Cognitive-Behavioral Treatment of Panic Disorder: Confronting Situational Precipitants

Panic Disorder is a common, debilitating psychological problem which is often effectively treated through cognitive behavioral approaches. Cognitive-behavioral treatment incorporates education, relaxation training, cognitive therapy, behavioral exposure, and relapse prevention treatment strategies. A case illustration demonstrates how cognitive-behavioral treatment facilitated a client's ability to identify and confront situational precipitants to panic in a gradual and systematic manner. A therapeutic and collaborative relationship provided the foundation for treatment, while education helped the client to understand the vicious cycle between somatic symptoms, catastrophic thoughts, and anxiety. Passive relaxation training incorporated deep breathing, muscle relaxation, and positive imagery generated from the client's own experience. Cognitive restructuring involved identifying automatic thoughts related to panic, challenging dysfunctional beliefs associated with the client's depression and low self-esteem, and generating alternative ways of thinking. Behavioral exposure (e.g., imaginal exposure, behavioral rehearsal, in vivo techniques) helped the client gain a greater sense of mastery over panic attacks triggered by his fear of hypodermic needles. Over the course of treatment, the frequency and intensity of the client's panic attacks decreased. Furthermore, the client's sense of mastery over panic had beneficial effects on his mood and self-esteem. Treatment gains were maintained at one-year follow-up.     

Cognitive-Behavioral Treatment of Depression, Part IX: Confronting Predisposing Factors

Cognitive-behavioral therapy can help many depressed clients learn more effective ways of coping with problems in their lives. However, for many clients with chronic or recurrent depression, it can be helpful to examine the biological, psychological, and social/cultural factors that may predispose a person toward depressive episodes. In order to address possible biological predispositions, it is important to assess for a positive family history of depression, evaluate family members' response to previous treatments, and refer for medications when needed. In order to address possible psychological predispositions, it is useful to evaluate long-standing personality styles, identify negative events from childhood, examine the client's relationship with his or her parents, evaluate the history of abuse, and identify early loss experiences. Cultural factors may play an influential role in the etiology of depression, and can be useful to incorporate into a broad treatment plan. However, cultural factors are difficult to modify through individual psychotherapy. Hence, they are unlikely to play a central role in cognitive-behavioral therapy for depression. Overall, therapists working with depressed clients should be prepared to confront a broad range of biological, psychological, and environmental factors that can create or perpetuate a client's risk for depression.     

A Comparison of Computer-Assisted Psychotherapy and Cognitive-Behavioral Therapy in Groups

This study is the first independent, randomized controlled study in a clinical setting of a computer-assisted therapy program (Therapeutic Learning Program; TLP) developed to permit individualized therapy in a group setting. This software differs from other computer-assisted approaches in that targets for change are chosen by the patient rather than determined by the software. TLP was compared to a standard cognitive-behavioral treatment in 109 patients with 6-month follow-up. Although both treatments were associated with a significant reduction in symptoms of anxiety and depression at posttreatment and follow-up, no differences were found between treatments with respect to patient-rated satisfaction and effectiveness, clinician ratings of improvement, and scores on measures of anxiety and depression. At treatment midpoint patients tended to give more neutral ratings of satisfaction and treatment effectiveness of the TLP treatment, perhaps suspending judgment about this more novel treatment until its completion. It is concluded that at least one form of computer-assisted psychotherapy is as effective and acceptable to patients in a clinical setting as standard short-term cognitive-behavioral therapy conducted by experienced clinicians.     

The client-therapist relationship in rational-emotive therapy

In this article, an analysis of rational-emotive therapy (RET) is made with particular attention to the client-therapist relationship as well as to the personal therapeutic style and influence of its founder, Albert Ellis, on patients in therapy. Features of RET and its practice by Albert Ellis which appear to foster the therapist-client relationship include: 1. varying therapy style depending on client characteristics; 2. persistently pointing out client's irrational thoughts as a way of demonstrating therapist's helping efforts; 3. successful completion by client of assigned homework; 4. therapy is focused on current, meaningful problems of client; 5. RET therapists' communication to client's of their own faith in the validity of RET therapy; 6. use by therapist of compliments about client's brightness, competence and likelihood of success in therapy. While RET may not be everybody's cup of tea (e.g., religious individuals), it does appear that the aspects noted above contribute to the fostering of a positive relationship in therapy and can be influential in producing positive outcomes in therapy. The present article is a condensed and updated version of a previously published chapter: Garfield, S.L., The client-therapist relationship in rational-emotive therapy. In M.E. Bernard & R. DiGiuseppe (Eds.),Inside rational-emotive therapy (pp. 113–134). San Francisco, CA: Academic Press.     

Cognitive-Behavioral Treatment of Men and Anger: Three Single Case Studies

The treatment of men with anger problems presents significant challenges for practitioners. This article discusses a cognitive-behavioral, individual therapy, approach within the framework of three single case studies involving men. Treatment challenges and methodology are presented. Key treatment issues included: establishing a therapeutic relationship; facilitating understanding of the cognitive basis of anger; and addressing male-role socialization messages and male-identity schema that contributed to the experience and expression of anger in these men. Limitations relative to the small sample (n = 3) and the lack of a randomized control group preclude any definitive statements regarding the effectiveness or generalizability of the intervention. Nevertheless, the study highlights important theoretical and practical concerns for practitioners and future researchers to consider when working with men and anger.     

Nonspecific elements in therapy with stutterers

Currently, many different strategies are employed by respected professionals working in the area of therapy for persons who stutter. This phenomenon serves as a point of departure for reflections on the nonspecific elements involved in therapy. Drawing on the literature of holistic medicine and psychotherapy these elements are identified as follows: (1) active participation of the client in the therapy process; (2) role of self-management skills; (3) influence of client's expectations regarding treatment; (4) suggestion as a factor in therapy; and (5) the therapeutic relationship.     

Greater Expectations: Using Hierarchical Linear Modeling to Examine Expectancy for Treatment Outcome as a Predictor of Treatment Response

A client's expectation that therapy will be beneficial has long been considered an important factor contributing to therapeutic outcomes, but recent empirical work examining this hypothesis has primarily yielded null findings. The present study examined the contribution of expectancies for treatment outcome to actual treatment outcome from the start of therapy through 12-month follow-up in a clinical sample of individuals (n = 72) treated for fear of flying with either in vivo exposure or virtual reality exposure therapy. Using a piecewise hierarchical linear model, outcome expectancy predicted treatment gains made during therapy but not during follow-up. Compared to lower levels, higher expectations for treatment outcome yielded stronger rates of symptom reduction from the beginning to the end of treatment on 2 standardized self-report questionnaires on fear of flying. The analytic approach of the current study is one potential reason that findings contrast with prior literature. The advantages of using hierarchical linear modeling to assess interindividual differences in longitudinal data are discussed.     

Comparing Values and Methods in Psychodynamic and Cognitive-Behavioral Therapy: Commonalities and Differences

To determine the underlying values and methods in cognitive-behavioral and psychodynamic therapy and to address the implications of those values and methods for integrating the two therapies, the Process Value and Methods Survey was sent to members of The Association for Advancement of Behavior Therapy (cognitive-behavioral sample) and Division 39 of American Psychological Association (psychodynamic sample). Members were asked to endorse items based on their ideal understanding of their respective orientations. A Principal Components Analysis (PCA) of the combined samples yielded six components for values, of which four were significant according to orientation. A second PCA, for therapeutic methods, yielded six components, five of which were significant according to orientation. In both PCAs, components significant for an orientation were consistent with the corresponding constructs of that orientation. The relationship between method and value components as well as how value components may be related to clinical practice and psychotherapy integration is discussed.     

Arts for the blues – a new creative psychological therapy for depression

ABSTRACT

Routinely prescribed psychological therapies for depression are not always effective. Arts therapies, particularly Dance Movement Psychotherapy, may offer additional therapeutic mechanisms for depression. Therefore, client-reported helpful factors from various therapy types, along with client preferences, are key in devising new therapeutic interventions. We present a framework for a new pluralistic “meta-approach” of therapy for depression, based on an interdisciplinary thematic synthesis (Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8[1], 45) of active ingredients from both talking therapies and creative approaches. Lastly, we offer an illustrative group therapy workshop based on this approach, to be piloted with clients and practitioners within an NHS mental health service. Further research is required to evaluate this pilot and to devise a full treatment for trialling within the service.     

Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder

Cognitive-behavioral therapy can be effective for many clients who have obsessive-compulsive disorder. Despite its effectiveness, many treatment guidelines fail to describe cognitive-behavioral therapy procedures in adequate detail. The present paper will review the literature on cognitive-behavioral therapy for OCD in an attempt to provide concise, meaningful guidelines for the psychological treatment of this disorder. Cognitive-behavioral therapy includes four general components: initial preparation for therapy, development of applied coping skills, exposure with ritual prevention, and relapse prevention. The four general treatment components are described, and clinical examples are provided.     

An Evaluation of the Effects of Diagnostic Composition on Individual Treatment Outcome Within Transdiagnostic Cognitive–Behavioral Group Therapy for Anxiety

Recently, studies have supported the efficacy of treating anxiety disorders utilizing a transdiagnostic, or non-diagnosis-specific, framework (Erickson, D. H. (2003). Group cognitive behavioural therapy for heterogeneous anxiety disorders. Cognitive Behaviour Therapy, 32, 179–186; Garcia, M. S. (2004). Effectiveness of cognitive-behavioural group therapy in patients with anxiety disorders. Psychology in Spain, 8, 89–97; Norton, P. J., & Hope, D. A. (2005). Preliminary evaluation of a broad-spectrum cognitive-behavioral group therapy for anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 36, 79–97). Transdiagnostic group treatment packages focus on the common aspects inherent across the anxiety disorders such as behavioral and cognitive avoidance, and faulty cognitive appraisals of threat potential or meaning (Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230). Although research supports the overall efficacy of transdiagnostic cognitive behavior therapy (CBT) for anxiety disorders (Norton, P. J., & Philipp, L. M. (2008). Transdiagnostic approaches to the treatment of anxiety disorders: A quantitative review. Psychotherapy: Theory, Research, Practice and Training, 45, 214–226), the effect of diagnostically mixed group composition on individual outcomes is less clear. This study investigated the relationship between group composition and treatment outcome within diagnostically heterogeneous groups with the purpose of determining if diagnostic heterogeneity differentially impacted treatment outcome for 84 individuals during a 12-week transdiagnostic cognitive–behavioral group anxiety treatment program (Norton, P. J. (2012a). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford). The diagnostic makeup of the treatment group was examined at the beginning of treatment and at the end of treatment, and the results indicated that the diagnostic makeup of the treatment group had no significant impact on individual treatment outcome. These findings have direct implications for the delivery of transdiagnostic treatments, and are discussed in terms of their global implications for the transdiagnostic approach to the treatment of anxiety disorders.     

Emotion Regulation as a Moderator of Outcomes of Transdiagnostic Group Cognitive-Behavioral Therapy for Emotional Disorders

The aim of this study was to examine the potential moderating effect of baseline emotion regulation skills—cognitive reappraisal and expressive suppression—on the relationship between treatment allocation and treatment outcomes in primary care patients with emotional symptoms. A total of 631 participants completed scales to evaluate emotion regulation, anxiety, depression, functioning, and quality of life (QOL). The moderation analysis was carried out using the SPSS PROCESS macro, version 3.5. Expressive suppression was a significant moderator in the relationship between treatment allocation and treatment outcomes in terms of symptoms of anxiety (b = −0.530, p = .026), depression (b = −0.812, p = .004), and QOL (b = 0.156, p = .048). Cognitive reappraisal acted as a moderator only in terms of QOL (b = 0.217, p = .028). The findings of this study show that participants with higher scores of expressive suppression benefited more from the addition of transdiagnostic cognitive-behavioral therapy to treatment as usual (TAU) in terms of anxiety and depressive symptoms, and QOL. Individuals with higher levels of cognitive reappraisal obtained a greater benefit in terms of QOL from the addition of psychological treatment to TAU. These results underscore the relevant role that emotion regulation skills play in the outcomes of psychological therapy for emotional symptoms.     

Trajectory of change in anxiety sensitivity in relation to anxiety,depression, and quality of life among persons living with HIV/AIDS following transdiagnostic cognitive-behavioral therapy

ABSTRACT

Persons living with HIV/AIDS (PLHIV) disproportionately suffer from anxiety and depressive symptoms and disorders. Although past work has examined the efficacy of cognitive-behavioral therapy (CBT) for depression, and to a lesser extent anxiety, among PLHIV, little is known regarding potential mechanisms underlying improvement in anxiety/depression among this group. Anxiety sensitivity is a well-established risk/maintenance factor for anxiety and depressive disorders and is hypothesized to play an important role in maintaining anxiety among PLHIV. Past work has identified anxiety sensitivity as a mechanism of action underlying changes in various anxiety domains yet it is unknown whether changes in anxiety sensitivity relate to changes in anxiety symptoms among PLHIV undergoing transdiagnostic CBT for anxiety. The current study sought to examine treatment-related changes in anxiety sensitivity and how the trajectory of change relates to anxiety and depressive symptoms as well as overall quality of life. Individuals (n = 35) with HIV/AIDS and elevated anxiety symptoms received CBT for anxiety. Results indicated that reductions in anxiety sensitivity were significantly related to changes in anxiety, depression, and quality of life. Together, these data suggest that changes in anxiety sensitivity are significantly related to changes in anxiety/depression and quality of life among PLHIV seeking treatment.     

Modified Dialectical Behavior Therapy and Problem Solving for Obsessive-Compulsive Personality Disorder

The impact of a modified dialectical behavior therapy and problem-solving model is examined on the work environment of a patient with an obsessive-compulsive personality disorder (OCPD). A case study is presented examining the impact this client's OCPD behavior in the work environment and on his subordinates. Discussed are interventions that were useful in treating a motivated patient employing cognitive-behavioral models of treatment for this disorder. The case study focuses on the work setting and the issues tied to the work environment wherein subordinates are required to work under a supervisor with OCPD. Lessons learned, issues and import for further study are offered.     

Successful Treatment of Olfactory Reference Syndrome With Cognitive Behavioral Therapy: A Case Study

Olfactory reference syndrome (ORS) is characterized by a preoccupation with the belief that one's body emits a foul odor. Cognitive behavioral therapy (CBT) was used to treat a woman in her 50s who presented in our outpatient anxiety disorders specialty clinic with ORS, accompanied by embarrassment, shame, distress, avoidance behavior, and social isolation. Monitoring and systematic reduction of safety behaviors, combined with exposure to anxiety-provoking situations, resulted in elimination of the perceived body odor over the course of ten treatment sessions. Scores on the Overvalued Ideas Scale indicated improvements in the client's insight over the course of treatment, and there was an 82.6% reduction in her preoccupation and compulsive behaviors as measured by the Body Dysmorphic Disorder Yale-Brown Obsessive Compulsive Scale. Indices of depression, anxiety, and stress as measured by the 21-item version of the Depression Anxiety Stress Scales were also reduced from the extremely severe to normal range. These findings suggest further investigation of CBT in the treatment of ORS is warranted.     

Sudden Gains: How Important Are They During Exposure and Response Prevention for Obsessive-Compulsive Disorder?

Symptom reduction over the course of cognitive-behavioral therapy is not always distributed evenly across sessions. Some individuals experience a sudden gain, defined as a large, rapid, and stable decrease in symptoms during treatment. Although research documents a link between sudden gains and treatment for depression and anxiety, findings in the context of obsessive-compulsive disorder (OCD) treatment are mixed. The present study investigated the relationship between sudden gains and treatment outcome in 44 adults with OCD and addressed limitations of previous studies by measuring OCD symptoms dimensionally and comparing individuals who experience sudden gains to those who experience gradual gains of similar magnitude. Sudden gains were observed among 27% of participants, with highest rates among individuals with primary contamination symptoms. Participants who experienced a sudden gain had greater OCD symptom reductions at posttreatment (but not at follow-up), and this difference did not persist after controlling for gain magnitude. Thus, the importance of sudden gains during OCD treatment may be limited. Findings are discussed in light of inhibitory learning models of cognitive-behavioral therapy.