An Exposure-Based Cognitive-Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy

OBJECTIVE

Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design.

METHOD

N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive-behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms.

RESULTS

No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > -0.04, ps < .011, Cohen's d range: -0.33 to -0.98). Treatment gains were maintained at follow-up (all βs(39) < -0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure.

CONCLUSIONS

Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.

Boredom Susceptibility and Quit Smoking: The Role of Anxiety Symptoms

Boredom is one of the main reported motives for smoking. However, scarce research has examined the relationship between boredom susceptibility and abstinence achievement in treatment-seeking smokers. The aim of this study is to examine the mediating effect of anxiety symptoms in the relationship between boredom susceptibility and abstinence at the end of a smoking cessation treatment. The sample was composed of 481 Spanish smokers who received a cognitive-behavioral treatment to quit (M_age= 45.51, SD = 11.16; 60.6% female). The Boredom Susceptibility subscale of the Sensation Seeking Scale Form-V and the Beck Anxiety Inventory were used. Pearson correlations and mediation analyses were conducted to examine the relationships between the study variables. Boredom susceptibility was significantly and positively correlated to anxiety symptoms, but not to abstinence. Anxiety symptoms were significantly and negatively correlated to abstinence. A significant indirect effect of boredom susceptibility on abstinence at the end of treatment through anxiety symptoms was found. There was no direct relation between boredom susceptibility and abstinence. These findings extend previous literature by showing that higher boredom susceptibility is associated with less likelihood to be abstinent at the end of the treatment through higher anxiety symptoms. These results highlight the relevance of considering the inclusion of boredom and anxiety management techniques in smoking cessation interventions.

[Effectiveness of a Multidimensional Psychotherapeutic Treatment for Kindergardeners and Preschoolers with Post-Traumatic Stress Disorder]

Despite the increased vulnerability of very young children when confronted with traumatic experiences, and also the massive impact on their development, this topic has been much neglected in German health care research so far; in fact trauma-related treatments are particularly low. Due to this, we are exploring in this pilot study the evaluation of a standard health care system in the community ("Trauma first") for very young children suffering from the impact of traumatic experiences. Our analysis looks at the effectiveness of a cognitivebehavioural treatment for the age group 2-6 suffering from trauma disorders. A pre-post test design without a control group was carried out.The severity of symptoms of 39 children (age: 2-6 years; 46.2 % female) with traumatic experiences was recorded using disorder-specific diagnostics and broad-spectrum diagnostics before and after the therapy treatment, and was both self-assessed and externally assessed. The results show a significant reduction in children's PTSD symptoms, and internalizing behaviour problems, and some regressive behaviours in the caregiver rating, but not in the education rating. The effect sizes were between Cohen's d = 0.89 and d = 2.71. With regard to externalizing behavior and anxiety symptoms, positive tendencies could be found after treatment, but there was no significant decrease. The present pilot study provides initial indications of the effectiveness of the "Trauma First" care programunder ecologically valid conditions in children between the ages of 2 and 6 years. It serves as a preliminary stage of analyzing the psychotherapeutic effectiveness of traumatherapy treatment in young children, which should be followed up by a randomized-controlled study design.

Daily drinking and social network interactions in network support treatment

OBJECTIVE

Social networks can be powerful determinants of drinking. Network Support (NS) treatment was designed to help persons with alcohol use disorder alter their social network to be more supportive of abstinence and less supportive of drinking. The present study was intended to determine how NS treatment altered behavior on a daily basis. It was expected that, relative to those treated in a packaged cognitive-behavioral treatment (PCBT), NS patients would report fewer daily contacts with drinking persons and increased contacts with nondrinking persons.

METHOD

Patients (N = 193) treated in our second NS trial provided daily recordings of drinks consumed, urge to drink, and self-efficacy for not drinking, as well as reports of associations with drinking and nondrinking friends, via an interactive voice response system. Daily recordings (N = 146) were collected during the first 6 months of the 27-month study. Multilevel modeling was used to analyze daily network variables over time by treatment. Time-varying effect model (TVEM) analyses were also conducted to assess the influence of daily-varying social contacts on daily drinking, drinking urges, and self-efficacy.

RESULTS

Consistent with hypotheses, NS patients reported significantly less daily drinking associated with contacts with drinkers than did PCBT patients. Patients in both treatments reported increases in self-efficacy and decreases in urges to drink over days as a function of contact with nondrinkers.

CONCLUSIONS

NS treatment was successful in helping patients change their social networks, as well as their responses to social influences, and those changes had effects on day-to-day drinking levels. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparative effectiveness of cognitive behavioral treatment, serotonin, and serotonin noradrenaline reuptake inhibitors for anxiety in children and adolescents: a network meta-analysis

AIM

Cognitive behavioral treatment (CBT) and selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for childhood anxiety disorders (ADs). The objective of this current analysis was to conduct a network meta-analysis to evaluate the comparative effectiveness of CBT, pharmacotherapy, and the combination of the two in treating pediatric ADs.

METHODS

The studies included consisted of randomized controlled trials evaluating non-selective serotonin reuptake inhibitors (e.g. clomipramine), SSRIs, selective noradrenaline reuptake inhibitors, CBT, or a combination of CBT and pharmacotherapy. Studies were eligible for inclusion if participants were 18 years or younger.

RESULTS

A total of 86 studies were included, with a total of 7594 participants, of which 41.51% were females. For remission, all three treatments were significantly more effective than both placebo (ORs ranging from 0.07 and 0.18) and wait-list (ORs ranging from 0.06 and 0.16). In terms of the severity of anxiety symptoms, all treatment forms were significantly more effective for reducing anxiety than wait-list (standardized mean differences (SMDs) ranging from 0.98 and 2.91). Only pharmacotherapy was significantly more effective in reducing anxiety symptoms than placebo (SMD = 2.01, 95% confidence interval, 1.02 to 3.01). Overall, the results demonstrate that CBT, pharmacotherapy, and their combination are effective treatments for childhood ADs. There was no significant difference between the three treatment forms. However, CBT was associated with lower attrition rates.

CONCLUSION

CBT, pharmacotherapy, and the combination of the two should all be considered to treat youths with ADs. However, potential risks and benefits should be considered before devising a treatment plan.

Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder

Sophisticated multicomponent treatments for adults with generalized anxiety disorder (GAD) have been developed over the past three decades. Although these comprehensive treatments have produced encouraging results, they appear to be less efficacious than treatments for other anxiety disorders. The goal of this randomized controlled trial is to test a newly developed, highly focused treatment for adults with GAD: Behavioral Experiments for Intolerance of Uncertainty. Sixty (60) participants (51 women, 9 men), with a mean age of 34.60 years (range: 19 to 67 years), were randomized to either treatment (n = 30) or wait-list control (n = 30). Treatment consisted of 12 weekly 1-hour sessions in which participants learned to use behavioral experiments to test their catastrophic beliefs about uncertainty. Assessments were conducted at pre-, mid- and postcondition, and at 6- and 12-month follow-up. The primary outcome was the severity of GAD, and secondary outcomes were worry, depression, somatic anxiety, and intolerance of uncertainty. Using growth curve modeling, we found that (1) the treatment group was superior to the wait-list group in terms of change from pre- to posttest on all outcomes; (2) the combined sample (once wait-listed participants received treatment) evidenced large and significant decreases on all outcomes; and (3) treatment gains were either maintained or increased over the 12-month follow-up period of the study. The new treatment is a promising treatment option for adults with GAD considering that it may be as efficacious as more comprehensive evidence-based psychological treatments for GAD.

Obsessive-Compulsive Disorder and Illness Anxiety: Examining Commonalities and Comorbidity

Obsessive-compulsive disorder (OCD) and illness anxiety disorder (IAD) often co-occur. Cognitive-behavioral models of both disorders overlap and include maladaptive attentional processes, misinterpretation of thoughts and physical sensations, and engagement in repetitive behaviors in an attempt to reduce associated distress. Given commonalities in their presentation and their common co-occurrence, it is important to understand how illness anxiety affects the presentation and treatment of OCD. In this article, theoretical conceptualizations of OCD and IAD and their comorbid presentation are outlined, and assessment and differential diagnosis of these conditions are discussed. Despite shared cognitive vulnerabilities and behavioral patterns, well-validated symptom measures, along with careful functional analysis, can be used to distinguish between OCD, IAD, and comorbid presentations. Best practices for the cognitive-behavioral treatment of these co-occurring conditions are also presented, with suggestions based on both the empirical literature and detailed case studies. Finally, recommendations for future research on co-occurring OCD and IAD and their treatment are explored.

An Internet-Based Multi-Approach Intervention Targeting University Students Suffering from Psychological Problems: Design, Implementation, and Evaluation

Despite the widespread prevalence of mental health problems, most psychological distress remains untreated. Internet-based psychological interventions can be an essential tool for increasing treatment availability and accessibility. The main objective of the MindBlooming project is to design and implement an innovative Internet-based multi-approach treatment for university students suffering from psychological or physical problems. The intervention will focus on symptoms of depression, anxiety, sleep problems, self-destructive thoughts, job- and study-related stress and burnout, and chronic pain. It will be based on different approaches, primarily psychoeducation, Cognitive-Behavioral Treatment (CBT), and third-wave CBT. At the end of the treatment, user satisfaction and usability will be assessed. In addition, two further aims will be evaluating the treatment efficacy through a randomized controlled trial and tuning a predictive model through Machine Learning techniques. The intervention consists of a 7-week treatment on two problematic areas according to each students’ personal needs, identified through an initial assessment. Besides the treatment assigned following the initial screening, participants will also be assigned to a different module to improve their relational skills. The treatment, which can be accessed through a mobile app, consists of psychoeducational videos followed by related exercises. We expect MindBlooming to be a remarkable tool for promoting the mental health of university students.

Estimated Intelligence Moderates Cognitive Processing Therapy Outcome for Posttraumatic Stress Symptoms

Although patient intelligence may be an important determinant of the degree to which individuals may comprehend, comply with, and ultimately benefit from trauma-focused treatment, no prior studies have examined the impact of patient intelligence on benefit from psychotherapies for PTSD. We investigated the degree to which educational achievement, often used as a proxy for intelligence, and estimated full scale intelligence quotient (FSIQ) scores themselves moderated treatment outcomes for two effective psychotherapies for PTSD: Cognitive Processing Therapy (CPT) and Written Exposure Therapy (WET). Participants, 126 treatment-seeking adults with PTSD (52% male; mean age = 43.9, SD = 14.6), were equally randomized to CPT and WET; PTSD symptom severity was measured at baseline and 6-, 12-, 24-, 36-, and 60-weeks following the first treatment session. Multilevel models revealed that participants with higher FSIQ scores experienced significantly greater PTSD symptom reduction through the 24-week assessment in CPT but not WET; this effect did not persist through the 60-week assessment. Educational achievement did not moderate symptom change through either 24- or 60-weeks. Individuals with higher FSIQ who are treated with CPT may experience greater symptom improvement in the early stages of recovery.

Examining How CBT Interventions for Anxious Youth Are Delivered Across Settings

Most efforts to assess treatment integrity-the degree to which a treatment is delivered as intended-have conflated content (i.e., therapeutic interventions) and delivery (i.e., strategies for conveying the content, such as modeling). However, there may be value in measuring content and delivery separately. This study examined whether the quantity (how much) and quality (how well) of delivery strategies for individual cognitive behavioral therapy (ICBT) for youth anxiety varied when the same evidence-based treatment was implemented in research and community settings. Therapists (N = 29; 69.0% White; 13.8% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.4% white; 52.9% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols for therapists were comparable across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess the quantity and quality of delivery of interventions found in ICBT approaches. Overall, both the quantity and quality of delivery of interventions found in ICBT approaches were significantly lower in the community settings. The extent to which didactic teaching, collaborative teaching, and rehearsal were used systematically varied over the course of treatment. In general, differences in the quantity and quality of delivery observed between settings held when differences in youth characteristics between settings were included in the model. Our findings suggest the potential relevance of measuring how therapists deliver treatment separate from the content.

Isolating the Effects of Mindfulness Training Across Anxiety Disorder Diagnoses in the Unified Protocol

The Unified Protocol for Transdiagnostic Treatment (UP; Barlow et al., 2011) has recently demonstrated statistically equivalent therapeutic effects compared to leading cognitive behavioral therapy (CBT) protocols for anxiety disorders designed to address disorder-specific symptoms (i.e., single-disorder protocols [SDP]); Barlow et al., 2017). Although all treatment protocols included similar evidence-based CBT elements, investigation of those related to symptom improvement in the UP is warranted. Because the UP is unique from the SDPs for its inclusion of mindfulness, the present study evaluated mindfulness as a primary treatment element. We explored whether UP participants, compared to SDP, demonstrated greater improvements in mindfulness from pre- to posttreatment, and whether these improvements predicted posttreatment severity across anxiety disorder diagnoses. Participants were individuals with a principle anxiety disorder (N = 179) randomized to receive either the UP or SDP. Results indicated significant improvements pre- to posttreatment in mindfulness for participants receiving either the UP or SDP. However, at posttreatment, mindfulness scores were significantly greater for the UP condition. At the diagnosis level, posttreatment scores in mindfulness were significantly greater in the UP condition than the respective SDP conditions for principal Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SOC). Moreover, results suggest that change in mindfulness is related to posttreatment severity, when moderated by treatment condition, but only for participants with principal GAD. Taken together, the UP is effective in improving mindfulness in a sample with heterogeneous anxiety disorders, but this change seems particularly relevant for reduction in symptom severity for individuals with principal GAD.

Specific Relapse Predictors: Could Cognitive-Behavioral Treatment for Smoking Cessation Be Improved?

Relapse remains a frequent and complex phenomenon that is not yet well understood. An under-researched area of study that may provide relevant information concerns the assessment of specific post-treatment variables, rather than the composite measures commonly used to predict smoking relapse. The current study sought to examine the effects of post-treatment smoking-related variables, including withdrawal symptomatology, abstinence self-efficacy, and smoking urgency in negative-affect situations and smoking relapse at the 3 month follow-up. The sample comprised 130 participants who achieved abstinence for at least 24 h through a cognitive-behavioral smoking cessation treatment. Regression analysis was conducted for both composite measures and specific subscales and items. Data showed that composite measures of tobacco withdrawal, self-efficacy, and smoking urgency in negative-affect situations were not significant predictors of smoking relapse. However, the analysis including subscales, and specific items showed that lower self-efficacy in negative-affect-related situations (OR = 1.36) and three withdrawal symptoms—irritability/frustration/anger (OR = 2.99), restlessness/impatience (OR = 1.87), and craving (OR = 2.31)—were significant predictors of relapse. These findings offer new insights into the role of different smoking-related post-treatment variables in short-term relapse. Considering and specifically targeting these variables after achieving abstinence may potentially contribute to reducing smoking relapse.

Development and Preliminary Evaluation of a Positive Emotion Regulation Augmentation Module for Anxiety and Depression

Research has shown that positive emotions are important to optimal health, functioning, and well-being, and contribute to resilience against psychological dysfunction. Many clinical disorders, particularly anxiety and mood disorders, are associated with deficits in positive emotion that may contribute to disorder severity and prevent full recovery, and these deficits have received insufficient attention in treatment. The present study represents a preliminary evaluation of the feasibility and utility of adding a novel brief intervention module for enhancing positive emotion in anxiety and depressive disorders to existing evidence-based treatment. This intervention was evaluated in nine patients with a range of principal anxiety disorders who had previously completed an initial course of cognitive-behavioral treatment, utilizing a multiple baseline experimental-across-participants design. Results indicated that the intervention was effective in improving positive emotion regulation skills for five of nine participants. The intervention was also associated with further improvements in anxiety and depressive symptoms, positive and negative emotion, functioning, quality of life, and well-being. Participants reported high acceptability and satisfaction with the study intervention. Future research is needed to confirm the validity of these findings and evaluate the generalizability of these effects across patients and settings.

The global therapist competence scale for youth psychosocial treatment: Development and initial validation

OBJECTIVE

We describe the development and initial psychometric properties of the observer-rated Global Therapist Competence Scale for Youth Psychosocial Treatment (G-COMP) in the context of cognitive-behavioral treatment (CBT) for youth anxiety disorders.

METHOD

Independent coders rated 744 sessions from a sample of 68 youth (mean age = 10.56 years) using the G-COMP and the instruments of alliance, involvement, CBT adherence, CBT competence.

RESULTS

Inter-rater reliability coefficients, ICC(2,2), were greater than .60 for the 5 G-COMP domain scores. G-COMP scores yielded small to medium correlations with instruments of alliance (rs = .17-.44) and youth involvement in treatment (rs = .08-.53), and medium to large correlations with instruments of CBT competence and adherence (rs = .26-.63). Therapists in the research setting were rated higher compared to newly trained therapists in community clinics.

CONCLUSION

Preliminary reliability and validity of the G-COMP are promising, but future research is needed with non-CBT samples.

Assessing Therapist Competence: Development of a Performance-Based Measure and Its Comparison With a Web-Based Measure

BACKGROUND

Recent research interest in how best to train therapists to deliver psychological treatments has highlighted the need for rigorous, but scalable, means of measuring therapist competence. There are at least two components involved in assessing therapist competence: the assessment of their knowledge of the treatment concerned, including how and when to use its strategies and procedures, and an evaluation of their ability to apply such knowledge skillfully in practice. While the assessment of therapists' knowledge has the potential to be completed efficiently on the Web, the assessment of skill has generally involved a labor-intensive process carried out by clinicians, and as such, may not be suitable for assessing training outcome in certain circumstances.

OBJECTIVES

The aims of this study were to develop and evaluate a role-play-based measure of skill suitable for assessing training outcome and to compare its performance with a highly scalable Web-based measure of applied knowledge.

METHODS

Using enhanced cognitive behavioral therapy (CBT-E) for eating disorders as an exemplar, clinical scenarios for role-play assessment were developed and piloted together with a rating scheme for assessing trainee therapists' performance. These scenarios were evaluated by examining the performance of 93 therapists from different professional backgrounds and at different levels of training in implementing CBT-E. These therapists also completed a previously developed Web-based measure of applied knowledge, and the ability of the Web-based measure to efficiently predict competence on the role-play measure was investigated.

RESULTS

The role-play measure assessed performance at implementing a range of CBT-E procedures. The majority of the therapists rated their performance as moderately or closely resembling their usual clinical performance. Trained raters were able to achieve good-to-excellent reliability for averaged competence, with intraclass correlation coefficients ranging from .653 to 909. The measure was also sensitive to change, with scores being significantly higher after training than before as might be expected (mean difference 0.758, P<.001) even when taking account of repeated data (mean difference 0.667, P<.001). The major shortcoming of the role-play measure was that it required considerable time and resources. This shortcoming is inherent in the method. Given this, of most interest for assessing training outcome, scores on the Web-based measure efficiently predicted therapist competence, as judged by the role-play measure (with the Web-based measure having a positive predictive value of 77% and specificity of 78%).

CONCLUSIONS

The results of this study suggest that while it was feasible and acceptable to assess performance using the newly developed role-play measure, the highly scalable Web-based measure could be used in certain circumstances as a substitute for the more labor-intensive, and hence, more costly role-play method.

Commentary: Development of a new, much-needed, cognitive-behavioral intervention for adolescents with ADHD - a reflection on Sprich et al. (2016)

Adolescents with attention deficit hyperactivity disorder (ADHD) can be challenging to treat. often, they are resistant to taking medication. Furthermore, the behavioral and cognitive-behavioral interventions developed for children and adults with ADHD, are not appropriate or are not effective for adolescents. Thus, this study, showing the effectiveness of a cognitive-behavioral treatment (CBT) program specifically designed for adolescents, represents an important step forward. Methodological strengths include a wait-list control group and outcome ratings by a blind evaluator. We look forward to further development of this treatment, particularly a trial in adolescents not concomitantly medicated for ADHD and comparison to an active control group.

Residential cognitive-behavioral weight-loss intervention for obesity with and without binge-eating disorder: A prospective case-control study with five-year follow-up

OBJECTIVE

The aim of this prospective case-control study was to compare the long-term effects of a residential cognitive-behavioral treatment (CBT) for weight loss in severely obese patients with and without binge-eating disorder (BED).

METHODS

We assessed weight-loss outcomes and psychological impairment in 54 severely obese female patients with BED and 54 patients matched by age, gender, and body mass index (BMI) without BED admitted to a residential CBT program. Body weight was measured at baseline and at 6-month follow-up and was reported by patients in a telephone interview at 5-year follow-up. Depression, eating disorder psychopathology, general psychopathology, and quality of life were assessed using validated instruments at baseline and at 6-month follow-up.

RESULTS

Obese patients with and without BED had similar weight loss at 6-month and 5-year follow-ups. Although both groups showed improved psychosocial variables, at 6 months the BED group maintained higher psychological impairment. Nevertheless, at 5-year follow-up more than half of the BED participants were no longer classifiable as having BED.

DISCUSSION

The presence of BED does not affect weight-loss outcome in obese patients treated with the residential CBT for weight loss program considered. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:723-730).

A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

OBJECTIVE

The aim of this study is to conduct a preliminary examination of long-term outcomes on a broad range of affective disorder symptoms treated with a newly developed intervention: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP).

METHOD

Maintenance of treatment gains at long-term follow-up (LTFU) were explored in patients (N=15, mean age=32.27; 60% female) who completed a clinical trial of the UP.

RESULTS

Treatment gains observed at 6-month follow-up (6MFU) on measures of clinical severity, general symptoms of depression and anxiety, and a measure of symptom interference in daily functioning were largely maintained 12months later (at an average of 18months posttreatment), and any significant changes from 6MFU to LTFU reflected small increases in symptoms that remained, on average, in the subclinical range.

CONCLUSIONS

These findings provide the first initial support for the durability of broad treatment gains following transdiagnostic treatment.

Individual Versus Individual and Group Therapy Regarding a Cognitive-Behavioral Treatment for Battered Women in a Community Setting

The current study aimed to test the clinical effectiveness of a cognitive-behavioral therapy (CBT) program for battered women in a community setting and to find out whether effectiveness of individual therapy can be improved in conjunction with group therapy. One hundred sixteen treatment-seeking battered women were assigned either to CBT on an individual basis or an individual and group basis. Psychological treatment, focused on post-traumatic stress disorder (PTSD), emotional discomfort, and impaired functioning, comprised a 17-session program, including emotional expression, psychoeducation, trauma re-exposure, coping skills, and problem-solving training. Although most treated patients in both groups improved in all variables (PTSD, emotional discomfort, and impaired functioning) at all assessments, the combined individual and group therapy did better than the individual therapy regarding PTSD symptoms and impaired functioning at follow-up assessments. These findings partially support the beneficial effects of group CBT as adjunctive therapy to individual CBT. Implications of this study for clinical practice and future research in this field are commented on.

Piloting a cognitive-behavioral intervention for family members living with individuals with severe mental disorders

Living with a person who experiences mental health problems can have an adverse effect on well-being. The aim of this study is to evaluate the effectiveness of a psychological treatment for relatives of people with mental health problems, byusing an interrupted time-series design. The sample comprised 20 individuals, who completed assessment measures at baseline and 6 months later. Sixteen of these participants then received the treatment and were assessed again at the end of the program. There were no significant changes in outcomes between the baseline and the second assessments done 6 months later and there were significant improvements in well-being following treatment The program shows promise as a treatment for relatives of people with mental health problems and therefore warrants further evaluation in more controlled studies.

Short-term cognitive-behavioral treatment in multicultural primary care of patients with longstanding backache

The efficacy of cognitive-behavioral therapy in multi-cultural primary care patients with longstanding backache is not evaluated. The purpose of this study was to investigate the outcome of a four weekly-treatment given by primary care physicians regarding pain-related worry, depression and severe pain and to determine which social, clinical or gender factors were associated with outcome.The study group consisted of 245 patients in consecutive order from 19 countries, 18 to 45 years, entering rehabilitation program because of longstanding backache. Prevalences of pain-related worry and depression and severe pain was counted and compared before and after. Logistic regression was used to calculate the odds (OR; 95% CI) for persistent pain-related worry and/or persistent depression and severe pain (VAS ≥ 50). The prevalences of pain-related worry and depression were both significantly lower after treatment (pain-related worry 83% before vs. 38% after; depression 43% before vs. 31% after). Also the number of patients scoring ≥ 50 VAS was a little, but significantly, fewer (68% vs. 61%). Use of interpreter doubled the risk of having persistent pain-related worry (OR 2.1; 95% CI 1.1-4.1) but the risk was not significant regarding persistent depression (OR 1.8; 0.6-5.4). The rating of VAS rating ≥ 50 after treatment was twice as high, OR 2.3 (95% CI 1.1-4.6) in the 38-45 year old age group. To conclude, a focus on pain ideas reduced pain-related worry and depression in these patients with various sociocultural backgrounds and longstanding backache.

Behavioral management of night eating disorders

Night eating syndrome (NES) is a form of disordered eating associated with evening hyperphagia (overeating at night) and nocturnal ingestions (waking at night to eat). As with other forms of disordered eating, cognitive and behavioral treatment modalities may be effective in reducing NES symptoms. This review presents evidence for a variety of behavioral treatment approaches, including behavioral therapy, phototherapy, behavioral weight loss treatment, and cognitive-behavioral therapy. A more detailed overview of cognitive-behavioral therapy for NES is provided. All of these studies have been case studies or included small samples, and all but one have been uncontrolled, but the outcomes of many of these approaches are promising. Larger randomized controlled trials are warranted to advance NES treatment literature. With the inclusion of NES in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a “Feeding or Eating Disorder Not Elsewhere Classified,” more sophisticated, empirically-supported, behaviorally-based treatment approaches are much needed.

Therapy of the burnout syndrome

Background

The prevalence, diagnostics and therapy of the burnout syndrome are increasingly discussed in the public. The unclear definition and diagnostics of the burnout syndrome are scientifically criticized. There are several therapies with unclear evidence for the treatment of burnout in existence.

Objectives

The health technology assessment (HTA) report deals with the question of usage and efficacy of different burnout therapies.

Methods

For the years 2006 to 2011, a systematic literature research was done in 31 electronic databases (e.g. EMBASE, MEDLINE, PsycINFO). Important inclusion criteria are burnout, therapeutic intervention and treatment outcome.

Results

17 studies meet the inclusion criteria and are regarded for the HTA report. The studies are very heterogeneous (sample size, type of intervention, measuring method, level of evidence). Due to their study design (e.g. four reviews, eight randomized controlled trials) the studies have a comparable high evidence: three times 1A, five times 1B, one time 2A, two times 2B and six times 4. 13 of the 17 studies are dealing with the efficacy of psychotherapy and psychosocial interventions for the reduction of burnout (partly in combination with other techniques). Cognitive behaviour therapy leads to the improvement of emotional exhaustion in the majority of the studies. The evidence is inconsistent for the efficacy of stress management and music therapy. Two studies regarding the efficacy of Qigong therapy do not deliver a distinct result. One study proves the efficacy of roots of Rhodiola rosea (evidence level 1B). Physical therapy is only in one study separately examined and does not show a better result than standard therapy.

Discussion

Despite the number of studies with high evidence the results for the efficacy of burnout therapies are preliminary and do have only limited reach. The authors of the studies complain about the low number of skilled studies for the therapy of burnout. Furthermore, they point to the insufficient evaluation of the therapy studies and the need for further research. Some authors report the effects of considerable natural recovering.

Numerous limitations affect the quality of the results. Intervention contents and duration, study design and study size are very diverse and do not permit direct comparison. Most of the samples are small by size with low statistical power, long-term follow-ups are missing. Comorbidities and parallel utilized therapies are insufficient documented or controlled. Most of the studies use the Maslach Burnout Inventory (MBI) as diagnostic or outcome-tool, but with different cut-off-points. It should be noticed that the validity of the MBI as diagnostic tool is not proved. Ethical, juridical and social determining factors are not covered or discussed in the studies.

Conclusion

The efficacy of therapies for the treatment of the burnout syndrome is insufficient investigated. Only for cognitive behavioural therapy (CBT) exists an adequate number of studies which prove its efficacy. Big long-term experimental studies are missing which compare the efficacy of the single therapies and evaluate their evidence. The natural recovering without any therapy needs further research. Additionally, it has to be examined to what extent therapies and their possible effects are thwarted by the conditions of the working place and the working conditions.

DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial

Background and aims Limited treatment options are available for trichotillomania (TTM) and most have modest outcomes. Suboptimal treatment results may be due to the failure of existing approaches to address all TTM styles. Methods Thirty-eight DSM-IV TTM participants were randomly assigned across two study sites to Dialectical Behavior Therapy (DBT) -enhanced cognitive-behavioral treatment (consisting of an 11-week acute treatment and 3-month maintenance treatment) or a minimal attention control (MAC) condition. MAC participants had active treatment after the 11-week control condition. Follow-up study assessments were conducted three and six months after the maintenance period. Results Open trial treatment resulted in significant improvement in TTM severity, emotion regulation (ER) capacity, experiential avoidance, anxiety and depression with changes generally maintained over time. In the randomized controlled trial, those with active treatment had greater improvement than those in the MAC condition for both TTM severity and ER capacity. Correlations between changes in TTM severity and ER capacity were not reported at post-treatment but did occur in maintenance and follow-up indicating reduced TTM severity with improved ER capacity. Conclusions DBT-enhanced cognitive-behavioral treatment is a promising treatment for TTM. Future studies should compare this approach to other credible treatment interventions and investigate the efficacy of this approach in more naturalistic samples with greater comorbidity.

Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial

This study further evaluates the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). A diagnostically heterogeneous clinical sample of 37 patients with a principal anxiety disorder diagnosis was enrolled in a randomized controlled trial (RCT) involving up to 18 sessions of treatment and a 6-month follow-up period. Patients were randomly assigned to receive either immediate treatment with the UP (n=26) or delayed treatment, following a 16-week wait-list control period (WLC; n=11). The UP resulted in significant improvement on measures of clinical severity, general symptoms of depression and anxiety, levels of negative and positive affect, and a measure of symptom interference in daily functioning across diagnoses. In comparison, participants in the WLC condition exhibited little to no change following the 16-week wait-list period. The effects of UP treatment were maintained over the 6-month follow-up period. Results from this RCT provide additional evidence for the efficacy of the UP in the treatment of anxiety and comorbid depressive disorders, and provide additional support for a transdiagnostic approach to the treatment of emotional disorders.

Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: a systematic review

OBJECTIVE

Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Threat reappraisal is considered a key mediator underlying the effects of cognitive-behavioral therapy (CBT) for anxiety disorders. The present study systematically reviewed the evidence for the threat reappraisal mediation hypothesis.

METHOD

In our review, we included studies that (a) investigated the threat reappraisal mediation hypothesis; (b) included adults with an anxiety disorder diagnosis; (c) used a longitudinal design; and (d) did not report on previously published findings (to avoid the inclusion of multiple reports of the same data). After data extraction, we made review-specific quality judgments for each study using the following a priori criteria informed by mediation theory: (a) demonstrated statistical mediation; (b) demonstrated that CBT caused threat reappraisal; (c) demonstrated that threat reappraisal caused anxiety reduction; and (d) demonstrated specificity of the threat reappraisal-anxiety reduction relation.

RESULTS

Of the 2,296 studies we identified, 25 met inclusion criteria. Of these studies, 56% tested and 52% established statistical mediation, 52% tested and 28% established CBT as a cause of threat reappraisal, 28% tested and 24% established threat reappraisal as a cause of anxiety reduction, and 44% tested and 36% established specificity of the threat reappraisal-anxiety reduction relation.

CONCLUSIONS

While threat reappraisal is related to anxiety symptom improvement with CBT, there are few extant studies that meet most of the criteria necessary to conclusively demonstrate that it causes symptom improvement in CBT and that it is not a proxy for other third variables. Recommendations for future research in this area are discussed.

A review on experimental and clinical genetic associations studies on fear conditioning, extinction and cognitive-behavioral treatment

Fear conditioning and extinction represent basic forms of associative learning with considerable clinical relevance and have been implicated in the pathogenesis of anxiety disorders. There is considerable inter-individual variation in the ability to acquire and extinguish conditioned fear reactions and the study of genetic variants has recently become a focus of research. In this review, we give an overview of the existing genetic association studies on human fear conditioning and extinction in healthy individuals and of related studies on cognitive-behavioral treatment (CBT) and exposure, as well as pathology development after trauma. Variation in the serotonin transporter (5HTT) and the catechol-o-methyltransferase (COMT) genes has consistently been associated with effects in pre-clinical and clinical studies. Interesting new findings, which however require further replication, have been reported for genetic variation in the dopamine transporter (DAT1) and the pituitary adenylate cyclase 1 receptor (ADCYAP1R1) genes, whereas the current picture is inconsistent for variation in the brain-derived neurotrophic factor (BDNF) gene. We end with a discussion of the findings and their limitations, as well as future directions that we hope will aid the field to develop further.

Social disinterest attitudes and group cognitive-behavioral social skills training for functional disability in schizophrenia

The majority of clinical trials of cognitive-behavioral therapy (CBT) for schizophrenia have used individual therapy to target positive symptoms. Promising results have been found, however, for group CBT interventions and other treatment targets like psychosocial functioning. CBT for functioning in schizophrenia is based on a cognitive model of functional outcome in schizophrenia that incorporates dysfunctional attitudes (eg, social disinterest, defeatist performance beliefs) as mediators between neurocognitive impairment and functional outcome. In this report, 18 clinical trials of CBT for schizophrenia that included measures of psychosocial functioning were reviewed, and two-thirds showed improvements in functioning in CBT. The cognitive model of functional outcome was also tested by examining the relationship between social disinterest attitudes and functional outcome in 79 people with schizophrenia randomized to either group cognitive-behavioral social skills training or a goal-focused supportive contact intervention. Consistent with the cognitive model, lower social disinterest attitudes at baseline and greater reduction in social disinterest during group therapy predicted better functional outcome at end of treatment for both groups. However, the groups did not differ significantly with regard to overall change in social disinterest attitudes during treatment, suggesting that nonspecific social interactions during group therapy can lead to changes in social disinterest, regardless of whether these attitudes are directly targeted by cognitive therapy interventions.

Predictors of response to Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder: an exploratory study

OBJECTIVE

Few predictors of treatment outcome or early discontinuation have been identified in persons with borderline personality disorder (BPD).

AIM

The aim of the study was to examine the relationship between baseline clinical variables and treatment response and early discontinuation in a randomized controlled trial of System Training for Emotional Predictability and Problem Solving, a new cognitive group treatment.

METHOD

Improvement was rated using the Zanarini Rating Scale for BPD, the Clinical Global Impression Scale, the Global Assessment Scale and the Beck Depression Inventory. Subjects were assessed during the 20 week trial and a 1-year follow-up.

RESULTS

Higher baseline severity was associated with greater improvement in global functioning and BPD-related symptoms. Higher impulsivity was predictive of early discontinuation. Optimal improvement was associated with attending > or = 15 sessions.

CONCLUSION

Subjects likely to improve have the more severe BPD symptoms at baseline, while high levels of impulsivity are associated with early discontinuation.

Coping skills training and contingency management treatments for marijuana dependence: exploring mechanisms of behavior change

AIMS

Achieving abstinence in the treatment of marijuana dependence has been difficult. To date the most successful treatments have included combinations of motivation enhancement treatment (MET) plus cognitive-behavioral coping skills training (CBT) and/or contingency management (ContM) approaches. Although these treatment approaches are theoretically based, their mechanisms of action have not been explored fully. The purpose of the present study was to explore mechanisms of behavior change from a marijuana treatment trial in which CBT and ContM were evaluated separately and in combination.

DESIGN

A dismantling design was used in the context of a randomized clinical trial.

SETTING

The setting was an out-patient treatment research facility located in a university medical center.

PARTICIPANTS

Participants were 240 adult marijuana smokers, meeting criteria for cannabis dependence.

INTERVENTIONS

Participants were assigned to one of four 9-week treatment conditions: a case management control condition, MET/CBT coping skills training, ContM and MET/CBT + ContM.

MEASUREMENTS

Outcome measures were total 90-day abstinence, recorded every 90 days for 12 months post-treatment.

FINDINGS

Regardless of treatment condition, abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence.

CONCLUSIONS

It was concluded that the most efficacious treatments for marijuana dependence are likely to be those that increase self-efficacy.