Cognitive behavioural therapy for insomnia (CBT-I) is the gold-standard insomnia treatment, which also produces medium-to-large antidepressant effects at a group level. However, not everyone benefits equally and CBT-I related factors associated with varying depression outcomes are not well understood, limiting the capacity for treatment optimisation and uptake of CBT-I in routine care. This study examined whether trajectories of change in daytime and bedtime general repetitive negative thinking (RNT), daytime and bedtime sleep-related RNT, and low activity levels (improved behavioural activation) were related to the degree to which depressive symptoms improve among individuals receiving CBT-I. Eighty-eight adults (72% females) participated. Data collected at baseline, post-intervention, and 12-week follow-up were analysed using latent growth curve modelling. Participants exhibited clinically significant reductions in depressive symptoms and improvements in both general and sleep-related RNT during daytime and bedtime, along with a boost in activity levels. Moreover, improvement rates in daytime sleep-related RNT and bedtime general RNT were strongly associated with the degree to which depressive symptoms improved, while improvement rates in activity levels were moderately associated with the rate at which depressive symptoms improved. Current preliminary findings suggest that improvements in RNT that is related to insomnia, either conceptually (daytime sleep-related RNT) or temporally, (bedtime general RNT), and improvements in activity levels may be associated with the extent to which depression outcomes improve following CBT-I. This highlights the need for further investigation of these factors as potential mechanisms of change influencing depressive symptoms, using causal experimental designs.
Exposure therapy is an effective treatment for anxiety disorders, but its mechanisms remain unclear. We explored the violation of threat-predictions during exposure, which has been hypothesized as necessary for symptom change. Forty-three adults undergoing exposure therapy for social anxiety disorder recorded their experiences during 523 in- and between-session exposures by completing smartphone surveys. Participants rated their threat-predictions, threat-outcomes, anxiety levels, surprise, and learning outcome for each exposure. We used multilevel models to explore the effect of prediction error (threat-prediction from outcome) during exposure on anxiety symptoms at the next session, and on symptom change from baseline to three months follow-up. Exposures successfully generated threat-prediction error and unexpected exposure outcomes were experienced as more surprising and likely to stimulate learning. However, larger threat-prediction error during exposure did not predict lower symptoms at the next session, nor overall symptom improvement. These findings suggest that the magnitude of threat-prediction error is not, in itself, sufficient for successful exposure therapy.
Background: Mindfulness-based interventions are increasingly used to target transdiagnostic processes implicated in emotional distress, yet little is known about whether post-treatment mindfulness outcomes can be predicted from clinically interpretable participant profiles. This secondary analysis examined whether machine-learning models could predict post-intervention mindfulness following a Mindfulness-Based Stress Reduction (MBSR) program. Methods: The sample comprised 378 adults who completed an 8-week, face-to-face MBSR program. Candidate predictors included sociodemographic, health, meditation-history, baseline psychological, and practice-related variables. Outcomes were post-intervention Five Facet Mindfulness Questionnaire total and facet scores. Four regression approaches (i.e., XGBoost, least-squares support vector machines, LASSO, and Elastic Net) were compared using 10 × 10-fold cross-validation. Cohort-level generalizability was further evaluated using nested leave-one-intake-out validation. Results: Post-intervention mindfulness was predicted with moderate accuracy. LASSO matched or outperformed more complex algorithms while yielding the most interpretable solution. A four-predictor model (i.e., baseline mindfulness, hedonic well-being, frequency of informal meditation practice during the program, and current meditation practice before the program) achieved stable performance for total mindfulness scores (cross-validated R2≈.50), with similar performance under leave-one-intake-out validation. Baseline mindfulness was the dominant predictor across total and facet-level models. Informal practice emerged as a recurring predictor, particularly for Observing, Describing, and Non-Reactivity. Conclusions: These findings suggest that post-MBSR mindfulness outcomes are partly forecastable from a small set of psychologically meaningful and practice-related variables. Interpretable prognostic models may support stratified delivery of mindfulness-based interventions, although external validation and outcomes beyond self-reported mindfulness are needed before clinical implementation.
Attention appears to be impaired in hoarding disorder (HD), although it remains unclear whether this can be conceptualized as co-occurring ADHD or intrinsic to hoarding pathology. Self-reported cognitive impairment tends to be inconsistent in HD, with individuals tending to overestimate cognitive impairment compared with performance on neuropsychological tests. A behavioral index of attentional impairment during decision making, ex-Gaussian modeling of reaction times, has been commonly used as an index of inattention in ADHD, with more skew (i.e., higher tau values) suggestive of attentional lapses. We used a sample of 43 individuals with hoarding disorder who completed a decision task, comparing their ex-Gaussian reaction time curves, ex-Gaussian vectors, and similarities between them, to samples of individuals high in anxiety and depression ("anxiety and mood", n = 25) and nonclinical controls ("healthy control," HC, n = 39). Results indicated that individuals with HD exhibited tau (and sigma and mu) profiles in their scalar and vectorial metrics that were like those of the AM and HC groups, suggesting a lack of ADHD-like attentional lapses. However, the HD group showed significantly greater within-group variance than the other two diagnostic groups, suggesting substantial within-HD heterogeneity, and possibly implying inattentive and non-inattentive subtypes of HD. Hence, HD shows heterogeneous RT dynamics without generalized attentional slowing.
Sleep disturbances are a transdiagnostic risk factor for affective dysregulation, which is assumed to mediate the association with suicide-related thoughts and behaviors (STBs). Yet most ecological momentary assessment (EMA) studies rely on single-night sleep metrics. With the aim of examining the link between sleep and affect, this study compared the predictive utility of multiple EMA-derived sleep indices with raw sleep measures in a sample at high risk of STBs. Following discharge, psychiatric inpatients with recent suicidal crises (N = 136) completed EMAs of sleep quality (SQ), total sleep time (TST), and affect. Multilevel models examined whether cumulative or variability-sensitive sleep indices better predicted next-day positive and negative affect (PA, NA) and affective instability compared to raw scores. Cumulative SQ, indexed by a three-night pile-up measure, consistently outperformed raw SQ and alternative indices in predicting higher PA and lower NA at both within- and between-person levels. In contrast, TST indices showed no robust associations with affect. These findings highlight cumulative sleep quality as a clinically relevant marker of short-term affective vulnerability. Future studies should explore whether this translates into increased STB risk to explore potential implications for risk monitoring and just-in-time interventions.
Anxiety problems are one of the most prevalent mental health conditions in children, placing a significant burden on families and mental health services. This creates an urgent need for early and accessible preventive interventions that maintain clinical effectiveness while optimizing time and costs for both families and therapists. The present study examined the effectiveness of an evidenced-based preventive anxiety parenting intervention, delivered in a live, online, group-based format using a randomized controlled trial (N = 148). Parents of behaviorally inhibited children aged three to six years were allocated to either the intervention, a Dutch adaptation of 'Cool Little Kids', or a control condition consisting of a book with general parenting advice. To enhance ecological validity, the study was conducted in a naturalistic setting in collaboration with Dutch public and mental health organizations. Linear mixed models analyses (n = 128) demonstrated that parents in the intervention condition reported lower child anxiety symptoms than those in the control condition at post-intervention (d = -.35), six and twelve month follow-up (d = -.46 and d = -.31). Group differences were no longer statistically significant at the twelve month follow-up, potentially due to gradual improvements within the active control condition and the possibility that the study was underpowered to detect smaller intervention effects. However, effect sizes remained comparable to post-intervention, suggesting sustained long-term clinical relevance. Overall, these findings provide novel evidence for live, online, parent-focused, group-based delivery as an effective approach to reducing anxiety symptoms in young, anxiety-prone children. CLINICAL TRIAL REGISTRY: This trial was prospectively registered in the Netherlands Trial Register (NL9633).
Despite decades of meditation research, there is a lack of preregistered and well-powered studies that investigate the effects of brief meditation practices on subjective wellbeing and use data-driven approaches to predict response to these interventions. Using representative samples of the US and UK adult populations with regards to age, sex, and ethnicity (N = 5049), we conducted a preregistered and well-powered randomized controlled trial to investigate the effects of three brief (5-10 min) meditation practices (i.e., mindfulness, self-compassion, gratitude) relative to a control condition. We also examined whether a data-driven approach can predict an individual's response to these interventions from their pre-intervention characteristics. Taken together, our findings suggest that brief meditation practices modestly improve an aspect of subjective wellbeing (negative affect) and such response can be predicted using pre-intervention characteristics. Future prospective randomized trials should examine algorithm-guided intervention assignment to directly test the potential of personalized meditation recommendations to improve subjective wellbeing.
Exposure therapy is considered the leading evidence-based treatment for anxiety disorders. Yet, a significant number of individuals fail to benefit from its efficacy due to their reluctance to confront themselves with the feared situation. With evidence indicating a link between approach motivation and reward processing in socially anxious individuals, prospective mental imagery may serve to enhance anticipatory reward processes and promote approach motivation for exposure to feared situations and subsequently behavioral engagement with feared social situations. The present study tested the impact of prospective mental imagery on anticipatory reward processes, approach motivation and behavioral engagement. Socially anxious participants (N = 136) were randomly assigned to either a prospective mental imagery group or a psychoeducation-only control group. Anticipatory reward processes and approach motivation were assessed before and after the intervention and behavioral engagement one week later. The prospective mental imagery group reported greater increases in anticipated and anticipatory pleasure as well as approach motivation towards feared social situations compared to the control group. No differences in reward anticipation and behavioral engagement with feared social situation were found. Mediational analyses indicated that the association between prospective mental imagery and increases in approach motivation was statistically mediated by increases in anticipatory reward processing, although the lack of temporal precedence between mediator and outcome precludes causal conclusions. Exploratory analyses further suggest that higher vividness of mental imagery was associated with greater efficacy of prospective mental imagery on reward processing and approach motivation.
Post-traumatic stress disorder (PTSD) is characterized by strong and persistent emotional responses to stimuli that have previously been associated with danger. It has been argued that fear conditioning paradigms can be used as a laboratory model of this disorder, with people with PTSD showing differences in fear and extinction learning. Previous studies have been inconsistent in showing differences at either stage. This may result from a combination of small sample sizes and variations in analytic strategies. In a large sample of individuals exposed to a traumatic stressor within the past two years, we examined whether those who met DSM-5 criteria for PTSD exhibited different patterns of fear conditioning and extinction learning compared to those who did not meet PTSD criteria. Fear responses were measured using skin conductance responses (SCRs) and retrospective shock expectancy ratings. The statistical analyses were pre-registered. Participants first completed a fear acquisition phase immediately followed by the extinction phase. No group differences were seen in responses to the fear-related stimulus compared to the safety stimulus in either outcome measure for either the acquisition or extinction phase. There were no correlations between PTSD severity and the differentiated fear response. In summary, our results did not provide support for individuals with a PTSD diagnosis compared to trauma-exposed controls displaying differences in fear and extinction learning in either SCRs or subjective shock expectancy ratings. A major limitation of the study was the fixed orders of stimulus presentations, which risks confounding learning effects from order effects in the SCR data.
BACKGROUND:Digital mental health interventions can improve distress and well-being, but the processes statistically accounting for these effects remain unclear. We examined emotion regulation and insomnia as candidate processes in university students. METHODS:Data came from a three-arm randomized trial of the ETUCARE program, an eight-week multicomponent program for French university students. The ITT dataset contained 1064 participants (online: n = 460; hybrid: n = 235; control: n = 369); 947 contributed to FIML estimation. Parallel mediation estimated indirect effects through emotion regulation and insomnia. A ≥70%-adherence sample provided a per-protocol sensitivity analysis, and an exploratory cross-lagged model examined longitudinal associations. RESULTS:ETUCARE assignment was associated with improved emotion regulation (β = .166, p < .001) and reduced insomnia (β = -.142, p < .001). Both showed significant indirect effects on distress and well-being: better emotion regulation and lower insomnia were associated with lower distress and higher well-being. Combined pathways accounted for 33.6% of the total association with distress. A constrained model was compatible with similar absolute magnitudes but opposite directions across outcomes, without establishing equivalence. ITT and per-protocol estimates were closely aligned. CONCLUSIONS:These findings are consistent with a process-based account of digital interventions in which emotion regulation and sleep represent candidate shared processes statistically associated with changes across multiple domains of mental health. The findings do not establish causal mechanisms or temporal precedence. Nevertheless, targeting emotion regulation and sleep may represent a promising strategy for scalable digital interventions. Future experimental research should clarify their temporal dynamics and identify the most active intervention components.
Anxiety disorders are common and despite effective treatments relapse rates remain high. In the laboratory, fear conditioning is used to investigate the processes underlying the acquisition, extinction and subsequent return of fear. It is understood that in extinction, the original fear is not unlearnt, but rather overlayed with new safety learning. It is currently unclear why this safety learning remains for some while it disappears for others leading to relapse. In human fear conditioning, electrodermal responding and self-reported fear of the conditional stimuli (CSs) are often used to monitor fear conditioning. It is known that self-reported CS pleasantness is also impacted by fear conditioning and un-pleasantness of a CS remains even when fear has been extinguished. Past research suggests that residual unpleasantness at the end of extinction can predict return of fear. However, these studies employed long duration CSs or non-standard measures of fear conditioning and are limited to fear reinstatement. This study aims to extend these findings in a standard renewal paradigm. Using 72 first year Psychology students (65 female, 7 male), we show that the residual CS un-pleasantness at the end of extinction predicts self-reported fear after the renewal test. However, the relationship is not found between pleasantness and electrodermal responding during renewal, possibly due to other non-fear related drivers of electrodermal responding at the start of renewal like orienting. This research provides further evidence that self-reported CS un-pleasantness predicts return of fear.
BACKGROUND:Irritability comprises two related but distinct dimensions: tonic irritability, reflecting persistently angry mood, and phasic irritability, reflecting temper outbursts. Distinguishing these forms is important given their differential associations with psychopathology. The Tonic and Phasic Irritability Scale (TAPIS) is the first measure designed to assess these constructs. This study evaluated the structural and external validity of the TAPIS in young children. METHOD:Participants were 213 parents of 5-6-year-old children (50% female), oversampled for high irritability. At screening, caregivers completed the TAPIS and other irritability and impairment measures to determine eligibility. Eligible families completed a full evaluation an average of 2.76 months later (SD = 2.84; range = 0.07-21.28 months), including parent-report measures of child psychopathology, temperament, and parenting. RESULTS:The TAPIS demonstrated a two-factor structure (robust CFI = 0.92, TLI = 0.91, SRMR = 0.03) with excellent internal consistency (α = .95 tonic; 0.94 phasic). Both dimensions were associated with established irritability measures and impairment. When modeled simultaneously, phasic irritability uniquely predicted multiple irritability indicators and impairment across domains, whereas tonic irritability uniquely predicted caregiver-reported irritability, temper loss, and child-domain impairment. TAPIS demonstrated incremental validity in predicting impairment beyond most comparison measures. Prospectively, tonic irritability predicted affective, anxiety, depressive, ADHD, and oppositional symptoms and higher negative affect, whereas phasic irritability predicted oppositional and conduct symptoms and lower effortful control. CONCLUSION:Findings support the reliability and validity of the TAPIS in early school-age children and provide evidence for the short-term predictive validity of tonic and phasic irritability dimensions.
Psychological First Aid (PFA) has been widely promoted as a universal intervention following traumatic incidents. However, early interventions once considered preventative were later found harmful, underscoring the importance of testing before widespread use. This randomised controlled trial examined the efficacy of PFA compared to natural recovery in reducing psychological distress using a validated stress-video paradigm. Based on recent evidence, it was hypothesised that PFA would alleviate short-term anxiety but show no long-term benefits. Eighty-four participants were randomised to either PFA (n = 47) or control (n = 37) following video exposure. Psychological distress was assessed using self-report measures over two weeks, with 74 participants completing follow-up (PFA n = 39, Control n = 35). The video reliably induced immediate distress. However, post-intervention analyses showed greater stress reduction in the control group compared with PFA, with a medium effect size. At two-week follow-up, no differences emerged between groups on any distress measures. Notably, participants experiencing higher initial distress displayed significantly greater trauma symptoms two weeks later-but only if they had received PFA. These findings challenge the classification of PFA as best practice, instead suggesting its similarity to previously discredited trauma interventions such as debriefing. Rather than being universally beneficial, group PFA may interfere with natural recovery in highly distressed individuals. Caution is warranted in its continued implementation, and post-trauma care should prioritise stepped, individualised approaches for those who develop clinically significant difficulties.
Excessive avoidance is a key contributor to chronic pain-related disability. In the acute stage, pain-related avoidance prevents further harm, but when it persists beyond healing time it becomes maladaptive. Exposure therapy is the preferred treatment, yet avoidance often returns. Changing contexts (e.g., from therapy to home) may contribute to avoidance returning, referred to as renewal. This study aimed to experimentally investigate the moderating effects of trait anxiety on renewal of fear and avoidance, as well as on fear and avoidance during acquisition, generalization and response prevention with extinction. Eighty-eight pain-free adults, pre-selected based on high vs. low trait anxiety performed a conditioning paradigm: certain visual stimuli (conditioned stimuli, CS+) were paired with pain (unconditioned stimulus, US), while others were not (CS-). Participants then learned to avoid the US via button presses. Generalization to stimuli perceptually similar to the CSs was subsequently tested. During response prevention with extinction, CSs were presented in a new context, the CS+ was no longer followed by the US, and participants were not allowed to avoid. Renewal was tested in both the acquisition and extinction contexts, with avoidance available. Our study replicated the renewal of avoidance. Moreover, compared to low-anxious individuals, high-anxious individuals showed increased fear generalization, but not reduced differential learning, increased avoidance generalization, reduced extinction, or more renewal. High-anxious individuals did avoid more on the CS+ during the renewal test, but this effect was not modulated by context. These results support that individuals with high trait anxiety are more prone to developing anxiety-related disorders.
Dampening of positive affect is a transdiagnostic vulnerability factor for various mental health problems, yet the underlying mechanism driving this process remains unclear. The Contrast Avoidance Model (CAM) offers a potential explanation, proposing that individuals may intentionally downregulate positive emotions to prevent distressing negative emotional contrasts (NECs). The present preregistered experimental study examined the applicability of the CAM to dampening. In a randomized controlled design with an unselected community sample, participants first underwent a happiness induction and were then randomly assigned to either a 2-min dampening induction (n = 50) or a relaxation induction (n = 52) prior to a sadness induction, to test whether the dampening induction reduced the strength of a downward shift from high to low positive affect (i.e., NEC). Positive and negative affect were assessed before and after each induction. Multilevel analyses indicated that the negative emotional contrast from before versus after the sadness induction was less pronounced in the dampening condition compared to the relaxation condition. These findings provide initial experimental support for the applicability of the CAM to dampening as an emotional contrast avoidance strategy. Clinical implications and directions for future research are discussed.
Childhood trauma, cold and controlling parenting experiences, and attachment difficulties are common in individuals with hoarding disorder (HD). One theory suggests that strong attachment to objects may arise as a compensatory response for early thwarted relatedness needs. However, first-line cognitive behavioural therapies (CBT) for HD rarely address these early adverse experiences during treatment. This study evaluated the feasibility, acceptability, and preliminary efficacy of an imagery rescripting intervention targeting early aversive memories in 10 individuals diagnosed with HD (Mage = 65.80 years; 80% female) who failed to sufficiently benefit from CBT. Participants attended an assessment appointment, followed by 12 bi-weekly sessions of imagery rescripting. Primary outcomes included hoarding symptoms, hoarding beliefs, and negative intrusive imagery, whereas secondary outcomes included anxiety, depression, obsessive-compulsive symptoms, and attachment difficulties. Measures were taken before a randomised baseline monitoring period, at pre-, mid-, and post-treatment, and at 1-month follow-up. Treatment credibility and acceptability were also assessed. We found that patients rated rescripting as moderately credible, and most participants (9 of 10) completed treatment with high satisfaction ratings. Significant and large reductions in hoarding symptoms (hedge's g = 0.90, p = .04), hoarding beliefs (hedge's g = 1.13, p = .01), depression (hedge's g = 1.18, p < .01), and avoidant attachment (hedge's g = 1.12, p < .01) were observed post-treatment and largely maintained at follow-up. Anxiety (hedge's g = 0.92, p =.04) and obsessive-compulsive symptoms (hedge's g = 1.28, p <. 01) also decreased by follow-up, whereas negative intrusive imagery and anxious attachment showed minimal change. Clinically significant improvements in hoarding symptoms occurred for half the sample, with three participants classifiable as 'recovered'. These findings suggest imagery rescripting may be a feasible, acceptable and promising adjuvant intervention for HD treatment non-responders. Future research should evaluate its efficacy in randomised controlled trials.
Individuals with chronic pain have increased risk of suicide, however, few receive suicide prevention interventions. Problem-solving therapy is an evidence-based treatment for chronic pain that seeks to improve problem-solving ability, an executive function associated with suicide risk and related outcomes. The goal of this pilot randomized controlled trial was to estimate if problem-solving therapy improves problem-solving ability and other outcomes for Veterans with chronic pain and moderate suicide risk (n = 44). Veterans were randomized to receive 12-weeks of video delivered problem-solving therapy or supportive psychotherapy. At post-treatment, problem-solving therapy was estimated to result in a greater increase in problem-solving ability (Cohen's d = 0.33, small effect) and a greater reduction in perceived burdensomeness (Cohen's d = 0.60, large effect), compared to supportive psychotherapy. These between-group differences were estimated to be maintained for problem-solving ability (Cohen's d = 0.94, large effect) and perceived burdensomeness (Cohen's d = 0.45, medium effect) at 6-month follow-up. It was estimated that problem-solving therapy did not have a differential effect on thwarted belongingness compared to supportive psychotherapy. In exploratory analysis, problem-solving therapy was estimated to reduce suicide ideation intensity, suicide ideation frequency, and suicide coping at post-treatment, however, in between-group analysis, only suicide ideation frequency was estimated to be reduced as compared to supportive psychotherapy. Results for the exploratory pain outcomes were mixed. This study suggests problem-solving therapy may improve problem-solving ability and reduce feelings of perceived burdensomeness. A fully powered clinical trial is needed to confirm these results and to determine if problem-solving therapy reduces suicide risk and improves pain outcomes.
