Background: Self-esteem is a major concern in the treatment of patients with personality disorders in general. In patients with borderline personality disorder, low self-esteem is associated with factors contributing to suicidal and self-injurious behaviour. At the moment there are no well-proven interventions that specifically target low self-esteem. Recently, a new approach, Competitive Memory Training or COMET, aimed at the enhancement of retrieving beneficial information from memory, appeared to be successful in addressing low self-esteem in different patient populations. Aims: To assess whether COMET for low self-esteem is also an effective intervention for patients with personality disorders. Method: 91 patients with personality disorders who were already in therapy in a regular mental health institution were randomly assigned to either 7 group sessions of COMET in addition to their regular therapy or to 7 weeks of ongoing regular therapy. These latter patients received COMET after their “7 weeks waiting period for COMET”. All patients that completed COMET were contacted 3 months later to assess whether the effects of COMET had remained stable. Results: Compared to the patients who received regular therapy only, patients in the COMET + regular therapy condition improved significantly and with large effect sizes on indices of self-esteem and depression. Significant differential improvements on measures of autonomy and social optimism were also in favour of COMET, but had small to intermediate effect sizes. The therapeutic effects of COMET remained stable after 3 months on three out of the four outcome measures. Conclusion: COMET for low self-esteem seems to be an efficacious trans-diagnostic approach that can rather easily be implemented in the treatment of patients with personality disorders.

Background: Childhood worry is common, and yet little is known about why some children develop pathological worry and others do not. Two theories of adult worry that are particularly relevant to children are Davey's problem-solving model in which perseverative worry occurs as a result of thwarted problem-solving attempts, and Wells’ metacognitive model, in which positive and negative beliefs about worry interact to produce pathological worry. Aims: The present study aimed to test hypotheses that levels of worry in young children are associated with poor or avoidant solution generation for social problems, and poor problem-solving confidence. It also aimed to explore beliefs about worry in this age group, and to examine their relationships with worry, anxiety and age. Method: Fifty-seven young children (6–10 years) responded to open ended questions about social problem-solving situations and beliefs about worry, and completed measures of worry, anxiety and problem-solving confidence. Results: Children with higher levels of worry and anxiety reported using more avoidant solutions in social problem situations and children's low confidence in problem solving was associated with high levels of worry. Children as young as 6 years old reported both positive and negative beliefs about worry, but neither were associated with age, gender, or level of anxiety or worry. Conclusions: Results indicate similarities between adults and children in the relationships between problem-solving variables and worry, but not in relationships between beliefs about worry and worry. This may be due to developmental factors, or may be the result of measurement issues.

Background: Cognitive behavioural therapy has been established as an effective treatment for residual psychotic symptoms but a substantial proportion of people do not benefit from this treatment. There has been little direct study of predictors of outcome, particularly in treatment targeting auditory hallucinations. Method: The Psychotic Symptom Rating Scales (PSYRATS) and Positive and Negative Syndrome Scale (PANSS) were administered pre- and post-therapy to 33 people with schizophrenia-related disorders receiving CBT for auditory hallucinations in a specialist clinic. Outcome was compared with pre-therapy measures of insight, beliefs about the origin of hallucinations, negative symptoms and cognitive disorganization. Results: There were significant improvements post-treatment on the PSYRATS and PANSS Positive and General Scales. Improvement on the PSYRATS was associated with lower levels of negative symptoms, but was unrelated to overall insight, delusional conviction regarding the origins of hallucinations, or levels of cognitive disorganization. Conclusions: Lack of insight and presence of formal thought disorder do not preclude effective cognitive-behavioural treatment of auditory hallucinations. There is a need to further understand why negative symptoms may present a barrier to therapy.

Background: Although rumination is a key process in the onset and maintenance of depressive symptoms and a powerful predictor of persistent posttraumatic stress disorder (PTSD), little is known about the differences and similarities of rumination in these conditions. Previous research has not always differentiated between rumination and intrusive images. Aims: We sought to systematically evaluate rumination and to gather more information about the content and associated emotions in three patient groups (PTSD, and depressed with and without trauma; n = 65). Furthermore, we examined the interaction between rumination and another predominant intrusive cognition, intrusive image. Method: A multi-method assessment for rumination, including a rumination questionnaire and a rumination log (kept for one week), was employed. Results: Rumination was found to be complex and composed of subcomponents that are similar across the diagnostic groups. Rumination rarely stopped intrusive images and it made the participants feel worse. There were, however, also important differences: in PTSD, rumination always or often triggered intrusive images and the traumatized individuals (PTSD and depressed with trauma) ruminated more than non-traumatized depressed patients. Conclusions: The results corroborate the assumption of rumination being a transdiagnostic process, with similarities but also with important differences across diagnostic groups. Moreover, the findings support recent research on the intricate relationship between different types of intrusive cognitions.

Background: Common factors are important for the therapy outcome and also mediate the specific factors of therapy. As one of the common factors, client's expectations towards treatment have been understudied. Aims: The aim was to examine the pre-treatment expectations of outpatient substance abuse treatment clients (N = 327, 111 females, 216 males) and its impact on retention, effectiveness and satisfaction at 6-month follow-up. Method: Dependent variables included the clients’ attitudes towards the twelve-step principles and participation, medical treatment and therapists’ role. Results: An emphasis on the importance of medical treatment at baseline predicted dropping out. Similarly, it predicted a lower percent days abstinent (PDA6) at 6 months follow-up in comparison to those who did not consider medical treatment important for recovery. Percent days abstinent increased with a more positive attitude to mutual support. At follow-up, those who had assessed the therapist's role in recovery to be most important at the baseline were most satisfied with the treatment. Conclusions: The client's pre-treatment expectations have an impact on treatment retention and effectiveness. Further effort should be made to study how clients’ image of treatment could be improved and also how the commitment of the clients with multiple problems could be improved.

Background: There is a dearth of information about imagery in pain sufferers. Aim: The aim of this study was to collect data on the characteristics, prevalence, and potency of imagery associated with pain. Method: The images of 59 pain sufferers were assessed by means of a semi-structured interview. The emotional, cognitive, behavioural, and pain-inducing properties (potency) of their index images were assessed by an image induction procedure and self-report scales of anxiety, depression and trauma symptoms. Results: The results showed a remarkably high incidence of images in pain sufferers, with 78% of participants reporting one or more repetitive images when in pain. Exposure to their most powerful/distressing image (Index image) resulted in significant increases in negative emotions, negative cognitive appraisals, and in pain levels. In a sub-group of sufferers with significant levels of trauma symptoms, the index images elicited significantly higher levels of emotion and pain increment than did those respondents in a low/no trauma group. Conclusion: It was concluded that imagery is a prevalent, often “unobserved” but potent cognition in pain sufferers. The implications for CBT approaches to chronic pain, including image rescripting, are considered.

Background: Research has demonstrated the effectiveness of computerized cognitive behaviour therapy (cCBT) for depression and anxiety in adults, but there has been little work with children and adolescents. Aims: To describe the development of a cCBT intervention (Think, Feel, Do) for young people, and preliminary outcomes and feedback from a pilot randomized controlled trial. Method: Twenty participants aged 11 to 16 with depression or anxiety were randomized to receive cCBT immediately or after a delay. Standardized measures were used to assess self-reported anxiety, depression, self-esteem and cognitions, as well as parent rated strengths and difficulties. A feedback form was also completed to assess young people's views of the programme. Results: A total of 15 participants completed the pre and post assessments in the trial, and 17 provided feedback on the intervention. Paired samples t-tests demonstrated significant improvements on 3 subscales in the control condition, compared to 7 subscales in the cCBT condition. Feedback showed moderate to high satisfaction for participants. Conclusions: This study provides encouraging preliminary results for the effectiveness and acceptability of cCBT with this age group.

Background: Paranoia is a common experience in the non-clinical population. We use a novel experimental methodology to investigate paranoid ideas in individuals without a history of mental illness. Aims: We aimed to determine whether this paradigm could elicit unfounded paranoid thoughts and whether these thoughts could be predicted by factors from a cognitive model. Method: Fifty-eight individuals took part and completed measures assessing trait paranoia, mood, self and other schema and attributional style. They were exposed to two experimental events: 1) an interruption to the testing session by a stooge, and 2) a recording of laughter played outside the testing room and subsequently asked about their explanations for these events. Results: 15.5% (n = 9) of the sample gave a paranoid explanation for at least one of the experimental events. The remainder reported generally neutral explanations. Individuals with a paranoid explanation reported significantly higher levels of trait paranoia. Factors predictive of a paranoid interpretation were interpersonal sensitivity and attributional style. Conclusions: The results show that spontaneous paranoid explanations can be elicited in non-clinical individuals, even for quite neutral events. In line with current theories, the findings suggest that emotional processes contribute to paranoid interpretations of events, although, as a novel study with a modest sample, it requires replication.

Background: Magical thinking (MT), which has historically been associated with psychotic disorders, has more recently been found to be a central cognitive construct in Obsessive-Compulsive Disorder (OCD) that is associated with a poor prognosis (Einstein and Menzies, 2008). Although MT has been found to distinguish OCD from Panic Disorder (PD) (Einstein and Menzies, 2006), little is known about its role in other anxiety disorders. Aims: This study aimed to compare whether elevated levels of magical thinking could distinguish individuals with OCD from non-anxious controls and individuals with Generalized Anxiety Disorder (GAD). Method: The Magical Ideation Scale (MIS, Eckblad and Chapman, 1983) was used to compare levels of magical thinking in groups of individuals with OCD (n = 40), GAD (n = 15), and a normal control group (n = 19). Results: As expected, the mean MIS score of the OCD group was significantly higher than that of the non-clinical group. Interestingly, there was no significant difference between the mean MIS scores of the OCD and GAD group. However, the results of correlational analyses suggest that it may have differing roles in these disorders. Conclusions: Although elevated MT is evident in individuals with OCD, it may not be specific to OCD and may also be prominent in GAD. Further research is recommended to elucidate the exact role of this construct in these disorders.

Background: The use of Cognitive Behavioural Therapy (CBT) self-help materials for depression is increasingly recommended as part of stepped care service models. Such resources can be delivered by both new specialist workers (such as the IAPT services in England), or by introducing this style of working into an existing workforce as described in the current paper. The Structured Psychosocial InteRventions in Teams (SPIRIT) course consists of 38.5 hours of workshops, and 5 hours of clinical supervision in the use of CBT self-help (CBSH). Method: This study describes an evaluation of the effectiveness of the course when offered to community and inpatient mental health staff from a wide range of adult and older adult mental health teams in NHS Greater Glasgow Mental Health Division. Results: Training resulted in both subjective and objective knowledge and skills gains at the end of training that were largely sustained 3 months later. At that time point, 40% of staff still reported use of CBSH in the last week. Satisfaction with the training is high, using validated rating scales. Conclusions: The SPIRIT training has gone some way to increasing access to CBSH for use in everyday clinical practice.

Background: Motivational Interviewing (MI) and Acceptance and Commitment Therapy (ACT) are two emerging therapies that focus on commitment to behavior change. Aim: The aim was to provide the first systematic comparison of MI with ACT. Method: A systematic comparison was undertaken of MI and ACT at the conceptual level, with a focus on their philosophical and theoretical bases, and at the clinical level, with a focus on the therapeutic relationship, use of language in therapy, and use of values in therapy. Results: Conceptually, MI and ACT have distinct philosophical bases. MI's theoretical basis focuses on language content, whereas ACT's theoretical basis focuses on language process. Clinically, ACT and MI have distinct approaches to the therapeutic relationship, fundamentally different foci on client language, and different uses of client values to motivate behavior change. ACT, but not MI, directly targets the willingness to experience thoughts, feelings, and sensations. Conclusions: Despite their conceptual and clinical differences, MI and ACT are complementary interventions. Collaborations between MI and ACT researchers may yield fruitful cross-fertilization research on core processes and clinical outcomes.

Background: It has been suggested that the perinatal period is a period of increased risk for the development and/or exacerbation of OCD and that postpartum OCD (ppOCD) presents a distinct clinical picture. This raises the possibility that ppOCD might be a distinct subtype of OCD. This review examines this contention. Method: A search using Ovid (Medline, PsycINFO and Embase), EBSCO, Cochrane Library, Web of Science (ISI), Pubmed databases and Google Scholar was carried out using the key words: “obsessive compulsive disorder” (and derivatives), “perinatal”, “pregnancy”, “postnatal”, “postpartum”, “mothers” (and derivatives), “anxiety disorders” and “subtypes.” These articles and their references were reviewed. Results: The majority of studies reviewed were retrospective, which makes it impossible to infer causality. Two prospective studies found a higher incidence of OCD in the postpartum period. These were carried out in Turkey and Brazil and, as such, may be limited in their applicability to other cultural groups. Conclusion: The concept of ppOCD as a specific subtype has not been robustly demonstrated. The evidence that OCD is more prevalent in the postpartum period is mixed. The evidence that OCD in the postpartum period presents a distinctive clinical picture with specific symptomatology and course is more compelling. In view of the impact of culture and religion on the expression of OCD, collaborative, international, prospective studies that take into account the methodological and definitional issues raised in this review are necessary to provide clarification.

Background: The Self-Regulation Model (SRM) has been presented as a framework for assessing the perceptions people hold about their mental health problem. Currently no direct attempts have been made to assess the association between illness perceptions and engagement in psychosis. Engagement is an important issue for health professionals providing support to people with psychosis; therefore, research demonstrating a link between illness perceptions and engagement may enable targeted interventions to facilitate engagement and enhance outcome. Aim: To assess whether beliefs about mental health are associated with self-perceptions of engagement in people with psychosis. Method: Participants with psychosis completed two questionnaires; beliefs about mental health and self-perceptions of engagement with mental health services. Results: A belief that the mental health difficulty has fewer negative consequences, increased perceptions of personal ability to control the mental health difficulty, a belief that treatment is helpful in controlling symptoms and a more coherent understanding of the mental health difficulty were all associated with higher self-perception engagement scores. Multivariate analyses indicated that a more coherent understanding and a belief that treatment is helpful were the strongest and most consistent predictors of higher self-perception engagement scores. However, the direction of the associations cannot be established. Conclusions: This study suggests that the SRM is a promising model for mental health problems and that beliefs about mental health are associated with self-perceptions of engagement in people with psychosis. The importance of further intervention-based research studies that examines causality is highlighted.

Background: High levels of multidimensional perfectionism may be dysfunctional in their own right and can also impact on the maintenance and treatment of Axis I psychiatric disorders. Aims: This paper sought to describe the behavioural expressions and imagery associated with perfectionism in a non-clinical sample. Method: Participants (n = 59) completed a newly developed questionnaire to assess behavioural expressions of perfectionism, and an adapted interview to assess perfectionism-related intrusive mental images. Results: The study found that those high in perfectionism took longer to complete tasks, experienced more checking and safety behaviour whilst carrying out tasks, and had greater trouble actually completing tasks compared to those low in perfectionism. In addition, those with higher levels of perfectionism experienced intrusive mental imagery, which was more distressing, harder to dismiss, and had more impact on behaviour than those with lower levels of perfectionism. Conclusions: This research provides an initial exploration of the specific behaviours and intrusive mental imagery associated with perfectionism. The new behavioural measure of perfectionism could prove useful clinically in the assessment of change; however, these findings are preliminary and warrant replication in a clinical sample in order to examine their treatment implications.

Background: This study reports the development and revision of the Beliefs about Paranoia Scale (BaPS), a self-report measure to assess metacognitive beliefs about paranoia in non-patients. We aimed to confirm the factor structure of a revised 50-item version of the measure and test the specific hypotheses that positive beliefs about paranoia would predict frequency of paranoia, and that negative beliefs about paranoia would predict distress associated with paranoia. Method: 185 non-patient participants completed questionnaires assessing beliefs about paranoia, thought control, self-consciousness, anxiety, depression and paranoia. Results: The results showed that the original four-factor solution could not be replicated. Instead a three-factor solution comprising Negative Beliefs about Paranoia, Paranoia as a Survival Strategy, and Normalizing Beliefs was developed. The revised 18-item measure showed good internal consistency. Stepwise regression analysis showed that, BaPS-negative beliefs accounted for 34% of the variance with R2 of 0.339, with a multiple R of 0.585 in relation to frequency of paranoia. In relation to distress arising from paranoia, stepwise regression analysis showed that BaPS-negative beliefs accounted for 34% of the variance with R2 of 0.339, with a multiple R of 0.585. In both analyses, BaPS-Survival strategy showed a small but significant incremental increase in the variance accounted for in the overall model. Conclusions: These findings suggest that a metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat may have some utility. The clinical implications of the findings are also discussed.

Background: Guided internet-delivered CBT for anxiety disorders has received increasing empirical support, but little is known regarding the role of the therapist. Aims: This study addressed therapist factors in guided internet-delivered cognitive behavioural therapy for anxiety disorders. Method: Data from three controlled trials with a total N of 119 were analyzed with attention to differences between eight therapists. Results: No significant mean level differences between therapists appeared in the dataset. However, one significant intraclass correlation between participants was found, suggesting that the outcome on the Beck Anxiety Inventory might have been influenced by the impact of the individual therapists. Conclusion: The therapist can possibly have some influence on the outcome of guided internet-delivered CBT for anxiety disorders, but studies with more statistical power are needed to establish whether therapist effects are present in this modality of psychological treatment. The present study was underpowered to detect minor therapist effects.

Background and aims: The efficacy and effectiveness of a computerized cognitive behavioural therapy (CCBT) package, Beating the Blues, has been demonstrated in a large randomized controlled trial and several pragmatic studies in the National Health Service (NHS). The current study tests the generalizability of this finding to the implementation of CCBT in a service user-led, third sector Self Help Clinic. Method: 510 referrals for the Beating the Blues program were received over a 16 month period in routine care. The Patient Health Questionnaire Depression (PHQ-9) and Anxiety (GAD-7) Scales were administered pre-treatment and during each treatment session. The 10-item Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), Work and Social Adjustment Scale and Patient Experience Questionnaire were also administered pre-treatment and immediately on completing treatment. Results: More than two-thirds of referrals were suitable for treatment and completed a baseline assessment; 84% of these started the Beating the Blues program. Two-hundred and twenty-six people meeting caseness criteria at baseline completed at least two sessions of CCBT. Of these, 50% met recovery criteria at their final point of measurement. Completer and intention-to-treat analysis also demonstrated statistically and clinically significant improvements on key outcome measures. Conclusion: CCBT can be effectively implemented in a service user-led, third sector Self Help Clinic, increasing access to psychological therapies to meet local needs for tier two interventions for depression and anxiety.

Background: The Vancouver Obsessive Compulsive Inventory (VOCI) is a self-report measure of the severity of obsessive-compulsive problems such as contamination, checking, obsessions, hoarding, needing things to be just right, and indecisiveness. In the seminal paper a six-correlated-factor structure was found in a sample of OC patients, but the issue of the factor structure of the VOCI in non-clinical populations was not addressed. Aim: This study assesses the psychometric properties and the factor structure of the Italian version of the VOCI in a non-clinical sample. Method: The VOCI was administered to a large community sample (n = 445). Some participants also completed a battery including measures of OC behaviour, worry, anxiety and depression (n = 89) and were administered the VOCI twice at an 8-week interval (n = 46). Results: Confirmatory factor analyses replicated the six-correlated-factor structure originally found in a patient sample, but a more parsimonious, second-order-factor model showed a statistically higher fit, suggesting that VOCI subscales can be considered as facets of a higher-order OCD factor. The whole item pool and each of the subscales showed good internal consistency, unidimensionality, test-retest reliability and convergent construct validity. As in the original version, limited support for discriminant validity was found. Scores were weakly associated with age, gender and education. Conclusions: Although some key issues still need to be investigated (e.g. sensitivity to change), the VOCI seems to be a psychometrically sound instrument for the assessment of OCD-related behaviours and thoughts and can be used in cultural contexts different from the original.

Background: There is sufficient research evidence in favour of cognitive therapy in western world. However, only limited research has been carried out on its effectiveness in other countries. It is suggested that adaptations in content, format and delivery are needed before CBT can be employed in non-western cultures. We describe a preliminary evaluation of culturally adapted CBT for depression in Pakistan. Aims: We aimed to evaluate the efficacy of this culturally adapted CBT using a therapist manual. Method: In a randomized controlled trial we compared combination of CBT and antidepressants with antidepressants alone (treatment as usual) in primary care. Referred patients with ICD-10 diagnosis of depression were invited to participate and randomized to the intervention and control groups. Hospital Anxiety and Depression Scale (HADS) and Bradford Somatic Inventory (BSI) were used to measure changes in depression, anxiety and somatic symptoms. Results: Seventeen patients each were randomized to each arms of the trial. Except for financial status there were no differences between the two groups on various demographic variables. Patients receiving CBT showed statistically significant improvement on measures of depression (p < .001), anxiety (p < .001) and somatic symptoms (p < .000) as compared to antidepressant alone group. 82% patients attended six or more sessions of therapy. Conclusions: A culturally sensitive manualized CBT was effective in reducing symptoms of depression and anxiety in Pakistan.

Background: The current nonrandomized clinical trial explored changes over time in children with an anxiety disorder during stepped care, manual-based cognitive behaviour therapy (CBT). Methods: Clinically anxious children (8–12 years, n = 133) and their parents participated in child focused CBT (10 sessions). If assessments indicated additional treatment was necessary, participants could step up to a second and possibly third treatment phase (each 5 sessions) including more parental involvement. Results: After the first treatment phase 45% of the Intention-To-Treat sample was free of any anxiety disorder; after the second and third phase an additional 17% and 11% respectively. In total, 74% of the children no longer met criteria for any anxiety disorder following treatment. Child and parent reported anxiety and depression symptoms of children improved significantly during all treatment phases, as well as child reported anxiety sensitivity and negative affect. Children participating in more treatment showed significant improvements during additional treatment phases, indicating that late change occurred for the subgroup that had not changed during the first phase. Conclusions: Stepped care offers a standardized, assessment based, yet tailored treatment approach for children with anxiety disorders. A more intensive treatment is offered when initial CBT is insufficient, providing children additional opportunities to reach the desired outcome.