Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.     

Sleep predicts the response to rTMS and CBT in patients with OCD: an open label effectiveness study

BackgroundAlthough many OCD patients benefit from repetitive transcranial magnetic stimulation (rTMS) as treatment, there is still a large group failing to achieve satisfactory response. Sleep problems have been considered transdiagnostic risk factors for psychiatric disorders, and prior work has shown comorbid sleep problems in OCD to be associated with non-response to rTMS in OCD. We therefore set out to investigate the utility of sleep problems in predicting response to rTMS in treatment resistant OCD.MethodA sample of 61 patients (treated with 1-Hz SMA or sequential 1-Hz SMA+DLPFC rTMS, combined with cognitive behavioral therapy) were included. Sleep disturbances were measured using the PSQI, HSDQ and actigraphy. Treatment response was defined as a decrease of at least 35% in symptom severity as measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).Results32 of 61 patients (52.5%) responded to rTMS, and trajectories of response were similar for both rTMS protocols. Three PSQI items (Subjective Sleep Quality; Sleep Latency and Daytime Dysfunction) and the HSDQ-insomnia scale were found to predict TMS response. A discriminant model yielded a significant model, with an area under the curve of 0.813.ConclusionFuture replication of these predictors could aid in a more personalized treatment for OCD.     

Alphabet Soup: ERP,CT, and ACT for OCD

The present article comments on the case conference presented in this issue, namely, Himle and Franklin's (Himle & Franklin, 2009) exposure and response prevention (ERP); Chosak and colleagues' (Chosak, Marques, Fama, Renaud, & Wilhelm, 2009) cognitive therapy (CT); and (Twohig, 2009) Acceptance and Commitment Therapy (ACT). Two questions are addressed: (1) How different are these treatments? (2) What are the active vs. inert ingredients of each treatment? With regard to the first question, it is concluded that ERP and ACT appear more similar than dissimilar in terms of actual therapist/patient behaviors. CT shows more substantial differences from ERP and ACT, primarily in the therapist's direct efforts to target antecedent cognitions. With regard to the second question, examination of the likely active ingredients of each treatment suggests that interventions that encourage direct behavioral change (described as a characteristic feature of ERP and ACT and an incidental feature of CT) are most likely responsible for improvement in all three treatments, whereas evidence for the importance of altering antecedent cognitions (a characteristic feature of CT and an incidental feature of ERP) is less clear. Additional controlled research is recommended to identify which aspects of treatment are truly efficacious for OCD and other conditions.     

Parameters for Creating Culturally Sensitive CBT: Implementing CBT in Global Settings

The current article is a commentary on the article, “A Common Elements Approach for Adult Mental Health Problems in Low- and Middle-Income Countries,” which describes a form of transdiagnostic CBT and its implementation among a highly traumatized Burmese and Iraqi group. Murray et al.’s (this issue) article is one of several new studies indicating the efficacy of CBT in global contexts. In this commentary, we suggest a set of parameters to create culturally sensitive CBT in global settings in a way to maximize efficacy and effectiveness. When applicable, we will discuss ways in which these parameters are illustrated by Murray et al. in this pilot study. These parameters can be used more generally to design culturally sensitive CBT studies in global contexts and to evaluate such studies. Some examples of these parameters are culturally appropriate framing of CBT techniques, assessing and addressing key local complaints (e.g., somatic symptoms) and local catastrophic cognitions, and incorporating key local sources of recovery and resilience.     

Computer-Assisted CBT for Child Anxiety: The Coping Cat CD-ROM

Empirical data support the efficacy of cognitive-behavioral therapy (CBT) for child anxiety, but there is need and merit in the development and evaluation of cost-effective and transportable CBT approaches. Relatedly, a widely endorsed goal is the dissemination of evidence-based treatments from research clinics to community settings. Computer-based and computer-assisted treatment programs may provide a cost-effective and efficient way to increase the accessibility of CBT treatment strategies to anxious youth. In this research update, we introduce the Coping Cat CD-ROM, a computer-assisted CBT for the treatment of anxiety disorders in youth ages 7 to 13, in its initial phases of development and evaluation.     

Adaptation of Transdiagnostic CBT for Turkish Adolescents: Examples From Culturally Adapted Multiplex CBT

The present article illustrates how cognitive-behavioral therapy (CBT) was adapted for an adolescent Turkish population with mood and anxiety disorders. The resulting 10-session treatment—based on multiplex CBT—was efficacious in a treatment trial, showing large effect sizes (Acarturk et al., 2018). This paper discusses the cultural grounding of CBT, which increases effectiveness by such means as increasing acceptability and positive expectancy. We describe a culturally sensitive assessment measure of somatic complaints and cultural syndromes, the Turkish Symptom and Syndrome Addendum. We discuss how, in a culturally sensitive way, we normalized symptoms, conducted interoceptive exposure, and created positive reassociations to sensations. We describe how we used Turkish metaphors and religious ideas to teach CBT principles. We show how we adapted mindfulness and “loving kindness” for a Turkish population, and how we utilized transition “rituals” at the end of the treatment to give a sense of closure and a positive feeling of transformation. Two case examples are provided to further illustrate how we adapted multiplex CBT to a Turkish adolescent population.     

Adaptation of CBT for Traumatized South African Indigenous Groups: Examples from Multiplex CBT for PTSD

This article describes how Culturally Adapted Multiplex CBT, a treatment that emphasizes somatic processing and emotion regulation, was adapted for a traumatized South African indigenous group, the Sepedi. A model of psychopathology is presented, the Multiplex Model of Trauma-Related Disorder, which depicts the processes that generate multiple comorbidities and prominent somatization in minority, refugee, and other non-Western populations. The nine dimensions of Culturally Adapted Multiplex CBT are discussed, and so too the “cultural adaptation diamond.” Concepts such as “explanatory model bridging” are presented. A culturally sensitive assessment measure of local somatic complaints and cultural syndromes (the Sepedi Symptom and Syndrome Addendum, or Sepedi SSA) is detailed, as well as how CBT techniques were implemented with this group—for example, modification of culturally specific catastrophic cognitions, doing exposure (e.g., interoceptive exposure), teaching attentional control and mindfulness techniques, and teaching “loving kindness.” Case examples with clinical outcomes are provided to further illustrate how Multiplex CBT was adapted for the South African indigenous group.     

Adaptation of CBT for Traumatized Egyptians: Examples from Culturally Adapted CBT (CA-CBT)

In this article we illustrate how CBT can be adapted to a traumatized Egyptian population with Islamic beliefs, giving examples from our adaptation of Culturally Adapted–CBT (CA-CBT) for this cultural group. We discuss a culturally sensitive assessment measure of local somatic complaints and cultural syndromes that was devised based on clinical experience with traumatized Egyptians. We also demonstrate how to normalize symptoms, create positive expectancy about the treatment, and educate about trauma. We give examples of how mindfulness can be adapted for an Egyptian Islamic population, and we describe local religious strategies, such as dhikr (religious chanting), salah (ritualistic prayer), and dua (supplication), that may be used to promote attentional shift from rumination topics and to teach attentional control. We describe how “loving kindness” can be adapted for this group. We outline how to modify culturally generated catastrophic cognitions and how to conduct interoceptive exposure and to create positive re-associations in a culturally sensitive manner. We describe how worry themes are explored and addressed based on a heuristic panic attack–PTSD model; how to teach anger management in a culturally sensitive way; and how to address sleep-related problems in this population. We suggest using cultural transitional “rituals” at the end of the treatment to give patients a sense of closure and a positive feeling of transformation. A case example is presented to illustrate cultural challenges associated with delivering CA-CBT to an Egyptian population. We introduce certain concepts such as cultural grounding and explanatory model bridging, both therapeutic techniques that increase adherence, positive expectancy, and cultural consonance.     

Subtyping OCD: Prospects and problems

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that fall into a variety of well-established categories. Some recent arguments have been made supporting the creation of OCD subtypes in order to better understand the psychopathology of different manifestations of OCD. It is hoped that recent advances in our knowledge of the cognitions associated with OCD could be beneficial in this endeavor. This article will review the advantages, possible obstacles, and' problems that may result from this effort. Ultimately, the creation of OCD subtypes could hold promise for improved assessment and treatment strategies, although a series of theoretical, conceptual, and practical considerations must be addressed before this categorization of OCD is undertaken.     

The SOMPA: A brief examination of technical considerations,philosophical rationale,and implications for practice

The SOMPA is examined in terms of the multicultural model and Mercer's justification for multiple normal distributions within that model. The philosophical basis of the approach and the environments in which any assessment strategy must function are also examined. It is concluded that multiple normal distributions are not justified based on the variance accounted for in WISC-R scores by the Sociocultural Scales of the SOMPA. The pholosophical basis of the SOMPA, the sociology of knowledge, is not considered helpful or useful in the assessment process because of internal logic problems associated with the paradigm and because it creates an artificial separation of populations. Some of the components which influence education are examined in an effort to place the SOMPA in a realistic operational environment and to contrast the complexity of that environment with the oversimplified view offered by the SOMPA.     

Learning to Live with OCD: Labeling,the Self,and Stigma

Researchers have long questioned relationships among self-conceptions, “mental illness,” and stigma. This article looks at these issues through the lens of Obsessive-Compulsive Disorder (OCD), as minimal research has focused on the lived experience of OCD. We examine the impact of OCD on constructions of identity and the management/resistance of stigma. We do this through in-depth interviews with an untraditional Internet-based sample. We find respondents experience a crisis of self that leads them to a variety of strategies to deal with self-stigma, experienced stigma, and anticipated stigma.     

Optimising Exposure for Children and Adolescents with Anxiety,OCD and PTSD: A Systematic Review

Clinical Child and Family Psychology Review - Cognitive behavioural therapy is an effective treatment for anxiety disorders in children and young people; however, many do not benefit. Behavioural...