The treatment of hypochondriasis: exposure plus response prevention vs cognitive therapy

In this study (1) exposure in vivo plus response prevention, (2) cognitive therapy and (3) a waiting-list control condition were compared on their efficacy on the treatment of hypochondriasis. Seventy-eight patients with a DSM-IV diagnosis of hypochondriasis were randomly assigned to one of these conditions. Patients in both active treatment conditions improved significantly on all the measures, whereas the patients in the waiting-list control condition did not improve. The improvements were clinically significant. Exposure in vivo plus response prevention and cognitive therapy were equally effective. The improvements were maintained at the 7 months follow up.     

The effects of prolonged exposure to phobic situations upon agoraphobic patients treated in groups

Nineteen female agoraphobic patients were treated by exposure to imaginal and real phobic stimulation in groups. There were three groups, including 7, 5 and 6 patients respectively, and each group received 9 hr of treatment spread over three sessions. The first two treatment hours of the first two sessions were arranged as a crossover design, patients being randomly allocated at the first session to imaginal or reality treatment for an hour followed by the other treatment for an hour, and receiving the treatments in reverse order at the second session. On both occasions there was a third hour of treatment after 1 hr unstructured group discussion over lunch. Psychological and behavioural measures were made before and after each part of treatment, and at follow-up 5 months after treatment.

Patients were significantly helped by this procedure. Practice sessions were associated with much more improvement than imaginal ones, and there was also an order effect, the first treatment received on each treatment day being more effective than the second. Group discussion over lunch did not improve the patient's phobias. The implications of these findings are discussed.     

Treatment of Hypochondriasis with Exposure

Cognitive-behavioral therapy has been shown to be an effective treatment for hypochondriasis. An important element of most of the empirically validated CBT protocols for this problem is exposure. Various approaches to exposure may be useful including in vivo exposure to health and death-related situations, interoceptive exposure to feared bodily symptoms, and imaginal exposure to symptoms and feared illnesses that are difficult to reproduce in real life. Strategies for enhancing the effectiveness of exposure, such as response prevention, cognitive reappraisal, and acceptance, are also discussed. Practical suggestions for implementation of exposure with this population are provided.     

Cue exposure and response prevention with alcoholics: a controlled trial

Ten severely alcohol-dependent subjects were divided into two groups, one of which received only 6 sessions of in-vivo cue exposure and response prevention and the other of which received 6 sessions of imaginal cue exposure, followed by 6 sessions of in-vivo cue exposure and response prevention. The in-vivo cue exposure produced significant decrements on behavioural and subjective measures for both experimental groups on Desire to Drink and Difficulty to Resist Alcohol. Imaginal cue exposure produced trivial changes on these measures. The implications for both theory and practice are discussed.     

Do self-statements enhance the effectiveness of virtual reality exposure therapy? A comparative evaluation in acrophobia.

There is a clear need for more detailed analysis of the role of cognitive self-statements in virtual reality exposure therapy (VRET). To date, no research on this topic has been done. The primary aim of this study was to investigate whether coping self-statements would enhance the effectiveness of VRET. In a randomized crossover design, 26 patients with acrophobia (DSM-IV diagnosis of specific phobia) were randomly assigned to two sessions of VRET followed by two sessions of VRET plus coping self-statements, or the other way around: first two sessions of VRET plus coping self-statements followed by two sessions of VRET. Results showed that VRET, regardless of addition of coping self-statements, decreased anxiety of heights, decreased avoidance of height situations, and improved attitudes towards heights. However, at 6-month follow-up, most gains during treatment were not fully retained.     

Manualisierte psycho- dynamisch-interaktionelle Gruppentherapie

20–40% of the patients in general practices, as well as in different departments in hospitals, suffer from somatoform diseases. 70% of these patients have pain as their main complaint. The present treatment manual is the first disease-specific, psychodynamically oriented group-treatment for these patients. Compared to other psychodynamic treatment settings this therapy is a short and cost-effective approach to treat these patients. It is based on a so-called psychodynamic-interactional group psychotherapy and focuses on disease-specific parts of the problem, as well as on psychic and interpersonal problems resulting from adverse childhood experiences. Over a period of six months 7 to 9 patients are treated in 40 group therapy sessions. Two weekly meetings are held during the first four months and one weekly session is held during the last two months. The concept contains psycho-educational elements, the discussion and formulation of individual treatment goals as well as work with a psychodynamic and relationship- oriented treatment focus. The efficacy of this concept is planned to be evaluated in a randomised, controlled clinical trial, including two treatment conditions and one control condition. One of the two treatment conditions is, beneath the concept already discussed, a cognitive behavioural group therapy.     

Brief cognitive therapy for social phobia: a case series

Social phobia is a common and disabling anxiety disorder. The most effective psychological treatments for social phobia are cognitive therapy and exposure. However, the degree of improvement across these treatments is variable, and their implementation is costly and time-consuming. This study aimed to conduct a preliminary clinical evaluation of the effectiveness of a brief, new form of cognitive therapy based on a recent cognitive model of social phobia. Six consecutively referred patients with social phobia were treated using established single case series methodology. Brief cognitive therapy was effective with all patients demonstrating clinically significant improvements in all measures. Treatment gains were maintained at follow-up. The mean number of treatment sessions delivered was 5.5 and improvements compare favourably with previous treatment studies. Brief cognitive therapy for social phobia appears promising and it is potentially cost-effective. Future randomised and controlled evaluations of this brief treatment are warranted.     

A comparison of two psychological treatments for bulimia nervosa: Implications for models of maintenance

In an effort to elucidate the role of cognitive factors in the maintenance of bulimia nervosa, the efficacy of two psychological treatments was examined in a randomised control trial: cognitive behaviour therapy in the absence of explicit exposure instructions was compared with exposure and response prevention treatment in the absence of cognitive restructuring procedures. In the short term both treatments were successful at effecting substantial improvement in both the specific and the non-specific psychopathology of the disorder. However, at a one year follow up, whilst improvements were well maintained for those who had received the cognitive-behavioural treatment, virtually all of those who had responded to the purely behavioural treatment had relapsed. This provides some support for the cognitive model of the maintenance of bulimia nervosa. Nevertheless, the two treatment groups could not be distinguished on post-treatment measures of cognitive disturbance and neither was it the case that residual levels of cognitive disturbance, as assessed, predicted relapse. This may suggest that the level at which the necessary cognitive change takes place may not be accessible by conventional assessment procedures.     

The process of cognitive therapy: The first dysfunctional thought changes less than the last one

An observant cognitive therapy patient reported that the first dysfunctional thought elicited and treated in homework sessions was more resistant to change than later distorted thoughts. To determine whether this was due to the fact that this thought was elicited first, or to the fact that it was treated first, systematic data were collected from 9 patients in 48 sessions of cognitive therapy. In half of these sessions, dysfunctional thoughts were treated in the order they were elicited; in half of the sessions, they were treated in the reverse order. Results showed that the first dysfunctional thought elicited changed least; there was no effect of order of treatment. Several possible explanations of this finding are offered.     

The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

Cognitive therapy with obsessive-compulsive disorder: a comparative evaluation.

After a 4-week waiting period 21 obsessive-compulsives were randomly allocated to two treatment conditions (1) Rational Emotive Therapy (RET) and (2) exposure in vivo. RET consisted of analysing irrational thoughts; exposure in vivo was self-controlled. After six sessions and another 4-week waiting period all patients received six sessions of exposure in vivo. Both treatments resulted in significant improvement on anxiety/discomfort, Maudsley Obsessional Compulsive Inventory, and Dutch Obsessional Compulsive Questionnaire and in a reduction of scores on the Irrational Beliefs Test. Results were maintained to a follow-up 6 months later. No significant differences were found between the two conditions.     

Social phobia: individual response patterns and the effects of behavioral and cognitive interventions

In the present study, the role of individual response patterns in the treatment of social phobic patients was investigated. Seventy-four patients were diagnosed as social phobics. On the basis of extreme scores on a behavioral test (the Simulated Social Interaction Test) and on a cognitive measure (the Rational Behavior Inventory), the response patterns of 39 patients were analyzed, and the patients themselves were classified as either 'behavioral reactors' or 'cognitive reactors'. Half of the patients with each response pattern received a behavioral focused treatment, i.e. social skills training (SST), while the other half received a cognitive oriented treatment, i.e. rational emotive therapy (RET). Patients received group therapy in eight weekly sessions. Within-group differences showed a considerable improvement in all treatment groups. Between-group differences failed to lend support to the hypothesis that treatment that fits a response pattern (i.e. SST for behavioral reactors and RET for cognitive reactors) will result in a greater improvement than one that does not.     

Telephone-administered cognitive behavior therapy for obsessive-compulsive disorder

Exposure with response prevention and cognitive behavior therapy are widely recognized as effective treatments for obsessive-compulsive disorder. Unfortunately, many people with obsessive-compulsive disorder--particularly those living in rural areas--do not have access to therapists providing these treatments. Accordingly, we investigated the efficacy of telephone-administered cognitive behavior therapy for obsessive-compulsive disorder. Two open trials are reported, for a total of 33 people with obsessive-compulsive disorder (without major depression). The first trial consisted of 12 weeks on a waiting list followed by 12 weeks of treatment (delayed treatment). The second trial consisted of 12 weeks of immediate treatment. Obsessive-compulsive symptoms did not change during the waiting period. Symptoms declined from pre- to post-treatment, with gains maintained at 12-week follow-up. For the pooled sample our pre-to-post-treatment effect size was as large or larger than those obtained in other studies of reduced contact treatment, and similar to those of face-to-face exposure with response prevention. Our proportion of treatment dropouts tended to be lower than those of other reduced contact interventions. The results suggest that telephone-administered cognitive behavior therapy is effective and well-tolerated, at least for people with obsessive-compulsive disorder without major depression. It remains to be seen whether this treatment is safe and effective when comorbid major depression is present.     

The effect of concordance in the treatment of clients with dental anxiety.

This study followed from an earlier case study in which an agoraphobic client was treated daily for a period of four weeks by in vivo exposure. Ratings of his perceived anxiety responses in the behavioural, cognitive, and physiological systems were monitored throughout treatment. Concordance between these ratings was associated with positive outcome. This study was an attempt to replicate some of these findings. A group programme involving four sessions in which clients were taught anxiety management skills, exposed in imagination to situations relating, to dentistry, and given homework assignments was carried out with clients presenting with disproportionate dental anxiety. The subjects were obtained by means of local newspaper and radio advertisements and randomly assigned to a massed or spaced treatment condition. It was predicted that the massed condition involving shorter intersession intervals would be superior at producing habituation and concordance than the spaced condition. The results failed to show differences between the massed and spaced treatment condition with regard to concordance and outcome. However, it was confirmed, once more, that concordance between the three modes of anxiety responding was positively related to outcome.     

The potential role of state-dependent learning in cognitive therapy with spider phobics

Investigated the potential role of state-dependent learning in cognitive therapy with spider phobics. It was hypothesized that one strategy for increasing the effectiveness of cognitive therapy for anxiety would be to induce anxiety in subjects while they were learning the cognitive restructuring principles (i.e., during treatment). Thirty-two undergraduate volunteers were randomly assigned to one of six experimental conditions. Subjects in the five treatment conditions (the sixth was a no-treatment control condition) met for three sessions of cognitive restructuring,in vivo exposure, or a facts lecture (i.e., the placebo group). Results indicated that when working with spider phobics, three sessions of cognitive restructuring,in vivo exposure, or a facts lecture resulted in equal effectiveness immediately following treatment, but are more effective than no-treatment at all.     

Telephone-Administered Cognitive Behavior Therapy for Obsessive-Compulsive Disorder

Exposure with response prevention and cognitive behavior therapy are widely recognized as effective treatments for obsessive-compulsive disorder. Unfortunately, many people with obsessive-compulsive disorder - particularly those living in rural areas - do not have access to therapists providing these treatments. Accordingly, we investigated the efficacy of telephone-administered cognitive behavior therapy for obsessive-compulsive disorder. Two open trials are reported, for a total of 33 people with obsessive-compulsive disorder (without major depression). The first trial consisted of 12 weeks on a waiting list followed by 12 weeks of treatment (delayed treatment). The second trial consisted of 12 weeks of immediate treatment. Obsessive-compulsive symptoms did not change during the waiting period. Symptoms declined from pre- to post-treatment, with gains maintained at 12-week follow-up. For the pooled sample our pre-to-post-treatment effect size was as large or larger than those obtained in other studies of reduced contact treatment, and similar to those of face-to-face exposure with response prevention. Our proportion of treatment dropouts tended to be lower than those of other reduced contact interventions. The results suggest that telephone-administered cognitive behavior therapy is effective and well-tolerated, at least for people with obsessive-compulsive disorder without major depression. It remains to be seen whether this treatment is safe and effective when comorbid major depression is present.     

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.     

Cue-exposure vs self-control in the treatment of binge eating: a pilot study.

From a recent theory on the learned nature of craving responses and binge eating, it follows that craving will extinguish when the CS-US bond is broken by prolonged exposure to the cues predicting excessive food intake with response prevention. The present authors treated six obese bulimics with cue exposure and response prevention. Six other patients learned to avoid or escape the binge-related cues with the aid of self control techniques. Although both treatments appeared to be effective in reducing the binge frequency, a most remarkable finding of the present study is that all patients treated by cue exposure were abstinent, directly after treatment and during the 1 yr follow-up. In contrast to the 100% binge-free subjects treated by cue exposure, self control techniques and relapse prevention led to abstinence in merely 33% of the subjects.     

Experimental modification of beliefs in obsessive-compulsive disorder: a test of the metacognitive model

Metacognitive beliefs about the threatening meaning and significance of intrusions are fundamental to the development and maintenance of obsessive-compulsive disorder (OCD) in the metacognitive model (Cognitive therapy of anxiety disorders: a practice manual and conceptual guide, Chichester, UK, Wiley, 1997; Emotional disorders and metacognition: innovative cognitive therapy, Chichester, UK, Wiley, 2000). This predicts that reductions in metacognitive beliefs about intrusions will result in decreased anxiety and compulsions. It was hypothesized that brief (5min) exposure and response prevention configured as a behavioural experiment to challenge metacognitive beliefs would lead to reductions in anxiety, thought fusion beliefs and the urge to neutralize. Furthermore, these reductions would be greater than the effects observed in the same exposure and response prevention task, accompanied by a habituation rationale. The results were consistent with the hypotheses. The clinical implications for the treatment of OCD are discussed.