Attention bias modification: the Emperor's new suit?

BMC Med. 2012 Jun 25;10(1):63
Emmelkamp PM.

Abstract

ABSTRACT: A series of primarily laboratory-based studies found attention bias modification in socially anxious participants to lead to reduced anxiety. It is argued that the failure to replicate the positive results of attention bias modification in the study of Carlbring et al. may be due to reasons other than the application through the Internet. A number of controlled studies failed to replicate the positive effects of attention modification bias in clinically rather than subclinically socially anxious subjects. Given the lack of robust evidence for attention bias modification in clinically socially anxious individuals, the author is inclined to consider attention bias modification as 'the Emperor's new suit'. Results achieved with regular Internet-based treatments for social anxiety disorder based on cognitive therapy and exposure methods are much better than those achieved with attention bias modification procedures delivered 'face to face' in clinically distressed participants. . Given the lack of robust evidence for attention bias modification in clinical samples, there is no need yet to investigate the implementation of attention bias modification through the Internet. Please see related article: http://www.biomedcentral.com/1471-244X/12/66.

Five sessions and counting: considering ultra-brief treatment for panic disorder.

Depress Anxiety. 2012 Jun;29(6):465-70. doi: 10.1002/da.21910.
Otto MW, Tolin DF, Nations KR, Utschig AC, Rothbaum BO, Hofmann SG, Smits JA.

Source: Boston University, Boston, Massachusetts.

Abstract

BACKGROUND: Brief cognitive-behavioral therapy for panic disorder has the potential to lower health care costs and enhance dissemination of evidence-based interventions to clinical practice. This manuscript evaluates the utility of brief cognitive-behavioral therapy for panic disorder.
METHODS: A narrative review of studies examining the efficacy of cognitive-behavioral brief treatment of panic disorder, with a specific focus on an ultra-brief, 5-session, intervention developed by our group.
RESULTS: Brief cognitive-behavioral therapy for panic disorder is associated with clinically meaningful symptom improvement reflecting large effect sizes, comparable to those observed for standard protocols.
CONCLUSIONS: Growing evidence encourages the further evaluation and application brief cognitive-behavioral therapy for panic disorder. Controlled trials of cognitive-behavioral therapy have established the dramatic benefit that can be offered by brief treatment (often 12-15 sessions) approaches for Axis I disorders. Yet, as the field advances and core mechanisms of change are identified, there is the potential for offering efficacy in even briefer treatment protocols. In this manuscript, we describe the elements and initial efficacy estimates, based on published studies, for an ultra-brief treatment approach for panic disorder. We also discuss the potential impact, and such brief treatment can have relative to dissemination issues and the desire for the timely end to psychological suffering.

A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia.

Psychol Med. 2012 Apr 30:1-12. [Epub ahead of print]
Vos SP, Huibers MJ, Diels L, Arntz A.

Source: Department of Clinical Psychological Science, Faculty of Neuroscience and Psychology, Maastricht University, The Netherlands.

Abstract

BACKGROUND: Interpersonal psychotherapy (IPT) seems to be as effective as cognitive behavioral therapy (CBT) in the treatment of major depression. Because the onset of panic attacks is often related to increased interpersonal life stress, IPT has the potential to also treat panic disorder. To date, a preliminary open trial yielded promising results but there have been no randomized controlled trials directly comparing CBT and IPT for panic disorder.MethodThis study aimed to directly compare the effects of CBT versus IPT for the treatment of panic disorder with agoraphobia. Ninety-one adult patients with a primary diagnosis of DSM-III or DSM-IV panic disorder with agoraphobia were randomized. Primary outcomes were panic attack frequency and an idiosyncratic behavioral test. Secondary outcomes were panic and agoraphobia severity, panic-related cognitions, interpersonal functioning and general psychopathology. Measures were taken at 0, 3 and 4 months (baseline, end of treatment and follow-up).
RESULTS: Intention-to-treat (ITT) analyses on the primary outcomes indicated superior effects for CBT in treating panic disorder with agoraphobia. Per-protocol analyses emphasized the differences between treatments and yielded larger effect sizes. Reductions in the secondary outcomes were equal for both treatments, except for agoraphobic complaints and behavior and the credibility ratings of negative interpretations of bodily sensations, all of which decreased more in CBT.
CONCLUSIONS: CBT is the preferred treatment for panic disorder with agoraphobia compared to IPT. Mechanisms of change should be investigated further, along with long-term outcomes.

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology.

Behav Ther. 2012 Sep;43(3):518-32. Epub 2012 Mar 9.
Schmidt NB, Buckner JD, Pusser A, Woolaway-Bickel K, Preston JL, Norr A.

Source: Florida State University.

Abstract

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.

Threat Reappraisal as a Mediator of Symptom Change in Cognitive-Behavioral Treatment of Anxiety Disorders: A Systematic Review.

J Consult Clin Psychol. 2012 Jun 11. [Epub ahead of print]
Smits JA, Julian K, Rosenfield D, Powers MB.

Abstract

Objective: Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Threat reappraisal is considered a key mediator underlying the effects of cognitive-behavioral therapy (CBT) for anxiety disorders. The present study systematically reviewed the evidence for the threat reappraisal mediation hypothesis. Method: In our review, we included studies that (a) investigated the threat reappraisal mediation hypothesis; (b) included adults with an anxiety disorder diagnosis; (c) used a longitudinal design; and (d) did not report on previously published findings (to avoid the inclusion of multiple reports of the same data). After data extraction, we made review-specific quality judgments for each study using the following a priori criteria informed by mediation theory: (a) demonstrated statistical mediation; (b) demonstrated that CBT caused threat reappraisal; (c) demonstrated that threat reappraisal caused anxiety reduction; and (d) demonstrated specificity of the threat reappraisal-anxiety reduction relation. Results: Of the 2,296 studies we identified, 25 met inclusion criteria. Of these studies, 56% tested and 52% established statistical mediation, 52% tested and 28% established CBT as a cause of threat reappraisal, 28% tested and 24% established threat reappraisal as a cause of anxiety reduction, and 44% tested and 36% established specificity of the threat reappraisal-anxiety reduction relation. Conclusions: While threat reappraisal is related to anxiety symptom improvement with CBT, there are few extant studies that meet most of the criteria necessary to conclusively demonstrate that it causes symptom improvement in CBT and that it is not a proxy for other third variables. Recommendations for future research in this area are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

D-Cycloserine as an Augmentation Strategy for Cognitive Behavioral Therapy for Anxiety Disorders: An Update.

Curr Pharm Des. 2012 May 24. [Epub ahead of print]
Hofmann SG, Sawyer AT, Asnaani A.

Source: Department of Psychology Boston University 648 Beacon Street, 6th Floor Boston, MA 02215-2002. shofmann@bu.edu.

Abstract

Cognitive behavioral therapy (CBT) has been shown to be an effective intervention for anxiety disorders. However, despite its proven efficacy, some patients fail to respond to an adequate course of treatment. In attempts to improve the efficacy of CBT, researchers have augmented the core learning processes of the intervention with d-cycloserine (DCS), an N-Methyl-D-Aspartate partial agonist. This article reviews the current literature on DCS as an augmentation strategy for CBT for anxiety disorders. We will describe the memory enhancing properties of DCS, review findings from randomized controlled studies of DCS in anxious populations and discuss mechanism, dosing and timing issues.

Cognitive Reappraisal Self-Efficacy Mediates the Effects of Individual Cognitive-Behavioral Therapy for Social Anxiety Disorder.

J Consult Clin Psychol. 2012 May 14. [Epub ahead of print]
Goldin PR, Ziv M, Jazaieri H, Werner K, Kraemer H, Heimberg RG, Gross JJ.

Abstract

Objective: To examine whether changes in cognitive reappraisal self-efficacy (CR-SE) mediate the effects of individually administered cognitive-behavioral therapy (I-CBT) for social anxiety disorder (SAD) on severity of social anxiety symptoms. Method: A randomized controlled trial in which 75 adult patients (21-55 years of age; 53% male; 57% Caucasian) with a principal diagnosis of generalized SAD were randomly assigned to 16 sessions of I-CBT (n = 38) or a wait-list control (WL) group (n = 37). All patients completed self-report inventories measuring CR-SE and social anxiety symptoms at baseline and post-I-CBT/post-WL, and I-CBT completers were also assessed at 1-year posttreatment. Results: Compared with WL, I-CBT resulted in greater increases in CR-SE and greater decreases in social anxiety. Increases in CR-SE during I-CBT mediated the effect of I-CBT on social anxiety. Gains achieved by patients receiving I-CBT were maintained 1-year posttreatment, and I-CBT-related increases in CR-SE were also associated with reduction in social anxiety at the 1-year follow-up. Conclusions: Increasing CR-SE may be an important mechanism by which I-CBT for SAD produces both immediate and long-term reductions in social anxiety.

A controlled trial of the adjunct use of d-cycloserine to facilitate cognitive behavioral therapy outcomes in a cocaine-dependent population.

Addict Behav. 2012 Aug;37(8):900-7. Epub 2012 Mar 13.
Kennedy AP, Gross RE, Whitfield N, Drexler KP, Kilts CD.

Source: Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, USA.

Abstract

Cocaine dependence is a chronically relapsing disorder for which its predominant behavioral therapies are associated with only partial efficacy. The goal of this study was to determine if the N-methyl-d-aspartate (NMDA) glutamate receptor partial agonist and cognitive enhancer, d-cycloserine (DCS), could boost the cocaine abstinence and treatment retention goals of cognitive behavioral therapy (CBT). This study employed a placebo-controlled, randomized double-blind trial design of 44 cocaine-dependent men enrolled in a 4-week outpatient Substance Abuse Treatment Program (SATP) at the Atlanta Veteran's Administration Medical Center. Subjects received 50mg of DCS or placebo prior to four weekly sessions of a condensed version of a manual-based CBT for cocaine dependence. Cocaine abstinence and treatment retention measures represented primary outcome variables. Relative to a 12-step based treatment-as-usual, an under-dosed CBT was associated with significant improvements in drug abstinence and treatment retention at 4-weeks and for maintenance of drug abstinence after four more weeks of follow-up. The robust response to the under-dosed CBT was not enhanced by the adjunct administration of DCS at either the 4- or 8-week endpoints. This controlled clinical trial failed to demonstrate an ability of DCS to boost the relapse prevention or treatment retention goals of CBT.

Generalized anxiety disorder: A comparison of symptom change in adults receiving cognitive-behavioral therapy or applied relaxation.

J Consult Clin Psychol. 2012 Jun;80(3):490-6. Epub 2012 Apr 16.
Donegan E, Dugas MJ.

Source: Department of Psychology, Concordia University.

Abstract

Objective: Generalized anxiety disorder (GAD) is characterized by excessive worry and somatic symptoms of anxiety (e.g., restlessness, muscle tension). Several psychological treatments lead to significant reductions in GAD symptoms by posttreatment. However, little is known about how GAD symptoms change over time. Our main goal was to examine how GAD symptoms changed in relation to one another during 2 distinct but efficacious psychological treatments: cognitive-behavioral therapy (CBT) and applied relaxation (AR). Specifically, we asked whether change in worry accounted for change over time in somatic anxiety (or the reverse) to the same degree in CBT and AR. Method: We examined data from 57 individuals with GAD enrolled in a randomized controlled trial. Self-report measures of worry and somatic anxiety were obtained daily during treatment. Results: Although the direction of influence between changes in worry and somatic anxiety was bidirectional to some extent in both treatments, a significant difference was also observed: Change in worry accounted for subsequent change in somatic anxiety to a greater extent in CBT than in AR. Conclusions: These findings allowed us to identify differences in a mechanism of change in GAD symptoms during 2 treatments and to provide some support for the idea that similarly efficacious treatments may produce symptom change via different mechanisms in a manner that is consistent with the theoretical rationales on which the treatments are based.

Does Fear Reactivity During Exposure Predict Panic Symptom Reduction?

J Consult Clin Psychol. 2012 Apr 9. [Epub ahead of print]
Meuret AE, Seidel A, Rosenfield B, Hofmann SG, Rosenfield D.

Abstract

Objective: Fear reactivity during exposure is a commonly used indicator of learning and overall therapy outcome. The objective of this study was to assess the predictive value of fear reactivity during exposure using multimodal indicators and an advanced analytical design. We also investigated the degree to which treatment condition (cognitive training vs. respiratory skill training) moderated fear reactivity and therapeutic outcome. Method: Thirty-four patients with panic disorder and agoraphobia completed a total of 123 in-vivo exposure sessions, comprising 3 weekly sessions and a 4th session 2 months following therapy completion. Sessions varied in length and phobic stimuli. Cardiorespiratory physiology (heart rate, carbon dioxide partial pressure [PCO2], respiration rate) and experiential symptoms (panic symptoms and anxiety) were assessed repeatedly throughout exposure sessions, in addition to weekly assessments of panic cognitions, avoidance, and functioning. Results: Panic symptomatology decreased substantially in both treatment conditions during therapy and follow-up. Significant cardiorespiratory and experiential reactivity was observed during all exposures, characterized by activation followed by reduction. Greater within-session activation of anxiety and panic symptoms was inversely related to improvement in panic symptoms severity, but neither physiological activation nor within- or between-session reduction of either physiological or experiential variables was predictive of outcome. No moderating effects of treatment condition were found. Conclusions: Fear activation and reduction during exposure are weak predictors of corrective learning and fear extinction. Clinical implications for exposure therapy and directions for future research are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder.

Behav Res Ther. 2012 May;50(5):287-91. Epub 2012 Feb 28.
Boden MT, John OP, Goldin PR, Werner K, Heimberg RG, Gross JJ.

Source: Department of Psychology, Stanford University, CA, USA. matthew.t.boden@gmail.com

Abstract

Beliefs that are negatively biased, inaccurate, and rigid are thought to play a key role in the mood and anxiety disorders. Our goal in this study was to examine whether a change in maladaptive beliefs mediated the outcome of individual cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). In a sample of 47 individuals with SAD receiving CBT, we measured maladaptive interpersonal beliefs as well as emotional and behavioral components of social anxiety, both at baseline and after treatment completion. We found that (a) maladaptive interpersonal beliefs were associated with social anxiety at baseline and treatment completion; (b) maladaptive interpersonal beliefs were significantly reduced from baseline to treatment completion; and (c) treatment-related reductions in maladaptive interpersonal beliefs fully accounted for reductions in social anxiety after CBT. These results extend the literature by providing support for cognitive models of mental disorders, broadly, and SAD, specifically.

Changes in intolerance of uncertainty during cognitive behavior group therapy for social phobia.

J Behav Ther Exp Psychiatry. 2012 Jun;43(2):849-54. Epub 2011 Dec 16.
Mahoney AE, McEvoy PM.

Source: Clinical Research Unit for Anxiety and Depression, University of New South Wales at St Vincent's Hospital, Level 4 O'Brien Centre, 394-404 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia. amahoney@stvincents.com.au

Abstract

BACKGROUND AND OBJECTIVES: Recent research suggests that intolerance of uncertainty (IU), most commonly associated with generalized anxiety disorder, also contributes to symptoms of social phobia. This study examines the relationship between IU and social anxiety symptoms across treatment.
METHOD: Changes in IU, social anxiety symptoms, and depression symptoms were examined following cognitive behavior group therapy (CBGT) for social phobia (N=32).
RESULTS: CBGT led to significant improvements in symptoms of social anxiety and depression, as well as reductions in IU. Reductions in IU were associated with reductions in social anxiety but were unrelated to improvements in depression symptoms. Reductions in IU were predictive of post-treatment social phobia symptoms after controlling for pre-treatment social phobia symptoms and changes in depression symptoms following treatment.
LIMITATIONS: The relationship between IU and social anxiety requires further examination within experimental and longitudinal designs, and needs to take into account additional constructs that are thought to maintain social phobia.
CONCLUSIONS: Current findings suggest that the enhancing tolerance of uncertainty may play a role in the optimal management of social phobia. Theoretical and clinical implications are discussed.

The Role of Early Symptom Trajectories and Pretreatment Variables in Predicting Treatment Response to Cognitive Behavioral Therapy.

J Consult Clin Psychol. 2012 Jun 25. [Epub ahead of print]
Lewis CC, Simons AD, Kim HK.

Abstract

Objective: Research has focused on 2 different approaches to answering the question, "Which clients will respond to cognitive behavioral therapy (CBT) for depression?" One approach focuses on rates of symptom change within the 1st few weeks of treatment, whereas the 2nd approach looks to pretreatment client variables (e.g., hopelessness) to identify clients who are more or less likely to respond. The current study simultaneously examines these 2 lines of research (i.e., early symptom change and pretreatment variables) on the prediction of treatment outcome to determine the incremental utility of each potential predictor. Method: The sample consists of 173 clients (66.47% female, 92.49% Caucasian), 18-64 years of age (M = 27.94, SD = 11.42), receiving treatment for depression and anxiety disorders in a CBT-oriented psychology training clinic. Results: The rate of change in depressive symptom severity from baseline over the 1st 5 treatment sessions significantly predicted treatment outcome. A contemplative orientation to change and medication status positively predicted early symptom change, whereas student status negatively predicted early symptom change. Higher levels of baseline anxiety, precontemplative readiness to change, and global functioning predicted lower levels of depressive symptom severity at termination. Conclusions: The findings suggest achieving rapid symptom change early in treatment may be integral to overall success. As such, therapists may wish to target factors such as readiness to change to potentially maximize rapid rate of symptom change and subsequent treatment outcome. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

What makes a quality therapy? A consideration of parsimony, ease, and efficiency.

Behav Ther. 2012 Sep;43(3):468-81. Epub 2011 May 25.
Cougle JR.

Abstract

Evaluations of psychotherapy have traditionally focused on symptom reduction as the primary standard by which their value is determined. This has contributed to the appearance of equivalence between many therapies that may differ considerably in complexity, feasibility, amount of homework and therapist contact required, expected cost, speed of symptom decline, and transdiagnostic utility. In the current paper, I make the case that these are fundamental features related to quality that should be considered in psychotherapy development, randomized controlled trials, and dissemination efforts. Empirically supported treatments for different disorders are evaluated based on these criteria, and special consideration is given to cognitive-behavioral treatments for anxiety disorders. Specific recommendations for a quality-oriented clinical research agenda are also provided.

Aaron T. Beck's drawings and the psychoanalytic origin story of cognitive therapy.

Hist Psychol. 2012 Feb;15(1):1-18.
Rosner RI.

Source: rachael@denenberg.com

Abstract

In this essay the author challenges the standard origin story of cognitive therapy, namely, that its founder Aaron T. Beck broke with psychoanalysis to pursue a more pragmatic, parsimonious, and experimentalist cognitive model. It is true that Beck broke with psychoanalysis in large measure as a result of his experimental disconfirmation of key psychoanalytic ideas. His new school of cognitive therapy brought the experimental ethos into every corner of psychological life, extending outward into the largest multisite randomized controlled studies of psychotherapy ever attempted and inward into the deepest recesses of our private worlds. But newly discovered hand-sketched drawings from 1964 of the schema, a conceptual centerpiece of cognitive therapy, as well as unpublished personal correspondence show that Beck continued to think psychoanalytically even after he broke with psychoanalysis. The drawings urge us to consider an origin story much more complex than the one of inherited tradition. This new, multifaceted origin story of cognitive therapy reaches beyond sectarian disagreements and speaks to a broader understanding of the theoretical underpinnings of cognitive therapy.

Cognitive behavioural group therapy for social phobia: evidence of transportability to community clinics.

Behav Res Ther. 2012 Apr;50(4):258-65. Epub 2012 Feb 8.
McEvoy PM, Nathan P, Rapee RM, Campbell BN.

Source: Centre for Clinical Interventions, Northbridge, WA, Australia. peter.mcevoy@health.wa.gov.au

Abstract

Cognitive Behavioural Group Therapy (CBGT) for social phobia has been shown to be efficacious within research units and effective within a variety of real world clinical settings. However, most effectiveness studies of CBGT for social phobia have (a) used protocols without demonstrated efficacy, (b) not included direct comparison groups, and/or (c) contained features of efficacy trials. This study addressed these limitations by using a benchmarking strategy to compare outcomes from the same CBGT protocol used in both a research unit and a community clinic. Research (N = 71) and community (N = 94) patients completed the same 12-session protocol, which resulted in significant reductions in social anxiety and life interference at post-treatment. Compared to research unit patients, community patients had more severe symptoms and life interference at pre-treatment, and were more likely to be male, use medication, have comorbid disorders, and have lower educational attainment. Importantly, degree of improvement on social anxiety symptoms and life interference did not differ across the treatment settings for either completer or intention-to-treat analyses. There was some evidence that being younger, single, and having a depression diagnosis were associated with dropout. Pre-treatment symptoms and number of diagnoses predicted post-treatment symptoms. Consistent with previous uncontrolled trials, it is concluded that CBGT is effective within community mental health clinics.

The effects of cognitive behavior therapy delivered by students in a psychologist training program: an effectiveness study.

Behav Ther. 2012 Mar;43(1):160-73. Epub 2011 May 24.
Öst LG, Karlstedt A, Widén S.

Source: Department of Psychology, Stockholm University, S-106 91 Stockholm, Sweden. ost@psychology.su.se

Abstract

Relatively little is known about the efficacy of clinically inexperienced student therapists carrying out cognitive behavior therapy (CBT) under supervision during a professional, psychologist training program. The current study evaluated this by collecting pre- and posttreatment data on 591 consecutive patients receiving treatment at the Psychotherapy Clinic of the Department of Psychology, Stockholm University, Sweden, over an 8-year period. The patients had mainly anxiety disorders or depression with a mean duration of 15 years, and received individual CBT for a mean of 18 sessions. They improved significantly on both general measures (Beck Anxiety Inventory [BAI], Beck Depression Inventory [BDI], and Quality of Life Inventory [QOLI]) and disorder-specific self-report scales. The proportions of recovered patients on the BAI (63%) and the BDI (60%) were higher than those of a comparison effectiveness study. On the specific self-report scales the current sample improved as much as the samples in extant efficacy trials. We conclude that clinically inexperienced student therapists who receive supervision from experienced supervisors can achieve treatment effects that are on a par with those of experienced licensed psychotherapists.

A Randomized Clinical Trial of Mindfulness-Based Cognitive Therapy Versus Unrestricted Services for Health Anxiety (Hypochondriasis).

J Consult Clin Psychol. 2012 Jun 18. [Epub ahead of print]
McManus F, Surawy C, Muse K, Vazquez-Montes M, Williams JM.

Abstract

Objective: The efficacy and acceptability of existing psychological interventions for health anxiety (hypochondriasis) are limited. In the current study, the authors aimed to assess the impact of mindfulness-based cognitive therapy (MBCT) on health anxiety by comparing the impact of MBCT in addition to usual services (unrestricted services) with unrestricted services (US) alone. Method: The 74 participants were randomized to either MBCT in addition to US (n = 36) or US alone (n = 38). Participants were assessed prior to intervention (MBCT or US), immediately following the intervention, and 1 year postintervention. In addition to independent assessments of diagnostic status, standardized self-report measures and assessor ratings of severity and distress associated with the diagnosis of hypochondriasis were used. Results: In the intention-to-treat (ITT) analysis (N = 74), MBCT participants had significantly lower health anxiety than US participants, both immediately following the intervention (Cohen's d = 0.48) and at 1-year follow-up (d = 0.48). The per-protocol (PP) analysis (n = 68) between groups effect size was d = 0.49 at postintervention and d = 0.62 at 1-year follow-up. Mediational analysis showed that change in mindfulness mediated the group changes in health anxiety symptoms. Significantly fewer participants allocated to MBCT than to US met criteria for the diagnosis of hypochondriasis, both immediately following the intervention period (ITT 50.0% vs. 78.9%; PP 47.1% vs. 78.4%) and at 1-year follow-up (ITT 36.1% vs. 76.3%; PP 28.1% vs. 75.0%). Conclusions: MBCT may be a useful addition to usual services for patients with health anxiety. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Effects of Mindfulness-Based Cognitive Therapy on Specificity of Life Goals.

Cognit Ther Res. 2012 Jun;36(3):182-189. Epub 2011 Jan 21.
Crane C, Winder R, Hargus E, Amarasinghe M, Barnhofer T.

Abstract

This study explored the immediate effects of a course of Mindfulness-Based Cognitive Therapy (MBCT) for chronically depressed participants with a history of suicidality on the specificity of important goals for the future. Participants were randomly allocated to immediate treatment with MBCT or to a waitlist condition and life goals were assessed both before and after the treatment or waiting period. Results showed that participants receiving MBCT reported significantly more specific goals post-treatment whereas those allocated to the waitlist condition showed no significant change. Similarly, participants allocated to MBCT regarded themselves as significantly more likely to achieve their important goals post-treatment, whilst again there was no significant change in the waitlist group. Increases in goal specificity were associated with parallel increases in autobiographical memory specificity whereas increases in goal likelihood were associated with reductions in depressed mood. These results suggest that MBCT may enable participants to clarify their important goals and in doing so increase their confidence in their capacity to move in valued life directions.

Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders.

Behav Res Ther. 2012 Aug;50(7-8):469-78. Epub 2012 May 7.
Arch JJ, Wolitzky-Taylor KB, Eifert GH, Craske MG.

Source: University of Colorado Boulder, Department of Psychology and Neuroscience, 345 UCB Muenzinger, Boulder, CO 80309-0345, USA.

Abstract

OBJECTIVE: To assess the relationship between session-by-session putative mediators and treatment outcomes in traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for mixed anxiety disorders.
METHOD: Session-by-session changes in anxiety sensitivity and cognitive defusion were assessed in 67 adult outpatients randomized to CBT (n = 35) or ACT (n = 32) for a DSM-IV anxiety disorder.
RESULTS: Multilevel mediation analyses revealed significant changes in the proposed mediators during both treatments (p < .001, d = .90-1.93), with ACT showing borderline greater improvements than CBT in cognitive defusion (p = .05, d = .82). Anxiety sensitivity and cognitive defusion both significantly mediated post-treatment worry; cognitive defusion more strongly predicted worry reductions in CBT than in ACT. In addition, cognitive defusion significantly mediated quality of life, behavioral avoidance, and (secondary) depression outcomes across both CBT and ACT (p < .05, R(2) change = .06-.13), whereas anxiety sensitivity did not significantly mediate other outcomes.
CONCLUSIONS: Cognitive defusion represents an important source of therapeutic change across both CBT and ACT. The data offered little evidence for substantially distinct treatment-related mediation pathways.

Mindfulness-based cognitive therapy improves emotional reactivity to social stress: results from a randomized controlled trial.

Behav Ther. 2012 Jun;43(2):365-80. Epub 2011 Oct 1.
Britton WB, Shahar B, Szepsenwol O, Jacobs WJ.

Source: Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University, 185 Brown Street, Providence, RI 02906, USA. Willoughby_Britton@Brown.edu

Abstract

The high likelihood of recurrence in depression is linked to a progressive increase in emotional reactivity to stress (stress sensitization). Mindfulness-based therapies teach mindfulness skills designed to decrease emotional reactivity in the face of negative affect-producing stressors. The primary aim of the current study was to assess whether Mindfulness-Based Cognitive Therapy (MBCT) is efficacious in reducing emotional reactivity to social evaluative threat in a clinical sample with recurrent depression. A secondary aim was to assess whether improvement in emotional reactivity mediates improvements in depressive symptoms. Fifty-two individuals with partially remitted depression were randomized into an 8-week MBCT course or a waitlist control condition. All participants underwent the Trier Social Stress Test (TSST) before and after the 8-week trial period. Emotional reactivity to stress was assessed with the Spielberger State Anxiety Inventory at several time points before, during, and after the stressor. MBCT was associated with decreased emotional reactivity to social stress, specifically during the recovery (post-stressor) phase of the TSST. Waitlist controls showed an increase in anticipatory (pre-stressor) anxiety that was absent in the MBCT group. Improvements in emotional reactivity partially mediated improvements in depressive symptoms. Limitations include small sample size, lack of objective or treatment adherence measures, and non-generalizability to more severely depressed populations. Given that emotional reactivity to stress is an important psychopathological process underlying the chronic and recurrent nature of depression, these findings suggest that mindfulness skills are important in adaptive emotion regulation when coping with stress.

Using session-by-session measurement to compare mechanisms of action for acceptance and commitment therapy and cognitive therapy.

Behav Ther. 2012 Jun;43(2):341-54. Epub 2011 Aug 7.
Forman EM, Chapman JE, Herbert JD, Goetter EM, Yuen EK, Moitra E.

Source: Drexel University, Department of Psychology, 245 N 15th Street, MS 626, Philadelphia, PA 19102, USA. evan.forman@drexel.edu

Abstract

Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive "defusion" (the ability to see one's thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.

Treatment-specific changes in decentering following mindfulness-based cognitive therapy versus antidepressant medication or placebo for prevention of depressive relapse.

J Consult Clin Psychol. 2012 Jun;80(3):365-72. Epub 2012 Mar 12.
Bieling PJ, Hawley LL, Bloch RT, Corcoran KM, Levitan RD, Young LT, Macqueen GM, Segal ZV.

Source: St. Joseph's Healthcare.

Abstract

[Correction Notice: An Erratum for this article was reported in Vol 80(3) of Journal of Consulting and Clinical Psychology (see record 2012-09923-001). There is an error in the sentence beginning "For TMS-C . . ." in the paragraph below Table 5.] Objective: To examine whether metacognitive psychological skills, acquired in mindfulness-based cognitive therapy (MBCT), are also present in patients receiving medication treatments for prevention of depressive relapse and whether these skills mediate MBCT's effectiveness. Method: This study, embedded within a randomized efficacy trial of MBCT, was the first to examine changes in mindfulness and decentering during 6-8 months of antidepressant treatment and then during an 18-month maintenance phase in which patients discontinued medication and received MBCT, continued on antidepressants, or were switched to a placebo. In total, 84 patients (mean age = 44 years, 58% female) were randomized to 1 of these 3 prevention conditions. In addition to symptom variables, changes in mindfulness, rumination, and decentering were assessed during the phases of the study. Results: Pharmacological treatment of acute depression was associated with reductions in scores for rumination and increased wider experiences. During the maintenance phase, only patients receiving MBCT showed significant increases in the ability to monitor and observe thoughts and feelings as measured by the Wider Experiences (p < .01) and Decentering (p < .01) subscales of the Experiences Questionnaire and by the Toronto Mindfulness Scale. In addition, changes in Wider Experiences (p < .05) and Curiosity (p < .01) predicted lower Hamilton Rating Scale for Depression scores at 6-month follow-up. Conclusions: An increased capacity for decentering and curiosity may be fostered during MBCT and may underlie its effectiveness. With practice, patients can learn to counter habitual avoidance tendencies and to regulate dysphoric affect in ways that support recovery. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Individually tailored internet-based treatment for young adults and adults with panic attacks: randomized controlled trial.

J Med Internet Res. 2012 Jun 26;14(3):e65.
Silfvernagel K, Carlbring P, Kabo J, Edström S, Eriksson J, Månson L, Andersson G.

Source: Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden. kristin.silfvernagel@liu.se.

Abstract

BACKGROUND: Previous studies on Internet-based treatment with minimal therapist guidance have shown promising results for several specific diagnoses.
OBJECTIVE: To (1) investigate the effects of a tailored, therapist-guided, Internet-based treatment for individuals with reoccurring panic attacks, and (2) to examine whether people in different age groups (18-30 years and 31-45 years) would respond differently to the treatment.
METHODS: We recruited 149 participants from an online list of individuals having expressed an interest in Internet treatment. Screening consisted of online questionnaires followed by a telephone interview. A total of 57 participants were included after a semistructured diagnostic interview, and they were randomly assigned to an 8-week treatment program (n = 29) or to a control condition (n = 28). Treatment consisted of individually prescribed cognitive behavior therapy text modules in conjunction with online therapist guidance. The control group consisted of people on a waitlist who later received treatment.
RESULTS: All dependent measures improved significantly immediately following treatment and at the 12-month follow-up. The between-group effect size on the primary outcome measure, the Panic Disorder Severity Scale, was d = 1.41 (95% confidence interval 0.81-1.95) at posttreatment. The within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% confidence interval 1.14-2.35). Age group had no effect, suggesting that age did not influence the outcome.
CONCLUSIONS: Tailoring an Internet-based treatment can be a feasible approach in the treatment of panic symptoms and comorbid anxiety and depressive symptoms. Younger adults benefit as much as adults over 30 years and up to 45 years of age.

A randomized controlled trial of internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus.

J Consult Clin Psychol. 2012 Jan 16. [Epub ahead of print]
Hesser H, Gustafsson T, Lundén C, Henrikson O, Fattahi K, Johnsson E, Westin VZ, Carlbring P, Mäki-Torkko E, Kaldo V, Andersson G.

Abstract

Objective: Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format. Method: Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up. Results: Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16). Conclusions: Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients: a randomized trial.

JAMA. 2012 Jun 6;307(21):2278-85.
Mohr DC, Ho J, Duffecy J, Reifler D, Sokol L, Burns MN, Jin L, Siddique J.

Source: Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA. d-mohr@northwestern.edu

Abstract

CONTEXT: Primary care is the most common site for the treatment of depression. Most depressed patients prefer psychotherapy over antidepressant medications, but access barriers are believed to prevent engagement in and completion of treatment. The telephone has been investigated as a treatment delivery medium to overcome access barriers, but little is known about its efficacy compared with face-to-face treatment delivery.
OBJECTIVE: To examine whether telephone-administered cognitive behavioral therapy (T-CBT) reduces attrition and is not inferior to face-to-face CBT in treating depression among primary care patients.
DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial of 325 Chicago-area primary care patients with major depressive disorder, recruited from November 2007 to December 2010.
INTERVENTIONS: Eighteen sessions of T-CBT or face-to-face CBT.
MAIN OUTCOME MEASURES: The primary outcome was attrition (completion vs noncompletion) at posttreatment (week 18). Secondary outcomes included masked interviewer-rated depression with the Hamilton Depression Rating Scale (Ham-D) and self-reported depression with the Patient Health Questionnaire-9 (PHQ-9).
RESULTS: Significantly fewer participants discontinued T-CBT (n = 34; 20.9%) compared with face-to-face CBT (n = 53; 32.7%; P = .02). Patients showed significant improvement in depression across both treatments (P < .001). There were no significant treatment differences at posttreatment between T-CBT and face-to-face CBT on the Ham-D (P = .22) or the PHQ-9 (P = .89). The intention-to-treat posttreatment effect size on the Ham-D was d = 0.14 (90% CI, -0.05 to 0.33), and for the PHQ-9 it was d = -0.02 (90% CI, -0.20 to 0.17). Both results were within the inferiority margin of d = 0.41, indicating that T-CBT was not inferior to face-to-face CBT. Although participants remained significantly less depressed at 6-month follow-up relative to baseline (P < .001), participants receiving face-to-face CBT were significantly less depressed than those receiving T-CBT on the Ham-D (difference, 2.91; 95% CI, 1.20-4.63; P < .001) and the PHQ-9 (difference, 2.12; 95% CI, 0.68-3.56; P = .004).
CONCLUSIONS: Among primary care patients with depression, providing CBT over the telephone compared with face-to-face resulted in lower attrition and close to equivalent improvement in depression at posttreatment. At 6-month follow-up, patients remained less depressed relative to baseline; however, those receiving face-to-face CBT were less depressed than those receiving T-CBT. These results indicate that T-CBT improves adherence compared with face-to-face delivery, but at the cost of some increased risk of poorer maintenance of gains after treatment cessation.

Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: a randomized controlled trial.

Psychol Med. 2012 Feb 21:1-11. [Epub ahead of print]
Andersson E, Enander J, Andrén P, Hedman E, Ljótsson B, Hursti T, Bergström J, Kaldo V, Lindefors N, Andersson G, Rück C.

Source: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.

Abstract

BACKGROUND: Cognitive behaviour therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) but access to CBT is limited. Internet-based CBT (ICBT) with therapist support is potentially a more accessible treatment. There are no randomized controlled trials testing ICBT for OCD. The aim of this study was to investigate the efficacy of ICBT for OCD in a randomized controlled trial.MethodParticipants (n=101) diagnosed with OCD were randomized to either 10 weeks of ICBT or to an attention control condition, consisting of online supportive therapy. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (YBOCS) administered by blinded assessors.
RESULTS: Both treatments lead to significant improvements in OCD symptoms, but ICBT resulted in larger improvements than the control condition on the YBOCS, with a significant between-group effect size (Cohen's d) of 1.12 (95% CI 0.69-1.53) at post-treatment. The proportion of participants showing clinically significant improvement was 60% (95% CI 46-72) in the ICBT group compared to 6% (95% CI 1-17) in the control condition. The results were sustained at follow-up.
CONCLUSIONS: ICBT is an efficacious treatment for OCD that could substantially increase access to CBT for OCD patients. Replication studies are warranted.

Web-based cognitive-behavioral therapy for perfectionism: a randomized controlled trial.

Psychother Res. 2012 Mar;22(2):194-207. Epub 2011 Nov 28.
Arpin-Cribbie C, Irvine J, Ritvo P.

Source: Laurentian University, Psychology, Barrie, Ontario, Canada. carpincribbie@laurentian.ca

Abstract

This study assessed the effectiveness of a web-based cognitive behavioral intervention (CBT) in reducing perfectionism and psychological distress in post-secondary students. Participants assessed as high in perfectionism (n=77) were randomized to one of three 10-week, web-based, intervention conditions (no treatment [NT], general stress management [GSM], or CBT). Results indicated the CBT condition was effective in reducing perfectionism, and supported a pattern of significantly greater improvement than observed in participants in the GSM or NT conditions. While both CBT and GSM demonstrated capacities to significantly reduce distress, for CBT participants changes in perfectionism were significantly correlated with changes in depression and anxiety. Results offer support for the effectiveness of web-based CBT in positively affecting perfectionist-related problems. Given the considerable proportion of individuals who suffer from perfectionism-related distress, the intervention's apparent effectiveness, cost-effectiveness and ease of dissemination warrant future replication studies.

Moving From Efficacy to Effectiveness in Cognitive Behavioral Therapy for Psychosis: A Randomized Clinical Practice Trial.

J Consult Clin Psychol. 2012 Jun 4. [Epub ahead of print]
Lincoln TM, Ziegler M, Mehl S, Kesting ML, Lüllmann E, Westermann S, Rief W.

Abstract

Objective: Randomized controlled trials have attested the efficacy of cognitive behavioral therapy (CBT) in reducing psychotic symptoms. Now, studies are needed to investigate its effectiveness in routine clinical practice settings. Method: Eighty patients with schizophrenia spectrum disorders who were seeking outpatient treatment were randomized to a specialized cognitive behavioral intervention for psychosis (CBTp; n = 40) or a wait list (n = 40). The CBTp group was assessed at baseline, posttreatment, and 1-year follow-up. The wait list group was assessed at baseline, after a 4-month waiting period, at posttreatment, and after 1 year. The primary outcome measure was the Positive and Negative Syndrome Scale (PANSS). Results: The CBTp group showed significant improvement over the wait list group for the total PANSS score at posttreatment-postwaiting. CBTp was also superior to the wait list group in regard to the secondary outcomes positive symptoms, general psychopathology, depression, and functioning, but not in regard to negative symptoms. The number of dropouts during the treatment phases was low (11.3%). Participants perceived the treatment as helpful (98%) and considered themselves improved (92%). Significant pre- and posttreatment effect sizes varied between 0.77 for general psychopathology and 0.38 for delusional conviction. The positive effects of treatment could be maintained at 1-year follow-up, although the number of patients who had deteriorated was higher than at postassessment. Conclusions: Large proportions of patients in clinical practice settings benefit from CBTp. The efficacy of CBTp can be generalized to clinical practice despite the differences in patients, therapists, and deliverance. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders.

Behav Res Ther. 2012 Feb;50(2):110-21. Epub 2011 Dec 8.
Shawyer F, Farhall J, Mackinnon A, Trauer T, Sims E, Ratcliff K, Larner C, Thomas N, Castle D, Mullen P, Copolov D.

Source: School of Psychological Science, La Trobe University, Victoria 3086, Australia. fshawyer@gmail.com

Abstract

Command hallucinations represent a special problem for the clinical management of psychosis. While compliance with both non-harmful and harmful commands can be problematic, sometimes in the extreme, active efforts to resist commands may also contribute to their malignancy. Previous research suggests Cognitive Behaviour Therapy (CBT) to be a useful treatment for reducing compliance with harmful command hallucinations. The purpose of this trial was to evaluate whether CBT augmented with acceptance-based strategies from Acceptance and Commitment Therapy could more broadly reduce the negative impact of command hallucinations. Forty-three participants with problematic command hallucinations were randomized to receive 15 sessions of the intervention "TORCH" (Treatment of Resistant Command Hallucinations) or the control, Befriending, then followed up for 6 months. A sub-sample of 17 participants was randomized to a waitlist control before being allocated to TORCH or Befriending. Participants engaged