Whatever happened to symptom substitution?

The 'revolving door' of mental illness: A meta-analysis and systematic review of current versus lifetime rates of psychological disorders

OBJECTIVES

Therapists have long observed a phenomenon referred to as the 'revolving door' of mental health services, in which individuals often develop, seek treatment for, and recover from multiple mental illnesses across their life. However, this has not been systematically examined. If this phenomenon is widespread, one would expect that the number of lifetime disorders would exceed that of current disorders. The aim of this meta-analysis was to test this hypothesis.

METHODS

A search was conducted of the following databases: MEDLINE, PsycINFO and Web of Science. In total, 38 studies were included in the current review; 27 of these contained sufficient quantitative data to be included in the meta-analysis, addressing the primary research aim. The remaining 11 studies were included in the systematic review only.

RESULTS

Meta-analyses of the 27 studies indicated that the average number of lifetime disorders was 1.84 times that of current disorders. Previous treatment significantly moderated this relationship, while the clinical nature of the sample did not. Examination of the remaining studies revealed common temporal sequences, indicating disorders which typically develop first or consequently to other disorders.

CONCLUSIONS

These findings provide support for the revolving door of mental illness, suggesting a need for transdiagnostic treatments and broader conceptualisation of relapse prevention.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond

BACKGROUND

Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however.

AIMS

In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment.

METHOD

The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general.

CONCLUSION

Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

Network Analysis of Psychopathology: Controversies and Challenges

Empirical publications inspired by the network approach to psychopathology have increased exponentially in the twenty-first century. The central idea that an episode of mental disorder arises from causal interactions among its symptomatic elements has especially resonated with those clinical scientists whose disenchantment with traditional categorical and dimensional approaches to mental illness has become all too apparent. As the field has matured, conceptual and statistical concerns about the limitations of network approaches to psychopathology have emerged, inspiring the development of novel methods to address these concerns. Rather than reviewing the vast empirical literature, I focus instead on the issues and controversies regarding this approach and sketch directions where the field might go next.

Eating disorder recovery is associated with absence of major depressive disorder and substance use disorders at 22-year longitudinal follow-up

BACKGROUND

Psychiatric comorbidity is common in eating disorders (EDs) and associated with poor outcomes, including increased risk for relapse and premature death. Yet little is known about comorbidity following ED recovery.

METHODS

We examined two common comorbidities, major depressive disorder (MDD) and substance use disorder (SUD), in adult women with intake diagnoses of anorexia nervosa and bulimia nervosa who participated in a 22-year longitudinal study. One hundred and seventy-six of 228 surviving participants (77.2%) were interviewed 22 years after study entry using the Eating Disorders Longitudinal Interval Follow-up Evaluation to assess ED recovery status. Sixty-four percent (n = 113) were recovered from their ED. The Structured Clinical Interview for DSM-IV was used to assess MDD and SUD at 22 years.

RESULTS

At 22-year follow-up, 28% (n = 49) met criteria for MDD, and 6% (n = 11) met criteria for SUD. Those who recovered from their ED were 2.17 times more likely not to have MDD at 22-year follow-up (95% CI [1.10, 4.26], p = .023) and 5.33 times more likely not to have a SUD at 22-year follow-up than those who had not recovered from their ED (95% CI [1.36, 20.90], p = .008).

CONCLUSION

Compared to those who had not fully recovered from their ED, those who had recovered were twice as likely not to be diagnosed with MDD in the past year and five times as likely not to be diagnosed with SUDs in the past year. These findings provide evidence that long-term recovery from EDs is associated with recovery from or absence of these common major comorbidities. Because comorbidity in EDs can predict poor outcomes, including greater risk for relapse and premature death, our findings of reduced risk for psychiatric comorbidity following recovery at long-term follow-up is cause for optimism.

Cognitive Behavioral and Psychodynamic Therapies: Points of Intersection and Divergence

Cognitive behavioral therapy (CBT) and psychodynamic therapy (PDT) are two major paradigms in the mental health care field. The present article reviews broad similarities and differences between each tradition while acknowledging that such generalizations may overlook heterogeneity within each. However, it is believed that a comparison between CBT and PDT is beneficial in dispelling myths about each tradition, fostering dialogue, encouraging further scholarship and research. While not an exhaustive account, this article will examine how CBT and PDT differ in how they view several topics such as the unconscious, the therapeutic alliance, the role of homework, symptom reduction, and therapeutic heuristics. Commentary is also offered on how research may be more effectively and collaboratively integrated with clinical work from both traditions. Future directions for partnership and improving mental health treatments are also discussed.

An Empirical Examination of Symptom Substitution Associated With Behavior Therapy for Tourette's Disorder

Over the past six decades, behavior therapy has been a major contributor to the development of evidence-based psychotherapy treatments. However, a long-standing concern with behavior therapy among many nonbehavioral clinicians has been the potential risk for symptom substitution. Few studies have been conducted to evaluate symptom substitution in response to behavioral treatments, largely due to measurement and definitional challenges associated with treated psychiatric symptoms. Given the overt motor and vocal tics associated with Tourette's disorder, it presents an excellent opportunity to empirically evaluate the potential risk for symptom substitution associated with behavior therapy. The present study examined the possible presence of symptom substitution using four methods: (a) the onset of new tic symptoms, (b) the occurrence of adverse events, (c) change in tic medications, and (d) worsening of co-occurring psychiatric symptoms. Two hundred twenty-eight participants with Tourette's disorder or persistent motor or vocal tic disorders were randomly assigned to receive behavioral therapy or supportive therapy for tics. Both therapies consisted of eight sessions over 10 weeks. Results indicated that participants treated with behavior therapy were not more likely to have an onset of new tic symptoms, experience adverse events, increase tic medications, or have an exacerbation in co-occurring psychiatric symptoms relative to participants treated with supportive therapy. Further analysis suggested that the emergence of new tics was attributed with the normal waxing and waning nature of Tourette's disorder. Findings provide empirical support to counter the long-standing concern of symptom substitution in response to behavior therapy for individuals with Tourette's disorder.

“I Don't Remember Dying”. A Case Study of the Resolution of Chronic Pain Utilising Medical Hypnoanalysis

While chronic pain is a major challenge to clinicians, advances in epigentics and analytical hypnotherapy provide both an understanding of how they develop and the means to bring relief. Many of these conditions are based on faulty subconscious belief systems as a result of early life imprints — particularly in reference to spiritual issues. A brief explanation of Medical Hypnoanalysis and its usefulness is provided in a case history in which the underlying dynamics are discussed and followed to a successful outcome.

Changes in alcohol intake in response to transdiagnostic cognitive behaviour therapy for eating disorders

OBJECTIVE

The aim of this study was to examine how alcohol intake changes during and after transdiagnostic cognitive behaviour therapy for eating disorders (CBT-E). Additionally, the paper considers the relationship between alcohol consumption, eating disorder diagnosis and current major depressive episode at the time of first assessment.

METHOD

One hundred and forty nine outpatients with an eating disorder (body mass index over 17.5) were divided into high or low alcohol intake groups (HIG and LIG) according to their intake at pre-treatment assessment. Their alcohol intake and eating disorder psychopathology were examined over the course of treatment and follow-up.

RESULTS

There was no difference between the groups on response of the eating disorder to treatment. The HIG significantly reduced their alcohol intake following treatment whilst the intake of the LIG remained stable over the course of treatment and follow-up. There were no group differences in major depression and overall severity of eating disorder at baseline.

CONCLUSIONS

The response to CBT-E was not influenced by baseline level of alcohol use. The mean alcohol intake of the heavy drinking subjects decreased without being specifically addressed by the treatment.

An evidence-based causal model of panic disorder

Recently, Fava and Morton (2009) described what they termed a 'causal model' of panic disorder (Causal modeling of panic disorder theories, Clinical Psychology Review, 29, 623-637). We examined several critical tenets of this proposed model, and offer significant revisions. Our revised causal model includes elements that have received empirical support, and exclude those with known limitations in explaining the etiology and treatment of panic disorder. Chief among these revisions are (1) an increased emphasis on anxiety sensitivity, (2) elimination of the more general psychodynamic conceptualization in favor of empirically supported findings regarding early attachment, and (3) placing biological and psychophysiological reactions as outcomes of false alarm threat, rather than causal mechanisms of panic.