In anxiety and related disorders, Virtual Reality Exposure Therapy (VRET) was one of the first steps toward integrating technology into psychological treatments. In this article, we discuss crucial therapeutical skills and provide a case conceptualisation for the treatment of social anxiety disorder with VRET. The case conceptualisation is based on evidence-based cognitive-behavioural treatment approaches. Social anxiety can be very challenging to treat with exposure in vivo, and virtual reality exposure offers the added benefit of being able to create social situations and real-time interactions within the therapeutic context. The case conceptualisation presented is worked out for a 23-year-old female with social anxiety disorder who is increasingly hindered by her anxiety in her professional and personal life. The treatment rationale of VRET, homework assignments, and progress of therapy are presented. Additionally, this paper discusses what steps to take if the first exposure experiences are not successful and how to progress in such cases. Therapeutic pitfalls are illustrated within this case and potential solutions on how to avoid these pitfalls are addressed.

The aim of this review is to evaluate the state of the art of studies investigating failures in cognitive behavior therapy (CBT). The last couple of years relatively few studies have specifically focused on failures in CBT. Generally, clinicians underestimate the number of therapies that fail and therapists are no better than chance at predicting effectiveness classification. In patients treated in outpatient clinics, effects of therapy were lower than effects of therapy in disorder-specific CBT efficacy randomized controlled trials. In eating disorders, results of CBT are moderate with high remission rates. In severe eating disorders compassion focused therapy was more effective than CBT at one year follow-up among patients with a history of childhood trauma. Co-morbid personality disorders and depression were significant negative predictors of treatment response in CBT. Few studies have investigated which processes are associated with failure of CBT in patients with PTSD. Drop-out rates for treatments for adult PTSD are rather high. One study reported significantly more drop-outs in cognitive processing therapy compared with exposure therapy. There is only limited evidence that CBT including dialectical behavior therapy and schema therapy are more effective than treatment as usual especially with patients with borderline personality disorder. To prevent failures in CBT, a good working alliance is of high importance. Engagement in measurement-based care may help to prevent treatment failures as well.

Background: Individuals suffering from PTSD following childhood abuse represent a large subgroup of patients attending mental health services. The aim of phase-based treatment is to tailor treatment to the specific needs to childhood abuse survivors with PTSD with a Skills Training in Affective and Interpersonal Regulation (STAIR) phase, in which emotion dysregulation and interpersonal problems are targeted, and a trauma-focused phase.Objective: The purpose of this study was to compare STAIR + Eye Movement Desensitization and Reprocessing (EMDR) vs. STAIR + Narrative Therapy (NT) as treatments for PTSD following childhood-onset trauma in a routine clinical setting.Method: Sixty-eight adults were randomly assigned to STAIR/EMDR (8 STAIR-sessions followed by 12 EMDR-sessions) or STAIR/NT (8 STAIR-sessions followed by 12 NT-sessions). Assessments took place at pre-treatment, after each treatment phase and at 3 and 12 months post-intervention follow-up. Primary outcomes were interviewer-rated and self-reported symptom levels of PTSD. Secondary outcomes included symptom levels of depression and disturbances in emotion regulation and interpersonal skills.Results: Multilevel analyses in the intent-to-treat sample indicated that patients in both treatments improved substantially on PTSD symptom severity (CAPS: d = 0.81 to 1.29; PDS: d = 1.68 to 2.15), as well as on symptom levels of depression, anxiety, emotion regulation, dissociation and interpersonal skills. Effects increased or were maintained until 12-month follow-up. At mid-treatment, after STAIR, patients in both treatments improved moderately on PTSD symptom severity (PDS: d = 1.68 to 2.15), as well as on symptom levels of depression (BDI: d = .32 to .31). Symptoms of anxiety, emotion dysregulation, interpersonal problems and dissociation were not decreased after STAIR. There were no significant differences between the two conditions on any outcome.Conclusion: PTSD in adult survivors of childhood interpersonal trauma can effectively be treated by phase-based interventions using either EMDR or NT in the trauma-processing phase.Trial registration: ClinicalTrials.gov identifier: NCT01443182..

Purpose of review To provide an update of systematic reviews, meta-analyses and recent clinical outcome studies for personality disorder (PD) in order to investigate the state of the art of the evidence of psychotherapy for personality disorders Recent findings Few outcome studies in patients with Cluster A and Cluster C PD have been conducted, which limits the conclusions which can be drawn. Most recently published research has been conducted with borderline PD. There is limited evidence that dialectical behavior therapy (DBT), mentalization based therapy and schema therapy are more effective than treatment as usual. There is no convincing evidence that long and intensive therapy is more effective than short and less intensive therapy. Drop-out is rather high for patients with borderline PD. Group therapy results in more drop-outs than individual therapy Summary There is a clear need of studies evaluating whether psychotherapies developed for PDs are more effective than CBT for patients with Cluster C PD. Given that studies with patients with Cluster B PD suggest that longer treatment of DBT and mentalization-based treatment is not more effective than shorter treatment this needs to be studied with other evidence-based therapies as well. Serious efforts are needed to evaluate therapies for patients with Cluster A PDs.

Personality disorders are highly prevalent in clinical practice. With the introduction of the Diagnostic Statistical Manual - 5th Edition (DSM-5) the multi-axial system of diagnosis for mental disorders has disappeared, which has led to an increase in research on personality disorders (e.g. Emmelkamp & Meyerbröker, 2020). In this Special Issues, several recent developments are discussed. In the first article (Crisan et al., 2023) in this Special Issue, a meta-analysis is reported investigating the results of studies on the association between adverse childhood events and cluster C personality disorders including avoidant personality disorder, dependent personality disorder and obsessive–compulsive personality disorder. Adverse childhood events included cumulative adverse experiences, childhood maltreatment, dysfunctional parental behaviours, household dysfunction and peer bullying. This meta-analysis found a strong association between childhood adversity and each specific cluster C personality disorder across studies with larger effect sizes in studies that used clinical interviews, compared to studies that used self-report questionnaires. Interestingly, this association decreased with age. Results of a systematic review of Fanti et al. (2023) revealed that paranoia may be transdiagnostic in a variety of personality disorder diagnoses. They found evidence of mild-to-severe paranoia not only in paranoid personality disorder and schizotypal personality disorder but also in borderline personality disorder as well. In addition, they also found evidence of paranoia in a number of patients with antisocial personality disorder, avoidant personality disorder and narcissistic personality disorder. In a study by van der Linde et al. (2023), who investigated complex dissociative disorders, questionnaires measuring personality disorder traits, schema modes and coping styles were completed by patients with avoidant personality disorder, borderline personality disorder and complex dissociative disorder. Results revealed that patients with the complex dissociative disorder—in contrast with patients with avoidant personality disorder and borderline personality disorder—were characterized by specific schizoid, schizotypal, borderline and avoidant personality traits. Interestingly, patients with complex dissociative disorder reported early maladaptive schemas in the domains of disconnection and rejection, and over-vigilance and inhibition. Risky, self-destructive impulsivity and emotion dysregulation are core features of borderline personality disorder (Waite et al., 2024). Two studies in this Special Issue investigated altered emotional patterns in borderline personality disorder. Pyszkowska et al. (2023) studied in patients with borderline personality disorder and in patients with depression whether internalized stigmatization and emotional dysregulation may enhance avoidance strategies, including maladaptive daydreaming. Maladaptive daydreaming was associated with emotional dysregulation and negative attitudes towards oneself. Results revealed further significant differences between borderline personality disorder and depression with higher scores reported by patients with borderline personality disorder in areas of negative affect and emotional dysregulation. Lopez-Villatoro et al. (2023) investigated—using the International Affective Picture System—whether an altered emotional pattern in borderline personality disorder patients was associated with traumatic experiences and attachment bonds towards their primary caregivers. As concluded, the authors' results of this study highlight the relevance of treatment focused on traumatic attachment events for the improvement of emotional instability in patients with borderline personality disorder. The following articles in this Special Issue are focused on evidence-based psychotherapy on patients with personality disorders. In the first study (Nielsen et al., 2023), a scoping review was conducted to identify relevant existing psychotherapy research with patients with schizotypal personality disorder. Unfortunately, very few relevant studies have been conducted with this group of patients and results are inconclusive. Schema therapy is one of the evidence-based psychotherapies for personality disorders (Emmelkamp & Meyerbröker, 2020), but most studies have involved individual schema therapy. Wibbelink et al. (2023) investigated in a large multicentre open trial the effectiveness of group schema therapy for cluster C personality disorders. Results revealed that 30 sessions of group schema therapy resulted in significant improvements with medium to large effect sizes after 2 years for avoidant and dependent personality disorder, but results for obsessive–compulsive personality disorder are inconclusive. In the study of Khasho et al. (2023), the effectiveness of schema therapy was investigated in older adults with borderline personality disorder using a multiple baseline case series design. Results revealed that schema therapy led to a significant decrease in negative core beliefs. In addition, patients no longer fulfilled the criteria of borderline personality disorder. Few studies have investigated the treatment of borderline problems in adolescents (e.g. Schuppert et al., 2012). In the next article in this Special Issue (Gilbey et al., 2023), 6 months of mentalization-based therapy is investigated in a therapeutic community setting with adolescents with borderline personality problems. Results indicate that participants show a reduction in self-harm and internalizing symptoms. High rates of dropout have been widely reported in evidence-based psychotherapies for patients with borderline personality disorder. In the following study published in this Special Issue, De Freixo Ferreira et al. (2023) investigated drop-out in published randomized controlled trials in which patients with borderline personality disorder were treated with evidence-based psychotherapy. Results revealed that patients with weaker therapeutic alliance scores and higher hostility presented with higher dropout rates. Last but not least, comorbid personality disorder has been studied as a predictor for treatment efficacy and dropout in treatments, especially with patients treated for post-traumatic stress disorder (e.g. Snoek et al., 2021). In the last study in this Special Issue, van den End et al. (2023) investigated whether co-morbid personality disorder had negative effects on treatment outcomes for post-traumatic stress disorder. Interestingly, the results were negative: personality disorder did not predict change in post-traumatic stress disorder.

Mood and anxiety disorders are not only common and responsible for much functional disability [1], but epidemiological studies also indicate that their prevalence, circa 10% in Western countries, has not fallen since the 1970s despite the development of evidence-based treatments [2–8]. Prevalence refers to the percentage of adults in the general population that meet diagnostic criteria in a defined period, usually the 30 days (point prevalence) or 12 months (12-month prevalence) preceding the examination irrespective of possible earlier episodes. In sharp contrast, multiple studies have documented substantial increases in expenditures on mental health care and in treatment rates in Western countries [9–15]. The evidence on increased treatment rates comes from both general practice [16–18], nation-wide morbidity registrations [19, 20], and repeated population-based surveys [8, 21]. The treatment rate increase was bolstered by the introduction of a new class of drugs in the 1980s, the selective serotonin reuptake inhibitors, aggressively marketed by Big Pharma [22]. In addition, a number of evidence-based psychological treatments became available for people with mood and anxiety disorders. The trend data on prevalence and treatment rate reveal a remarkable paradox: more treatment but not less disorders, the treatment-prevalence paradox. The expectation to see a declining trend in the prevalence of mood and anxiety disorders with an increasing trend in treatment is not unfounded. Treatment seeks to shorten illness episodes, prevent worsening and the development of comorbidity, reduce relapses and curtail recurrences. If effective, increased treatment rates should result in lower prevalence rates in the general population, but this prevalence reduction has not occurred. The increase in the use of statins has led to significant reduction in population cholesterol levels [23]. Likewise, more and better treatment of hypertension has led to less hypertension and associated illness such as heart attacks and strokes illness [24, 25]. At least seven hypotheses can explain why more and better treatments have not reduced common mental disorder prevalence: 1. Increased willingness of individuals to report symptoms and pressures to diagnose distress as anxiety or depression has inflated prevalence rates and masked a true treatment-driven prevalence drop (further: diagnostic inflation).

Major depressive disorder is a debilitating and common mental disorder with a prevalence of nearly 5%, affecting more than 280 million people worldwide (Global Health Data Exchange, 2021) and characterized not only by depressed mood but also by family distress, substance abuse, suicidal ideation and suicide. In the first article in this Special Issue, a meta-ethnography of 21 qualitative studies exploring Mindfulness-based Cognitive Therapy for people with major depression is reported (Williams et al., 2022). This study supports the view that Mindfulness-based Cognitive Therapy enables the development of new skills and different ways of responding. ‘Acceptance’ proved to be an overarching theme encompassing many changes in the relationship with depression, self and others. Clear recommendations for practice for Mindfulness-based Cognitive Therapy by clinicians and researchers are reported. Difficulty in accessing specific autobiographical memories about one's personal past experiences, referred to as reduced memory specificity or overgeneral memory, has been established as a cognitive marker of depression. Past research has revealed that difficulty in recalling specific memories is a predictor of future depressive symptoms (Hallford et al., 2021). In this issue Hallford et al. (2022) provide a systematic review and meta-analysis of empirical studies evaluating whether or not remitted depression is associated with retrieving fewer specific and more overgeneral autobiographical memories. Results provide some evidence for a cognitive deficit that persists beyond episodes of major depression, suggesting that poorer autobiographical memory may be a vulnerability for future episodes. Recent research has shown that Emergency Departments are important environments for suicide prevention, particularly in providing clinicians the opportunity to support those presenting with suicidal ideation (Griffin et al., 2019). In the third article in this issue, Fawcett and O'Reilly (2022), present a systematic literature review on hospital presenting suicidal ideation. The findings from this review show that people presenting to Emergency Departments with suicidal ideation vary in age, gender, ethnic background and socio-economic status. Importantly, previous suicide attempt appears to be a risk factor in such presentations. The authors' review identifies key gaps and weaknesses in the literature and a clear need for future research. Although there is much evidence, over the years, that Cognitive Behavioural Therapy (CBT) is effective for major depression, not every patient responds to CBT and relapse rates remain high. Jelinek et al. (2016) developed a depression-specific low-intensity group programme (Meta-Cognitive Training for Depression) which addresses a broad range of depression-related (meta-)cognitive biases. In a recent version of this programme, two new modules were added to address suicidality (Jelinek et al., 2020). In this issue, a randomized controlled clinical trial is published in which Meta-Cognitive Training for Depression in acute-psychiatric inpatient care is investigated in Germany (Hauschildt et al., 2022). Results revealed that this treatment is highly accepted by patients in acute-psychiatric inpatient care, but that there was no additional effect of Meta-Cognitive Training for depression compared to inpatient care. However, individuals who received Meta-Cognitive Training for Depression showed a greater reduction of depressive beliefs and dysfunctional metacognitions after 3 months. Sudden gains have been found to be a consistent phenomenon among depressed individuals in evidence-based psychological therapies, including Cognitive Therapy and Interpersonal Therapy. Such sudden gains early in therapy have been associated with better treatment outcomes. Most studies have assessed the occurrence of sudden gains on a weekly or biweekly basis. In the article in this issue (Terrill et al., 2022), rates of sudden gain occurrence, pretreatment factors and posttreatment outcomes were examined in US patients who received daily, intensive therapy. Depressed patients who experienced sudden gains reported significantly greater improvement at the end of treatment, not only on depressive and anxiety symptoms but also in coping skills, functioning and positive mental health. Results suggest that measuring sudden gains in patients who receive intensive treatment for major depression, on a daily basis and early in therapy, can help clinicians in conducting psychological treatment with these patients. Sensory integration helps people, after having perceived sensory stimuli in the environment and body, to process it. Sensory processing disorders have been described in people with depression and might be a trait of individuals suffering from major depression (Engel-Yeger et al., 2018). In the article of Paquet et al. (2022), it was investigated whether sensory profiles assessed with the Adult/Adolescent Sensory Profile Scale among French patients with Major Depressive Disorder were associated with anxiety, depression, psychomotor retardation or self-esteem. Results revealed that extreme sensory processing patterns emerged among patients suffering from Major Depressive Disorder. Results suggest that further research is needed to investigate the interaction between body and environment in affective disorders. A variety of negative mood states have been shown to be proximal predictors of suicide ideation in high-risk individuals (Ben-Zeev et al., 2012). In the sixth article of this issue (Lucht et al., 2022), the role of mood and affect as a proximal risk factor of suicidal ideation was investigated. This was done by using Ecological Momentary Assessment (EMA) in a high-risk sample of depressed patients in Germany with current and/or lifestime suicidal ideation. Results indicated that both negative valence of mood and low positive affect were predictors of subsequent intensity of suicidal ideation as well as predictors of change in suicidal ideation. The researchers advocate that both mood and affect should be taken into account as important proximal risk factors of active and passive suicidal ideation. The need for replication studies with larger samples and longer EMA follow-ups is noted. Attachment insecurity is significantly more likely to be found among individuals experiencing psychological difficulties (Zortea et al., 2021). Previous reviews suggest that insecure attachments are a risk factor for suicidal thoughts and behaviours (Zortea et al., 2021). In the article of Turton et al. (2022) in this issue, the relationships between attachment insecurity and suicidal ideation and behaviour were examined in the UK in a sample of individuals with experience of suicidal ideation. Results showcased a direct relationship between avoidant attachment and suicide ideation after controlling for age and gender with multiple suicide attempters found to be higher in anxious attachment. Emotion dysregulation did not mediate the relationship between attachment insecurity and suicide ideation. The researchers concluded that those experiencing suicidal ideation may benefit from exploring attachment-related difficulties. The researchers recommended that future studies investigate the mechanisms that may explain the association between attachment and suicidality in order to refine psychological interventions for suicidality. The construct of sense of coherence (SOC) has garnered research interest over the last 40 years (Antonovsky, 1993); however, few studies have examined the role of SOC in adjustment to bereavement. In the last article of this issue, Boelen and O'Connor (2022) examine the role of SOC in recovery and loss in elderly spousally bereaved people in Denmark using a longitudinal research design. Results from the study show that the original three-factor model of the SOC 13-item scale demonstrates a good fit to the data. Furthemore, the SOC factors were found to be correlated with prolonged grief disorder, depression and satisfaction with life, predicting outcomes at Wave 2 and Wave 3 of the study. These findings, argue the researchers, indicate that meaningfulness may increase healthy and attenuate unhealthy responses to loss. The practical implication of this work is that helping bereaved people to experience life's demands is likely to be an important target for bereavement care.

Background The efficacy of virtual reality exposure therapy (VRET) for fear of flying has been well established. Yet, little is known about the extent to which anxiety sensitivity and self-efficacy predict the efficacy of VRET. We aimed at investigating these cognitive predictors as well as the contribution of the therapeutic alliance to treatment outcome. Methods In a within-subjects design with 67 patients with fear of flying, four sessions of an exposure-based treatment using VRET were given. Sessions were held every week, each consisting of two virtual flights of 25 min. Results Results showed that pre-treatment levels of anxiety sensitivity, initial improvement in self-efficacy (and not pre-treatment levels of self-efficacy), and the quality of the therapeutic alliance significantly predicted treatment outcome. Conclusions The findings provide evidence that initial changes in self-efficacy, pre-treatment anxiety sensitivity, and therapeutic alliance are significant predictors of response to VRET for specific phobia.

Background Existing therapies for depression are effective, but many patients fail to recover or relapse. To improve care for patients, more research into the effectiveness and working mechanisms of treatments is needed. We examined the long-term efficacy of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for Major Depressive Disorder (MDD), testing the hypothesis that CBT outperforms ACT and that both therapies work through their designated mechanisms of change. Methods We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before, during and after treatment, and at 12-month follow-up, assessing symptoms of depression, quality of life, dysfunctional attitudes, decentering , and experiential avoidance. Results Patients in both conditions reported significant and large reductions of depressive symptoms ( d = -1.26 to -1.60) and improvement in quality of life ( d = 0.91 to -1.28) 12 months following treatment. Our findings indicated no significant differences between the two interventions. Dysfunctional attitudes and decentering mediated treatment effects of depressive symptoms in both CBT and ACT, whereas experiential avoidance mediated treatment effects in ACT only. Conclusions Our results indicate that CBT is not more effective in treating depression than ACT. Both treatments seem to work through changes in dysfunctional attitudes and decentering, even though the treatments differ substantially. Change in experiential avoidance as an underlying mechanism seems to be an ACT-specific process. Further research is needed to investigate whether ACT and CBT may work differently for different groups of patients with depression.

381 ple based on machine learning approaches applied to large datasets in order to recommend the optimal treatment, treatment strategy, or therapist for an individual patient. During treatment, therapists are made aware of patients at risk for treatment failure, dropout or self-harm by adaptive decision tools. Additionally, therapists are provided with feedback and clinical problem-solving tools to support treatment for these patients. Currently, the implementation and prospective evaluation of such systems are rare. However, such studies and new developments are already on their way. For example, more than a decade of our department’s research activity has resulted in the development of a digital decision support and navigation system called the Trier Treatment Navigator (TTN). The system combines outcome tracking, prediction, and prescription tools, providing continuous feedback to clinicians and supporting them to apply targeted clinical strategies at the onset of and during treatment. The online navigation system includes two components of patient-specific treatment recommendations: a) a pre-treatment clinical strategy recommendation and b) adaptive recommendations and support tools for patients at risk for treatment failure. The prospective evaluation on 538 patients showed an advantage in outcomes, with an effect size of about 0.3, when patients were treated with the recommended strategy during the first ten sessions. Furthermore, therapist symptom awareness, attitude, and confidence using the system were found to be significant predictors of outcome, while therapist-rated usefulness of such feedback moderated the feedback-outcome association. A similar approach, the Leeds Risk Index (LRI), was developed based on a sample of 1,347 patients and prognostically tested on 282 patients in the Improving Access to Psychological Therapies (IAPT) programme, to recommend either low or high intensity treatments. Results indicated that such stratified care improves efficiency by generating comparable outcomes with less treatment sessions. The goal of these developments is the time ly translation of research into clinical practice. Of course, many more prospective studies are necessary. However, in the future, the field might be better able to operationalize change processes, regarding both how patients experience them and how therapists induce them. These developments could be the basis of a trans-theoretical, process-based, personalized and data-informed psychological treatment approach, which includes both an idiographic (e.g., intensive longitudinal assessments on single cases) and a nomothetic (e.g., large databases of patients and therapists) perspective. Such advancements could finally make a difference for patients previously not profiting from psychological interventions.