Self-Regulation and Chronic Pain:The Role of Emotion

Adjustment to chronic pain is examined within the context of a model that emphasizes goal-centered self-regulatory processing. Individual differences in adjustment to chronic illness have typically been examined from within the framework of stressful person–environment transactions. However, it may be useful to examine a broader array of person–environment transactions encountered in the context of working toward personal goals. Self-regulation may be especially challenging for people with chronic pain because of the link between pain and emotion. Consistent with this perspective, we will focus on the role of emotion as an energizing force in self-regulation and discuss the implications for managing pain. We will suggest that pain and concomitant negative emotion pervasively bias information processing, constrain the selection of goals, and the ongoing process of self-regulation.     

The Effects of Treatments for Depression on Perceived Failure in Self-Regulation

Two studies examined the effect of treatments for depression on perceived failure in self-regulation, operationalized as within-self discrepancy. In Study 1, patients received group cognitive–behavioral therapy (CBT); in Study 2, patients received either individual CBT, interpersonal psychotherapy (IPT), or medication. Treatments showed equivalent efficacy, but only psychotherapy was associated with decreased self-discrepancy and priming reactivity. Highly self-discrepant patients showed less improvement than other patients in all treatments, even after controlling for initial severity. The findings suggest that treatments differ in their impact on self-regulatory cognition, and that highly self-discrepant patients may require longer or alternative treatment.     

Development of an integrated cognitive-behavioral and social skills training intervention for older patients with schizophrenia

There is considerable evidence that psychosocial treatments benefit younger adults with schizophrenia. However, no studies have been undertaken of such interventions for older patients with schizophrenia. This report describes the development of a novel integrated treatment combining cognitive-behavioral therapy (CBT) and social skills training (SST). This intervention is designed to address the needs of older patients with schizophrenia by challenging beliefs common in this population that interfere with treatment and by providing repetitive practice of behaviors to improve retention and skill development. The authors provide two case reports and pilot data suggesting benefits of this approach.     

The role of psychotherapy in treating psychiatric disorders

Psychotherapy has shifted from long-term to short-term approaches, which have been found to be effective for the treatment of specific psychiatric disorders. These psychotherapy interventions (primarily behavior therapy, CBT, and IPT) have been found useful in presenting an educational framework for disorders and the treatment rationale for intervention programs. Short-term and maintenance empirical data support the effectiveness of using behavior therapy and CBT as adjunctive interventions with medications for bipolar I disorder and schizophrenia. In major randomized clinical trials, psychotherapy interventions (primarily behavior therapy, CBT, and IPT) have been shown to be effective as primary treatments (treatments of choice) for the major psychiatric problems of obsessive-compulsive disorder, panic disorder, and major depression as well as several other psychiatric disorders. The combination of psychotherapy and psychotropic medications is not always additive for acute treatment effects or especially for the maintenance of treatment effects so that the combination of psychotherapy and medications is not the most effective treatment for all psychiatric disorders. Badly needed, additional randomized controlled trials of psychotherapy, medications, and their combinations are under way in large, NIMH-supported studies of the treatment of several psychiatric disorders.     

Using mindfulness-based therapeutic interventions in psychiatric nursing practice--part I: Description and empirical support for mindfulness-based interventions

Finding effective nursing interventions for the treatment of mental illness is a major concern for advanced practice psychiatric nurses (APPN). Increasingly, innovative psychotherapeutic treatment modalities are being used for the treatment of individuals with serious mental illness. One such innovative approach, mindfulness-based therapeutic interventions, has been shown to relieve distress for individuals with medical and psychiatric illnesses. In part one of this two-part article, the investigators describe principle concepts of mindfulness, review current research in the usefulness of mindfulness practice for treatment of psychiatric illnesses, and outline the theoretical basis for this treatment modality, including mindfulness-based cognitive therapy (MBCT). In Part II, the writers detail the therapy phases of MBCT and present a clinical case in which an advance practice psychiatric nurse integrates mindfulness-based psychotherapeutic approaches into her treatment. This clinical case may inform future clinical nursing research and advanced psychiatric nursing practice.     

Using mindfulness-based therapeutic interventions in psychiatric nursing practice--part II: Mindfulness-based approaches for all phases of psychotherapy--clinical case study

Finding effective nursing interventions for the treatment of mental illness is a major concern for advanced practice psychiatric nurses (APPN). Increasingly, innovative psychotherapeutic treatment modalities are being used for the treatment of individuals with serious mental illness. One such innovative approach, Mindfulness-based therapeutic interventions, has been shown to relieve distress for individuals with medical and psychiatric illnesses. In Part I of this two-part article, the authors described principle concepts of mindfulness, reviewed current research in the usefulness of mindfulness practice for treatment of psychiatric illnesses. The structure and content of mindfulness-based cognitive therapy (MBCT) was also outlined and provided the theoretical basis for this treatment approach. This alternative therapeutic approach offers potential usefulness for the treatment of individuals suffering from mental illness. Part II of this article presents a more detailed explanation of mindfulness-based therapeutic approaches for all phases of psychotherapy and identifies relevant research questions that will provide an empirical base to guide clinical practice. A case study illustrates mindfulness-based therapeutic interventions.     

Delivering happiness: translating positive psychology intervention research for treating major and minor depressive disorders

Despite the availability of many treatment options, depressive disorders remain a global public health problem. Even in affluent nations, 70% of reported cases either do not receive the recommended level of treatment or do not get treated at all, and this percentage does not reflect cases of depression that go unreported due to lack of access to health care, stigma, or other reasons. In developing countries, the World Health Organization estimates that <10% receive proper depression care due to poverty, stigma, and lack of governmental mental health resources and providers. Current treatments do not work for everyone, and even people who achieve remission face a high risk of recurrence and residual disability. The development of low-cost effective interventions that can serve either as initial therapy for mild symptoms or as adjunctive therapy for partial responders to medication is an immense unmet need. Positive activity interventions (PAIs) teach individuals ways to increase their positive thinking, positive affect, and positive behaviors. The majority of such interventions, which have obtained medium-size effect sizes, have been conducted with nondepressed individuals, but two randomized controlled studies in patients with mild clinical depression have reported promising initial findings. In this article, the authors review the relevant literature on the effectiveness of various types of PAIs, draw on social psychology, affective neuroscience and psychophamacology research to propose neural models for how PAIs might relieve depression, and discuss the steps needed to translate the potential promise of PAIs as clinical treatments for individuals with major and minor depressive disorders.     

Psychotherapy for depression

Research on the treatment of depression has shown that both pharmacological and psychosocial interventions are equally efficacious in mild depression as well as moderate and severe depression. Combined psychosocial and pharmacological interventions are also thought to be effective even for severe and chronic depression. Among psychosocial treatments, cognitive behavior therapy, behavior therapy, and interpersonal psychotherapy have been proved to effective. Cognitive behavior therapy is a structured short-term therapy designed to change the patient's negatively distorted cognition. Behavior therapy is a therapy developed based on the understanding that depression is related to a decrease of behaviors that produce positive reinforcement. Interpersonal psychotherapy is a form of short-term therapy to focus on the patient's interpersonal relations with significant others.     

Reports of Therapy Skill Use and Their Efficacy in Daily Life in the Short-Term Treatment of Depression

Previous studies have shown that the use of therapy skills in between sessions is an important mechanism of symptom improvement. The current study expands this line of research by using a diary approach to examine the use of therapy skills in daily life. A sample of 39 depressed adults (85% female, mean age 38) were signaled twice per week throughout the course of either cognitive-behavioral therapy (CBT) or self-system therapy (SST). Results showed that, on days when participants reported greater use of therapy skills, they reported better mood and functioning in almost all domains. Additionally, participants in CBT reported greater use of cognitive skills while participants in SST reported greater use of self-regulatory skills. This study demonstrates that repeated assessments of daily events and experiences, which prevent retrospective reporting biases, further confirm the importance of therapy skill use as a mechanism of action in psychotherapy.     

Electrophysiological kindling and behavioral sensitization as models for bipolar illness: Implications for nursing practice

Animal models of electrophysiological kindling and behavioral sensitization describe a process of progressively enhanced neurobiochemical and behavioral excitability that initially occurs in response to intermittent stimulation but eventually becomes spontaneous. This process appears to occur at the level of gene expression and may result in permanent neuroanatomic alterations, as well as alterations in neural and behavioral excitability. Although kindling evolution is not a homologous model for bipolar illness evolution because none of the observed behaviors are similar to those in patients with bipolar illness, behavioral sensitization directly models many aspects of affective illness, particularly euphoric and dysphoric manias, and represents a model for mania in evolution.Understanding the neurobiologic mechanisms underlying the progressive increases in behavioral responsivity thus may provide a useful paradigm for elucidating progressive alterations in manic symptomatology and the differential response or lack of response to pharmacotherapeutic interventions. These models can also be useful as a conceptual framework to inform decisions about other psychotherapeutic modalities of treatment and in increasing patients' understanding of illness evolution and the importance of treatment adherence.     

A review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice

This article explores the common factors model of psychotherapeutic intervention and discusses its relevance for physical therapy practice. The model provides an explanation for why the effects associated with specific technical approaches only minimally explain successful psychotherapy clinical outcomes. It postulates that factors common across diverse interventions (i.e. 'nonspecific' mechanisms) are responsible for a larger component of treatment efficacy. We outline the applicability of the common factors model to physical therapy and provide supportive evidence from evaluation and prognostic research on interventions for conditions seen in musculoskeletal physical therapy practice. The relevancy and consequences of applying the common factors model to physical therapy practice and research are discussed. The continued advance and evolution of the physical therapy profession requires creative and comprehensive analysis of all factors impacting clinical effectiveness. Additional research is needed to more clearly delineate the common factors that are operational in physical therapy practice and to measure their relative impact on clinical outcomes.     

RURAL WOMAN ABUSE AND SEXUALLY TRANSMITTED DISEASE: AN ETHICAL ANALYSIS OF CLINICAL DILEMMAS

Women who have experienced abuse are often offered individual and group psychotherapeutic interventions to help them overcome psychological aftereffects of abuse and avoid future abusive relationships. Clinical cases that are complicated by the existence of abuse and sexually transmitted diseases (STDs) often involve ethical issues concerning patient privacy and legitimate breaches of confidentiality that can potentially harm the individual. There is little known about the experiences of abused rural women with STDs, underscoring the need for modification of existing interventions for this patient population. This paper presents the application of an ethical framework to an actual case involving an abused rural woman with an STD that utilizes the concepts of casuistry, or case-based reasoning. A methodological tool for ethical analysis of the clinical dilemmas involving evidence-based psychotherapeutic interventions for abused rural women with STDs is used to apply the concepts of casuistry to the development of the taxonomy of cases for clinical practice.     

Goals and Depressive Symptoms: Cross-lagged Effects of Cognitive versus Emotional Goal Appraisals

Relationships between work goal appraisals and depressive symptoms were investigated in a 2-wave study of health care employees spanning a 2-year period. Cross-lagged models were tested and compared in structural equation modeling analyses. The results suggest that the direction of longitudinal relationships between work goal appraisals and depressive symptoms may depend on the nature of the appraisals. In the best-fitting model, goal self-efficacy cognitions predicted depressive symptoms 2 years later. This finding supports cognitive/self-regulatory theories positing that dysfunctional cognitions form a vulnerability factor in the etiology of depressive symptoms. On the other hand, we found no evidence that depressive symptoms predicted goal cognitions. Instead, depressive symptoms were associated with goal-related emotions two years later, suggesting that depressive symptoms may lead over time to greater negative emotional arousal. Implications for depression theory and goal research are discussed.     

Rural woman abuse and sexually transmitted disease: an ethical analysis of clinical dilemmas

Women who have experienced abuse are often offered individual and group psychotherapeutic interventions to help them overcome psychological aftereffects of abuse and avoid future abusive relationships. Clinical cases that are complicated by the existence of abuse and sexually transmitted diseases (STDs) often involve ethical issues concerning patient privacy and legitimate breaches of confidentiality that can potentially harm the individual. There is little known about the experiences of abused rural women with STDs, underscoring the need for modification of existing interventions for this patient population. This paper presents the application of an ethical framework to an actual case involving an abused rural woman with an STD that utilizes the concepts of casuiStry, or case-based reasoning. A methodological tool for ethical analysis of the clinical dilemmas involving evidence-based psychotherapeutic interventions for abused rural women with STDs is used to apply the concepts of casuistry to the development of the taxonomy of cases for clinical practice.     

Cognitive therapy integrated with life review techniques: an eclectic treatment approach for affective symptoms in older adults

Background. An important aspect of nursing theory development has been the adaptation of theory from other disciplines within the metaparadigm of nursing. This eclectic approach to theory development enhances the broad humanistic theory base on which effective, professional nursing practice is based. Aims and objectives. The aim of this article is to describe the process of integrating two distinct psychotherapeutic approaches into one coherent mental health nursing intervention for the treatment of affective symptoms in older adults. Guidelines for using this integration process in psychiatric mental health nursing clinical practice are presented and illustrated through the case study approach. Methods. A case study is presented describing a clinical situation in which life review techniques were used to enhance the outcomes of a cognitive therapy experience for older adults enrolled in outpatient psychotherapy treatment for acute adjustment disorder with an affective component. Conclusions and relevance to clinical practice. The advanced practice psychiatric mental health nurse who approaches psychotherapeutic interventions with older adult clients from an eclectic approach can achieve successful outcomes by having a clear understanding of (i) the dynamics of the various psychotherapeutic approaches, (i) the skill level of the practitioner, (iii) the psychosocial sophistication of the client, and (iv) the pathology being treated. In addition, active involvement by the client in a treatment process that matches his/her psychosocial skill and coping resource level will contribute to effective resolution of pathology. A cognitive therapy approach supplemented by life review techniques is an excellent example of an effective, eclectic treatment approach of affective disorders in older adults.     

The BestFIT trial: A SMART approach to developing individualized weight loss treatments

Behavioral weight loss programs help people achieve clinically meaningful weight losses (8–10% of starting body weight). Despite data showing that only half of participants achieve this goal, a “one size fits all” approach is normative. This weight loss intervention science gap calls for adaptive interventions that provide the “right treatment at the right time for the right person.” Sequential Multiple Assignment Randomized Trials (SMART), use experimental design principles to answer questions for building adaptive interventions including whether, how, or when to alter treatment intensity, type, or delivery. This paper describes the rationale and design of the BestFIT study, a SMART designed to evaluate the optimal timing for intervening with sub-optimal responders to weight loss treatment and relative efficacy of two treatments that address self-regulation challenges which impede weight loss: 1) augmenting treatment with portion-controlled meals (PCM) which decrease the need for self-regulation; and 2) switching to acceptance-based behavior treatment (ABT) which boosts capacity for self-regulation. The primary aim is to evaluate the benefit of changing treatment with PCM versus ABT. The secondary aim is to evaluate the best time to intervene with sub-optimal responders. BestFIT results will lead to the empirically-supported construction of an adaptive intervention that will optimize weight loss outcomes and associated health benefits.     

Major Depressive Disorder or Diabetes-Related Distress? Screening,Evaluation, and Treatment in Adults With Diabetes

Depression has long presented a challenge to successful diabetes management. As the burden of both diabetes and depression continue to rise, vigilant screening, early recognition, and prompt, effective treatments are imperative to help these patients achieve the best health outcomes. Symptoms of diabetes-related distress can mimic depression but must be differentiated from clinical depression because treatment approaches differ. Screening tools such as the World Health Organization Wellbeing Index, Diabetes Distress Scale 2, and Diabetes Distress Scale 17 guide the provider in making a distinction between these disorders. A combination treatment approach consisting of pharmacotherapy and psychotherapeutic interventions has consistently been shown to decrease the risk of complications and improve diabetes self-management skills.     

A framework to understand depression among older persons

Aims and objectives. To develop an explanatory framework to understand depression among community-dwelling Chinese older persons in Macau. Background. Depression has been described as the most common psychological problem among Chinese older persons. Dominant psychosocial theories are derived from research conducted mainly in western societies and similar research in Chinese populations is scant. Design. Mixed methods. Methods. Qualitative and quantitative methods (mixed methods) were employed to collect data from 31 participants between 2007-2009 in Macau. Results. Four categories of factors related to depression emerged: (1) negative thinking, (2) physical limitations and complaints, (3) present living conditions and social support and (4) past experiences. Each category interacts with the others and, consequently, one category both affects and is affected by others. The categories captured participants' life-long hardship and bio-psycho-social-cultural disability that lay at the root of their negative thinking. The consequences and impacts of their negative thinking appear to feed and sustain depression. Conclusion. The framework offers a deeper understanding of the nature and meaning of the experiences of depressed older persons in a Chinese context. Relevance to clinical practice. The findings have several implications for clinical practice. First, the cultural context of Chinese older persons should be emphasised in nursing practice. Second, the root of depression among Chinese older persons is seen to lie in their social, family, cultural and day to day living issues. Finally, this study illustrates the potential for incorporating psychosocial nursing interventions as a therapeutic approach on its own or as an adjunct to other therapy.     

Self-regulatory deficits in fibromyalgia and temporomandibular disorders

Chronic pain conditions such as fibromyalgia (FM) and temporomandibular disorders (TMDs) are accompanied by complex interactions of cognitive, emotional, and physiological disturbances. Such conditions are complicated and draining to live with, and successful adaptation may depend on ability to self-regulate. Self-regulation involves capacity to exercise control and guide or alter reactions and behavior, abilities essential for human adjustment. Research indicates that self-regulatory strength is a limited source that can be depleted or fatigued, however, and the current study aimed to show that patients with FM and TMD are vulnerable to self-regulatory fatigue as a consequence of their condition. Patients (N = 50) and pain-free matched controls (N = 50) were exposed to an experimental self-regulation task followed by a persistence task. Patients displayed significantly less capacity to persist on the subsequent task compared with controls. In fact, patients exposed to low self-regulatory effort displayed similar low persistence to patients and controls exposed to high self-regulatory effort, indicating that patients with chronic pain conditions may be suffering from chronic self-regulatory fatigue. Baseline heart rate variability, blood glucose, and cortisol predicted persistence, more so for controls than for patients, and more so in the low vs. high self-regulation condition. Impact of chronic pain conditions on self-regulatory effort was mediated by pain, but not by any other factors. The current study suggests that patients with chronic pain conditions likely suffer from chronic self-regulatory fatigue, and underlines the importance of taking self-regulatory capacity into account when aiming to understand and treat these complex conditions.