I Sverige beräknas 17 % av befolkningen ha en hörselnedsättning, vilket innebär att det är den vanligaste sensoriska funktionsnedsättningen. Idag finns det en mängd studier som visar att hörselnedsättning är relaterat till sämre psykisk hälsa. Acceptans av sin hörselnedsättning har visat sig vara positivt för hörselnedsatta och samvarierar med hjälpsökande. Acceptance and commitment therapy (ACT) är en transdiagnostisk behandling där psykopatologi antas bero på en hög grad av upplevelsemässigt undvikande och fusion med tankar. Målet i ACT är att öka psykologisk flexibilitet där acceptans är en betydande komponent. Denna explorativa studie undersökte förändringsprocesser i ACT för personer med hörselnedsättning där utfallet var känslomässig och social anpassning för hörselnedsättningen (HHIE-S). De förändringsprocesser som prövades var acceptans (HAQ), som tidigare visat på medierande effekt för ACT, samt två alternativa förändringsprocesser; self-efficacy (HSE-4) och upplevd stress (PSS-4). Behandlingen bestod av åtta internetadministrerade moduler givna med behandlarstöd där veckovisa mätningar av förändringsprocesser och utfall användes. Studiens resultat visar att behandlingsgruppen upplevde marginellt signifikant mindre problem med känslomässig och social anpassning för hörselnedsättningen (HHIE-S). Studiens resultat pekar på att hörselrelaterad acceptans (HAQ) och self- efficacy (HSE-4) medierar behandlingens effekt på deltagarnas känslomässiga och sociala anpassning för hörselnedsättning (HHIE-S). Således tillför denna studie ytterligare belägg för acceptans som förändringsprocess i ACT. Även self-efficacy kan vara en intressant mediator att beakta i fortsatt forskning.

Os exames de Ressonância Magnética vêm sendo muito requisitados nas diferentes especialidades médicas como complemento diagnóstico e acompanhamento evolutivo de diversas patologias. Embora seja um método diagnóstico de excelência, os pacientes que se submetem ao exame podem apresentar muito desconforto em razão do espaço restrito do aparelho. A fobia de espaços fechados é considerada um tipo de fobia específica, segundo o Manual Diagnóstico e Estatístico de Transtornos Mentais DSM 5 (APA, 2013). OBJETIVOS: Verificar se uma sessão de Terapia de Aceitação e Compromisso é tão eficaz quanto sete sessões deste mesmo modelo terapêutico no tratamento de pacientes com medo de realizar exames de Ressonância Magnética. MÉTODO: Foi realizado um ensaio clínico randomizado com dois grupos paralelos, um grupo recebeu uma sessão e o outro grupo recebeu sete sessões de tratamento de Terapia de Aceitação e Compromisso. Os participantes foram avaliados no início e ao final do tratamento a partir dos seguintes instrumentos: Inventário de Claustrofobia de Rachman e Taylor (1993), Inventário de Depressão de Beck et al. (1961) e Inventário de Ansiedade estado-traço de Spielberger, Gorsuch e Lushene (1970). O estudo foi realizado em um hospital público na cidade de São Paulo com 30 pacientes. Desfecho principal: permanecer dentro de um simulador de Ressonância Magnética por, no mínimo, trinta minutos após o término de cada um dos tratamentos. Desfechos secundários: as diferenças nos escores dos Inventários de Claustrofobia, Inventário de Depressão de Beck e Inventário de Ansiedade Estado-traço do início e do final do tratamento. RESULTADOS: 92,9% dos participantes (N) do grupo de sete sessões conseguiram realizar exame de Ressonância Magnética no simulador após o tratamento, enquanto que 50% dos participantes do grupo de uma sessão conseguiram realizar o exame no simulador (p=0,033). Dos sujeitos que tiveram melhor resposta ao tratamento, 78% eram do sexo masculino, 80% eram casados, 78% não faziam uso de medicação psiquiátrica e em relação ao diagnóstico, 20% deles tinham diagnóstico de fobia específica de Ressonância Magnética e 80% deles tinham diagnóstico de fobia de espaços fechados. Todos os sujeitos portadores do diagnóstico Fobia específica de realizar exames de Ressonância Magnética conseguiram realizar o exame no simulador independente do número de sessões. Já os portadores de fobia de espaços fechados responderam mais ao tratamento de sete sessões (92%, p=0.009). O inventário de claustrofobia evidenciou que os indivíduos do grupo sete sessões responderam ao tratamento (p=0,002) e mostrou diferenças significativas nos escores antes e depois do tratamento e que se mantiveram três meses depois. Já no inventário de Beck, observa-se melhora dos sintomas depressivos ao final do tratamento (p=0,015), porém não há diferença após três meses. Observou-se através dos coeficientes de Regressão que quanto maior a pontuação no inventário de claustrofobia e de Depressão de Beck, menor a probabilidade de conseguir permanecer no simulador. Entretanto, fazer pelo menos sete sessões de terapia aumenta a probabilidade do desfecho positivo desejado. O estudo mostrou ainda que sete sessões de terapia foram benéficas, pois mesmo com escores elevados de sintomatologia depressiva os pacientes foram bem sucedidos na realização do exame de Ressonância Magnética no simulador / The MRI exams have been in considerable demand in various medical specialties to diagnose diseases. Although it is an effective diagnostic method, patients who are subjected to the exam might present high levels of discomfort due to the confined space of the device. The phobia of enclosed spaces is considered a type of specific phobia, according to the Diagnostic and Statistical Manual of Mental Disorders 5 (APA, 2013). Objectives: to check if a single session of Acceptance and Commitment Therapy is as effective as seven sessions of the same therapeutic model for the treatment of patients with fear of undergoing MRI exams and enclosed spaces phobia. METHODS: A randomized clinical trial study with two parallel groups was performed, one group underwent one session and the other group underwent seven sessions of Acceptance and Commitment Therapy. Participants were assessed at the beginning and at the end of treatment with the following instruments: Claustrophobia Inventory from Rachman and Taylor (1993), Beck Depression Inventory from beck et al. (1961) and Anxiety Inventory State - Trait from Spielberger, Gorsuch and Luschene (1970). The study was performed in a public hospital in the city of Sao Paulo with 30 patients. Main outcome: to remain in a MRI simulator for at least 30 minutes after each treatment. Secondary outcomes: compare the differences in the inventories of Claustrophobia, Beck Depression Inventory and the Anxiety Inventory Trait- State scores compared at the beginning and at the end of treatments. RESULTS: 92.9% of participants (N) on the seven sessions group were able to carry out the MRI exam simulator after treatment, while 50% of participants of the one session group were able carry out the post treatment session in the simulator (p = 0.033). From the participants who had better response to treatment, 78 % were male, 80 % were married, 78 % did not use psychiatric medication and 20 % had a diagnosis of specific MRI phobia, 80% had a diagnosis of enclosed spaces phobia. All subjects with the Specific Phobia of performing MRI exams diagnosis were able to perform at the simulator test without considering the number of treatment sessions. Those with phobia of enclosed spaces responded more to the seven sessions treatment (92 %, p = 0.009). The inventory of claustrophobia showed that individuals in the seven sessions group performed the treatment (p = 0.002), showing significant differences before and after treatment and the level of performance was the same three months later. The Beck Inventory showed that there was improvement in depressive symptoms at the end of treatment (p = 0.015), but there was no difference after three months. It was observed through the regression coefficients that the higher the score on the inventory of claustrophobia and Beck Depression Inventory, the lower the probability of performing in the simulator. However, doing at least seven sessions of therapy increases the likelihood of the desired positive outcome. The study also showed that seven therapy sessions were beneficial, because even with high scores of depressive symptoms patients were successful in the test of the MRI simulator

Transtornos Alimentares (TA) são transtornos mentais considerados graves. Dentre eles, Anorexia Nervosa e Bulimia Nervosa compartilham sintomas e características psicopatológicas como hábitos desregulados de alimentação, métodos extremos para controle do peso, e preocupações exageradas com a forma e o peso corporal. Os TA compartilham ainda sintomas comuns em outros transtornos psiquiátricos, como Depressão e Ansiedade. Pesquisas sobre o tema devem levar em conta este amplo espectro de sintomas. A meditação é uma prática que tem recebido crescente atenção de pesquisadores de diversas áreas de saúde. Dentro da área de Psiquiatria, a meditação mindfulness tem sido estudada como terapia complementar para diversos transtornos, sendo os mais pesquisados os transtornos de ansiedade, a depressão e a dependência química. Alguns programas baseados em mindfulness já demonstraram resultados positivos em pacientes com Compulsão Alimentar e Bulimia Nervosa. Este é um projeto que teve a intenção de desenvolver e mensurar os efeitos de uma nova intervenção baseada em meditação mindfulness para pacientes internados na Enfermaria de Comportamentos Alimentares (ECAL) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A hipótese primária foi que o treinamento em mindfulness diminuiria sintomas de ansiedade e depressão, em comparação com os pacientes que seguiram o tratamento usual da enfermaria. O projeto todo teve duração de três anos, sendo dividido em fase piloto, fase grupo controle e fase grupo intervenção. Cada fase aconteceu em diferentes períodos de tempo, para que um número adequado de indivíduos fosse alcançado para fins de pesquisa. Avaliações foram feitas sempre nos mesmos períodos para os três grupos: durante a primeira semana de internação e após 8 semanas, ou antes, se o paciente recebesse alta. Os resultados do grupo piloto foram positivos e ajudaram a delinear os exercícios que compuseram o programa aplicado na intervenção. A comparação dos resultados do grupo controle com o grupo intervenção apresentou significativa diferença para os índices de ansiedade (p < 0,01), depressão (p < 0,03), capacidade de agir com atenção (p < 0,01) e atitudes alimentares relacionadas a dietas (p < 0,04). Como previsto e em linha com outras pesquisas utilizando mindfulness para indivíduos com TA menos grave, este protocolo de oito sessões demonstrou efeito positivo e significativo apesar dos desafios de trabalhar com esta população neste contexto. Estes resultados dão suporte a novas pesquisas que poderão testá-los e compreender melhor a duração dos efeitos terapêuticos deste treinamento. Também, devem ser considerados aprimoramentos necessários, como refinamento dos exercícios, capacitação de outros terapeutas no protocolo e treinamento em mindfulness para outros profissionais envolvidos / Eating disorders (ED) are considered severe mental disorders. Anorexia Nervosa and Bulimia Nervosa are disorders that share symptoms and psychopathological characteristics such as deregulated feeding habits, extreme methods for weight control and exaggerated concerns about shape and weight. Eating Disorders also share common symptoms with other psychiatric disorders such as depression and anxiety. Research on eating disorders should take into account this wide spectrum of symptoms. Meditation is a practice that has received increasing attention from researchers in various areas of healthcare. Within the area of Psychiatry, mindfulness meditation has been studied as a complementary therapy for many disorders, and the most researched are anxiety, depression and addiction. Some mindfulness-based programs have already shown promising results in patients with Binge Eating Disorder and Bulimia Nervosa. This research project aimed to measure the effects of a mindfulness meditation intervention delivered to patients admitted to the Eating Disorders Ward at the Institute of Psychiatry in the Clinical Hospital for the Medical School, University of São Paulo. The primary hypothesis was that mindfulness training would lower symptoms measuring anxiety and depression compared to inpatients that received treatment as usual. The entire project was conducted during three years, with a pilot group phase, a control group phase and an intervention group phase. Each phase happened in different periods of time so the study could recruit a suitable number of participants. Assessments were made for all groups during the first week of admission and at eight weeks (or earlier if the patient were to be discharged). Pilot results were positive and helped delineate exercises that would be part of the main study intervention protocol. The final analysis comparing control and intervention group showed significant differences for measures in anxiety (p < 0.01), depression (p < 0.03), acting with awareness (p < 0.01) and dieting attitudes (p < 0.04). As hypothesized and in line with previous research with less severe eating disorders samples, this novel eight week program showed a positive and significant effect despite the challenges of working with this population and in this setting. These findings will inform future research which will need to replicate the findings, understand more about the durability of the effects and consider the resource allocation (eg staff training) needed to offer this promising intervention in this setting

It is increasingly clear that pain and emotions are closely interconnected. Pain does not only cause psychological distress, but psychological distress also amplifies pain through neurological mechanisms. Treatment of both chronic and acute pain would benefit from acknowledging the psychological mechanisms of pain neurophysiology. Psychological acceptance predicts increased pain tolerance and decreased pain intensity and discomfort in experimentally induced pain and improved physical and psychosocial functioning for persons with chronic pain. The overall aim of this thesis was to evaluate acceptance-based interventions for persons suffering from pain. In Study I the effect of a manualised ACT-based self-help intervention for adults with chronic pain was evaluated in an RCT (n=90). The results showed improvements in satisfaction with life, physical functioning and pain intensity for the ACT group. Both the ACT and the control group improved regarding depression and anxiety. In Study II the mediating effect of acceptance for treatment change was evaluated, using data from Study I (n=64). The results showed indirect effects of treatment via acceptance for physical functioning but not for satisfaction with life. In Studies III and IV, instruments to measure psychological flexibility in relation to pain were developed for children with cancer, and their parents respectively, using factor analysis. The results showed that a two-factor solution for the child scale (n=61) and a three-factor solution for the parent scale (n=243), best represented the data. In Study V, an acceptance-based intervention was preliminarily evaluated in a single-subject study (n=5) for children reporting pain during cancer treatment. The intervention consisted of an approximately 15-minute long pain exposure exercise. All participants reported reduced discomfort of pain, and three of the participants reported reduced pain intensity. The results suggest that a manualised ACT-based self-help intervention is a valuable addition to the treatment repertoire for persons with chronic pain and that acceptance may mediate the effect of treatment on physical functioning. Furthermore, instruments to measure acceptance in the context of acute pain in children with cancer are now available, although further validation is needed. Lastly, the results indicate that an acceptance-based intervention may help children undergoing cancer treatment to cope with pain.

Le développement du Capital Emotionnel pour un Mindful Management et une Qualité de Vie au Travail : une approche de la prévention des risques psycho-sociaux, du stress en particulier, par la psychologie positive et la thérapie de l’acceptation et de l’engagement (ACT) chez les apprentis aides-soignants et futurs personnels éducatifs / The development of Emotional Capital for Mindful Management and Quality of Life at Work: an approach to prevention of psychosocial risks, stress in particular, positive psychology via the acceptance and commitment therapy approach for apprentices carers and futur educators

Background: Nonresponsiveness to therapy is generally acknowledged, but only a few studies have tested switching to psychotherapy. This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy (ACT). Methods: This was a randomized controlled trial that included 43 patients diagnosed with primary panic disorder and/or agoraphobia (PD/A) with prior unsuccessful state-of-the-art treatment (mean number of previous sessions = 42.2). Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months. They were randomized to immediate treatment (n = 33) or a 4-week waiting list (n = 10) with delayed treatment (n = 8). Treatment consisted of eight sessions, implemented twice weekly over 4 weeks. Primary outcomes were measured with the Panic and Agoraphobia Scale (PAS), the Clinical Global Impression (CGI), and the Mobility Inventory (MI). Results: At post-treatment, patients who received ACT reported significantly more improvements on the PAS and CGI (d = 0.72 and 0.89, respectively) than those who were on the waiting list, while improvement on the MI (d = 0.50) was nearly significant. Secondary outcomes were consistent with ACT theory. Follow-up assessments indicated a stable and continued improvement after treatment. The dropout rate was low (9%). Conclusions: Despite a clinically challenging sample and brief treatment administered by novice therapists, patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list, with medium-to-large effect sizes that were maintained for at least 6 months. These proof-ofprinciple data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients. Further work on switching to psychotherapy for nonresponders is clearly needed.

多くの肥満者は，生活習慣のセルフマネジメントが困難であると指摘される。これに対し本稿は，肥満者の行動的QOLの低さ，すなわち行動レパートリーの不足に着目し，それを拡大する援助方略を行動変動性の観点から検討した。その結果，行動変動性が回避場面で減少することが示され，行動変動性に対する強化手続きや，その応用であるアクセプタンス＆コミットメント・セラピーが行動的QOLの拡大に有効であることが示された。 / It has been argued that many individuals with obesity have difficulty managing their lifestyle. This study focused on lack of behavioral repertory as a cause of the difficulty and attempted to expand behavioral repertory and behavioral quality of life (QOL) from the viewpoint of behavioral variability. The result showed that the decrease in behavioral variability was related to avoidant behavior. Furthermore, the result showed that reinforcement of behavioral variability and Acceptance and Commitment Therapy (ACT) promoted behavioral QOL expansion and lifestyle improvement. / 博士(心理学) / Doctor of Philosophy in Psychology / 同志社大学 / Doshisha University

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<p>Examen i vårdadministration, YH-utbildning: 20 Yh-poäng</p>