Cognitive-behavioral therapy for patients with somatoform disorders: A pilot preliminary randomized controlled trial

Background and objective: Cognitive-behavioral therapy (CBT) for somatoform disorders (SFDs) is understudied in China. Western findings may not be applicable to Chinese culture. This preliminary study evaluated the efficacy of CBT for patients in China, relative to treatment-as-usual (TAU). Methods: Seventy patients with SFDs randomly received either combined CBT and TAU (CBT + TAU), or TAU alone between January 2018 to May 2019. The CBT + TAU group received 12 weekly individual 50-minute CBT sessions. Participants were blindly assessed at 4 timepoints (baseline, week 6, end of treatment: week 12; 12 weeks post-treatment: week 24) using the following outcome measures: SQSS (Self-screening Questionnaire for Somatic Symptoms); PHQ-15 (Patient-Health-Questionnaire-15) and the WI (Whiteley Index); GAD-7 (General Anxiety Disorder-7); HAMD-17 (Hamilton Depression Rating Scale-17); Family Burden Interview Schedule (FBIS); Sheehan Disability Scale (SDS); and the Short Form of Quality-of-Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF). The primary endpoint was the difference between the SQSS total score at week 24 and the baseline. A mixed model for repeated measures was used to analyze inter- and intra-group changes from the baseline. Results: At week 24, The least-squares mean (LSM) change of the total score on the SQSS was -18.87 points and -9.69 points, respectively in the CBT + TAU group and in the TAU group (LSM difference, -9.18 points; 95% confidence interval, -15.72 to -2.64; P = 0.0068). At week 24, the LSM changes from baseline in the WI, HAMD, PHQ15, FBIS and SDS total scores were significantly different between the two groups, however, there was no significant difference in the Q-LES-Q-SF. The SQSS of group effect sizes were 0.63 at 24 weeks. The dropout rates of the CBT + TAU and TAU groups were comparable (22.9% and 19.3%). Conclusions: These preliminary findings suggest that CBT may be helpful for improving the symptoms of patients with SFDs in China.

A cognitive-behavioral digital health intervention for sickle cell disease pain in adolescents: a randomized, controlled, multicenter trial

ABSTRACT

Severe acute and chronic pain are the most common complications of sickle cell disease (SCD). Pain results in disability, psychosocial distress, repeated clinic visits/hospitalizations, and significant healthcare costs. Psychosocial pain interventions that teach cognitive and behavioral strategies for managing pain have been effective in other adolescent populations when delivered in person or through digital technologies. Our aim was to conduct a multisite, randomized, controlled trial to improve pain and coping in youth aged 12 to 18 years with SCD using a digital cognitive-behavioral therapy program (iCanCope with Sickle Cell Disease; iCC-SCD) vs Education control. We enrolled 137 participants (ages 12-18 years, 59% female) and analyzed 111 adolescents (107 caregivers), 54 randomized to Education control and 57 randomized to iCC-SCD. Ninety-two percent of youth completed posttreatment assessments and 88% completed 6-month follow-up. There was a significant effect of treatment group (iCC-SCD vs Education) on reduction in average pain intensity from baseline to 6-month follow-up (b = -1.32, P = 0.009, 95% CI [-2.29, -0.34], d = 0.50), and for the number of days with pain, adolescents in the iCC-SCD group demonstrated fewer pain days compared with the Education group at 6-month follow-up (incident rate ratio = 0.63, P = 0.006, 95% CI [0.30, 0.95], d = 0.53). Treatment effects were also found for coping attempts, momentary mood, and fatigue. Several secondary outcomes did not change with intervention, including anxiety, depression, pain interference, and global impression of change. Future studies are needed to identify effective implementation strategies to bring evidence-based cognitive-behavioral therapy for sickle cell pain to SCD clinics and communities.

Characterizing Distress and Identifying Modifiable Intervention Targets for Family Caregivers of Patients with Malignant Gliomas

Background: Individuals caring for patients with malignant gliomas experience high rates of anxiety; however, an in-depth understanding of their distress and evidence-based interventions to target their needs are lacking. Objective: We conducted semistructured interviews with caregivers with elevated anxiety to characterize their drivers of anxiety, identify modifiable intervention targets, and capture their preferences for a psychosocial intervention. Design: From 9/2017 to 3/2019, we conducted semistructured interviews with 21 caregivers of patients with malignant gliomas, at time points following the patient's diagnosis or within one to three months after the patient's death. Setting/Subjects: Eligible caregivers in the United States had clinically significant anxiety as measured by a Hospital Anxiety and Depression Scale-Anxiety score >7. Measurements: Three independent coders employed thematic content analysis to analyze the qualitative data with NVivo 12, achieving high intercoder agreement (Kappa = 0.98). Results: On average, caregivers were 54.81 years old (SD = 10.85) with elevated anxiety (M = 10.90, SD = 3.25). We identified six themes in which caregivers described (1) coping through reassurance seeking or avoidance, (2) changes in their relationship with the patient, (3) challenges with social support, (4) vacillation between certainty and uncertainty regarding the future, (5) devaluation of self-care for the patients' needs, and (6) challenges communicating with the health care team. Caregivers were interested in an intervention soon after the patient's diagnosis, yet expressed concern about finding the time to participate. Conclusions: Emergent themes characterized the distress experienced by caregivers of patients with malignant gliomas and provided insight into their psychosocial intervention preferences. We identified evidence-based intervention components based on the modifiable factors arising from these themes.

Therapist's interventions immediately after exceeding the client's therapeutic zone of proximal development: A comparative case study

OBJECTIVE

When therapists' proposals are too demanding exceeding clients' readiness to move into change, clients may resist advancing. We aimed to understand how a therapist behaved immediately after the client resisted advancing into change within Cognitive-Behavioral Therapy.

METHODS

We analyzed a recovered and an unrecovered case, both with Major Depression, and followed by the same therapist. Through the Therapeutic Collaboration Coding System, we analyzed 407 exchanges of interest.

RESULTS

In both cases, clients resisted more in advancing at intermediate sessions, mainly by the therapist's challenges to raise insight and debate cognitive beliefs in the recovered case, and to seek experiential meanings in the unrecovered case. Immediately after clients resisted advancing, the therapist tended to insist on challenging them in the same direction. In the recovered case, the therapist did so continually throughout the therapy, sometimes balancing between insisting or stepping back. In the unrecovered case, the therapist insisted on challenging, but mostly at the final session. Occasionally, the therapist insisted on challenging, and clients resisted over consecutive exchanges.

CONCLUSION

Our results reinforce that to enact progress and change clients need to be pushed into change, however it requires therapists' skillful assessment of clients' tolerance to move in time.

Effect of cognitive-behavioral training on fear of childbirth and sleep quality of pregnant adolescent slum dwellers

BACKGROUND

Fear of childbirth is a common problem during pregnancy, which can give rise to sleep disorders and diminish sleep quality. This study aimed to determine the effect of cognitive-behavioral training on fear of childbirth and sleep quality of pregnant adolescent slum dwellers who visited the slum health centers of Zahedan city, Iran, in 2020.

MATERIALS AND METHODS

This quasi-experimental study was conducted in 2020 on 100 pregnant adolescent slum dwellers between 11 and 19 years old at 24-28 weeks pregnant. Multi-stage sampling was used and the participants were randomly divided into an intervention and a control group. The intervention group received four sessions of cognitive-behavioral training at weekly intervals. The control group only received routine care. The Wijma Delivery Expectancy/Experience Questionnaire and the Pittsburgh Sleep Quality Index were filled before and 4 weeks after the training course. The data were analyzed in SPSS 21 using independent t-test, paired t-test, Fisher's exact test, and Chi-squared test. and covariance. A P value of < 0.05 was considered significant.

RESULTS

After the intervention, the fear of childbirth significantly decreased (P = 0.004), and sleep quality significantly improved (P = 0.001) in the intervention group compared with the control group. The results of analysis of covariance to control the significant effect of pre-test scores showed that the mean score of fear of childbirth (P = 0.03) and mean score of sleep quality (P = 0.001) in the two groups after the intervention was statistically significant.

CONCLUSION

The results showed that in addition to reducing fear of childbirth, cognitive-behavioral training improved the sleep quality of women in the intervention group. Therefore, this training could be used as an easy and accessible method without complications to improve women's health.

"What shall we focus on?" - A thematic analysis of what characterizes cognitive-behavior therapy sessions with high or low quality of working alliance

OBJECTIVE

Several studies have shown that the quality of the working alliance predicts symptomatic improvement session-by-session, including in cognitive-behavioral therapy (CBT). We wanted to explore what characterizes CBT sessions with high and low alliances further using qualitative analysis.

METHOD

Ten CBT-sessions were selected from eight patients' therapies in a larger research project on psychotherapy for patients with major depression. Five sessions were chosen from high- and five from low-alliance sessions, based on therapist- and patient-reported Working Alliance Inventory scores. Transcripts of these sessions were analyzed using thematic analysis.

RESULTS

The analysis yielded four themes, each structured into two sub-themes: Therapist style, Person in focus, Content focus, and Therapeutic direction. In contrast to low-alliance sessions, high-alliance sessions were characterized by a more exploring as opposed to expert therapist style; a focus on the patient's thoughts, feelings, and behavior, rather than a diffuse focus or a focus on other people's actions/external events; and a sense of moving forward rather than stagnation.

CONCLUSION

Our qualitative analysis showed theoretically and clinically meaningful processes in CBT sessions of high- vs low working alliance. This method is a useful complement to quantitative within-patient analyses, to expand on the meaning of quantitative findings.

Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder: The Results of a Naturalistic Outcomes Study

Cognitive−behavioral therapy is a well-established treatment for obsessive−compulsive disorder (OCD). There are a variety of cognitive and behavioral strategies, and it is necessary to analyze the outcomes of the treatments. The aim of the present study is to verify the effectiveness of a treatment that combines evidence-based procedures and specific cognitive interventions highlighting the issue of acceptance. Forty patients with OCD were recruited and underwent a specific treatment procedure. All patients had a psychodiagnostic assessment for OCD using the Y−BOCS (Yale−Brown obsessive−compulsive scale) performed twice: before treatment (t0) and after nine months (t1). Data analysis showed a decrease in the scores between t0 and t1 according to the Y−BOCS in terms of the interference, severity, and impairment of obsessive−compulsive symptoms. A repeated-measures ANOVA showed a significant reduction in symptoms after treatment, with values of F (1, 39) = 137.56, p < 0.001, and η2 = 0.78. The ANOVA results were corroborated by a Wilcoxon signed-rank test. A reliable change index analysis indicated that 33 participants reported improvements in symptoms, of which 23 were clinically significant. The results showed clinical relevance for OCD treatment and highlighted how this cognitive procedure favored positive outcomes.

Irrational Beliefs and Their Role in Specific and Non-Specific Eating Disorder Symptomatology and Cognitive Reappraisal in Eating Disorders

BACKGROUND

Research on which specific maladaptive cognitions characterize eating disorders (ED) is lacking. This study explores irrational beliefs (IBs) in ED patients and controls and the association between IBs and ED-specific and non-specific ED symptomatology and cognitive reappraisal.

METHODS

79 ED outpatients with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorders and 95 controls completed the Attitudes and Beliefs Scale-2 (ABS-2) for IBs. ED outpatients also completed the Eating Disorder Inventory-3 (EDI-3) for ED-specific (EDI-3-ED Risk) and non-specific (EDI-3-General Psychological Maladjustment) symptomatology; General Health Questionnaire (GHQ) for general psychopathology; Emotion Regulation Questionnaire (ERQ) for cognitive reappraisal.

RESULTS

Multivariate analysis of variance with post hoc comparisons showed that ED outpatients exhibit greater ABS-2-Awfulizing, ABS-2-Negative Global Evaluations, and ABS-2-Low Frustration Tolerance than controls. No differences emerged between ED diagnoses. According to stepwise linear regression analyses, body mass index (BMI) and ABS-2-Awfulizing predicted greater EDI-3-ED Risk, while ABS-2-Negative Global Evaluations and GHQ predicted greater EDI-3-General Psychological Maladjustment and lower ERQ-Cognitive Reappraisal.

CONCLUSION

Awfulizing and negative global evaluation contribute to better explaining ED-specific and non-specific ED symptoms and cognitive reappraisal. Therefore, including them, together with BMI and general psychopathology, when assessing ED patients and planning cognitive-behavioral treatment is warranted.

A Blended Cognitive-Behavioral Intervention for the Treatment of Postpartum Depression: Study Protocol for a Randomized Controlled Trial

Despite the existence of effective treatment for postpartum depression, few women seek professional help, indicating the need for a new and innovative format of treatment that can overcome help-seeking barriers. This article presents the study protocol for a blended cognitive–behavioral intervention for the treatment of postpartum depression, by integrating face-to-face sessions with a web-based program (Be a Mom) into one treatment protocol. This study will be a two-arm, noninferiority randomized controlled trial comparing blended intervention to usual treatment for postpartum depression provided in healthcare centers. Portuguese postpartum adult women diagnosed with postpartum depression (according to the DSM-5 diagnostic criteria for major depressive disorder) will be recruited during routine care appointments in local healthcare centers and will be eligible to participate. Measures will be completed at baseline, postintervention, and at three- and six-month follow-ups. The primary outcome will be depressive symptoms. Secondary outcomes will include anxiety symptoms, fatigue, quality of life, marital satisfaction, maternal self-efficacy, and mother–child bonding. Cost-effectiveness analysis and mediator and moderator analysis will be conducted. This study will provide insight into the efficacy and cost-effectiveness of a blended psychological intervention in the Portuguese context and increase the empirically validated treatment options for postpartum depression.

A qualitative study of the feasibility and acceptability of a smoking cessation program for people living with HIV and emotional dysregulation

Despite high rates of co-occurring tobacco use and anxiety among persons living with HIV, evidence-based interventions for these individuals are limited. An existing cognitive-behavioral treatment protocol for smoking cessation and anxiety (Norton, P. J., & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: A preliminary randomized controlled noninferiority trial. Depression and Anxiety, 29(10), 874-882. https://doi.org/10.1002/da.21974) was modified to address transdiagnostic constructs, such as anxiety sensitivity, distress tolerance, and depressive symptomatology (Labbe, A. K., Wilner, J. G., Kosiba, J. D., Gonzalez, A., Smits, J. A., Zvolensky, M. J., … O'Cleirigh, C. (2017). Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People with HIV: A Clinical Case Study. Cognitive and Behavioral Practice, 24(2), 200-214. https://doi.org/10.1016/j.cbpra.2016.03.009). This study examines the feasibility and acceptability of the intervention as determined from qualitative data from structured exit interviews from 10 participants who completed treatment. Results demonstrated that participants were very motivated to quit smoking and enrolled in the program for health-related reasons and to be able to quit. Participants found nearly all the treatment components to be useful for reaching their smoking cessation goal and in managing emotional dysregulation. Last, all participants stated that they would strongly recommend the treatment program. This qualitative study provides initial evidence for the feasibility and acceptability of a modified smoking cessation treatment protocol for HIV+ individuals with anxiety and emotional dysregulation. Future research will focus on evaluating the efficacy of the protocol in a full-scale randomized controlled trial, as well as working to collect qualitative data from participants who discontinue treatment to better understand reasons for treatment attrition.

Longitudinal Investigation of Psychotherapy Outcomes (LIPO): Description of the Study Protocol

Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations. Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels. Methods: Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy [psychodynamic psychotherapy (PDT), interpersonal psychotherapy (IPT), and cognitive-behavioral psychotherapy (CBT)] were included. Measure: Primary outcomes are divided into three domains of variables: clinical (general psychiatric symptoms), biological (serum BDNF levels), and psychosocial (resilience, quality of life, coping strategies, social support, and quality of life-adjusted years of life). Confounding/mediator variables included clinical (personality traits, type of psychotherapy, number of sessions, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, and psychiatric diagnosis), psychosocial (psychosocial stressors, therapeutic alliance, and defense mechanism style), and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20-30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression. Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions.

A Successful Model for Clinical Training in Child/Adolescent Cognitive Behavior Therapy for Graduate Psychiatric Advanced Practice Nursing Students

BACKGROUND

Graduate faculty in advanced practice nursing programs seek to provide clinical training in psychotherapy for psychiatric mental health nurse practitioner (PMHNP) students and prepare them for practice with patients across the lifespan, including children and adolescents.

OBJECTIVE

To develop a clinical training model for child/adolescent cognitive behavior therapy (CBT) that is adaptable to all graduate nursing programs including online, classroom, and blended programs.

DESIGN

Clinical training included a didactic 4-hour workshop and 7 small group practice sessions utilizing Creating Opportunities for Personal Empowerment (COPE), a manualized CBT program for teens. Students completed post-clinical training evaluations. Using qualitative design, responses to the open-ended questions were analyzed and common themes identified.

RESULTS

One hundred seven PMHNP students completed evaluations. Four themes emerged from the data: (a) therapeutic understanding of adapting CBT for children and adolescents, (b) therapeutic skills and techniques for use with children/adolescents, (c) improved level of confidence through participation in the CBT program, and (d) therapeutic benefits of being in a group.

CONCLUSIONS

Positive PMHNP student evaluations indicated that this clinical training model is feasible both online and face-to-face and acceptable for providing clinical training in CBT for children and adolescents.

Insomnia Patients With Objective Short Sleep Duration Have a Blunted Response to Cognitive Behavioral Therapy for Insomnia

Study Objectives

This study examined whether individuals with insomnia and objective short sleep duration <6 h, a subgroup with greater risks of adverse health outcomes, differ in their response to cognitive-behavioral therapy for insomnia (CBT-I) when compared to individuals with insomnia and normal sleep duration ≥6 h.

Methods

Secondary analyses of a randomized, clinical trial with 60 adult participants (n = 31 women) from a single academic medical center. Outpatient treatment lasted 8 weeks, with a final follow-up conducted at 6 months. Mixed-effects models controlling for age, sex, CBT-I treatment group assignment, and treatment provider examined sleep parameters gathered via actigraphy, sleep diaries, and an Insomnia Symptom Questionnaire (ISQ) across the treatment and follow-up period.

Results

Six months post-CBT-I treatment, individuals with insomnia and normal sleep duration ≥6 h fared significantly better on clinical improvement milestones than did those with insomnia and short sleep duration <6 h. Specifically, individuals with insomnia and normal sleep duration had significantly higher insomnia remission (ISQ < 36.5; χ2[1, N = 60] = 44.72, p < .0001), more normative sleep efficiency (SE) on actigraphy (SE > 80%; χ2[1, N = 60] = 21, p < .0001), normal levels of middle of the night wake after sleep onset (MWASO) <31 minutes (χ2[1, N = 60] = 37.85, p < .0001), and a >50% decline in MWASO (χ2[1, N = 60] = 60, p < .0001) compared to individuals with insomnia and short sleep duration. Additionally, those with insomnia and normal sleep duration had more success decreasing their total wake time (TWT) at the 6-month follow-up compared to those with insomnia and short sleep duration (χ2[2, N = 60] = 44.1, p < .0001). Receiver-operating characteristic curve analysis found that using a 6-h cutoff with actigraphy provided a 95.7% sensitivity and 91.9% specificity for determining insomnia remission, with the area under the curve = 0.986.

Conclusions

Findings suggest that individuals with insomnia and objective short sleep duration <6 h are significantly less responsive to CBT-I than those with insomnia and normal sleep duration ≥6 h. Using an actigraphy TST cutoff of 6 hours to classify sleep duration groups was highly accurate and provided good discriminant value for determining insomnia remission.

Group cognitive-behavioral therapy in insomnia: a cross-sectional case-controlled study

BACKGROUND

Group cognitive-behavioral therapy (GCBT) might meet the considerable treatment demand of insomnia, but its effectiveness needs to be addressed.

PARTICIPANTS

This study recruited 27 insomnia patients treated with 16-weeks of zolpidem (zolpidem group), 26 patients treated with 4-weeks of zolpidem and also treated with 12-weeks of GCBT (GCBT group), and 31 healthy control volunteers.

METHODS

Before treatment and 16 weeks after intervention, participants were evaluated using the Patient Health Questionnaires (Patient Health Questionnaire-9 [PHQ-9] and Patient Health Questionnaire-15 [PHQ-15]), the Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16), and the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Compared to the zolpidem and healthy control groups, the scale scores of PHQ-9, PHQ-15, DBAS-16 and PSQI were significantly reduced after intervention in the GCBT group. Regarding the score changes, there were correlations between PSQI, DBAS-16, PHQ-9, and PHQ-15 scales in the zolpidem group, but there were limited correlations between PSQI and some DBAS-16 scales in the GCBT group.

CONCLUSION

Our results indicate that GCBT is effective to treat insomnia by improving sleep quality and reducing emotional and somatic disturbances; thus, the study supports the advocacy of applying group psychotherapy to the disorder.

Changes in functional connectivity of the amygdala during cognitive reappraisal predict symptom reduction during trauma-focused cognitive-behavioral therapy among adolescent girls with post-traumatic stress disorder

BACKGROUND

While trauma-focused cognitive-behavioral therapy (TF-CBT) is the 'gold standard' treatment for pediatric post-traumatic stress disorder (PTSD), little is known about the neural mechanisms by which TF-CBT produces clinical benefit. Here, we test the hypothesis that PTSD symptom reduction during TF-CBT among adolescent girls with PTSD is associated with changes in patterns of brain functional connectivity (FC) with the amygdala during cognitive reappraisal.

METHOD

Adolescent girls with PTSD related to physical or sexual assault (n = 34) were enrolled in TF-CBT, delivered in an approximately 12-session format, in an open trial. Before and after treatment, they were engaged in a cognitive reappraisal task, probing neural mechanisms of explicit emotion regulation, during 3 T functional magnetic resonance imaging.

RESULTS

Among adolescent girls completing TF-CBT with usable pre- and post-treatment scans (n = 20), improvements in self-reported emotion from pre- to post-treatment were positively related to improvements in PTSD symptoms. Adolescent girls with greater post-treatment symptom reduction were also able to suppress amygdala-insula FC while re-appraising, which was not evident in girls with less symptom reduction. Pre- to post-treatment changes in right amygdala to left insula FC that scaled with PTSD symptom reduction also scaled with improvements in emotion regulation.

CONCLUSIONS

These preliminary results suggest the neurocircuitry mechanisms through which TF-CBT produces clinical outcomes, providing putative brain targets for augmenting TF-CBT response.

Harnessing group composition-related effects in pain management programs: a review and recommendations

Cognitive-behavioral therapy, an effective management strategy for chronic pain, is frequently conducted in groups. Although clinicians often report 'knowing when a group will go well or badly', investigations of the effect that group composition might have on outcomes is lacking. Conceptual models, explanatory theories and experiments have been developed in fields of psychotherapy, organizational, social and educational psychology, but there has been no attempt to take on this issue in our field. The current hypothesis-generating review synthesizes these substantial bodies of literature to identify common themes across fields and integrate them with current concepts of cognitive-behavioral therapy-based pain management. We present a putative conceptual model with testable hypotheses relating to features of each group as a whole, the individuals in that group and the group's leader.

The Impact of a Cognitive-Behavioral Therapy on Event-Related Potentials in Patients with Tic Disorders or Body-Focused Repetitive Behaviors

CONTEXT

Tic disorders (TD) are characterized by the presence of non-voluntary contractions of functionally related groups of skeletal muscles in one or multiple body parts. Patients with body-focused repetitive behaviors (BFRB) present frequent and repetitive behaviors, such as nail biting or hair pulling. TD and BFRB can be treated with a cognitive-behavioral therapy (CBT) that regulates the excessive amount of sensorimotor activation and muscular tension. Our CBT, which is called the cognitive-psychophysiological (CoPs) model, targets motor execution and inhibition, and it was reported to modify brain activity in TD. However, psychophysiological effects of therapy are still poorly understood in TD and BFRB patients. Our goals were to compare the event-related potentials (ERP) of TD and BFRB patients to control participants and to investigate the effects of the CoPs therapy on the P200, N200, and P300 components during a motor and a non-motor oddball task.

METHOD

Event-related potential components were compared in 26 TD patients, 27 BFRB patients, and 27 control participants. ERP were obtained from 63 EEG electrodes during two oddball tasks. In the non-motor task, participants had to count rare stimuli. In the motor task, participants had to respond with a left and right button press for rare and frequent stimuli, respectively. ERP measures were recorded before and after therapy in both patient groups.

RESULTS

CoPs therapy improved symptoms similarly in both clinical groups. Before therapy, TD and BFRB patients had reduced P300 oddball effect during the non-motor task, in comparison with controls participants. An increase in the P300 oddball effect was observed posttherapy. This increase was distributed over the whole cortex in BFRB patients, but localized in the parietal area in TD patients.

DISCUSSION

These results suggest a modification of neural processes following CoPs therapy in TD and BFRB patients. CoPs therapy seems to impact patients' attentional processes and context updating capacities in working memory (i.e., P300 component). Our results are consistent with a possible role of the prefrontal cortex and corpus callosum in mediating interhemispheric interference in TD.

The Effect of a New Therapy for Children with Tics Targeting Underlying Cognitive, Behavioral, and Physiological Processes

Tourette disorder (TD) is characterized by motor and vocal tics, and children with TD tend to present a lower quality of life than neurotypical children. This study applied a manualized treatment for childhood tics disorder, Facotik, to a consecutive case series of children aged 8-12 years. The Facotik therapy was adapted from the adult cognitive and psychophysiological program validated on a range of subtypes of tics. This approach aims to modify the cognitive-behavioral and physiological processes against which the tic occurs, rather than only addressing the tic behavior. The Facotik therapy lasted 12-14 weeks. Each week 90-min session contained 20 min of parental training. The therapy for children followed 10 stages including: awareness training; improving motor control; modifying style of planning; cognitive and behavioral restructuring; and relapse prevention. Thirteen children were recruited as consecutive referrals from the general population, and seven cases completed therapy and posttreatment measures. Overall results showed a significant decrease in symptom severity as measured by the YGTSS and the TSGS. However, there was a discrepancy between parent and child rating, with some children perceiving an increase in tics, possibly due to improvement of awareness along therapy. They were also individual changes on adaptive aspects of behavior as measured with the BASC-2, and there was variability among children. All children maintained or improved self-esteem posttreatment. The results confirm the conclusion of a previous pilot study, which contributed to the adaptation of the adult therapy. In summary, the Facotik therapy reduced tics in children. These results underline that addressing processes underlying tics may complement approaches that target tics specifically.

Are self-management strategies effective in chronic pain treatment?

It has long been recognized that in the management of chronic illnesses generally, medical care alone is unlikely to be sufficient without the active contribution of the patient. This perspective has also been enunciated in numerous guidelines for the management of chronic pain. However, in the case of chronic pain at least, the nature and role of self-management have been poorly defined and, as a result, poorly understood and researched. This review considers the nature of self-management strategies for chronic pain, evidence of their effectiveness and ways in which self-management can be facilitated for those in chronic pain. A research and training agenda is proposed for where this work could go next.

What does best evidence tell us about the efficacy of group cognitive-behavioral therapy for obsessive-compulsive disorder? Protocol for a systematic review and meta-analysis

Group cognitive–behavioral therapy (GCBT) may be a cost-effective alternative modality for the treatment of obsessive–compulsive disorder (OCD). In the last decade, a great deal of research has been conducted to evaluate the efficacy of GCBT for OCD. Despite promising results, studies have produced inconclusive evidence. The current paper will present a protocol for a systematic review and meta-analysis of randomized controlled trials assessing the efficacy of GCBT compared with control conditions or individual CBT at post-treatment and follow-up on OCD symptoms, anxiety, depression, obsessive beliefs, quality of life, and functioning. Another aim will be to compare the levels of early drop out from GCBT relative to control conditions or individual CBT. Finally, the study will investigate potential outcome moderators (age, sex, OCD severity, severity of concurrent depression, comorbid personality disorders, duration of OCD symptom onset, duration of treatment, intensity of treatment, generation cohort, methodological quality, and publication date). A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be conducted using random-effects meta-analyses. Online databases and trial registries will be searched, the corresponding authors will be contacted, and conference proceedings and relevant journals will be hand-searched to locate published and unpublished studies. Risk of bias will be assessed using the Cochrane Collaboration’s tool.

A Pilot Study of a Cognitive-Behavioral Treatment for Anxiety and Depression in Patients With Parkinson Disease

Anxiety and depression often remain unrecognized or inadequately treated in patients with Parkinson disease (PD). Cognitive-behavioral therapy (CBT) is effective, but limited evidence supports its use for anxiety and depression in patients with PD. Sixteen patients with PD having significant anxiety and/or depressive symptoms were assigned to CBT or enhanced usual care. Assessments occurred at baseline, posttreatment, and 1-month follow-up. The CBT intervention included tools for anxiety, depression, and healthy living with PD symptoms. Individual sessions were delivered by telephone or in person, based on patient preference. Treatment was feasible with participants choosing 67% of sessions by telephone and 80% completed treatment. The between-group effect sizes for change scores from baseline to posttreatment and baseline to 1-month follow-up were large (posttreatment: d = 1.49 for depression and 1.44 for anxiety; 1-month follow-up: d = .73 for depression and 1.24 for anxiety), although only the posttreatment effect size for depression was significant. This pilot CBT program is feasible for treatment of anxiety and depression in patients with PD.

Neurobiological factors as predictors of cognitive-behavioral therapy outcome in individuals with antisocial behavior: a review of the literature

This review focuses on the predictive value of neurobiological factors in relation to cognitive-behavioral therapy outcome among individuals with antisocial behavior. Ten relevant studies were found. Although the literature on this topic is scarce and diverse, it appears that specific neurobiological characteristics, such as physiological arousal levels, can predict treatment outcome. The predictive value of neurobiological factors is important as it could give more insight into the causes of variability in treatment outcome among individuals with antisocial behavior. Furthermore, results can contribute to improvement in current treatment selection procedures and to the development of alternative treatment options.

Rethinking family caregiving: tailoring cognitive-behavioral therapies to the hospice experience

Hospice family caregivers experience significantly higher rates of psychological distress than demographically similar noncaregivers. Interventions based on cognitive-behavioral therapy have been shown to reduce psychological distress in the general population by providing tools to modify thinking patterns that directly affect emotions and behavior. Such interventions might reasonably be incorporated into hospice social work; however, numerous contextual factors must be taken into account to ensure that any interventions are appropriate to the unique needs of clients. The purpose of the study discussed in this article was to contex- tualize one aspect of the cognitive-behavioral model based on firsthand accounts of hospice family caregivers. Following a modified grounded theory approach, researchers engaged in a secondary analysis of data from a larger study provided in a subsample of 90 audio-recorded conversations between hospice family caregivers and interventionists. Findings indicated that distressed caregivers engaged in five dominant thinking patterns: (1) "should" statements, (2) catastrophizing or minimizing, (3) personalizing, (4) absolute thinking, and (5) making assumptions. Implementing cognitive-behavioral therapies based on identified caregiver thinking patterns will allow hospice social workers to empower caregivers to cope more effectively with the numerous stressors they encounter while caring for a dying loved one.

Eight years later: outcomes of CBT-treated versus untreated anxious children

BACKGROUND

Anxiety disorders are the most common psychiatric disorders of childhood, generate significant distress, are considered precursors to diverse psychiatric disorders, and lead to poor social and employment outcomes in adulthood. Although childhood anxiety has a significant impact on a child's developmental trajectory, only a handful of studies examined the long-term impact of treatment and none included a control group. The aim of this study was to conduct a long-term follow-up (LTFU) of anxious children who were treated with Cognitive-Behavioral Therapy (CBT) compared to a matched group of children who were not.

METHODS

Subjects comprised 120 children: a treatment group which included the first 60 consecutive consenting children who were diagnosed with an anxiety disorder and treated with CBT between the years 1997 and 2003 and a control group, 60 matched children who were assessed but not treated with CBT. An "ex-post-facto" design was used to compare the two groups.

RESULTS

Children showed lower rates of anxiety diagnosis (about 50% for both groups) and significantly improved functioning at LTFU (time effect P < 0.0001; no group difference). Anxiety levels were significantly lower in the nontreatment group at LTFU as compared to initial assessment (P = 0.02), but not in the treatment group, and a significant between-group difference was found (P = 0.01) according to child. An inverse relationship was found between self-efficacy/self-esteem and anxiety outcome ([P = 0.0008] and [P = 0.04], respectively).

CONCLUSIONS

This study supports the assumption that childhood anxiety disorders may improve without treatment and highlights self-efficacy/self-esteem as potential factors in recovery.

Cognitive-behavioral treatment of depression in men: tailoring treatment and directions for future research

Depression is a significant public health issue and many researchers have suggested that modifications to conventional cognitive-behavioral therapy (CBT) are required to address infrequent help-seeking in men and counter negative effects of traditional masculinity on therapeutic engagement. This narrative review summarizes recommended alterations to CBT in the areas of therapeutic setting, process, and content. Key themes from this literature include a focus on behavioural interventions, and harmful cognitions that orginate from the traditional male gender stereotype. This literature is marked by limited empirical support for many of the recommended treatment modifications, and several options for future research are outlined.

Understanding why cognitive-behavioral therapy is an effective treatment for adolescents with juvenile fibromyalgia

Recent studies have demonstrated that cognitive-behavioral therapy (CBT) is an effective treatment for children and adolescents with juvenile fibromyalgia. Unfortunately, the specific psychological changes that occur during treatment that explain why CBT works are not well understood. Historically, the increased use of specific coping strategies learned during CBT was thought to be the primary reason for why CBT was effective. However, evidence to support the notion that increases in adaptive coping directly lead to patient improvement is minimal. Instead, a growing number of studies in adults suggest that CBT results in more global changes of psychological perceptions of the pain itself (cognitive appraisals) and one's ability to manage the pain. This report discusses the role of coping and aspects of cognitive appraisal as potential psychological changes that explain CBT-related improvements for youths with juvenile fibromyalgia.

Behavioral therapy across the spectrum

Numerous effective behavioral therapies have been developed that can bring the treatment to the patient rather than bringing the patient to treatment. These behavioral therapy techniques, which can provide effective treatment across the spectrum of severity of alcohol abuse disorders, include facilitated self-change, individual therapies, couples and family approaches, and contingency management. New methods of delivery and successful adjuncts to existing behavioral treatments also have been introduced, including computerized cognitive-behavioral treatments, Web-based guided self-change, and mindfulness-based approaches. Although a wide variety of behavioral approaches have been shown to have good efficacy, choosing the treatment most appropriate for a given patient remains a challenge.

Matching motivation enhancement treatment to client motivation: re-examining the Project MATCH motivation matching hypothesis

AIMS

The current study was designed to re-examine the motivation matching hypothesis from Project MATCH using growth mixture modeling, an analytical technique that models variation in individual drinking patterns.

DESIGN, SETTING AND PARTICIPANTS

Secondary data analyses of data from Project MATCH (n = 1726), a large multi-site alcoholism treatment-matching study.

MEASUREMENTS

Percentage of drinking days was the primary outcome measure, assessed from 1 month to 12 months following treatment. Treatment assignment, alcohol dependence symptoms and baseline percentage of drinking days were included as covariates.

FINDINGS

The results provided support for the motivation matching hypothesis in the out-patient sample and among females in the aftercare sample: the majority of individuals with lower baseline motivation had better outcomes if assigned to motivation enhancement treatment (MET) compared to those assigned to cognitive behavioral treatment (CBT). In the aftercare sample there was a moderating effect of gender and alcohol dependence severity, whereby males with lower baseline motivation and greater alcohol dependence drank more frequently if assigned to MET compared to those assigned to CBT.

CONCLUSIONS

Results from the current study lend partial support to the motivation-matching hypothesis and also demonstrated the importance of moderating influences on treatment matching effectiveness. Based upon these findings, individuals with low baseline motivation in out-patient settings and males with low levels of alcohol dependence or females in aftercare settings may benefit more from motivational enhancement techniques than from cognitive-behavioral techniques.

Management of functional abdominal pain and irritable bowel syndrome in children and adolescents

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are among the most commonly diagnosed medical problems in pediatrics. Symptom-based Rome III criteria for FAP and IBS have been validated and help the clinician in making a positive diagnosis. The majority of patients with mild complaints improve with reassurance and time. For a distinct subset of patients with more severe and disabling illness, finding effective treatment for these disorders remains a challenge. Over the years, a wide range of therapies have been proposed and studied. The lack of a single, proven intervention highlights the complex interplay of biopsychosocial factors probably involved in the development of childhood FAP and IBS, and the need for a multidisciplinary, integrated approach. This article reviews the current literature on the efficacy of pharmacologic, dietary and psychosocial interventions for FAP and IBS in children and adolescents.

A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face

OBJECTIVE

A major problem in the delivery of mental health services is the lack of availability of empirically supported treatment, particularly in rural areas. To date no studies have evaluated the administration of an empirically supported manual-based psychotherapy for a psychiatric condition via telemedicine. The aim of this study was to compare the relative efficacy and acceptability of a manual-based cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) delivered in person to a comparable therapy delivered via telemedicine.

METHOD

One hundred twenty-eight adults meeting DSM-IV criteria for BN or eating disorder-not otherwise specified with binge eating or purging at least once per week were recruited through referrals from clinicians and media advertisements in the targeted geographical areas. Participants were randomly assigned to receive 20 sessions of manual-based, CBT for BN over 16 weeks delivered either face-to-face (FTF-CBT) or via telemedicine (TV-CBT) by trained therapists. The primary outcome measures were binge eating and purging frequency as assessed by interview at the end of treatment, and again at 3- and 12-month follow-ups. Secondary outcome measures included other bulimic symptoms and changes in mood.

RESULTS

Retention in treatment was comparable for TV-CBT and FTF-CBT. Abstinence rates at end-of-treatment were generally slightly higher for FTF-CBT compared with TV-CBT, but differences were not statistically significant. FTF-CBT patients also experienced significantly greater reductions in eating disordered cognitions and interview-assessed depression. However, the differences overall were few in number and of marginal clinical significance.

CONCLUSIONS

CBT for BN delivered via telemedicine was both acceptable to participants and roughly equivalent in outcome to therapy delivered in person.

Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects

Relapse and recurrence following response to acute-phase treatment for major depressive disorder (MDD) are prevalent and costly. In a meta-analysis of 28 studies including 1,880 adults, the authors reviewed the world's published literature on cognitive-behavioral therapies (CT) aimed at preventing relapse-recurrence in MDD. Results indicate that after discontinuation of acute-phase treatment, many responders to CT relapse-recur (29% within 1 year and 54% within 2 years). These rates appear comparable to those associated with other depression-specific psychotherapies but lower than those associated with pharmacotherapy. Among acute-phase treatment responders, continuation-phase CT reduced relapse-recurrence compared with assessment only at the end of continuation treatment (21% reduction) and at follow-up (29% reduction). Continuation-phase CT also reduced relapse-recurrence compared with other active continuation treatments at the end of continuation treatment (12% reduction) and at follow-up (14% reduction). The authors discuss implications for research and patient care and suggest directions, with methodological refinements, for future studies.

Sudden gains during therapy of social phobia

The present study investigated the phenomenon of sudden gains in 107 participants with social phobia (social anxiety disorder) who received either cognitive-behavioral group therapy or exposure group therapy without explicit cognitive interventions, which primarily used public speaking situations as exposure tasks. Twenty-two out of 967 session-to-session intervals met criteria for sudden gains, which most frequently occurred in Session 5. Individuals with sudden gains showed similar improvements in the 2 treatment groups. Although cognitive-behavioral therapy was associated with more cognitive changes than exposure therapy, cognitive changes did not precede sudden gains. In general, the results of this study question the clinical significance of sudden gains in social phobia treatment.