Treatment of anxiety in autism spectrum disorders using cognitive behaviour therapy: A systematic review

OBJECTIVE

To review studies involving the treatment of anxiety in people with autism spectrum disorders (ASD) using Cognitive Behaviour Therapy (CBT) with the intent to inform practice and to identify areas for future research.

METHODS

Systematic searches of electronic databases, reference lists and journals identified nine studies. Each identified study that met pre-determined inclusion criteria was analysed and summarized in terms of: (a) participants, (b) intervention procedures, (c) dependent variables, (d) results of intervention and (e) certainty of evidence. To assess the certainty of evidence, each study's design and related methodological details were critically appraised.

RESULTS

Positive outcomes were ubiquitous, suggesting CBT is an effective treatment for anxiety in individuals with Asperger's. However, data involving other ASD diagnostic sub-types is limited.

CONCLUSIONS

CBT has been modified for individuals with ASD by adding intervention components typically associated with applied behaviour analysis (e.g. systematic prompting and differential reinforcement). Future research involving a component analysis could potentially elucidate the mechanisms by which CBT reduces anxiety in individuals with ASD, ultimately leading to more efficient or effective interventions.

Crucial issues in the applied analysis of verbal behavior: reflections on crucial conversations: tools for talking when the stakes are high

A popular-press self-help manual is reviewed with an eye toward two issues. First, the popularity of such books documents the existence of considerable demand for technologies that address the everyday problems (in the present case, troublesome conversations) of nondisordered individuals. Second, many ideas invoked in popular-press books may be interpretable within an analysis of verbal behavior, although much more than casual translation is required to develop technologies that outperform self-help manuals. I discuss several challenges relevant to research, theory refinement, technology development, and dissemination, and conclude that behavioral alternatives to existing popular-press resources may not emerge anytime soon.

Hatha yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research

BACKGROUND

The purpose of this article is to review the evidence for the efficacy of hatha yoga for depression and possible mechanisms by which yoga may have an impact on depression, and to outline directions for future research.

METHODS

Literature review and synthesis.

RESULTS AND CONCLUSIONS

A literature search for clinical trials examining yoga for depression uncovered eight trials: 5 including individuals with clinical depression, and 3 for individuals with elevated depression symptoms. Although results from these trials are encouraging, they should be viewed as very preliminary because the trials, as a group, suffered from substantial methodological limitations. We would argue, however, that there are several reasons to consider constructing careful research on yoga for depression. First, current strategies for treating depression are not sufficient for many individuals, and patients have several concerns about existing treatments. Yoga may be an attractive alternative to or a good way to augment current depression treatment strategies. Second, aspects of yoga-including mindfulness promotion and exercise-are thought to be "active ingredients" of other successful treatments for depression. Third, there are plausible biological, psychological, and behavioral mechanisms by which yoga may have an impact on depression. We provide suggestions for the next steps in the study of yoga as a treatment for depression.

Perceived changes associated with autogenic training for anxiety: a grounded theory study

OBJECTIVES

Autogenic training (AT) is a behaviourally orientated intervention usually taught in eight or nine sessions in the United Kingdom: clients are taught six simple mental formulae designed to induce a calm state of mind and body, five additional emotional expression exercises, and individually tailored 'personal formulae' for supporting positive change. In the absence of existing psychological (as opposed to neuro-physiological) models of AT's mechanisms, this study aimed to produce the first such model, drawing on the perceptions of recent AT clients.

DESIGN

An abbreviated form of grounded theory was used to explore retrospectively and in detail the experiences of a small sample of people of the process of change.

METHODS

Forty people were approached and 12 women participated who had completed AT in group form after referral for anxiety. Each was interviewed individually. A preliminary model of change was produced, grounded in the interview data.

RESULTS

Factors reported to be salient were learning in a group, the core AT experience (the six standard exercises), difficulties with practice, the importance of regular practice integrated into daily life, and enhanced well-being and coping, which incorporated reduced worrying and clearer thinking. Limitations of the study are discussed, as are areas for further research and implications for anxiety treatment.

CONCLUSIONS

This was a small study with a self-selected sample. However, theoretical generalizations can be made about the process of change. Since AT does not specifically focus on challenging negative cognitions, the cognitive changes reported have implications for anxiety treatments.

Theoretical and Empirical Developments of the Mindfulness-Acceptance-Commitment(MAC) Approach to Performance Enhancement

As long as athletes strive to attain optimal performance states and consistently reach high performance goals, psychological interventions will be used to assist in the development of skill and the maintenance of performance. In the pursuit of these goals, newer evidence-driven models based on mindfulness- and acceptance-based approaches have been designed to achieve these ends. Based upon questionable efficacy data for traditional psychological skills training procedures that emphasize reduction or control of internal processes, mindfulness- and acceptance-based approaches develop skills of nonjudging mindful awareness, mindful attention, and experiential acceptance to aid in the pursuit of valued goals. The most formalized and researched mindfulness- and acceptance-based approach within sport psychology is the manualized Mindfulness-Acceptance-Commitment (MAC) protocol. In the 8 years since the MAC was first developed and presented, and the 5 years since the first publication on the protocol, the MAC program has accumulated a continually growing empirical base for both its underlying theory and intervention efficacy as a performance enhancement intervention. This article reviews the empirical and theoretical foundations of the mindfulness- and acceptance-based approaches in general, and MAC in particular; reviews the accumulated empirical findings in support of the MAC approach for performance enhancement; and presents recent MAC developments and suggested future directions.

Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. This article, one of five in the series, reviews new studies of psychotherapy in the acute and maintenance phase of MDD, including computer-based and telephone-delivered psychotherapy.

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. Evidence-based responses are based on updated systematic reviews of the literature and recommendations are graded according to the Level of Evidence, using pre-defined criteria. Lines of Treatment are identified based on criteria that included evidence and expert clinical support.

RESULTS

Cognitive-Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) continue to have the most evidence for efficacy, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. CBT is well studied in conjunction with computer-delivered methods and bibliotherapy. Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence, but need replication. Newer psychotherapies including Acceptance and Commitment Therapy, Motivational Interviewing, and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments; nor does psychodynamic therapy.

LIMITATIONS

Although many forms of psychotherapy have been studied, relatively few types have been evaluated for MDD in randomized controlled trials. Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly.

CONCLUSIONS

CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance. Both computer-based and telephone-delivered psychotherapy--primarily studied with CBT and IPT--are useful second-line recommendations. Where feasible, combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD.

First-line treatment: a critical appraisal of cognitive behavioral therapy developments and alternatives

In this article, the authors assess the successes, remaining challenges, and new developments in cognitive behavioral therapy (CBT) for anxiety disorders. They define CBT, examine treatment components, review treatment efficacy, and discuss the challenges of attrition, long-term follow-up, co-occurring/comorbid disorders, limited treatment comparisons, treatment mediators, and broader implementation. In addition, they present recent developments in cognitive behavioral therapy for anxiety disorders, including linking exposure therapy to basic science, mindfulness and acceptance-based treatments, and unified or transdiagnostic treatment protocols.

Enhancing the Therapy Relationship in Acceptance and Commitment Therapy for Psychotic Symptoms

The article demonstrates how acceptance and commitment therapy (ACT) may effectively alter the function of positive psychotic symptoms and how functional analytic psychotherapy (FAP) may provide a complimentary framework for interpersonal change. ACT differs with many psychosis approaches in that it does not attempt to reduce psychotic symptoms; instead, it aims to increase psychological flexibility (e.g., acceptance) in the presence of psychotic symptoms while actively pursuing valued living. The study involves, John, a 21-year-old college student, who presented with depressive symptoms, delusional and brief visual hallucinatory episodes, and severe social isolation. ACT interventions emphasize acceptance of, and mindful reactions to, psychotic symptoms while pursuing valued life goals. As John's main goal of treatment was to develop more intimate interpersonal relationships, FAP techniques were introduced as behaviors that seemed to be distancing him from peers manifested themselves in session. The benefits and challenges of integrating ACT and FAP are discussed.

Creating a strategy for progress: a contextual behavioral science approach

Behavior analysis is a field dedicated to the development and application of behavioral principles to the understanding and modification of the psychological actions of organisms. As such, behavior analysis was committed from the beginning to a comprehensive account of behavior, stretching from animal learning to complex human behavior. Despite that lofty goal, basic behavior analysis is having a generally harder time finding academic support, and applied behavior analysis has narrowed its focus. In the present paper we argue that both of these trends relate to the challenge of human language and cognition, and that developments within clinical behavior analysis and the analysis of derived relational responding are providing a way forward. To take full advantage of these developments, however, we argue that behavior analysts need to articulate their unique approach to theory, to develop more flexible language systems for applied workers, and to expand their methodological flexibility. This approach, which we term contextual behavioral science, is meant as an evolutionary step that will allow behavior analysis to better capture the center of modern psychological concerns in both the basic and applied areas. Clinical behavior analysis is showing a way forward for behavior analysis to regain its vision as a comprehensive approach to behavior.

Current empirical status of acceptance and commitment therapy

PURPOSE OF REVIEW

Acceptance and commitment therapy (ACT) is one of the several psychotherapies that have been described as 'third wave' cognitive behavioral therapies (CBTs). The present editorial review examines the current status of ACT with a focus on previous reviews, a meta-analysis and new studies that have been published between January 2006 and August 2008.

RECENT FINDINGS

Recent studies on ACT suggest that ACT may be effective for a variety of disorders, including several anxiety disorders, depression, pain, trichotillomania, psychotic disorder, drug abuse and the management of epilepsy and diabetes.

SUMMARY

The available evidence suggests that ACT works through different processes than active treatment comparisons, including traditional CBT. Although currently available data are promising, there is, however, a need for more well controlled studies to verify whether ACT is generally as or more effective than other active treatments across the range of problems examined.

Acceptance and commitment: implications for prevention science

Recent research in behavior analysis and clinical psychology points to the importance of language processes having to do with the control of negative cognition and emotion and the commitment to valued action. Efforts to control unwanted thoughts and feelings, also referred to as experiential avoidance (EA), appear to be associated with a diverse array of psychological and behavioral difficulties. Recent research shows that interventions that reduce EA and help people to identify and commit to the pursuit of valued directions are beneficial for ameliorating diverse problems in living. These developments have the potential to improve the efficacy of many preventive interventions. This paper reviews the basic findings in these areas and points to some ways in which these developments could enhance the impact of preventive interventions.

Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders

Acceptance and commitment therapy (ACT) has previously been shown to alter stigmatizing attitudes and to be relatively useful for psychologically inflexible participants. The present study is the first to bring those two findings together by comparing ACT to an education intervention for reducing stigma toward people with psychological disorders, and examining whether results differ for psychologically inflexible versus flexible individuals. A sample of college students (N =95) was randomly assigned to a 2(1)2h ACT or educational workshop. Measures were taken before and after the workshop and at a 1-month follow-up. ACT reduced mental health stigma significantly regardless of participants' pre-treatment levels of psychological flexibility, but education reduced stigma only among participants who were relatively flexible and non-avoidant to begin with. Acceptance could be an important avenue of exploration for stigma researchers.