A systematic review of behavioral experiments vs. exposure alone in the treatment of anxiety disorders: A case of exposure while wearing the emperor's new clothes?

Is repeated mistake-making an effective treatment strategy for perfectionism? Findings from a randomized controlled trial

BACKGROUND AND OBJECTIVES

Perfectionism has been linked to self-criticism, procrastination, and psychological disorders. In a previous study, an exposure-based treatment for perfectionism (ETP), which included exposures targeted at concern over mistakes, showed positive outcomes when compared to waitlist. The aim of this study was to further investigate ETP by comparing it to a stress-management condition and assessing durability of treatment effects by conducting a one-month follow-up assessment.

METHODS

Eighty-five individuals with elevated perfectionism were randomly assigned to receive ETP (n = 43) or a stress management treatment (n = 42). ETP involved repeatedly practicing mistake-making by completing computerized tasks engineered to cause individuals to make mistakes. The stress management condition included listening to videos and answering questions about healthy habits, such as diet, exercise, and sleep, as well as viewing calming videos. Participants completed eight treatment sessions as well as baseline, post-test, and one month follow-up self-report questionnaires.

RESULTS

Contrary to predictions, compared to ETP, stress management led to significantly lower overall perfectionism, depression, generalized anxiety, and social anxiety at post and significantly lower depression, generalized anxiety, and social anxiety at follow-up. Further, individuals who completed ETP did not habituate to the exposure tasks, but distress increased from the first to the last treatment session.

LIMITATIONS

The duration of treatment was relatively brief.

CONCLUSIONS

This study highlights the importance of using active psychological control conditions in treatment outcome studies and the need to test various components of treatments for perfectionism to observe what may be effective or even potentially iatrogenic.

Mechanisms underlying interoceptive exposure: belief disconfirmation or extinction? A preliminary study

Interoceptive exposure, or exposure to one's feared physical sensations, has been shown to be an important technique in cognitive behavioral therapies for anxiety disorders and related constructs, such as anxiety sensitivity (AS). The current study sought to further clarify the underlying cognitive-behavioral mechanisms of interoceptive exposure in a lab-based, analog study with individuals high in AS. Participants (n = 59) were randomized into three groups: a cognitive-behavioral intervention emphasizing belief disconfirmation (CbI), a behavioral intervention emphasizing exposure (BI), and a control condition. Self-report measures assessing AS, catastrophizing of bodily sensations, and subjective units of distress (SUDS) were collected before, during and after the intervention. Participants also completed online questionnaires at a one-month follow-up. Following the CbI but not BI, a decrease was observed in both AS and catastrophizing interpretations. Furthermore, only the CbI group exhibited a decrease in SUDS ratings, whereas the BI group exhibited a significant increase. Notably, these effects were not maintained at a one-month follow-up. Findings suggest that cognitive interventions without repeated behavioral exposure may be sufficient in reducing self-reported anxiety-related symptoms and catastrophic misinterpretations, though not at maintaining them. This raises questions regarding the role of pure behavioral mechanisms in exposure.

Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder

Sophisticated multicomponent treatments for adults with generalized anxiety disorder (GAD) have been developed over the past three decades. Although these comprehensive treatments have produced encouraging results, they appear to be less efficacious than treatments for other anxiety disorders. The goal of this randomized controlled trial is to test a newly developed, highly focused treatment for adults with GAD: Behavioral Experiments for Intolerance of Uncertainty. Sixty (60) participants (51 women, 9 men), with a mean age of 34.60 years (range: 19 to 67 years), were randomized to either treatment (n = 30) or wait-list control (n = 30). Treatment consisted of 12 weekly 1-hour sessions in which participants learned to use behavioral experiments to test their catastrophic beliefs about uncertainty. Assessments were conducted at pre-, mid- and postcondition, and at 6- and 12-month follow-up. The primary outcome was the severity of GAD, and secondary outcomes were worry, depression, somatic anxiety, and intolerance of uncertainty. Using growth curve modeling, we found that (1) the treatment group was superior to the wait-list group in terms of change from pre- to posttest on all outcomes; (2) the combined sample (once wait-listed participants received treatment) evidenced large and significant decreases on all outcomes; and (3) treatment gains were either maintained or increased over the 12-month follow-up period of the study. The new treatment is a promising treatment option for adults with GAD considering that it may be as efficacious as more comprehensive evidence-based psychological treatments for GAD.

Erwartungsfokussierte psychotherapeutische Interventionen bei Depression: ein Behandlungsmanual

Hintergrund

Kognitive Verhaltenstherapie (KVT) ist bei Depression langfristig wirksam, jedoch besteht Verbesserungsbedarf. In der Forschung zum Placeboeffekt und der Neurowissenschaft wird die zentrale Bedeutung von Erwartungen immer deutlicher. Neue Therapieansätze zur Modifikation dysfunktionaler Erwartungen (erwartungsfokussierte psychotherapeutische Interventionen, EFPI) scheinen ein vielversprechender Baustein zur Verbesserung der klassischen KVT zu sein.

Ziel der Arbeit

Die wesentlichen Bausteine eines EFPI-Behandlungsmanuals bei Depression werden vorgestellt.

Material und Methoden

Das Manual ist auf 24 Sitzungen (Kurzzeittherapie) ausgelegt. Es umfasst 5 Sitzungen Psychoedukation zu Erwartungsformulierung, -überprüfung und -verletzung sowie zur kognitiven Immunisierung (nachträgliche Umbewertung erwartungsverletzender Erfahrungen). Nach der Psychoedukation folgt eine Phase, in der in jeder Sitzung ein Verhaltensexperiment durchgeführt oder geplant wird. Die Verhaltensexperimente sollen zentrale krankheitsaufrechterhaltende Erwartungen herausfordern („Erwartungsverletzung“). Zusätzlich werden kognitive Immunisierungsstrategien besprochen und nach Möglichkeit verhindert. In der letzten Sitzung erfolgen eine Zusammenfassung und Konsolidierung des Erarbeiteten im Sinne einer Rückfallprophylaxe. Das Manual wurde in einer kleinen Pilotstudie (n = 5) erprobt.

Ergebnisse

Die EFPI-Therapie wurde von allen Beteiligten gut angenommen. Eine umfassende Evaluation erfolgt derzeit.

Diskussion

Das EFPI-Manual stellt die Fokussierung einer KVT auf möglichst viele, deutliche Erwartungsüberprüfungen bei zusätzlicher Adressierung kognitiver Immunisierung dar. Gezielt können persistierende, dysfunktionale Erwartungen von Personen mit Depression behandelt werden.

Psychosocial treatment for panic disorder: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

Panic disorder is a common and disabling psychiatric condition marked by sudden onset of physiological sensations that are appraised as dangerous. A number of studies and reviews have examined the efficacy of psychosocial treatments for PD; however, there is a lack of overarching reports that discuss the strength of evidence for the different psychosocial treatments for PD. This umbrella review provides an overview of systematic reviews and meta-analyses on psychosocial treatments for PD.

METHODS

A systematic search and review of the literature was conducted according to PRISMA guidelines.

RESULTS

A total of 38 reviews (31 meta-analyses and 7 systematic reviews) were included in the umbrella review. Most of the 38 reviews were focused on the use of CBT, both in-person and internet-based, to treat PD among adults, generally finding it to be an efficacious treatment compared to control conditions. A limited number of the 38 reviews included other age ranges or examined other forms of psychosocial treatments. The methodological quality of most included reviews was rated as critically low according to the AMSTAR-2 rating system.

CONCLUSIONS

Future reviews should focus on improving their methodological quality. Although the included reviews supported CBT as an efficacious treatment for reducing panic symptoms among adults, future research could focus on how CBT compares to other psychosocial treatments and the efficacy of CBT for PD among other populations (e.g., children and adolescents) and among diverse cultural groups.

Response to unexpected social inclusion: A study using the cyberball paradigm

BACKGROUND

Dysfunctional expectations are considered core characteristics of Major Depressive Disorder (MDD) and should be focused in psychotherapy. Dysfunctional expectations are especially pronounced in the interpersonal area (social expectations). In the present study, we examine the effect of unexpected social inclusion (expectation violation) on the change of generalized and specific depression-typical social expectations.

METHOD

We conducted an online study to investigate the impact of social inclusion after a period of social exclusion (unexpected social inclusion) on social expectation change (sample size 144) in a non-clinical sample. Depressive symptoms were assessed via self-reporting. Participants took part in two rounds of the online ball-game Cyberball. In the first round, all participants were socially excluded by their two co-players (acquisition of negative social expectations). In the second round, participants were either once more excluded (expectation confirmation) or included equally (expectation violation) by the same co-players. Specific and generalized social expectations were assessed after each round.

RESULTS

Specific and generalized social expectations increased following expectation violation. Even though depressive symptoms were related to lower levels of social expectations, we found that depressive symptoms did not moderate expectation change after positive expectation violations.

CONCLUSIONS

In the present experimental setup including the use of the online ball-game Cyberball, the establishment and change of social expectations can be experimentally manipulated. Under the given circumstances and in a non-clinical sample, negative expectations can be updated after unexpected positive experiences regardless of the number of depressive symptoms. The results are discussed in the context of current models of Major Depressive Disorder (MDD), expectation change, and cognitive behavioral therapy.

Expositionsübungen und Verhaltensexperimente: Varianten des erfahrungsbasierten Lernens in der Verhaltenstherapie

Expositionsübungen (Reizkonfrontationen) stellen die wichtigste Interventionskomponente bei Angststörungen dar; Verhaltensexperimente die wichtigste beobachtungsbezogene Disputationsmethode. Beides sind Beispiele erfahrungsorientierten Lernens in der Verhaltenstherapie. In der vorliegenden Übersichtsarbeit werden diese Vorgehensweisen definiert, in ihren Durchführungsvarianten dargestellt und hinsichtlich ihrer logischen Begründung sowie ihrer hypothetischen Wirkmechanismen verglichen. Dabei wird deutlich, dass beide Ansätze gemäß dem Prinzip der Erwartungs- bzw. Befürchtungswiderlegung (expectancy violation) erwartungs- bzw. einstellungskonträre Erfahrungen ermöglichen sollen. Der Schwerpunkt bei den Expositionsübungen liegt auf der Veränderung des emotionalen Erlebens und automatisierter Vermeidungsreaktionen in bestimmten Zielsituationen, bei den Verhaltensexperimenten liegt er auf der Veränderung von Einstellungen und Erwartungen. Ferner wird bei den Expositionsübungen der Erwerb emotionaler Kompetenzen (Furchttoleranz) angestrebt, was bei Verhaltensexperimenten zumindest nicht primär intendiert ist. Zwar zielt die Fallkonzeption bei Expositionen mehr auf die Veränderung problematischer Handlungen/Vermeidungsreaktionen und bei Verhaltensexperimenten mehr auf die Veränderung problematischer Kognitionen, beide Interventionsvarianten konvergieren aber grundsätzlich hinsichtlich des übenden Ansatzes, bei dem durch häufige Wiederholung im Alltag positive Kontrasterfahrungen stabil im Gedächtnis verankert werden sollen.

Exploring the impact of safety behaviour use on cognitive, psychophysiological, emotional and behavioural responses during a speech task

BACKGROUND

There is a debate among researchers and clinicians regarding whether the judicious use of safety behaviours (SBs) during exposure therapy is helpful or detrimental. Central to this debate is the premise that SBs may interfere with one's ability to gather disconfirmatory evidence.

AIMS

No study to date has assessed how SB use may impact cognitive mechanisms implicated during an exposure-like task. We investigated multiple cognitive, emotional, psychophysiological and behavioural underpinnings of exposure with and without SBs.

METHOD

Speech anxious participants (n = 111) were randomly assigned to deliver an evaluated speech with or without SBs. Self-reported anxiety ratings and psychophysiological arousal measures were recorded at baseline, in anticipation of the speech, and following the speech. Measures of working memory, ability to gather disconfirmatory evidence, speech duration, objective and subjective speech performance, and speech task acceptability were administered.

RESULTS

There were no differences between conditions on working memory, self-reported anxiety, psychophysiological arousal, ability to gather disconfirmatory evidence, speech duration, or objective and subjective speech performance. All participants were able to gather disconfirmatory evidence. However, condition did influence willingness to deliver future speeches. Our sample was largely female undergraduate students, and we offered only a small number of specific safety behaviours.

CONCLUSIONS

Judicious SB use may not necessarily be detrimental, but clients may believe them to be more helpful than they actually are.

Helping clients ‘restart their engine’ – use of in-session cognitive behavioural therapy behavioural experiments for engagement and treatment in persistent depression: a case study

Behavioural experiments (BEs) are a major cognitive ingredient in the cognitive behavioural therapy (CBT) model which can be applied in-session or between-sessions. In-session BEs are particularly effective and widely demonstrated in anxiety disorders, yet they remain under-utilised in depression. Clients presenting with persistent depression are often difficult to engage due to the chronicity of their symptoms and their learnt self-perpetuating demoralised states. Research to date demonstrates the effectiveness of in-session BEs in engagement and treatment in depression. This case study details the treatment of a client presenting with persistent major depressive disorder (MDD) with hopelessness and how in-session BEs effected engagement and treatment. This case study is discussed with reference to strengths, limitations, clinical implications and recommendations for practice and development.

Key learning aims

It is hoped that the reader of this case study will increase their understanding of the following: (1)

One pathway to cognitive behaviour therapy integration: introducing assimilative integrative rational emotive behaviour therapy

In this paper, rational emotive behaviour therapy (REBT) is presented as the most comprehensive cognitive behavioural therapy (CBT) to date, with over-arching influence on most of the other therapies that came after it. However, despite REBT’s comprehensiveness and the limitations inherent in other CBT approaches, REBT has its limitations. Limitations in REBT theory are explored and an argument is made in favour of rectifying these limitations by incorporating other approaches into REBT (namely cognitive therapy and compassion-focused therapy) to create a more complete integrative psychotherapy model. It is then argued that psychotherapy integration is the future of CBT mainly due to the fact that it reflects how most therapists practise, and due to its utilization of the common factors theory. Finally, the integrative model – which I callAssimilative Integrative Rational Emotive Behaviour Therapy– is presented and demonstrated using a clinical case example.

Key learning aims

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Grant Report on Anxiety-CBT: Dimensional Brain Behavior Predictors of CBT Outcomes in Pediatric Anxiety

In the following grant report, we describe initial and planned work supported by our National Institute of Mental Health R01-funded, Research Domain Criteria (RDoc) informed project, “Dimensional Brain Behavior Predictors of CBT Outcomes in Pediatric Anxiety”. This project examines response to cognitive behavioral therapy (CBT) in a large sample of anxiety-affected and low-anxious youth ages 7 to 18 years using multiple levels of analysis, including brain imaging, behavioral performance, and clinical measures. The primary goal of the project is to understand how brain-behavioral markers of anxiety-relevant constructs, namely acute threat, cognitive control, and their interaction, associate with CBT response in youth with clinically significant anxiety. A secondary goal is to determine whether child age influences how these markers predict, and/or change, across varying degrees of CBT response. Now in its fourth year, data from this project has informed the examination of (1) baseline (i.e., pre-CBT) anxiety severity as a function of brain-behavioral measures of cognitive control, and (2) clinical characteristics of youth and parents that associate with anxiety severity and/or predict response to CBT. Analysis of brain-behavioral markers before and after CBT will assess mechanisms of CBT effect, and will be conducted once the data collection in the full sample has been completed. This knowledge will help guide the treatment of clinically anxious youth by informing for whom and how does CBT work.

Efficacy of Behavioral Experiments in Cognitive Therapy for Social Anxiety Disorder: Study protocol for a randomized controlled trial

Background

While the efficacy of cognitive therapy (CT) has been well established for social anxiety disorder (SAD) in several randomized controlled trials, there are still large differences between trials with respect to effect sizes. The present study investigates the question of whether enhanced training and the use of behavioral experiments (BEs) increases the efficacy of traditional CT, based on verbal methods of cognitive restructuring.

Methods/design

A mixed within/between conditions design will be applied, with therapists and patients being randomly allocated to one of two conditions: (1) training of CT plus BEs, (2) training of CT “as usual”.

Sixty patients with the primary diagnosis of SAD will be recruited and treated in the outpatient clinic of the Department of Psychology, University of Frankfurt. To ensure adherence to therapist protocols, all therapists will be trained and supervised by the project coordinators. In addition, videotaped treatment sessions will be independently evaluated to guarantee both adherence to protocols and the quality of the intervention. Treatment effects will be assessed by independent SAD symptom ratings using the Liebowitz Social Anxiety Scale as the primary outcome measure and self-report measures as secondary outcome measures.

Discussion

The present cognitive behavioral therapy (CBT) trial will be the first to clarify the contribution of BEs to the efficacy of CT in a randomized controlled design. Study results are relevant to clinical training and implementation of evidence-based treatments.

Trial registration

German Clinical Trials Register International Clinical Trials Registry Platform (ICTRP) identifier: DRKS00014349. Trial status: recruiting.

Patients' Perspectives About the Acceptability and Effectiveness of Audiologist-Delivered Cognitive Behavioral Therapy for Tinnitus and/or Hyperacusis Rehabilitation

Objective The aim of this study was to evaluate the views of patients who completed audiologist-delivered cognitive behavioral therapy (CBT) about (a) the effectiveness of the treatment, (b) the acceptability of receiving CBT from audiologists, and (c) the most effective treatment components. Design This was a service evaluation survey with a cross-sectional design. Study Sample The study population comprised 40 consecutive adult patients who received a full course of audiologist-delivered CBT for tinnitus and/or hyperacusis management at a Tinnitus and Hyperacusis Therapy Specialist Clinic in the United Kingdom over a 1-year period. Thirty-one of 40 patients who attended their final session as planned completed the survey questionnaire. Data Collection and Analysis As a part of their routine care, all patients completed a wide range of questionnaires before and after receiving audiologist-delivered CBT. These comprised Tinnitus Handicap Inventory (Newman, Sandridge, & Bolek, 2008); Hyperacusis Questionnaire (Khalfa et al., 2002); Insomnia Severity Index (Bastien, Vallieres, & Morin, 2001); Visual Analogue Scale (Maxwell, 1978) for tinnitus loudness, tinnitus annoyance, and effect of tinnitus on life; Generalized Anxiety Disorder (Spitzer, Kroenke, Williams, & Lowe, 2006) questionnaire; and Patient Health Questionnaire (Kroenke, Spitzer, & Williams, 2001). In addition, patients were asked to complete the survey questionnaire at their final session to provide feedback with regard to their therapy. Results The majority of patients reported that it was very acceptable to them to receive CBT focused on tinnitus and hyperacusis from a specialist audiologist; the median response was 10/10. The majority of patients felt that the CBT was very effective (median response 8/10) and that they were able to manage their tinnitus and/or hyperacusis well (median response 9/10). The effect sizes of treatment based on pre- and postintervention comparison of scores for the Tinnitus Handicap Inventory, Visual Analogue Scale of tinnitus annoyance and effect on life, Hyperacusis Questionnaire, Insomnia Severity Index, Generalized Anxiety Disorder, and Patient Health Questionnaire were large. Conclusions Audiologist-delivered CBT is acceptable to patients and is effective in the management of tinnitus and/or hyperacusis from the patients' perspectives.

Utilization of learned skills in cognitive behavioural therapy for panic disorder

BACKGROUND

Research has long investigated the cognitive processes in the treatment of depression, and more recently in panic disorder (PD). Meanwhile, other studies have examined patients' cognitive therapy skills in depression to gain insight into the link between acquiring such skills and treatment outcome.

AIMS

Given that no scale exists to examine in-session patient use of panic-related cognitive behavioural therapy (CBT) skills, the aim of this study was to develop a new measure for assessing patients' cognitive and behavioural skills in CBT for PD.

METHOD

This study included 20 PD patients who received 12 weekly individual therapy sessions. The Cognitive Behavioral Therapy Panic Skills (CBTPS) rating system was developed. Three independent raters coded tapes of therapy sessions at the beginning and end of treatment.

RESULTS

The coefficient alphas and inter-rater reliability were high for the cognitive and behavioural subscales. Improvement in the patients' CBTPS scores on both subscales indicated overall symptom improvement, above improvement in anxiety sensitivity.

CONCLUSION

To our knowledge, this is the first study examining the impact of patient acquisition of CBT PD skills on treatment outcome. A new measure was developed based on the observations and was deemed reliable and valid. The measure facilitates the examination of the mechanisms of change in treatment for PD. An in-depth examination of the CBTPS may refine our understanding of the impact of each skill on PD treatment outcome. Further research relating to acquiring CBT skills could shed light on the mechanisms of change in treatment.

Cue Exposure Therapy for Alcohol Use Disorders: What Can Be Learned from Exposure Therapy for Anxiety Disorders?

Background: Cue Exposure Therapy (CET) has shown efficacy for treating alcohol use disorders (AUDs). Exposure therapy is highly effective for treating anxiety. Both techniques involve repeated, controlled exposures to alcohol or fear-related stimuli. Objectives: We considered the mechanisms of CET for AUDs by comparing it to exposure therapy for anxiety. Method: We conducted a narrative review contrasting theoretical literature examining the mechanisms of CET versus exposure therapy for anxiety. We reviewed RCTs and acute laboratory paradigms examining CET for AUDs. We considered common areas of emerging research, including the use of d-Cycloserine (DCS) and virtual reality (VR). Results: We found evidence that exposure therapy and CET at least partially achieve their effects through extinction learning. We found evidence that CET for AUDs is effective, with comparable benefits to other effective psychosocial treatments. DCS and VR have shown some limited success for augmenting CET for AUDs, so further research is needed to determine their value. Conclusions: There are theoretical and practical similarities between exposure to fear cues and cues of addiction, especially regarding extinction learning. However, these processes are also unique, particularly regarding the differing motivational properties of fear versus reward-related stimuli. We propose that unlike exposure for anxiety, CET takes effect by increasing self-control with each unreinforced exposure. We consider reasons for CET's limited use for AUDs, including its lower acceptability to clients and clinicians. We also note the limited evidence for CET for other substance use disorders, highlighting the need for continued investigation into its mechanisms and efficacy.

Development of a Moderated Online Intervention to Treat Social Anxiety in First-Episode Psychosis

Background: It is well established that social anxiety disorder (SAD) is a significant clinical problem for individuals with a psychotic disorder. Comorbid social anxiety in individuals with psychosis has been associated with poorer premorbid functioning, increased depression, and a reduced quality of life. Cognitive behavior therapy (CBT) is recommended for people with psychosis as a first-line psychological treatment; however, its focus and evaluation primarily revolves around reducing psychotic symptoms and not necessarily targeting comorbid social anxiety symptoms. We developed a novel online social cognitive behavioral intervention (entitled EMBRACE) specifically designed to treat social anxiety symptoms in first episode psychosis (FEP). Methods: The key clinical and engagement features of the intervention were established through integrating evidence-based material derived from 1) CBT-based treatment models for SAD, 2) relevant literature findings related to psychosis and its clinical correlates (e.g., shame, social rank, and its relationship with social anxiety and paranoia), 3) feedback from youth focus groups in order to inform a user-centered intervention design, and 4) a highly multidisciplinary collaborative development approach to design therapy comics. Results: A detailed description of the final version of the 12-week online social intervention to treat social anxiety in FEP is presented. Conclusion: The EMBRACE intervention was designed to provide young people with the necessary skills and confidence to overcome social anxiety within a supportive, safe online space. By design, it allows young people the opportunity to practice their newly learnt skills to connect with others and in doing so, learn to embrace their true authentic selves.

Predicting post treatment client satisfaction between behavioural activation for depression delivered either in-person or via home-based telehealth

Introduction

Treatment engagement, adherence, cancellations and other patient-centric data are important predictors of treatment outcome. But often these data are only examined retrospectively. In this investigation, we analysed data from a clinical trial focused on innovative delivery of depression treatment to identify which patients are likely to prefer either in-home or in-person treatment based on pre-treatment characteristics.

Methods

Patient satisfaction was assessed in a trial of individuals with depression treated using identical behavioural activation therapy protocols in person or through videoconferencing to the home ( N = 87 at post treatment: 42 in-person and 45 in-home participants). The Client Satisfaction Questionnaire was administered at the end of the treatment. A Tobit regression model was used to assess moderation using treatment assignment. Regression lines were generated to model treatment satisfaction as a function of treatment assignment and to identify whether and where the groups intersected. We examined the distributions of the contributing moderators to the subsets of participants above and below the intersection point to identify differences.

Results

While no significant differences in patient satisfaction were observed between the two groups, or between patients receiving treatment by different providers, baseline characteristics of the sample could be used to differentiate those with a preference for traditional, in-office care from those preferring in-home care.

Discussion

Participants who were more likely to prefer in-home care were characterized by larger proportions of veterans and lower-ranked enlisted service members. They also had more severe symptoms at baseline and less formal education. Understanding client reactions when selecting treatment modality may allow for a more satisfying patient experience.

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck's cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.

Mental Health Smartphone Apps: Review and Evidence-Based Recommendations for Future Developments

BACKGROUND

The number of mental health apps (MHapps) developed and now available to smartphone users has increased in recent years. MHapps and other technology-based solutions have the potential to play an important part in the future of mental health care; however, there is no single guide for the development of evidence-based MHapps. Many currently available MHapps lack features that would greatly improve their functionality, or include features that are not optimized. Furthermore, MHapp developers rarely conduct or publish trial-based experimental validation of their apps. Indeed, a previous systematic review revealed a complete lack of trial-based evidence for many of the hundreds of MHapps available.

OBJECTIVE

To guide future MHapp development, a set of clear, practical, evidence-based recommendations is presented for MHapp developers to create better, more rigorous apps.

METHODS

A literature review was conducted, scrutinizing research across diverse fields, including mental health interventions, preventative health, mobile health, and mobile app design.

RESULTS

Sixteen recommendations were formulated. Evidence for each recommendation is discussed, and guidance on how these recommendations might be integrated into the overall design of an MHapp is offered. Each recommendation is rated on the basis of the strength of associated evidence. It is important to design an MHapp using a behavioral plan and interactive framework that encourages the user to engage with the app; thus, it may not be possible to incorporate all 16 recommendations into a single MHapp.

CONCLUSIONS

Randomized controlled trials are required to validate future MHapps and the principles upon which they are designed, and to further investigate the recommendations presented in this review. Effective MHapps are required to help prevent mental health problems and to ease the burden on health systems.

New Developments in Cognitive-Behavioral Therapy for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent and chronic disorder that causes considerable psychosocial impairment. This article reviews recent changes in the definition of SAD in DSM-5 and summarizes the current evidence for effective cognitive-behavioral treatments in adults, children, and adolescents. Current data suggests that cognitive-behavioral therapy (CBT) is efficacious in the treatment of this condition. Among different CBT approaches, individual cognitive therapy may be associated with the largest effect sizes. In this review, interventions targeting dysfunctional cognitive processes that contribute to the effective treatment of SAD are discussed. Some recent findings from neuroimaging research and studies on the augmentation of CBT using neuroenhancers indicate that changes in emotion regulation as well as fear extinction are important psychological mediators of positive outcome. Furthermore, internet-delivered CBT is a promising field of technological innovation that may improve access to effective treatments. Despite the availability of effective treatments, treatment-resistant SAD remains a common problem in clinical practice that requires more research efforts. Finally, potential areas for further development of CBT as well as its dissemination in health care are summarized.

Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT), which encompasses exposure with response prevention (ERP) and cognitive therapy (CT), has demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). However, the samples studied (reflecting the heterogeneity of OCD), the interventions examined (reflecting the heterogeneity of CBT), and the definitions of treatment response vary considerably across studies. This review examined the meta-analyses conducted on ERP and cognitive therapy (CT) for OCD. Also examined was the available research on long-term outcome associated with ERP and CT. The available research indicates that ERP is the first line evidence based psychotherapeutic treatment for OCD and that concurrent administration of cognitive therapy that targets specific symptom-related difficulties characteristic of OCD may improve tolerance of distress, symptom-related dysfunctional beliefs, adherence to treatment, and reduce drop out. Recommendations are provided for treatment delivery for OCD in general practice and other service delivery settings. The literature suggests that ERP and CT may be delivered in a wide range of clinical settings. Although the data are not extensive, the available research suggests that treatment gains following ERP are durable. Suggestions for future research to refine therapeutic outcome are also considered.

Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT), which encompasses exposure with response prevention (ERP) and cognitive therapy, has demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). However, the samples studied (reflecting the heterogeneity of OCD), the interventions examined (reflecting the heterogeneity of CBT), and the definitions of treatment response vary considerably across studies. This review examined the meta-analyses conducted on ERP and cognitive therapy (CT) for OCD. Also examined was the available research on long-term outcome associated with ERP and CT. The available research indicates that ERP is the first line evidence based psychotherapeutic treatment for OCD and that concurrent administration of cognitive therapy that targets specific symptom-related difficulties characteristic of OCD may improve tolerance of distress, symptom-related dysfunctional beliefs, adherence to treatment, and reduce drop out. Recommendations are provided for treatment delivery for OCD in general practice and other service delivery settings. The literature suggests that ERP and CT may be delivered in a wide range of clinical settings. Although the data are not extensive, the available research suggests that treatment gains following ERP are durable. Suggestions for future research to refine therapeutic outcome are also considered.

A non-linear dynamical approach to belief revision in cognitive behavioral therapy

Belief revision is the key change mechanism underlying the psychological intervention known as cognitive behavioral therapy (CBT). It both motivates and reinforces new behavior. In this review we analyze and apply a novel approach to this process based on AGM theory of belief revision, named after its proponents, Carlos Alchourrón, Peter Gärdenfors and David Makinson. AGM is a set-theoretical model. We reconceptualize it as describing a non-linear, dynamical system that occurs within a semantic space, which can be represented as a phase plane comprising all of the brain's attentional, cognitive, affective and physiological resources. Triggering events, such as anxiety-producing or depressing situations in the real world, or their imaginal equivalents, mobilize these assets so they converge on an equilibrium point. A preference function then evaluates and integrates evidentiary data associated with individual beliefs, selecting some of them and comprising them into a belief set, which is a metastable state. Belief sets evolve in time from one metastable state to another. In the phase space, this evolution creates a heteroclinic channel. AGM regulates this process and characterizes the outcome at each equilibrium point. Its objective is to define the necessary and sufficient conditions for belief revision by simultaneously minimizing the set of new beliefs that have to be adopted, and the set of old beliefs that have to be discarded or reformulated. Using AGM, belief revision can be modeled using three (and only three) fundamental syntactical operations performed on belief sets, which are expansion; revision; and contraction. Expansion is like adding a new belief without changing any old ones. Revision is like adding a new belief and changing old, inconsistent ones. Contraction is like changing an old belief without adding any new ones. We provide operationalized examples of this process in action.

Kognitive Therapie bei körperdysmorpher Störung

In den letzten Jahren ist die Erkenntnis gewachsen, dass die Körperdysmorphe Störung (KDS) viele Gemeinsamkeiten hinsichtlich klinischer Charakteristika und aufrechterhaltender Prozesse mit Zwangsstörungen (z. B. ritualisierte Kontrollhandlungen, wiederkehrende persistierende Gedanken) und sozialer Angststörung (z. B. exzessive Selbstaufmerksamkeit, mentale Vorstellungsbilder) aufweist. Neuere Behandlungsansätze bei KDS fokussieren insbesondere auf die Veränderung der gemeinsamen aufrechterhaltenden Prozesse. Diese Ansätze verbinden klassische kognitiv-behaviorale Techniken (Exposition mit Reaktionsverhinderung und kognitive Umstrukturierung) mit Interventionen aus der Kognitiven Therapie (Aufmerksamkeitstraining, Imagery Rescripting, Videofeedback, Verhaltensexperimente). Im vorliegenden Artikel werden die unterschiedlichen Behandlungsbausteine vorgestellt und die Vorgehensweise detailliert beschrieben. Die Interventionen aus der Kognitiven Therapie haben sich aus klinischer Erfahrung bei der Behandlung als hilfreich erwiesen, wurden bislang jedoch noch nicht für die KDS evaluiert.

Mechanisms of change in psychosocial interventions for autism spectrum disorders

Research into psychosocial interventions (particularly cognitive-behavior therapies and social skills training) for social-communication deficits among individuals with autism spectrum disorder (ASD) has proliferated over the past decade. While this research has provided some empirical support for the efficacy of these interventions, little work has begun to elucidate therapeutic mechanisms-the when, why, how, for whom, and under what conditions an intervention may produce change, identification of mechanisms underlying these effects should help advance ASD intervention research. This article describes methods for assessing such mechanisms (ie, mediators and moderators) and presents promising candidates for common mechanisms impacting treatment response: behavior modification, therapeutic relationship, social knowledge, social motivation, social information processing, executive functioning, and internalizing comorbidities. Finally, future directions are discussed as a program of psychosocial intervention research designed to identify predictors of individual differences in treatment response (including biomarkers), isolate active therapeutic ingredients, and promote dissemination of optimized interventions.

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

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.

Exposure therapy triggers lasting reorganization of neural fear processing

A single session of exposure therapy can eliminate recalcitrant and disabling fear of phobogenic objects or situations. We studied neural mechanisms of this remarkable outcome by monitoring changes in brain activity as a result of successful 2-h treatment. Before treatment, phobogenic images excited activity in a network of regions, including amygdala, insula, and cingulate cortex, relative to neutral images. Successful therapy dampened responsiveness in this fear-sensitive network while concomitantly heightening prefrontal involvement. Six months later, dampened fear-network activity persisted but without prefrontal engagement. Additionally, individual differences in the magnitude of visual cortex activations recorded shortly after therapy predicted therapeutic outcomes 6 mo later, which involved persistently diminished visual responsiveness to phobogenic images. Successful therapy thus entailed stable reorganization of neural responses to initially feared stimuli. These effects were linked to fear-extinction mechanisms identified in animal models, thus opening new opportunities for the treatment and prevention of debilitating anxiety disorders.

Examining the effects of thought records and behavioral experiments in instigating belief change

OBJECTIVE

While the efficacy and effectiveness of CBT protocols are well established, much less is known about the comparative contribution of the various techniques within CBT. The present study examined the relative efficacy, in comparison to a control condition, of two central techniques in CBT: thought records (TRs) and behavioral experiments (BEs).

METHOD

A mixed within and between participants design was used to compare the efficacy of a single session TR and a single session BE intervention with a control intervention, in a non-clinical sample. Ninety one participants were randomly allocated to one of the three conditions.

RESULTS

The overall pattern of results suggests that both TR and BE had a beneficial therapeutic impact in comparison to the control condition on beliefs, anxiety, behavior and a standardized measure of symptoms. There was evidence of a small advantage of the BE over the TR intervention in that the target belief changed earlier and change generalized to beliefs about others as well as the self.

CONCLUSIONS

The findings confirm the utility of both TR and BE interventions and point to BEs as more useful in effecting belief change in that the change in the BE condition occurred sooner and generalized further.

Inflexible parents, inflexible kids: a 6-year longitudinal study of parenting style and the development of psychological flexibility in adolescents

Parenting behaviors have been linked to children's self regulation, but it is less clear how they relate to adolescent psychological flexibility. Psychological flexibility is a broad construct that describes an individual's ability to respond appropriately to environmental demands and internal experiences in the service of their goals. We examined the longitudinal relationships between perceived parenting style and psychological flexibility among students at five Australian schools (N= 749) over 6 years, beginning in Grade 7 (50.3% female, mean age 12.39 years). Parenting style was measured in Grades 7 and 12, and psychological flexibility from Grade 9 through 12. Psychological flexibility decreased, on average, with age. Multi-level modelling indicated that authoritarian parenting (low warmth, high control) in Grade 7 predicted later (low) psychological flexibility. Moreover, increases in authoritarian parenting and decreases in authoritative parenting (high warmth and control) were associated with adolescent psychological flexibility across the high school years. Change in parenting predicted future psychological flexibility but did not predict change over time. Structural Equation Modelling revealed that adolescent psychological flexibility in Grade 9 predicted later decreases in authoritarian and increases in authoritative parenting. We discuss the implications of these findings for understanding how parenting changes and the consequences of such change for the development of psychological flexibility.

Serotonin transporter gene and childhood trauma--a G × E effect on anxiety sensitivity

BACKGROUND

Genetic factors and environmental factors are assumed to interactively influence the pathogenesis of anxiety disorders. Thus, a gene-environment interaction (G × E) study was conducted with respect to anxiety sensitivity (AS) as a promising intermediate phenotype of anxiety disorders.

METHOD

Healthy subjects (N = 363) were assessed for AS, childhood maltreatment (Childhood Trauma Questionnaire), and genotyped for functional serotonin transporter gene variants (5-HTTLPR/5-HTT rs25531). The influence of genetic and environmental variables on AS and its subdimensions was determined by a step-wise hierarchical regression and a multiple indicator multiple cause (MIMIC) model.

RESULTS

A significant G × E effect of the more active 5-HTT genotypes and childhood maltreatment on AS was observed. Furthermore, genotype (LL)-childhood trauma interaction particularly influenced somatic AS subdimensions, whereas cognitive subdimensions were affected by childhood maltreatment only.

CONCLUSIONS

Results indicate a G × E effect of the more active 5-HTT genotypes and childhood maltreatment on AS, with particular impact on its somatic subcomponent.

Pathways to change in one-session exposure with and without cognitive intervention: an exploratory study in spider phobia

It is well established that exposure therapy is an effective treatment for anxiety disorders. It is less clear, however, which mechanisms are crucial in explaining its success. In previous studies, cognitive change has been identified as a mediating variable. Several theorists have argued that the addition of cognitive interventions will, therefore, result in enhanced treatment effects. We tested this hypothesis by examining cognitive mediation of treatment in a purely behavioral versus a cognitive-behavioral exposure format. Thirty-one spider phobics were randomly assigned to either behavioral exposure or to exposure as a test for maladaptive cognitions (i.e., behavioral experiments). Both treatment formats showed large treatment effects and strong cognitive mediation of these effects. This indicates that, even when cognitions are not explicitly targeted, exposure effects are cognitively mediated. This challenges the idea that cognitions have to be explicitly challenged to elicit cognitive change in exposure treatment.

Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis

PURPOSE

Mindfulness- and acceptance-based interventions (MABIs) are receiving increasing attention in the treatment of mental disorders. These interventions might be beneficial for patients with anxiety disorders, but no prior reviews have comprehensively investigated the effects of this family of interventions on clinical samples. The aim of this study was to review and synthesize extant research on MABIs for patients with diagnoses of anxiety disorders.

METHODS

We conducted a systematic search of relevant databases according to pre-defined criteria. Studies were eligible for inclusion if they employed MABIs for patients diagnosed with anxiety disorders.

RESULTS

Nineteen eligible studies were found. Meta-analysis of within-group pre- to post-treatment effects yielded overall Hedges'g effect sizes of 1.08 for anxiety symptoms and 0.85 for depression symptoms. For controlled studies, overall between-group Hedges'g was 0.83 for anxiety symptoms and 0.72 for depression symptoms. Moderator analyses examined whether intervention type, design, treatment dosage, or patient sample was associated with systematic variation in effect sizes. No significant moderating effects were found on the variables examined, apart from an observed superiority in effect size for clinical trials on samples of patients with mixed anxiety disorders. However, differential effect sizes indicated benefits of adding specific psychotherapeutic content to mindfulness training, as well as an advantage of individual over group treatment.

CONCLUSIONS

MABIs are associated with robust and substantial reductions in symptoms of anxiety and comorbid depressive symptoms. More research is needed to determine the efficacy of MABIs relative to current treatments of choice, and to clarify the contribution of processes of mindfulness and acceptance to observed outcome.

[Psychotherapy for obsessive-compulsive disorder: what is evidence based?]

Obsessive-compulsive disorder is a severe, very disabling condition that usually takes a chronic course if no adequate treatment is applied. Up to now, cognitive behavioural therapy with exposure and response prevention (CBT) is the most thoroughly investigated and most effective intervention, leading to a clinically significant symptom reduction in 60-70% of the patients. Correctly applied, this treatment can be equally effective as its combination with pharmacological management. For a correct implementation, however, several points have to be considered which are described in the following review. Considering the fact that some of the patients are unable to benefit sufficiently from this approach, potential alternatives and extensions of CBT are discussed. To date, however, no other treatment approach has proven to be effective based on randomised controlled trials.