The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder

Beliefs that are negatively biased, inaccurate, and rigid are thought to play a key role in the mood and anxiety disorders. Our goal in this study was to examine whether a change in maladaptive beliefs mediated the outcome of individual cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). In a sample of 47 individuals with SAD receiving CBT, we measured maladaptive interpersonal beliefs as well as emotional and behavioral components of social anxiety, both at baseline and after treatment completion. We found that (a) maladaptive interpersonal beliefs were associated with social anxiety at baseline and treatment completion; (b) maladaptive interpersonal beliefs were significantly reduced from baseline to treatment completion; and (c) treatment-related reductions in maladaptive interpersonal beliefs fully accounted for reductions in social anxiety after CBT. These results extend the literature by providing support for cognitive models of mental disorders, broadly, and SAD, specifically.     

Videoconferencing-based cognitive-behavioral therapy for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a prevalent, chronic and disabling anxiety disorder. Despite the efficacy and strength of pharmacologic interventions for OCD, medications are not always well accepted or effective, making an efficacious psychosocial alternative especially attractive. Cognitive-behavioral therapy (CBT) has been established as an effective treatment for adult OCD, yet access to such treatment is limited, especially in rural areas. Technological advances allow for therapy to be provided in a real-time format over a videoconferencing network. This method allows therapists to provide state-of-the-art treatment to patients who would not otherwise have access to it. This paper presents three cases of OCD successfully treated via videoconferencing CBT. The presence of OCD was established via structured clinical interview and clinician-rated outcome measures were completed by evaluators blinded to the method of treatment. A multiple baseline across individuals design was used to support the internal validity of the CBT outcome data. Patient ratings of therapeutic alliance were high across all three cases. Information gathered from qualitative interviews post-treatment confirmed quantitative measures finding high levels of patient satisfaction. This pilot study suggests that videoconferencing-based CBT is a promising method to bring appropriate treatment to thousands who live far distances from well-trained therapists.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.     

Antidepressants and cognitive-behavioral therapy for symptom syndromes

Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.     

Modular cognitive-behavioral therapy for body dysmorphic disorder

This study pilot tested a newly developed modular cognitive–behavioral therapy (CBT) treatment manual for body dysmorphic disorder (BDD). We tested feasibility, acceptability, and treatment outcome in a sample of 12 adults with primary BDD. Treatment was delivered in weekly individual sessions over 18 or 22 weeks. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-month follow-ups. At posttreatment, BDD and related symptoms (e.g., mood) were significantly improved. Treatment gains were maintained at follow-up. A relatively low drop-out rate, high patient satisfaction ratings, and patient feedback indicated that the treatment was highly acceptable to patients. To our knowledge, this represents the first test of a broadly applicable, individual psychosocial treatment for BDD.     

Brief cognitive-behavioral internet therapy for irritable bowel syndrome

While cognitive-behavioral therapy for IBS is quite effective, the limited availability of competent therapists and lack of access to treatment remain problematic. This paper reports on a small, randomized, controlled trial of a five week internet based cognitive-behavioral intervention for IBS with limited therapist feedback via e-mail. Fifty-four IBS patients were recruited via the internet and randomly assigned to either immediate treatment or a wait-list control group. Thirty-one subjects completed the post-treatment assessment. 77% of treatment completers also completed a 3-month follow-up assessment. Treatment completers experienced statistically and clinically significant declines in IBS symptoms and improvements in quality of life. Those gains were substantially maintained at follow-up. Treatment efficacy was partially mediated by reductions in the tendency to catastrophize the social and occupational implications of symptoms, suggesting that catastrophizing may be an important target for treatment.     

An open trial of cognitive-behavioral therapy for compulsive hoarding

The aim of the present study was to provide preliminary data on the efficacy of a new cognitive-behavioral treatment (CBT) for compulsive hoarding. Fourteen adults with compulsive hoarding (10 treatment completers) were seen in two specialty CBT clinics. Participants were included if they met research criteria for compulsive hoarding according to a semistructured interview, were age 18 or above, considered hoarding their main psychiatric problem, and were not receiving mental health treatment. Patients received 26 individual sessions of CBT, including frequent home visits, over a 7-12 month period between December 2003-February 2005. Primary outcome measures were the Saving Inventory-Revised (SI-R), Clutter Image Rating (CIR), and Clinician's Global Impression (CGI). Significant decreases from pre- to post-treatment were noted on the SI-R and CIR, but not the CGI-severity rating. CGI-Improvement ratings indicated that at mid-treatment, 40% (n=4) of treatment completers were rated "much improved" or "very much improved;" at post-treatment, 50% (n=5) received this rating. Adherence to homework assignments was strongly related to symptom improvement. CBT with specialized components to address problems with motivation, organizing, acquiring and removing clutter appears to be a promising intervention for compulsive hoarding, a condition traditionally thought to be resistant to treatment.     

Who is a candidate for cognitive-behavioral therapy for insomnia?

Chronic insomnia impacts 1 in 10 adults and is linked to accidents, decreased quality of life, diminished work productivity, and increased long-term risk for medical and psychiatric diseases such as diabetes and depression. Recent National Institutes of Health consensus statements and the American Academy of Sleep Medicine's Practice Parameters recommend that cognitive-behavioral therapy for insomnia (CBT-I) be considered the 1st line treatment for chronic primary insomnia. Growing research also supports the extension of CBT-I for patients with persistent insomnia occurring within the context of medical and psychiatric comorbidity. In the emerging field of behavioral sleep medicine, there has yet to be a consensus point of view about who is an appropriate candidate for CBT-I and how this determination is made. This report briefly summarizes these issues, including a discussion of potential contraindications, and provides a schematic decision-to-treat algorithm.     

Group cohesion in cognitive-behavioral group therapy for social phobia

Cognitive-behavior therapy (CBT) for Social Phobia is effective in both group and individual formats. However, the impact of group processes on treatment efficacy remains relatively unexplored. In this study we examined group cohesion ratings made by individuals at the midpoint and endpoint of CBT groups for social phobia. Symptom measures were also completed at the beginning and end of treatment. We found that cohesion ratings significantly increased over the course of the group and were associated with improvement over time in social anxiety symptoms, as well as improvement on measures of general anxiety, depression, and functional impairment. In conclusion, findings are consistent with the idea that changes in group cohesion are related to social anxiety symptom reduction and, therefore, speak to the importance of nonspecific therapeutic factors in treatment outcome.     

Sudden gains in group cognitive-behavioral therapy for panic disorder

The current study investigates sudden gains (rapid symptom reduction) in group cognitive-behavioral therapy for panic disorder. Sudden gains occurring after session 2 of treatment predicted overall symptom reduction at treatment termination and some changes in cognitive biases. Meanwhile, sudden gains occurring immediately following session 1 were not associated with symptom reduction or cognitive change. Together, this research points to the importance of examining sudden gains across the entire span of treatment, as well as the potential role of sudden gains in recovery from panic disorder.     

Group rational-emotive and cognitive-behavioral therapy.

The theory of rational-emotive therapy (RET) and of cognitive-behavioral therapy (CBT) is briefly explained and is applied to group therapy. It is shown how RET and CBT therapy groups deal with transference, countertransference, levels of group intervention, process versus content orientation, identifying underlying group process themes, here-and-now activation, working with difficult group members, activity levels of therapist and group members, and other group problems. Although they particularly concentrate on people's tendencies to construct and create their own "emotional" difficulties, RET and CBT group procedures fully acknowledge the interactions of human thoughts, feelings, and actions and active-directively employ a variety of cognitive, emotive, and behavioral group therapy techniques.     

Emotion-focused cognitive-behavioral therapy for anxious youth: A multiple-baseline evaluation

Examined the efficacy of an Emotion-focused Cognitive-Behavioral Therapy (ECBT) for six anxious youths ages 7–13 years. All participants had a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia) based on the Anxiety Disorder Interview Schedule for Children—Child and Parent versions. Children and parents reported on anxious symptomatology using the Multidimensional Anxiety Scale for Children (MASC). To assess emotion-related competencies, children were administered the Kusche Affective Interview—Revised and children and parents completed the Emotion Expression Scale for Children (EESC) and Emotion Regulation Checklist (ERC), respectively. Cases began treatment after baselines of 0, 2, or 3 weeks. At posttreatment, the majority of children demonstrated improvements in anxious symptomatology, emotion understanding and regulation skills, and overall functioning. Such improvements in emotion-related skills, in addition to anxiety, are significant given that emotional competence is a crucial component in children's adaptive social functioning and psychological adjustment. These findings provide initial support for ECBT.     

Age analysis of cognitive-behavioral group therapy for chronic pain outpatients

This study explored the effectiveness, in terms of age of the client, of a 10-week cognitive-behavioral group therapy (stress inoculation training) for chronic pain. A total of 69 outpatients between the ages of 27 and 80 (M = 52.74 years, SD = 14.40) with diverse types of chronic pain were assigned randomly to immediate or wait-list-delayed therapy. Self-report measures of pain, activities, coping, and the use of medications and other physical pain control techniques were obtained at baseline, during therapy, and at 1- and 6-month follow-up. Treatment decreased the degree to which pain interfered with activity, increased ability to cope with pain, and decreased use of some medications and other physical treatments. It had little effect on perceived pain intensity. Gains were maintained through 6-month follow-up. Age was unrelated to outcome. Stress inoculation training appears to be an effective method of ameliorating the interference of chronic pain with the daily activities of life for adults of all ages.     

A pilot study of two-day cognitive-behavioral therapy for panic disorder

The present study investigated the short-term efficacy of brief, intensive cognitive-behavioral therapy (CBT) for panic disorder (PD). The treatment involved 9h of therapist contact over two consecutive days and was developed for the purpose of delivering CBT for PD to a largely rural patient population that must travel long distances to find a treatment provider. Ten patients who elected to participate in brief, intensive CBT instead of weekly CBT were recruited from routine clinical practice in a hospital-based anxiety disorders clinic. Patients were not excluded based on the presence of agoraphobia, diagnostic comorbidity, concurrent use of PRN benzodiazepine medications, or previous nonresponse to psychotherapy for PD. Assessments conducted at pre-treatment and 1-month follow-up revealed large, clinically significant reductions in PD symptoms, anxiety sensitivity, body vigilance, and anxiety and depressive symptoms. Most patients (60%) were panic-free after treatment and evidenced normative levels of symptomatology at follow-up. The present study suggests that brief, intensive treatment may be an effective means of delivering CBT for PD.     

A cognitive-behavioral therapy for sleep-maintenance insomnia in older adults.

Older adults (3 men, 4 women, aged 55 to 68 years) with chronic sleep-maintenance insomnia were treated sequentially with relaxation therapy (RT) and then with a cognitive-behavioral therapy (CBT) specifically designed for alleviating sleep maintenance problems. Sleep diaries and an objective measure of sleep, the sleep assessment device, showed only modest improvements in measures of wake time after sleep onset, sleep efficiency, and night-to-night sleep variability following RT. However, significant improvements in these measures were observed following CBT and at a 3-month follow-up. These findings, considered in conjunction with previous reports, suggest that CBT specifically addresses factors that sustain sleep maintenance complaints. Additional trials of CBT with larger samples are warranted.