Baseline Patient Characteristics Predicting Outcome and Attrition in Cognitive Therapy for Social Phobia: Results from a Large Multicentre Trial

The Efficacy of Web-Based Cognitive Behavioral Therapy With a Shame-Specific Intervention for Social Anxiety Disorder: Randomized Controlled Trial

Background

Social anxiety disorder (SAD) is one of the most prevalent psychological disorders and generally co-occurs with elevated shame levels. Previous shame-specific interventions could significantly improve outcomes in social anxiety treatments. Recent review suggests that integrating a more direct shame intervention could potentially increase the effectiveness of cognitive behavioral therapy. Web-based cognitive behavioral therapy (WCBT) has proven efficacy, sustaining benefits for 6 months to 4 years. Previous evidence indicated that shame predicted the reduction of social anxiety and mediated between engagements in exposure and changes in social anxiety during WCBT.

Objective

This study aimed to design a shame intervention component through a longitudinal study and conduct a randomized controlled trial to investigate the effectiveness of a shame intervention component in reducing social anxiety symptoms and shame experience in a clinical sample of people with SAD.

Methods

The development of a shame intervention component was informed by cognitive behavioral principles and insights from longitudinal data that measured the Experience of Shame Scale (ESS), the Coping Styles Questionnaire, and the Social Interaction Anxiety Scale (SIAS) in 153 participants. The psychoeducation, cognitive construct, and exposure sections were tailored to focus more on shame-related problem-solving and self-blame. A total of 1220 participants were recruited to complete questionnaires, including the ESS, the SIAS, the Social Phobia Scale (SPS), and diagnostic interviews. Following a 2-round screening process, 201 participants with SAD were randomly assigned into a shame WCBT group, a normal WCBT group, and a waiting group. After the 8-week WCBT intervention, the participants were asked to complete posttest evaluations, including the ESS, SIAS and SPS.

Results

Participants in the shame WCBT group experienced significant reductions in shame levels after the intervention (ESS: P<.001; ηp2=0.22), and the reduction was greater in the shame intervention group compared to normal WCBT (P<.001; mean deviation -12.50). Participants in both the shame WCBT and normal WCBT groups experienced significant reductions in social anxiety symptoms (SIAS: P<.001; ηp2=0.32; SPS: P<.001; ηp2=0.19) compared to the waiting group after intervention. Furthermore, in the experience of social interaction anxiety (SIAS), the shame WCBT group showed a higher reduction compared to the normal WCBT group (P<.001; mean deviation -9.58). Problem-solving (SE 0.049, 95% CI 0.025-0.217) and self-blame (SE 0.082, 95% CI 0.024-0.339) mediated the effect between ESS and SIAS.

Conclusions

This is the first study to design and incorporate a shame intervention component in WCBT and to validate its efficacy via a randomized controlled trial. The shame WCBT group showed a significant reduction in both shame and social anxiety after treatment compared to the normal WCBT and waiting groups. Problem-solving and self-blame mediated the effect of shame on social anxiety. In conclusion, this study supports previous findings that a direct shame-specific intervention component could enhance the efficacy of WCBT.

Predicting non-improvement of symptoms in daily mental healthcare practice using routinely collected patient-level data: a machine learning approach

Objectives

Anxiety and mood disorders greatly affect the quality of life for individuals worldwide. A substantial proportion of patients do not sufficiently improve during evidence-based treatments in mental healthcare. It remains challenging to predict which patients will or will not benefit. Moreover, the limited research available on predictors of treatment outcomes comes from efficacy RCTs with strict selection criteria which may limit generalizability to a real-world context. The current study evaluates the performance of different machine learning (ML) models in predicting non-improvement in an observational sample of patients treated in routine specialized mental healthcare.

Methods

In the current longitudinal exploratory prediction study diagnosis-related, sociodemographic, clinical and routinely collected patient-reported quantitative outcome measures were acquired during treatment as usual of 755 patients with a primary anxiety, depressive, obsessive compulsive or trauma-related disorder in a specialized outpatient mental healthcare center. ML algorithms were trained to predict non-response (< 0.5 standard deviation improvement) in symptomatic distress 6 months after baseline. Different models were trained, including models with and without early change scores in psychopathology and well-being and models with a trimmed set of predictor variables. Performance of trained models was evaluated in a hold-out sample (30%) as a proxy for unseen data.

Results

ML models without early change scores performed poorly in predicting six-month non-response in the hold-out sample with Area Under the Curves (AUCs) < 0.63. Including early change scores slightly improved the models' performance (AUC range: 0.68-0.73). Computationally-intensive ML models did not significantly outperform logistic regression (AUC: 0.69). Reduced prediction models performed similar to the full prediction models in both the models without (AUC: 0.58-0.62 vs. 0.58-0.63) and models with early change scores (AUC: 0.69-0.73 vs. 0.68-0.71). Across different ML algorithms, early change scores in psychopathology and well-being consistently emerged as important predictors for non-improvement.

Conclusion

Accurately predicting treatment outcomes in a mental healthcare context remains challenging. While advanced ML algorithms offer flexibility, they showed limited additional value compared to traditional logistic regression in this study. The current study confirmed the importance of taking early change scores in both psychopathology and well-being into account for predicting longer-term outcomes in symptomatic distress.

The association between social class and the impact of treatment for mental health problems: a systematic review and narrative synthesis

PURPOSE

This systematic review aimed to synthesise all quantitative literature on the association between social class and the effectiveness of interventions for mental health disorders.

METHODS

Systematic literature searches (inception-March 2021) were conducted across 7 databases, and all quantitative studies meeting inclusion criteria, examining the impact of social class on access to treatment, or intervention effectiveness, or the impact of treatment on social mobility, were synthesised narratively.

RESULTS

Evidence suggests that lower social class may be associated with reduced access to primary and secondary mental health care and increased likelihood of access via crisis services, and patients of lower social class may not benefit from all mental health interventions, with reduced effectiveness. While limited, there was some indication that psychosocial interventions could encourage increased employment rates.

CONCLUSION

Social class is associated with the effectiveness of psychological interventions, and should be considered when designing new interventions to prevent barriers to access and improve effectiveness.

Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial

BACKGROUND

In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC).

METHODS

Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7).

OUTCOMES

change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation.

RESULTS

Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment.

CONCLUSION

As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.

The Nature, Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.

Examining the relationship between shame and social anxiety disorder: A systematic review

This paper is the first systematic review of the literature on the relationship between shame and social anxiety (SA). We reviewed a total of 60 peer-reviewed empirical articles that met criteria for inclusion. We begin by summarizing literature investigating the empirical association between shame and SA and review literature on whether this association is impacted by cultural or diagnostic differences. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of social anxiety disorder (SAD; Heimberg, Brozovich, & Rapee, 2014) and propose how shame may interact with five processes described therein: environmental experiences, observations/images of the self, perceived negative evaluation by others, post-event cognitive processes, and behavioral manifestations of SA. We review the current literature on shame and SA as it relates to each of these domains. Thereafter, we discuss existing research on the role of shame in the treatment of SAD and the implications of the research discussed in this review. Finally, we conclude with a discussion of some key limitations in the existing literature and areas for future research.

Patterns of care and dropout rates from outpatient mental healthcare in low-, middle- and high-income countries from the World Health Organization's World Mental Health Survey Initiative

BACKGROUND

There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.

METHODS

Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan-Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.

RESULTS

Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.

CONCLUSIONS

Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.

The Cooperative Revolution Reaches Clinical Psychology and Psychotherapy: An Example From Germany

Background

Psychology is at the beginning of a cooperative revolution. Traditionally, psychological research has been conducted by individual labs, limiting its scope in clinical samples and promoting replication problems. Large-scale collaborations create new opportunities for highly powered studies in this resource-intensive research area. To present the current state of a Germany-wide platform for coordinating research across university outpatient clinics for psychotherapy.

Method

Since 1999, over 50 such clinics were created in Germany. They represent a unique infrastructure for research, training, and clinical care. In 2013, a steering committee initiated a nationwide research platform for systematic coordination of research in these clinics (German abbreviation "KODAP"). Its main goal is to aggregate and analyze longitudinal treatment data - including patient, therapist, and treatment characteristics - across all participating clinics.

Results

An initial survey (100% response rate) yielded recommendations for improved integration of data collection. Pilot data from 4,504 adult (16 clinics) and 568 child and adolescent patients (7 clinics) proved feasibility of data transfer and aggregation despite different data formats. Affective, neurotic, stress, and somatoform (adults) and anxiety and behavioral (children and adolescents) disorders were most frequent; comorbidity was high. Overcoming legal, methodological, and technical challenges, a common core assessment battery was developed, and data collection started in 2018. To date, 42 clinics have joined.

Conclusions

KODAP shows that research collaboration across university outpatient clinics is feasible. Fulfilling the need for stronger cumulative and cooperative research in Clinical Psychology will contribute to better knowledge about mental health, a core challenge to modern societies.

[Psychometric evaluation of the Experiences in Close Relationships Revised German 12-item version (ECR-RD 12) in a sample of psychotherapeutic inpatients]

Psychometric evaluation of the Experiences in Close Relationships Revised German 12-item version (ECR-RD 12) in a sample of psychotherapeutic inpatients Objectives: The ECR-R assesses the self-description of adult attachment strategies in romantic relationships. The present study evaluates the psychometric properties of the German 12-item short version ECR-RD 12 in a large sample of patients in psychotherapeutic inpatient treatment. Method: Inpatients in psychotherapeutic treatment (N = 2231) were assessed using the ECR-RD 12 and other clinical questionnaires. Its psychometric properties and factor structure of were evaluated. Results: The psychometric properties of the short form measure were in line with the German full length version (ECR-RD). In contrast to theoretical assumptions, factor analysis suggested a three factor solution in the present sample. Discussion: The ECR-RD 12 can be recommended as a screening measure for assessing attachment styles in inpatient psychotherapeutic settings. Further studies are required to investigate the factor structure of the measure in clinical samples.

Typical symptom change patterns and their predictors in patients with social anxiety disorder: A latent class analysis

OBJECTIVES

The use of trajectories and analysis of change patterns is a promising way toward better differentiation of subgroups in psychotherapy studies. Research on change patterns in social anxiety disorder (SAD) are still rare, although SAD is one of the most common mental disorders. In a secondary analysis of data from the SOPHO-NET-trial (ISRCTN53517394) this study aimed to investigate change patterns and their predictors in a sample of SAD patients.

METHODS

Patients with SAD (N = 357) were randomly assigned to cognitive-behavioral or psychodynamic therapy. The Liebowitz Social Anxiety Scale (LSAS) was assessed at 1^st session (pre), 8th session, 15th session and at the end of treatment (post). We used latent state variables and latent class analysis for the classification of change patterns and logistic regression for the identification of different predictors.

RESULTS

Analyses revealed three typical patterns: (i.) responders with a high initial impairment (N = 57), (ii.) responders with a moderate initial impairment (N = 225), and (iii.) patients with a high initial impairment and no remission (N = 75). Among other significant predicators, patient´s attachment anxiety and therapeutic alliance at session eight contributed to the prediction of change patterns.

DISCUSSION

Psychotherapy of SAD should consider patient's attachment and focus on the establishment of a solid therapeutic alliance in an early therapy stage.

Personality functioning in anxiety disorders

PURPOSE OF REVIEW

The alternative model for personality disorders in DSM-5 and the upcoming ICD-11 stimulated an increased interest in the concept of personality functioning for the diagnosis of personality disorders. Furthermore, the impact of personality functioning on other mental disorders has become the focus of recent research efforts. The purpose of this review is to provide a comprehensive and critical study of the empirical literature on the relationship between personality functioning and anxiety disorders.

RECENT FINDINGS

Recent studies predominantly show a positive association of anxiety symptoms and disorders with an impairment in personality functioning. However, no evidence was found for different levels of personality functioning according to the type of anxiety disorder. Anxiety disorders can occur at all levels of personality organization.

SUMMARY

Anxiety disorders are associated with significant impairment in personality functioning. As the underlying personality structure is known to play a crucial role for treatment outcome, the evaluation of personality functioning should be a central part of a comprehensive diagnostic process and treatment planning in patients with anxiety disorders.

Symptombezogene Subgruppen von Patienten mit agoraphobischer Angst

Zusammenfassung. Theoretischer Hintergrund: Bisher ist wenig über symptombezogene Teilgruppen von Patient_innen mit agoraphobischer Angst über die Betrachtung als mit oder ohne Panikstörung hinausgehend bekannt. So sind existierende Behandlungsprogramme meist nicht modularisiert und berücksichtigen die möglicherweise vorhandenen spezifischen Bedarfe kaum. Daher untersuchten wir die Frage, welche Subgruppen anhand von symptombezogenen Variablen identifiziert werden können. Methode: N = 290 Patient_innen mit SKID-Diagnose Agoraphobie mit oder ohne Panikstörung, in einer auf die Behandlung von Angststörungen spezialisierten universitären Tagesklinik, wurden anhand von Skalenwerten des Fragebogens zu angstbezogenen Kognitionen (ACQ) sowie der Panik- und Agoraphobie-Skala (PAS) mittels einer Clusteranalyse nach dem Ward-Verfahren mit anschließender k-means-Optimierung nach inhaltlicher Interpretierbarkeit gruppiert. Die Validität wurde am externen Kriterium „Therapieerfolg“ geprüft. Ergebnisse: Neben zwei Subgruppen mit sehr hoher ( n = 67) und sehr niedriger ( n = 56) Symptomausprägung auf sämtlichen Skalen, wurden zwei qualitativ-symptomatisch differentielle Subtypen identifiziert: der Typus „Körperliche Befürchtungen“ ( n = 81) und der Typus „Verhaltenskontrollverlust“ ( n = 86). Letztere zeigten keine Unterschiede im Therapieerfolg. Schlussfolgerungen: Die Identifikation spezifischer Patient_innengruppen impliziert spezifische Therapiebedarfe und -erwartungen über das Vorliegen einer Paniksymptomatik hinaus. Es zeigte sich, dass der individuellen agoraphobischen Befürchtung bei den unterschiedlichen Patient_innengruppen besondere Bedeutung zukommt, weswegen diese bei der Therapieplanung besondere Beachtung erfahren sollte.

Genetics of response to cognitive behavior therapy in adults with major depression: a preliminary report

Major depressive disorder is heritable and a leading cause of disability. Cognitive behavior therapy is an effective treatment for major depression. By quantifying genetic risk scores based on common genetic variants, the aim of this report was to explore the utility of psychiatric and cognitive trait genetic risk scores, for predicting the response of 894 adults with major depressive disorder to cognitive behavior therapy. The participants were recruited in a psychiatric setting, and the primary outcome score was measured using the Montgomery Åsberg Depression Rating Scale-Self Rated. Single-nucleotide polymorphism genotyping arrays were used to calculate the genomic risk scores based on large genetic studies of six phenotypes: major depressive disorder, bipolar disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, intelligence, and educational attainment. Linear mixed-effect models were used to test the relationships between the six genetic risk scores and cognitive behavior therapy outcome. Our analyses yielded one significant interaction effect (B = 0.09, p < 0.001): the autism spectrum disorder genetic risk score correlated with Montgomery Åsberg Depression Rating Scale-Self Rated changes during treatment, and the higher the autism spectrum disorder genetic load, the less the depressive symptoms decreased over time. The genetic risk scores for the other psychiatric and cognitive traits were not related to depressive symptom severity or change over time. Our preliminary results indicated, as expected, that the genomics of the response of patients with major depression to cognitive behavior therapy were complex and that future efforts should aim to maximize sample size and limit subject heterogeneity in order to gain a better understanding of the use of genetic risk factors to predict treatment outcome.

The Relationship between Adult Attachment and Mental Health Care Utilization: A Systematic Review

OBJECTIVE

Several studies have shown a relationship between individual attachment and various aspects of treatment utilization in individuals with medical problems as well as mental health disorders. This review systematically evaluates existing literature targeting the relationship between attachment and all aspects of treatment utilization, such as engagement, participation, and completion, in adults with mental health problems.

METHOD

A computerized search of PsycINFO, Medline, Embase, PubMed, and Healthstar and a manual search were employed. Of 5733 titles, 105 abstracts were selected. Of these, 18 studies met full inclusion criteria. The quality of studies was evaluated and scored according to 9 characteristics.

RESULTS

Most studies supported an association between attachment and treatment engagement and participation. In general, attachment anxiety was associated with higher engagement and participation in services while attachment avoidance was associated with less. Data regarding attachment dimensions and treatment completion were less conclusive.

CONCLUSIONS

The review suggests a clear relationship between attachment and stages of treatment engagement and participation in a variety of psychiatric populations and treatments. The 2 attachment dimensions appear to have opposite effects, with possible risks for either treatment over- or underutilization. Clinical implications are discussed.

Metacognitive Therapy for Depression Reduces Interpersonal Problems: Results From a Randomized Controlled Trial

Interpersonal problems are significantly elevated in patients with depression. Metacognitive therapy (MCT) for depression does not address interpersonal problems but is associated with large reduction in depressive symptoms. The main aim of the current study was to explore whether MCT leads to improvements in interpersonal problems in patients with depression. The study was a waitlist controlled trial and assessments took place at pre- and post-treatment as well as 6-month follow-up. At pre-treatment, the sample had more interpersonal problems compared to samples from other studies of psychiatric outpatients. MCT was associated with large reductions in interpersonal problems. Level of interpersonal problems were not related to poorer treatment response. MCT, which does not directly target interpersonal problems, worked well for patients with depression and interpersonal problems. Future research should compare MCT with other evidence-based treatments for patients with depression and interpersonal problems.

Associations between socioeconomic status and psychological therapy outcomes: A systematic review and meta-analysis

BACKGROUND

Socioeconomic deprivation is associated with higher prevalence of mental health problems; however, the influence of socioeconomic status (SES) on psychological therapy outcomes is as yet unclear.

AIM

To review published evidence on the association between indicators of SES (income, education, employment, neighborhood deprivation, social position) and the outcomes of psychological interventions for depression and anxiety.

METHODS

Systematic review and meta-analysis of outcomes research studies published in the last 10 years.

RESULTS

Seventeen studies including 165,574 patients measured at least one indicator of SES and its relationship with psychological therapy outcomes. Twelve of these studies found significant relationships between SES measures and mental health outcomes. Six studies focusing on employment status offered sufficient quantitative information to conduct meta-analysis. The overall effect of employment was not significant (-0.66, confidence of interval (CI) -1.33, 0.02). A sensitivity analysis (k = 5) showed a small effect (-0.22, CI -0.36, -0.09) of employment on treatment outcomes.

CONCLUSIONS

There is some evidence to indicate that socioeconomic deprivation is associated with poorer treatment outcomes, although limitations of the available data warrant treating this as a preliminary conclusion.

Changes of attachment characteristics during psychotherapy of patients with social anxiety disorder: Results from the SOPHO-Net trial

Objectives

Within a randomized controlled trial contrasting the outcome of manualized cognitive-behavioral (CBT) and short term psychodynamic therapy (PDT) compared to a waiting list condition (the SOPHO-Net trial), we set out to test whether self-reported attachment characteristics change during the treatments and if these changes differ between treatments.

Research design and methods

495 patients from the SOPHO-Net trial (54.5% female, mean age 35.2 years) who were randomized to either CBT, PDT or waiting list (WL) completed the partner-related revised Experiences in Close Relationships Questionnaire (ECR-R) before and after treatment and at 6 and 12 months follow-up. The Liebowitz Social Anxiety Scale (LSAS) was administered at pre-treatment, post-treatment, and at 6-month and 1-year follow-up. ECR-R scores were first compared to a representative healthy sample (n = 2508) in order to demonstrate that the clinical sample differed significantly from the non-clinical sample with respect to attachment anxiety and avoidance.

Results

LSAS scores correlated significantly with both ECR-R subscales. Post-therapy, patients treated with CBT revealed significant changes in attachment anxiety and avoidance whereas patients treated with PDT showed no significant changes. Changes between post-treatment and the two follow-ups were significant in both conditions, with minimal (insignificant) differences between treatments at the 12- month follow-up.

Conclusions

The current study supports recent reviews of mostly naturalistic studies indicating changes in attachment as a result of psychotherapy. Although there were differences between conditions at the end of treatment, these largely disappeared during the follow-up period which is line with the other results of the SOPHO-NET trial.

Trial registration

Controlled-trials.com ISRCTN53517394

Methodenpapier zur Koordination der Datenerhebung und -auswertung an Hochschul- und Ausbildungsambulanzen für Psychotherapie (KODAP)

Zusammenfassung. Die Forschung an psychotherapeutischen Hochschulambulanzen (HSA) leistet einen entscheidenden Beitrag zur Behandlung von Menschen mit psychischen Störungen und zur Weiterentwicklung und wissenschaftlichen Fundierung von Psychotherapie im Kindes-, Jugend- und Erwachsenenalter. Durch das im Jahr 2013 gestartete Projekt zur Koordination der Datenerhebung und -auswertung an Forschungs- und Ausbildungsambulanzen für Psychotherapie (KODAP) sollen unter der Trägerschaft des Verbundes universitärer Ausbildungsgänge für Psychotherapie unith.ev ab 2018 jährlich relevante Daten aus den teilnehmenden HSA aggregiert und gemeinsam ausgewertet werden. Im vorliegenden Beitrag beschreiben wir die mit dem Projekt im Zusammenhang stehenden rechtlichen, methodischen und durchführungstechnischen Herausforderungen sowie den derzeitigen Stand des Kooperationsprojektes, einschließlich einer für das Jahr 2017 geplanten Pilotstudie.

Emotion regulation related neural predictors of cognitive behavioral therapy response in social anxiety disorder

Social anxiety disorder (SAD) is characterized by aberrant prefrontal activity during reappraisal, an adaptive cognitive approach aimed at downregulating the automatic response evoked by a negative event. Cognitive behavioral therapy (CBT) is first-line psychotherapy for SAD, however, many remain symptomatic after treatment indicating baseline individual differences in neurofunctional activity may factor into CBT outcome. An emotion regulation strategy practiced in CBT is cognitive restructuring, a proxy for reappraisal. Therefore, neural response during reappraisal may serve as a brain-based predictor of CBT success. Prior to 12weeks of individual CBT, 34 patients with SAD completed a validated emotion regulation task during fMRI. Task instructions included 'Reappraise,' that is, use a cognitive approach to reduce affective state to a negative image, which was contrasted with looking at a negative image ('Look'). Regression results for Reappraise (vs. Look) revealed greater reduction in symptom severity was predicted by less pre-CBT activation in the dorsolateral prefrontal cortex (DLPFC). Regarding predictive validity, DLPFC significantly classified responder status. Post-hoc analysis revealed DLPFC activity, but not demographic data, baseline clinical measures, or reappraisal-related affective state during fMRI, significantly accounted for the variance in symptom reduction. Findings indicate patients with SAD are more likely to benefit from CBT if there is less pre-treatment DLPFC recruitment, a region strongly implicated in emotion regulation. Patients with reduced baseline frontal activation when reappraising negative stimuli may be especially helped by explicit cognitive interventions. Further research is necessary to establish DLPFC as a stable brain-based marker of treatment outcome.

A systematic review of adult attachment and social anxiety

BACKGROUND

Attachment has been implicated in the development of social anxiety. Our aim was to synthesise the extant literature exploring the role of adult attachment in these disorders.

METHOD

Search terms relating to social anxiety and attachment were entered into MEDLINE, PsycINFO and Web of Science. Risk of bias of included studies was assessed using and adapted version of the Agency for Healthcare Research and Quality assessment tool. Eligible studies employed validated social anxiety and attachment assessments in adult clinical and analogue samples. The review included cross sectional, interventional and longitudinal research.

RESULTS

Of the 30 identified studies, 28 showed a positive association between attachment insecurity and social anxiety. This association was particularly strong when considering attachment anxiety. Cognitive variables and evolutionary behaviours were identified as potential mediators, concordant with psychological theory.

LIMITATIONS

Due to a lack of longitudinal research, the direction of effect between attachment and social anxiety variables could not be inferred. There was substantial heterogeneity in the way that attachment was conceptualised and assessed across studies.

CONCLUSIONS

The literature indicates that attachment style is associated with social anxiety. Clinicians may wish to consider attachment theory when working clinically with this population. In the future, it may be useful to target the processes that mediate the relationship between attachment and social anxiety.

Transfer of manualized Short Term Psychodynamic Psychotherapy (STPP) for social anxiety disorder into clinical practice: results from a cluster-randomised controlled trial

BACKGROUND

Despite growing evidence for manualized psychodynamic treatments, there is a lack of studies on their transfer to routine practice. This is the first study to examine the effects of an additional training in manualized Short Term Psychodynamic Psychotherapy (STPP) on the outcome in routine psychotherapy for social anxiety disorder (SAD). The study is an extension to a large RCT comparing STPP to Cognitive-Behavioral Therapy of SAD.

METHODS

The manualized treatment was designed for a time limited approach with 25 individual sessions of STPP over 6 months. Private practitioners were randomized to training in manualized STPP (mSTPP) vs. treatment as usual without a specific training (tauSTPP). A total of 109 patients were enrolled (105 started treatment; 75 completed at least 20 treatment sessions). Assessments were conducted pre-treatment, after 8 and 15 weeks, after 25 treatment sessions, at the end of treatment, 6 and 12 months after termination of treatment. Remission as primary outcome was defined by the Liebowitz-Social-Anxiety-Scale (LSAS) score ≤30. Secondary outcomes were response (at least 31% reduction in LSAS), treatment duration and number of sessions, changes in social anxiety (LSAS, SPAI), depression (BDI), clinical global impression (CGI), and quality of life (EQ-5D).

RESULTS

Remission rates of mSTPP (9%) resp. tauSTPP (16%) and also response rates of 33% resp. 28% were comparable between the two treatment approaches as well as treatment duration and number of sessions. Most of the within-group differences (baseline to 25 sessions) indicated moderate to large improvements in both treatments; within-group differences from baseline to 12 months follow-up (LSAS, SPAI, BDI, CGI) were large ranging from d = -0.605 to d = -2.937. Benefits of mSTPP were limited to single outcomes.

CONCLUSIONS

Findings are discussed with regard to implementation and dissemination of empirically validated treatments in psychodynamic training and practice. SAD patients with a high comorbidity of personality disorders and a long treatment history may need longer treatments.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00000570 , registered 03. March 2011.

Low pre-treatment end-tidal CO2 predicts dropout from cognitive-behavioral therapy for anxiety and related disorders

Recent clinical trial research suggests that baseline low end-tidal CO₂ (ETCO₂, the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO₂ among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO₂, and respiration rate (the first minute was analyzed). Lower ETCO₂ was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO₂ significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO₂ significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO₂ patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO₂ is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO₂ might benefit from additional intervention that targets respiratory abnormality.

Long-term cost-effectiveness of cognitive behavioral therapy versus psychodynamic therapy in social anxiety disorder

BACKGROUND

To determine the cost-effectiveness of cognitive behavioral therapy (CBT) versus psychodynamic therapy (PDT) in the treatment of social anxiety disorder after a follow-up of 30 months from a societal perspective.

METHODS

This analysis was conducted alongside the multicenter SOPHO-NET trial; adults with a primary diagnosis of social anxiety disorder received CBT (n = 209) or PDT (n = 207). Data on health care utilization and productivity loss were collected at baseline, after 6 months (posttreatment), and three further follow-ups to calculate direct and indirect costs. Anxiety-free days (AFDs) calculated based on remission and response were used as measure of effect. The incremental cost-effectiveness ratio (ICER) was determined. Net benefit regressions, adjusted for comorbidities and baseline differences, were applied to derive cost-effectiveness acceptability curves.

RESULTS

In the descriptive analysis, the unadjusted ICER favored CBT over PDT and the adjusted analysis showed that CBT's cost-effectiveness relative to PDT depends on the willingness to pay (WTP) per AFD. As baseline costs differed substantially the unadjusted estimates might be deceptive. If additional WTPs for CBT of €0, €10, and €30 were assumed, the probability of CBT being cost-effective relative to PDT was 65, 83, and 96%. Direct costs increased compared to baseline across groups, whereas indirect costs did not change significantly. Results were sensitive to considered costs.

CONCLUSIONS

If the society is willing to pay ≥€30 per additional AFD, CBT can be considered cost-effective, relative to PDT, with certainty. To further increase the cost-effectiveness more knowledge regarding predictors of treatment outcome seems essential.

Do Patient Characteristics Predict Outcome of Psychodynamic Psychotherapy for Social Anxiety Disorder?

OBJECTIVES

Little is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder.

RESEARCH DESIGN AND METHODS

In the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions.

RESULTS

Pre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not.

CONCLUSIONS

We argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research.

TRIAL REGISTRATION

Controlled-trials.com/ISRCTN53517394.