Pharmacologic treatment of body dysmorphic disorder: review of the evidence and a recommended treatment approach

Research on effective pharmacotherapy for body dysmorphic disorder (BDD) has rapidly increased in recent years, with emerging data consistently indicating that serotonin reuptake inhibitors (SRIs) are often efficacious for this disorder. Although data are limited, it appears that higher SRI doses and longer treatment trials than those used for many other psychiatric disorders are often needed to treat BDD effectively. Approaches to treatment-resistant BDD have received little investigation, but available data indicate that switching to another SRI and several SRI-augmentation strategies may be helpful. This article reviews the empirical literature on BDD and offers a recommended approach to the pharmacotherapy of this distressing and often disabling disorder.     

Cognitive Behavioral Therapy Across the Stages of Psychosis: Prodromal, First Episode, and Chronic Schizophrenia

Since the early 1990s, cognitive behavioral therapy (CBT) has been increasingly used as an adjunctive treatment for psychotic disorders. This paper describes the CBT of three cases, each at a different stage of psychotic disorder: at-risk mental state, first-episode psychosis, and chronic psychotic disorder. For the at-risk mental state, treament focused on anxiety and social phobia, whereas the treatment of first-episode psychosis focused on the development of a shared formulation of the factors leading to and maintaining psychotic symptoms. For the chronic case, treatment emphasized the possibility of improving strategies to prevent symptoms from interfering with life goals. The potential contribution of CBT to improve outcomes in psychotic disorders beyond those obtained through traditional pharmacotherapy is discussed.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

Psychotherapy and Pharmacotherapy Treatment Outcome Research in Pediatric Populations

Reviewed treatment interventions for pediatric populations involving the combination of pharmacotherapy or psychotherapy or either treatment employed alone. The literature revealed a dearth of psychotherapy and pharmacotherapy outcome studies, with the exception of investigations of children diagnosed with attention-deficit hyperactivity disorder (ADHD). Issues pertaining to design, including sample selection, treatment integrity and comparability, and placebo controls also are reviewed. A potpourri of other issues are noted including parental attitudes toward the use of medication versus psychotherapy, treatment adherence, and patient/provider relationship. For children diagnosed with ADHD, the use of stimulant medication appears to be superior to psychotherapy employed alone in managing the behavior of these children as well as their classroom functioning. Recommendations are made for multimodal trials that examine the combined and individual use of pharmacotherapies and psychotherapies for various developmental and psychiatric disorders that occur in childhood and adolescence. Future studies also need to address the durable effects of these treatment options.     

Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach

Body dysmorphic disorder (BDD) is a relatively common and often disabling disorder with high morbidity and mortality. Both psychotropic medication and cognitive behavioral therapy (CBT) are considered first-line treatments for BDD, and medication treatment is often essential for more severely ill and suicidal patients. In this practical overview of the pharmacotherapy of BDD, we briefly describe BDD's clinical features, associated morbidity, and how to recognize and diagnose BDD. We describe the importance of forming a therapeutic alliance with the patient, the need for psychoeducation, and other essential groundwork for successful treatment of BDD. We review available pharmacotherapy research, with a focus on serotonin-reuptake inhibitors (SSRIs, or SRIs), which are currently considered the medication of choice for BDD. Many patients have substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, suicidality, and other aspects of BDD when treated with appropriate pharmacotherapy that targets BDD symptoms. We also discuss practical issues such as dosing, length of treatment, and potential side effects associated with the use of SRIs. In addition, we discuss pharmacotherapy approaches that can be tried if SRI treatment alone is not adequately helpful. Finally, some misconceptions about pharmacotherapy, gaps in knowledge about BDD's treatment, and the need for additional research are discussed.     

Frequency, comorbidity, and psychosocial impairment of specific phobia in adolescents

Investigated the frequency, comorbidity, and psychosocial impairment of specific phobia and specific fears among 1,035 adolescents 12 to 17 years old. The adolescents were recruited from 36 schools in the province of Bremen, Germany. Specific phobia and other psychiatric disorders were coded based on Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria using the computerized Munich version of the Composite International Diagnostic Interview (Wittchen & Pfister, 1996). Thirty-six (3.5%) of the adolescents met DSM-IV criteria for specific phobia sometime in their life. Of all the subtypes of specific phobia, animal and natural environment phobia were the most common. More girls than boys received the diagnosis of specific phobia. One third of the adolescents with specific phobia also had depressive and somatoform disorders. Despite the high level of psychosocial impairment experienced by individuals with specific phobia both during the worst episode of their disorder and in the last 4 weeks, only a small portion of them sought professional help.     

The Sequential Combination of Pharmacotherapy and Psychotherapy in Mood Disorders

The aim of this review was to consider the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood disorders. Review of the clinical trials where treatment components were used in a sequential order were identified by using MEDLINE, a manual search of the literature and the Index Medicus. In unipolar recurrent depression, the sequential use of pharmacotherapy and psychotherapy was found to improve relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already assuming mood stabilizers was also found to yield clinical benefits. The sequential model has the potential for improving the logic and timing of interventions. A conceptual shift in current assessment methods (staging) is needed.     

One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission

Non-response to pharmacotherapy for panic disorder (PD) is a well-documented problem. However, little information exists to guide next-step strategies for these non-responders. In addition to pharmacologic augmentation strategies, several studies support the efficacy of cognitive-behavior therapy (CBT) for these patients, although data on long-term outcomes has been lacking. In this study, we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy. Sustained significant benefit was found for all dimensional outcome scores, and nearly two-thirds of the sample met remission criteria. This occurred with reductions in medication use over the follow-up period. Negative predictors of remission status included comorbid dysthymia, social phobia, and generalized anxiety disorder. These results provide additional evidence for the efficacy of CBT for medication non-responders with PD.     

First-Line Treatment for Pediatric Obsessive–Compulsive Disorder

Pediatric obsessive–compulsive disorder (OCD) is a common psychiatric disorder that impairs children’s functioning in home, school, and community settings. Once thought to be an untreatable or treatment refractory disorder, evidence-based treatments now exist for pediatric OCD. Various psychological treatment approaches for pediatric OCD have been investigated and research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and combined CBT/E/RP with serotonin reuptake inhibitor pharmacotherapy. This paper reviews these approaches and highlights the prominent role of CBT/E/RP as a first-line treatment for pediatric OCD.     

The Social Thoughts and Beliefs Scale: a new inventory for assessing cognitions in social phobia

Development and initial psychometric features of a new inventory to assess cognitions associated with social phobia are described. The Social Thoughts and Beliefs Scale (STABS) is designed to assess cognitions in individuals with social phobia. In the 1st study, an initial pool of 45 items was reduced to 21. In the 2nd study, psychometric features of the scale were examined in a sample of individuals with social phobia, other anxiety disorders, and no psychiatric disorder. Total scores and two factor scores significantly differentiated individuals with social phobia from those in the other groups and were found to have adequate test-retest reliability and internal consistency. Potential usefulness of the STABS for assessing cognitions associated with social phobia is discussed.     

Sociodemographic, clinical and outcome differences among anxiety disorders

The aims of this paper are to analyze differences in sociodemographic and clinical characteristics among the various anxiety disorders treated in a Psychology Clinic, and the results of treatment in each anxiety disorder. Data from 282 patients of University Psychology Clinic at the Complutense University of Madrid, who had at least one diagnosis of anxiety according to DMS-IV-TR criteria, were analyzed. The most frequent anxiety disorders were nonspecific anxiety disorder (19.1%) and social phobia (18.8%). Significant differences were observed according to sex (in all disorders, the percentage of women was significantly higher than that of men, except for obsessive-compulsive disorder). Unspecific anxiety disorder required a smaller number of assessment and treatment sessions, whereas obsessive-compulsive disorder required a greater number of sessions. There were no significant differences between the percentage of patients who completed treatment and dropout rates in specific phobia, general anxiety disorder and obsessive-compulsive disorder. Differences between epidemiological and clinical data are discussed.     

Screening for ADHD in an adult social phobia sample

Objective: Recent studies have suggested a link between a primary anxiety disorder and ADHD. Method: A total of 39 participants with a primary diagnosis of social phobia were compared with 178 patients with ADHD and 88 patients with other psychiatric disorders on measures for childhood and adult ADHD (the Wender Utah Rating Scale and the Adult ADHD Self-Report Scale). Results: Childhood symptoms of ADHD were reported by 7.8% of the social phobia participants, and 5.1% scored within the range of adult ADHD. The social phobia group reported significantly fewer ADHD symptoms than both of the comparison groups, who frequently reported social anxiety. Conclusion: Participants with social phobia recruited from the general population are less likely to suffer from ADHD. In contrast, patients with ADHD and patients with other psychiatric disorders appear to be likely to suffer from social anxiety.     

Psychological Factors Behind Truancy,School Phobia,and School Refusal: A Literature Study

Truancy is a problem that normally leads to treatment interventions within different organizations. Within these organizations different perspectives on the causes and consequences of the above problem can be found. The purpose of this literature study is to map out and describe the current state of research within the fields of school refusal, truancy, and school phobia. The investigation was carried out in the form of a systematic review of the relevant research literature. Research shows that approximately 90% of all young people who refuse to go to school have some form of psychiatric diagnosis.     

Psychiatric Comorbidity and Functional Status in Adult Patients with Asthma

The goals of this study were to characterize the frequency of psychiatric disorders among patients with asthma, and to compare differences in functional status among asthma patients with and without comorbid depression and anxiety disorders. Fifty patients with confirmed asthma were administered the Diagnostic Interview Schedule for DSM-III-R and completed the Medical Outcomes Study Short Form-36 Health Survey. Patients with asthma had a higher lifetime prevalence of major depression, panic disorder, and agoraphobia, but a lower prevalence of social phobia, compared to lifetime prevalence rates for psychiatric disorders in a national probability sample. Participants with comorbid asthma and major depression had poorer physical and mental health functioning and health perception than did asthma patients without major depression. The results suggest that certain psychiatric disorders are common among patients with asthma and that depression is associated with significantly increased functional morbidity. These findings underscore the need for the appropriate detection and treatment of these comorbid conditions.     

The impact of an 8-day intensive treatment for adolescent panic disorder and agoraphobia on comorbid diagnoses

Previous research findings have shown positive effects of cognitive-behavioral therapy for primary anxiety disorders as well as for nonprimary, co-occurring anxiety disorders. In this study, we analyzed data from an existing randomized controlled trial of intensive treatment for panic disorder with or without agoraphobia (PDA) to examine the effects of the treatment on comorbid psychiatric diagnoses. The overall frequency and severity of aggregated comorbid diagnoses decreased in a group of adolescents who received an 8-day treatment for PDA. Results suggest that an 8-day treatment for PDA can alleviate the symptoms of some specific comorbid clinical diagnoses; in particular specific phobias, generalized anxiety disorder, and social phobia. These findings suggest that an intensive treatment for PDA is associated with reductions in comorbid symptoms even though disorders other than PDA are not specific treatment targets.     

Cognitive-behavioral therapy for panic disorder: a review of treatment elements,strategies, and outcomes

This article provides an overview of cognitive-behavioral therapy (CBT) for panic disorder. CBT is currently considered a first-line treatment for panic disorder. It offers benefit after short-term intervention, typically consisting of 12-15 sessions conducted in either an individual or a group format. The treatment focuses on the elimination of the patterns that underlie and perpetuate the disorder. Through CBT, patients learn about the nature of the disorder and acquire a set of strategies that counter the fears of panic attacks themselves, and break the recurring cycle of anticipatory anxiety, panic, and agoraphobic avoidance. The collaborative format of treatment, and a focus on elimination of core fears may be factors in enhancing longer-term outcome. In this article, we review the efficacy of CBT as a first-line treatment, a strategy for medication nonresponders, a replacement strategy for patients who wish to discontinue pharmacotherapy, and a potential preventive strategy for at-risk individuals. We also discuss some of the complex issues involved with combination-treatment strategies.     

Social phobia in disabled workers with chronic musculoskeletal pain

The present study assessed the prevalence and impact of social phobia and other anxiety disorders in disabled workers with chronic musculoskeletal pain. Potential participants were 200 disabled workers consecutively referred to an interdisciplinary tertiary care centre. A two stage screening process was used in which: (a) a self-report battery was given during a pre-admission visit, and (b) preplanned selection criteria were applied to the self-report instruments to select patients for a structured diagnostic interview. Fifty-four of the 146 patients who provided complete responses on the self-report battery met criteria for interview. Twenty-six patients (17.8%) met DSM-IV criteria for a current anxiety disorder and, of these, 16 (11.0%) were diagnosed with social phobia. Subjects with social phobia rated themselves as having less social support than subjects with no psychiatric disorder, but the groups did not differ in pain-related life interference, personal control, or health care utilization. The results suggest that social phobia is over-represented in disabled workers with chronic musculoskeletal pain and should be noted as a comorbid condition that may compound both suffering and disability.     

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.     

Shyness: relationship to social phobia and other psychiatric disorders

The relationship between shyness, social phobia and other psychiatric disorders was examined. The prevalence of social phobia was significantly higher among shy persons (18%) compared with non-shy persons (3%). However, the majority of shy individuals (82%) were not socially phobic. A significant and positive correlation was found between the severity of shyness and the presence of social phobia, but the data suggest that social phobia is not merely severe shyness. Social phobia was also positively and moderately correlated with introversion and neuroticism. Thus, shy persons with social phobia were shyer, more introverted, and more neurotic than other shy people, but none of these factors was sufficient to distinguish shy persons with social phobia from those without social phobia. The proportion of the shy group with psychiatric diagnoses other than social phobia was significantly higher than among the non-shy group, indicating that various diagnostic categories are prominent among the shy. The results are discussed in terms of the overlap in shyness and social phobia and the relationship of shyness to other psychiatric diagnoses and personality dimensions.     

An overview of the current status of social phobia

Social phobia is a common and debilitating anxiety disorder that is associated with serious impairment in social and vocational functioning and increased risk of comorbid psychopathology. The disorder typically begins in adolescence and left untreated follows a chronic, unremitting course. Although little is currently known about the etiology of the condition, dramatic developments have been made in the assessment and treatment of social phobia over the past decade. Various medications and forms of behavior therapy have been shown to be effective, although many patients do not respond fully to treatment. The current status of social phobia and directions for future research are discussed.