The Economic and Mental Health Impact of IAPT: Pragmatic Trial in Three English Regions

Background

Improving Access to Psychological Therapies (IAPT) programme is the English’s major initiative for treating anxiety and depression, currently provided to over 1 million people. We tested whether IAPT could reduce healthcare costs and improve employment in persons with long-term chronic conditions.

Methods

Stepped-wedge design of two cohorts covering 560 patients each with depression and/or anxiety and comorbid long-term physical health conditions, namely diabetes, chronic obstructive pulmonary disease (COPD) and cardio-vascular disease (CVD) from three areas in Thames Valley (Berkshire, Oxfordshire and Buckinghamshire) for the period March 2017 - August 2017. Panels were balanced. Difference-in-difference models were used and intention-to-treat analysis.

Results

Based on the step-wedge modelling, IAPT treatment decreased costs by £497 (95% CI: -£770 to -£224) total per person (pp) (from £1266 pp before starting the treatment to £768 pp since the treatment started)in the first 3 months. Results also showed a decrease by about 5.55 [95% CI: -6.35, -4.75] (-4.18 [95%CI: -4.91, -3.45]) points per person in the PHQ9 (GAD7). Our results show that IAPT increased the probability to an employment for those who were unemployment by about 7.92% (95% CI: 0.94% to 14.9%).

Conclusions

IAPT treatment significantly reduced healthcare utilization and costs among persons with chronic conditions. It also significantly increased the probability of employment.

Key messages

IAPT treatment significantly reduced healthcare utilization and costs among persons with chronic conditions. IAPT was significantly associated with increased probability to find employment for those unemployed.

Suppression of cooling by strong magnetic fields in white dwarf stars

Isolated cool white dwarf stars more often have strong magnetic fields than young, hotter white dwarfs, which has been a puzzle because magnetic fields are expected to decay with time but a cool surface suggests that the star is old. In addition, some white dwarfs with strong fields vary in brightness as they rotate, which has been variously attributed to surface brightness inhomogeneities similar to sunspots, chemical inhomogeneities and other magneto-optical effects. Here we describe optical observations of the brightness and magnetic field of the cool white dwarf WD 1953-011 taken over about eight years, and the results of an analysis of its surface temperature and magnetic field distribution. We find that the magnetic field suppresses atmospheric convection, leading to dark spots in the most magnetized areas. We also find that strong fields are sufficient to suppress convection over the entire surface in cool magnetic white dwarfs, which inhibits their cooling evolution relative to weakly magnetic and non-magnetic white dwarfs, making them appear younger than they truly are. This explains the long-standing mystery of why magnetic fields are more common amongst cool white dwarfs, and implies that the currently accepted ages of strongly magnetic white dwarfs are systematically too young.

Intensive group cognitive treatment and individual cognitive therapy vs. treatment as usual in social phobia: a randomized controlled trial

To compare the effects of an intensive group cognitive treatment (IGCT) to individual cognitive therapy (ICT) and treatment as usual (TAU) in social phobia (DSM-IV).

METHOD

Hundred patients were randomized to: IGCT involving 16 group sessions spread over three weeks; ICT involving 16 shorter weekly sessions in 4 months and; TAU involving an indicated selective serotonin reuptake inhibitor (SSRI) with therapy sessions as required for 1 year. The main outcome measure was a Social Phobia Composite that combined several standardized self-report measures. Diagnostic assessment was repeated at 1-year follow-up.

RESULTS

Significant improvements were observed with all treatments. ICT was superior to IGCT and TAU, which did not differ in overall effectiveness.

CONCLUSION

The study confirms and extends previously reported findings that ICT is more effective than group cognitive treatment and treatment with SSRIs. IGCT lasts only 3 weeks, and is as effective as more protracted TAU.

Unwanted memories of assault: what intrusion characteristics are associated with PTSD?

Intrusive memories are common in the immediate aftermath of traumatic events, but neither their presence or frequency are good predictors of the persistence of posttraumatic stress disorder (PTSD). Two studies of assault survivors, a cross-sectional study (N=81) and a 6-month prospective longitudinal study (N=73), explored whether characteristics of the intrusive memories improve the prediction. Intrusion characteristics were assessed with an Intrusion Interview and an Intrusion Provocation Task. The distress caused by the intrusions, their "here and now" quality, and their lack of a context predicted PTSD severity. The presence of intrusive memories only explained 9% of the variance of PTSD severity at 6 months after assault. Among survivors with intrusions, intrusion frequency only explained 8% of the variance of PTSD symptom severity at 6 months. Nowness, distress and lack of context explained an additional 43% of the variance. These intrusion characteristics also predicted PTSD severity at 6 months over and above what could be predicted from PTSD diagnostic status at initial assessment. Further predictors of PTSD severity were rumination about the intrusive memories, and the ease and persistence with which intrusive memories could be triggered by photographs depicting assaults. The results have implications for the early identification of trauma survivors at risk of chronic PTSD.

Negative self-imagery blocks inferences

Previous research has shown that, unlike non-anxious individuals, people with social phobia fail to generate non-threatening inferences when ambiguous social information is first encountered (i.e. 'on-line'; Hirsch and Mathews Journal of Abnormal Psychology, 109 (2000) 705-712). Patients with social phobia also report negative self-imagery in social situations, while individuals without high social anxiety do not. The negative self-imagery in social phobia may prevent the generation of non-threatening inferences. If so, then training non-anxious individuals to hold in mind a negative self-image should remove the 'on-line' non-threat inferential bias normally evident in this population. In the present study, low anxious volunteers were allocated to negative image training or a control task that did not manipulate self-imagery. Following negative image training, or the control task, volunteers read descriptions of job interviews and at certain points during the text performed lexical decisions. Some decisions were made after ambiguous text that could have been interpreted in both a threatening and a non-threatening manner. In a baseline condition, decisions were made following the text for which there was only one possible inference (either threat or non-threat). The results for the control group replicated earlier findings of a non-threat inferential bias for non-anxious individuals. In contrast, and as predicted, non-anxious volunteers who were trained to hold a negative image in mind lacked any non-threatening inferential bias, and also experienced higher levels of state anxiety.

Selective attention in social phobia and the moderating effect of a concurrent depressive disorder

Studies using the modified Stroop colour naming task have provided results consistent with the hypothesis that social phobia is associated with an attentional bias towards negative social-evaluative words. However, these results could also have arisen as a consequence of non-attentional processes. For this reason, the present study uses a modified version of MacLeod et al.'s (J. Abnorm. Psychol. 95 (1986) 15) dot-probe task, which provides a more direct measure of attention. Patients with social phobia (n=28), patients with social phobia and a concurrent depressive disorder (n=33), and non-patients (n=40) were presented with word pairs each consisting of a neutral word and a threat word. The results indicated that patients with social phobia show an attentional bias towards social-threat words while non-patients tend to avoid social-threat words. Patients with social phobia and a concurrent depressive disorder behaved like non-patients, indicating that concurrent depression abolishes the attentional bias. Physical threat words were also included in the study. The main analysis indicated that social phobia is also associated with an attentional bias to physical threat. However, a post hoc analysis (which requires replication) suggested that the physical threat bias might have arisen because some social phobia patients also had another anxiety disorder in which physical concerns are likely to have been prominent. Overall, the results emphasise the importance of assessing comorbidity when investigating attentional biases.

Cognitive therapy for social phobia: individual versus group treatment

Cognitive-behavioural group treatment is the treatment of choice for social phobia. However, as not all patients benefit, an additional empirically validated psychological treatment would be of value. In addition, few studies have examined whether a group treatment format is more effective than an individual treatment format. A randomized controlled trial addressed these issues by comparing individual cognitive therapy, along the lines advocated by Clark and Wells (Clark, D.M. and Wells, A., 1995. A cognitive model of social phobia. In: R. G. Heimberg, M. Liebowitz, D. Hope and F. Schneier (Eds.), Social Phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York: Guilford.), with a group version of the treatment and a wait-list control condition. 71 patients meeting DSM-IV criteria for social phobia participated in the trial, 65 completed the posttreatment assessment and 59 completed a six-month follow-up. Social phobia measures indicated significant pretreatment to posttreatment improvement in both individual and group cognitive therapy. Individual cognitive therapy was superior to group cognitive therapy on several measures at both posttreatment and follow-up. The effects of treatment on general measures of mood and psychopathology were less substantial than the effects on social phobia. The results suggest that individual cognitive therapy is a specific treatment for social phobia and that it's effectiveness may be diminished by delivery in a group format.

Cigarette package design: opportunities for disease prevention

Objective

To learn how cigarette packages are designed and to determine to what extent cigarette packages are designed to target children.

Methods

A computer search was made of all Internet websites that post tobacco industry documents using the search terms: packaging, package design, package study, box design, logo, trademark and design study. All documents were retrieved electronically and analyzed by the first author for recurrent themes.

Data Synthesis

Cigarette manufacturers devote a great deal of attention and expense to package design because it is central to their efforts to create brand images. Colors, graphic elements, proportioning, texture, materials and typography are tested and used in various combinations to create the desired product and user images. Designs help to create the perceived product attributes and project a personality image of the user with the intent of fulfilling the psychological needs of the targeted type of smoker. The communication of these images and attributes is conducted through conscious and subliminal processes. Extensive testing is conducted using a variety of qualitative and quantitative research techniques.

Conclusion

The promotion of tobacco products through appealing imagery cannot be stopped without regulating the package design. The same marketing research techniques used by the tobacco companies can be used to design generic packaging and more effective warning labels targeted at specific consumers.

The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis

BACKGROUND

A self-rated measure of health anxiety should be sensitive across the full range of intensity (from mild concern to frank hypochondriasis) and should differentiate people suffering from health anxiety from those who have actual physical illness but who are not excessively concerned about their health. It should also encompass the full range of clinical symptoms characteristic of clinical hypochondriasis. The development and validation of such a scale is described.

METHOD

Three studies were conducted. First, the questionnaire was validated by comparing the responses of patients suffering from hypochondriasis with those suffering from hypochondriasis and panic disorder, panic disorder, social phobia and non-patient controls. Secondly, a state version of the questionnaire was administered to patients undergoing cognitive-behavioural treatment or wait-list in order to examine the measure's sensitivity to change. In the third study, a shortened version was developed and validated in similar types of sample, and in a range of samples of people seeking medical help for physical illness.

RESULTS

The scale was found to be reliable and to have a high internal consistency. Hypochondriacal patients scored significantly higher than anxiety disorder patients, including both social phobic patients and panic disorder patients as well as normal controls. In the second study, a 'state' version of the scale was found to be sensitive to treatment effects, and to correlate very highly with a clinician rating based on an interview of present clinical state. A development and refinement of the scale (intended to reflect more fully the range of symptoms of and reactions to hypochondriasis) was found to be reliable and valid. A very short (14 item) version of the scale was found to have comparable properties to the full length scale.

CONCLUSIONS

The HAI is a reliable and valid measure of health anxiety. It is likely to be useful as a brief screening instrument, as there is a short form which correlates highly with the longer version.

Cigarette package design: opportunities for disease prevention

OBJECTIVE

To learn how cigarette packages are designed and to determine to what extent cigarette packages are designed to target children.

METHODS

A computer search was made of all Internet websites that post tobacco industry documents using the search terms: packaging, package design, package study, box design, logo, trademark and design study. All documents were retrieved electronically and analyzed by the first author for recurrent themes.

DATA SYNTHESIS

Cigarette manufacturers devote a great deal of attention and expense to package design because it is central to their efforts to create brand images. Colors, graphic elements, proportioning, texture, materials and typography are tested and used in various combinations to create the desired product and user images. Designs help to create the perceived product attributes and project a personality image of the user with the intent of fulfilling the psychological needs of the targeted type of smoker. The communication of these images and attributes is conducted through conscious and subliminal processes. Extensive testing is conducted using a variety of qualitative and quantitative research techniques.

CONCLUSION

The promotion of tobacco products through appealing imagery cannot be stopped without regulating the package design. The same marketing research techniques used by the tobacco companies can be used to design generic packaging and more effective warning labels targeted at specific consumers.

Patients with generalized social phobia direct their attention away from faces

The experiment tested whether patients with social phobia direct their attention to or away from faces with a range of emotional expressions. A modified dot probe paradigm (J. Abnorm. Psychol. 95 (1986) 15) measured whether participants attended more to faces or to household objects. Twenty patients with social phobia were faster in identifying the probe when it occurred in the location of the household objects, regardless of whether the facial expressions were positive, neutral, or negative. In contrast, controls did not exhibit an attentional preference. The results are in line with recent theories of social phobia that emphasize the role of reduced processing of external social cues in maintaining social anxiety.

Aggressive sino-nasal non-Hodgkin's lymphoma diagnosed in Nottinghamshire, UK, between 1987 and 1996

In the 10-year period 1987 to 1996, 24 patients were diagnosed with aggressive non-Hodgkin's lymphoma of the nasal cavities or paranasal sinuses. The disease occurred in a relatively elderly population of median age 72 years (range 42 to 96) with a male predominance (male 15; female nine). The histology on review was mostly of the large B-cell subtype (21 patients); peripheral T-cell subtype (one), anaplastic large cell of T-cell type (one) and T/natural killer cell nasal lymphoma (one). The disease was localized in 20 patients (Stage IEA). The overall survival at 5 years was 40% (95% confidence interval (CI) 19-61); at 10 years it was 33% (95% CI 12-54). The cause-specific survival (excluding deaths from causes other than lymphoma) at 5 years and 10 years was 62% (95% CI 39-86).

A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault

The effectiveness of psychological treatments for PTSD is likely to be enhanced by improved understanding of the factors involved in maintaining the disorder. Ehlers and Clark [A cognitive model of persistent posttraumatic stem disorder Behav. Res. Ther. 38 (2000) 319-345] recently proposed a cognitive model of maintenance. The current study aimed to investigate several cognitive factors highlighted in Ehlers and Clark's model using a prospective design. Fifty-seven victims of physical or sexual assault participated in the study. Cognitive factors were assessed within 4 months of assault and victims were followed-up 6 and 9 months after the assault. Cognitive variables which significantly predicted PTSD severity at both follow-ups were: cognitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoidance/safety seeking). Relationships between early appraisals, control strategies, and processing styles and subsequent PTSD severity remained significant after statistically controlling for gender and perceived assault severity. These findings support the cognitive model of PTSD proposed by Ehlers and Clark and suggest that effective treatment will need to address these cognitive factors.

The use of specific dental school-taught restorative techniques by practicing clinicians

In 1995, a survey requesting information about the utilization of certain prosthodontic techniques was mailed to 3,544 graduates of a midwestern dental school. Responses were received from 1,455 alumni, representing a 41 percent return rate. In general, the results are consistent with international and national trends and show significant disparity in the utilization rates of certain procedures between general dentists and prosthodontists, as well as a disconnect between what is taught in the undergraduate dental educational program and what is applied in practice. For example, while prosthodontists typically apply what was taught in their educational program, utilization rates of general dentists for the facebow was 29.64 percent; the custom tray 68.48 percent; border molding 58.67 percent; altered casts 24.10 percent; custom posts 49.29 percent; prefabricated posts 67.54 percent; and semi-adjustable articulators 50.64 percent. While no solutions to this disconnect are offered the authors do pose important questions that must be addressed by the dental educational community.

Delayed spontaneous superior vena cava perforation associated with a SVC wallstent

A patient was referred for superior vena cava (SVC) stenting prior to surgical biopsy of a mediastinal mass. A technically satisfactory insertion was followed 6 months later by cardiac tamponade with two legs of the Wallstent having perforated the wall of the SVC.

Social anxiety and self-impression: cognitive preparation enhances the beneficial effects of video feedback following a stressful social task

Negative and distorted images of the observable self are important in the development and maintenance of social phobia. Previous research has shown that video feedback has potential to correct the distorted self-perception [Rapee, R. M. & Hayman, K. (1996). The effects of video feedback on the self-evaluation of performance in socially anxious subjects. Behaviour Research and Therapy, 34, 315-322]. The present experiment investigated whether the construction of a self-image prior to viewing the video may enhance the therapeutic effects of video feedback. High and low socially anxious individuals gave a speech and then viewed the video of their performance. Half of the sample were given cognitive preparation prior to viewing the video. Cognitive preparation involved asking participants to (1) predict in detail what they will see in the video, (2) form an image of themselves giving the speech and (3) watch the video as though they were watching a stranger. Participants who received cognitive preparation prior to the video feedback made higher ratings of their overall performance and of specific aspects of their performance compared to those who were not given cognitive preparation and compared to the same ratings made prior to the video feedback. These results suggest that the therapeutic effects of video feedback can be enhanced by careful cognitive preparation which maximises the perceived discrepancy between self and video images.

Exclusions of infertility treatment in the aftermath of Bragdon v. Abbott

This article analyzes the Supreme Court's decision in Bragdon v. Abbott to determine whether the Court's reading of ADA necessarily leads to the conclusion that a group health plan's or insurer's exclusion or limitation of coverage with respect to infertility is prohibited by ADA. The authors conclude that it may be advisable for plans to perform at least minimal actuarial calculations with respect to the current or anticipated costs of covering infertility treatments prior to adopting any exclusions or limitations of coverage.

Recurrent images and early memories in social phobia

A recent model [Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guildford Press] suggests that a distorted image of one's public self lies at the heart of social phobia. A previous study of spontaneous imagery [Hackmann, A., Surawy, C. & Clark, D. M. (1998) Seeing yourself through others' eyes: a study of spontaneously occurring images in social phobia. Behavioural and Cognitive Psychotherapy, 26, 3-12] confirmed that patients with social phobia frequently report experiencing negative, distorted, observer-perspective images when in anxiety provoking social situations. In the present study, 22 patients with social phobia were given a semistructured interview which aimed to further explore the nature of social phobic imagery. All participants were able to identify negative spontaneous images that were recurrent in the sense that their content appeared to be relatively stable over time and across different feared social situations. Most recurrent images involved several sensory modalities. Most recurrent images were linked to memories of adverse social events that clustered in time around the onset of the disorder. Taken together, the results suggest that in patients with social phobia, early unpleasant experiences may lead to the development of excessively negative images of their social selves that are repeatedly activated in subsequent social situations and fail to update in the light of subsequent, more favourable experiences. Implications of the findings for the understanding and treatment of social phobia are discussed.

Coronary arteritis in Wegener's granulomatosis causing fatal myocardial infarction

Wegener's granulomatosis is a systemic, granulomatous, inflammatory disorder affecting small vessels, which classically presents with respiratory tract involvement and focal segmental necrotizing glomerulonephritis but not usually with cardiac manifestations. Post-mortem histological examination revealed a diffuse coronary arteritis with an inflammatory infiltrate producing arterial occlusion and subsequent infarction of the myocardium. Post-mortem also showed lung granulomas, generalized small vessel vasculitis and focal segmental necrotizing glomerulonephritis.

A cognitive model of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or its sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualization, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies have provided preliminary support for several aspects of the model.

Social phobia and interpretation of social events

It has been suggested that social phobia may be characterized by two interpretation biases. First, a tendency to interpret ambiguous social events in a negative fashion. Second, a tendency to interpret unambiguous but mildly negative social events in a catastrophic fashion. To assess this possibility, patients with generalized social phobia, equally anxious patients with another anxiety disorder, and non-patient controls were presented with ambiguous scenarios depicting social and non-social events, and with unambiguous scenarios depicting mildly negative social events. Interpretations were assessed by participants' answers to open-ended questions and by their rankings and belief ratings for experimenter-provided, alternative explanations. Compared to both control groups, patients with generalized social phobia were more likely to interpret ambiguous social events in a negative fashion and to catastrophize in response to unambiguous, mildly negative social events.

The role of the Sysmex SE9000 immature myeloid index and Sysmex R2000 reticulocyte parameters in optimizing the timing of peripheral blood stem cell harvesting in patients with lymphoma and myeloma

Peripheral blood CD34/45+ cell (CD34/45) enumeration is an expensive and labour-intensive investigation but remains the standard assay for optimizing yield and timing of peripheral blood stem cell harvesting (PBSCH). The present study examined the value of the Sysmex SE9000 parameters (WBC, neutrophil count, and immature myeloid index (IMI)) and Sysmex R2000 reticulocyte parameters (absolute, high and medium fluorescence reticulocytes) in predicting the optimum timing of PBSCH in comparison to peripheral blood CD34/45. Sixty-four PBSCH from 23 patients with haematological malignancies were assessed with a variety of mobilization regimes used. Reticulocyte parameters showed high interpatient variability and did not prove clinically useful. IMI did not consistently predict satisfactory PBSCH yield except when > 1000 x 10(6)/l. Peripheral blood CD34/45 was the most useful predictor of yield. IMI > 20 x 10(6)/l was, however, a useful surrogate for predicting a rise in peripheral blood CD34/45 from nadir and proved to be superior to WBC or neutrophil count. A rising IMI is a marker of early regeneration and has a role in determining when to initiate enumeration of peripheral blood CD34/45.

Brief cognitive therapy for panic disorder: a randomized controlled trial

Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.

Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault

Cognitive factors hypothesised to influence the development and maintenance of PTSD were investigated. 92 assault victims completed questionnaires assessing a range of cognitive variables. Factors relating to onset of PTSD were investigated by comparing victims who did and who did not suffer PTSD. Factors relating to maintenance of PTSD were investigated by comparing victims who had recovered from PTSD with victims who had persistent PTSD. Cognitive factors associated with both onset and maintenance of PTSD were: appraisal of aspects of the assault itself (mental defeat, mental confusion, appraisal of emotions); appraisal of the sequelae of the assault (appraisal of symptoms, perceived negative responses of others, permanent change); dysfunctional strategies (avoidance/safety seeking) and global beliefs impacted by assault. Cognitive factors that were associated only with the onset of PTSD were: detachment during assault; failure to perceive positive responses from others and mental undoing. Relationships between the cognitive variables and PTSD remained significant when variations in perceived and objective assault severity were statistically controlled. The cognitive factors identified in the study may contribute to PTSD directly, by generating a sense of ongoing threat, or indirectly, by motivating cognitive and behavioural strategies that prevent recovery, or by affecting the nature of the traumatic memory.

Brief cognitive therapy for panic disorder: a randomized controlled trial

Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.

Anxiety disorders: why they persist and how to treat them

Anxiety disorders are characterised by distorted beliefs about the dangerousness of certain situations and/or internal stimuli. Why do such beliefs persist? Six processes (safety-seeking behaviours, attentional deployment, spontaneous imagery, emotional reasoning, memory processes and the nature of the threat representation) that could maintain anxiety-related negative beliefs are outlined and their empirical status is reviewed. Ways in which knowledge about maintenance processes has been used to develop focussed cognitive therapy programmes are described and evaluations of the effectiveness of such programmes are summarized. Finally, ways of identifying the effective ingredients in cognitive therapy programmes are discussed.

Optical transmembrane potential recordings during intracardiac defibrillation-strength shocks

BACKGROUND

The prolongation of the action potential after defibrillation-strength shocks is believed to be a critical component of defibrillation. The response of the transmembrane potential to the shock may affect this prolongation. We studied the effects of an intracardiac shock on the transmembrane potential and action potential duration at multiple sites on the epicardium using a voltage-sensitive dye and optical mapping system.

METHODS AND RESULTS

A laser scanner recorded optical action potentials with voltage-sensitive dye at 63 spots on both the left and right ventricles of six isolated, perfused rabbit hearts. Hearts were paced with epicardial point stimulation followed by the delivery of a 2 A and 20 ms rectangular waveform shock during the relative refractory period. The shock was given between right atrial and right ventricular electrodes. Of 621 total spots analyzed, 241 spots hyperpolarized and 76 spots depolarized with a right ventricular anode, whereas 159 spots hyperpolarized and 145 spots depolarized with a right ventricular cathode (P < 0.05). Both hyperpolarized and depolarized spots exhibited prolonged action potential duration, although prolongation was greater with depolarizing responses (16.7 +/- 9 ms vs. 13.3 +/- 13.4 ms, p<0.001). Hyperpolarized and depolarized spots were not randomly distributed, but clustered into regions. The size of the hyperpolarized regions was larger than the depolarized regions with RV anodal stimulation (27 +/- 20 spots/hyperpolarized region vs. 8.5 +/- 9 spots/depolarized region, p < 0.03) but not with RV cathodal stimulation. With reversal of electrode polarity, spots hyperpolarized near the shocking electrodes frequently did not reverse polarization but remained hyperpolarized.

CONCLUSIONS

Distinct regions of either polarization occur during intracardiac defibrillation-strength shocks. Although hyperpolarizing membrane responses were observed more often than depolarizing responses, depolarizing membrane polarization resulted in greater action potential prolongation. The absence of sign change in polarization in some regions with shocks of opposite polarities suggests that nonlinear intrinsic membrane properties are operative during strong electrical stimulation.

An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia

This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.

How do I appear to others? Social anxiety and processing of the observable self

Two information processing biases that could maintain social anxiety were investigated. High and low socially anxious individuals encoded positive and negative trait words in one of three ways: public self-referent, private self-referent, and other-referent. Half were then told they would soon have to give a speech. As predicted, compared to low socially anxious individuals, high socially anxious individuals recalled less positive public self-referent words, but only when both groups were anticipating giving a speech. No memory biases were observed for private self-referent or other-referent words. Next all participants gave a speech. Correlational analyses suggested that high socially anxious individuals may use the somatic concomitants of anxiety to overestimate how anxious they appear and underestimate how well they come across.

D-fenfluramine challenge in posttraumatic stress disorder

BACKGROUND

Much progress has been made in understanding the role of catecholamines in the pathophysiology of posttraumatic stress disorder (PTSD). Recent research has broadened the scope of neuroregulation of PTSD to include serotonin.

METHODS

We used the serotonin-releasing agent and reuptake inhibitor, d-fenfluramine, to assess the integrity of the serotonin-mediated prolactin release in 8 men with combat-induced PTSD and 8 healthy men.

RESULTS

The veterans with PTSD had a significantly lower prolactin response to d-fenfluramine as compared to healthy control subjects. The prolactin response to d-fenfluramine was inversely correlated with the patient's level of PTSD symptomatology and measures of aggression.

CONCLUSIONS

This study demonstrates a central serotonin dysfunction, as reflected in a lower prolactin response to d-fenfluramine, in patients with PTSD.

Two psychological treatments for hypochondriasis. A randomised controlled trial

BACKGROUND

Hypochondriasis is generally considered difficult to manage. This study aimed to assess the effectiveness of cognitive therapy and to compare it with an equally credible, alternative treatment.

METHOD

Forty-eight patients with hypochondriasis were initially randomly assigned to either cognitive therapy, behavioural stress management or a no treatment waiting list control group. At the end of the waiting period, patients in the control group were randomly assigned to one of the two treatments. Assessments were at pre-, mid- and post-treatment or waiting list and at three-, six- and 12-month post-treatment follow-up.

RESULTS

Comparisons with the waiting list group showed both treatments were effective. Comparisons between the treatments showed that cognitive therapy was more effective than behavioural stress management on measures of hypochondriasis, but not general mood disturbance at mid-treatment and at post-treatment. One year after treatment patients who had received either treatment remained significantly better than before treatment, and on almost all measures the two therapies did not differ from each other.

CONCLUSIONS

Cognitive therapy is a specific treatment for hypochondriasis. Behavioural stress management is also effective but its specificity remains to be demonstrated.

Predicting response to exposure treatment in PTSD: the role of mental defeat and alienation

Not all patients with posttraumatic stress disorder benefit from exposure treatment. The present paper describes two cognitive dimensions that are related to inferior response to exposure in rape victims. First, individuals whose memories during relieving of the trauma reflected mental defeat or the absence of mental planning showed little improvement. Second, inferior outcome was correlated with an overall feeling of alienation or permanent change following the trauma. These results are based on blind ratings of transcripts of exposure treatment sessions from 10 women with good outcome and 10 women with inferior outcome. Patients in the two groups were matched for initial symptom severity and were comparable in many aspects of the assault. Patients who experienced mental defeat, alienation, or permanent change may require cognitive restructuring in addition to exposure.

Thought suppression produces a rebound effect with analogue post-traumatic intrusions

Attempts to suppress traumatic material may be involved in the development and maintenance of post-traumatic stress disorder (PTSD). In order to investigate this possibility, analogue post-traumatic intrusions were induced in normal participants by means of a distressing film. For comparison, a second film was used to induce intrusions about polar bears. It was hypothesized that the suppression of these intrusions would produce an immediate decrease but a delayed increase ("rebound effect") in their frequency. It was also predicted that the rebound effect would be larger for the analogue traumatic intrusions. Each film was followed by two consecutive time periods during which participants' thoughts were recorded. During the first period, the suppression group was instructed to suppress thoughts about the film whilst the control group merely recorded their thoughts. During the second period, both groups merely recorded their thoughts. The results supported the immediate decrease hypothesis for both types of intrusion. As predicted, there was a rebound effect for analogue traumatic intrusions although not for polar bear thoughts. Several methodological issues relating to the findings are highlighted. The possible implications of a rebound effect with trauma-relevant intrusions are discussed with reference to PTSD.

How do I look with my minds eye: perspective taking in social phobic imagery

This study explored perspective taking in social phobics' images of past anxiety-provoking social situations and non-social situations. For images of social situations, social phobics were significantly more likely than non-patient controls to take an observer perspective, viewing themselves as if from an external point of view. In contrast, social phobics and controls did not differ in the perspective taken in images of non-social situations, which were generally viewed from a field perspective (seeing the situation as if looking out through their own eyes). The clinical significance of these findings is briefly discussed.

Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation

OBJECTIVES

The aim of this study was to determine the independent hemodynamic effects of an irregular sequence of ventricular cycle lengths in patients with atrial fibrillation (AF).

BACKGROUND

Atrial fibrillation may reduce cardiac output by several possible mechanisms, including loss of the atrial contribution to left ventricular filling, valvular regurgitation, increased ventricular rate or irregular RR intervals. This study was designed to evaluate the effects of an irregular RR interval, independent of the average ventricular rate, on cardiac hemodynamic data during AF.

METHODS

Sixteen patients with AF were studied invasively. During intrinsically conducted AF (mean rate 102 +/- 22 beats/ min), the right ventricular apex electrogram was recorded onto frequency-modulated (FM) tape. After atrioventricular node ablation, the right ventricular apex was stimulated in three pacing modes in randomized sequence: 1) VVI at 60 beats/min; 2) VVI at the same average rate as during intrinsically conducted AF (102 +/- 22 beats/min); and 3) during VVT pacing in which the pacemaker was triggered by playback of the FM tape recording of the right ventricular apex electrogram previously recorded during intrinsically conducted AF (VVT 102 +/- 22 beats/min).

RESULTS

Compared with VVI pacing at the same average rate, an irregular sequence of RR intervals decreased cardiac output (4.4 +/- 1.6 vs. 5.2 +/- 2.4 liters/min, p < 0.01), increased pulmonary capillary wedge pressure (17 +/- 7 vs. 14 +/- 6 mm Hg, p < 0.002) and increased right atrial pressure (10 +/- 6 vs. 8 +/- 4 mm Hg, p < 0.05).

CONCLUSIONS

An irregular sequence of RR intervals produces adverse hemodynamic consequences that are independent of heart rate.

Misinterpretation of body sensations in panic disorder

Cognitive accounts of panic predict that panic disorder patients will be particularly prone to misinterpret autonomic sensations. Several studies have produced results consistent with this prediction, but each is open to alternative interpretation. To clarify matters, 2 studies administered the Body Sensations Interpretation Questionnaire (BSIQ) to panic patients and controls. Panic patients were more likely to interpret ambiguous autonomic sensations as signs of immediately impending physical or mental disaster and were more likely than other anxiety disorder patients and nonpatients to believe these interpretations. In a 3rd study, a brief version of the BSIQ was shown to have satisfactory test-retest reliability, to change with treatment, and to discriminate treatments that varied in their effects on panic.

Misinterpretation of body sensations in panic disorder

Cognitive accounts of panic predict that panic disorder patients will be particularly prone to misinterpret autonomic sensations. Several studies have produced results consistent with this prediction, but each is open to alternative interpretation. To clarify matters, 2 studies administered the Body Sensations Interpretation Questionnaire (BSIQ) to panic patients and controls. Panic patients were more likely to interpret ambiguous autonomic sensations as signs of immediately impending physical or mental disaster and were more likely than other anxiety disorder patients and nonpatients to believe these interpretations. In a 3rd study, a brief version of the BSIQ was shown to have satisfactory test-retest reliability, to change with treatment, and to discriminate treatments that varied in their effects on panic.

A controlled trial of cognitive-behavioural treatment of hypochondriasis

BACKGROUND

Hypochondriasis is a distressing disorder for which there is no adequate established treatment. This study evaluates the effect of cognitive-behavioural treatment of hypochondriasis, compared with a waiting list control.

METHOD

Thirty-two patients were randomly assigned to either cognitive-behavioural therapy or a no treatment waiting list control. Cognitive-behavioural treatment consisted of 16 individual treatment sessions over a four-month period. The waiting list control lasted for four months and was followed by 16 sessions of cognitive-behavioural treatment. Assessments were made before allocation and after treatment or waiting list control. Patients who had cognitive-behavioural treatment were reassessed three months after completion of treatment.

RESULTS

Paired comparisons on post-treatment/wait scores indicated that the cognitive-behavioural group showed significantly greater improvements than the waiting list on all but one patient rating, all therapist ratings and all assessor ratings. After three months the benefits of therapy were maintained.

CONCLUSIONS

Cognitive-behavioural treatment is an effective therapy for hypochondriasis. Implications of the study are discussed.

Cognition-behaviour links in the persistence of panic

The cognitive theory of panic disorder proposes that panic attacks occur as a result of an enduring tendency to misinterpret bodily sensations as a sign of imminent catastrophe such as a heart attack. The persistence of such catastrophic cognitions is in part due to the tendency of patients to avoid and/or escape situations where panic occurs. It is proposed that within-situation safety seeking behaviours also have the effect of maintaining catastrophic cognitions in the face of repeated panics during which the feared catastrophe does not occur. The association between catastrophic cognitions and within-situation safety behaviours matched the pattern predicted from the cognitive theory in 147 panic disorder patients. The implications of these findings for the way in which therapy is conducted are discussed.

Social anxiety, fear of negative evaluation and the detection of negative emotion in others

The present study sought to investigate whether social anxiety is associated with enhanced ability to detect negative emotion in others. Subjects scoring high and low on Fear of Negative Evaluation (FNE) performed two tasks before and after a social threat induction. The first task involved identifying the affect (negative vs neutral) in briefly presented (60 msec) slides of faces. The second involved rating the overall emotion conveyed in brief video clips of an actor and detecting discrepancies in the affect conveyed by the visual and auditory channels of the video. Overall the results suggest that high social anxiety subjects have a bias towards identifying others' emotional expressions as negative in the absence of an enhanced ability to discriminate between different emotional states in others. Implications and limitations of the results are discussed.