Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians

Cognitive-behavioral therapy (CBT) is an empirically supported psychological treatment for anxiety disorders. These treatments have primarily been developed to target primary anxiety disorders, despite the fact that these disorders frequently co-occur with a diagnosis of depression. Empirical evidence provides guidance regarding how to treat an individual with a primary anxiety disorder with comorbid depression; however, there is limited data regarding how to translate these findings into clinical practice. Improving our understanding of how CBT is currently being used in practice among experts is integral to learning whether modifications to protocols lead to more or less effective treatments. Accordingly, we surveyed expert CBT clinicians about their assessment and treatment approaches and what challenges they face in formulating and treating mood and anxiety comorbidity. Most experts reported that their assessment includes a semistructured interview and self-report measures to determine breadth and hierarchical ordering of comorbidity severity. Symptom severity, client's goals, temporal onset of disorders, presence of suicide risk, and potential for early treatment success were reported as factors to consider when deciding where to begin treatment. Almost three quarters of experts surveyed indicated that they usually take some type of sequential treatment approach when treating primary anxiety disorders with comorbid depression. The top three reported challenges associated with treating comorbid presentations were client's motivation/energy, hopelessness/pessimism, and ongoing need for risk assessment. Implications for the nature and timing of CBT interventions in “real-world” clinical practice are discussed.     

Internal cohesion psychotherapy: The nature,principles and application

Psychotherapy is widely used to treat different mental health disorders and emotional difficulties. The main objective of psychotherapy is to help clients become aware of and have control over their thoughts, moods, feelings and behaviours, as well as create healthy strategies to respond to challenging situations. Since the existing psychotherapy approaches and other methods of treatment are not always effective in treating mental health disorders, there is still space for new approaches to fill this gap. In this paper, we provide information about internal cohesion psychotherapy, which is a new integrative approach. This paper presents a new approach to eclectic psychotherapy, focussing on four detrimental aspects of human functioning through different time perspectives.     

A SIKH PERSPECTIVE ON ALCOHOL AND DRUGS: IMPLICATIONS FOR THE TREATMENT OF PUNJABI-SIKH PATIENTS

This paper presents a Sikh perspective on the use of alcohol and drugs. In doing so, it takes into account the dichotomy that exists between Sikh ethical values and the Punjabi cultural attitude toward alcohol and drugs. It further discusses the Sikh perspective on treating substance-related disorders in the light of contemporary approaches to addiction, such as the bio-psychosocial model and the Alcoholics Anonymous twelve-step program. The paper concludes by highlighting the treatment issues that need to be taken into consideration when helping Punjabi-Sikh patients recover from alcohol or drug related addiction.     

A Public Health Framework for Preventing Mental Disorders in the Context of Pandemics

The COVID-19 pandemic has universally threatened the building blocks of mental health, well-being, and quality of life, namely, expectations of safety, connectedness, hope, and individual and societal efficacy. Consequently, unprecedently large numbers of individuals are significantly stressed and many are at risk for relapse of mental health problems, exacerbations of existing mental and behavioral health problems, and new onset clinical problems. Because of the scope of the problem, a population-based public health perspective is needed, which in the context of disasters has well-established theories and prevention approaches. Public health approaches to disasters and pandemics focus on preventing subclinical problems from becoming clinical disorders, in comparison to clinical care approaches that focus on treating established disorders. Fortunately, specialty care clinicians who typically think about assessing and treating established disorders have the training and clinical competencies to deliver prevention-focused interventions. This paper is designed to help specialty care clinicians who use cognitive-behavioral strategies to understand the biopsychosocial impacts and resource deficits associated with COVID-19-related stressors and the public health perspective to address them. We also provide ways clinicians can help people who are suffering from significant stress and resource deficits bounce back and regain functioning. We describe psychological first aid, stress management, repeated ecological assessment, writing about stressors, problem-solving, and behavioral activation approaches to assist individuals at risk for enduring stress-linked problems.     

Emotion Regulation Therapy: An Integrative Approach to Treatment-Resistant Anxiety Disorders

Cognitive-behavioral, psychodynamic, and experiential approaches have historically been characterized by differing definitions of emotions and beliefs concerning their role in psychopathological process and treatment. However, given recent advances in the basic psychological sciences of emotion and emotion regulation, theoretical orientations are converging on similar viewpoints as to the functional role of emotions in conceptualizing and treating of a variety of disorders. One such area where emotions and their regulation may play a significant role is in chronic, complex, and treatment-resistant forms of anxiety disorders such as generalized anxiety disorder (GAD). A review of the historical approaches to emotions in the major theoretical orientations is presented. Following this, a model of emotion disruption and dysregulation is presented as it relates to anxiety disorders and GAD, in particular. Finally, a new treatment for GAD, emotion regulation therapy, aimed at ameliorating dysfunctional affective processes, is described.     

Targeting Common Factors Across Anxiety and Depression Using the Unified Protocol for the Treatment of Emotional Disorders in Adolescents

Clinical approaches to mood and anxiety disorders in children and adolescents have historically been confined to either diagnosis- [e.g., for obsessive–compulsive disorder vs. generalized anxiety disorder (GAD), etc.] or domain-specific (e.g., for anxiety disorders vs. depressive disorders) treatments. However, as conceptualizations of mental illness shift towards a more dimensional model [e.g., the recent Research Domain Criteria (RDoC) from the National Institutes of Health], transdiagnostic treatments, such as the unified protocol for the treatment of emotional disorders in adolescents (UP-A; Ehrenreich et al. in Child Fam Behav Ther 31(1):20–37, 2008), are gaining support in the empirical literature. This paper reviews the common treatment targets across three emotional disorders commonly found in adolescence: GAD, social anxiety disorder, and major depressive disorder. In particular, similarities and differences across potential treatment mechanisms, including cognitive and information processing deficits, problem-solving difficulties, and avoidance strategies are examined. Finally, the case of 17-year-old “Andrea” is presented to demonstrate how transdiagnostic approaches like the UP-A can be effective in treating a range of emotional disorders in youth.     

Pediatrician/Psychologist Collaboration: Opportunities for Clinical Child Psychologists

In the United States, pediatricians prescribe the majority of medications used to treat children with psychological disorders, such as ADHD. However, because pediatricians have limited background in psychology or psychiatry, opportunities exist for properly trained clinical child psychologists to assist pediatricians in assessing and treating youngsters with psychological disorders. Psychologists with additional training in psychopharmacology can make even greater contributions by helping pediatricians select and monitor appropriate medications. This paper reviews models of consultation that are especially relevant to psychologists who seek to expand their practice by consulting with pediatricians. Consultant-centered models seem most appropriate in private practice settings, but institutionally employed psychologists have opportunities to also utilize some system-centered approaches. Examples of methods in which pediatric clinical psychologists and child psychologists with psychopharmacology training can assist pediatricians in treating a child with ADHD are discussed.     

A Model of Therapist Competencies for the Empirically Supported Cognitive Behavioral Treatment of Child and Adolescent Anxiety and Depressive Disorders

While a plethora of cognitive behavioral empirically supported treatments (ESTs) are available for treating child and adolescent anxiety and depressive disorders, research has shown that these are not as effective when implemented in routine practice settings. Research is now indicating that is partly due to ineffective EST training methods, resulting in a lack of therapist competence. However, at present, the specific competencies that are required for the effective implementation of ESTs for this population are unknown, making the development of more effective EST training difficult. This study therefore aimed to develop a model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders using a version of the well-established Delphi technique. In doing so, the authors: (1) identified and reviewed cognitive behavioral ESTs for child and adolescent anxiety and depressive disorders, (2) extracted therapist competencies required to implement each treatment effectively, (3) validated these competency lists with EST authors, (4) consulted with a panel of relevant local experts to generate an overall model of therapist competence for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders, and (5) validated the overall model with EST manual authors and relevant international experts. The resultant model offers an empirically derived set of competencies necessary for effectively treating children and adolescents with anxiety and depressive disorders and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines for working with this population. This model thus brings us one step closer to bridging the gap between science and practice when treating child and adolescent anxiety and depression.     

On the scientific status of cognitive appraisal models of anxiety disorder

The cognitive paradigm for understanding and treating anxiety disorders comprises two distinct and potentially incompatible approaches: appraisal and information-processing. Advocates of the latter approach have sharply criticized the scientific adequacy of the appraisal models popularized by cognitive therapists. The purpose of this essay is to provide a reappraisal of these critiques of appraisal, and to defend an argument for methodological pluralism.     

Stimulating a normal adjustment: misbehavior, amphetamines, and the electroencephalogram at the Bradley Home for children

This article uses an historical case study to describe the influence of social and contextual factors on the adoption of somatic approaches to children's misbehavior. The child guidance movement and the emergence of medicalized residential treatment facilities for children influenced the theoretical orientations of physicians treating children's behavior disorders in the United States in the 1930s. Charles Bradley and his colleagues at the Bradley Home in Rhode Island defined behavior disorders in social terms but investigated and treated misbehavior with somatic tools. The use of amphetamines and the electroencephalogram reorganized concepts of maladjustment along neurological lines, even as the research relied on the Home's social priorities. Electroencephalographic investigations especially shaped an organic concept of misbehavior. Ultimately, the somatic orientation obscured the central role of local context in Bradley Home physicians' research.     

Enhancing exposure-based therapy from a translational research perspective

Combining an effective psychological treatment with conventional anxiolytic medication is typically not more effective than unimodal therapy for treating anxiety disorders. However, recent advances in the neuroscience of fear reduction have led to novel approaches for combining psychological therapy and pharmacological agents. Exposure-based treatments in humans partly rely on extinction to reduce the fear response in anxiety disorders. Animal studies have shown that D-cycloserine (DCS), a partial agonist at the glycine recognition site of the glutamatergic N-methyl-D-aspartate receptor facilitates extinction learning. Similarly, recent human trials have shown that DCS enhances fear reduction during exposure therapy of some anxiety disorders. This article discusses the biological and psychological mechanisms of extinction learning and the therapeutic value of DCS as an augmentation strategy for exposure therapy. Areas of future research will be identified.     

Integrated treatment of co-occurring mental illness and addiction: clinical intervention, program, and system perspectives

Individuals with mental illness and addiction comprise at least half of the patients in most mental health treatment systems. This combination results in increased risk for frequent psychiatric relapses, poor medication compliance, violence, suicide, legal problems, and high utilization of the emergency room or inpatient services. Traditional mental health and addiction treatments have not adequately addressed these co-occurring disorders due to clinical interventions, programs, and system flaws that have not addressed the individual's needs. Integrated treatment requires both an understanding of mental illness and addiction and the means to integrate and modify the traditional treatment approaches in both the mental health and addiction treatment fields. There is strong evidence to support the efficacy and effectiveness of integrated treatment in this population. All mental health clinicians should become experienced and skilled in the core psychotherapy approaches to treating substance use disorders, including motivational enhancement therapy, relapse prevention (cognitive-behavioral therapy), and 12-step facilitation. In addition, integrated treatment includes integrating medications for both addiction and mental illness with the behavioral therapies and other psychosocial interventions. This article reviews the clinical intervention, program, and system components of integrated treatment and specific clinical interventions for this population.     

Clinical efficacy and potential mechanisms of neurofeedback

Although many psychological disorders have significant basis in neurobiological dysfunction, most treatment approaches either neglect biological aspects of the problem, or approach dysfunction through pharmacological treatment alone, which may expose individuals to negative side effects. In recent decades, neurofeedback has been promoted as an alternative approach to treating neurobiological dysfunction. Neurofeedback helps individuals gain control over subtle brain activity fluctuations through real-time rewards for pre-established target brainwave frequencies at specific cortical locations. This paper reviews the effectiveness of neurofeedback in a range of conditions, including ADHD, autism spectrum disorders, substance use, PTSD, and learning difficulties. Neurofeedback has emerged as superior or equivalent to either alternative or no treatment in many of the examined studies, suggesting it produces some effects worthy of further examination. In light of its potential to address neurobiological dysfunction directly, future research is suggested in order to refine protocols, as well as to establish effectiveness and efficacy. Potential mechanisms of neurofeedback are discussed, including global connectivity, neuroplasticity, and reinforcement of the default mode network, central executive network, and salience network.     

Sleep disorders, epilepsy, and autism

The purpose of this review article is to describe the clinical data linking autism with sleep and epilepsy and to discuss the impact of treating sleep disorders in children with autism either with or without coexisting epileptic seizures. Studies are presented to support the view that sleep is abnormal in individuals with autistic spectrum disorders. Epilepsy and sleep have reciprocal relationships, with sleep facilitating seizures and seizures adversely affecting sleep architecture. The hypothesis put forth is that identifying and treating sleep disorders, which are potentially caused by or contributed to by autism, may impact favorably on seizure control and on daytime behavior. The article concludes with some practical suggestions for the evaluation and treatment of sleep disorders in this population of children with autism.     

Converted patients and clinic patients as control cases: a comparison with implications for psychoanalytic training

All twenty-eight respondents to a recent poll of the thirty institutes affiliated with the American Psychoanalytic Association reported that they now accept cases converted from psychotherapy to psychoanalysis as control cases. This study was designed to compare converted cases to clinic cases systematically with respect to patient characteristics, treatment, and the educational experience of the treating candidate. The study followed twenty-four candidates entering analytic training between 1992 and 1995, who treated thirty-four clinic cases and forty-three converted cases between February 1993 and July 2000. Clinic and converted patients were comparable with regard to demographics, prior treatment histories, structural diagnoses, and Axis I diagnoses. In addition, the two groups of cases were indistinguishable with respect to the rate at which candidates received credit toward graduation requirements. Candidates treating converted cases earned approximately dollars 7,600 per patient per year, compared to candidates treating clinic cases, who earned nothing. Eighty-four percent of converted patients diagnosed with a mood disorder by the treating candidate were on medication, in contrast to only 20% of clinic patients with the same diagnosis. Similar differences were seen in the case of anxiety disorders. Given the prevalence of affective and anxiety disorders in control cases and the availability of a variety of medications and psychotherapies with documented efficacy in treating these disorders, candidates should be trained to discuss treatment options with patients who present with Axis I disorders.     

The psychotherapy adaptation and modification framework: application to Asian Americans

Although effective treatments for many mental disorders have been developed, little research has been conducted to determine whether these interventions are effective in treating those from diverse backgrounds. Recent reports have suggested that ethnic minorities are less likely to receive quality health services and that they evidence worse treatment outcomes when compared with other groups. To improve care for those from diverse backgrounds, Western-developed psychotherapies may need to be culturally modified or adapted to become more effective in treating ethnic minorities. This article addresses the need for adapting psychotherapy and provides a conceptual framework for making such modifications. The psychotherapy adaptation and modification framework model is applied to recent Asian American immigrants as an illustrative example. However, it may also serve as a point of departure to adapt therapies for other ethnocultural groups.     

Disordered Attention: Implications for Understanding and Treating Internalizing and Externalizing Disorders in Childhood

In this article, we present evidence that disorders of attention are present in wide range of psychological disorders, and that the appropriate assessment and treatment of these attention difficulties can be an important adjunct to traditional therapeutic approaches. We review approaches to attention training in some detail and discuss how attention-focused treatment might be implemented in clinical practice.     

浅谈妇外科医生手术操作的四个层次

手术是处理妇科疾病的主要手段之一。本文从作者的经历和感触出发,就妇外科医师的成长过程中的共性规律进行总结。对于住院医师,熟悉解剖结构、练习基本操作是主要目标;对于主治医师,归纳手术套路、学会独立操作是主要任务;对于主任医师,承担常规工作的同时,条件和能力许可应有所创新。只有将手术从工作变为创作,将技术升华为艺术时,才能完成从“手术匠”到“大师”的飞跃。     

Obesity in America: Implications for Clinical and Health Psychologists

The number of individuals classified as overweight and obese is increasing at alarming rates and these conditions are associated with numerous psychological and physiological health problems. Within this epidemic, there is an increasing need and demand for psychologists and other mental health professionals to participate in the care of patients with obesity, both in assessment and treatment domains. The current paper provides a review of the status of the obesity epidemic, including psychological comorbidities and treatment approaches. Throughout this review, we highlight and discuss the important roles and impact psychologists can have. These roles include serving as members of multidisciplinary obesity treatment programs, conducting assessments for bariatric surgery, and treating related psychiatric disorders, such as depression and disordered eating. Other considerations, such as weight gain associated with psychiatric medications, and directions for future involvement of psychologists in addressing the obesity epidemic are also discussed.