Background: Computer-delivered cognitive behavioural therapy (cCBT) is an effective alternative to provider-delivered treatment for depression and anxiety, but high attrition poses a significant challenge to its use. Peer support is a feasible approach to improving cCBT engagement, but less is known about its acceptability among Veterans. Aims: To obtain feedback from Veterans (n = 24) with depression and/or anxiety on their preferences for (a) activities of Veterans Administration Peer Support Specialists (VA PSS) in helping Veterans use Moving Forward, a cCBT-based protocol developed by VA, and (b) methods for delivering support to Veterans using this programme. Method: Four focus groups (5–7 Veterans per group) provided feedback to be used in the development of a peer-supported engagement intervention to help Veterans with depression and anxiety use Moving Forward. Content areas included roles that a VA PSS might play in supporting the use of and engagement in Moving Forward, as well as methods of delivering that support. Results: Veteran preferences for PSS activity focused on practical aspects of using Moving Forward, including orientation to the programme, technical support, and monitoring progress. Feedback also suggested that Veterans preferred more personal roles for the PSS, including emotional support, as well as application of Moving Forward to ‘real life’ problems. Conclusions: The findings extend the literature on online, patient-facing mental health protocols by identifying emotional support and ‘real life’ skills application as Veteran-preferred components of a peer-support protocol designed to enhance use of and engagement in cCBT for depression and anxiety.

Background: Approximately one in three children and young people with chronic fatigue syndrome (CFS/ME) also have probable depression. Cognitive behaviour therapy (CBT) has a growing evidence base as an effective treatment approach for CFS/ME and for depression in this population. Aims: Given the high degree of co-morbidity, this discussion paper aims to compare and contrast CBT for CFS/ME and CBT for depression in children and young people. Method: The existing literature on CBT for depression and CBT for CFS/ME, in relation to children and young people was reviewed. Results: Whilst there are commonalities to both treatments, the cognitive behavioural model of CFS/ME maintenance includes different factors and has a different emphasis to the cognitive behavioural model of depression, resulting in different intervention targets and strategies in a different sequence. Conclusions: A collaborative, formulation-driven approach to intervention should inform the intervention targets and treatment strategies.

Background: The integrative cognitive model of mood swings proposes that mood symptoms are driven by extreme, self-referent appraisals. For example, if activated mood is appraised positively, this prompts selection of mood regulation strategies that act to up-regulate mood. Appraisals are driven by fast and automatic Type 1 cognitive processes, which, left unchecked, can cause activated mood to escalate. Aims: It was hypothesized that greater propensity to override these automatic processes by engaging in reflective (Type 2) thinking would be negatively associated with extreme appraisals of activation and activation. Method: Study 1 (n = 150) was a cross-sectional survey consisting of measures of activation, extreme appraisals, and an objective performance-based measure of the propensity to engage in reflective thought (cognitive reflection test; CRT). In Study 2 (n = 241) participants completed these measures plus three alternative measures of effortful cognitive engagement (CRT-2, Need for Cognition and Actively Open-Minded Thinking). Results: In Study 1, propensity to engage in reflective thought (higher CRT scores) was not significantly associated with activated mood or extreme appraisals, but activated mood and extreme appraisals were positively correlated. In study 2, the association between activation and extreme appraisals was replicated. Predicted associations between alternative measures of reflective thinking, activated mood, and extreme appraisals were not found. Conclusions: Extreme appraisals of internal states may be a psychological mechanism underlying activated mood. Propensity to reflect on and override default cognitions was unrelated to these extreme appraisals and activated mood. Further research in a clinical sample using mood-relevant measures of reflective thinking is warranted.

Background: Although negative beliefs have been found to be associated with worry symptoms and depressive rumination, negative beliefs have yet to be examined in relation to post-event processing and social anxiety symptoms. Aims: The purpose of the current study was to examine the psychometric properties of the Negative Beliefs about Post-Event Processing Questionnaire (NB-PEPQ). Method: A large, non-referred undergraduate sample completed the NB-PEPQ along with validation measures, including a measure of post-event processing and social anxiety symptoms. Results: Based on factor analysis, a single-factor model was obtained, and the NB-PEPQ was found to exhibit good validity, including positive associations with measures of post-event processing and social anxiety symptoms. Conclusions: These findings add to the literature on the metacognitive variables that may lead to the development and maintenance of post-event processing and social anxiety symptoms, and have relevant clinical applications.

Background: Patients with social anxiety disorder (SAD) report fear content relating to the perceived aversive consequences of their anxiety for others in their social environment. However, no studies to date have examined the diagnostic specificity of these fears to SAD as well as predictors to treatment response of these fears. Aims: To examine relative specificity of fears related to causing discomfort to others, as measured by Social Anxiety–Fear of Causing Discomfort to Others (SA-DOS), among patients with anxiety disorders, obsessive compulsive disorder (OCD) and major depressive disorder (MDD), in addition to relation between dysfunctional attitudes and treatment response among patients with SAD. Method: In study 1, a large (n=745) sample of DSM diagnosed OCD, MDD and anxiety disorder participants completed the SA-DOS. In study 2, patient participants with SAD (n=186) participated in cognitive behavioural group therapy (CBGT) and completed measures of social anxiety symptoms and dysfunctional attitudes. Results: In study 1, the SAD group demonstrated significantly elevated SA-DOS scores compared with participants with generalized anxiety disorder (GAD), OCD and panic disorder with or without agoraphobia (PD/A), but not the MDD group. In study 2, CBGT treatment was found to lead to significant reductions in SA-DOS scores. Need for approval (NFA) but not perfectionism, predicted treatment response to fears related to causing discomfort to others, with greater change in NFA relating to greater change in SA-DOS scores. Conclusions: These findings extend previous research linking allocentric fears to the phenomenology and treatment of SAD.

Aims: This study aimed to assess the validity of two models which integrate the cognitive (satisfaction with life) and affective (symptoms of anxiety and depression) aspects of subjective well-being within the framework of rational emotive behaviour therapy (REBT) theory; specifically REBT's theory of psychopathology and theory of psychological health. Method: 397 Irish and Northern Irish undergraduate students completed measures of rational/irrational beliefs, satisfaction with life, and anxiety/depression symptoms. Structural equation modelling techniques were used in order to test our hypothesis within a cross-sectional design. Results: REBT's theory of psychopathology (χ2 = 373.78, d.f. = 163, p < .001; comparative fit index (CFI) = .92; Tucker Lewis index (TLI) = .91; root mean square error of approximation (RMSEA) = .06 (95% CI = .05 to .07); standardized root mean square residual (SRMR) = .07) and psychological health (χ2 = 371.89, d.f. = 181, p < .001; CFI = .93; TLI = .92; RMSEA = .05 (95% CI = .04 to .06); SRMR = .06) provided acceptable fit of the data. Moreover, the psychopathology model explained 34% of variance in levels of anxiety/depression, while the psychological health model explained 33% of variance. Conclusions: This study provides important findings linking the fields of clinical and positive psychology within a comprehensible framework for both researchers and clinicians. Findings are discussed in relation to the possibility of more effective interventions, incorporating and targeting not only negative outcomes, but also positive concepts within the same model.

Background: It has been suggested that the behavioural activation (BA) treatments for depression unfold their effects, at least partly, through changes in approach and avoidance tendencies. However, as yet, little research has examined the cognitive effects of these interventions. Aims: This study investigated the impact of a single session of BA on depressive symptomatology, self-reported avoidance, and behavioural approach and avoidance tendencies. Method: Forty-six patients with a diagnosis of Major Depression were recruited from primary care psychological therapies services and block randomized to either a single session of behavioural activation (n = 22) or waiting list control (n = 24) delivered by an unblinded therapist. Self-reports of symptoms and cognitive factors were assessed before and after the one-week intervention phase. Approach and avoidance behavioural tendencies were assessed using the Approach-Avoidance Task (AAT). Results: Data from 40 participants (n = 20 in each group) was available for analyses. Depressive symptoms significantly decreased, and activation significantly increased from before to after treatment in the treatment group, but not in the control group. Performance on the AAT showed a trend indicating increased approach to positive valence stimuli in the treatment group, but not in the control group. Mediational analyses indicated small indirect effects of self-reported change in activation as mediators of the effect of condition on symptoms. Conclusions: The findings suggest that a single session of BA can have significant effects on symptoms in clinically depressed patients. Results hint at the possibility that increased behavioural approach might mediate the effect of BA.

Background: There is a lack of treatment plurality at step 2 of Improving Access to Psychological Therapies (IAPT) services. This project therefore sought to develop and pilot a cognitive analytic informed guided self-help treatment for mild-to-moderate anxiety for delivery by Psychological Wellbeing Practitioners (PWPs). Method: Medical Research Council treatment development guidelines were used. Phase I included development of the six-session treatment manual using practice guidelines, small-scale modelling (n = 3) and indicated manual iterations. Phase II consisted of a mixed methods case series design (n = 11) to index feasibility, uptake and clinical outcomes. Results: Cognitive analytic guided self-help (CAT-SH) met established quality parameters for guided self-help. A high treatment completion rate was observed, with 10/11 patients who attended the first treatment session subsequently completing full treatment. Six out of ten patients completing full treatment met reliable recovery criteria at follow-up. Effect sizes and recovery rates equate with extant PWP outcome benchmarks. Practitioner feedback indicated that delivery of CAT-SH was feasible. Conclusion: CAT-SH shows promise as a low-intensity treatment for anxiety, and so further, larger and more controlled evaluations are indicated.

Background: Cognitive-behavioural models of chronic fatigue syndrome (CFS) suggest that personality factors such as perfectionism and high moral standards may contribute to the development of CFS. Aims: To investigate cognitive, behavioural and emotional processing risk factors for CFS. Method: CFS patients (n = 67) at a UK specialist clinic completed questionnaires about psychological characteristics both currently and retrospectively (6 months pre-CFS onset). Responses were compared with those of healthy individuals (n = 73) who rated their current characteristics. Forty-four relatives retrospectively rated the pre-morbid psychological characteristics of the CFS participants. Results: CFS patients showed similar levels of current perfectionism to controls, though higher pre-morbid perfectionism. CFS patients showed greater self-sacrificial beliefs and more unhelpful beliefs about experiencing and expressing negative emotions, both currently but more markedly prior to onset. In the 6 months pre-illness onset, CFS patients showed more disruption to their primary goal and greater general stress than controls. Ratings of pre-morbid psychological characteristics by relatives were consistent with patients’ self-reports. The extent of overinvestment in one goal was significantly associated with fatigue. Conclusions: Perfectionism, self-sacrificial tendencies, unhelpful beliefs about emotions, and perceived stress may be present to a greater extent pre-morbidly in CFS patients compared with healthy individuals.

Background: Therapist self-practice, in its various forms, is common across therapeutic modalities, but a measure of its impact on participants does not yet exist. Aims: This paper describes the development and reliability testing of the ‘Self-focused Practice Questionnaire’ (SfPQ), a measure of self-perceived impact of one's self-focused practice. Method: Exploratory factor analysis (EFA), internal consistency and reliability were assessed in a convenience sample of 112 trainee therapists. Results: Five factors, rating impacts on therapist Personal-self (Awareness of Developmental experiences, Experience of Personal Change and Felt-sense/Self-awareness), and Therapist-self (Internalization of the Model, and Development of Empathy) were identified, with good internal consistency and acceptable to good test–retest reliability. Conclusions: Though more work is needed, these preliminary results support the SfPQ's reliability and validity. The SfPQ is an important measure, which may enhance routine rating of self-focused practice in training institutions.

Background: Self-critical thinking is common across psychological disorders. This study hypothesized that it may play an important role in ‘overgeneralization’, the process of drawing general implications from an isolated negative experience. Aims: To explore the impact of two experimental tasks designed to elicit self-critical thoughts on the endorsement of general negative self-views of clinical and non-clinical populations. Method: Three groups (depression, eating disorders and non-clinical controls), completed standardized questionnaires and the two tasks. Participants rated their self-critical thinking and general negative self-beliefs before and after each task. Results: Following a failure experience, both clinical groups showed a greater increase in general negative self-views compared with controls, indicating greater overgeneralization. Both habitual and increases in state self-critical thinking were associated with overgeneralization while negative perfectionism was not. Overgeneralization was more strongly associated with post-task reduced mood than self-criticism. Conclusions: Self-critical thinking may be an important factor in the process of overgeneralization, and the increase in general negative self-views may be particularly crucial for lowering of mood.

Background: Beliefs that it is unacceptable to experience or express negative emotions have been found to be associated with various clinical problems. It is unclear how such beliefs, which could be viewed as a form of unhelpful perfectionism about emotions, may contribute to symptomatology. Aims: This study investigated two hypotheses: a) greater endorsement of beliefs about the unacceptability of negative emotions will be associated with greater emotional avoidance and lower levels of support-seeking and self-compassion; b) these beliefs about emotions will be associated with higher levels of symptoms of depression, anxiety and fatigue and that this relationship will be mediated by social support-seeking, emotional avoidance and self-compassion. Method: Online questionnaires were completed by 451 community participants. Mediational analyses were undertaken to investigate emotional avoidance, social support-seeking and self-compassion as mediators of the relationship between beliefs about emotions and symptoms of depression, anxiety and fatigue. Results: Beliefs about the unacceptability of negative emotions were significantly associated with more emotional avoidance and less self-compassion and support-seeking. The relationships between beliefs about emotions and depression, anxiety and fatigue were significantly mediated by self-compassion and emotional avoidance but not social support-seeking. Conclusions: Future research should investigate whether interventions that pay particular attention to emotional avoidance and self-compassion, such as mindfulness-based therapy or modified forms of CBT, may be beneficial in reducing distress and fatigue associated with beliefs about the unacceptability of negative emotions.

Background: Pre-treatment role induction interventions have been suggested to potentially enhance attendance and clinical outcomes in psychotherapy. Aims: This study aimed to evaluate the effects of a programme of three transdiagnostic seminars (TDS) for patients with common mental disorders accessing cognitive behavioural therapy (CBT) in primary care. TDS included CBT psychoeducation and role induction. Method: A random sample of patients (n = 49) participated in TDS followed by CBT (TDS+CBT) and they were compared with matched controls (n = 49) accessing usual CBT. TDS participants rated the relevance and quality of this intervention using an acceptability questionnaire (AQ). Treatment completion (vs dropout) rates were compared across groups using chi-square tests. Post-treatment changes in depression (PHQ-9) and anxiety (GAD-7) symptoms were compared between groups using analysis of covariance controlling for potential confounders. Analyses were based on intention-to-treat principles. Results: Mean AQ ratings of the TDS intervention were comparable across diagnostic groups (p = .05). Treatment completion rates were significantly higher (p = .02) in the TDS+CBT group (87.8%) by comparison with usual CBT (68.8%). However, no significant differences in post-treatment symptom changes were found for depression (p = .34) or anxiety measures (p = .71). Conclusions: Incorporating a psychoeducational role induction prior to CBT significantly improved treatment retention, but not overall symptom reductions.

Background: Negative mental imagery is ubiquitous in cognitive models of social anxiety and in the social anxiety literature. Previous research has shown that it is causal of increased anxiety, lower social performance ratings and lower implicit self-esteem. Despite its prevalence, few studies have investigated this imagery directly. Aims: This study aimed to provide an in-depth analysis of the phenomenology of negative imagery experienced by socially anxious individuals, and to compare recurrent and intrusive images with images deliberately generated by participants during the study. Method: Thirty-eight undergraduate students screened to be above average in social anxiety scores completed a computerized imagery questionnaire adapted from previous qualitative work. Results: Thematic analyses revealed four major image themes for intrusive images and three for deliberately generated images including interacting with others and anxiety symptoms. Most intrusive images were based on negative episodic memories and were experienced at least fortnightly. Images were primarily visual, auditory and somatic but could involve any sensory modality. Depression anxiety stress scale (DASS-21) scores were higher in participants who experienced intrusive imagery and increased with the frequency of intrusions. Emotionality was generally higher in intrusive images than generated images. Conclusions: The phenomenology of negative imagery experienced by socially anxious individuals is idiosyncratic and may be inherently different from images generated for use in experimental research. Theoretical and clinical implications are discussed.

Background: Cognitive behavioural interventions for excessive reassurance seeking (ERS) typically focus on encouraging individuals to refrain from seeking any reassurance and in some cases banning caregivers (e.g. family members) from providing it. However, this blanket consideration that reassurance is a bad thing that should simply be stopped may not always be appropriate or helpful. Cognitive behavioural treatment (CBT) targeting ERS by helping the sufferer to shift from seeking reassurance to seeking support may be a promising treatment intervention. Aims: This study aims to examine the targeted treatment of ERS in an older adult who has been suffering from severe obsessive compulsive disorder (OCD) for seven decades. Method: Using a single case quasi-experimental design (ABCD), the frequency of reassurance seeking, urges to seek reassurance, OCD beliefs and anxiety were measured daily for almost a year in addition to standard symptom measures. Results: At the end of treatment, visual inspection showed that reassurance seeking was no longer considered excessive and OCD severity fell from the severe to non-clinical range across the treatment sessions. All treatment gains were maintained at follow-up. Conclusions: This study illustrates how CBT can be successfully applied to treat long-standing OCD and ERS in an older adult. Engendering support as an alternative to reassurance seeking in CBT may be a particularly promising intervention for ERS.

Background: The evidence base for behavioural activation (BA) is mainly grounded in the individual delivery method, with much less known about the impact of group delivery. Aims: To conduct a pilot study of behavioural activation in groups (BAG) for depression delivered in a routine service setting, in order to explore acceptability, effectiveness and predictors of outcome. Methods: The manualized group treatment format was delivered in a Primary Care mental health setting, at step three of an Improving Access to Psychological Therapies (IAPT) service. BAG was facilitated by cognitive behavioural psychotherapists, and outcome measures (depression, anxiety and functional impairment) were taken at each session. Seventy-three participants were referred and treated within nine groups. Results: BAG was an acceptable treatment generating a low drop-out rate (7%). Significant pre–post differences were found across all measures. There was a moderate to large depression effect size (d+ = 0.74), and 20% met the criteria for a reliable recovery in depression. Greater severity of initial depression and attendance of at least four BAG sessions predicted better outcomes. Conclusions: BAG appears to be an effective depression treatment option that shows some clinical promise. Further larger and more controlled studies are nevertheless required.

Background: Paruresis, or “shy bladder syndrome”, is a relatively common anxiety disorder, yet little is known about the causes of, and effective treatments for this disabling condition. Aim: This report describes a case study in which a man (Peter) presenting with paruresis was treated using formulation-driven CBT, which aimed to address the idiosyncratic processes that were maintaining his anxiety and avoidance of urinating in public. Method: Peter attended 12 sessions of CBT including one follow-up session a month after treatment had ended. Treatment involved collaboratively developing an idiosyncratic case conceptualization (identifying longitudinal and cross-sectional factors involved in the development and maintenance of his difficulties), followed by a number of standard cognitive and behavioural interventions commonly used in evidence-based CBT protocols for other anxiety disorders. Peter completed sessional outcome measures of paruresis symptomatology, anxiety, depression, social anxiety and functional impairment. Results: Peter subjectively found the intervention helpful and his scores on all of the outcome measures reduced over the course of his therapy, and were maintained at one month follow-up. Conclusions: This report adds to the scarce literature regarding effective treatments for individuals suffering with paruresis. Limitations of the design are acknowledged and ideas for further research in this area are discussed.

Background: Rumination predicts depression in adults and adolescents. The development of rumination has been linked to parenting practices, but only limited research has investigated this and research has tended to rely on self-report parenting measures. Aims: To investigate the relationship between female adolescent rumination and maternal modelling, criticism and positivity using an observational measure of parental behaviour. Method: A cross-sectional design was used. Daughters aged 16–18 years and their mothers (n = 154 dyads) completed questionnaire measures of rumination and affect. Mothers of girls with rumination scores in the upper and lower quartile (both n = 26) also completed the Five Minute Speech Sample, which was used to measure maternal criticism and positivity. Results: Mothers of low rumination girls made significantly more positive comments about their daughters than the mothers of high ruminators. Mothers made very few critical comments. Self-reported rumination was not correlated in mothers and daughters, suggesting a lack of support for the potential role of modelling. Conclusion: Overall, low maternal positivity was associated with rumination in female adolescents. There was no evidence that maternal rumination or criticism were associated with adolescent rumination. The results suggest a number of implications for future research, including the need for prospective longitudinal studies using observational parenting measures.

Background: Paediatric specialist dental practitioners are often faced with the challenge of disruptive behaviour or refusal to comply with treatment. Behaviour management skills are an essential component of their role. However, little is known of the confidence or competence of practitioners in these approaches. Aim: To identify paediatric dentists’ knowledge of behavioural management principles as applied to paediatric dentistry. Method: Postal questionnaire survey of all specialists in Paediatric Dentistry on the General Dental Council UK register (n = 234), using the Knowledge of Behavioural Principles as Applied to Children Questionnaire (KBPACQ; O'Dell, 1979) adapted for the dental setting. Information was also gathered on experience in using behavioural management techniques and demographics. Results: Responses were received from 105 practitioners (45%). Participants gave the correct answer, on average, to 38% of the items (range 0 to 75%). Conclusion: Knowledge of behavioural principles amongst paediatric dentists in the United Kingdom is poor, despite their widespread reported use of such techniques.

Background: Addison's disease (AD) is a rare chronic illness caused by adrenocortical insufficiency. Due to the pivotal role of the regulating hormone cortisol in AD, there is a common symptom overlap between the presentation of anxiety and adrenal crisis. Previous literature has identified the prevalence of anxiety in endocrinological disorders, however there is a paucity of research examining the complex interplay between AD and anxiety. Aims: This paper describes a single case study of a patient with severe health anxiety and co-morbid AD. The aims of the study were to establish if standard cognitive behavioural therapy for health anxiety in AD can lead to a reduction in psychological distress, and whether this approach is an effective intervention for the reduction of Emergency Department admissions. Method: A single case design was used, with pre- and post-measures of health anxiety, general anxiety and depression. Data on Emergency Department admissions prior to and following treatment were used to assess change in this domain. Results: Reliable and clinically significant reductions were seen across all measures, from severe to sub-clinical levels. There was a complete amelioration of Emergency Department admissions in the 12 months following completion of treatment. Conclusions: This preliminary study provides a sound rationale for further research into AD complicated by anxiety. Findings support the clinical utility of the cognitive behavioural therapy model for complex presentations of AD, offering a potential treatment option where anxiety is elevated and interfering with self-management and leading to high levels of health service use.