Cognitive-behavioural approaches in the treatment of hypochondriasis: six single case cross-over studies.

This study evaluates a cognitive and a behavioural treatment protocol for hypochondrical complaints. In a cross-over design, six patients with a primary diagnosis of hypochondriasis were treated. Three of them first received a block of behavioural therapy (exposure in vivo and response prevention), followed by a block of cognitive therapy. The other three patients were first treated with cognitive therapy followed by behavioural therapy. The results were promising: four patients made significant improvements. The behavioural therapy sessions appeared to account more often for improvement than did the cognitive sessions. The sequence of behavioural therapy followed by cognitive therapy tended to be more successful than the other way around. The results of these six case studies suggest that exposure in vivo with response prevention and cognitive therapy may both be useful in the treatment of hypochondriasis. A journal controlled study is recommended.     

A randomized, controlled clinical trial of in virtuo and in vivo exposure for spider phobia

The present study compared the efficacy of virtual reality (VR) in virtuo exposure and in vivo exposure in the treatment of spider phobia. Two treatment conditions were compared to a waiting-list condition. A 3-month follow-up evaluation was conducted in order to assess the durability of the treatment effects. Participants were randomly assigned to the treatment groups. A total of 16 participants received the in virtuo treatment, and 16 received the in vivo treatment. The waiting-list condition included 11 participants. Participants received eight 1.5-hour treatment sessions. Efficacy was measured with the Fear of Spiders Questionnaire, the Spider Beliefs Questionnaire (SBQ-F), and a Behavioral Avoidance Test (BAT). In addition, a clinician administered the Structured Interview for DSM-IV to assess DSM-IV's criteria for specific phobia and severity. Clinical and statistically significant improvements were found for both groups. Differences in treatment groups were found on one of five measures of fear: greater improvement on the SBQ-F beliefs subscale was associated with in vivo exposure.     

An evaluation of group therapy for adolescents using social skills training

The present study investigated the hypothesis that social skills training is more effective in increasing socially acceptable behaviour in adolescents than is a generalized or non-specific form of group therapy. Forty-two subjects were selected to participate in the study from among adolescents referred for group therapy at two youth guidance clinics in Brisbane, Australia. The 23 males and 19 females were randomly assigned to one of three treatment conditions: a social skills training group, a non-specific therapy group and a waiting-list-for-therapy (control) condition. All subjects were assessed before and after treatment on five measures of social skills. Subjects in the social skills training group showed significant improvements on three of these measures while the non-specific therapy and waiting-list control groups showed no specific changes on any of the measures.     

An Evaluation of Two Types of Cognitive Intervention in the Management of Chronic Tinnitus

Abstract

Fifty-four subjects with chronic distressing tinnitus were randomly allocated to one of four experimental treatment conditions: (1) attention control and imagery training (AC1); (2) cognitive restructuring (CR); (3) combined attention control and imagery training plus cognitive restructuring (ACI + CR); and (4) a waiting list control (WLC). Significant overall improvements were found on measures of distress associated with tinnitus, and on a number of other measures of cognition and coping strategies. These improvements were maintained at the six-month follow-up. Relative to the WLC, the three treatment conditions (combined) were associated with improvements in tinnitus-related distress, reductions in tinnitus-related dysfunctional cognitions and an increase in the frequency of use of coping strategies. There was a significant effect in favour of the ACI group compared to the CR group on the measure of irrational beliefs. The analyses also revealed that the combined treatment condition (ACI + CR) showed significantly greater improvement on a measure of psychological distress and achieved a higher clinical response rate compared to the two single treatments. There were significant improvements from pretreatment to follow-up on some measures, although the mean scores revealed that some of the gains had been lost at this stage on the main measure of tinnitus-related distress. There were no significant group X time effects for any of the dependent variables at the six-month follow-up. The results were interpreted as supporting the practice of combining the two cognitive approaches.     

Individual response patterns and the effects of different behavioral methods in the treatment of claustrophobia

The importance of individual response patterns in claustrophobic patients was examined in the present study. Thirty-four psychiatric outpatients with a phobia of enclosed spaces were assessed in a small test chamber. During the test their overt behavior was video-taped, heart-rate was measured continuously, and self-ratings of experienced anxiety were made at certain intervals. On the basis of their reactions in the test situation, the patients were divided into two groups showing different response patterns—behavioral and physiological reactors. Within each group the patients were randomly assigned to one behaviorally-focused method (exposure), one physiologically-focused method (applied relaxation) and a waiting-list control group. The patients were treated individually in eight sessions. The between-group comparisons showed that both exposure and applied relaxation were significantly better than the waiting-list condition. Furthermore, exposure yielded better results than applied relaxation for the behavioral reactors, while applied relaxation was better than exposure for the physiological reactors. The improvements were maintained at a follow-up assessment 14 months after the end of treatment. The results support the hypothesis that greater effects are achieved when the method used fits the patient's response pattern than when it does not.     

Treatment of Hypochondriasis with Exposure

Cognitive-behavioral therapy has been shown to be an effective treatment for hypochondriasis. An important element of most of the empirically validated CBT protocols for this problem is exposure. Various approaches to exposure may be useful including in vivo exposure to health and death-related situations, interoceptive exposure to feared bodily symptoms, and imaginal exposure to symptoms and feared illnesses that are difficult to reproduce in real life. Strategies for enhancing the effectiveness of exposure, such as response prevention, cognitive reappraisal, and acceptance, are also discussed. Practical suggestions for implementation of exposure with this population are provided.     

The role of client choice and target selection in self-management therapy for depression in older adults

In a study designed to maximize the effectiveness of treatment by allowing participants to select the target of treatment, 40 depressed older adults were randomly assigned to a waiting-list control condition or to conditions in which the target of treatment was either chosen or assigned. All participants received self-management therapy and the choice was between changing behavior or changing cognition. It was found that individually administered self-management therapy was effective in treating depression for older adults. There were no differences in outcome between versions of self-management therapy that targeted behavioral or cognitive change. Among those who completed treatment, there were no differences in outcome between those who received a choice and those who did not. Individuals who were given a choice of treatment options, however, were less likely to drop out of treatment prematurely.     

Exercise, changes in aerobic capacity, and changes in self-perceptions: An experimental investigation

Subjects in an exercise training condition participated in a 10-week aerobic exercise class, whereas subjects in waiting-list control and independent control conditions did not. The results indicated that subjects in the training condition evidenced reliably greater improvements in physical fitness (aerobic capacity) and reported reliably greater improvements in their abilities and confidence in both the physical area (e.g., ability to run distances) and nonphysical area (e.g., frustration tolerance) than did subjects in the control conditions. On the other hand, improvements in physical fitness were not related to reported improvements in abilities and confidence. These findings are of interest because they indicate that some of the important personal changes that are associated with physical fitness training are not due to changes in fitness, but appear to be due to other factors (e.g., group participation and expectancies).     

Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Hypochondriasis Among Patients with Multiple Somatoform Symptoms—Psychopathology and Outcome of a Cognitive-Behavioral Therapy

As hypochondriasis often occurs with somatization, patients with somatization disorder plus hypochondriasis were compared to patients with somatization syndrome alone regarding psychopathology, patterns of physical symptoms and outcome of a cognitive-behavioral inpatient treatment. A sample of patients with DSM-IV hypochondriasis and multiple somatoform symptoms(N = 27) and a matched sample of patients with multiple somatoform symptoms but without hypochondriasis (N = 27) were assessed. All subjects obtained a cognitive-behavioral treatment for somatization and hypochondriasis. Assessment took place at admission and at one-year follow-up. Only a few differences between the groups were found: Hypochondriacs suffered more often from abdominal pain, and they reported a higher intolerance of bodily complaints. At follow-up, all outcome variables improved significantly. High effect sizes were found for the reduction of symptoms and the mean number of visits to the doctor. The specific effect on health care use highlights the socioeconomic relevance of these results.     

Effectiveness and cost offset analysis of group CBT for hypochondriasis delivered in a psychiatric setting: an open trial

Hypochondriasis is highly prevalent in medical settings, has detrimental effects for affected individuals, and is associated with high societal costs. Although cognitive behavior therapy (CBT) has been shown to be effective in the treatment of hypochondriasis, it is not widely available because of a lack of properly trained therapists. Therefore, it is essential to evaluate therapy forms that require less therapist time. The authors investigated the effect and economic impact of group CBT delivered in a psychiatric setting among 24 people with hypochondriasis. A within-group design with prolonged baseline was used, and all participants received 10 weeks of group-based treatment. The primary outcome measures were the Health Anxiety Inventory and the Illness Attitude Scales. Results indicate significant improvement on both measures at posttreatment and 6-month follow-up (Cohen's d = 1.03-1.72). Medical and nonmedical costs were substantially lowered. The authors conclude that group-based CBT delivered in a psychiatric setting is an effective and potentially highly cost-effective treatment for hypochondriasis.     

Influence of Co‐Morbid Generalized Anxiety Disorder,Panic Disorder and Personality Disorders on the Outcome of Cognitive Behavioural Treatment of Obsessive‐Compulsive Disorder

This study examined co‐morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive‐compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co‐morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention‐to‐treat criteria, patients with generalized anxiety disorder and/or panic disorder co‐morbidity showed less treatment gains at post‐treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post‐treatment and the 12‐month follow‐up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co‐morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12‐month follow‐up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post‐treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Experimental and Behavioral Approaches to Alcoholism: Kongressrapport

Hypochondriasis is highly prevalent in medical settings, has detrimental effects for affected individuals, and is associated with high societal costs. Although cognitive behavior therapy (CBT) has been shown to be effective in the treatment of hypochondriasis, it is not widely available because of a lack of properly trained therapists. Therefore, it is essential to evaluate therapy forms that require less therapist time. The authors investigated the effect and economic impact of group CBT delivered in a psychiatric setting among 24 people with hypochondriasis. A within-group design with prolonged baseline was used, and all participants received 10 weeks of group-based treatment. The primary outcome measures were the Health Anxiety Inventory and the Illness Attitude Scales. Results indicate significant improvement on both measures at posttreatment and 6-month follow-up (Cohen's d = 1.03–1.72). Medical and nonmedical costs were substantially lowered. The authors conclude that group-based CBT delivered in a psychiatric setting is an effective and potentially highly cost-effective treatment for hypochondriasis.     

The effects of brief cognitive-behaviour therapy for pathological skin picking: A randomized comparison to wait-list control

Thirty-four college students suffering from pathological skin picking were randomly assigned to a four-session cognitive-behavioural treatment (n = 17) or a waiting-list condition (n = 17). Severity of skin picking, psycho-social impact of skin picking, strength of skin-picking-related dysfunctional cognitions, and severity of skin injury were measured at pre-, post-, and two-months follow-up assessment. Participants in the treatment condition showed a significantly larger reduction on all measured variables in comparison to the waiting-list condition. The obtained effect sizes for the outcome measures were large, ranging from .90 to 1.89. Treatment effects were maintained at follow-up. In conclusion, cognitive-behavioural therapy, even in brief form, constitutes an adequate treatment option for pathological skin-picking behaviour.     

A comparison of two psychological treatments for bulimia nervosa: Implications for models of maintenance

In an effort to elucidate the role of cognitive factors in the maintenance of bulimia nervosa, the efficacy of two psychological treatments was examined in a randomised control trial: cognitive behaviour therapy in the absence of explicit exposure instructions was compared with exposure and response prevention treatment in the absence of cognitive restructuring procedures. In the short term both treatments were successful at effecting substantial improvement in both the specific and the non-specific psychopathology of the disorder. However, at a one year follow up, whilst improvements were well maintained for those who had received the cognitive-behavioural treatment, virtually all of those who had responded to the purely behavioural treatment had relapsed. This provides some support for the cognitive model of the maintenance of bulimia nervosa. Nevertheless, the two treatment groups could not be distinguished on post-treatment measures of cognitive disturbance and neither was it the case that residual levels of cognitive disturbance, as assessed, predicted relapse. This may suggest that the level at which the necessary cognitive change takes place may not be accessible by conventional assessment procedures.     

Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa

Does higher level of individualization increase treatment efficacy? Fifty patients with bulimia nervosa were randomized into either manual-based (focused) or more individualized (broader) cognitive behavioral therapy guided by logical functional analysis. Eating disorders Examination and a series of self-report questionnaires were used for assessment at pre-, and post-treatment as well as at follow-up. Both conditions improved significantly at post-treatment, and the results were maintained at the 6 months follow-up. There were no statistically and clinically significant differences between the two conditions at post-treatment with the exception of abstinence from objective bulimic episodes, eating concerns, and body shape dissatisfaction, all favoring the individualized, broader condition. Both groups improved concerning self-esteem, perceived social support from friends, and depression. The improvements were maintained at follow-up. Ten patients (20%) did not respond to the treatment. Notably, a majority of non-responders (80%) were in the manual-based condition. Non-responders showed extreme dominance of rule-governed behavior, and lack of contact with actual contingencies compared to responders. The study provided preliminary support for the superiority of higher level of individualization (i.e. broader CBT) in terms of the response to treatment, and relapses. However, the magnitude of effects was moderate, and independent replications, with blind assessment procedures, and a larger sample sized are needed before more clear cut conclusions can be drawn.     

Internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help

Internet-delivered self-help for depression with therapist guidance has shown efficacy in several trials. Results from meta-analyses suggest that guidance is important and that self-help programs without support are less effective. However, there are no direct experimental comparisons between guided and unguided internet-based treatments for depression. The present study compared the benefits of a 10-week web-based unguided self-help treatment with the same intervention complemented with weekly therapist support via e-mail. A waiting-list control group was also included. Seventy-six individuals meeting the diagnostic criteria of major depression or dysthymia were randomly assigned to one of the three conditions. The Beck Depression Inventory (BDI-II) was used as the primary outcome measure. Secondary outcomes included general psychopathology, interpersonal problems, and quality of life. Sixty-nine participants (91%) completed the assessment at posttreatment and 59 (78%) at 6-month follow-up. Results showed significant symptom reductions in both treatment groups compared to the waiting-list control group. At posttreatment, between-group effect sizes on the BDI-II were d = .66 for unguided self-help versus waiting-list and d = 1.14 for guided self-help versus waiting-list controls. In the comparison of the two active treatments, small-to-moderate, but not statistically significant effects in favor of the guided condition were found on all measured dimensions. In both groups, treatment gains were maintained at 6-month follow-up. The findings provide evidence that internet-delivered treatments for depression can be effective whether support is added or not. However, all participants were interviewed in a structured diagnostic telephone interview before inclusion, which prohibits conclusions regarding unguided treatments that are without any human contact.     

Bulimia nervosa: group behavior therapy with exposure plus response prevention

Exposure plus response prevention has been demonstrated to be effective in the treatment of bulimia nervosa. However, when done individually, it is labor intensive and cost-ineffective. In the present study exposure plus response prevention was used in the context of a 6-wk., 12-session behavioral group. In addition to the exposure plus response-prevention component, other techniques included self-monitoring, cognitive restructuring, eating-habit stabilization and problem-solving. Eight bulimic women, vomiting a minimum of five times per week for at least a year, participated in the group. At the end of treatment significant reductions in bingeing and vomiting behaviors were reported by all but one subject, substantiated by significantly lower depression scores (Beck Depression Inventory) and binge-eating scores (Binge Eating Scale). At 6 mo. and 1 yr. posttreatment, 6 of 8 subjects reported averaging less than one binge-purge episode per week, one subject continued unchanged, and one subject had relapsed. A group of wait-list control subjects reported essentially no change in binge-purge frequency over the treatment period. Exposure plus response prevention conducted in a behavioral group context appears to be a cost-effective alternative to individual treatment.     

Behavioral treatment of insomnia in older adults: an open clinical trial comparing two interventions

Fifty-five insomniacs, 60 years or above, participated in a behavioral treatment program, comparing two interventions (sleep hygiene+stimulus control vs sleep hygiene+relaxation tape). Half of the subjects were randomized to a waiting-list condition prior to treatment. No significant changes were observed during the waiting-list period. During the treatment period however, the subjects improved on several sleep parameters, and treatment gains were maintained at a 6-month follow-up. The effects of treatment were greater for nocturnal measures (e.g. sleep onset latency and total sleep time) as compared to daytime measures (e.g. life satisfaction, daytime alertness) and not-targeted behavior (medication use). There were no differences in treatment effects for the two interventions.     

Enhancing the effectiveness of self-administered videotape parent training for families with conduct-problem children

Parents of 43 conduct-problem children, aged 3-8 years, were randomly assigned to one of two treatments: an individually self-administered video-tape modeling treatment (IVM) and IVM treatment plus therapist consultation (IVMC). Randomization also included a waiting-list control group (CON). Compared with the control group, both treatment groups of mothers reported significantly fewer child behavior problems, reduced stress levels, and less use of spanking. Home visit data indicated that both treatment groups exhibited significant behavioral changes. There were relatively few differences between the two treatment conditions. However, the IVMC children were significantly less deviant than the IVM children, suggesting that the IVMC (with therapist consultation) treatment was superior to self-administered treatment with no therapist involvement. The added benefits of therapist involvement are discussed.