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Pathologische Sorgen sind ungenau definiert. Für die Behandlungsplanung bleiben wichtige Fragen offen: Welche Merkmale sind für die Unterscheidung zwischen behandlungsbedürftigen und nicht behandlungsbedürftigen Sorgen relevant? Welche Art von Sorgen muss wie behandelt werden? Und: Welche Art von Sorgen gilt es eher zu akzeptieren? Wir machen praxisnahe Vorschläge dafür, wie Sorgen mittels einer einfachen Heuristik auch vom Patienten selbst als «pathologisch» identifiziert werden können. Im Sinne eines therapeutischen Arbeitsmodells ergeben sich differentielle Bearbeitungsstrategien, je nachdem, ob es sich um wichtige oder weniger wichtige, auf lösbare oder unlösbare Probleme bezogene sowie angemessene oder überzogene Sorgen handelt. Das vorgestellte Arbeitsblatt zu den Sorgen soll vor allem die wahrgenommene Kontrolle des Patienten stärken und die Psychoedukation zur Generalisierten Angststörung erleichtern. / Pathological worries have not yet been clearly defined. As a consequence, practically relevant questions remain open: Which characteristics distinguish worries relevant for treatment from those which are not? What kind of worries has to be treated in which way? And: What kind of worries is rather to be accepted? We propose a simple rationale which helps the therapist and the patient to identify pathological worries. According to this working model, different treatment strategies result depending on whether worries are central or not, whether they relate to a problem which can be solved or not, and whether they seem proportionate or exaggerated. The presented worksheet is meant to strengthen the perceived control of the patient and to help facilitate psychoeducation for generalised anxiety disorder. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Made available in DSpace on 2016-04-29T13:17:49Z (GMT). No. of bitstreams: 1 Michaele Terena Saban.pdf: 1151659 bytes, checksum: 94dd30825fe6f10b8238f90f701afb68 (MD5) Previous issue date: 2013-05-28 / The objective of this study was to analyze the effect of the protocol adaptation "Live with Chronic Pain: An Acceptance-based Approach" (Vowles & Sorrell, 2007), based on Acceptance and Commitment Therapy (1999) in three participants with chronic pain who attended the Rehabilitation Centre and Day Hospital Psychiatry Institute of a public hospital in São Paulo. A multiple baseline design was used, where intervention was initiated to two participants at a time and the last participant to four weeks later. The forms of measurement data were questionnaires (Profile Questionnaire, Questionnaire History of Pain, Brief Pain Inventory, WHOQOL-Brev, HAD Scale and Chronic Pain Acceptance Questionnaire) applied an initial interview, before the intervention, during, and 6-9 weeks follow-up depending on participant; observation time speech of the participants in the session; and an auto registration contingency in which the participant fulfilled when was in pain for a week before the intervention and during the weeks that occurred in the eight sessions. The results demonstrate that the intervention was benefit to participants, particularly in the reduction of pain episodes, reduction of medication use and rest due to pain. Comparing pre-intervention and follow-up, all participants improved in relation to anxiety and social relationships. The auto record was the instrument that yields information about the therapeutic process and was methodologically the most interesting option for measuring in this search / O objetivo deste trabalho foi analisar o efeito da adaptação do protocolo Live with Chronic Pain: An Acceptance-based Approach (Vowles & Sorrell, 2007), baseado na Terapia de Aceitação e Compromisso (1999) em três participantes com dor crônica que frequentavam o Centro de Reabilitação e Hospital Dia de um hospital público da cidade de São Paulo. Foi utilizado um delineamento de linha de base múltipla em que a intervenção foi iniciada para dois participantes num momento e para o último participante quatro semanas depois. As formas de mensuração dos dados foram questionários (Questionário de Perfil, Questionário de Histórico da Dor, Inventário Breve de Dor, WHOQOL-BREV, Escala HAD, e Questionário de Aceitação da Dor Crônica) aplicados numa entrevista inicial, antes da intervenção, durante, após e no seguimento de seis a nove semanas depois da intervenção a depender do participante; observação do tempo de fala dos participantes na sessão; e um auto-registro da contingência em que o participante sentia dor por uma semana antes da intervenção e no decorrer das semanas em que ocorreram as oito sessões. Os resultados demonstram que a intervenção beneficiou os participantes, principalmente na diminuição dos episódios de dor, na diminuição da utilização de medicação e descanso devido à dor. Comparando antes da intervenção e o seguimento, todos os participantes melhoraram em relação à ansiedade e suas relações sociais. O auto-registro foi o instrumento que mais forneceu informações sobre o processo terapêutico e mostrou-se metodologicamente a opção mais interessante de mensuração nesta pesquisa

Kognitiv beteendeterapi (KBT) har mest evidens vid social fobi, och på senare år har även guidad självhjälp baserad på KBT visat goda resultat. Acceptance and commitment therapy (ACT) är en del av den tredje vågens KBT och har visat lovande resultat vid ångestsyndrom. Företrädare för ACT har varnat för riskerna med tekniker för att utmana negativa automatiska tankar. Studien syftar till att med en single case experimentell design med multipel baslinje (N=9) studera effekterna av kognitiv omstrukturering (KO) och kognitiv defusion (KD) i form av guidad självhjälp på social ångest, socialt undvikande, psykologisk flexibilitet, defusion, samt frekvens av och trovärdighet hos negativa automatiska tankar. Resultaten visade att KO och KD inte enbart påverkade de processer som teorierna predicerar utan även den andra behandlingens processer.

Att hitta preventiva metoder för att motverka ungdomars psykiska ohälsa är ett angeläget forskningsområde, både sett till mänskligt lidande för individen och ur ett samhällsekonomiskt perspektiv. Föreliggande kontrollerade studie, som är randomiserad stratifierat för kön avsåg undersöka om en gruppbaserad ACT-intervention (n=15) kunde vara statistiskt signifikant mer effektiv än sedvanligt omhändertagande (n=17) av ungdomar med eller i riskzonen för psykisk ohälsa. Psykisk ohälsa operationaliserades i termer av ångest, depression, stress, upplevd global livskvalitet, allmän psykisk hälsa, psykologisk flexibilitet, beteendemässigt och emotionellt undvikande, samt medveten närvaro. Resultatet visar att interventionen hade starka positiva effekter på stress, upplevd global livskvalitet och medveten närvaro, samt måttliga effekter på allmän psykisk hälsa, och svaga effekter på depression, ångest, psykologisk flexibilitet, beteendemässigt och emotionellt undvikande. P.g.a. det låga antalet deltagare och otillräcklig statistisk power uppnåddes statistisk säkerställda skillnader (<0,05) endast på två mått (stress och medveten närvaro). Vidare forskning bör undersöka effekterna över en längre tidsperiod, samt replikera studien i ett större format.

Fatigue is common in the general population, and is the hallmark of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Although the occurrence of sleep difficulties is known to be common in subjects with fatigue, research on insomnia in such subjects is absent. The current study sought to examine the impact comorbid insomnia has on level of fatigue in subjects with chronic fatigue. The aim of this study is to assess the relationship between insomnia and chronic fatigue, and examine if the relationship is affected by the endocrine activity in the HPA axis. The following hypotheses were tested: 1) Do patients with chronic fatigue and comorbid insomnia experience more fatigue than patients with chronic fatigue without comorbid insomnia? 2) Do patients with chronic fatigue and with initially comorbid insomnia experience more fatigue after treatment than chronic fatigue patients without comorbid insomnia? 3) Do patients with chronic fatigue who experience improvement in insomnia after treatment also experience less fatigue by the end of treatment compared with patients who do not experience improvement in insomnia? 4) Is the potential relationship between insomnia and chronic fatigue influenced by the activity of the HPA axis as expressed by variation in cortisol output measured by Trier Social Stress Test for Groups (TSST-G)? The study sample consisted of 75 patients with chronic fatigue. Thirty-three met criteria for insomnia, while 42 did not. While staying at Hysnes Rehabilitation Center in Trondheim, Norway, they received a work-related Acceptance and Commitment Therapy (ACT) treatment intervention lasting 3.5 weeks. In addition, they participated in a standardized stress test (Trier Social Stress Test) pre- and post-treatment. Saliva cortisol samples were collected during the test in order to measure variation in cortisol output. The current finding is the first description of how insomnia in patients with chronic fatigue is associated with higher levels of fatigue (p < .05). Further, this study gives preliminary support indicating that remission of insomnia in patients with chronic fatigue can significantly reduce levels of fatigue (p < .05), and furthermore improve the physiological stress-response (p < .05). These results might encourage clinicians to assess and provide specific treatment for insomnia in patients with chronic fatigue as this might improve their treatment results. An aim for further research should be to investigate the effect of specified treatment for insomnia in patients with chronic fatigue.

Anorexia nervosa (AN) is a serious disorder with long-term consequences for those afflicted. No evidence-based care is available for adults with full or subthreshold AN. The thesis research investigated aspects of emotion and cognition relevant to the maintenance of AN that might inform psychological treatment. In addition, the effectiveness of a recent psychotherapy model of AN was investigated. Study I investigated alexithymia and emotional awareness and their associations with depression, anxiety, and perfectionism among patients with AN compared with a control group. The AN group exhibited the same level of emotional awareness as did the control group and the same level of alexithymia when controlling for depression and anxiety. Alexithymia and emotional awareness were not associated, despite representing an overlapping construct. The results of the present study indicate that those with AN can trust their emotional awareness. Study II explored implicit pro-thin and anti-fat attitudes (towards the self and others), striving for thinness (loosely corresponding to positive reinforcement), and avoidance of fatness (loosely corresponding to negative reinforcement). The AN and the control groups were found to have equally strong implicit pro-thin and striving for thinness attitudes. The AN group exhibited stronger implicit anti-fat and avoidance of fatness attitudes (loosely corresponding to negative reinforcement) than did the control group. There was no association between implicit and explicit measures. The results are in line with the over-evaluation of weight and shape as a core feature of eating disorders. Study III compared the effectiveness of Acceptance and Commitment Therapy (ACT) and treatment as usual (TAU) for adults with AN after day-care. Follow-up measures indicated no difference in improvement or deterioration between the two groups. The level of perfectionism was reduced in the ACT group relative to the TAU group. The study was compromised by a lower inflow of patients than anticipated and by a high drop-out rate, and thus fails to provide evidence of a difference between the two groups. The present thesis demonstrates that emotional awareness is intact in those with AN and that implicit attitudes concerning weight and shape reflect the explicit attitudes, although without association. The treatment study indicates that, when designing treatment, it is important to consider the ambivalence to treatment among those suffering from AN, which is reflected in the high drop-out rate in the present study.

Purpose: The systematic review summarised the research investigating Acceptance and Commitment Therapy (ACT) with older adults. The empirical study explored psychosocial adjustment patterns to a diagnosis of mild cognitive impairment, a condition characterised by memory or thinking problems. Method: The review included 14 studies identified through database searches using predefined eligibility criteria. The empirical study employed a cross-sectional design. Thirty-five participants completed a short cognitive assessment and a series of questionnaires measuring perceptions of MCI, cognitive fusion (i.e. how caught up someone is with their thoughts), anxiety, depression and quality of life. Results: The review found initial evidence to suggest that ACT is an acceptable and effective intervention for reducing distress in older adults. The empirical study found that threatening perceptions of MCI were more strongly related to psychosocial adjustment outcomes than objective level of cognitive impairment. The study also found evidence to suggest that cognitive fusion is associated with adjustment outcomes in an MCI population. Conclusions: The systematic review highlights the limited, but promising evidence-base for the application of ACT with older adults. The review emphasises the need for further research with improved methodological rigor. Findings from the empirical study need to be replicated with a larger sample, however the results indicate that psychological interventions such like ACT could have utility for MCI patients with adjustment difficulties.

Il presente elaborato ha come tema il ruolo dello psicologo clinico nella riabilitazione cardiologica, con una particolare attenzione alle sfide poste nel sostenere e facilitare il cambiamento dello stile di vita del paziente affetto da cardiopatia ischemica. La tesi si articola in tre sezioni, ognuna delle quali comprende un’introduzione teorica, con spunti sia di natura clinica che riferimenti al contesto della riabilitazione, e un contributo empirico che intende fornire una prospettiva innovativa al campo di riferimento. Il primo capitolo si apre con una breve descrizione della cardiopatia ischemica e dei fenomeni ad essa clinicamente legati. Queste informazioni introduttive si riveleranno preziose nello svolgersi dei capitoli successivi, in quanto consentono di approfondire il contesto della riabilitazione cardiologica, i suoi principali obiettivi e il razionale alla base dell'intervento clinico proposto. A questo proposito, verrà sottolineata la centralità dell’esercizio fisico come outcome funzionale della riabilitazione. In linea con questo affondo teorico, il primo contributo empirico è volto a indagare la relazione tra ridotta capacità di esercizio e sintomatologia ansiosa e depressiva, e a valutare la direzione di questa associazione attraverso un Cross-Lagged Panel Design che ha incluso 212 pazienti afferenti all’Unità di Riabilitazione Cardiovascolare dell’Ospedale S. Luca di Milano. I risultati sono discussi alla luce del ruolo che lo psicologo può svolgere per massimizzare il beneficio che il paziente può ottenere dalla riabilitazione, anche nei termini di capacità d’esercizio. Questo tema, accennato nella discussione del primo studio, viene ampliato nel secondo capitolo. Il secondo capitolo introduce infatti il modello dell’Acceptance and Commitment Therapy (ACT), riferimento teorico che costituisce l’ossatura dell’intervento presentato nella terza parte dell’elaborato. In particolare viene approfondito il ruolo della flessibilità psicologica, che rappresenta il cuore clinico del modello ACT, in quanto meccanismo primario di azione terapeutica. Per quanto esistano diversi strumenti per misurare questo costrutto, nessuno di essi è stato pensato e validato per il contesto cardiovascolare. La sezione empirica del secondo capitolo si riferisce allo sviluppo di un nuovo questionario per la misurazione della flessibilità psicologica adatto al contesto in esame - il CVD-AAQ, ovvero CardioVascular Disease Acceptance and Action Questionnaire - di cui vengono valutate le proprietà psicometriche. Lo studio si è avvalso di un secondo campione di 275 pazienti, arruolati nella medesima Unità Operativa. Il CVD-AAQ viene proposto e descritto in quanto misura di outcome dello studio presentato nella terza e ultima parte dell’elaborato. 8 Il terzo capitolo presenta lo studio ACTonHEART, un trial clinico randomizzato finalizzato a valutare l’efficacia e la fattibilità di un protocollo di intervento basato sull’ACT, cui scopo è migliorare il benessere e sostenere il cambiamento dello stile di vita dei pazienti ischemici in riabilitazione, aumentandone la flessibilità psicologica. Novantadue pazienti sono stati arruolati e allocati al gruppo sperimentale (N= 59) e di controllo (N= 33), seguendo uno schema di randomizzazione sbilanciata 2:1. Il gruppo di controllo ha svolto la sola riabilitazione, quello sperimentale in aggiunta ha partecipato all’intervento di gruppo ACTonHEART, il cui manuale è presentato integralmente in forma manualizzata. Il protocollo ha una durata di sei ore, suddivise in tre sedute, ognuna delle quali è incentrata su un principio clinico dell’ACT e affronta un aspetto diverso del cambiamento dello stile di vita richiesto al paziente ischemico in un’ottica di prevenzione secondaria. Gli outcome dell’ACTonHEART sono i seguenti: Body Mass Index, flessibilità psicologica e benessere. Ognuno di essi è stato misurato in tre occasioni: prima della riabilitazione (t0), al suo termine (t1) e in un follow-up a sei mesi (t2). Considerata la presenza di tre misurazioni e il fatto che solo i pazienti assegnati al gruppo sperimentale hanno partecipato a un trattamento di gruppo, da un punto di vista metodologico l’ACTonHEART si configura come un Partially Nested Design a tre livelli, un disegno di ricerca la cui struttura verrà brevemente descritta in una sezione dedicata. Per valutare l’efficacia del trattamento è stata infine svolta un’analisi multilivello, i cui risultati sono presentati e discussi nella sezione finale dell’elaborato. / The thematic core of the present paper consists in the role of clinical psychology in cardiac rehabilitation, with a specific focus on the challenges faced when supporting the changes in lifestyle required to patients suffering from ischemic heart disease. This thesis is divided into three broad sections. Every section includes a theoretical introduction, describing both clinical and rehabilitation state-of-the art practices and research results, and an empirical contribution aiming to provide an innovative perspective on the topics considered. The first chapter includes a brief description of ischemic heart disease and its clinically related phenomena. This introductory information will prove valuable in the subsequent chapters, as it deepens the context of cardiovascular rehabilitation, describing its main goals and the rationale behind its mode of intervention, as well as the centrality of exercise capacity as functional outcome. Starting from this theoretical background, the first empirical contribution aims at investigating the relationship between reduced exercise capacity and symptoms of anxiety and depression. The direction of this association will be evaluated through a Cross-Lagged Panel Design that included 212 patients recruited in the Cardiovascular Rehabilitation Unit of S. Luca Hospital in Milan. Results are discussed in light of the role the psychologist plays in order to maximize the impact the rehabilitation has on the patient, even in terms of exercise capacity. This theme, introduced in the discussion of the first study, is further explored in the second chapter. The second chapter introduces Acceptance and Commitment Therapy (ACT), the theoretical framework of ACTonHEART, which is the intervention presented in the third part of the thesis. In particular, psychological flexibility will be discussed as the primary mechanism of therapeutic action proposed by the ACT model. While there are several tools to measure this construct, none of them have been validated for the cardiovascular context. The empirical section of the second chapter presents a disease-specific new questionnaire for measuring the psychological flexibility, the Cardiovascular Disease Acceptance and Action Questionnaire (CVD-AAQ), whose psychometric properties are evaluated. The validation study examined a second sample of 275 patients enrolled in the same hospital. The CVD-AAQ will be used as a measure of outcome for the intervention presented in the third and last part of the elaborate. The third chapter presents the ACTonHEART study, a RCT aimed at evaluating the effectiveness and feasibility of an ACT-based intervention protocol, whose purpose is to improve well-being and support the change in lifestyle of ischemic patients, through an increase in psychological flexibility. 10 Ninety-two patients were enrolled and randomized, following an unbalanced randomization ratio of 2:1, to the experimental group (N= 59) and the control group (N= 33). The control group was administered Treatment-as-Usual (TAU), while experimental subjects participated in the ACTonHEART group intervention in addition to the cardiac rehabilitation process. In this section the ACTonHEART protocol will be entirely presented in its manualized form. The ACTonHEART protocol consists in three sessions for a total of six hours. Each session focuses on an ACT clinical principle and addresses a different aspect of the lifestyle changes asked to the ischemic patient for secondary prevention. The outcomes considered for the ACTonHEART are the following: Body Mass Index, Psychological Flexibility and Well-Being. Participants were assessed at baseline (t0), at the end of the rehabilitation period (t1), and at a six-month follow-up (t2). The ACTonHEART is a Partially nested Design with three levels, a research methodology whose structure will be briefly outlined in this section. An appropriate multilevel analysis was carried out to evaluate the effectiveness of the intervention, whose results are presented and discussed in the final section of the thesis.

Public speaking anxiety (PSA), widespread amongst students and also the general population, is associated with substantial distress and interferes with a person’s ability to give a presentation or speech. This can lead to difficulties in social, occupational and academic areas of functioning. Despite its pervasiveness, very few individuals will seek help, most will tend to avoid the anxiety-provoking situations. This can be a serious issue if left untreated, leading to negative impacts on quality of life, for example dropping out of education early and subsequently having limited job opportunities. The literature review explored the existing body of work regarding PSA and presented the rationale for the current research, beginning with a conceptual framework and the manner in which PSA is related to Social Anxiety Disorder (SAD). This was followed by a detailed investigation of existing influential models and treatment modalities for both PSA and SAD. It identified that CBT has been the most effective treatment and has been delivered via different formats; however some individuals with SAD/PSA did not respond to a mainstream CBT approach and continued presenting residual symptoms after therapy. Thus, Acceptance and Commitment Therapy (ACT) was introduced, with an examination of its model and potential to help PSA. Preliminary research employing acceptance-based strategies have provided promising results. The literature review indicated a need for investigation of (i) more readily disseminated, briefer formats of ACT and (ii) whether differences exist in efficacy and sustainability between non-guided self-help and group-led therapies format. Given the large number of individuals experience PSA/SAD and the limited availability of resources, there is a need to consider ways of improving access. Thus, development of ultra-brief interventions would potentially reduce delivery cost and enhance dissemination to a larger population. Keywords: public speaking anxiety, social anxiety, interventions, experiential avoidance, fear of negative evaluation, acceptance.