioural
response (resistance/engagement) were investigated using the Beliefs About Voices Questionnaire-Revised (Chadwick, Lees & Birchwood, 2000) in 46
voice-hearers recruited from a specialist psychological clinic. It was predicted that beliefs about voices would be better predictors of distress than voice
severity. In a series of regression analyses, omnipotence was the strongest predictor of all measures of distress included in the study, namely, voice
associated distress, depression, anxiety, suicidal ideation and self-esteem. As predicted, voice intensity and frequency did not predict distress on any of the
above measures. Beliefs about purpose were not related to distress but to individuals' response towards the voices, with malevolence being related to
resistance, and benevolence to engagement. These findings suggest that beliefs about voice power are key determinants of distress in voice hearers, and
should be targeted specifically in psychological interventions.
Psychological processes underlying symptoms of thought interference
Linney, Y.M. & Peters, E.R., Birmingham and Solihull Mental Health Trust, UK
Morrison and his colleagues have proposed that positive psychotic symptoms, particularly auditory hallucinations, are the result of cognitive intrusions being
attributed to an external source. They further suggest that the motivation for an external attribution arises from the reduction of cognitive dissonance,
resulting from the occurrence of such intrusions conflicting with the person's beliefs about their own mental processes (metacognitions). This aim of this
study was to investigate the applicability of this model to psychotic symptoms of thought interference, such as thought insertion or thought broadcast. Fifty
psychotic patients with and without symptoms of thought interference were tested on (i) frequency of cognitive intrusions; (ii) metacognitive beliefs; and (iii)
source monitoring. Beliefs that may be implicated in the development of symptoms of thought interference were also assessed by examining participant's
appraisals of an unrelated anomalous event (a Card Trick task). Individuals with symptoms of thought interference had increased cognitive intrusions, more
negative interpretations of cognitive intrusions, an external attribution bias, and were more likely to endorse appraisals regarding 'permeability' of the mind
and conspiracy on the Card Trick task, in comparison to individuals without such symptoms. When the patient group was divided into those who currently
experienced auditory hallucinations, and those who did not, few significant differences remained. These findings suggest that previous studies may have
been confounded by the presence of thought interference, and that Morrison's model may be more appropriate for symptoms of thought interference, than
for auditory hallucinations.
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Symposium 180
Cognitive behavioral approach to the psychology on symptoms of psychosis
Convenor: Yoshihiko Tanno, The University of Tokyo, Japan
Delusion-like Ideation and Coping: Avoidant vs. Planning Problem-solving Coping Strategy
Syudo Yamasaki 1),Hiromi Arakawa 2),Yoshihiko TANNO 2), 1) The University of Tokyo Hospital, Japan 2) Graduate school of Arts and Sciences,
The University of Tokyo, Japan
The purpose of this study was to investigate the relationship between delusion-like ideation and coping strategy in college students, using covariance
structure analysis of panel data. First, it was demonstrated that delusion-like ideation was frequently experienced among college students. Second, it was
hypothesized that avoidant coping strategy would increase distress of delusion-like ideation, and that planning problem-solving coping would reduce distress
of delusion-like ideation. The two hypotheses were tested with a reciprocal effect model. Peters et al. Delusions Inventory and Stress Coping Inventory were
administered twice at a month interval to 318 college students. A large majority (95.3%) of the participants had experienced delusion-like ideation.
Covariance structure analysis was performed on data of 186 students who experienced such ideation during the interval. A reciprocal effect model with
instrumental variables revealed that avoidant coping would increase distress of delusion-like ideation, although planning problem-solving coping was not
shown to reduce it.
Conditions for emergence of JTC reasoning bias among Japanese college students with delusional ideation
Hiromi Arakawa, Yoshihiko Tanno, The University of Tokyo, Japan
Delusion is one of the core symptoms in patients with schizophrenia. Recently, it is found that the thoughts like delusion are commonly observed in normal
population, especially in adolescent period. These thoughts named delusional ideation (Peters et al., 1999). A number of studies have been conducted on
reasoning bias in people with delusional ideation. Especially, studies have focused on "Jumping-To-Conclusion (JTC)" reasoning bias in people with
delusion. Garety and Freeman (1999) insisted that the JTC reasoning bias was specifically related to the formations of delusional ideation. However, it is
not clear yet that JTC reasoning bias always affect judgements in people with delusional ideations. The purpose of the present study is to investigate that
data-gathering bias will be showed among college students with delusional ideations regardless of any task conditions. Participants rated Peters et al.
Delusions Inventory (Peters et al., 1999; PDI) and required performing probabilistic judgement task called beads task. Only in the condition that had a high
degree of freedom for available amount of information, the students with many delusional ideations showed JTC reasoning bias. They gathered as much
information as students with not much delusional ideations in the condition that had limited degree of freedom. These results imply that data-gathering bias
among students with delusional ideation may appear only in the situation which given high degree of freedom.
The effects of self-relevant material on reality monitoring in hallucination-prone subjects
Eriko Sugimori, The University of Tokyo, Japan
Several studies have reported that hallucinating subjects may have a specific bias toward attributing their thoughts to an external source. However, the
stimuli used in previous experiments were neutral to participants, and differences in the relevance of stimuli to participants were not addressed. In this study,
we investigated how the relevance of material to participants influences reality monitoring by comparing hallucination-prone and non-hallucination-prone
subjects using personality-trait adjectives as stimuli. We assessed 175 normal subjects using the Auditory Hallucination-like Experience Scale (AHES) and
grouped subjects according to their scores. We obtained two main results. First, in the old-new recognition task, HP subjects were more likely to respond
with “I learned it” than were NHP subjects, even when they had not learned it (false alarms), while the response “I learned it” when they had actually learned
the word did not differ between HP subjects and NHP subjects. Second, the self-referent ratings for the false alarms in HP subjects were higher than those
for any other response in HP subjects, while no significant difference was observed in the self-referent ratings for all responses in NHP subjects. These two
results suggest that compared to NHP subjects, HP subjects are more likely to respond “I learned it” to that which they subjectively regard as relevant to
themselves, even when the adjectives were not actually learned. Below, we discuss the factors causing this response bias in HP subjects.
Highly schizotypal students have weaker sense of self-agency
Tomohisa Asai, Yoshihiko Tanno, The University of Tokyo, Japan
Schizotypy may be seen as an indicator of the predisposition to schizophrenia. It is possible that schizotypal people have the abnormal self-consciousness,
especially sense of self-agency, that is, the sense that it is oneself who is causing or generating an action. Method: Students were rated with Schizotypy
Traits Questionnaire (STA; Claridge & Broks, 1984; Gregory, Claridge, Clark, & Taylor, 2003). STA is a 37-item true or false self-report questionnaire based
on the Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III) diagnostic criteria for schizotypal personality disorder. In the Experiment, they
pressed the key and the tone was generated after some delay(Sato & Yasuda, 2005). They were required to judge whether they felt they generated the tone
or whether there was a temporal delay. Results: The results show that while the high schizotypy group judged the sense of self-agency closely according to
the perception of temporal delay, the low schizotypy group may feel the sense of self-agency even when they perceived temporal delay. Discussion: These
results means that the high schizotypy group has weaker sense of self-agency than the low schizotypy group. The present study showed schizotypal traits
are correlate with the abnormal sense of self-agency, using an experimental method. The finding that high schizotypal students have a weaker sense of selfagency is consistent with the idea that schizophrenic experiences, including auditory hallucination, thought insertion, and delusions of control, could occur
because of the feeling that one is not at the origin of one's own acts.
The structure of situations that induce paranoid thoughts in a non-clinical population
Takashi Yamauchi 1), Yoshihiko Tannp 1), Anju Sudo 3), 1) University of Tokyo, Japan; 2) Graduate School of Medicine, University of Tokyo,
Paranoid thought is a common experience that is not unique to clinical population. Studies have been conducted on cognitive and affective vulnerability
related to development of paranoid thoughts. However, few studies examined the effects of situational factor on development of paranoid thoughts. This
explorative study examined the situations that induced paranoid thoughts in a non-clinical population and the features of these situations.In the first
preliminary studies, a wide range of items indicating situations induced paranoid thoughts was collected and these items were refined. Three hundred and
two undergraduates completed a questionnaire assessing paranoid thoughts that induced in certain situation of checklist. Results of factor analysis revealed
that the situations induced paranoid thoughts consisted of two factors: physical and material persecutory situations and psychological persecutory ones.In
the second study, one hundred and fifty-three undergraduates completed a questionnaire to compare physical and material persecutory situations with
psychological persecutory ones in terms of frequency of experience, degree of distress, conviction of planned harm by others and subjective probability of
illusion of experience. There were significant differences between two categories of situations in frequency of experience, conviction of bad intention and
ambiguity of experience in the past (p<.001). Moreover, results of multiple regression analyses indicated that frequency and distress of experience of
psychological persecutory situations were associated with current paranoid thoughts (p<.05). Results suggested that it was important to consider the
situations i.e. social factors that induced paranoid thoughts as well as the content of thoughts and vulnerability to paranoia.
Roundtable 2
Certificate 18: the right to be lost to the system
Convenor: Derek Indoe, Bristol Royal Hospital For Children & The Bath Clinic, U.K.,
Sam Duprey's 18 year-old son Joe suffered an acute psychotic bipolar episode in 2005. The round table discussion will start with an outline presentation of
the difficulties and successes that the speaker (Sam Duprey) experienced when trying to support his son. It is hoped that a pre-recorded contribution from
the patient will be available for the panel. A second speaker (an accredited cognitive behavioural therapist) will firstly put forward a professional view and
then a critical cognitive behavioural view of the treatment. Both speakers will address communications-the loss of the rights of the parents of a young adult
psychiatric patient; an illness in the family-the trauma of loving and caring and losing; education - what can be done by parent and professional to help; the
vicious circle of the bipolar patient- the right to be lost in the system. The question will be posed as to how parents and health professionals can improve
current provision and how this can be best effected. Both the parental and professional experience will be examined within a cognitive behavioural
framework.There will then follow an examination and discussion of the interface between patient professional and parent within a cognitive behavioural
framework. The central theme will be the correlation between current mental health policy in England and Wales and its actual implementation in the lives of
patients, parents and carers. The audience will be asked to contribute to an action plan that addresses the considerable systemic difficulties presented by
the case and form the basis of a report to be delivered to relevant organisations.
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Panel Debate 6
Innovations in Schizophrenia Treatment: New Concepts in CBT and Implementation Difficulties
Convenor: Nir Essar , Psagot Institute, Israel,
Innovations in Schizophrenia Treatment: New Concepts in CBT and Implementation Difficulties
Psagot Institute, Israel
Training Chronic Patients to Help Other Patients: Learning the Motivational Cognitive Errors and the Specificity of Mental Disability Tammy Essar, Psagot
Institute A teaching class of twenty-three non functioning (part of whom were actively psychotic) chronically mentally ill persons was set up in order to teach
them to be “empowerers” for persons that are not well enough to by themselves go to the doctor or psychologist and not ill enough to be hospitalized. At the
end of 12 meetings a dramatic personal change was found in the sixteen remaining students / patients, which will be demonstrated by a film. A short
curriculum of the course with its special cognitive motivational psychology and therapeutic means will be presented.
Evidence Based Psychotherapy:
What Went Wrong Menachem Ben Ezra, Tel-Aviv University We accompanied the 'Training Chronic Patients to Help Other Patients' project with self rated
questionnaires. Questionnaires were filled by the students, about their functioning, and by their relatives, about burden. No difference was found before and
after the course, despite the dramatic personal change demonstrated by the film. I'll try to elaborate on the pitfalls of questionnaire in this instance. Psagot
Psychotic Normalization Procedure (PPNP): A Family Intervention Nir Essar, Psagot Institute Psychotic persons are considered crazy with no possibility of
being understood. Family members often think that they have no coherent reasoning. We have developed five ninety minute treatments of normalization to
increase understanding and mutual cooperation within the families. I will outline the treatment manual which includes circular questioning, subjective reality,
ambivalent perceptions (especially sight), problems occurring during hearing of voices and intra-family communication enhancement; in a few cases we
encountered dramatic outcomes. Bach Merav Barkavi-Shani, Psagot Institute Homework assignments are one of the most difficult things to fulfill by
severely mentally ill patients. We have pioneered a telephone-based method where an automatic answering system with previously recorded questions by
the therapists, using IVR technology, affects the patients to complete assignments with surprisingly good results; examples of such interventions will be
demonstrated with various diagnoses.
Evidence Based Psychotherapy for ASR (Acute Stress Reactions): The Role of Organizational Politics Menachem
Ben Ezra, Tel-Aviv University It is well known that interventions, like psychological debriefing, once in use are hard to eradicate. An intervention used on
rescue personnel prior to exposure to dead and mutilated bodyes, was found to be successful in reducing peritraumatic dissociation. This intervention was
accompanied by empirical study. The common logic will be to expand it and test it beyond the preliminary study. Unfortunately, politics within the
organization and the existence of alternative intervention that were not evidence based took precedence (psychological debriefing). It seems that evidence
based intervention is not enough. The discussion will talk about the role of professional people in large organizations and the politics of decision making.
Open Paper Symposium 16
Issues in Psychosis
Effects of positive and negative delusional proneness on memory
Eriko Sugimori, The University of Tokyo, Japan; Yoshihiko Tanno, The University of Tokyo, Japan
Previous studies have revealed some relationships between delusions and memory investigated (Moritz, & Woodward, 2006; Laws, & Bhatt, 2005).
However, the relationships between specific types of delusions and memory have not yet been investigated. In this study, we classified participants into
delusion-prone and non-delusion-prone, and into subcategories of those with positive and negative delusions, and investigated the relationships between
positive and negative delusions and memory. The subjects were selected according to their scores on a positive or a negative paranoid ideation scale
(DICL). This experiment consisted of two phases: a learning phase and a test phase. In the learning phase, 40 adjectives were presented one at a time on a
computer screen, and participants were asked to try to remember as many adjectives as possible. After the learning phase, the participants performed a filler
task (solving math questions) for 15 min before they proceeded to the test phase. During the test phase, 40 pairs of adjectives consisting of learned and
non-learned items similar to the learned items were presented one at a time on a computer screen (e.g., patient-persistent), and the participants were asked
which adjectives had been learned during the learning phase. From 18 to 24 days after that, participants were asked to return and the test phase was
repeated. The same 40 pairs of adjectives were presented one at a time on a computer screen (e.g., patient-persistent), and the participants were asked
which adjectives had been learned in the learning phase. We obtained two novel findings. First, in the immediate two forced-choice test, there was no
significant difference among all conditions. Furthermore, the hit rate was above 90%. That is, the delusion-prone group was able to distinguish between what
had and had not been learned just like the non-delusion-prone group, even though the unlearned word was associated with the learned word. Second, when
the delayed two forced-choice test was conducted, the rate of hits for positive personality-trait adjectives was higher in the PDP group than in the NPDP
group, while the rate of hits for negative personality-trait adjectives was higher in the NDP group than in the NNDP group. These results indicate that the
internal condition of each participant has an increasingly strong effect on memory retrieval as time passes. It is interesting that even though the activation of
learned items was higher than that of non-learned items immediately after the learning phase, participants were more likely to depend on their internal
conditions (positive vs. negative), and that several days after the learning phase, the activation in the encoding was not dependent on the test.
An exploration of self-complexity in individuals experiencing auditory hallucinations
Virginia Bell, Clinical and Community Psychology Services, Devon Partnership Trust, Exeter, Anja Wittkowski, University of Manchester, UK
The structure of the self-concept refers to how its contents are organized, and interest in this area has followed from the increasing recognition that the self
is multifaceted, rather than unitary (Kihlstrom & Klein, 1994). The relationship between the structure of the self-concept and psychological adjustment has
enjoyed more prominence in the recent literature. Linville's (1987) self-complexity theory is significant as a relatively comprehensive model of the structural
properties of the self-concept. According to SC theory (Linville, 1985), self-descriptive information is organised into 'self-aspects', consisting of roles,
relationships, abilities and the like. Linville's self-complexity theory (1987) suggests that reduced SC exacerbates the effects of stress, thereby creating a
vulnerability to psychopathology. Research investigating self-structure in schizophrenia found decreased elaboration of self-structures in schizophrenia
patients compared to controls (Gara et al, 1989), which was taken as support for the theory that schizophrenia represents the fragmentation of the self
(Bleuler, 1911/1950; Sullivan, 1953). However, Gara et al's study did not specifically investigate SC employing Linville's methodology and analysis. As a
core symptom of schizophrenia, auditory hallucinations are often the most distressing symptom experienced (Barrowclough & Tarrier, 1992). However, to
date, SC in individuals specifically experiencing auditory hallucinations has not been explored. This study investigated if SC in individuals experiencing
auditory hallucinations would be less complex compared to control participants. We also expected that auditory hallucinations might be related to decreased
pos-SC and increased neg-SC. Twenty-two clinical participants experiencing auditory hallucinations were recruited from inpatient and outpatient services.
Twenty-two control participants, matched on age and gender, were recruited from non-clinical settings. All participants completed a card sort task relating to
the self, and questionnaires of affect (HADS; Snaith & Zigmond, 1994) and self-esteem (Rosenberg, 1965). Clinical participants were also assessed using
the positive subscale of the PANSS (Kay et al, 1987) to confirm inclusion criteria. Using Linville's (1987) conception of SC as being reflected in values of H,
three SC scores were calculated for each participant (see Woolfolk et al, 1995): uni-SC H, pos-SC H and neg-SC H. As the clinical group obtained higher
anxiety and depression scores and lower self-esteem scores, an ANCOVA was conducted to test whether clinical participants displayed reduced uni-SC
compared to control participants. There was a non-significant main effect for group, indicating that, contrary to hypotheses, the clinical group's uni-SC
scores were not significantly lower than the control group's uni-SC scores, when group differences were controlled for. However, a multivariate analysis of
covariance (MANCOVA) revealed a significant difference between the two groups. Therefore, as predicted, the groups differed on a combination of the posSC and neg-SC scores, when the influence of depression, anxiety and self-esteem scores was controlled for. The results indicated that the clinical group's
pos-SC scores were significantly lower than the control group's pos-SC scores. Although Uni-SC scores were unrelated to measures of psychological wellbeing across both groups, pos-SC and neg-SC scores were correlated in the expected direction with anxiety, depression and self-esteem scores. These
findings are in line with other studies taking into account the valence of SC which have predominantly found reduced pos-SC, and increased neg-SC, to be
related to depression and low self-esteem (Brown et al, 1995; Gara et al, 1993, 2002; Woolfolk et al, 1995; 1999). In light of the lack of relationships found
between the unitary measure and psychological well-being, the current findings support the argument for splitting SC by valence (Woolfolk et al, 1995).
The findings of the current study potentially have a wide range of implications for treatment. Firstly, it might be relevant to assess for reduced positive (or
increased negative) SC in clients experiencing auditory hallucinations. In addition, the reduced pos-SC found to characterise individuals experiencing
auditory hallucinations indicates the potential value of interventions which support an individual in developing increased positive aspects to the self.
Cognitive therapy could address underlying cognitive biases or core beliefs which might be interfering with the identification and recognition of SC (i.e. that
the self is comprised of a multitude of differentiated aspects). In conclusion, the findings from the current study indicate that alterations in this psychological
construct may be implicated in the phenomena of auditory hallucinations. Continued investigation of SC associated with auditory hallucinations would seem
to be called for in order that clinical practice might derive benefits from improvements to interventions that this line of research might feasibly lead to.
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Relative's involvement in relapse prevention for individuals with bipolar disorder: a qualitative study of value and barriers to
Sarah Peters, University of Manchester, Ellie Pontin, University of Liverpool, Fiona Lobban, University of Manchester, UK
Bipolar disorder is a common and severe form of mental illness characterised by repeated relapses of mania or depression. Recurrence rates are high and
psychopharmacological treatments have limited effectiveness. NICE guidelines recommend that structured psychological interventions, in particular focusing
on self-management for relapse prevention, should be offered as an adjunctive intervention. More recently, services are increasingly aiming to involve
friends and families in interventions to maximise effectiveness. Little is known about what those involved consider the value of this approach and what
barriers exist to care being delivered in this way. The aim of the study was to explore, from the perspectives of case managers, patients and relatives, the
value of, and barriers to, involving friends and family in relapse prevention interventions. Using a qualitative methodology, semi-structured interviews were
conducted with a purposive sample of 50 participants including service users, relatives and case managers. Data were analysed using an iterative approach
to develop conceptual categories from the dataset. Analysis was conducted by researchers of different professional backgrounds including clinical and health
psychology, sociology and psychiatry. Early analyses of the three sets of interviews show that all parties recognised value in involving relatives in relapse
prevention. Benefits were many and included: improved understanding of bipolar disorder; feeling involved in illness prevention and management; and
improved relationships amongst relatives and between relative and mental health team. Having a functional relationship with case managers was particularly
valued by relatives during relapse episodes when they felt responsible for accessing services.
Case managers, whilst recognising a role for relatives, did not encourage their involvement as they perceived it to increase the complexity of their own role
and workload. Service users also resisted involving their family in their care: they valued the exclusivity of their relationship with their case manager and
wished to take responsibility for their illness. These barriers were heightened when family relationships were poor. Including relatives in relapse prevention
has value, but can increase the complexity of managing bipolar disorder for service users, their families and case managers. Interventions targeted at
involving family members should ensure that the function is understood and that additional training and support for case managers is provided.
Open Paper Symposium 19
Cognitive and Interpersonal Processes in Psychosis
Patient perceptions of caregiver criticism in psychosis: links with patient and caregiver functioning
Juliana Onwumere, Institute of Psychiatry, London, UK; Elizabeth Kuipers, Institute of Psychiatry, London, UK; Paul Bebbington, Institute of
Psychiatry, London, UK; Graham Dunn, University of Manchester, UK; David Fowler, University of East Anglia, UK; Daniel Freeman, Institute of
Psychiatry, London, UK; Philippa Garety, Institute of Psychiatry, London, UK
Expressed emotion (EE), a globally researched construct, has been described as a measure of caregivers' appraisal of the quality of their relationship with
the patient. However, far less is known about how patients with psychosis perceive caregivers' EE. The current study measured patient ratings of carer
criticism and explored its association with patient and carer characteristics. Further, patient ratings of carer criticism were compared with carer ratings drawn
from the Camberwell Family Interview (CFI). This was a cross-sectional design. Sixty-seven patient-carer dyads were recruited as part of the Psychological
Prevention of Relapse in Psychosis (PRP) Trial (ISRCTN83557988). Perceived carer criticism was positively linked with affect and general psychopathology
in patients but not with overall levels of positive or negative symptoms of psychosis. Patients with poorer levels of social functioning and higher levels of
negative schematic beliefs about other people tended to perceive greater criticism. Perceptions of carer criticism were associated with CFI ratings of carer
criticism, hostility and high EE independently of affect and poorer functioning. This study supports the validity of using feedback from patients as a tool to
assess the emotional climate of the family environment.
Evidence of an association between attachment style, social mentalities and paranoid ideation in an analogue sample
Angus MacBeth, Section of Psychological Medicine, Univeristy of Glasgow, Andrew Gumley, Section of Psychological Medicine, Univeristy of
Glasgow, Matthias Schwannauer, Clinical Psychology, School of Health in Social Science, University of Edinburgh, UK
There is emerging evidence that belief schemas regarding self and other are crucial in an individual's appraisal of the distress of psychotic experiences
(Fowler 2006). Gilbert (2001) and Gumley and Schwannauer (2005) have contended that social mentalities play a crucial role in the development and
maintenance of persecutory ideation and delusions. Gumley and Schwannauer (2006) also suggest that vulnerability to a paranoid social mentality would be
increased by negative developmental experiences, particularly with attachment figures. Attachment theory (Bowlby 1969/1982, 1973, 1980), addresses the
dynamics involved in the development and maintenance of interpersonal processes between the individual and key figures in their life. However, to date,
attachment theory has seldom been applied to studying psychosis. The current study aimed to investigate the strength of relationships between attachment
status, interpersonal problems, and psychotic phenomenology. In particular, we hypothesized that attachment avoidance will be associated with higher
endorsement of paranoid ideation, and that higher levels of interpersonal problems will be associated with higher paranoia scores and greater attachment
avoidance. Using an analogue cross-sectional cohort design, 213 individuals (male: female ratio of 47:166, mean age of 20.28 years, S.D = 2.82) completed
the Relationship Styles Questionnaire (RSQ, Bartholomew & Horowitz 1994), Inventory of Interpersonal Problems (Horowitz et al 2000), Paranoia Scale
(Fenigstein & Vanable 1994), Peters Delusions Inventory (Peters et al 2004, Revised Hallucinations Scale (Morrison et al 2000), and the Hospital Anxiety
and Depression Scale (Zigmond & Snaith 1983). Confirmatory Factor Analysis of the RSQ suggested a parsimonious two-factor structure: Attachment
Anxiety and Avoidance. There were significant associations between both attachment factors and paranoid ideation. In a multiple regression analysis,
paranoid ideation was predicted by attachment anxiety, avoidance, interpersonal distancing and general anxiety (R= 0.722, Adjusted R2 = 0.503, F (8, 204 =
27.821; P<0.000)). Attachment anxiety and avoidance were not predictive of hallucinations (R = 0.474, Adjusted R2 =0.194, F (8, 204 = 7.383; P<0.000)).
The findings confirm that a two factor dimensional model is the optimum model for attachment self-report data. The role of attachment avoidance in the
regression models appears to be specific to paranoia, consistent with a link between a paranoid social mentality and more negative attachment models. We
suggest that attachment avoidance, attachment anxiety and interpersonal distancing may be interacting as a defensive social mentality to protect a fragile
sense of self from interpersonal threat. Combining attachment theory and social mentalities appears to be a promising framework for exploring
developmental aspects of psychotic phenomenology. Future studies in a clinical population are warranted.
An investigation of beliefs, well-being, cognitive biases and the psychosis continuum across Australian community groups.
Michelle Lim, The University of Melbourne, John Gleeson, The University of Melbourne, Henry Jackson, The University of Melbourne, Australia
People who experience psychosis are often known to experience highly distressing voices and beliefs. This often leads to devastating effects on the
individual's life. Interventions, both pharmacological and psychological, are often delivered with the main aim of reducing distress elicited by psychotic
symptoms and to minimise the negative impact on the person's life. In the past decade, researchers have found that not all individuals who report psychoticlike phenomena also report negative impacts on their life. In line with the continuum model of psychosis, researchers have reported that the incidence of
psychotic-like phenomena in the normal population was more common than previously thought. Some of these individuals belong to a subgroup the
researchers have identified as 'New Religious Movements' (NRMs). Further research findings have suggested that individuals from particular NRMs have
similar delusional ideas which were held as strongly as those held by people with psychotic disorders. However, NRM members reported significantly less
distress and preoccupation elicited by their beliefs as compared to people with psychotic disorders. No further research has been conducted into why this
phenomenon occurs in these particular NRMs. These findings contributed to the ongoing debate regarding the continuum versus categorical approaches to
psychosis. This leads to hypotheses regarding the mediating factors implicated in distress and preoccupation associated with beliefs.
The primary objective of the present study, which is in progress, is to investigate what factors contribute to or attenuate distress and preoccupation elicited
by delusional ideation. Factors hypothesised to attenuate distress and preoccupation associated with beliefs include reasoning biases, attentional biases,
complexity and reciprocity of social networks, quality of life, global and social functioning. A cross-sectional design was employed. Participants aged between
18 and 60 years from various community groups across metropolitan Melbourne participated in the study. Outpatients receiving treatment from mental health
services across north-western and central east metropolitan Melbourne were recruited for a clinical sample. The control group consisted of people from
various mainstream Christian groups and people who did not identify with any religious organisation. Participants were also recruited from non-conventional
religious and spiritual organisations. All participants completed a battery of instruments administered in one or two sessions. The instruments were designed
to measure current and past psychiatric symptoms (if present); the occurrence of stressful life events; jumping-to-conclusions biases; attention-to-threat
biases; presence of delusional ideation; conviction, preoccupation, and distress associated with delusional ideation; constructs of schizotypy; social
relationships; quality of life; and current global, social, and intellectual functioning Preliminary findings comparing the different groups on the variables of
interest will be presented. The open paper will conclude with a general discussion of possible buffering factors implicated in the cognitive mechanisms
underlying psychosis.
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The structure of interpersonal representations of auditory hallucinations in schizophrenia
Hamish McLeod, University of Wollongong, Australia; Chris Brewin, University College London, UK; Neil Thomas, Mental Health Research
Institute of Victoria, Australia
A central component of cognitive behavioural models of auditory verbal hallucinations (e.g. Chadwick & Birchwood, 1994) is the premise that patients assign
interpersonal meaning to this experience, viewing and responding to their voices in a similar manner to other people. Interpersonal relationships are often
represented in terms of a circular statistical structure termed a circumplex, which can be used to make specific predictions about patterns of inter-item
correlation and patterns of reciprocal interaction within a relationship. This study used a model of interpersonal relationships to examine the extent to which
interpersonal appraisals of voices are structured in a similar manner to normal interpersonal relationships. 35 participants with schizophrenia or
schizoaffective disorder and auditory verbal hallucinations completed a questionnaire based upon the Structural Analysis of Social Behaviour (SASB;
Benjamin, 1974) rating interpersonal perceptions of their voices and their responses to their voices. They also completed a measure of distress related to
voices adapted from the Profile of Mood States, and the Calgary Depression Scale. Participants showed clear evidence of regarding their voices in similar
terms to normal interpersonal relationships, with both between-subject and within-subject item distributions conforming to the predicted circumplex statistical
structure of the SASB. The interpersonal appraisals made by participants were predictive of their behavioural response to voices in line with the principle of
complementarity within interpersonal relationships as operationalised by the SASB. Furthermore, the degree of perceived hostility expressed by voices
predicted levels of distress. Depression was associated with appraisals of voices as more controlling. Differences noted from conventional interpersonal
relationships included levels of hostility being much higher, some facets of interpersonal relating having poor internal consistency when applied to voices,
and appraisals of voice dominance/control being correlated with perceptions of voice hostility. This study confirms the importance of interpersonal aspects of
appraisals of hallucinatory experience as a target for cognitive behavioural therapy. Distress and maladaptive responses such as compliance, resistance
appeasement may be conceptualised in terms of normal responses to hostile and controlling relationships. This provides a context for helping patients
develop alternative responses to this interpersonally salient experience.
Open Paper Symposium 43
Advances in CBT with Pyschosis and Severe Mental Health Problems
Evaluation and implementation of Cognitive Milieu Therapy (CMT) within a dual diagnosis inpatient setting
Irene Oestrich, St Hans University Hospital, Center for Cognitive Therapy, Jorn Lykke, St Hans University Hospital, Department M, Stephen
Austin, St Hans University Hospital, Center for Cognitive Therapy, Denmark
Dual diagnosis is a psychiatric condition involving a co-occurring serious mental illness and substance dependence. People with a dual diagnosis
experience higher rates of homelessness, HIV and poorer prognosis than those people with schizophrenia alone (Alversson 2001). There is general
consensus amongst researchers and clinicians that the optimal intervention for this population is the concurrent treatment of mental health and substance
abuse problems (DiClemente & Bellack 1999). The following study evaluated the impact of Cognitive Milieu Therapy (CMT) within a dual diagnosis inpatient
population. CMT is an integrated treatment carried out within a supportive inpatient environment that focuses on patients learning and using a range of
cognitive and behavioural strategies to deal with distressing psychiatric symptoms and substance abuse problems (Oestrich & Holm 2001, 2006). A
convenience sample of dual diagnosis inpatients (N=130) were assessed by independent raters at the commencement and completion of inpatient
treatment. Patients were evaluated on levels of psychiatric symptoms, functioning and substance abuse. Patients also completed relevant questionnaires
measuring anxiety, depressive symptoms and self esteem, before and after treatment. Results collected post treatment revealed a significant decrease in
psychiatric symptoms and substance abuse as evaluated by independent assessors (p<.001). Patients also reported significantly lower levels of anxiety,
depressive symptoms and self esteem after participation in treatment (p<.001). The implications of this pilot study are examined in terms of the central
elements of CMT that contributed to positive patient outcomes along with the challenges encountered when implementing and evaluating an intervention for
dual diagnosis within an everyday psychiatric setting.
A real-world effectiveness trial of CBT for psychosis in a prospective, representative sample of service users
John Farhall, La Trobe University, Nerelie Freeman, North Western Mental Health, Frances Shawyer, The Mental Health Research Institute of
Victoria, Australia
Recent reviews (e.g., Gaudiano, 2005) concur that Cognitive Behaviour Therapy for psychosis (CBTp) is efficacious, particularly for persisting psychotic
symptoms, although packages typically include additional components such as psychoeducation, and relapse prevention (e.g., Fowler et al.,1995). The
evidence has been sufficient for inclusion of CBTp in some Clinical Practice Guidelines (e.g., NICE, 2002). However, new treatments can be difficult to
disseminate into routine clinical practice (Tarrier et al., 1999), and despite the public importance of dissemination, it receives relatively little attention (Drake
et al., 2001). Differences between routine practice and efficacy trials may include: implementation by less expert therapists, a loss of strict fidelity to the
original treatment; and the inclusion of a greater variety of patients, rather than exclusion of 'unsuitable' patients, such as those with co-morbid disorders.
Only a few CBTp studies touch upon these real-world effectiveness issues (e.g., Jakes et al. 1999; Turkington and Kingdon, 2000; Valmaggia et al., 2005).
Thus, the current study was designed to determine the applicability, acceptance and effectiveness of CBTp when offered as a routine treatment by a public
mental health service in Australia. The design was a RCT adhering to (most) CONSORT guidelines. All patients with psychotic disorders presenting for case
management within a geographic catchment area were invited to participate. Consenting patients were randomised to the local CBTp (“Recovery Therapy”)
plus treatment as usual (TAU), or TAU alone. The therapists were local psychologists who negotiated agreed goals with patients and flexibly utilised
treatment components from a guidelines manual. Intention-to-treat analyses used data at baseline, 9 months (i.e., post treatment) and 18 months. The
therapy components implemented were recorded via a checklist completed by therapists each session. The 92 patients randomised to condition were
representative of the clinic population. Working Alliance Inventory and Client Satisfaction Questionnaire scores indicated excellent acceptability. Withingroups analyses showed statistically significant improvements on the Rosenberg Self-esteem Scale, and anxiety reduction on the Hospital Anxiety and
Depression Scale, for the Recovery Therapy group, but not the TAU group. Both groups improved significantly over the treatment period on the Positive and
Negative Syndrome Scale. However, a repeated measures MANOVA showed no overall advantage for the CBTp treatment. The most frequent CBTp
components implemented were, co-morbid disorders/personal issues and personalised psychoeducation (16%; 14% of sessions respectively). Working with
persisting positive symptoms was the main focus in only 6% of sessions. This is the first CBTp implementation trial we are aware of that has prospectively
recruited a representative sample of a mental health service population and reported the treatment focus of therapy. The infrequent utilisation by local
therapists of the treatment components for persisting positive symptoms was unexpected and may explain the lack of advantage for the therapy group on
the PANSS. The relative advantage for this group on self-esteem and anxiety is consistent with the frequently-used components of therapy. We conclude
that the priority domain of “need” for CBTp therapy may be emotional disturbance (Birchwood et al., 2004) and sense of self rather than persisting positive
Group Cognitive Therapy for Schizophrenia: Randomised Controlled Trial
Christine Barrowclough, University of Manchester, Gillian Haddock, University of Manchester, Fiona Lobban, University of Manchester, Steven
Jones, University of Manchester, Ron Siddle, North Manchester NHS Trust, UK
The efficacy of CBT for schizophrenia is established but there is less evidence for a group format. This paper will describe a RCT to evaluate the
effectiveness of group CBT for people diagnosed with schizophrenia One hundred and thirteen patients with persistent positive symptoms were assigned to
receive group CBT or treatment as usual (TAU). The primary outcome was positive symptom improvement on the Positive and Negative Syndrome Scales
(PANSS). Secondary outcome measures included symptoms, functioning, relapses, hopelessness & self esteem. There were no significant differences
between the CBT and TAU on measures of symptoms or functioning or relapse, but group CBT treatment resulted in reductions in feelings of hopelessness
and low self esteem. Although group CBT may not be the optimum treatment method for reducing hallucinations and delusions, it may have important
benefits including feeling less negative about oneself and less hopeless for the future.
A new application of CBT for anxiety for individuals with severe mental illness returning to university.
Annette Krochmalik, Boston University Center for Psychiatric Rehabilitation, USA
Current reports have suggested that the number of university students with a serious mental illness (such as bipolar disorder or schizophrenia) has risen
significantly (Mowbray, Megivern & Mandiberg, 2006). It has been reported that as much as 37% of young adults aged between 15 and 24 have a
diagnosable mental illness (Kessler, Olfson & Berglund, 1998). This crucial age is the time at which these young adults are either formulating plans to enter
university, have just begun their university education, or are already in the midst of their university experience. The onset of a psychiatric illness for these
individuals often interrupts their entrance to university or for many, disrupts the completion of their training (Unger, 1998). Kessler, Foster, Saunders and
Page 48
Stang (1995) have estimated that 86% of individuals who have a psychiatric disorder withdraw from university before the completion of their degree. While
much effort has been spent on attempting to retain students on campus who are experiencing a mental illness for perhaps the first time (Beamish, 2005;
Nolan, Ford, Kress, Anderson & Novak, 2005), individuals who are keen on pursuing their interrupted higher education goals are often neglected. When
these individuals feel that they are once again ready to enroll in a program that they have previously been unable to complete, often guidance to achieve
this goal is absent. Supported education is a recent intervention that specifically concentrates on increasing access to higher education for individuals with
mental illness who are choosing to re-enroll in a higher education program (Mowbray, Collins, Bellamy, Megivern, Bybee & Szilvagyi, 2005). The transition
to college can be an anxiety-provoking experience for any individual about to embark on this experience (Price & Johnson, 1999). It comes as no surprise
then that individuals with a mental illness attempting to re-enroll in a higher education program may express concerns of anxiety perhaps even greater than
those concerns that they may have had enrolling their first time around. It seems fitting that a Supported Education intervention would offer some sort of
package designed to address this anxiety within their framework. At present, no specific package currently exists as part of the Supported Education service.
Cognitive-behavioural training for anxiety has long been established as a solid, drug-free method of successfully ameliorating anxiety for individuals who
express these concerns (Butler, Chapman, Forman & Beck, 2006; Chambless & Gillis, 1993). The present study will administer a CBT package designed to
address anxiety to a group of 15 individuals already receiving Supported Education services. This group will be compared to a control group receiving
services from Supported Education as usual. Results will be discussed in terms of how effective the CBT training was in helping these individuals manage
their anxiety. Implications of this intervention include a higher success rate of individuals attaining their higher education goals in addition to the increase in
employment rate for these individuals.
Acceptance and Commitment Therapy (ACT) for a Heterogeneous group of Treatment Resistant Patients.
Jessica Kingston, University of Southampton, Susan Clarke, University of Southampton, Bob Remington, University of Southampton, Helen
Bolderston, National Health Service, Kelly Wilson, University of Mississippi, USA
Acceptance and Commitment Therapy (ACT) is a promising third wave behavioural intervention, which is thought to have specific applicability to chronic,
treatment resistant, multiply disordered patient groups (Kohlenberg, Hayes & Tsai, 1993). ACT is a generic intervention whose technologies should have
applicability across different diagnostic patient groups. The present study is an uncontrolled, pre-post pilot trial investigating the effectiveness of ACT for a
heterogeneous group of patients who have been resistant to previous intervention. Two 16-week ACT groups were run sequentially by two clinicians. Clinical
supervision was provided by Dr. K. Wilson, co-author of the ACT manual (Hayes, Strosahl & Wilson, 1999). The inclusion criterion was having attended at
least one previous therapeutic intervention that lasted 8+ sessions. Exclusion criteria were; (a) current eating disorder or BMI < 16, (b) parasuicidal
behaviour in the last 6 months, (c) current drug or alcohol dependency (d) Schizophrenia or other psychotic disorder and/or (e) learning disability.
Participants completed the SCID-II, the BDI, the STAI, the SCL-90, the Millon and the AAQ pre and post intervention, and at 6-month follow-up (SCID-II at
pre and 6 months only). Group 1 (N = 6) had attended a mean of 3.3 previous therapeutic interventions. All patients had co-morbid Axis I presentations and
three had personality disorders (PD). Group 2 (N = 5) had attended a mean of 3.8 previous interventions; three were PD and all patients had Axis I
symptomatology. (At present, post-intervention data is only available for group 1. Post-intervention scores for group two and 6-month SCID-II data for group
1will be available in time for the conference). Using Jacobson and Truax's (1991) criteria for clinical significance; 5 participants in Group 1 had clinically
reliable reductions in depression, and 4 reached normative levels of functioning. Four patients demonstrated a reliable reduction in anxiety with 3 reached
normative levels of functioning. Millon scores evidenced some meaningful reductions in personality profiles for 5 of the patients. Although this data is
preliminary, it does implicate the utility of ACT for reducing Axis I and Axis II symptomatology in a heterogeneous, hard-to-treat patient group. One patient
was largely unresponsive to ACT. Future pilot research is underway to compare ACT and CBT in a randomised control trial for this target group; and to
conduct descriptive patient profiling in order to help determine characteristics related to continued resistance.
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Adult Trauma
Invited Addresses
Scientific Principles of CBT: Retrieval competition between multiple memories
Chris Brewin, University College London, UK
How does CBT actually work? Does cognitive vulnerability lie in abstract summaries of self-related information gleaned from the past? Is it true that
dysfunctional schemas can be altered or traumatic memories processed to bring about permanent change? Emerging evidence points towards a much more
dynamic view of mental representations in which creativity and imagination play prominent roles. I will propose that CBT does not primarily act by correcting
distorted information contained in schemas or memories but by producing changes in the relative activation of positive and negative representations such that
the positive ones are assisted to win the retrieval competition. Freed from a reliance on rationality and logical reasoning, the CBT therapist is now enabled to
use some powerful new techniques that rely on alternative principles of associative reasoning. These ideas are related to the treatment of common symptoms
typical of emotional disorders, such as phobic reactions, rumination, and intrusive images and memories. They provide a parsimonious set of principles that
have the potential to unify traditional and more modern variants of CBT.
The Phenomenology, Theory and Treatment of Posttraumatic Stress Disorder
Edna Foa, University of Pennsylvania, USA
Research and clinical observations clearly document that individuals differ in their ability to successfully process the traumatic event and thus recover naturally
with the passage of time. In this presentation I will invoke concepts from emotional processing theory to help us understand why some traumatized individuals
recover while others go on to develop chronic disturbances, notably post traumatic stress disorders (PTSD). I will then discuss how these concepts inform
cognitive behavioral interventions and will give an overview of what we know about the efficacy of cognitive behavioral therapy (CBT) for chronic PTSD. Finally,
I will present data indicating that Prolonged Exposure, a CBT program, is safe and acceptable to patients and easily disseminated to non-experts.
Symposium 33
Individual differences in vulnerability to Posttraumatic Stress symptoms
Convenor: Sippie Overwijk, University of Groningen, the Netherlands
Cognitive Control and Intrusive Memory
Sippie Overwijk, Ineke Wessel, and Peter J. de JongDivision of Clinical and Developmental Psychology, Faculty of Behavioural and Social
Sciences, University of Groningen, Groningen, The Netherlands, University of Groningen, The Netherlands
Intrusive memory is a hallmark symptom of posttraumatic stress disorder and is defined as the unwanted recollection of the trauma. Vulnerability to intrusive
memories has been found to be related to cognitive control (i.e. a domain-free capacity to prevent irrelevant information from entering working memory), in
that lower cognitive control leads to a higher susceptibility to intrusions. In this paper, we investigated whether a causal relationship exists between cognitive
control and the development of intrusive memories. There is evidence that cognitive (inhibitory) control is susceptible to circadian variation. Therefore, we
aimed at experimentally manipulating cognitive control by testing people at their off-peak time of day (morning types in the evening and evening types in the
morning) and comparing them to people who were tested at their peak time. We hypothesized that participants that are tested at their optimal time of
performance would have higher cognitive control and would experience fewer intrusions after a distressing film in a thought suppression paradigm than
participants that were tested on their non optimal time. Preliminary results suggest that young adults' cognitive control and the number of intrusions they
experience following a distressing film is not influenced by this manipulation in an important way. Interestingly, overall higher attentional control was related
to more film-related intrusions. This may indicate that reports of intrusive memories in a thought suppression paradigm reflect the ability to actively monitor
task goals in working memory. Implications for using thought suppression as a model for naturally occurring intrusions will be discussed.
Pre-trauma trait anxiety and post-trauma stress
Iris M. Engelhard and Marcel A. van den Hout, Iris M. Engelhard Utrecht University, The Netherlands
There has been debate about the relative importance of the severity of traumatic experience versus pre-existing factors in the development of posttraumatic
stress disorder (PTSD). The aim of this study was to investigate to what extent pre-existing neuroticism confounds the relationship between appraisals of the
severity of major and minor stressors and PTSD symptoms. Method. Prior to a four-month tour of duty in Iraq, neuroticism was measured in Dutch
peacekeepers (n=383). About five months after their return, the severity of major and minor stressors during deployment and PTSD symptoms were
measured.Results. Appraisals of major stressor severity in Iraq were significantly related to PTSD symptoms. However, the strength of the association
between minor stressor severity and PTSD symptoms dropped with 34% after statistically controlling for neuroticism. Conclusion. Neuroticism may partly
compromise the relationship between perceived minor stressor severity and PTSD symptoms.
Predictors of intrusive memories of a stressful life-event
Ineke Wessel and Mariëlle G. van Pampus*Division of Clinical and Developmental Psychology, Faculty of Behavioural and Social Sciences,
University of Groningen, Groningen, The Netherlands * Department of Obstetrics and Gynecology, University Medical Center Groningen,
University of Groningen, Groningen, The Netherlands., University of Groningen, the Netherlands
Not everyone develops Posttraumatic Stress Disorder after experiencing a shocking event. The question rises what pre-trauma characteristics render people
vulnerable to developing symptoms. The present contribution focuses on two types of potential pre-trauma risk factors. First, as it has been suggested that
less efficient executive functioning is associated with the specific symptom of intrusive memory, we looked at the predictive value of performance on tasks
requiring the regulation of Working Memory content. Second, the role of the personality trait of neuroticism in the development of more general PTSD and
depressive symptoms was explored. Because of the unpredictability of traumatic events, we carried out a prospective study in a high risk sample. More
specifically, we studied pregnant women with a high risk of obstetric complications resulting in life-threat to themselves and/or their unborn baby. Participants
were tested upon admission to the university hospital using several measures of cognitive control (Random Number Generation, Operation Span task) and
an index of neuroticism (EPQ). Futhermore, six weeks after delivery, intrusive memories of the event, as well as more general symptoms of PTSD and
depression were assessed. Preliminary results will be presented.
Explaining the relation between dissociation and PTSD symptoms
Nicole Buck, Merel Kindt *, Marcel van den Hout**Maastricht University; * University of Amsterdam; ** Utrecht University, Maastricht University,
The Netherlands
Dissociation is related to symptoms of Posttraumatic Stress Disorder (PTSD). Few studies have tested the underlying mechanism of this relation. A possible
underlying mechanism is a dysfunctional processing style of the traumatic event, more specifically a predominance of data-driven processing (i.e. processing
mainly the physical features of the event rather than the meaning of the situation). Two studies will be presented. An analogue study with a quasiexperimental design tested the relation between dissociation and data-driven processing. A prospective study tested the relation between data-driven
processing and PTSD symptoms. The first study showed that dissociation is related to perceptual memory representations (the supposed output of a datadriven processing style). The second study showed that data-driven processing (operationalized as perceptual memory representations and memory
disorganization) shortly after a traumatic event was predictive of PTSD symptoms four months later. These findings implicate that disturbances in information
processing are plausible candidates to explain the relation between dissociation and PTSD symptoms.
Encoding conditions of traumatic material and their effect on the development of PTSD-like symptoms
S. Schönfeld, S. Gaisser, Clinical Psychology and Psychotherapy Unit, Bielefeld, Germany, University of Bielefeld, Germany
After a traumatic event patients with Posttraumatic Stress Disorder (PTSD) often report of distressing memories about the event, which appear to be
fragmented and disorganised and not related to other autobiographical information. It has been assumed that peritraumatic dissociation might impede or
influence the encoding of the traumatic event, thus contributing to the development of PTSD (Foa & Hearst-Ikeda, 2006). However, a study showing that
disorganised encoding of traumatic material leads to PTSD-like symptoms has not yet been conducted. The objective of this study was to investigate the
association between the type of trauma encoding and the development of PTSD-like symptoms. Forty-two participants watched either coherent or
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disorganised (30 parts a ca. 30 seconds) version of a distressing film (a 3 minute scene of “city of god”). The number and quality (distress, vividness, here
and now quality) of intrusions were obtained after the experiment, and for four days subsequently to the study day via a diary. After the four days participants
also filled in questionnaires assessing appraisals of and strategies in reaction towards the memories.Participants in the experimental group (cut version)
reported a higher frequency of intrusions in the four days after the study than the control group (uncut version). However, the control group reported a higher
degree of distress in the four days after the study than the experimental group. There were no group differences in respect to appraisals or strategies related
to the intrusions. The results will be discussed in respect to current theories of PTSD.
Symposium 50
Cognitive Mechanisms of Traumatic Experiences
Convenor: Richard Bryant, University of New South Wales, Australia
Vantage Point of Memory in Posttraumatic Stress Disorder
Lucy Kenny & Richard Bryant, University of New South Wales, Australia
People can adopt an observer perspective to trauma memories as a means of avoiding the distress associated with the memory. Two studies investigated
this hypothesis in trauma survivors. In Study 1, 60 trauma survivors with differing levels of avoidance were interviewed about the vantage point of their
memory for trauma, a positive memory, and a neutral memory. Avoidant individuals were more likely to remember their trauma from an observer perspective
than individuals with a lower level of avoidance. Avoidance did not influence vantage point for positive or neutral memories. Study 2 prospectively assessed
vantage point of memory in 1032 trauma survivors within one week of trauma, and again at 3 months, and at 12 months. Observer memories initially were
associated with both more severe PTSD reactions at the time, and were also predictive of subsequent PTSD. These data support the proposal that
adoption of the observer vantage point for trauma memories may serve an avoidant function for people affected by trauma.
Time Perception in Trauma
Leah Campbell & Richard Bryant, University of New South Wales, Australia
Although time distortion is commonly reported during a traumatic experience, there is little research addressing the phenomenon. Two studies investigated
time perception in the context of high arousal. Study 1 investigated the role of affect in time perception in a very stressful experience by indexing novice
tandem skydivers' (N = 67) levels of fear and excitement before the skydive and soon after landing. Estimations of how long skydivers thought their
experience lasted were obtained after landing. Whereas increased fear was associated with the perception of time passing slowly, increased excitement
was associated with the perception of time passing quickly. Study 2 investigated the influence of emotional valence on retrospective time perception. In
order to test the hypothesis that negative events are perceived to last longer than neutral events, participants (N=58) were shown a negative or neutral
version of a slideshow and asked to retrospectively estimate the duration. A significant difference was found between participants shown the negative
version and the neutral version. Participants who were shown the negative version significantly overestimated slideshow duration. These data support
models of time perception based on avoidance and approach motivations influencing time distortion.
Autobiographical Memory in Complicated Grief
Fiona MacCallum & Richard Bryant, University of New South Wales, Australia
Autobiographical memory plays an important role in many psychological disorders. There is robust evidence that depression and posttraumatic stress
disorder is characterised by overgeneral autobiographical memories. There are conceptual reasons to suggest that similar patterns may occur in
complicated grief. To date, no studies have studied autobiographical memory in complicated grief. Recent theories of autobiographical memory hold that
retrieval of personal memories is guided by our current goals and motivations. It is probable that complicated grief is characterised by a preoccupation with
the loss, and this should shape the nature of autobiographical memories. This study provided bereaved individuals (N = 40) with and without complicated
grief with the Autobiographical Memory Task, as well as measures of goals and self- defining memories. Complicated grief was associated with overgeneral
retrieval of autobiographical memories. Further, retrieval of grief-related memories was associated with goals concerning the loss of their loved one. These
data will be discussed in terms of models of autobiographical memory and the self-memory system, and how these factors contribute to theories of
complicated grief.
Autobiographical Memory in Mandaean Refugees
Angela Nickerson & Richard Bryant, University of New South Wales, Australia
Although autobiographical memory plays an important role in posttraumatic stress disorder (PTSD), there is little research on the nature of autobiographical
memory across cultures. There is initial evidence to suggest that people from non-western societies have a more collective identity than western societies,
and therefore tend to retrieve more collective rather than individualistic memories. This study focused on Mandaean refugees in Australia. Mandaeans are
refugees from Iraq, and they are a religious group that has been persecuted for many years, and are currently facing threat of genocide in Iraq. Most
Mandaeans in Australia fear for family members' safety who are in Iraq. This study provided Mandaean individuals (N = 40) with and without PTSD with the
Autobiographical Memory Task, as well as measures of goals. It is hypothesised that Mandaeans with PTSD will retrieve more trauma-related memories
than those without PTSD. Moreover, it is hypothesised that there will be a strong relationship between concerns for family members and autobiographical
memories involving family members. These data will build on current models of autobiographical memory and the self-memory system by extending the
models to incorporate cross-cultural differences in self-identity.
Symposium 62
Cognitive processes in PTSD: Integrating and expanding cognitive models
Convenor: Marci Regambal & Lynn Alden, University of British Columbia, Canada
Processing style as an explanation for PTSD
Merel Kindt, PhD, Professor Nicole Buck, PhD, Assistant Professor b, a University of Amsterdam, The Netherlands; b Erasmus University Medical
Centre, The Netherlands
A predominance of perceptual processing during and after a traumatic experience is supposed to explain the development of chronic PTSD. This hypothesis
was tested in two analogue studies in normal volunteers and in a clinical prospective study. Experiment 1 tested whether manipulation of the processing
styles after the presentation of an aversive film resulted in PTSD-like symptoms. In line with the prediction, a predominance of perceptual processing
resulted in more intrusions. Experiment 2 was designed to replicate and extend these findings. Again, induced perceptual processing during the presentation
of the aversive film predicted the reported tendency to suppress intrusions during 1-week follow-up. The results of these two experiments indicate that
perceptual processing -as opposed to conceptual processing- is related to the development of PTSD-like symptoms.Exp.3 tested whether a predominance of
perceptual processing predicted PTSD symptoms in patients who were discharged from an Intensive Care Unit (ICU). It is assumed that a predominance of
perceptual processing results in perceptual memory representations, whereas a lack of conceptual processing results in memory fragmentation. Independent
judges used a scoring manual to determine the percentage of perceptual memories and the degree of narrative incoherence. Trauma narratives were
obtained within 1-2 weeks after ICU discharge. In line with the prediction, perceptual memories predicted PTSD symptoms at 4 months follow-up, even after
controlling for initial PTSD symptoms. Although narrative incoherence did not predict PTSD symptoms, it predicted depressive symptoms. The data
demonstrate the viability of processing style for the understanding of PTSD.
The role of dissociation, emotional impact, and chewing gum in intrusion development
Julie Krans, MSc a Gérard Näring, PhD, Associate Professor aEni Becker, PhD, Professor a Emily Holmes, PhD, Royal Society Dorothy Hodgkin
Fellow b, a Radboud University, The Netherlands ; b Oxford University, UK
Recent trauma theories propose a dual information processing during trauma that is responsible for intrusion development (Brewin, Dalgleish, & Joseph,
1996; Ehlers & Clark, 2000). The lack of integration between automatic sensory processing on the one hand, and controlled conceptual processing on the
other hand is proposed to be the source of intrusion development. The trauma film paradigm has shown that certain visuospatial tasks conducted during a
trauma film appear to reduce intrusions (Brewin & Saunders, 2001; Holmes, Brewin, & Hennessy, 2004). It has been proposed that visuospatial tasks use up
capacity involved in traumatic image encoding, thus leading to fewer intrusions. To make these findings more ecologically valid, we attempted to replicate
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them with a chewing gum task. Healthy participants (N = 68), watched a trauma film while either chewing gum, tapping visuospatially, or having no extra
task. Before and after the film questionnaires were administered: trait dissociation (DES-C), state dissociation (DSS), and mood (emotion questionnaire and
STAI). The week following the experiment, participants kept an intrusion diary. The results suggested that we could not replicate the findings for the
visuospatial tasks. Interestingly however, the emotional impact of the film was linked to intrusion development through peritraumatic dissociation. We hope
that the traumatic stress film paradigm may help improve our understanding of peritraumatic processing and intrusion development. Further, such data
should ultimately help us evaluate tasks with respect to their potential usefulness in clinical samples.
Cognitive processes mediate the relationship between traumatic events and work-related PTSD symptoms in emergency
healthcare personnel
Lynn E. Alden, PhD, Professora Marci J. Regambal, MA a Judith M. Laposa, PhD b, a University of British Columbia, Canada; b Centre for
Addiction and Mental Health & University of Toronto, Canada
Hospital emergency department (ED) health care personnel are vulnerable to work-related PTSD following traumatic events that they witness in their
patients or directly experience through workplace violence. PTSD symptoms have been found to contribute to absenteeism and staff turn-over in ED
settings. Maintaining a viable ED workforce is one of the most significant challenges facing health care delivery today. Despite the importance of ED
personnel, little is known about the factors that contribute to the onset of PTSD in emergency healthcare settings. Here, we present results of a study that
examined situational factors associated with PTSD symptoms and then used Ehlers and Clark's (2000) cognitive model to explore the processes that
mediate the link between traumatic work events and ongoing PTSD symptoms. ED personnel (N=107) at three Vancouver-area hospitals completed a
questionnaire battery that assessed the characteristics of traumatic work events, PTSD symptoms, peritraumatic dissociation, and post-event appraisals and
coping. A hierarchical regression analysis was conducted to examine theoretically proposed links between these variables. Consistent with the cognitive
model, peritraumatic dissociation, post-event appraisals and coping predicted current PTSD symptoms and mediated the link between traumatic work events
and PTSD. Interestingly, post-event rumination mediated the link between dissociation and PTSD symptoms. Discussion will focus on the implications of the
findings for interventions for health care personnel.
Pathways to intrusive thoughts in a trauma analogue paradigm: A structural equation model
Marci J. Regambal, MA Lynn E. Alden, PhD, Professor, University of British Columbia, Canada
Structural equation modeling was used to examine the prediction of intrusive thoughts from the theoretically proposed pathways in the Ehlers and Clark
cognitive model of posttraumatic stress disorder (Behav. Res Ther., 38 (2000) 319), and to examine the links between the cognitive processes central to that
model, preexisting vulnerabilities, and emotional reactivity. Using a prospective design, 148 undergraduate students viewed a distressing film and recorded
their film-related intrusive thoughts over the following week. The results indicated that a preexisting emotional vulnerability predicted dysfunctional cognitive
processing during the film, which in turn predicted dysfunctional coping strategies (i.e., rumination, thought suppression, and safety behaviors). Furthermore,
emotional reactivity and dysfunctional coping strategies directly predicted intrusive thoughts. The observed model supported the importance of cognitive
variables central to the Ehlers and Clark model, placing it in a broader context.
Do explicit and implicit vulnerability associations before and after trauma exposure predict PTSD symptoms?
Iris M. Engelhard, PhD, Assistant Professor aJorg Huijding, PhD, Assistant Professor b Marcel A. van den Hout, PhD, Professor aPeter J. de Jong,
PhD, Professor c, a Utrecht University, The Netherlands; b Erasmus University, The Netherlands; c University of Groningen, The Netherlands
Structural equation modeling was used to examine the prediction of intrusive thoughts from the theoretically proposed pathways in the Ehlers and Clark
cognitive model of posttraumatic stress disorder (Behav. Res Ther., 38 (2000) 319), and to examine the links between the cognitive processes central to that
model, preexisting vulnerabilities, and emotional reactivity. Using a prospective design, 148 undergraduate students viewed a distressing film and recorded
their film-related intrusive thoughts over the following week. The results indicated that a preexisting emotional vulnerability predicted dysfunctional cognitive
processing during the film, which in turn predicted dysfunctional coping strategies (i.e., rumination, thought suppression, and safety behaviors). Furthermore,
emotional reactivity and dysfunctional coping strategies directly predicted intrusive thoughts. The observed model supported the importance of cognitive
variables central to the Ehlers and Clark model, placing it in a broader context.
Symposium 78
Intrusions as a transdiagnostic symptom: Recent developments on the etiology of intrusions in PTSD and other
Convenor: Muriel Hagenaars, Radboud University Nijmegen, Netherlands, Netherlands
The effect of peritraumatic somatoform dissociation on intrusion development: An experimental study
M. Hagenaars, A. van Minnen, E. Holmes, C. Brewin, & K. Hoogduin, Radboud University Nijmegen, Netherlands
Peritraumatic dissociation is thought to effect the encoding of trauma information, leading to PTSD symptoms like intrusive memories of the trauma.
Peritraumatic dissociation has been linked to PTSD development in several studies (Ozer, Best, Lipsey, & Weiss, 2003), but many of these studies suffer
from methodological shortcomings. For example, many studies are retrospective, and even in prospective studies, peritraumatic dissociation is often
measured days, weeks or even months after the traumatic event. Experimental studies on this subject are rare and mostly, one form of dissociation
(detachment) is measured. Recently, some controlled studies did not find the association between peritraumatic dissociation and later PTSD development.
The present study investigated the association between dissociation and the development of one specific PTSD symptom, namely, intrusions. A highly
aversive film was used analogue to trauma. Dissociation was hypnotically induced by catalepsy in one experimental group. Catalepsy was chosen to reflect
an dissociative, involuntary non-movement reaction like freezing. Two experimental groups served as control groups: one intentionally standing still control
group and one free to move control group. Implicit and explicit memory of the film was measured in addition to intrusion frequency. The dissociative nonmovement group did not experience more intrusions than the intentional non-movement group but both the dissociative and intentional non-movement group
experienced more intrusions of the film than the free to move control group and. Dissociation across conditions was positively related to implicit cognitive
bias to film-related words and negatively related to explicit memory for the film.
Avoidance behavior in PTSD compared with panic disorder; Implications for intrusions and treatment
Agnes van Minnen & Muriel Hagenaars, Outpatient Clinic for Anxiety Disorders, Netherlands
Avoidance behavior is one of the key features of anxiety disorders. PTSD patients typically avoid stimuli associated with the trauma. It is assumed that
patients thereby prevent themselves from intrusive memories. In this study, avoidance behavior and its relationship with intrusions will be assessed more
specifically. Is avoidance behavior aimed at prevention of intrusions? Do patients avoid trauma-related stimuli only? What are the differences between
avoidance behavior of PTSD patients compared with patients with Panic Disorder? Is avoidance behavior related to intrusions?To answer these questions,
we developed the Posttraumatic Avoidance Behavior Questionnaire, which is described and tested in 56 PTSD patients, 54 patients with panic disorder with
agoraphobia (PDA) and 144 healthy controls. Item reduction and explorative factor analyses yielded 40 items reflecting seven factors: Visual Reminders,
Being Alone/in the Dark, Thoughts and Conversations, Social Interaction, Agoraphobia, Inactivity, and Sensations and Sex. Avoidance behavior in the PTSD
group was not only attributable to prevention of distressing memories but also to preventing future threat, losing control or panic attacks. What is more,
PTSD patients also avoided non-trauma related generalized situations. In addition, it was found that the reasons for reverting to avoidant patterns not only
differed between the PTSD and PDA patients but also within PTSD patients, which may have significant clinical implications. To study these clinical
implications, the reason for avoidance behavior (prevention of intrusions vs future threat) was explored for its predictive value in prolonged exposure therapy
What is an intrusion and what makes it special? A comparison of four types of intrusions (OCD, Depression, PTSD and GAD) in
healthy subjects
Sabine Schönfeld*, Karina Wahl, Karen Schulenberg, Sabine Behrensen, University of Bielefeld, Germany
Repetitive, intrusive thoughts and memories are a core and often maintaining symptom of several disorders such as OCD, MDD, PTSD and GAD. The fact
that intrusions a common in several disorders challenges the functionality of diagnostic categories in general. Cognitive models usually link psychopathology
rather to appraisals of intrusions and reactions toward them than to the mere content of them. This study is part of a project where intrusions are compared
in terms of their general form, appraisal, emotional reactions and coping strategies across several disorders. 185 healthy participants were asked to identify
four different types of intrusions (an OCD like intrusive thought, a MDD like ruminative thought, a GAD like worry related thought and a PTSD like traumatic
event related memory) and to evaluate them on an extended version of the cognitive intrusions questionnaire (CIQ, Freeston et al. 1994; the version of this
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study assessing general descriptors, emotional reactions, appraisals and coping strategies) respectively (within-design). Additionally, symptom measures for
these disorders were obtained. Data will be presented in respect to the respective dimensions across all intrusion types, as well as in respect to differences
between the different intrusions and their possible relation to clinical symptoms. The practicability of usage of a transdiagnostic intrusion focused measure
will be discussed. Additionally, cognitive models of these disorders, and a transdiagnostic view will be addressed.
Deficient executive control and neuroticism as vulnerability factors for the development of intrusive memories after a
stressful event.
Johan Verwoerd, Ineke Wessel, Peter de Jong, University of Groningen, The Netherlands
In the direct aftermath of a traumatic event, most people would experience undesirable intrusive memories. However, only in a small group of trauma
survivors, these symptoms persist longer than a normal healthy stress reaction. In the present talk, we will discuss the role of two potential pre-trauma
vulnerability factors: deficient executive/inhibitory control and high levels of neuroticism. The idea is that a weakened ability to resist or inhibit goal-irrelevant
material from working memory, together with a neurotic personality might set people at risk for persistent intrusive memories after a traumatic event. The
results of several analogue studies will be presented. First, in a cross-sectional study, evidence was found for a relationship between a behavioural index of
resistance to proactive interference (via an AB-AC list-learning paradigm) and a self-report measure of intrusive memories. In a second study which used a
prospective design, both low levels of self-reported attentional control and high levels of neuroticism predicted subsequent diary intrusions related to a
stressful film fragment. Finally, we will present preliminary results from a prospective study investigating the idea that the additional effects of executive
control and neuroticism may play a role in individual differences in attentional bias towards stressful trauma reminders. More specifically, the association of
both risk factors with intrusive re-experiencing may be partly mediated by an inability to disengage attention from trauma reminders.
Differences and similarities between obsessive thoughts and ruminative thoughts in obsessive compulsive and depressed
Karina Wahl, Sabine Schönfeld, Johanna Hissbach, Sebastian Küsel, Bartosz Zurowski & Andreas Kordon, Medical University of Luebeck,
Repetitive, intrusive cognitive phenomena are central both to obsessive-compulsive (OC) patients (typically as obsessive thoughts) and to depressed
patients (typically as ruminative thoughts). Additionally, OC patients often experience ruminative thoughts and depressed patients often experience intrusive
obsessive thoughts. The objective of the study is to compare obsessive and ruminative thoughts in terms of general form, appraisal, emotional reactions and
coping strategies in depressed and OC patients. Whereas previous studies have compared worrisome and obsessive thoughts (Langlois et al, 1999) or
worrisome and ruminative thoughts (Watkins et al., 2005) in student samples, obsessive and ruminative thoughts in clinical samples have never been
compared directly before. Thirty patients diagnosed with OCD and 30 patients diagnosed with Major Depression were asked to identify both a personally
relevant obsessive thought and a personally relevant ruminative thought and to subsequently evaluate these thoughts on a modified version of the Cognitive
Intrusions Questionnaire (CIQ, Freeston et al., 1992). The CIQ assesses general descriptors, emotional reactions, appraisal and coping strategies on a ninepoint Likert-scale. Within-subject comparison and between-subject comparisons are presented. Results demonstrate that obsessive and depressive thoughts
were clearly distinguishable in form, appraisal and temporal orientation across disorders. In OCD patients, ruminative thoughts and a ruminative coping style
were more common and more distressing than predicted. In depressed patients, obsessive thoughts occur infrequently and are not associated with high
negative emotions. Data suggest that in OCD patients, rumination is often inherently linked to the chain of obsessive thoughts and mental neutralising. In
depressed patients, obsessive thoughts do not appear to be different from intrusive thoughts in healthy individuals.
Symposium 91
Cognitive processes in posttraumatic stress disorder
Convenor: Birgit Kleim, Institute of Psychiatry London, UK
The effects of rumination on analogue posttraumatic stress symptoms
Thomas Ehring, PhD, Anna-Christina Szeimies, MA, and Christina Schaffrick, MA, University of Bielefeld, Germany
In their cognitive model, Ehlers and Clark (2000) suggest that excessive rumination about the trauma is an important maintaining factor of PTSD. Supporting
evidence comes from correlational studies showing that rumination predicts chronic PTSD. However, this has not been tested experimentally and only few
studies have investigated the processes involved in this relationship. The results of two experimental studies testing the effects of rumination on analogue
posttraumatic stress symptoms will be presented. In Study 1, 52 University students who had recently experienced a stressful event were randomly assigned
to (a) a rumination or (b) a distraction condition. Results showed that experimentally induced rumination significantly increased intrusive memories and
maintained negative mood. Study 2 aimed to test the hypothesis that the negative effects of rumination are confined to an abstract style of ruminative
thinking about the trauma. 81 students who had not experienced a traumatic event were shown a video graphically depicting the aftermath of road traffic
accidents, which had been shown in earlier studies to induced analogue posttraumatic stress symptoms. They were then randomly allocated to three
conditions: (a) abstract rumination, (b) concrete rumination or (c) distraction. Results showed that abstract, but not concrete rumination, significantly
impacted on negative mood, psychophysiological responding and intrusions about the video. Taken together, the results from these studies support the idea
that rumination maintains PTSD symptoms and that an abstract style of processing trauma-related information might be involved in this relationship.
Implications for cognitive models of PTSD and future research will be discussed.
Past lives: memories from the personal past and from the life of the deceased in sufferers of traumatic (complicated) grief
Golden, A, PhD1, Dalgleish T, PhD1, Mackintosh B, PhD2, 1 University of Cambridge, UK;2 University of East Anglia
Research has shown that individuals who have experienced significant trauma have difficulty accessing specific autobiographical memories when given
memory cues. In theoretical terms it has been proposed that this over-generality might represent a form of affect regulation and aimed at avoiding specific,
distressing information. The fact that trauma survivors are over-general when cued about their past is somewhat paradoxical, as a core feature of
psychological trauma is the experience of spontaneous intrusive and distressing recollection of very specific details of the personal past. One reason for this
contrast may be that memories for the source of the person's distress, i.e. of the trauma, are immune to the over-general effect. This may be because they
are so emotionally laden that they override any such attempts at avoidance/regulation. Alternatively, spontaneous trauma memories may be retrieved in a
different way to the types of retrieval invoked by memory cues. We examined this idea that memories for the source of distress are immune to the overgeneral effect by looking at autobiographical memories to cue words in individuals who have experienced traumatic bereavement and who have a diagnosis
of complicated grief (CG) and comparing them to memories to cue words from the life of the deceased person. Our hypothesis was that Data are presented
from groups of CG individuals and controls and the clinical implications are discussed.
Intrusive memories in posttraumatic stress disorder: an experimental test of the perceptual priming hypothesis
Birgit Kleim, PhD, Thomas Ehring, PhD, Anke Ehlers, PhD, Institute of Psychiatry, UK
Traumatic events often produce intrusive experiences, one of the hallmark symptoms of posttraumatic stress disorder (PTSD). A central question is how
such intrusions are triggered. Previous studies have highlighted that a wide range of external and internal triggers can set off intrusive memories, that
triggers often bear no meaningful connection to the trauma, and intrusive memories often appear to be coming “out of the blue”. In their cognitive model of
PTSD, Ehlers and Clark (2000) highlight perceptual priming for trauma-related stimuli as one of the mechanisms involved in triggering intrusions. Perceptual
stimuli associated with the trauma are thought to have a processing advantage, to be more likely to be noticed, and to directly trigger memory of the trauma
in an unintentional intrusive fashion. We aimed to experimetally test this hypothesis and employed a blurred picture identification task in a cross-sectional
(n= 100 accident survivors) and a prospective (n= 221 assault survivors) study of trauma survivors. We found support for a lowered perceptual threshold for
trauma-related blurred pictures in acute stress disorder (ASD) and PTSD. Participants with ASD/PTSD, but not those without the disorder, showed enhanced
priming for trauma-specific pictures compared to household pictures, while there was no such effect for general threat pictures. Enhanced priming for
trauma-related pictures predicted reexperiencieng symptoms at follow-up in the prospective sample. Together, the results concur with the assumption that
ASD and PTSD are associated with a lower perceptual threshold for trauma-related perceptual cues, which, in turn, can involuntaryly trigger intrusive
traumatic memories.
Does emotional reasoning causally affect emotional vulnerability?
Engelhard, I.M., PhD, Utrecht University, The Netherlands
Cognitive theories (e.g., Ehlers & Clark, 2000) start from the idea that PTSD and other anxiety disorders arise from overgeneralizing threat, and that
treatment should focus on disconfirming such beliefs. But why does disconfirmation fail to occur spontaneously? One possible mechanism is making invalid
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inferences through emotional reasoning: “if anxiety, then threat”. Patients with PTSD (Engelhard, Macklin, McNally, van den Hout, & Arntz, 2001) and other
anxiety disorders (Arntz, Rauner, & van den Hout, 1995), compared to healthy controls, indeed, judge situations as more dangerous if they imagine that they
would feel anxious, even if there is no objective indication of threat. There is support for the hypothesis that emotional reasoning causes emotional
vulnerability from longitudinal (Engelhard, van den Hout, Arntz, & McNally, 2002) and clinical (Arntz, 2001) studies. In a prospective study of Dutch soldiers
deployed to Iraq and Afghanistan, we are currently testing whether pre-trauma individual differences in emotional reasoning predispose to later PTSD.
Symposium 107
Enhancing Cognitive Behaviour Therapy of Posttraumatic Stress Disorder
Convenor: Richard Bryant, University of New South Wales, Australia
A Comparison of Imaginal Exposure, In Vivo Exposure, and Their Combination with Cognitive Therapy in the Treatment of
Posttraumatic Stress Disorder
Angela Nickerson, Lucy Kenny, Sally Hopwood, Julie Mastrodomenico, & Kim Felmingham, Richard A. Bryant,, University of New South Wales,
Exposure has been a highly efficacious intervention for posttraumatic stress disorder for many years. Exposure usually takes the form of either imaginal
exposure to trauma memories or in vivo exposure to feared situations. Although exposure has been studied repeatedly in the treatment of PTSD, there is
currently no reliable evidence pertaining to the relative efficacy of different forms of exposure. This paper reports the results of an ongoing study that
compares four treatments of PTSD: (a) imaginal exposure, (b) in vivo exposure, (c) combined imaginal and in vivo exposure, and (d) their combination with
cognitive therapy. Treatment comprised 8 weekly 90-minute sessions administered on an individual basis. Civilian trauma survivors (N = 103) were
randomly allocated to one of the four treatment conditions. Data will be presented on 6-month follow-up assessments. Imaginal exposure involves repeated
exposure to memories of the traumatic experience. In vivo exposure involves graded exposure to a hierarchy of feared situations. Cognitive therapy
involves identification and modification of maladaptive appraisals of the trauma. Participants were assessed, in part, with the Clinician Administered PTSD
Scale, Impact of Event Scale, and Beck Depression Inventory. Blind assessments were conducted at pretreatment, posttreatment, and six months
posttreatment. Objective treatment fidelity ratings were conducted. Intent-to-treat analyses indicate that participants in the combined treatment made greater
treatment gains than those in the three other conditions
Enhancing Treatment Effectiveness for Acute Stress Disorder
Eva Kandris, Sally Hopwood, Julie Mastrodomenico, Kim Felmingham, & Richard A. Bryant,, University of New South Wales, Australia
The majority of people who meet criteria for acute stress disorder (ASD) subsequently develop chronic posttraumatic stress disorder (PTSD). Although
previous cognitive behavior therapy studies for ASD have demonstrated the efficacy of CBT in reducing subsequent PTSD, significant proportions of
participants drop out of exposure-based therapy. Although exposure is not a significant cause of drop-out in more chronic PTSD, acutely traumatized people
appear susceptible to not tolerating exposure. This study aims to increase the effectiveness of treating ASD by evaluating non-exposure-based treatment.
Specifically, ASD participants were randomly allocated to either (a) prolonged exposure (PE), (b) cognitive restructuring (CR), or (c) wait-list control (WL).
Therapy comprised five weekly sessions of individual therapy. PE comprised education, imaginal exposure, in vivo exposure, and relapse prevention. CR
comprised education, identification of cognitive errors, daily monitoring of thoughts and affective states, and to modify thoughts by Socratic questioning,
probabilistic reasoning, and evidence-based thinking. Manualized treatments were followed and independent fidelity checks were conducted. Blind
assessments were conducted at 3 months, 6 months, and 12 month posttreatment. Data will be presented on 93 participants who completed treatment and
6-month follow-up assessment. Initial intent-to-treat analyses indicate that participants in PE displayed greater PTSD reduction than participants in CR, who
in turn had greater reductions than WL. Findings will be discussed in terms of optimal interventions for acutely traumatized individuals.
A Pilot Study of Cognitive Behaviour Therapy for Police Officers
Lucy Kenny, Sally Hopwood, Julie Mastrodomenico, Kim Felmingham, & Richard A. Bryant,, University of New South Wales, Australia
Although cognitive behaviour therapy (CBT) has been proven to be effective in treating PTSD in civilian populations, it has yet to be demonstrated in police
organizations. Police officers are exposed to multiple traumatic events and operate in a culture that is often not amenable to therapeutic interventions.
Initial trials of our standard CBT indicated that it failed with police officers. A modified CBT was developed that commenced wit 6 sessions of distress
tolerance, and skills training in management of anger, insomnia, alcohol use, and panic. Therapy then involved 8 sessions of exposure and cognitive
therapy. Twenty police officers were treated in an open trial. Participants were assessed, in part, with the Clinician Administered PTSD Scale, Impact of
Event Scale, and Beck Depression Inventory. Based on intent-to-treat analyses, police officers enjoyed a marked reduction in PTSD symptoms (effect size:
1.25) and depression (effect size: 1.50). Interestingly, mid-therapy assessments conducted after the skills training indicated that PTSD and depression did
not decrease after skills training; only at the completion of exposure/cognitive therapy were symptom reductions observed. Findings are discussed in terms
of optimal interventions for police officers.
The Benefit of Adding Coping Skills to Cognitive Behaviour Therapy for Posttraumatic Stress Disorder
Fiona MacCallum, Sally Hopwood, Julie Mastrodomenico, Kim Felmingham, & Richard A. Bryant,, University of New South Wales, Australia
Cognitive behaviour therapy (CBT) has been a highly efficacious intervention for posttraumatic stress disorder. Some commentators have suggested that
the capacity to manage the anxiety elicited by exposure may be limited in some individuals, and they may benefit from learning coping skills to equip them to
manage the distress elicited by exposure. This paper reports the results of an ongoing study that compares two forms of CBT for PTSD: (a) standard CBT,
and (b) a skills training program that preceded the CBT. Treatment comprised 8 weekly 90-minute sessions administered on an individual basis. Civilian
trauma survivors (N = 68) were randomly allocated to one of the two treatment conditions. Data will be presented on posttreatment and 6-month follow-up
assessments. The modified CBT included 4-6 sessions that taught distress tolerance, anxiety management, and related coping skills. Participants were
assessed, in part, with the Clinician Administered PTSD Scale, Impact of Event Scale, and Beck Depression Inventory. Blind assessments were conducted
at pretreatment, posttreatment, and six months posttreatment. Updated results will be presented on intent-to-treat analyses.
Symposium 122
Integrating Imagery Interventions in Cognitive Therapy of Posttraumatic Stress Disorder
Convenor: Mervin R. Smucker, Medical College of Wisconsin, Milwaukee, USA, Norway
Implementing Imagery Rescripting and Reprocessing Therapy in an Inpatient Treatment Programme for Posttraumatic Stress
Disorder: Preliminary data
Hoffart, A., Langkaas, T. F., Borge, F.-M., Modum Bad Research Institute, Norway; Institute of Psychology, University of Oslo, Norway
Preliminary data of process and weekly outcome in a treatment programme for posttraumatic stress disorder (PTSD) at the Modum Bad Psychiatric Clinic
will be presented. Weekly measures include intensity and frequency of DSM-IV PTSD symptoms, alliance with individual therapist, alliance with group,
outcome expectations, and beliefs related to the trauma and its symptoms. Global changes are measured from pre- to post-treatment regarding intrusions,
avoidance, dissociation and cognitions (IES, DES, PTCI).
Implementing Imagery Rescripting and Reprocessing Therapy in an Inpatient Treatment Programme for Posttraumatic Stress
Disorder: Description of implementation
Langkaas, T. F., Hoffart, A., Borge, F.-M., Modum Bad Research Institute, Norway; Institute of Psychology, University of Oslo, Norway
Practical applications of how imagery has been integrated and adapted to an inpatient treatment programme for posttraumatic stress disorder (PTSD) at the
Modum Bad Psychiatric Clinic in Norway will be presented and discussed. The treatment programme is designed for patients suffering from PTSD due to
traumatic events that have occurred during adulthood. Treatment is based on a combination of group, individual and milieu therapy.
A Conceptual Framework for the Integration of Imagery Interventions in CBT Treatment of PTSD
Smucker, M. R., Medical College of Wisconsin, Milwaukee, USA
Dr. Smucker will offer a conceptual framework for the integration of imagery interventions in the CBT treatment of PTSD and demonstrate how the activation
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and modification of distressing images is very much part of the Beckian cognitive model. As such, when the distressing cognitions are encoded verbally,
then verbal interventions are used to activate, challenge, and modify the upsetting cognitions. By contrast, when the distressing cognitions are embedded in
images, then accessing, activating, and modifying the distressing images (and associated beliefs) become the intervention of choice. Imagery rescripting
will be presented as an extension of Beck's cognitive therapy model in the treatment of trauma and PTSD. Case examples will be used to demonstrate
application of this model in clinical practice with this population.
Symposium 138
Psychological treatment for severe, complex and chronic Posttraumatic Stress Disorder
Convenor: Regina Steil, Central Institute of Mental Health, Mannheim, Germany, Germany
A Dismantling Study of the Components of Cognitive Processing Therapy
Patricia A. Resick, National Center for PTSD, Boston VA Healthcare System and Boston University
Cognitive Processing Therapy (CPT) consists of two major components, cognitive therapy and a written form of exposure. In order to determine the relative
effectiveness of each component and whether each component is essential, we conducted a dismantling study with three randomly assigned conditions: full
CPT, cognitive therapy only (CT) and written exposure only (WE). The sample consists of 150 sexually or physically assaulted women who began one of
the three treatment conditions. Assessments of PTSD with the Clinician Administered PTSD Scale (CAPS) were conducted at pre-treatment, post-treatment
and at six months follow-up along with a range of other measures. Brief PTSD and depression scales were also implemented weekly. There were no
differences between the three group on demographic variables. Repeated measures ANOVA on the CAPS total resulted in significant assessment period
effect, but no main effect for group or interaction. Pre-post effect sizes were 1.87, 1.22, and 1.62 for CPT, WE, and CT respectively. On the BDI, there was
also a significant assessment period effect but no group effect or interaction. The pre-post effect size for CPT was 1.23, for WE it was .96, and for CT it was
1.66. However, in examining within treatment change using random regression analyses, it was found that there were significant differences between
groups throughout most of the treatment. CT had the fastest trajectory of change followed by CPT and then WE. By posttreatment assessment, the latter
two conditions caught up with CT. These findings have implications for conducting brief treatments, for treating clients who are at risk of dropping out.
Furthermore these findings call into questions theories about habituation as the mechanism of change.
Characteristics of intrusive memories and non-memory intrusions and their change in treatment in multiple traumatized
patients with PTSD.
Anne Boos, PhD; Anna Hoese, Dipl. Psych.; Angelika Linke, Dipl. Psych., Technical University Dresden, Germany., Department of Clinical
Psychology and Psychotherapy, Technical University of Dresden, Germany Anne Boos, PhD; Anna Hoese, Dipl. Psych.; Angelika Linke, Dipl.
Psych., Technical University Dresden, Germany.
Intrusive memories belong to the core symptoms of PTSD. Previous studies report intrusive memories of the trauma or intrusive non-memory thoughts about
the trauma (Hackmann, 2005: Reynolds et al., 1999, 1998). The study compares the content, frequence and distress of non-memory intrusions (thoughts
about the trauma) and intrusive memories of the trauma at the beginning of treatment in patients after multiple trauma. It was hypothesized that the sample
perceives intrusive memories as more distressing as the associated non-memory thoughts. The later one are believed to be more frequent. It is
hypothesized that patients with DESNOS-like symptoms differ in number and quality of their memory intrusions from patients with more limited trauma
sequelae. Number of session needed to treat PTSD are predicted by a combination of several factors (i.e. borderline and dissociative symptoms, severity of
PTSD, quality of the intrusion, cognitive distortions etc.). Implications for the treatment of PTSD in a multiple traumatized patients will be discussed.
Dialectical Cognitive Trauma Therapy as a New Treatment for Patients Suffering from Chronic Posttraumatic Stress Disorder
and Comorbid Symptomatology after Childhood Sexual Abuse: a Pilot Study.
Regina Steil (PhD), Anne Dyer , Nikolaus Kleindienst , Martin Bohus, Central Institute of Mental Health, Mannheim, Germany
Treatment manuals are missing for patients with severe PTSD and comorbid psychopathology. Dialectical cognitive trauma therapy (DCT) has been
specifically designed to treat patients suffering from severe and chronic PTSD plus comorbid symptoms such as self-injurious behaviour, drug abuse etc..
DCT includes elements of emotion regulation, mindfulness exercises, cognitive therapy, and exposure treatment as well as new elements. This pilot study
aims to evaluate the effect of inpatient DCT. Nineteen patients suffering from PTSD (DSM-IV) after childhood sexual abuse and from severe comorbid
psychopathology were assessed prior to (t0), post (t1), 6 weeks post (t2), 6 months post (t3) inpatient treatment of 68 days on average. Assessments
included Posttraumatic Diagnostic Scale (PDS), Beck Depression Inventory (BDI), State Trait Anxiety Inventory (STAI) and Symptom Checklist-90 Revised
(SCL-90-R). Comparison of t0 and t2 revealed both significant response and remission for the primary outcome (PDS) as well as for the secondary
outcome-criteria (STAI, SCL-90R, BDI). Pre to 6 weeks post comparisons yielded medium to large effect-sizes. None of the patients dropped out during the
active treatment phase. The data consistently suggest that inpatient CDT might be helpful in reducing severe and complex posttraumatic symptomatology.
Symposium 157
The role of case studies in the refinement of evidence-based practice in the treatment of posttraumatic stress
Convenor: David Edwards, Rhodes University, South Africa
The role of case studies in the development and refinement of evidence-based practice
David Edwards, Rhodes University, South Africa
Recent conceptualizations of the scientific basis of evidence-based practice in psychotherapy have recognized the fundamental role of case studies in
building applied clinical knowledge. While there is an increasing call for manualized treatments which can be systematically evaluated in randomized
controlled trials, authors of several contemporary treatment manuals emphasise the important of flexibility and lay out theoretical and practical principles as a
basis for informing the process of assessment, case formulation and selection and sequencing of interventions. A great deal of observation within cases
needs to take place before any treatment can be systematized and manualized, and even when manualized treatments have been evaluated within RCTs,
there is still room for development and refinement and adaptation to specific contexts. Case-based observations and systematic case studies make an
important contribution to this process. Presentations in this symposium will describe case studies formulated within two current systematic approaches to the
treatment of posttraumatic stress disorder which use the analysis of detailed aspects of the case material to examine how it contributes to the clinical
knowledge base either by validating the existing model, refining it, or extending its reach to address psychological processes not catered for in the current
Combining cognitive restructuring and exposure/reliving to enhance treatment for PTSD
David Edwards, Rhodes University, South Africa
When traditional, existing treatments are not fully effective, clinicians need to draw on the theory and evidence currently available but be creative in adapting
interventions to the idiosyncratic features of the case. Both prolonged exposure and broader cognitive behavioural therapy are highly effective treatments for
PTSD. However, even if clients fully emotionally engage with the traumatic material they do not all exhibit habituation of distress. Similarly, following
cognitive interventions, clients sometimes say that although they believe the new information logically they do not believe it emotionally or show any change
in emotion. This paper presents part of the treatment of a man who was raped. He benefited from exposure/reliving but he continued to experience certain
intrusions. Careful attention during the exposure helped to identify particular worst moments of the experience and the cognitive themes within the traumatic
memories. Traditional cognitive restructuring of these themes also led to some improvement. However he continued to have some re-experiencing
symptoms. Developments in cognitive models for PTSD (Ehlers & Clark, 2000) suggest possible clinical adaptations. A more direct interweaving of cognitive
restructuring within the reliving/exposure techniques resulted in increased effectiveness in this case. The case presented shows how treatment may be
enhanced when clinicians both use available theoretical models and closely examine the phenomenology of the presenting problems.
Using imagery techniques to elaborate and contextualise traumatic memories of death of others, and thus soften their impact
Nick Grey, South London and Maudsley NHS Trust & Institute of Psychiatry, UK.
Ehlers and Clark's model of PTSD suggests that during trauma memories are processed in a special way. This leads to fragmented sensory memories,
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which are easily triggered and very aversive, and so are avoided or suppressed. These fragments are stored with their original disturbing meanings, which
were never updated. Nor were the memories given their proper time code. Successful therapy involves accessing and updating the hotspots in memory, by
elaborating and contextualizing them amongst other autobiographical knowledge. The goal is to see the original event as time limited, and rather less toxic
than it appeared at the time of the trauma.Therapists are therefore somewhat disconcerted when the trauma involves the actual death of another person.
Obviously such a presentation will involve real grief, which will need to be acknowledged and addressed in the normal way. However, clinical experience
suggests that there is often still room for cognitive interventions to help patients deal with distorted cognitions about the death itself, as opposed to the sense
of loss. In addition, the emotional impact of such interventions often appears to be greatly enhanced by the use of imagery techniques. The presenters will
report on several cases where imagery interventions were utilized to soften the impact, when the deaths of other people had led to an exaggerated sense of
guilt, shame, anger, horror or fear. The way in which such interventions still fit within the Ehlers and Clark model will be discussed.
Treatment of PTSD and depression in a black South African rape survivor: A case based evaluation of Ehlers and Clark's
clinical model
Dr Ann Hackmann and Dr. Rachel Handley,, Institute of Psychiatry, UK
This paper documents the treatment, based on Ehlers and Clark's (2000) cognitive therapy for PTSD, of a 21 year old black woman with Posttraumatic
Stress disorder (PTSD) and Major Depressive Disorder (MDD) who had been raped 2 years previously. The assessment and therapy process were
documented using Fishman's (2005) model for a pragmatic psychotherapy case study. Repeated measures were taken on several scales including the Beck
Depression Inventory-II and the Posttraumatic Diagnostic Scale, and a selective thematic narrative was written. The case formulation highlighted a) three
intrusions (rapist lying on her, his triumphant smile, and his order to her to clean up afterwards), b) beliefs that included 'my future is over', 'I am responsible
for what happened', 'this is a punishment for disobeying my parents', 'men can't be trusted', 'I am unworthy' and 'I am helpless', c) fear of being HIV+ and the
decision not to get tested and to live as if she was infected, d) a social life characterized by fear of disclosing personal information to friends and family and
a coping strategy of “fake it till you make it”. Interventions included imaginal reliving, restructuring of hotspots during and outside of reliving, building social
support, re-evaluating and challenging beliefs associated with guilt and decatastrophising HIV infection. At termination, Oratilwe has still not had an HIV test
but she no longer met the criteria for PTSD or MDD. The paper evaluates the impact of these interventions, difficulties pertinent to this particular case and
the transportability and cultural applicability of the model.
Applying a CBT Treatment Algorithm for Victims of Trauma and PTSD
Amy Davidow and David Edwards, Rhodes University, South Africa
Acknowledging that roadblocks, failures, and drop-outs continue to plague CBT treatments of PTSD, Dr. Smucker will discuss how clinicians can significantly
improve their treatment outcomes with victims of trauma and PTSD by applying a CBT Treatment Algorithm. He will examine several trauma cases that
poignantly demonstrate: (1) How CBT failures may result from a “mismatch” between the CBT interventions being applied and the specific trauma
characteristics of the client, (2) How an algorithmic treatment model that assesses the specific trauma characteristics of each client can aid the clinician in
finding the best individualized “treatment fit” for each trauma case, and (3) How imagery can be used as a primary therapeutic agent to foster rapid cognitive
and emotional processing of traumatic material encoded and embedded in the traumatic imagery. Essential components of Smucker and colleagues' PTSD
algorithmic treatment model involve: (a) distinguishing between Type I and Type II traumas, (b) assessing the predominant PTSD emotion(s) for each client
(e.g., fear, anger, guilt, shame), (c) determining whether the initial treatment focus should be on stabilization or trauma-processing interventions, (d)
determining how much exposure is necessary and how to effectively integrate its use with cognitive restructuring interventions, and (e) applying imagery to
enhance the effects of both exposure and cognitive restructuring. An empirical critique of the use of exposure and cognitive restructuring interventions in the
treatment of PTSD will be offered.
Open Paper Symposium 49
PTSD Interventions
Early Intervention and Outreach for Trauma Survivors: the Effects of CBT
Sara Freedman, Dept. of Psychiatry, Hadassah University Hospital, Jerusalem, Israel, Rhonda Adessky, Dept. of Psychiatry, Hadassah University
Hospital, Jerusalem, Israel, Arieh Y Shalev, Dept. of Psychiatry, Hadassah University Hospital, Jerusalem, Israel
CBT has been consistently shown to be an effective treatment for chronic PTSD. Both Foa's Prolonged Exposure (PE), which focuses on in vivo and
imaginal exposure, and Cognitive Therapy which focuses on changes in thoughts regarding the trauma, have been shown to reduce PTSD symptoms
significantly. The literature regarding the use of CBT early after the traumatic event, in an attempt to prevent the development of PTSD is much smaller.
However, 6 studies have shown that up to five sessions of PE, or PE with CT, are effective at preventing PTSD in individuals with Acute Stress Disorder. The
study presented here aimed to address two major questions regarding early interventions for PTSD: firstly, whether CT and PE produced differential effects,
and secondly, to examine the rate of uptake of therapy in the context of outreach to trauma survivors. An outreach program contacted all trauma survivors
that attended a general hospital's Emergency Room by telephone one week post-trauma. Symptomatic survivors were invited to attend a clinical interview,
around two weeks following the trauma. Treatment for those with ASD began within 28 days of the trauma. Using equipoise stratified randomization, patients
(N=170) were assigned to five optional treatment conditions: Prolonged Exposure (PE), Cognitive Therapy, Active Medication (SSRI), Placebo, and Waitlist.
Subjects on the waitlist received PE at four months. Clinical interviews were also carried out at four and seven months post-trauma, and telephone
interviews at eight and fourteen months. The latter included both subjects who had received treatment, as well as those who were asymptomatic at first
interviews. Preliminary data analyses have shown the following results. Firstly, subjects are extremely receptive to telephone outreach, with a refusal rate of
around 6%. Subjects who are symptomatic and invited to a clinical interview are reluctant to attend, with a refusal rate of around 50%. Of those referred to
treatment, about a quarter do not attend. At follow up (7 & 14 months) subjects who did not attend a clinical interview are relatively symptom-free, whereas
those who did not attend treatment show higher symptom levels. Preliminary results looking at the outcome of treatments show that early interventions are
extremely successful at lowering symptom levels, and these gains are maintained at follow up. There are no significant differences between the treatment
types. Analyses regarding differences between early and late (post Waitlist) PE will be presented. These results will be discussed in terms of the importance
of providing outreach, the effectiveness of early interventions, in comparison to later treatment (at 4 months), and the efficacy in general of these treatments.
A randomised controlled trial investigating the effectiveness of writing as a self-help intervention for traumatic injury patients
at risk of developing post-traumatic stress disorder
Alison Bugg, University of Sheffield, Graham Turpin, University of Sheffield, Suzanne Mason, University of Sheffield, UK
Background: A large percentage of people who attend Accident & Emergency following a traumatic accident or injury will develop long-term psychological
difficulties. There is therefore a need to be able to identify these individuals and develop effective, low-cost, interventions that can be administered on mass.
Previous studies of the provision of self-help information to A&E attenders (e.g. Turpin et al. 2005) have failed to demoinstrate any benfits of information
compared to a control group. This study is a replication of previous attempts at providing self-help information but is also augmented by an experimental
group that recieved 3 sessions of "Writing Therapy" based on Pennebaker's writing paradigm. Aims: To investigate the effects of writing and self-help
information on the severity of psychological symptoms in a group of A&E attenders at risk for developing PTSD. A&E attenders who had sustained injuries
as a result of a RTA, occupational injury or assault were recruited into the study on the basis of scores on an Acute Stress Disorder screening measure.
People who scored in the high range were assigned to an information control group (N=36) or a writing and information group (N=31). Participants in both
groups received an information booklet on coping with traumatic injury, one-month post-injury. Participants in the writing and information group also wrote
about emotional aspects of their trauma during three 20-minute writing sessions at five to six weeks post injury. Self-reported questionnaires measuring
PTSD, anxiety and depression were completed within one month and at three and six months post injury. Self-reported perceptions of quality of life were
also obtained at three and six months post injury. Results: Comparisons of the information control group and the writing and information group showed that
there were no group differences in symptom severity ratings of PTSD, anxiety and depression at three months post-intervention. Additionally, there were no
significant differences between groups in their quality of life ratings at three months post intervention. However, 71% of participants in the writing group
rated writing as very or extremely useful. Conclusions: No evidence was obtained to support beneficial effects of providing self-help information or getting
people to write about their trauma as an early intervention prevention technique for traumatic injury patients at risk of developing PTSD. The failure of selfhelp provision in reducing psychological symtoms post trauma is consistent with previous reserach. However, participant's subjective ratings of the
usefulness of writing were very high. Further reserach around the writing paradigm and the provision of guided self-help for these clients is warranted.
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Outcome Evaluation of Individual Therapy for Trauma Victims Seen in Private Practice
Chris Mackey, Chris Mackey & Associates, Specialist Psychology Services Australia
Much research on clinical outcomes for trauma victims has been conducted in the context of programmatic treatment interventions offered to highly selected
client groups. In contrast, this paper presents outcome data on the effectiveness of therapy offered in general clinical practice, which may be more
generalizable to a range of other clinical settings. Treatment outcome data were collected (following principles outlined by Lyons et al., 1997) for 120 clients
offered individual therapy for trauma reactions in a clinical psychology private practice. Client groups included victims of crime and those who had suffered
from motor vehicle or industrial accidents. Evaluation measures included the Impact of Event Scale, Beck Anxiety Inventory, and the Beck Depression
Inventory. Treatment interventions offered within a cognitive-behavioural framework included psychoeducation, relaxation techniques, and EMDR or
exposure. Exploratory statistical analyses were used to investigate factors affecting treatment outcome such as the source of treatment funding, nature and
recency of the trauma, and treatment techniques used. Clients showed both statistically and clinically significant reductions in post-traumatic stress, anxiety
and depressive symptoms. Clients typically experienced no more than mild symptomatic distress following psychological treatment. Several factors were
identified which affected treatment outcome. These results might also offer comparative data for private practitioners and other clinicians who wish to gauge
the severity of their clients' trauma reactions and degree of symptomatic improvement using objective measures. In addition this paper may demonstrate
that such analyses are accessible and useful to clinicians in private practice.
Cognitive therapy for Post-traumatic Stress Disorder in the context of terrorism and other civil conflict in Northern Ireland.
Michael Duffy, University of Ulster and N. I. Centre for Trauma and Transformation, Kate Gillespie, Northern Ireland Centre for Trauma and
Transformation, David M. Clark, Institute of Psychiatry, Kings College, London, UK
Little is known about how to successfully treat the trauma resulting from events such as the recent London Bombings, the Twin Towers attack in New York,
the Madrid train bombings and other terrorist incidents. A new Northern Ireland treatment centre (NICTT) was established in 2002 with a remit to offer
trauma-focused cognitive therapy to people affected by terrorism and other civil conflict over the last four decades. The present study evaluates the cognitive
therapy provided by the Centre and is, as far as we are aware, the first controlled trial of treatment for terrorism related PTSD. Patients were assessed using
the Semi-Structured Clinical Interview for DSM-IV and the Clinician- Administered PTSD Scale for DSM-IV (CAPS). Primary outcome variables were:
severity of PTSD, assessed by the Posttraumatic Stress Diagnostic Scale (PDS), and severity of depression, assessed by the Beck Depression Inventory
(BDI). The secondary outcome variable was the Sheehan Disability Scale (SDS), which has separate items for work, family and social disability. Patients
were randomly allocated to either immediate cognitive therapy (CT) or a 12 week wait, followed by CT. Treatment involved up to 12 weekly therapy sessions
in the first twelve weeks, To determine the extent to which therapy gains were maintained, patients were offered follow-up appointments at 1, 4 and 12
months post-treatment. Fifty-eight patients who met DSM-IV criteria for PTSD participated in the trial. Intention-to-treat (ITT) and completers only analyses
were conducted. Comparisons at 12 weeks between immediate CT and wait were based on analyses of covariance (ANCOVA) with pretreatment/wait
scores as covariates. Within treatment comparisons between pre-treatment, posttreatment and follow-up used t tests. At 12 weeks, ANCOVA's (with pretreatment/wait scores as covariates) indicated that the immediate CT group scores were significantly lower than the wait group on the PDS, BDI and SDS.
Within group t-tests showed that the wait group did not improve on any measure and that the immediate CT group improved on all measures (p < .001) For
all patients who received cognitive therapy (immediate and delayed treatment combined t - tests showed highly significant pre-treatment to post treatment
reductions in the symptoms of PTSD and depression and in work, family and social life related disability . t-tests comparing patients scores at post-treatment
and follow-up indicated that treatment gains were well maintained. The study demonstrated that CT is an effective treatment for PTSD resulting from
terrorism related traumatic events. Patients allocated to immediate cognitive therapy showed significant and substantial reductions in the symptoms of PTSD
and depression and also marked improvements in self-reported work, family and social functioning. In contrast, patients allocated to a no treatment (Wait
List) control condition showed no change.
Interpersonal Psychotherapy: Adjunct to CBT for Military Veterans with PTSD
Rebecca Ray, The University of Newcastle, Rosemary Webster, The University of Newcastle, UK
Interpersonal Psychotherapy (IPT) aims to reduce interpersonal difficulties. Since this is common in individuals with PTSD, the current study proposed using
IPT as an adjunctive treatment (following CBT) for military Veterans with chronic PTSD to specifically address their comorbid social and interpersonal
difficulties. Nine male Vietnam veterans with Posttraumatic Stress Disorder (PTSD) completed an eight-week program of group-based Interpersonal
Psychotherapy (IPT-G) adapted for PTSD. Veterans who had received CBT without remission of symptoms were included in this program with an aim to
improve interpersonal functioning and thereby reduce PTSD and depressive symptoms. The following were assessed: PTSD symptoms (Impact of Event
Scale - Revised), depression symptoms (Beck Depression Inventory -II), interpersonal functioning (Inventory of Interpersonal Problems - 32, Social and
Occupational Functioning Assessment Scale), global functioning (Health of the Nation Outcome Scales, Global Assessment of Functioning rating). Measures
were administered during treatment, pre- and post-treatment and at two and four-month follow up. Reliable change indices demonstrated significant
improvements in PTSD and depression symptoms, as well as interpersonal and global functioning but treatment gains were generally not maintained at
follow up. However, qualitative feedback was positive with veterans indicating they had experienced reduced levels of anger and stress and improved
relationships as a result of the program. IPT-G for PTSD demonstrates promise as an effective adjunct to CBT in improving Psychological functioning of
veterans with chronic PTSD. However, future research should consider conducting the program over a longer time frame and using a graduated termination
phase to prevent relapse.
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Applied Behaviour Analysis & Acceptance and Commitment
Invited Addresses
The Implications of ACT and RFT for CBT
Steven Hayes, University of Nevada, USA
The third generation of behavioral and cognitive therapies have the potential to fundamentally alter the landscape of CBT. ACT and RFT in particular seemed
positioned to do so because they contain an entirely new, empirical approach to cognition. In this talk, I will explain the behavioral basis of that approach to
cognition and will show how it alters how we think of thinking. I will then focus on how it leads to a new theory of psychopathology and health and will review
some of the recent evidence on the ACT approach. I will show how the intrusion of modern forms of contextualistic behavior analysis into territories previously
reserved to more cognitive approaches within CBT is challenging the status quo and the progressive narrative of traditional CBT.
Symposium 14
Basic processes underlying the expansion and treatment of anxiety disorders
Convenor: M. Carmen Luciano, University of Almería, Spain
Transformation of respondent elicitation functions established with aversive conditioning
Miguel Rodríguez 1Carmen Luciano 2Dermot Barnes-Holmes1Sonsoles Valdivia1Francisco Ruiz, University of Jaén, Spain 1 University of Almería,
Spain 2 University of Maynooth, Ireland 3
This study presents experimental data on the transformation of respondent elicitation functions according to symbolic comparative relations of size (larger
and smaller-than). This study experimentally analyses the historical interactions that are responsible for the emergence of fear reactions (autonomic arousal
responses) in the presence of stimuli lacking a history of direct conditioning with a traumatic event. After establishing a series of comparative relations
between different visual stimuli, one of the stimuli in the relational network was employed as a CS in an aversive single-cue conditioning procedure. Once
conditioning effects were well established for that stimulus, the other elements in the relational network were tested to see if they would elicit activation
responses [skin conductance responses (SCRs) and heart rate responses (HRRs)] according to the comparative relations previously established among the
network elements. A stimulus that was previously trained to be symbolically “smaller than” the CS should elicit smaller SCRs and smaller accelerative HRRs
than the directly conditioned responses (CRs), while a stimulus previously trained to be symbolically “larger than” the CS+ should elicit SCRs and
accelerative HRRs larger than the CRs. These results were obtained in the absence of direct conditioning contingencies with either the “smaller-than” or the
“larger-than” stimuli. Although symbolically different in “size”, the actual physical dimensions of all the stimuli in the experimental task were identical. This
effect can only be explained in terms of a previous history of arbitrary relational training. Implications for a novel behaviour-analytic approach to the study of
anxiety will be discussed.
Acquisition of functions and transference of the extinction by relational means.
Carmen Luciano Sonsoles Valdivia Francisco Ruiz1 Dermot Barnes-Holmes 2 Francisco Cabello 3 Michael Dougher 4 Miguel Rodriguez5 Olga
Gutierrez 1 Yvonne Barnes-Holmes, University of Almería, Spain1 University of Maynooth, Ireland 2University of Murcia, Spain3University of New
Mexico, U.S.A.4University of Jaén, Spain5University of Huelva, Spain
This study concerns the transference of function for respondent elicitation and avoidant functions by relational means as well as the transference of the
extinction functions also by relational means. In the first phase, two equivalent classes of 6 stimuli each one (A1-B1-C1-D1-E1-F1; A2-B2-C2-D2-E2-F2)
were trained. Secondly, A1-B1 were aversively conditioned with electric stimulation and A2-B2 were positively conditioned. Transference of functions are
tested with the D and F stimuli. Later extinction of A1-B1 was implemented, and the extinction of the respective functions were tested with the D and F. This
procedure is proposed: (a) as an analogue of a trauma spreading effects to give an account of the expansion of such a trauma throughout related and
apparently unrelated life domains, and (2) an analogue of in-vivo exposure to the feared stimulus aiming at eliminating the avoidance responses and its
transfer to arbitrary related stimuli. Other practical implications for psychopathology with be discussed concerning the expansion of experiential avoidance.
Impact of several protocols in the acquisition of functions and transference of the extinction by relational means.
Carmen Luciano Sonsoles Valdivia Francisco Ruiz 1Olga Gutiérrez 2Dermot Barnes-Holmes 2Yvonne Barnes-Holmes 3Michael Dougher
Francisco Molina 4Francisco Cabello 5Miguel Rodríguez, University of Almería, Spain1 University of Huelva, Spain 2University of Maynooth,
Ireland3University of New Mexico, U.S.A.4University of Murcia, Spain 5University of Jaén, Spain
This study is proposed as an extension of the previous one, and shows data of the impact of several protocols in the transference of respondent elicitation
and avoidant functions by relational means and the transference of the extinction of these functions also by relational means. In the first phase, two
equivalent classes of 6 stimuli each one (A1-B1-C1-D1-E1-F1; A2-B2-C2-D2-E2-F2) were trained. Then, one discomfort-control and two acceptancedefusion protocols were implemented, both in the context of values, with the aim of altering the transference of functions that would be typical according to
derived functions. In the third phase, A1-B1 were aversively conditioned with electric stimulation and A2-B2 were positively conditioned. Transference of
functions are tested with the D and F stimuli. Later, extinction of A1-B1 was implemented, and the extinction of the respective functions were tested with the
D and F.
This procedure is proposed as an experimental analogue of a preventive intervention to undermine the effects of a trauma situation (either in the
emotional as well as in the valued behaving domains). The results the study is discussed in terms of the relative effectiveness of several therapeutic
techniques in accordance with the characteristics of relational responding in humans.
Experimental analysis of the use of metaphor for clinical purpose
Carmen Luciano 1Francisco Cabello Francisco Ruiz, University of Almería, Spain 1University of Murcia, Spain
The current study analyze the use of metaphors as a clinical method. Metaphors has received increased interest from a number of behavior therapies in
recent years (e.g. ACT, DBT, MBCT), and have been applied for the treatment of anxiety. However, the conditions under which metaphors are useful and
have a real impact on psychological functions are not well known nor have been studied systematically. The current paper reports an empirical study that
attempts to provide a preliminary account of this issue, and that indicates at least some of the conditions under which metaphors can be effectively used for
the treatment of psychological disorders.
Symposium 28
Experimental analysis of several strategies to cope with aversive private experiences. Implications in the clinical
Convenor: Olga Gutiérrez Martínez, University of Granada, Spain
Rebound effects of thought suppression and derived relational responding
Olga Gutiérrez Carmen Luciano1Yvonne Barnes-Holmes2Dermot Barnes-Holmes2, University of Granada, Spain1University of Almería,
Spain2University of Maynooth, Ireland
Research has shown that attempts to suppress a thought can cause anincrease in the frequency of the thought (for example, the classic "white bear"
experiment by Wegner, Schneider, Carter and White, 1987), but it is still unknown the conditions under which the paradoxical effects of thought suppression
may extend beyond immediately stimuli to indirectly related events. This study examines for the very first time if laboratory paradigms used in controlled
thought suppression studies can be extended via equivalence procedures. Specifically, it was used the word-association paradigm commonly used on
cognitive research. This paradigm was employed by Wegner & Erber (1992). Present study aims to replicate Wegner & Erber (1992) study and to extend it
via equivalence procedures. Subjects were trained to form two three-members equivalence classes with natural language words as stimuli(A1-B1-C1, A2B2-C2). Then subjects were asked not to think about A1. No special instructions were given for A2. Then, subjects performed the word-association task. The
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results showed that, in general, the rebound effects is not readily obtained under word-association paradigm. However, for the participants clearly showing a
rebound effect, it was found that the paradoxical effects of word suppression (A1) transferred to the remaining class members (B1 and C1) that have never
been suppressed, by means of their participation in equivalence classes with the target directly suppressed. It suggests that paradoxical increase in thought
frequency may occur not only after repeated attempts to suppress an specific thought, but also with new contents. Conceptual and clinical implications for
the understanding of several psychological disorders are discussed.
The rebound effect of the suppressed pain experience
Marisa Páez2 Carmen Luciano3Olga Gutiérrez4José Ortega, Spanish Cancer Association 2University of Almería, Spain3University of Granada,
Spain4National University of Distance Education
This experimental study compares the effects of two coping with pain strategies: trought suppression (TS) and sensory monitoring (SM), in terms on their
long term effects, from the perspective of the functional analytical account of acceptance and psychological avoidance. During the tourniquete pain induction
procedure, ten subjects were instructed either to remove awareness of their arm sensations from mind (TS) or pay close attention to them (SM). The
rebound effect defined in mental control studies (Wegner, 1994; Wenzlaff, Wegner y Klein, 1991) as the derived effects of the suppressed strategies in terms
of the delayed re-emergency of the private events initially suppressed, was taken as the dependent variable. In this study it was described as the recovery
from pain time and the percentage of words related to pain during the rebound effect phase. Results showed any difference between the strategies when the
rebound effect was measured as the recovery from pain time but when the verbal reports were take into account the thoughts rebound effect was found.
This suggests that pain can persist not in spite of such mental efforts but because of them. These results are discussed in the context of the arbitrarily
behaviour - behaviour relations and the clinical implications of this effect are considered in terms of the discriminative function of this class of verbalizations.
The suppression of permitted and forbidden sexual fantasies: Are taboo sexual fantasies more difficult to suppress?
Laura Sánchez Carmen Luciano1Dermot Barnes-Holmes, University of Almería, Spain1; University of Maynooth, Spain
The current research focused on the effects of suppression versus concentration in relation to sexual fantasies in both male and female undergraduate and
postgraduate student from a range of countries. Participants were asked to choose from a range of either appropriate or inappropriate sexual practices (as
defined by the views of the general population), and to engage in a sexual fantasy about the chosen practice. Half of the participants were then asked to
suppress any thoughts of the fantasy while engaging in a distraction task; the remaining participants were asked to concentrate on any fantasy related
thoughts that occurred during the task. The relative effects of suppression and concentration were assessed using a word association test, answering with a
word to a word given (10 sexual words and 10 non sexual words), a measure employed by Wegner in his studies on thoughts suppression.
The following
task was the IRAP, a tool for assessing attitudes or beliefs that are easily hidden when explicit measures are employed such as questionnaires. The
participants had to answer as quickly and accurately as possible concerning whether specific sexual practices are arousing or not.
The correlation
between these two measurements was analyzed.
Symposium 40
Application of Acceptance and Commitment Therapy (ACT) to the prevention and treatment of health
problems.Convenor: Sonsoles Valdivia, University Almería, Spain
A Comparison between two psychological treatments oriented to smoking-cessation: ACT-based treatment vs. Cognitivebehavioural treatment.
Mónica Hernández, Jesús Gil, Carmen Luciano, University of Valladolid (Spain);University of Almeria (Spain)
This study compares two different psychological treatments aimed at smoking-cessation. One of them focuses in the acceptance of aversive sensations as
urges related to nicotinic abstinence, and is an adaptation of the core components of Acceptance and Commitment Therapy (ACT). The other one focuses in
controlling those aversive urges, and consists of a multi-component cognitive-behavioral intervention program that is currently employed by the Spanish
Association against Cancer. Eighty-one smokers took part in the study, all of which went through an individual assessment session in which data were
collected about personal-historical variables [such as demographic information, consumption history, situations and cognitions related to smoking,
contingencies related to smoking, previous attempts to quit, smoking context, stage of change (Prochaska & DiClemente, 1983), different aspects related to
motivation, psychological diagnosis, health habits, some aspects related to self-control, etc.] and different questionnaires were administrated: Nicotine
dependence (Fagerström, 1978); Self-control (Rosenbaum, 1980); Self-efficacy related to smoking (Condiotte y Lichtenstein, 1981), AAQ (Hayes, Strosahl y
Wilson, 1999); Believability of reasons to smoke (made on purpose for this study). Treatments were conducted in seven group sessions. Forty-three
smokers received the ACT-based treatment, and the other thirty-eight received the multi-component cognitive-behavioral treatment. At the end of treatment
new data were collected (satisfaction with the treatment, adherence of participants to different treatment elements, withdrawal symptoms, health and
psychological benefits, etc.) and the same questionnaires were administered (except for Fagerström, 1978). Follow-up data were taken one, three, six, and
twelve months after treatment. The results showed that ACT was clearly more effective to quit, both short and long-term. These differences are statistically
significant for participants who completed al least five treatment sessions. Finally, results are discussed in terms of the change processes that may be
operating for each treatment.
Prevention of HIV among adolescents. Comparing the effect on information-based protocols vs. information plus values-based
protocols on risky patterns of behaviour.
Olga Gutiérrez; M. Carmen Luciano;M. Paz Bermúdez, University of Huelva (Spain);University of Almeria (Spain); University of Granada (Spain)
There is an increasing interest on the emergence, prevention and change of risk behaving among adolescents and the HIV contagion. The efforts to have
individuals well educated regarding the prevention of HIV are important, still the available literature points out that the prevention programs have had, in
general, little effect on reducing the risk behaviours directly related to the HIV contagion. For this reason, research on the isolation of the several
components comprising the usual protocols is needed. We present the results of a study where the adolescents were presented with either 1) an
information-based protocol, aimed at promoting an increased consciousness of the necessity of behaving to prevent HIV, for instance, by using condoms,
restricting the number of sexual partners, or keeping abstinent; or 2) a protocol where such information was framed in the context of personal values. This
protocol was aimed at connecting the increased consciousness of the necessity of behaving to prevent HIV with the values stated by each of the participants
(family, education, social relations, etc.). Results show that the strategies directed to clarify values may be successful to increment several preventing
behaviours. This highlights the importance of designing HIV prevention programs which are based on the empirical evidence available.
ACT in the sanitary context. The effect of a brief ACT protocol in post-surgery recovery.
M. Dolores Fernández;M.Carmen Luciano; Sonsoles Valdivia, Torrecardenas Hospital (Spain);University of Almería (Spain);University of Almería
Acceptance and Commitment Therapy is showing highly effective in its application to diverse alterations. Originally, it was developed to be implemented in a
number of sessions. Lately, however, the interest on isolating the “active components” of the therapy in a more precise way, and hence, on elucidating why it
is that the therapy works, is increasing as both a basic and an applied research issue. With this purpose, the application of shortened protocols focusing
each in a different aspect of the therapy is especially relevant. The present study addresses this topic. A total of 13 patients hospitalized to go through the
same kind of surgery participated. A quasi-experimental pre-post design with a control condition was employed. In the experimental condition, the patients
were presented with a very brief ACT protocol including: 1) the value of the surgery, 2) assessment of the fears and worries related to the surgery, 3)
normalization and exposition to such worries by means of metaphors and exercises directed toward distancing from them. In the control condition, the
patients were not presented with any protocol. The most salient result was the reduction in the number of days of post-surgery hospitalization in the ACT
condition. The role of the components included in the ACT protocol in altering the function of aversive private events like pain or fears, is discussed.
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Basic Processes
Invited Addresses
Uncertainty in OCD
Marcel van den Hout, Utrecht University, The Netherlands
Obsessive Compulsive perseveration is typically motivated by uncertainty about memory for earlier checking. We developed an experimental model of
perseverative checking and observed that perseveration has ironical effects: it serves to reduce memory certainty instead of increasing it. Data from a series
of experiments will be presented and the psychological mechanisms involved will be discussed. Replications from other groups indicate that the perseverationinduced memory uncertainty is robust: it survives changes in stimulus material and it occurs rapidly, memory confidence getting compromised after very few
checks. We recently observed that individuals with sub-clinical OCD report memory uncertainty already after one check, and independent from any
perseveration. We suggest that individuals with sub-clinical OCD share a general and mild meta-cognitive uncertainty about e.g. memory, reasoning, perception
etc. In clinical OCD, but not in sub clinical OCD, this general/mild uncertainty is combined with specific and intense uncertainty. This general/mild metauncertainty may motivate to check matters that others leave unchecked. It is speculated that the transition between sub-clinical (mild/general uncertainty) and
clinical OCD (specific/intense uncertainty) is the paradoxical result of the very effort to combat uncertainty by perseveration
Metacognitive Therapy: Nature and effectiveness across disorders
Adrian Wells, University of Manchester, UK
Metacognitive Therapy (MCT) is concerned with reactions to thoughts and beliefs. Everyone experiences negative thoughts and believes them, but not
everyone develops prolonged psychological suffering. MCT proposes that prolonged distress results from the activation of a style of thinking called the
Cognitive Attentional Syndrome (CAS). The CAS consists of excessive thinking in the form of worry and rumination, maintaining attention on threat (Threat
monitoring), and coping behaviours that fail to modify dysfunctional knowledge. The CAS arises from the individual's beliefs but these are not the beliefs
emphasized by traditional CBT but are positive and negative metacognitive beliefs. The basic model is the grounding for disorder-specific formulations and
treatments of the CAS and metacognitions. Three important aspects of treatment consist of: (1) enabling patients to experience their thoughts and beliefs in
new ways; (2) removing the CAS, and (3) modifying positive and negative metacognitions. There is a large data-base supporting key aspects of the theory,
and evidence is growing concerning the effects of specific MCT treatment techniques and full MCT across disorders. In this Keynote address, common
techniques of MCT will be described with reference to ways of treating GAD, PTSD, depression, and OCD. Data on the effects of individual techniques and of
full treatment will be presented. Suggested reading:Wells A. (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy: Chichester, UK:
WileyWells A. (2005). Detached mindfulness in cognitive therapy: A metacognitive analysis and ten techniques. Journal of Rational Emotive and Cognitive
Behavior Therapy, 23, 4, 337-355. Wells A. & Sembi S. (2004). Metacognitive Therapy for PTSD: A core treatment manual. Cognitive and Behavioral Practice,
11, 365-377.
Cognitive and Neural Systems Underlying the Control of Intrusive Memories: Implications for theories of thought
Michael C. Anderson, University of Oregon, USA
People often confront reminders to events that they would prefer not to think about. When this happens, they frequently try to exclude the intrusive memory
from awareness. Here, I review our recent cognitive and neurobiological research on the mechanisms underlying people's ability to control unwanted
memories. The ability to control memory builds on basic neural systems involved in overriding prepotent responses, and involves the inhibition of the
declarative memory representation underlying the intrusive trace. This work establishes that individual differences in the suppression of intrusive memories
are produced by variability in the engagement of these neural systems, and for many subjects suppression is an effective means of regulating awareness.
This new synthesis of basic cognitive neuroscience research on executive function and memory control suggests insights on when and why thought
suppression may be effective and provides new methods to study this process. Implications for theories of thought suppression and its efficacy will be
Symposium 5
New advances in understanding key cognitive processes that maintain anxiety and depression
Convenor: Jennifer Wild, Institute of Psychiatry, UK
Why worriers can't stop worrying: Restricted working memory capacity during worry
Hayes, S., Hirsch, C., & Mathews, A., Institute of Psychiatry, King's College, University of London, UK
Evidence has suggested that working memory (a limited capacity store needed to engage in different tasks and switch between tasks) is reduced in high
worriers due to worry consuming limited capacity resources. As a result, high worriers may be less able to redirect thoughts away from worry and onto nonworry topics than low worriers, resulting in perseverance of worry. The current study is the first to assess how much working memory (WM) capacity is taken
up when people worry. Participants were required to think about either a current worry topic or a positive personally relevant thought topic whilst
simultaneously performing a random key-press task in which more random performance indicates more residual WM capacity available. High worriers were
less random (indicating less residual WM capacity) when thinking about a worry topic than when thinking about a positive topic. In contrast, low worriers did
not differ in terms of randomness when thinking about a worry or a positive topic. As predicted, high worriers had more WM capacity taken up by worry than
a positive thought topic. In contrast, low worriers had the same amount of WM capacity taken up when thinking about a worry or a positive topic. Such
findings suggest that high worriers have less WM capacity available when engaging in worry and as such, have less WM available to enable them to switch
their thinking away from worry onto non-worry topics. These results may have important implications for models of worry persistence and GAD.
Social anxiety and source errors in the recall of social scenarios
Paula Hertel, Faith Brozovich, Eric Robinson, & Leda McDaniel, Trinity University, USA
Individuals diagnosed with Generalized Social Phobia (GSP) and non-disordered controls read ambiguous social scenarios and provided their own
continuations, which were used to disambiguate their interpretations of the scenarios. As has been documented in other studies, GSP participants'
interpretations were categorized as socially anxious and otherwise negative, more frequently than interpretations made by the controls. Subsequently, they
attempted to recall the scenarios and, separately, their own continuations. The number of scenarios that contained intrusions of nonpresented material was
significantly greater in the control group. However, the number of social scenarios that contained intrusions related to the corresponding continuations was
greater in the GSP group, particularly when those continuations revealed interpretations that were socially anxious, otherwise negative, and even positive.
Such errors reflect difficulty in distinguishing between internally and externally generated information (reality monitoring, Johnson & Raye, 1981). This
process will be discussed in light of evidence from an experiment performed with nonanxious controls who attempted to remember the scenarios and the
continuations provided by the GSP participants in the previous study.
Negative Interpretations of Intrusive Memories in Depression
Michelle L. Moulds, Alishia D. Williams, & Susannah Starr, The University of New South Wales, Australia
Recent investigations have shown that intrusive memories of negative past events, the hallmark symptom of PTSD, are also common in depression. This
paper reports two studies that explored the utility of Ehlers and Steil's (1995) model of PTSD maintenance, which emphasises the role of negative
interpretations of intrusions, in accounting for the persistence of intrusive memories in depression. In Study 1, non-clinical participants who experienced an
intrusive memory in the previous week completed measures that indexed cognitive and affective responses to memories. Negative interpretations of
intrusive memories were significantly correlated with cognitive avoidance (particularly rumination) and depression, after controlling for intrusion frequency
and severity of memory content. Negative meaning of intrusions was the strongest predictor of depression, explaining variance over and above intrusion
frequency. Study 2 extended these findings by replicating Study 1 in a dysphoric sample and including a broader range of measures to tap negative
appraisals and avoidant cognitive processes. In accord with Study 1, intrusion-related distress correlated with dysphoria, irrespective of intrusion frequency.
Assigning negative appraisals to an intrusive memory and attempts to control the memory were positively associated with intrusion-related distress,
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depression and cognitive avoidance. High dysphoric participants reported more frequent intrusive memories, more intrusion-related distress, and were more
likely to engage in rumination, suppression and emotional detachment in response to memories. The convergent findings demonstrate the applicability of a
cognitive model of PTSD to explain the maintenance of intrusive memories in depression, supporting the value of a transdiagnostic approach to
psychological disorders.
New Advances in understanding key cognitive processes that maintain anxiety and depression
Jennifer Wild, Janet Faigenbaum, Ruben Gur, Institute of Psychiatry, UK
Recent investigations have shown that intrusive memories of negative past events, the hallmark symptom of PTSD, are also common in depression. This
paper reports two studies that explored the utility of Ehlers and Steil's (1995) model of PTSD maintenance, which emphasises the role of negative
interpretations of intrusions, in accounting for the persistence of intrusive memories in depression. In Study 1, non-clinical participants who experienced an
intrusive memory in the previous week completed measures that indexed cognitive and affective responses to memories. Negative interpretations of
intrusive memories were significantly correlated with cognitive avoidance (particularly rumination) and depression, after controlling for intrusion frequency
and severity of memory content. Negative meaning of intrusions was the strongest predictor of depression, explaining variance over and above intrusion
frequency. Study 2 extended these findings by replicating Study 1 in a dysphoric sample and including a broader range of measures to tap negative
appraisals and avoidant cognitive processes. In accord with Study 1, intrusion-related distress correlated with dysphoria, irrespective of intrusion frequency.
Assigning negative appraisals to an intrusive memory and attempts to control the memory were positively associated with intrusion-related distress,
depression and cognitive avoidance. High dysphoric participants reported more frequent intrusive memories, more intrusion-related distress, and were more
likely to engage in rumination, suppression and emotional detachment in response to memories. The convergent findings demonstrate the applicability of a
cognitive model of PTSD to explain the maintenance of intrusive memories in depression, supporting the value of a transdiagnostic approach to
psychological disorders.
Symposium 12
Information-processing of emotion in depression: clinically relevant insights from cognitive neuroscience
Convenor: Rudi De Raedt, Department of Psychology, Ghent University, Belgium, Belgium
Information processing in depression: converging evidence from clinical, experimental and neurobiological research
Rudi De Raedt & Ernst Koster, Ghent University, Belgium
A deeper understanding of the disruptions in information processing characterizing depression -how people attend to, remember, and interpret informationrequires the integration of findings from clinical, cognitive, and neurobiological research. Research efforts are focused around the development of a general
model that links attention processes and schema-activation to negative mood states, to investigate vulnerability factors for depression. The model is in line
with findings based on affective modifications of experimental psychology paradigms, neuroimaging research, psychophysiological data and methods that
allow the experimental modification of information-processing biases, such as repetitive Transcranial Magnetic Stimulation. The basic idea of the model is
that negative information in the environment triggers mood-congruent information-processing, characterized by reduced attentional and inhibitory control,
related to clinical symptoms such as rumination, increased elaboration of depressogenic schemata and prolonged experience of negative emotional states.
The neural circuitry involved in these disruptions consists of the anterior cingulate, the dorsolateral prefrontal cortex and the amygdala, brain regions that
have been shown to be related to the pathophysiology of depression. The aim of our model is to gain a deeper understanding in the working mechanisms of
mood disorders, in order to stimulate translational research to improve the effectiveness of interventions by tailoring them to account for individual
differences in information processing styles.
Automatic judgmental bias in major depression: neural correlates and genetic susceptibility
Udo Dannlowski1/5, Patricia Ohrmann1, Jochen Bauer1, Carsten Konrad1/5, Sonja Schöning1/5, Jürgen Deckert1/3, Christa Hohoff1, Harald
Kugel2, Volker Arolt1, Walter Heindel2, Anette Kersting1, Bernhard T. Baune1/4, Thomas Suslow1, 1 University of Münster, Germany 3 University
of Würzburg, Germany. 4 Department of Psychiatry, James Cook University, Townsville, Australia. 5 IZKF-Research Group 4, IZKF Münster,
University of Münster, Germany
According to appraisal theories of emotion, automatic evaluative responses to incoming stimuli are crucial components of emotion processing. In a series of
studies, automatic evaluative processes were studied in major depression by means of masked affective priming paradigms that characterize automatic
emotion processing by investigating the biasing effect of subliminally presented emotional faces on evaluative ratings to subsequently presented neutral
stimuli. In a first longitudinal study, it was demonstrated that strong automatic judgmental biases in depressed patients were associated with poor therapy
response after 7 weeks. In a second study, we investigated the neural substrates of negatively biased automatic emotion processing by means of fMRI in a
sample of healthy volunteers. We found a strong and specific correlation of amygdala reactivity in response to masked negative faces with automatic
negative judgmental biases in the affective priming task. A third study replicated these findings in a sample of depressed patients. Furthermore, automatic
negative judgmental bias was strongly associated with a longer and severer history of depression. In a final study, it was demonstrated that amygdala
reactivity to masked facial emotions was modulated by a common genetic polymorphism (5-HTTLPR) in the serotonergic system. We conclude that the
amygdala plays a pivotal role in automatic evaluative responses. A probably genetically influenced amygdala hyper-reactivity might affect the onset and
maintenance of depression by eliciting dysfunctional negative biases already at automatic stages of emotion processing.
Emotional information processing and the regulation of mood state and cortisol levels
Mark A. Ellenbogen, Alex E. Schwartzman, & Caroline Ostiguy, Concordia University, Montreal, Quebec, Canada
There is increasing evidence that stress and cognitive processes are important factors in the development of psychopathology. We propose that the ease in
which a person disengages attention from negative stimuli may serve an adaptive self-regulatory function, and that these mechanisms are maladaptive
during states of depression and anxiety. Using a design that allows us to concurrently monitor the emotional, attentional, and hypothalamic-pituitary-adrenal
axis (HPA) response to stress, we have found that the ability to efficiently disengage from supraliminal negative pictures was associated with subsequent
mood state, while disengagement from masked pictures was associated with subsequent cortisol levels. These findings suggest that effortful and automatic
processing may regulate different aspects of the stress response. Among clinical samples, the disengagement of attention from supraliminal stimuli was
associated with the regulation of mood state in both depressed and anxious participants. For masked stimuli, there was a robust association between
attentional disengagement and subsequent cortisol levels among anxious participants (r=0.39, p<0.05), but no relationship (r=0.02, NS) among depressed
participants. These results suggest that the ability to regulate one's mood state using an attentional mechanism is intact in depressed and anxious
participants, and is therefore an appropriate target of cognitive-behavioural therapy. In contrast, cognitive control over the HPA axis may be dysfunctional in
depressed, but not anxious participants. We are currently examining whether disengagement from emotional stimuli is associated with indices of functioning
in the natural environment, including cortisol levels sampled at home, interpersonal functioning, and stressful life events. Preliminary results will be
Neuro-cognitive effects of Hf-rTMS over the dorsolateral prefrontal cortex on attentional modulation of emotional information
in healthy subjects
Lemke Leyman1, Rudi De Raedt1, Chris Baeken2, Peter Clerinckx3, Marie-Anne Vanderhasselt1,& Hugo D'Haenen2, 1 Ghent University, Belgium
2Deparment of Psychiatry, Free University Brussels, Belgium3Department of Radiology, Free University Brussels, Belgium
A review of literature reveals that Repetitive Transcranial Magnetic Stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC) might be a new
promising treatment procedure for depression. Evidence suggests that multiple sessions of High Frequency (HF) rTMS can be effective in reducing
depressive symptoms. However, the essential working mechanisms of this technique are still unclear. Because multiple sessions of rTMS may cause
structural changes in brain activity patterns, it can be hypothesized that stimulation of prefrontal regions may primary lead to enduring alternations in
cognitive functioning. Investigating the effects of rTMS on proposed underlying cognitive vulnerability factors for depression such as a dysfunctional
attentional processing of negative information can therefore be an interesting pathway filling up this gap in research. The most straightforward method to
start investigating this causal relationship is by assessing the temporary effects of one session of Hf-rTMS applied to the DLPFC on cognitive functioning in
healthy persons. Results indicate that Hf-rTMS to the right DLPFC causes no significant self-reported mood changes in healthy volunteers but succeeds in
establishing a significant decrease in inhibitory control towards negative information, measured using a negative affective priming task. Similar results were
found using an exogenous cueing task, demonstrating a difficulty to disengage from negative information after stimulation. These findings will be discussed
in light of the corresponding changes in brain activation patterns investigated using event-related fMRI.
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Attentional influences on the encoding of emotional information in dysphoria
Ernst Koster & Rudi De Raedt, Ghent University, Belgium
Research has suggested that depression is characterized by maintained attention for negative information. In the present study the temporal characteristics
of maintained attention for emotional words were investigated in a sample of stable dysphoric (n = 14) and non-dysphoric (n = 14) undergraduates in a rapid
serial visual presentation. It was found that presentation of negative words hampered identification of a word presented immediately after the negative word.
Furthermore, impaired disengagement has also been related to reduced inhibition of return effects in the spatial cueing task. In the same population we
performed a spatial cueing task with negative, positive, and neutral words presented for 250 ms with a short and a long cue-target onset. It was found that
dysphoria was associated with an attentional bias on trials with a long cue-target onset. These results add to the current understanding of attentional bias as
possible cognitive vulnerability factor in the development and maintenance of depression. Especially, the demonstration that mood-congruent attentional bias
impairs processing of schema-disconfirming material may be of particular importance in the maintenance of depressed mood.
Symposium 13
Why can't I stop thinking about it': The role of post-event processing in social anxiety
Convenor: Lusia Stopa, University of Southampton, UK
Self-appraisal and post-event processing in social anxiety
Laura Dannahy* & Lusia Stopa, University of Southampton, UK
The cognitive model of social phobia by Clark and Wells (1995) proposes that following a social event, individuals with social phobia will engage in postevent processing, during which they conduct a detailed review of the event. This study investigated the relationship between self-appraisals of performance
and post-event processing in individuals high and low in social anxiety. Participants appraised their performance immediately after a conversation with an
unknown individual and prior to an anticipated second conversation task one week later. The frequency and valence of post-event processing during the
week following the conversation was also assessed. The study also explored differences in the metacognitive processes of high and low socially anxious
participants. The high socially anxious group were found to experience more anxiety, predict worse performance, underestimate their actual performance,
and engage in more post-event processing than low socially anxious participants. The degree of negative post-event processing was linked to the extent of
social anxiety and negative appraisals of performance, both immediately after the conversation task and one week later. Differences were also observed in
some metacognitive processes. The results are discussed in relation to current theory and previous research.
The Effect of Positive or Negative Post-Event Processing on Socially Anxious Individuals
Michelle James & Lusia Stopa*, University of Southampton, UK
Clark and Wells (1995) propose that after participating in social situations individuals with social phobia engage in post-event processing (PEP) where they
review the event in detail. They suggest that the content of PEP is dominated by the negative thoughts and anxious feelings processed while the individual
was in the social situation. This results in the interaction being viewed as more negative than it actually was, thereby increasing anxiety. This study
manipulated PEP by asking participants to focus on either the positive or the negative aspects of a social situation, and examined the effect on imagery,
thinking, performance appraisals, and mood in high and low socially anxious individuals. Consistent with both Clark and Wells' model, and previous
research, high socially anxious individuals rated their performance as worse, predicted worse performance, had more negatively valenced images, thought
more about negative aspects of their performance in PEP and reported higher levels of anxiety in a social situation compared to low socially anxious
individuals. This study also provides preliminary evidence to suggest that engaging in positive PEP may have beneficial effects on ratings of performance,
future performance, image and impression valence and thoughts during PEP in high socially anxious participants
State anxiety experienced in response to public speaking in social phobic and nonclinical participants: Testing a theoretical
Ronald M. Rapee1* & Maree J. Abbott2, 1 Macquarie University, Sydney, Australia 2 University of Sydney, Sydney, Australia
Cognitive models of social phobia predict that several cognitive processes will mediate the relationship between trait levels of social anxiety and the extent of
anxiety experienced in a specific social-evaluative situation. The current study aimed to provide a test of these relationships. Clinical participants with social
phobia (N=230) and non-clinical participants (N=89) completed trait measures of social anxiety and a week later performed a brief impromptu speech. They
completed a measure of state anxiety in response to the speech as well as questionnaires assessing several cognitive constructs including focus of
perceived attention, perceived performance, and probability and cost of negative evaluation. A week later they completed measures of rumination and
distress experienced over the week. Structural equation modelling provided support for a model in which the cognitive factors mediated between trait social
anxiety and the degree of anxiety experienced in response to the speech as well as the distress experienced over the following week.
Post Event Processing in Social Phobia: Changes Throughout the Course of Treatment
Sarah Perini* and Peter McEvoy, St Vincent's Hospital, Sydney, Australia
Cognitive-behavioural models of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997) propose a number of maintaining factors, including postevent processing (PEP) about perceived inadequacy in past social situations. There is increasing empirical support for the role of PEP in maintaining social
phobia, but there is little evidence about the time point at which this, and other maintaining factors, change during the course of therapy. This study involved
the development and weekly administration of a brief measure of several proposed maintaining factors, along with measures of social anxiety, depression
and PEP to a clinical sample receiving seven weeks of group cognitive behavioural therapy for social phobia. The aim was to investigate when changes
occurred throughout the treatment process, and how these changes related to treatment outcome.
Symposium 26
Human fear conditioning: an excellent paradigm to study the basic processes of behaviour change.
Convenor: Dirk Hermans, University of Leuven, Belgium
Associative Learning and the Indirect Pathways to Fear in Children
Andy Field & Chris Askew, University of Sussex, UK
Verbal threat information and observational learning have long been assumed to play an important role in the development of fears and phobias. Although
evidence for the contribution of indirect pathways to fear has traditionally been based on retrospective reports recent work has begun to experimentally
manipulate threat information and vicarious learning experiences about novel animals in pre-teenage children (e.g. Field & Lawson, 2003). These
experiments show that threat information can change fear beliefs in children (measured explicitly and implicitly) that persist over long periods of time and
create behavioural avoidance and attentional biases. However, the mechanisms underlying these effects remain unexplored. This talk presents experiments
that test the notion that effects of threat information and vicarious learning in the development of fear in children are driven by associative learning
processes. The first two experiments adapt Field and Lawson's (2003) paradigm in 7-9 year old children and the results showed that fear beliefs induced by
threat information are sensitive to the contingency between the novel animal and information given and are also affected by devaluation of the information.
The second two experiments test the same phenomena in a vicarious learning paradigm in which novel animals and scared or happy facial expressions
were contiguously presented. The results showed little effect of contingency or US revaluation in vicarious learning. These experiments suggest that
associative learning is a versatile framework within which to explain the developmental acquisition of fears in children; however, they imply that there are
differences in the extent to which threat information and vicarious learning experiences conform to the known 'rules' of associative learning.
Is high trait anxiety characterized by impaired inhibitory fear learning?
Merel Kindt, University of Amsterdam, The Netherlands
There is substantial evidence that trait anxiety or neuroticism poses a risk factor for the development of anxiety disorders, but the mechanism remains
unclear. The prevailing hypothesis that may account for the etiological contribution of high trait anxiety states that trait anxiety may give rise to increased
excitatory fear learning. Although this hypothesis is appealing, a recent meta-analysis showed no convincing evidence for this hypothesis. An alternative
hypothesis may be that anxiety give rise to impaired inhibitory fear learning. The present paper will present two studies that tested this alternative hypothesis
using a recently developed AX+/BX- discrimination procedure in a fear-potentiated startle paradigm
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Experimental models of fear and anxiety: contrasting cue and contextual stimuli
Christian Grillon, National Institute of Mental Health, USA
Advances from pre-clinical research on the neurobiology of aversive motivational states have not been accompanied by similar progress in elucidating the
pathophysiologic underpinnings of the anxiety disorders. Keys to successful translational research are the development of experiments that closely model
clinical phenomena and that can be replicated across species. The cross-species methodologies of fear conditioning and fear-potentiated startle provide
important avenues toward this end (Grillon & Baas 2002). Fear-potentiated startle refers to the increase in startle reactivity during the anticipation of aversive
stimuli. In rodents, fear-potentiated startle is mediated by two different structures, the amygdala and the bed nucleus of the stria terminalis. These two
structures mediate the distinct aversive states of fear, a phasic response to a clearly identified danger, and anxiety, a more sustained aversive state not
clearly linked to a cue. Fear-potentiated startle can also be obtained in humans with experiments analogous to those used in animals. This presentation will
focus on the pharmacological and clinical validation of procedures in which startle is elicited during threat of predictable and unpredictable aversive stimuli in
humans, as model of fear and anxiety, respectively. We will show that the benzodiazepine alprazolam reduces fear-potentiated startle to unpredictable
shock. We will discuss the effect of acute and semi-chronic citalopram. We will also show that across the spectrum of anxiety disorders, individuals with
generalized anxiety show greater sensitivity to shock unpredictability than those with specific phobias, a finding consistent with characterizing anxiety
disorders subtypes as primarily anxiety- or fear-related, respectively.
Safe and unsafe contexts: preconditions for contextual fear
Debora Vansteenwegen, Carlos Iberico & Bram Vervliet, University of Leuven, Belgium
Two experiments will be presented. In a first experiment the relation between predictability and contextual fear was investigated using a within-subject
human fear conditioning preparation. In this experiment, 62 participants were presented with two different contexts (switching on and off the central lighting
of the experimental room). In one context, the predictable context, a visual cue (CS+) was systematically followed by an electrocutaneous stimulus (US) and
another visual cue was not (CS-).In the other context, the unpredictable context, CSs were presented explicitly unpaired with the US. Dependent variables
were electrodermal responding and fear-potentiated startle. First, the results showed differential CS+/CS- conditioning in the electrodermal and startle
responses in the predictable context. Second and more importantly, larger startle amplitudes during the inter-trial-intervals demonstrated more contextual
fear in the unpredictable than in the predictable context. In a second experiment, the onset of the shocks was predictable in both contexts, however the
location of the shock presentations was variable in one context and fixed in the other contexts. We investigated the effects of location unpredictability on
contextual fear.
Return of fear after confrontation with unpredicted aversive events: differential and non-differential reinstatement
Dirk Hermans & Trinette Dirikx, University of Leuven, Belgium
A series of fear conditioning studies will be presented that demonstrate that unpredicted aversive events can 'reinstate' extinguished fears. Interestingly,
these data show that under some circumstances even former 'safety signals' can develop into a source of fear responses after confrontation with such
unpredicted aversive events.
Symposium 27
Dismantling Ruminative Thinking
Convenor: Hans Reinecker, University of Bamberg, Germany , , Germany
Development and validation of a content-independent measure of perseverative thinking
Thomas Ehring, University of Bielefeld, Germany
:Accumulating evidence shows that perseverative thinking is involved in the maintenance of various disorders, including depression, GAD and PTSD. A
number of measures have been developed to assess perseverative thinking as relevant to different emotional disorders (e.g., PSWQ for chronic worry, RSQ
for depressive rumination). Most measures are focussed on thought content rather than the characteristic process or style of thinking. Therefore, they have
been criticized for being highly confounded with the severity of symptoms they are meant to predict. In addition, the strong focus on thought content makes it
difficult to compare perseverative thinking across disorders.The aim of the current study was to develop and evaluate a content-independent trait measure of
perseverative thinking as relevant to emotional disorders. For this purpose, perseverative thinking was defined as a style of thinking that is (a) repetitive, (b)
partly intrusive/involuntary, (c) characterized by difficulties to disengage from the thoughts, (d) unproductive and (e) capturing mental capacity. The
Perseverative Thinking Questionnaire (PTQ) was developed as a self-report measure that consists of 15 items assessing the different process
characteristics described above (e.g., "The same thoughts keep coming back to my mind again and again."; "I can't stop dwelling on it."). Item
characteristics, factor structure, internal consistency, re-test reliability as well as concurrent, discriminant and predictive validity of the measure were
investigated in a diverse sample of non-clinical and clinical individuals (total N = 1400).Results suggest that the PTQ is a reliable and valid measure of
perseverative thinking. Implications for future research will be discussed.
What makes the difference? Rumination and Worry in depressive and non-depressive persons
Angela Rischer, Christine Glueckler, Hans Reinecker*, Johannes Kornhuber, University of Erlangen-Nuernberg, Germany*; University of Bamberg,
Worry and rumination both occur in depressive and non-clinical individuals. Therefore it would be crucial to understand what exactly differentiates between
functional and dysfunctional worry and rumination (Watkins &Teasdale 2003). Recent research also compared overlapping and distinctive features of worry
and rumination (Watkins, Moulds & Mackintosh 2005, Fresco et al. 2002, Segerstrom et al. 2000). More profound knowledge would help to develop so far
neglected cognitive-behavioural interventions for the co-morbidity of depression and anxiety disorders. To our knowledge, there is only one empirical study
so far that directly compared worry and rumination in a clinical and a nonclinical sample (Papageorgiou & Wells 1999 a, b).Therefore, our aim was to
examine qualitative and quantitative differences between a) worry and rumination itself as well as b) between worry and rumination in depressive and nondepressive persons. In a multi-centre approach, patients with Major Depression (n=104) and non-depressed subjects (n=390) were questioned. Recurring
thoughts were assessed with the modified Cognitive Intrusion Questionnaire (Freeston et al. 1992, Watkins et al. 2005).The present study could a) partly
replicate the finding of Watkins, Moulds & Mackintosh (2005) concerning a potential overlap between worry and rumination: There were only a few distinctive
features of worry and rumination. The study revealed b) that the most relevant differences in worry and rumination between depressive and non-depressive
subjects concerned emotional reactions, appraisals and coping-strategies. Implications for the treatment of recurrent thinking in Major Depression as well as
in the co-morbidity of depression and anxiety disorders will be discussed.
Thinking Too Much of One's Preferences:Self-focused Thinking Mediates the Effects of Rumination on Indecisiveness in
Depressed Mood
Annette van Randenborgh, Renate de Jong-Meyer, University of Muenster, Germany
:A self-focused, repetitive, and abstract style of thinking, i.e. rumination, has shown to be detrimental for executive functioning (e.g. concentration, social
problem solving). This study investigates if rumination also impairs decision making, a complex executive function which is severely impaired in depression.
In addition we test mediating processes. In the laboratory, a ruminative style of thinking was induced in dysphoric and non-dysphoric subjects. Subsequently,
participants had to solve decisional dilemmas, blinded for the real purpose of the study. The primary dependent variable was the perceived difficulty in
decision making. As possible mediators, the extent of self-focus experienced during the decision phase and affect were measured. The rumination induction
had several consequences for dysphoric participants (e.g. increase in negative affect, less confidence in own abilities) that are related to different features of
rumination. The extent of self-focused thinking was the only aspect of rumination that mediated impaired decision making. Our results indicate that the
tendency to ruminate has a causal influence on indecisiveness in depression. There are hints that an elevated self-focus, which is one feature of rumination,
is especially detrimental to decision making.
Selective attention following the experimental induction of rumination versus distraction
Renate de Jong-Meyer and Ralf Eßmann, University of Muenster, Germany
Rumination has been shown to affect strategic cognitive processes in dysphoria and depression. So far it has not been studied whether rumination also has
an influence on automatic attentional processes, where specific biases have been primarily documented in the anxiety disorders. The study aims at
provoking changes in these biased response patterns in the Emotional Stroop Task by manipulating ruminative thinking. It will be studied whether the
induction of rumination versus distraction affects the attentional bias of participants with elevated anxiety compared to control participants, and whether this
effect will be specific for anxiety related as compared to depression related stimuli, taken into account anxiety as well as depressiveness of participants.
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Following randomization into a rumination (N=27) or a distraction condition (N=28) 23 participants with elevated anxiety scores (BAI>15) and 32 non-anxious
control participants received an Emotional Stroop task with neutral, anxiety and depression related words. Depressiveness, anxiety, mood, and dimensions
of functional and dysfunctional self related thinking were assessed by questionnaires.The induction produced differential mood changes: mood worsened
after rumination and improved after distraction. A stronger attentional bias regarding anxiety words was found after rumination compared to distraction for
participants with elevated anxiety. This interaction was specific as it was not found for depression related words. Results are discussed in relation to the
model of Williams and coworkers regarding attentional versus memory biases in affective disorders.
Symposium 42
The Role of Mood in Perseverative Psychopathologies
Convenor: Graham Davey, University of Sussex, U.K., UK
Compulsive Perseveration: Empirical Criticism On The Mood-As-Input Model
M Van Den Hout ; M. Kindt ; J Luigjes And C. Marck, University Of Utrecht, The Netherlands; University of Amsterdam, The Netherlands
It has been proposed that the 'Mood as Input' model provides an explanation of the perseverative nature of Obsessive Compulsive (OC) behaviour
(MacDonald & Davey, 2005).The model implies that task perseveration occurs when individuals a) experience a bad mood and b) ask themselves “did I do
as much as I can?' Given that OC patients typically experience a negative mood whilst ritualizing and that they ask questions of the 'did I do as much as I
can?' type, the model may be applied to OC behaviour. In two earlier experiments with healthy participants (MacDonald & Davey, 2005) it was found that
when the allegedly critical conditions were met (negative mood and 'as many as can' stop rule) perseveration occurred on a text-correction task. This finding
was held to support a 'mood as input' explanation of compulsive perseveration. In the present study we compared the effects of the original preparation to
effects of text correction tasks that were simpler and more OCD- like. It was found first of all that, using the text correction paradigm, “perseveration” was
highly functional: the more “perseveration” the more text-errors were detected. Secondly, to the degree that tasks became simpler and more OCD-like, the
effects of the 'Did I do as much as I can?” stop rule became smaller. The findings raise questions about the validity of the paradigm as a model of OC
What Ends A Worry Bout? An Analysis Of Changes In Mood And Stop Rule Use Across The Catastrophising Interview
Benie A. Macdonald1, Graham C.L. Davey1, Fiona Eldridge1, & Jolijn Drost2, University of Sussex, UK 1 ; University of Maastricht, The
Netherlands 2
This paper reports the results of two experiments designed to test predictions from the mood-as-input hypothesis about the factors that contribute to the
ending of a worry bout. Experiment 1 looked at changes in self-reported mood across a catastrophising interview task. Experiment 2 investigated whether
there were any changes in stop rule deployment between the beginning and end of a catastrophising interview task. Experiment 1 demonstrated that
worriers tended to show increases in negative mood and decreases in positive mood over the course of catastrophising. In Experiment 2, participants
exhibited a significant shift away from endorsing the use of 'as many as can' stop rules and a significant increasing tendency to endorse the use of 'feel like
continuing' stop rules over the course of catastrophising. These results suggest that worriers exhibit increases in negative mood across the worry bout, but
shift from the use of 'as many as can' to 'feel like continuing' stop rules. Mood-as-input hypothesis predicts that if high worriers ask the question “do I feel
like continuing?” in the context of increasing negative mood, this will imply that the activity is no longer enjoyable or profitable and should be terminated. The
results are discussed in the context of mood-as-input accounts of pathological worrying and the therapeutic implications of these findings are reviewed.
Dieting Stop Rules As Predictors Of Pathological Eating Patterns
Graham C.L. Davey & Hussien Niyazi, University of Sussex, Uk
This paper describes three studies investigating how mood-as-input predictions might be applied to perseverative dieting and eating disorder
symptomatology. Study 1 describes the development of an instrument for measuring dieting stop rule use. Study 2 used structural equation modeling to
determine how dieting stop rule use related to variables associated with eating disorder symptomatology. In particular, use of 'as many as can' stop rules
was associated with 'drive for thinness', and both 'as many as can' and 'feel like continuing' stop rules were associated with bulimia. Negative mood was
also a significant variable interacting with both types of stop rule to predict both 'drive for thinness' and bulimia. Study 3 investigated how dieting stop rules
might interact with variables central to the restrained eating hypothesis (Herman & Polivy, 1980). The findings suggest that 'as many as can' stop rules
predicted restrained eating while use of 'feel like continuing' stop rules predicted disinhibition. The paper also discusses some of the theoretical benefits of
viewing dieting behaviour as an open-ended task that is influenced by the deployment of different types of stop rules.
Task Persistence In Chronic Pain: A Mood-As-Input Account.
Johan W.S. Vlaeyen, Petra Karsdorp, Stephen Morley, University Of Leuven, Belgium; University Of Maastricht, Netherlands
In some patients with chronic pain, persistence in assumingly painful tasks, rather than avoidance from these tasks is observed. For the latter, cognitivebehavioral mechanisms have been a neglected area in pain research and are just beginning to be scrutinized. In this presentation, we will review the
existing theoretical models explaining task persistence in chronic pain, pointing at its strengths and weaknesses. It also suggests that the mood-as-input
model, which predicts task performance from the interaction between current mood and so-called “stop rules”, may provide a inciting framework that may
enhance our understanding of disability both due to avoidance behavior and activity overuse. Preliminary findings as well as future research avenues will be
discussed. The latter will include the explicit vs. implicit priming of stop rules, the influence of stop-rules/mood configurations on pain intensity vs task
performance, the role of attentional control, and implications for cognitive-behavioral treatment of chronic pain.
Feeling Guilty As A Source Of Information About Threat And Performance
Francesco Mancini A; Amelia Gangemia,B; Marcel Van Den Hout C;, A Scuola Di Specializzazione In Psicoterapia Cognitive & Apc, Roma, Italy; B
Department Of Psychology, University Of Cagliari.Cdepartment Of Clinical Psychology, Utrecht University.
OCD patients experience increased feelings of guilt, threat, and uncertainty about harm prevention. As to the relation between these phenomena, it was
hypothesised that the experience of guilt acts as “information” that increases the sense of threat and decreases the sense that preventive action is effective.
In an experiment we tested whether state guilt is used as information about risk and prevention effects and whether people high in trait guilt do so more than
others. 120 participants high and low in trait guilt were included. Three types of affect were experimentally induced: guilt, anxiety and a neutral affect. Then,
participants estimated the likelihood and severity of a negative outcome, and the dissatisfaction with preventive performances in 2 OCD relevant scenarios.
Relative to low trait guilt participants, people high in trait guilt had higher ratings of risk after induction of state guilt, using state guilt as a source of
information: there were effects of the experimental manipulation in the high trait guilt group but not in the low trait group. With regards to dissatisfaction with
preventive performance, there was only a trend for high trait guilt participants to respond stronger to state guilt. The results suggest that people with a
general inclination to feel guilty use temporary feelings of guilt as information about the threat content of a situation and do so even if the source of state
guilt is unrelated to the situation. Implications for the understanding of OCD will be discussed.
Symposium 43
The Therapeutic, Organisational, and Conceptual Implications of Understanding the Nature of Perceptual Control
Convenor: Tim Carey, Department of Clinical Psychology, NHS Fife, United Kingdom
Conflict, as the Achilles heel of perceptual control, offers a unifying approach to the formulation of psychological problems.
Timothy A. Carey, Department of Clinical Psychology, NHS Fife, UK
The formulation of psychological problems is an important aspect in the successful resolution of these problems. Since Perceptual Control Theory (PCT)
explains how problem-free living occurs it also suggests the form that problems might take when satisfactory day-to-day living is disrupted. In this
presentation I briefly outline perceptual control theory and explain how psychological difficulties are conceptualised with this theory. An initial effort at building
a model to simulate this conflict will be demonstrated along with experimental findings from animal studies of conflict. Next I offer some examples from
clinical practice which illustrate the problem formulation of perceptual control theory. Finally I explore the implications of this approach to formulation for
people who assist others in the amelioration of psychological troubles.
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Patients taking the lead. A naturalistic investigation of a patient led approach to treatment in primary care.
Timothy A. Carey & Richard J. Mullan, Department of Clinical Psychology, NHS Fife, UK
In an earlier paper (Carey, 2005) an approach to treatment delivery was examined in which the duration and frequency of the appointments was scheduled
by patients. Results of this approach were encouraging but the generalisability of the results was constrained because only one clinician trialled the
approach and no standardised assessment measures were used. In the present study there are two, rather than one clinicians involved and the Depression
Anxiety Stress Scale (DASS) is used. The approach was introduced at one GP practice and monitored over a six-month period. Results suggest that this
approach might be an effective way of promoting patient access to and involvement in service delivery as well as reducing waiting times. Both GPs and
patients reported being satisfied with this approach and questionnaire results suggested that positive changes in psychological symptomatology were being
experienced. Over the six-month period 101 patients were offered appointments. Patients presented with problems ranging from the less severe (such as
self-esteem problems and assertiveness problems) to the more severe (such as paranoid schizophrenia). Significant differences were found in pre and post
DASS scores for those patients attending more than one appointment indicating that beneficial reductions in symptomatology had occurred. These findings
have implications for the structure of psychological treatments in terms of the duration and frequency of psychotherapy and how these parameters are
An assessment of the statistical, clinical, and personal significance of the Method of Levels in a naturalistic setting.
Timothy A. Carey, Margaret Carey, Richard J. Mullan, Christopher G. Spratt, & Margaret B. Spratt, Psychiatric Services, NHS Fife, UK
Although a large body of research exists regarding the effectiveness of psychotherapy there is still uncertainty as to how psychotherapy produces its effects.
One hypothesis from the perspective of Perceptual Control Theory (PCT) is that the facilitation of cognitive reorganisation by shifting awareness is a basic
process common to successful psychotherapies. We operationalised shifts of awareness as disruptions to streams of dialogue or 'meta comments' about the
topic under discussion. A study lasting 12 months was conducted with 120 patient participants and 4 clinicians who employed a tailored intervention to shift
awareness in this manner. The intervention is called the Method of Levels (MOL). Data were collected on the attendance patterns of patients, their ages,
referral problem, and socio-economic background. Standardised questionnaires (Depression Anxiety Stress Scale - DASS21)were also administered to
measure pre and post treatment effects. The null hypothesis of no difference between pre and post treatment scores was examined by the derivation of p
values and the construction of 95% confidence intervals. In all cases the null hypothesis was rejected with the largest p value obtained being 0.002. These
results provide preliminary evidence to suggest that helping people shift awareness might be an important basic therapeutic process.
Symposium 112
The identification and modification of attentional bias to threat in anxiety: From cognitive science to clinical
Convenor: Ernst Koster, Ghent University, Belgium, Belgium
Identification of Emotional Expressions in Rapidly Changing Facial Displays- Influence of Social Anxiety
Peter J. de Jong, Sander Martens, University of Groningen, The Netherlands
Previous studies on attentional processes in social phobia primarily focused on the selective allocation of attention during the concurrent presentation of
static safe and threatening facial stimuli. Yet, facial expressions in the context of social interactions are highly dynamic and may vary very rapidly from
interested/approving to disapproving or even angry and vice versa. Despite these time-specific elements of facial expressions, little research has
investigated the temporal characteristics of attentional bias. The purpose of the this study was to explore the temporal characteristics of visual attention for
approving and disapproving faces in a group of high (n = 16) and a group of low (n = 16) socially anxious individuals. In the present study we adopted the
rapid serial visual presentation paradigm (RSVP), which is a procedure that is widely used for examining temporal visual attention. For each trial there were
always two targets that should be identified, and fourteen non-targets (distractors). All targets were emotional facial expressions (happy or angry) and all
distractors were rotated neutral facial expressions. Results indicate both a low threshold of identification (attenuating the AB) and prioritized access to the
limited cognitive resources (inducing a “backward blink”) for angry faces. Unexpectedly, neither the attenuated attentional blink for angry faces, nor the
strength of the backward blink was influenced by social anxiety levels. If anything, high anxious individuals showed worse rather than better detection of
angry faces than low anxious individuals.
Focusing on threat in anxiety: Evidence from eye-movements
Dr Nazanin Derakshan, Birkbeck University of London, UK
High anxiety is associated with an attentional bias towards threatening stimuli, and with a failure to disengage from the processing of this material. However,
previous research has relied almost exclusively on reaction time data. In this talk I will present some new work that measured participants' eye-movements
during visual search. Participants were presented with a circle of faces, and identified the 'odd-one-out'. The emotional expressions assigned to the 'target'
and 'crowd' faces were manipulated. Results showed that an angry crowd slowed down detection of happy targets in high-anxious individuals. Eyemovement analysis revealed that high-anxious individuals made more non-target fixations in a crowd of angry faces that contained a happy target. The
reaction-time data replicated and extended previous findings showing that anxiety delays attentional disengagement from threatening stimuli. The data
provide strong evidence that these effects are attributable to differences in the visual search process. Implications of the findings are discussed with
reference to the new attentional control theory of anxiety (Eysenck, Derakshan, Santos, & Calvo, 2007).
Exploring training methodologies in the context of attention and emotional disorders
Saskia Baert, Rudi De Raedt, & Ernst H.W. Koster, Ghent University, Belgium
Cognitive theories suggest that specific information-processing biases can cause and maintain emotional disorders. Only recently, methodology has been
developed to examine the contribution of these biases to psychopathology. This methodology consists of an experimental manipulation of attentional bias
through training and is recently being examined in anxiety, depression and alcohol abuse. Considered the crucial importance of experimental evidence on
the causality of information-processing biases and the promising advantages of this new methodology in science as well as in practice, it is interesting to
explore this format of training in depth. In the present study, the original training paradigm as developed by MacLeod and collaborators (2002) was
investigated compared to small variations on the methodology. Based on the results within a group of 250 psychology students which were presented a
short training procedure of 320 trials during 15 minutes, it was found that extra manipulations can enhance the training effect of the original procedure.
Implications for further causal investigation and for practical application in therapy will be discussed
Experimentally manipulating attentional bias to threat: Effects on trait anxiety, attention, and psychophysiological responses
Ernst H.W. Koster and Bruno Verschuere, Ghent University, Belgium
According to cognitive models of anxiety, attentional bias for negative information plays a causal role in anxiety vulnerability. In the present study, we
examined whether experimental manipulation of attentional bias was successful in reducing emotional reactivity to threat and trait anxiety levels. Individuals
with elevated trait anxiety scores were allocated to an attentional retraining (n = 20) or a control group (n = 19). Emotional reactivity and trait anxiety were
measured before and directly after training using psychophysiological measures and questionnaires. In addition, anxiety scores were also examined at 6
weeks follow-up. Results show that attentional retraining leads to attentional avoidance of threat and was successful in reducing trait anxiety levels from preto post-training. The reduction in trait anxiety scores was maintained at follow-up. Moreover, attentional retraining methodology changed emotional startle
modulation. However, data of the psychophysiological measures were inconclusive. These results provide preliminary evidence that attentional retraining
procedures are effective in reducing anxiety levels.
Symposium 121
Metacognitive processes in OCD: theoretical and clinical perspectives.
Convenor: Dirk Hermans, University of Leuven, Belgium, Belgium
Considering the boundaries of the OC Spectrum: The role of metacognition and obsessive beliefs
Meredith E. Coles1, Laura M. Cook1, and Dirk Hermans2, 1 Binghamton University, USA; 2 University of Leuven, Belgium
Current efforts to develop the 5th edition of the DSM have generated much discussion among OCD researchers regarding the potential creation of a group
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of “OC Spectrum Disorders.”
The current study evaluated the potential utility of cognition in furthering our understanding of the hypothesized OC
Spectrum. Specifically, we tested whether measures of metacognition and beliefs would differentiate between a number of hypothesized spectrum disorders:
OCD, trichotillomania, compulsive buying, pathological gambling, and kleptomania. Metacognition and beliefs were studied given the current dominance of
cognitive theories of OCD (Frost & Steketee, 2002) and data demonstrating a role of metacognition in OCD (e.g., decreased memory confidence; Foa et al.,
1997). Responses to the Obsessive Beliefs Questionnaire (OBQ-44; OCCWG, 2005) and the Cognitive Confidence Questionnaire; Engelen, Hermans,
Pieters & Grouwels, unpublished), were obtained for 199 undergraduates. Results showed that measures of metacognition (memory confidence and
perceptual confidence) and obsessional beliefs (e.g., heightened responsibility, perfectionism) were useful in distinguishing OCD from the other hypothesized
spectrum disorders. Specifically, results showed that these measures of cognition were significantly more strongly correlated with OCD symptoms than with
symptoms of trichotillomania, compulsive buying, pathological gambling, and kleptomania. In conclusion, the current study is novel in examining the
potential underlying correlates of a variety of hypothesized OC Spectrum disorders. It is hoped that the current data, in combination with other studies
examining the shared versus unique features of the hypothesized spectrum disorders, will inform future classification schemes.
The Relationships between Thought Suppression, Meta-cognitive Beliefs and Obsessive-Compulsive Tendencies
Orna Reuven-Magril, Avital Kremerman, Nira Liberman, Reuven Dar, Tel-Aviv University, Israel
Abstract: The present research provides empirical support to current cognitive models of OCD, which regard thought suppression as a key factor in the
perseverance of obsessions (e.g., Rachman, 1998; Salkovskis, 1996). The first experiment explored a paradigm of voluntary (not instructed) thought
suppression. Non-clinical participants read an anxiety provoking text and rated their wish and effort to suppress specific thoughts evoked while reading. They
then completed a recognition task, designed to explore the effect of suppression on the accessibility of the thoughts evoked earlier. In line with our
predictions, we found a relation between OC tendencies, wish and effort to suppress thoughts and high accessibility of these contents. Path analysis
showed that thought suppression mediated the effect of OC tendencies on the memory of the anxiety provoking thoughts, which can be understood as a
paradoxical effect of suppression.The second experiment explored the relations between thought suppression and meta-cognitive beliefs about the meaning
of intrusive thoughts. Non-clinical participants read a text which evoked aggression and were asked to express their thoughts aloud. They were instructed
not to think about aggression and to mark any occurrences of such thoughts. In addition, participants received a negative or a reassuring interpretation of
potential intrusive thoughts. The negative interpretation stated that failures to suppress aggressive thoughts may reflect preoccupation with one's own
aggressive impulses, while the reassuring interpretation suggested that failing to suppress aggressive thoughts is a natural psychological phenomenon
which does not have any particular meanings or implications. We compared estimations of effort invested in suppression and suppression failures in both
interpretation conditions. In accordance with our predictions, the correlations between OC tendencies, effort invested in suppression and suppression
failures were significant in the negative interpretation condition, but non-significant in the reassuring interpretation condition.
Compulsive checking and confidence in memory, attention and perception
Dirk Hermans & Guido Pieters, University of Leuven, Belgium
It has been suggested that OCD, and particularly compulsive checking, is related to memory deficits related to general memory functioning. In spite of
preliminary evidence, most studies failed to demonstrate such cognitive deficits. In contrast, a finding that has been replicated in almost all studies is that
OCD is characterised by a lack of confidence in memory functioning. In previous research (Hermans et al., 2003), the Metacognition Questionnaire was
employed to assess cognitive confidence in a group of patients with OCD. In addition to reduced confidence in memory for actions, this group showed
reduced confidence in attentional functioning. The present study aimed at further investigating the role of reduced confidence in attention for OCD. A
group of patients, diagnosed with OCD participated in the study. Two control groups were included as well (psychiatric inpatients without OCD diagnosis
and normal controls). All participants were asked to complete measures of compulsive checking (Padua) and of cognitive confidence (Cognitive Confidence
Questionnaire). In addition, OCD patients were asked to perform a number of simple actions, of which some were OCD-relevant (e.g. checking a gas-stove)
and others were not. The control groups performed these actions as well. Each action was performed 5 times. After the first, third and fifth performance
the level of cognitive confidence was assessed (for attention, memory, and perception) as well as the current level of fear.
The results further
corroborate the idea that 'cognitive confidence' and particularly 'confidence in attention' is a relevant factor in OCD.
Metacognitive Therapy for Obsessive-Compulsive Disorder
Peter Fisher & Adrian Wells, University of Liverpool, UK
It has been proposed that the role of metacognition in OCD may advance our understanding of the disorder and in turn lead to an improvement in treatment
efficacy. Wells (1997,2000) developed a metacognitive model of OCD in which metacognitive beliefs and processes are pivotal in the maintenance of the
disorder. Two studies will be presented; the first describes an experimental manipulation of metacognitive beliefs about intrusions and subsequent changes
in distress, the urge to neutralise and metacognitive beliefs, relative to a habituation condition. The second study describes a single case series evaluating
the efficacy of metacognitive therapy for OCD.
Symposium 137
Information processing research in OCD: New advances and future directions
Convenor: Adam S. Radomsky, Concordia University, Canada
The Impact of Repeated Checking on Memory Confidence: Further Exploration
Meredith E. Coles, Casey Schofield, and Ashley Pietrefesa, Binghamton University, USA
There is a growing body of data showing that repeated checking of both computerized and real stoves leads to decreased memory confidence.
Consequently, research has begun to examine the conditions under which this decrease occurs. This talk will present results of two studies testing potential
moderators of the impact of repeated checking on memory confidence. First, we tested the impact of perceived threat. Eighty-one undergraduates
completed checks of both threatening and non-threatening objects (a real stove and a fake stove made of plywood). Memory characteristics and personal
responsibility were assessed before and after either 2 checks or 15 checks. Results replicated the basic finding that repeated checking (15 checks) lead to
decreased memory confidence. However, perceived threat was not found to moderate the impact of repeated checking. Participants that performed 15
checks of the fake stove showed decrements in memory confidence parallel to those observed for participants that performed 15 checks of the real stove. In
our second study, we will replicate and extend these initial findings. We will extend the previous study by also examining the potential impact of perceived
responsibility on changes in memory confidence. Participants will again be randomly assigned to check either a threat or non-threat object (real or fake
stove). However, in this study they will also be randomly assigned to perform the checks under conditions of high or low responsibility. Following from
cognitive models of checking it is hypothesized that heightened responsibility will intensify the impact of repeated checking on memory confidence.
Probing threatening memory associations in panic disorder.
Dirk Hermans, University of Leuven, Klara De Cort, Koen Schreurs, Maastricht University, Deb Vansteenwegen, University Of Leuven & Adriaan
Spruyt, Ghent University, University of Leuven, Belgium;Maastricht University, the Netherlands;Ghent University, Belgium
One of the central assumptions of cognitive models of panic disorder is that patients interpret bodily symptoms in a threatening/catastrophic way. These
negative interpretations are assumed to further fuel the 'threatening' symptoms. Studies employing self-rating scales like the Body Sensations Interpretation
Questionnaire (BSIQ) have provided support for this interpretation bias. Theoretically, these effects can be explained by assuming that - for panic patients in long term memory the associations between representations of bodily symptoms (e.g., breathlessness) are more strongly associated with representations
of threatening outcomes (e.g., suffocation). So, when confronted with a relevant bodily symptom, the catastrophic outcomes are more readily activated. To
test this model more directly, we employed a lexical decision task in a modified semantic priming paradigm. The study included 31 panic patients, 25
anxious controls and two nonanxious control groups. There were 4 types of prime-target combinations. The crucial combinations consisted of a 'bodily
symptom prime' followed by a 'threatening interpretation target' (panic-panic; e.g. chest pain - heart attack). Additionally there were three types of control
pairs (a) panic-neutral (e.g. chest pain - study), (b) neutral-panic (e.g. garden chair - heart attack) or (c) neutral - neutral (e.g. garden chair - study).
Consistent with predictions, there was a significant interaction between Group and Trial Type. For the panic group responses were significantly faster for
panic-panic trials compared to control trials. Interestingly, a similar pattern was observed for mental health workers without a history of panic disorder.
Results support and at the same time challenge information processing models of panic disorder.
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Attentional Bias to Ideographically Selected Threat Relevant Information in Individuals with Obsessive Compulsive Symptoms
Nader Amir, Ph.D., & Alex De Nadai,, San Diego State University, USA
Individuals with OCD tend to focus on disorder-related information in their environment. Moreover, some studies suggest that in the laboratory, these
individuals pay particular attention to OCD-related information. However, researchers have not examined the extent to which ideographically selected OCDrelated information captures the attention of individuals with and without obsessive-compulsive symptoms. We asked individuals with OCD symptoms to
complete an ideographic word selection task where they rated the emotional valence of OCD-related (e.g., germs) and neutral words. They then completed
a probe detection task. In this task participants see two words on a computer screen. Words were presented if the participant had previously rated them as
either negative or neutral. These words then disappear and a probe (i.e., the letter “E” or “F”) appears in the location of one of the words. Participants are
asked to press a corresponding key on the mouse to indicate whether they saw “E” or “F.” Faster response latency in identifying probes replacing threat
words compared to probes replacing neutral words suggests attention deployment toward threat words. Slower response latency differences suggest
avoidance of threat words. Preliminary data suggest that individuals with OCD symptoms showed significant avoidance of ideographically selected OCDrelated words compared to non-anxious controls. This is in contrast to previous research examining this question in OCD. However, because our
participants selected words that were relevant to their own concerns, they may have been more motivated to avoid them.
Memory bias for threatening information that was neutral at encoding: Implications for anxiety disorders with delayed onset
Adam S. Radomsky, Ph.D., Monique Lahoud, B.A. & Laurie Gelfand, M.A.,, Concordia University, Canada
Memory bias for threatening information, demonstrated by the preferential recall of threat-related information has been observed in association with a
number of different anxiety disorders. However, all studies demonstrating a memory bias have compared memory for encoded information that was
threatening against encoded information that was not threatening. The objective of the current project is to investigate a memory bias for threatening
information in a novel way by having participants encode only neutral information, half of which is made threatening following encoding. Undergraduate
participants were read a vignette about two individuals in a benign situation. Participants were then asked to recall all of the information remembered from
the vignette (pre-test). The researcher then presented the participants with new threatening information about one of the characters in the story.
Participants were then asked to recall once more all of the information remembered from the vignette (post-test). It was hypothesized that participants would
remember more threatening information than non-threatening information from the vignette at post-test. Preliminary analyses indicated that participants
recalled significantly more threatening information than non-threatening information at post-test, and recalled significantly more threatening information for
the 'threatening' individual compared to the 'nonthreatening' individual. These results support the presence of a memory bias for information made
threatening only after it has been encoded. The results of this study will be discussed in terms of cognitive approaches of understanding OCD, information
processing, and psychopathology with delayed onset.
Symposium 154
Metacognition Across Disorders : Theory And Evidence
Convenor: Adrian Wells, University of Manchester, UK
Emotional schemas and personality disorders
Robert L. Leahy and Lisa Napolitano, American Institute for Cognitive Therapy, USA
Personality disorders may be viewed as organized strategies to anticipate and manage threatening emotion and events. Leahy's meta-emotional model
proposes that there are 14 dimensions that individuals can conceptualize and strategize regarding their emotions. These include beliefs that one's emotions
are incomprehensible, unique to the self, shameful, will last a long time, are out of control and dangerous, cannot be accepted, expressed or validated, and
that one needs to ruminate, avoid or be consistently logical and rational. 411 patients completed the Leahy Emotional Schemas Scale and the Millon
Multiaxial Clinical Inventory (MMCI). Personality disorders were diffentially related to emotional schemas. Histrionic and narcissistic personality were related
to positive emotional schemas while borderline, dependent and avoidant personality are related to the view that painful emotions are unacceptable, do not
make sense, and should be avoided. Further, in order to evaluate how personality disorders differ in their utilization of meta-cognitive strategies for worry,
359 patients completed the Metacognitions Questionnaire and the MMCI. Personality disorders differed considerably in metacognitive strategies, with
dependent, avoidant and borderline patients viewing worry as serving a positive funtion, uncontrollable, negative and superstitious, low cognitive
competence and high cognitive self-consciousness, while histrionic and narcissistic personality showed the direct opposite pattern. Data support the view
that personality disorders reflect significant differences in strategies of emotional control and processing and strategies of anticipating and managing threat.
A metacognitive model of problem drinking
Marcantonio M. Spada & Adrian Wells, Roehampton University, UK
Two studies investigating the nature of metacognitions in problem drinking are presented. The first study reports on the metacognitive assessment of 10
patients with problem drinking. Results of this study revealed that these patients: (1) hold positive and negative metacognitive beliefs about alcohol use; (2)
use alcohol to regulate thoughts, negative emotions and self-concept; (3) report that alcohol reduces their self-consciousness; and (4) do not appear to know
when they have achieved their goal of emotional self-regulation. These findings align themselves with a metacognitive conceptualisation (Wells & Matthews,
1994; 1996) in which problem drinking is supported by disruptions of metacognitive monitoring and control. The second study reports the development and
testing of a metacognitive model of problem drinking. In this model positive metacognitive beliefs motivate individuals to engage in alcohol use as a means
to cope with negative emotions. Concurrently to the activation of positive metacognitive beliefs, metacognitive monitoring of the self in relation to goals is
disrupted as a consequence of the initiation of instrumental behaviours aimed at attaining and using alcohol. Once alcohol use is initiated it brings to a
further disruption in metacognitive monitoring, leading to a continuation in drinking. During and following a drinking episode individuals appraise their alcohol
use as both uncontrollable and dangerous through the activation of negative metacognitive beliefs. The activation of these beliefs leads to a reduction in
attempts to control alcohol use, further locking the person into the drinking vicious cycle. The clinical implications of this model are discussed.
Cross-Sectional and Prospective Tests of a Metacognitive Model of Rumination and Depression
Costas Papageorgiou, University of Lancaster, UK and Adrian Wells, University of Manchester, UK, University of Lancaster, UK
Rumination plays a key role in the onset, perpetuation, exacerbation, and recurrence of depression. Knowledge of the mechanisms involved in initiating and
maintaining depressive rumination may aid the development of more effective interventions. Grounded on Wells and Matthews' (1994) Self-Regulatory
Executive Function (S-REF) theory of emotional disorders, Papageorgiou and Wells (2003) proposed a clinical metacognitive model of rumination and
depression. In this model, positive metacognitive beliefs about rumination motivate individuals to engage in sustained rumination. Once rumination is
activated, individuals appraise this process as uncontrollable and harmful, and likely to lead to negative interpersonal and social consequences. The
activation of negative metacognitive beliefs about rumination then contributes to the experience of depression. In this presentation, two studies are described
that support the central hypothesised links in the model. In the first study, the cross-sectional relationships between depression, rumination, and
metacognition were examined in a depressed sample. The statistical fit of the model was tested using structural equation modelling. A good model fit was
obtained where theoretically consistent paths between positive metacognitive beliefs, rumination, negative metacognitive beliefs, and depression were
evident. In the second study, a prospective investigation was conducted to examine the causal status of the relationships between rumination, negative
metacognitive beliefs, and depression in a non-clinical sample. The results showed that negative metacognitive beliefs about the uncontrollability and harm
associated with rumination prospectively predicted depression even after statistically controlling for initial levels of depression and rumination. Implications
for a metacognitive-focused cognitive therapy for depression and future research are discussed.
The Metacognitive Model of Obsessive-Compulsive Symptoms : An Empirical Test
Samuel G. MyersPeter L. FisherAdrian Wells, The University of Manchester, UK
The metacognitive model of obsessions and compulsions (Wells, 1997) specifies particular belief domains and specific relationships between them in the
maintenance of OCD. According to Wells (1997) intrusions activate metacognitive beliefs about the importance and power of thoughts. These in turn lead
to negative appraisals of intrusions and activate beliefs about the use of rituals to minimize threat. Beliefs about rituals contain information which both
initiates and signals when to stop behaviour.In this study, 238 students completed measures of symptoms and of metacognitive and non-metacognitive
beliefs. Multiple regression analysis showed that metacognitive beliefs predicted O-C symptoms but responsibility and perfectionism (non-metacognitive
beliefs) did not when their common variances were controlled. Consistent with the model, beliefs about intrusions, beliefs about rituals, and stop signals
made significant incremental contributions to O-C symptoms. Structural Equation Modelling was used to test the fit of the specified metacognitive model
against possible alternative models. A range of goodness of fit indices showed that the model was a good fit to the data whilst the alternative models were
not.Implications for the metacognitive treatment of OCD will be discussed.
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Symposium 166
Implicit cognitive processing in substance abuse and eating disorders
Convenor: Lusia Stopa, University of Southampton, UK
Executive functions moderate the impact of implicit appetitive associations
Reinout W. Wiers* (1, 2, 3), Carolien Thush (1),Jerry Grenard (4) Susan L. Ames (4) & Alan W. Stacy (4), 1) Maastricht University, The Natherlands;
(2) Radboud University,Nijmegen; (3) IVO Addiction Research Institute Rotterdam; (4) Universityof Southern California
In several studies we have found that individual differences in executive functions moderate the impact of automatic appetitive associations in addictive
behaviours. The general pattern is that in adolescents with below average scores on working memory, automatic appetitive associations predict substance
abuse (alcohol, cigarettes, marijuana), while in adolescents with above average scores on working memory this is not found. Instead, in these individuals,
explicit expectancies are better predictors of their substance abuse pattern.
Cognitive biases, craving, and inhibitory control in substance abuse: investigating the causal relationships
Matt Field, University of Liverpool, UK
In substance abusers, impulsive decision-making and elevated craving are associated with subtle biases in the cognitive processing of drug-related cues, as
predicted by contemporary models of addiction. Investigators have explored the possibility that direct manipulation of cognitive bias could influence
subsequent craving and drug-seeking behaviour. In heavy social drinkers, increasing the magnitude of attentional bias for alcohol-related cues through
'attentional training' increases craving and alcohol consumption, although effects are fairly weak. However, although attentional training can also be
successfully employed to decrease the magnitude of attentional biases, there are no noticeable effects on craving or drinking behaviour, at least in the shortterm. Furthermore, effects of attentional training do not appear to generalise to alcohol-related stimuli that were not used during training. Research in
progress aims to extend this work by examining effects of attentional training procedures in tobacco smokers, and to investigate their mediation by individual
differences in aspects of inhibitory control and impulsive decision-making. Results from the studies with heavy drinkers are theoretically informative, as they
suggest that attentional processes play important roles in the generation or potentiation of drug cravings. The clinical significance of these early studies with
alcohol abusers is less promising, although it is possible that multiple sessions of attentional training, aimed at inhibiting automatic capture of attention by
drug-related cues, may prove to be useful for drug users attempting abstinence.
Attentional bias for snacks and healthy foods is moderated by hunger and restraint
Anne Roefs*, Chantal Nederkoorn, Stephanie Macoy, & Anita Jansen, Maastricht University, the Netherland
Currently the consensus in the literature seems to be that eating disordered samples show an attentional bias for food, whereas this could not be
demonstrated consistently for dieting samples (see Dobson & Dozois, 2004). Other studies (e.g., Mogg et al., 1998) showed that hunger is also correlated
with a food attentional bias: hungry participants showed increased attention for food stimuli compared to controls. In the current study, we investigated the
role of dietary restraint and hunger in the attention for two types of foods: snacks and healthy foods. We used the visual search paradigm to be able to
separate effects of speeded detection and increased distraction, and to study attentional bias more directly than is possible in the emotional Stroop task. In
the hunger-group (n = 25, 18 hours food deprived) attentional bias for food was modulated by restraint, whereas no effects were found in the satiated group
(n = 24). In a hungry state, participants were more distracted by snack foods than by healthy foods with increasing levels of restraint, and conversely, they
were more distracted by healthy foods than by snack foods with decreasing levels of restraint. So, when hungry, restrained eaters show an attentional bias
for exactly those foods they do not allow themselves to eat in comparison to healthy foods.
View of self in eating disorders: an investigation of implicit self-esteem
Elaine Cockerham1, Lusia Stopa1*, Lorraine Bell2, & Aiden Gregg1, 1 University of Southampton, UK;2 Eating Disorders Team, Hampshire
Partnership NHS Trust, UK
Current cognitive models emphasise the role of self-esteem in the aetiology and maintenance of eating disorders. The aim of this study was to compare
explicit and implicit self-esteem in a group of female participants with bulimia nervosa and binge eating disorder (n = 20) and a healthy control group (n =
20). We predicted lower explicit and less positive implicit self-esteem in the clinical group. Participants completed a self-esteem version of the Implicit
Association Test and two explicit self-esteem measures. The eating disordered group had lower explicit self-esteem, but more positive implicit self-esteem
than controls. We consider whether this was due to a methodological artefact or whether it reflects fragile self-esteem (discrepancies between implicit and
explicit self-esteem). We conclude that current cognitive models of eating disorders need to take account of implicit as well as explicit self-esteem.
Symposium 169
Basic Processes in the Eating Disorders
Emotional Factors in Eating Disorders: Consideration of New Findings and the Development of a New Model.
John Fox, University of Manchester, Mick Power, University of Edinburgh, UK
Research into emotional processing in eating disorders (ED) is very much in its infancy. Milligan and Waller (2000), Waller et al (2003) and others have
shown that there is a difficulty with the emotion of anger, especially in its expression. Whilst others (Troop et al, 2000) have demonstrated an increased
sensitivity for disgust towards the body with an ED population. Other researchers have demonstrated high levels of alexithymia in Anorexia nervosa (Kessler
et al, 2006). There has been significant developments in CBT models of eating disorders, in particular, bulimia nervosa. These models suggest that eating
disorder symptomology acts as an emotional regulator (Cooper et al, 2004; Waller et al, 2005). What is currently lacking is a theoretical understanding of
why people with eating disorders have particular difficulties with certain emotions? Moreover, it still remains an empirical question on whether individuals with
an eating disorder experience higher levels of painful affect, when compared to controls, or if they experience comparable levels of affect, but have particular
difficulty with the experiencing of certain emotions. This paper will present the data from two studies that have taken a close look at emotional factors in both
anorexia and bulimia nervosa. Both of these studies have been informed by recent theoretical developments in emotional processing (SPAARS model,
Power and Dalgleish, 1997, 1999). According to the SPAARS model, emotions can be connected in a 'coupled way', and the first study in this paper will
report on data that aimed to investigate whether anger and disgust could potentially act as 'coupled emotions' within individuals with symptoms of bulimia
nervosa. The design of this study was a mixed design where individuals with bulimic symptoms were compared to normal controls. Each group rated their
levels of anger and disgust prior to the experimental manipulation of the emotion of anger. These were then rated again at the end of the experiment. The
second study was a qualitative study that investigated perceptions of the basic emotions and the developmental histories of emotions within a group of 15
people with severe anorexia nervosa. It will be argued that these individuals, with careful questioning, are able to reflect on there emotional states. For the
first study, the multi-factorial analyses revealed that the induction of anger had a significant increase in state anger and disgust sensitivity for the group with
the individuals with bulimic symptoms, when compared to the healthy control group. For the second study, the results across the interviews demonstrated a
consistent picture of their difficulty to express either sadness or anger, and the results suggested a number of beliefs about the threat of expressing emotion,
or not feeling entitled to express sadness and anger. They all shared 'emotionally cold' histories, with a significant amount of trauma. This paper will use the
data from these studies (and others within the literature) to consider a new model of eating disorders that is based upon the SPAARS model. It is hoped that
this will lead to a fuller consideration of emotions within eating disorders
The effects of analytical and experiential self-focus on responses to a mild stressor in individuals with eating disorder
Adhip Rawal, University of Oxford, United Kingdom; Rebecca Park, University of Oxford, United Kingdom; Mark Williams, University of Oxford,
United Kingdom
Research in depression and dysphoric individuals (e.g., Watkins & Teasdale, 2004) has suggested that the precise manner of attending to aspects of selfexperience may be crucial in determining its effects on emotions and cognitions. These studies have generally shown that an analytical style of self-focus
(thinking about the self) is maladaptive, whereas an experiential style of self-focus (focusing on one's experience) has adaptive outcomes. There is a marked
paucity of research into such processes of thinking and feeling in eating disorders (ED). The importance of maladaptive thinking in ED has previously been
highlighted, and it has been found that merely thinking about eating food can lead to increased shape/weight concerns and an urge to neutralise these
(Shafran, Teachman, Kerry, & Rachman, 1999). The present study was the first to examine effects of modes of self-focus in individuals with ED concerns in
order to better understand these processes and their relevance to this psychopathology. As such, we investigated reactions to a mild ED relevant stressor
(an imaginary meal task), predicting that experiential self-focus would lead to more adaptive reactions than analytical self-focus (less neutralising
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behaviours/cognitions) in high ED concerns individuals. High and low ED psychopathology groups were recruited from a student population. Watkins and
Teasdale's (2001) self-focus manipulation was used to induce analytical or experiential modes of self-focus. The high ED group also completed a filler task
as a reference condition. Mood and signature size were assessed before and after manipulations. Shafran et al's (1999) imaginary meal procedure was
adapted as a stressor, after which participants were left alone for two minutes to allow neutralisations of potential negative feelings in any way if needed.
The high ED group was less likely to perform neutralising behaviours/cognitions after experiential self-focus than after analytical or the reference condition (p
< .005; p = .03, respectively). The latter two conditions showed no difference in neutralisation. No associations were found in the low ED group. There
were no differential self-focus effects on mood. Both ED groups showed a significant increase in signature size following experiential self-focus and a
reduction after analytical (p < .005). The study confirmed the hypothesis that experiential self-focus would be associated with more adaptive reactions to an
imaginary mealtime experience in high ED psychopathology individuals. Following experiential self-focus, participants were significantly more likely to
experience the imagery task without subsequently having to neutralise thoughts, in absence of self-focus effects on mood. This study is the first to show
differential effects of modes of self-focus in individuals with ED concerns, paralleling findings in depression. The increase in signature size after experiential
self-focus, and concurrent decrease after analytical, indicates that these manipulations also exert some effect on implicit aspects of emotional states,
perhaps similar to prior findings of effects of subliminal conditioning (Rawal & Harmer, 2006). A better understanding of these processes, extending to
clinical populations could be important to developing novel treatments. These preliminary results suggest that training non-clinical populations with high ED
concerns in experiential forms of self-awareness may be helpful.
Body image assessment in eating disorders and controls: testing Body Image Assessment Software (BIAS)
Marta Ferrer-García, University of Barcelona, José Gutiérrez-Maldonado, University of Barcelona, Ivan Alsina-Jurnet, University of Barcelona,
María Virginia Rangel-Gómez, University of Barcelona, Ernesto Mijal Magallón-Neri, University of Barcelona, Spain
The Body Image Assessment Software (BIAS) is a new computer program for body image disturbances assessment. The program proposes two visual
tasks, which can be carried out independently: body size estimation task and body dissatisfaction assessment task. Main advantages of BIAS are: Firstly, it
allows generating a figure that fits with the proportions of the subject because it is created from his/her objective measures (length and width of the different
body parts); secondly, it allows the modification of different body parts while simultaneously giving a holistic vision of it; finally, it can be run on any computer
that has Windows and Microsoft Access 2000 or Microsoft Access 2000 RunTime, and the data can be exported to applications such as SPSS and Excel.
The aims of the present study are to analyse the psychometrical characteristics of BIAS and to assess body size estimation, and body dissatisfaction in
patients with eating disorders and controls. The program was tested on 252 psychology students at the University of Barcelona and 52 patients with eating
disorder (ED). The participants filled in the Eating Attitudes Test-26, the Body Shape Questionnaire, the Body Dissatisfaction Scale of the Eating Disorders
Inventory-2 and the Body Image Assessment-Revised (a test of silhouettes). Results show good internal consistency (Cronbach's Alpha of 0.9148 in the
body size estimation task and Cronbach's Alpha of 0.941 in the body dissatisfaction assessment task). Principal components analysis of body image
distortion scale yielded a single main factor which accounted for 61.85% of variance. Principal components analysis of body dissatisfaction scale yielded a
single main factor too, which accounted for 70.38% of variance. Scores obtained in BIAS's body image distortion and body image dissatisfaction scales have
been correlated with those obtained with other instruments with known validity. All correlations are significant. Finally, BIAS allows to discriminate between
the participants that do not show risk of ED (EAT-26 < 20), participants that do show risk of ED (EAT-26 > 20 and patients diagnosed with ED. Results show
significant differences between groups in both body image distortion (F = 222.016; p <0.001) and body dissatisfaction (F = 56.766; p <0.001). No significant
differences have been found in body image distortion (F = 0.209; p = 0.889) and body image dissatisfaction (F = 0.073; p = 0.974) between patients with
different diagnoses of ED (anorexia nervosa, bulimia nervosa and not specified eating disorder). Results show good internal consistency, construct validity,
convergent validity and discriminant validity. Furthermore, BIAS is able to discriminate between individuals who are at risk of ED and those who are not; and
between individuals with a diagnosis of ED and those without. Those at risk of ED and those with ED showed more body image distortion (overestimation of
body size) and body image dissatisfaction.
The effect of attentional bias towards weight and shape related information on body dissatisfaction.
Evelyn Smith, University of Sydney, Elizabeth Rieger, University of Sydney, Australia
The objective of this study was to investigate the causal role of selective attention to shape/weight related information in terms of intensifying body
dissatisfaction. Participants were 70 female first year Psychology students aged between 17-28 years. An attentional probe task was used to induce
attention towards either negative shape/weight related words, neutral words, or negatively valenced emotion words. Thereafter vulnerability towards the
development of body dissatisfaction was assessed in the three groups after being exposed to a body image challenge. The induction of an attentional bias
towards shape/weight related information resulted in higher body dissatisfaction compared to both control groups. Results support the notion that an
attentional bias towards shape/weight related information plays a causal role in body dissatisfaction, suggesting that such biases may prove to be a useful
target in cognitive interventions designed to improve body image.
Investigating Cognitive Distortions in Eating Disorders: Experimental Induction of Thought-Shape Fusion
Jennifer Coelho, Maastricht University, Jacqueline Carter, University Health Network/University of Toronto, Traci McFarlane, University Health
Network/University of Toronto, Janet Polivy, University of Toronto, Canada
Cognitive distortions maintain dysfunctional behaviour; therefore, addressing cognitive distortions may diminish psychopathology. Shafran et al. (1999)
proposed that thought-shape fusion (TSF) is a cognitive distortion associated with eating disorders which encompasses three beliefs: 1) thinking about
eating forbidden food results in weight gain; 2) thinking about eating forbidden food is as morally wrong as actually eating it; and 3) thinking about eating
forbidden food increases feelings of fatness. TSF is associated with eating disorder symptomatology (Shafran et al., 1999; Shafran & Robinson, 2002).
Furthermore, TSF can be experimentally induced. After thinking about eating a fattening food, individuals with anorexia nervosa, as well as individuals high
in trait TSF, had increased feelings of anxiety and guilt, and reported that they felt fatter and perceived that they had gained weight (Shafran et al., 1999;
Radomsky et al., 2002). Previous inductions of TSF have not included a control group; therefore, it is possible that increased feelings of fatness
experienced by individuals with eating disorders after TSF induction can be explained by a body displacement hypothesis, in which a state of anxiety in
general increases feelings of fatness (e.g., Bruch, 1973; Geller et al., 2000). Furthermore, a direct comparison of the effects of a TSF induction on both
clinical and non-clinical participants has not yet been performed. Individuals with eating disorders (ED, n = 33), restrained eaters (R, n = 29), and
unrestrained eaters (UR, n = 48) participated, and were randomly assigned to one of three conditions: TSF induction (imagining eating a fattening food),
anxiety induction (imagining giving a speech), or control induction (imagining chatting with a friend). It was expected that the TSF induction would increase
anxiety, guilt, feelings of fatness, and moral wrong-doing relative to the control induction. Differences between the TSF, anxiety and control inductions were
investigated in order to test the body displacement hypothesis. It was also expected that UR would report less anxiety, guilt, and feelings of fatness after
TSF induction than would R and ED.
After arriving at the laboratory, participants underwent a TSF, anxiety or control induction. They then completed a questionnaire assessing their anxiety,
guilt, feelings of fatness, perceived likelihood of weight gain, and feeling of moral wrong-doing. Finally, participants completed a battery of questionnaires,
including the Beck Depression Inventory, Thought-Shape Fusion Questionnaire, and Eating Disorder Examination. TSF induction resulted in higher guilt and
feelings of fatness relative to the control induction in ED, R, and UR, indicating that elements of TSF can be induced in both clinical and non-clinical
participants. As expected, ED exhibited a stronger reaction to the TSF induction than did UR and R; however, there were no clear differences between UR
and R. There were no differences between the control and anxiety induction for reported feelings of fatness for ED patients. TSF appears to be a unique
type of cognitive distortion, and the increased feelings of fatness associated with TSF cannot be accounted for by anxiety or the body displacement
hypothesis. This study will be discussed in the context of previous research on TSF, and clinical implications will be explored.
Symposium 179
Maladaptive perfectionism: Recent developments in conceptualization, assessment and treatment
Convenor: Richard Ohring, Netanya Academic College, Israel
Understanding DAS perfectionism as a predictor of depressive symptoms and maladjustment over time in a clinical sample:
Perfectionistic strvings or self-criticism?
David M. Dunkley,Charles A. Sanislow, Charles M. Grilo, and Thomas H. McGlashan, McGill University, Canada;Yale University, USA
.Perfectionism, assessed by the DAS, has emerged as an important cognitive-personality factor that negatively influences treatment process and outcome
across various treatments of depression, including CBT. However, the interpretation of these previous findings is unclear because little information is
available regarding what exactly is being measured by DAS perfectionism. The present paper reports the results of three studies using data from a
heterogeneous clinical sample (N = 132). Study 1 examined DAS perfectionism in relation to the revised NEO Personality Inventory (NEO-PI-R). The
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results indicated that DAS perfectionism was primarily related to self-consciousness, low warmth, anhedonia, and mistrust, but was not related to
conscientiousness. This suggests that DAS perfectionism reflects the self-critical aspect of perfectionism rather than the perfectionistic strivings aspect of
perfectionism. Study 2, a 3-year, prospective study, also indicated that DAS perfectionism primarily reflects self-criticism rather than active striving to attain
perfection, and is distinguished from neuroticism in terms of its negative interpersonal and cognitive content. Study 3 presents new findings that compare
DAS perfectionism with neuroticism as a predictor of depressive symptoms and psychosocial functional impairment over a 4-year period. The results
indicated that Time 1 DAS perfectionism uniquely predicted self-report depressive symptoms and interviewer-rated major depression, global satisfaction,
global social adjustment, and global assessment of functioning 4 years later over and above the Time 1 assessments of these outcomes, respectively, and
neuroticism. These findings provide further support for DAS perfectionism as a promising prospective predictor of depressive symptoms and psychosocial
Perfectionism in anxiety and depression: Evaluating two new measures across disorders and as a function of treatment
Heather A. Wheeler, Kirk Blankstein, Martin M. Antony, Randi E. McCabe, and Peter J. Bieling, St. Joseph's Healthcare and McMaster University,
Canada;2 University of Toronto at Mississauga, Canada; 3 Ryerson University, Canada
Evaluative concerns and self-critical perfectionism are key cognitive-personality vulnerability components or dimensions of perfectionism in non-clinical
populations. We investigated perfectionism in clinical samples using new measures developed to assess specifically maladaptive perfectionism-the
Evaluative Concerns Perfectionism (ECP) and Self-Critical Perfectionism (SCP) scales, in conjunction with the two major extant measures-the Frost et al.
(1990) Multidimensional Perfectionism Scale (FMPS) and the Hewitt and Flett (1991) Multidimensional Perfectionism Scale (HMPS)..In our first study, 190
adult outpatients with a primary diagnosis of either social phobia (SP), panic disorder (PD), obsessive-compulsive disorder (OCD), or major depressive
disorder (MDD) were compared to non-psychiatric controls. High HMPS-self-oriented perfectionism was uniquely associated with MDD and SP. Patients with
OCD were higher than controls on the SCP, ECP-performance dissatisfaction, and FMPS-doubts about actions and concern for mistakes subscales. Patients
with OCD scored higher than did those with PD on SCP, and FMPS-concern with mistakes and doubts about actions subscales only. Patients with PD were
most similar to controls but scored higher on SCP, ECP-performance dissatisfaction and lower on FMPS-parental expectations.In the second study the
MDD, SP, and PD groups receive a standardized course of group CBT for either anxiety or depression. We will present data on (a) the influence of CBT on
pre/post perfectionism levels and (b) the consequences of pre-treatment perfectionism and pre/post changes in perfectionism for the efficacy of CBT in these
patients. Implications for assessment and treatment of perfectionism in patients with anxiety and depression will be discussed.
The nature and treatment of clinical perfectionism in patients with eating disorders and other axis I disorders
Roz Shafran, Oxford University, UK
In this paper data on the nature and treatment of 'clinicalperfectionism' in patients with clinical eating disorders and other AxisI disorders will be presented.
The relationship between 'clinical perfectionism' andtreatment outcome in a small randomized controlled trial of a brieftreatment for eating disorders will also
be presented
Maladaptive perfectionism (MP) and anxiety disorder symptoms: A test of a new measure for MP
Richard Ohring, Netanya Academic College, Israel
Recently, there has been much debate in the literature regarding the conceptualization and assessment of maladaptive perfectionism (MP), and its
relationship with psychopathology. In this paper a new unidimensional conceptualization of MP will be introduced. In addition, a self report scale that was
developed according to this new conceptualization will be presented. The results of a study that examined the relationship between MP (assessed by this
new measure) and anxiety disorder symptoms in a student sample will also be presented. Implications of these findings for the assessment and treatment
of maladaptive perfectionism will be discussed.
The relevance of dysfunctional self perceptions and maladaptive cognitions relating to perfectionism for obsessivecompulsive symptoms
Guy Doron, R Moulding, Michael Kyrios, Maja Nedeljkovic, Swinburne Institute of Technology, Australia
The relevance of dysfunctional self perceptions and maladaptive cognitions relating to perfectionism for obsessive-compulsive symptoms.Doron, G. ,
Moulding, R., Kyrios, M. , Nedeljkovic, M.Swin-PsyCHE Research Unit, Faculty of Life & Social Sciences, Swinburne University of TechnologyMaladaptive
cognitions such as perfectionism, importance and control of thoughts and exaggerated threat beliefs have been implicated in obsessive compulsive disorder
(OCD), depression and other disorders. Dysfunctional self perceptions have also been associated with psychological disorders such as OCD and depression
(see Doron & Kyrios, 2005; Beck 1976). This pilot study investigates the link between self structure and maladaptive OCD-related cognitions in a student
cohort (n=90). Consistent with hypotheses, participants indicating they value a particular self domain more than other domains equated competence in the
valued domain with the need for perfect performance, less uncertainty, and more control over thoughts compared to participants who did not indicate such
preference. For all participants, the belief that competence in a valued domain would increase perfect performance and control was associated with higher
obsessive compulsive symptoms and depression. Implications of these findings for theory, research and treatment of OCD are discussed.
Perfectionistic strivings and perfectionistic concerns: Differential relations with psychological adjustment and maladjustment
Joachim Stoeber, University of Kent, UK
Perfectionistic strivings and perfectionistic concerns: Differential relations with psychological adjustment and maladjustmentJoachim Stoeber University of
Kent, United Kingdom Studies on multidimensional perfectionism have shown that twodimensions of perfectionism can be differentiated:
perfectionisticstrivings and perfectionistic concerns (Stoeber & Otto, 2006).Whereas perfectionistic concerns have been associated with anxiety,depression,
and other indicators of psychological maladjustment,perfectionistic strivings have been associated with academicachievement, positive affect, and other
indicators of goodpsychological adjustment, suggesting that only perfectionisticconcerns are clinically relevant whereas perfectionistic strivingsmay be
considered to form part of a "healthy striving for excellence"(Shafran et al., 2002). Findings from a number of new studies showinghow perfectionistic
strivings and perfectionistic concerns showdifferential relations with achievement, motivation, affect, coping,and distress will be presented and their
implications for clinicalperspectives on multidimensional perfectionism discussed
Panel Debate 2
When is Thought Suppression Dysfunctional?
Convenor: Warren Mansell, University of Manchester, UK,
Thought suppression has been identified as a key cognitive process in the maintenance of psychological disorders, including OCD, PTSD and depression.
The term is often used to refer to not only the inhibition of upsetting thoughts, but also the cognitive avoidance of distressing memories and emotions. The
mechanisms of its action and its effects have recently been studied in detail within cognitive psychology and cognitive neuroscience. It is often tackled in
CBT as a key process to facilitate change - with the view that letting go of thought suppression facilitates the emotional processing of suppressed
information. But is thought suppression always dysfunctional? Can it sometimes be helpful? Is it the way that thought suppression is carried out that is the
problem? Or is it the function or motivations behind the suppression that make it problematic, or not so? There are broader questions too. What is the
relationship between thought suppression, memory suppression and the avoidance of emotions? How do we best assess these processes - self-report or
controlled experimental paradigms? This panel debate brings together international experts in the research of thought and memory suppression and how it
is targeted during CBT, to struggle with this theoretically exciting and therapeutically important issue. Mike Anderson is a leading international researcher in
the neural mechanisms underlying memory suppression. Christine Purdon is a leading international clinical researcher on the association between thought
suppression and psychopathology. Adrian Wells is a leading international figure in the development of metacognitive approaches to CBT. Ineke Wessel is an
international researcher on memory, emotion and psychopathology. Tim Dalgleish, who will chair the debate, is a leading international researcher on clinical
and non-clinical aspects of cognition and emotion.
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Open Paper Symposium 2
Basic Cognitive Processing in Anxiety and Trauma
The role of dissociation, emotional impact, and chewing gum in intrusion development
Julie Krans, BSI Radboud University Nijmegen, Gérard Näring, BSI Radboud University Nijmegen, Emily Holmes, University of Oxford, Eni Becker,
BSI Radboud University Nijmegen, Netherlands
Experiencing intrusions is a core symptom of PTSD. Intrusions are described as unwanted and uncontrollable images or thoughts of the trauma. Two recent
trauma theories that attempt to explain intrusion development are the dual representation theory (Brewin, Dalgleish, & Joseph, 1996) and the cognitive
model of PTSD (Ehlers & Clark, 2000). Both theories propose a dual processing of trauma information: 1) an automatic, parallel processing of sensory
information; and 2) a more controlled processing of (sensory) information leading to meaningful memory representations. The lack of integration between
these two processes is to be the source of intrusion development. These theories have been tested on several occasions. For example, one method is to
use the traumatic film paradigm, after which participant monitor their analogue flashbacks to the film. Certain visuospatial tasks during the film such as
complex pattern tapping appear to reduce intrusions. (Brewin & Saunders, 2001; Holmes, Brewin, & Hennessy, 2004). More recently more 'every day life'
tasks (rather than computer apparatus tasks) have also been tested. For example, using modelling clay, proposed to be a therapeutic visuospatial
grounding task a similar reduction in intrusions was found (Stuart, Holmes, & Brewin, 2006). It has been proposed that visuospatial tasks use capacity for
visuospatial processing involved in traumatic image encoding, so there was less capacity available for the trauma information, and thus less intrusions.
Support for this hypothesis has been that the reverse pattern was found for a verbal interference task (Holmes, Brewin, & Hennessy, 2004). Such a verbal
task was hypothesized to use part of the capacity of verbal processing necessary for elaboration of the trauma information, thus leading to more intrusions.
To create a link to more 'every day life' tasks, we attempted to replicate these findings with a chewing gum task. Subjects, healthy psychology students (N =
68), watched a trauma film in one of three conditions: chewing gum, visuospatial tapping, or a no-task control condition. Before and after the film, subjects
filled in several questionnaires: trait dissociation (DES-C), state dissociation (DSS), and mood (emotion questionnaire and STAI-DY1 and STAI-DY2). The
week following the experiment, subjects kept an intrusion diary. Then, subjects returned for a recognition and recall test. We could not replicate the findings
for the visuospatial tapping or chewing gum. We did find that the film had an emotional impact which was linked to intrusion development. Interestingly, we
found that both trait dissociation and peri-traumatic dissociation were related to intrusion development. Several theoretical and methodological issues are
discussed and implications for further studies are given. We hope that the traumatic stress film paradigm may help improve our understanding of peritraumatic processing and trauma intrusion development. Further, such data should ultimately help us evaluate tasks with respect to their potential usefulness
in clinical samples.
Heart rate responses to trauma-related pictures in recent trauma survivors with and without PTSD
Oliver Suendermann, Institute of Psychiatry, King's College London, UK; Anna Vossbeck-Elsebusch, Institute of Psychiatry, King's College
London UK; Inga Boellinghaus, Institute of Psychiatry, London, UK; Anke Ehlers, Institute of Psychiatry, King's College London UK
Aim: This study aimed to investigate heart-rate responses to trauma-related visual stimulus material, using two different samples of civilian traumas.
Furthermore, it was aimed to investigate the relationship between heart-rate reactivity and cognitive and emotional processes during the trauma.
Background: Several models of posttraumatic stress disorder (PTSD) suggest that associative learning plays a key role for the development of PTSD
symptoms (Brewin, Dalgleish & Joseph, 1996; Foa & Rothbaum, 1998; Ehlers & Clark, 2000). A common way of investigating the role of associative learning
for PTSD symptoms is to measure psycho-physiological responses to trauma-related stimuli; most studies demonstrated a heightened reactivity in the group
of PTSD patients. The majority of these studies used samples of combat veterans or people sexually abused in the past, making it difficult to generalise the
findings to recent civilian traumas. In addition, the findings are limited as there are only few studies that used stimulus material other than a confrontation
with an audio-script of the trauma. However, few recent studies addressed these limitations by using visual stimulus material in samples of civilian traumas,
demonstrating higher heart-rate reactivity in PTSD patients (Elsesser, Sartory & Tackenberg, 2004, 2005; Rabe, Dorfel, Zollner, Maercker & Karl, 2006).
Methods: We conducted a prospective study with survivors of road traffic accidents (RTAs) and physical assaults. Four weeks after their traumatic
experience, 94 RTA survivors and 69 victims of physical assaults were presented with a standardised picture set of trauma-related, general-threat and
neutral pictures. While watching the pictures, the participants' heart-rate responses were recorded. PTSD symptoms were assessed using the semistructured interviews Posttraumatic Stress Symptom Scale Interview (Foa & Tolin, 2000) and the Structured Clinical Interview for DSM-IV. Furthermore, the
relationship between heart-rate reactivity, the severity of PTSD-symptoms and cognitive and emotional processes during the trauma, namely anger, fear and
data-driven processing were investigated. According to the cognitive model of PTSD by Ehlers & Clark (2000), it was assumed that these processes
enhance the conditioning of emotional responses to trauma-related stimuli, thereby accounting for the development of PTSD symptoms. Results: After an
initial heart-rate deceleration, participants with PTSD showed significant stronger heart-rate acceleration to trauma-related pictures. Furthermore, heart-rate
reactivity at the time of the maximal heart-rate acceleration was positively associated with severity of PTSD symptoms as well as fear and data-driven
processing during the trauma. Discussion: The results are in line with previous studies showing that PTSD patients show stronger physiological responses to
trauma-related picture material. In addition, this study extends earlier findings by showing that cognitive and emotional processes during the trauma are
significantly associated with heart-rate reactivity to trauma-related material. Results are discussed in relation to the cognitive model of PTSD by Ehlers &
Clark (2000).
The Role of Automatic Cognitive Processing Deficits within the Formation of Obsessive-Compulsive (OC) Tendencies
Assaf Soref, Tel Aviv University, Reuven Dar, Tel Aviv University, Nira Liberman, Tel Aviv University, Israel
Several recent studies found that patients with obsessive-compulsive disorder show deficient performance on tasks that require implicit or automatic
processing (Deckersbach et al 2002, Joel et al 2004, Rauch et al 1997, 2000). It is unclear, however, whether this finding reflects a deficit in the capacity of
these patients for automatic processing or a tendency to prefer controlled to automatic processing. The purpose of the present study was to examine
whether non-clinical participants with high OC tendencies would tend to employ controlled processing in tasks that are normally handled by automatic
processes. Two hundred and thirty eight university students were screened using a combined index of the OCI and the WISPI. The 36 Students who scored
in the top and bottom of the distribution were selected for participation in the study. These participants performed a modified serial reaction time task, in
which they were required to press keys spatially corresponding to the location of single target stimulus that successively appear at one of four locations
according to an underlying sequence. The target was removed as soon as a key had been pressed, and the next stimulus appeared after either a 0-msec
(no-RSI condition) or a 250-msec (RSI condition) interval, depending on the condition. The no-RSI condition was found in previous studies to limit the
knowledge acquired while performing the task to essentially implicit ("automatic") knowledge, while the RSI-condition was found to allow acquisition of both
implicit and explicit ("automatic" and "controlled", respectively) knowledge (Destrebecqz & Cleeremans, 2001). To assess whether high OC participants are
more prone than low OC participants to assert control over automatic processing, we informed half of the participants in each group that the target stimulus
location was determined by an underlying sequence, and instructed them to try to find out what the sequence is. The other half of the participants was not
informed of the existence of the underlying sequence. We predicted that the informed participants of both groups will show an impaired performance as a
result of the sequence searching. We also predicted that this effect will interact with OC level, so that high OC participants will show a stronger effect of the
manipulation compared to the low OC participants. As predicted, in the no-instructions condition, high OC participants showed a similar capacity for
automatic processing to low OC participants. However, high OC participants who were instructed to search for the underlying sequence had shown
significantly stronger effect of the manipulation, compare to low OC instructed participants. This result was evident only at the no-RSI condition, where the
use of explicit knowledge was not available. Our findings suggest that high OC tendencies are associated with a potentially intact automatic processing
capacity together with a tendency for controlled processing to take over and interfere with automatic processing. This may explain the deficient performance
of OCD patients on tasks which require automatic or implicit processes for optimal performance.
Do activated threat schemas influence facilitation and inhibition processes in Obsessive Compulsive Disorder?
Craig Gonsalvez, Brain & Behaviour Research Institute, School of Psychology, University of Wollongong, Shelley Bannon, Brain & Behaviour
Research Institute, School of Psychology, University of Wollongong, Rodney Croft, Swinburne University of Technology, Australia
Recent inquiries into the pathology of OCD have been dominated by a proliferation of research within the neurobiological domain indicating the likelihood of
an underlying neurobiological deficit in OCD. A central problem identified is impaired inhibition. Within the therapy domain, cognitive therapy models posit
that the key to the psychopathology of OCD does not reside in the occurrence, but in the meaning and personal significance attached to obsessional
phenomena. Pre-existent, underlying cognitive schema (e.g., about sexuality or religion) are theorized to have the power to imbue certain thoughts and
doubts with anxiogenic properties, thereby granting them salience over other mental phenomena. The current study examines whether activation and
inhibition processes are disordered in OCD, whether activated threat schemas affect these processes in OCD, and whether symptomatic status influences
the manifestation of these deficits. Participants were 20 persons with symptomatic OCD, 11 with remitted OCD, 20 with panic disorder, and 20 normal
control subjects. Participants were required to respond to target words, that during an immediately preceding trail were responded to as targets (facilitation)
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or inhibited as nontargets (inhibition effects). Study 1 employed neutral words and Study 2, personally threatening words. Response time measures that
indicated general processing speed, facilitation effects and inhibition effects were obtained for threat and neutral conditions for the four groups and analysed
by ANOVA and t-tests. OCD participants displayed greater activation-strength (facilitation) to repeating target stimuli and impaired inhibition to appropriately
suppressed nontarget stimuli. The two abnormalities were independent of each other, specific to the OCD groups, and unrelated to symptomatic status,
medication, or personality. The threat condition had no effect on facilitation measures, but reduced otherwise normal inhibitory capabilities of the Panic
group, and exacerbated inhibition problems in the symptomatic OCD group. The combination of excessive activation strength to salient stimuli AND weaker
inhibition of rejected responses is the signature dysfunction in OCD, and underlies the intrusive, recurring properties of its clinical symptoms. Anxiety
exacerbates inhibition impairments in OCD and non-OCD groups, but has no effect on facilitation processes.
Worry in Generalised Anxiety Disorder: An Inhibitory Deficit?"
Ileana Hatton, PhD student, University of Sydney, Caroline Hunt, Director of Clinical Training, University of Sydney, Maree Abbott, Senior Lecturer,
University of Sydney, Tamsen St Clare, Head Clinical Psychologist, Anxiety Treatment and Research Unit Cumberland Hospital, Australia
Recent treatment outcome studies clearly identify Generalised Anxiety Disorder (GAD) as one of the most difficult to treat of the anxiety disorders with less
than 50% of patients achieving recovery after routine treatment (Yonkers, 2000). Researchers have indicated that; “…if treatments of GAD are to be
improved, it will help to understand the mechanisms that contribute to and maintain excessive and uncontrollable worry, the predominant symptom of this
disorder” (Wells, 2000). In an attempt to address these concerns, the current study investigates the validity of the Defective Inhibition Hypothesis (Fox, 1994)
an established theory, which proposes that the cognitive symptomatology found in many psychological disorders (e.g. OCD, PTSD, schizophrenia) is due to
a breakdown in cognitive inhibition (e.g. the ability to suppress and delete irrelevant information from working memory). The researchers postulate that
reduced inhibitory efficiency is responsible for the cognitive intrusions (e.g. persistent worry) that characterise GAD. The second part of the study
investigates the efficacy of a new treatment component, the Attention Training Technique (Wells, 1997) in the treatment of GAD, with specific focus on the
impact of this component on inhibitory function. To date Attention Training has been used with a range of disorders including depression, panic disorder, and
social phobia (Wells, 2000), however it has not been applied to GAD. Therefore the current study aims to address this gap in the literature by exploring the
utility of this component alone and in addition to standard cognitive-behavioural (CBT) treatment. Equal numbers of GAD subjects and non-anxious controls
matched on age and sex were tested on two computer-based negative priming tasks measuring inhibitory function for neutral and threat-related information.
GAD subjects were then randomly allocated to either Attention Training (5 sessions, 1 hour/ week) or Wait-List. All GAD participants then completed
standard CBT treatment (8 sessions, 2 hours/ week). Subjects were retested following Attention Training, CBT treatment and at 6-month follow-up. Findings
to date suggest the presence of an inhibitory deficit in GAD subjects compared to non-anxious controls, however results are still in the preliminary stages of
analysis. Reasons for these findings will be discussed along with preliminary data on treatment outcome following Attention Training and CBT treatments
with particular focus on the implications of these results for the future treatment of GAD.
Open Paper Symposium 4
Personality and Emotional Regulation
Adult Attachment Style, Self-Esteem Stability and Emotional Reactivity to Daily Life Events in Cluster B Personality Disorders:
An Experience Sampling Approach
Gordon Milson, Pennine Care NHS Trust, Sara Tai, The University of Manchester, UK
Cluster B personality disorders are chronic, often disabling conditions that are ultimately associated with a shorted lifespan. Understanding of the
processes involved in the difficulties experienced by people with personality disorders, particularly those associated with interpersonal difficulties remain
unclear. Empirical research has demonstrated that there are similarities between the problems associated with cluster B personality disorders and bipolar
spectrum disorders; these syndromes may be part of the same spectrum and share the same underlying psychological processes. However, key processes
implicated in bipolar disorder such as affect regulation and a stable sense of self have not been examined alongside attachment styles in people with
personality disorders. The current study examined attachment styles; affect and self-esteem fluctuations and social satisfaction in people with cluster B
personality disorders utilising an experience sampling methodology. Adult attachment styles, affect and self-esteem fluctuation and social satisfaction ratings
were examined in a group of people with cluster B personality disorders and compared with matched controls. Differences were observed in adult
attachment styles, negative affect fluctuation and self-esteem fluctuation with the clinical group exhibiting greater fluctuations in negative affect and selfesteem. Individuals with cluster B personality disorders exhibit more insecure attachment styles and experience greater negative affect fluctuation and selfesteem fluctuations in daily life. These findings have clinical implications for therapeutic interventions for people with cluster B personality disorders and
support the need for further investigation into problems existing within a spectrum of bipolar disorders.
Functionality of self-injury in male and female patients: (dis)similar?
Laurence Claes, Catholic University Leuven, Department of Psychology, Walter Vandereycken, Catholic University Leuven, Department of
Psychology, Hans Vertommen, Catholic University Leuven, Department of Psychology, Belgium
Self-injurious behavior (SIB) is 1.5-3 times more likely in women than in men. However, there is minimal research on the functionality of SIB in male
populations. Recently, Nock and Prinstein (2004, 2005) developed a comprehensive theoretical model including four primary functions of SIB that differ
along two dichotomous dimensions: contingencies for SIB that are automatic (within the self versus social), and reinforcement that is positive (followed by a
favorable stimulus) versus negative (followed by the removal of an aversive stimulus). Using Nock and Prinsteins framework, we carried out a comparative
study in 399 psychiatric inpatients (265 females and 134 males) by means of a self-reporting questionnaire assessing affective and cognitive antecedents
and consequences of SIB (Self-Injurious Questionnaire; Claes, et al., 2006). Subjects are asked if they have deliberately injured themselves in the past year.
If so, they have to specify - for each behavior separately - how long ago this happened, how often, if they felt some pain, what kind of emotional experiences
they had before and after the self-injurious act, and what the motive of this behavior was.
To analyze group differences (male/female and SIB/non-SIB) with respect to interval-scaled variables, we made use of multivariate analyses of variance.
Compared to female patients with SIB (46.2%), males admitting SIB (31.3%) showed more burning, reported more pain experience, took less care of their
wounds and concealed the less often. The function “to avoid or suppress negative feelings” (automatic negative reinforcement) had the highest score for
both male and female patients. The only two scales on which the males on average scored higher than the females were “to get attention from others” and
“to show other how strong I am” (social positive reinforcement). Overall, we found significant differences between male and female patients with respect to
the intensity of emotions before and after SIB. Before SIB, both males and females had the highest scores on “angry at self” and “sad”, and the lowest
scores on “glad” and “relieved”. After SIB, both males and females had the highest scores on “relieved”, “angry at self”, and “guilt” and the lowest score on
“bored”. Overall, we found an increase in positive emotions and a decrease in negative emotions after the act of SIB for male as well as for females. In
accordance with the general literature, females displayed significantly more SIB than males (except for burning). In our study, males injured themselves
more frequently per day, took less care of their wounds and concealed them less than females. The latter finding may be related to the finding that SIB in
males was serving more social-oriented functions. Further evidence of the emotion regulation function of SIB comes from our findings that both male and
female patients reported an increase in positive emotions and a decrease in negative emotions after SIB.
With respect to cognitive-behavioral treatment planning, one should take into account that for male patients SIB appears to have more socially-oriented
functions (e.g. getting attention) than for female patients.
The Expression of Positive and Negative Schizotypy in Daily Life: An Experience Sampling Study
Thomas Kwapil, University of North Carolina at Greensboro, Leslie Brown, University of North Carolina at Greensboro, Paul Silvia, University of
North Carolina at Greensboro, Inez Myin-Germeys, University of Maastricht, Neus Barrantes-Vidal, Universitat Autònoma de Barcelona, Spain
Psychometrically identified positive and negative schizotypy are differentially related to psychopathology, personality, and social functioning. However, little is
known about the experience and expression of schizotypy in daily life. The present study employed the experience sampling method (ESM) to assess
positive and negative schizotypy in daily life in a nonclinical sample of 412 young adults. ESM is a structured diary technique in which participants are
prompted at random times during the day to complete an assessment of their current experiences. As hypothesized, positive schizotypy was associated with
affective dysregulation (especially increased negative affect), thought impairment, suspiciousness, negative beliefs about current activities, and feelings of
rejection, but not with social disinterest or decreased positive affect. Negative schizotypy, on the other hand, was associated with schizoidal adjustment
involving decreased positive affect and pleasure in daily life, and marked decreases in social contact and interest. Positive schizotypy was associated with
increased thought impairment and distress when alone, but discomfort when with unfamiliar or untrusted people. Thus the road to beneficial social contact is
difficult for positive schizotypes (consistent with the social anxiety and suspiciousness characteristic of schizotypal personality disorder).The findings support
the construct validity of a multidimensional model of schizotypy and the use of psychometric inventories for assessing these dimensions. ESM appears to be
a promising method for examining the daily life experiences of schizotypic individuals.
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The Modified Affective Contol Scale for Adolescents: Internal consistency and discriminative ability in matched clinical and
non-clinical samples.
Keren Geddes, Murdoch University, Suzanne Dziurawiec, Murdoch University, Christopher Lee, Murdoch University, Australia
Problematic emotion regulation is widely accepted as a central feature of many psychopathologies and has been found to be particularly problematic in
individuals diagnosed with Borderline Personality Disorder. Current statistics indicate an increasing number of young people presenting at community based
mental health services with self-harm and suicidal ideation, indicators of emerging borderline pathology. However, currently there is no available measure of
emotion regulation within an adolescent population. Development of such a measure is critical to determining the efficacy of interventions used within this
population. The current study modified an adult measure of emotion regulation, the Affective Control Scale (Williams, 1992) and tested its reliability within an
adolescent population. Further to this, the current study tested the ability of the Modified Affective Control Scale for Adolescents (MACS-A) to discriminate
between matched clinical and non-clinical adolescent groups. In study 1, 2,128 male and female secondary school students aged between 12 and 18 years,
from diverse socio-economic backgrounds, completed the ten minute 41 item MACS-A. Internal consistency of the scales four sub-scales and total scale
score were calculated. In study 2, 60 adolescents, currently attending a community based mental health service also completed the MACS-A, and were
matched to two independent samples (Public school system and Private school system) drawn from study 1 on gender and age (within two months)
variables. The Public school sample was considered equivalent to the clinical sample as both were representative of a low to middle socio-economic status.
One-way ANOVA's were used to test significance of group mean differences. In study 1 all four subscales and the total scale were found to be internally
consistent and highly comparable to the results found for the original ACS. The MACS-A was also found to be highly reliable within the clinical sample.
Additionally, the MACS-A effectively discriminated between the clinical sample and both the public and private school samples with the clinical sample
scoring significantly higher (p < .001) than both the public school sample and the private school sample on the subscales of Fear of Anger, Fear of
Depressive Mood and Fear of Anxiety, and the total scale of Fear of Emotion. The MACS- A was shown to be a reliable measure of emotion regulation in 12
to 18 year old adolescents and to effectively discriminate between clinical and non-clinical groups. Recommendations for further development of the scale
are made.
Narcissism and the narcissistic defenses: Experimental evidence of externalized criticism
Jennie Sines, Loughborough University, Caroline Meyer, Loughborough University, Glenn Waller, Institue of Psychiatry, London, UK
While narcissism is a construct that has traditionally been described in a psychoanalytic framework, recent research has begun to understand this trait in
cognitive-behavioural terms. While core narcissism is marked by entitlement cognitions (which enhance self-esteem), it is also necessary to understand two
patterns of narcissistic defense (which support self-esteem when it is perceived to be threatened). The first of these defenses is a martyred, 'poor me'
response to threat, while the second is a more critical, 'bad you' response. Each construct has been shown to be linked to different patterns of core beliefs.
However, the links to specific behaviours remain to be elaborated. The objective of the present study is to demonstrate a specific behavioural manifestation
of narcissism - how individuals with relatively narcissistic traits appraise their own bodies and those of others. Forty-six non-clinical women (aged 18-40)
completed an eye-movement tracking task while they observed photos of their own bodies and photographs of others' bodies. The times spent observing the
'most beautiful' and 'most ugly' parts of each body (as rated by the participant after the observation) were recorded. Each woman completed a standard
measure of narcissism and narcissistic defenses, as part of a larger set of questionnaires. The women were divided into high- and low-narcissism groups by
using median splits on each scale of the questionnaire measure. There were no differences in visual tracking between the women scoring high and low on
either the core narcissism scale or the 'poor me' defense. However, those who score high on the 'bad you' scale had a different pattern to those scoring low
on that scale, indicating that those women with high levels of trait externalized criticism were likely to focus more on other's 'ugly' body parts, and more on
their own 'beautiful' parts. These results provide behavioural validation for the narcissistic construct, showing that the 'bad you' defense is associated with
hostility towards others' appearance. Future research is needed, not only to further explore the link between 'bad you' narcissism and criticism of others, but
also to discover effective ways to challenge this maladaptive behaviour pattern.
Open Paper Symposium 28
Basic Processes and Impulse Control Across Disorders
Cognition and Meta-Cognition in Tourette's and Tic Disorders
Kieron O'Connor, Centre de recherche Fernand-Seguin, Canada; JérémyDohan, Centre de recherché Fernand-Seguin, Montreal, Canada;
Geneviève Paradis, Centre de recherché Fernand-Seguin, Montreal, Canada; Natalia Koszegi, Centre de recherché Fernand-Seguin, Montreal,
Canada;Catherine Séguin, Centre de recherché Fernand-Seguin, Montreal, Canada
Tics and Tourette syndrome are classified as neuropsychiatric disorders, but recent work has shown the efficacy of behavioral treatments, in particular habitreversal in tic management. However, the role of cognitive and meta-cognitive factors in ticcing and tic onset have so far been neglected. Anecdotally people
with tics can report that anticipation of a tic can trigger ticcing. A previous series of studies examining activities related to tic onset identified a number of
negative appraisals such as fear of judgement or the feeling of being under pressure consistently to be linked with increased tension. The present study
examined cognitive and meta-cognitive beliefs by questionnaire and interview and through use of Kelly's personal construct theory in 30 participants. The 30
participants were recruited from an ongoing clinical referrals for participation in a cognitive-behavioral treatment program for tics and Tourette's. The groups
were diagnosed as either chronic disorder, tic or Tourette's syndrome. Results indicated that a wide range of beliefs coexisted in both groups. These beliefs
concerned the negative and positive utility of ticcing, beliefs about tic disorder, expectations concerning tic onset, appraisals of high risk situations,
perfectionist ideas concerning planning actions and personal organization. Some of these (meta) cognitive factors were closely linking with behaviours
maintaining sensori-motor activation, and tension and the likelihood of tic onset. Changes post-treatment support targeting such (meta) cognitive factors
during cognitive-behavoral therapy.
Does active regulation of negative emotions lead to binge eating in patients with Binge Eating Disorder?
Alexandra Dingemans, Center for Eating Disorders Ursula, Anita Jansen, Maastricht University, Department of Experimental Psychology, Carolien
Martijn, Maastricht University, Department of Experimental Psychology, Eric van Furth, Center for Eating Disorders Netherlands
Negative mood states were found to influence eating disordered behaviors in subjects with Binge Eating Disorder (BED): A link exists between emotional
disturbances or negative emotional states and binge eating behaviours (Grilo & Shiffman, 1994). Although mood is worse overall for women with BED, mood
is especially poor before binge episodes (Greeno, Wing, & Shiffman, 2000). To control these urges to binge or to regulate negative emotions, one needs to
exert self-control. Self-control involves regulating or inhibiting competing urges, behaviours and desires. Controlling one's own behaviour requires the
expenditure of some inner limited resource that is depleted afterwards. Baumeister, Muraven and colleagues (2000) proposed that 'people have a limited
quantity of resources available for self-control and that various acts of self-control draw on this limited stock'. When a situation demands two consecutive
acts of self-control, performance on the second (unrelated) act is frequently impaired. The current study investigates whether (negative) emotions per se, or
attempts to actively regulate one's emotions cause more loss of control over eating in patients with BED. Sixty BED-patients with high and low depressive
symptoms (as measured by the Beck Depression Inventory) were randomly allocated to either a condition in which they have to actively suppress their
emotions or to a condition in which they are instructed to express their natural emotions while watching a sad film fragment. Subsequently all participants
are submitted to a taste task. We expect that BED patients in the suppress condition eat more during the taste task than those in the express condition.
Furthermore, we expect that the high-depressive group eat more than the low depressive group. The results will be presented and the clinical relevance will
be discussed.
Exploring the Relationship between Explicit and Implicit Measures in the Evaluation of Sexual Fantasies'
Laura C. Sánchez-Sánchez, University Of Almería, Spain; Dermot Barnes-Holmes, University Of Maynooth, Ireland; Carmen Luciano Soriano ,
University Of Almería Spain
The study examined the difference between explicit and implicit measurements to assess what kind of practices arouses people. Irish and Spanish
populations completed the experiment to explore possible variations between cultures. The IRAP (Implicit Relational Assessment Procedure) was the implicit
measurement used in the experiment. This method is a tool for assessing attitudes or beliefs that are easily hidden when explicit measures are employed
such as questionnaires and open-ended interviews. This procedure aims to address problems inherent in other implicit measurements. For example, the IAT
(Implicit Association Test), and its variants focus on associations rather than relations among stimuli or events, and as such they provide only an indirect
measure of beliefs. However, IRAP is designed to assess beliefs directly rather than the putative underlying associations. Wilson's Sex Fantasy
Questionnaire (SFQ; Wilson, 1978; Wilson & Lang, 1981) and Hulbert Index of Sexual Fantasy (HISF) were used as explicit measurements for the sexual
fantasies. The participants were randomly assigned to eight conditions. In each condition they had to choose one practice from a list of words. The
conditions depended on the words: unacceptable sexual practices, acceptable sexual practices, unacceptable non sexual practices and acceptable non
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sexual practices. Then, they were asked to think about the word chosen for two minutes; one minute to think about other people involved in that practice and
one minute to think about themselves engaging in the practice. Afterwards they were asked to complete a distracting task while they were asked to
concentrate on or suppress thoughts of the practice they had chosen. As a result, there were four experimental conditions: suppression of unacceptable
sexual practices (Condition 1), concentration on unacceptable sexual practices (Condition 2), suppression of acceptable sexual practices (Condition 3) and
concentration on acceptable sexual practices (Condition 4). And there were four control conditions: suppression of unacceptable non sexual practices
(Condition 5), concentration on unacceptable non sexual practices (Condition 6), suppression of acceptable non sexual practices (Condition 7) and
concentration on acceptable non sexual practices (Condition 8). Finally, participants were asked to answer some questions about the ease or the difficulty
they experienced in suppressing or concentrating on the practices chosen and to what extent they were successful in doing that. The following task was the
IRAP, which the participants had to complete as quickly and accurately as possible. The IRAP task targeted participants beliefs concerning whether specific
sexual practices are arousing or not.Participants were asked finally to complete two questionnaires about sexual fantasies. The English versions were
applied to the Irish participants and two reliable and valid Spanish versions to the Spanish participants. The correlation between the implicit and the explicit
measurements were analyzed to examine the difference in the arousal when one person can or can't hide his/her real opinion about an 'embarrassing'
Psychological factors associated to physical exercise in undergraduate Mexican students
Bernardo Hernández-Prado, National Institute of Public Health, Mexico; Luis Flórez-Alarcón National University of Colombia; Sandra Ceja-Padilla,
National University of Mexico; Dulce María Díaz-Sosa, National University of Mexico; Mario Rojas-Russell National University of Mexico
Physical activity (PA) is a major health protective factor. However, most individuals practice less exercise as recommended. Several psychosocial factors
have been associated with this behavior. The aim of this research was to study the association between perceived self-efficacy and readiness to change to
self-reported PA in undergraduate students. 357 random-selected first-year students (234 women, 123 men) from six careers, mean age 19.3 years (s.d. =
3.2), answered a questionnaire containing a PA Self-efficacy scale, an algorithm based on the Proschaska and DiClemente's model of change to evaluate
the readiness to change for the accomplishment of physical exercise, the General Questionnaire of Health (GHQ), a visual-analog scale about attitude
toward physical exercise, and a Questionnaire on PA. Self-reported PA activity was measured in METs. Body mass index and waist-to-hip ratio were
computed also. Men reported practicing more PA than women (z = 6.06, p = .00). Significant associations between PA and readiness to change (?2=133.3,
p=.00), self-efficacy (? = .33, p =.00), positive attitude towards physical exercise (? = .37, p =.00) and GHQ (? = -.22, p=.00; lower scores mean better
perceived health) were found. Self-efficacy was significantly associated with readiness to change also (F (4,347) = 19.35, p=.00). In a multiple regression
analysis (F=30.8, p=.00), controlling by sex and anthropometric measures, both stages of change and self-efficacy were significantly associated with PA.
Taking into account a number of confounding variables, readiness to the change seems to be the major variable associated with the self-reported physical
activity. In order to be successful, interventions to promote physical activity should take into account cognitive and behavioral processes involved in the
process of change. Self-efficacy seems to be a valuable predictor of the change. Limitations of the study are commented: the cross-sectional design, and
the type of measurement of physical activity.
Open Paper Symposium 37
Cognitive Biases in Anxiety and Derpression
The Memory-Bias in Anxiety - Fact or Fiction? A meta-analysis
Kristin Mitte, University of Jena, Dept. of Psychology, Germany
Cognitive processes are important for the maintenance of anxiety and anxiety disorders. Different biases are postulated, for example patients with an anxiety
disorder have been shown to have an attentional bias. The present meta-analysis investigates the memory-bias in anxiety and in the anxiety disorders.
There are different assumptions concerning the importance of implicit and explicit memory in anxiety depending on the theoretical model. Whereas the
models of Beck et al. (1985) and Bower (1981) assume both a memory-bias for explicit and implicit memory, the model of Williams et al. (1988, 1997)
assumes only an implicit memory-bias. Experimental studies show different results concerning these cognitive processes in anxiety, thus a meta-analytic
combination of these results seems important. After a comprehensive literature search, the results of more than 160 studies with 9000 subjects were
integrated in the meta-analysis. The computation of effect sizes was done with Hedges g using both random and fixed effects-model. We present here the
results for recall only which is the most commonly used paradigm in anxiety memory research. When investigating the between-groups effect sizes, there
were no important effect sizes for the different stimulus material (negative, neutral, positive). However, results of regression analyses suggest a memory-bias
for negative stimuli when using the appropriate experimental design. Thus, both the number of stimuli, the encoding procedure, and the time between
encoding and retrieval seems to be important moderator variables. In contrast, there seems to be no significant impact of patient status on results (i.e.
whether patients were compared with normal controls or high-anxious subjects with low-anxious subjects), suggesting a dimensional approach of anxiety
and not a categorical approach. The memory-bias seems to be more related to trait-anxiety than to state-anxiety or depression. Additionally, we investigated
the within-group effect sizes. The finding will be discussed concerning the validity of memory-research and possible implications for cognitive models in
Self-Focus as a Determinant of Autobiographical Memory Deficits in Social Anxiety Disorder
Janet Dickson, Swinburne University of Technology, Glen Bates, Swinburne University of Technology, Lorraine Fleckhammer, Swinburne
University of Technology, Australia
Self-focused information processing is a central aspect of cognitive explanations of social anxiety disorder, highlighting Clark and Wells' (1995) notion of
processing of the self as a social object as a key feature. When socially anxious individuals enter feared situations, attention shifts to a focused monitoring of
self. Such self-focused attention is assumed to trigger recollections of negative experiences from the past and directs attention towards signs of threat. This
interferes with the processing of situations and leads to misinterpretation of others' behaviours. There is considerable support for Clark and Wells' model
from research on imagery, post-event and anticipatory processing. However, unlike mood disorders, deficits in accessing autobiographical memories have
not been found for social anxiety. Thus, the role of memory in the maintenance of social anxiety is unclear. The absence of evidence of memory deficits in
social anxiety may be due to methodological limitations of earlier research. Despite the centrality of self-focused processing in models of social anxiety, no
study of autobiographical memories has manipulated respondents' levels of self-focus during recollection. Therefore, this study focused on the accessibility
and quality of the autobiographical memories of socially anxious and non-socially anxious individuals, obtained under conditions of self-focus, compared to
responses obtained without self-focus. Groups were formed according to cut-offs on measures of social anxiety, the Social Phobia and Anxiety Inventory
(SPAI; Turner, Beidel, Dancu & Stanley, 1989b), and trait anxiety and depression from the Depression, Anxiety and Stress Scale (DASS; Lovibond &
Lovibond, 1995). A group of socially anxious (SA) individuals (n = 54) without comorbid depression was included. This group was compared to two control
groups, one non-socially anxious (NSA) group (n = 53), and one socially anxious group (SAD) with comorbid depression (n = 36). Groups were roughly
matched in terms of gender and age, and social anxiety status was confirmed with the anxiety disorder interview schedule (ADIS-IV-L; Di Nardo, Brown &
Barlow, 1994). Approximately half of each group was primed to self-focus, following an adaptation of a priming methodology by Perowne and Mansell
(2002). The other half of the participants were other-focused. Priming occurred prior to written responses to positive and negative (social anxiety) cue words
using Williams' (2002) Autobiographical Memory Test. Memory quality was measured according to overgenerality for positive and negative cues and reaction
time was recorded. Results confirmed that greater levels of generality and longer reaction time to positive cues (not to negative cues) were evident when
comparing self-focused SA with self-focused non-socially anxious (NSA) individuals, reflecting findings for other emotional disorders such as depression. In
the self-focused condition, SA respondents did not differ significantly from the SAD respondents for memories for positive cues. Therefore, comorbid
depression made no difference. Both groups were similar for negative memory cues. Without priming, SA individuals did not demonstrate autobiographical
memory deficits in quality or accessibility. Overall, the self-focusing manipulation unearthed a memory processing deficit in socially anxious individuals,
similar to that found in most emotional disorders in terms of both quality and accessibility of the memories. The findings are consistent with the Clark and
Wells' (1995) model, emphasising the role of the self as central to the disorder. Processing deficits of socially anxious individuals are confined to the selffocus condition. The study provides evidence that self-related memories are important targets for treatment and individuals have a lack of positive material
with which to combat negative experiences during significant social interactions. Memory, along with imagery, post-event, and anticipatory processing, is
important in the maintenance of social anxiety disorder.
Alcohol eliminates attentional bias in social phobics
Stephan Stevens, University of Muenster, Germany, Institute for Clinical Psychology, Alexander L. Gerlach, University of Muenster, Germany,
Institute for Clinical Psychology, Fred Rist, University of Muenster, Germany, Institute for Clinical Psychology, Germany
Epidemiological studies show a substantial association of social phobia and alcohol related problems. However, the responsible mechanism is not well
understood. According to Sayette (1993) anxiety is reduced by alcohol through disrupting initial appraisal of threatening stimuli under the condition that the
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stimuli cannot be processed automatically. Thus, we tested the influence of alcohol on primary appraisal of ambiguous and non-ambigous social threat
stimuli in social phobics and controls. 40 participants with social phobia (DSM-IV) and 40 controls performed a visual dot probe task with either drinking
alcohol resulting in a BAC of 0.6 ‰ or after drinking orange juice. Expressions were happy, angry, neutral or ambiguous. The two ambiguous facial
expressions were the result of mixing angry or happy with neutral faces. Without alcohol, social phobics showed an attentional bias towards explicitly angry
facial expressions, indicating preferential processing of threat related stimuli (vigilance). Alcohol eliminated this attentional bias for social phobics. There
were no attentional bias effects for other emotional face stimuli. Only in the orange juice condition, significant correlations with measures of social anxiety
could be found. The results suggest that social phobic patients show initial vigilance for angry facial expressions compared to healthy controls. This bias can
be eliminated by drinking alcohol. This effect may explain the increased use of alcohol in social phobic patients.
Threat preference in attentional and interpretive processing: Different emotional processing biases or differing expressions of
the same bias?
Sian Jeffery, The University of Western Australia, Colin MacLeod, The University of Western Australia, Australia
Anxiety vulnerability is characterised by biased patterns of selective information processing that operate to favour threatening information. Both attentional
and interpretive bias have been shown to causally impact upon anxiety vulnerability, but the relationship between attentional and interpretive bias is unclear.
Two alternative hypotheses regarding this relationship can be delineated. One possibility is that attentional and interpretive bias are concurrent expressions
of a single underlying biased selectivity mechanism that characterises anxiety vulnerability (the Common Mechanism account). In contrast, a quite different
possibility is that attentional and interpretive biases are quite independent cognitive anomalies that represent separate pathways to anxiety vulnerability (the
Independent Mechanisms account). These alternative accounts of the relationship between attentional and interpretive bias generate differing predictions
concerning the impact of directly manipulating attentional bias upon measures of interpretive bias. The present experiment adopted the attentional probe
training procedure developed by MacLeod et al. (2002), and the word fragment completion interpretive assessment task employed by Grey and Mathews
(2000), to examine cross- bias transfer of training and hence test these differing predictions generated by the Common Mechanism and Independent
Mechanisms accounts. The results confirm that attentional training serves also to modify interpretive bias. This observation, that the direct manipulation of
attentional bias impact also upon measures of interpretive bias, provides support for the Common Mechanism account of the relationship between anxietylinked patterns of selective attention and selective interpretation. Thus, the findings are consistent with the proposal that attentional and interpretive bias
represent concurrent manifestations of a common underlying mechanism, responsible for the selective processing of threatening information. Consideration
will be afforded to specific models of emotion and cognition that represent exemplars of this class of account, and hence are supported by this empirical
data, and comment will be made about the specific influential models of emotional and cognition that are challenged by the current findings. The applied
importance of the present support for the Common Mechanism account, which carries practical implications for the assessment and treatment of anxiety
pathology, also will be discussed.
Attentional bias in depression and anxiety: A negative priming paradigm
Patrick Leung, Department of Psychology, The Chinese University of Hong Kong, Josephine Yau, Department of Psychology, The Chinese
University of Hong Kong, China
Introduction: Content-specificity hypothesis suggested that people with mood disorders tended to attend to stimuli that were congruent with their emotional
problems. In order to investigate such an emotion-congruent attentional bias, a variety of experimental paradigms had been applied to individuals with
depression or anxiety.Despite such endeavors, empirical findings had been inconsistent and contradicting. In the present study, a modified negative priming
paradigm was used to examine this content-specific attentional bias in individuals with depression and/or anxiety. According to Milliken and colleagues'
(1998) temporal discrimination hypothesis, a negative priming effect would be evoked from an intermediate match between the cognitive representation of
the probe target and that of an unattended prime of related identity. On the other hand, such an effect could be reduced or eliminated by attending to the
prime stimulus. The aim of the present study was to test the hypothesized emotion-congruent attentional bias in individuals with different emotional problems
by examining reduced negative priming effect of primes of the corresponding emotional valences. Methods: A total of 134 participants (52 males, 82
females) were recruited in the present study and divided into four groups (depression, anxiety, comorbid depression/anxiety, and normal control groups)
according to their scores on two scales, Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and Beck Anxiety Inventory (BAI; Beck, Epstein,
Brown, & Steer, 1988). Participants completed the negative priming task with sad- and threat-related word stimuli. In each trial of the task, participants were
briefly presented with a red single prime word followed by a probe display. In each probe display, two interleaved words, one above the other, were
presented. One of the words was in red (the target) and the other in green (the distractor). By varying the emotional valence of the prime and probe target,
five experimental conditions were produced with different prime-probe target combinations: sad-sad, neutral-sad, neutral-neutral (unrelated words), neutralthreat, and threat-threat. The probe distractor word was neutral across the experiment. Participants' response times (RTs) to the probe target were recorded
and used for analyses. The effect of the priming manipulation was measured by subtracting the RTs of probe target in conditions with same prime-probe
target emotional valence from those with different emotional valence. Results: Findings from repeated measures analyses indicated a reduced negative
priming effect of sad words in the depression and comorbid groups as hypothesized, but not in the anxiety and normal control groups. However, a positive
priming effect of threat-related words was found generally across all groups. Discussion/Conclusion: Findings from the negative priming task suggested that
attentional bias occurred specifically in participants with depression, but not in those with anxiety. In other words, the content-specificity hypothesis regarding
attention bias to emotional-congruent stimuli of a disorder was supported in depression but not in anxiety. Implication of the findings and the interaction
between emotional valence of the stimuli and psychopathologies would be discussed.
Open Paper Symposium 38
Metacognition and Avoidance
Incompleteness and harm avoidance in OCD symptom dimensions
Willi Ecker, Institute of Behaviour Therapy (IFKV) Bad Dürkheim, Germany, Sascha Gönner, Psychosomatic Clinic of Bad Dürkheim, Germany
In recent research on obsessive-compulsive disorder (OCD), there has been a renewed interest in incompleteness feelings and "not just right experiences"
(Coles et al., 2003, 2005) with an inability to achieve "closure" concerning actions/perceptions and a compensatory urge to generate "just right" feelings.
Clinical observation suggests that incompleteness feelings are more prevalent in patients with certain symptom subtypes (Summerfeldt, 2004), but also that
the same symptom can be motivated by harm avoidance (washing to decontaminate) or incompleteness (washing to feel "just right") (Calamari et al., 2004).
In our study, we tested hypotheses a) concerning differences between OCD symptom dimensions in the degree of association with incompleteness feelings
and b) concerning the degree of motivational homogeneity/heterogeneity of specific OCD symptom dimensions (are they predominantly related to harm
avoidance or incompleteness or significantly related to both harm avoidance and incompleteness?). So far, 98 patients with OCD were diagnosed according
to ICD-10 criteria by experienced behaviour therapists via an interview that utilized the International Diagnostic Checklists. In July 2007, we will be able to
present results based on a sample of at least 150 OCD patients. Incompleteness and Harm Avoidance were measured by the corresponding subscales of
the bidimensional Obsessive-Compulsive Trait Core Dimensions Questionnaire (OC-TCDQ; Summerfeldt et al., 2001; authorized German translation).
Scores on OCD symptom dimensions were obtained using the following instruments (authorized German translations): Yale-Brown Obsessive-Compulsive
Scale (Y-BOCS, self-report version), Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002), Padua Inventory-Revised (PI-R; van Oppen et al.,
1995), Vancouver Obsessive Compulsive Inventory (VOCI; Thordarson et al., 2004), Symmetry, Ordering and Arranging Questionnaire (SOAQ; Radomsky &
Rachman, 2004). As monosymptomatic OCD is rare, patients were not categorized into mutually exclusive subgroups, but correlations between OCD
symptom dimensions were examined. Preliminary results (based on n=98) confirm our hypotheses a) that checking and ordering are more closely
associated with incompleteness than washing/cleaning and obsessional thoughts and b) that ordering (almost exclusively associated with incompleteness)
and obsessional thoughts (predominantly associated with harm avoidance) are relatively homogeneous symptom dimensions, whereas washing/cleaning,
checking and rumination tend to be related to both incompleteness and harm avoidance (high motivational heterogeneity). Hoarding (no specific prediction)
seems to be clearly related to incompleteness, but not to harm avoidance. Recently, it has been emphasized that OCD is a highly heterogeneous condition
(McKay et al., 2004). Our results suggest that - in line with the model of Summerfeldt (2004; Summerfeldt et al., 2004) - incompleteness and harm
avoidance may be "core dimensions" contributing to a better understanding of this heterogeneity. They clearly demonstrate that some symptom dimensions
are more closely linked to incompleteness or harm avoidance than others, but also that there is motivational heterogeneity even within symptom dimensions.
As a substantial subgroup of OCD patients perform rituals in order to reduce incompleteness feelings and "not just right experiences", a conceptualization of
OCD as an anxiety disorder is too narrow, and innovative treatment approaches for this subgroup are needed. - PS: The paper is suitable for a symposium
on 'cognition and emotion in OCD', 'OCD heterogeneity' or related topics.
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Worry in Generalised Anxiety Disorder: Avoidance of more distressing cognitions?
Lexine Stapinski, Macquarie University, Maree Abbott, Sydney University, Macquarie University, Ronald Rapee, Macquarie University, Australia
Generalized Anxiety Disorder (GAD) is characterised by excessive and uncontrollable worry that causes marked interference to the person's daily routine,
and social and occupational functioning. Borkovec and colleagues have proposed that although worry is unpleasant, the worry process may be negatively
reinforcing for high worriers, because it allows for cognitive avoidance of more distressing thoughts and affect (Borkovec & Hu, 1990; Borkovec, Ray &
Stober, 1998). According to Borkovec's cognitive avoidance model of GAD, the verbal-linguistic nature of worry limits access to parallel-processed threat
imagery. As a consequence, aversive imagery and associated physiological arousal is avoided, and thus worry is negatively reinforced. However, in the long
term, this suppression of imaginal processing and associated affect prevents activation and modification of the fear network, thus maintaining threat
associations and perpetuating anxiety. Data from a number of empirical studies have supported the hypothesis that the worry process suppresses
physiological responding (Borkovec & Hu, 1990; Borkovec, Lyonfields, Wiser & Diehl, 1993), however, other studies have produced inconsistent results
(Hazlett-Stevens & Borkovec, 2001; Peasley-Miklus & Vrana; 2000). The hypothesis that worry prolongs threat associations and perpetuates anxiety is yet to
be examined empirically. The present study employed a within-subjects repeated measures design to examine the impact of worry on physiological
responding, and the maintenance of threat appraisal and anxiety. Sixty treatment-seeking participants diagnosed with GAD were exposed to an anxiety
induction, and randomly allocated to either worry, relax or imaginally process the threat content. Participants' physiological responding was monitored, and
threat appraisal, anxiety and worry were evaluated immediately, and over the subsequent week. This design allowed for investigation of the hypothesis that
worry functions as a cognitive avoidance mechanism that suppresses physiological responding in the short term, but consequently maintains anxiety and
threat associations over time. Results will be presented discussed in terms of current models of GAD.
Intolerance of Uncertainty, Emotional Reasoning And their Relation to the Appraisal of Uncertain Situations
Naomi Koerner, Psychology Department, Concordia University, Michel J. Dugas, Psychology Department, Concordia University, Canada
Studies have demonstrated a consistent association between intolerance of uncertainty, a putative cognitive vulnerability for excessive worry and
generalized anxiety disorder (GAD), and the increased tendency to appraise ambiguous events as unpleasant and disconcerting (Dugas et al., 2005;
Koerner & Dugas, in press). The cognitive processes that may give rise to these appraisals are not entirely known. This study examined how individuals use
anxious affect in the processing of uncertain events to ascertain whether emotional reasoning can serve as an explanatory factor for the negative appraisals
observed in individuals who are disposed to worry excessively. It was predicted (1) that both individuals low on intolerance of uncertainty and high on
intolerance of uncertainty would appraise low threat situations containing anxious cues as more threatening, unsafe, uncontrollable, anxiety-provoking, and
likely to result in a negative outcome than identical situations not containing affective information; (2) that the inflating effect of anxious cues on appraisals of
low threat situations would be significantly more pronounced in individuals high on intolerance of uncertainty than in individuals low on intolerance of
uncertainty; and (3) that the presence of anxious cues in high threat situations would lead to significant inflations of negative appraisals in individuals high on
intolerance of uncertainty only. Individuals low (n=37) and high (n=39) on intolerance of uncertainty (Buhr & Dugas, 2002; Freeston et al., 1994) completed
an emotional reasoning task (Engelhard et al. 2002) which was used to examine the influence of affective cues on five types of appraisals. Participants
completed process and symptom measures. In the overall sample, participants who scored higher on measures of depressive and anxious symptoms, GAD
symptoms, habitual cognitive avoidance, and fear of anxious arousal were more inclined to make appraisals that were more negative. These variables were
entered as covariates in subsequent analyses. Irrespective of level of intolerance of uncertainty, participants appraised low threat situations more negatively
when they were paired with anxious cues. The inflating effect of anxious cues was more pronounced for individuals high on intolerance of uncertainty for a
subset of the appraisals. With respect to high threat situations, the presence of anxious cues significantly inflated negative appraisals in individuals high on
intolerance of uncertainty; however, this effect was not found in individuals low on intolerance of uncertainty. Under low threat conditions, when there are no
objective features to process, affective cues may serve to “prime” individuals to the possibility of danger. This appears to be the case for individuals low or
high on intolerance of uncertainty. However, in ambiguous situations containing contextual cues, anxious cues may inflate threat-related appraisals in
individuals high on intolerance of uncertainty. The prioritization of affective information might lead to disturbances in adaptive information processing and
coping, and to the perpetuation of worry and anxiety in individuals who are at risk for developing excessive worry by virtue of having a high level of
intolerance of uncertainty.
Automatic thoughts and meta-cognitions as predictors of psychiatric symptoms: A prospective study
Odin Hjemdal, Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway, Tore C. Stiles, Department of
Psychology, Norwegian University of Science and Technology, Trondheim, Norway
The purpose of this prospective study was to explore the Automatic Thought Questionnaire (ATQ) and Meta-Cognitive Questionnaire (MCQ-30) as predictors
for developing psychiatric symptoms. A healthy sample (N = 201) completed the ATQ, MCQ-30, and the Hopkins Symptom Checklist-25 (HSCL-25) twice
with a three month interval. The HSCL-25 measures both depressive and anxiety symptoms. Multiple hierarchical regressional analyses indicated that the
ATQ and MCQ-30 both predict the total level of HSCL-25 post, when controlling for gender, age and prelevels of psychiatric symptoms (HSCL-25 pre). The
MCQ-30 does however explain a unique part of the variance of psychiatric symptoms (HSCL-25 total score). For depressive symptoms the ATQ predicts
unique variance, while for anxiety symptoms the MCQ-30 predicts unique variance. The findings suggest that both ATQ and MCQ-30 are significant predictor
of psychiatric symptoms but have different predictive ability. ATQ predicts the development of depressive symptoms, while MCQ-30 predicts anxiety.
The causal role of metacognitions in the development of anxiety and depression: A prospective study
Adviye Esin Yilmaz, Department of Psychology, Abant Izzet Baysal University, Bolu, Turkey, Tülin Gençöz, Department of Psychology, Middle East
Technical University, Ankara, Turkey, Adrian Wells, Department of Clinical Psychology, University of Manchester, Manchester, UK
According to the metacognitive theory of psychological disorder (Wells, 2000; Wells & Matthews, 1994), metacognitions are vulnerability factors in predicting
the development of psychological disorder. Since evidence from cross-sectional designs prevents causal interpretations, a prospective test is necessary to
draw firmer conclusions regarding the role of metacognitive factors in the etiology of psychopathology. The present study investigated metacognitive factors
in a two-time measurement design testing the causal role of metacognitions in the development of anxiety and depression symptoms. It was hypothesized
that metacognitive beliefs measured at time 1 would prospectively predict symptoms of anxiety and depression at time 2, when the symptom level at time 1
and the stressful life events between time 1 and time 2 were controlled. Participants were 172 students and adults recruited in Ankara and Bolu, Turkey.
They completed questionnaires twice, six months apart. The questionnaires were the Meta-Cognitions Questionnaire-30 (MCQ-30), Beck Anxiety Inventory
(BAI), Beck Depression Inventory (BDI), and Life Experiences Survey (LES). To test the hypothesis, two separate hierarchical regression analyses were
conducted. In these analyses, time 2 depression, or anxiety was regressed on MCQ-30 subscales using forward entry after controlling for baseline symptom
levels and negative effect of life events. Results revealed that negative metacognitive beliefs about the uncontrollability and danger of worry significantly
predicted residual change in both the BAI and BDI after controlling for the effect of stressful events. The results support the metacognitive theory of
*This work has been supported by the Scientific and Technological Research Council of Turkey (TUBITAK), in the framework of the 2214-Abroad Research
Grant Program.
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Behavioural Medicine
Invited Addresses
CBT in Behavioural Medicine in the 21st Century
Neil Schneiderman, University of Miami, USA
There is substantial evidence that cognitive/behavioral/psychosocial interventions are efficacious in alleviating distress and improving quality of life in medical
populations. These have included pain patients as well as patients medically treated for such disorders as Cancer, HIV/AIDS and Cardiovascular Disease
(CVD). The evidence is also strong that behavioural (lifestyle) intervention can decrease the dangers of Type 2 diabetes and CVD in high-risk individuals.
Evidence also indicates that behavioural/psychosocial interventions can help prevent HIV infection, that adherence training based upon learning principles can
help manage HIV/AIDS, and that cognitive-behavioral stress management (CBSM) may provide benefits to HIV/AIDS patients in addition to those provided by
adherence training. The effects of cognitive-behavioural and other psychosocial interventions on morbidity and mortality in post-myocardial infarction patients
are more equivocal and require further study in clinical trials. As an experimental intervention cognitive-behavioral treatment can also help to explore the
biological and cognitive-affective mechanisms by which changes in behaviour and cognitions influence quality of life and disease processes.
Insomnia: Bridging the Gaps Between Research Evidence and Clinical Practice
Charles Morin, Laval University, Canada
Insomnia is a prevalent public health problem which carries significant burden for the individual (e.g., reduced quality of life, increased risks of depression) and
society (e.g., reduced productivity and higher health-care costs). There is increasing evidence that psychological (cognitive-behavioral) approaches are
effective and produce durable benefits in the treatment of primary and comorbid insomnia. This lecture will highlight important gaps between research evidence
and current clinical practices, and propose some solutions to bridge these research-practice gaps. For instance, despite its high prevalence and significant
burden, insomnia often remains untreated, and even with the increasing evidence-based regarding its efficacy, cognitive-behavior therapy remains underutilized in the management of insomnia in clinical practice. Some elements of solutions include the design and validation of more cost-effective treatment
implementation models, more efficient dissemination of validated therapies to potential users (patients and clinicians), and better incentives to ensure that these
therapies are used in various clinical settings.
Symposium 71
Using cognitive behaviour therapy self-help: what works in practice?
Convenor: Catherine Sykes, City University London, UK
CBT for heart failure patients. A case study
Catherine Sykes and Kirat Virdis, City University London, UK
There is plenty of evidence to suggest psychological therapy helps coronary heart disease patients during Cardiac Rehabilitation (CR) to change their
lifestyle and coping mechanisms. Heart failure patients face several issues such as heart failure related depression and anxiety, urgency about life planning,
sleep disturbances, lifestyle adjustments - (smoking, diet, exercise), adherence to medication and accepting the heart failure diagnosis. Currently there is not
sufficient evidence on the effectiveness of psychological therapy for heart failure patients, research has concentrated on the effectiveness of psychological
therapy for patients who have had coronary artery by-pass graft (CABG) and angioplasties. Heart failure patients face similar lifestyle change challenges as
CABG and angioplasty patients however they face these challenges with a less optimistic prognosis. This paper presents a brief three session CBT
intervention for heart failure patients and the treatment of a 65 year old man. Six month follow up data are presented which show some improvement of the
patient's coping skills and emotional heart failure quality of life issues. The patient also self-reported better sleeping at 6 months. The patient was still
depressed at 6 months and had made no change in his behavioural disengagement coping style. The session evaluation shows that when the patient
reported being more able to control their thoughts during the week before the session the patient was more able to use more positive coping strategies.
Psycho-education in phase III cardiac rehabilitation
Esther Murray and Catherine Sykes, City University London, UK
Depression and anxiety are common in patients with coronary heart disease (CHD) and psychological problems can be a barrier to recovery and to making
necessary lifestyle changes. Not all CHD patients in South East London receive psychological support (Marks & Filer 2005). Reviews of psycho-educational
programmes in cardiac rehabilitation (Dusseldorp 1999 and Bennett & Carroll 1994) have found that group interventions can be effective in reducing
emotional distress, targeting risk factors and increasing active coping. Cognitive behavioural techniques such as goal setting and evidence checking have
been found to be effective when working with CHD patients (Lewin 2002).
A psycho-education session based on cognitive behavioural techniques was delivered to CHD patients as part of their usual cardiac rehabilitation
programme. Two types of session were compared: didactic and individualised. All patients received a written handout summarising the session. Patients
were randomly allocated to the individualised or didactic group. Outcomes were measured with HADS, Dartmouth COOP and a behavioural questionnaire
pre and post session. A total of 93 patients completed both sets of questionnaires. Control data came from patients who had attended rehab before the
intervention was begun. The results showed high levels of patient satisfaction with the intervention. Anxiety and depression were reduced, health related
quality of life improved and behavioural changes made in both intervention groups though these results are not statistically significant.
This project highlights the complexities of carrying out research with limited resources in the setting of the NHS.
Evaluation of a group CBT breathlessness clinic for severe chronic obstructive pulmonary disease patients.
Claire Howard, City University London, UK
This study evaluated a 4-week breathlessness clinic for severe Chronic Obstructive Pulmonary Disease (COPD) patients. The intervention was delivered in
a group setting by a multidisciplinary team, using a cognitive-behavioural framework, based on Clark's (1986) cognitive-behavioural model of panic.
Methods: The non-pharmacological intervention included addressing anxiety and panic attacks, education, planning and pacing activities, relaxation,
breathing retraining and goal-setting. The St. George's Respiratory Questionnaire (SGRQ) and Hospital Anxiety and Depression Scale (HADS) were
administered 6 weeks before the clinic, at the start and end of the clinic and at 6 weeks follow up. In addition, hospital admissions were recorded 6 months
before and 6 months after the clinic and this data was compared with a waiting list control group.Results: There was a significant improvement in health
status and disease impact as well as a reduction in anxiety and depression following the intervention. These improvements were sustained at 6 weeks
follow up. Furthermore, COPD patients in the control group were twice as likely to attend A&E and have twice as many bed days compared to the
intervention group.Conclusions: This intervention can help improve the quality of lives of those suffering from breathlessness as well as reduce hospital
admissions and has the potential to be offered to other disease groups. Applying a cognitive-behavioural approach within a health psychology context
appears beneficial.
Cognitive Behavioral Group Therapy for Smoking and the Pharmaceutical Competition
David F Marks, City University London, UK
Cognitive behavior therapy is of proven efficacy in the treatment of smoking. In spite of the strong evidence base the treatment is rarely offered to smokers
in the UK National Health Service (NHS). The Department of Health guidelines support CBT for conditions such as depressive disorders, panic disorder,
agoraphobia, generalised anxiety disorder, post-traumatic stress disorder, bulimia, and chronic fatigue. However, for treating smoking, the National Health
Service (NHS) adopted and recently extended a pharmacological approach, nicotine replacement therapy (NRT). Reviewers have generally concluded that
NRT is most effective when combined with intensive behavioural support. Yet even this combined approach has not been made available to patients. Fears
for the safety of NRT and doubts concerning its effectiveness require that a review of the current NHS services for smokers is urgently necessary. No
randomized controlled trials have been carried out on the effectiveness of NHS smoking cessation services. The principal evaluation work has consisted of
an observational study which showed that quitters using NRT had a 10.3% reduced chance of a successful outcome at one year compared to non-NRT
users. RCTs carried out with cognitive behaviour therapy have found one-year CO-validated abstinence rates 2-3 times higher than rates observed in the
NRT-based services. An entrenched bias towards the medical model and pharmaceuticals even among some psychologists remains a significant obstacle to
the evidence-based adoption of CBT to give patients the best chances of quitting. Many thousands of painful yet preventable deaths caused by smoking are
the inevitable consequence.
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Symposium 86
Advances in clinical interventions for sleep disturbance: Recent findings across disorders
Convenor: Allison Harvey, University of California, Berkeley, USA
Treatment of chronic insomnia with cognitive behavioral therapy vs zopiclone
Børge Sivertsen (1) Siri Omvik (1) Ståle Pallesen (2) and Inger Hilde Nordhus (1), (1) University of Bergen, Norway; (2) University of Bergen,
Insomnia is a common condition in older adults and is associated with several adverse medical, social, and psychological consequences. Previous research
has suggested beneficial outcomes of both psychological and pharmacological treatments, but blinded placebo-controlled trials comparing the effects are
lacking. The objective of the present study was to examine the clinical efficacy of cognitive behavioral therapy (CBT) and pharmacological treatment in older
adults suffering from chronic primary insomnia.Methods: 46 adults (mean age, 60.8) with chronic primary insomnia were randomized into CBT, sleep
medication, or placebo medication. All treatments lasted 6 weeks, and the 2 active treatments were followed up after 6 months. Treatment outcomes were
assessed using ambulant clinical polysomnography and sleep diaries.Results: CBT resulted in improved short- and long-term outcomes compared with
zopiclone, and for most outcomes, zopiclone did not differ from placebo. Patients receiving CBT improved their sleep efficiency from 81.4% to 90.1% at 6month follow-up compared with a decrease from 82.3% to 81.9% in the zopiclone group. CBT recipients also spent more time in slow-wave sleep (stages 3
and 4) compared with those in other groups, and spent less time awake during the night. Total sleep time was similar in all 3 groups; at 6 months, patients
receiving CBT had better sleep efficiency using polysomnography than those taking zopiclone.Conclusion: These results suggest that interventions based on
CBT are superior to zopiclone treatment both in short- and long-term management of insomnia in older adults.
Should we Combine Medication with Cognitive-Behavior Therapy when Treating Chronic Insomnia ?
Morin CM, Vallières A, Guay B, Guay C, Savard J, Mérette C, Bastien C, Baillargeon L, Grégoire JP., Université Laval, Québec, Canada
Combining medication with CBT should theoretically optimize outcome by capitalizing on the more rapid effects of medication and the more sustained
benefits of CBT. It is unclear, however, whether a combined intervention has an additive effect on outcome. This study evaluated the short-term effects of
CBT, alone and combined with medication, and examined different maintenance strategies on long-term outcomes. Methods. 160 adults (61% women; mean
age of 50.3) with chronic insomnia were randomized to CBT alone or CBT plus nightly zolpidem for an initial 6-week treatment trial. They were then
randomized for an extended 6-month treatment. Patients treated with CBT alone initially continued with individualized CBT or no additional treatment; those
who received combined treatment initially continued with extended CBT plus intermittent medication or CBT without additional medication.Results. CBT was
equally effective when used alone or combined with medication for improving sleep continuity during the initial phase of therapy. The addition of
individualized CBT during the 6-month maintenance phase did not enhance outcome relative to no additional treatment. However, the proportion of
treatment responders was higher among those receiving maintenance CBT compared to those not receiving it. Patients treated with combined therapy
initially did better during maintenance therapy when medication was tapered relative to intermittent usage. Conclusions. The findings suggest that combined
CBT and medication does not always produce an additive effect. Even if combined therapy may provide an initial advantage on some sleep variables, it is
best to discontinue medication after a short-term trial in order to enhance long-term outcome.
Efficacy of internet based multi-component CBT treatment of insomnia
Winni F. Hofman1, Anand Kumar2, 1University of Amsterdam, the Netherlands; 2 Personal Health Institute international, Amsterdam, the
Cognitive Behavioral Therapy has been recognized as an effective treatment of chronic insomnia. A knowledge-based system to give CBT for insomnia via
internet was developed. This system offers computer supported personalization and cost-effective delivery of CBT via internet and contributes to the solution
of the problem of the tremendous lack of capacity for treatment. The website provides information on sleep and evaluates the sleep profile and sleepdisorder symptoms for all visitors. Patients who sign up for treatment complete a detailed sleep interview and a questionnaire to assess faulty beliefs and
attitudes. They also keep a diary of sleep wake schedule and subjective perception of sleep. After each week the sleep diary is analyzed and a personalized
treatment is provided, supported by a knowledge-based system with comprehensive rules. 19935 individuals visited the website and completed a short self
test for the first sleep assessment. This paper reports data on self reported improvement by 50 insomniacs who were treated. The effectiveness of the
internet-CBT was assessed every week by self-reported sleep quality and feeling in the morning on VAS, nap duration during the day, sleep latency, number
of awakenings and minutes awake during sleep.After eight sessions, the patients showed a significant improvement on all variables except daytime nap
duration (p<0.04, Mann-Whitney U).This study shows that a knowledge based approach for CBT is instrumental in supporting the therapist for systematic
individualization of the treatment. At the same time it increases efficiency and quality by using comprehensive rules and quantitative data.
Insomnia and Depression
Michael L. Perlis, University of Rochester Medical Center, USA
Over the course of the last 30 years there has been a great deal of research into sleep abnormalities in patients with Major Depression. Only a small
proportion of this work, however,has focused on sleep continuity disturbance (as opposed to abnormalities in sleep micro- and macro-architecture). This is
surprising given that insomnia is a defining feature of depression.The lack of work in this area may be attributed to the view that insomnia is nothing more
than a symptom of depression. In recent years this perception has shifted to the alternative point of view that insomnia is less a symptom and more a
comorbid disorder. This talk provides an overview of the data that suggests that:1) insomnia and depression are separable entities 2) insomnia is a risk for
greater depressive morbidity; and 3) targeted treatment for insomnia may influence the clinical course of major depression.
Is there a bi-directional association between insomnia and mood in adults with bipolar disorder?
Allison G. Harvey, Lisa S. Talbot, Ilana S. Hairston, June L. Gruber & Polina Eidelman, University of California, Berkeley, USA
Several lines of evidence suggest that disturbed sleep is an important risk factor for, or prodrome of, mood disorders. Such relationships have been
inadequately explored in most mood disorders, but particularly in bipolar disorder. The results of three studies will be summarized. In the first study, we
investigated sleep-related functioning in euthymic bipolar patients. Bipolar (n=20), insomnia (n=20) and good sleeper (n=20) groups were compared on
interviews, questionnaires, and over eight consecutive days and nights of sleep diary keeping (subjective sleep estimate) and actigraphy (objective sleep
estimate). Seventy percent of the euthymic bipolar group exhibited a clinically significant sleep disturbance. The bipolar group exhibited impaired sleep
efficiency, increased anxiety and fear of poor sleep, lower daytime activity levels, and a tendency to misperceive sleep. The bipolar group held a level of
dysfunctional beliefs about sleep that was comparable to the insomnia group and significantly higher than the good sleepers. In the second study, which is
currently in progress, we are testing the hypothesis that mood regulation difficulty causally contributes to sleep disturbance. Participants include individuals
with bipolar disorder (n=20), insomnia (n=20) and good sleepers (n=20). Participants sleep in the lab on three nights, spaced approximately one week apart.
Prior to sleep, participants are administered a negative, positive or neutral mood induction (order counterbalanced). The prediction tested is that patients
with bipolar disorder, relative to patients with insomnia and good sleepers, will have more difficulty regulating their mood following both the negative and
positive mood inductions and that this will adversely affect their subsequent sleep. In the third study we are piloting the application of CBT for insomnia for
patients with bipolar disorder. The hypothesis is that a Sleep Intervention for patients with bipolar disorder suffering from sleep disturbance will: (a) improve
sleep, (b) improve inter-episode quality of life and (c) improve emotional functioning.
Are we pushing the right buttons? Recommendations for cognitive behaviour therapy in patients with chronic
somatic complaints.
Convenor: Stefaan Van Damme, Ghent University, Belgium, Belgium
Benefits of flexible goal adjustment in patients with chronic somatic complaints
Stefaan Van Damme, Herlinde Logie, & Geert Crombez, Ghent University, Belgium
When suffering from somatic complaints, active control and problem-solving are without doubt the best ways to initially cope with the symptoms. However,
we will argue from a theoretical perspective that persisting attempts to control symptoms and disability are not always the best approach in treating patients
suffering from chronic somatic complaints. In most patients with chronic pain and chronic fatigue syndrome, no medical solution is available for the problem.
When patients keep searching for a solution and keep attempting to control their symptoms, this may have negative effects in the long-term. It becomes
problematic when these coping efforts dominate the life of the patient and interfere with other important aspects of life such as work, recreation, and social
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contacts. All energy and resources are allocated to the goal of control, and unsuccessful attempts to obtain this goal may result in frustration and
depression, having a negative impact upon quality of life. Available research in line with these ideas will be shortly reviewed. Finally, new data collected in a
large sample of patients with chronic fatigue syndrome (N = 309) will be presented. It is demonstrated that giving up attempts to control symptoms, and
accepting their chronic nature leads to better adjustment and well-being, even when controlling for fatigue severity, attribution style, and self-efficacy. It is
concluded that CBT in many patients may benefit from a more explicit and systematic use of acceptance-based strategies.
"Do-be-do-be-do" - The importance of action in maintaining identity
Stephen Morley, University of Leeds, UK
Identity is emerging as an important topic and as possible focus for intervention in chronic pain (and other chronic conditions). This presentation suggests
that the impact of pain on identity can be construed in terms of a self-regulation model of goal attainment (after Carver and Scheier). This model captures
multiple goal directed activity, including both approach and avoidance motivated goals, and the hierarchical relationship between 'being' (high level goals)
and 'doing' (lower level goals). I suggest that the impact of pain is primarily at the 'doing' level. This has implications for the regulation of meaning via actionidentification and potentially blocking access to 'being' levels of the hierarchy. Self-pain enmeshment is described within the context of this general model of
self regulation. The model implies that goal referenced action-based strategies are crucial for maintaining and developing identity and emotional adjustment
in the presence of continuing pain.
Task performance in chronic pain: fear, avoidance and beyond
Johan W.S. Vlaeyen, Petra Karsdorp, Stephen Morley, Universities of Leuven, Belgium, and Maastricht, Netherlands
The Fear-Avoidance (FA) model has become influential as a valid explanation for the transition from acute pain to chronic pain disability in patients with
musculoskeletal pain in particular. The FA model predicts that catastrophic (mis)interpretations of pain are the source of increased fear of pain and
associated safety behaviours, including avoidance behaviours and hypervigilance. Although there is accumulating research evidence supporting the FA
model in various chronic pain syndromes, there are also unresolved issues that merit further scientific attention. First, it is difficult to apply the model to
musculoskeletal pain syndromes associated with task persistence and overuse, rather than to avoidance and disuse. Second, there are several anomalous
findings in the current literature that cannot be explained by the FA model. For example in a number of studies, persistence, rather than avoidance, is
observed in patients with increased negative mood. These intriguing findings suggest that pathways to disability other that that described in the FA may
exist. This contribution will focus on alternative models that account for both task persistence and task avoidance, provide an explanation for inconsistencies
within the FA model, and that build on existing and empirically supported knowledge from the study of normal psychological processes.
Treatment of Chronic Fatigue Syndrome: The devil is in the detail
Trudie Chalder, King's College London, UK
The chronic fatigue syndrome (CFS) is a condition characterised by chronic disabling fatigue and other symptoms, which are not better explained by an
alternative diagnosis. As many as half the patients with CFS/ME are unemployed, and they have 10 times the amount of sick-leave of other general medical
outpatients. The prognosis is poor: in primary care only a third improve by one year, and of those referred to secondary care less than 10% return to premorbid functioning. The management of patients with CFS/ME currently consumes significant resources in both primary and secondary care. There is now
some evidence that specific treatments can improve these poor outcomes. Although two independent systematic reviews have found that cognitive
behaviour therapy (CBT) and graded exercise therapy (GET) were the most promising treatments for CFS/ME in secondary care long term outcome studies
are lacking. The aim of this lecture is to review the evidence for CBT and GET and to examine how effective the treatment actually is and for how long. A
number of specific questions will be addressed. For example “Do symptoms and disability improve differentially?”; “Are gains maintained long term?”; “Is
complete recovery possible?”; and “Why do symptoms persist and is it possible to address factors which interfere with change
Screening for tailored cognitive-behavioral treatment in fibromyalgia
Andrea W.M. Evers, Saskia van Koulil, Wim van Lankveld, & Floris W. Kraaimaat, Radboud University Nijmegen Medical Centre, Netherlands
To screen for tailored cognitive-behavioral treatment in fibromyalgia (FM), the validity of a screening instrument on self-reported pain avoidance behavior
was examined to discriminate between fibromyalgia (FM) patients with pain-persistence and pain-avoidance patterns. In a three-part study, a self-reported
screening instrument that assesses the level of pain-avoidance behavior was used to screen FM patients. The resultant groups with pain-persistence and
pain-avoidance patterns were compared with regard to several pain-related cognitive-behavioral factors for 359 patients (Study 1), performance on a
physical fitness test in a sample of 112 patients (Study 2) and with the judgments of trained therapists (blind to the patient patterns) based on a semistructured interview for 77 patients (Study 3). Results indicated that patients with pain-persistence and pain-avoidance patterns, characterized by low and
high degrees of pain-avoidance behavior respectively, differed on several pain-related cognitive-behavioral factors, including fear of pain, heightened
attention for pain (hypervigilance) and worrying about pain. Discriminant analyses showed that a high level of pain-avoidance behavior was best
discriminated by more pain-related retreating, less persistence statements and more social reinforcement. The physical fitness test also showed patients
with high pain-avoidance behavior to have a poorer physical condition. Finally, the results of the screening instrument demonstrated relatively high
correspondence with the therapists' interview-based judgments. These findings suggest that the screening instrument can be used to distinguish between
pain-persistence and pain-avoidance patterns within the heterogeneous population of FM patients, which offers promising possibilities to improve treatment
efficacy by tailoring treatment to specific patient patterns.
Symposium 114
Cognitive and behavioral interventions for family caregivers of stroke and dementia patients
Convenor: Gabriele Wilz, Technical University of Berlin, Germany
Tailoring interventions for ethnically and culturally diverse dementia family caregivers
Dolores Gallagher-Thompson, Stanford University, USA
The increasingly diverse population of older adults in the United States affects the health care system's provision of care on all levels, with dementia care
being prominent. In our laboratory for the past decade we have focused on tailoring interventions to meet the needs of diverse caregivers, using a
"stress/process coping" model, and incorporating theories and techniques from cognitive/behavioral therapy into the interventions. Our work has shown that
this kind of approach leads to significant improvement in psychological distress, along with adoption of more adaptive coping styles, in family caregivers who
are Euro-American in background, as well as those who classify themselves as Hispanic/Latino, Black/African American, and Chinese/Asian American. We
currently are working with adaptations for Farci-speaking Persian Americans, and for Japanese speaking Japanese Americans, with very good success.
Factors that repeatedly prove important in the "tailoring" process include: initially conducting focus groups with the population of interest, to gain
understanding of their needs and their preferred ways of coping; inclusion of individuals from that culture in the entire process; development of written and
other materials that are culturally appropriate for the age and education level of the group; and most importantly, incorporation of their own values and
beliefs into the intervention process. For example, in the various Hispanic/Latino communities, there tend to be strong religious affiliations and practices. In
this presentation we will present concrete examples of how theoretically sound and empirically supported interventions, can be tailored for use with many
ethnically, culturally, and linguistically diverse groups of caregivers.
Long term effects of a CBT based group program for spouses of stroke patients
Gabriele Wilz, Technical University of Berlin, GermanyDepartment of Clinical and Health Psychology
Following hospital discharge the majority of stroke survivors are cared for by relatives. In most cases, this results in long-term demands being placed on
primary caregivers which can have a negative impact on their health and quality of life.This study focuses on long term effects of a cognitive behavioural
group program for spouses of stroke patients. The program consists of 15 bi-monthly 1 1/2 hour sessions. The intervention is aimed at reducing the
prevalence of mental disorders and burnout among the care-giving spouses of stroke patients. The group program focuses on four main goals and is
approached using the following therapeutic strategies: Expressing emotions and social sharing; psycho-education combined with cognitive restructuring;
improving competence in active problem solving and encouraging healthy behaviour.The sample (stroke patients and their spouses) consisted of one
intervention group (n=38 couples) and two different control conditions (n=35 and n=51 couples). We used the following instruments to measure spouses'
mental health and quality of life: Beck's Anxiety Inventory, Beck's Depression Inventory, WHO Quality of Life Questionnaire. Measurements were taken
before the intervention (T1), directly following the intervention (T2) and six months after T2 (T3). Several regression analyses allowed for examination of
long-term effects of the intervention. The spouses' participation at the intervention program was significantly associated with long-term changes in their
quality of life and depression.
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CBT and Occupational Therapy: an interdisciplinary psychoeducational intervention for dementia caregivers
Losada, A.1, Márquez, M.2, Peñacoba, C.1, Gallagher-Thompson, D.3, Knight, B.G.4, Cigarán, M.1 & Moreno, R.1, 1 Universidad Rey Juan Carlos,
Spain; 2 Universidad Autónoma de Madrid, Spain; 3 Stanford Univ, USA; 4 University of Southern California, USA
Caring for dementia relatives generates important negative psychological and physical consequences for the caregivers, which clearly impact the way they
provide care. In this work, a multicomponent and interdisciplinary psychoeducational intervention for dementia family caregivers is described, and preliminary
results of its efficacy are presented. Baseline and post-intervention assessments are conducted, using measures of physical health, depression, and
dysfunctional thoughts. Treatment implementation data are also presented. In the first component of the intervention, caregivers are trained in cognitivebehavioral techniques (CBT) aimed at the modification of dysfunctional thoughts about caregiving, promoting self care, and increasing participation in
pleasurable activities. In the second component, caregivers are trained in occupational therapy techniques aimed at improving their ability to transfer their
care receiver, ergonomic factors in caregiving, and strategies to avoid excess disability. The principal aim of this intervention is to reduce caregivers´
negative psychological and physical distress, through the training of caregivers in skills and strategies which allow them to take a better care of themselves
and their relatives, thus helping them to cope better with their demanding role with higher preparation and security.
Starting problem solving with sorting cards - a diagnostic approach for family caregivers in chronic stroke care
Pfeiffer K, Beische D, Becker C, Heyl R, Lindemann B, Hautzinger M*, Robert-Bosch-Hospital, Stuttgart, Germany; *University of Tuebingen,
Defining and analysing the specific problem areas are fundamental steps for an effective problem-solving in caregiver counselling. To facilitate this crucial
process a specific set of cards has been developed in several steps using different sources. The final version consists of 40 cards, with each card displaying
one specific problem identified as important for family caregivers in chronic stroke care. Additional blank cards can be labelled as individually needed.After
selection of the relevant cards by the caregiver two methods of sorting are used. In a first step he or she has to rank the individual cards according to the
perceived burden. Second the caregiver is asked to build groups and to label and characterize them. This card sorting task helps caregivers to consider
issues that may be outside their immediate awareness and allows them to talk about problems that they may have been previously unwilling or unprepared
to discuss. In practice it has proven to be an effective and well accepted way to focus on relevant problem constellations and to convey to the caregiver a
first understanding of problem interaction. The development of the cards and their linkage to an intervention are presented with the data and experience
from an ongoing study. Future perspectives for different target groups are discussed.
Dementia-Care-Related Burden:A Comparison of Spouse and Adult-Child Caregivers in Shared and Separate Households
Tanja Kalytta & Gabriele Wilz, Technical University of Berlin, Germany
This research is part of a study that examines the effect of a cognitive-behavioral intervention program for family caregivers of persons with dementia. In this
paper we examine the role that the household arrangement has in explaining the levels of care-related stress and burden experienced by spouse and adultchild caregivers in shared and separate residences at baseline.The participants were 125 female caregivers of relatives with dementia. A controlled 6-month
follow-up study was conducted. The Beck Depression Inventory, the short version of the SF-36 Health Survey (SDF-12), the Hospital Anxiety and
Depression Scale German Version (HADS-D) and a German self-report questionnaire for the assessment of social support (F-SozU) were administered at
baseline and at follow-up intervals. We also used a self-conducted questionnaire that identifies the household arrangement, social demographic factors,
cognitive symptoms, behaviour problems and depressive symptoms in the patient. The caregivers were assigned to either a group receiving treatment or a
group receiving usual care (control group). Caregivers in the treatment group were provided with 20 sessions of a cognitive-behavioral group-intervention
program.Data from 130 spouse and adult-child caregivers at baseline were analyzed to identify differences in caregiver depression and body complaints
across these settings when the effects of elder cognitive impairment and caregiver age are controlled. Results show that spouse and adult children in shared
households experience similar levels of care-related strain. However, comparison of adult children in shared and separate households show differences in
burden. These findings have implications for the delivery of the intervention program.
Symposium 123
Gaining No Pain?: Cutting Edge Approaches to Chronic Pain and Disability
Convenor: Nicole Tang, Institute of Psychiatry, King's College London, UK, UK
Recent Findings from A Contextual Cognitive-Behavioral Approach to Chronic Pain and Suffering
Lance M. McCracken, Royal National Hospital for Rheumatic Diseases & University of Bath, UK
From a general cognitive-behavioral model, people with chronic pain suffer and function poorly from the presence and interactions of physical and emotional
experiences, thoughts and beliefs, and unhealthy behavior patterns. Unfortunately, the nature of the processes between the experiences of pain and the
suffering and behavior patterns of pain are not well understood, and treatment processes, likewise, are unclear. Developments from so-called “third
generation” cognitive-behavioral therapies attempt to address this. These include Acceptance and Commitment Therapy (ACT), Mindfulness-Based
Approaches (e.g., MBCT), and Contextual Cognitive-Behavioral Therapy (CCBT), for chronic pain. This presentation will describe the CCBT model and
review recent data from our Unit in the UK. For example, “psychological flexibility,” is the overarching treatment process from ACT and it includes
acceptance, mindfulness, values-based action, and cognitive defusion. Data from adults seeking treatment for chronic pain (N = 260) demonstrated that
when compared with traditional pain management strategies (such as relaxation, pacing, and positive self-talk), psychological flexibility is a stronger
predictor of patient functioning. Results from treatment effectiveness analyses (N = 171) showed that CCBT produces significant improvements in patient
health and functioning, mean post treatment effect size d=1.13, and changes in acceptance and value-based action accounted for significant variance in
patient improvements. Data from more than 20 studies build a case for an approach to chronic pain that includes processes from an ACT-based, contextual,
cognitive-behavioral model. The goals of this talk are to describe these processes and show how research in chronic pain is applying them.
Addressing sleep disturbance associated with chronic pain: A practical approach to reduce distress and improve functioning?
Nicole K. Y. Tang, Institute of Psychiatry, King's College London, UK
Sleep disturbance is perhaps one of the most prevalent complaints amongst patients with chronically painful conditions. Experimental studies of healthy
subjects and cross-sectional research in clinical populations have converged to suggest a reciprocal relationship between pain and sleep disturbance, such
that pain disturbs sleep continuity/quality and poor sleep further exacerbates pain. This presentation is structured into two parts: The first part will examine
the prevalence of 'clinical insomnia' in patients seeking treatment for chronic pain and review the psychological factors identified in the latest research to be
involved in the manifestation of insomnia in pain patients. Given the suggestion of a reciprocal relationship between pain and sleep and the growing
recognition of sleep as an important parameter determining quality of life, the second part of the presentation will consider the potential benefits of
addressing sleep disturbance in patients suffering from both pain and insomnia. Possible intervention strategies will also be discussed.
Regaining identity: self-pain enmeshment
Stephen Morley, University of Leeds, UK
Chronic pain has profound effects on individuals. This presentation distinguishes between 3 'I's: interruption, interference and identity. Interruption and
interference have traditionally been the focus of CBT interventions. Recently facets related to identity, briefly defined as the sense of who one is and what
one might become, have been identified as potential targets for treatment. This presentation outlines a framework describing the enmeshment of pain with
aspects of the self. Some evidence for the enmeshment model is presented and clinical-research tool for assessing self-pain enmeshment is described and
illustrated with case material. The tool is derived from methods used measure self-discrepancies and possible selves. The method is closely related to the
conceptualization of values based action.
Developing a specific model of chronic pain based on cognitive-behavioural approaches to health anxiety
Paul M. Salkovskis, Institute of Psychiatry, King's College London, UK
If people worried about their health primarily focus on symptoms of pain, they receive a diagnosis of Idiopathic Pain Disorder rather than “Hypochondriasis”.
This accident of definition means that the treatment of those pain patients with high levels of health anxiety has not developed in the way that one might
expect given advances in CBT. A specific model of chronic pain developed from cognitive behavioural approaches to health anxiety is outlined. Recent
research by our group based on this model indicates (a) that a high proportion of pain clinic patients suffer from clinical levels of health anxiety and (b) that it
is possible to identify common maintaining factors. Key features are catastrophising, specifically defined according to Beck's cognitive therapy approach, and
the closely related concept of safety seeking behaviour. Implications for treatment are considered; in particular, the possibility for boosting the effects of
“traditional” CBT/BT approaches to pain by adding other elements drawn from CBT for health anxiety and elsewhere.
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Symposium 139
Mindfulness & Health
Convenor: Dolores Foley, Macquarie University, NSW, Australia, Australia
The Effect of Mindfulness Training on Mood and Measures of Fatigue, Activity, and Quality of Life in Patients with Chronic
Fatigue Syndrome on a Hospital Waiting List: A Series of Exploratory Studies.
Surawy, C., Roberts, J. & Silver, A., John Radcliffe Hospital in Oxford & Oxfordshire and Bucks mental health care NHS trust, UK
The sudden and often puzzling onset of chronic fatigue syndrome (CFS) presents challenges to the sufferer in terms of identity, role in life and physical
functioning. A vicious circle of maintaining factors can arise in which the struggle to regain control over symptoms and activity levels leads to either bursts of
activity followed by excessive rest or a gradual avoidance of activity accompanied by decreasing levels of fitness, poor sleep and general body disregulation.
Frustration, low mood and anxiety can also be part of the picture.Mindfulness, a way of paying attention to current experience that is encouraged by the
practice of meditation, relates well to our understanding of the factors that maintain CFS. Participants in mindfulness classes learn to observe the thoughts,
emotions and physical sensations that arise without making judgements about their truth, importance or value, and without trying to escape, avoid or change
them.Christina Surawy has worked in a specialist service for CFS since 1998 and, together with colleagues, has developed a programme of mindfulness
based cognitive therapy for people with CFS over the past 5 years. The classes have proved popular, and participants have shown significant improvements
in levels of fatigue functioning and mood. In the presentation, the rationale for using this approach with CFS patients will be discussed as well as relevant
outcome data.
Mindfulness Based Cognitive Therapy for individuals whose lives have been affected by cancer: A randomised controlled trial.
Foley, D., Baillie, A., Huxter, M., Deveney, C. & Price, M., Macquarie University & NSW Cancer Institute, Australia
A diagnosis of cancer can have profound effects on psychological functioning. Research has indicated that patients and carers can experience comparable
levels of distress. This study evaluated the effectiveness of Mindfulness Based Cognitive Therapy (MBCT) for individuals with a diagnosis of cancer and
their carers. The diagnoses varied across cancer streams and stages. Eligible individuals were randomly allocated to immediate or delayed treatment
conditions. Treatment involved participation in 8 weekly 2 hour sessions that largely focused on mindfulness meditation and related discussion. Group
participants were also required practice mindfulness meditation daily between sessions. Participants were monitored at an initial assessment, 10 weeks
following this assessment (post/pre) and at 3 months post treatment. Outcome measures of depression, anxiety, rumination, pain, coping, optimism and
quality of life were collected. Results are based on 14 MBCT groups. Clinician rated and self-report data will be presented for the treatment verses waitlist
conditions. A discussion of implications for future research will follow.
The Breathworks Self-Management Mindfulness-Based Pain Management Programme: Measuring its Effectiveness using
Qualitative and Quantitative Research
Burch, V., Hennessey, G. & Fricker, S., Manchester Buddhist Centre, UK
The Breathworks Mindfulness-Based Pain Management Programme was developed for individuals experiencing a chronic health condition, often involving
persistent physical pain. The programme focuses on helping individuals learn to make choices about how they respond to their experience. Participants
engage in a 10 week course of 2.5 hrs per week, offered over two time periods. Qualitative and quantitative outcome data that has been collected over the
last 5 years will be presented. These results give evidence of clinically significant change in health status across all scales used - i.e. Pain Questionnaire
(Pain Scale), PSEQ, BDI, CSQ, SF-36, WHO Well Being Questionnaire - following participation in the Breathworks Programme. A discussion of the
implications of these findings will follow.
Mindfulness-based stress reduction program as an intervention in patients with fibromyalgia - A three-armed randomized
clinical trial
Schmidt, S., Grossman, P., Jena, S., Schwarzer, B., Naumann, J. & Walach, H., University Medical Centre, Freiburg, Germany
Mindfulness-based stress reduction (MBSR), an eight-week group program, has been shown to produce health benefits in a number of pilot studies,
uncontrolled observational studies, and randomized investigations of chronic pain disorders. Fibromyalgia is a clinical syndrome with chronic pain, fatigue,
and sleep disorders as major symptoms. The effectiveness of MBSR on fibromyalgia patients was investigated in a three-arm randomized controlled trial.
Because fibromyalgia is almost exclusively a female disorder, only women were studied. 168 female patients were randomized either to (i) a wait list (ii) an
active control intervention to account for nonspecific effects of treatment or (iii) MBSR. Evaluation was according to intention-to-treat. 137 (81.5 %) patients
completed the study per protocol. The main outcome criteria is self-reported general quality of life at 4-month post-treatment. In addition, a Biobehavioral
Fibromyalgia Index composed of a variety of psychophysiological and behavioral variables will be computed. This index will be generated from data
gathered via an ambulatory psychophysiological monitoring system, which comprises parameters of mobility, sleep quality, and cardiovascular well-being.
Primary and secondary outcome variables (e.g. fibromyalgia-specific quality of life, depression score, pain, anxiety, mindfulness, compliance, and number of
tender points) were assessed at beginning and end of the training, as well as at 4- and 12-month post-treatment. Patients had an average age of 54 years.
31.5 % completed the German equivalent of the A-level (13 years in school). Baseline characteristics were similar among groups. Patients improved from
pre-treatment to 4 months post-treatment on the primary outcome (p=.006), and secondary analyses suggested individual treatment effects of specific
dimensions of well being.
Symposium 158
Tailored Cognitive Behavioural Therapy for Somatic Illnesses
Convenor: Floor Bennebroek Everts Claudi Bockting, University of Amsterdam, the Netherlands,
Inflammatory Bowel Disease: Cognitive Behaviour Therapy in the Light of Medical and Psychological characteristics.
B. Wijnberg-Williams; F. Albersnagel; G.Dijkstra, University Medical Center Groningen, The Netherlands
A review of the state of the art in behavioural-scientific research on inflammatory bowel disease (IBD) will be presented. After a short introduction on
medical aspects of the two diseases that constitute IBD, I.e. Crohn's disease and ulcerative colitis, the factors that may influence the quality of life of IBD
patients are outlined: disease activity, quality of care, state of mind, personality, life events and circumstances, as well as social support. In addition,
interventions aimed at assisting IBD patients to deal with their 'concerns' are described, within the realm of (controlled) research literature. The following
topics will be discussed: stress, anxiety, depression, coping and communication; fatigue; smoking cessation and (non-) adherence. Finally, behavioural
interventions relevant to increasing the quality of patients suffering from IBD will be summarised.
Cognitive Behavioural group treatment in patients with inflammatory bowel disease.
M. Mussell; U. Bocker; N. Nagel; M.V. Singer, University of Heidelberg, Germany
In the current understanding inflammatory bowel diseases (IBD, including Crohn's disease and ulcerative colitis) are caused by environmental triggers and
an imune dysregulation in a genetically susceptible host. The course of these chronic diseases is characterised by episodes of relapse and remission. The
unpredictability of the natural course and the physical complaints during exacerbation of the disease (e.g., diarrhoea, pain, fatigue) affect psychosocial
distress. Aims of a psychological treatment for patients with ~IBD could be 1) improvement of the natural course of the disease, 2) decrease of
psychological distress and/or 3) enhancement of the patient's quality of life. Despite the long tradition of psychological interventions in IBD results are
inconsistent due to heterogeneity in outcomes and methodological issues. From our work we here report a cognitive behavioural treatment (CBT) group
program accompanying medical standard care to reduce psychological distress in patients with IBD.
Methods: Twenty-eight outpatients (14 with Crohn's disease and 14 with ulcerative colitis) completed the treatment program. The CBT group program
consisted of 12 weekly sessions with the following components: a) psycho-education about IBD provided by a gastroenterologist, b) psycho-education about
the role of cognition and emotion on the generation of distress, c) training in cogntive and behavioural strategies for coping with disease related and
everyday stress, and d) relaxation training and building up of positive activities. Disease activity indices and psychometric measures were assessed at the
beginning of the 3-months pre-treatment waiting period, at pre- and post-treatment, and at the 3, 6 and 9-months follow-ups. Psychological distress was
measured using the Rating Form of IBD Patient Concerns (RFIPC), the CES-D for depressive sympstoms, and the Global Symptom Index (GSI) derived
from the SCL-90/R. Dimensions of coping were assessed by the Freiburg Questionnaire of Copint with Illness (FQCI).
Results: During the waiting period psycholgical distress did not change. Disease related concerns decreased significantly from pre-treatment to the followups. However, between pre- and post-treatment concerns decreased in patients with ulcerative colitis, but not Crohn's disease. The decline in concerns
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was associated with a longer duration of disease. At the follow-ups concerns were significantly reduced in both groups. Depressive symptoms decreased
significantly in women but not in men. The same gender effect was found for depressive coping. Reduction of psychological distress was not associated
with a change in disease activity. Conclusion:s The exploratoy findings suggest that the CBT group for outpatients is a feasible and effective approach for
the short- and long-term reduction of disease related distress for patients with IBD. The effect of gender found on the change of depression and coping
might indicate the necessity to consider gender specific aspects of distress in IBD, when designing and evaluating psychological interventions. In view of
new findings on the link between psychological stress and IBD well designed studies should address the effect of CBT on relapse in the long-term course of
the disease.
What for Whom in CBT for Chronic Pain?
J.W.S. Vlaeyen; S. Morley, University of Leuven, Belgium & university of Maastricht, The Netherlands; University of Leeds, UK
Since the introduction of Behavioural Medicine in the early seventies, cognitive-behavioural treatment interventions for chronic pain have expanded
considerably. It is now well established that these interventions are effective in reducing the enormous suffering that chronic pain patients have to bear.
Despite these achievements, there is still room for improvement. First, there is substantial proportion of patients who do not appear to benefit from
treatment interventions available. Second, although the effect sizes of most cognitive-behavioural treatments (CBT) for chronic pain are comparable to
those in psychopathology, they are quite modest. Third, there is little evidence for differential outcomes for different treatment methods. Fourth, there still is
relatively little known about the specific bio-behavioural mechanisms that lead to chronic pain and pain disability. One direction is to better match treatment
programs to patients' characteristics. This can be done according to a Moderator-Mediator distinction perspective. We argue in favour of theory-driven
research as the only way to define specific a priori hypotheses about which patient-treatment interactions to expect. As an illustration, we will highlight the
application of exposure-based interventions in chronic pain patients who report substantial pain-related fear.
Tailored Cognitive-Behavioural Therapy for Chronic Physical Conditions: Implementation of stepwise care in clinical practise.
Andrea W.M. Evers,, University Medical Center St Radboud, The Netherlands
In patients with chronic physical conditions, there is increasing evidence that a stepwise care approach of tailored cognitive behaviour (CBT) for patients at
risk is effective for physical and psychological functioning of the patients. Tailored, stepwise care makes it possible to offer treatments to selected risk
groups of patients, to vary the timing of treatment in correspondence with different stages of the disease and to make use of tailored treatment modules,
consisting for examples of modules for pain and functional disability, fatigue, negative mood and social relationships in patients with chronic rheumatoid
diseases. Results of a randomised, controlled trial in patients with rheumatoid arthritis has shown that this type of tailored CBT is effective for physical and
psychological functioning and results were maintained at follow-up. A comparable approach was developed for patients with chronic skin diseases, with
disease specific treatment modules for chronic itching and scratching behaviours. Again, treatment evaluations indicated that this CBT approach is effective
for patients with chronic skin diseases at post-treatment and follow-up assessments. Subsequently, these treatments were implemented in daily clinical
practice of departments of rheumatology and dermatology. Following the stepwise care approach, all patients receive a standardized screening by
computerised questionnaire assessments, followed by tailored treatment options of individualised or group CBT for patients at risk. To enable broader
implementation and applications of these tailored treatment approaches, corresponding E-health CBT programs of psychological screening and treatment for
patients at risk are currently developed. Recent developments of these implementation strategies of tailored CBT for chronic physical conditions in daily
clinical practice will be discussed.
"How to Regain Positive Thoughts About Sex." An Important Element in the Sexuological-Behavioural Group Treatment of
Women with Chronic Superficial Dyspareunia.
Ingeborg Timmerman, Kennemer Gasthuis, The Netherlands
Painful intercourse can be caused by a yeast infection or dryness of the vagina due to lack of sexual arousal. When the pain is ignored several times, this
can cause vulvar vestibulitis. This chronic condition is often accompanied with insufficient lubrication, low subjective arousal and negative emotions. Painful
sexual intercourse is for most women the reason to seek medical attention. In Holland, it has become common practise to regard this complaint as a multifactorial sexual disorder. Treatment approaches require consideration of the full range of contextual factors, including relationship quality, personality factors,
past experience and mental and physical health. During group therapy women become conscious of their negative attitudes towards sex and intimacy,
which they developed over time. By using cognitive therapy they learn to change their negative dysfunctional ideas into more realistic thoughts about
intimacy and sexual contact. A lot of these negative ideas are the offspring of the idea; “in a good relationship one should always be ready to have sex.
Having sex is equal to sexual intercourse. A good lover/partner should always be able to have intercourse.” Since intercourse became painful, the whole
sexual encounter will be negatively influenced. A lot of women who present this problem, develop a negative self-esteem; The combination of low self
esteem and a negative expectation of the sexual encounter (it will be painful) often leads to avoidance of sex and intimate contact. In therapy it is difficult to
change the avoidance of sex into a more positive and open attitude, which is necessary for sexual arousal. They will learn that sexual arousal is necessary
for the development of a pleasant and painless sexual encounter. Women can profit tremendously from cognitive therapy in combination with a
behaviouristic sexuological approach focused on desensitisation of the fear of penetration in combination with exercises to relax the pelvic floor. I will
present a model I developed to combine all the different elements of therapy into an appealing group therapy. I will show video fragments of the group
sessions to show how cognitive therapy can be successfully used with extremely delicate subjects.
Symposium 178
Cognitive Behavioural models and treatment of dizziness and syncope
Convenor: Christine Baker, Newcastle Primary Care NHS Trust, UK, UK
Do psychological factors predict response to conventional treatment of vasovagal syncope?
Beverley Flint, Christine Baker*, Julia Newton** and Mark Freeston***, Central and North West London Mental Health NHS Trust, UK;*Department
of Clinical Health Psychology, Newcastle Primary Care NHS Trust, Newcastle-upon-Tyne, UK**Falls and Syncope Service, Newcastle upon Tyne
Hospitals Trust, UK***Department of Clinical Psychology, University of Newcastle upon Tyne, UK
This study examined the relationship between psychosocial factors and response to conventional treatment of the condition 'vasovagal syncope' (VVS).
VVS is defined as an increased tendency towards the common faint and can be due to a marked drop in blood pressure. It is not a life-threatening
condition, but sufferers are at risk of causing injury to themselves and others. Previous investigation reported that VVS sufferers who have not responded to
first-line treatment report higher levels of impairment and psychological distress when compared to those who have responded. It was not clear whether
these higher levels are the result or cause of non-response to treatment. Method: A naturalistic prospective two-group comparison design (participants: n=
103) was used to consider the impact of psychological and syncope-specific dysfunction factors (including fear, worry and negative cognitions) on response
to the conventional treatment algorithm. Results: This study found that non-responders report higher levels of impairment, negative cognitions and
psychological distress at the point of diagnosis when compared to those who go on to respond to treatment after three months. Logistic regression analysis
indicated that a higher level of impairment is more likely to predict non-response to first-line medical treatment.Conclusions: These findings have implications
for treatment. Those VVS sufferers who report high levels of impairment and/or psychological distress at the point of diagnosis may benefit from receiving
specific interventions to address misconceptions and promote symptom management and effective coping.
Cognitive and Psychodynamic Vulnerability Factors in the Development of Panic Disorders - A Prospective Trial in Patients
After Vestibular Neuritis
Frank Godemann, St Josephs Hospital, Berlin, Germany
The incidence of panic in people with vestibular neuritis is high. The occurrence of psychiatric disorders has no connection with a persistent functional
vestibular impairment. This trail prospectively examined the significance of cognitive and psychodynamic factors in the development of panic disorders in this
population.Methods: In a two-year prospective study, cognitive and psychodynamic factors were recorded. The cognitions were recorded at four stages,
between one day and 6 months after the occurrence of an acute vestibular event. Psychodynamic variables were recorded once six weeks after the event.
The analysis addressed whether vestibular disorder-related fears or psychodynamic variables can predict the development of a panic disorder, diagnosed
after 2 years. Results: Poor psychosocial integration, a lack of social support, a high burden of suffering, and moderate to severe impairment of selfexperience could account for 32.1% of variance in the development of panic disorder over the course of 2 years. However, contrary to what might have been
expected based on psychodynamic theory, patients who later developed a panic disorder did not exhibit any differences in their scores compared to patients
who remained psychologically healthy. Cognitive factors like persistent fear of vertigo, vomiting or loosing control predicted approximately 30% of the
variance of the occurrence of panic disorders. After 6 months these variables predicted 40% and, including body-related anxiety, up to 60% of the variance
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in the development of panic disorder. Conclusion: Fundamental assumptions of cognitive theory on the development of anxiety disorders could be
prospectively confirmed. Participants who experience vertigo as particularly alarming, but also poor psychosocial integration, were prone to develop panic
Evaluation of a cognitive-behavioural approach to booklet-based self-management in Ménière's disease
Sarah Kirby & Lucy Yardley, University of Southampton, UK
This randomised controlled trial examined the effects of booklet-based education in illness management techniques based on cognitive-behavioural theory to
manage dizziness symptoms due to Ménière's disease. Two approaches were compared. Vestibular Rehabilitation (VR) involved provoking dizziness in a
controlled manner by making repeated head movements. The rationale was that repeated controlled exposure would promote both neurological and
psychological habituation and build confidence in coping. Symptom Control (SC) involved using applied relaxation, challenging negative beliefs and lifestyle
modification. The rationale was that this would reduce emotional distress, handicap and amplification of dizziness by anxiety.Methods: Participants (n = 360)
were randomised to receive the VR self-management booklet, the SC booklet, or to a waiting list control group. Subjective improvement in health and
enablement (perceived ability to understand and cope with symptoms) were measured by postal questionnaire at 3 and 6 months. Adherence and
problematic experiences of therapy were assessed at 3 months. Symptoms, handicap, anxiety and depression, and negative beliefs about symptoms were
assessed using validated questionnaires pre-treatment and at 3 and 6 months. Results: At 3 and 6 month follow-up both intervention groups reported more
improvement in health and greater enablement than controls. Post-treatment (3 months) the VR group had reduced symptoms, anxiety, handicap and
negative beliefs about dizziness, the SC group had reduced handicap, but the control group showed no improvement. Conclusions: Self-management
booklets using cognitive-behavioural methods offer an inexpensive and easily disseminated means of helping people with Ménière's disease to cope with
dizziness symptoms.
Cognitive Behavioural Therapy for people suffering from Vasovagal Syncope - a case series
Janet King*, Christine Baker** & Mark Freeston*, *University of Newcastle Upon Tyne, UK;**Department of Clinical Health Psychology, Newcastle
Primary Care NHS Trust, Newcastle-upon-Tyne, UK.
Vasovagal syncope is a tendency towards fainting and is a common condition with transient loss of consciousness followed by spontaneous recovery. It has
proved difficult to treat. A recent audit suggests that up to fifty percent of patients presenting for treatment at the Falls and Syncope Service in Newcastle
upon Tyne do not respond to conventional medical treatment. Research suggests that psychological factors, such as cognitions and anxiety, are related to
non-response (Gracie et al, 2006; Flint, 2006).Newton et al (2003) have provided retrospective data to support the benefit of cognitive behavioural therapy to
help reduce distress and improve symptom management for people with vasovagal syncope resistant to conventional medical treatment.Here we present a
case series. Using a single case multiple baseline design, this case series has the objective of furthering our understanding of the process and impact of a
manualised cognitive behaviour therapy protocol on distress and interference in day to day functioning among people with treatment-resistant vasovagal
syncope. A close analysis of the therapy process will be presented and discussed
Open Paper Symposium 5
Health Problems and Insomnia
What are the most essential factors in a CBT case formulation in a physical health context? An exploration using Qmethodology.
Rose Jones, Northumberland Tyne & Wear Mental Health NHS Trust, Mark Freeston, University of Newcastle upon Tyne and Newcastle Cognitive
and Behavioural Therapies Centre, Chris Baker, Newcastle Acute Hoapitals NHS Trust, UK
Cognitive Behavioural Therapy (CBT) case formulation is deemed the 'cornerstone' of this psychotherapy (Salkovski, 1996). Despite formulation being
considered central to CBT (Johnstone & Dallos, 2006), it is an area that is under researched (Bieling & Kuyken, 2003). CBT is increasingly being used to
treat the psychological distress experienced by people suffering from chronic and acute physical illness, trauma and accident (White, 2001). In order to
explore what CBT therapists, working in physical health settings, believed were the most essential factors in a CBT case formulation, a study using Qmethodology was carried out. Q-methodology involves the development of a Q-set, a collection of statements that represent a broad variety of attitudes and
opinions on the chosen subject. The Q-set statements in this study, were based on open-ended interviews with seven, experienced CBT trained therapists
working in physical health. Literature on CBT case formulation, health psychology, and a local Health Psychology Special Interest Group also informed the
Q-set statements. Thirty-four CBT therapists were then asked to sort the 65 statements and attach them to a quasi-normally distributed grid, to represent
how essential they believed each item to be (-5 least essential to +5 most essential). The data was correlated and factor analysed using the PQMethod
software (Schmolck, 2002). Three factors were identified as being essential to a CBT case formulation in physical health. The factors were named according
to the items identified as most essential (+4 and +5): Factor 1: Psychological Aspects of Health - Psychological impact of the physical illness; Factor 2:
Historical Information - Childhood and experience of illness; Factor 3: Generic CBT Formulation - Traditional CBT formulation, not specific to physical
health. The aim of this study was to explore what factors CBT therapists consider are most essential in a CBT case formulation in physical health, using Qmethodology. Results showed a high level of agreement between participants who loaded on Factor 1, with 56% demonstrating a shared view of what the
most essential factors in a CBT case formulation in physical health are. Two other factors were identified as being important in a case formulation in physical
health, with 9% of participants loading significantly on Factors 2 and 6% loading significantly on Factor 3. Guidelines for essential factors to include in a case
formulation could be informed by the results of this study and would be especially useful for trainee and novice CBT therapists. The items that comprised the
Q-set were informed by the literature that is available describing what a CBT case formulation should contain and the Q-set encompassed a range of items
considered important (e.g. Butler, 1998, Beiling & Kuyken, 2003).
Causal attributions for common bodily perceptions: measurement and validation models for the Symptom Interpretation
Questionnaire (SIQ)
Angelika Gloeckner-Rist, Center for Survey Methodology of GESIS, Peter Pruefer, Center for Survey Methodology of GESIS, Margrit Rexroth,
Center for Survey Methodology of GESIS, Fred Rist, University of Muenster,Germany
Robbins and Kirmayer (1991) introduced the Symptom Interpretation Questionnaire (SIQ) to assess the causal attributions of common somatic symptoms.
Since then, the SIQ was used in numerous studies of medically unexplained or somatoform symptoms and hypochondriasis to find distinct attributional
styles for particular syndromes. Although pecularities of attributional style were frequently reported, these are rarely confined to one dimension, as would be
theoretically expected. E.g., patients with somatoform disorder employ somatic attributions more than healthy controls, but they also use more externalising
and more psychological attributions than healthy controls (Bailer et al., 2005). Also, scores for the three causal attributional dimensions are generally
intercorrelated (Lundh und Wangby, 2002). Reasons for this situation may lie in the mode of construction of the SIQ, which deviates from established
psychometric practice. In this study, we examined the items of a German version for ambiguity, established measurement models and validated the
dimensional structure by relating it to other constructs, and explored the presence of distinct attributional style clusters. For the measurement models and
the validation of a german version of the SIQ, we conducted four studies with student samples (N between 500 and 1000). To examine the validity of the
SIQ dimensions, their answers to the SIQ, the Health anxiety inventory (HAI; Salkovskis et al, 2002), the Whiteley Index (Pilowsky, 1967) and the PSWQ
(Meyer et al., 1990) were used. Computations were performed with MPLUS, taking care of nonlinear relations between items and latent traits and biased
answer distributions. To establish attribution style clusters, a latent class analysis was performed (LatentGold). A final version was derived taking into
account the results of cognitve pretests. Following a standardized protocol, 20 respondents were questioned in detail how they interpreted the instruction,
the symptoms, and the attributional statements presented for the symptoms. Based on the results, the instruction and several of the items were reworded.
The measurement models confirmed the three-dimensional structure of the SIQ. Meaningful relations of these dimensions to the WI, the HAI and the PSWQ
were established in the structural equation models. Reformulating items following the pretest reduced the interdependence of the three attributional
dimensions. The Latent Class Analysis produced four classes, based on the high or low endorsement of somatic and psychological attribution styles. In
particular, the dimension of externalising attribution did not help to assign the respondents to classes. The measurement models again confirmed the three
dimensions, despite using a rigorous nonlinear confirmatory factor analysis model. Somatizing and psychological attribution are related differentially to
somatic complaints, health anxiety and to worrying, proving the validity of the attributional dimensions. However, the most important result is the latent class
solution: the possibility to assign persons to one of four attributional clusters makes it possible to identifiy people at risk for certain disorders, based on
attributional style. Reducing ambiguity of the wording of the SIQ items improves the measurement quality of the SIQ. However, several more items may
have to be changed.
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Internet-delivered cognitive-behavioural self-help treatment for insomnia; a randomised controlled trial
Victor Spoormaker, University of Oxford & Utrecht University, UK; Paul Montgomery, University of Oxford, UK
Chronic insomnia - difficulty initiating and/or maintaining sleep - is a prevalent mental disorder affecting around 8-12% of the general adult population (Ford
& Camerow, 1989; Ohayon, 2002). It has been associated with daytime fatigue, limitations in cognitive functioning and with mood and anxiety complaints.
Primary insomnia is a prevalent condition, but insomnia also frequently occurs in affective disorders, and is a risk-factor for the development of posttraumatic stress disorder (Koren et al., 2002) and depression (Chang et al., 1997; Foley et al., 1999). Although insomnia receives little attention in the mental
health care, it is a persistent disorder that does not resolve without specific treatment. This also applies to insomnia occurring during the course of another
disorder, e.g. insomnia seems resistant to PTSD treatment (Zayfert & DeViva, 2004). While the use of pharmacological agents for chronic insomnia is
questionable due to tolerance and dependency, specific cognitive-behavioural treatment for insomnia, typically administered in 6-8 (group) sessions, does
show long-term sleep improvements (Morin et al., 1999). However, it is questionable as to how much can be added to the already high volume of work of
mental health professionals. It seems warranted to study less intensive treatment delivery methods, such as self-help interventions. As cognitive-behavioural
treatment for insomnia mainly consists of psycho-education and exercises, the effects of self-help interventions for insomnia are positive and promising
(Mimeault & Morin, 1999). Moreover, self-help can be delivered using novel multi-media approaches, such as TV or internet. One previous study (Ström,
Pettersson & Andersson, 2004) found modest but significant improvements in sleep after internet-delivered self-help treatment with minimal therapist
interaction. The current study aims to evaluate the effects of internet-delivered cognitive-behavioural self-help treatment for insomnia, without any therapist
interaction. As part of a larger sleep programme adult persons of a company were invited to fill out an online sleeptest - the SLEEP-50, a validated sleep
questionnaire that has shown good predictive validity for diagnoses obtained in a sleep clinic (Spoormaker et al., 2005). Participants with insomnia
complaints could register for inclusion in the current study. 74 participants did and were randomised into the treatment group (n = 38) or waiting list (n = 36).
The treatment group received a self-help treatment in PDF-format. This self-help treatment employed stimulus control (re-associating the bed and bedroom
with sleep compatible activities), sleep hygiene education (improving health behaviours or environmental factors affecting sleep), cognitive restructuring
(changing faulty beliefs about sleep) and progressive muscle relaxation. Participants were measured twelve weeks later with the SLEEP-50 (online) to
evaluate insomnia complaints, sleep quality and duration, and psychosocial functioning. 43 participants completed the online sleep questionnaire at follow-up
(treatment group n = 23). The effects of cognitive-behavioural self-help treatment on SLEEP-50 variables will be presented. Conclusions, clinical implications
and limitations will be discussed.
Impulsivity as a Risk Factor for Insomnia
Ralph E. Schmidt, Department of Psychology, University of Geneva, Switzerland, Philippe Gay, Department of Psychology, University of Geneva,
Switzerland, Martial Van der Linden, Department of Psychology, University of Geneva, Switzerland
There is considerable evidence that individuals suffering from insomnia experience unwanted intrusive and worrisome thoughts during sleep onset and that
they attribute their sleep disturbances to a “racing mind” (for a review, see Harvey, 2005). There is also growing evidence that thought suppression might
fuel the experience of negative cognitive arousal during sleep onset, thereby contributing to the maintenance of insomnia (for reviews, see Espie, 2002;
Harvey, 2002). Research has, for example, shown that insomniacs report using suppression during the presleep period more than good sleepers do (Harvey,
2001), and that the more frequent use of suppression is associated with more frequent sleep-interfering thoughts and poorer sleep quality (Ree et al., 2005).
Comparatively little is known about personality factors that might predispose people to suppress unwanted intrusive thoughts when trying to fall asleep.
Despite its prominent status in psychopathology, impulsivity has rarely been considered as a potential risk factor for insomnia in previous research, and the
few studies that have done so produced equivocal evidence (Dorsey & Bootzin, 1997; Ireland & Culpin, 2006; Lundh et al., 1995). Meanwhile, indirect
evidence continues to hint at a possible link between impulsivity and insomnia, for example, well-documented sleep disturbances in impulsivity-related
disorders such as borderline personality disorder (de la Fuente et al., 2001; Lindberg et al., 2003). The purpose of the present study was to investigate the
relationship between impulsivity and insomnia based on the comprehensive approach to impulsivity proposed by Whiteside and Lynam (2001). According to
these authors, four facets of impulsivity can be distinguished: urgency, lack of premeditation, lack of perseverance, and sensation seeking. The present
study involved 233 undergraduate students who completed Whiteside and Lynam's UPPS Impulsive Behavior Scale, Morin's (1993) Sleep Impairment Index,
and a short questionnaire on hypnagogic and dreamlike mentation. The main findings were that both urgency and lack or perseverance was related to
insomnia severity. Furthermore, urgency was associated with frequency of aggressive suppression of unwanted thoughts, and with frequency of upsetting
thoughts at sleep onset. Critically, the effect of urgency on difficulty in falling asleep was partially mediated by frequency of upsetting thoughts and images at
sleep onset. To our knowledge, the present study is the first to provide clear evidence for a link between two facets of impulsivity (urgency, lack of
perseverance) and insomnia, and for a link between urgency and sleep-interfering cognitive activity. The specific relations between facets of impulsivity and
aspects of insomnia might open up new avenues for modeling the development and maintenance of insomnia and for clinical interventions.
The application of accaptance and commitment therapy to chronic pain
Tony Merritt, Royal Prince Alfred Hospital, Sydney, Australia; Susan Pervan, Royal Prince Alfred Hospital, Sydney, Australia; Heidi Rolland-Kenn,
Royal Prince Alfred Hospital, Sydney, Australia; Graeme Campbell, Royal Prince Alfred Hospital, Sydney, Australia; Tim Austin, Camperdown
Physiotherapy, Sydney, Australia
ACT has been shown to be a potentially effective alternative to traditional CBT for treatment of chronic pain. ACT is conceptually more compatible with
accepted theories of chronic pain. Specifically, ACT targets experiential avoidance; promotes the view that suffering is inevitable; and advocates a refocus on
life direction and values. These factors are relevant because people with chronic pain try to avoid the inescapable experience of pain; fail to accept their pain
and suffering; and focus on pain at the expense of living a fulfilling life. ACT has been shown to be a potentially effective alternative to traditional CBT for
treatment of chronic pain. ACT is conceptually more compatible with accepted theories of chronic pain. Specifically, ACT targets experiential avoidance;
promotes the view that suffering is inevitable; and advocates a refocus on life direction and values. These factors are relevant because people with chronic
pain try to avoid the inescapable experience of pain; fail to accept their pain and suffering; and focus on pain at the expense of living a fulfilling life. Aims: To
evaluate an ACT based intensive pain programme (PMP-I). Methods: An intention to treat analysis was conducted on the first 60 participants in the PMP-I.
Standardised outcome pain measures included self efficacy (PSEQ); acceptance (CPAQ), catastrophising (PRSS), self reported disability (MRM),
depression, anxiety and stress (DASS); pain-related anxiety (TSK-11). Follow ups were conducted at 1, 3 and 6 months post-treatment. Results: Clinically
significant improvements were shown post-treatment and these outcomes were maintained at follow-up. Conclusions: (a) ACT appears to be effective for
addressing chronic pain; (b) outcomes were indicative of sustainable improvements in long term functioning; (c) the conceptual compatibility between ACT
and theories of chronic pain suggests potential enhanced outcomes when applying ACT to chronic pain.
Open Paper Symposium 10
CBT for Pain and Fatigue
Hypervigilance as a predictor of outcome in acute pain patients: Clinical Implications
Sonia Haggman, Clinical Psychology Unit, School of Psychology,The University of Sydney, Louise Sharpe, Clinical Psychology Unit, School of
Psychology, The University of Sydney, Leigh Carpenter, Clinical Psychology Unit, School of Psychology, The University of Sydney, Kathryn
Refshauge, School of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Michael Nicholas, Pain Management & Research
Centre, Royal North Shore Hospital, Sydney, Australia
Theories of chronic pain suggest that hypervigilance to pain following an acute injury has a causal role in the development of chronic pain. Although there is
emerging evidence that hypervigilance is associated with chronic pain, there is no evidence that hypervigilance precedes the development of chronic pain.
The present study aimed to determine: a) whether acute pain patients who are hypervigilant to pain-related stimuli are more likely to develop chronic pain;
and b) whether hypervigilance predicts chronicity and indices of disability. One hundred and thirty patients with acute low back pain were assessed at their
second physiotherapy appointment and completed measures of hypervigilance (Dot-Probe) and other demographic and clinical variables. Participants were
followed-up at three and six months to ascertain subsequent pain status and disability. At six months, participants were re-administered the Dot-Probe.
Those participants who subsequently developed chronic pain had significant biases towards affective pain, threatening and disability related stimuli at
baseline compared to those who recovered. The reverse was true for sensory pain words. That is, those who became chronic were more likely to avoid the
sensory aspects of pain. Subsequent pain status (ie whether chronic, recurrent or recovered) was independently predicted by baseline fear of pain and
hypervigilance. Indeed, when controlling for other demographic and clinical features, hypervigilance accounted for nearly 15% of the variance in pain status.
Significant correlations were also found between baseline hypervigilance and other indices of disability, including the highest and average pain ratings, days
in pain, time off work, the number of visits to health professionals. This study suggests that during an acute injury, patients attend to the emotionally salient,
rather than sensory aspects of pain. These biases were found to differ significantly between those who subsequently recovered and those that did not.
Strong relationships were also found between indices of hypervigilance and subsequent pain status. These findings support the claim that attentional biases
do have a causal role in the development of chronic pain.
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Chronic Pain: Is A Behaviour Focused Rehabilitation Enough? Preliminary Results Of A Randomised Controlled Trial In An
Interdisciplinary Pain Management Intervention, With And Without CBT
Inga Hrefna Jonsdottir, Reykjalundur Rehabilitation Centre, Iceland, Iceland; Magnus Olason Reykjalundur Rehabilitation Centre, Iceland; Hlin
Kristbergsdottir, Reykjalundur Rehabilitation Centre, Iceland; Thora Hjartardottir, Reykjalundur Rehabilitation Centre, Iceland; Gunnhildur L.
Marteinsdottir, Reykjalundur Rehabilitation Centre, Iceland; Runar Helgi Andrason, Reykjalundur Rehabilitation Centre, Iceland
The co-morbidity of pain and depression has been supported by recent research (see review by Williams, Jacka, Pasco, Dodd & Berk, 2006) and the
experience of pain can be intensified by the coexistence of a depressive disorder, as depression may reduce pain thresholds and tolerance. Cognitive
behaviour therapy (CBT) has been extensively evaluated and shown to be effective in terms of its impact on a number of biopsychosocial variables in
chronic pain (see Linton, 2000; Winterowd, Beck & Gruener, 2003). According to a recent review of meta-analyses, effect sizes for CBT for chronic pain
were in the moderate range (Butler, Chapman, Forman & Beck, 2006). The aim of this study is to evaluate the outcome of CBT in an interdisciplinary pain
management intervention, to examine whether rehabilitation including CBT is more effective than pain management treatment as usual, in improving health
outcomes compared with a waiting list control group. Every fifth patient referred to the pain section at Reykjalundur Rehabilitation Centre was allocated to
the study by systematic randomization, a total of 150 chronic pain patients. All the patients got a conventional interdisciplinary pain management treatment
for 6 weeks. The programme consisted of, in addition to physical endurance and fitness training, education such as a stress management and relaxation
programme, a back-school that addresses the nature of chronic pain and coping methods, nutrition, sleep, exercise and a healthy lifestyle. To evaluate the
outcome, the results from series of measures; questionnaires, clinical examinations and evaluations were analysed six weeks prior to admittance to the
rehabilitation programme (baseline - waiting list), at the start of treatment and after six weeks of rehabilitation. Patients who met the criteria for CBT, at start
of treatment, on the basis of their scores on questionnaires that measure anxiety (BAI) and depression (BDI-II), fear and avoidance behaviour (FABQ) and
catastrophizing (PCS) were randomly divided into two groups; one group receiving CBT and the other not. The CBT group received in addition to treatment
as usual, 12 sessions of individual manual-based CBT, delivered by CBT trained therapists; psychologists, nurses, social workers and occupational
therapists. Follow-up period was one and two years respectively. The preliminary results of the first 78 patients will be presented (64% female; mean age: 38
(17-58); duration of pain 5 years or more: 49%); 30 who did not meet the criteria for CBT, 25 from the CBT group and 23 who met the criteria but did not get
CBT. The findings indicate that the 6 weeks interdisciplinary pain management programme is very effective in improving health outcomes compared to the
waiting list. The symptoms of anxiety and depression were substantially reduced (p< .001 for both CBT groups). However there are not significant
differences in health outcomes, at the end of treatment, between the group that received interdisciplinary pain management as usual and the group that
received CBT in addition. It is difficult to eliminate the indirect effect of CBT on the programme since the behavioural approach has flavoured the programme
for over 15 years and CBT has been the main therapeutic approach in the team for over 7 years. Furthermore, other studies have failed to show significant
differences between CBT and other active behavioural treatments. Smeets et al. (2006) compared three kinds of rehabilitation for non-specific chronic low
back pain patients and did not find clinically relevant differences between a physical, a cognitive-behavioral treatment and a combination of both, all three
active treatments were effective in comparison to no treatment. The interdisciplinary pain management programme with CBT is effective in reducing
symptoms of anxiety and depression. Although there was not a difference in outcome at the end of treatment between the treatment groups, the
improvements may last longer for the CBT group in the follow-up or we could conclude that when the rehabilitation programme is interdisciplinary, active
both with physical and mental training, teaching relaxation and coping methods for changing to a better lifestyle, behaviour focused rehabilitation is enough.
Graded exposure in vivo in chronic low back pain patients: results of a randomized controlled trial at six months after
Maaike Leeuw, Department of Medical, Clinical and Experimental Psychology, Maastricht University, Maastricht, The Netherlands, Mariëlle
Goossens, Department of Medical, Clinical and Experimental Psychology, Maastricht University, Maastricht, The Netherlands, Jeroen de Jong,
Department of Medical, Clinical and Experimental Psychology, Maastricht University, Maastricht, The Netherlands; Department of rehabilitation,
University Hospital Maastricht, Maastricht, the Netherlands, Peter Heuts, Rehabilitation Foundation Limburg, Hoensbroek, the Netherlands, Albere
Köke, Centre for Clinical Rehabilitation, Hoensbroek, The Netherlands; Pain Research and Management Centre, University Hospital, Maastricht,
The Netherlands,
Pain-related fear has been assigned a prominent role in a cognitive behavioural account explaining the development and maintenance of chronic low back
pain (CLBP) in a subgroup of patients (e.g. Vlaeyen et al., 1995; Vlaeyen & Linton, 2000). This model proposes that catastrophic misinterpretations of pain,
and associated pain-related fear cause patients to avoid various activities and demonstrate excessive attention to pain, possibly leading to functional
disability, depressed mood and physical deconditioning. The results of numerous suggest that pain-related fear may not only be associated with the
inception of a LBP episode, but also with the transition from acute to CLBP, and the maintenance of chronic pain (see for an overview of studies: Leeuw et
al., In press). Pain-related fear could therefore be an important target for intervention. Derived from similarities between pain-related fear and simple
phobias, an exposure in vivo treatment was developed for application in fearful CLBP patients. This treatment gradually confronts patients with activities they
feared and avoided for a long time due to the belief that these might be damaging for the back. Due to this, these patients may become convinced that the
expected detrimental consequences of these feared activities are in fact a catastrophic overestimation. Their fear may diminish and functional abilities might
be promoted (Vlaeyen et al., 2004). Several experimental single case studies, including replications of 2 to 6 high fearful patients, demonstrated greater
reductions in pain-related fear and disability, as well as greater increases in activity levels in the home situation, after exposure in vivo treatment than after
graded activity (e.g. Boersma et al., 2004; de Jong et al., 2005; Vlaeyen et al., 2002). The current study aimed at examining the effectiveness of exposure in
vivo as compared to graded activity in CLBP patients by use of a randomized controlled trial. CLBP patients were referred to the study by various
rehabilitation facilities in the Netherlands. A total of 85 CLBP patients met the selection criteria and were included in this study, of which 42 were randomly
allocated to exposure in vivo and 43 to graded activity. Before the start of treatment, participants completed two pre-treatment measurements within a twoweek time-interval to increase power. After treatment, and six months after termination of treatment, participants completed the same measurement. During
these measurements, data were gathered about functional disability, fear of movement/(re)injury, pain catastrophizing, pain severity, pain vigilance, general
health status, depression, and quality of life. Furthermore, patients wore an accelerometer designed to monitor the physical activity level in the everyday life.
Data collection will be finished in January 2007. The results and conclusions will be presented in the open paper presentation.
Tailored cognitive-behavioral therapy for FM patients at risk: preliminary results of a randomized, controlled trial
S. van Koulil, Radboud University Nijmegen Medical Centre, Department Medical Psychology, W. van Lankveld, Sint Maartenskliniek Nijmegen,
Department Rheumatology, A.W.M. Evers, Radboud University Nijmegen Medical Centre, Department Medical Psychology, F.W. Kraaimaat,
Radboud University Nijmegen Medical Centre, Department Medical Psychology, T. van Helmond, Sint Maartenskliniek Nijmegen, Department
Rheumatology, P.L.C.M. Netherlands
The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms has been proposed to underlie varying treatment outcomes in patients
with fibromyalgia (FM), a chronic musculoskeletal pain disorder characterized by widespread pain of unknown origin. Recent studies have suggested that
distinctive cognitive-behavioral patient profiles can be identified within the patient population. One group of patients is characterized by the dysfunctional
mechanisms of pain-avoidance behavior and fear of pain as specified in fear-avoidance models, i.e. pain-avoidance risk profile, in contrast to patients
distinguished by task persistence and overactivity, i.e. pain-persistence profile. Tailoring cognitive-behavioral therapy (CBT) to the patient's main cognitivebehavioral mechanisms has been suggested as a promising way to improve the effectiveness of CBT in FM and other chronic pain conditions. In a
randomized controlled trial of FM patients, a validated screening instrument of pain-avoidance behavior is used to discriminate between patients with painavoidance (high level of pain-avoidance behavior) and pain-persistence profiles (low level of pain-avoidance behavior). Depending on their specific profile,
patients are assigned to tailored CBT conditions consisting of a psychological and a physical component. In addition to increasing the physical condition of
the patients in both treatment conditions, the treatment for the pain-avoidant group focuses on increasing activities in daily life and diminishing fear of pain,
whereas pacing of activities and more acceptance-based approaches are part of the program for the patients with pain-persistence profiles. Assessments
were made at baseline, post-treatment and 6 months after treatment on the outcome measures pain, functional disability, fatigue and psychological distress
using validated, self-report questionnaires. In addition, the physical condition of the patient was assessed by a shuttle-walking test during physical therapist
examination at baseline, post-treatment and 3 months after treatment. First results of the treatment groups indicate beneficial effects of tailored CBT on
physical and psychological functioning for both treatments. Specifically, significant reductions were found post-treatment on symptoms of pain, functional
disability, fatigue, and psychological distress and these results were overall maintained during 6-month follow-up for both groups. In addition, the physical
condition of patients was significantly improved after treatment and at the 3-month follow-up. Effect sizes of the outcome measures indicated large effects (>
0.7) for both treatment conditions at post-treatment and follow-up assessment. These preliminary results suggest that tailored CBT for FM patients at risk is
effective is improving physical and psychological functioning. Customizing treatment to specific cognitive-behavioral patient profiles might be a promising
new way to increase treatment efficacy in patients with FM.
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The efficacy of self-instructions in the treatment of patients with Chronic Fatigue Syndrome: a randomised controlled study.
Hans Knoop, Expert Centre Chronic Fatigue, Radboud University Nijmegen Medical Centre, Jos W.M. van der Meer, Department of Internal
Medicine, Radboud University Nijmegen Medical Centre, Gijs Bleijenberg, Expert Centre Chronic Fatigue, Radboud University Nijmegen Medical
Centre the Netherlands
Chronic Fatigue Syndrome (CFS) is characterised by severe fatigue, lasting longer than six months and leading to functional impairment. It is not the result
of an organic disease or ongoing exertion and not alleviated by rest. Cognitions and behaviour can perpetuate CFS. Several controlled trials have shown
that Cognitive Behaviour Therapy (CBT) aimed at these perpetuating factors leads to a reduction of fatigue and disabilities. Clinical practice suggests that
there is a subgroup of CFS patients for whom a less intensive treatment suffices. Therefore we developed a Self-Instruction (SI) program based on the
current protocol of individual CBT for CFS.
The objectives of this study were 1) to evaluate the efficacy of the SI program; 2) to identify the subgroup of patients who profit from the SI program. We
assumed that CFS patients with a shorter symptom duration and less severe symptoms would benefit the most from SI. In a randomised controlled trial the
SI condition was compared with a waiting list condition. Patients were included if they met the 1994 US Center for Disease Control criteria for CFS and gave
written informed consent. Consecutive patients were randomly assigned to SI or a waiting list condition. All patients were assessed at baseline and after 6 to
12 months. Main outcome measures were fatigue severity (Checklist Individual Strength; CIS) and functional impairment (Sickness Impact Profile; SIP).
The patients in the SI condition followed a written self instruction program of 16 weeks. The program was aimed at changing fatigue related cognitions and a
gradual increase of activity. Patients in the SI condition had a two weekly email contact with a therapist to report on their progress and ask questions about
the program. Until November 2006, 160 CFS patients were included in the study. Currently, 93 patients completed both the baseline and post intervention
assessment (46 SI and 47 waiting list). The data were analysed on the basis of an intention to treat analysis. In case of missing data the last observation
was carried forward The preliminary analysis showed a significant larger decrease in fatigue severity (CIS) and functional disabilities (SIP) in de SI condition
compared to the waiting list. Also, significantly more patients in the SI condition than patients in the waiting list had a level of fatigue following treatment that
was within the range of the mean plus two standard deviations of healthy controls. Patients who showed a positive response to SI were less severely
fatigued at baseline but did not have a shorter symptom duration. Preliminary results of the trial show that a SI program for CFS patients leads to a
significant decrease of fatigue and disabilities. These results suggest that for a subgroup of CFS patients with a less severe level of fatigue a minimal
intervention suffices. This is a first step towards a model of stepped care for CFS.
Open Paper Symposium 14
CBT for Nerve and Blood Disorders
A randomised controlled trial of cognitive behaviour therapy for Multiple Sclerosis fatigue.
Rona Moss-Morris, University of Southampton, Kirsten van Kessel, The University of Auckland,, Trudie Chalder, Institute of Psychiatry, Malcolm
Johnson, The University of Auckland,, New Zealand
Multiple Sclerosis (MS) is an incurable and unpredictable demyelinating disease of the central nervous system, with fatigue being one of the more common
yet least understood symptoms. We developed a manualised eight session cognitive behaviour therapy (CBT) programme to treat MS fatigue based on a
biopsychosocial model of MS fatigue. The purpose of this study was to compare the efficacy of this CBT package with relaxation training in a randomized
controlled trial. Seventy-two patients with MS fatigue were randomly assigned to either eight sessions of CBT or eight sessions of relaxation training,
designed to control for therapist time and attention. CBT treatment included gradual exposure to consistent activity and rest, and cognitive restructuring,
which focused on symptom and illness beliefs and personal expectations. Participants were assessed before and after treatment, and at three and six
months follow-up. The primary outcome was the Chalder Fatigue Scale. Secondary outcome measures included the Work and Social Adjustment Scale,
the Hospital Anxiety and Depression Scale and the Perceived Stress Scale. To investigate mechanisms of change across the CBT programme, participants
also completed the Cognitive and Behavioural Responses to Symptoms Questionnaire and the Brief Illness Perception Questionnaire. Of the 72 participants
randomised, 2 dropped out of treatment. Both groups significantly improved on all outcome measures (p<.01 for all). Improvements in fatigue, anxiety and
stress over the eight sessions of treatment were significantly greater for the CBT group compared with relaxation (p<.04 for all) at the end of eight weeks
treatment. However, by six months follow-up there were no significant differences between the CBT and relaxation groups, as the relaxation group continued
to improve while the CBT maintained their improvement. At the follow-up point both groups reported fatigue levels equivalent to those of a matched healthy
control group. Cognitive behavioural variables changed more significantly for the CBT group during treatment (p<.02 for all), including symptom focusing,
beliefs that symptoms are a sign of damage, catastrophizing about the consequences of symptoms, fear avoidance and embarrassment avoidance in
response to symptoms, all-or-nothing behaviour and excessive resting. The CBT group also showed significantly more positive views of their fatigue after
treatment. Both relaxation training and CBT appear to be effective treatments for MS fatigue. The effect for CBT may work in part by changing the way
patients think about and respond to their symptoms. The effects for CBT were also significantly greater than those of relaxation therapy at the end of
treatment, but the CBT group did not continue to improve during follow-up. This suggests that follow-up sessions may help to maximise the effects of the
CBT to ensure that patients continue to improve after treatment completion.
Five Year Follow Up Of Manual-Assisted Cognitive Behavioural Therapy In Sickle Cell Disease
Kofi Anie, Central Middlesex Hospital / Imperial College London, Sonia Patel, Central Middlesex Hospital, London, Philip Tata, St Mary's Hospital,
London, UK
Sickle cell disease (SCD) is a genetic blood condition found worldwide, and predominantly affecting people of African, Arabian, Asian, Mediterranean and
Southern European origin. The hallmark manifestation of SCD is acute pain and complications with grave psychological implications. Cognitive Behavioural
Therapy (CBT) combined with medical treatment has been shown to be effective, addressing quality of life problems including severe recurrent pain and
psychological distress (Anie & Green, 2002). We developed a structured self-help manual to assist a CBT programme for patients with SCD, which
comprises patient education (including pain control and general management), cognitive therapy, behaviour therapy including communication skills training,
and relaxation (Anie et al, 2002). This study evaluates the manual-assisted CBT programme aimed at reducing physical and psychological problems
associated with SCD at about 5 years follow-up. Adult patients attending a London hospital outpatient SCD Clinic were invited to 6 sessions of manualassisted CBT over 12 weeks. At 5 years follow-up (during their routine outpatients clinic appointment) 13 patients were administered a Pain Interview
(including health service utilisation), the Coping Strategies Questionnaire Revised for SCD, Hospital Anxiety and Depression Scale, and Medical Outcomes
Survey Short Form 36 (SF-36). We report the outcome by assessing changes in pain, health service utilisation, psychological coping, health-related quality
of life, and mood. Results showed that some of the initial improvements shown after the CBT intervention were still evident at 5 years. Significant
improvements in psychological coping strategies such as those dealing with affect, and quality of life measured on the SF-36 were maintained. However,
significant reduction in anxiety, which was evident immediately after CBT was lost over 5 years. These findings suggest that a brief manual-assisted CBT
programme is still beneficial after 5 years, although it seems continuity of therapy is required to preserve positive gains in mood and other psychological
coping strategies. Psychological interventions such as CBT should be incorporated in the standard care of patients with SCD complementary to medical
treatment for better outcome.
Depression and Hepatitis C: Can CBT Prevent Medically Induced Depression?
Lata McGinn, Yeshiva UNiveristy, Ferkauf Graduate School, Donald Gardenier, Mount Sinai School of Medicine, David Alfandre, Mount Sinai
School of Medicine, Israel
It is estimated that 4 million people in the U.S. and 100 million worldwide have hepatitis C (HCV) and that 75% of these individuals are likely to develop
chronic infection, and of these,35 percent will develop cirrhosis within the first 20 years of infection, resulting in an estimated 8,000 to 10,000 deaths per
year in the U.S. Furthermore, HCV is the most common cause of liver disease in the United States and chronic liver disease due to HCV is the leading
indication for liver transplantation. A large number of the HCV population is currently asymptomatic and will begin to exhibit symptoms in the next 10-20
years. Amongst HIV positive patients HCV is now one of the leading causes for admission to the hospital and responsible for close to 50% of AIDS mortality.
The treatment for active hepatitis C is a long and difficult course, involving combination therapy of interferon and ribavirin for 6 to 12 months, a therapy with
significant side effects. Up to 40% of patients being treated will develop depression due to the medication, which in turn leads to discontinuation of therapy
and lost opportunities to prevent end stage liver disease6. In fact, the presence of depression prior to interferon treatment often excludes patients from
receiving interferon therapy, thereby denying them a potentially life-saving treatment. Currently, only one study has been performed to demonstrate the
efficacy of antidepressant medication to prevent interferon-induced depression7 and no studies have yet examined the potential of preventing interferoninduced depression using CBT. We have recently started enrolling patients into an NIH funded demonstration project to assess the feasibility of an 8
session cognitive behavioral therapy (CBT) program to reduce depression and depressive symptoms among 40 patients randomized to the CBT compared
to 20 patients in an 'attention only' control group. Patients randomized to the CBT intervention will attend 8 sessions (each lasting 2 hours) led by a clinical
psychologist experienced in CBT. Three of these sessions will take place before the interferon begins, and five will occur after it begins since the risk of
Page 86
interferon-induced depression is greatest in the first 3 months. Patients in each arm will undergo assessment for depression and depressive symptoms at
baseline and 3 and 6 months after beginning interferon/ribavirin therapy using the Beck Depression Inventory II (BDI-II), with moderate to severe depression
defined as a BDI-II greater then 20. Enrollment has only recently begun and preliminary results will be presented at the meeting including number of patients
recruited, number who successffully particpated in CBT and comply with therapy. If available data on the impact of CBT on compliance and completion of
therapy will be presented . CBT may not only prevent depression in patients being treated with inferon for hepatitis C but also offer the synergistic effect of
bolstering cognitive and behavior skills that enhance the patient's ability to adhere to the arduous HCV drug regimen.
Eating disorders and body image in HIV clinic attenders
Lucy Serpell, CNWL NHS Foundation Trust/St Mary's Hospital, London, UK; Karen Klassen, St Mary's Hospital, London, UK
This study aimed to examine the prevalence of eating and body image problems amongst HIV positive men and women attending a large HIV clinic. It was
hypothesised that such individuals may be at risk of body image/eating problems for a number of reasons, including the stress of living with HIV, the
emphasis on physical appearance amongst gay men who make up a large proportion of clinic attenders and the impact of HIV and HIV treatment on the
body and body image. One major aspect of this is the risk of HIV medications leading to lipodystrophy, a condition in which fat is redistributed around the
body, often being depleted from the face and extremities and deposited on the abdomen and back. We recruited 93 patients attending an outpatient HIV
clinic at St. Mary's Hospital. Participants completed a demographic/dietary questionnaire, the SCOFF eating disorder screen (Morgan et al, 1999) and a
body image silhouettes scale (Ryan et al, 2005). 20 participants were female, 72 male and 1 male-to-female transgender. Eighty one percent of men
described themselves as homosexual, 7% as heterosexual and 7% as bisexual/other. Eighty percent of women were heterosexual. Fifty seven percent were
white, 26% black and 15% other/mixed ethnicity.. Mean age was 40 yrs and mean time since diagnosis was 9 yrs (range 0-24 years)
76% were taking HAART and 14% were diagnosed with lipodystrophy . 65% reported gastro-intestinal symptoms related to HIV/HAART in the previous 3
months.. 28% were overweight, 11% underweight and 60% average weight (using a BMI range of 20-25 for 'average'). Overall, 23% of participants scored
above the cut off on the SCOFF, suggesting that they may be suffering from a clinically significant eating disorder. 40% of women (n=8), 17% of men and
20% of gay men scored about the cut off. There were no significant gender or ethnic differences on SCOFF scores or BMI, but gay men scored significantly
higher on the SCOFF than heterosexual men. Gender differences were not significant. Results from the body image measure suggested that many
respondents were disatisfied with their body fat and or muscularity. The commonest pattern amongst men was to wish to be thinner and more muscular.
Women showed a more mixed picture. This pilot study suggests there may be an increased risk of eating disorders in people with HIV. This has implications
for medication compliance and HIV prognosis. The risk appears to be highest amongst women and gay men. Further research is needed to confirm and
extend findings. There may be a role for screening for eating disorders using a measure such as the SCOFF in HIV clinic attenders. Our group are currently
conducting a qualitative study exploring meaning of HIV/body image amongst HIV positive gay men.
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Challenging Behaviour and Personality Disorder
Invited Addresses
Cognitive Therapy for Borderline Personality Disorder
Judith Beck, Beck Institute, Philadelphia, US
Why do Axis II patients sometimes pose such a challenge in treatment? Part of the answer lies in the negative, rigid, overgeneralized ideas (core beliefs) they
have about themselves, their worlds, and other people. They developed these beliefs as a result of the meaning they ascribed to early adverse experiences.
Patients then developed certain behavioral tendencies, or coping strategies, to get along in life. Once these beliefs became entrenched, the patient began to
view his or her subsequent experience through the lens of these powerfully negative ideas. When Axis II patients enter treatment, they often view their therapy
experiences through the lens of their core beliefs and employ their usual coping strategies, which can interfere with “standard” treatment. It is useful for
clinicians to understand the particular set of beliefs and coping strategies that characterize each personality disorder in order to conceptualize the individual
patient. The therapist then uses this conceptualization to plan treatment and solve therapeutic problems. Therapists often must use specialized strategies to
develop and maintain a strong therapeutic alliance, set goals, structure the session, and help patients to focus on solving problems, learning skills and
completing homework. It is essential to educate patients about their core beliefs, help them cope with schema activation, modify their core beliefs at both an
intellectual and emotional level, and develop alternate beliefs, often using experiential techniques.
Compulsory Therapy for Challenging Behaviour: The Debate and the Dat
John Monahan, University of Virginia School of Law, USA
An intense policy debate is occurring in many countries on the legitimacy of laws compelling people with challenging behaviour to accept cognitive behavioral
and other outpatient therapy. Much of this debate on “outpatient commitment,” or “community treatment orders,” assumes that court-ordered therapy in the
community is simply an extension of long-existing policies authorizing involuntary commitment as a hospital inpatient. In fact, however, outpatient commitment
is only one of a growing array of legal tools used to compel adherence to therapy in community settings. For example, benefits disbursed by money managers
and the provision of subsidized housing have both been used as leverage to compel adherence to outpatient therapy. Similarly, for people who commit a
criminal offense, adherence to outpatient therapy may be made a condition of probation. Ongoing research on the empirical outcomes produced by “mandated
community treatment” will be described in this address.
Symposium 57
Measurement, Etiology and Treatent of Borderline Personality Disorder
Convenor: Sven Barnow, University of Greifswald, Germany
Emotional instability and attentional bias in patients with BPD
Sven Barnow, Ernst-Moritz-Arndt University, Greifswald, Germany
The borderline personality disorder (BPD) is characterized by emotional instability, impulsive behavior and interpersonal problems. Research has indicated
that the BPD results from both the influence of specific biological factors (e.g. affective instability), as well as negative environmental (e.g. maladaptive
parental behavior) or psychological effects (e.g. dysfunctional beliefs). The main assumption of the Neurobehavioral Model (NBM) of BPD developed by
Marsha Linehan is that most symptoms of BPD patients result from their affective instability. However, she has never tested this hypothesis.Introduction:
Method: multi-method approach using data of several clinical and non-clinical samples of patients with BPD and healthy controls Results: Results indicate
that emotional instability may be important, however, the primary finding was that these patients show an attentional bias for negative stimuli which in turn
have an influence on their interpersonal behavior Conclusions: The strong negative attentional bias in these patients supports the assumptions of the
cognitive theory of Beck and associates. Further therapy studies should use the extent of attentional bias as outcome variable.
Emotional Startle Modulation During Script Driven Imagery In Patients With Borderline Personality Disorder
Anke Limberg, Harald J. Freyberger, Alfons O. Hamm, & Sven Barnow, Hospital and Clinic for Psychiatry Stralsund, Germany
Affective dysregulation is a core feature of Borderline Personality Disorder (BPD). Affect-induced modulation of startle response provides a reliable measure
of emotional processing. The aim of this study was to assess psychophysiological responding to emotional scripts. In 18 unmedicated patients with BPD and
18 healthy controls, startle responses were recorded while the subjects were first reading and then imagining standardized and personalized scripts with
different emotional content. According to the most prominent model of BPD (Linehan's biosocial theory) patients should have deficits in negative emotion
regulation. Thus, it was hypothesized that patients with BPD would show enhanced startle responses for unpleasant scripts, in particular. Data analyses
revealed a comparable affect modulation of startle responses for both groups. BPD patients however, showed a signifikant reduction of their startle response
magnitudes during imagery but not during reading relative to controls. Interestingly, patients with BPD rated most of the scripts (including the pleasant ones)
as more unpleasant and arousing. On the other hand they reported less vividness of the pleasant images. The assumption of emotional hyperreactivity of
Linehan´s theory could not be confirmed. Results will be discussed regarding possible moderating factors.
Pathogenesis of Borderline Personality Disorder (BPD)Neurobiological findings and clinical implications
Ludger Tebartz van Elst, University Clinic Freiburg, Germany
The recent years have seen a surging interest in the neurobiology of BPD. Many neurophysiological and brain imaging studies have aimed to understand
the neurobiology of BPD. In fact, most of these studies did find clear brain abnormalities in BPD. However, many findings remained unreplicated and at
present the neurobiological research is far from defining a clear aetiology of BPD. One reason for this unfortunate lack of replication of BPD research might
be due to the fact, that BPD is not a clear-cut and well-defined clinical entity. Instead it most likely embraced a number of etiologically different but clinically
similar nosologic entities. In this presentation, we will summarize the neurobiological findings in BPD focusing on brain imaging studies. We will try to
summarise the findings within a functional and neuroanatomical model of affect regulation. Finally, in presenting a special case we want to illustrate possibly
important clinical implications of a thorough neuropsychiatric diagnostic in patients with BPD phenomenology.
The executive (dys)function problem in Borderline Personality Disorder
Kathleen Anna Voelker, Ernst-Moritz-Arndt University, Greifswald, Germany
Several studies tried to find executive function impairments in borderline personality disorder (BPD). Not at least because of the heterogenicity of this
disorder it is still unclear if and in which field such deficits can be found. The aim of this study was to determine specific neuropsychological impairments in
patients with BPD with a special focus on borderline key symptoms like impulsivity, emotional dysregulation, and frequent comorbid disorders like
depression. Method: A neuropsychological test battery was administered to a BPD group consisting of 17 non-medicated female patients with BPD, a
healthy control group (neither axis I nor -II diagnosis) of 17 subjects matched for sex, age, and intelligence with the BPD group, a third group of 23 female
subjects with a lifetime depression diagnosis, and a high impulsivity group of 20 female subjects. Results: The BPD group showed impairements in inhibitory
capacities compared with the healthy control group in some of the neuropsychological tests. But these impairments mainly disappear in contrast to the other
two groups. Conclusions: Even if these results show that executive dysfunctions are not borderline-specific, this study supports the hypothesis of an
impairment in executive functioning in BPD and emphasize the impact of impulsivity and comorbid depression on the etiology of this disorder.
Can Dialectiv-Behavioral Therapy (DBT) treat trait based symptoms in patients with borderline personality disorder ?
Dorothee Bernheim & Sven Barnow, Ernst-Moritz-Arndt University, Greifswald, Germany
The borderline personality disorder is characterized by three essential symptoms: lack of stable sense of self, aims and inner preference, intensive, instable
relations and fear of abandonment. Transference - Focused Psychotherapy aims at improving structural aspects in borderline personality disorder.We
hypothesized, that DBT (Linehan, 1993) could achieve this aim with its specialized setting too. Its high requirements of self-regulating abilities and a stable
therapeutic relationship leads to a structural change in personality organisation and an improvement of regulation of near and distance.For that reason we
defined aspects of personality structure about the character dimension self-directedness (SD) according to Cloninger. The quality of near - distance regulation was characterized by predominance of primitive defense mechanisms according to Kernberg. Additionally we measured impulsivity and
alexithymia as “traitlike” features. We present first results of an ongoing intervention study with three inpatient therapy blocks over 1.5 years, which included
traditional elements of DBT like skills-training and improvement of self-esteem. Furthermore the results of a randomised control group are reported.
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Symposium 74
Early Maladaptive Schemas: from theory to empirical assessment
Convenor: Daniel Rijo, Faculty of Psychology and Educational Sciences. University of Coimbra, Portugal
Empirical studies on Early Maladaptive Schemas assessment.
Daniel Rijo, Jordi Cid Colón*, and José Pinto Gouveia, University of Coimbra, Portugal
The development of Young's Schema Questionnaire (YSQ - Young & Brown, 1990; Young, 1991) provided clinicians and researchers with a self-report
instrument for Early Maladaptive Schemas (EMSs) assessment. Research has shown that the YSQ possesses good psychometric properties (Schmidt,
Joiner, Young, & Telch, 1995; Lee, Taylor, & Dunn, 1999; Glaser, Campbell, Calhoun, Bates, & Petrocelli, 2002) and recent studies addressed the issue of
EMS's sensitivity to psychotherapy interventions (Halford, Brenoth-Doolan, Eady, 2002; Welburn, Dagg, Coristine, Pontefrac, 2002).In this paper, the authors
review existing research data about the YSQ from a critical poont of view, looking at results about the factor structure of the questionnaire as well as data
available about its clinical sensitivity .However, and from a methodologiacal point of view, an instrument of this kind presents some limitations when
assessing core cognitive structures, once it appeals to conscious self-knowledge without activating schema-congruent emotional states, thus enabling
avoidance and compensation processes to occur and influence the scores obtained.Some critical reflections are made about the assessment of core
cognitive structures such as EMSs using this kind of methodology.
Are Schemas Dysfunctional And Related To Pschobiological Variables?
Jordi Cid Colón, Rafael Torrubia*, Servei de Rehabilitació. Parc Hospitalari Marti i Julià. I.A.S. Girona;*Unitat de Psicología Mèdica. Universitat
Autònoma de Barcelona
Schema theory assumes maladaptiveness of early maladaptive schemas (EMS), and emphasizes that emotional temperament interacts with painful
childhood events in the development of schemas. However, there are not empirical studies that tested these hypothesized relationships. The first goal of our
study is to know if there are EMS differences when we compare in a patients group individuals who had previous psychiatric illness with individuals without
previous psychiatric illness. And also, EMS differences in a patients group between people with relatives presenting psychiatric illness and people with
relatives without psychiatric illness. Finally, EMS differences between patients taking and not taking psychotropic drugs are studied.The second goal is to
know the role of emotional temperament in EMS development.437 psychiatric patients from a Catalonian Mental Health Centre were included in the studies.
To evaluate schemas, we used the Spanish Version of the Young Schema Questionnaire (Cid, Tejero & Torrubia, 1999; Cid & Torrubia, 2001); to evaluate
psychobiological variables we used the Karolinska Personality Scale (KPS) (Gustavsson, 1997; Schalling et al., 1987) witch aims to operationally define
important theoretical constructs in psychobiological research: negative emotionality, social withdrawal, impulsive-unsocialized, sensation-seeking, and
aggressive non-conformity. Statistical analyses consisted in mean differences studies between groups (for the first goal) and regression analysis including
each EMS as a dependent variable and the KPS scales as independent variables (for the second goals).Our results showed that all schemas are predicted
by negative emotionality scales, and partially by other psychobiological constructs. EMS's are related to negative childhood experiences and negative family
adjustment. Also EMS's scores are significantly higher in the patient group which had previous psychiatric illness and with relatives having psychiatric illness.
EMS's are significantly higher in the patients group taking medication drugs for their mental health disturbance, comparing to patients not taking medication.
A necessary(?) change on EMSs assessment: from "cold" to "hot" assessment instruments.
Daniel Rijo and José Pinto Gouveia, University of Coimbra, Portugal
Young's Schema Focused Therapy is an exception in what concerns the development of an instrument regarding the assessment of core cognitive
structures - the Young's Schema Questionnaire (YSQ). The YSQ has been developed since 1990 and several versions of it have been made, ending in the
revised 90 items randomized form (Young, 2005).Nevertheless, the YSQ methodology may be criticised from a theoretical point of view once it appeals to
conscious self-knowledge for schema assessment to occur. As recent theoretical developments and research have stated, people diverge in their
metacognitive capacities, besides the fact that emotional states also influence our metacognition. Finally, clinical experience shows that patients using
avoidance and/or compensation processes tend to answer the YSQ in a distorted way, making EMSs scores difficult to interpret when not contradicting
clinical assessment results.The authors developed a new method to assess EMSs - the Schema Assessment Inventory through Activating Scenarios Revised (SAIAS-R; Rijo & Pinto-Gouveia, 1999, 2006) in order to overcome some of the limitations pointed above. The SAIAS uses descriptions of several
life events, representing specific scenarios theoretically related to the origin and present activation of specific EMSs. It is postulated that once the subject,
according to instructions, reads and imagines each situation described in the SAIAS, EMSs will become activated, thus leading to higher scores in the items
assessing that specific EMS.This paper presents the new revised version of the SAIAS, and preliminary results of a study comparing EMSs assessment with
the SAIAS-R and the YSQ-S3 in a normal and patient sample.
The Nature of Coping?The perspectives of avoidance and overcompensation
A. Karaosmanoglu and G. Soygut*, Psikonet Psychotherapy Centre, Istanbul, Turkey & Hacettepe University, Ankara, Turkey *
Coping Styles are the ways the child adapts to EMS's. These adaptation behaviors are Surrender, Avoidance and Overcompensating. Our study aims to
provide empirical data for the relations between EMS's and coping behaviors and to investigate the nature of coping by the use of YSQ-S3, YCI and YRAI
on a clinical population of 690 patients. Different perspectives of coping are examined by studying the first and the higher order factors that emerged. The
correlations of these factors with EMS's are also investigated. The results of PCA of YCI showed that ten factors exist in over-compensation: Intolerance to
Confrontation, Distant, Orderliness, Control, Rebelion, Status Seeking, Over Autonomy, Aggressiveness, Ego-Centrism, Manuplation. Examining the higherorder factor structure of YCI, two overcompensation domains appeared as separate factors: Over-Control (as it reflects a style that is occupied with rules,
order and control) and Over-Assertiveness (as reflects a style that one is focusing on his short term gratification, wishes, impulses and has problem with the
rules). The eight factors extracted after PCA of YRAI are Self Soothing, Psychosomatism, Emotional Block, Substance Use, Social Withdrawal, Thought
Block, Memorial Block and Over Rationality. Two higher-order factors extracted: Experiential Avoidance and Cognitive Avoidance. Experiential Avoidance is a
style that one tries to avoid from painful feelings by changing his experience in that moment by sensational and/or behavioral actions. The significant
correlations between these factors supports the theory that postulates coping styles are the adaptation ways to EMS's.
Symposium 102
Borderline Persoanlity Disorder: Connecting basic research to cognitive-behavioral treatment
Convenor: Arnoud Arntz, University of Maastricht, the Netherlands
Construct Validity and Prevalence of Borderline Personality Disorder Among Chinese Psychiatric Patients in China
Freedom Leung, Kit Chan & Fanny Cheung, Chinese University of Hong Kong, China
The Chinese Classification of Mental Disorders-III (CCMD-III; CPA, 2001) rejects borderline personality disorder (BPD) as a valid diagnostic category. As a
result, few clinicians in China are familiar with the BPD construct, and no systematic research has been conducted to examine the construct validity and
prevalence of BPD among Chinese psychiatric patients. The present study explored the construct validity and the prevalence of BPD among Chinese
psychiatric patients in China. Participants, 696 psychiatric patients with major depression, anxiety disorders or substance dependence, were part of a larger
standardization sample for the Chinese Personality Assessment Inventory (CPAI). Subjects completed the Chinese Personality Disorders Inventory (CPDI)
and the CPAI under the supervision of their attending clinicians. Findings indicated that the DSM-IV-TR BPD criteria set has good internal consistency (with
alpha = .71, and item-total correlations ranged from .30 to .47). Using a rigorous simulated diagnostic procedure, 10.5% of patients were found to meet the
diagnosis of BPD. Among the BPD patients, two interesting subgroups were identified. One group displayed concurrent mood and impulse dysregulation,
another group mood dysregulation only. When compared to the non-BPD patients, both BPD subgroups reported elevated disturbances in affective,
impulsive, interpersonal and cognitive domains as assessed by CPAI. The BPD subgroup with both mood and impulse dysregulation, however, showed the
most disturbed personality profile. Findings of this study support the generalizability of the BPD construct to the Chinese population. Implications of these
findings for the future version of the Chinese Classification of Mental Diseases (CCMD) were discussed.
Hypersensitivity to rejection in borderline personality disorder
Babette Renneberg (1,2), Kerstin Herm (2), Katja Friemel (3), Stefan Roepke (4) and Claas-Hinrich Lammers(5), (1) University of Frankfurt,
Germany,(2) Free University of Berlin, Germany; (3) University of Heidelberg, Germany; (4) Charité, Department of Psychiatry, Berlin; (5)
Asklepsios Klinik Nord, Hamburg, Germany
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Patients with BPD are extremely sensitive for and have strong reactions to specific themes like abandonment, loneliness and often feel neglected. One
trigger that causes emotional turmoil in these patients is (perceived) rejection. Aims of the study were to compare BPD patients with a non clinical group in
their reactions to an experimentally induced exclusion situation.Method: 30 patients with BPD and 30 non-clinical control participants played “cyberball”
(Williams, 2001), a virtual ball-tossing game that induces ostracism experimentally by including or excluding the participant. Participants were randomly
assigned to the experimental situation. Before and shortly after playing cyberball participants completed several self-report questionnaires. Borderline
patients received three-months inpatient dialectical behavior therapy. The relationship of hypersensitivity to rejection and treatment outcome is
examined.Results: Even in the inclusion condition patients with BPD underestimated the percentage of time they received the ball significantly. When
included, their fundamental needs (belonging, self-esteem, control and meaningful existence) were met to the extend control participants reported after
exclusion. When excluded, patients with BPD reported a significantly larger threat of fundamental needs compared to the non-clinical sample. This was
accompanied by reports of strong negative emotional reactions. The extent to which BPD patients felt excluded is currently examined in its relationship to
treatment outcome. Discussion: Patients with BPD perceive exclusion from a game even when they are included. Results highlight the extreme need for
BPD patients to receive attention. The relationship of the perceived hypersensitivity to treatment outcome for BPD will be discussed.
Effects of Dialectic-Behavioral-Therapy on the Neural Correlates of Affective Hyperarousal in Borderline Personality Disorder
Knut Schnell, M.D.1) Sabine C. Herpertz M.D.2), 1) University of Cologne, Germany; 2) Rostock University, Germany
The effects of psychotherapy are thought to be mediated by changes in the cerebral networks (Martin et al., 2001; Goldapple et al., 2004; Paquette et al.,
2003; Furmark et al., 2002). Our pilot study examined whether improved regulation of affective arousal following dialectic-behavioral therapy (DBT) in
Borderline personality disorder (BPD) translates into changes in relevant neural systems. Methods: We applied five sequential fMRI scans over a 12-week
in-patient treatment program. Six female BPD patients and six controls were included in an event-related fMRI design which induced emotional arousal
through standardized images. In addition to analyzing valence-based stimulus categories over time, the study assessed the correlation between the extent of
hemodynamic responses and the magnitude of subjectively experienced emotional arousal. Results: BPD data revealed a decreasing hemodynamic
response to negative stimuli in the right-sided anterior cingulate, temporal and posterior cingulate cortices as well as in the left insula. In addition, these
areas displayed a continuous decrease of correlation between hemodynamic responses and subjectively experienced arousal in BPD patients. Moreover the
four DBT-responders displayed a reduction of this correlation in the left amygdala and both hippocampi. Conclusions: fMRI designs that use multiple
repeated measures are suitable for application in therapy research. In our pilot study DBT treatment was accompanied by functional neural changes in limbic
and cortical regions resembling those reported on psychotherapy effects in other mental disorders.
Central and Peripheral Emotional Responses in BPD and Changes due to Treatment: a fMRI Study.
Arnoud Arntz1, Freddy van der Veen2, Pieter van der Heijden1 & Dominique Gielen1., 1 University of Maastricht, the Netherlands; 2 Erasmus
Medical Center Rotterdam, the Netherlands
Borderline Personality Disorder is known as a disorder characterized by hyper-emotionality. Brain imaging studies have indeed indicated that brain regions
related to processing of (negative) emotions are hyperactive in BPD (notably the amygdala). Remarkably, the evidence from studies using peripheral
psychophysiological measures is inconclusive, as previous studies found normal or even subnormal psychophysiological responses to emotional stimuli in
BPD. This dissociation may be related to the high levels of childhood traumata common in BPD. We studied within the same session central (notably
amygdala), peripheral (skin conductance responses and heart rate), and subjective responses (valence ratings) to emotionally negative, positive and neutral
slides. Two types of emotional stimuli were used: purely visual stimuli, assumed to evoke primary emotional reactions, and neutral pictures combined with a
sentence conveying a negative, neutral or positive meaning related to BPD specific themes like abandonment, abuse and rejection. The last type was used
to study whether amygdala hyper-responsivity was also elicited by ecologically more valid complex emotions, which are elicited by cognitively mediated
meanings. BPD patients were compared to Cluster-C patients and nonpatients to investigate the specificity of previously reported effects. Next, to study
whether or not successful treatment leads to normalizing of emotional processing, we compared BPD patients before and after successful psychological
treatment. The first results of this study will be presented.
Symposium 117
Comparing direct and indirect assessment of cognitions and emotions in patients with personality disorders and
Convenor: Jill Lobbestael, Maastricht University, The Netherlands
Activation of latent self-schemas as a cognitive vulnerability factor for depression: the potential role of implicit self-esteem
Erik Franck, Rudi De Raedt, & Jan de Houwer, Ghent University, Belgium.
To date, only two studies investigated implicit self-esteem in currently depressed individuals. Surprisingly, both studies found evidence against the cognitive
theory of depression. We tried to replicate these findings by investigating implicit self-esteem using the Implicit Association Test (IAT) in never depressed
controls (ND), formerly depressed individuals (FD), and currently depressed patients (CD). Furthermore, we investigated the influence of a negative mood
induction (MIP) on implicit self-esteem in ND controls and FD individuals. The results are in line with the previous two studies suggesting no difference in
implicit self-esteem between CD patients and ND controls. In addition, compared to ND participants, FD individuals showed a significant drop in implicit selfesteem after the negative MIP, but this was due to a higher implicit self-esteem before the MIP. These results are discussed in the light of new perspectives
on implicit self-esteem and depression.
Intensity of emotional reactions in Patients with Borderline Personality Disorder
Gitta Jacob, PhD; Klaus Lieb, MD, University of Freiburg Medical School, Germany
Emotional dysregulation is a prominent feature of borderline personality disorder (BPD). In the clinical impression, BPD patients react strongly to emotional
stimuli and return to baseline slower than other patient groups or healthy persons. However, this mechanism has hardly been tested experimentally. In our
study we induce the emotions anger, joy and shame in patients with BPD, patients with major depression and healthy control persons and investigate the
intensity and the duration of the induced emotions. Emotions are induced via auditively presented short stories, the intensity of emotions is assessed with
repeated self ratings. Preliminary results show a similar joy reaction in patients with BPD and healthy controls, and a prolonged, but not stronger, anger
reaction. Shame is stronger in BPD. We discuss the results with regard to the connection between different BPD symtoms such as emotional dysregulation
and impulsivity.
Indirect assessment of cognitive self- and other schemas in patients with Personality Disorders
Lotte Bamelis, Maastricht University, The Netherlands
This presentation will focus on the use of an indirect measure, the Semantic Simon Paradigm, in a randomized controlled study, in which the (cost-)
effectiveness of Schema Focused Therapy (SFT) will be assessed. This large multi center trial is currently in progress in the Netherlands and compares the
clinical effectiveness of SFT, Client Centered Therapy (CCT) and Treatment as Usual (TAU) for people with 6 personality disorders (cluster C, paranoid,
narcissistic and histrionic PD).After a baseline assessment prior to treatment, people are randomly assigned to SFT, TAU or CCT. During treatment,
assessments occur every 6 months, and at 1-year follow-up. A substantial part of the outcome measures comprises the study of self- and other related
schema's in people with the abovementioned disorders. Next to studying specific schemas in the 6 different PD's at baseline assessment, focus will also be
on the possible effect of therapy in changing (dysfunctional) schema's and cognitions.Most of the instruments assessing schemas and beliefs in this study
rely on explicit measures. Because this onesided use could have some serious disadvantages, an indirect measure (the Semantic Simon Paradigm) was
modified and added to the test battery. This presentation will focus on the developmental process of creating an indirect paradigm suitable for studying
change and effectiveness. We believe that in July 2007 some preliminary data regarding the self- and other schemas in the current trial can be presented.
Indirect assessment of cognitive self- and other schemas in patients with Personality Disorders
Jill Lobbestael & Arnoud Arntz, Maastricht University, The Netherlands
This study assessed the effects of inductions of anger and abuse related emotions in patients with BPD and antisocial personality disorder, as compared to
patients with cluster C personality disorders and healthy controls. Patients were administered a stress induction interview, aimed at eliciting anger related
emotions. Retrieval of abuse related emotions were induced by means of a film fragment. In this study, the effect of induced emotions on self-reported
emotional state and cognitive beliefs was measured. Since antisocial populations frequently demonstrate under reportage of negative emotions, indirect
assessment methods may more reliable indicate changes in experienced emotions. Therefore, physiological reactivity (heart rate, blood pressure and skin
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conductance) and implicit associations tasks were measured as well. These implicit tasks are variants of the Implicit Association Task (IAT); for anger related
emotions, one IAT was developed to measure the association between the self and anger, and one for the association between the aggressor (identified by
the participant) and swearwords. For abuse related emotions, an IAT was developed to measure the association between self and abuse-related words.
Preliminary results demonstrate that there were no differences between groups on the explicit measures. In contrast, group differences were found as to the
implicit level. Further results will be discussed at the conference.
Cognitive-Behavioral Therapies for Forensic Patients with Personality Disorders: Toward Evidence-Based Clinical
Convenor: David Bernstein, University of Maastricht, Department of Clinical Psychological Science, The Netherlands, The
Kerry Beckley, Rampton Hospital, UK
Research and service provision for personality disordered offenders in the UK has increased significantly in the last decade. Livesley (2003) identifies a
number of factors considered essential to the delivery of effective treatments with personality disordered individuals and these have been adhered to in the
development of Rampton Hospitals Personality Disorder Directorate Treatment Pathway. The Schema Therapy Programme has been developed within this
existing treatment framework which caters for some of the most complex and high risk individuals within psychiatric settings. The Schema Therapy
Programme incorporates various components (individual therapy, group therapy, team formulation and staff training) and aims to have a more wide-ranging
impact on the service, as well as the individuals the service aims to treat. The role of each component will be considered in terms of how it contributes to
the overall aim of reducing risk of recidivism in the patient group. The challenges faced in conducting research and developing treatment protocols using
Schema Therapy with such a heterogeneous group of individuals are also identified and consideration is given to how these can be most effectively
Jill Lobbestael, MSc., & Arnoud Arntz, Ph.D., University of Maastricht, the Netherlands
In this study, patients with antisocial personality disorder were assigned to high, middle of low psychopathy subgroups, based on their PCl-r score. In
addition, these patients were compared to patients with borderline and cluster C personality disorder (all assessed with SCID II), next to a non-patient
control group. They were administered a stress induction interview, aimed at eliciting anger related emotions, and were shown an abuse film fragment. At
pre- and post stages of this interview, self reported levels of basic emotions were assessed (POMS). Since antisocial population frequently demonstrate
under reportage of negative emotions, indirect assessment methods may more reliable indicate changes in experienced emotions. Therefore, the current
study incorporated two additional implicit methods. First, changes in physiological indices of heart rate, skin conductance response, blood presses and facial
EMG (corrugator supercilii) were measured. Secondly, three variants of the Implicit Association Task (IAT) were developed; one to measure the association
between the self and anger, one for the association between the aggressor (identified by the participant) and swearwords, and one to measure the
association between self and abuse. During the presentation, results will be discussed.
Robert L. Trestman, University of Connecticut Health Center, CT, USA
Based on preliminary work with an adaptation of Dialectical Behavior Therapy in three Connecticut prisons, we developed a new evidence-informed, manualguided skills training program for offenders with behavioral disorders. The structure & design of START NOW was designed to take into account the
pragmatic limitations of most correctional facilities. Behaviorally disordered individuals often have cognitive, emotional, and interpersonal deficits limiting their
ability to benefit from some frequently employed cognitive behavioral approaches. Such individuals often require extensive institutional resources for
behavioral management. As many offenders have limited education, it is written at a fifth grade reading level. As information processing and retention is
often impaired, it is highly graphic, employs many iconic images and avoids jargon. START NOW skills training was designed to target the needs of these
individuals, and is informed by a number of theoretical approaches & models. It is primarily a cognitive behavioral skills training model that includes a
detailed facilitator protocol and fidelity monitoring tools. It is influenced by findings from our research with an adaptation of DBT and incorporates a cognitive
neurorehabilitative approach. Motivational interviewing principles & practices are inherent in its design. Further, it incorporates a gender specific approach
and is informed by trauma sensitive care principles.
Symposium 136
Recent developments in antisocial and borderline personality disorder: experimental and intervention studies
Convenor: Kate Davidson, University of Glasgow, UK, UK
Further analysis from the BOSCOT trial
Kate M Davidson & John Norrie*, University of Glasgow Scotland, UK.;.*CHART, University of Aberdeen, Scotland
In this talk we further explore the estimated treatment effects found in the BOSCOT randomised controlled trial of cognitive behavioural therapy (CBT) on top
of treatment as usual (TAU) compared with TAU in 106 people with borderline personality disorder, recently reported in the Journal of Personality Disorder
(Davidson et al, 2006). Those results were based on the principle of intention-to-treat (ITT), which is recognised as the appropriate methodology for the
principle reporting of a randomised controlled trial. The additional analyses presented here go beyond the ITT results, and seek to further illuminate and
interpret them by reporting information on the quantity and quality of therapy received, and relating this information to the study outcomes using causal
modelling (in particular, the Complier-Adjusted Causal Effects, or CACE estimate, as discussed by Dunn et al, 2003 & 2005). In addition, we investigate any
possible delay in the treatment effect manifesting itself (sometimes a feature of complex interventions (MRC Guidelines, 2001) such as CBT), and finally
present a predictive model for suicidal behaviour using covariates measured at the time of randomisation. We also discuss our plans for the long term follow
up of the BOSCOT participants.
Impulsivity in Borderline Personality Disorder and Antisocial Personality Disorder: A review of the evidence from experimental
tasks and self-report measures
Anna Sutherland, University of Glasgow, UK.
To review the experimental and self-report evidence regarding impulsivity in BPD and ASPD, with the aim of providing a conceptual basis for the subsequent
development of a cognitive model of impulsivity in the context of personality disorder.Design: An electronic search of relevant databases was conducted:
Evidence Based Medicine Reviews Collection, CINAHL, EMBASE, MEDLINE, PsychINFO and Web of Science. Hand searches of the reference lists of the
reviewed studies and of six key journals were conducted.Method: Studies involved either a BPD or an ASPD adult sample, and a comparison nonpsychiatric adult sample. Studies also included i) behavioural experimental tasks related to impulsivity, ii) psychometric self-report measures related to
impulsivity. Behavioural and psychometric measures of impulsivity were detailed as outcome variables. All studies were experimental. Results: Nine studies
were included in this review. An adapted SIGN Checklist was utilised in the evaluation of the methodological qualities of each study. Conclusion: Results
from experimental tasks and self-report measures facilitate the understanding of impulsivity in BPD and ASPD. Based on evidence from the reviewed
studies, it is proposed that impulsivity in BPD and ASPD can be considered in terms of subtypes that are manifested under certain conditions. The reviewed
studies report evidence supporting the presence of delay-aversion, feedback-insensitivity, non-planning, time-perception and reflection-impulsivity subtypes
in BPD, and the presence of a feedback-insensitivity subtype in ASPD. Recommendations for further investigation of these subtypes are made.
Clarity of self-concept and identity in Borderline Personality Disorder.
MC Obonsawin 1, KM Davidson 2 and J Carlisle 1, University of Strathclyde, UK 1 and University of Glasgow 2
Developmental identity disturbance is a diagnostic criteria for Borderline Personality Disorder (BPD) (Lieb et al, 2004; Sanislow et al., 2000), and is a
consistent feature in many conceptualisations of BPD (Livesley, 1998). Despite clear agreement about the importance of identity disturbance in BPD, there
is only one previous empirical report on the issue (Wilkinson-Ryan and Westen, 2000). The data about identity disturbance for that study was obtained from
clinicians, and the authors defined the components of identity disturbance with factor analysis. The aim of this study is to investigate the nature of the
identity disturbance in BPD by obtaining information from the individuals with BPD. To reduce the demand characteristics of the study, we will obtain the
information about identity by requesting individuals with BPD to complete some tasks. Individuals with a diagnosis of BPD, Major Depressive Disorder
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(MDD) and individuals without a psychiatric diagnosis will rate the extent to which a particular word reflects who they are (a score of 5) and who they are not
(score of 1). Participants will also complete a speeded computerised task during which they will make a forced choice as to whether a word reflects who
they are (me) or who they are not (not me). The data will provide information on the level of certainty of these individuals about their identity, the stability of
their identity schemas, the range of the identity disturbance, and on the similarities between the identity disturbance in individuals with BPD with that of
individuals with MDD.
A randomised controlled trial of cognitive behaviour therapy for violent men with antisocial personality disorder: trial aims
and design.
Kate Davidson & Judith Halford*, University of Glasgow, Scotland;* NHS Greater Glasgow and Clyde
We report on a randomised controlled trial of CBT for violent men with ASPD Design: MASCOT is a pilot multi-centre randomised controlled trial of CBT for
men who are violent and who meet diagnostic criteria of ASPD. Over 50 participants were randomised to either treatment as usual or to CBT for ASPD.
Experienced mental health professionals trained in CBT undertook to provide either 6 and12 months of therapy with the above patientsMethods: Trial
methodology, measures and milestones will be described.Results: All participants met diagnostic criteria for antisocial personality disorder and had a history
of violent acts towards others. Baseline socio-demographic, mental health and social functioning, characteristics of the group will be described.Discussion:
Trial participants with ASPD are a disadvantaged group. The learning outcomes from delivering therapy should help to take future research trials forward
and help the transfer of research into the reality of clinical practice.
Symposium 159
Interventions for Anger and Violence
Convenor: Raymond Novaco, University of California, Irvine, USA, USA
Jumping in at the deep end: Can we reduce violence risk in high-risk violent offenders?
Devon Polaschek, Victoria University of Wellington, New Zealand
In 1998 the doors opened for the first time at Unit 9, Rimutaka prison, which is the first, and still the only purpose-built unit in the New Zealand prison system
for rehabilitating serious violent offenders. Over the intervening years, there have been many challenges in developing and managing this 30-bed
programme, but a recent evaluation of its impact on subsequent convictions for violence suggests that we should persevere in our endeavours to reduce the
impact these men have on the communities into which they seek to be paroled. This paper presents violent and general recidivism outcome data on more
than 100 men who entered the programme and a matched group of violent prisoners who did not. In making sense of the results, I touch on some of the
challenges to treatment integrity posed by these clients and the system in which they are embedded.
Anger and aggression in Swedish prisoners and forensic psychiatric patients
Judit Lindqvist1 and Heidi Selenius2, 1 Växjö University, Sweden;2 Stockholm University
Anger and violent behaviour have emphasis with criminal offenders. In Sweden, as elsewhere, the presence of serious mental disturbance determines
whether violent offenders are sentenced to prison or to forensic psychiatric care. Accordingly, we examined levels of anger and aggression in 95 prison
inmates in the Kumla, Norrtälje, and Mariefred prisons and in 45 forensic psychiatric patients of comparable age at the Forensic Psychiatric Centre in
Sundsvall. We examined relationships between anger, aggression, and ADHD. Participants completed the Novaco Anger Scale (NAS), the Aggression
Questionnaire (AQ), and the Wender Utah Rating Scale (WURS), a retrospective measure of ADHD in childhood.Compared with forensic psychiatric
patients, prison inmates reported significantly higher anger and lower anger regulation on the NAS. They were significantly higher on the AQ Physical
Aggression and Total scores, but not on Verbal Aggression, Hostility, or Anger, although there was a higher trend on the latter two indices. Among the
forensic psychiatric patients, there were significant relationships between NAS, AQ, and WURS. The differences may be due to prison inmates being in their
initial phase of their sentences, compared with the forensic patients who had longer institutional care and had received psychopharmacological medicine.
Differences between these groups in types of psychological disturbances are examined pertinent to intervention for anger and aggression. The relationship
between anger and ADHD and between them and violent behaviour suggests a need to look at intersecting factors when attempting aggression reducing
strategies for forensic psychiatric patients.
The Contribution of Anger to the Behaviours and Psychological Difficulties of Personality Disordered Offenders
Stanley J. Renwick, Ron Tulloch, & Helen Green, Care Principles, Linden House, UK
Despite the acknowledged relevance of anger and anger regulation difficulties to the behavioural manifestations of a number of personality disorders, it is
argued that the role and contribution of anger in such circumstances is poorly understood and operationalised. Correspondingly, the scope and utility of
anger interventions with personality disordered patients remains to be articulated with regard to both the remediation of offending behaviour and influence of
underlying personality structures.Utilising experience from a new specialised medium secure service for personality disordered offenders in the UK, empirical
evidence will be presented regarding the nature and degree of anger problems amongst this population. This will involve both anger self report (NAS &
STAXI-II) and clinician-rated (WARS) assessment of anger and aggression. The psychometric findings illustrate the clinical and forensic salience of anger
problems for this personality disordered offender population. Clinical vignettes buttress the quantitative findings and portray the multifaceted nature of anger
presentations.Further, evidence will be provided regarding the relationship between constituent elements of the described anger problems (self-reported and
clinician rated) and diagnostic measures of Personality Disorder (MCMI-III & SCID-II). Consideration of underlying cognitive schematic configuration (YSQ)
and interpersonal functioning (CIRCLE) variables will be given to elaborate the anger construct in conjunction with the psychosocial deficits of this clinical
sample. This, it will be proposed, carries significant implications for both current conceptualisations of personality disorders in offender populations, as well
as highlighting critical therapeutic interventions with these patients.
Group-based CBT Anger Treatment in a High Security Forensic Hospital and Changes in Emotional Intelligence
Carolin Walker1, John D. McGinley1, and Raymond W. Novaco2, 1The State Hospital, Scotland, UK;2 University of California, Irvine, USA
Forensic hospital patients, detained because of their “dangerous and criminal propensities”, often have substantial difficulties associated with anger. In
particular, the role of anger as a likely causal factor in the activation of aggression before hospitalisation, during hospitalisation, and after hospital discharge
is becoming acknowledged. Anger is a dynamic variable that is responsive to treatment, particularly CBT, as a number of meta-analyses have
demonstrated. Many anger treatment studies, however, have not involved seriously disordered patients, and most CBT-based interventions for anger have
been conducted in an individual-based format. A group-based, 18-session CBT anger treatment for high security forensic patients at The State Hospital,
Scotland, will be described in its components and systems-level implementation. Its procedural innovations are designed to address treatment-resistant
characteristics of the client population, including cognitive impairment, suspiciousness, demoralization, low support resources, chaotic life circumstances,
and general entrenchment of anger in their personality. Treatment efficacy concerning the 6-8 patient groups has been evaluated through multiple measures
of anger and antagonistic behaviour on psychometric instruments in a wait-list control design with 4 cohorts (Ramm & Novaco, 2007). Elaboration of the
treatment and outcome results for its ongoing implementation is presented, including findings from patient focus-groups conducted on follow-up. In
conjunction with gains in anger control, we have found significant changes in emotional intelligence (EQi), particularly on intrapersonal dimensions of
emotional self-awareness, assertiveness, and independence. The emotional intelligence findings have relevance for our views of forensic patients and for
the interventions that we attempt with them.
Anger Treatment for Offenders With Intellectual Disabilities: A Digest of Outcomes, Process and Theoretical Issues
John L. Taylor, Northumbria University and Northumberland, Tyne & Wear NHS Trust, UK
Aggressive behaviour is common in intellectual disability populations and is the most frequent reason for the hospitalisation and prescription of behaviour
control drugs amongst people in this population. It also carries high costs for staff and services working with this client group. Anger has also been shown to
be strongly associated with and predictive of aggression in forensic intellectual disability services. For these reasons anger is a legitimate target for
treatment in offenders with intellectual disabilities residing in secure settings.
Page 92
Symposium 175
Schema-focused therapy for borderline personality disorder
Convenor: Philip Spinhoven, Leiden University, The Netherlands
One-year follow-up of schema-focused therapy and transference-focused psychotherapy for BPD, and the influence of drop-out
status, treatment status and medication
Josephine Giesen-Bloo, PhD; Richard van Dyck; Philip Spinhoven; Willem van Tilburg; Carmen Dirksen; Thea van Asselt; Ismay Kremers; Marjon
Nadort, MSc & Arnoud Arntz, University of Maastricht, The Netherlands
Results will be presented on the effectiveness of three years of Schema Focused Therapy (SFT) and Transference Focused Psychotherapy (TFP) in a
multicenter randomized controlled two group design and maintenance of the results after a 1-year follow-up period. Three years of twice weekly SFT and
TFP proved to be effective in reducing borderline specific psychopathology and co-morbid psychopathology. After three years, SFT was more effective than
TFP on all measures. One-year follow-up results continue to show a positive treatment perspective for BPD, as more BPD-patients achieved recovery and/or
reliably changed status than after 3 years. The influence of drop-out status, treatment status and medication will also be discussed.
Outpatient psychotherapy for borderline personality disorder: The cost-effectiveness of schema-focused therapy versus
transference-focused psychotherapy
Thea van Asselt; Carmen Dirksen, Arnoud Arntz, Josephine Giesen-Bloo, Richard van Dyck, Philip Spinhoven, ; Willem van Tilburg, Ismay
Kremers, PhD; Marjon Nadort, MSc & Hans Severens, PhD, University Hospital Maastricht, The Netherlands
This study aimed to assess the cost-effectiveness of Schema Focused Therapy (SFT) and Transference Focused Psychotherapy (TFP) for Borderline
Personality Disorder (BPD) in a randomized multicenter trial. Final analysis was performed with 86 patients (42 for TFP and 44 for SFT). Treatment
consisted of three years of twice-weekly sessions. A cost-interview was administered every three months for three years, and once again at follow-up at 4
years. Quality of Life was measured with the EuroQoL-5D. Outcomes were costs per recovered patient as measured with the Borderline Personality
Disorder Severity Index-IV (BPDSI), and costs per Quality Adjusted Life Years (QALYs). Bootstrapped total costs over 4 years for SFT were €37,826, and
€46,795 for TFP (95% uncertainty interval for the difference: -€21,775 to €3,546). QALYs were 2,15 for SFT and 2,27 for TFP (ns), due to a lower utility
score for SFT in the first 18 months of treatment. For cost per recovered patient, SFT is dominant (i.e more effective and less costly). For the QALY
outcome, SFT is less costly and slightly less effective than TFP; €90,457 savings for one QALY loss. Extrapolating the QALY outcome results for time
horizons of 10 and 15 years leads to SFT being dominant. Although both therapies save costs and improve QoL compared to baseline, SFT is superior in
costs and effects in terms of recovered patients. In terms of QALYs, the conclusion is uncertain, but in the longer run, QALYs seem