Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension

Race Matters in Assessment of Familial Criticism

Introduction: Two findings in the Expressed Emotion (EE) literature fail to hold for Black psychiatric patients: EE (predominantly criticism) fails to predict treatment outcome, and measures of EE fail to correlate with patients' perceptions of relatives' criticism. To understand these findings, we tested whether non-Black coders of observable criticism (a) rate Black relatives higher in criticism than White relatives, or (b) are generally less accurate when rating Black relatives. Method: Familial dyads [31 Black; 87 White] participated in video recorded problem-solving interactions. Each interaction was reliably coded for observed criticism by two-four non-Black coders; participants rated perceived criticism (the criterion measure) post-interaction. Results: Coders were less accurate in rating criticism from Black than White relatives. Discussion: These data suggest patients' ratings of perceived criticism might be the measure of choice for identification of Black families who should be engaged in the treatment process to help reduce criticism-associated treatment failure

Expressed emotion and long-term outcome among adolescents with anorexia nervosa

OBJECTIVE

The purpose of the current study is to examine expressed emotion (EE) and long-term treatment outcome among adolescents participating in a randomized controlled trial (RCT) for treatment of anorexia nervosa (AN). It was hypothesized that patients with high EE parents at baseline would show more severe symptoms at end-of-treatment, 12-month follow-up, and 4-year follow-up than patients from low EE families.

METHOD

Secondary data analysis was conducted of original RCT data from a two-site eating disorder treatment trial conducted in the United States. Participants were 121 adolescents with AN who completed measures of EE, eating disorder psychopathology, depression, and self-esteem.

RESULTS

Generalized estimating equations showed that participants who were in the Low EE group achieved a more accelerated drop in depression scores in the context of treatment (first 12 months) than participants in the High EE group. No other significant Group × Time interactions were found.

DISCUSSION

Findings suggest that high parental EE at baseline does not indicate that adolescent patients with AN will fare poorly 4 years later.

Testing Clinical Intuitions About Barriers to Improvement in Cognitive-Behavioral Therapy for Panic Disorder

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians' beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians' intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = -0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = -.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

Social criticism moderates the relationship between anxiety and depression 10 years later

BACKGROUND

Research has consistently documented anxiety and depression as bidirectional risk factors for one another. However, little research investigates the sequential comorbidity of anxiety and depression over lengthy durations, and the influence of contextual variables on this relationship have not been fully empirically investigated.

METHOD

The current study examined perceived social criticism as a moderator of the relationship between a history of anxiety and a past 12-month depressive episode at least 10 years later (and vice versa) utilizing the National Comorbidity Survey Baseline (N = 8,098) and Re-interview data (N = 5,001). History of anxiety and depressive diagnoses were assigned at Wave 1, past year diagnosis at Wave 2, and perceived social criticism was assessed at Wave 1.

RESULTS

Structural equation modeling indicated that when controlling for a Wave 1 latent depression factor, a positive relationship between Wave 1 latent anxiety and a Wave 2 latent depression emerged for those endorsing higher perceived social criticism from friends and relatives, respectively. Unexpectedly, when controlling for Wave 1 latent anxiety, a negative relationship between Wave 1 latent depression and Wave 2 latent anxiety emerged for those endorsing higher perceived social criticism from friends, but no relationship when moderated by perceived social criticism from relatives.

LIMITATIONS

Perceived social criticism was self-reported, which may introduce self-perception bias.

CONCLUSIONS

Results identified perceived social criticism as an important moderator in the sequential comorbidity of anxiety and depression over a long period of time.

Comparative clinical trials in psychotherapy: Have large effects been replicated?

AIMS

The purpose of this review is to examine the replication attempts of psychotherapy clinical trials for depression and anxiety. We focus specifically on replications of trials that exhibit large differences between psychotherapies. The replicability of these trials is especially important for meta-analysis, where the inclusion of false-positive trials can lead to erroneous conclusions about treatment efficacy.

METHODS

Standard replication criteria were developed to distinguish direct from conceptual replication methodologies. Next, an exhaustive literature search was conducted for published meta-analyses of psychotherapy comparisons. Trials that exhibited large effects (d > 0.8) were culled from these meta-analyses. For each trial, a cited replication was conducted to determine if the trial had been subsequently replicated by either 'direct' or 'conceptual' methods. Finally, a broader search was conducted to examine the extent of replication efforts in the psychotherapy literature overall.

RESULTS

In the meta-analytic search, a total of N = 10 meta-analyses met the inclusion criteria. From these meta-analyses, N = 12 distinct trials exhibited large effect sizes. The meta-analyses containing more than two large effect trials reported evidence for treatment superiority. A cited replication search yielded no direct replication attempts (N = 0) for the trials with large effects, and N = 4 conceptual replication attempts of average or above average quality. However, of these four attempts, only two partially corroborated the results from their original trial.

CONCLUSION

Meta-analytic reviews are influenced by trials with large effects, and it is not uncommon for these reviews to contain several such trials. Since we find no evidence that trials with such large effects are directly replicable, treatment superiority conclusions from these reviews are highly questionable. To enhance the quality of clinical science, the development of authoritative replication criteria for clinical trials is needed. Moreover, quality benchmarks should be considered before trials are included in a meta-analysis, or replications are attempted.

Social Anxiety Disorder and Perceived Criticism in Intimate Relationships: Comparisons With Normal and Clinical Control Groups

Individuals with social anxiety disorder (SAD) have difficulties in their romantic relationships, including decreased satisfaction and intimacy, but the reasons for these difficulties are poorly understood. Because fear of negative evaluation is a cardinal feature of SAD, perceived criticism from a romantic partner may play a central role in socially anxious individuals' relationships. In the present study, we compared levels of perceived, expressed, and observed criticism and reactions to criticism among individuals with SAD and their partners (n = 21), individuals with other anxiety disorders and their partners (n = 35), and couples free of psychopathology (n = 30). Participants rated both global criticism and criticism during a 10-minute problem-solving task, which was also coded for criticism by observers. Individuals with anxiety disorders showed elevated levels of interaction-specific perceived criticism, expressed criticism, and upset and stress due to criticism relative to normal controls; they also reported that the interaction was more stressful. However, there were no group differences on global measures of criticism, and the two anxious groups did not differ on any measures. Findings suggest that the high levels of criticism anxious individuals perceive and their corresponding negative reactions to criticism, though not specific to SAD, may account for some of the relationship difficulties that have been identified in SAD. Results also indicate that anxious individuals may contribute to their relationship difficulties by being highly critical themselves. Overall, our findings point to the need for a clinical focus on decreasing perceived criticism among individuals with anxiety disorders.

Social support, negative social exchange, and response to case formulation-based cognitive behavior therapy

We investigated associations between pretreatment social support, negative social exchange, and slope of weekly symptom change for depression, anxiety, and stress over the course of ideographic, case formulation-based, cognitive behavior therapy. Participants were 74 adults treated in a private practice setting. We used self-report measures to assess social support and negative social exchange at intake and to assess symptoms on a weekly basis. At pretreatment, a higher level of social support was associated with lower levels of depression, and a higher level of negative social exchanges was associated with higher levels of depression and stress. Pretreatment social support was not significantly associated with slope of symptom change. However, a higher level of pretreatment negative social exchanges was associated with steeper slope of change in symptoms of depression and stress during treatment. These findings suggest that the association between pretreatment negative social exchanges and subsequent symptoms may be stronger than that of social support and subsequent symptoms. Additionally, we discuss the possibility that having data on negative social exchanges at the start of treatment may benefit the outcome of ideographic, case formulation-based, cognitive behavior therapy.

Perceived Criticism in the Treatment of a High-Risk Adolescent

Perceived criticism (PC) is a construct that plays a key role in family relationships of persons with psychiatric disorders. It can be assessed in a brief and simple way using the Perceived Criticism Measure. PC ratings made by patients about their caregivers predict adverse clinical outcomes including increases in symptoms and relapse across a broad range of psychiatric diagnoses. Although research supports the concurrent and predictive validity of PC, the measure is not widely used in clinical practice. Here, we describe the construct of PC and review evidence supporting its clinical utility. We then illustrate how criticism and perceptions of criticism can be addressed in a clinical context, describing a family focused treatment approach used with a depressed adolescent at high risk for bipolar disorder.