本論文の目的は，Acceptance & Commitment Therapy (ACT) に含まれる価値の明確化の手続きが，身体的な痛みを抱える者の行動を活性化させるかどうかを検討することであった。その結果，基礎研究（研究1, 2）からは，自らの過去の行動の機能を記述することにより，特定の課題の遂行量や時間が増加することが示された。また，臨床研究（研究3, 4）からは，価値の明確化を含むACTにより，慢性疼痛患者の価値に基づく活動や日中活動量が増加することが示された。 / 博士(心理学) / Doctor of Philosophy in Psychology / 同志社大学 / Doshisha University

博士(心理学) / Doctor of Philosophy in Psychology / 同志社大学 / Doshisha University

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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

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

<p>Among some researchers, there is an emerging conceptualization of chronic tic disorders (CTDs) as conditions that are partially rooted in avoidance of tic-related private experiences (i.e., painful or difficult thoughts and feelings) and internal sensations (i.e., premonitory urges to tic). The first specific aim of the present research was to investigate the possibility that experiential avoidance is related to tic severity and perceived quality of life in individuals with CTDs. The second aim was to determine whether the efficacy of Habit Reversal Training (HRT), the most prevalent and effective behavioral intervention for CTDs to date, might be enhanced by combining it with Acceptance and Commitment Therapy (ACT), an intervention that directly targets experiential avoidance. These aims were addressed by conducting two related studies. Study I, an online survey, included 239 adults (<italic>M</italic> = 37.6 years; <italic>SD</italic> = 13.8 years) who reported having been previously diagnosed with a CTD. Results showed that levels of premonitory urges, as well as both general and tic-specific experiential avoidance, were significantly positively related to tic severity. General and tic-specific experiential avoidance were also significantly negatively related to perceived quality of life. Psychometric analyses of two novel measures developed for Study I (i.e., the Yale Global Tic Severity Scale-Self-Report Version and the Acceptance and Action Questionnaire-Tic-Specific Version) demonstrated excellent internal consistency and convergent validity. Study II, a multi-site pilot investigation, involved 13 adolescents (<italic>M</italic> = 15.4 years; <italic>SD</italic> = 1.3 years) who were treated with either HRT alone or a novel HRT+ACT intervention. Results suggest that the HRT+ACT treatment is feasible, highly acceptable to both patients and parents, and as effective as HRT alone at reducing tic severity from pre-treatment through week 22 follow-up. Participants in both groups reported clinically significant post-treatment decreases in general and tic-specific experiential avoidance and improvements in overall functioning. Researchers concluded that experiential avoidance plays an important role in tic expression and overall functioning for individuals with CTDs. Results support additional development and testing of the promising HRT+ACT intervention, to evaluate its efficacy alone and in comparison to other relevant psychosocial and pharmacological interventions.</p> / Dissertation

Objectives: The World Health Organisation has predicted that by 2020, brain injury will be one of the leading causes of disability in the world (Hyder et al, 2007). Psychological difficulties are common in this population, with up to 60% of individuals experiencing mental health difficulties (Acquired Bain injury Outreach Service, 2012). Therefore, with the rapid rise in referrals, services are under increasing pressure to provide innovative ways of offering effective and cost-efficient care. This research aimed to evaluate a novel transdiagnostic Acceptance and Commitment Therapy group approach for supporting individuals adjusting to life following the diagnosis of a neurological condition. Methods: A mixed-methods waiting-list control design was used and carried out across two sites of Hertfordshire Neurological Outpatients Service. The outcomes of the group were assessed using four outcome measures evaluating acceptance, self-identified difficulties, low mood and anxiety, as well as a semi-structured interview to identify mediators of change. Results: Ten participants from the intervention group completed, equating to a 76.9% completion rate. The results indicated that those in the intervention group made significant improvements across all measures of acceptance, self-identified difficulties and psychological distress. Those in the waiting list groups did not experience any change in these domains. The qualitative feedback from participants was also highly positive. Participants reported the usefulness of the ACT strategies, in addition to valuing being in a group with others with a range of difficulties. Participants reported greater awareness and acceptance, as well as increased activity and improved mood. Conclusions: The ACT group is a potentially effective and cost-efficient method of supporting individuals with adjustment following diagnosis of a neurological condition. Despite these promising findings it is important to acknowledge the limitations, such as the small sample size and research design. Further research would be beneficial in order to evaluate the intervention using more rigorous methods.

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