Does neuroscience hold promise for the further development of behavior therapy? The case of emotional change after exposure in anxiety and depression

Over the last few years, the integration of biological and psychological models has become increasingly important in clinical psychology. This paper presents a neurobiological framework for exploring how neuroscience research may be valuable in the context of new developments in behavior therapy. The importance of the cortical-subcortical circuitry of emotion processing for investigating the working mechanisms of exposure therapy is illustrated by current neuroimaging research. The implication is that during exposure therapy the focus of attention must be fully directed towards the emotional content of the threatening situation to facilitate prefrontal control over the amygdala and that new contextual information, of emotional salience, must be added to create inhibitory projections from the hippocampus. In addition, some possible mechanisms of action for different therapeutic approaches to both anxiety and depression and the role of neuroimaging techniques in predicting treatment outcome are discussed.     

Does enhanced cognitive behaviour therapy for eating disorders improve quality of life?

Quality of life (QOL) is the degree of enjoyment and satisfaction experienced in life, and embraces emotional well-being, physical health, economic and living circumstances, and work satisfaction. QOL recovery with eating disorder treatment has received sparse attention, and until now, no study has investigated QOL recovery with enhanced cognitive behaviour therapy (CBT-E). Patients (n?=?196) admitted to a specialist eating disorders outpatient programme and receiving CBT-E completed measures of QOL, eating disorder psychopathology, depression, anxiety and self-esteem, before and after treatment. QOL at intake was compared with community norms, and QOL below the norm was predicted from sociodemographic and clinical correlates with logistic regression. Baseline QOL below the norm was associated with depression and anxiety Axis I comorbidity, and severity of depressive symptoms. Predictors of post-treatment QOL were baseline QOL and level of depressive symptoms and self-esteem at post-treatment. CBT-E was associated with gains in QOL over the course of treatment, in addition to eating disorder symptom relief. Copyright ? 2012 John Wiley & Sons, Ltd and Eating Disorders Association.     

Does the level at which cognitive change occurs change with age?

Increased age in adulthood is associated with systematically more negative cognitive change, but relatively little is known about the nature of change at different ages. The present study capitalized on the hierarchical structure of cognitive abilities to investigate possible age differences in the level at which change operates. Reductions in the longitudinal associations between test scores when across-time relations were specified at different levels in the hierarchical structure were used to infer contributions to change from the level of abilities and from the level of a general factor. Although the pattern of influences varied across different cognitive abilities, the results revealed little or no age differences in the relative contributions to change from different levels in the hierarchy.     

Increased skills usage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy for depression and anxiety: a randomised controlled trial

Cognitive–behavioural therapy (CBT) is an effective treatment for clinical and subclinical symptoms of depression and general anxiety, and increases life satisfaction. Patients’ usage of CBT skills is a core aspect of treatment but there is insufficient empirical evidence suggesting that skills usage behaviours are a mechanism of clinical change. This study investigated if an internet-delivered CBT (iCBT) intervention increased the frequency of CBT skills usage behaviours and if this statistically mediated reductions in symptoms and increased life satisfaction. A two-group randomised controlled trial was conducted comparing internet-delivered CBT (n = 65) with a waitlist control group (n = 75). Participants were individuals experiencing clinically significant symptoms of depression or general anxiety. Mixed-linear models analyses revealed that the treatment group reported a significantly higher frequency of skills usage, lower symptoms, and higher life satisfaction by the end of treatment compared with the control group. Results from bootstrapping mediation analyses revealed that the increased skills usage behaviours statistically mediated symptom reductions and increased life satisfaction. Although skills usage and symptom outcomes were assessed concurrently, these findings support the notion that iCBT increases the frequency of skills usage behaviours and suggest that this may be an important mechanism of change.     

Does family therapy produce change? an overview of outcome studies

Summary Families were randomly assigned to one of two forms of conjoint marital therapy: an insight-oriented treatment (n=10) or a problem-solving intervention (n=10.). The results on self-report measures of family functioning indicate that the problem-solving intervention produced more favorable changes after three months. However on long-term follow-up after a year, this more positive effect did not apparently persist, since the insight treatment group reported better results. Experienced therapists did better than inexperienced therapists in the insight treatment condition, but level of experience did not make a difference in the problem-solving intervention. A group of eight families who dropped out of the insight treatment group provided data on correlates of premature termination. Several of the practical obstacles to implementing an experimental design in a clinic setting are illustrated by the research.As we develop more sophisticated methodology, we hope that is the near future family therapy researchers will be better able to state which type of approach is more effective for whom and under what circumstances. A review of current studies of family therapy outcome research indicates that family therapy seems to be as effective as individual psychological treatment.     

A randomized pilot study of motivation enhancement therapy to increase utilization of cognitive–behavioral therapy for social anxiety

Despite the efficacy of cognitive–behavioral therapy (CBT), most socially anxious individuals do not seek treatment or seek treatment only after many years of suffering. This study evaluated the efficacy of a three-session motivation enhancement therapy (MET) designed to increase CBT utilization among socially anxious individuals. Twenty-seven non-treatment-seeking socially anxious individuals (92.6% met current DSM-IV criteria for social anxiety disorder) were randomly assigned to either MET for CBT (n = 12) or a control condition (n = 15). The primary outcome was attendance at first CBT appointment. Secondary outcomes included openness to therapist contact and willingness to schedule a CBT appointment. After the intervention, seven of the 12 (58.3%) participants in the MET condition attended a CBT appointment compared to two of 15 (13.3%) control participants. Eight of 11 (72.7%) participants in the MET condition indicated they would like a CBT therapist to contact them compared to four of 12 (33.3%) controls. Further, willingness to schedule a CBT appointment increased at a significantly greater rate in the MET condition. Results suggest MET for CBT may be a time-efficient means to increase CBT utilization among socially anxious individuals.     

Why worry? The cognitive function of anxiety

The phenomenon of worry is considered to arise from cognitive processes involved in anxiety, that serve to maintain high levels of vigilance for personal danger. Rather than rely on self-report alone, the research described here draws on information processing methodology, to investigate this hypothesized cognitive function. Evidence is summarized to show that anxious subjects selectively attend to threatening information, and interpret ambiguous events in a relatively threatening way. However, the evidence on memory suggests that although such information may be easily activated, it is not necessarily more accessible. The allocation of attentional priority to threatening information is seen as a characteristic of anxious (rather than depressed) mood, while the ease with which this processing mode is adopted may underlie trait anxiety and vulnerability to anxiety disorders.     

Learning to re-appraise the self during video feedback for social anxiety: Does depth of processing matter?

Video feedback (VF) with cognitive preparation (CP) has been widely integrated into cognitive-behavioral therapy (CBT) protocols for social anxiety disorder (SAD) due to its presumed efficacy in improving negative self-perception. However, previous experimental studies have demonstrated that improvements in negative self-perception via VF + CP do not typically facilitate anxiety reduction during subsequent social interactions - a troubling finding for proponents of cognitive models of social anxiety. We examined whether VF + CP could be optimized to enhance participants’ processing of corrective self-related information through the addition of a post-VF cognitive review (CR). Sixty-eight socially anxious individuals were randomly assigned to perform two public speeches in one of the following conditions: a) exposure alone (EXP); b) CP + VF; and c) CP + VF + CR. Those in the CP + VF + CR condition demonstrated marginally significant reductions in anxiety from speech 1 to speech 2 relative to those who received EXP - an improvement not shown for those in the CP + VF condition. Furthermore, only those who received CP + VF + CR demonstrated significant improvements in self-perception and performance expectations relative to EXP. Decreases in anxiety among participants who received CP + VF + CR relative to EXP were fully mediated by improvements in self-perception. Implications are discussed in the context of cognitive models of social anxiety and mechanisms of exposure-based learning.     

Is cognitive behaviour therapy for chronic fatigue syndrome also effective for pain symptoms?

Patients with chronic fatigue syndrome (CFS) frequently report chronic pain symptoms. Cognitive behavioural therapy (CBT) for CFS results in a reduction of fatigue, but is not aimed at pain symptoms. In this study, we tested the hypothesis that a successful treatment of CFS can also lead to a reduction of pain. The second objective was to explore possible mechanisms of changes in pain. The third objective was to assess the predictive value of pain for treatment outcome. Data from two previous CBT studies were used, one of adult CFS patients (n=96) and one of adolescent CFS patients (n=32). Pain severity was assessed with a daily self-observation list at baseline and post-treatment. The location of pain in adults was assessed with the McGill Pain Questionnaire (MPQ). Patients were divided into recovered and non-recovered groups. Recovery was defined as reaching a post-treatment level of fatigue within normal range. Recovered adult and adolescent CFS patients reported a significant reduction of pain severity compared to non-recovered patients. Recovered adult patients also had fewer pain locations following treatment. The decrease in fatigue predicted the change in pain severity. In adult patients, a higher pain severity at baseline was associated with a negative treatment outcome.     

Is reasoning from counterfactual antecedents evidence for counterfactual reasoning?

In most developmental studies the only error children could make on counterfactual tasks was to answer with the current state of affairs. It was concluded that children who did not show this error are able to reason counterfactually. However, children might have avoided this error by using basic conditional reasoning (Rafetseder, Cristi-Vargas, & Perner, 2010). Basic conditional reasoning takes an antecedent, which like in counterfactual reasoning can be counter to fact, and combines it with a conditional (or set of conditionals reflecting knowledge of how the world works) to draw a likely conclusion. A critical feature of counterfactual reasoning then is that these additional assumptions be modelled after the actual events to which the counterfactual is taken to be counterfactual. In contrast in basic conditional reasoning one enriches the given antecedent with any plausible assumptions. In our tasks basic conditional reasoning leads to different answers than counterfactual reasoning. For instance, a doctor, sitting in the park with the intention to read a paper, is called to an emergency at the swimming pool. The question, "if there had been no emergency, where would the doctor be?" should counterfactually be answered "in the park". But ignoring the doctor's intentions and just reasoning on plausible grounds one might answer: "in the hospital". Only by 6 years, did children give mostly correct answers.     

Is reasoning from counterfactual antecedents evidence for counterfactual reasoning?

In most developmental studies the only error children could make on counterfactual tasks was to answer with the current state of affairs. It was concluded that children who did not show this error are able to reason counterfactually. However, children might have avoided this error by using basic conditional reasoning (Rafetseder, Cristi-Vargas, & Perner, 2010 Perner, J. and Rafetseder, E. 2010. “Counterfactual and other forms of conditional reasoning: Children lost in the nearest possible world”. In Understanding counterfactuals/Understanding causation, Edited by: Hoerl, C., McCormack, T. and Beck, S. R. New York: Oxford University Press.  [Google Scholar]). Basic conditional reasoning takes background assumptions represented as conditionals about how the world works. If an antecedent of one of these conditionals is provided by the task, then a likely conclusion can be inferred based only on background assumptions. A critical feature of counterfactual reasoning is that the selection of these additional assumptions is constrained by actual events to which the counterfactual is taken to be counterfactual. In contrast, in basic conditional reasoning one enriches the given antecedent with any plausible assumptions, unconstrained by actual events. In our tasks basic conditional reasoning leads to different answers from counterfactual reasoning. For instance, a doctor, sitting in the park with the intention of reading a paper, is called to an emergency at the swimming pool. The question, “If there had been no emergency, where would the doctor be?” should counterfactually be answered “in the park”. But by ignoring the doctor's intentions, and just reasoning from premises about the default location of a hospital doctor who has not been called out to an emergency, one might answer: “in the hospital”. Only by 6 years of age did children mostly give correct answers.     

Does anxiety affect children's reports of memory for a stressful event?

The study was conducted to explore the effects of anxiety on children's memory for a naturalistic, potentially stressful event. Eighty children of two age groups, 4-5 and 7-8 years, visited the dentist for either a teeth-cleaning check-up or an operative procedure. Anxiety was assessed by a behavioural rating scale, as well as through Likert-scale ratings by the hygienist, parent, and child. Memory for the event was elicited through free recall and specific central and peripheral questions. High anxiety had a debilitative effect on the reports of the older children, but not on young children's reports. However, experience with the dental event mediated the influence of age and anxiety on memory. Although all measures of anxiety were significantly associated with each other, only the behavioural rating scale yielded statistically reliable effects of anxiety on memory. The anxiety-memory relationship is believed to be more complex than previous research with children suggests.     

How does mindfulness-based cognitive therapy work?

Mindfulness-based cognitive therapy (MBCT) is an efficacious psychosocial intervention for recurrent depression ( [Kuyken et?al., 2008], [Ma and Teasdale, 2004] and [Teasdale et?al., 2000]). To date, no compelling research addresses MBCT’s mechanisms of change. This study determines whether MBCT’s treatment effects are mediated by enhancement of mindfulness and self-compassion across treatment, and/or by alterations in post-treatment cognitive reactivity. The study was embedded in a randomized controlled trial comparing MBCT with maintenance antidepressants (mADM) with 15-month follow-up (Kuyken et al., 2008). Mindfulness and self-compassion were assessed before and after MBCT treatment (or at equivalent time points in the mADM group). Post-treatment reactivity was assessed one month after the MBCT group sessions or at the equivalent time point in the mADM group. One hundred and twenty-three patients with ≥3 prior depressive episodes, and successfully treated with antidepressants, were randomized either to mADM or MBCT. The MBCT arm involved participation in MBCT, a group-based psychosocial intervention that teaches mindfulness skills, and discontinuation of ADM. The mADM arm involved maintenance on a therapeutic ADM dose for the duration of follow-up. Interviewer-administered outcome measures assessed depressive symptoms and relapse/recurrence across 15-month follow-up. Mindfulness and self-compassion were measured using self-report questionnaire. Cognitive reactivity was operationalized as change in depressive thinking during a laboratory mood induction.MBCT’s effects were mediated by enhancement of mindfulness and self-compassion across treatment. MBCT also changed the nature of the relationship between post-treatment cognitive reactivity and outcome. Greater reactivity predicted worse outcome for mADM participants but this relationship was not evident in the MBCT group.MBCT’s treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment.     

Materials used to support cognitive behavioural therapy for depression: a survey of therapists’ clinical practice and views

ABSTRACT

Use of supporting materials in cognitive behavioural therapy (CBT) is widely advocated, and homework increases effectiveness. The study aimed to identify materials most frequently used by CBT therapists to support CBT for depression, and those perceived clinically most effective. Questionnaires were sent to 3665 accredited CBT therapists asking about their use of resources commonly described in CBT manuals, and their views on effectiveness. Of 3665 approached by post/email, 994 (27%) responded. Another 33 completed the questionnaire via the study website. 818/1027 (80%) of respondents were accredited practitioners who deliver one-to-one therapy. Symptom measures, lists of problems/goals, activity schedules, behavioural activation diaries/plans, and case formulation worksheets were used “frequently” or “very frequently” by over 85% of respondents. Sleep diaries and computerised CBT were used least. Most resources were used within and between sessions. Activity schedules, behavioural activation diaries/plans, case formulation worksheets, thought records, and resources to support the identification of conditional beliefs were regarded as most effective. Symptom measures, sleep diaries, and computerised/online materials were considered only moderately effective. Therapists use a wide range of materials to support individual CBT. For delivering CBT, technology-enabled approaches should incorporate a range of materials to enable therapists to tailor treatment effectively.     

Does the direction and magnitude of cognitive change depend on initial level of ability?

Longitudinal change in five cognitive abilities was investigated to determine if the direction or magnitude of change was related to the individual's ability level. Adults between 18 and 97 years of age performed three versions of 16 cognitive tests on two occasions separated by an average of 2.7 years. In order to control for influences associated with regression toward the mean, level of ability was determined from scores on the first version of the cognitive tests on the first occasion, and across-occasion change was examined on the second and third versions. Change in every cognitive ability was significantly more negative with increased age. However, there was little indication of ability-dependent change in any of the five cognitive abilities, either in differences between composite scores, or in estimates of latent change. Although there are reasons to expect cognitive change to be less negative at either high or low levels of ability, these data suggest that neither the direction nor magnitude of change is related to initial ability when influences of regression toward the mean are controlled.