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.     

Memory in schizophrenia and affective disorders*

The purpose of the present study was to investigate the stability of memory and information processing in schizophrenics and affectively disturbed patients. Twenty-two schizophrenics, eight affectives and 14 normal controls were tested twice, with an interval of approximately one year. Results showed that normals performed better than schizophrenics and affectively disturbed patients on almost all of the cognitive measures. The differences reached a level of significance on a reaction time test, a vigilance task and a long-term memory task. The only measure where the difference did not reach a level of significance was on a short-term memory test. Groups' performance to some extent changed over time on most of the measures, but the changes were not significantly different for different groups.     

Behavioral assessment and treatment of acquired visuoperceptual disorders

Visuoperceptual deficits are common sequelae of damage to either hemisphere of the brain, but are typically more pronounced following injuries involving the right cerebral hemisphere. Common visuoperceptual disorders include visual field cuts, hemi-inattention and hemi-spatial neglect, hemi-perceptual deficits, and gaze and visual pursuit disturbances. A number of behavioral interventions have been developed to teach patients to compensate for acquired visual deficits. Studies addressing assessment and treatment issues in this area are reviewed, and future directions for research are outlined.     

Observational assessment of behavioral changes accompanying clinical improvement in hospitalized psychiatric patients

Naturalistic observational techniques were employed over a four-week period to assess the behavior of clinically improved (n=7) and unimproved (n=12) hospitalized patients suffering from acute psychiatric disorders. The population was selected from four clinical diagnostic groups. Patients were sampled on an individual basis. Categories of recorded behaviors included social behavior as well as spatial proximity measures between individuals. Social behavior was further divided into components of sending and receiving. Results showed that patients who clinically improved had significantly different behavioral profiles and greater degrees of behavioral change for the following categories: send affiliation, receive affiliation, send assertion, and receive assertion. Improved patients also maintained closer distance to other individuals during the latter stages of hospitalization. In most cases, week 2 of hospitalization marked the point at which behavioral divergence between improved and unimproved patients occurred. Clinical and theoretical implications of observational procedures are discussed.     

Behavioral measures of assertiveness: A comparison of audio and audiovisual coding of structured interactions

This study assessed the relative utility of audio and audiovisually recorded versions of structured interactions from the Behavioral Assertiveness Test-Revised. The subjects were 28 adult male psychiatric patients who participated in an assertion training program. The systems were evaluated on a number of dimensions including reliability, comparability, sensitivity to change, concurrent and discriminant validity, and cost. The two systems were found to be approximately equally reliable, to produce comparable results on measures that were assessed by both systems, and to be approximately equally sensitive to change. The main advantage of the audiovisual system was the inclusion of a measure of eye contact — which proved to be one of the most valid component behaviors assessed. Potential users need to weigh the additional information obtained from this measure against the substantially greater cost of the audiovisual system. It was concluded that both systems could be simplified, and limitations of the study were noted.     

Use of the Beck Scale for suicide ideation with psychiatric inpatients diagnosed with schizophrenia,schizoaffective, or bipolar disorders

To ascertain how useful the Beck Scale for Suicide Ideation (BSI; Beck & Steer, Manual for Beck Scale for Suicide Ideation (1991)) would be for assessing the severity of suicidal ideation in patients who were diagnosed with schizophrenia, schizoaffective, or bipolar disorders, 142 inpatients were asked to complete the BSI. Eight (6%) patients refused, and four patients (3%) were unable to complete the BSI because they were unable to concentrate. Of the 130 patients who completed the BSI, 53 (41%) had schizoaffective, 37 (28%) had paranoid schizophrenia, 30 (23%) had manic bipolar, and 10 (8%) had depressed bipolar disorders. The coefficient alpha for the BSI was .96, and its one-week test-retest reliability for a subsample of 15 inpatients was 0.88, p < 0.001. The BSI total scores were positively correlated with having ever attempted suicide, r = 0.46, p < 0.001. According to the BSI, 36 (28%) patients were classified as current suicide ideators. The results were discussed as supporting the use of the BSI with inpatients who are diagnosed with schizophrenia, schizoaffective, or bipolar disorders.     

Developing an Acceptance-Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges

Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.     

A multilevel investigation of antecedents of employee positive affective displays: the roles of customer negative affective displays and employee perceived supervisory support

Much past research on employee positive affective displays have explored their antecedents using a single level of analysis. The present study extends previous research by capturing the complex phenomenon of employee affective displays from a multilevel perspective. We used an event-sampling methodology to address a gap in the literature by examining affective displays at the intra-individual level and inter-individual level. Results based on 67 postal clerks completing 420 transactions in post offices in Taiwan show that customer negative affective displays were negatively correlated with employee positive affective displays. Moreover, employee perceived instrumental supervisory support had a cross-level moderating effect on the within-individual relationship between customer-displayed negative emotions and employee-displayed positive emotions. Specifically, those with perceived higher levels of instrumental supervisory support tended to express friendlier emotions while interacting with unhappy or angry customers than those with perceived lower levels of instrumental supervisory support. At the inter-individual level, results show that employee perceived emotional supervisory support was positively related to their affective displays at the aggregated employee level.     

Behavioral neuropsychology: Past,present, and future direction with organically based affect/mood disorders

Affective/mood disturbances have been widely described in association with central nervous system dysfunction. There have been multiple divergent viewpoints regarding the origin of these disorders, however. This is not surprising, as theories evolve in relation to our degree of technological advancement. This review describes the evolution of some of these views, and discusses the advantages of behavioral neuropsychology as an effective approach to assessment/treatment in this context. Although there have been few articles published describing the use of behaviorally based approaches to treat these disorders, it is thought that this approach shows promise, particularly when combined with information based on neuropsychological assessment data. Future directions for the continued evolution of this field are outlined.     

A different kind of pain: affective valence of errors and incongruence*

People hiss and swear when they make errors, frown and swear again when they encounter conflicting information. Such error- and conflict-related signs of negative affect are found even when there is no time pressure or external reward and the task itself is very simple. Previous studies, however, provide inconsistent evidence regarding the affective consequences of resolved conflicts, that is, conflicts that resulted in correct responses. We tested whether response accuracy in the Eriksen flanker task will moderate the effect of trial incongruence using affective priming to measure positive and negative affect. We found that responses to incongruent trials elicit positive affect irrespective of their accuracy. Errors, in turn, result in negative affect irrespective of trial congruence. The effects of conflicts and errors do not interact and affect different dimensions of affective priming. Conflicts change the speed of evaluative categorisation while errors are reflected in categorisation accuracy. We discuss the findings in light of the “reward value and prediction” model and the “affect as a feedback for predictions” framework and consider the possible mechanisms behind the divergent effects.     

Modified Comprehensive Behavioral Intervention for Tics: Treating Children With Tic Disorders,Co-Occurring ADHD,and Psychosocial Impairment

Our objective was to evaluate the feasibility and acceptability, and preliminary efficacy of a modified comprehensive behavioral intervention for tics (MCBIT) therapy for youth with chronic tic disorders (CTDs), co-occurring attention-deficit hyperactivity disorder (ADHD), and associated psychosocial impairment. Seventeen youth ages 10–17 with CTD and co-occurring ADHD were randomly assigned to the MCBIT group (n = 9) or to a control group where they received traditional comprehensive behavioral intervention for tics (CBIT) therapy (n = 8). Both groups received ten 55-minute weekly treatment sessions, and two 55-minute biweekly relapse prevention sessions. Sixteen of the 17 participants completed the study, and acceptability ratings in both treatment groups were high with no significant differences in expectation of improvement. The MCBIT and CBIT groups in combination showed significant improvement in tic severity, ADHD symptom severity, and tic-related impairment. Group differences were not significant. The results indicate that MCBIT treatment is feasible and acceptable for youth with CTD and ADHD, and is similarly well tolerated relative to traditional CBIT. Results were not sufficiently superior to recommend MCBIT over CBIT for this population. However, given the demonstrated benefit of behavioral treatments that target co-occurring conditions concurrently, continuing to examine novel behavioral approaches that can target tics and related conditions simultaneously and successfully is recommended.     

Cognitive Behavioral Therapy and the Treatment of Posttraumatic Stress Disorder: Where Counseling and Neuroscience Meet

There is increasing evidence to support the biological basis of mental disorders. Subsequently, understanding the neurobiological context from which mental distress arises can help counselors appropriately apply cognitive behavioral therapy and other well‐researched cognitive interventions. The purpose of this article is to describe the neurobiological context underlying the formation and treatment of posttraumatic stress disorders, a mental disorder frequently encountered by counselors, from a cognitive therapy framework.     

Behavioral assessment of psychiatric inpatients and normal controls across different environmental contexts

Objectively defined, publicly observable behaviors were time sampled for hospitalized psychiatric patients and normal controls in three distinct environmental contexts: lunch time, free time, and gym time. The behaviors sampled included body activity, extremity activity, proximity, social interactions, participation, visual scanning, laughing/smiling, and idiosyncratic behavior. Patient behaviors were recorded during both a drug-free baseline period and a subsequent medication period. The data suggest that consistent and reliable differences between patients and normals in most behaviors can be observed and that environmental context is an important determinant of these differences. Results are discussed in terms of their implications for assessment procedures and treatment decisions.These investigations were supported in part by State of Illinois Department of Mental Health and Developmental Disabilities Grants RD836-13 and RD622-02 to the first author. The cooperation of the Illinois State Psychiatric Institute staff is gratefully acknowledged.     

Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder

Hellvin, T., Sundet, K.,Vaskinn, A., Simonsen, C.,Ueland, T., Andreassen, O.A. & Melle, I. (2010). Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder. Scandinavian Journal of Psychology 51, 525–533. Studies of social functioning in severe mental disorders are disadvantaged by the multitude of different assessment instruments in use. The present study aims to establish reliability and validity of the Norwegian version of the Social Functioning Scale (SFS) and to examine social functioning in bipolar disorder (BD) compared to schizophrenia (SZ) and healthy controls (HC). SFS, a 76 item questionnaire divided into seven subscales measuring various aspects of daily life functioning, was administered to samples diagnosed with BD (n = 100) or SZ (n = 100) and to HC (n = 100), recruited from the ongoing Tematic Organized Psychosis (TOP) study. Reliability analyses prove adequate psychometric properties both for the composite full scale score (α: 0.81) as well as for the seven subscale scores (α: 0.60–0.88). Principal component analysis of the subscales confirms a one‐component structure, explaining 59% of the variance. Although significantly correlated with the Global Assessment of Functioning, our results indicate that the SFS measures different aspects of social functioning, is less influenced by demographic and clinical characteristics, but differentiates at the same time significantly BD from SZ. Thus, SFS adds valuable information as a supplement to standard clinician‐rated assessment tools of social functioning, suited both for research and clinical work.     

Cognitive Behavioral Therapy for Attention-Deficit/Hyperactivity Disorder in College Students: A Review of the Literature

The current review presents a theory-guided review of the existing cognitive behavioral therapy (CBT) interventions for attention-deficit/hyperactivity disorder (ADHD) in college students. Across the eight studies that investigated this topic, moderate reductions were shown in inattentive symptoms but little to no change was reported in hyperactive/impulsive symptoms. Results indicated a moderate treatment effect on self-reported quality of life and school/work functioning, yet less of an impact on GPA, response inhibition, social functioning, and executive functioning. Methodological and statistical problems and inconsistencies were noted. Since college students are emerging adults, it is likely that the optimum CBT intervention for college students with ADHD lies somewhere in between the existing clinic-based adult ADHD CBT interventions as well as the school-based adolescent ADHD psychosocial interventions. Directions for future research and recommendations for clinicians in university settings are provided in an attempt to further develop the existing college students CBT clinical research evidence base.     

Behavioral variability in SHR and WKY rats as a function of rearing environment and reinforcement contingency.

The spontaneously hypertensive rat (SHR) may model aspects of human attention deficit hyperactivity disorder (ADHD). For example, just as responses by children with ADHD tend to be variable, so too SHRs often respond more variably than do Wistar-Kyoto (WKY) control rats. The present study asked whether behavioral variability in the SHR strain is influenced by rearing environment, a question related to hypotheses concerning the etiology of human ADHD. Some rats from each strain were reared in an enriched environment (housed socially), and others were reared in an impoverished environment (housed in isolation). Four groups--enriched SHR, impoverished SHR, enriched WKY, and impoverished WKY--were studied under two reinforcement contingencies, one in which reinforcement was independent of response variability and the other in which reinforcement depended upon high variability. The main finding was that rearing environment did not influence response variability (enriched and impoverished subjects responded similarly throughout). However, rearing environment affected body weight (enriched subjects weighted more than impoverished subjects) and response rate (impoverished subjects generally responded faster than enriched subjects). In addition, SHRs tended to respond variably throughout the experiment, whereas WKYs were more sensitive to the variability contingencies. Thus, behavioral variability was affected by genetic strain and by reinforcement contingency but not by the environment in which the subjects were reared.     

情绪通路异常与认知情绪偏差:慢性痛与抑郁症共病的神经心理机制

慢性疼痛与抑郁症具有高度共病性,但迄今尚无成熟理论能够阐释二者共病的神经心理机制。对慢性痛与抑郁的脑机制研究提示,慢性痛和抑郁常常涉及到相似的情绪脑区活动的异常改变;与此相对应的是,行为学研究发现,疼痛患者与抑郁患者在加工疼痛或抑郁相关信息时表现出了模式相似的认知情绪偏差(CAB)。近年来,越来越多证据趋于一致,指出慢性痛和抑郁共有的情绪通路异常变化可能导致了相似的信息加工异常,是二者共病的神经心理基础,而认知情绪偏差则在行为上反映了这种变化,并且很可能是共病发生、发展及维持的重要因素。     

Direct assessment of the cognitive correlates of attention deficit disorders with and without hyperactivity

The cognitive functioning of children identified as attention deficit disorder with hyperactivity (ADD/H) was compared to that of children identified as attention deficit disorder without hyperactivity (ADD/WO). Based on information on symptoms supplied by teachers, 20 ADD/H and 15 ADD/ WO children were selected according to DSM-III criteria from a large elementaryschool learning disabilities and behavior disorders population. For comparison purposes, 16 normal children from regular classrooms were also selected. Children from all three groups were evaluated with a battery of cognitive tests. Intelligence test scores differentiated the two ADD groups, with the ADD/H children obtaining significantly lower Full Scale IQ scores than both ADD/WO and control children. In addition, ADD/H children obtained significantly lower Verbal IQ scores than ADD/WO children. Both ADD groups performed more poorly than controls on Spelling and Reading Achievement, and the ADD/WO group performed more poorly on Math Achievement. The two ADD groups took longer to complete six Stroop and rapid naming tasks than the control groups but did not differ among themselves. The ADD/WO group made more errors on a visual matching task than the controls, but neither ADD group differed from controls on the accuracy of the Stroop tasks, rapid naming tasks, measures of receptive and expressive language, visual-motor integration, or sustained visual attention. The differences between the two ADD groups were fewer than expected on the basis of previous research and are more global than specific.The assistance of John Junginger, Jason Walker, and Cynthia Jones at various stages of the project is gratefully acknowledged. Particular thanks are extended to the teachers and staff of Clarke County schools.     

Observation procedure, observer gender, and behavior valence as determinants of sampling error in a behavior assessment analogue

Several factors thought to influence the representativeness of behavioral assessment data were examined in an analogue study using a multifactorial design. Systematic and unsystematic methods of observing group behavior were investigated using 18 male and 18 female observers. Additionally, valence properties of the observed behaviors were inspected. Observers' assessments of a videotape were compared to a criterion code that defined the population of behaviors. Results indicated that systematic observation procedures were more accurate than unsystematic procedures, though this factor interacted with gender of observer and valence of behavior. Additionally, males tended to sample more representatively than females. A third finding indicated that the negatively valenced behavior was overestimated, whereas the neutral and positively valenced behaviors were accurately assessed.