Hoarding Disorder and a Systematic Review of Treatment with Cognitive Behavioral Therapy

Until recently, compulsive hoarding has been treated as a type of obsessive-compulsive disorder with mixed results. Little research exists on the efficacy of behavioral interventions specifically designed to treat hoarding disorder, and most existing research is limited with regard to the numbers of participants, their ethnic and cultural diversity, and study replication; therefore, the generalizability of findings is limited. This article reviews the prevalence of hoarding disorder, cognitive behavioral therapy treatment approaches, and measurement of symptoms. A systematic review compares the efficacy of various CBT methods, with particular attention to comparing therapy that is traditionally used to treat OCD with those designed specifically to treat hoarding disorder. Only clinical studies using CBT interventions designed to treat hoarding associated with OCD or hoarding disorder were included. Studies included participants of all ages, and articles were published in peer-reviewed journals. Case studies were excluded. After a comprehensive search and removing duplicates from databases and references, 65 articles were reviewed, of which 12 met criteria for review. Preliminary results demonstrate improvement in hoarding symptoms with CBT interventions that are both for OCD and those designed to specifically treat hoarding disorder; however, when compared to each other, the efficacy of these treatments is inconclusive, thus more research is needed.     

Group Cognitive Behavioral Treatment for PTSD: Treatment of Motor Vehicle Accident Survivors

Individual cognitive behavioral therapies (CBT) are now considered the first-line treatment for posttraumatic stress disorder (PTSD; Foa, Keane, & Friedman, 2000). As mental health reimbursement becomes more restricted, it is imperative that we adapt individual-format therapies for use in a small group format. Group therapies have a number of advantages, including provision of a natural support group, the ability to reach more patients, and greater cost efficiency. In this article, we describe the development of a group CBT for PTSD in the aftermath of a serious motor vehicle accident (MVA). Issues unique to the group treatment format are discussed, along with special considerations such as strategies to reduce the potential for triggering reexperiencing symptoms during group sessions. A case example is presented, along with discussion of group process issues. Although still in the early stages, this group CBT may offer promise as an effective treatment of MVA-related PTSD.     

Integrating Psychotherapeutic Processes with Cognitive Behavioral Procedures

There has been a recent focus on the processes that underlie intervention delivery for children and adolescents throughout the Cognitive-Behavioral Therapy (CBT) literature. Certain process variables have been associated with treatment outcome among youth receiving CBT. Data for these process variables including: the therapeutic alliance or therapeutic relationship, child and parent involvement, other child and therapist variables, and issues of diversity, are reviewed. Based on this data, specific clinical recommendations are made. The treatment relationship as a very important process (VIP), and the facilitation of CBT so that it is real and relevant to youth are emphatically discussed. Process issues in modular CBT are identified. Ultimately, genuine collaborative empiricism and guided discovery preserve the therapeutic relationship as a VIP, and foster the customization of therapeutic tools and the treatment trajectory.     

Group Cognitive Behavioral Treatment for Parents and Children At-Risk for Physical Abuse: An Initial Study

To compare the relative efficacy of two types of group cognitive-behavioral therapy for treating the traumatized child and at-risk or offending parent in cases of child physical abuse (CPA), 24 parents and their children were treated with Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT) and 20 parents were treated with Parent-Only CBT. Outcome measures assessing children's emotional and behavioral functioning and parents' parenting skills were administered to both parent and child participants before treatment, after 15 sessions of treatment, and 3 months after the completion of treatment. A series of correlated t tests and analyses of covariance were used to compare the scores on the outcome measures. The children and parents in the CPC-CBT group demonstrated greater improvements in total posttraumatic symptoms and positive parenting skills, respectively, compared to those who participated in the Parent-Only CBT group. The parents in the Parent-Only CBT group reported using less corporal punishment to manage their children's behavior at posttest than the parents in the CPC-CBT group. The differential benefits of including the child in treatment are discussed.     

Mechanisms of Behavioral and Affective Treatment Outcomes in a Cognitive Behavioral Intervention for Boys

Evidence for effective treatment for behavioral problems continues to grow, yet evidence about the effective mechanisms underlying those interventions has lagged behind. The Stop Now and Plan (SNAP) program is a multicomponent intervention for boys between 6 and 11. This study tested putative treatment mechanisms using data from 252 boys in a randomized controlled trial of SNAP versus treatment as usual. SNAP includes a 3 month group treatment period followed by individualized intervention, which persisted through the 15 month study period. Measures were administered in four waves: at baseline and at 3, 9 and 15 months after baseline. A hierarchical linear modeling strategy was used. SNAP was associated with improved problem-solving skills, prosocial behavior, emotion regulation skills, and reduced parental stress. Prosocial behavior, emotion regulation skills and reduced parental stress partially mediated improvements in child aggression. Improved emotion regulation skills partially mediated treatment-related child anxious-depressed outcomes. Improvements in parenting behaviors did not differ between treatment conditions. The results suggest that independent processes may drive affective and behavioral outcomes, with some specificity regarding the mechanisms related to differing treatment outcomes.     

Tailoring Cognitive Behavioral Treatment for Binge Eating in Adolescent Girls

Whereas effective treatments exist for adults with recurrent binge eating, developmental factors specific to adolescents point to the need for a modified treatment approach for youth. We adapted an existing cognitive behavioral therapy treatment manual for adults with bulimia nervosa and binge eating disorder (Fairburn, 2008) for use with adolescents. This paper presents a number of clinical case vignettes, drawn directly from interactions with teen participants, that illustrate some of the developmental factors common to adolescents—as well as the importance of our adaptations to address for these factors.     

Changes in Decentering Across Cognitive Behavioral Group Therapy for Social Anxiety Disorder

To further improve treatments, we need to better understand potential common treatment mechanisms, such as decentering, or the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with them (Safran & Segal, 1990). Therefore, this study examined whether 12 sessions of Cognitive Behavioral Group Therapy (CBGT) for 63 clients (57.6% female, 50.8% White) diagnosed with social anxiety disorder led to increases in decentering and whether increased decentering was associated with improved outcome. Furthermore, this study examined whether decentering was associated with outcome over and above a competing mechanism—cognitive reappraisal. Overall, results indicated that CBGT in this study led to similar outcomes compared to previous studies and decentering increased over CBGT (d’s from 0.81 to 2.23). Change in decentering predicted improvement on most, but not all, measures of outcome and those who no longer met criteria for social anxiety disorder at posttreatment had significantly greater change in decentering across therapy and significantly higher decentering scores at post-treatment compared to those who retained a social anxiety disorder diagnosis at posttreatment. Finally, changes in decentering predicted outcome over and above changes in reappraisal on all outcome measures. These results largely support the role of decentering in CBGT for social anxiety; however, the implications of the inconsistencies in results based on which outcome measure was used are discussed.     

Group Cognitive Behavioral Therapy for Delusions: Helping Patients Improve Reality Testing

Group Cognitive Behavior Therapy (CBT) was used to treat residual delusions in patients with schizophrenia. Initially all patients (N = 6) reported delusions of various types, such as persecution, body/mind control, grandiosity, and religious themes. The group format allowed patients to share their experiences and beliefs, thereby eliminating shame and providing support and coping strategies; as well as allowing for peer–peer discussion of irrationalities and inconsistencies in each other's beliefs. After 13 sessions there was a statistically significant reduction in delusional conviction, unhappiness associated with thinking about a delusion, intensity of distress associated with delusion, and an increased ability to dismiss a delusional thought.     

Panic Disorder: Cognitive Behavioral and Pharmacological Treatment Strategies

The past decade has seen significant advances in both psychosocial, notably cognitive behavioral (CBT), and pharmacological treatments for panic disorder. Given the widely acknowledged efficacy of both forms of treatment, it is reasonable to consider that the combination of approaches should yield an extremely potent strategy to treating panic disorder. The present report summarizes scientific evidence for the singular and combined treatment approaches to panic disorder. Data across studies indicate that combined treatments yield immediate and short-term benefits above those provided by either pharmacologic treatment or CBT alone. In the long-term, however, these benefits disappear. In fact, the combination of benzodiazepines and CBT appears to produce poorer end-state functioning than CBT alone. Other data indicate that the sequencing of pharmacotherapy and CBT may be useful for benzodiazepine fading. Although these data are preliminary, combined treatments do not appear to be the treatment of choice for patients with panic disorder. Treatment algorithms are suggested based on existing data.     

Motivational Interviewing Versus Cognitive Behavioral Group Therapy in the Treatment of Problem and Pathological Gambling: A Randomized Controlled Trial

Pathological gambling is a widespread problem with major implications for society and the individual. There are effective treatments, but little is known about the relative effectiveness of different treatments. The aim of this study was to test the effectiveness of motivational interviewing, cognitive behavioral group therapy, and a no-treatment control (wait-list) in the treatment of pathological gambling. This was done in a randomized controlled trial at an outpatient dependency clinic at Karolinska Institute (Stockholm, Sweden). A total of 150 primarily self-recruited patients with current gambling problems or pathological gambling according to an NORC DSM-IV screen for gambling problems were randomized to four individual sessions of motivational interviewing (MI), eight sessions of cognitive behavioral group therapy (CBGT), or a no-treatment wait-list control. Gambling-related measures derived from timeline follow-back as well as general levels of anxiety and depression were administered at baseline, termination, and 6 and 12 months posttermination. Treatment showed superiority in some areas over the no-treatment control in the short term, including the primary outcome measure. No differences were found between MI and CBGT at any point in time. Instead, both MI and CBGT produced significant within-group decreases on most outcome measures up to the 12-month follow-up. Both forms of intervention are promising treatments, but there is room for improvement in terms of both outcome and compliance.     

Examining the Link Between Hoarding Symptoms and Cognitive Flexibility Deficits

Executive functioning deficits have been found to underlie primary symptoms of hoarding, such as difficulty discarding belongings and significant clutter. Cognitive flexibility—the ability to inhibit irrelevant material and attend flexibly between different mental sets—may be impaired as well, as individuals experience difficulty staying on task and are often distracted by specific possessions that tend to evoke an exaggerated emotional response. The present study investigated cognitive flexibility deficits via eye-tracking technology as a novel approach. Participants (N = 69) with high and low self-reported hoarding symptoms were asked to respond to a series of auditory cues requiring them to categorize a small target number superimposed on one of three distractor image types: hoarding, nature, or a blank control. Across a range of behavioral and eye-tracking outcomes (including reaction time, accuracy rate, initial orientation to distractors, and viewing time for distractors), high hoarding participants consistently demonstrated greater cognitive inflexibility compared to the low hoarding group. However, high hoarding participants did not evidence context-dependent deficits based on preceding distractor types, as performance did not significantly differ as a function of hoarding versus nature distractors. Current findings indicate a pervasive, more global deficit in cognitive flexibility. Those with hoarding may encounter greater difficulty disengaging from previous stimuli and attending to a given task at hand, regardless of whether the context of the distractor is specifically related to hoarding. Implications and future directions for clarifying the nature of cognitive inflexibility are discussed.     

Cognitive Behavioral Principles Within Group Mentoring: A Randomized Pilot Study

This study evaluated the effectiveness of a group mentoring program that included components of empirically supported mentoring and cognitive behavioral techniques for children served at a community mental health center. Eighty-six 8- to 12-year-old children were randomly assigned to either group mentoring or a wait-list control group. Group mentoring significantly increased children's reported social problem-solving skills and decreased parent-reported child externalizing and internalizing behavior problems after controlling for other concurrent mental health services. Attrition from the group mentoring program was notably low (7%) for children. The integration of a cognitive behavioral group mentoring program into children's existing community mental health services may result in additional reductions in externalizing and internalizing behavior problems.     

Cognitive Behavioral Treatment of PTSD with Comorbid Panic Attacks

Many individuals that experience traumatic events such as sexual and physical assault develop posttraumatic stress disorder (PTSD). More recently, research has indicated that a significant proportion of PTSD sufferers may also have comorbid panic attacks. Although there are several effective treatments that focus on alleviating PTSD symptoms, until now there were no treatments that focused on also treating comorbid panic attacks. Multiple channel exposure therapy (M-CET) is the first treatment developed to specifically treat comorbid PTSD and panic attacks. It is also unique in that it has been used to treat women who have multiple trauma histories as well as a wide range of different types of traumatic event exposure in a group format. This treatment is described in a session by session format and special considerations in implementing the treatment are discussed.     

Insight-Related Challenges in the Treatment of Hoarding

Compulsive hoarding is a chronic and debilitating condition that has proven difficult to treat. The cognitive behavioral approaches that have otherwise been successful for people suffering from obsessive-compulsive disorder do not work very well for hoarding (Abramowitz, Franklin, Schwartz, & Furr, 2003). Many have suggested that this is due to the ego-syntonic nature of the symptoms and the accompanying lack of insight. This paper describes several challenges related to insight that limit the effectiveness of traditional cognitive behavioral approaches for compulsive hoarding. Problems with anosognosia, overvalued ideation, and defensiveness that characterize hoarding are described and suggestions offered for dealing with them.     

Boundary Management for Cognitive Behavioral Therapies

In recent years, the scholarship regarding professional boundaries has increased significantly in a variety of areas. Despite many advances in this line of research, less attention has been devoted to the question of boundary maintenance and its relationship to theoretical orientation. In this article we examine these issues for cognitive-behavioral therapies. After a brief historical review of the evolution of the concept of boundaries, we select three procedures integral to cognitive-behavioral practice and discuss how they may create boundary problems for practitioners. We conclude with recommendations for practice.     

抑郁症的计算机化认知行为治疗

计算机化认知行为治疗(computerized cognitive-behavioral therapy, CCBT), 即指通过电脑交互界面, 以清晰的操作步骤, 高度结构化的多种媒介互动方式(如网页、漫画、动画、视频、声音等)来表现认知行为治疗基本原则和方法的治疗方式。抑郁症的CCBT近年来在西方崭露头角, 目前Beating The Blues、MoodGYM、E-Couch和Good Days Ahead等抑郁症CCBT程序在西方使用较为广泛。从可行性分析上发现, 该疗法较受病人接纳、具有较高的成本效用和易用性; 现有实验研究证明了抑郁症采用CCBT是有效的, 但其有效性仍取决于诸多因素。以往研究存在着较少关注治疗有效性的内在机制、治疗效果差异较大、风险评估简化和被试选择偏向等问题, 建议未来研究应加强：(1)中介效应及机制研究; (2)以人为本的个性化服务研究; (3)风险评估与隐私保护研究; (4)在“弱势群体”中的研究与运用。最后, 对其在中国发展的必要性与可行性进行了展望。     

Cognitive Behavioral Therapy for Insomnia in Older Adults

Insomnia is associated with significant morbidity and is often a persistent problem, particularly in older adults. It is important to attend to this complaint and not assume that it will remit spontaneously. In many cases, unfortunately, insomnia remains unrecognized and untreated, often because it is presumed that insomnia is an inevitable consequence of aging. Although the sleep structure naturally changes with advancing age, these changes are not necessarily associated with complaints of poor sleep, distress, or daytime consequences, while chronic insomnia clearly is. There is increasing evidence that cognitive behavioral therapy (CBT) is effective for the management of chronic insomnia in the elderly and that it is of significant benefit for insomnia comorbid with medical and psychological conditions, also more prevalent in older age. The aim of this article is to familiarize clinicians working with older adults with the different components of CBT for insomnia and how to adapt the treatment to this population. A clinical case and session-by-session implementation of CBT for insomnia are described to illustrate information and guidelines provided in this article.     

Ethical Considerations in the Treatment of Compulsive Hoarding

Although empirically supported treatment for compulsive hoarding is in its preliminary stages, some information has emerged regarding ethical challenges experienced in treating this population. Our aims are twofold: (a) to inform the clinical community of ethical complications when conducting treatment for hoarding clients, and (b) to provide a decision-making model for ensuring quality and ethical care of hoarding clients. The ethical challenges (boundary crossings, dual roles, privacy/confidentiality, record keeping, fees, and cultural competence in treatment) were discovered through multiple roundtable discussions, supervision, and in the course of delivering empirically supported treatment protocols. A literature search was conducted to identify research that addressed ethical concerns. A decision-making model addressing ethical challenges in treatment of compulsive hoarding was developed.     

Longitudinal Results of Cognitive Behavioral Treatment for Youths with Inflammatory Bowel Disease and Depressive Symptoms

Youths with chronic physical illnesses face increased rates of psychological problems and the burden of coping with physical illness-related challenges. The following data describes treatment outcome maintenance results from a randomized clinical trial investigating the impact of a cognitive behavioral intervention Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) as compared to treatment as usual (TAU) on youths with inflammatory bowel disease (IBD). Forty-one participants aged 11-17 with IBD and concurrent depressive symptomatology were randomized to PASCET-PI (n?=?22) or TAU (n?=?19). Self-reported depressive features, global functioning, and DSM-IV depressive symptomatology were assessed immediately post-treatment (T2), followed by assessments at 6-months (T3) and 12-months (T4) post-treatment initiation. Repeated measure models revealed significantly improved global psychosocial functioning in youths randomized to PASCET-PI compared to youths randomized to TAU. Improvements in self-reported depressive features and DSM-IV depressive symptoms were found at the trend level for youths randomized to PASCET-PI relative to those receiving TAU. Effect size estimates for all outcome variables suggested large to medium treatment effects.