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Recent research: mindfulness (mechanisms & practice), prevalence (abuse & suicidality), health anxiety imagery & CBT for kids

Here are half a dozen recent research studies - two on aspects of mindfulness, two on sobering prevalence rates, one on imagery in health anxiety, and one on CBT with children.  Fuller details, links and abstracts for all studies are listed further down this page.  Willem Kuyken and colleagues looked at "How does mindfulness-based cognitive therapy (MBCT) work?" in helping recurrent depression sufferers.  They came up with some fascinating and provocative findings.  For example it appears that MBCT acts differently from standard CBT, although they are both helpful in reducing risk of depressive relapse.  Standard CBT (and maintenance antidepressants too) reduce cognitive reactivity to experiences of induced low mood, and this appears important in how they lessen relapse risk.  MBCT however seems to act not by reducing cognitive reactivity so much as by decoupling the reactivity from a tendency then to slide into depression.  It appears this decoupling is mediated more by increases in self-compassion than by increases in global mindfulness.  In a further study on mindfulness, Huppert and Johnson reported on "A controlled trial of mindfulness training in schools: The importance of practice for an impact on well-being".  They bravely explored teaching mindfulness to adolescent boys.  Interestingly they noted "Most students reported enjoying and benefiting from the mindfulness training, and 74% said they would like to continue with it in the future."  There are sometimes discussions whether learning mindfulness is a skill that develops with practice or whether it is more of a "yes or no" process of "getting it" that thoughts & feelings aren't reality, they are our interpretation, our "story" about reality.  Interesting that in this study the authors found that " ... there was a significant positive association between the amount of individual practice outside the classroom and improvement in psychological well-being and mindfulness."  This doesn't prove the skill viewpoint, but it supports it.

As for the two sobering studies on prevalence rates, Bebbington et al analysed "Child sexual abuse reported by an English national sample" finding that "2.9% of women and 0.8% of men reported CSA (sexual abuse before the age of 16) involving non-consensual intercourse, figures that rose to 11.1 and 5.3% if experiences involving sexual touching were included. CSA was common before puberty, but peaked in adolescence. CSA greatly increased the chance in adulthood both of further sexual abuse and of prostitution. There was no association with ethnicity or social class ... The odds of CSA were doubled in those not brought up with both biological parents until the age of 16."  In a further paper Bebbington & colleagues reported on "Suicidal ideation, self-harm and attempted suicide" finding that  "Suicidal phenomena were common ... a fifth had experienced tedium vitae, and nearly one in six had had death wishes or considered suicide. 4.4% of the study population had attempted suicide at some time. The relationships between individual elements of suicidality ... tended to be hierarchical. The results suggested that suicidal thinking represents a strong indicator of vulnerability to suicidal acts, less so to self-harm."  Interestingly, in a further paper published last year in the American Journal of Psychiatry, Bebbington linked these two sets of findings showing that "Sexual abuse was strongly associated with a history of suicide attempts as well as of suicidal intent ... The population attributable risk fraction was considerably greater in female respondents (28%) than in male respondents (7%), which is consistent with more prevalent exposure to sexual abuse among women. The effect of sexual abuse on suicidal attempts and suicidal intent was reduced by controlling for affective symptoms, suggesting that the effect of the former was likely to be mediated by affective changes. " and they concluded "Sexual abuse is a significant antecedent of suicidal behavior, particularly among women. In identifying suicidal behavior, it is important to consider the possibility of sexual abuse, since it implies a need for focused treatment."

The final two recent studies I mention in this "recent research" report are one on imagery in health anxiety and one on CBT for children.  The former paper looked at imagery in 55 sufferers from severe health anxiety and found "Over 78% of participants reported experiencing recurrent, distressing intrusive images, the majority (72%) of which either were a memory of an earlier event or were strongly associated with a memory. The images tended to be future orientated, and were reliably categorised into four themes: i) being told ‘the bad news' that you have a serious/life threatening-illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%). Participants reported responding to experiencing intrusive images by engaging in avoidance, checking, reassurance seeking, distraction and rumination. Potential treatment implications and links to maintenance cycles are considered."  I've written before about the potential importance of "flash-forwards" as well as the more widely recognised "flash-backs" with intrusive imagery - see for example "Writing can help past, present & future concerns" (23 august) and "More news from the imagery front" (21 july).  Intelligent exposure-based treatments may help here - for example, using mindfulness practices - as too may forms of reappraisal and cognitive restructuring.  The last of the six recent studies I'm mentioning is by Hirshfeld-Becker et al on "Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: a randomized clinical trial."  Participants were randomised to a parent-child CBT intervention or wait-list control.  Results showed "The response rate (much or very much improved on the Clinical Global Impression Scale for Anxiety) among 57 completers was 69% versus 32% (CBT vs. controls) ... Treated children showed a ... significantly better ... improvement on social phobia/avoidant disorder, separation anxiety disorder, and specific phobia, but not on generalized anxiety disorder. ... Treatment response was unrelated to age or parental anxiety ... Gains were maintained at 1-year follow-up."  Good stuff!

Kuyken, W., T. Dalgleish, et al. "How Does Mindfulness-based Cognitive Therapy Work?"  [Abstract/Full Text] 
Mindfulness-based cognitive therapy (MBCT) is an efficacious psychosocial intervention for recurrent depression (Kuyken et al., 2008; Ma & Teasdale, 2004; Teasdale et al., 2000). To date, no compelling research addresses MBCT's mechanisms of change. This study determines whether MBCT's treatment effects are mediated by enhancement of mindfulness and self-compassion across treatment, and/or by alterations in post-treatment cognitive reactivity. The study was embedded in a randomized controlled trial comparing MBCT with maintenance antidepressants (mADM) with 15-month follow-up (Kuyken et al., 2008). Mindfulness and self-compassion were assessed before and after MBCT treatment (or at equivalent time points in the mADM group). Post-treatment reactivity was assessed one month after the MBCT group sessions or at the equivalent time point in the mADM group. One hundred and twenty-three patients with 3 prior depressive episodes, and successfully treated with antidepressants, were randomized either to mADM or MBCT. The MBCT arm involved participation in MBCT, a group-based psychosocial intervention that teaches mindfulness skills, and discontinuation of ADM.  The mADM arm involved maintenance on a therapeutic ADM dose for the duration of follow-up.  Interviewer-administered outcome measures assessed depressive symptoms and relapse/recurrence across 15-month follow-up. Mindfulness and self-compassion were measured using self-report questionnaire. Cognitive reactivity was operationalized as change in depressive thinking during a laboratory mood induction.  MBCT's effects were mediated by enhancement of mindfulness and self-compassion across treatment.  MBCT also changed the nature of the relationship between post-treatment cognitive reactivity and outcome. Greater reactivity predicted worse outcome for mADM participants but this relationship was not evident in the MBCT group.  MBCT's treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment.

Huppert, F. A. and D. M. Johnson (2010). "A controlled trial of mindfulness training in schools: The importance of practice for an impact on well-being." The Journal of Positive Psychology 5(4): 264 - 274.  [Abstract/Full Text]  
We report the results of a short programme of mindfulness training administered to adolescent boys in a classroom setting. Intervention and control groups (N = 155) were compared on measures of mindfulness, resilience and psychological well-being. Although the overall differences between the two groups failed to reach significance, we found that within the mindfulness group, there was a significant positive association between the amount of individual practice outside the classroom and improvement in psychological well-being and mindfulness. We also found that the improvement in well-being was related to personality variables (agreeableness and emotional stability). Most students reported enjoying and benefiting from the mindfulness training, and 74% said they would like to continue with it in the future. The results of this preliminary study are encouraging. Further work is needed to refine the training programme and undertake a definitive randomised controlled trial, using both subjective and objective outcome measures, with long-term follow-up.

Bebbington, P. E., S. Jonas, et al. (2010). "Child sexual abuse reported by an English national sample: characteristics and demography." Soc Psychiatry Psychiatr Epidemiol.  [PubMed] 
AIM: The 2007 adult psychiatric morbidity survey in England provides detailed information of high quality about sexual abuse. Given the major psychiatric implications of child sexual abuse (CSA), we aimed to establish its sociodemographic distribution in the general population. METHOD: The experience of sexual abuse was elicited in a random sample of the English household population (N = 7,353), using computer assisted self-completion interviewing. Respondents were handed a laptop, and entered their responses to detailed questions. The interviewer was blind to their responses. CSA was defined as occurring before the age of 16. RESULTS: 2.9% of women and 0.8% of men reported CSA involving non-consensual intercourse, figures that rose to 11.1 and 5.3% if experiences involving sexual touching were included. CSA was common before puberty, but peaked in adolescence. CSA greatly increased the chance in adulthood both of further sexual abuse (OR 10.6; CI 8.9-12.6), and of prostitution (OR 3.3; CI 1.9-5.5). There was no association with ethnicity or social class, but people over 65 were less likely to report CSA. The odds of CSA were doubled in those not brought up with both biological parents until the age of 16. CONCLUSION: CSA is common, particularly in women, and is not the preserve of any particular social group. Its frequency and its association with psychiatric consequences render it a major public health issue.

Bebbington, P. E., S. Minot, et al. (2010). "Suicidal ideation, self-harm and attempted suicide: Results from the British psychiatric morbidity survey 2000." Eur Psychiatry.  [PubMed] 
PURPOSE: To examine relationships between suicidal ideation, self-harm, and suicide attempts, including the timing of the phenomena. SUBJECTS AND METHODS: The British National Psychiatric Morbidity Survey (NPMS) 2000, a randomised cross-sectional survey of the British population (n=8,580), included detailed questions about suicidal phenomena. RESULTS: Suicidal phenomena were common in the survey population: a fifth had experienced tedium vitae, and nearly one in six had had death wishes or considered suicide. 4.4% of the study population had attempted suicide at some time. The relationships between individual elements of suicidality, though not absolute, were strong. The relationships tended to be hierarchical. The results suggested that suicidal thinking represents a strong indicator of vulnerability to suicidal acts, less so to self-harm. Although suicidal phenomena were more common in women, the relationship of the different elements were not affected by gender. DISCUSSION: Studies in non clinical populations allow full appreciation of the nature and burden of suicidality. The topic of suicide is sensitive, so there may have been under-reporting, although the level of missing data was around 0.1%. Nevertheless, the sample was large and closely representative of the whole British populace. CONCLUSIONS: Suicidality is common in the British population. The strong relationships between elements of suicidality are clinically important.

Muse, K., F. McManus, et al. (2010). "Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles." Behaviour Research and Therapy 48(8): 792-798.  [Abstract/Full Text]  
Increased understanding of the nature and role of intrusive imagery has contributed to the development of effective treatment protocols for some anxiety disorders. However, intrusive imagery in severe health anxiety (hypochondriasis) has been comparatively neglected. Hence, the current study investigates the prevalence, nature and content of intrusive imagery in 55 patients who met DSM-IV-TR (APA, 2000) criteria for the diagnosis of hypochondriasis. A semi-structured interview was used to assess the prevalence, nature and possible role of intrusive imagery in this disorder. Over 78% of participants reported experiencing recurrent, distressing intrusive images, the majority (72%) of which either were a memory of an earlier event or were strongly associated with a memory. The images tended to be future orientated, and were reliably categorised into four themes: i) being told ‘the bad news' that you have a serious/life threatening-illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%). Participants reported responding to experiencing intrusive images by engaging in avoidance, checking, reassurance seeking, distraction and rumination. Potential treatment implications and links to maintenance cycles are considered.

Hirshfeld-Becker, D. R., B. Masek, et al. (2010). "Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: a randomized clinical trial." J Consult Clin Psychol 78(4): 498-510.  [PubMed] 
OBJECTIVE: To examine the efficacy of a developmentally appropriate parent-child cognitive behavioral therapy (CBT) protocol for anxiety disorders in children ages 4-7 years. METHOD: Design: Randomized wait-list controlled trial. Conduct: Sixty-four children (53% female, mean age 5.4 years, 80% European American) with anxiety disorders were randomized to a parent-child CBT intervention (n = 34) or a 6-month wait-list condition (n = 30). Children were assessed by interviewers blind to treatment assignment, using structured diagnostic interviews with parents, laboratory assessments of behavioral inhibition, and parent questionnaires. Analysis: Chi-square analyses of outcome rates and linear and ordinal regression of repeated measures, examining time by intervention interactions. RESULTS: The response rate (much or very much improved on the Clinical Global Impression Scale for Anxiety) among 57 completers was 69% versus 32% (CBT vs. controls), p < .01; intent-to-treat: 59% vs. 30%, p = .016. Treated children showed a significantly greater decrease in anxiety disorders (effect size [ES] = .55) and increase in parent-rated coping (ES = .69) than controls, as well as significantly better CGI improvement on social phobia/avoidant disorder (ES = .95), separation anxiety disorder (ES = .82), and specific phobia (ES = .78), but not on generalized anxiety disorder. Results on the Child Behavior Checklist Internalizing scale were not significant and were limited by low return rates. Treatment response was unrelated to age or parental anxiety but was negatively predicted by behavioral inhibition. Gains were maintained at 1-year follow-up. CONCLUSIONS: Results suggest that developmentally modified parent-child CBT may show promise in 4- to 7-year-old children.

 

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