Implementation of Cognitive Therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample

ObjectiveTrauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.MethodA consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.ResultsCT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.ConclusionsThe results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.     

Cognitive therapy for post-traumatic stress disorder: development and evaluation

The paper describes the development of a cognitive therapy (CT) program for post-traumatic stress disorder (PTSD) that is based on a recent cognitive model (Behav. Res. Therapy 38 (2000) 319). In a consecutive case series, 20 PTSD patients treated with CT showed highly significant improvement in symptoms of PTSD, depression and anxiety. A subsequent randomized controlled trial compared CT (N = 14) and a 3-month waitlist condition (WL, N = 14). CT led to large reductions in PTSD symptoms, disability, depression and anxiety, whereas the waitlist group did not improve. In both studies, treatment gains were well maintained at 6-month follow-up. CT was highly acceptable, with an overall dropout rate of only 3%. The intent-to-treat effect sizes for the degree of change in PTSD symptoms from pre to post-treatment were 2.70-2.82 (self-report), and 2.07 (assessor-rated). The controlled effect sizes for CT versus WL post-treatment scores were 2.25 (self-report) and 2.18 (assessor-rated). As predicted by the cognitive model, good treatment outcome was related to greater changes in dysfunctional post-traumatic cognitions. Patient characteristics such as comorbidity, type of trauma, history of previous trauma, or time since the traumatic event did not predict treatment response, however, low educational attainment and low socioeconomic status were related to better outcome.     

The clinical effectiveness of cognitive behaviour therapy: outcome for a large sample of adults treated in routine practice

There is increasing interest in questions about how far the demonstrated efficacy of psychological therapies in research trials can be translated into clinical effectiveness in routine practice. This paper summarises outcome data from several hundred patients treated with CBT in routine clinical practice in a National Health Service psychology service, and compares their outcomes with some of the published research. Although the data have flaws common in ordinary clinical practice (no untreated controls, missing data, uncontrolled pharmacotherapy, etc.), the analyses suggest that CBT in this context is an effective treatment, albeit with probably not quite such good results as it achieves in research trials. Using clinical significance statistics on standardised measures, about half of the sample reliably improved over a course of therapy, including about a third who recovered to normal range.     

Cognitive-behaviour therapy for chronic fatigue syndrome: comparison of outcomes within and outside the confines of a randomised controlled trial

Outcomes for cognitive-behaviour therapy (CBT) in randomised controlled trials (RCTs) have rarely been compared to those in routine clinical practice. Taking the case of CBT for chronic fatigue syndrome (CFS), we evaluated the results of a successful RCT against those of the same treatment given in the same setting as part of routine practice. Fatigue and social adjustment scores were compared for patients who received CBT for CFS as part of a RCT (N=30) and patients who received CBT as part of everyday clinical practice (N=384). The results in the RCT were superior to those in routine clinical practice. Between pre-treatment and 6-month follow-up, the RCT showed a larger reduction in fatigue and greater improvement in social adjustment than those in routine treatment. The changes in fatigue scores were similar for both groups during treatment but were greater in the RCT between post-treatment and follow-up. Potential reasons for the superior results of the RCT include patient selection, therapist factors and the use of a manualised treatment protocol. Practitioners need to pay particular attention to relapse prevention and ensuring adequate follow-up in addition to encouraging patients to continue with cognitive-behavioural strategies once treatment has ended.     

Provoked vestibulodynia: Psychological predictors of topical and cognitive-behavioral treatment outcome

Psychological factors have been found to impact the pain experience and associated sexual impairment of women suffering from provoked vestibulodynia (PV). Despite a lack of randomized treatment outcome studies, particularly concerning psychological predictors of outcome, recent studies have shown that topical applications and cognitive-behavioral therapy (CBT) are among the most popular first-line interventions for PV. The present study aimed to determine the extent to which baseline fear-avoidance variables and pain self-efficacy were differentially associated with topical application and CBT outcomes at six-month follow-up. Data were obtained from 97 women who completed a randomized trial comparing these two treatments. Regression analyses revealed that for topical treatment, higher levels of baseline avoidance predicted worse pain and sexual functioning outcomes, whereas higher levels of pain self-efficacy predicted better outcomes. For CBT, higher levels of baseline fear of pain and catastrophizing contributed to higher pain intensity at follow-up, whereas higher levels of pain self-efficacy were associated with less pain. Psychological factors did not predict sexual functioning outcomes for CBT. Consistent with biopsychosocial models of pain and sexual dysfunction, results indicate that psychological factors contribute to pain and sexual impairment following treatment for PV. Specifically, findings suggest that fear-avoidance variables and pain self-efficacy are significant predictors of topical and CBT treatment outcomes in women with PV.     

Differences in alexithymia and emotional awareness in exhaustion syndrome and chronic fatigue syndrome

Symptoms of Exhaustion Syndrome (ES) and Chronic Fatigue Syndrome (CFS) are overlapping and create difficulties of differential diagnosis. Empirical studies comparing ES and CFS are scarce. This study aims to investigate if there are any emotional differences between ES and CFS. This cross‐sectional study compared self‐reported alexithymia and observer‐rated emotional awareness in patients with ES (n = 31), CFS (n = 38) and healthy controls (HC) (n = 30). Self‐reported alexithymia was measured with the Toronto Alexithymia Scale‐20 (TAS‐20) and emotional awareness with an observer‐rated performance test, the Level of Emotional Awareness Scale (LEAS). Additionally, depression and anxiety were scored by the Hospital Anxiety and Depression Scale (HADS). Results show that patients with ES expressed higher self‐reported alexithymia in the TAS‐20 compared to HC, but had similar emotional awareness capacity in the observer‐rated performance test, the LEAS. Patients with CFS expressed more difficulties in identifying emotions compared to HCs, and performed significantly worse in the LEAS‐total and spent more time completing the LEAS as compared to HC. Correlation and multiple regressions analyses revealed that depression and anxiety positively correlated with and explained part of the variances in alexithymia scores, while age and group explained the major part of the variance in LEAS. Findings of this study indicate that emotional status is different in patients with ES and CFS with respect to both self‐reported alexithymia and observer‐rated emotional awareness. Emotional parameters should be approached both in clinical investigation and psychotherapy for patients with ES and CFS.     

Development of a measure of symptoms in chronic fatigue syndrome: The profile of fatigue-related symptoms(pfrs)

Abstract

Chronic fatigue syndrome (CFS) is a disorder of uncertain aetiology which attracts increasing research interest. This paper describes the development of a multidimensional measure incorporating the diverse symptoms associated with the illness. The Profile of Fatigue-Related Symptoms (PFRS) has four scales: emotional distress, cognitive difficulty, fatigue and somatic symptoms. These showed good convergence with comparison measures, high reliability and high internal consistency. CFS patients had markedly elevated scores compared with a student comparison group, and these scores correlated with indices of illness severity. The PFRS is a short and easily administered measure which, it is suggested, may be used to assess patients in terms of the severity and pattern of their disorder, to relate subjective symptoms to immunological and other findings, to evaluate the effects of treatments, and to compare the symptomatology of CFS with that in other fatiguing illnesses.     

Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy

Using a sample of over 125 patients with irritable bowel syndrome (IBS) who were treated with cognitive therapy administered in small groups, we sought to predict end of treatment and 3-month follow-up improvement in two changes indices of gastrointestinal (GI) symptoms (Pain/Discomfort Index which assessed change in abdominal pain, abdominal tenderness and bloating and Bowel Regularity Index which assessed change in diarrhea and constipation). We also sought to predict scores on IBS specific quality of life (QOL) and overall level of psychological distress using the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant, but modest, levels of prediction were found for prediction of improvement in GI symptoms (4-15% of variance). Stronger significant prediction was obtained for the QOL and global psychological distress measure with R(2)'s ranging from 0.36 to 0.50. A wide variety of demographic, GI symptom, psychological status and psychiatric status variables entered the final prediction equations.     

Extended network learning error: A new way of conceptualising chronic fatigue syndrome

Abstract

The cause of chronic fatigue syndrome (CFS) is controversial: psychological, hypothalamic and immune mechanisms have been proposed as well as the possibility of some form of interaction between these mechanisms. Patients' own conceptual models vary and sometimes adversely affect self-management. This paper suggests an interactional way of conceptualising CFS using developments in complexity theory (networks, parallel processing or connectionism). I propose that the neurological, immune and endocrine systems are pan of a single, self-regulatory, extended brain-body network. Furthermore, that CFS is caused by self-organisational change in this extended network created by normally adaptive error-sensitive learning rules that malfunction when physiological and psychological challenges coincide. This psychoneuroimniunoendocrinological model shows how previously proposed mechanisms could interact to cause CFS. explains the heterogeneity of the presentation of the disease, and provides a conceptual model that may be acceptable to patients but is also consistent with effective self-management.     

Stigma and the delegitimation experience: An interpretative phenomenological analysis of people living with chronic fatigue syndrome

Individual in-depth interviews with 14 people with chronic fatigue syndrome (CFS) were conducted, focusing on the experience of living with CFS. The interviews were transcribed verbatim and were analysed for recurrent themes using interpretative phenomenological analysis (IPA). Here we present two inter-related themes: “Negotiating a diagnosis” and “Negotiating CFS with loved ones”. Participants reported delay, negotiation and debate over diagnosis: further, they perceived their GPs to be sceptical, disrespectful and to be lacking in knowledge and interpersonal skills. However, participants found delegitimising encounters with their partners more difficult to deal with. Participants viewed such delegitimation as a form of personal rejection; they were hurt by their loved ones’ reactions and subsequently pondered the price of love, respect and friendship. The findings are discussed in relation to extant literature, and recommendations for future research are suggested.     

The effectiveness of enhanced cognitive behavioural therapy for eating disorders: an open trial

The aim of this study was to examine the effectiveness of Enhanced Cognitive Behaviour Therapy (CBT-E) for eating disorders in an open trial for adults with the full range of eating disorders found in the community. The only previously published trial of CBT-E for eating disorders was a randomised controlled trial (RCT) conducted in the U.K. for patients with a BMI ≥ 17.5. The current study represents the first published trial of CBT-E to include patients with a BMI < 17.5. The study involved 125 patients referred to a public outpatient clinic in Perth, Western Australia. Patients attended, on average, 20–40 individual sessions with a clinical psychologist. Of those who entered the trial, 53% completed treatment. Longer waiting time for treatment was significantly associated with drop out. By the end of treatment full remission (cessation of all key eating disorder behaviours, BMI ≥ 18.5 kg/m², not meeting DSM-IV criteria for an eating disorder) or partial remission (meeting at least 2 these criteria) was achieved by two thirds of the patients who completed treatment and 40% of the total sample. The results compared favourably to those reported in the previous RCT of CBT-E, with one exception being the higher drop-out rate in the current study. Overall, the findings indicated that CBT-E results in significant improvements, in both eating and more general psychopathology, in patients with all eating disorders attending an outpatient clinic.     

Personality and perfectionism in chronic fatigue syndrome: A closer look

Objective: To test the hypothesis that people with chronic fatigue syndrome (CFS) would differ significantly from a healthy control group on measures of general personality and perfectionism, specifically on measures of neuroticism and unhealthy perfectionism. Method: A total of 27 female CFS outpatients and 30 female healthy controls completed questionnaires, including the NEO Personality Inventory-Revised, the Multi-dimensional Perfectionism Scale and measures of anxiety and depression. Results: The CFS group was significantly more fatigued, anxious and depressed than healthy controls. They scored significantly higher on neuroticism and unhealthy perfectionism. Healthy and unhealthy perfectionism were positively correlated in the CFS group, but not in the control group. Conclusion: The present study confirms the link between neuroticism and fatigue and finds a link between unhealthy perfectionism and fatigue. A ‘healthy trait’, such as healthy perfectionism, when coupled with evaluative concerns is not necessarily healthy in a fatigued population. Researchers and clinicians should note the context in which apparently benign traits are expressed, and how they interact with other traits.     

Resistance and outcome expectations in cognitive‐behavioural therapy for generalised anxiety disorder

Greater client resistance has been consistently found to be negatively associated with outcome in psychotherapy. However, the pathways through which resistance impacts such outcomes are underexplored. Given that client outcome expectation (OE) has been identified as an important common factor in psychotherapy, the goals of the present study were to examine: (a) the impact of resistance on subsequent client and therapist OE (COE & TOE, respectively); and (b) whether COE and/or TOE mediate the relationship between resistance and outcome. These relationships were tested among 44 clients with severe generalised anxiety disorder treated with cognitive‐behavioural therapy in the context of a randomised controlled trial (Westra, Constantino, & Antony, 2016). Resistance was measured at a mid‐treatment session, and COE and TOE were assessed at baseline and immediately after the resistance session. Treatment outcome was measured via client‐rated worry severity at post‐treatment. As predicted, higher resistance was associated with lower subsequent COE and TOE; B = ?.73, p < .001 and B = ?.46, p < .001, respectively. In turn, lower post‐resistance COE predicted higher post‐treatment worry (B = ?.5, p < .001), indicating mediation. In contrast, TOE did not mediate the relationship between resistance and outcome (B = ?.02, p = .876). These results suggest that resistance can be demoralising to both clients and therapists. However, only lower client morale may be detrimental to therapy outcome. This study contributes to understanding outcome pathways through two common therapy processes.     

A body with chronic fatigue syndrome as a battleground for the fight to separate from the mother

I describe the therapy of a 20-year-old woman who believed that her difficulties in concentrating and remembering were caused by her 'ME' (Myalgic encephalomyelitis, Chronic fatigue syndrome, or CFS). She had been fathered by a man who never left his own wife. Work with her dreams revealed a within-body drama in which she was locked in an unspeakable fight to the death with her mother. Her symptoms improved after parallels between a dream and an accident showed her own self-destructive hand in her story. Another dream, reflecting her first 'incestuous' affair, showed her search for her original father-self as someone separate from mother, and a later affair provided a between-body drama, helping her to own the arrogant and abject traits she had before seen only as her mother's. I show how we worked in the area of Winnicott's first 'primitive agony' as experienced by a somatizing patient, stuck in a too-close destructive relationship with her mother-body. I discuss how analytical work can be done with the primitive affects and conflicts against which the ME symptoms may be defending.     

Effectiveness of cognitive behavioural group therapy for social phobia in a community clinic: a benchmarking study

This study used a benchmarking strategy to investigate the transportability of cognitive behavioural group therapy (CBGT) for social phobia to a community mental health clinic. The influence of common exclusion criteria on effect sizes was also examined. Patients (N=153) attended seven 4-h sessions of CBGT, which resulted in significant reductions in symptoms of social anxiety and depression. Effect sizes compared favourably to previous efficacy and effectiveness studies of both group and individual treatment. More than half of the treatment completers achieved reliable change. One-third achieved clinically significant change (CSC) on the Social Phobia Scale and the Beck Depression Inventory, but fewer achieved CSC on the Social Interaction and Anxiety Scale. Restricting the sample on the basis of depression symptoms, age above or below 50 years, comorbidity, alcohol problems, or student status did not significantly moderate effect sizes for social anxiety. It is concluded that CBGT is effective within community mental health clinics.     

The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study

Low self esteem in individuals with a psychotic disorder is common and may be related to poorer clinical outcomes. However, there has been little research on devising treatment methods to improve self-esteem either generally or in psychotic patients in particular. The aims of this study were to evaluate the efficacy of a simple cognitive behavioural intervention to improve self esteem in psychotic patients who scored poorly on a self-esteem measure. This pilot study was a randomised control trial with a convenience sample of chronic psychotic inpatients. The cognitive behavioural self-esteem intervention, as an adjunct to treatment as usual (TAU), was compared to TAU alone in patients with psychosis. The individual self-esteem intervention as described by Tarrier (The use of coping strategies and self-regulation in the treatment of psychosis. (2001)) consisted of working with participants to elicit positive self-attributes and then identify specific behavioural examples to provide evidence of this attribute. Emphasis was given to any consequential change in the patient's belief that they had the attribute. The results indicated that this cognitive behavioural treatment for self-esteem used as an adjunct treatment in psychosis, resulted in clinical benefits in terms of increased self-esteem, decreased psychotic symptomatology and improved social functioning. These benefits were largely maintained at 3-month follow-up.     

Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase

The concept of acceptance is receiving increased attention as an alternate approach to the suffering that is often associated with persistent and disabling pain. This approach differs from established treatments in that it does not principally focus on reducing pain, but on reducing the distressing and disabling influences of pain as they concern important areas in patients' lives. The present analyses represent a preliminary evaluation of an acceptance-based approach to chronic pain within an interdisciplinary treatment program. One hundred and eight patients with complex chronic pain conditions completed treatment and provided data for the current study. Treatment was conducted in a 3- or 4-week residential or hospital-based format. It included a number of exposure-based, experiential, and other behavior change methods focused on increasing (a) engagement in daily activity regardless of pain and (b) willingness to have pain present without responding to it. Significant improvements in emotional, social, and physical functioning, and healthcare use were demonstrated following treatment. The majority of improvements continued at 3-months post-treatment. Improvements in most outcomes during treatment were correlated with increases in acceptance, supporting the proposed process of treatment.     

Emotion recognition and emotional theory of mind in chronic fatigue syndrome

Background: Difficulties with social function have been reported in chronic fatigue syndrome (CFS), but underpinning factors are unknown. Emotion recognition, theory of mind (inference of another's mental state) and ‘emotional’ theory of mind (eToM) (inference of another's emotional state) are important social abilities, facilitating understanding of others. This study examined emotion recognition and eToM in CFS patients and their relationship to self-reported social function.

Methods: CFS patients (n?=?45) and healthy controls (HCs; n?=?50) completed tasks assessing emotion recognition, basic or advanced eToM (for self and other) and a self-report measure of social function.

Results: CFS participants were poorer than HCs at recognising emotion states in the faces of others and at inferring their own emotions. Lower scores on these tasks were associated with poorer self-reported daily and social function. CFS patients demonstrated good eToM and performance on these tasks did not relate to the level of social function.

Conclusions: CFS patients do not have poor eToM, nor does eToM appear to be associated with social functioning in CFS. However, this group of patients experience difficulties in emotion recognition and inferring emotions in themselves and this may impact upon social function.     

Coniunctio—in bodily and psychic modes: dissociation, devitalization and integration in a case of chronic fatigue syndrome

Three years of analytical psychotherapy with a professional woman in mid-life, suffering from chronic fatigue syndrome (CFS), is described. Gradual recovery merged into mid-life changes; marriage, along with a new balance of maternal and paternal imagos, enabled her to trust enough to become pregnant— coniunctio in the most primal bodily and psychic modes.
Her life-long, schizoid type pattern, 'the pendulum of closeness and isolation', with its extreme of psycho-physical collapse and devitalization, was replayed in therapy. The analyst's symbolic attitude is emphasized, containing the patient's initial affective explosion and validating the physicality of her condition. Mirroring and steady rhythmic attunement became a new, pre-verbal, source of trust—vitalization; differentiation and separation replaced defensive splitting and dissociation. Then the overwhelmingly powerful bodily/maternal could be counterbalanced by the masculine, and a transitional space emerged for symbolic work.
Both the regressive and the dynamic aspects of CFS are located in the earliest undifferentiated, archetypal, bodily/psychic modes, when the frustration of primary needs evokes the defences of the self. It is argued that our psychodynamic understanding can contribute to the stalemate in seeing chronic fatigue syndrome as either an organic illness or depression, and that a new linking of the somatic and psychic calls for a new professional collaboration.