Comorbidity and the treatment of principal anxiety disorders in a naturalistic sample

Psychological interventions for generalized anxiety disorder: Effects and predictors in a naturalistic outpatient setting

OBJECTIVE

Numerous randomized controlled trials (RCTs) demonstrate the efficacy of cognitive behavioral therapy (CBT), metacognitive therapy (MCT), and methods to reduce intolerance of uncertainty (IU-CBT) in the treatment of generalized anxiety disorder (GAD). However, few studies have investigated these treatments under conditions of routine clinical care. The main objective of this study was to investigate the effectiveness of psychotherapy for GAD in an outpatient setting and to identify factors influencing treatment outcome.

METHODS

Fifty-nine GAD patients received naturalistic CBT (including MCT and IU-CBT) in an outpatient clinic and postgraduate training center for psychotherapy. Patients completed self-report questionnaires at the beginning and end of therapy regarding the main outcome worry as well as metacognitions, intolerance of uncertainty, depression, and general psychopathology.

RESULTS

Worry, negative metacognitions, intolerance of uncertainty, depression, and general psychopathology decreased significantly (p's < .001) with large effect sizes for all symptoms (d = 0.83-1.49). A reliable change in the main outcome worry was observed in 80% of patients, and recovery occurred in 23%. Higher worry scores at posttreatment were predicted by higher pretreatment scores, female sex, and less change in negative metacognitive beliefs during treatment.

CONCLUSIONS

Naturalistic CBT for GAD appears to be effective in routine clinical care for worry as well as depressive symptoms, with particular benefits associated with altering negative metacognitions. However, a recovery rate of only 23% is lower than the rates reported in RCTs. Treatment needs to be improved, especially for patients with more severe GAD and for women.

κ Opioid Receptor-Dynorphin Signaling in the Central Amygdala Regulates Conditioned Threat Discrimination and Anxiety

Neuropeptides within the central nucleus of the amygdala (CeA) potently modulate neuronal excitability and have been shown to regulate conditioned threat discrimination and anxiety. Here, we investigated the role of κ opioid receptor (KOR) and its endogenous ligand dynorphin in the CeA for regulation of conditioned threat discrimination and anxiety-like behavior in mice. We demonstrate that reduced KOR expression through genetic inactivation of the KOR encoding gene, Oprk1, in the CeA results in increased anxiety-like behavior and impaired conditioned threat discrimination. In contrast, reduction of dynorphin through genetic inactivation of the dynorphin encoding gene, Pdyn, in the CeA has no effect on anxiety or conditioned threat discrimination. However, inactivation of Pdyn from multiple sources, intrinsic and extrinsic to the CeA phenocopies Oprk1 inactivation. These findings suggest that dynorphin inputs to the CeA signal through KOR to promote threat discrimination and dampen anxiety.

Anxiety sensitivity and emotion regulation as mechanisms of successful CBT outcome for anxiety-related disorders in a naturalistic treatment setting

BACKGROUND

Numerous randomized controlled trials (RCTs) have examined the efficacy of cognitive behavioral therapy (CBT) in reducing anxiety symptoms. However, relatively fewer studies have examined the effectiveness of CBT in naturalistic treatment settings. There is even less known about the mechanisms underlying successful outcomes in naturalistic samples receiving CBT. This study aimed to examine the absolute and relative mediation of emotion regulation (ER) difficulties and anxiety sensitivity (AS) on anxiety symptom reduction.

METHODS

Participants were treatment-seeking patients (N = 247) at an outpatient anxiety clinic. Measures of difficulties in ER, AS, and disorder specific symptoms were administered at baseline, mid, and post-treatment. A composite anxiety score was calculated to measure anxiety disorder symptom severity across anxiety-related diagnoses.

RESULTS

Individual mediation models revealed that both AS and ER significantly mediated the reduction in anxiety-related symptoms over the course of treatment. A multiple mediation model found that ER was the strongest mediator (indirect effect = -1.030, 95% CI = -2.172 to -0.153). Further analyses revealed that the ER subscale of impulse control difficulties (e.g., the tendency to avoid when confronted with a feared stimulus) was the strongest mediator (indirect effect = -0.849, 95% CI = -1.913 to -0.081).

LIMITATIONS

This study relied solely on self-report measures of ER, AS, and anxiety pathology, and did not have a control group.

CONCLUSIONS

These results suggest that improvement in the ability to control impulses may act as a mechanism of anxiety symptom reduction and may be important to target in CBT with naturalistic samples.

Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders

OBJECTIVE

This study aimed to examine whether the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy for emotional disorders (i.e., anxiety, mood, and related disorders), is efficacious in the treatment of co-occurring emotional disorders compared to established single disorder protocols (SDPs) that target specific disorders (e.g., panic disorder).

METHOD

Participants included 179 adults seeking outpatient psychotherapy. Participant age ranged from 18 to 66 years, with an average of 30.66 years (SD = 10.77). The sample was 55% female and mostly Caucasian (83%). Diagnostic assessments were completed with the Anxiety Disorder Interview Schedule (ADIS), and disorder-specific, clinician-rated measures for the comorbid diagnoses of interest.

RESULTS

In both treatment conditions, participants' mean number of diagnoses dropped significantly from baseline to posttreatment, and baseline to 12-month follow-up. Additionally, large effects were observed for changes in comorbid generalized anxiety (ESSG: UP = -1.72; SDP = -1.98), social anxiety (ESSG: UP = -1.33, -0.86; SDP = -1.60, -1.54), and depression (ESSG: UP = -0.83; SDP = -0.84). Significant differences were not observed in between-group comparisons.

CONCLUSIONS

Results suggest that both the UP and SDPs are efficacious in reducing symptoms of comorbid emotional disorders. The clinical, practical, and cost-effective advantages of transdiagnostic CBT are discussed.

Secondary depression in transdiagnostic group cognitive behavioral therapy among individuals diagnosed with anxiety disorders

Anxiety and depression co-occur at high rates, and their comorbidity typically creates a more severe clinical presentation then either alone. The effect of comorbid depression appears to vary across anxiety and related disorders. Transdiagnostic treatments present a promising option to improve comorbid conditions by targeting shared factors (e.g., information processing biases). The purpose of this study was to examine the reciprocal effects of secondary depression in transdiagnostic group cognitive behavioral therapy for anxiety (TGCBT). 120 individuals diagnosed with a primary anxiety disorder, 42 of whom had a depressive diagnosis, were enrolled in 12 weeks of TGCBT. Depressed individuals were compared to those without a depressive diagnosis on both clinician-rated and self-reported anxiety and depression following TGCBT. Although depressed individuals scored higher on most indices of anxiety at pre-treatment, both groups improved similarly with some evidence of greater improvement among those with comorbid depression. All individuals improved in self-reported depressive symptoms and comorbid depression improved to subclinical levels. These results posit TGCBT as an effective, efficient option for treating patients with anxiety and comorbid depression.

Transdiagnostic group CBT vs. standard group CBT for depression, social anxiety disorder and agoraphobia/panic disorder: Study protocol for a pragmatic, multicenter non-inferiority randomized controlled trial

BACKGROUND

Transdiagnostic Cognitive Behavior Therapy (TCBT) manuals delivered in individual format have been reported to be just as effective as traditional diagnosis specific CBT manuals. We have translated and modified the "The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders" (UP-CBT) for group delivery in Mental Health Service (MHS), and shown effects comparable to traditional CBT in a naturalistic study. As the use of one manual instead of several diagnosis-specific manuals could simplify logistics, reduce waiting time, and increase therapist expertise compared to diagnosis specific CBT, we aim to test the relative efficacy of group UP-CBT and diagnosis specific group CBT.

METHODS/DESIGN

The study is a partially blinded, pragmatic, non-inferiority, parallel, multi-center randomized controlled trial (RCT) of UP-CBT vs diagnosis specific CBT for Unipolar Depression, Social Anxiety Disorder and Agoraphobia/Panic Disorder. In total, 248 patients are recruited from three regional MHS centers across Denmark and included in two intervention arms. The primary outcome is patient-ratings of well-being (WHO Well-being Index, WHO-5), secondary outcomes include level of depressive and anxious symptoms, personality variables, emotion regulation, reflective functioning, and social adjustment. Assessments are conducted before and after therapy and at 6 months follow-up. Weekly patient-rated outcomes and group evaluations are collected for every session. Outcome assessors, blind to treatment allocation, will perform the observer-based symptom ratings, and fidelity assessors will monitor manual adherence.

DISCUSSION

The current study will be the first RCT investigating the dissemination of the UP in a MHS setting, the UP delivered in groups, and with depressive patients included. Hence the results are expected to add substantially to the evidence base for rational group psychotherapy in MHS. The planned moderator and mediator analyses could spur new hypotheses about mechanisms of change in psychotherapy and the association between patient characteristics and treatment effect.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02954731 . Registered 25 October 2016.

Toward a Unified Treatment for Emotional Disorders: Update on the Science and Practice

Mental health professionals have long been concerned with describing and proscribing a structure around the myriad variations of psychological and emotional distress that are deemed to be disordered. This has frequently been characterized as a conflict between so-called "lumpers" and "splitters"-those who advocate broad categorizations based on overarching commonalities versus those who endeavor toward a highly refined structure emphasizing unique characteristics. Many would argue that with the era of the modern Diagnostic and Statistical Manual of Mental Disorders (DSM-III to DSM-5), a splitting ideology has been dominant despite re-emerging concerns that some groups of diagnoses, particularly disorders of anxiety and other emotions, may be more similar than different. As a result of such concerns, transdiagnostic or unified models of psychopathology have burgeoned. In this review, we describe the work of Barlow, Allen, and Choate (2004), whose invited paper "Toward a Unified Treatment for Emotional Disorders" reignited transdiagnostic perspectives of emotional disorders. We provide an update on the scientific models and evidence-based treatments that have followed in the wake of this 2004 publication, including key areas for future study in the advancement of transdiagnostic and unified treatment of emotional disorders.

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.

Parental Involvement in Intensive Treatment for Adolescent Panic Disorder and Its Impact on Depression

The present study investigated whether an 8-day intensive treatment for panic disorder in adolescents conferred a corollary benefit of ameliorating symptoms of depression. Participants included 57 adolescents between the ages of 11 and 18 who were randomly assigned to an intensive panic treatment for adolescents with or without parental involvement. Paired samples t tests and hierarchical linear models (HLM) indicated that participants' total depression score and scores on depression subscales declined from baseline to the 3-month follow-up. Additional HLM analyses indicated that the interaction term between age and parent involvement was a significant moderator in the negative slope for adolescent depression, with younger participants benefitting more from treatment without parent involvement than older participants with regard to depression symptoms.

A Dutch version of the Overall Anxiety Severity and Impairment Scale (OASIS): Psychometric properties and validation

BACKGROUND

The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that can be used to assess the impact of any anxiety disorder or multiple anxiety disorders. Prior US investigations have shown the OASIS to be a reliable and valid measure. To date the OASIS has not been validated for use in a Dutch sample of anxiety disordered patients.

METHODS

The present study assessed the psychometric properties of a Dutch version of the OASIS in a clinical sample of anxiety patients. Latent structure, internal consistency, convergent and discriminant validity, and cutoff score analyses were conducted. Results were compared to those obtained from a clinical sample of patients with psychiatric diagnoses other than anxiety disorders.

RESULTS

Principal component analysis supported a unidimensional structure. The five OASIS items loaded strongly on a single factor (eigenvalue=3.682, loadings=.80-.89) which accounted for 73.65% of the variance, and had a high degree of internal consistency (Cronbach׳s α=91). OASIS scores demonstrated robust correlations with other measures of anxiety, neuroticism and general distress. Correlations with unrelated constructs were weak. Mean score (8.46) and cutoff score of the Dutch sample of anxiety patients were lower than scores previously found in American samples. A cutoff score of 5 correctly classified 82.5% of this sample as having an anxiety disorder diagnosis or not. An improvement of 4 points is indicative of a clinically significant change.

LIMITATIONS

This study mainly relied on self-report measures in order to assess validity. Other types of measures should be used in future studies.

CONCLUSIONS

The Dutch version of the OASIS showed good reliability and validity. Its brevity and sound psychometric properties make it a good instrument for screening and assessment purposes in the field of anxiety disorders.

Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement

OBJECTIVE

The present study explored treatment dose and patient engagement as predictors of treatment outcome in cognitive behavioral therapy (CBT) for anxiety disorders.

METHOD

Measures of high versus low treatment dose and high versus low patient engagement in CBT were compared as predictors of 12- and 18-month outcomes for patients being treated for anxiety disorders with CBT (with or without concurrent pharmacotherapy) in primary care settings as part of a randomized controlled effectiveness trial of the Coordinated Anxiety Learning and Management (CALM) intervention. Measures of dose (attendance, exposure completion) and engagement in CBT (homework adherence, commitment) were collected throughout treatment, and blinded follow-up phone assessments of outcome measures (12-item Brief Symptom Inventory, Patient Health Questionnaire 8, Sheehan Disability Scale) were completed at 12 and 18 months. Propensity score weighting controlled for baseline differences in demographics and symptom severity between patients with high and low dose and engagement. These analyses included the 439 patients who selected CBT as treatment modality.

RESULTS

Completing exposures, having high attendance, and being more adherent to completing homework predicted better outcomes across all measures at 12 and 18 months, and high CBT commitment predicted better outcomes on all measures at 18 months.

CONCLUSIONS

This study found that higher treatment dose and patient engagement in CBT for anxiety disorders were stable and robust predictors of greater reductions in anxiety symptoms, depression symptoms, and functional disability.

Effect of transdiagnostic cbt for anxiety disorders on comorbid diagnoses

OBJECTIVE

The present study examines the effectiveness of a 12-week transdiagnostic cognitive-behavioral group in reducing comorbid diagnoses.

METHOD

Data from 79 treatment completers (60.8% women; M age = 32.57 years) during three previous trials of transdiagnostic cognitive behavior therapy (CBT) were examined to compare treatment effects between those with and without comorbid diagnoses. Additionally, rates of remission of comorbid diagnoses were compared to published diagnosis-specific CBT trials.

RESULTS

Results indicate that a majority of clients (64.6%) had at least one comorbid disorder and that those with comorbid diagnoses had higher primary diagnosis severity scores than did those without comorbid diagnoses. The presence of a comorbid diagnosis at pretreatment was not associated with differential improvement in primary diagnosis severity following treatment. Two-thirds of completers with comorbid diagnoses at pretreatment (66.7%) no longer met criteria for a clinically severe comorbid diagnosis at posttreatment, a rate higher than that associated with most trials of diagnosis-specific CBT for anxiety disorders used as benchmarks.

CONCLUSIONS

These results suggest that transdiagnostic cognitive-behavioral group treatment for anxiety may be associated with greater decreases in comorbidity than traditional diagnosis-specific CBT.

Flexible Application of Interoceptive and Situational Exposure-Based Treatment for an Outpatient With Multiple Anxiety and Mood Disorders

Cognitive-behavioral therapy (CBT) is efficacious and effective in the treatment of anxiety disorders. However, few guidelines exist on how to efficiently provide CBT when comorbidity is present. Given that anxiety disorders may share underlying mechanisms of maintenance, targeting such mechanisms may be fruitful when working with individuals who suffer from extensive anxiety-related comorbidity. The present study describes an interoceptive and situational exposure-based treatment with a 40-year-old outpatient whose presentation was complicated by multiple anxiety disorders and related difficulties. A comprehensive assessment monitored mechanisms targeted in treatment, symptoms associated with clinical diagnoses, and related impairment. Treatment gains were clinically and statistically significant. Improvements were maintained 1-month post-treatment. These results add to the growing literature focused on transdiagnostic interventions that successfully target broad-based mechanisms of maintenance for multiple types of psychopathology. Theoretical and technical issues related to this type of intervention are discussed throughout the article.

An open trial investigation of a transdiagnostic group treatment for children with anxiety and depressive symptoms

The current study investigates the feasibility and preliminary outcomes associated with a transdiagnostic emotion-focused group protocol for the treatment of anxiety disorders and depressive symptoms in youth. Twenty-two children (ages 7 to 12; M=9.79) with a principal anxiety disorder and varying levels of comorbid depressive symptoms were enrolled in an open trial of the Emotion Detectives Treatment Protocol (EDTP; Ehrenreich-May & Bilek, 2009), an intervention adapted from existent unified protocols for the treatment of emotional disorders among adults and adolescents. Results indicate that participants experienced significant improvements in clinician-rated severity of principal anxiety disorder diagnoses (d=1.38), the sum of all anxiety and depressive disorder severity ratings (d=1.07), and child-reported anxiety (d=0.47) and parent-reported depressive symptoms (d=0.54) at the posttreatment assessment. EDTP had good retention rates and reports of high satisfaction. Thus, preliminary evidence suggests that EDTP is a feasible and potentially efficacious treatment of youth anxiety disorders and co-occurring depressive symptoms. Children experiencing a range of internalizing symptoms may benefit from this more generalized, emotion-focused treatment modality, as it offers flexibility to families and the mental health clinician, while maintaining a concurrent focus on the provision of cognitive-behavioral treatment skills vital to the amelioration of anxiety and depressive disorder symptoms in youth.

Depression does not affect the treatment outcome of CBT for panic and agoraphobia: results from a multicenter randomized trial

BACKGROUND

Controversy surrounds the questions whether co-occurring depression has negative effects on cognitive-behavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology.

METHODS

Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional).

RESULTS

Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression.

CONCLUSIONS

Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology.

Trauma reactivation under the influence of propranolol: an examination of clinical predictors

BACKGROUND

In two recent studies conducted by our group, a treatment combining propranolol with a brief reactivation session subsequently reduced posttraumatic stress disorder (PTSD) symptom severity and diagnosis, as well as reducing psychophysiological responses during trauma-related script-driven imagery. One likely explanation for those results is that memory reconsolidation was blocked by propranolol.

OBJECTIVE

We explored the influence of various predictors on treatment outcome (i.e., PTSD severity), and whether the treated individuals improved in other important domains of functioning associated with PTSD.

METHOD

Thirty-three patients with longstanding PTSD participated in a 6-week open-label trial consisting of actively recalling one's trauma under the influence of propranolol, once a week.

RESULTS

Treated patients reported a better quality of life, less comorbid depressive symptoms, less negative emotions in their daily life and during trauma recollections. Women were also found to improve more than men. Type of trauma (childhood vs. adulthood), time elapsed since trauma, borderline personality traits, depressive symptoms severity, Axis I comorbidity, and age did not influence treatment outcome.

CONCLUSION

These results must await publication of a randomized-controlled trial to further delineate effectiveness with this novel treatment approach.

Psychotherapies for comorbid anxiety in bipolar spectrum disorders

BACKGROUND

Comorbid anxiety disorders are highly prevalent in bipolar disorder and have been shown to have serious negative impacts on the course of illness. The pharmacological treatment of anxiety can interact with the bipolar disorder and has not been proven effective. As such, many have recommended the psychological treatment of anxiety. This paper reviews the literature on psychological treatments for anxiety comorbid to bipolar disorder.

METHOD

The Medline, PsychInfo and Web of Science databases were thoroughly examined for relevant treatment studies.

RESULTS

Despite frequent recommendations in the literature, surprisingly few have studied the psychological treatment of comorbid anxiety in bipolar disorders. Nevertheless, preliminary results suggest that comorbid anxiety disorders can be effectively treated in a bipolar clientele using cognitive-behavioral therapy, mindfulness-based cognitive-behavioral therapy or relaxation training. In contrast, interpersonal, family therapy and psychoeducation alone would not seem to be beneficial treatment alternatives for anxiety. Cognitive-behavioral therapy appears to reduce the symptoms of obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder and general symptoms of anxiety among patients with bipolar disorder. However, the long-term maintenance of anxiety treatment effects may be somewhat reduced and adaptations may be called for to augment and sustain benefits.

CONCLUSIONS

There is an urgent need for randomized controlled trials of different forms of psychotherapy for anxiety disorders comorbid to bipolar disorder. Until such trials are available, the most promising approach would appear to be the sequential or modular CBT-based treatment of the anxiety disorder.

Perceived Causal Relations

Researchers have argued that the investigation of causal interrelationships between symptoms may help explain the high comorbidity rate between certain psychiatric disorders. Clients’ own attributions concerning the causal interrelationships linking the co-occurrence of their symptoms represent data that may inform their clinical case conceptualization, treatment, and psychological theory regarding the etiology of comorbid disorders. The present study developed and evaluated a novel psychological assessment methodology for measuring Perceived Causal Relations (PCR) and examined its psychometric properties as applied to the question of whether posttraumatic stress and anxiety symptoms represent causal risk factors for depressive symptoms in 225 undergraduates. Participants attributed their symptoms of anxiety and posttraumatic reexperiencing as significant causes of their depressive symptoms. Exploratory analyses identified a listing of symptoms reliably attributed as significant causes of other symptoms and functional impairment, as well as a listing of symptoms reliably attributed as significant effects (outcomes) of other symptoms and functional impairment. The PCR method has promise as an idiographic approach to assessing the causes and consequences of comorbid psychiatric symptoms and associated functional impairment. Research is required to assess the relevance and replicate these findings in distinct psychiatric groups experiencing various symptomatic presentations. Future research may also examine PCR ratings associating other individual differences, for example, between measures of history (e.g., life events), life choices, and personality.

Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity

OBJECTIVES

To compare quality of life (QoL) in mental health outpatients to non-clinical norms, and examine the associations between QoL and principal diagnosis, number of comorbid Axis I diagnoses, and type of comorbidity.

METHODS

Consecutively referred and assessed patients (n = 2024) formed the study sample pool. Of these, 1486 individuals who had completed a QoL instrument at intake and had a principal diagnosis amenable to comparison by group analysis were included in the study. Principal diagnoses were unipolar mood disorder (n = 687), eating disorder (n = 226), bipolar disorder (n = 165), social anxiety disorder (n = 165), generalized anxiety disorder (n = 125), and panic disorder (n = 118). QoL for psychiatric groups was compared to non-clinical norms using a valid and reliable measure.

RESULTS

QoL was significantly impaired in all psychiatric groups compared to nonclinical norms. There was a significant interaction between principal diagnosis and number of comorbid Axis I disorders, controlling for age, sex, marital status, employment, and years of school. The addition of one comorbidity significantly attenuated QoL in social anxiety disorder, panic disorder, and bipolar disorder. For all other conditions, a significant loss in QoL occurred with two or more comorbidities. Axis I depressive and anxiety comorbidity significantly attenuated QoL across all diagnostic groups.

CONCLUSIONS

QoL is significantly impaired in psychiatric outpatients and diagnostic groups vary in the extent to which they experience additional QoL burden with increasing comorbidities.

Predictors of treatment outcome in modular cognitive therapy for obsessive-compulsive disorder

BACKGROUND

The present study sought to identify predictors of outcome for a comprehensive cognitive therapy (CT) developed for patients with obsessive-compulsive disorder (OCD).

METHODS

Treatment was delivered over 22 sessions and included standard CT methods, as well as specific strategies designed for subtypes of OCD including religious, sexual, and other obsessions. This study of 39 participants assigned to CT examined predictors of outcomes assessed on the Yale-Brown Obsessive Compulsive Scale. A variety of baseline symptom variables were examined as well as treatment expectancy and motivation.

RESULTS

Findings indicated that participants who perceived themselves as having more severe OCD at baseline remained in treatment but more severe symptoms were marginally associated with worse outcome for those who completed therapy. Depressed and anxious mood did not predict post-test outcome, but more Axis I comorbid diagnoses (mainly major depression and anxiety disorders), predicted more improvement, as did the presence of sexual (but not religious) OCD symptoms, and stronger motivation (but not expectancy). A small rebound in OCD symptoms at 1-year follow-up was significantly predicted by higher scores on personality traits, especially for schizotypal (but not obsessive-compulsive personality) traits.

CONCLUSIONS

Longer treatment may be needed for those with more severe symptoms at the outset. CT may have positive effects not only on OCD symptoms but also on comorbid depressive and anxious disorders and associated underlying core beliefs. Findings are discussed in light of study limitations and research on other predictors.