Influence of transdiagnostic factors on the course of quality of life in people with complex psychological problems.

In third-line highly specialised treatment centres, patients with various
complex psychological problems are treated. These patients often have, on the
one hand, severe psychological disorders and a chronically lower level of
functioning in various areas and, on the other hand, the potential to benefit
from intensive psychotherapy. Often there is multimorbidity and the patients
have had several evidence-based psychotherapies and pharmacotherapies which
were not (permanently) effective. Multidisciplinary guidelines for the
treatment of various disorders then prescribe intensive treatment in a highly
specialised centre. Unfortunately, these treatments are not always effective
and some patients drop out prematurely. This is a problem because these
treatments are very expensive and for patients and their families this
treatment is their last hope. The aim of this study is to generate knowledge
that can contribute to the prevention of early drop-out from intensive
high-specialty treatment and to more effective treatment of people with complex
psychological problems.
To give an outline of the scope of the problem the following should be noted:
Previous research shows that 50-60% of patients with a previously
therapy-resistant obsessive-compulsive disorder as their main diagnosis improve
substantially after intensive highly specialised treatment (Balachander et al.,
2020; Brennan et al., 2014; Siwiec, Riemann, & Lee, 2019; Veale et al., 2016;
Van Geijtenbeek de Vos van Steenwijk et al., 2021). A similar proportion
(51-64%) of patients with a previously therapy-resistant personality disorder
or post traumatic stress disorder as their main diagnosis, recover from
intensive highly specialised treatment (Solbakken & Abbass, 2015; Steil, Dyer,
Priebe, Kleindienst, & Bohus, 2011; Werbart, Forsström, & Jeanneau, 2012).
Thus, in these studies among various patient groups, treatment had no effect in
approximately 40-50%.

We do not know why almost half of the people with complex mental disorders do
not recover from such treatments. As outlined above, it applies to different
patient groups. It is possible that there is a common cause of limited
treatment outcome. A potential explanation is that important transdiagnostic
factors are insufficiently addressed in the treatment.

A transdiagnostic approach to psychopathology assumes that the same underlying
genetic, neurobiological and psychological mechanisms can lead to and sustain
different disorders. Examples of transdiagnostic factors (TDFs) are negative
self-image and insufficient emotion regulation skills. TDFs explain chronicity,
suicidality and the development of new additional mental disorders
(comorbidity) better than the presence of specific mental disorders (Kessler et
al., 2011; Naragon-Gainey & Watson, 2011). If TDFs not only predict the
development of disorders but also maintain psychopathology, they should be
addressed in treatment. TDF intervention is already used in less complex
populations. Its success is not inferior to, but also does not appear to be
superior to, disorder-specific treatment (McHugh, Murray, & Barlow, 2009).
Especially in the most complex populations, in which multimorbidity is present
by definition, an addition of transdiagnostic treatment to disorder-specific
treatment might be appropriate. However, there is a lack of knowledge in the
literature about which TDFs are associated with dropout from and outcome from
intensive highly specialised treatment. The aim of the present study is to
address this lack of knowledge. This can be done by repeatedly measuring TDFs
in a prospective naturalistic cohort study involving patients with complex
problems who are intensively treated in a highly specialised centre.

Two core temperament factors, Anxiety/Neuroticism/Behavioral Inhibition and
Extraversion/behavioural activation/positive affect, dominate the
transdiagnostic literature. Both have a strong genetic basis underlying
emotional disorders (Brown, 2007; Brown & Barlow, 2009; Rodriguez-Seijas,
Eaton, & Krueger, 2015). In addition, previous research suggests that the
following pathological factors are underlying or maintaining various
psychological disorders: Childhood trauma(Curran, Adamson, Rosato, De Cock, &
Leavey, 2018; K. M. Keyes et al, 2012), insecure attachment style, emotion
regulation problems(Aldao, Gee, De Los Reyes, & Seager, 2016), negative
self-image (Korrelboom, 2014) intolerance of uncertainty (Dupuy & Ladouceur,
2008; Mahoney & McEvoy, 2012), experiential avoidance (Spinhoven, Drost, de
Rooij, van Hemert, & Penninx, 2014), alexithymia (Dimaggio, Vanheule, Lysaker,
Carcione, & Nicolò, 2009). There are also indications that deficits in
well-being and sense of purpose (C. L. Keyes, Dhingra, & Simoes, 2010; Lamers,
Bolier, Westerhof, Smit, & Bohlmeijer, 2012), healthy lifestyle (eating,
exercise, resources, sleep)(Zaman, Hankir, & Jemni, 2019), self-compassion
(MacBeth & Gumley, 2012) and playfulness (Farley, Kennedy-Behr, & Brown, 2020),
are underlying or maintaining psychopathology in people with various mental
illnesses.

By following a cohort of patients with complex problems for a period of time
and measuring TDFs repeatedly, it can be examined which developments in TDFs
are associated with improvements in functioning, quality of life and symptom
reduction. This may provide clues as to which TDFs offer the most relevant
entry points for treatment in this complex group.

Since, to the best of our knowledge, no knowledge is yet available about which
TDFs are associated with the persistence of problems in the group described
here, we opted for an exploratory approach.

Objective of the quantitative and qualitative study:
To gain knowledge about which transdiagnostic factors are associated with
dropout from and outcome of intensive high-specialty treatment.

Objective of the pilot study:
To gain insight into the role of transdiagnostic factors in the treatment of
different target groups. Namely, also in a target group of patients with less
complex problems, or where despite complex problems a part-time or clinical
treatment is not (yet) indicated. This contributes to the adaptation of
treatments to specific patient profiles.

Longitudinal cohort study

There is a mild cognitive load due to the duration of the questionnaires.
There is no risk for the participants.

The participants complete the questionnaires during the intake as part of the
treatment as usual and then annually for evaluation. Within the framework of
the scientific research, subjects will be asked to fill in the questionnaires
several times, initially more frequently and later at a lower frequency.
The duration of each measurement for the scientific research is estimated at 75
minutes. An explanation will be given beforehand and permission will be asked
by means of an Informed Consent. It will be explicitly stated that
participation is voluntary and that the choice made has no consequences
whatsoever for the treatment to be followed. In this way, participants are
given as much opportunity as possible to make a voluntary choice whether or not
to participate in this study. Also during the study, participants can stop
his/her participation at any time.
Questionnaires can cause mild disruption, because of the confrontation with
certain complaints and/or the (experienced) absence of results, for example.
However, at the same time, the themes of the questionnaires are in line with
the complaints and/or the (possible) origin of the complaints and therefore
relevant and not new/unknown to the participants. These themes will also be
addressed in the treatment.