Background: Previous studies of self-practice/self-reflection (SP/SR) CBT training have found that trainees report significant benefits from practising CBT techniques on themselves (self-practice) and reflecting on their experience (self-reflection) as a formal part of their CBT training. However, not all trainees experience the same level of benefit from SP/SR and not all types of training course produce benefits to the same extent. Aims: This paper examines the question: What factors influence trainees’ reported benefit from SP/SR? The aim was to develop a model to maximize the value of SP/SR training. Method: The authors used a grounded theory analysis of four SP/SR training courses, varying along several dimensions, to derive a model that could account for the data. Results: A model was derived comprising of seven elements: Two outcomes – “Experience of Benefit” and “Engagement with the Process” – that mutually influence one another; and five other influencing factors – “Course Structure and Requirements”, “Expectation of Benefit”, “Feeling of Safety with the Process”, “Group Process”, and “Available Personal Resources” – that mediate the impact on Engagement with the Process and Experience of Benefit from SP/SR. Conclusions: A model that provides guidance about the best ways to set up and develop SP/SR programs has been developed. This model may now be subject to empirical testing by trainers and researchers. Implications and recommendations for the design and development of future SP/SR programs are discussed.

Background: Hoarding is associated with significant impairment. Although traditionally considered as a symptom of obsessive-compulsive disorder (OCD), some authors have proposed that pathological hoarding could be considered as a stand alone condition. The prevalence of pathological hoarding behaviour has been shown to be high in some countries, but little is known about the prevalence and correlates of hoarding in the non-clinical population in Italy. Method: We studied the prevalence of self-reported hoarding behaviour using the Italian version of the Saving Inventory-Revised, as well as the association between hoarding and various clinical correlates, including obsessive-compulsive symptoms, compulsive buying, anxiety, and depression. Results: The prevalence of pathological hoarding behaviour in two studies was between 3.7 and 6.0%. No differences were found between hoarding and non-hoarding participants with regard to gender, age, marital status, level of education, and employment status. Significant correlations were found between compulsive hoarding and obsessive-compulsive symptoms and also between hoarding and a measure of compulsive buying, even after controlling for anxiety and depressive symptoms. Conclusions: These results indicate that pathological hoarding may also be prevalent in Italy and highlight the need for further epidemiological studies using validated instruments to assess hoarding disorder.

Background: Recent work on cognitive-behavioural models of obsessive-compulsive disorder has focused on the roles played by various aspects of self-perception. In particular, moral self-ambivalence has been found to be associated with obsessive-compulsive phenomena. Aims: In this study we used an experimental task to investigate whether artificially priming moral self-ambivalence would increase participants’ deliberation on ethical problems, an index that might be analogous to obsessive-compulsive behaviour. Method: Non-clinical participants completed two online tasks designed to prime either moral self-ambivalence, general uncertainty, or neither. All participants then completed a task requiring them to consider solutions to moral dilemmas. We recorded the time participants took to respond to the dilemmas and the length of their responses; we then combined these variables to create a measure of deliberation. Results: Priming moral self-ambivalence led to increases in deliberation, but this was only significant among those participants who scored highly on a baseline measure of moral self-ambivalence. Priming general uncertainty had no significant effect upon deliberation. Conclusions: The results suggest that moral self-ambivalence may play a role in the maintenance of obsessive-compulsive behaviour. We propose that individuals who are morally self-ambivalent might respond to situations in which this ambivalence is made salient by exhibiting behaviour with obsessive-compulsive characteristics. These findings have implications for the incorporation of ideas about self-concept into theories of obsessive-compulsive disorder.

Background: More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. Aims: Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. Method: Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. Results: Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. Conclusions: Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.

Background: Rational Emotive Behaviour Therapy (REBT) assumes that rational beliefs act as cognitive protective factors against the development of psychopathology; however little empirical evidence exists regarding the nature of the possible protective effects that they offer. Aims: The current study investigates whether rational beliefs moderate the impact of irrational beliefs on posttraumatic stress symptomology (PTS). Method: Three hundred and thirteen active law enforcement, military, and related emergency service personnel took part in the current study. Sequential moderated multiple regression analysis was employed to investigate: (i) the direct impact of irrational beliefs on PTS; (ii) the direct impact of rational beliefs on PTS; (iii) the moderating effects of rational beliefs in the relationship between irrational beliefs and PTS. Results: The irrational beliefs predicted by REBT theory emerged as critical predictors of PTS symptomology, in particular Depreciation beliefs. Rational beliefs (Preferences, and Acceptance beliefs) had a direct, negative impact on levels of PTS, and Acceptance beliefs moderated the impact of Catastrophizing beliefs on PTS. Conclusions: Irrational beliefs are important cognitive vulnerability factors in symptoms of PTS, while rational beliefs (Acceptance) appear to have a protective role in the emergence of PTS symptoms, both directly and by moderating the impact of Catastrophizing beliefs.

Background: Self-regulatory executive function theory (Wells and Matthews, 1994; Wells, 2008) stresses the role of metacognitions in the development of emotional disorders. Within this metacognitive model, positive beliefs about ruminative thinking are thought to be a risk factor for engaging in rumination and subsequently for depression. However, most of the existing research relies on retrospective self-report trait measures. Aims: The aim of the present study was to examine the theory's predictions with an Ecological Momentary Assessment approach capturing rumination as it occurs in daily life. Method: Non-clinical participants (N = 93) were equipped with electronic diaries and completed four signal-contingent momentary self-reports per day for 4 weeks. A multilevel mediation model was computed to examine associations between positive beliefs about rumination and ruminative thinking and negative affect in daily life. Results: Positive beliefs about rumination were significantly associated with ruminative thinking as it occurs in daily life. We further found evidence for a negative association with positive affect that was completely mediated via ruminative thinking in daily life occurring in response to negative emotions. Conclusions: Our results add ecologically valid corroborating evidence for the metacognitive model of emotional disorders within the framework of self-regulatory executive function theory.

Background: Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. Aim: To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. Method: This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. Results: More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. Conclusion: Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

Background: Paramedics are frequently subjected to traumatic experiences and have higher PTSD prevalence rates than people in the general population. However, the vast majority of paramedics do not develop PTSD. While several risk factors for PTSD have been established, little is known about protective factors. It has been suggested that a good sense of coherence (SOC) and high resilience lower the risk for developing PTSD. Aims: To examine whether SOC and resilience are associated with PTSD severity in paramedics. Method: A cross-sectional study investigated SOC, resilience and PTSD in paramedics (N = 668). PTSD was assessed with the Posttraumatic Stress Diagnostic Scale (PDS); resilience and SOC were measured with the Resilience Scale (RS-11) and the Sense of Coherence Scale (SOC-L9). Further measures included preparation of dealing with traumatic events and availability of psychological help. Results: As expected, both resilience and SOC were negatively correlated with PTSD symptoms. The regression analysis showed that 19.2% of the total variance in symptom severity was explained by these variables. However, SOC was a better predictor than resilience for PTSD severity, as it accounted for more unique variance. Paramedics who were prepared for dealing with work-related traumatic events and who received psychological help had less severe PTSD symptoms and higher SOC scores than paramedics for whom these services were not available. Conclusions: Enhancing resilience, and especially SOC, seems a promising approach to reduce PTSD symptom severity in high risk groups like paramedics.

Background: Dysfunction is an integral part of chronic insomnia. Despite this, very little effort has yet been made to design and psychometrically validate an insomnia-specific measure of dysfunction. Aims: The purpose was to examine the psychometric properties of the Work and Social Adjustment Scale (WSAS) as a measure of dysfunction in chronic insomnia. Method: Seventy-three patients with chronic insomnia from three subsamples participated. All the patients completed the WSAS, the Insomnia Severity Index (ISI), and sleep diaries over one week. Results: An exploratory factor analysis suggested a one-factor solution for the WSAS, determining dysfunction, accounting for 73.7% of the variance. The internal consistency of the WSAS was α = .91. The test-retest reliability for the WSAS items was high at .90–.99 and for the entire scale .99. A cut-off at 17 points was established, discriminating those with subclinical versus moderate or severe clinical insomnia (88% sensitivity and 78% specificity). Evidence of convergent and criterion validity was documented via (1) a significant, positive association between the WSAS and ISI and (2) a higher WSAS score among those with severe clinical insomnia, relative to those with moderate clinical and subthreshold insomnia, as well as a higher WSAS score among those with moderate clinical insomnia relative to those with subthreshold insomnia. The WSAS was also shown to be a treatment-sensitive measure for insomnia patients. Conclusions: The WSAS appears as a reliable and valid measure of dysfunction in chronic insomnia. Additional advantages are its shortness, easiness, and treatment-sensitivity.

Background: Different body-related behaviours and cognitions (checking, avoidance, comparison, display) have been shown to be related to unhealthy eating attitudes in a non-clinical sample. Aims: This study tested whether the use of body-related behaviours is higher in eating-disordered women than in non-clinical women. It also examined whether the use of body-related behaviours is associated with psychological characteristics (particularly anxiety, depression and narcissistic characteristics), controlling for age and eating pathology. Method: Ninety-nine adult women with diagnosed eating disorders (mean age = 30.4 years, SD = 9.44; mean body mass index = 21.9, SD = 6.39) completed standardized measures of eating pathology, anxiety and depression, narcissistic characteristics, and body-related behaviours and cognitions. Results: The Body-Related Behaviours Scale (BRBS) had acceptable levels of internal consistency in this group, and its scales were only weakly to moderately correlated with each other. There were no differences between diagnostic groups, but the clinical group had higher scores that a previous non-clinical sample on three of the scales. The four body-related behaviours had different patterns of association with eating pathology, depression and narcissistic features. However, anxiety was not associated with BRBS scores. Conclusions: The findings support the importance of a wide range of body-related behaviours and cognitions in understanding the eating disorders. However, the lack of an association with anxiety is counter to the suggestion that the various behaviours measured by the BRBS reflect safety behaviours on the part of sufferers. Depression and narcissistic features might be more important in maintaining such behaviours.

Background: Cognitive behavior therapy (CBT) has been found to be generally effective for persons with schizophrenia. Less is known however about those who will engage in this treatment, and among those who engage, who benefits more versus less from this intervention. Aims: This study sought to identify factors associated with treatment engagement and response in persons with psychosis engaged in CBT focused on enhancing work function. Method: Participants were 50 adults with schizophrenia-spectrum disorders participating in a randomized control trial that offered both CBT and a protected employment position over 26 weeks. Survival analysis and discriminant analyses were used to analyze the data. Results: Results indicated that poor treatment engagement and engagement in work was associated with lower educational attainment, more severe baseline levels of negative symptoms, and lower baseline scores on the Arithmetic and Digit Symbol subscales of the WAIS-III. Amongst those participants who did engage, younger age and poorer working memory as assessed by the Arithmetic subscale predicted shorter initial job tenure. More severe levels of positive symptoms and lower self-esteem during the later stages of treatment were associated with worse employment outcomes across the study period. Conclusions: These findings evidence differential predictors of engagement and success and suggest that a subgroup of persons with schizophrenia engaged in CBT and a vocational placement are at risk for poor functional outcomes associated with psychological factors that evolve over time.

Background: Prominent models of social phobia highlight the role played by attentional factors, such as self-focused attention, in the development and maintenance of social phobia. Elevated self-focused attention is associated with increases in self-rated anxiety. Treatments that aim to modify and change attentional processes, specifically self-focused attention, will have a direct effect on social phobia symptoms. Thus, Attention Training targets attentional focus. Aim: The present study aimed to investigate the efficacy of Attention Training in comparison to an established treatment for social phobia, Cognitive Therapy. Method: Participants (Intention-to-treat = 45; completers = 30) were allocated to either 6 weeks of Attention Training or Cognitive Therapy. It was hypothesized that both treatments would be effective in reducing social phobia symptoms, but that Attention Training would work primarily by reducing levels of self-focused attention. Results: The results found an overall effectiveness of both treatment conditions in reducing social phobia symptoms. However, Attention Training significantly improved scores on the Self-Focused Attention questionnaire and the Brief Fear of Negative Evaluation questionnaire compared to Cognitive Therapy. Conclusion: Attention Training seems to be a promising treatment for social phobia.

Background: There is a strong evidence base for psychological treatments in younger adults with schizophrenia, but limited work has been done on adapting these interventions for older people. Aims: We describe a study of a pilot psychosocial intervention group specifically designed to meet the needs of older people with schizophrenia in NHS settings. Method: We used a mixed-methods approach to evaluate the group. We assessed feasibility and acceptability by monitoring uptake and retention in the study. We used a within groups design comparing participants on a range of potentially relevant outcomes at baseline and posttreatment. Treatment acceptability was also assessed by semi-structured interviews conducted at the end of treatment. Results: We recruited 11 participants to the study and 7 of these completed the majority of the group sessions. At a group level participants made improvements in self-esteem and negative symptoms that were statistically significant even in this small sample. Feedback interviews suggested that participants valued the social contact provided by the group and made actual changes in their day-to-day lives as a result of attending. Conclusion: The intervention could offer help with some of the secondary disability associated with the diagnosis of schizophrenia and is acceptable to older adults. Further evaluation is, however, warranted.

Background: Research on post-event processing (PEP), where individuals conduct a post-mortem evaluation of a social situation, has focused primarily on its relationship with social anxiety. Aims: The current study examined: 1) levels of PEP for a standardized event in different anxiety disorders; 2) the relationship between peak anxiety levels during this event and subsequent PEP; and 3) the relationship between PEP and disorder-specific symptom severity. Method: Participants with primary DSM-IV diagnoses of social anxiety disorder (SAD), obsessive compulsive disorder (OCD), panic disorder with/without agoraphobia (PD/A), or generalized anxiety disorder (GAD) completed diagnosis specific symptom measures before attending group cognitive behavioural therapy (CBT) specific to their diagnosis. Participants rated their peak anxiety level during the first group therapy session, and one week later rated PEP in the context of CBT. Results: The results indicated that all anxiety disorder groups showed heightened and equivalent PEP ratings. Peak state anxiety during the first CBT session predicted subsequent level of PEP, irrespective of diagnostic group. PEP ratings were found to be associated with disorder-specific symptom severity in SAD, GAD, and PD/A, but not in OCD. Conclusions: PEP may be a transdiagnostic process with relevance to a broad range of anxiety disorders, not just SAD.

Background: Different theories concerning pathways to insight have been proposed which underpin the numerous assessment measures. Cognitive behavioural therapy (CBT) is one treatment approach that has been used to improve insight. Aims: The aim of this review was to promote a greater focus on developing effective CBT strategies to ameliorate insight in psychosis through the exploration of the concept of insight in psychosis and evaluation of research in the area. Method: A comprehensive search and review of published studies examining the impact of CBT on insight in psychosis was conducted. We searched the databases PubMed, Medline, PsychInfo, the Psychology and Behavioral Sciences Database, and CINAHL with limits set to 10 years, humans, and English language. We hand-searched reference lists of major studies on insight, and theoretical review papers. We filtered our results according to relevance and chose 50 papers for final consideration. Results: The multidimensionality of insight is reflected in the variety of different insight measures in clinical use. Research findings on the impact of CBT on insight are conflicting. Cognitive insight and clinical insight appear to be different concepts that are not fully captured by existing measurement scales. Conclusions: The conflicting results found in research examining the impact of CBT on insight may be partially explained by the different theories underpinning insight in psychosis communicated through psychoeducation in CBT. Furthermore, the use of more than one insight assessment measure may capture the complexity of insight more effectively. Qualitative research with service users would enrich the knowledge in this area.

Background: The perception of self-discrepancies between the actual self and the ideal self has been defined as a cognitive risk factor for depression (Higgins, 1987). In this view, self-discrepancy monitoring (SDM) refers to the voluntary re-orientation of attention towards detecting discrepancies between ideal and actual selves, even in a positive situation. Aims: The goal of this study was to explore the impact of SDM on levels of mood in the face of positive stimuli. Method: Two clinical and two non-clinical samples were recruited from two different European countries (Italy and Romania). All participants were asked to focus on a past positive experience, and were then randomly allocated to one of two induction tasks. The experimental condition consisted of monitoring discrepancies between personal goals and the recalled positive experience, while the control condition consisted of observing what the participant was feeling. Results: The findings show that, after recalling a positive memory, SDM leads to a significant decrease in mood over a short period independent of the severity of depressive symptoms. This effect is partially mediated by the concurrent change in levels of brooding. Conclusions: Self-discrepancy monitoring in response to positive stimuli tends to lower current mood independent of the initial level of depressive symptoms, and seems to be a global trigger of emotional distress that does not refer only to a depressed cognitive style.

Background: Research suggests that core schemas are important in both the development and maintenance of psychosis. Aims: The aim of the study was to investigate and compare core schemas in four groups along the continuum of psychosis and examine the relationships between schemas and positive psychotic symptomatology. Method: A measure of core schemas was distributed to 20 individuals experiencing first-episode psychosis (FEP), 113 individuals with “at risk mental states” (ARMS), 28 participants forming a help-seeking clinical group (HSC), and 30 non-help-seeking individuals who endorse some psychotic-like experiences (NH). Results: The clinical groups scored significantly higher than the NH group for negative beliefs about self and about others. No significant effects of group on positive beliefs about others were found. For positive beliefs about the self, the NH group scored significantly higher than the clinical groups. Furthermore, negative beliefs about self and others were related to positive psychotic symptomatology and to distress related to those experiences. Conclusions: Negative evaluations of the self and others appear to be characteristic of the appraisals of people seeking help for psychosis and psychosis-like experiences. The results support the literature that suggests that self-esteem should be a target for intervention. Future research would benefit from including comparison groups of people experiencing chronic psychosis and people who do not have any psychotic-like experiences.

Background: Video feedback (VF) interventions effectively reduce social anxiety symptoms and negative self-perception, particularly when they are preceded by cognitive preparation (CP) and followed by cognitive review. Aims: In the current study, we re-examined data from a study on the efficacy of a novel VF intervention for individuals high in social anxiety to test the hypothesis that physical appearance anxiety would moderate the effects of VF. Method: Data were analyzed from 68 socially anxious participants who performed an initial public speech, and were randomly assigned to an Elaborated VF condition (VF plus cognitive preparation and cognitive review), a Standard VF condition (VF plus cognitive preparation) or a No VF condition (exposure alone), and then performed a second speech. Results: As hypothesized, when appearance concerns were low, both participants who received Elaborated and Standard VF were significantly less anxious during speech 2 than those in the No VF condition. However, when levels of appearance concern were high, neither Elaborated nor Standard VF reduced anxiety levels during speech 2 beyond the No VF condition. Conclusions: Results from our analog sample suggest the importance of tailoring treatment protocols to accommodate the idiosyncratic concerns of socially anxious patients.

Background: To date no research has investigated the link between Post Traumatic Stress Disorder (PTSD) and perfectionism in a clinical sample. Aims: The aim of the current study was to examine whether there is a relationship between PTSD and perfectionism. This is important to address as many studies have demonstrated a link between other anxiety disorders, eating disorders, depression and perfectionism. The research also aimed to examine whether rumination was a mediator of the relationship between PTSD and perfectionism. Method: The sample consisted of 30 participants who were currently in treatment for PTSD. Results: The results suggest that perfectionism and PTSD symptoms were significantly correlated. In addition, rumination was a significant mediator of the relationship between Concern over Mistakes and PTSD. Conclusions: These findings help increase understanding about the relationships of perfectionism and rumination in PTSD and have implications for the treatment of PTSD.

Background: Alcohol dependence is known to impact upon sleep, and poor sleep has been shown to affect relapse rates following treatment for alcohol dependence. Aims: The aim of this study was to investigate the association between sleep problems and relapse in dependent drinkers in an inpatient setting. This was done by studying sleep related cognitions in individuals undergoing medically assisted alcohol withdrawal. Method: Sleep and sleep-related cognitions data were collected for 71 individuals undergoing detoxification treatment. Sleep was measured using sleep diaries and actigraph motion monitors. Participants completed sleep-related cognition questionnaires and were subject to telephone follow-up interviews. The results were then used to predict relapse rates 4 weeks after discharge. Results: Longer sleep onset latency recorded on the unit predicted relapse at 4 weeks. Higher dysfunctional beliefs about sleep were found to be associated with lower relapse rates. Conclusions: This study suggests that some dysfunctional beliefs about sleep may support recovery following discharge from treatment. The study further supports the need for tailored cognitive-behavioural treatments for sleep difficulties in this population to reduce relapse rates.