Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Comorbidity of Pediatric Obsessive–Compulsive Disorder and Anxiety Disorders: Impact on Symptom Severity and Impairment

This study explored the impact of comorbidity on symptom severity and treatment outcome in a sample of 75 pediatric Obsessive–Compulsive Disorder (OCD) patients. Forty received cognitive–behavioral therapy (CBT). Overall, 56% had a comorbid disorder. Results revealed that youth with comorbid disorders (anxiety or otherwise) endorsed significantly more anxiety symptoms than youth with OCD only. Youth with comorbidities instead of or in addition to anxiety exhibited more severe OCD symptoms than youth with OCD alone or an anxiety-only comorbidity. Youth in the comorbidities instead of or in addition to anxiety group had the poorest CBT response relative to the other groups. These results suggest that relative to those with OCD alone or with an anxiety disorder comorbidity, youth with comorbidities instead of or in addition to anxiety have a differing clinical presentation (e.g., more severe symptoms) and worse psychotherapy outcome.

Effect of a Vocationally‐Focused Brief Cognitive Behavioural Intervention on Employment‐Related Outcomes for Individuals with Mood and Anxiety Disorders

Internet-delivered cognitive behavioural therapy (CBT) can be an effective method for treating major depression, but it often works best when therapist support is provided in the form of e-mail support or telephone calls. The authors investigated whether there were any intraclass correlations within therapists when delivering CBT for major depression via the Internet. They included data from two trials involving 10 therapists treating a total of 103 patients. The results of a nested one-way model in which participants were treated as raters for different therapists indicated that measures pertaining to symptom reductions (Beck Depression Inventory, Montgomery-Åsberg Depression Rating Scale–Self Report, and Beck Anxiety Inventory) did not support a clustering of data within therapists. However, the outcome on a secondary measure of life satisfaction (Quality of Life Inventory) yielded a significant intraclass correlation coefficient for therapists (r = .24, p = .001). The authors propose that text-based treatments are less sensitive to therapist effects when it comes to the primary symptom measures, but that treatment effects not directly targeted by the specific treatment program may be more dependent on the way the support is given and by whom (therapist effect). Limitations of the study are discussed.     

Validation of Self-Report Impairment Measures for Section III Obsessive–Compulsive and Avoidant Personality Disorders

This study examined the validity of newly developed disorder-specific impairment scales (IS), modeled on the Level of Personality Functioning Scale, for obsessive–compulsive (OCPD) and avoidant (AvPD) personality disorders. The IS focused on content validity (items directly reflected the disorder-specific impairments listed in DSM-5 Section III) and severity of impairment. A community sample of 313 adults completed personality inventories indexing the DSM-5 Sections II and III diagnostic criteria for OCPD and AvPD, as well as measures of impairment in the domains of self- and interpersonal functioning. Results indicated that both impairment measures (for AvPD in particular) showed promise in their ability to measure disorder-specific impairment, demonstrating convergent validity with their respective Section II counterparts and discriminant validity with their noncorresponding Section II disorder and with each other. The pattern of relationships between scores on the IS and scores on external measures of personality functioning, however, did not indicate that it is useful to maintain a distinction between impairment in the self- and interpersonal domains, at least for AvPD and OCPD.     

An Evaluation of the Effects of Diagnostic Composition on Individual Treatment Outcome Within Transdiagnostic Cognitive–Behavioral Group Therapy for Anxiety

Recently, studies have supported the efficacy of treating anxiety disorders utilizing a transdiagnostic, or non-diagnosis-specific, framework (Erickson, D. H. (2003). Group cognitive behavioural therapy for heterogeneous anxiety disorders. Cognitive Behaviour Therapy, 32, 179–186; Garcia, M. S. (2004). Effectiveness of cognitive-behavioural group therapy in patients with anxiety disorders. Psychology in Spain, 8, 89–97; Norton, P. J., & Hope, D. A. (2005). Preliminary evaluation of a broad-spectrum cognitive-behavioral group therapy for anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 36, 79–97). Transdiagnostic group treatment packages focus on the common aspects inherent across the anxiety disorders such as behavioral and cognitive avoidance, and faulty cognitive appraisals of threat potential or meaning (Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230). Although research supports the overall efficacy of transdiagnostic cognitive behavior therapy (CBT) for anxiety disorders (Norton, P. J., & Philipp, L. M. (2008). Transdiagnostic approaches to the treatment of anxiety disorders: A quantitative review. Psychotherapy: Theory, Research, Practice and Training, 45, 214–226), the effect of diagnostically mixed group composition on individual outcomes is less clear. This study investigated the relationship between group composition and treatment outcome within diagnostically heterogeneous groups with the purpose of determining if diagnostic heterogeneity differentially impacted treatment outcome for 84 individuals during a 12-week transdiagnostic cognitive–behavioral group anxiety treatment program (Norton, P. J. (2012a). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford). The diagnostic makeup of the treatment group was examined at the beginning of treatment and at the end of treatment, and the results indicated that the diagnostic makeup of the treatment group had no significant impact on individual treatment outcome. These findings have direct implications for the delivery of transdiagnostic treatments, and are discussed in terms of their global implications for the transdiagnostic approach to the treatment of anxiety disorders.     

The “Brightening” Effect: Reactions to Positive Events in the Daily Lives of Individuals With Major Depressive Disorder and Generalized Anxiety Disorder

Depressed individuals are less reactive than healthy individuals to positive stimuli in the laboratory, but accumulating evidence suggests that they are more emotionally reactive to positive events in their daily lives. The present study probed the boundaries of this curious “mood brightening” effect and investigated its specificity to major depressive disorder (MDD) vis-à-vis generalized anxiety disorder (GAD), its closest boundary condition. We used ecological momentary assessment to measure reactions to positive events over one week in individuals with MDD (n = 38), GAD (n = 36), comorbid MDD-GAD (n = 38), and no psychopathology (n = 33). Depressed individuals responded to positive events with larger changes in affect, cognition, reported withdrawal (but not approach) behavior, and symptoms than healthy controls. More severe depression assessed before the sampling week predicted greater brightening. Altered reactivity to positive events was relatively specific to MDD when compared with GAD, similar to patterns found for other positive emotional processes. The robustness, scope, and relative specificity of the brightening effect highlights the need to resolve conflicting findings across laboratory and non-laboratory studies to advance understanding of altered reactivity in emotional disorders.     

Immigrant Families’ Perception of the Causes,First Manifestations,and Treatment of Autism Spectrum Disorder

Compared to families from their host country, families from immigrant backgrounds who have a child with autism spectrum disorder (ASD) tend to experience greater difficulties in accessing, using, and complying with intervention services for their child. This disparity may be partially accounted for by cultural differences in how families perceive the causes and symptoms of ASD as well as their treatment priorities. The present study sought to document these perceptions in immigrant families living in a Canadian city. Forty-five parents from Latin America, Africa, Western and Eastern Europe, the Caribbean, East Asia, and the Middle East participated in a semi-structured interview. These data were examined qualitatively through thematic analysis to first document all parents’ perceptions, then to contrast mothers’ and fathers’ responses, and finally to examine common themes as a function of country of origin. The most frequently mentioned causes of ASD were environmental factors such as vaccines and diet. Moreover, some participants did not know the cause of their child’s ASD. The majority of parents cited the absence of speech as one of the first symptoms noted in their child. Priorities for intervention varied: mothers tended to prioritize speech therapy, whereas fathers favored support in school. Taken as a whole, these findings highlight the need to implement informational programs for these families.     

Effects of the KiVa Anti-bullying Program on Adolescents’ Depression, Anxiety, and Perception of Peers

The present study investigated the effects of the KiVa antibullying program on students’ anxiety, depression, and perception of peers in Grades 4–6. Furthermore, it was investigated whether reductions in peer-reported victimization predicted changes in these outcome variables. The study participants included 7,741 students from 78 schools who were randomly assigned to either intervention or control condition, and the program effects were tested with structural equation modeling. A cross-lagged panel model suggested that the KiVa program is effective for reducing students’ internalizing problems and improving their peer-group perceptions. Finally, changes in anxiety, depression, and positive peer perceptions were found to be predicted by reductions in victimization. Implications of the findings and future directions for research are discussed.     

Response to Nadler's Commentary on Arch and Craske's (2011) “Addressing Relapse in Cognitive Behavioral Therapy for Panic Disorder: Methods for Optimizing Long-Term Treatment Outcomes”

Nadler (this issue), in his commentary of our article, “Addressing Relapse in Cognitive Behavioral Therapy for Panic Disorder: Methods for Optimizing Long-Term Treatment Outcomes” (Arch & Craske, 2011), argues that we misrepresent the role of panic attacks within learning theory and overlook cognitive treatment targets. He presents several case studies that he argues demonstrate how to target fears regarding the consequences of panic itself. We appreciate his raising these issues and creating the opportunity for discussion. We take issue, however, with two aspects of his commentary. First, his case studies beautifully illustrate a central point we make in our article regarding the importance of violating patient expectancies, and as such, exemplify our recommendations rather than illustrate what we may have overlooked. Second, Nadler's argument that we misidentify the role of panic attacks contradicts itself in ways that reveal his misunderstanding of the complexity of panic attacks from the perspective of learning theory (e.g., Bouton, Mineka, & Barlow, 2001), and disregard an important point we make in our article.     

The “Perseverant” Personality: A Preattachment Perspective on the Etiology and Evolution of Binge/Purge Eating Disorders

The author integrates “psycho-digestive” metaphor with contemporary relational perspectives and developmental research to propose a way of thinking about the etiology and evolution of binge/purge eating disorders—including “purging anorexia,” bulimia, and “yo-yo” binge/dieting—and the personality organization that may underlie them. Focusing on the unifying, cyclical nature of these disorders, the author hypothesizes that an early-developing, fear-based form of somatopsychic perseveration may be set in motion from the beginning of life when a nursing infant is unable to achieve a psychic connection with a physically present and feeding (m)other. Without intervention, such a preattachment failure in (m)other/infant synchrony would inevitably impact all subsequent development. The author proposes that it may also lay the foundation for a uniquely intertwined somatopsychic personality organization—what she calls a “perseverant” personality—that fosters the development of binge/purge eating disorders. A perseverant personality is defined as a solitary and circular mode of being, thinking, and relating that is organized around a sustained physiological and psychological reliance on the feeding as a mode of thought-processing and affect regulation.     

Settling on what we are: The central place of the sense‐of‐self in education,and the implication of the concepts of the teleon and telentropy for the development of the sense‐of‐self

The purpose of this article is to illustrate the centrality of the development of a person's sense‐of‐self in his or her personal growth, and so to justify why educators should deliberately focus the attention of learners on the development of their own senses‐of‐self.

We describe the sense‐of‐self as a person's working hypothesis of what he or she is, as a functioning being. (This is in contrast to the notion of self‐concept, which is composed of the beliefs and evaluations that one has about oneself as a person in a social context.)

To illustrate the centrality of the sense‐of‐self we introduce two associated concepts—the teleon and telentropy. Teleons are “purposeful action patterns,” which may be regarded as the defining characteristic of any living system, including human beings.

Telentropy is similar to entropy (encountered in physics and chemistry), but instead of dealing with the level of disorder in externally described systems, it represents the level of informational confusion existing within an organism regarding its own true nature.

We discuss the implications of the concepts “teleon” and “telentropy” for a person's educability, using examples from daily life and educational institutions.

We provide a number of suggestions for the revising of educational practice to foster the development of the sense‐of‐self in learners. This we demonstrate to have potentially beneficial effects of the general stress levels of society.     

The Use of Stimulant Medication and Behavioral Interventions for the Treatment of Attention Deficit Hyperactivity Disorder: A Survey of Parents’ Knowledge, Attitudes, and Experiences

We examined parents’ knowledge, attitudes, and information sources regarding Attention-Deficit/Hyperactivity Disorder (ADHD), including treatment with stimulant medication and behavioral interventions. Responses from parents with a child diagnosed with ADHD and parents without a child diagnosed with ADHD were also compared. Participants consisted of 146 parents of elementary age children from Wisconsin. The surveyed parents were aware of issues surrounding ADHD and the use of stimulant medication, but there were several areas where they possessed inaccurate or incomplete factual information. Parents who had a child diagnosed with ADHD rated the effects of stimulant medication more positively and side effects as less severe than other parents. They also rated behavioral interventions as less effective on all questions. Implications of the study are discussed.     

Testing the Effectiveness of Brief Behavioral Activation Treatment for Depression—Revised: Changes in Depression,Anxiety, Dysfunctional Attitudes,and Mindfulness

We tested the effectiveness of Brief Behavioral Activation Treatment for Depression-Revised (BATD-R), and its impact on secondary outcomes: anxiety, dysfunctional attitudes, and mindfulness. It was expected that individuals who completed BATD-R would exhibit decreased depression, anxiety, and dysfunctional attitudes, as well as increased mindfulness. A sample of adults with depression (n?=?42) was recruited to complete the 10-week treatment. A healthy control group (n?=?38) was included for comparison. Outcomes (depression, anxiety, dysfunctional attitudes, and mindfulness) were assessed at pre-treatment, post-treatment or 10 weeks for the healthy control group, and three-month follow-up. At pre-treatment, the clinical group reported greater depression, anxiety, and dysfunctional attitudes, and less mindfulness than the healthy control group. At post-treatment, the clinical group reported decreased depressive symptoms, trait anxiety, and dysfunctional attitudes, and increased mindfulness, compared to pre-treatment. The control group did not exhibit changes across the 10 weeks. Clinical and healthy control group post-treatment scores did not differ. At three-month follow-up, the clinical group reported a slight increase in depressive symptoms from post-treatment, but still maintained lower depressive symptoms than pre-treatment. The clinical group maintained treatment gains in dysfunctional attitudes, and mindfulness. Results support the effectiveness of BATD-R and suggest BATD-R may influence dysfunctional attitudes and mindfulness.

     

Client Versus Clinicians’ Standards of Clinically Meaningful Change and the Effects of Treatment Expectations on Therapeutic Outcomes in Individuals With Posttraumatic Stress Disorder

There is limited research on the concordance between client perceptions and clinician standards of the degree of symptom change required to achieve meaningful therapeutic improvement. This was investigated in an adult sample (N = 147) who received trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder (PTSD). We examined whether clients’ benchmarks of change were related to actual outcomes and the relationship between client expectations and their treatment outcomes. Clients completed measures indexing the level of symptom reduction required (in their view) to reflect a benefit or recovery from treatment and treatment expectations. Actual PTSD severity was indexed pre- and posttreatment via self-report and clinician-administered interview. Results demonstrated that the amount of change clients said they required to experience a benefit or recovery was significantly larger than typical clinical research standards. Nonetheless, the majority of client benchmarks of change (79.7–81.8%) were consistent with clinical research standards of what constitutes benefit or recovery. Client benchmarks were generally positively correlated with their actual outcomes. Clients’ belief that treatment would be successful was associated with greater reductions in PTSD symptoms. These findings provide preliminary evidence that the standards used to determine clinically significant change are somewhat consistent with clients’ own perceptions of required symptom change.     

Personality traits,gender differences and symptoms of anhedonia: What does the Hospital Anxiety and Depression Scale (HADS) measure in nonclinical settings?

In healthy populations men report more depressive symptoms than women when depression is measured by the Hospital Anxiety and Depression Scale (HADS). This study aims to investigate the role of neuroticism and extroversion in symptom reporting by men and women and whether anhedonia can explain these reversed gender differences in depression observed when using HADS. HADS, Positive and Negative Affect Schedule (PANAS) and NEO Five Factor Inventory (NEO FFI) were administered twice to a sample of university students. Number of subjects at T1 was 372 and 160 at T2, measured two months apart. Men had a higher average score on depressive symptoms measured by HADS‐D compared to women (p = 0.029). Women scored higher than men on HADS‐A (p = 0.012), neuroticism (p < 0.001) and PANAS‐negative affect (p < 0.029). No significant gender differences were observed in extroversion and positive affect. Test‐retest stabilities on HADS‐A and HADS‐D were high. Neuroticism predicted HADS‐A at Time 2. Gender, extroversion, and neuroticism predicted HADS‐D at Time 2. The anhedonic content in HADS may be a plausible explanation of reversed gender differences in the HADS depression scale. HADS‐D represents a specific anhedonic subtype of depression where symptom reporting reflects dispositional tendencies related specifically to extroversion.     

Culture,Influence, and the “I-ness” of Me: Commentary on Papers by Susan Bodnar,Gary B. Walls,and Steven Botticelli

The undeniable realities of globalization at the dawn of the 21st century have brought the United States and its citizens to the startling realization that we must grapple politically, economically, and culturally with the wide range of diversity existing within and without our borders. As greater numbers of culturally diverse persons are now represented in their caseloads, psychoanalysts are also forced to examine the relevance of psychoanalytic theories and practice in meeting their needs. The author discusses three papers that propose overlapping and differing opinions as to the function of psychoanalysis in the lives of culturally diverse patients, and its capacity to influence more public, social and political change. This paper questions the meaning of the term “culture.” It attempts to tease apart the nature of memory and dissociation among those who suffer intergenerational trauma because of their membership in particular cultural or ethnic groups. Also addressed is the extent to which, as described by social constructivist theory, self is entirely a socially constructed phenomenon. The author questions the extent to which, alternatively, “self,” possessed of will, agency and authority, exists in a mutually influencing relationship with the social world.     

A Missing Dimension of European Influence on English Protestantism: The Heidelberg Catechism and the Church of England, 1563–1663

ABSTRACT

While historians of the early-modern Church of England have become familiar with the influence exerted upon it by Genevan and Zurich theologians, the impact of Heidelberg University and the Rhineland Palatinate was arguably equally important and has hitherto been neglected. That influence is charted here through the impact of the Heidelberg Catechism and the commentaries upon it by the Heidelberg divines Jeremias Bastingius and especially Zacharias Ursinus. While these were almost ubiquitous in the late-Elizabethan and Jacobean churches, Heidelberg divinity nevertheless came increasingly to be viewed with suspicion by churchmen under Charles I because of its alleged (and not entirely illusory) links to puritanism. It is argued here that with the creation of the Westminster Greater and Lesser Catechisms, the Heidelberg Catechism and commentaries on it no longer served a useful purpose even for puritans, and that later churchmen were unfamiliar with the influence that it had exerted in the recent past.     

Is collective intelligence (mostly) the General Factor of Personality? A comment on Woolley,Chabris, Pentland,Hashmi and Malone (2010)

A recent paper [Woolley, Chabris, Pentland, Hashmi, & Malone. (2010). Evidence for a collective intelligence factor in the performance of human groups. Science, 330, 686–688] presents evidence for the existence of a general collective intelligence factor, ‘c,’ which may undergird performance on a variety of group tasks. This factor appears to be only modestly correlated with the average and maximum intelligence of group members whilst being more strongly correlated with the average social sensitivity of group members, a tendency for several members to contribute to group conversations rather than a small number dominating the discussions, and the proportion of females in the group. An alternative hypothesis, not considered by the authors, is that the General Factor of Personality (GFP) is able to account for the correlates of c observed, and that c may therefore be primarily a group level manifestation of the GFP, with a subordinate contribution from general intelligence. We maintain that a consideration of the GFP and its correlates as potential confounding variables would be of considerable benefit to future research into collective intelligence.