Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Sexually abused children and post-traumatic stress disorder

Sexually abused children often develop post-traumatic stress disorder, a distressing and debilitating condition that is typically unresponsive to non-directive counselling. Empirically supported abuse-confronting, structured interventions are urgently required for use by counselling psychologists responsible for the management of this challenging clinical population. Given the success of cognitive-behavioural interventions with adult trauma victims, it has been suggested that this treatment approach be applied to sexually abused children. This paper presents a cognitive-behavioural treatment framework comprising two levels of intervention: child therapy and parent training. We selectively review emerging empirical support for the efficacy and acceptability of this treatment approach.     

Psychophysiological and cognitive responses to stressful stimuli in subjects practicing progressive relaxation and clinically standardized meditation

Thirty-six volunteer subjects were assigned to one of three conditions: progressive relaxation, clinically standardized meditation, or a waiting list control group asked to relax daily (without specific instruction). Subjects were given paper and pencil tests two times, separated by 5 weeks during which time the two treatment groups received 4 weekly sessions of group training. All subjects were tested in the psychophysiology laboratory at the end of the 5-week period, during which time they were exposed to 5 very loud tones. While relaxing as deeply as possible using the techniques they had learned and anticipating the loud tones, the meditation group exhibited higher heart rates and higher integrated frontalis EMG activity, but they also showed greater cardiac decelerations following each tone, more frontal alpha, and fewer symptoms of cognitive anxiety than the other two groups. The relaxation group reported more sensations of muscular relaxation than the other groups, but also some symptoms of hyperventilation. The results are generally consistent with Davidson and Schwartz's (1976) categorization of meditation as a ‘cognitive’ technique, and suggest that frontal EEG alpha may be a physiological marker for the absence of cognitive anxiety. Physiological findings also support Goleman and Schwartz's (1976) suggestion that meditation prepares people to cope with stress.     

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12–15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.     

A comparative outcome study of four cognitive therapies in the treatment of social anxiety

This clinical outcome study compared four separate cognitive behavioral and one behavioral treatment for reducing social anxiety with a waiting list control. Subjects were adults who responded to advertisements for treatment. In the cognitive-behavioral conditions, subjects were trained to modify their disruptive cognitions and/or emit adaptive cognitions relevant to interpersonal behavior with the specific content and techniques determined by the particular cognitive therapy. In the behavioral condition, subjects modeled and rehearsed appropriate social interpersonal behaviors. Subjects were assessed pre and post-treatment on self-report measures of social anxiety, measures of general anxiety, clinical scales of anxiety, depression and hostility, and behavioral, and physiological concomitants of social anxiety. Subjects in all active treatment conditions showed improvement on the measures of social anxiety and the behavioral measure. However, only those in the cognitive treatment conditions, demonstrated treatment effects on general anxiety and the clinical scales. The results indicate the efficacy of both cognitive and behavioral approaches to the reduction of social anxiety. However, they fail to demonstrate clear distinctions between the various cognitive therapies.     

Cognitive-behaviour therapy in the treatment of chronic, occupational pain of the upper limbs: a 2 yr follow-up.

Nineteen Ss who experienced chronic, occupational pain of the upper limbs and who had previously completed a programme of either individual or group cognitive-behaviour therapy were followed up 2 yr later. Significant improvements on measures of depression, anxiety, coping strategies and interference in daily living were found following treatment. Such improvements were not evident for the waiting list control Ss and no difference was found between group vs individual applications of therapy. A 2 yr follow-up, significant improvements from pre-treatment levels were evident for depression, coping strategies, significant other report of disability, self monitored pain and distress caused by pain. While there was generally little evidence of relapse, a significant decline from post-treatment levels was found for the individual therapy condition compared to the group therapy condition on measures of self monitored pain and interference caused by pain. Since post-treatment levels tended to be somewhat superior for the individual therapy condition, the overall finding at 2 yr follow-up was of minimal difference in outcome for group vs individual forms of cognitive-behaviour therapy. Despite improvements from pre-treatment levels, the vast majority of Ss still reported significant and distressing levels of pain at 2 yr follow-up.     

Cognitive behavior therapy for driving fear: A pilot randomized controlled trial

Fear of driving is common in clinical practice, while its treatment programs are understudied. This is the first randomized controlled trial to evaluate a newly developed protocol for cognitive behavior therapy (CBT) for driving fear compared with a wait list and to use specific assessment scales. 34 participants (30 women, 4 men) in an outpatient psychotherapy clinic were randomly allocated to either 18 sessions of CBT or a wait list (n = 17 each). After treatment, CBT was significantly more efficacious than the wait list with large effect sizes on the Instrument for Fear of Driving (IFD) (Cohen’s d = 2.58) and on the Driving Cognitions Questionnaire (DCQ) (Cohen’s d = 2.14). Driving fear is a condition treatable by CBT and the suggested protocol is safe, feasible and acceptable. Further studies with larger samples and active controls (e.g., virtual reality therapy) are required to draw generalizable conclusions on effect sizes.     

Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder

The present study investigated the efficacy of a coping-technique, applied relaxation (AR) and cognitive therapy (CT), in the treatment of generalized anxiety disorder. Thirty-six outpatients fulfilling the DSM-III-R criteria for generalized anxiety were assessed with independent assessor ratings and self-report scales before and after treatment and at a 1 yr follow-up. The patients were randomized and treated individually for 12 weekly sessions. The results showed that both treatments yielded large improvements, which were maintained, or furthered at follow-up. There was no difference between AR and CT on any measure. The drop-out rate was 12% for AR and 5% for CT. The proportions of clinically significantly improved patients were 53 and 62% at post-treatment and 67 and 56% at follow-up for AR and CT, respectively. Besides affecting generalized anxiety the treatments also yielded marked and lasting changes on ratings of worry, cognitive and somatic anxiety and depression. The conclusion that can be drawn is that both AR and CT have potential as treatments for generalized anxiety disorder but they have to be developed further in order to increase the efficacy to the level usually seen in panic disorder, 80-85% clinically improved.     

The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study.

In this study, Herbert Benson's (1975) Relaxation Response Meditation program was tested as a possible treatment for Irritable Bowel Syndrome (IBS). Participants were 16 adults who were matched into pairs based on presence of Axis I disorder, primary IBS symptoms and demographic features and randomized to either a six week meditation condition or a six week wait list symptom monitoring condition. Thirteen participants completed treatment and follow-up. All subjects assigned to the Wait List were subsequently treated. Patients in the treatment condition were taught the meditation technique and asked to practice it twice a day for 15 minutes. Composite Primary IBS Symptom Reduction (CPSR) scores were calculated for each patient from end of baseline to two weeks post-treatment (or to post wait list). One tailed independent sample t-tests revealed that Meditation was superior to the control (P=0.04). Significant within-subject improvements were noted for flatulence (P=0.03) and belching (P=0.02) by post-treatment. By three month follow-up, significant improvements in flatulence (P<0.01), belching (P=0.02), bloating (P=0.05), and diarrhea (P=0.03) were shown by symptom diary. Constipation approached significance (P=0.07). Benson's Relaxation Response Meditation appears to be a viable treatment for IBS.     

Comparison of Cognitive-Behavioral Stress Management Techniques With Adolescent Boys

This study examined the effectiveness of two cognitive-behavioral interventions to help adolescent boys cope with stress and other forms of negative emotional arousal. One group of youths, those receiving cognitive restructuring, learned how to identify and monitor stress-promoting cognitions, restructure these cognitions into more adaptive thoughts, and practice and apply these acquired skills. Another group of youths received anxiety management training, and they were taught to recognize cues that signal the onset of anxiety and to react to these cues using various relaxation skills to reduce the anxiety. The youths who received training were compared with a waiting list control group on measures of anxiety, anger, self-esteem, depression, and reports of anxious self-statements. Both groups that received the intervention showed significant reductions in levels of state and trait anxiety, state anger, anger expression, and depression. These treatment gains were maintained at an 11-week follow-up.     

Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying

This controlled clinical trial tested virtual reality exposure (VRE) therapy for the fear of flying (FOF), a relatively new and innovative way to do exposure therapy, and compared it to standard (in vivo) exposure therapy (SE) and a wait list (WL) control with a 6- and 12-month follow-up. Eighty-three participants with FOF were randomly assigned to VRE, SE, or WL. Seventy-five participants, 25 per group, completed the study. Twenty-three WL participants completed randomly assigned treatment following the waiting period. Treatment consisted of 4 sessions of anxiety management training followed either by exposure to a virtual airplane (VRE) or an actual airplane at the airport (SE) conducted over 6 weeks. Results indicate that VRE was superior to WL on all measures, including willingness to fly on the posttreatment flight (76% for VRE and SE; 20% for WL). VRE and SE were essentially equivalent on standardized questionnaires, willingness to fly, anxiety ratings during the flight, self-ratings of improvement, and patient satisfaction with treatment. Follow-up assessments at 6 and 12 months indicated that treatment gains were maintained, with more than 70% of respondents from both groups reporting continued flying at follow-up. Based on these findings, the use of VRE in the treatment of FOF was supported in this controlled study, suggesting that experiences in the virtual world can change experiences in the real world.     

Cognitive Coping vs Emotional Disclosure in the Treatment of Anxious Children: A Pilot-Study

The present pilot-study was a first attempt to examine the effectiveness of the cognitive component of cognitive behaviour therapy for children with anxiety problems. A total of 24 highly anxious children were assigned to 1 of 2 intervention conditions: a Cognitive Coping intervention, which focussed primarily on the cognitive component of cognitive behaviour therapy, or an Emotional Disclosure intervention in which children were invited to write about their fears and anxious experiences. Children completed self-report questionnaires of anxiety disorders symptoms and worry at 3 points in time: (i) 6 weeks before treatment (i.e. baseline), (ii) at pre-treatment, and (iii) at post-treatment. The results showed, firstly, that levels of anxiety disorder symptoms and worry remained relatively stable over a 6-week waiting period and then decreased substantially after the interventions. This suggests that the children did not suffer from momentary anxiety and worry complaints and that treatments generally were effective in reducing these symptoms. Secondly, although within-group comparisons suggested that treatment effects were somewhat larger in the Cognitive Coping condition than in the Emotional Disclosure condition (effects sizes for anxiety disorders symptoms and worry were, respectively, 1.03 and 0.87 for Cognitive Coping vs 0.54 and 0.39 for Emotional Disclosure), statistical tests could not substantiate this impression, probably due to a lack of power as a result of the small numbers of children in both intervention conditions.     

A Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults With Generalized Anxiety Disorder

This randomized clinical trial compared cognitive-behavioral therapy (CBT), applied relaxation (AR), and wait-list control (WL) in a sample of 65 adults with a primary diagnosis of generalized anxiety disorder (GAD). The CBT condition was based on the intolerance of uncertainty model of GAD, whereas the AR condition was based on general theories of anxiety. Both manualized treatments were administered over 12 weekly 1-hour sessions. Standardized clinician ratings and self-report questionnaires were used to assess GAD and related symptoms at pretest, posttest, and at 6-, 12-, and 24-month follow-ups. At posttest, CBT was clearly superior to WL, AR was marginally superior to WL, and CBT was marginally superior to AR. Over follow-up, CBT and AR were equivalent, but only CBT led to continued improvement. Thus, direct comparisons of CBT and AR indicated that the treatments were comparable; however, comparisons of each treatment with another point of reference (either waiting list or no change over follow-up) provided greater support for the efficacy of CBT than AR.     

Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: a preliminary examination

The present study examined the effect of the presence of borderline personality disorder characteristics (BPC) on patients' responses to cognitive behavioral treatment for chronic PTSD. Seventy-two female victims of sexual and non-sexual assault were randomly assigned to one of four treatment conditions: prolonged exposure (PE), stress inoculation training (SIT), combined treatment (PE/SIT), and wait list control (WL). Treatment consisted of nine bi-weekly individual sessions. Seventeen percent of the patients met full (10%) or partial criteria (7%) for borderline personality disorder. A greater number of patients with BPC reported sexual assault in childhood compared to those without the symptomatology. Patients with BPC also reported more pre-treatment anger. In general, those with BPC benefited significantly from treatment, although at post-treatment, they were less likely to achieve good end-state functioning than those without such symptomatology. The relationship between BPC and treatment response will be discussed.     

Influence of Co‐Morbid Generalized Anxiety Disorder,Panic Disorder and Personality Disorders on the Outcome of Cognitive Behavioural Treatment of Obsessive‐Compulsive Disorder

This study examined co‐morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive‐compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co‐morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention‐to‐treat criteria, patients with generalized anxiety disorder and/or panic disorder co‐morbidity showed less treatment gains at post‐treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post‐treatment and the 12‐month follow‐up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co‐morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12‐month follow‐up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post‐treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

LearningRx Cognitive Training Effects in Children Ages 8–14: A Randomized Controlled Trial

In a randomized controlled study, we examined the effects of a one‐on‐one cognitive training program on memory, visual and auditory processing, processing speed, reasoning, attention, and General Intellectual Ability (GIA) score for students ages 8–14. Participants were randomly assigned to either an experimental group to complete 60 h of cognitive training or to a wait‐list control group. The purpose of the study was to examine changes in multiple cognitive skills after completing cognitive training with ThinkRx, a LearningRx program. Results showed statistically significant differences between groups on all outcome measures except for attention. Implications, limitations, and suggestions for future research are examined. © 2016 The Authors Applied Cognitive Psychology Published by John Wiley & Sons Ltd.     

A controlled trial of cognitive-behavior therapy combined with vestibular rehabilitation in the treatment of dizziness

Dizziness is a common and often untreated symptom in the general population. The aim of this study was to investigate the effects of a combined cognitive-behavioral/vestibular rehabilitation (VR) program, using a randomized control design. A total of 29 participants were randomized to treatment consisting of psychoeducation, vestibular exercises, relaxation and cognitive interventions, or to serve as waiting list controls. Measures of dizziness-related handicap, dizziness-provoking movements, and daily diary registrations of dizziness symptoms at pre- and post-treatment showed statistically significant improvements in many domains, which translated to moderate effect sizes. These findings provide preliminary support for the combination of Cognitive-behavioral therapy (CBT) and VR methods in the treatment of dizziness.     

Chronisches Ersch?pfungssyndrom

The treatment of chronic fatigue syndrome (CFS) may pose a challenge as controversial concepts of its aetiology are discussed. Psychotherapy and graded exercise therapy have been suggested for the treatment of CFS. The aim of the present literature review is to summarize the evidence for these treatments based on two meta-analyses and more recently published randomized controlled trials. There is robust evidence for the efficacy of cognitive-behavioural therapy for CFS, showing moderate effects especially on fatigue severity and physical functioning at post-treatment and at short to medium term follow-up. Other psychological treatments have mainly been tested as control conditions and not as bona fide psychotherapy; however, single trials suggest benefits of non-directive counselling and psycho-education. To further improve treatment results and their maintenance, relapse prevention strategies are important and a stronger empirical foundation of long-term effects is needed.     

A preliminary investigation of cognitive and relaxation treatment of panic disorder: effects on intense anxiety vs 'background' anxiety

In this study, three adult males complaining of Panic Disorders were treated with cognitive therapy followed by relaxation training combined with cognitive therapy in a multiple-baseline across Ss design. All Ss demonstrated a decrease in the number and duration of episodes of heightened or intense anxiety, which was maintained at 3-month follow-up. Daily time-sampled ratings of ‘background’ anxiety, not necessarily associated with periods of intense anxiety, showed a substantial decrease for S2, which was maintained at 3-month follow-up. However, S 1 and S 3 evidenced an increase in background anxiety during the combined treatment phase in contrast to the effects of treatment on periods of ‘intense’ anxiety. These results suggest that psychological treatments for patients classified as suffering from Panic Disorder are effective and lend some support to the differentiation of panic from ‘general’ anxiety. Recent observations of relaxation-induced anxiety were also replicated in this clinical setting. These data also illustrate the advantages and difficulties of self-monitoring anxiety over a period of time.     

A comparison of psychological and pharmacological treatment of pediatric migraine

A comparison was carried out of the efficacy of psychological and drug treatments for children with migraine. Forty-three children aged between 8 and 16 years (mean age: 11.3 years) who suffered from migraine received either progressive relaxation or cephalic vasomotor feedback, both with stress management training, or metoprolol, a beta-blocker. Psychological treatment was administered in ten sessions lasting six weeks and the drug treatment lasted ten weeks. Relaxation and stress management training reduced the headache index (frequency×intensity of headache episodes), more effectively than metoprolol with cephalic vasomotor feedback and stress management training in between. An overall improvement over time was found with regard to frequency and intensity of headache episodes and analgesics intake. When comparing pre- to post-treatment data, children treated with relaxation training improved significantly in headache frequency and intensity, whereas those treated with cephalic vasomotor feedback improved significantly in headache frequency and duration as well as mood. The clinical improvement was stable at an 8-months follow-up.