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BEATVIC, a Body-Oriented Resilience Training with Elements of Kickboxing for Individuals with a Psychotic Disorder: Study Protocol of a Multi-Center RCT Elisabeth C

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BEATVIC, a Body-Oriented Resilience Training with Elements of Kickboxing for Individuals with a Psychotic Disorder: Study Protocol of a Multi-Center RCT Elisabeth C van der Stouwe et al. BMC Psychiatry (2016) 16:227 DOI 10.1186/s12888-016-0918-2 STUDYPROTOCOL Open Access BEATVIC, a body-oriented resilience training with elements of kickboxing for individuals with a psychotic disorder: study protocol of a multi-center RCT Elisabeth C. D. van der Stouwe1,2*, Bertine de Vries3, André Aleman1,3, Johan Arends4, Clement Waarheid4, Aniek Meerdink4, Erwin van der Helm5, Jooske T. van Busschbach2,6 and Gerdina H. M. Pijnenborg1,2,3,4 Abstract Background: Individuals with a psychotic disorder are at an increased risk of becoming victim of a crime or other forms of aggression. Research has revealed several possible risk factors (e.g. impaired social cognition, aggression regulation problems, assertiveness, self-stigma, self-esteem) for victimization in patients with a psychotic disorder. To address these risk factors and prevent victimization, we developed a body-oriented resilience training with elements of kickboxing: BEATVIC. The present study aims to evaluate the effectiveness of the intervention. Methods/Design: Seven mental health institutions in the Netherlands will participate in this study. Participants will be randomly assigned to either the BEATVIC training or the control condition: social activation. Follow-ups are at 6, 18 and 30 months. Short term effects on risk factors for victimization will be examined, since these are direct targets of the intervention and are thought to be mediators of victimization, the primary outcome of the intervention. The effect on victimization will be investigated at follow-up. In a subgroup of patients, fMRI scans will be made before and after the intervention period in order to assess potential neural changes associated with the effects of the training. Discussion: This study is the first to examine the effectiveness of an intervention targeted at victimization in psychosis. Methodological issues of the study are addressed in the discussion of this paper. Trial registration: Current Controlled Trials: ISRCTN21423535. Retrospectively registered 30-03-2016. Keywords: Psychotic disorder, Training, Assertiveness, Psychomotor, Nonverbal therapy, Kickboxing, Victimization, Social cognition, Self-esteem, Neuroimaging Background study sample, in operationalization of victimization and Contrary to popular belief, an individual with a psychotic in examined time frame (de Vries et al. in prep). In a re- disorder is more likely to become the victim of a crime cent study investigating victimization in people with a or other forms of aggression, than to be the offender psychotic disorder, 39 % of patients had been severely [1, 2]. Prevalence rates of victimization vary across stud- physically threatened, 51 % of them reported physical ies from 20 % [3, 4] to 68 % [5], due to differences in violence and 32 % had been sexually victimized in the past year [3]. Moreover, a meta-analysis revealed that * Correspondence: [email protected] prevalence rates of victimization amongst severely men- 1Department of Neuroscience, BCN Neuroimaging Center, University of tally ill patients are 2 to 140 times higher than preva- Groningen, University Medical Center Groningen, Antonius Deusinglaan 2, lence rates in the general population [6]. Again, this 9713 AW Groningen, The Netherlands 2University of Groningen, University Medical Center Groningen, University wide range of prevalence rates is due to methodological Center of Psychiatry, Rob Giel Onderzoekcentrum, Hanzeplein 1, 9713 GZ differences between studies. Most of the violence occurs Groningen, The Netherlands in patients’ private environment, and is committed by Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. van der Stouwe et al. BMC Psychiatry (2016) 16:227 Page 2 of 10 people from their own social network [7]. Because leaving the setting before potential escalation. Another victimization can have a major impact on the lives of possible factor is insight. Poor insight in one’s own already vulnerable patients, and ultimately entails high psychotic symptoms is one of the pathways to aggressive costs for society [1], a preventive intervention is needed. behavior [18] which may evoke aggressive behavior in In the past, several interventions to prevent others resulting in victimization [19]. Aggression regula- victimization have been developed for severely mentally tion problems are associated with violent behavior in pa- ill patients [8–11]. However, to date only one of these – tients with a psychotic disorder and therefore these are a ‘street smart’ skills training for an urban setting – has another important risk factor [20]. Also, self-stigma may been investigated by means of an observational pilot indirectly play a role in victimization; there are a lot of study [11] while the other interventions have not yet prejudice beliefs about mental illnesses and most pa- been empirically investigated, nor have they been imple- tients are aware of these [21]. Self-stigma results in low mented in clinical practice. Moreover, none of these in- self-efficacy [22], low self-esteem and reduced empower- terventions was developed for individuals with a ment [23]. Consequently, individuals may be more prone psychotic disorder specifically [12], while the high to be victimized [24]. In turn, victimization may increase victimization rates [1–3] and both psychotic patients self-stigma and feelings of helplessness resulting in a vi- and caregivers indicate the need for an intervention tai- cious circle between self-stigma and victimization (Hors- lored to the needs of this specific group [13]. Therefore, selenberg et al. in prep). Victimization not only affects we developed an intervention that aims to prevent self-stigma but also reinforces the other risk factors in victimization in people with psychotic disorders. the victimization model, increasing the chance of revicti- In order to design an effective intervention we selected mization. For example, the traumatic experience of be- targets that are potentially amendable to change by an ing a victim could lead to a stronger physiological intervention, and constructed a model (see Fig. 1) based response to external stressors [25] and a compromised on an analysis of risk factors as suggested by previous inhibitory control [26]. People who experienced trauma research. One of the potential risk factors might be defi- or stress tend to react more aggressively in social situa- cits in social cognition [14]. Compared to individuals tions [27, 28]. This aggressive response may elicit con- from the general population, people with psychotic dis- flicts, again putting people at risk for victimization. orders experience more difficulties recognizing facial ex- Ultimately, patients can become trapped in a downward pressions [15], body language [16], and emotional spiral. prosody [17]. This may lead to inadequate social behav- We used this model to develop an intervention to de- ior and - more specifically - may have a negative effect crease the risk of victimization in individuals with a on their judgment of risky social situations. For instance, psychotic disorder. We chose an experience based ap- a patient may misinterpret the aggressive facial expres- proach which combines body awareness exercises with sion of another person, preventing him or her from physical activity, in contrast to primarily verbal Fig. 1 Victimization model van der Stouwe et al. BMC Psychiatry (2016) 16:227 Page 3 of 10 interventions because victimization often occurs and de- An additional aim of the study is to examine the effect rives from factors at a nonverbal level. This approach of the training at the cerebral level, by means of func- has its origin in what in some countries is called psycho- tional Magnetic Resonance Imaging (fMRI). Particular motor therapy [29] or body-oriented psychotherapy [30]. emphasis will be on cerebral activation during social Patients will be offered the opportunity to learn to cognitive processes, since social cognition is a direct tar- recognize their own emotional and behavioral reactions get of the intervention. We hypothesize enhanced in- to different social situations. In a safe and therapeutic volvement and connectivity of brain networks environment, new behavior and for instance other body underlying social cognitive functioning in patients after postures will be practiced stimulating adequate emo- the experimental intervention as compared to the con- tional awareness and emotion regulation. In addition, trol intervention. training with others and explicitly observing others dur- ing observational exercises facilitates participants to Methods/Design learn how others express themselves and to experiment The study is funded by the Netherlands Organization for within social interactions. These positive experiences Scientific Research (NWO grant nr 432-12-807). The resulting from the body-oriented approach will be mixed study has been approved by the medical ethical
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